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.

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.  


How Georgia’s Medicaid work requirement program will work
Becker’s Payer Issues, December 27 
Georgia’s Medicaid work requirement program is set to begin July 1, 2023, making it the only state with such requirements, Capital Beat News Service reported Dec. 23. Here are five notes on how the program, called Pathways to Coverage, will work: 1. The program will require enrollees to complete 80 hours of work, job training, education or community service per month to receive Medicaid coverage, according to the report. 2. Enrollees will need to certify their employment each month, according to the report.  read more


Provisions in an omnibus spending bill currently under consideration in Congress would require all states to adopt continuous eligibility for children in both Medicaid and the Children’s Health Insurance Program (CHIP) and would decouple the Medicaid continuous enrollment requirement from the public health emergency (PHE). States currently have the option to provide 12 months of continuous coverage for children in Medicaid and/or separate CHIP, and about half of states do so for all children in Medicaid.  read more


NBC News, December 20
Members of Congress reached a deal Tuesday to fund Puerto Rico’s Medicaid program in a way that prevents it from running out of federal money by the end of the year and ensures stable funding for the next five years. Ensuring consistent funding is crucial for the U.S. territory because of the way the money is allocated. Unlike the states — where Medicaid funding is open ended and can more easily adjust to the needs of the population in times if crisis — Puerto Rico and other U.S. territories receive a fixed amount of funding, or allotment, with a spending cap that can fall well short of expenditures.  read more


Republican-led legislatures have repeatedly thwarted Medicaid expansion in a dozen conservative states, despite high numbers of uninsured residents. In recent years, supporters of expansion have found success with another strategy: letting voters decide. Since 2017, Medicaid expansion has passed in seven states where the issue was put on the ballot, adopting the Affordable Care Act provision that would grant health insurance to hundreds of thousands living at or near the poverty line.  read more


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


Magellan Rx Management (Magellan Rx), a Prime Therapeutics LLC (Prime) company, released its 12th annual Medical Pharmacy Trend Report™, featuring a comprehensive view of provider-administered medical benefit drug trends — one of the largest drivers of total specialty drug spend. This report offers detailed analysis of medical benefit drug claims, data benchmarks and current medical benefit drug management strategies. In the Commercial space, claim volume had the highest influence on aggregate trend, due to more patients receiving medical drug therapy in 2021 versus 2020.  read more, December 14
A decline in federal government spending led to more modest growth in health care expenditures last year, according to figures released today by the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS). The 2021 National Health Expenditures (NHE) Report found that U.S. health care spending grew 2.7% to reach $4.3 trillion in 2021, slower than the increase of 10.3% in 2020. The slower growth in 2021 was driven by a 3.5% decline in federal government expenditures for health care that followed strong growth in 2020 due to the COVID-19 pandemic response.  read more


Medicaid is the nation’s single largest health insurance program, and Medicaid enrollment has grown since the start of the COVID-19 pandemic. Early in the pandemic marked what many described as one the most severe economic downturns in United States (US) history. The pandemic-induced recession looked different from historical recessions in a number of ways and was the first downturn with the Affordable Care Act’s (ACA) coverage expansions in place. Of the newly unemployed, many were projected to enroll in Medicaid or take up exchange-based health insurance coverage (though many also were temporarily furloughed and had their employer-sponsored health benefits continued).  read more


The Highland County Press, December 13
The Ohio Department of Medicaid (ODM) did not ensure County Department of Job and Family Services caseworkers processed system alerts to determine if benefits recipients were potentially receiving duplicative assistance from multiple states, according to a new report from Auditor of State Keith Faber. In total, 59% of the Public Assistance Reporting Information System Alerts reviewed by state auditors were not addressed as required, and the inaction could be costing the state between $5.3 million and $24.5 million annually if ineligible residents are receiving duplicative program support.  read more


Public News Service, December 12
Despite economic uncertainty of the pandemic, the number of West Virginia kids with health coverage remained roughly the same between 2019 and 2021, according to a new report. The Georgetown University Center for Children and Families report finds the number of uninsured kids nationwide dropped by 5% in the last three years. In West Virginia, Julianne Yacovone – director of child health with West Virginians for Affordable Healthcare – said the number of kids statewide with no health insurance has kept steady, at around 13,000.  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


The Centers for Medicare & Medicaid Services (CMS) is responsible for overseeing States’ design and operation of their Medicaid programs and ensuring that Federal funds are appropriately spent. CMS developed the Payment Error Rate Measurement (PERM) program to measure improper payments in Medicaid and the Children’s Health Insurance Program (CHIP).


The Biden administration released a proposal which, if finalized, would mandate Medicare Advantage (MA), Medicaid managed care, Affordable Care Act (ACA) plans and state Medicaid agencies implement electronic prior authorization systems by 2026. The proposed rule, released Tuesday by the Centers for Medicare & Medicaid Services (CMS), will require payers and states to streamline prior authorization processes and improve the electronic exchange of health data by 2026.  read more


The Centers for Medicare & Medicaid Services (CMS) is continuing to advance our interoperability goals and tackle process challenges related to prior authorization to increase efficiencies in health care. The proposals would place new requirements on Medicare Advantage (MA) organizations, state Medicaid and CHIP Fee-for-Service (FFS) programs, Medicaid managed care plans and Children’s Health Insurance Program (CHIP) managed care entities, and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs), (collectively “impacted payers”), to improve the electronic exchange of health care data and streamline processes related to prior authorization.  read more


With its 2016 Medicaid managed care regulations, CMS chose medical loss ratios (MLRs) as a policy tool to ensure appropriate stewardship of managed care funds. The Federal MLR is the percentage of premium revenue that a managed care plan spent on covered health care services and quality improvement activities during a 12-month period. Federal MLR requirements help ensure that managed care plans spend most of their revenue on services related to the health of their enrollees, thereby limiting the amount that plans can spend on administration and keep as profit.  read more