In the wake of the recent gubernatorial elections, Sellers Dorsey experts have gathered critical information and related analysis to navigate implications on state budgets and other initiatives across 36 states. Download the report here.
Check out our latest Staff Spotlight Q&A with CEO and Cofounder Marty Sellers. For over 20 years, Marty has built a team that continues to have a profound impact on improving health care access, quality, and equity for the Medicaid population. Read about Marty’s background, the recent work he has done, and more here.
The Senate Finance Committee has unveiled a draft legislative proposal that would direct Congress to provide a two-year pay bump for Medicare behavioral health integration services; directs the Center for Medicaid and Chip Services (CMCS) to provide guidance to states on supporting mental health and substance use disorder care integration with primary care; and requests the Center for Medicare and Medicaid Innovation to consider behavioral health integration when developing models (Inside Health Policy, November 11).
As a result of the COVID-19 pandemic, several states are rethinking their Medicaid enrollment policies for children. If the public health emergency (PHE) ends next year, approximately 5.3 million children stand to lose Medicaid coverage (Kaiser Health News, November 10).
South Dakota voters approved Medicaid expansion in the November 8 election (Kaiser Health News, November 10).
From November 10 to November 16, CMS approved one appendix K waiver and seven SPAs, two of which are COVID-19 disaster relief SPAs.
Senate Finance Releases Draft Bill to Integrate Behavioral Health
- The Senate Finance Committee has unveiled a draft legislative proposal that would direct Congress to provide a two-year pay bump for Medicare behavioral health integration services; directs CMCS to provide guidance to states on supporting mental health and substance use disorder care integration with primary care; and requests the Center for Medicare and Medicaid Innovation to consider behavioral health integration when developing models. The latest discussion draft was released on November 10, as stakeholders look to see what mental health provisions Congress will include in the year-end bill. The November 10 draft includes provisions for the improvement of quality and provider collaboration to connect patients to mental health care. Senators also hope CMS gives providers best practices for integration, analyzes integration models in Medicaid, and provides states guidance on options to adopt or expand value-based payment arrangements that integrate mental health within the primary care setting (Inside Health Policy, November 11).
- On November 15, CMCS released an informational bulletin on the 2023 and 2024 updates to child and adult core health care quality measurement sets. The core sets are the same for both years and were released together to provide states sufficient time to prepare for mandatory reporting. The reassessment of measures is a vital part of implementing an effective quality reporting program. CMCS will not retire any measures for either child core sets or adult core sets but added the following measures:
- Child Core Set: Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis, NQF# 0058; Lead Screening in Children (LSC CH).
- Adult Core Set: Long-Term Services and Supports (LTSS) Comprehensive Care Plan and Update (CPU-AD) (CMS, November 15).
- CMCS released a data snapshot on coverage and access in Medicaid and CHIP programs noting the following:
- As of July 2022, there are 89.96 million individuals enrolled in both programs (82.85 million in Medicaid and 7.11 million in CHIP).
- Medicaid and CHIP enrollment increased nationally in both 2020 and 2021, and the growth was vastly attributed to the onset of COVID-19 and subsequent COVID-19 PHE.
- 6% of Medicaid and CHIP beneficiaries enrolled at any time in 2018 experienced uninterrupted coverage for at least 12 months.
- Children enrolled in separate CHIP programs (S-CHIP) and Medicaid Modified Adjusted Gross Income (MAGI) adults were more likely to experience an interruption in coverage compared to other eligibility groups.
CMCS also focused on datapoints relating to access to mental health and substance use disorder (SUD) services. The following are the mental health data highlighted by CMCS:
- Rates of mental health services and mental health outpatient services provided to Medicaid and CHIP beneficiaries declined following the beginning of the PHE in March 2020.
- The rate of mental health service delivery via telehealth increased greatly during the PHE, peaking in April 2020 but remaining higher than pre-PHE levels through December 2021.
- The rate of SUD services and SUD outpatient services provided to Medicaid and CHIP beneficiaries declined during the PHE compared to pre-PHE levels in 2019.
Finally, CMCS included data on a beneficiary care experience survey from Consumer Assessment of Healthcare Provider and Systems (CAHPS) and found 83% of adult beneficiaries and 88% of child beneficiaries reported always or usually getting timely care (CMS, November 15).
- HHS pledged to give states 60 days’ notice before ending the PHE. The current PHE extension is set to expire on January 12, and there is no indication that HHS intends to issue the 60-day notice to end the PHE anytime soon. States will likely have until at least mid-April before starting their eligibility redetermination processes. Stakeholders have urged the administration to continue the PHE and associated policies through the winter to address a potential COVID-19 surge and give lobbyists more time to request Congress extend or make permanent telehealth regulatory flexibilities that expanded virtual care during the pandemic (Inside Health Policy, November 11).
