09 Sep MEDICAID NEWS RECAP – AUGUST 2024
Syrtis Solutions distributes a monthly Medicaid news summary to help you stay up-to-date. The monthly roundup focuses on developments, research, and legislation that relates to Medicaid program integrity, cost avoidance, coordination of benefits, improper payments, fraud, waste, and abuse. Below is a summary of last month’s Medicaid news.
INSURERS FACE FINANCIAL STRAIN FROM MEDICAID ENROLLMENT CHANGES Syrtis Solutions, August 30
During the pandemic, Medicaid enrollment surged due to federal measures that required states to maintain coverage for individuals, even if they gained other insurance. This policy, implemented in March 2020, lasted three years and added over 23.3 million people to Medicaid, pushing the total number of beneficiaries to 95 million at its peak. Private insurers managing Medicaid plans greatly benefited from this influx, as roughly 75% of Medicaid enrollees were under their care. However, with the end of the public health emergency, states have started removing individuals from Medicaid, leading to more than 20 million people being disenrolled over the past year. read more
During the pandemic, Medicaid enrollment surged due to federal measures that required states to maintain coverage for individuals, even if they gained other insurance. This policy, implemented in March 2020, lasted three years and added over 23.3 million people to Medicaid, pushing the total number of beneficiaries to 95 million at its peak. Private insurers managing Medicaid plans greatly benefited from this influx, as roughly 75% of Medicaid enrollees were under their care. However, with the end of the public health emergency, states have started removing individuals from Medicaid, leading to more than 20 million people being disenrolled over the past year. read more
Syrtis Solutions, August 29
Over the past three decades, Medi-Cal, California’s Medicaid program, has undergone significant changes and expansion. Since the 1990s, Medi-Cal has grown substantially, particularly after the implementation of the Affordable Care Act (ACA). By 2016, the program provided coverage to more than one in three Californians, and as of January 2024, eligibility has been expanded to include all residents with incomes below certain thresholds. In 1990, Medi-Cal served about one in eight Californians, with eligibility limited to specific low-income groups like children, parents or caretakers of dependent children, and people with disabilities.
Over the past three decades, Medi-Cal, California’s Medicaid program, has undergone significant changes and expansion. Since the 1990s, Medi-Cal has grown substantially, particularly after the implementation of the Affordable Care Act (ACA). By 2016, the program provided coverage to more than one in three Californians, and as of January 2024, eligibility has been expanded to include all residents with incomes below certain thresholds. In 1990, Medi-Cal served about one in eight Californians, with eligibility limited to specific low-income groups like children, parents or caretakers of dependent children, and people with disabilities.
Medicaid Managed Care U.S. DHHS – OIG, Agust 27
The growth of managed care over the last several years has changed fundamental aspects of the Medicare and Medicaid programs. This significant shift transformed how the government pays for and covers health care for approximately 100 million enrollees. The OIG has designated oversight of managed care as a priority area. OIG has developed a strategy to align its audits, evaluations, investigations, and enforcement of managed care. The HHS-OIG Strategic Plan for Oversight of Managed Care for Medicare and Medicaid has three goals: Promote access to care for people enrolled in managed care, Provide comprehensive financial oversight, Promote data accuracy and encourage data-driven decisions. read more
The growth of managed care over the last several years has changed fundamental aspects of the Medicare and Medicaid programs. This significant shift transformed how the government pays for and covers health care for approximately 100 million enrollees. The OIG has designated oversight of managed care as a priority area. OIG has developed a strategy to align its audits, evaluations, investigations, and enforcement of managed care. The HHS-OIG Strategic Plan for Oversight of Managed Care for Medicare and Medicaid has three goals: Promote access to care for people enrolled in managed care, Provide comprehensive financial oversight, Promote data accuracy and encourage data-driven decisions. read more
New York Runs Away from the Pack on Medicaid Spending Empire Center, August 15 Empire Center, August 15
New York’s per capita Medicaid spending jumped 14 percent in 2023, moving it further ahead of the rest of the country, recently released nationwide data show. In the federal fiscal year that ended last September, New York spent $95.6 billion on Medicaid health coverage for the low-income and disabled, according to an annual fiscal report from the Centers for Medicare & Medicaid Services. That amounted to more than $4,800 for each resident, which was 21 percent more than the No. 2 state, New Mexico, and 82 percent above the national average (see chart). That latter gap widened from 61 percent in 2019. The state-funded portion of New York’s Medicaid spending was $1,800 per capita, which was more than double the national average of $835. read more
New York’s per capita Medicaid spending jumped 14 percent in 2023, moving it further ahead of the rest of the country, recently released nationwide data show. In the federal fiscal year that ended last September, New York spent $95.6 billion on Medicaid health coverage for the low-income and disabled, according to an annual fiscal report from the Centers for Medicare & Medicaid Services. That amounted to more than $4,800 for each resident, which was 21 percent more than the No. 2 state, New Mexico, and 82 percent above the national average (see chart). That latter gap widened from 61 percent in 2019. The state-funded portion of New York’s Medicaid spending was $1,800 per capita, which was more than double the national average of $835. read more
