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Issue #161

Key Updates:

KFF issued a brief analyzing Medicaid enrollment and spending trends for FY2023 and FY2024, based on data provided from state Medicaid Directors as part of its 23rd survey of Medicaid Directors. Forty-eight states, including the District of Columbia, responded to the survey. (KFF, November 14)

On November 6, the Urban Institute released a brief, “Uninsured Veterans in the U.S. and Potential for Coverage Gains,” where analysis found that nearly half of uninsured veterans are eligible for ACA or Medicaid coverage. Findings demonstrated that 47% of the 400,000 uninsured veterans are eligible for Medicaid or marketplace coverage and that one in 10 of uninsured veterans would have access to Medicaid if their state had opted to expand via the ACA. (Inside Health Policy, November 10)

On November 11, Speaker Mike Johnson (R-LA) released a two-step continuing resolution proposal intended to prevent a government shutdown on November 17. However, the stopgap spending measure was quickly met with resistance from both parties in Congress. (Inside Health Policy, November 13; MSN, November 11).

From November 8 to November 15, CMS approved 27 SPAs and has two 1115 waiver amendments out for public comment.

Federal Updates

Featured Content

KFF Medicaid Director Survey Results

  • The Kaiser Family Foundation (KFF) issued a brief analyzing Medicaid enrollment and spending trends for FY2023 and FY2024, based on data provided from states as part of its 23rd annual survey of Medicaid Directors. Forty-eight states, including the District of Columbia, responded to the survey. The specific key takeaways are:
    • The onset of the COVID-19 pandemic and its economic impact had significant implications for Medicaid enrollment and spending.
    • State economic conditions worsened rapidly when the pandemic hit in March 2020 but recovered quickly compared to past recessions.
    • Fiscal conditions in most states remained strong in FY2023, but growth in revenue collections slowed and states expressed concerns regarding their longer-term fiscal outlook.
    • Medicaid enrollment grew more slowly in FY2023 and is expected to decline in FY2024 due to the unwinding of the continuous enrollment requirement.
    • While the largest driver of enrollment trends continues to be the continuous enrollment provision and its subsequent unwinding, state Medicaid agencies also reported eligibility policy changes as an upward pressure.
    • After peaking in FY 2022 at 9.8%, total Medicaid spending growth slowed to 8.3% in FY2023 and is expected to slow further to 3.4% in FY2024.
    • State Medicaid spending growth increased in FY 2023 and is projected to increase further in FY 2024 as the enhanced FMAP expires.
    • The unwinding of the Medicaid continuous enrollment provision and phase-down of the enhanced FMAP are expected to have a significant impact on Medicaid enrollment and spending in FY2024.
    • While most states at the time of the survey reported favorable state fiscal conditions, over half of responding states noted an uncertain fiscal outlook (KFF, November 14).

Report on Uninsured Veterans

  • On November 6, the Urban Institute released a brief, “Uninsured Veterans in the U.S. and Potential for Coverage Gains,” where analysis found that nearly half of uninsured veterans are eligible for Affordable Care Act (ACA) or Medicaid coverage. Findings demonstrated that 47% of the 400,000 uninsured veterans are eligible for Medicaid or marketplace coverage and that one in 10 of uninsured veterans would have access to Medicaid if their state had opted to expand via the ACA. The brief also projects that in 2024 approximately 57% of insured veterans will be covered through their employer, 22% will be insured through the VA or other military sources, and 9.4% will be covered through Medicaid. The brief encourages all states to expand Medicaid and recommends policymakers to maximize enrollment in VA health benefits through targeted outreach and enrollment assistance (Inside Health Policy, November 10).

