Election Brings Good News for Medicaid

Medicaid came out on top in elections throughout the country last week.

With the arrival of a Democratic majority in the House, attempts to repeal the Affordable Care Act, including its Medicaid expansion, appear to have come to an end – at least for now.

Voters in three states approved ballot questions to expand their states’ Medicaid programs.

And two states elected governors likely to expand their states’ Medicaid programs.

Learn more about what the mid-term elections meant to Medicaid and its future in this Washington Post story.

 

MACPAC: Let’s “hit the pause button” on Medicaid Work Requirements

The non-partisan legislative branch agency that advises Congress and the administration on Medicaid issues will ask the administration to delay approving any more state Medicaid work requirements.

That was the decision reached by the Medicaid and CHIP Payment and Access Commission when it met last week.

MACPAC warned that the work requirement currently being implemented in Arkansas, the first state to introduce such a requirement, is flawed and needs further work before moving forward.  The agency also believes the federal government should increase its oversight of new Medicaid work requirements before additional states begin implementing similar, already-approved Medicaid work requirements.

MACPAC plans to convey its concerns in a letter to Department of Health and Human Services Secretary Alex Azar.

Medicaid work requirements pose a potential challenge for private safety-net hospitals because they could leave meaningful numbers of low-income residents of the communities those hospitals serve without health insurance.

Learn more about MACPAC’s objections to the manner in which Medicaid work requirements are being introduced in this Bloomberg Law article.

 

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 2018 MACPAC meeting covered a range of front-line issues in Medicaid, leading off with an analysis of disproportionate share hospital (DSH) allotments on Thursday morning. Following the analysis, the Commission discussed options for March recommendations on how to structure DSH allotment reductions that are scheduled to begin in fiscal year 2020. The Commission later resumed the discussion it began in September on work and community engagement requirements, presenting new data from Arkansas on compliance and disenrollments, as well as information gathered since that meeting about Arkansas’s approach to implementation.

On Thursday afternoon, the Commission looked at the Department of Homeland Security’s proposed public charge regulations and their implications for Medicaid and the State Children’s Health Insurance Program (CHIP). A session responding to a congressional request to look at issues facing the Medicaid program in Puerto Rico was next on the agenda. A presentation from an ongoing project on how Medicaid drug coverage compares with Medicare Part D and commercial plans closed out the day.

On Friday, the Commission heard from Tom Betlach, director of the Arizona Health Care Cost Containment System, and Karen Kimsey, chief deputy at the Virginia Department of Medical Assistance Services, on their experiences integrating care for dually eligible beneficiaries.* At the final October session, the Commission reviewed the findings from a study of how six states carried out simplified Medicaid eligibility and enrollment established by the Patient Protection and Affordable Care Act (P.L. 111-148, as amended).

Supporting the discussion were the following presentations:

Because NAUH members serve so many Medicaid patients, MACPAC’s deliberations are especially relevant to them because its recommendations often find their way into future Medicaid and CHIP policies.

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 array of issues affecting Medicaid and the State Children’s Health Insurance Program.  Find its web site here.

New Report Looks at Medicaid Buy-In

While there has been a great deal of public discussion of late about “Medicare for all,” less attention has been paid to the concept of permitting people to buy into their state’s Medicaid program.

Now, the Rockefeller Institute of Government has published a new report that presents the different approaches to the concept of Medicaid buy-in.

It also seeks to address six major questions of potential Medicaid buy-in efforts:

  • How large is the intended population of new enrollees?
  • What kind of coverage would be offered?
  • How would enrollment be financed?
  • How would rates be set?
  • Would the program use standard Medicaid rate and would there be enough participating providers to meet enrollee demand?
  • How would such a program fit into individual states’ regulatory structure?

Medicaid buy-in would be of great interest to private safety-net hospitals because they serve communities in which many residents remain uninsured.

Learn more about how the concept of Medicaid buy-in and how it might work by reading the Rockefeller Institute of Government report “Medicaid Buy-In: Questions of Design and Purpose,” which can be found here.

Medicaid APMs Moving in New Directions

For the most part, states’ use of alternative payment models in their Medicaid programs so far have focused on the work done by primary and acute-care providers.  Now, a number of states are starting to extend their use of APMs in other areas, including:

  • behavioral health providers
  • safety-net providers
  • long-term care providers

Because safety-net hospitals serve so many more Medicaid patients than the typical hospital, they are more likely to be affected by this trend in the coming years.

For a look at what states are doing to drive value in Medicaid payments in these new areas, see the Commonwealth Fund article “The Next Generation of Paying for Value in Medicaid,” which can be found here.

Proposed “Public Charge” Regulation Could Hit Medicaid, Hospitals

If a regulation proposed by the Department of Homeland Security to redefine what constitutes a “public charge” is adopted, millions of people currently enrolled in the Medicaid and Children’s Health Insurance Program might choose to disenroll from those programs rather than risk losing their opportunity to obtain legal permanent resident status in the U.S.

The proposed regulation seeks to filter out of possible residency status individuals who might become public charges, or dependent on government programs, over time.

