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CMS Adopts Rule to Protect Medicaid Payments

A new Medicaid provider reassignment regulation eliminates the ability of states to divert any portion of Medicaid payments to third parties.

Such diversion was authorized, in a limited manner, in 2014, when CMS created an exception to the existing prohibition on the diversion of provider payments to third parties.  That exception involved diversion of payments to selected third parties, mostly in-home personal care workers, but in this new, final regulation, the agency eliminates this exception, maintaining that it is inconsistent with the Social Security Act.

Learn more about the new regulation in a CMS news release or see the new regulation itself.

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.”

 

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.

Hospitals, Others Oppose Easing Medicaid Access Requirements

Hospital groups and other health care interest organizations have expressed strong opposition to a Centers for Medicare & Medicaid Services proposal to ease requirements that states ensure adequate access to care for their Medicaid population.

Under current federal Medicaid law, states must periodically review their Medicaid provider networks to ensure that Medicaid recipients have adequate access to care.  Under a March CMS proposal, that requirement would exempt states from performing such reviews if at least 85 percent of their Medicaid population is enrolled in a managed care plan and similarly exempt them from reviewing the impact on their provider networks of rate cuts of less than four percent during a single state fiscal year or six percent over two consecutive years.

Fearing that the proposal could jeopardize access to care for Medicaid recipients, the overwhelming majority of comments submitted to CMS expressed strong opposition to the proposal.  Among those doing so were the Association of American Medical Colleges, the Federation of American Hospitals, the Medicaid and CHIP Payment and Access Commission, the Tennessee Hospital Association, the Virginia Hospital and Healthcare Association, the American Academy of Family Physicians, and others.

For a closer look at what the regulation proposes and how various groups have responded to it, see these Fierce Healthcare and Healthcare Dive articles.

 

CMS Proposes Easing Medicaid Access Requirement

Under a new regulation proposed by the Centers for Medicare & Medicaid Services, some states would no longer need to analyze access to care for their Medicaid population.

In a newly proposed regulation, CMS calls for eliminating the need for such a review in states with a high degree of Medicaid managed care penetration – 85 percent or more – and under certain circumstances when they reduce payments to providers.

According to CMS, existing regulations already enforce access requirements for Medicaid managed care plans, making a separate state obligation duplicative and unnecessary.

A CMS news release accompanying publication of the proposed rule quotes CMS administrator Seema Verma explaining that

These new policies do not mean that we aren’t interested in beneficiary access, but are intended to relieve unnecessary regulatory burden on states, avoid increasing administrative costs for taxpayers, and refocus time and resources on improving the health outcomes of Medicaid beneficiaries.

Learn more about the proposed regulation in this CMS news release and go here to see the proposed regulation itself.

New Help With Addressing Low-Income Patients’ Social Services Needs?

One of the long-time barriers to states and hospitals addressing low-income patients’ social services needs and the social determinants of health has been a lack of resources for such assistance.  Medicaid, in particular, has not been a financial participant in such efforts.

But that may be changing.

The new federal Medicaid managed care regulation, updated nearly two years ago, allows for the inclusion of some non-clinical services as covered Medicaid services and for funding for such services to be folded into Medicaid managed care plans’ capitation rates and medical loss ratios.  The updated regulation also encourages greater coordination of care for Medicaid patients and coverage for long-term services and supports in the home and community for medically qualified patients.

Because they serve so many low-income patients, private safety-net hospitals are especially interested in policy changes that might enable them to serve such patients more effectively.

The Commonwealth Fund has taken a closer look at how the 2016 Medicaid managed care regulation may facilitate addressing the psycho-social needs of Medicaid beneficiaries.  Go here to see its report “Addressing the Social Determinants of Health Through Medicaid Managed Care.”

Medicaid Directors Comment on Proposed Medicaid Pass-Through Regulation

national association of medicaid directorsLast November the Centers for Medicare & Medicaid Services proposed a new regulation governing the use of pass-through payments in state Medicaid managed care programs.

The National Association of Medicaid Directors submitted formal comments to CMS about that proposed regulation. See its comments here.

See NAUH’s comments on the same proposed regulation here.

FAQ on New Medicaid Managed Care Rule

The Centers for Medicare & Medicaid Services has published an FAQ on the new regulation that governs the use of managed care when serving Medicaid and CHIP populations.

Go here to find that FAQ and other links to other resources for learning more about the new Medicaid managed care regulation.

NAUH Comments on Proposed Medicaid DSH Regulation

The National Association of Urban Hospitals has written to the Centers for Medicare & Medicaid Services to object to how the agency proposes changing its methodology for calculating eligible hospitals’ Medicaid disproportionate share (Medicaid DSH) payments.

NAUH LogoIn particular, NAUH opposes the manner in which CMS would treat payments from Medicare and third-party payers made on behalf of Medicaid-eligible individuals.

In NAUH’s view, the letter notes,

…the hospital-specific DSH limit has come to penalize the very hospitals – including private urban safety-net hospitals – that Medicaid DSH payments were designed to support.

The NAUH letter explains that

What troubles NAUH at this time is CMS’s apparent decision to rationalize and codify in regulations a narrower interpretation of the Medicaid DSH limit than what Congress described in section 1923(g) of the Social Security Act.

Read NAUH’s complete letter here.

New Medicaid Regulation Clarifies Access to Home Health Services

Under a new regulation unveiled by the Centers for Medicare & Medicaid Services, physicians and other authorized providers now must document their face-to-face encounters with patients when they are authorizing home health services but those encounters can be conducted through telehealth.

iStock_000008112453XSmallThis approach, already part of the Medicare program, applies only to Medicaid fee-for-service patients and not to those served by managed care plans.

In addition, the rule regulates how recently providers must have their encounters with patients when prescribing home health services and provides those services in settings other than the home.

For a closer look at the new regulation, see this Fierce Healthcare article and this CMS fact sheet.