Medicaid Newsletter Syrtis Solutions Medicaid


Syrtis Solution’s June 2020 Medicaid News Recap: A roundup of Medicaid news, legislation, and industry developments relating to Medicaid integrity, cost avoidance, improper payments, fraud, waste, and abuse.

Oklahoma voters on Tuesday narrowly approved a ballot measure to extend Medicaid to tens of thousands of poor adults, making their state the first to expand government-backed health insurance during the pandemic. The vote, which passed with 50.5 percent support, also throws a wrench in the Trump administration’s plan to make Oklahoma the first state to receive its permission to cap Medicaid spending, a longtime goal of conservatives hoping to constrain the safety-net entitlement program. Ballot organizers said the coronavirus crisis would help make their case for expanding Medicaid in the deep-red state. The average number of new cases in Oklahoma has more than doubled in the past month, and the state reported a record 585 new infections on Tuesday.  read more


Syrtis Solutions Blog, June 29
Medicaid has been designated as a high-risk government program by the GAO since 2003. The Medicaid program has struggled over the past seventeen years due to poor fiscal oversight and other administrative issues. These challenges will be exasperated as the program expands and enrollment surges during the COVID-19 pandemic. If Medicaid is expected to deliver on its goal to serve the health and wellness needs of our nation’s most vulnerable low-income individuals and families, it is critical that these administrative challenges be addressed. In a recent report from the GAO, the agency assessed federal Medicaid policies, state perspectives on challenges they encounter due to current policies, and what federal actions might be taken to resolve these issues.  read more


AP news, June 27
A question on whether to expand Medicaid in Oklahoma and a crowded Republican field vying to challenge the state’s lone congressional Democrat are drawing the most attention ahead of Tuesday’s primary election. State Question 802 would amend the Oklahoma Constitution to expand Medicaid health insurance to those earning up to 138% of the federal poverty level, which is about $17,200 for an individual or $35,500 for a family of four. Oklahoma is one of 14 states — along with neighboring Texas and Kansas — that have not expanded Medicaid under the 2010 federal Affordable Care Act, mostly because Oklahoma’s Republican governors and Legislature have resisted. Residents instead petitioned to put the measure on the ballot.  read more


Syrtis Solutions Blog, June 24
Improper payments in the Medicaid universe are payments full or partial claims payments paid in error or payments made to the wrong party. Improper payments have been a major problem for Medicaid in recent years and have cost the program’s valuable resources.  Across all government programs, improper payments have been estimated to total nearly $1.7 trillion between 2003 and 2019. In March of this year, the GAO released its latest report, GAO-20-344, which estimated improper payments in federal agencies for FY 2019. The report specifies that federal agencies estimated improper payments amounted to a staggering  $175 billion in 2019. The bulk of the improper payments came from three programs: Medicaid, Medicare, and the Earned Income Tax Credit (EITC).  read more


Drug manufacturers should immediately evaluate whether they have been correctly classifying their products in data submitted to the Medicaid Drug Rebate Program (MDRP) to minimize penalties they could face for any errors. The Centers for Medicare and Medicaid Services (CMS) recently issued new guidance that sets a July 5 deadline for manufacturers to contact CMS to identify drugs that have been misclassified.1 The Medicaid Services Investment and Accountability Act of 2019 (MSIAA) gave CMS new authority to take compliance actions and impose monetary penalties when drugs are misclassified. In addition to repaying underpaid rebates, manufacturers could be liable for penalties of up to twice the amount of the underpayment for knowingly misclassifying drugs, so they will need to think carefully about how to identify and report misclassified drugs.  read more


Telehealth can help limit risk of coronavirus exposure during the COVID-19 pandemic, and is important both for those who are unable to physically go to the doctor and more broadly when in-person visits are inadvisable. Telehealth can enable remote screening for those with COVID-19 symptoms, while patients with other health concerns can use telehealth to avoid potential viral exposure at health care facilities. There are few federal requirements, or restrictions, involving coverage of telehealth in the Medicaid program.1 The federal Medicaid statute does not define telehealth as a specific service and CMS, prior to the COVID-19 pandemic, had issued little guidance on state use of telehealth. States have broad flexibility to determine whether to cover telehealth, which services to cover, geographic regions telehealth may be used, and how to reimburse providers for these services (including whether to require payment parity for services delivered via telehealth as compared to face-to-face services).  read more


A new study found that Medicaid managed care insurers’ business models are the reason their plans have become a dominant force in the Affordable Care Act’s (ACA’s) insurance exchanges. The study, from think tank Urban Institute and the Robert Wood Johnson Foundation, examined why Medicaid insurers have expanded their footprint in ACA exchanges in recent years. This year, Medicaid plans offered ACA coverage in 255 out of 502 rating regions. “Prior research indicates that the presence of a Medicaid insurer in the marketplace tends to be associated with lower premiums and smaller premium increases,” the analysis said. Researchers spoke with stakeholders in six states with one or more Medicaid insurers in 2020, including state departments of insurance, hospital associations, primary care provider associations and consumer advocates.  read more