House Speaker Offers Continuing Resolution

  • On November 11, Speaker Mike Johnson (R-LA) released a two-step continuing resolution proposal intended to prevent a government shutdown on November 17. However, the stopgap spending measure was quickly met with resistance from both parties in Congress. The measure would extend current funding for the FDA, Department of Agriculture, military construction and Veterans Affairs, and the departments of Transportation, Housing, and Urban Development until January 19, 2024. Community health centers, teaching hospitals, special diabetes programs, and a delay of Medicaid cuts to DSH hospitals would also be temporarily funded until January 19. The resolution would also extend Medicare geographic payment adjustments to physicians scheduled to conclude at the end of the year and suspend scheduled changes to Medicare clinical laboratory test payments for an additional year. Temporary funding for the HHS and the other remaining agencies would expire February 2, 2024. Congress is taking a clean continuing resolution approach, meaning that there will be no renewals of some key healthcare programs that expired during budget talks, including the Pandemic and All-Hazards Preparedness Act and the opioid treatment-focused SUPPORT Act. Some preparedness funding is included separately in the resolution (Inside Health Policy, November 13; MSN, November 11).

News

  • On November 10, the White House announced the expansion of healthcare coverage for veterans across the country. Beginning this month, all living WWII veterans can access “no cost” healthcare services from the Department of Veterans Affairs (VA), including nursing home care. The VA will also be accelerating eligibility under the PACT Act, a law passed in 2022 that expands benefits for veterans exposed to toxins and chemicals. The Biden Administration also announced the establishment of a new campaign and task force called Veteran Scam and Fraud Evasion (VSAFE) aimed at protecting veterans and their families from scams (The Hill, November 10).

Federal Regulation/Guidance

  • CMS has released guidance through an informational bulletin around three new, optional sexual orientation and gender identity (SOGI) questions on the single, streamlined application that started on November 1, 2023. The purpose of these questions is to improve the consumer experience, enhance demographic data collection to identify health disparities, and support equitable healthcare. Two questions focus on gender identity (sex assigned at birth and current gender) and one question asks about sexual orientation for applicants and all individuals aged 12 and older. The model application used by Marketplaces will continue to include the mandatory “Sex” question. State Medicaid and CHIP agencies may add the SOGI questions to the model application or a CMS-approved alternative application without seeking CMS approval, provided that the wording matches that of the model application. States that wish to modify the language or response options may need CMS approval. CMS emphasized the importance of protecting the privacy and security of collected SOGI data. Finally, CMS plans to begin receiving and accepting SOGI data as a part of T-MSIS data submissions for the states that choose to collect this data starting in 2025 (CMS, November 9).
State Updates

Waivers

  • Section 1115
    • Maryland
      • On October 25, 2023, Maryland submitted a request to amend its section 1115 demonstration titled “Maryland Health Choice,” to establish an Express Lane Eligibility program to utilize data from the Supplemental Nutrition Assistance Program for Medicaid redeterminations, as well as to continue Maryland’s waiver of the Four Walls Requirement for clinics, as previously granted under the COVID-19 public health emergency (PHE). The public comment period will be open from November 9 to December 9. Public comments can be submitted here.
    • Idaho
      • On November 7, 2023, Idaho requested to amend its Behavioral Health Transformation demonstration to allow spouses and parents of minor children to be reimbursed for providing personal care services to eligible individuals. Idaho currently has this authority through temporary COVID-19 authorities. The public comment period is open from November 8 through December 8. Public comments can be submitted here.