A new analysis published by the Kaiser Family Foundation concluded that

Under the proposed rule, individuals with lower incomes, a health condition, less education, and/or who are enrolled or likely to enroll in certain health, nutrition, and housing programs would face increased barriers to obtaining LPR [legal permanent residency] status.

The study notes that

Nearly all (94%) noncitizens who originally entered the U.S. without LPR status have at least one characteristic that DHS could potentially weigh negatively in a public charge determination.

To avoid losing eligibility for legal permanent residency status, the analysis suggests,

 The proposed rule would likely lead to disenrollment from Medicaid and other programs among noncitizens who intend to seek LPR status as well as among a broader group of individuals in immigrant families, including their primarily U.S. born children.

How many people might disenroll from Medicaid, CHIP, and other programs is difficult to project but the study notes that

If the proposed rule leads to Medicaid disenrollment rates ranging from 15% to 35% among Medicaid and CHIP enrollees living in a household with a noncitizen, between 2.1 to 4.9 million Medicaid/CHIP enrollees would disenroll.

And

Reduced participation in Medicaid and other programs would negatively affect the health and financial stability of immigrant families and the growth and healthy development of their children, who are predominantly U.S.-born.

This, in turn, could lead to financial challenges for health care providers serving communities with large numbers of low-income patients, many of whom could be individuals who do not have permanent residency status.  Some could seek to disenroll from Medicaid, or not to enroll if they qualify, leaving them uninsured if and when they need and seek medical care.  This could prove especially challenging for private safety-net hospitals, which serve communities with large numbers of low-income patients and often serve communities with large numbers of immigrant residents as well.

Learn more about the proposed regulation and its implications for those it might affect and their health status in the Kaiser Family Foundation report “Estimated Impacts of the Proposed Public Charge Rule on Immigrants and Medicaid,” which can be found here.

CMS Promises Enhanced Use of Medicaid Data to Improve Program Results

Centers for Medicare & Medicaid Services administrator Seema Verma intends to increase federal use of data reported by the states to improve the performance of state Medicaid programs.

In an article published on the CMS blog, Verma wrote that

Through strong data and systems, CMS and states can drive toward better health outcomes and improve program integrity, performance, and financial management in Medicaid and CHIP.

Verma pointed to two core sets of data she considers vital:  Medicaid and CHIP child and adult core sets, which are reported only voluntarily by states, and administrative data submitted through the relatively new Transformed-MIS system.  The latter, according to Verma.

…modernizes and enhances the way states submit operational data about beneficiaries, providers, claims and encounters.  It is the foundation of a national analytic data infrastructure to support programmatic and policy improvements and program integrity efforts and will help advance reporting on outcomes.  It also enhances the ability to identify potential fraud and improve program efficiency.

All states now use Transformed-MIS.

Learn more about how CMS uses data now and how it envisions using it in the future to improve the performance of state Medicaid programs in the CMS blog entry “CMS Promises Enhanced Use of Medicaid Data to Improve Program Results,” which can be found here.

Verma Speaks at Medicaid Managed Care Summit

Centers for Medicare & Medicaid Services administrator Seema Verma recently addressed the Medicaid Managed Care Summit, which was held in Washington, D.C.

Ms. Verma’s speech focused on four major areas:

  • Empowering states to function as laboratories for innovation by giving them the flexibility to introduce changes that work best for their own citizens.
  • Developing Medicaid and CHIP scorecards that present data on health outcomes, quality metrics, and CMS’s administrative performance.
  • Improving Medicaid program integrity, including through “…targeted audits to ensure that provider claims for actual health care spending match what the [Medicaid managed care] health plans are reporting financially.”
  • Strengthening CMS’s use of data in Medicaid oversight.

See Ms. Verma’s complete remarks here.

States Pursuing Medicaid Reforms

A new Commonwealth Fund report looks at some of the changes states are pursuing in how they deliver and pay for care for their Medicaid recipients.

The review groups the reforms into three categories:

  • Managed care reforms – demanding more data to support bids for Medicaid managed care contracts and favoring bidders that include strong value components in their bids and that seek to address recipients’ social needs.
  • Focusing on beneficiaries with complex health and social needs – working with Medicaid managed care plans to address both the medical problems of members with complex medical conditions and the social determinants of health that cause, contribute to, or impede the treatment of those problems.
  • Integrating behavioral and physical health – expanding prevention and treatment of substance abuse disorders by restructuring delivery and payment systems.

Learn more about what states are doing to improve their Medicaid programs in the Commonwealth Fund report “Considering Federal Medicaid Policy Changes in Light of State-Level Delivery System Reforms,” which can be found here.

MACPAC Meets

The Medicaid and CHIP Payment and Access Commission met recently in Washington, D.C. to review a number of Medicaid- and CHIP-related issues.

MACPAC members heard presentations on and discussed the following issues:

Find outlines of these subjects and additional materials by clicking the links above and go here for a transcript of the two days of public meetings.

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 array of issues affecting Medicaid and the State Children’s Health Insurance Program.  While its recommendations are binding on neither the administration nor Congress, MACPAC’s work is highly influential and often finds its way into future Medicaid and CHIP policy.  Because private safety-net hospitals serve so many Medicaid and CHIP patients, they have an especially major stake in MACPAC deliberations and recommendations.