Administration Continues Dismantling Medicaid Work Requirements

A week after announcing that it was withdrawing permission for states to implement approved Medicaid work requirements and would no longer entertain applications to introduce such programs, the Biden administration has asked the U.S. Supreme Court to cancel arguments next month on the legality of such requirements.

As reported in SCOTUSblog,

That argument is no longer necessary, Biden’s acting solicitor general, Elizabeth Prelogar, told the justices in a seven-page motion on Monday.  The Biden administration has “preliminarily determined” that work requirements do not serve Medicaid’s goals, Prelogar wrote.

Arkansas, one of the two states involved in the case, maintains that the arguments should still take place because the administration has not formally overturned Medicaid work requirements.

Learn more about the administration’s efforts to end Medicaid work requirements in the New York Times article “Biden Administration Moves to End Work Requirements in Medicaid” and about this latest move to withdraw the case from the Supreme Court in the SCOTUSblog article “Federal government asks court to scrap challenge to Medicaid work requirements.”

 

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.

MACPAC kicked off its January meeting with a review of a draft chapter for the March 2021 report to Congress and recommendations on a mandatory extension of Medicaid coverage for 12 months postpartum. The Commission received extensive public comment on the recommendations. On Friday, the Commission approved three recommendations as drafted related to postpartum coverage. The Commission recommended that Congress should:

  • extend the postpartum coverage period for individuals who were eligible and enrolled in Medicaid while pregnant to a full year of coverage, regardless of changes in income. Services provided to individuals during the extended postpartum coverage period will receive an enhanced 100 percent federal matching rate;
  • extend the postpartum coverage period for individuals who were eligible and enrolled in the State Children’s Health Insurance Program (CHIP) while pregnant (if the state provides such coverage) to a full year of coverage, regardless of changes in income; and
  • require states to provide full Medicaid benefits to individuals enrolled in all pregnancy-related pathways.

Commissioners then turned their attention to Medicaid estate recovery policies that affect beneficiaries using long-term services and supports (LTSS). Commissioners on Friday approved recommendations to:

  • make estate recovery optional rather than required;
  • allow states with managed long-term services and supports to pursue recovery based on the cost of services where it is less than the capitation payment paid to a managed care plan; and
  • direct the Secretary of the U.S. Department of Health and Human Services (HHS) to establish minimum hardship waiver standards, including a minimum estate value threshold for estate recovery.

Next, the Commission considered recommendations for countercyclical financing adjustments in Medicaid. This would allow federal financial stimulus to be directed to states more quickly during economic downturns and provide states with greater budget predictability. The Commission approved a recommendation that Congress should adopt a statutory mechanism to amend the Social Security Act to provide an automatic Medicaid countercyclical financing model, using the prototype developed by the U.S. Government Accountability Office as the basis. The Commission also recommended this policy change should include:

  • an eligibility maintenance of effort requirement for the period covered by an automatic countercyclical financing adjustment;
  • an upper bound of 100 percent on countercyclical adjusted matching rates; and
  • exclusion of countercyclical adjusted federal matching rate from services and populations that receive special matching rates (e.g., for the new adult group) or are otherwise capped or have allotments (e.g., disproportionate share hospital payments, territories).

After a break on Thursday, Commissioners discussed a draft chapter for the March 2021 report on design considerations for creating a new program for dually eligible beneficiaries and reviewed a report to Congress by the U.S. Secretary of Health and Human Services (HHS) on Medicaid housing supports for individuals with substance use disorder (SUD). The Commission plans to send a letter to HHS and leadership of relevant congressional committees commenting on the Secretary’s report to Congress on Medicaid housing supports for people with SUD who are experiencing or at risk of homelessness.

Next, Commissioners heard a panel discussion on the outlook for state budgets and the implications for Medicaid with Emily Blanford, program principal at the National Conference of State Legislatures; Shelby Kerns, executive director for the National Association of State Budget Officers; and Susie Perez Quinn, government affairs director for the National Governors Association. * The day ended with a presentation on value-based payment for maternity services.

On Friday, Commissioners heard a panel discussion on how Medicaid serves people with intellectual or developmental disabilities with Sharon Lewis, a principal at Health Management Associates; Melissa Stone, director of Arkansas’ Division of Developmental Disabilities Services; and Elizabeth Weintraub, a senior advocacy specialist at the Association of University Centers on Disabilities. * Additional sessions focused on a congressionally mandated MACPAC study of non-emergency medical transportation (NEMT), which will be included in the June 2021 report to Congress. In addition, Commissioners heard a new analyses of care integration for dually eligible beneficiaries, and a discussion of potential new models for payment and coverage of high-cost specialty drugs. The meeting concluded with a discussion of mental health parity in Medicaid.

