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, July 31 
In 2018, the Trump Administration and GOP made several attempts to repeal the ACA and impose federal spending caps on the Medicaid program to reduce costs. These efforts were ultimately unsuccessful; however, a handful of states expanded their Medicaid programs and introduced work requirements during this time. According to KFF, one out of five Americans receive healthcare through Medicaid. It has become the country’s largest source of healthcare coverage and accounts for 27% of total state expenditures. Due to program expansion and costs, House Republicans renewed their push for work requirements over the spring during debt ceiling negotiations with Democrats. They also proposed expanding the work requirements for individuals receiving food and cash assistance through SNAP and TANF.


Centene CEO says insurer’s Medicaid redeterminations ‘consistent’ with forecasts  Fierce Healthcare, July 28 
Centene executives report that Medicaid redeterminations are progressing as expected even as the payer lost nearly 263,000 Medicaid members in the second quarter amid ongoing eligibility checks. After tracking member data against state and sub-populations, CEO Sarah London and CFO Drew Asher said during a Friday morning call with investors that redeterminations are on track with previous forecasts. “We are excited to leverage our positive momentum as we work to support our state partners throughout the duration of redeterminations, maintain our leadership position in the marketplace and strategically realign our Medicare Advantage business, building momentum around stars and positioning our products for long-term growth and profitability,” London said during the company’s second-quarter earnings call.  read more


Four months into Medicaid unwinding, Iowa DHHS says around 120,000 Iowans have been disenrolled  Iowa Public Radio, July 28 
State officials are reporting around 120,000 Iowans have been disenrolled from Medicaid since April. The Iowa Department of Health and Human Services is four months into Medicaid unwinding, the process of redetermining thousands of Iowans’ eligibility for Medicaid following the end of the national public health emergency this spring. State Medicaid Director Elizabeth Matney told IPR that the state has sent Medicaid redetermination forms to around 257,000 Iowans so far, and has disenrolled about 25,000 people who no longer meet Medicaid eligibility requirements and another approximately 96,000 people for “procedural reasons,” such as not returning their redetermination paperwork by the 60-day deadline or failing to respond to requests for follow up information.  read more


CMS releases April Medicaid unwinding data. Total disenrollments top 3.8M  HealthcareDive, July 28 
The highly-anticipated data from the CMS is for the 18 states that renewed at least one cohort of Medicaid beneficiaries in April. Of those, almost 46% of beneciaries had their coverage renewed, while 22% of beneficiaries’ renewals are pending. Typically, roughly 17 million people lose Medicaid or Children’s Health Insurance Plan coverage each year. But this year, redeterminations are a whole different beast. States’ experience with conducting Medicaid eligibility checks has atrophied during COVID-19, when redeterminations were paused. Overall, more than 15 million people are expected to be removed from Medicaid during redeterminations, according to government estimates. More than six million could end up fully uninsured, reversing coverage gains during the pandemic.  read more


Health Payer Intelligence, July 27 
Almost four months after the Medicaid continuous enrollment provision ended, CMS has paused coverage redeterminations in at least six states. In a press call on July 19, CMS Administrator Chiquita Brooks-LaSure and Deputy Administrator of the Center for Medicaid and CHIP Services Dan Tsai discussed the instances that led to the pauses. The decisions stemmed from the fact that most coverage losses among Medicaid beneficiaries have been due to procedural reasons, meaning states have not been able to identify that someone is ineligible but the individuals have not completed the renewal process. According to Tsai, these procedural terminations occurred due to a lack of awareness, wrong addresses, and beneficiaries not receiving a Medicaid renewal form.  read more


ABC 8 News, July 26
Virginia paid insurers to cover Medicaid services for patients who had already died, a nearly $22 million mistake over three years that the state is working to recover and repay. A recent federal audit found that the Virginia Department of Medical Assistance Services, the state’s Medicaid office, accidentally paid out capitation payments – or monthly fixed payments for each enrollee – to Medicaid managed care organizations on behalf of dead patients from 2019 through 2021. The audit from the U.S. Health and Human Services’ inspector general’s office — first reported by the Richmond Times-Dispatch — estimated that the payments totaled at least $21.8 million on behalf of just over 12,000 enrollees. “Virginia made unallowable capitation payments on behalf of deceased enrollees because it did not have adequate controls in place to enable it to identify all deceased enrollees and properly cancel their enrollment,” the July 19 audit states.  read more


