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.

Lawmakers advance proposed adjustment to Medicaid expansion requirements  South Dakota Public Broadcasting, January 31 
The South Dakota House of Representatives is advancing a proposed ballot measure that opens the door to work requirements for people covered by Medicaid expansion. Voters approved Medicaid expansion through a constitutional amendment last year. House Joint Resolution 5004 says the state may consider work requirements for people who are “able-bodied” – something that’s not permitted in the current constitutional language.  read more


Idaho House recommends Medicaid expansion stay, but with concerns  
Idaho Press, January 31 
The House Health and Welfare Committee is recommending Medicaid expansion remain in Idaho, although it has “serious concerns” in its five-year review of Medicaid expansion. The committee finalized its letter addressed to House Speaker Mike Moyle, R-Star, Tuesday morning and it was later read across the House floor. The committee voted 9-3 to approve and send the letter.The letter said members have concerns over the “unsustainability of the current increased budget request” and made six recommendations for the program, which Idaho voters approved in 2018 and provides coverage to adults who made too much to qualify for traditional Medicaid health coverage but not enough to qualify for subsidies on the state’s health care exchange.  read more


Syrtis Solutions, January 31 
Medicaid currently fails at providing a system that efficiently and accurately stores and utilizes member data. As Medicaid is a joint state and federally run program, there are many problems with coordinating data platforms. Different states have their own unique data processing and storing, and while federal Medicaid data can show a clearer picture of consistent issues across state lines, lack of communication and data sharing produces significant barriers. While technology has progressed, holes in existing data or errors in computation have direct consequences to the swift identification of third party liability (TPL), leading to costly reimbursement strategies for Medicaid.  read more


NY comptroller audit reveals months totaling billions in improper Medicaid payments  CBS6, January 30
New York State Comptroller Thomas DiNapoli has released an audit of the Department of Health’s Medicaid claims processing program that he says identified more than $22 million in improper Medicaid payments from October of 2021 through March of 2022. Among the findings from the comptroller, $11.5 million was paid for managed care premiums on behalf of Medicaid recipients who also had concurrent comprehensive third-party health insurance. $8.9 million was paid for clinic, practitioner, inpatient, managed care and laboratory claims that did not comply with Medicaid policies, such as billing in excess of permitted limits.  read more


CMS releases more guidance for states unwinding Medicaid continuous enrollment requirement  American Hospital Association, January 30
The Centers for Medicare & Medicaid Services Friday released additional guidance on changes to the Medicaid continuous enrollment requirement under recently enacted legislation funding the federal government through fiscal year 2023. The Families First Coronavirus Response Act required states claiming a temporary 6.2 percentage point increase in the Federal Medical Assistance Percentage to continue Medicaid coverage for most enrollees through the COVID-19 public health emergency.  read more


Idaho Department of Health and Welfare, January 27
As the Idaho Legislature considers Medicaid Expansion this week, we’ve been called to answer a lot of questions about this complex program. As a reminder, the Division of Medicaid provides healthcare services for low-income people and families in Idaho. This includes adults and children, pregnant women, people over the age of 65, and people with disabilities who meet eligibility requirements. If you currently receive Medicaid, please take action to make sure you receive notices about your benefits and re-evaluations.  read more


CMS approves waiver to enable California to offer Medicaid coverage to incarcerated individuals  Fierce Healthcare, January 26 
The Biden administration approved a first-of-its-kind waiver that enables California to offer Medicaid coverage for beneficiaries before they get released from prison or jail. The Centers for Medicare & Medicaid Services (CMS) approved the Section 1115 waiver Thursday that helps connect Medicaid beneficiaries to providers before release. It is the first time Medicaid will offer coverage for those who are still in the justice system. “By helping these individuals access essential services and care coordination prior to release, we will also prevent gaps in care as they rejoin their communities,” said CMS Administrator Chiquita Brooks-LaSure in a statement.  read more


KFF, January 25
At the start of the pandemic, Congress enacted the Families First Coronavirus Response Act (FFCRA), which included a temporary requirement that Medicaid programs keep people continuously enrolled and, in exchange, states received enhanced federal funding. Under the continuous enrollment provision, Medicaid enrollment has grown substantially compared to before the pandemic and the national uninsured rate has declined. Provisions in the Consolidated Appropriations Act (CAA), signed into law in December 2022, end the continuous enrollment provision on March 31, 2023, and phase down the enhanced federal Medicaid matching funds through December 2023.  read more


PR Newswire, January 25 
Magellan Rx Management(Magellan Rx), a Prime Therapeutics LLC (Prime) company, released its seventh annual Medicaid Pharmacy Trend Report™, the industry report detailing trends in the Medicaid pharmacy fee-for-service (FFS) space. The Medicaid Pharmacy Trend Report highlights the evolving landscape of the Medicaid FFS segment and is a detailed industry source for the analysis of gross, net, and forecasted drug cost trends in the space. This year’s report tracks the top classes and individual drugs by spend, with a deep dive into the top 10 classes driving trend and their resulting impact on the Medicaid program.  read more