State Medicaid operations and Medicaid managed care plans will have more opportunities to use value-based purchasing arrangements for pharmaceuticals under a proposed rule from the Centers for Medicare & Medicaid Services (CMS). “This proposed rule really creates the pathway for private insurance companies to enter into value-based agreements with manufacturers,” CMS Administrator Seema Verma said on a call with reporters Wednesday evening. “Value-based payments generally are taking a hold of the healthcare system. This proposal doesn’t necessarily guarantee lower prices, but it provides a tool in the toolbox for plans to negotiate with manufacturers. It also shifts us away from our typical negotiations around drug pricing — which are usually volume-based — and it shifts that conversation to having negotiations around outcomes and increases competition for manufacturers to develop drugs that are not only cost-effective but having definitive clinical outcomes.”  read more


The Trump Administration has delivered significant policy advancements to lower the price of drugs and spur greater competition and innovation in the American health care system. As a result of actions by the Centers for Medicare and Medicaid Services (CMS), the average basic premium for Medicare Part D prescription drug plans was projected to decline 13.5 percent since 2017, to the lowest level in seven years, saving beneficiaries about $1.9 billion in premium costs over that time. Most recently, in March, CMS announced the Senior Savings Model, where participating enhanced Part D prescription drug plans across the country will provide Medicare beneficiaries access to a broad set of insulins at a maximum $35 copay for a month’s supply, saving beneficiaries on average 66 percent per year.  read more


HealthAffairs, June 17
As the number of individuals who find themselves unemployed due to COVID-19 continues to increase, reports have come out documenting that the majority of those filing unemployment claims are facing significant delays in confirming eligibility and receiving benefits. This led us to wonder if similar issues exist for individuals who are applying for Medicaid coverage after becoming newly eligible. As a result of the COVID-19 pandemic, the number of people unemployed has skyrocketed to more than 40 million individuals, with April 2020 having the greatest net change in unemployment in the past decade. The exact number of newly unemployed (or reduced work hour/incomes) individuals who are now eligible for Medicaid is unknown, but some are estimating a significant increase in people eligible for Medicaid, especially in Medicaid expansion states.  read more


PEW, June 16
Many of the tens of millions of Americans who have lost their health insurance along with their jobs are enrolling in Medicaid — and with state budgets decimated by the pandemic, state officials worry they won’t have the money to pay for their health care. Nearly 27 million Americans could lose their employer-sponsored health insurance over the course of the pandemic, the Kaiser Family Foundation projected last month. Medicaid, the joint federal-state health plan for low-income Americans, already consumes more than a fifth of state budgets. “When the economy goes down, people need Medicaid and other supports more than ever,” said Matt Anderson, assistant commissioner of Minnesota’s Health Care Administration and the state’s Medicaid director. “But for Minnesota and all other states, that is happening at the exact moment our budgets are suffering.”  read more


Health News Florida, June 12
As Floridians lost jobs during the coronavirus pandemic, tens of thousands of people enrolled in the state’s safety-net health program. State data show that 3.9 million Floridians were enrolled in Medicaid in April, more than a 4 percent increase over the prior month’s enrollment, according to the latest available numbers from the state. The overall 4.14 percent enrollment increase is the biggest one-month jump since July 2015, when the state started publishing monthly Medicaid information online. The state is expected to release May data in the coming days. Florida requires most – but not all – Medicaid beneficiaries to enroll in managed care plans.  read more


The Hill, June 5
While we all hope the novel coronavirus pandemic starts to wane throughout the country (and world), there is another public health storm approaching that stems from two opposing forces. First, the economic downturn will inevitably lead to all states reducing their budgets after collecting less income and sales tax. Simultaneously, many unemployed Americans have lost their health benefits and will be newly eligible for Medicaid, adding to the Medicaid rolls. Currently, the largest portion of states’ budgets is Medicaid, accounting for more than 25 percent. Hence, state health officials across the country — whether from red or blue states — will be facing tough choices about how to support the health of their residents with significantly fewer resources.  read more


Kentucky awards $8B in Medicaid contracts: 4 things to know  Becker’s Hospital Review, June 1 
Five healthcare companies were awarded contracts to manage Kentucky’s Medicaid health plan, Gov. Andy Beshear said May 29. Here are four things to know: 1. The five winners are Aetna, Humana, Molina Healthcare, UnitedHealthcare and WellCare. Anthem and Passport Health Plan are among the insurers that lost their bids. 2. Aetna was also selected to manage benefits for children in Kentucky’s foster care program and the Department for Juvenile Justice. 3. The contracts are worth $8 billion a year, and cover about 1.4 million people, according to the Courier Journal. 4. The contracts include a focus on quality measures, increased transparency, strengthened reporting and oversight requirements, and pharmacy program changes, according to state officials.  read more