Medicaid Enrollment on the Rise

More people are enrolling in Medicaid, and much of the increase is driven by the COVID-19 emergency.

Or so reports the organization Families USA in a new study.

According to the study,

Over half of the 38 states reporting monthly enrollment through May or later have seen greater than 7% growth in enrollment since February. For the eight states reporting August enrollment, their average enrollment growth since February is approximately 11%.

But the implications are even greater, according to the analysis, which found that in large part because of COVID-19 job loss,

Medicaid enrollment among the 38 states reporting has already increased by 4.3 million people and is poised to increase much more in the near future. Analysis by Health Management Associates projects that up to 27 million people will lose their job-based insurance this year and that Medicaid will see an increase in enrollment of up to 18 million people by the end of 2020, depending on the severity of the economic downturn.

Growing numbers of Medicaid patients can pose a challenge for many private safety-net hospitals because of the inadequacy of the reimbursement they receive from many state Medicaid programs.

Learn more in the Families USA report “Rapid Increases in Medicaid Enrollment: A Review of Data from Six Months.

How Medicaid Managed Care Cuts Costs

Low-cost Medicaid managed care plans mostly cut their costs by reducing how much care, and how much high-quality care, their members receive.

That is the conclusion of a new study published by the National Bureau of Economic Research.

According to the study, Medicaid managed care plans succeed in reducing costs less by cost-sharing, negotiating lower provider rates, employing narrow networks, and doing a better job of managing their members’ high-cost chronic medical conditions than they do by leading their members to use fewer high-value, low-cost services such as cancer and diabetes screenings and fewer high-value drugs.

The researchers note that

Effects via quantities, rather than differences in negotiated prices, explain these patterns.  Rather than reducing “wasteful” spending, low-spending plans cause broad reductions in the use of medical services – including low-cost, high-value care – and worsen beneficiary satisfaction and health.  Supply side tools circumvent the classic trade-off between financial risk protection and moral hazard, but give rise instead to a cost/quality trade-off.

Learn more from the National Bureau of Economic Research report “Are All Managed Care Plans Created Equal?  Evidence From Random Plan Assignment in Medicaid.”

NASH Endorses Bill to Delay MFAR

Implementation of the Medicaid fiscal accountability regulation, opposed by NASH and many others since its introduction in November of 2019, would be delayed under a new bill proposed in the House of Representatives.

The MFAR Transparency Act (HR 7606), sponsored by representatives Roger Williams (R-TX) and Eddie Bernice Johnson (D-TX), would delay implementation of the MFAR rule until the Government Accountability Office had an opportunity to assess its impact on individual states and identify the Medicaid transparency issues that need to be addressed.

Most important, the bill would prevent implementation of MFAR without specific authorization from Congress.

In a letter to the bill’s sponsors endorsing their proposal, NASH wrote that “The MFAR rule could jeopardize access to care for millions of Americans.”

NASH first expressed its opposition to the MFAR rule in a January letter to the Centers for Medicare & Medicaid Services.  Read its endorsement of the Williams-Johnson bill here.

NASH Asks Senate for COVID-19 Help

Private safety-net hospitals need help with the challenges posed by the COVID-19 public health emergency, NASH wrote yesterday in a letter to Senate majority leader Mitch McConnell and minority leader Charles Schumer.

In its letter, NASH asked for:

  • An additional $100 billion for hospitals.
  • Forgiveness for money provided to hospitals through the federal CARES Act’s Accelerated and Advance Payment Program.
  • Action to prevent implementation of the Medicaid fiscal accountability regulation.
  • An increase in the federal Medicaid matching rate (FMAP).
  • An increase in states’ Medicaid disproportionate share (Medicaid DSH) allotments.
  • A moratorium on changes in hospital eligibility for the 340B prescription drug discount program, Medicare indirect medical education program, Medicare disproportionate share (Medicare DSH) program, and other programs.

See NASH’s letter here.

 

NASH Calls for More COVID-19 Legislation

On Tuesday the National Alliance of Safety-Net Hospitals wrote to Senate leaders and asked them to advance legislation with five major COVID-19-related policy initiatives that private safety-net hospitals seek:

  1. An additional $100 billion for hospitals.
  2. A 14-point increase in the federal medical assistance percentage (FMAP).
  3. A 2.5 percent increase in states’ Medicaid disproportionate share (Medicaid DSH) allotments and another delay in implementation of Affordable Care Act-mandated cuts in those allotments.
  4. Reduced interest rates and a longer payback period for Medicare payments advanced to hospitals through the CARES Act’s Accelerated and Advance Payment Program.
  5. Prevention of implementation of the Medicare fiscal accountability regulation (MFAR).

