Protections Overlooked as Medicaid Reforms are Implemented

In its eagerness to help states introduce changes in their Medicaid programs and reduce administrative burdens, the Centers for Medicare & Medicaid Services is ignoring regulatory requirements designed to understand and measure the impact of those changes on beneficiaries.

According to an analysis by the Los Angeles Times, many states seeking to implement Medicaid work requirements have not projected how many of their beneficiaries would be affected by those requirements nor have they projected how many beneficiaries who are removed from the Medicaid rolls will gain employment after losing their Medicaid benefits.  Both projections are required under Medicaid regulations adopted in 2012, which call for states to assess the anticipated impact of proposed policy changes when seeking federal permission to implement such changes.

Similarly, many states have not proposed commissioning independent assessments to determine the impact of the Medicaid changes they have implemented with CMS’s approval – another requirement under 2012 regulations.

When pressed to explain its failure to enforce these regulations, according to the Times, CMS said only that regulations “…do not require that states provide precise numerical estimates of coverage impacts…” and that it is developing strategies for states to evaluate the impact of new work requirements.  The Medicaid and CHIP Payment and Access Commission wrote to Health and Human Services Secretary Alex Azar about Medicaid disenrollment in states with new work requirements but after three months, Secretary Azar has not responded to MACPAC’s inquiry.

Medicaid disenrollment is a particular challenge for private safety-net hospitals because they serve more Medicaid patients than most hospitals and patients who lose their Medicaid coverage and need hospital care typically cannot afford to pay for that care, leaving such hospitals with growing amounts of uncompensated care.

Learn more about the process for reviewing state requests to implement Medicaid work requirements and CMS’s enforcement of regulations governing its approval of such requirements in the Los Angeles Times article “In rush to revamp Medicaid, Trump officials bend rules that protect patients.”

 

NASH Registers Concerns Over Uncompensated Care Audits

The process the federal government is employing to audit the uncompensated care costs that hospitals report to Medicare is plagued with problems, the National Alliance of Safety-Net Hospitals has written in a letter to the Centers for Medicare & Medicaid Services.

Those problems could result in reduced Medicare disproportionate share hospital payments (Medicare DSH) to private safety-net hospitals in the future, NASH warned in the letter.

According to NASH, problems with the audits of hospitals’ Medicare cost report S-10 worksheets, where they report their uncompensated care, include inconsistencies in the methods auditors are using and the data they demand and unreasonable deadlines for submitting requested supplemental data.

To address these problems, NASH asked CMS to standardize the auditing process and to convey decisions about auditing standards, methodologies, and time frames to hospitals.

In light of these problems, NASH also asked CMS not to use audited data to calculate Medicare DSH uncompensated care payments for FY 2020.

The S-10 audits are so important to private safety-net hospitals because the uncompensated care reported on the S-10 is used in the calculation of participating hospitals’ Medicare DSH uncompensated care payments.  When auditors reduce eligible hospitals’ uncompensated care data, that will result in future reductions of the Medicare DSH payments hospitals receive.  Those Medicare DSH payments play a vital role in helping to underwrite the cost of the care private safety-net hospitals provide to uninsured patients, so any undeserved reduction in those payments could hurt those hospitals and result in reduced access to care in the communities they serve.

Learn more by reading NASH’s letter to CMS about current challenges with uncompensated care audits.

New Report Looks at Medicaid and Social Determinants of Health

A new report outlines how state Medicaid programs can improve the health of Medicaid beneficiaries through a more concerted approach to addressing social determinants of health.

The report, from the Institute for Medicaid Innovation, focuses on how state Medicaid programs, through alternative payment models and especially through managed care organizations, have implemented new programs designed to address social determinants of health such as inadequate social supports and housing, food insecurity, lack of transportation, and others.  It also highlights federal regulations that facilitate the implementation of new ways to address social determinants of health and presents brief case studies in which states, state Medicaid programs, and Medicaid managed care organizations tackle social determinants of health.

Such approaches are especially relevant to private safety-net hospitals because they care for so many more Medicaid patients than the typical community hospital.

Learn more from the Institute for Medicaid Innovation report “Innovation and Opportunities to Address Social Determinants of Health in Medicaid Managed Care.”

MACPAC: Slow Medicaid DSH Cuts

Slow the pace of scheduled cuts in Medicaid disproportionate share hospital payments (Medicaid DSH), the non-partisan agency that advises Congress and the administration will tell Congress in its next report of policy recommendations.

The Medicaid and CHIP Payment and Access Commission voted 16-1 recently to recommend to Congress that Medicaid DSH cuts, mandated by the Affordable Care Act but delayed three times by Congress, be reduced in size and spread out over a longer period of time.

Currently, Medicaid DSH allotments to the states are scheduled to be reduced $4 billion in FY 2020 and then $8 billion a year in FY 2021 through FY 2025.  MACPAC recommends that the cuts be reduced to $2 billion in FY 2020, $4 billion in FY 2021, $6 billion in FY 2022, and $8 billion a year from FY 2023 through FY 2029.