Supporting the discussion were the following briefing papers:

  1. Postpartum Coverage: Review of Draft Chapter and Recommendation Decisions
  2. Medicaid Estate Recovery Draft Chapter and Recommendations
  3. Automatic Countercyclical Financing Adjustment Review of Draft Chapter and Recommendation Decision
  4. Establishing a Unified Program for Dually Eligible Beneficiaries Design Considerations
  5. Review of the Secretary’s Report on Medicaid Housing Supports for Individuals with Substance Use Disorder
  6. Value-Based Payment for Maternity Care in Medicaid
  7. Mandated Report on Non-Emergency Medical Transportation Further Findings
  8. Integration of Care for Dually Eligible Beneficiaries: New Analyses
  9. Payment and Coverage of High-Cost Specialty Drugs Report from Technical Advisory Panel
  10. Implementation of the Mental Health Parity and Addiction Equity Act in Medicaid and CHIP

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.

 

Coronavirus Update for Friday, January 29

The following is the latest COVID-19 information from the federal government as of 2:30 p.m. on Friday, January 29.

The Biden Administration

The Biden administration has issued an “Executive Order on Strengthening Medicaid and the Affordable Care Act” to make it easier for the uninsured to get coverage during the COVID-19 pandemic.  The order:

  • reopens access to the federal Affordable Care Act health insurance marketplace for three months, from February 15 through May 15, and restores some of the Affordable Care Act exchange marketing funds that had been eliminated by the previous administration and
  • calls for the review of all existing regulations, orders, guidance documents, policies, and any other agency actions that may be inconsistent with the administration’s desire to enhance access to health insurance through the Affordable Care Act, including policies that undermine protections for people with pre-existing conditions and policies that make it harder for people to get insurance coverage or to enroll in Medicaid.

Resources for learning more about this executive order are:

Provider Relief Fund

HHS has updated its Provider Relief Fund FAQ with 19 new and modified questions.  The new information, marked “Modified 1/28/2021” or “Added 1/28/2021,” addresses the relationship between parent and subsidiary organizations receiving Provider Relief Fund grants, financial reporting and accounting requirements, the use of Provider Relief Fund money, and more.  The new information can be found on pages 10, 11, 16, 26, 28, 40, 41, 56, and 57 of the revised FAQ.  Providers that have received Provider Relief Fund grants or seek to receive such grants should review the new information carefully.

Department of Health and Human Services

  • HHS has established parameters under which retired and inactive health care providers may return to work to administer COVID-19 vaccinations.  It did so by amending the current COVID-19 emergency declaration under the Public Readiness and Emergency Preparedness Act (PREP Act).  See the HHS announcement of the new policy here and find the PREP Act amendment itself here.

HHS and CMS COVID-19 Stakeholder Calls

HHS Clinical Rounds Peer-to-Peer Virtual Communities of Practice

HHS’s Office of the Assistant Secretary for Preparedness and Response sponsors COVID-19 Clinical Rounds Peer-to-Peer Virtual Communities of Practice that are interactive virtual learning sessions that seek to create a peer-to-peer learning network in which clinicians from the U.S. and abroad who have experience treating patients with COVID-19 share their challenges and successes.  These webinar topics are covered every week:

  • EMS:  Patient Care and Operations (Mondays, 12:00-1:00 PM eastern)
  • Critical Care:  Lifesaving Treatment and Clinical Operations (Tuesdays, 12:00-1:00 PM eastern)
  • Emergency Department:  Patient Care and Clinical Operations (Thursdays, 12:00-1:00 PM eastern)

Go here for information about signing up to participate in the sessions and go here for access to materials and video recordings of past sessions.

CMS Stakeholder Calls

CMS hosts recurring stakeholder engagement sessions to share information about the agency’s response to COVID-19.  These sessions are open to members of the health care community and are intended to provide updates, share best practices among peers, and offer participants an opportunity to ask questions of CMS and other subject matter experts.

CMS COVID-19 Office Hours Calls

Tuesday, February 23 at 5:00 – 6:00 PM (eastern)

Toll Free Attendee Dial In:  833-614-0820; Access Passcode:  2528725

Audio Webcast link:  go here

Tuesday, March 16 at 5:00 – 6:00 PM (eastern)

Toll Free Attendee Dial In:  833-614-0820; Access Passcode:  4177586

Audio Webcast link:  go here

Tuesday, April 6 at 5:00 – 6:00 PM (eastern)

Toll Free Attendee Dial In:  833-614-0820; Access Passcode:  2769397

Audio Webcast link:  go here

Centers for Disease Control and Prevention

National Institutes of Health

  • An NIH news release explains that “An investigational COVID-19 vaccine developed by Janssen Pharmaceuticals appears to be safe and effective at preventing moderate and severe COVID-19 in adults, according to an interim analysis of Phase 3 clinical data conducted Jan. 21.”  This is a single-dose vaccine.  Learn more from the NIH news release.
  • Pregnant women who experienced severe symptoms of COVID-19 had a higher risk of complications during and after pregnancy, according to the preliminary findings of an NIH-funded study.  Compared to COVID-19 patients without symptoms, those with severe symptoms were at higher risk for cesarean delivery, postpartum hemorrhage, hypertensive disorders of pregnancy and preterm birth.  The study also suggests that mother-to-infant transmission of COVID-19 appears to be rare.