Learn more from NASH’s letter to Senate majority leader Mitch McConnell and Senate minority leader Chuck Schumer.

Coronavirus Update: March 31, 2020

Coronavirus Update: March 31, 2020.

Yesterday the federal Centers for Medicare & Medicaid Services (CMS) published a major update of Medicare and Medicaid regulations that included blanket waivers of a large number of Medicare and Medicaid regulations and requirements.  The following is a summary of the major aspects of this new regulation.

New Policies and Waivers From Medicare and Medicaid Regulations and Requirements

CMS has introduced dozens of changes that involve waivers from current regulations and requirements.  A comprehensive, 26-page CMS document describing these changes can be found here and below are the highlights organized into four broad categories:

  • increasing hospital capacity (what CMS calls “hospitals without walls”)
  • expanding the health care workforce
  • increasing the use of telehealth in Medicare
  • reducing paperwork

Increasing Hospital Capacity

  • CMS is waiving the enforcement of section 1867(a) of EMTALA to permit hospitals to screen patients at off-site locations to help prevent the spread of COVID-19.
  • CMS is waiving certain requirements under the Medicare conditions of participation allow for flexibilities during hospital and psychiatric hospital surges, permitting non-hospital buildings/space to be used for patient care and quarantine sites.
  • For the duration of the public health emergency, CMS is waiving certain requirements under the Medicare conditions of participation and the provider-based department requirements to permit hospitals to establish and operate as part of the hospital any location meeting those conditions of participation for hospitals that continue to apply during the public health emergency. This waiver also permits hospitals to change the status of their current provider-based department locations to the extent necessary to address the needs of hospital patients.
  • CMS is waiving requirements to permit acute-care hospitals to house acute-care inpatients in excluded distinct part units, such as excluded distinct part unit inpatient rehabilitation facilities or inpatient psychiatric facilities, where the distinct part unit’s beds are appropriate for acute-care inpatients.
  • CMS is permitting acute-care hospitals with excluded distinct part inpatient psychiatric units to relocate inpatients from the excluded distinct part psychiatric unit to acute-care beds and units as a result of a disaster or emergency.
  • CMS is permitting acute-care hospitals with excluded distinct part inpatient rehabilitation units that, as a result of a disaster or emergency, need to relocate inpatients from the excluded distinct part rehabilitation unit to an acute-care bed and unit.
  • CMS is waiving certain physical environment requirements. Provided that the state has approved the location as one that sufficiently addresses safety and comfort for patients and staff, CMS is waiving requirements to allow for a non-skilled nursing facility building to be temporarily certified and available for use by a skilled nursing facility in the event there are needs for isolation processes for COVID-19-positive residents, which may not be feasible in the existing skilled nursing facility structure to ensure care and services during treatment for COVID-19 are available while protecting other vulnerable adults.
  • CMS is waiving certain conditions of participation and certification requirements for opening a nursing facility if the state determines there is a need to quickly stand up a temporary COVID-19 isolation and treatment location.
  • CMS is waiving requirements to temporarily allow for rooms in a long-term care facility not normally used as a resident’s room to be used to accommodate beds and residents for resident care in emergencies and situations needed to help with surge capacity.

