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.

JD Supra, November 30
I. Introduction – Since 2014, states have had the option to expand Medicaid eligibility to most adults with incomes under 138 percent of the federal poverty level (FPL; approximately $30,300 in annual earnings for a family of three). Under this option, the federal government covers 90 percent of the cost of the new adult eligibility group (also known as the “expansion group”), a significantly higher rate than it covers for most Medicaid populations and services. (Mississippi’s matching rate for most services is 78.31 percent in FY 2022, prior to the application of the temporary 6.2 percentage-point increase available under the Families First Coronavirus Response Act.)  read more


Transitioning elderly and disabled Medicaid beneficiaries from fee-for-service Medicaid to a managed care model may lead to improved health outcomes and more than $100 billion of savings for states and the federal government, according to a report from UnitedHealth Group. Most Medicaid programs offer a managed care model, using these contracts to cover 80 million low-income individuals instead of a fee-for-service model. However, there is still a share of Medicaid beneficiaries who are still covered under a fee-for-service health plan.  read more


Syrtis Solutions, November 29 
Medicaid has been designated a high-risk program by the Government Accountability Office (GAO) since 2003 because of improper payments, poor quality data, and oversight challenges. Earlier this month the Department of Health and Human Services (DHHS) released its Agency Financial Report. In FY 2021 Medicaid’s estimated improper payments amounted to a staggering $98.72 billion. According to DHHS, the vast majority of these improper payments were a result of insufficient documentation and eligibility errors.  read more


Office of the New York State Comptroller Office, November 29
State Comptroller Thomas P. DiNapoli today released three reports that found more than $100 million in improper payments made by the Department of Health (DOH) for the Medicare buy-in program, maternity care, and drug and therapy claims. Nearly $400,000 in premiums may have been paid for deceased individuals. “The Medicaid program provides critical health care services to millions of New Yorkers but the program is dogged by oversight problems and payment errors,” DiNapoli said.  read more


Becker’s Payer Issues, November 29 
Continuing to use fee-for-service care for Medicaid and dual-eligible recipients could cost the federal government upwards of $4.4 trillion over the next 10 years, according to a UnitedHealth Group report. The Nov. 29 report says the price tag stems from covering over 10 million elderly or disabled Medicaid recipients. The report suggests shifting to managed care to combat steep costs. It estimates that a move from fee for service to managed care could save a total of $150 billion between Medicaid and Medicare.  read more


After a long legal battle, Missourians are currently able to enroll for Medicaid if they qualify under expansion. Over 54% of voters voted to pass the expansion last August, but lawmakers failed to fund it in their regular session. After this, the issue was then brought to court, in which it was ruled that Medicaid expansion could begin. In accordance with the original August ballot passed by voters, more than 270,000 Missourians became eligible on July 1.  read more


Health Payer Intelligence, November 24
The federal government could temporarily close the Medicaid coverage gap with the Build Back Better Act, but permanent coverage may ultimately depend upon state legislation around Medicaid expansion, according to the Kaiser Family Foundation (KFF). Twelve states have yet to expand Medicaid, leaving around 2.2 million individuals in a coverage gap due to their income levels. These individuals are not eligible for Medicaid but have incomes below the poverty level, rendering them ineligible for premium subsidies in the Affordable Care Act (ACA) marketplace.  read more


The state would be better off expanding Medicaid even if the federal Build Back Better bill that would provide health care coverage for poor Mississippians becomes law, a diverse group of health care advocates claim. Among the provisions in the $1.75 trillion Build Back Better legislation, which passed the U.S. House last week and faces a close Senate vote in coming days, is “workaround” language to provide health care coverage to primarily the working poor in the 12 states, including Mississippi, that have not expanded Medicaid.  read more, November 16 
U.S. Sen. John Barrasso thinks Wyoming should decide against expanding Medicaid. Acknowledging that the decision is a matter for state government, not the U.S. Senate, Wyoming’s senior senator said he worried about the efficiency and accountability of the proposed expansion of the low-income health insurance program in the state. Medicaid reimbursement expansion was authorized for states under the Affordable Care Act of 2014. Wyoming is one of a dozen states not to adopt the expansion availability, which analysts say could bring basic health coverage to as many as 38,000 residents who now have no health insurance.  read more


The Advocate, November 10 
Louisiana lawmakers are trying a new approach to determine how much the state will spend on Medicaid services each year, as the program has ballooned to more than one-third of the state’s budget and added hundreds of thousands of people during the pandemic. A Medicaid forecasting panel created by lawmakers last year held its first meeting Wednesday, to create a new process for estimating spending needs for a program that provides health care to 1.9 million people — about 41% of Louisiana’s population.   read more


KELO, November 5 
South Dakotans Decide Healthcare announced Friday its collected 33,921 valid signatures, which the group says means Medicaid expansion will be on South Dakota ballots in November 2022.South Dakotans Decide Healthcare is a group made up of patient advocates, nurses, health care providers, farmers, faith leaders, educators and more. The group issued a statement announcing the number of signatures attained and thanking those who participated.  read more


The US Department of Health and Human Services, Office of Inspector General (OIG) recently transmitted a memorandum to the Center for Medicaid and CHIP Services detailing the findings of the Massachusetts state auditor’s report on the commonwealth’s controls around dual-eligible hospice patients and weaknesses related to election statements and potential MassHealth overpayments for curative items and services related to hospice patients that should have been covered by the hospices.  read more


U.S. News, November 3 
The North Carolina Senate’s top Republican, a longtime opponent of expanding Medicaid through the 2010 federal health care law, says he’s now been willing to consider enacting expansion as part of horse-trading with Democratic Gov. Roy Cooper over a state budget. But Senate leader Phil Berger said this week that GOP legislators are not proposing expansion to Cooper in bargaining because legislative Republicans are divided over the merits of covering hundreds of thousands of additional adults, according to news outlets.  read more


McKinsey & Company, November 1  
In 2020, the COVID-19 pandemic created substantial shifts across the US healthcare ecosystem. Medicaid was no exception. As Medicaid enrollment grew rapidly, communities with high socioeconomic need also suffered disproportionate impact from the pandemic. Medicaid faces some unique factors that further expand near-term uncertainty. These include changes in member mix resulting from economic recovery and reduced unemployment, federal and state policies that change with the end of the public health emergency, patterns of care use, and the health impact of the pandemic itself within this highly heterogenous segment of approximately 80 million Americans.  read more