Food and Drug Administration

Department of Labor

Feds Give States Direction on Addressing Social Determinants of Health

Federal laws, regulations, and programs offer numerous tools to states seeking to address social determinants of health through their Medicaid and Children’s Health Insurance Program (CHIP).  Now, Centers for Medicare & Medicaid Services has written to state Medicaid directors outlining those tools.

In the 51-page letter, CMS notes that

Many Medicaid and CHIP beneficiaries may face challenges related to SDOH [social determinants of health], including but not limited to access to nutritious food, affordable and accessible housing, convenient and efficient transportation, safe neighborhoods, strong social connections, quality education, and opportunities for meaningful employment.  There is a growing body of evidence that indicates that these challenges can lead to poorer health outcomes for beneficiaries and higher health costs for Medicaid and CHIP programs and can exacerbate health disparities for a broad range of populations…

In the letter, CMS describes:

  • Overarching principles CMS expects states to adhere to in their Medicaid and CHIP programs when offering services and supports that address social determinants of health.
  • Services and supports that are commonly covered in Medicaid and CHIP programs to address social determinants of health.
  • Federal authorities and other opportunities under Medicaid and CHIP that states can use to address social determinants of health.

The letter does not introduce new opportunities or flexibilities under Medicaid and CHIP for addressing social determinants of health. Instead, it focuses on helping states identify existing tools, regulations, and programs they can use to facilitate their efforts to address social determinants of health in their individual Medicaid and CHIP programs.

Learn more from the CMS letter “Opportunities in Medicaid and CHIP to Address Social Determinants of Health.”

GAO: CMS Should Pay More Attention to States’ Financing of Medicaid

The federal government does not adequately monitor how states finance their Medicaid programs.

It also lacks a sufficiently clear understanding of how they pay providers of Medicaid-covered services.

These are among the conclusions in a new study on Medicaid financing and payments by the U.S. Government Accountability Office.

According to the GAO report,

GAO estimated that states’ reliance on provider taxes and local government funds decreased states’ share of net Medicaid payments (total state and federal payments) and effectively increased the federal share of net Medicaid payments by 5 percentage points in state fiscal year 2018.  It also resulted in smaller net payments to some providers after the taxes and local government funds they contribute to their payments are taken into account. While net payments are smaller, the federal government’s contribution does not change. This effectively shifts responsibility for a larger portion of Medicaid payments to the federal government and away from states.

To address this challenge, the GAO urged CMS to collect more complete and consistent information about both state financing of their Medicaid programs and the manner in which states pay Medicaid providers.  CMS neither agreed nor disagreed with the GAO’s recommendation.

Such a study could have implications for private safety-net hospitals located in states that have increased their dependence on provider taxes to fund their Medicaid programs in recent years.

Learn more about what the GAO found and recommended in its new report “Medicaid:  CMS Needs More Information on States’ Financing and Payment Arrangements to Improve Oversight.”

Recession Takes its Toll on State Medicaid Programs

State Medicaid programs are feeling the effects of the current recession, according to a new report by the Congressional Research Service.

According to the brief report, state Medicaid enrollment and costs have risen since the COVID-19 pandemic began and states expect them to continue rising into their 2021 fiscal years.  State efforts to reduce spending are limited by provisions in the Families First Coronavirus Response Act, which provided additional federal Medicaid matching funds to the states to assist them with their Medicaid costs during the COVID-19 pandemic but impose maintenance-of-effort requirements in exchange for continued state access to the enhanced federal matching funds.

Learn more about how the COVID-19 public health emergency is affecting state Medicaid programs in the Congressional Research Service report “Impact of the Recession on Medicaid.”

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 October 2020 MACPAC meeting opened with a panel discussion on restarting Medicaid eligibility redeterminations when the public health emergency ends.  It included Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities; René Mollow, deputy director for health care benefits and eligibility at the California Department of Health Care Services; and Lee Guice, director of policy and operations at the Department for Medicaid Services, Kentucky Cabinet for Health and Family Services.

