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Immigrants Intimidated by New Public Charge Guidelines?

Immigrants served by community health centers appear less inclined than in the past to seek public aid to help them with their medical problems.

And community health center staff believes this is the result of confusion and fear as a result of changing federal immigration policies.

As stated in the Kaiser Family Foundation issue brief “Impact of Shifting Immigration Policy on Medicaid Enrollment and Utilization of Care among Health Center Patients,”

  • Health centers reported that, in recent months, immigrant patients have declined to enroll or reenroll themselves and/or their children in Medicaid for fear of public charge.
  • Health center respondents reported patients are confused about the new rule and are afraid to provide identifying information.
  • According to respondents, the public charge rule is creating a “chilling” effect, leading to decreased enrollment in other programs not subject to public charge.
  • About half of health centers reported a drop in utilization by immigrant patients, especially among pregnant women.
  • Health centers are training staff to answer questions on public charge and are working to ensure access to care for their patients.

This can pose a challenge for private safety-net hospitals:  low-income individuals who avoid public aid programs often end up receiving uncompensated care from those hospitals.

Learn more in the Kaiser Family Foundation issue brief “Impact of Shifting Immigration Policy on Medicaid Enrollment and Utilization of Care among Health Center Patients.”

Millions Eligible for Health Insurance Remain Uninsured

More than 15 million Americans who are currently entitled to free or subsidized health insurance are currently uninsured.

Among them are 11 million who are eligible for Medicaid but have not applied for benefits and 4.2 million who could afford insurance with the help of federal premium subsidies and either have decided not to take advantage of those subsidies or are unaware of the availability of such subsidies.

In addition, another two million people would be eligible for Medicaid if their states expanded their Medicaid program as authorized by the Affordable Care Act.

In light of such figures, it is not entirely surprising that the uninsured rate, according to the census bureau, rose last year for the first time since implementation of the Affordable Care Act.  That uninsured rate, 15 percent at the time the law was adopted in 2010, fell to 7.9 percent in 2017 but rose to 8.5 percent in 2018.  The uninsured rate has especially risen among Hispanics and the foreign born.

Another possible reason for the rise in the number of uninsured Americans:  the federal government has greatly reduced its outreach effort to inform people about the various options they have for obtaining insurance.

Learn more about who is uninsured and why the uninsured rate has risen in the Washington Post story “Millions of Americans aren’t getting health insurance, even though they’re eligible for free or affordable plans.”

 

CMS Proposes Easing Medicaid Access Protections

States would have to do less to ensure access to Medicaid-covered services for their Medicaid population under a new regulation proposed by the Centers for Medicare & Medicaid Services.

In 2015, CMS required states to track their Medicaid fee-for-service payments and submit them to the federal government as part of a process to ensure that Medicaid payments were sufficient to ensure access to care for eligible individuals.  Now, CMS proposes rescinding this requirement, writing in a news release that

This proposed rule is designed to help streamline federal oversight of access to care requirements that protect Medicaid beneficiaries.  CMS anticipates that the proposed rule would, if finalized, result in overall cost savings for State partners that could be redirected to better serve the needs of their beneficiaries.

The proposed regulation itself explains that

While we believe the process described in the current regulatory text is a valuable tool for states to use to demonstrate the sufficiency of provider payment rates, we believe mandating states to collect the specific information as described excessively constrains state freedom to administer the program in the manner that is best for the state and Medicaid beneficiaries in the state.

CMS also notes that the current requirement applies only to Medicaid fee-for-service payments even though most Medicaid beneficiaries now receive care through managed care plans, the payments for which are not subject to the same process.

The agency adds that it intends to

…replace the ongoing access reviews required by current regulations with a more comprehensive and outcomes-driven approach to monitoring access across delivery systems, developed through workgroups and technical expert panels that include key State and federal stakeholders.

Because they care for so many Medicaid patients, the adequacy of the rates states pay for Medicaid services is especially important to private safety-net hospitals.

Learn more about CMS’s proposal in its news release on the subject or see the proposed regulation itself.  Learn about the process CMS intends to employ to replace its current approach to monitoring access to Medicaid services in this CMS informational bulletin.

 

Study Finds Surprise in Sources of Medicaid, CHIP Growth

While enrollment in Medicaid and CHIP has been greatest among low-income families working full-time for small businesses, growth in Medicaid and CHIP enrollment among low-income families employed full-time by big businesses has been rising faster in recent years.

According to a new study published in the journal Health Affairs, Medicaid and CHIP enrollment among low-income families employed full-time by large companies rose from 45 percent to 69 percent between 2008 and 2016.  The driving force behind this growing reliance on public insurance appears to be the shift of health insurance costs from companies to employees:  employee share of health insurance premiums rose 57 percent during that same period, leaving many families unable to afford even employer-subsidized health insurance.