Medicaid Net Drug Spend Hits Double-Digits for the First Time, Says Magellan Rx Report Managed  Healthcare Executive, January 25 
Net Medicaid drug costs increased by 11% from 2020 to 2021, according to Magellan Rx Management’s Medicaid Pharmacy Trend Report, which was published earlier today. It is the first time during the seven-year history of Magellan’s report on Medicaid drug expenditures trend that the increase has been in the double digits, according to the report. As is true for drug spending for almost all payers, specialty drugs — expensive drugs for rare disease — are accounting for a growing share of Medicaid drug spending and the year-to-year increases in spending, or “trend,” according to the Magellan.  read more


Medicaid: What to Watch in 2023  KFF, January 24
As 2023 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. The Consolidated Appropriations Act, passed in December 2022, ends the Medicaid continuous enrollment provision on March 31, 2023 with a phase-down in enhanced federal matching funds. The unwinding of this provision, as well as the trajectory of the pandemic and the economy, will have implications for Medicaid enrollees, providers, managed care plans, and the states that operate these programs.  read more


What Does the Recent Literature Say About Medicaid Expansion?: Economic Impacts on Providers  KFF, January 18 
A substantial body of research has investigated effects of the Affordable Care Act (ACA) Medicaid expansion, adopted by all but 11 states as of January 2023. Prior KFF reports published in 2020 and 2021 reviewed more than 600 studies and concluded that expansion is linked to gains in coverage, improvement in access and health, and economic benefits for states and providers; these generally positive findings persist even as more recent research considers increasingly complex and specific outcomes.  read more


Becerra renews COVID-19 public health emergency another 90 days, possibly for last time  Fierce Healthcare, January 11
Department of Health and Human Services (HHS) Secretary Xavier Becerra renewed Wednesday the COVID-19 public health emergency (PHE) for another 90 days, extending with it key waivers and regulatory flexibilities. The PHE—which has been in place since Jan. 31, 2020—will now run for another 90 days. Becerra has agreed, though, to give stakeholders a 60-day heads-up when the emergency will not be extended again. Once the PHE ends, so do flexibilities and waivers that have been frozen in place for several years.  read more


JPM23: Centene gears up for Medicaid redeterminations to begin this spring  Fierce Healthcare, January 9  
States now finally have a timeline for when Medicaid redeterminations, which were paused during the COVID-19 pandemic, can resume. Centene, a major player in Medicaid managed care, is gearing up to assist in this endeavor, executives said Monday during a J.P. Morgan Healthcare Conference session. CEO Sarah London said that because the timetable for the COVID public health emergency was nebulous, many state agencies have had a year to think about their strategy around determinations.  read more


CMS releases new Medicaid guidance for states to tackle unmet social needs  Healthcare Finance, January 5 
The Centers for Medicare and Medicaid Services has released new guidance for states to address health-related social needs for Medicaid beneficiaries. This is being done through the use of “in lieu of services and settings” in Medicaid managed care. The option will help states offer alternative benefits to meet needs from housing instability and food insecurity. States may adopt in “lieu of services and settings” to offer medically appropriate, cost-effective tailored meals for people with severe, chronic health conditions that are made worse by poor diet, a food desert location or lack of access to nutritious food choices, CMS said.  read more


The Gazette, January 3
Over 5,000 state workers. More than $2 billion in state funding, or more than a quarter of the state budget. And millions of Iowans — including those on Medicaid — impacted by the services offered. There is much at stake as the state of Iowa continues to cement in state law the merger of three state departments — human services, public health and aging — into one mega-department: the new Iowa Department of Health and Human Services. That work will continue in the 2023 session of the Iowa Legislature, which begins Monday.  read more


Forbes, January 3
Centene has landed several new contracts to administer Medicaid benefits in California, boosting the health insurer’s financial outlook after the recent loss of some other government business. With the Tuesday announcement that the California Department of Health Care Services has selected Centene subsidiary Health Net of California for “direct contracts in Los Angeles and Sacramento counties,” Centene has raised its projected 2024 adjusted earnings per share “floor to $7.15 from $7.00.” The state’s decision increases the “number of direct county contracts by DHCS to 10” in California.  read more


The Center Square, January 2 
The United States will have 100 million residents on Medicaid in the next 72 days, according to the Foundation for Government Accountability, meaning that nearly one-third of all Americans will be on the program for health care. Over the past three years, states have been prevented from removing recipients from the program through a federal COVID-19 emergency. Now, the date when states can begin to re-registering recipients when that emergency ends on April 1. Federal matching funds for the additional recipients will discontinue on that date, Tennessee’s program Director Stephen Smith said at a recent program budget hearing.  read more