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.

Crain’s Detroit Business, January 31
High quality is the gold standard of health care. A new study looking at measurable outcomes finds that managed care – where an insurer is required to work with all of an individual’s health care providers to ensure the best care is delivered at the right time by the right provider – is outperforming the old fee-for-service system. Health Management Associates (HMA), a top national healthcare research firm used by government and private sector entities to identify trends, statistical data, and measurable outcomes of healthcare policies across the world, conducted the study.  read more


Healthline, January 29
California is looking to introduce a state-funded single-payer healthcare system to provide quality healthcare and long-term care to its residents. A state assembly committee approved the proposal last week to create the system, AB-1400. The bill now heads to the California State Assembly, where it will be voted on by Jan. 31. California previously considered establishing a single-payer healthcare system in 2017, but the bill was quickly dismissed due to outstanding hurdles, such as how the system would be funded.  read more


You probably don’t want to ever find yourself surprised during a doctor’s visit that your health plan was automatically changed. So if you’re currently receiving health care through Medicaid in Ohio, you should make sure you actively choose your plan. The Ohio Department of Medicaid finalized enrollment details Friday for its rollout of a revamped and reformed Medicaid managed care system set to begin July. Part of that may include transferring up to 80,000 Ohioans to a different plan at the end of the year.  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


Section 1115 demonstration waivers provide states an avenue to test new approaches in Medicaid and generally reflect changing priorities from one presidential administration to another. The Trump Administration’s Section 1115 waiver policy emphasized work requirements and other eligibility restrictions, payment for institutional behavioral health services, and capped financing. The Biden Administration has signaled a shift in policy to emphasize waivers that expand, rather than restrict, Medicaid coverage and access to care (though still within the limits of budget neutrality).  read more


JD Supra, January 27
On January 21, 2022, Georgia sued HHS over its withdrawal of the approval of the work requirement policy as a requirement for Medicaid eligibility in the Georgia Pathways to Coverage demonstration. As previously reported, in December 2021, CMS formally rescinded its approval of the qualifying hours requirement. One month later, Georgia has now sued HHS and CMS in the Southern District of Georgia to enforce the terms under which Georgia’s Pathways was originally approved.  read more


A legal and regulatory dispute has been resolved involving whether the N.C. Department of Health and Human Services fairly awarded prepaid health-plan contracts for the state’s Medicaid managed care reform initiative. Two insurers whose contract bids were denied by DHHS — Aetna Better Health of N.C. Inc. and My Health by Health Providers — voluntarily dismissed their appeal to the N.C. Court of Appeals on Jan. 19, DHHS said.  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


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. In addition, Governors are poised to release proposed budgets amid continued uncertainty about the health and economic trajectory of the pandemic while the Biden Administration continues to use its authority to address the pandemic and to further strategic goals to expand coverage and access and to improve equity.  read more


Republican lawmakers are once again looking to put limits on Medicaid expansion, proposing a constitutional amendment that would impose work requirements on Missourians newly eligible for the government-funded health care program. The proposed constitutional amendment, sponsored by Rep. Cody Smith, R-Carthage, would give lawmakers legal authority to determine the amount and recipients of Medicaid funding, effectively determining Medicaid eligibility.  read more


Dayton Daily News, January 13
Ohio Medicaid overpaid managed care organizations more than $118.5 million in duplicate payments and for the managed care of prison inmates and deceased residents, according to a report released Thursday by the Auditor of State. The audit recommends Ohio Medicaid recoup the money from the managed care organizations and refund the federal share. “While $118.5 million might be a drop in the bucket for the Department of Medicaid, for Ohioans that is a lot of money — taxpayer money — that needs to be accounted for,” Auditor of State Keith Faber said.  read more


State Medicaid programs are using managed care and an array of other service delivery and payment system reforms, financial incentives, and managed care contracting requirements to help achieve better outcomes and lower costs. Common delivery and payment reform models used by state Medicaid programs include patient-centered medical homes (PCMHs), ACA Health Homes, accountable care organizations (ACOs), and episodes of care.  read more


KHN, January 6
South Dakota voters will decide in November whether the state should become the 39th to expand Medicaid under the Affordable Care Act, a move that would provide coverage to 42,000 low-income residents. State officials on Monday officially placed the issue on the ballot after validating thousands of petition signatures. For nearly a decade, the Republican legislature has opted against expansion, citing concerns about the federal debt and worries that Congress would eventually cut federal funding for the program.  read more


Healthcare Dive, January 5
Molina covers some 4.8 million people in the U.S., but Medicaid is the payer’s flagship business, representing more than three-fourths of its members (and premiums). The program has grown because of the pandemic, causing some players in Medicaid markets to ratchet up their investments and others to jump in for the first time. Molina is known for being acquisitive, but has been on a tear as it looks to capitalize on this growth. Currently, the payer offers Medicaid plans in 18 states, with the greatest scale and revenues stemming from health plans in California, Ohio, Washington and Texas.  read more


Government Executive, January 3
The Biden administration is doubling down on its commitments to accountability and efficiency in government in the wake of a recent uptick in improper payments, largely as a result of the coronavirus pandemic. The Office of Management and Budget released updated government-wide data on December 30 on improper payments, which are payments that either shouldn’t have been made or were made in an incorrect amount. This has been a years-long issue in the federal government, spanning different presidential administrations.  read more