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 noteworthy Medicaid news.

Syrtis Solutions Blog, December 1
The Trump administration’s Medicaid Managed Care Final Rule, CMS-2408-F, was finalized this November. The new rule implements proposals from the Notice of Proposed Rule Making from last November. Provisions from the rule will begin taking effect as early as December 14, 2020. According to Medicaid enrollment data from 2018, 66 million people are enrolled in managed care, making managed care arrangements the primary delivery system for Medicaid benefits. To support these programs, the rule reduces administrative burdens on Medicaid managed care plans and gives states more flexibility to determine capitation rates and appropriate payment rates.  read more


State leaders are weighing possible cuts to Medicaid services and health-care benefits to offset rising costs due to a surge of enrollees who have lost jobs and need health coverage as the coronavirus pandemic has intensified. Congress boosted federal matching funds to states for Medicaid as part of its first coronavirus relief package, but many states are still struggling to afford the increasing pace of sign-ups in the program for low income and disabled people. Enrollment for the fiscal year ending Sept. 30, 2021, is expected to jump 8.2%, with state spending accelerating by 8.4%, compared with 6.3% growth in the previous fiscal year, based on data from 42 state Medicaid directors compiled by the Kaiser Family Foundation.   read more


This week, U.S. Sen. Rick Scott, R-Fla., and U.S. Sen. Tom Cotton, R-Ark., sent a letter to Centers for Medicare & Medicaid Services Administrator Seema Verma requesting more information on the Federal Services Data Hub, and how it can be used to further reduce inefficiencies and improper payments in the Medicaid program and throughout the federal government. The letter is as follows: Thank you for your efforts to ensure greater transparency and accountability within the federal government. Eliminating duplication, overlap, and improper payments should be a top priority of the federal government to make sure taxpayer dollars are not wasted. read more


Health Payer Intelligence, November 25
New CMS regulations around Medicaid managed care include several major changes regarding network adequacy, beneficiary protection, quality, and payment, according to the Kaiser Family Foundation (KFF). Most of the changes go into effect on December 14, 2020. “While the new final rule is not a wholescale revision of the comprehensive 2016 final rule, it does make changes in key areas,” the researchers explained. “Federal rules governing Medicaid managed care are important as managed care remains the predominant care delivery system in most states.” Under the updated Medicaid managed care regulations, states can use other measures, apart from time and distance, to evaluate network adequacy.  read more


WUSF Public Media, November 24
State economists say enrollment in Medicaid will spike by 16.5 percent this fiscal year, fueled by the economic downturn during the COVID-19 pandemic. Nationwide, states are seeing substantial growth in the program that serves poor, elderly and disabled people, but a high-ranking Medicaid official conceded that Florida is experiencing some of the biggest increases. “When you look at across the nation, we are probably ranked within the top eight of all the states with the increased percentage,” Tom Wallace, the state Agency for Health Care Administration’s assistant deputy secretary for Medicaid finance analytics, told members of a panel known as the Social Services Estimating Conference last week.   read more


The Center on Budget and Policy Priorities issued the following commentary by senior policy analyst Jessica Schubel entitled “Medicaid Improper Payment Rates Don’t Signal Fraud or Abuse”: The Centers for Medicare & Medicaid Services (CMS) has released its 2020 Estimated Payment Error Rate Measurement (PERM) rate — which measures “improper” payments in Medicaid and the Children’s Health Insurance Program (CHIP) — but policymakers shouldn’t use it to justify imposing additional, burdensome verification and paperwork requirements or to distract from the larger problem of eligible people losing coverage and access to care.  read more


Governing, November 20
Ohio’s Medicaid system may have paid out hundreds of millions of dollars in improper claims last year to ineligible patients, due to glitches with the state’s computerized enrollment system, according to a new state audit. As part of a review of 27 counties, the Ohio Auditor’s Office found 16 out of 324 Medicaid customers, or 4.9 percent, shouldn’t have been eligible to enroll in the program. That translated to only $39,135 in improper payments. But extrapolating that number to the state’s overall enrollment numbers, it would translate to as much as $455 million, state Auditor Keith Faber said. State auditors couldn’t determine why people who should have been ineligible were allowed into the system.  


