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.

Hundreds of thousands in North Carolina will be added to Medicaid rolls this week  AP, November 30 
A decade after the federal government began offering expanded Medicaid coverage in states that opted to accept it, hundreds of thousands of adults in North Carolina are set to receive benefits, a development that boosters say will aid hospitals and local economies in addition to the long-term uninsured. North Carolina elected officials agreed this year to expand Medicaid, which will provide the government-funded health insurance to adults ages 19 to 64 who make too much money to receive traditional Medicaid but generally not enough to benefit from public subsidies available for private health insurance.  read more


Syrtis Solutions, November 29
Medicaid improper payments have caused the healthcare program to be on the Government Accountability Office’s High-Risk List since 2003. The GAO’s list identifies government-funded programs that involve substantial resources and provide critical services to the public that are vulnerable to fraud, waste, abuse, and mismanagement. For twenty years, Medicaid and other CMS programs have struggled with these erroneous payments, and it’s costing billions.  


Medicaid in the headlines: 7 recent updates 
Becker’s Payer Issues, November 28
New research found the number of self-pay patients increased as enrollees lost Medicaid coverage, and Georgia lawmakers are mulling a full expansion of the state’s Medicaid program. Here are seven Medicaid updates Becker’s has reported since Nov. 14. The Medicaid improper payment rate significantly decreased from 2022 to 2023, CMS reported. The improper payment rate in the program was 8.58%, or $50.3 billion, in fiscal year 2023, down from 15.62% in 2022.  read more


Multiple States Made Medicaid Capitation Payments to Managed Care Organizations After Enrollees’ Deaths
U.S. DHHS OIG, November 24
HHS-OIG has identified effectively administering the Medicaid program to improve oversight and address high improper payments as a top management challenge facing the HHS. Fourteen previous OIG audits found that State Medicaid agencies had improperly made capitation payments to managed care organizations (MCOs) on behalf of deceased enrollees. Our objective was to summarize the results of our previous audits of Medicaid capitation payments that States made to MCOs on behalf of deceased enrollees.  read more, November 21
The Centers for Medicare & Medicaid Services (CMS) reports that nearly 4.6 million Americans have signed up for 2024 individual market health insurance coverage through the Marketplaces since the start of the 2024 Marketplace Open Enrollment Period (OEP) on November 1. This includes 4.1 million plan selections in the 32 states using the platform for the 2024 plan year, through November 18, 2023 (Week 3), and 502,000 plan selections in the 17 states and the District of Columbia with State-based Marketplaces (SBMs) that are using their own eligibility and enrollment platforms, through November 11, 2023 (Week 2).  read more


Quality Outcomes Are Better When Medicaid MCOs Administer Pharmacy Benefits  Health Payer Intelligence, November 21 
Pharmacy-related quality outcomes were better in states where Medicaid managed care organizations administered health plans’ pharmacy benefits, according to a report from Elevance Health. The Menges Group, a healthcare consulting organization, used the National Committee for Quality Assurance (NCQA) Quality Compass data set, including Healthcare Effectiveness Data and Information Set (HEDIS) data from 2014 to 2022, to compare Medicaid managed care organization pharmacy-related quality outcomes.  read more


Big changes coming to Medi-Cal, the state’s health plan for 40% of Californians  San Francisco Chronicle, November 20
Some big changes are coming to Medi-Cal, California’s Medicaid health care program for low-income people, next year. Starting Jan. 1, two groups of people that had not been eligible for full-scale Medi-Cal will gain access: low-income adults ages 26-49 and some people who are disabled or older than 64. On the other hand, some current Medi-Cal enrollees will lose coverage as the state finishes unwinding the federal “continuous coverage” program that kept people on Medicaid in the pandemic, even if they no longer qualified.  read more, November 15
In the HHS Notice of Benefit and Payment Parameters (Payment Notice) for 2025 proposed rule released today, the Centers for Medicare & Medicaid Services (CMS) proposed standards for issuers and Marketplaces, as well as requirements for agents, brokers, web-brokers, direct enrollment entities, and assisters that help Marketplace consumers. This proposed rule also includes several proposals impacting the Medicaid program, Children’s Health Insurance Program (CHIP), and the Basic Health Program (BHP).  read more


Acentra Health Wins Contract for West Virginia Medicaid
WashingtonExec, November 15
Acentra Health won a 5-year contract from West Virginia’s Department of Health and Human Resources to continue delivering assessment and utilization management services for children and adults enrolled in the state’s Medicaid fee-for-service and waiver programs. “Our teams in West Virginia are passionate about their work and have a deep understanding of the cultural needs and challenges of the populations they serve, owing to their two-plus decades living and working in the state,” said Acentra Health CEO Todd Stottlemyer.  read more


Medicaid Enrollment and Spending Growth Amid the Unwinding of the Continuous Enrollment Provision: FY 2023 & 2024
KFF, November 14
For a three-year period following the onset of the COVID-19 pandemic, states provided continuous Medicaid enrollment in exchange for an increase in the federal share of Medicaid spending (known as the Federal Medical Assistance Percentage or “FMAP”). This policy increased Medicaid enrollment and helped decrease the uninsured rate. While total Medicaid spending also increased during the pandemic, a KFF analysis found that Medicaid spending from state and other non-federal sources remained comparable to pre-pandemic levels due to the increased federal financing.  read more


Audit: Security breach, staffing concerns contributed to ‘unsatisfactory’ accountability from Md. Medicaid agency  
Maryland Matters, November 10
Another audit within a branch of the Maryland Department of Health reveals years of “unsatisfactory” record-keeping that may have resulted in millions of Medicaid dollars improperly paid out for people who did not qualify and a lack of program oversight to ensure that people received adequate health care services, according to a Tuesday report from the Office of Legislative Audits.  read more


Navigating the Unwinding of Medicaid Continuous Enrollment: A Look at Enrollee Experiences  Biz KFF, November 9 
During the COVID-19 pandemic, states kept people continuously enrolled in Medicaid in exchange for enhanced federal funding. Leading up to the unwinding, many enrollees were unaware of the upcoming renewals and when informed, worried about losing coverage. With the end of the continuous enrollment provision on March 31, 2023, states are part-way through the process of redetermining eligibility for people enrolled in Medicaid and disenrolling those who are either no longer eligible or who are unable to complete the renewal process.  


Medicaid disenrollments pass 10M as states continue eligibility checks  HealthcareDive, November 6
Disenrollment rates have been rising steadily since this summer, as more states start rechecking their Medicaid members’ eligibility for the program. The Biden administration enticed states to put those checks on hold during the COVID-19 public health emergency in exchange for more generous federal funding. That continuous enrollment period caused Medicaid’s rolls to swell to some 94 million people earlier this year, making the program the largest source of insurance coverage in the U.S. during the pandemic.  read more


Daily Journal, November 5
As Indiana hits the halfway point for the Medicaid unwinding process, the rate of Hoosiers losing benefits seems to have slowed as the state reassesses the coverage of millions of beneficiaries following the expiration of pandemic protections. However, with a total of 231,403 Hoosiers kicked off of the rolls, Indiana could potentially exceed an earlier estimate that predicted only 300,000-400,000 Hoosiers would lose coverage.  read more