Expanding the Health Care Workforce

  • CMS is waiving current requirements to permit physicians whose privileges will expire to continue practicing at the hospital and for new physicians to be able to practice before full medical staff/governing body review and approval to address workforce concerns related to COVID-19.  CMS also is waiving requirements about details of the credentialing and privileging process.
  • CMS is waiving the requirement that Medicare patients be under the care of a physician.
  • CMS is waiving requirements that a certified registered nurse anesthetist (CRNA) work under the supervision of a physician. CRNA supervision will be at the discretion of the hospital and state law.
  • CMS is waiving the requirement that a skilled nursing facility and nursing facility may not employ anyone for longer than four months unless they meet current training and certification requirements. CMS is not waiving the requirement that such facilities ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents’ needs.
  • CMS is waiving the requirement that physicians and non-physician practitioners must perform in-person visits for nursing home residents and will permit visits to be conducted, as appropriate, via telehealth options.
  • CMS is temporarily waiving requirements that out-of-state practitioners be licensed in the state where they are providing services when they are licensed in another state. CMS will waive the physician or non-physician practitioner licensing requirements when the following four conditions are met:
    • must be enrolled as such in the Medicare program;
    • must possess a valid license to practice in the state which relates to his or her Medicare enrollment;
    • is furnishing services – whether in person or via telehealth – in a state in which the emergency is occurring to contribute to relief efforts in his or her professional capacity; and,
    • is not affirmatively excluded from practice in the state or any other state that is part of the 1135 emergency area.
    • This does not have the effect of waiving state or local licensure requirements or any requirement specified by the state or a local government as a condition for waiving its licensure requirements.
  • CMS has a toll-free hotline for physicians and non-physician practitioners and Part A-certified providers and suppliers establishing isolation facilities to enroll and receive temporary Medicare billing privileges. CMS is waiving the following screening requirements:
    • application fee,
    • criminal background checks associated with fingerprint-based criminal background checks,
    • site visits,
    • postpone all revalidation actions,
    • allow licensed providers to render services outside of their state of enrollment,
    • expedite any pending or new applications from providers,
    • allow physicians and other practitioners to render telehealth services from their home without reporting their home address on their Medicare enrollment while continuing to bill from their currently enrolled location, and
    • allow opted-out physicians and non-physician practitioners to terminate their opt-out status early and enroll in Medicare to provide care to more patients.
  • CMS has issued blanket waivers of sanctions under the Stark Act.  The blanket waivers may be used now without notifying CMS.  Individual waivers of sanctions under section 1877(g) of the Act may be granted upon request.  For more information, go here and here.

Increasing the Use of Telehealth in Medicare

  • CMS is waiving the requirement that physicians and non-physician practitioners must perform in-person visits for nursing home residents and will permit visits to be conducted, as appropriate, via telehealth options.
  • Clinicians can provide virtual check-in services to new and established patients.
  • CMS will pay for telephone evaluation and management services provided by physicians and the same services provided by qualified non-physician health care providers. These services may be used for telephone-only evaluation and management services.
  • Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can perform e-visits via telehealth.
  • Limits have been lifted for subsequent inpatient visits, subsequent skilled nursing visits, and critical care consult codes.
  • Physicians may provide supervision virtually using real-time audio/visual technology for services that require direct supervision by a physician or other type of practitioner.
  • For additional information on new flexibilities in the use of telehealth for Medicare patients, go here.

Reducing Paperwork

  • CMS is waiving various requirements that limit and define the use and documentation of verbal orders in a hospital.
  • CMS is waiving reporting requirements when patients who have passed away required soft restraints prior to their death.  If restraints were a factor in the death, the usual reporting requirements apply.
  • CMS is waiving the current requirements for providing “detailed information” in discharge planning as long as discharging hospitals continue to provide the data patients and their families need to make decisions about appropriate post-acute care.  This does not waive the requirement that patients have all of the necessary medical information they need for their post-acute setting.
  • While maintaining the discharge planning requirements that ensure that patients are discharged to an appropriate setting with the necessary medical information, CMS is waiving some of the specific components of discharge information acute-care hospitals are ordinarily required to provide.
  • CMS is waiving requirements involving the organization and staffing of medical records departments and requirements for the form and content of medical records and is allowing for flexibility in completion of medical records within 30 days following discharge from a hospital.
  • CMS is waiving the requirements for hospitals to provide information about their advance directive policies to patients.
  • CMS is waiving the requirement that hospitals participating in Medicare and Medicaid must have a utilization review plan that meets specified requirements. CMS is waiving the entire utilization review condition of participation.
  • CMS is waiving – for “surge facilities” only – the requirement that the emergency services function operate according to written policies and procedures during surge periods.
  • CMS is waiving the requirement that hospital emergency preparedness policies and procedures include specified elements for the emergency preparedness communication plans of hospitals when a hospital is a surge site.
  • CMS is waiving requirements for hospital quality assessment and performance improvement programs that address the scope of the program, the incorporation and setting of priorities for the program’s performance improvement activities, and integrated quality assurance and performance improvement programs. The requirement that hospitals maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program remains.
  • CMS is waiving the requirement that providers must have a current therapeutic diet manual approved by the dietitian and medical staff readily available to all medical, nursing, and food service personnel. Such manuals would not need to be maintained at surge capacity sites.
  • CMS is waiving the requirement for nursing staffs to develop and keep current a nursing care plan for each patient and to have policies and procedures in place establishing which outpatient departments are not required to have a registered nurse present.
  • Completed 2019 Occupational Mix Surveys, Hospital Reporting Form CMS-10079, for the Wage Index Beginning FY 2022, are due to the Medicare Administrative Contractors (MACs). CMS is granting an extension for hospitals nationwide affected by COVID-19 until August 3, 2020.
  • CMS is waiving requirements that govern pre-admission screening and annual resident review (PASARR) to permit states and nursing homes to suspend these assessments for new residents for 30 days. After 30 days, new patients admitted to nursing homes with a mental illness or intellectual disability should receive the assessment as soon as resources become available.
  • CMS is waiving many paperwork requirements for home health agencies, skilled nursing facilities, nursing facilities, end-stage renal dialysis facilities, home health agencies, and hospices. Find those changes here (pages 9-16).
  • Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) in the fee-for-service program may allow extensions to file an appeal. CMS is allowing MACs and QICs in the fee-for-service program and the MA and Part D independent review entities (IREs) to:
    • waive requests for timeliness requirements for additional information to adjudicate appeals;
    • process appeals even with incomplete appointment of representation forms;
    • process requests for appeals that do not meet the required elements using information that is available; and
    • use all flexibilities available in the appeal process if good cause requirements are satisfied.

