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In the last newsletter for 2016, we release our 5th Annual Operations Survey Report and release resources for federal policymakers for the new administration. NAMD also sent letters on MACRA and recommendations on managed care IMDs. Other areas we highlight are ACOs, CPC+, program integrity in personal care services, HCBS, CHIP, and Opioid Crisis.

December 20, 2016
From the NAMD Desk
NAMD Issues Statement on Transition, Releases Resources for Federal Policymakers
On December 14, NAMD issued a press release on the Association’s efforts to bring the expertise of Medicaid Directors to the table to inform forthcoming federal policy debates around the Affordable Care Act and the structure of the Medicaid program. To advance this goal, NAMD also released two documents highlighting key considerations for policymakers as these discussions unfold – one focused on the ACA, the other on Medicaid restructuring. These documents do not take a position on these issues, but instead provide the full spectrum of operational realities Medicaid Directors face, which should be considered as federal debates unfold.


Additionally, NAMD also released our legislative and regulatory priorities for the next Congress and Administration. These documents represent the bipartisan consensus of Medicaid Directors, and aim to identify key changes needed to streamline the Medicaid program, enhance the care of Medicaid beneficiaries, and support the delivery system and payment reform Medicaid Directors are leading in their states.


NOW AVAILABLE: NAMD’s Fifth Annual Medicaid Operations Survey
Today we released NAMD’s State Medicaid Operations Survey, an annual look into the distinctive priorities and challenges affecting Medicaid agencies. As we face the close of 2016 and a new presidential administration and Congress, the report describes Directors as committed champions of reform. It reveals how Directors are transforming the health care system’s core incentives away from volume and towards value in ways that reflect – and capitalize on – state differences. Summarizing the responses of 47 Medicaid programs, the report reveals that:
  • Delivery system and payment reform is the most commonly pursued priority among states, followed by systems/IT development and behavioral health improvements;
  • Directors are increasingly coordinating with outside entities like sister state agencies and contractors to support Medicaid operations, as well as tackle the social determinants of health;
  • States continue to face numerous challenges related to scant resources and capacity; and
  • The vast majority of Directors are new to their positions (in the job for two years or less).
For more information, please contact Cornelia Lluberes.
NAMD Weighs in on the Medicaid Implications of MACRA
Last week, NAMD sent a letter to CMS  on its final regulation that would implement the new Medicare payment programs under the Medicare Access and CHIP Reauthorization Act (MACRA). NAMD’s letter underscores the need for the Advanced Alternative Payment Model (APM) program under MACRA to reflect unique Medicaid considerations, given the implications it will have on Medicaid payment reform. Specifically, NAMD encourages CMS to:
Address the process for identifying Medicaid Advanced APMs.
  • Build into the program an Alternative Pathway for Medicaid APMs to be certified as Other Payer Advanced APMs.
  • Amend the financial risk requirements.
  • Clarify the intersection of the Advanced APM program with existing multi-payer innovation.
NAMD’s letter to CMS builds on the Association’s  earlier comments on the MACRA proposed rule. Additional background information on the Medicaid implications of the Advanced APM program is  available here.
NAMD Provides Managed Care IMD Recommendations to CMS
On December 14, NAMD send a letter to CMS Acting Administrator Andy Slavitt and CMCS Director Vikki Wachino discussing ongoing state concern with CMS’s implementation of the Medicaid managed care rule’s Institutions for Mental Diseases (IMDs) and “in lieu of” services (ILOS) provisions. The letter makes three recommendations for CMS to address these concerns. The letter requests that CMS:
  1. Allow targeted capitation rate recoupment for IMD stays over 15 days in a month;
  2. Develop distinct IMD stay limits appropriate for individuals with mental health and substance use disorder diagnoses; and
  3. Authorize targeted exceptions to the 15-day limit.
Read the letter here.


In This Issue

Reg Update


CMMI Announces Medicare-Medicaid ACO Opportunity
The Centers for Medicare and Medicaid Innovation (CMMI) recently announced a new Accountable Care Organization (ACO) model aimed at individuals dually eligible for Medicare and Medicaid. The model will build on the Medicare Shared Savings Program and be conducted in partnership with states to improve care delivery for Medicare-Medicaid beneficiaries.
CMMI intends to partner with a total of six states to deploy this model, and plans to give preference to states with low Medicare ACO saturation. This opportunity is open to states with a sufficient number of Medicare-Medicaid enrollees in fee-for-service Medicare and Medicaid.
Information on this model is available here.
CMMI Announces Second Round of CPC+
Last week, CMMI announced that it will be accepting payer applications for a second round of the Comprehensive Primary Care Plus (CPC+) model early next year. CMMI is seeking to create up to 10 new regions to participate in this multi-payer, primary care transformation model. As part of new round of CPC+, they are also opening applications for additional payers to participate in the existing 14 CPC+ regions. However,
practices located in the existing 14 regions are not eligible to apply to CPC+ Round 2.
Interested states and MCOs will be able to submit applications to participate in CPC+ beginning in mid-February 2017. Practices located in new regions will be eligible to apply in late spring or summer 2017.
Additional information can be  found here , and questions can be directed to