MACPAC commissioners also voted to urge Congress to restructure the manner in which Medicaid DSH allotments to the states are calculated based on the number of low-income individuals who reside in the states.

Most private safety-net hospitals receive Medicaid DSH payments and consider them a vital resource in helping to underwrite the uncompensated care they provide to uninsured patients.  NASH supports delaying the implementation of Medicaid DSH cuts and reducing the size of the cuts once implementation begins, doing so most recently in a letter to Senator Marco Rubio in response to Mr. Rubio’s introduction of Medicaid DSH legislation.

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.

Learn more about MACPAC’s actions on Medicaid DSH in the Fierce Healthcare article “MACPAC calls for Congress to delay cuts to safety-net hospitals.”

Chatter About Medicaid Block Grants Grows

A week after a published report suggested that the Trump administration might be working on a plan to introduce Medicaid block grants, the Washington Post reports that those efforts are under way in earnest.

According to the Post,

A small group of people within the Centers for Medicare and Medicaid Services is working on a plan to allow states to ask permission for their federal Medicaid dollars to be provided in a single lump sum instead of the way they are currently awarded as a percentage of states’ total costs.

While many, including members of Congress, insist that the administration cannot move forward with such a proposal without legislation, others suggest that the administration may offer states the opportunity to participate in Medicaid block grants voluntarily, by seeking a federal waiver.  What remains to be seen is whether the prospect of greater flexibility to shape their own Medicaid programs is sufficient to entice states to participate in an approach that almost certainly would result in less federal money for those programs.

NASH is concerned about the prospect of Medicaid block grants and their potential impact on private safety-net hospitals and addressed this issue in its 2019 advocacy agenda, writing that

If the policy focus shifts from participants to spending, an effort could be undertaken to attempt to introduce a major Medicaid change that has been much-discussed in the past: Medicaid block grants. Block grants, whether based on individual states’ Medicaid enrollment or on their past Medicaid spending, could impose unreasonable limits on Medicaid spending that could potentially leave private safety-net hospitals unreimbursed for care they provide to legitimately eligible individuals. NASH will work to ensure that any new approach that involves Medicaid block grant continues to give states the ability to pay safety-net hospitals adequately for the essential services they provide to the low-income residents of the communities in which those hospitals are located.

Learn more about what the administration is considering and how policy-makers, industry leaders, and others are reacting to the prospect of a push toward Medicaid block grants from the Washington Post story “The Health 202: The Trump administration is working on Medicaid block grants?

MedPAC Meets

Last week the Medicare Payment Advisory Commission met in Washington, D.C. to discuss a number of Medicare payment issues.

The issues on MedPAC’s December agenda were:

  • The Medicare prescription drug program (Part D)
  • Opioids and alternatives in hospital settings: payments, incentives, and Medicare data
  • Hospital inpatient and outpatient services payments
  • Redesigning Medicare’s hospital quality incentive programs
  • Physicians and other health professional services payments
  • Medicare payment policies for advanced practice registered nurses and physician assistants
  • Ambulatory surgical centers and hospice payments
  • Skilled nursing facilities, home health agency, and inpatient rehabilitation facilities payments
  • Long-term care hospital services payments
  • Outpatient dialysis payments
  • Future policy directions to address Medicare prescription drug spending
  • Analysis of Medicare Shared Savings Program (MSSP) performance

MedPAC is an independent congressional agency that advises Congress on issues involving the Medicare program.  While its recommendations are not binding on either Congress or the administration, MedPAC is highly influential in governing circles and its recommendations often find their way into legislation, regulations, and new public policy.  Many of the issues MedPAC addressed during its January meetings are very important to private safety-net hospitals.

Go here for links to the policy briefs and presentations that supported MedPAC’s discussion of these issues.

Proposed Public Charge Regulation Causes Confusion in Clinics, Elsewhere

A Trump administration proposal to redefine what constitutes a “public charge” is making life challenging for low-income immigrants and the clinics and other providers to which they turn for Medicaid-covered health care.

The proposed regulation from the Department of Homeland Security would establish new criteria for determining whether a person is a “public charge,” based on their participation in certain public programs, and therefore in jeopardy of losing their legal immigration status.

Some Medicaid patients who come to clinics ask if receiving Medicaid-covered services might jeopardize their legal immigration status; others fail to keep appointments or forego seeking care out of fear of the future implications.  Clinic operators walk a fine line between trying to provide the care their patients need and deciding how to answer patients’ questions honestly but without causing undue alarm.  Some choose not to address the issue at all; others seek to answer patient questions but only when asked; while still others provide information about the situation without being asked – doing so, they realize, at the risk of scaring off some of those patients.

Meanwhile, some legal experts believe that a new standard, if adopted, would not be retroactive and consider Medicaid enrollment prior to the regulation’s adoption.

The result is confusion and concern among providers, legal immigrants enrolled in Medicaid, and advocates.