Healthcare organizations ask Congress for continuous Medicaid eligibility Healthcare Finance, August 14
A group of 188 federal and state organizations have sent a joint letter to Congressional and committee leadership urging them to support 12-month continuous eligibility for adults enrolled in Medicaid and the Children’s Health Insurance Program. Specifically, the letter asks Congress to enact the Stabilize Medicaid and CHIP Coverage Act, H.R. 5434 and S. 3138. The latest action on the bill was in September 2023, when the House referred it to the Subcommittee on Health, according to Congress.gov. The groups signing the letter represent healthcare consumers, payers and providers including the Alliance of Community Health Plans, the American Academy of Family Physicians, America’s Essential Hospitals and Trinity Health. read more
A group of 188 federal and state organizations have sent a joint letter to Congressional and committee leadership urging them to support 12-month continuous eligibility for adults enrolled in Medicaid and the Children’s Health Insurance Program. Specifically, the letter asks Congress to enact the Stabilize Medicaid and CHIP Coverage Act, H.R. 5434 and S. 3138. The latest action on the bill was in September 2023, when the House referred it to the Subcommittee on Health, according to Congress.gov. The groups signing the letter represent healthcare consumers, payers and providers including the Alliance of Community Health Plans, the American Academy of Family Physicians, America’s Essential Hospitals and Trinity Health. read more
Medicaid State Fact Sheets KFF, August 14
Medicaid and the Children’s Health Insurance Program (CHIP) provide health and long-term care coverage to almost 82 million low-income children, pregnant women, adults, seniors, and people with disabilities in the United States. Medicaid is a major source of funding for hospitals, community health centers, physicians, and nursing homes. States operate their Medicaid programs within federal standards and a wide range of state options in exchange for federal matching funds. The fact sheets include both state and national level data. Where state-level data was not available, national-level data was used to provide additional context. read more
Medicaid and the Children’s Health Insurance Program (CHIP) provide health and long-term care coverage to almost 82 million low-income children, pregnant women, adults, seniors, and people with disabilities in the United States. Medicaid is a major source of funding for hospitals, community health centers, physicians, and nursing homes. States operate their Medicaid programs within federal standards and a wide range of state options in exchange for federal matching funds. The fact sheets include both state and national level data. Where state-level data was not available, national-level data was used to provide additional context. read more
The ACA Times, August 14
In December 2023, North Carolina joined 40 other states and Washington D.C. in expanding Medicaid. And less than a year after adopting the program, there has been an influx in participation throughout the Tar Heel State. As a result of the amendment to the state’s health legislature, adults between the ages of 19 and 64, who earn up to 138% of the federal poverty level, may be newly eligible for Medicaid enrollment. The coverage is extensive, including a wide breadth of services, such as primary care, hospital admissions, maternity care, vision and hearing, dental care, and more. read more
In December 2023, North Carolina joined 40 other states and Washington D.C. in expanding Medicaid. And less than a year after adopting the program, there has been an influx in participation throughout the Tar Heel State. As a result of the amendment to the state’s health legislature, adults between the ages of 19 and 64, who earn up to 138% of the federal poverty level, may be newly eligible for Medicaid enrollment. The coverage is extensive, including a wide breadth of services, such as primary care, hospital admissions, maternity care, vision and hearing, dental care, and more. read more
Drug Spending U.S. DHHS – OIG, August 9
For over 25 years, the HHS Office of Inspector General has conducted work to assess drug spending in HHS programs. This work covers three domains: reimbursement, program compliance, and incentive alignment. This page is a compilation of completed reports, unimplemented recommendations, enforcement actions, and industry guidance. According to data from the Centers for Medicare & Medicaid Services (CMS), U.S. prescription drug expenditures totaled $370 billion in 2019. Spending through Department of Health and Human Services (HHS) programs accounted for 41 percent ($151 billion) of this total. read more
For over 25 years, the HHS Office of Inspector General has conducted work to assess drug spending in HHS programs. This work covers three domains: reimbursement, program compliance, and incentive alignment. This page is a compilation of completed reports, unimplemented recommendations, enforcement actions, and industry guidance. According to data from the Centers for Medicare & Medicaid Services (CMS), U.S. prescription drug expenditures totaled $370 billion in 2019. Spending through Department of Health and Human Services (HHS) programs accounted for 41 percent ($151 billion) of this total. read more
Georgetown University CCF, August 8
There are many lessons to be learned from the unwinding, but among the top items on the list is the discovery that many states are not following federal renewal regulations that have been in place for more than a decade. Noting that, the Government Accountability Office (GOA) has released a report entitled: “Medicaid: Federal Oversight of State Eligibility Redeterminations Should Reflect Lessons Learned after COVID-19.” The report notes that amidst the complex and unprecedented undertaking of the unwinding, it has become clear that compliance with long-standing renewal requirements is lacking in many states.