CMS Issues Bulletin on Program Integrity in Personal Care Services
On December 13, the Center for Medicaid and CHIP Services and the Center for Program Integrity issued an informational bulletin discussing strategies for strengthening Medicaid program integrity in personal care services (PCS). The bulletin builds upon previous guidance on PCS, as well as findings from the Health and Human Services Office of the Inspector General (OIG).


The bulletin provides a brief overview of PCS, noting the distinctions between agency-directed and self-directed PCS and reiterating CMS’s general preference for self-direction as a means of actualizing person-centered planning and beneficiary choice. It also reviews the OIG’s findings regarding vulnerabilities in PCS and CMS recommendations in response to those findings. This includes a thorough review of PCS program integrity safeguards, including:
  • Provider qualifications and basic training;
  • Registries of PCS attendants;
  • Screening of PCS providers;
  • Verification of need for services;
  • Documentation of claims;
  • Prepayment edits;
  • Post-payment review; and
  • Audits.
Read the bulletin here.


CMS Bulletin Explores Managed Care Rule Provisions Impacting American Indians
On December 14, CMCS issued an informational bulletin, which summarizes the managed care rule’s provisions that impact American Indians and Alaska Natives. The bulletin also clarifies current statute and regulation regarding mandatory managed care enrollment for Indians, and provides a sample Indian Addendum for network provider agreements with Indian health care providers. In the discussion around mandatory enrollment, CMS reiterates the importance of the tribal consultation process and how the outcomes of that consultation may impact CMS approval of state authorities to mandatorily enroll Indian populations.


Read the bulletin here.


CMS Issues FAQs on Persons Exhibiting Wandering Behaviors in HCBS Settings
On December 15, the Centers for Medicare and Medicaid Services (CMS) issued a Frequently Asked Questions document on ways to address Medicaid beneficiaries in home and community-based services (HCBS) settings who exhibit unsafe wandering or exit-seeking behavior. The FAQ addresses how HCBS settings can effectively comply with CMS’s HCBS settings rule and simultaneously address beneficiaries with these types of behaviors. CMS focuses on the role of person-centered planning, staff training, setting design, and appropriate care delivery in its responses to the questions considered.


Read the FAQ here.


CMS Releases Money Follows the Person Evaluation
Recently, the Centers for Medicare and Medicaid Services (CMS) published a report assessing the Money Follows the Person (MFP) demonstration program. The evaluation, conducted by Mathematica Policy Research, found that adults under the age of 65 disproportionately benefited from the MFP rebalancing demonstration, while representing a small overall population (15%) of the 1.4 million individuals spending time in a nursing facility in 2014. To explore this finding, the evaluation conducted interviews with MFP demonstration leads in six states. Some lessons learned about the under-65 nursing home residents include:
  • This population tends to have stronger peer networks to support transitions to the community;
  • The population is more likely to benefit from MFP initiatives aimed at supportive housing, such as securing housing vouchers or rental assistance programs; and
  • Each state made improvements in integrating mental health services with other community-based long-term services and supports providers; and
  • MFP programs applied universal approaches to all transitioning nursing home residents; they were not designed or applied in a manner to produce the larger benefit seen in the non-aged population discussed above.
Read the evaluation here.
SAMHSA Announces State Funding Opportunity to Tackle Opioid Crisis
On December 14, the Substance Abuse and Mental Health Services Administration (SAMHSA) announced the availability of State Targeted Response to the Opioid Crisis grants. These grants will make available up to $970 million in funds over the next two federal fiscal years for states to address the opioid crisis. This funding was made available as part of the recently enacted 21st Century Cures legislation.


More information on this opportunity is available on SAMHSA’s website here. Grant applications are due on February 17, 2017, and technical assistance webinars are set for December 21 and January 18.