As Medicaid eligibility requirements return, thousands of West Virginians come off rolls  MetroNews, July 23
Thousands of West Virginians are coming off government health insurance programs as states snap back to Medicaid eligibility requirements that were in place before the covid-19 pandemic. More than half were ruled ineligible not because they wouldn’t qualify, but instead because they haven’t completed their paperwork. “Losing coverage presents a huge challenge for families and their children,” said Jim McKay, state coordinator of Prevent Child Abuse, West Virginia, a program of TEAM for West Virginia Children. “We know that access to Medicaid helps families access healthcare, substance use disorder treatment and postpartum services. It’s important for healthy births too.” Medicaid is the joint federal and state program for some low-income people, families and children, pregnant people, the elderly and people with disabilities.  read more


California’s 2023-24 budget allocates $156.6 billion to the Department of Health Care Services  State of Reform, July 21
The state of California recently adopted their $310 billion 2023-24 state budget, and despite a $31.5 billion shortfall, leaders prioritized investments in healthcare. Key healthcare investments include CalAIM and a renewed Managed Care Organization (MCO) Tax. The budget includes a total of $156.6 billion to support the Department of Health Care Services (DHCS). Of this total amount, $1.3 billion will be allocated to fund state operations, and $155.3 billion will support local assistance, such as funding for program costs. DHCS will receive an $11.8 billion increase when compared to last year’s budget funding that was $144.8 billion. The budget renews the MCO Tax, which will allow California to receive federal matching funds to support the Medi-Cal program.  read more


Magellan Healthcare Selected to Administer Idaho’s Behavioral Health Transformation  WVNews, July 20
Magellan Health, Inc., a leader in behavioral health, announced today that its subsidiary, Magellan Healthcare, Inc., has been selected by the State of Idaho to serve as the state-wide contractor for the Idaho Behavioral Health Plan (IBHP) and to bring Idaho’s transformational behavioral health program to life. The plan offers a system of medically necessary, integrated care and crisis services for individuals with a serious mental illness, severe and persistent mental illness, serious emotional disturbance, substance use disorder and those with co-occurring disorders. The contract includes Medicaid and non-Medicaid services, creating a transformational and seamless behavioral health system for Idahoans.  read more


Healthcare Providers Agreed to Repay About $8 Million in Improper Medicaid Payments  NJ Office of the State Comptroller, July 19
Healthcare providers agreed to repay about $8 million in improper Medicaid payments, the Office of the State Comptroller reported today. Under OSC’s self-disclosure program, providers can notify OSC of inappropriate New Jersey Medicaid payments and return the funds, and OSC may forgive or reduce interest payments and/or extend the repayment schedule. Self-disclosures accounted for about 11 percent of all improperly spent Medicaid dollars that OSC identified for recovery during fiscal years 2019-2023. During this period, OSC recovered $73,389,154 from healthcare providers, of which $7,925,231 was due to self-disclosures by 70 providers. “This is one of the valuable tools that OSC uses to mitigate fraud, waste, and abuse in New Jersey’s Medicaid program,” said Josh Lichtblau, Director of OSC’s Medicaid Fraud Division.  read more


CMS urges states to abide by Medicaid renewal requirements
Fierce Healthcare, July 19
As states continue to work through the lengthy backlog of Medicaid eligibility determinations, federal officials are urging them to do as much as possible to avoid large coverage losses. Dan Tsai, deputy administrator of the Centers for Medicare & Medicaid Services (CMS) and director of the Center for Medicaid and CHIP Services, told reporters Wednesday that the agency’s goal is for states to meet and exceed federal requirements in limiting how many individuals lose healthcare coverage.“We put out additional policy, levers and strategies for states that all get at reducing procedural termination rates, and our hope … is that all states take up every one of those policy flexibilities,” said Tsai during the press conference.  read more


