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.

On August 31, the Centers for Medicare and Medicaid released a proposed rule designed to make it easier for eligible people to obtain and maintain coverage in Medicaid and the Children’s Health Insurance Program (CHIP). Together, Medicaid and CHIP provide coverage to 89 million low-income people. The Affordable Care Act (ACA) made significant changes to help simplify, streamline, and coordinate eligibility and enrollment across health programs, especially for children and adults, but complexities remain, and some eligible people are not enrolled or churn on and off the program.  read more


Syrtis Solutions, September 30 
Changes in how pharmacy benefits are delivered under New York’s Medicaid program are coming. Earlier this year, the state announced that to reduce prescription drug costs, it would carve out its Medicaid pharmacy benefits and transition to a fee for service delivery model. Beginning April 1, 2023, Medicaid members will begin receiving their pharmacy benefits under the state’s new model, NYRx. New York’s carve out strategy is designed to reduce drug costs by consolidating the state’s purchasing power. In addition to lowering costs, the carve out is also geared to improve access to care and reduce restrictions by introducing a single drug formulary.  read more


NCDHHS, September 29 
To ensure beneficiaries can seamlessly receive care on day one, the North Carolina Department of Health and Human Services will delay the implementation of the NC Medicaid Managed Care Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans until April 1, 2023. Tailored Plans, originally scheduled to launch Dec. 1, 2022, will provide the same services as Standard Plans in Medicaid Managed Care and will also provide additional specialized services for individuals with significant behavioral health conditions, Intellectual/Developmental Disabilities and traumatic brain injury.  read more


KFF, September 29 
At the start of the pandemic, Congress enacted the Families First Coronavirus Response Act (FFCRA), which included a requirement that Medicaid programs keep people continuously enrolled through the end of the month in which the COVID-19 public health emergency (PHE) ends, in exchange for enhanced federal funding. Primarily due to the continuous enrollment requirement, Medicaid enrollment has grown substantially compared to before the pandemic and the uninsured rate has dropped.  read more


Section 1115 demonstration waivers offer states an avenue to test new approaches in Medicaid that differ from what is required by federal statute, as long as the federal Centers for Medicare and Medicaid Services (CMS) determines that such proposals are “likely to assist in promoting the objectives of the [Medicaid] program.” While Section 1115 waivers have been used over time, recent activity from the Trump Administration and into the Biden Administration has tested how these waivers can be used to advance administrative priorities and has also tested the balance between states’ flexibility and discretion by the federal government.  read more


Fierce Healthcare, September 28 
The Biden administration approved new initiatives in Oregon and Massachusetts to boost coverage in Medicaid, including keeping children in the program until they are 6 years old. The Centers for Medicare & Medicaid Services (CMS) announced Wednesday approvals for demonstrations in the two states. The demonstrations aim to also introduce new evidence-based measures to improve nutritional assistance and help ensure continuity of coverage, administration officials said.  read more


State of Reform, September 27 
The Biden administration wants to minimize the fallout from the expiration of the COVID-19 public health emergency (PHE), whenever it occurs. At the top of the list of concerns is the insurance status of people who have been able to stay on Medicaid or the Children’s Health Insurance Program (CHIP) without having to comply with reverification rules. To minimize coverage disruptions, the Centers for Medicare and Medicaid Services (CMS) is planning to restrict how states go about reviewing who remains eligible to stay on these programs.  read more


Nebraska officials announced Friday that they have chosen three health plans to manage the bulk of the state’s $1.8 billion Medicaid program. The three are Molina Healthcare of Nebraska, Nebraska Total Care and United HealthCare of the Midlands. Two, Nebraska Total Care and United HealthCare, have current contracts with the state. Molina Healthcare is new to Nebraska but provides Medicaid, Medicare and Affordable Care Act marketplace plans in several other states.  read more


The HHS Office of Inspector General found states frequently pay capitation benefits for Medicaid beneficiaries enrolled in multiple states. In an audit published Sept. 21, the OIG said capitation payments were made for 327,497 Medicaid beneficiaries double enrolled in multiple states’ Medicaid programs in August 2020. This number is an increase from 208,254 concurrent payments in August 2019. Capitation payments are fixed fees given to managed care organizations in exchange for making benefits available to Medicaid enrollees.  read more


KFF, September 22 
The recent passage of the Inflation Reduction Act of 2022 (IRA) includes a number of climate, tax, and health care provisions and prescription drug reforms. While the prescription drug reforms primarily apply to Medicare; some provisions interact with the Medicaid Drug Rebate Program (MDRP) and could increase overall Medicaid prescription drug spending. In FY 2020, Medicaid gross drug spending was $72 billion and $39 billion was offset by rebates, resulting in $33 billion of net spending that is shared by states and the federal government, accounting for approximately 5% of total Medicaid spending.  


The value of improper Medicaid capitation payments made by states to managed care providers for beneficiaries who were already enrolled in Medicaid programs in other states increased by 60% between 2019 and 2020, the first year of the coronavirus pandemic, federal auditors say. The Department of Health and Human Services Office of the Inspector General found that 47 state Medicaid agencies made improper capitation payments for beneficiaries enrolled in Medicare and living in other states totaling $117 million in August 2020, compared with $73 million in August 2019.  read more


Dayton-based insurance company CareSource announced today it is partnering with a Texas company in a joint venture to serve Medicaid customers in Texas. CareSource is partnering with Legacy Community Health, a health care system with over 50 locations in the Texas Gulf Coast region, to form CareSource Bayou Health, which plans to apply to serve Texas Medicaid managed care customers. CareSource Bayou Health will seek contracts to serve members in Harris and Jefferson counties who are part of the State of Texas Access Reform (STAR) Program and Children’s Health Insurance Program (CHIP) when the Texas Health and Human Services Commission releases its request for proposals.  read more


WV Public Broadcasting, September 2 
As President Joe Biden is expected to end the nation’s public health emergency later this year, pandemic related relief programs are going back to previous levels. More than 200,000 West Virginia children and their parents will have to renew their membership in Medicaid and the Children’s Health Insurance Program (CHIP). Those enrolled in Medicaid and CHIP should prepare for the shift. Most children covered with CHIP will still qualify for the health insurance program. West Virginia parents who still qualify should receive a renewal letter in the mail.  read more


Starting next year, Centene, Elevance and Molina will help managed Iowa’s Medicaid program, which supports more than 790,000 low-income residents of the state. It’s Molina’s first contract in the Hawkeye State, as the California-based insurer continues to grab Medicaid market share following last week’s California win. California — the largest Medicaid market in the country — also awarded Medicaid contracts to Elevance and Centene. Centene lost contracts in three counties, including Los Angeles, causing shares in the company to flag.  read more


Administration overhauling Medicaid, CHIP enrollment  Healthcare Finance, September 1 
In an effort to improve healthcare access, the Biden Administration has proposed a new rule that would overhaul the enrollment processes for Medicaid, the Children’s Health Insurance Program (CHIP) and Basic Health Programs (BHPs), and eliminate what it considers arbitrary coverage caps for children in CHIP. In a Notice of Proposed Rule Making, the Department of Health and Human Services, through the Centers for Medicare and Medicaid Services, is working to reduce red tape and simplify application and verification processes in a bid to make it easier for children, older adults and people with lower incomes with Medicaid and CHIP coverage to enroll in and retain insurance.   read more