Others

  • CMS offers stakeholders examples of section 1135 waivers available to individual providers.  Find those examples here beginning on page 23.
  • CMS is waiving certain patient rights involving copies of medical records, patient visitation limits, and quarantine processes in states that have had more than 50 confirmed COVID-19 cases.

For further information:

To learn more about these changes, you may wish to consult the following resources:

The following is the latest information from the administration and federal regulators as of 4:30 today.

The White House

President Trump has issued a presidential memorandum to the Secretary of Defense and the Secretary of Homeland Security authorizing the use of the National Guard to provide COVID-19-related services to the states of Connecticut, Illinois, Massachusetts, and Michigan, with the federal government to pay 100 percent of the cost of such a deployment.  The federal assumption of 100 percent of this cost expires in 30 days.

Centers for Medicare & Medicaid Services

Department of Health and Human Services

The Department of Health and Human Services has posted a news release in which it outlines the steps it has taken and will be taking to accelerate clinical trials for possible COVID-19 vaccines and to prepare for the manufacture of approved vaccines.

U.S. Public Health Service

The U.S. Public Health Service has issued a letter on optimizing ventilator use during the COVID-19 pandemic.

Food and Drug Administration

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CMS Posts COVID-19 FAQ for State Medicaid and CHIP Agencies

State Medicaid agencies and CHIP programs have received new guidance on the federal resources available to them to fight the COVID-19 national health emergency through a new FAQ published by the Centers for Medicare & Medicaid Services last week.

Among the issues addressed in the FAQ are eligibility, enrollment, benefits, cost sharing, workforce issues, telehealth, and more.  Health care providers may find this information useful when serving their patients.

See CMS’s news release describing the FAQ here and the FAQ itself here.

Block Grants Could Hurt Medicaid, Study Finds

A switch to block grants to fund state Medicaid programs “…would require states to cut coverage, reduce benefits, increase cost-sharing, lower provider payment rates, or otherwise reduce Medicaid expenditures as compared to current law spending levels” according to a new Commonwealth Fund study.

The study, conducted in the wake of the Trump administration’s new guidance on how states can transform their Medicaid programs into block grants and its encouragement that they do so, suggests that such efforts could result in considerable harm to Medicaid beneficiaries, providers of Medicaid-covered services, and state government finances.  Meanwhile, the federal government’s share of state Medicaid spending would likely decline as states reduce their Medicaid spending.  If block grants were to be adopted nation-wide – something that is highly unlikely – federal spending would fall more than $110 billion a year while state Medicaid spending would dip between 6.5 percent and 14.1 percent a year.

States that move to block grants would gain new flexibility to reduce benefits, charge co-pays and premiums, eliminate retroactive eligibility, impose work requirements, introduce closed drug formularies, change managed care network adequacy standards, spend unused federal money for non-health care purposes, and more.

Learn more about the various implications of a shift to Medicaid block grants in the Commonwealth Fund study “The Fiscal Impact of the Trump Administration’s Medicaid Block Grant Initiative.”

 

MACPAC Meets

The Medicaid and CHIP Payment and Access Commission met for two days last week in Washington, D.C.

