North Carolina Launches Medicaid Expansion

• On December 1, North Carolina became the fourth state to expand Medicaid during the Biden-Harris administration, joining Missouri, Oklahoma, and South Dakota. An additional 600,000 North Carolinians between the ages of 19 and 64 who make less than $20,120 annually are now eligible for comprehensive healthcare coverage. This coverage includes primary and preventative care, mental health and substance use disorder treatments, emergency care, and prescription drug benefits. North Carolina expects to receive approximately $1.8 billion in additional federal American Rescue Plan funding due to the expansion (Medicaid.gov, December 1).

News

• Sanford Health is preparing to launch an acute home care program in Fargo, North Dakota. In mid-November, CMS approved an Acute Care at Home waiver that permits launch of the model from Sanford Medical Center. The hospital is expected to start offering home-based hospital care to individuals within a 25-mile radius of Fargo by March 2024. The model is designed to boost care in rural communities, but has had a slow start so far, possibly due to provider shortages and the lack of Medicaid reimbursement for home-based hospital care in most states. In the future, Sanford Medical Center plans to provide care to people living in rural areas up to 100 miles away and use nurses and emergency medical technicians from its critical access hospitals in North Dakota and northwest Minnesota. More than 300 hospitals in 37 states offer hospital-at-home care, and a study published in JAMA Health Forum “found that more than 11,000 patients admitted to hospital-at-home programs during a 16-month period experienced low mortality rates and minimal complications.” With rural areas having lost 140 hospitals in the last ten years, researchers and other healthcare providers believe that this model could help fill the void in rural healthcare (Modern Healthcare, December 1).
• On November 30, CMS released the latest enrollment figures for Medicare, Medicaid, and CHIP, reflecting data from August of this year. In the latest report, there were 66,338,178 people enrolled in Medicare, an increase from the last report. Over 32 million were enrolled in Medicare Advantage or other health plans, including plans with and without prescription drug coverage. Nearly 34 million were enrolled in Original Medicare. Over 12 million individuals are dually eligible for Medicare and Medicaid and are included in the enrollment counts for both programs. In August 2023, there were 89,994,594 people enrolled in both Medicaid and CHIP. This is a decrease of 1,518,581 from the previous report. Of this number, nearly 7 million were enrolled in CHIP. The previous report was published on October 31, 2023, reflecting data from July of this year (CMS, November 30).

Federal Regulation

• On December 1, the Centers for Medicare & Medicaid Services (CMS) released State Health Official (SHO) letter SHO#23-005, “Initial Core Set Mandatory Reporting Guidance” to define expectations and provide guidance for the mandatory reporting on the Child Core Set measures and behavioral health measures of the Adult Core Set. These requirements were established in the Mandatory Medicaid and CHIP Core Set Reporting final rule in August 2023 and were also authorized in previous legislation. The letter explains that states can expect resources to be shared annually before the reporting system opens in addition to describing the process for exempting populations from reporting, phased-in stratification requirements, and the forthcoming Medicaid SPA package states will need to submit to attest to compliance.

Sellers Dorsey summarized the letter with everything you need to know. For the Sellers Dorsey summary click here (Medicaid.gov, December 1).

SPAs

• On November 30, Texas Attorney General, Ken Paxton, filed a 54-page lawsuit against Pfizer, Inc., alleging that Pfizer “engaged in false, deceptive, and misleading acts and practices by making unsupported claims regarding the company’s COVID-19 vaccine in violation of the Texas Deceptive Trade Practices Act” (The Texas Tribune, November 30).
• On December 1, Centene and UnitedHealth Group were awarded Arizona’s long-term care contract, ALTCS-EPD, valued at $1.6 billion and covering approximately 26,000 older adults and individuals with physical disabilities. Incumbent plans, Banner University Family Care and Mercy Care Plan, were not awarded a new contract as well as Blue Cross Blue Shield of Arizona, another bidder. Winning plans must offer a D-SNP that is operational by January 1, 2025, including designation from CMS as a fully integrated special needs plan. The plans will provide coverage for dental, hearing, vision, fitness benefits, over the counter (OTC) drugs, and telehealth services (Health Payer Specialist, December 4).
• In Indiana, State Representative Ed Clere has raised concerns about the implementation of the state Medicaid agency’s new long-term care program slated to begin in July 2024. The state is transitioning to managed care entities (MCEs) to provide long-term care services under a capitation arrangement, called the Pathways for Aging (Pathways) program. Representative Clere has said that he has heard differing perspectives from the state’s Area Agencies on Aging (AAAs) and at the committee meetings on the Pathways program. According to Representative Clere, AAAs will be losing revenue that subsidizes the other functions of the agencies as the MCEs take over care management (WBAA, December 1).
• Pennsylvania has announced a significant improvement in the state’s payment errors for Medicaid and CHIP, with improper payments dropping well-below the national average. Improper payments include accountability issues such as a lack of supporting paperwork and does not necessarily mean the payments are fraudulent. Pennsylvanias’ improper Medicaid payments have dropped from 14.2% in 2019 to 2.5% and the CHIP errors dropped from 20.7% in 2019 to 5.6%. These drops demonstrate better numbers than the current national average of 8.9% and 12.8% for Medicaid and CHIP, respectively. Pennsylvania Governor Shapiro’s administration says the decline in error rates is partially due to federal-level changes that added eligibility determinations during reviews. Additionally, monthly case record reviews were added in order to improve payments (MSN, December 1).
• Following a 2022 study from New Mexico’s Human Services Department, the state has raised reimbursement rates for most Medicaid healthcare providers. Medicaid claims from July 1, 2023, forward will be processed with the new rates and as a result, healthcare providers will gain an additional $409 million. The rate increase is part of a larger strategy to increase payments to providers, and an additional rate increase is a component of the budget request for fiscal year 2025 (MSN, December 1).

News

• On December 1, Tennessee-based Community Health Systems (CHS) sold three Florida hospitals, including clinics and outpatient services, to Tampa General Hospital (TGH) in a cash deal worth $294 million. The acquisition of these three hospitals allows TGH to form TGH North, its most significant expansion in recent years. Alternatively, CHS left West Virginia earlier in 2023 and has plans to exit North Carolina next year, with plans to sell two hospitals to Novant Health for $320 million (Modern Healthcare, December 1).

• America is facing a looming crisis in long-term care. From a shortage of qualified caregivers to inadequate reimbursement rates, the challenges are surmounting. In our NEW blog, Managing Director of Sellers Dorsey and former state Medicaid Director, Suzanne Bierman, addresses navigating the future of long-term services and supports and shares her insights on innovative financing models that can serve as solutions. Click the link here to read Suzanne’s article!