Medicaid to Help Pay for Food, Heat, Rent?

Maybe.

At least that is what Department of Health and Human Services Secretary Alex Azar hinted during a recent symposium held in Salt Lake City.

During the event, Azar said that HHS’s Center for Medicare and Medicaid Innovation seeks

…solutions for the whole person, including addressing housing, nutrition, and other social needs.

Azar hinted at future CMMI action, saying that

What if we gave organizations more flexibility so they could pay a beneficiary’s rent if they were in unstable housing, or make sure that a diabetic had access to, and could afford, nutritious food? If that sounds like an exciting idea … I want you to stay tuned to what CMMI is up to.

CMMI currently operates one major program that seeks to address social determinants of health:  the Accountable Health Communities model, which screens participants based on social determinants of health metrics, identifies those it considers to be at risk, and then works to link those individuals to local and community services that can help them address their health-related needs.

Significant numbers of the patients served by private safety-net hospitals face challenges posed by social determinants of health.

Learn more about Secretary Azar’s comments and the federal government’s outlook on using Medicaid to help address social determinants of health in this article in Becker’s Hospital Review.

HHS Gives States New Options for Medicaid-Covered Behavioral Health Treatment

The U.S. Department of Health and Human Services has informed state Medicaid programs that it is giving them new opportunities to pay for hospitalization to care for recipients with behavioral health problems.

For years Medicaid has greatly limited the ability of state Medicaid programs to pay for inpatient care for many behavioral health problems – a limit commonly known as the IMD (institution of mental disease) exclusion.  Earlier this year the Centers for Medicare & Medicaid Services eased this long-time limit, announcing that it would make it easier for states to secure waivers from it.  CMS has announced in a formal guidance letter to state Medicaid directors that it is extending this policy, according to a CMS news release, which explains that the agency offers

…both existing and new opportunities for states to design innovative delivery systems for adults with serious mental illness (SMI) and children with serious emotional disturbance (SED).  The letter includes a new opportunity for states to receive authority to pay for short-term residential treatment services in an institution for mental disease (IMD) for these patients.  CMS believes these opportunities offer states the flexibility to make significant improvements on access to quality behavioral health care.

Under this new approach, states are invited to develop new delivery systems for serving patients with behavioral problems, and especially substance abuse disorders, that make greater use of inpatient behavioral health services and to receive federal Medicaid matching funds for pay for this care – something that has been greatly limited in the past.  In offering this opportunity, CMS notes that a number of states that have already obtained waivers from the IMD exclusion since its easing of the limit on such waivers earlier this year and are already showing encouraging results in their battle against opioid abuse.

Learn more about this new policy, its intentions, and how it will work in this CMS news release or go here to see the CMS guidance letter to state Medicaid directors.

Medicaid Birthing Model Improves Outcomes

A federal program to improve birth outcomes among Medicaid-covered women has produced positive results:  lower rates of pre-term births, fewer low birthweight babies, fewer C-sections, lower delivery costs, and lower first-year health care spending.

The “Strong Start for Mothers and Newborns” program was a four-year initiative established by the Affordable Care Act and developed by the U.S. Department of Health and Human Services’ Center for Medicare and Medicaid Innovation to employ patient education, nutrition, exercise, preparation for childbirth, breast-feeding, and family planning rather than strictly medical interventions and was delivered through three evidence-based prenatal care models:  Birth Centers, Group Prenatal Care, and Maternity Care Homes.

The program, operated in 219 separate sites in 32 states, served participants with especially challenging socio-economic risk factors:  unemployment, lack of a high school degree or GED, food insecurity, transportation challenges, chronic health problems, and previous poor birth outcomes.  The objective of the program was to find ways to overcome these social determinants of health and produce better birth outcomes and now, a new, independent evaluation has found that it did.

Learn more about Strong Start for Mothers and Newborns and what it has produced in the official program evaluation document.

CMS Proposes New Medicaid Managed Care Regulation

Just two years after a major overhaul of Medicaid managed care regulations, the Centers for Medicare & Medicaid Services is again proposing changes in how the federal government regulates the delivery of managed care services to Medicaid beneficiaries.

Under the newly proposed regulation, states would:

  • be free to implement more changes in their managed care programs without seeking federal permission;
  • have slightly more flexibility in how supplemental payments are made to hospitals through managed care plans and implement some such changes without federal approval;
  • be permitted to redefine what constitutes an adequate provider network for managed care plans; and
  • not be required to publicize beneficiary grievance and appeals processes as prominently as they currently do.

Overall, the proposed regulation appears to help managed care insurers a great deal, states a little, and hospitals barely at all.  It also could have serious implications for private safety-net hospitals, most of which are located in states that employ managed care in their Medicaid programs.

Stakeholders have until January 14 to submit formal comments about the proposal to CMS.

To learn more about the proposed Medicaid managed care regulation, go here to see CMS’s news release presenting the regulation, go here to see a more detailed CMS fact sheet, and go here to see the proposed regulation itself.

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.