Sellers Dorsey is delighted to announce that Matt Salo, former Executive Director of the National Association of Medicaid Directors (NAMD), recently joined the firm as a Senior Strategic Advisor. Welcome, Matt!
On November 1, CMS published a final rule that will invest in rural and underserved accountable care organizations (ACOs) and introduce more flexibility to the Medicare Shared Savings Program with the goal of kickstarting enrollment and bridging health equity gaps (Modern Healthcare, November 1).
Children’s hospitals across the country are pulling out emergency preparedness policies and activating everything possible due to surging respiratory disease outbreaks in addition to an increase in COVID-19 cases and a mental health epidemic (Modern Healthcare, November 4).
Due to continued federal aid throughout the COVID-19 public health emergency (PHE), Virginia’s Medicaid program is set to deliver $279.3 million in savings this year. The program is also projecting a small increase in state funds in the next fiscal year (Richmond Times-Dispatch, November 3).
Sellers Dorsey is a proud sponsor of the NAMD Annual Conference in Washington, DC. Stop by our booth to meet our experts, including former Medicaid directors, former health care executives, and policy experts with extensive experience in the development, administration, and operation of Medicaid programs. Learn more about our work here.
From November 4 to November 10, CMS approved two Appendix K waivers and two SPAs, neither of which is a COVID-19 disaster relief SPA.
CMS Makes Changes to Medicare Shared Savings Program
- On November 1, CMS published a final rule that will invest in rural and underserved ACOs and introduce more flexibility to the Medicare Shared Savings Program with the goal of kickstarting enrollment and bridging health equity gaps. Additionally, CMS finalized adjustments to ACO benchmarks to incentivize long-term participation. These updates are part of the physician fee schedule regulation, and regulators anticipate the changes will lead to $650 million in higher shared savings payments to ACOs. CMS will provide eligible ACOs with one-time payments of $250,000 and quarterly payments, based on the need of beneficiaries, for the first two years of the five-year agreement (Modern Healthcare, November 1).
- On November 1, simultaneous with the first day of the Affordable Care Act (ACA) open enrollment, the largest nonunion strike since the start of 2021 began. Less than 200 Maximus call center employees responsible for meeting the influx of open enrollment calls went on strike for fair wages and treatment. Maximus is the nation’s largest federal call center contractor. Workers have pledged to strike until they receive a base pay of $25 and 30 minutes of break time within an eight-hour shift. Maximus employees are also demanding clear policies protecting them from abusive calls by having the ability to disconnect or escalate calls without consequences. A spokesperson from Maximus recently responded that employees are allowed to disconnect calls without seeking permission from their supervisors if the caller is disrespectful or inappropriate (Fierce Healthcare, November 2).
- An Indiana lawsuit, filed by a woman alleging a nursing facility and its parent company improperly managed her father’s care before he died, has made its way to the United States Supreme Court. The defendant, the Health and Hospital Corporation of Marion County, requested and the Court agreed to weigh in on a much broader issue than the particular patient’s case: should individuals receiving services from publicly funded programs like Medicaid be allowed to sue states when they believe their rights have been violated? The outcome of this case could have far-reaching implications for the right of civil action in state Medicaid programs. The Supreme Court heard the oral argument on November 8 (Kaiser Health News, November 7).
- Families USA, a consumer advocacy group, has requested the Biden administration to extend the COVID-19 PHE beyond January 11 to provide states with more time to prepare for eligibility redeterminations of an estimated 90 million Medicaid beneficiaries once the PHE ends. The nursing home lobby and the American Health Care Association also made similar calls for a PHE extension (Inside Health Policy, November 8).
- A rigorous study shows Pfizer’s updated COVID-19 booster has significantly increased adults’ virus-fighting antibodies. Pfizer reports that individuals aged 55 and older who received the omicron-targeting booster had four-fold higher antibody levels than those given an extra dose of the original vaccine. The original COVID-19 vaccines still offer strong protection against severe illness and death, but effectiveness decreases as new mutants emerge (Modern Healthcare, November 4).
Virginia’s Medicaid Program Expected to Save Millions This Year
- Due to continued federal aid throughout the COVID-19 PHE, Virginia’s Medicaid program is set to deliver $279.3 million in savings this year. The $20 billion Medicaid program, run by the Department of Medical Assistance Services, is also projecting a small increase of $12.3 million in state funds in the next fiscal year. The newest forecast anticipates the program cost will rise by 3.1% in the next fiscal year, and 2.9% the following year, which is not currently accounted for in the state budget. However, almost all of the anticipated additional costs are projected to fall on the federal government and hospital provider assessment that pays for Virginia’s share of eligibility expansion (Richmond Times-Dispatch, November 3).
- 1915(c) Appendix K
- Revises the definition for Supported Employment (Individual) to include internships.
- Amends the rate methodology for Supported Employment (Individual) and Prevocational Services to include increased incentive payments for service providers who assist individuals in obtaining and maintaining competitive integrated paid employment.
- Amends the rate methodology for Supported Employment (Individual) to include incentive payments for service providers who assist individuals in obtaining and maintaining an internship.
- Temporarily adds dental services to the Individuals with Intellectual and Developmental Disabilities existing waiver services (as “Other”) for adult recipients.