SPAs

  • Payment SPAs
    • Alabama (AL-23-0003, effective July 1, 2023): Increases payments to providers associated with teaching hospitals.
    • California (CA-23-0019, effective July 1, 2023): Updates Medi-Cal FFS reimbursement rates for clinical laboratory or laboratory services.
    • California (CA-23-0025, effective July 1, 2023): Clarifies the reimbursement methodology for care coordination, recovery support services, peer support specialist services, and Medication Addiction Treatment (MAT) when provided in a residential treatment setting.
    • Illinois (IL-23-0030, effective January 1, 2024): Updates the rates for Nursing Services under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program.
    • Iowa (IA-23-0020, effective July 1, 2023): Changes the language of the state’s Third Party Rules related to prior authorization.
    • Kansas (KS-23-0036, effective October 1, 2023): Increases reimbursement rates for lactation consulting services.
    • Maryland (MD-23-0018, effective July 1, 2023): Implements a 3% rate increase provided by the Maryland Budget Bill for the 1915(i) Home and Community-Based Services (HCBS) program.
    • Michigan (MI-23-0025, effective October 1, 2023): Increases rates for Behavioral Health Treatment and Personal Care Services Direct Care Workers.
    • Michigan (MI-23-0027, effective October 1, 2023): Updates rates for Home Health Services.
    • Missouri (MO-23-0016, effective July 1, 2023): Updates the inpatient hospital reimbursement rate to include a new supplemental payment known as the Psych Adjustment Payment.
    • Nevada (NV-23-0015, effective July 1, 2023): Updates the payment methodology for certain providers of Applied Behavioral Analysis.
    • New Hampshire (NH-23-0044, effective July 1, 2023): Updates rates and methodology for Personal Care Assistant Services.
    • New Hampshire (NH-23-0047, effective July 1, 2023): Updates the rates for Targeted Case Management (TCM) Services.
    • New Hampshire (NH-23-0049, effective July 1, 2023): Increases the rate for Freestanding Birthing Center Services.
    • New Hampshire (NH-23-0051, effective July 1, 2023): Updates the rates for Physicians and Other Licensed Practitioner (OLP) Services.
    • New Hampshire (NH-23-0054, effective July 1, 2023): Updates the fee schedule rates for the 1915(i) Supported Housing Services.
    • Oregon (OR-23-0022, effective May 12, 2023): Authorizes the state to continue the ambulance “treat in place” rate that was originally approved in Disaster Relief SPA 20-0014.
    • Washington (WA-23-0050, effective July 1, 2023): Brings the state into compliance with the reimbursement requirements in the Covered Outpatient Drug final rule with comment period (CMS-2345-FC).
    • Wisconsin (WI-23-0019, effective July 1, 2023): Modifies the reimbursement methodology for nursing homes and ICF-IIDs. Modifications include adjustments to the targets, maximums, labor factors, property adjustments, and other payments parameters.
    • Wyoming (WY-23-0012, effective July 1, 2023): Updates the reimbursement methodology for durable medical equipment/supplies and allows for a non-rural and rural rate according to the member’s physical address.
  • Services SPAs
    • Idaho (ID-23-0005, effective March 13, 2020): Temporarily adds homemaker services and corresponding rates during the COVID-19 PHE for the state’s 1915(i) HCBS Adult Developmental Disability Program. The SPA also authorizes a waiver of signatures for drug dispensing during the PHE.
    • Illinois (IL-23-0016, effective March 1, 2020): Temporarily allows the state to waive signature requirements for the dispensing of drugs during the COVID-19 PHE; authorizes reimbursement rates for COVID-19 monoclonal antibody treatment and administration that are set equal to 100% of the Medicare rate; and other temporarily enhanced payment rates for various services during the PHE.
    • Missouri (MO-23-0022, effective July 7, 2023): 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). With this approval, Missouri is the 40th state to offer a full year of Medicaid coverage after pregnancy.
    • North Carolina (NC-23-0029, effective December 1, 2023): Defines the Alternative Benefit Plan (ABP) that will be used to implement certain requirements for the new North Carolina Expansion eligibility group as required by SL 2023-7. The Affordable Care Act (ACA) allows for the inclusion of Medicaid eligibility to individuals aged 19-64 with incomes at or below 133% FPL who are not enrolled or eligible for Medicare, consistent with the new adult group eligibility criteria as defined by the ACA.
    • Ohio (OH-23-0022, effective July 1, 2023): Revises the State Plan to comply with a CMS directive to remove non-emergency medical transportation services from the list of services covered under a Medicaid waiver.
    • Vermont (VT-23-0039, effective August 15, 2023): Specifies that select incontinence supplies must be supplied by the statewide contracted vendor unless prior authorization is granted.
    • Virginia (VA-23-0017, effective July 1, 2023): Establishes a nursing facility value-based purchasing program and payment methodology to enhance funding for nursing facilities that meet or exceed performance and/or improvement thresholds.

