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Verma Addresses Medicaid Issues

Yesterday, Centers for Medicare & Medicaid Services administrator Seema Verma spoke at a conference of the National Association of Medicaid Directors.

In addition to discussing a proposed regulation posted earlier in the day that would introduce changes in the regulation of state financing of their Medicaid programs, Verma also addressed:

  • Medicaid demonstration programs
  • Medicaid work requirements
  • a shift toward value-based payments
  • better coordination of care for the dually eligible (individuals serve by both Medicaid and Medicare)
  • enrollment issues
  • improvements in the efficiency of the federal Medicaid bureaucracy

Because private safety-net hospitals care for so many more Medicaid patients than the typical hospital, these issues are especially important to them.

Read Verma’s complete remarks here.

Verma Hints at More Medicaid Changes, Deregulation

Stay tuned for more Medicaid changes, Centers for Medicare & Medicaid Services administrator Seema Verma told a Las Vegas health care gathering last week.

CMS, she told her audience, will

…soon outline new opportunities for states to flip the Medicaid paradigm and free themselves from federal micromanagement.

While Verma offered few details, one idea clearly emerged:  there will be more deregulation.  She insisted, for example, that Medicaid work requirements are not dead.  While such requirements have run into trouble in the courts in recent months, she explained that CMS is developing new implementation guidelines to address some of the challenges states have faced when introducing such requirements and made it clear that CMS would continue to approve state requests to require their Medicaid population to work or engage in volunteer activities.

Because they care for more Medicaid patients than the typical hospital, private safety-net hospitals could be disproportionately affected by any changes in the Medicaid program.

Learn more about Verma’s remarks and the context in which they were offered in the Healthcare Dive article “CMS chief Verma teases more Medicaid deregulation.”

Bureaucratic Requirements May Be Driving Medicaid Enrollment Decline

State eligibility redetermination processes may be pushing down Medicaid enrollment nation-wide.

Last year, national Medicaid enrollment fell 1.5 million, more than half of them children, and according to a new report from Families USA, much of that decline may be attributable to the challenging eligibility redetermination requirements imposed on Medicaid-eligible individuals by some states.

Those requirements include a 98-page packet that Tennessee sends to individuals seeking to retain their Medicaid eligibility; Arkansas’ limit of 10 days to respond to requests for information to redetermine eligibility; and Missouri’s decision to discontinue using data from other public safety-net programs to redetermine eligibility.

Others point to an improving national economy and new Medicaid work requirements as the primary causes of declining Medicaid enrollment.

Declining Medicaid enrollment can be especially challenging for private safety-net hospitals because they are located in lower-income communities than the typical hospital.  When Medicaid enrollment falls, these hospitals often find themselves serving more patients without health insurance and providing more uncompensated care.

Learn more in the Families USA report “The Return of Churn: State Paperwork Barriers Caused More Than 1.5 Million Low-Income People to Lose Their Medicaid Coverage in 2018.”

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.”

 

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.

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.

 

Battle Over Medicaid Work Requirements Not Over

The Secretary of Health and Human Services is not accepting a recent federal court ruling as the final word on Medicaid work requirements.

Although the court ruled against a federally approved plan to permit the state of Kentucky to implement a work requirement for some able-bodied Medicaid recipients, HHS Secretary Alex Azar insists that his department will continue to support work requirements for Medicaid beneficiaries.

Azar told a Heritage Foundation audience that

We suffered one blow in district court in litigation, but we are undeterred.  We’re proceeding forward…We’re fully committed to work requirements and community participation in the Medicaid program…we will continue to litigate, we will continue to approve plans, we will continue to work with states.  We are moving forward.

Learn more about the ruling against Kentucky’s Medicaid work requirement, which was approved by HHS, and the federal government’s determination to enable states to impose such requirements in this Washington Post article.

Medicaid Changes: More Than Just Work Requirements Coming?

While the green light for state applications to impose work requirements on their Medicaid recipients is receiving all of the attention, the Trump administration has issued guidance that appears to pave the way for other major changes in the Medicaid program as well.

Specifically, the Centers for Medicare & Medicaid Services has issued guidance that will enable states to pursue section 1115 waivers to test different ways of serving Medicaid patients that are otherwise not permitted under federal Medicaid law, including:

  • establishing time limits on how many months or years individuals may be enrolled in Medicaid;
  • locking out for a specified period of time Medicaid recipients who have not gone through annual eligibility redetermination or have failed to pay Medicaid premiums;
  • prohibiting hospitals from making presumptive eligibility determinations when they encounter new, low-income patients who are not enrolled in Medicaid at the time;
  • tightening their eligibility requirements;
  • excluding family planning providers like Planned Parenthood; and
  • establishing closed drug formularies for their Medicaid population.

Learn more about how the foundation has been laid for such changes if states are so inclined to pursue them and the implications of such changes if they are implemented in the article “State Waivers as a National Policy Lever:  The Trump Administration, Work Requirements, and Other Potential Reforms in Medicaid, which can be found here, on the Health Affairs Blog.

Medicaid in the Spotlight

State-option work requirements.

A cap on federal spending.

New flexibility for states to address eligibility, benefits, and provider payments.

Rolling back the Affordable Care Act’s eligibility expansion.

Medicaid is under the policy microscope in Washington these days in ways it has not been for many years as the new administration continues to work to put its stamp on the federal government’s major program to provide health care to low-income Americans.

These and other possible changes are of great interest to the nation’s private safety-net hospitals because these hospitals care for so many more Medicaid and low-income patients than the typical community hospital.

What are policy-makers considering and what are the potential implications of their efforts?  Learn more in the new Health Affairs blog article “Medicaid Program Under Siege,” which can be found here.