- In its efforts to close the health equity gap, CMS announced its intention to standardize and gradually implement equity scores, pursue new equity requirements for payers and providers, and emphasize value-based care payment models (CMS, November 10).
- The Supreme Court is revisiting the question of affirmative action in higher education, spurred by lawsuits against admissions practices at the University of North Carolina and Harvard University that have been in process since 2014. The baseline for permissible affirmative action programs in higher education dates back to 1978. The legal question is whether public or private institutions that receive federal funding can use race as a factor to determine if applicants are qualified to enroll. Higher education and health care leaders are weighing how to maintain progress on workforce diversity, which is a key element in addressing health disparities. Research has demonstrated that a diverse workforce improves clinical outcomes and patient experiences. Additionally, health systems are focused on diversity, equity, and inclusion as they build out their workforces and are leaning on higher education institutions to send them more professionals of color (Modern Healthcare, November 10; NPR, October 31).
- The World Health Organization has reported a 90% decrease in global COVID-19 deaths since February 2022, noting a drop from 75,000 weekly deaths in February to 9,400 weekly deaths last week (MSN, November 11).
Millions of Children at Risk of Losing Medicaid Coverage
- As a result of the COVID-19 PHE, several states are rethinking Medicaid enrollment policies for children. As of now, the PHE is expected to end in 2023, at which point Oregon will become the first state to allow children who qualify for Medicaid to enroll at birth and maintain coverage until they turn six years of age, regardless of changes in family income. California, New Mexico, and Washington are all looking to implement similar policies for their Medicaid plans. If the PHE ends next year, approximately 5.3 million children stand to lose Medicaid coverage. Of those, nearly 1.4 million will lose coverage because they no longer qualify, while almost four million will lose coverage for administrative reasons, such as failing to submit paperwork (Kaiser Health News, November 10).
South Dakota Approves Medicaid Expansion
- South Dakota voters approved Medicaid expansion in the November 8 election. While voters were supportive of the expansion, easy and quick implementation is not anticipated. As seen in some of the other states that approved Medicaid expansion at the ballot box, outdated computer systems, politicians and administrators who may not rush to implement the change, and inferior publicity efforts led to a glacial pace of enrollments, even leaving some individuals uninsured after they became eligible for Medicaid (Kaiser Health News, November 10).
- 1915(c) Appendix K
- New Mexico
- Changes several sections in the Developmental Disabilities, Medically Fragile, Mi Via, and Supports waivers to use funding available under the American Rescue Plan Act (ARP) to temporarily exceed service limitation and certain payment rates.
- New Mexico
- Administrative SPAs
- Minnesota (MN-22-0027, effective July 1, 2022): Proposes to make optional the Early Intensive Developmental and Behavioral Intervention Qualified Supervising Professional’s involvement in the coordinating care conference discussion.
- Mississippi (MS-22-0001, effective March 11, 2021): Allows the Division of Medicaid to comply with the ARP requirements regarding coverage of U.S. Food and Drug Administration (FDA) authorized COVID-19 diagnostic and screening tests consistent with the Centers for Disease Control and Prevention’s definitions and recommendations when ordered by a practitioner.
- New York (NY-22-0077, effective July 1, 2022): Proposes to add Licensed Psychologist to the provider qualification under Other Licensed Practitioner by agencies designated under the Child and Family Treatment and Support Services designation process.
- Ohio (OH-22-0027, effective July 1, 2022): Proposes to remove telehealth references from the state plan since the coverage provisions and payment rates for services delivered via telehealth are the same as services delivered face-to-face.
- COVID-19 SPAs
- New Mexico (NM-22-0020, effective July 1, 2022): Allows hospital providers to bill and be paid for pasteurized donor human milk services separate from the Diagnosis-Related Group in addition to the inpatient hospital stay for infants through New Mexico Medicaid enrolled medical supply companies. This time-limited COVID-19 SPA terminates at the end of the PHE.
- Oregon (OR-22-0020, effective January 1, 2021): Provides a temporary 5% rate increase for nursing facilities, assisted living facilities, and residential care facilities. This time-limited COVID-19 SPA terminates at the end of the PHE.
- Service SPAs
- Louisiana (LA-22-0026, effective January 1, 2023): Amends the provisions governing behavioral health rehabilitation services to update Community Psychiatric Support and Treatment and Psychosocial Rehabilitation services.
