06 Oct MEDICAID NEWS RECAP – SEPTEMBER 2023
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.
HHS Takes Action to Provide 12 Months of Mandatory Continuous Coverage for Children in Medicaid and CHIP HHS.gov, September 29
Today, as part of its ongoing work to make sure all Americans have access to health care coverage, the U.S. Department of Health and Human Services, through the Centers for Medicare & Medicaid Services (CMS), sent a letter to state health officials reinforcing that states must provide 12 months of continuous coverage for children under the age of 19 on Medicaid and the Children’s Health Insurance Program (CHIP) beginning January 1, 2024. read more
Today, as part of its ongoing work to make sure all Americans have access to health care coverage, the U.S. Department of Health and Human Services, through the Centers for Medicare & Medicaid Services (CMS), sent a letter to state health officials reinforcing that states must provide 12 months of continuous coverage for children under the age of 19 on Medicaid and the Children’s Health Insurance Program (CHIP) beginning January 1, 2024. read more
HOW MUCH ARE IMPROPER CLAIMS PAYMENTS COSTING YOUR SMA OR MCO? Syrtis Solutions, September 29
Improper claims payments are costing the Medicaid program billions of dollars every year. A common misconception is that improper claims payments come from fraud and abuse when, in reality, the majority stem from prosaic, mundane issues such as eligibility errors and antiquated data systems. Fraud in the Medicaid program may still be a significant issue, but when improper payments are the outcome of eligibility errors rather than fraud, the problem’s true scope can be better addressed. read more
Improper claims payments are costing the Medicaid program billions of dollars every year. A common misconception is that improper claims payments come from fraud and abuse when, in reality, the majority stem from prosaic, mundane issues such as eligibility errors and antiquated data systems. Fraud in the Medicaid program may still be a significant issue, but when improper payments are the outcome of eligibility errors rather than fraud, the problem’s true scope can be better addressed. read more
Medicaid in the headlines: 10 recent updates
Becker’s Payer Issues, September 28
HHS paused Medicaid enrollments in 30 states reporting issues with their automatic renewal systems, and some states are enacting or considering Medicaid expansion. A government shutdown could cause hiccups in the unwinding of Medicaid continuous coverage requirements. Adena Regional Medical Center is terminating its contract with Anthem BCBS’ Medicare Advantage and managed Medicaid plans in Ohio, effective Nov. 2. read more
Becker’s Payer Issues, September 28
HHS paused Medicaid enrollments in 30 states reporting issues with their automatic renewal systems, and some states are enacting or considering Medicaid expansion. A government shutdown could cause hiccups in the unwinding of Medicaid continuous coverage requirements. Adena Regional Medical Center is terminating its contract with Anthem BCBS’ Medicare Advantage and managed Medicaid plans in Ohio, effective Nov. 2. read more
Four States Reviewed Received Increased Medicaid COVID-19 Funding Even Though They Terminated Some Enrollees’ Coverage for Unallowable or Potentially Unallowable Reasons
U.S. DHHS Office of Inspector General, September 22
The COVID-19 pandemic was declared a nationwide Public Health Emergency (PHE) in January 2020. In March 2020, Congress enacted the Families First Coronavirus Response Act (FFCRA), which provided States with a temporary increase of 6.2 percentage points to their regular Federal medical assistance percentage (FMAP) rates. To qualify, States must meet certain FFCRA requirements. read more
U.S. DHHS Office of Inspector General, September 22
The COVID-19 pandemic was declared a nationwide Public Health Emergency (PHE) in January 2020. In March 2020, Congress enacted the Families First Coronavirus Response Act (FFCRA), which provided States with a temporary increase of 6.2 percentage points to their regular Federal medical assistance percentage (FMAP) rates. To qualify, States must meet certain FFCRA requirements. read more
CMS requires 30 states to pause Medicaid disenrollments after systems error HealthcareDive, September 22
More than seven million Medicaid beneficiaries have been disenrolled from the program geared toward low-income people since the redeterminations process began this spring, according to health policy research firm KFF. States are required to figure out which enrollees are still eligible for the safety-net program after a long period of continuous enrollment during the COVID-19 pandemic, where beneficiaries were kept enrolled in Medicaid to avoid coverage losses during a public health emergency. read more