- Administrative SPAs
- Alaska (AK-22-0008, effective July 1, 2022): Reflects the state’s reorganization of the Department of Health and Social Services into two new departments – the Department of Health and the Department of Family and Community Services. The SPA also approves the Department of Health as the single Medicaid agency.
- Payment SPAs
- Oregon (OR-22-0015, effective July 1, 2022): Allows for home-based Behavior Rehabilitation Services to be paid based on a state-wide fee schedule per service, updates minimum requirements for staff to address staffing shortages, and updates terminology to avoid confusion between mental health and substance use disorder rehabilitation services.
- South Dakota residents voted to expand Medicaid coverage under the ACA through a ballot initiative. The ballot passed with 56% support paving the path for the state to adopt Medicaid expansion that could cover more than 40,000 people (Politico, November 9).
- Despite having a significant number of Medicaid enrollees, along with many institutional and professional health care providers, Hawaii has the lowest rate amongst states of fraud and abuse charges and prosecutions within its program. The state attorney general has a 15-person Medicaid Fraud Control Unit that looks for provider overbilling and enrollee abuse or neglect. However, in 2021 only one person was charged in the state. The state has recently hired an investigator and prosecutor and implemented new training and processes in an attempt to deal with the lag in charges and prosecutions. Part of the issue in the lag of charges and prosecution was due to COVID-19, which shut down Hawaii courts and Medicaid facilities (MSN, November 4).
Private Sector Updates
Children’s Hospitals in Crisis Mode Due to Respiratory Outbreak
- Children’s hospitals across the country are pulling out emergency preparedness policies and activating everything possible due to surging respiratory disease outbreaks in addition to an increase in COVID-19 cases and a mental health epidemic. While children’s hospitals were spared during much of the COVID-19 pandemic, cases of both COVID-19 and respiratory syncytial virus (RSV) are beginning to increase in hospitals that are already strained due to the increased numbers of adolescents with behavioral health conditions. Health care policy experts and trade associations have both proposed short-term solutions to improve capacity and long-term solutions to stabilize the pediatric sector (Modern Healthcare, November 4).
- According to a new study completed by the Commonwealth Fund, the 17 states that operate their own health insurance exchanges have lower uninsured rates than states relying on the federal Healthcare.gov marketplace. The study noted that the higher insured rate is a result of more aggressive practices when it comes to promoting enrollment, such as outreach and advertising in multiple languages, and longer open enrollment periods. The Commonwealth Fund noted that such methods utilized at a state level could be beneficial during the PHE unwinding process (Health Payer Specialist, November 7).
- VillageMD, a unit of Walgreens Boots Alliance, will acquire a majority stake in Summit Health-CityMD for $8.9 billion. Summit Health-CityMD provides primary, specialty and urgent care across the northeast and in Oregon. The acquisition is expected to close January 1, at which time VillageMD and Summit will have over 680 locations in 26 markets. Walgreens is investing $3.5 billion to support the acquisition and will own 53% of VillageMD shares (Modern Healthcare, November 7).
- On November 4, the Institute for Medicaid Innovation (IMI) released results from its 2022 Medicaid managed care organizations survey. IMI’s annual survey findings highlight the long-standing systemic issues in data collection and communication that ultimately affect enrollee care. These issues became more pronounced during the COVID-19 pandemic and contributed to uncertainty around data sharing policies and differences in state-level regulation. The survey resulted in many findings that provide key insight into current health plan struggles and areas where they are excelling. The following are notable statistics from the survey results:
- 71% of health plans cited access to information from previous providers as a key barrier to care coordination.
- 67% of health plans said their information technology systems were a barrier to setting up effective telehealth delivery services.
- 90% of health plans reported enacting service and benefit flexibilities and strengthening their telehealth capabilities.
- 71% of health plans said telehealth increased access to patient care, and 48% of payers reported telehealth increased their overall satisfaction.
- 90% of health plans reported lack of broadband access among their membership is an issue.
- 88% of Medicaid carriers revised health management tools to remove biases that negatively affected the health of people of color over the year prior to the survey.
- 90% of health plans said their state Medicaid programs should improve data-sharing between foster care agencies and the criminal justice system (Health Payer Specialist, November 7; Institute for Medicaid Innovation, November 4; Modern Healthcare, November 4).
Sellers Dorsey Updates
- Sellers Dorsey is a proud sponsor of the NAMD Annual Conference in Washington, DC. Stop by our booth to meet our experts, including former Medicaid directors, former health care executives, and policy experts with extensive experience in the development, administration, and operation of Medicaid programs. Learn more about our work here.
- Attending the IAMHP Annual Conference? Come hear Sellers Dorsey Director Jill Hayden speak at the November 15 session, “Changes Expected in 2023 and What it Means For You.” She will also be speaking at the November 16 session titled “PHE Unwind, Lessons Learned, Future Opportunities & Challenges.”
- In case you missed it, check out our summaries of three recently approved 1115 demonstrations: Arizona Health Care Cost Containment System, MassHealth, and Oregon Health Plan. The approved demonstrations support these states’ Medicaid programs to better serve beneficiaries and sustain health care access and quality to include targeted services to address health-related social needs and health equity. Learn more about these approvals and what they mean.