- The November 2022 midterm elections had a record number of proposals related to abortion on the ballot in five states. California, Michigan, and Vermont all voted to secure the right to reproductive freedom, including the right to abortion and contraceptives. In Kentucky, voters rejected to remove the right to abortion from the state constitution, while voters in Montana rejected the proposal that would have made health care providers subject to criminal charges if they did not attempt life-saving care when an abortion results in a live birth (New York Times, November 15).
- The rollout of Nebraska’s next cycle of Medicaid managed care has been further delayed as the losing bidder, Healthy Blue, appealed the denial of its bid and asserts the Nebraska Department of Health and Human Services (DHHS) engaged in a “flawed” RFP process by awarding contracts to UnitedHealthcare, Nebraska Total Care (Centene), and Molina Healthcare of Nebraska. Healthy Blue claims DHHS reached an “arbitrary and capricious award determination” by finding that Molina, Centene, and United’s proposals were responsive and not subject to disqualification (Health Payer Specialist, November 11).
Private Sector Updates
- On November 14, the American Hospital Association (AHA) released a report with findings that safety net and charity care hospitals are losing millions due to drug companies cutting off sales of pharmaceuticals discounted under the 340B program to contract pharmacies. The federal government and some of the drug companies have been battling in court. The findings are based on a survey of over 300 hospitals and health systems that are a part of the 340B program and focus on the impact of restrictions conducted by almost 20 drugmakers. Results demonstrate that the average 340B critical access hospitals with 25 beds or less reported annual losses of $507,000, and the average 340B disproportionate share hospitals suffered annual losses of nearly $3 million. The legal dispute over the cuts continues to make its way through the courts (Fierce Healthcare, November 15).
- AHA has released a statement requesting Congressional leaders prevent implementation of the Statutory Pay-As-You-Go (PAYGO) sequester over concerns of additional reductions in hospital payments. The Statutory PAYGO sequester requires mandatory spending and revenue legislation not increase the federal budget deficit over a 5- or 10-year period. AHA claims that failing to waive Statutory PAYGO would result in nearly $10 billion in cuts to hospital providers in fee-for-service Medicare next year (AHA, November 14).
- Walmart has agreed to pay approximately $3.1 billion to settle opioid lawsuits brought against the company by several states and municipalities. Each state, local government, and tribe will have the opportunity to decide whether they will accept and participate in the settlement. Walmart disputes accusations made in the lawsuits and states that deciding to settle is not an admission of liability (Wall Street Journal, November 15).
- Many health insurers, hospitals, pharmaceutical companies, and group purchasing organizations are joining the White House climate pledge aimed at reducing emissions and investing in climate resiliency. Anthem, New York-based Mount Sinai, Kaiser Permanente, Mass General Brigham, BCBS Massachusetts, American Medical Colleges, and National Academic of Medicine have all signed up to the climate pledge and have agreed to cut emissions by 50% by 2030 and achieve net-zero emissions by 2050 (Modern Healthcare, November 10).
- On November 10, Elevance Health announced the expansion of its specialty pharmacy business with the acquisition of BioPlus. The financial terms of the deal were not disclosed, but the acquisition is expected to close during the first half of 2023. BioPlus offers specialty pharmacy services geared towards individuals living with complex and chronic conditions like cancer, Hepatitis C, autoimmune disorders, and multiple sclerosis (Health Payer Specialist, November 10).
- According to a study released by a team of University of Massachusetts public health researchers in JAMA Network Open, approximately 37% of women involved in the study changed insurance plans in the 12 months before and after giving birth. Women with commercial insurance are the least likely to switch, with only five percent opting to change plans in the 12 months before and after giving birth. Women with fee-for-service Medicaid are most likely to switch into a Medicaid managed care plan (Health Payer Specialist, November 9).
Sellers Dorsey Updates
- Sellers Dorsey is delighted to announce that Matt Salo, former Executive Director of the National Association of Medicaid Directors, recently joined the firm as a Senior Strategic Advisor. Leveraging his unique experience in government relations and health care, he will provide subject matter expertise for a variety of client engagements. Welcome, Matt!
- In the wake of the recent gubernatorial elections, Sellers Dorsey experts have gathered critical information and related analysis to navigate implications on state budgets and other initiatives across 36 states. Download the report here.
- Check out our latest Staff Spotlight Q&A with CEO and Cofounder Marty Sellers. For over 20 years, Marty has built a team that continues to have a profound impact on improving health care access, quality, and equity for the Medicaid population. Read about Marty’s background, the recent work he has done, and more here.