For the second time this week, a review has revealed widespread problems with Ohio’s $1.2 billion online system for determining eligibility for Medicaid. The faulty and complex system, state Auditor Keith Faber said, is costing taxpayers hundreds of millions in erroneous payments. “As one of Ohio’s largest budget items, with annual spending in excess of $27 billion, any inefficiencies in the Medicaid system can quickly run up a large tab,” Faber said. “We must reduce the chance for error by streamlining and simplifying processes and ensuring accuracy in enrollment and reporting. The systemic problems we identified arose over several administrations and must be fixed now.”  read more


KRQE, November 19
Spending on federally subsidized Medicaid health care across New Mexico has surged to an all-time high as the coronavirus pandemic throws more people of all ages into poverty, state program analysts and health officials said Wednesday. An independent evaluation of the state’s flagship managed care program for Medicaid insurance found that enrollment is surging to new heights, adding more than 52,000 people to the state’s “Centennial Care” program that serves about 80% of New Mexico’s Medicaid patients. It’s the largest surge in enrollment since New Mexico expanded Medicaid in 2014 to include more people on the cusp of poverty under the Affordable Care Act.  read more


Spectrum News 13, November 18
Amid a pandemic that has cost hundreds of thousands of Floridians their jobs and their health insurance, Democratic state lawmakers are demanding a “fresh look” at expanding Medicaid. Over the last eight years, the Republican-controlled Florida Legislature has twice rejected proposals to accept $54 billion in federal funding to cover as many as a million uninsured Floridians who don’t currently qualify for Medicaid and are unable to afford private policies. A 2015 Medicaid expansion measure backed by Senate leaders was stymied by House Republicans, who warned that long-term costs would ultimately be borne by state taxpayers despite federal assurances to the contrary.  read more


Health Payer Intelligence, November 18
States that did not opt into Medicaid expansion under the Affordable Care Act (ACA) experienced worse emergency access to acute care hospitals compared to states that did, according to recent study. Overall, states that expanded Medicaid saw an increase in access to care. In 2007, 5.65 percent of the population did not have access to hospitals. By 2017, that number decreased to 5.35 percent in 2017. On the other hand, states that did not expand Medicaid saw an increase in the population without access to hospitals overall, rising from 6.76 percent in 2007 to 6.79 percent in 2017. If access changes in non-expansion states were the same as expansion states, approximately 421,000 more people would have had access to acute care hospitals.  read more


The Center Square, November 10
The U.S. Supreme Court heard arguments Tuesday in California v. Texas, a case seeking to overturn the Affordable Care Act after the penalty for its individual insurance mandate was set to zero. The case initially was filed by the Texas Attorney General’s Office with a coalition of 20 Republican attorneys general and governors as plaintiffs. Several blue states, led by California, joined the lawsuit to defend the ACA, also known as Obamacare. According to an analysis published by CNBC, the ACA “seems likely to withstand its third challenge at the Supreme Court” because “Chief Justice John Roberts and Justice Brett Kavanaugh both suggested that the court may cast aside a challenged provision of the law, known as the individual mandate, while leaving the rest of it standing.”  read more


A provision tucked into the budget this year, based on a recommendation by the state’s Medicaid Redesign Team, would “carve out” the discount and shift payment to a fee-for-service reimbursement starting next April. That means hospitals that care for large numbers of people with Medicare, Medicaid or those without insurance would lose out on the savings and the state would instead capture the rebate, a move that could decimate essential services for communities hardest hit by the coronavirus pandemic, opponents argue. “It’s essential to maintain the safety net for our state’s most vulnerable populations,” said Guillermo Chacon, president of the Latino Commission on AIDS and founder of the Hispanic Health Network. “The State’s budget changes to ‘carve-out’ Medicaid prescription drugs will devastate the 340B drug discount program for the poorest New Yorkers in need of health services.”  read more


The Ohio Department of Medicaid on Thursday started the process of hiring a private administrator to oversee its $3 billion pharmacy benefit program. The department requested proposals for a pharmacy operational support vendor to help design its program and provide financial oversight once it’s up and running. Medicaid created the new post as part of a broader overhaul of its managed care program. In addition to rebidding contracts with private managed care organizations that oversee the program, the state agency is also replacing five pharmacy benefit managers hired by those private organizations to process claims with one company hired by the state and monitored by the administrator.  read more