Last month NASH wrote to the Department of Homeland Security to convey its objections to the proposed legislation, expressing concern about its potential impact on private safety-net hospitals and the patients and communities they serve.

Learn more about the proposed regulation and the challenges providers face as they await a decision on whether it will be implemented in the Kaiser Health News report “Providers Walk ‘Fine Line’ Between Informing And Scaring Immigrant Patients.”

Could Medicaid Buy-In Push Aside Medicare for All?

Officials in ten states are giving consideration, in one form or another, to permitting uninsured low-income residents to buy into their Medicaid programs.

So while Washington considers the possibility of Medicare for all, the ten states – Nevada, New Mexico, California, Delaware, Oregon, Washington, Connecticut, Illinois, Minnesota, and Wisconsin – are tackling the many issues they must address if they intend to pursue such a ground-breaking option.  Among them:

  • Who would be eligible to participate?
  • What benefits would be offered?
  • Would health plans be available on Affordable Care Act health exchanges, and if so, would ACA subsidies be available to potential purchasers?
  • How would cost-sharing, such as premiums, co-pays, and deductibles, be addressed?
  • In the absence of federal matching funds, how would the states pay for their share of Medicaid benefits purchased by those not eligible for Medicaid?
  • Would such as effort be approved by the federal government?

To the extent that Medicaid buy-in would turn uninsured patients into insured patients, Medicaid buy-in would be beneficial for private safety-net hospitals.

Learn more about what the states are considering and the potential obstacles they face in the Stateline article “Medicaid ‘Buy-In’ Could Be a New Health Care Option for the Uninsured.”

 

NASH Comments Proposed Medicaid Managed Care Reg

 

The National Alliance of Safety-Net Hospitals has submitted formal comments to the Centers for Medicare & Medicaid Services in response to CMS’s proposed changes in federal Medicaid managed care regulations.

NASH’s letter addressed three aspects of the proposed regulation:  payment rate ranges, directed Medicaid payments, and Medicaid pass-through payments.  The overall theme underlying NASH’s comments was that the proposed changes represent positive steps but could be taken further to provide additional flexibility for state Medicaid programs to take stronger steps to ensure the ability of private safety-net hospitals to serve their communities.

NASH expressed support for CMS’s restoration of the use of actuarial rate ranges in setting Medicaid managed care rates but urged CMS to make those rate ranges even broader or even eliminate them provided that negotiated rates still meet formal criteria for actuarial soundness.

NASH endorsed CMS’s expanded parameters for the use of Medicaid directed payments through managed care but encouraged CMS to expand those parameters even further than it has proposed.

And NASH called on CMS to restore the ability of states to use pass-through payments in Medicaid managed care programs, as they can do through Medicaid fee-for-service programs, so long as those payments remain actuarially sound.  In 2016 a new Medicaid managed care regulation called for the phase-out of such payments over a period of ten years but NASH asked CMS to suspend that phase-out.

Learn more about NASH’s perspective by reading NASH’s comment letter to CMS in response to the proposed Medicaid managed care regulation.

End Run Around Congress for Medicaid Block Grants?

The Trump administration reportedly is considering introducing Medicaid block grants through regulations rather than legislation, according to published reports.

Those reports explain that the administration may seek to offer states an opportunity to apply to the federal government to use Medicaid block grants by obtaining section 1115 Medicaid waivers, a commonly used tool for states seeking exemptions from federal legislative or regulatory requirements.

As reported by the online publication The Hill,

…the Trump administration is now considering issuing guidance to states encouraging them to apply for caps on federal Medicaid spending in exchange for additional flexibility on how they run the program, according to people familiar with the discussions.

Proposals to implement Medicaid block grants have arisen periodically over the past decade but have never gotten beyond the discussion stage because of how difficult it would probably be to gain congressional approval for such a program.  This latest proposal would seek to circumvent that problem by making Medicaid block grants optional for states and permitting those states interested in using them to apply for a Medicaid waiver from Centers for Medicaid & Medicaid Services to do so.

It is not clear whether such an approach would be legal.

NASH has long been skeptical about Medicaid block grants, concerned that the manner in which such block grants are implemented could impose artificial limits on state Medicaid spending that could be especially harmful during economic downturns when Medicaid enrollment typically rises and the demand for Medicaid-covered services falls especially heavily on private safety-net hospitals.  NASH’s advocacy agenda for 2019 addresses this very issue, explaining that

Block grants, whether based on individual states’ Medicaid enrollment or on their past Medicaid spending, could impose unreasonable limits on Medicaid spending that could potentially leave private safety-net hospitals unreimbursed for care they provide to legitimately eligible individuals. NASH will work to ensure that any new approach that involves Medicaid block grants continues to give states the ability to pay safety-net hospitals adequately for the essential services they provide to the low-income residents of the communities in which those hospitals are located.

Learn more about this latest proposal in The Hill article “Trump officials consider allowing Medicaid block grants for states.”