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.

According to federal agency data from and the Office of Management and Budget, the federal government spent an estimated $247 billion in improper payments in 2022. The data also revealed that the Department of Health and Human Services’ Medicaid program accounted for the majority of these payments at $80.6 billion. Medicaid has become the largest single budget item on states’ budgets, and in order for the program to remain solvent, states must address Medicaid’s improper payment problem.  read more


The Medicaid Enrollment and Unwinding Tracker presents the most recent data on monthly Medicaid enrollment, renewals, disenrollments, and other key indicators reported by states during the unwinding of the Medicaid continuous enrollment provision. The unwinding data are pulled from state websites, where available, and from the Centers for Medicare & Medicaid Services (CMS). At least 1,536,000 Medicaid enrollees have been disenrolled as of June 29, 2023, based on the most current data from 27 states and the District of Columbia.  read more


The Government Accountability Office is urging CMS to consider adding Medicaid managed care programs to the scope of its recovery audit program. In a report published June 28, the Congressional watchdog office recommended CMS study if it is cost effective to require states to audit Medicaid managed care plans for potential overpayments.   read more


MassHealth errantly paid more than $84 million related to care for residents who were living in other states, Auditor Diana DiZoglio’s office concluded in a new report that the executive branch criticized as “overly broad” and “misleading.” State law requires members of MassHealth, which combines Medicaid and the Children’s Health Insurance Program under a single umbrella, to live in Massachusetts to remain eligible.  read more


Medicaid has been on GAO’s High Risk List since 2003, partly due to concerns about its fiscal oversight. Medicaid has a program to identify and recoup overpayments. But Medicaid hasn’t studied whether including managed care payments in this program would be cost effective—even though managed care makes up more than half of Medicaid expenditures. Managed care plans use federal and state Medicaid funds to pay providers for services. Agency officials said there aren’t plans to include managed care payments because states individually decide if such audits would be cost effective for them.   read more


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


OIG released its Semiannual Report to Congress (the Report) which summarizes the agency’s activities from October 1, 2022, through March 31, 2023 (the Reporting Period). Among other accomplishments, the Report highlights $892.3 million in expected recoveries as a result of HHS-OIG audits and investigations. In the Report, OIG also explains its continued focus on significant and high-risk issues in healthcare, including the COVID-19 pandemic, nursing homes, Medicare and Medicaid integrity, cybersecurity, and prescription drug issues.  read more


A new KFF analysis finds that states received over $117 billion in enhanced federal Medicaid funding in exchange for pausing disenrollments during the first three years of the pandemic. The injection of federal money enabled states to spend less of their own funds on Medicaid even as enrollment rose by more than 23 million people nationally and total Medicaid spending increased by billions of dollars.  read more


For a three-year period, states provided continuous enrollment in Medicaid in exchange for an increase in the percentage of Medicaid spending that is paid for by the federal government (the Federal Medical Assistance Percentage or “FMAP”). A recent KFF analysis estimated that over 23 million people gained Medicaid coverage during the continuous enrollment period. Beginning April 1, 2023, states could begin disenrolling individuals from Medicaid, but phased-down federal matching funds will be available through the end of the year if states comply with certain rules.  read more


Health Payer Intelligence, June 14
Inflationary rebates for generic drugs helped offset Medicaid spending from 2017 to 2020, but additional policies are needed to improve generic competition, according to a study published in Health Affairs. Competition from generic drugs helps reduce spending on expensive brand-name drugs. Between 2014 and 2017, one in five generic drugs doubled in price over one year, leading to $1.5 billion of excess Medicaid spending.  read more


CMS to states: Slow down Medicaid determinations   Becker’s Payer Issues, June 13
CMS officials are urging states to double-down on efforts to prevent people from unnecessarily losing Medicaid coverage. “I, and everyone at CMS, are deeply concerned about eligible people losing healthcare coverage during the renewal process,” CMS Administrator Chiquita Brooks-LaSure told reporters on a June 13 call. During the COVID-19 pandemic, states were required to keep Medicaid recipients continuously enrolled in the program.  read more


The Biden administration is rolling out new flexibilities that aim to prevent procedural coverage losses as states work through a backlog of Medicaid eligibility determinations. The Department of Health and Human Services announced that managed care plans can take on a more direct role in assisting members in completing renewal forms. This extends to filling out certain parts of the paperwork on behalf of the member.  read more


Idaho County Free Press, June 12
The Idaho Legislature’s Medicaid Managed Care Task Force discussed the program’s growing budget, how it could contract with a managed care organization and challenges faced by the division at its first meeting Monday. The task force was created to look at how potentially implementing managed care — or contracting with a third party to administer and oversee Medicaid benefits — could reduce costs in the program.  read more


The amount spent on medications through Medicaid in Nevada increased 126% from 2017 to 2022, according to a state report on prescription drug pricing. The Nevada Department of Health and Human Services (DHHS) annual Drug Transparency Report tracks drug manufacturer costs and profits, financial assistance and rebates for prescriptions, sales representatives’ compensation, Medicaid spending on prescriptions, and suppliers’ justifications for increased costs, based on data collected from manufacturers.  read more


The New Mexico state agency that oversees the Medicaid program for nearly 990,000 state residents is pushing back the scheduled contract expiration date for its three current providers. The move by the New Mexico Human Services Department to extend the existing contracts through June 2024 – instead of the end of this year – comes after Gov. Michelle Lujan Grisham’s administration made a last-minute decision in January to cancel a procurement process for new contracts and start over.  read more


The cracks in Medicaid that some experts feared eligible beneficiaries could slip through during the disenrollment process appear to be forming, according to a new KFF survey. Many people eligible for Medicaid have not gone through the reenrollment process before. Many others simply aren’t aware that they’re eligible, according to KFF’s review of early data from 11 states. These “procedural disenrollments” might wind up causing thousands of Medicaid-eligible people to lose coverage, according to the report.  read more


On May 26, 2023, the Centers for Medicare and Medicaid Services (CMS) proposed an update to the Medicaid Drug Rebate Program (MDRP) rules, which includes provisions aimed at preventing 340B duplicate discounts on claims billed to Medicaid managed care organizations (MCOs). Duplicate discounts arise when both 340B discounts and Medicaid rebates are provided by a manufacturer for the same drug.  read more


House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-WA), Subcommittee on Health Chair Brett Guthrie (R-KY), and Subcommittee on Oversight and Investigations Chair Morgan Griffith (R-VA), on behalf of the Health and Oversight Subcommittee Republicans, today sent a letter to Department of Health and Human Services (HHS) Inspector General (IG) Christi Grimm.  read more


Later in 2023, UnitedHealthcare Community Plan of Virginia will complete its transition to Virginia’s rebranded Medicaid program, called Cardinal Care. Cardinal Care unifies the existing Medicaid program’s Medallion 4.0 and Commonwealth Coordinated Care Plus (CCC Plus). In March 2023, UnitedHealthcare Community Plan of Virginia began issuing member ID cards and other printed materials revised to include new Cardinal Care logos and remove the former Medicaid Program names, Medallion 4.0 and CCC Plus.   read more