Syrtis Solutions publishes an annual Medicaid review to help you stay informed. The annual recap focuses on developments, research, and legislation that relates to Medicaid integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Here is a summary of significant Medicaid developments in 2022.

Syrtis Solutions, December 30
Over the last three years, the Coronavirus public health emergency was extended several times. The PHE and the Families First Coronavirus Response Act altered Medicaid eligibility, and as a result, Medicaid enrollment surged during the pandemic. Between February 2020 and July 2022, 82 million people enrolled in the Medicaid program, but millions are expected to lose coverage in 2023. Last week, Congress published H.R. 2617 and within the $1.7 trillion spending bill was a requirement for states to begin Medicaid eligibility redeterminations by April 1.


Axios, December 20
The number of Americans on Medicaid is expected to surpass 100 million as early as next month, according to a new projection from the Foundation for Government Accountability. Why it matters: The record uninsured rate — achieved through both ACA subsidies and Medicaid expansion — has been a point of pride for the Biden administration, particularly in light of stark health disparities exacerbated by the pandemic. Yes, but: The right-leaning think tank FGA points out, the record Medicaid enrollment means nearly 1 in 3 Americans will be on the federal government’s rolls.  read more


At the start of the pandemic, Congress enacted the Families First Coronavirus Response Act (FFCRA), which included a requirement that Medicaid programs keep people continuously enrolled through the end of the month in which the COVID-19 public health emergency (PHE) ends, in exchange for enhanced federal funding. Primarily due to the continuous enrollment requirement, Medicaid enrollment has grown substantially compared to before the pandemic and the uninsured rate has dropped.  read more


KFF, October 25
Since March 2020, the COVID-19 pandemic and its economic impact have had significant implications for Medicaid spending and enrollment. To provide broad fiscal relief to states while preventing coverage losses during the pandemic, Congress passed the Families First Coronavirus Response Act (FFCRA) early in the pandemic to provide a 6.2 percentage point increase in the federal Medicaid match rate (“FMAP”) for states that meet certain “maintenance of eligibility” (MOE) requirements, including a continuous enrollment requirement.  read more


Syrtis Solutions, September 30
Changes in how pharmacy benefits are delivered under New York’s Medicaid program are coming. Earlier this year, the state announced that to reduce prescription drug costs, it would carve out its Medicaid pharmacy benefits and transition to a fee for service delivery model. Beginning April 1, 2023, Medicaid members will begin receiving their pharmacy benefits under the state’s new model, NYRx. New York’s carve out strategy is designed to reduce drug costs by consolidating the state’s purchasing power. In addition to lowering costs, the carve out is also geared to improve access to care and reduce restrictions by introducing a single drug formulary.  read more


On August 31, the Centers for Medicare and Medicaid released a proposed rule designed to make it easier for eligible people to obtain and maintain coverage in Medicaid and the Children’s Health Insurance Program (CHIP). Together, Medicaid and CHIP provide coverage to 89 million low-income people. The Affordable Care Act (ACA) made significant changes to help simplify, streamline, and coordinate eligibility and enrollment across health programs, especially for children and adults, but complexities remain, and some eligible people are not enrolled or churn on and off the program.  read more


Section 1115 demonstration waivers offer states an avenue to test new approaches in Medicaid that differ from what is required by federal statute, as long as the federal Centers for Medicare and Medicaid Services (CMS) determines that such proposals are “likely to assist in promoting the objectives of the [Medicaid] program.” While Section 1115 waivers have been used over time, recent activity from the Trump Administration and into the Biden Administration has tested how these waivers can be used to advance administrative priorities and has also tested the balance between states’ flexibility and discretion by the federal government.  read more


The HHS Office of Inspector General found states frequently pay capitation benefits for Medicaid beneficiaries enrolled in multiple states. In an audit published Sept. 21, the OIG said capitation payments were made for 327,497 Medicaid beneficiaries double enrolled in multiple states’ Medicaid programs in August 2020. This number is an increase from 208,254 concurrent payments in August 2019. Capitation payments are fixed fees given to managed care organizations in exchange for making benefits available to Medicaid enrollees.  read more