CMS Launches New HIV Health Improvement Affinity Group Website
In collaboration with the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA), CMS recently launched the HIV Health Improvement Affinity Group (HHIAG), a 12-month initiative aimed at improving sustained virologic suppression among Medicaid and CHIP enrollees living with HIV. The states participating in HHIAG (Alaska, California, Connecticut, Georgia, Illinois, Iowa, Louisiana, Maryland, Massachusetts, Michigan, Mississippi, Nevada, New Hampshire, New York, North Carolina, Rhode Island, Virginia, Washington, and Wisconsin) will develop and implement performance improvement projects that address gaps along the HIV care continuum.

The initiative’s new website can be found here.

CMS Publishes Person and Family Engagement Strategy
Finalized on November 22, CMS’s Person and Family Engagement (PFE) Strategy supports the implementation of the CMS Quality Strategy Goal 2 (“Strengthen persons and families as partners in their care”). The main elements of the Strategy include self-management, informed and empowered decision-making, adequate health literacy, and (when appropriate) engagement of family and friends. Through the PFE Strategy, CMS hopes to actively encourage PFE by:
  • Promoting tools and strategies that reflect person and/or family values and preferences;
  • Creating an environment where persons and their families work in partnership with their health care providers; and
  • Developing criteria for identifying PFE best practices and techniques in the field from CMS programs, measurements, models and initiatives.
Read more about the Strategy here.


ASPE Issue Brief Highlights Minnesota’s Integrated Care Experience
On December 5, the Assistant Secretary for Planning and Evaluation (ASPE) released an issue brief on Minnesota’s Senior Health Options (MSHO) program, discussing its impact and its future direction. The issue brief highlights the findings from ASPE’s recent study on MSHO. It notes that when compared to similar beneficiaries, MSHO enrollees were 48% less likely to have a hospital stay and 6% less likely to have an outpatient ED visit between 2010 and 2012. Making better use of primary care, MSHO enrollees also had 26% fewer specialist visits and were more likely to use home and community-based long-term care services, potentially helping to prevent long-term nursing facility use.

Despite the progress achieved via MSHO, the issue brief discusses opportunities to further improve beneficiary experience by strengthening administrative integration of the Medicare and Medicaid programs.

Please find link to brief here.


Hill Update


Congressional Committee Leaders Seek Medicaid Expansion Oversight Details from CMS
On December 19, Senate Finance Committee Chairman Orrin Hatch, House Energy and Commerce Committee (E&C) Subcommittee on Health Chairman Joseph Pitts, and E&C Subcommittee on Oversight and Investigations Chairman Tim Murphy sent a letter to CMS Acting Administrator Andy Slavitt seeking detailed information regarding CMS’s oversight of the Medicaid expansion. The letter calls out the fiscal impact of the Medicaid program to states and the federal government, in part due to the Medicaid expansion under the Affordable Care Act. It goes on to ask a series of questions related to:
  • Eligibility and FMAP.
  • How CMS is working with states.
  • Per capita spending for Medicaid expansion individuals.
  • The role of Medicaid expansion and other federal programs.
Read the letter here.
Congressional Republicans Seek Input on Medicaid Reform from Governors
On December 13, Republican members of the Senate Finance Committee sent a letter to the Republican Governors Association seeking input on Medicaid reforms. The letter requests input on pathways for states to: enhance the federal/state partnership, design flexible Medicaid programs, improve care for dually eligible Medicare-Medicaid beneficiaries, and streamline federal approval of state innovations. In the letter, the Senators note that responses will be used to help inform a roundtable discussion between Senators and Governors in January.


A similar letter originating in the House was recently sent to all Governors, with an additional focus on potential private insurance reforms stemming from repeal of the Affordable Care Act.


Congressional Republicans Seek Input on MDRP Oversight, EpiPen Misclassification
On December 9, House Energy and Commerce (E&C) Chairman Fred Upton, E&C Health Subcommittee Chairman Joe Pitts, E&C Oversight and Investigations Subcommittee Chairman Tim Murphy, and Senate Finance Committee Chairman Orrin Hatch sent a letter to CMS Acting Administrator Andy Slavitt on the misclassification of the EpiPen product in the Medicaid drug rebate program (MDRP). The letter reviews the history of EpiPen manufacturer Mylan’s misclassification of the product, and expresses concern that CMS failed to take action upon learning that the product was misclassified.


The congressional leaders request CMS answer several questions concerning EpiPen, including:
  • When the misclassification was discovered, what steps were taken to notify CMS leadership and Mylan, when Mylan was told to be in compliance, and what the current EpiPen classification is;
  • Whether CMS worked with the Department of Justice or the HHS Office of the Inspector General to explore the use of civil monetary penalties against Mylan;
  • Whether Mylan is using the processes for an exception to MDRP classification outlined in the final outpatient drug rule;
  • How much savings would have been achieved if Mylan properly classified EpiPen in 1997; and
  • Whether the misclassification impacted the 340B program.
Read the letter here.


