Issue #135

Featured Content

CMS Updates End of PHE Guidance

• On May 12, the Centers for Medicare & Medicaid Services (CMS) released answers to frequently asked questions (FAQs) about the unwinding of the COVID-19 public health emergency (PHE) and the continuous coverage requirements. The FAQ document clarified requirements around Medicaid premiums, and explained when states must attempt to recontact a beneficiary due to returned mail. The guidance also advises state Medicaid agencies about sharing beneficiary information with providers so they can encourage their patients to renew coverage. States are not permitted to adjust their Medicaid premiums schedule until January 1, 2024, unless it’s for new eligibility groups, to reduce premium amounts, or to exempt new populations from premiums. States were required to “undertake a good-faith effort to contact an individual using more than one modality prior to terminating their enrollment on the basis of returned mail” to be eligible to claim enhanced federal matching dollars during the unwinding period. The FAQ document comes shortly after Arkansas dropped coverage for more than 72,800 Medicaid and CHIP beneficiaries on April 1 (CMS, May 11; Inside Health Policy, May 15).

Appeals Court Stays ACA Ruling

• On May 15, the U.S. Court of Appeals for the Fifth Circuit in New Orleans put an administrative stay, or a freeze, on a lower court ruling that scrapped the Affordable Care Act requirement for health plans to fully cover preventative healthcare services. The March 30 lower court ruling out of Texas struck down the preventative care mandate, putting coverage for certain cancer screenings, behavioral counseling HIV prevention and other services recommended by the U.S. Preventative Services Task Force in jeopardy. The U.S. Department of Justice has appealed that decision, kicking off a process where the ultimate decision on mandating preventative care has the potential to end up in the U.S. Supreme Court (Health Payer Specialist, May 16; Axios, May 15).

News

• On Tuesday, the Department of Education released a proposed rule that would amend regulations that govern the Assistance to States for the Education of Children with Disabilities program, including the preschool grants program. The Secretary of Education, Dr. Miguel Cardona, proposes to modify the Individuals with Disabilities Education Act (IDEA) Part B rules to eliminate the obligation for public agencies to get parental consent prior to accessing a child’s public benefits or insurance (e.g., Medicaid, Children’s Health Insurance Program (CHIP)) for the first time to provide or pay for required IDEA Part B services. Currently, there are no comparable consent requirements prior to accessing public benefits for children without disabilities. The removal of this requirement would align the public benefit consent requirements for children with disabilities and children without disabilities, ensuring equal treatment of both groups. The proposed rule is scheduled to be published on May 18, 2023. The Department of Education is requesting public comments by August 1, 2023 (Federal Register, May 16).
• In a discussion paper released May 10, the Food and Drug Administration (FDA) announced that it was seeking input from stakeholders on how to regulate the utilization of artificial intelligence and machine learning in drug development as well as in the development of medical devices intended to be used with drugs. In addition to stakeholder feedback, the FDA plans to follow up with workshops and other opportunities for stakeholders to engage with the agency on the topic. The three areas in which the FDA is seeking feedback are “human-led governance, accountability, and transparency; quality, reliability, and representativeness of data; and model development, performance, monitoring, and validation” (Inside Health Policy, May 10).
• As demand for weight loss drugs increases, both insurers and pharmacy benefit managers (PBMs) are inhibiting access to the drugs. The new class of drugs known as glucagon-like peptide agnostics, or GLP-1s, are pricey and the potential market is vast. As with many expensive prescriptions, payers want to provide members with access to GLP-1s but can’t provide as much as they’d like because of the high costs set by the manufacturers. Additionally, drugmakers continue to fault PBMs for the lack of coverage and high out-of-pocket expenses. The FDA imposes restrictions on the label, but many insurers are going beyond these restrictions and only allowing the most obese patients access to the drug, requiring patients to enroll and complete diet and exercise programs, or test and fail lower-cost drugs before agreeing to pay for GLP-1s (Modern Healthcare, May 16).