More than seven million Medicaid beneficiaries have been disenrolled from the program geared toward low-income people since the redeterminations process began this spring, according to health policy research firm KFF. States are required to figure out which enrollees are still eligible for the safety-net program after a long period of continuous enrollment during the COVID-19 pandemic, where beneficiaries were kept enrolled in Medicaid to avoid coverage losses during a public health emergency. read more
CMS says 500K will regain Medicaid coverage as it takes aim at autorenewal issues Fierce Healthcare, September 21
As states continue to work through the yearslong backlog of Medicaid eligibility determinations, procedural coverage losses remain a major concern. The Centers for Medicare & Medicaid Services (CMS) on Thursday issued new, self-reported data from states that offer a look at where they stand with automatic, or ex parte, renewals, which have been circled as a key way to potentially avoid unneeded disenrollments. read more
As states continue to work through the yearslong backlog of Medicaid eligibility determinations, procedural coverage losses remain a major concern. The Centers for Medicare & Medicaid Services (CMS) on Thursday issued new, self-reported data from states that offer a look at where they stand with automatic, or ex parte, renewals, which have been circled as a key way to potentially avoid unneeded disenrollments. read more
Alabama Did Not Always Invoice Rebates to Manufacturers for Pharmacy and Physician-Administered Drugs U.S. DHHS Office of Inspector General, September 21
For a covered outpatient drug to be eligible for Federal reimbursement under the Medicaid program’s drug rebate requirements, manufacturers must pay rebates to the States for the drugs. However, prior OIG audits found that States did not always invoice and collect all rebates due for drugs administered by pharmacies and physicians. Our objective was to determine whether Alabama complied with Federal Medicaid requirements for invoicing manufacturers for rebates for pharmacy and physician-administered drugs. read more
For a covered outpatient drug to be eligible for Federal reimbursement under the Medicaid program’s drug rebate requirements, manufacturers must pay rebates to the States for the drugs. However, prior OIG audits found that States did not always invoice and collect all rebates due for drugs administered by pharmacies and physicians. Our objective was to determine whether Alabama complied with Federal Medicaid requirements for invoicing manufacturers for rebates for pharmacy and physician-administered drugs. read more
Medicaid Program Integrity: Opportunities Exist for CMS to Strengthen Use of State Auditor Findings and Collaboration
GAO.gov, September 21
States and the federal government work together to fund Medicaid and protect it from payment errors and fraud. State auditors provide independent reviews of their state’s compliance with federal funding requirements and other program rules. Their findings reveal problems such as ineligible beneficiaries and errors in state spending. Federal Medicaid officials started using these findings and collaborating with state auditors to improve the program, but they could do more. read more
GAO.gov, September 21
States and the federal government work together to fund Medicaid and protect it from payment errors and fraud. State auditors provide independent reviews of their state’s compliance with federal funding requirements and other program rules. Their findings reveal problems such as ineligible beneficiaries and errors in state spending. Federal Medicaid officials started using these findings and collaborating with state auditors to improve the program, but they could do more. read more
WellCare of Kentucky Held Fourth Annual Community Health Champions Awards, Recognizing Individuals Helping to Support Healthy Communities Across the Commonwealth PR Newswire, September 21
WellCare of Kentucky, a prominent statewide provider of Medicaid managed care services, hosted its fourth annual Community Health Champions Awards on Wednesday, September 20, at Churchill Downs to honor individuals and organizations that have played a pivotal role in removing healthcare barriers, improving outcomes and supporting community wellbeing throughout the Commonwealth. read more
WellCare of Kentucky, a prominent statewide provider of Medicaid managed care services, hosted its fourth annual Community Health Champions Awards on Wednesday, September 20, at Churchill Downs to honor individuals and organizations that have played a pivotal role in removing healthcare barriers, improving outcomes and supporting community wellbeing throughout the Commonwealth. read more
Becker’s Payer Issues, September 20
Virginia reinstated around 45,000 people improperly removed from its Medicaid program, the Richmond Times-Dispatch reported Sept. 20. Around half of those reinstated are children, according to the report. Those reinstated will have their eligibility reevaluated by Sept. 30, after Virginia upgrades its automated system. On Aug. 30, CMS sent a letter to Medicaid directors in all 50 states, warning them automatic renewal systems in several states are calculating eligibility at the family income level, rather than the individual level. read more
