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 noteworthy Medicaid news.

Syrtis Solutions, July 30
Last year, the Wisconsin Department of Health Services carved out prescription drugs from the Family Care Partnership Program and transitioned to a Fee-for-Service (FFS) delivery model. The carve-out ensured compliance with the 2020 Medicaid and CHIP M anaged Care Final Rule and eliminated the need for Managed Care Organizations (MCOs) to implement their own drug utilization review program. In addition, Wisconsin believes that the carve-out will reduce Medicaid costs by lowering prescription drug prices. To date, Wisconsin, Tennessee, West Virginia, and Missouri have carved-out their Medicaid pharmacy benefits.  read more


Centene’s membership grew by more than 1.3 million in the second quarter compared to a year ago thanks to a big increase in enrollment in its Medicaid plans during the Covid-19 pandemic. Centene’s revenue was up 12% to $31 million in the second quarter ended June 30 compared to $27.7 billion in the year-ago period, largely due to the growth of Medicaid enrollment, the company reported Tuesday. Centene reported a loss of more than $530 million in the quarter compared to a $1.2 billion profit a year ago.  read more


Efforts to create a federal public option health plan may have stalled, but public options on the state level are slowly emerging, according to a Manatt Health mid-year update. While President Biden’s health reform supported a federal public health insurance option through the Affordable Care Act (ACA) marketplace, it has hit legislative obstacles. Instead, the Biden administration has focused on expanding and eventually making permanent the ACA subsidies under the American Rescue Plan Act.  read more


Thursday’s ruling delivers a decisive victory for Medicaid expansion proponents. It also marks another victory via a ballot box strategy. In some red states, proponents have chosen to circumvent state legislatures, which have refused to expand the program, by putting a vote to the people. Missouri voters approved an amendment to the state’s constitution in 2020, paving the way for adults without children and incomes at or below 138% of the federal poverty level to gain coverage starting July 1 through the state’s Medicaid program, known in Missouri as Mo HealthNet.  read more


An employer considering the structure of its employee health insurance plan must make several consequential decisions about benefit design. One key choice is whether to exclude (ie, “carve out”) benefits for certain services or patient populations from core medical benefits or to offer an integrated benefits package from a single vendor (ie, to “carve in” these services). Extensive debate about the relative merits of these 2 approaches followed the emergence of pharmacy benefits managers (PBMs) in the 1980s1 and mental health and substance abuse (MH/SA) carve-out plans in the 1990s.2  read more


State officials on Tuesday submitted their application to President Joe Biden’s administration for a waiver to retool Arkansas’ version of Medicaid expansion. The program provides health care coverage to more than 300,000 low-income Arkansans. The Medicaid expansion program provides private health insurance coverage for adults aged between 19 and 64 who earn up to 138% of the federal poverty level, which is $17,774 for a single person and $36,570 for a family of four. Its enrollment totaled 321,053 on June 1, according to the latest figures on the state Department of Human Services’ website.  read more, July 20
The Office of the State Auditor (OSA) receives an annual appropriation for the operation of a Medicaid Audit Unit to help prevent and identify fraud, waste, and abuse in the Commonwealth’s Medicaid program. This program, known as MassHealth, is administered under Chapter 118E of the Massachusetts General Laws by the Executive Office of Health and Human Services, through the Division of Medical Assistance. Medicaid is a joint federal-state program created by Congress in 1965 as Title XIX of the Social Security Act.  read more


HealthAffairs, July 20
A recent report released by the Department of Health and Human Services (HHS) claims that 31 million Americans were enrolled in coverage related to the Affordable Care Act (ACA). Without proper context, this number is misleading and is being misinterpreted. Here is what you need to know: There has been virtually no change in private health insurance coverage because of the ACA. The net gain in health coverage because of the ACA is entirely or almost entirely due to an increase in Medicaid enrollment. A sizeable percentage of the new enrollees in Medicaid do not meet eligibility rules for the program. On a per enrollee basis, the ACA’s cost is far higher than was projected.  read more


KFF, July 13
The recent approval of Aduhelm (aducanumab), which treats Alzheimer’s disease and carries an expected annual price tag of $56,000, has brought increased attention to high-cost drugs approved through the FDA’s accelerated approval pathway. While Medicare and its beneficiaries likely will be most impacted by the costs of the drug, as Alzheimer’s disease is most prevalent among older adults, the drug approval also has implications for Medicaid spending. Medicaid covers more than 80 million people, including many older adults who have not yet reached the age of Medicare eligibility.  read more


AP, July 12
Three Democratic U.S. senators from states that have refused to expand Medicaid want the federal government to set up a mirror plan to provide health insurance coverage to people in those states. Sens. Raphael Warnock and Jon Ossoff of Georgia and Tammy Baldwin of Wisconsin are introducing the bill Monday, they told The Associated Press. Congressional Democrats are pushing for a coverage expansion in upcoming legislation. “The single most effective solution to closing our state’s coverage gap is to expand Medicaid,” Warnock said after a June 29 meeting with health care executives.  read more


Iowa Public Radio, July 8
Iowa Medicaid officials said the state plans to start taking applications for a third managed care organization later this year. Iowa has had just two managed care organizations for its Medicaid program since United Healthcare left the state in June 2019. Amerigroup and Iowa Total Care, which joined the state on July 1, 2019, the day after United Healthcare officially pulled out, are the state’s two current MCOs. State Medicaid Director Liz Matney, who started in her new position last month, told the Council on Human Services on Thursday that the state intends to search for another MCO.  read more


Governor JB Pritzker signed legislation Tuesday that aims to make healthcare more accessible and affordable for Illinois residents that rely on the state’s Medicaid system. Senate Bill 2294 makes multiple changes to Illinois’ Medicaid system including expansion of the program to cover new services and the implementation of new Medicaid-adjacent services by the Illinois Department of Health and Family Services (HFS) and other agencies.  read more


NC Health News, July 2
Dave Richard woke up at midnight on July 1, sent a few emails to legislators and to people on his work team, and went back to sleep. It was a rather unremarkable evening, and by his account, a peaceful sleep for Richard, given that something remarkable was happening. Midnight was the time that the state’s Medicaid plan made the big switchover from being a state-run and managed program to care for millions of low income North Carolinians to being a program managed by private insurance companies. Richard is the program’s director.  read more


HealthcareDrive, July 1
Following ballooning enrollment during the coronavirus pandemic, Medicaid is now the largest source of coverage in the U.S., covering roughly one in four Americans. About one million people, or 25% of the state’s total population, are already enrolled in Medicaid. But due to the state’s expansion of the safety-net insurance program, up to 190,000 additional individuals between the ages of 19 to 64 with an income of $35,245 for a family of four, or at or below 133% of the federal poverty line, are newly eligible for coverage.  read more