read more
There are many lessons to be learned from the unwinding, but among the top items on the list is the discovery that many states are not following federal renewal regulations that have been in place for more than a decade. Noting that, the Government Accountability Office (GOA) has released a report entitled: “Medicaid: Federal Oversight of State Eligibility Redeterminations Should Reflect Lessons Learned after COVID-19.” The report notes that amidst the complex and unprecedented undertaking of the unwinding, it has become clear that compliance with long-standing renewal requirements is lacking in many states.
read more
Coordination of Benefits CMS.gov, August 6
Under HIPAA, HHS adopted standards for electronic transactions, including for coordination of benefits. The coordination of benefits transaction is the transmission from any entity to a health plan for the purpose of determining the relative payment responsibilities of a health plan for health care claims or payment information. See the Coordination of Benefits Transactions Basics. Coordination of benefits (COB) applies to a person who is covered by more than one health plan. The COB regulations, as well as the HIPAA Privacy Act, permit Medicare to coordinate benefits with other health plans and payers to reduce administrative burden and enable patients to obtain payment of the maximum benefit they are allowed. read more
Under HIPAA, HHS adopted standards for electronic transactions, including for coordination of benefits. The coordination of benefits transaction is the transmission from any entity to a health plan for the purpose of determining the relative payment responsibilities of a health plan for health care claims or payment information. See the Coordination of Benefits Transactions Basics. Coordination of benefits (COB) applies to a person who is covered by more than one health plan. The COB regulations, as well as the HIPAA Privacy Act, permit Medicare to coordinate benefits with other health plans and payers to reduce administrative burden and enable patients to obtain payment of the maximum benefit they are allowed. read more
Medi-Cal Enrollment Tracking Tool California Health Care Foundation, August 6
This tool provides quick visual access to Medi-Cal enrollment figures – in total and by enrollee characteristics. The tool covers 2012 to the present and will be updated quarterly. Use the blue navigation buttons at the top to skip among the six pages. Full-screen mode and an option to download a PDF with the data are available by hovering in the upper right corner of the tool. The Sources page provides links to all the original source data. Most charts also feature a download data button. Explore county-level information on the Snapshot and Maps pages. Share your feedback on this tool by sending a note to senior program officer Amy Adams.
This tool provides quick visual access to Medi-Cal enrollment figures – in total and by enrollee characteristics. The tool covers 2012 to the present and will be updated quarterly. Use the blue navigation buttons at the top to skip among the six pages. Full-screen mode and an option to download a PDF with the data are available by hovering in the upper right corner of the tool. The Sources page provides links to all the original source data. Most charts also feature a download data button. Explore county-level information on the Snapshot and Maps pages. Share your feedback on this tool by sending a note to senior program officer Amy Adams.
Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State KFF, August 2
This page tracks approved and pending Section 1115 Medicaid demonstration waivers, which offer states an avenue to test new approaches in Medicaid that differ from what is required by federal statute. Key themes in current approved and pending waivers include targeted eligibility expansions, benefit expansions (particularly in the area of behavioral health, such as coverage of services provided in IMDs), and provisions related to social determinants of health. States may obtain “comprehensive” Section 1115 waivers that make broad changes in Medicaid eligibility, benefits, provider payments, and other rules across their programs; other waivers may be more narrow and address specific populations or benefits. read more
This page tracks approved and pending Section 1115 Medicaid demonstration waivers, which offer states an avenue to test new approaches in Medicaid that differ from what is required by federal statute. Key themes in current approved and pending waivers include targeted eligibility expansions, benefit expansions (particularly in the area of behavioral health, such as coverage of services provided in IMDs), and provisions related to social determinants of health. States may obtain “comprehensive” Section 1115 waivers that make broad changes in Medicaid eligibility, benefits, provider payments, and other rules across their programs; other waivers may be more narrow and address specific populations or benefits. read more