After a break, Commissioners heard a panel discussion with Kevin Prindiville, executive director at Justice in Aging; Mark Miller, executive vice president of healthcare at Arnold Ventures; and Charlene Frizzera, senior advisor at Leavitt Partners, on creating a new program for dually eligible beneficiaries. Later, staff presented preliminary findings from a mandated report on non-emergency medical transportation. The day concluded with a report on nursing facility acuity adjustment methods.

On Friday, the day began with a session on access to mental health services for adults in Medicaid. It was followed by a related panel discussion on mental health services with Sandra Wilkniss, director of complex care policy and senior fellow at Families USA; Melisa Byrd, senior deputy director for the District of Columbia Department of Health Care Finance; and Dorn Schuffman, director of the CCBHC Demonstration Project at the Missouri Department of Mental Health.

Next, the Commission considered the merits of extending Medicaid coverage for pregnant women beyond 60 days postpartum. Staff then provided an update on a statutorily required analysis of disproportionate share hospital (DSH) allotments, as well as an analysis of addressing high-cost drugs and the challenges they present to Medicaid.

The meeting concluded with comment on the Secretary’s report to Congress on Reducing Barriers to Furnishing Substance Use Disorder (SUD) Services Using Telehealth and Remote Patient Monitoring for Pediatric Populations under Medicaid. The Commission decided to send a letter to Congress and the Secretary commenting on this report.

Supporting the discussion were the following briefing papers:

  1. Mandated Report on Non-Emergency Medical Transportation: Work Plan and Preliminary Findings
  2. Changes in Nursing Facility Acuity Adjustment Methods
  3. Access to Mental Health Services for Adults in Medicaid
  4. Considerations in Extending Postpartum Coverage
  5. Required Annual Analysis of Disproportionate Share Hospital (DSH) Allotments
  6. Addressing High-Cost Drugs and Pipeline Analysis
  7. Comment on Secretary’s Report to Congress on Reducing Barriers to Substance Use Disorder Services Using Telehealth for Pediatric Populations under Medicaid

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.

Off-Again, On-Again Public Charge Rule is Off Again

A federal rule that would have limited immigration to the U.S. for people who might at some point become dependent on public aid programs has been put on hold again by a federal judge.

Implementation of the rule, delayed by several courts and then authorized by the U.S. Supreme Court until the merits of challenges could be heard, was delayed again by a federal court, which said the rule contained “numerous unexplained flaws” that made it “arbitrary and capricious.”

Health care advocates feared the rule would discourage some immigrants to whom the rule does not even apply from seeking to participate in certain public aid programs and even encourage some to whom the rule does not apply to disenroll from the public aid programs, such as Medicaid, in which they are already legally enrolled.  A recent study published in the journal Health Affairs found that the parents of a projected 260,000 children have disenrolled their children from Medicaid or the Children’s Health Insurance Program (CHIP) because of their fear of the rule’s implications for their families.

NASH has conveyed its opposition to the public charge rule on a number of occasions, including in this 2019 position statement.

Learn more about the rule and this latest court decision in the New York Times article “Trump’s ‘Public Charge’ Immigration Rule Is Vacated by Federal Judge

States Expect Medicaid Enrollment, Spending to Rise in FY 2021

States expect to see their Medicaid enrollment and spending rise in FY 2021, driven by increases in unemployment resulting from the COVID-19 pandemic and maintenance-of-effort requirements in legislation enacted earlier this year.

A Kaiser Family Foundation survey of state Medicaid directors found that those officials expect their Medicaid enrollment to rise 8.2 percent in FY 2021 and their Medicaid spending to increase 8.4 percent that same year.  Most states expect the 6.2 percentage point increase in federal Medicaid matching funds that was included in the Families First Coronavirus Response Act, passed this March, to expire at the end of 2020.

Learn more about how states see their Medicaid responsibilities changing in the coming year and the underlying causes of those changes in the Kaiser Family Foundation report “Medicaid Enrollment & Spending Growth: FY 2020 & 2021.”

Medicaid and CHIP Enrollment Rising in Pandemic

Medicaid enrollment rose 6.2 percent and CHIP enrollment 0.5 percent during the first four months of the COVID-19 public health emergency, the Centers for Medicare & Medicaid Services reports.

The enrollment increase can be traced to rising unemployment, with many people losing their employer-sponsored health insurance.  The new figures cover five months, from February through June, the latter four of which marked the beginning of the COVID-19 pandemic.

Private safety-net hospitals already serve significant numbers of Medicaid and CHIP patients; an increase in their rolls will prove financially challenging to them.

The information comes from CMS’s first monthly “Medicaid and CHIP Enrollment Trends Snapshot.”  Go here for CMS’s news release explaining its new initiative and here to see the trends snapshot itself.