News

  • Doula services will be covered for all Medicaid enrollees in New York starting on January 1, 2024. Currently, patients must pay for doula services out-of-pocket. With the new legislation signed by Governor Hochul, New York Medicaid will cover $1,325 for doula services in the Update region and $1,500 for services in the New York City boroughs. The legislation also directs the New York State Department of Health to create and maintain a directory of doulas. This legislation was first introduced by state Senator Samra Brouk (MSN, November 9).
  • Nevada legislators have joined national civil rights and health equity organizations to call on states to stop disenrolling individuals from Medicaid for procedural reasons. Since the Medicaid unwinding began in June, Nevada has had the nation’s highest procedural enrollee termination rate. Because of this, CMS required Nevada and other states to pause disenrollment. However, as of now, Nevada plans to resume disenrollment for procedural reasons in January 2024 for individuals who received requalification packets this November (Reno, November 12).
Private Sector Updates

News

  • According to a U.S. Food and Drug Administration (FDA) report, over 50% of American adults have one or more diet-related chronic diseases, such as type 2 diabetes, obesity, and different kinds of cancer. With the increase in value-based care options, improving the diet of health plan members is a desirable goal. Kaiser Permanente is investing $50 million into its Food is Medicine program to include initiatives to support medically tailored meals and produce prescriptions targeted to meet specific nutritional needs. Kaiser will then study outcomes of the interventions to determine which of them helped reduce healthcare-related costs for members and payers. Kaiser also partners with Instacart to determine whether access to healthy food will improve blood sugar levels in pre-diabetic and diabetic patients and people with other diet-related diseases. The partnership will also follow diet-related disease quality of life, patient readiness to change, and hospitalizations or emergency department visits. Over a six-month period, Kaiser will give participants $100 per month that they can use to buy items from a virtual Instacart storefront that offers fresh produce and nutritious pantry items. In addition to Kaiser, Instacart partners with Alignment Health and Mount Sinai Solutions (Modern Healthcare, November 10; Health Payer Specialist, November 13).
  • Smaller Pharmacy Benefit Managers (PBMs) such as AffirmedRx, Liviniti, MedOne Pharmacy Solutions Rx, and others, are advocating for a more transparent business model and lobbying Congress to pass legislation to regulate major PBMs like CVS Caremark, OptumRx, and Express Scripts. These large PBMs have nearly 80% of the market. A bipartisan PBM bill is under consideration, but time constraints and other legislative priorities pose challenges to move the bill forward. Smaller PBMs consider themselves to be affordable, efficient, and transparent alternatives. However, there have been challenges in persuading employers and insurers to switch to the smaller companies. Transparency-Rx is a coalition of smaller PBMs that has emerged to advocate for transparency in drug pricing. They support legislation to mandate sharing negotiated drug rebates, limiting spread pricing, and separating PBM compensation from list prices. The Pharmaceutical Care Management Association, affiliated with the major PBMs, opposes these legislative changes (Modern Healthcare, November 13).
  • Optum RX, the UnitedHealth Group-owned pharmacy benefit manager, now has eight types of insulin products available for reduced prices. Optum Rx added these insulins to its tier 1, or preferred, list of medications. Out-of-pocket costs for each of the insulins will be capped at $35 starting January 1, 2024 (Health Payer Specialist, November 10).
Sellers Dorsey Updates
  • Housing and health are deeply intertwined. Given this close connection, CMS has recently begun to view housing as a healthcare issue that can be addressed through Medicaid-funded programs. We sat down with Senior Strategic Advisor to Sellers Dorsey and former Arizona state Medicaid Director, Jami Snyder, to discuss housing challenges in relation to social determinants of health and how innovative Medicaid funding can provide solutions. Click here to view the full conversation.


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