Syrtis Solutions, July 28
Medicaid has evolved to become an integral safety net program that provides access to health care for millions of Americans. Payment for this health care is either delegated to Medicaid or other third party insurance coverage. In 2012, 7.6 million people on Medicaid had other private coverage, and 10.6 million had other public coverage. Medicaid is considered the “payer of last resort”: if the Medicaid recipient has additional insurance, that third party insurance is responsible for primary payment.  read more


Syrtis Solutions, April 29
The federal government doled out close to $100 billion in “improper” Medicaid payments in 2021– accounting for about one-fifth of all Medicaid payments, according to estimates. The figure represents Washington’s current accounting of payments that didn’t meet the numerous criteria for the Medicaid program, which the federal government manages jointly with the states and allows millions of low-income people access to healthcare. The numbers were also high in 2020, with approximately $86.5 billion in Medicaid payments deemed improper, or just over 21%.  read more


HealthcareDive, April 19
The lawsuits challenging Medicaid work requirements have been on hold since the nation’s highest court previously canceled arguments planned for March 2021. On Monday, the Supreme Court said the requirements were now moot, given the Biden administration’s dismissal of the policies, and sent them back to the trial court, instructing that court to dismiss its prior judgments. Republicans saw instituting work requirements as a way to incentivize work, while eventually shifting Medicaid beneficiaries to more comprehensive private coverage and hopefully saving states money.  read more


The federal government doled out nearly $100 billion in what it calls “improper” Medicaid payments in 2021 — accounting for approximately one-fifth of all Medicaid payments, according to estimates. The figure represents Washington’s latest accounting of payments that didn’t meet the various requirements for the Medicaid program, which the federal government runs jointly with the states and allows millions of low-income people access to healthcare.  


Syrtis Solutions, February 28
Since its passage in 1965, the Medicaid program has expanded to become the single largest payer for health care in the United States, costing $671.2 billion in 2020. Due to surges in enrollment from the pandemic and the current administration’s priorities, spending is only expected to increase. Considering that Medicaid improper payments now account for more than twenty percent of federal Medicaid expenditures, this is a problem. Improper payments are threatening the program’s solvency and sustainability.  read more


The National Law Review, February 25
The Families First Coronavirus Response Act (FFCRA), passed in response to the COVID-19 pandemic, offered states the option to expand Medicaid eligibility for coverage of COVID-19 testing and treatment.1 FFCRA also increased federal financial participation for state Medicaid programs by 6.2% – on the condition that states must maintain beneficiaries’ Medicaid enrollment status until the end of the month following the end of the COVID-19 public health emergency (PHE). read more


Cision PRWeb, February 22
A recent Foundation for Government Accountability (FGA) report shows that conditions included in exchange for increased federal Medicaid funding have led to unsustainable Medicaid enrollment growth that is now costing states more than they are receiving from the increased funding. By agreeing to not strengthen program eligibility standards, adjust the enrollment processes, or remove individuals from their Medicaid rolls even when they become ineligible for the program, states are spending more than they are receiving from the federal funding increase.  read more


Syrtis Solutions, January 28
The Social Security Act, signed into law by President Franklin Roosevelt in 1934, specifies in statute § 1902( a)( 25) of the law “… that the State or local agency administering such plan will take all reasonable measures to ascertain the legal liability of third parties … to pay for care and services” delivered to Medicaid recipients. Basically, it means that Medicaid becomes the payer of last resort (PLR), a term also known as third party liability (TPL), or the Coordination of Benefits (COB).  read more


Health Payer Intelligence, January 24
Payers can elevate their payment integrity strategy to do much more than fraud, waste, and abuse prevention. A comprehensive payment integrity strategy is key to lowering costs and achieving higher quality of care for members. “The real goal of payment integrity is to free up money for improvements that impact patient care,” says Timothy Garrett, MD, chief medical officer, CCS, at Zelis. When payers reimburse providers fairly and accurately the first time, they have access to more resources for other areas, such as member experience.  read more


KFF, January 18
As 2022 kicks off, a number of issues are at play that could affect coverage and financing under Medicaid, the primary program providing comprehensive health and long-term care coverage to low-income Americans. New COVID variants are surging and the fate of the Build Back Better Act (BBBA), a reconciliation bill that includes significant changes to health coverage and Medicaid, is hanging in the balance.