Learn more about the growing Medicaid and CHIP participation rates among different economic groups in the Health Affairs report “Growth Of Public Coverage Among Working Families In The Private Sector.”

CMS Outlines New Medicaid Program Integrity Activities

The federal government will introduce a number of initiatives to combat Medicaid waste, fraud, and abuse in the coming months.

In an article on the Centers for Medicare & Medicaid Services’ blog, CMS administrator Seema Verma outlined her agency’s major Medicaid program integrity efforts of the past year, including:

  • Oversight of state Medicaid claiming and program integrity
  • Disallowing unallowable claims of federal funding
  • Increased audits and oversight
  • Data sharing and partnerships
  • Education, technical assistance, and collaboration
  • Reducing improper payments

Initiatives to be introduced in the coming months include (as described in the blog post):

  • A proposed comprehensive update to Medicaid’s fiscal accountability regulations, to increase states’ accountability for supplemental payments. The update includes additional state reporting, clearer financial definitions, and stronger federal guidance to ensure that states use supplemental payments properly.
  • A proposed regulation to further strengthen the integrity of the Medicaid eligibility determination process, including enhanced requirements around verification, monitoring changes in beneficiary circumstances, and eligibility redetermination.
  • Additional guidance on the Medicaid Managed Care Final Rule from 2016 to further state implementation and compliance with program integrity safeguards, such as reporting overpayments and possible fraud.
  • Release of improvements to the Medicaid and CHIP Scorecard—a dashboard of program measures that increases public transparency about the programs’ administration and outcomes. The improvements include two program integrity measures to enhance transparency and continue to provide states with performance measures related to their Medicaid programs. Examples of such program integrity measures may include measures based on state initiation of collaborative investigations with their UPIC, state participation in the HFPP at any level, and performance data derived from improper payment drivers.
  • Conduct provider screening on behalf of states for Medicaid-only providers to improve efficiency and coordination across Medicare and Medicaid, reduce state and provider burden, and address one of the biggest sources of error as measured by PERM.
  • Medicaid provider education through Targeted Probe and Educate—which identifies providers who have high error rates and educates them on billing requirements—to reduce aberrant billing, as well as education provided through Comparative Billing Reports—which show providers their billing patterns compared to their peers.
  • Audit state claiming of federal matching dollars to address areas that have been identified as high-risk by GAO and OIG, as well as other behavior previously found detrimental to the Medicaid program.

Learn more in the CMS blog article “Medicaid Program Integrity: A Shared and Urgent Responsibility.”

Tackling Social Determinants of Health

Two states are working to address social determinants of health through their Medicaid programs.

In California and Oregon, the state Medicaid programs are using care coordination and funding from multiple sources, including traditional Medicaid funding, alternative payment approaches, and savings from care coordination to provide services such as housing, food, and legal assistance while also building the capacity of health care and community groups to support such efforts.  Both states obtained federal Medicaid waivers to enable them to expend Medicaid resources on non-Medicaid-covered services.

Learn more about how California and Oregon are using their Medicaid programs to address social determinants of health in the Health Affairs report “Medicaid Investments To Address Social Needs In Oregon And California.”

Medicaid Transportation Services in Jeopardy?

The White House has proposed removing non-emergency transportation from the list of mandatory Medicaid benefits.

The proposed FY 2020 budget released last week explained that

Statute allows, but does not require, States to provide non-emergency medical transportation (NEMT).  Instead, these services were made mandatory Medicaid benefits by regulation.  Further, a Government Accountability Office study found Medicaid NEMT spending totaled $1.5 billion in 2013, and NEMT programs face multiple challenges, including difficulties in obtaining costs and maintaining program integrity.  To address these issues, this proposal would update regulations to clarify the NEMT benefit is strictly optional.

Medical transportation has long been viewed as vital means for helping Medicaid patients keep doctors’ appointments and recover from their illnesses and injuries and for overcoming some social determinants of health.  Loss of this tool would be harmful for private safety-net hospitals and the patients and communities they serve.  NASH will closely monitor the progress of this proposal.

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.”

 

Government More Effective Than Private Sector at Controlling Health Care Costs

For the past dozen years, Medicare and Medicaid have done a better job of controlling rising health care costs than private insurers.

Since 2016, according to a new report from the Urban Institute, private insurers’ costs per enrolled member have risen an average of 4.4 percent a year.  By contrast, Medicare costs have risen an average of 2.4 percent per enrollee and Medicaid costs have risen just 1.6 percent per enrollee.

The primary driver of Medicare cost increases has been prescription drug spending.  For Medicaid the primary driver has been physician services and administrative costs.  For private insurers, the main reason for increasing costs has been spending for hospital care.

Learn more about the differences in cost containment in these different sectors and the implications of those differences in the Urban Institute report “Slow Growth in Medicare and Medicaid Spending Per Enrollee Has Implications for Policy Debates.”

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.”