In the News


Morning Consult Covers CDC Findings on 2015 Opioid Overdose Deaths
New data released by the CDC on Friday, December 16 show that nearly two-thirds (63%) of the 52,000 drug overdose deaths in 2015 were linked to a prescription or illicit opioid, Morning Consult reports. The data also reveal that the death rates for synthetic opioids grew by 72.2% from 2014 to 2015, with synthetic opioid and heroin death rates up across all age groups for men and women over 15, and among all races and ethnicities. The CDC data coincide with a bill President Barack Obama signed into a law last week, awarding $1 billion in funding to aid states in the fight against opioid addiction.


Please find link to article here.
California Health Line Reports on Plans for DSRIP
This article explores how California is seeking to use its DSRIP to reduce unnecessary emergency room visits and hospital stays among vulnerable individuals, including ex-prisoners and the homeless, as well as people who have multiple chronic illnesses, substance abuse problems, and mental health disorders. It discusses how the initiative will blend physical care, mental health care, and social services for the participants. Spanning 18 counties, the effort’s mechanisms will vary per what’s most structurally and politically appropriate for each setting. In Orange County, for example, officials plan to link homeless residents to primary care providers and help them find places to live, whereas in Placer County, participants will each have an intensive care plan including abuse treatment, mental health care, and/or peer support.


Please find link to article here.


Take Note


MACPAC Recommends Five Year CHIP Funding Extension
Last Thursday, December 15, the Medicaid and CHIP Payment and Access Commission (MACPAC) recommended five additional years of federal funding for the CHIP (extending it to FY 2022), calling for action “as soon as possible” to preserve coverage for more than 8 million low- to moderate-income children and mitigate budget uncertainty for states. This recommendation is part of a broader set of MACPAC recommendations on insurance coverage for low- and moderate-income children and innovations that could improve children’s coverage in the future. Other MACPAC recommendations include:
  • Extending the current CHIP maintenance of effort provision (MOE)-now set to expire at the end of FY 2019-for three additional years, through FY 2022, as well as the current federal CHIP matching rate;
  • Creating a new state demonstration grant program to support the development and testing of state-based innovations;
  • Ending waiting periods in CHIP in order to minimize the potential for gaps in children’s coverage;
  • Eliminating CHIP premiums for children with family incomes below 150% of the federal poverty level;
  • Permanently extending states’ authority to use Express Lane Eligibility to streamline and facilitate the application process; and
  • Providing five years of additional funding for grants to support outreach and enrollment of Medicaid and CHIP eligible children, the Childhood Obesity Research Demonstration project, and the Pediatric Quality Measures program.
Please find link to recommendations here.


NGA Report Explores Strategies to Improve Data Sharing Among Providers
The National Governors Association (NGA)’s recently released roadmap outlines strategies for improving health information flow among providers, designed to increase access to information, reduce repetition and errors, and ensure high-quality, affordable care. The roadmap aims to help providers overcome the variety of legal and market-based barriers which preclude the exchange of clinical health information, while still preserving patient privacy.
Please find link to roadmap here.


SHVS Issue Brief Considers Key ACA Repeal Questions for States
A new issue brief from Robert Wood Johnson’s State and Health Value Strategies reflects on the future of the Affordable Care Act (ACA), with a particular focus toward low-income individuals. Developed by Manatt Health, the brief provides a series of questions and answers on the potential repeal of the Medicaid expansion, reviewing available information, and highlighting critical questions that states will want to consider as Congress and the incoming Administration continue to debate ACA repeal and replacement.
Please find link to brief here.


Pew Report Considers PDMP Optimization Approaches
This report, written by researchers from the Institute for Behavioral Health, Heller School for Social Policy and Management at Brandeis University in collaboration with The Pew Charitable Trusts, discusses ways to maximize Prescription Drug Monitoring Programs (PDMPs). The report notes opportunities to improve these state-based electronic databases, which contain information on controlled substance prescriptions dispensed by pharmacies and prescribers to help reduce their misuse and “diversion.” The report identifies several strategies for increasing provider utilization of the databases, including provider use mandates, delegation, streamlined enrollment, and more proactive communication.


Please find the link to the report here.


Maryland Seeking Deputy Director for Budget
Maryland Medicaid is seeking a budget direct to lead the preparation of the annual administrative and provider reimbursement budgets.


More details and application can be found here.



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