The following is MACPAC’s own summary of the sessions.

The February 2020 MACPAC meeting opened with a continuation of MACPAC’s examination of Medicaid’s role in maternal health, when Medicaid officials from Michigan, New Jersey, and North Carolina joined the Commission to discuss how their states are addressing maternal morbidity and mortality.* The Commission plans to include a chapter on maternal health in its June 2020 report to Congress. Commissioners later turned their attention to policy options for improving enrollment in the Medicare Savings Program.

The Commission later took a deep dive into value-based payment in Medicaid managed care. This three-part session began with findings from a series of interviews with state officials, managed care organizations, and other stakeholders aimed at understanding how states use managed care to promote payment reform, conducted by MACPAC contractor Bailit Health. Then, representatives from three of these organizations shared their reactions to the findings and talked about how value-based payment models are working in practice.* The session concluded with Commissioners’ perspectives on the study’s findings and the panelists’ reactions to them, and possible next steps.

The final session of the afternoon continued a line of inquiry begun at the October 2019 meeting: third-party liability coordination between Medicaid and TRICARE. MACPAC estimates that almost 1 million Medicaid enrollees have primary coverage through TRICARE, which provides health benefits for military personnel, military retirees, and their dependents. Commissioners explored making recommendations in the June report to improve coordination between the two programs.

On Friday, the Commission returned to the theme of improving care for dually eligible beneficiaries, looking more closely at the rise of so-called dual-eligible special needs plan (D-SNP) look-alikes and how changes in the Medicare Advantage market are affecting efforts to integrate care. Commissioners also reviewed a rule proposed in February that would, among other things, restrict the growth of look-alikes.

Following that session, the Commission discussed draft recommendations to improve integration of Medicare and Medicaid benefits for dually eligible beneficiaries. The February meeting wrapped up with a discussion of a forthcoming rule expected to affect the Medicaid eligibility determination process.

Supporting the discussion were the following briefing papers:

  1. State Medicaid Initiatives to Improve Maternal Health
  2. Improving Participation in the Medicare Savings Programs: Decisions on Draft Recommendations for the June Report to Congress
  3. State Strategies to Promote the Use of Value-Based Payments in Medicaid Managed Care
  4. Medicaid and TRICARE: Third-Party Liability Coordination
  5. How Changes in the Medicare Advantage Market Are Affecting Integration of Care for Dually Eligible Beneficiaries: Analysis and Comments on Proposed Rule
  6. Improving Integrated Care for Dually Eligible Beneficiaries: Decisions on Recommendations to be Included in June Report to Congress
  7. Forthcoming Rule on Program Integrity and Eligibility Determination Processes

Because they serve so many Medicaid and CHIP patients – more than the typical hospital – MACPAC’s deliberations are especially important to private safety-net hospitals.

MACPAC is a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of the U.S. Department  of Health and Human Services, and the states on a wide variety of issues affecting Medicaid and the State Children’s Health Insurance Program.  Find its web site here.

MFAR Backlash Continues

Diverse health care and government interests are rallying around their opposition to the proposed Medicaid fiscal accountability rule.

The regulation, proposed by the Centers for Medicare & Medicaid Services in November would impose new limits on the ability of states to finance their share of their Medicaid spending, potentially jeopardizing provider payments and the ability of high-volume Medicaid providers to operate without suffering great losses.

In all, CMS received more than 4200 written comments in response to the proposed regulation, most of them expressing opposition.  Among those doing so were state governments, the National Governors Association, hospitals and hospital associations, nursing home operators, and health advocacy organizations.  Also among them was the National Alliance of Safety-Net Hospitals.  In summarizing its opposition, NASH wrote in a formal comment letter to CMS on behalf of private safety-net hospitals that

While NASH supports greater transparency in Medicaid, that support is outweighed by too many troubling aspects of the proposed regulation. In this letter, NASH is especially interested in commenting on five aspects of the proposed regulation: how it would deprive states of important, established policy-making prerogatives; its creation of major new administrative burdens for state governments and for hospitals; its inappropriate regulation of financing of the state share of Medicaid spending; its proposed introduction of new, unspecified standards that state Medicaid programs would be held accountable for meeting; and its violation of the Administrative Procedures Act.

See NASH’s entire letter here.

Learn more about the Medicaid fiscal accountability rule, what it seeks to do, and why so many oppose in the Stateline article “Medical Groups Slam Trump Medicaid Rule.”