Virginia Made Capitation Payments to Medicaid Managed Care Organizations After Enrollees’ Deaths  US DHHS Office of Inspector General, July 19
Virginia pays Medicaid managed care organizations (MCOs) to make services available to Medicaid enrollees in return for a monthly fixed payment for each enrollee (capitation payment). Previous OIG audits found that State Medicaid agencies had improperly paid capitation payments on behalf of deceased enrollees. We conducted a similar audit of Virginia. Our objective was to determine whether Virginia made capitation payments to MCOs on behalf of deceased Medicaid enrollees. Our audit covered 58,351 capitation payments totaling over $70.8 million that Virginia made to MCOs and claimed for Federal reimbursement during calendar years 2019 through 2021 (audit period) on behalf of 12,054 enrollees whose dates of death, as recorded in one or more of the data sources we consulted, preceded the monthly service periods covered by the capitation payments.  read more


CMS approves Washington’s Medicaid Transformation Project waiver extension request for five more years  State of Reform, July 14
The Centers for Medicare & Medicaid Services (CMS) recently approved Washington’s request to extend and amend its Section 1115 Medicaid Transformation Project waiver. The extension will allow Washington to implement new policies and use federal Medicaid funds to improve Apple Health, the state’s Medicaid program. The waiver ended on June 30th, and the extension runs through June 30th, 2028. Washington Medicaid Director Charissa Fotinos, MD, said the extension will allow the state to test the effectiveness of innovative practices aimed at promoting consistently high-quality, evidence-based, coordinated, and integrated care in a statement following CMS’ approval of the state’s request. The extension permits the state to continue its Medicaid Alternative Care and Tailored Supports for Older Adults programs by adding covered services and increasing TSAO eligibility standards.  read more


South Dakota Medicaid expansion is underway, July 14
South Dakota’s Medicaid expansion makes coverage available to many low-income adults who weren’t previously eligible and now meet eligibility criteria. This includes adults who: Are under age 65. Have a household income up to 138% of the poverty level. (For a single person, that’s $20,120 in 2023; for a household of four, it’s $41,400.) Are not eligible for or enrolled in Medicare. Are lawfully present in South Dakota and have or have applied for a Social Security number. Have been lawfully present in the U.S. for at least five years. (Low-income lawfully present immigrants who have been in the U.S. for any amount of time are eligible for premium subsidies in the Marketplace instead.) Previously, non-disabled adults under age 65 were only eligible for South Dakota Medicaid if they had minor children and a household income that didn’t exceed 46% of the poverty level. (For a household of two, that was just over $9,000 in total annual income.)  read more


NH Journal, July 10
Intended to be primarily a state-run program, the Biden administration is attempting to expand its power over the management of Medicaid. The Centers for Medicare & Medicaid Services (CMS) is reviving the Medicaid Fiscal Accountability Rule (MFAR) regulating how Medicaid funds are handled and putting at risk matching federal dollars for states like New Hampshire. The proposed rule was the topic of an Inside Sources/NHJournal Roundtable featuring state Senate President Jeb Bradley (R-Wolfeboro), former U.S. Department of Health and Human Services Deputy Secretary Eric Hargan, and N.H.-based Republican strategist David Carney. Originally proposed in 2019, the goal of MFAR was to contain costs and make state Medicaid payment programs more transparent.  read more


Idaho looks to restructure Medicaid funding. But clear answers are hard to find.  Idaho Capital Sun, July 10 
Idaho is looking at restructuring how it pays for Medicaid, a free health insurance program that insures about 458,000 Idahoans, costing state taxpayers more than $4 billion last fiscal year. But there’s mixed evidence that the funding structure that’s used by 41 state Medicaid programs, called managed care, leads to less spending on health expenses or better health care outcomes for patients, a panel of Idaho legislators on the Medicaid Managed Care Task Force heard in presentations Monday at the Idaho Statehouse in Boise. Idaho’s Medicaid program is currently spread out between a mix of funding structures. Dental care, mental health care and substance abuse treatment are under a managed care structure, where a business contracts with the state to manage patient treatment.  read more