Federal Legislation

• There is increasing bipartisan pushback on the CMS decision to limit coverage of anti-amyloid class of emerging drugs used to treat early stages of Alzheimer’s disease. Members of both parties are calling for a reversal of the restriction and are instead putting together draft legislation that would require CMS to consider each of the FDA-approved drugs individually rather than by class. Lawmakers have also raised concerns over equity due to the limitation of clinical trial coverage for individuals who are participating in drug research residing in rural areas. Stakeholders and advocates for the reversal of the restriction believe that paying for these medications will likely decrease the overall cost burden on the healthcare system since Alzheimer’s patients have extensive long-term needs (Inside Health Policy, May 12).

Featured Content

Montana Nursing Homes to See Medicaid Rate Increase

• Montana nursing homes are set to see an approximate increase of 33% in Medicaid rates over the next two years. In 2024, facilities will receive a 28% increase in the base Medicaid rate, from $209 per resident per day to $268. In 2025, the increase will change from $268 to $278 per resident per day, amounting to a net 33% increase over the two years. Since February 2022 the state has lost at least 12 nursing homes with a total of 65 nursing homes remaining as of November 2022. It remains to be seen if the increase in rates will be enough to stabilize the facilities across the state as many providers have made it clear to lawmakers the depth of issues facing the nursing home sector due to underfunding (McKnights, May 15).

Waivers

• Section 1115
  • Texas
    • On May 1, 2023, Texas submitted an amendment to its section 1115(a) waiver demonstration, the Texas Healthcare Transformation and Quality Improvement Program (THTQIP). The amendment proposes to use different data sets for the second reassessment of the Uncompensated Care Pool due to the potential impact of COVID-19 on the data, and to add a footnote to Table 4a in its Special Terms and Conditions as a technical correction. The federal public comment period is open from May 17, 2023, through June 16, 2023.
• 1915(c) Appendix K
  • Hawaii
    • Increases provider payment rates for waiver emergency services for the period from May 1, 2023, to six months after the conclusion of the PHE under the Home and Community Based Services for People with Intellectual and Developmental Disabilities (I/DD) waiver.
  • Montana
    • Includes rate increases for identified services under the Montana Big Sky Home and Community Based Waiver, Montana Home and Community Based Waiver for Individuals with Developmental Disabilities, and Montana Behavioral Health Severe Disabling Mental Illness Home and Community Based Services Waiver starting July 1, 2023.

