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.

Pharmacy Experts: Data-Readiness Key in Reaching Medicaid Population  Healthcare Innovation, June 28 
In an online event on June 20, hosted by CaryHealth in collaboration with Medicaid Health Plans of America (MHPA), industry experts discussed innovative pharmacy strategies and the latest in technology to close care gaps in Medicaid populations. According to MPHPA, “In 2025, healthcare will generate 36 percent of the world’s data volume.” “Barriers to utilizing this wealth of data often include insufficient human or clinical resources and the inability to turn raw data around into actionable insights in a timely manner,” MHPA stated in an announcement.  

Syrtis Solutions, June 28 
Payment integrity programs are designed to ensure accurate claims processing, adherence to contractual rates, and compliance with payment rules. These efforts are vital for maintaining the financial stability of healthcare systems and ensuring that patients receive proper care. However, they can create friction between payers and providers, stemming from disputes over claim denials, reduced reimbursements, and the administrative burden associated with claims adjudication.  read more

The Center Square, June 25 
West Virginia now has less than 514,000 residents on Medicaid managed care plans after the yearlong post-pandemic unwinding of eligibility checks. That state had a high of more than 667,000 on those Medicaid plans in April 2023 as the federal governments pause on eligibility checks – which began in March 2020 – ended. States were then required to check the eligibility of all of those on Medicaid in the year from April 2023 to March 2024.  read more

Cook Children’s sues Texas over Medicaid contract denial
Kera News, June 26 
Cook Children’s is suing the state of Texas after it denied the hospital’s health plan a new Medicaid contract. Officials with the Fort Worth-based health care system announced the lawsuit during a news conference Wednesday. The Texas Health and Human Services Commission’s $116 billion Medicaid procurement — which is set to start in September 2025 — would remove Cook Children’s and two other hospital-affiliated children’s health plans from Medicaid STAR and CHIP programs, which serve low-income children and families.  read more

States using unwinding lessons to improve Medicaid: KFF 
Healthcare Dive, June 21 
During the pandemic, states agreed not to kick any beneficiaries off Medicaid in return for more generous federal funding. As a result, Medicaid enrollment snowballed to roughly one in four Americans. However, states resumed checking beneficiaries’ eligibility for Medicaid last spring, and have removed an estimated 23 million people from the program since. Redeterminations have not been easy for the states for a number of reasons, including the sheer size of the task, a lack of resources at Medicaid agencies, shifting federal guidance and difficulty contacting enrollees to determine eligibility.  read more

KFF, June 20 
In early 2023, states began final preparations for the end of the pandemic-related Medicaid continuous enrollment provision following passage of the Consolidated Appropriations Act (CAA) of 2023, which lifted the requirement effective March 31, 2023. During the three-year pause on Medicaid disenrollments, Medicaid and CHIP enrollment grew by 32% from 71.3 million to 94.1 million, resulting in the largest ever number of enrollees in Medicaid, which, along with enhanced subsidies in the Affordable Care Act (ACA) Marketplaces, contributed to the lowest ever uninsured rate.  read more

Lawmakers press CMMI’s Fowler on lack of cost savings for alternative payment models  Fierce Healthcare, June 18 
Republicans on the House Energy and Commerce Committee lambasted the failure of CMS’ Innovation Center to save U.S. healthcare dollars during a recent hearing on value-based care. Republicans suggested a variety of drastic actions like stopping projects that haven’t demonstrated cost savings, slimming the Center’s funding or shutting it down. The Center for Medicare and Medicaid Innovation (CMMI) is tasked with driving the transition to value-based care.  read more

Missouri bill would open federal drug discount to all pharmacies working with Medicaid providers  KY3, June 18 
Missouri Governor Mike Parson has yet to sign or veto a bill, SB 751, aimed at blocking drug manufacturers from restricting which pharmacies can participate in a federal drug price discount program. The federal 340-B program requires drug makers to provide deep discounts to pharmacies that are partnered with an eligible, Medicaid provider. The goal of the program was to support entities that exist in underserved areas with a higher percentage of uninsured or financially strapped patients.  read more

Health Insurance Coverage Projections For The US Population And Sources Of Coverage, By Age, 2024–34  Health Affairs, June 18 
In the Congressional Budget Office’s projections of health insurance coverage, 92.3 percent of the US population, or 316 million people, have coverage in 2024, and 7.7 percent, or 26 million, are uninsured. The uninsured share of the population will rise over the course of the next decade, before settling at 8.9 percent in 2034, largely as a result of the end of COVID-19 pandemic–related Medicaid policies, the expiration of enhanced subsidies available through the Affordable Care Act health insurance Marketplaces, and a surge in immigration that began in 2022.  read more

Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State  KFF, June 18 
This page tracks approved and pending Section 1115 Medicaid demonstration waivers, which offer states an avenue to test new approaches in Medicaid that differ from what is required by federal statute. Key themes in current approved and pending waivers include targeted eligibility expansions, benefit expansions (particularly in the area of behavioral health, such as coverage of services provided in IMDs), and provisions related to social determinants of health.

Aquino leads new law to strengthen Medicaid system, improve reimbursement  Illinois State Democrats Caucus, June 17 
Illinois will boost reimbursement for critical health services supporting vulnerable children and families, thanks to a new law led by State Senator Omar Aquino aimed at strengthening the Medicaid system. “In Illinois, we are advancing equity by investing in the residents and health care providers who deserve a better system that meets their needs,” said Aquino (D-Chicago).  read more

Medicaid Expansion: Frequently Asked Questions 
Center On Budget and Policy Priorities, June 14 
The Affordable Care Act (ACA) permits states to expand Medicaid coverage to adults with incomes up to 138 percent of the poverty level (about $20,780 annually for an individual or $35,630 for a family of three). States that have adopted the expansion have dramatically lowered their uninsured rates. Extensive research finds that the people who gained coverage have grown healthier and more financially secure, while long-standing racial inequities in health outcomes, coverage, and access to care have shrunk.  read more

CMS Roundup (June. 14, 2024), June 14 
Today, the Centers for Medicare & Medicaid Services (CMS) provides an at-a-glance summary of news from around the agency. CMS Announces Recipients of the 2024 CMS Health Equity Award. May 30: CMS announced the recipients of the 2024 CMS Health Equity Award. The CMS Health Equity Award is given to organizations working towards advancing health equity by showing others how to reduce disparities in health care access, quality, and outcomes.