Florida is one of two states declining federal waivers to help with Medicaid unwinding  WUSF Public Media, July 7
The waivers aim to reduce the risk of eligible families losing Medicaid coverage due to procedural errors. Federal health officials are urging states like Florida to make it easier for people to renew their Medicaid coverage as a mass unwinding following the COVID-19 public health emergency continues. Thousands of Floridians have been disenrolled from Medicaid since the state began redetermining eligibility in May, after a federal directive that states suspend such efforts during the pandemic was lifted. Florida began its process earlier than some others, but committed to spreading out renewals over the course of a year. Health care advocates have been raising the alarm about large numbers of people in Florida and nationally who are losing coverage not because they no longer qualify but because of procedural issues, such as failing to respond to renewal notices or submitting information incorrectly.  read more


Insurers Say New Medicaid Regs Will Overburden MCOs, States
MMIT, July 7
In comments submitted to CMS about two new proposals aimed at improving the Medicaid program, health insurers and their lobbying groups told the agency in no uncertain terms that implementing the regulations could require more resources than health plans currently have — especially since they’re also trying to navigate the recently resumed Medicaid redetermination process. The regulations in question are both notices of proposed rulemaking (NPRM) that CMS introduced in May — the “Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality” NPRM, and the “Ensuring Access to Medicaid Services” NPRM. Together, the two proposals represent the first significant regulatory update to Medicaid managed care since 2020.  read more


Managed Healthcare Executive, July 5 
The current news cycle is filled with stories about Medicaid unwinding, as well as the efforts to help. From hospitals to President Joe Biden to federal and state agencies to private sector businesses, many are making enormous efforts to mitigate the damage we are starting to see in states such as Florida, where nearly 303,000 people have already lost coverage. These efforts — largely based on consumer awareness campaigns — will absolutely prevent some people from losing their coverage. But they are not enough. With 1.5 million Americans already disenrolled, it’s time to talk about the ramifications of pulling the rug out from the low-income and disabled individuals who rely on Medicaid’s basic healthcare services. We need to think ahead to what our already strained helathcre system will look like if unwinding continues at this pace.  read more


Minnesota extends deadline to keep Medicaid coverage
The Journal Record, July 3
Minnesota is extending its deadline for eligible Medicaid recipients to give 35,000 people more time to complete and submit their renewal paperwork to maintain their coverage. Julie Marquardt, acting Medicaid director at the state Department of Human Services, told Minnesota Public Radio that the extension to Aug. 1 gives her agency more time to work with community partners, managed care organizations, counties and tribes to do additional targeted outreach to prevent gaps in health care coverage. Minnesota’s original plan to start removing ineligible people from Medicaid in July already put it among the last batch of states to resume disenrollment after the end of a pandemic prohibition on trimming Medicaid rolls. Some states already will have dropped hundreds of thousands of people from Medicaid by the time Minnesota starts doing so in August.  read more


Governor Cooper Urges Legislature to Separate Medicaid Expansion from Budget  NC Governor Roy Cooper, July 3
Today, Governor Roy Cooper released the following statement on the importance of separating Medicaid Expansion from the state budget: “Making Medicaid Expansion contingent on passing the budget was and is unnecessary, and now the failure of Republican legislators to pass the budget is ripping health care away from thousands of real people and costing our state and our hospitals millions of dollars. Tying it to the budget is tying our hands, and the legislature should decouple the two and start Medicaid Expansion now.” Governor Cooper signed a bill authorizing Medicaid Expansion into law March 27, 2023, but a provision that the Governor opposed in the bill, House Bill 76, Access to Healthcare Options, delayed its start date to adoption of the state budget.  read more


The Hill, July 2
Georgia is set to become the only state in the country to impose work requirements on Medicaid recipients, and the success or failure of its plan could be a test case for other states that are planning ahead for the next Republican White House. The new program, set to launch this weekend, will allow able-bodied adults who have never qualified for Medicaid to join. It could offer health care coverage to tens of thousands additional residents — but only if they can prove they work or are enrolled in job training or other activities for 80 hours a month. There is a renewed focus on Medicaid work requirements among conservatives, and while the Biden administration is not likely to approve any states’ request, a future GOP president likely would.  read more