SPAs

• COVID-19 SPAs
  • Arkansas (AR-23-0007, effective May 12, 2023): Temporarily extends Therapeutic Community rates originally approved in AR-22-0015 until December 31, 2023, with the following modifications: Therapeutic Community, Level 1 at $500.00 per day and Therapeutic Community, Level 2 at $358.00 per day.
  • Arkansas (AR-23-0012, effective May 12, 2023): Temporarily extends reassessment interview requirements for telehealth utilization originally approved in AR-22-0016 until December 31, 2023.
  • District of Columbia (DC-23-0003, effective May 1, 2022): Modifies the re-evaluation process for participants in the 1915(i) Housing Supportive Services program and allows for supplemental payments to direct care workers under section 9817 of the American Rescue Plan Act. This time-limited COVID-19 SPA terminated at the end of the PHE.
  • District of Columbia (DC-23-0004, effective May 12, 2023): Extends 1915(i) Housing Support Services, direct support worker supplemental payments, and 1915(i) Adult Day Health Program flexibilities with modifications to provide additional protections for individuals receiving telehealth services.
  • Idaho (ID-23-0019, effective May 12, 2023): Extends for one year the telehealth flexibilities for Idaho’s three Section 1915(i) programs that were originally approved in ID-20-0014, ID-21-0008, ID-23-0018.
  • Iowa (IA-23-0006, effective May 12, 2023): Temporarily extends 1915(i) flexibilities originally approved in IA-20-0008 and IA-21-0007 with the following modification: the state will include telehealth and other provisions from Section 7.4 in IA-21-0007 originally approved on June 30, 2021.
  • Kansas (KS-23-0016, effective March 11, 2021): Revises Attachment 7.7-A to include COVID-19 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) stand-alone vaccine counseling.
  • Minnesota (MN-23-0012, effective July 1, 2021): Increases the pharmacist dispensing fee from $10.48 to $10.77 per prescription. This time-limited COVID-19 SPA terminated at the end of the PHE.
  • Mississippi (MS-23-0006, effective March 1, 2023): Makes a one-time, lump-sum payment to all Mississippi hospitals eligible for supplemental payments. This time-limited COVID1-9 SPA terminated at the end of the PHE.
• Eligibility SPAs
  • Connecticut (CT-23-0006, effective January 1, 2023): Memorializes the new income standards for its optional state supplement program, the beneficiaries of which are eligible for Medicaid under the state plan.
• Services SPAs
  • Colorado (CO-23-0006, effective May 12, 2023): Removes Prior Authorization Request requirements for Home Health Services and allows practitioners to order and re-order that the patient is eligible for such services.
  • Delaware (DE-22-0011, effective July 1, 2022): Provides for 12 months of extended postpartum coverage to individuals who were eligible and enrolled under the Medicaid state plan during their pregnancies (including during a period of retroactive eligibility).
  • Michigan (MI-23-0005, effective May 1, 2023): Adds coverage and reimbursement for diabetes prevention services for eligible beneficiaries.
  • Minnesota (MN-23-0008, effective January 1, 2023): Removes the requirement that an Individual Behavior Plan guides the work of a Mental Health Behavioral Aide (MHBA) who is providing Mental Health Behavioral Aide Services to a child receiving CTSS skills training. Additionally, treatment supervisors are no longer required to be present on-site at a Day Treatment program while a supervisee is providing mental health services to children and the treatment supervisors are no longer required to review and sign the record of a child’s day treatment care.
  • New Hampshire (NH-23-0023, effective October 1, 2020): Attests to medication-assisted treatment (MAT) as a mandatory benefit in the Medicaid state plan pursuant to 1905(a)(29) of the Social Security Act and Section 1006(b) of the SUPPORT Act. This SPA also confirms coverage for related counseling and behavioral health therapies. The benefit is effective until September 30, 2025.
  • Oregon (OR-21-0015, effective May 12, 2023): Provides for a correction to the effective date of an SPA approved on December 1, 2021 that authorized changes to the definition of home with settings in which normal life activities take place to better align the language with CMS regulations from 2017.
  • Oregon (OR-23-0009, effective January 1, 2023): Adds coverage and reimbursement of community violence prevention services performed by certified violence prevention professionals under the state’s alternative benefit plan (ABP).
  • Vermont (VT-23-0019, effective January 1, 2023): Amends prior authorization requirements for chiropractic services, physical therapy, occupational therapy, speech therapy and hearing aids.

News

• On May 13, Governor Roy Cooper (D-NC) vetoed Senate Bill 20 (SB 20), a bill passed by the North Carolina General Assembly that limited most abortions after 12 weeks and created new requirements for women and their providers to complete in order for the procedure to occur. The veto-stamped bill returns to the General Assembly where 30 votes in the Senate and 72 votes in the House are necessary to override the governor’s vetoe. The bill is opposed by the North Carolina Medical Society, the North Carolina Obstetrical and Gynecological Society, the North Carolina Academy of Family Physicians and the North Carolina affiliate of the American College of Nurse-Midwives (North Carolina Health News, May 15).
• On May 12, the Illinois Department of Healthcare & Family Services and the Illinois Department of Human Services were victims of a data breach that leaked information of individuals enrolled in state-funded programs, including Medicaid, the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF). It is not clear how many individuals were affected by the breach but the departments stated all affected individuals have been notified of the breach. Additionally, the departments are deploying new software to prevent anything else from happening at this time (Modern Healthcare, May 12)