Virginia reinstated around 45,000 people improperly removed from its Medicaid program, the Richmond Times-Dispatch reported Sept. 20. Around half of those reinstated are children, according to the report. Those reinstated will have their eligibility reevaluated by Sept. 30, after Virginia upgrades its automated system. On Aug. 30, CMS sent a letter to Medicaid directors in all 50 states, warning them automatic renewal systems in several states are calculating eligibility at the family income level, rather than the individual level. read more
Officials say about 125,000 Louisiana residents on Medicaid lost their coverage The Center Square, September 19
About 125,000 Louisiana Medicaid recipients have lost coverage during the first two months of re-eligibility reviews by the Department of Health following the end of federal pandemic regulations. The end of a continuous enrollment provision imposed by the federal government during the pandemic that prohibited eligibility reviews means states are now reviewing Medicaid eligibility over the next year, and Louisiana Medicaid Executive Director Tara LaBlanc provided an update on that process to lawmakers last week. LaBlanc told the Joint Legislative Committee on the Budget Friday that during June and July, the first two months of the unwinding, the department automatically renewed 158,000 Medicaid recipients for another year. read more
About 125,000 Louisiana Medicaid recipients have lost coverage during the first two months of re-eligibility reviews by the Department of Health following the end of federal pandemic regulations. The end of a continuous enrollment provision imposed by the federal government during the pandemic that prohibited eligibility reviews means states are now reviewing Medicaid eligibility over the next year, and Louisiana Medicaid Executive Director Tara LaBlanc provided an update on that process to lawmakers last week. LaBlanc told the Joint Legislative Committee on the Budget Friday that during June and July, the first two months of the unwinding, the department automatically renewed 158,000 Medicaid recipients for another year. read more
Key Strategies That States Used for Managing Medicaid and Marketplace Enrollment During the COVID-19 PHE
U.S. DHHS Office of Inspector General, September 18
This brief highlights strategies that State Medicaid agencies and State-based Marketplace—collectively, “States”—described as beneficial for their enrollment processes during the COVID-19 Public Health Emergency (PHE). Although this brief does not contain recommendations from OIG, it does provide insights that State officials might find helpful to consider for their program operations. read more
U.S. DHHS Office of Inspector General, September 18
This brief highlights strategies that State Medicaid agencies and State-based Marketplace—collectively, “States”—described as beneficial for their enrollment processes during the COVID-19 Public Health Emergency (PHE). Although this brief does not contain recommendations from OIG, it does provide insights that State officials might find helpful to consider for their program operations. read more
Medicaid disenrollment rates by state
Becker’s Payer Issues, September 11
The Medicaid disenrollment rate for reporting states as of Sept. 8 ranges from 72 percent in Texas to 9 percent in Michigan, according to KFF. KFF said there is a wide variation in disenrollment rates across states, which is likely explained by differences in who states are targeting with early renewals as well as differences in renewal policies and system capacities. Some states, such as Texas and South Carolina, targeted people early in the unwinding period that they thought were no longer eligible or who did not respond to renewal requests during the COVID-19 pandemic, according to KFF. read more
Becker’s Payer Issues, September 11
The Medicaid disenrollment rate for reporting states as of Sept. 8 ranges from 72 percent in Texas to 9 percent in Michigan, according to KFF. KFF said there is a wide variation in disenrollment rates across states, which is likely explained by differences in who states are targeting with early renewals as well as differences in renewal policies and system capacities. Some states, such as Texas and South Carolina, targeted people early in the unwinding period that they thought were no longer eligible or who did not respond to renewal requests during the COVID-19 pandemic, according to KFF. read more
Puerto Rico Claimed Over $7 Million in Federal Reimbursement for Medicaid Capitation Payments Made on Behalf of Enrollees Who Were or May Have Been Deceased U.S. DHHS Office of Inspector General, September 11
Previous OIG audits identified unallowable Federal Medicaid reimbursement for managed care payments (known as capitation payments) made on behalf of deceased enrollees. We audited the Puerto Rico Department of Health (DOH) because we previously identified factors that may increase the risk of similar overpayments. Our objective was to determine whether DOH claimed Federal Medicaid reimbursement for capitation payments to managed care organizations (MCOs) on behalf of deceased enrollees. read more
Previous OIG audits identified unallowable Federal Medicaid reimbursement for managed care payments (known as capitation payments) made on behalf of deceased enrollees. We audited the Puerto Rico Department of Health (DOH) because we previously identified factors that may increase the risk of similar overpayments. Our objective was to determine whether DOH claimed Federal Medicaid reimbursement for capitation payments to managed care organizations (MCOs) on behalf of deceased enrollees. read more
U.S. DHHS Office of Inspector General, September 11
Texas pays managed care organizations to make services available to eligible Medicaid enrollees in return for a monthly fixed payment (capitation payment) for each enrollee. Previous OIG audits found that State Medicaid agencies made capitation payments on behalf of enrollees who were residing and enrolled in Medicaid in another State. We are concerned that the concurrent Medicaid enrollment identified in our previous audits could be an issue that negatively impacts Texas’ Medicaid program. read more
Texas pays managed care organizations to make services available to eligible Medicaid enrollees in return for a monthly fixed payment (capitation payment) for each enrollee. Previous OIG audits found that State Medicaid agencies made capitation payments on behalf of enrollees who were residing and enrolled in Medicaid in another State. We are concerned that the concurrent Medicaid enrollment identified in our previous audits could be an issue that negatively impacts Texas’ Medicaid program. read more
The Center Square, September 6
The U.S. Department of Health and Human Services released an audit report that says Florida did not refund more than $106 million in federal Medicaid managed care rebates. Medicaid provides medical assistance to low-income individuals and individuals with disabilities and is jointly funded and administered by state and federal governments. Although states have a considerable amount of flexibility in the operation of their Medicaid programs, states are also required to comply with federal requirements. read more
The U.S. Department of Health and Human Services released an audit report that says Florida did not refund more than $106 million in federal Medicaid managed care rebates. Medicaid provides medical assistance to low-income individuals and individuals with disabilities and is jointly funded and administered by state and federal governments. Although states have a considerable amount of flexibility in the operation of their Medicaid programs, states are also required to comply with federal requirements. read more
Audit finds hospitals improperly billing Medicaid for pricier, inpatient care Politico, September 5
Hospitals may be improperly billing Medicaid for inpatient services that should have been billed as outpatient care, a new audit by the office of New York state Comptroller Thomas P. DiNapoli suggests. The audit, which was shared exclusively with POLITICO, identified nearly $361 million worth of fee-for-service inpatient claims for Medicaid enrollees discharged within 24 hours of hospital admission — suggesting a portion of those 34,000-plus claims were improperly billed as pricier inpatient claims instead of outpatient services, which are generally less expensive. read more
Hospitals may be improperly billing Medicaid for inpatient services that should have been billed as outpatient care, a new audit by the office of New York state Comptroller Thomas P. DiNapoli suggests. The audit, which was shared exclusively with POLITICO, identified nearly $361 million worth of fee-for-service inpatient claims for Medicaid enrollees discharged within 24 hours of hospital admission — suggesting a portion of those 34,000-plus claims were improperly billed as pricier inpatient claims instead of outpatient services, which are generally less expensive. read more
CMS prods states to examine auto-renewal as possible cause of Medicaid disenrollments Healthcare Finance, September 1
The Centers for Medicare and Medicaid Services has sent a letter to Medicaid directors in all 50 states directing them to determine whether they have an eligibility systems issue that could cause people, especially children, to be disenrolled from Medicaid or the Children’s Health Insurance Program (CHIP) even if they are still eligible for coverage. The letter also requires states to act immediately so the problem can be corrected and coverage reinstated.
The Centers for Medicare and Medicaid Services has sent a letter to Medicaid directors in all 50 states directing them to determine whether they have an eligibility systems issue that could cause people, especially children, to be disenrolled from Medicaid or the Children’s Health Insurance Program (CHIP) even if they are still eligible for coverage. The letter also requires states to act immediately so the problem can be corrected and coverage reinstated.