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In the NAMD newelstter, the Senate fails to pass Health Reform; Medicare Part-D; core quality measures; MACPAC issue briefs.

August 1, 2017
From the NAMD Desk
In This Issue

Save the Date
NAMD Fall Meeting
November 6-8, 2017
Hyatt Regency Crystal City
Register here.


Reg Update


Informational Bulletin: Annual Re-determination of Medicare Part D Low-Income Subsidy Deemed Status
Last Tuesday, the Centers for Medicare and Medicare Services (CMS) issued an Informational Bulletin (IB) providing information to help states understand the process and their role in ensuring that dual eligible beneficiaries have timely, affordable, and comprehensive coverage under the Medicare Part D prescription drug benefit. As a reminder, the Medicare Part D LIS provides extra help for beneficiaries who have limited income and resources to help them pay for their Medicare prescription drug plans’ premiums, co-payments, and the annual deductible. Medicare beneficiaries who automatically qualify include full-benefit dual eligible individuals, partial dual eligible individuals (Qualified Medicare Beneficiaries (QMB-only), Specified Low-Income Medicare Beneficiaries (SLMB-only), Qualifying Individuals (QI), and people who receive Supplemental Security Income (SSI) benefits but not Medicaid.
The IB can be accessed on here.
NPRM: Proposes a Medicaid Disproportionate Share Hospital (DSH) allotment reduction methodology to implement the annual reductions from FY 2018 through FY 2025
Last week, CMS released a proposed rule delineating a methodology to implement the annual reductions to state Medicaid Disproportionate Share Hospitals (DSH) as required by the Affordable Care Act (ACA). The ACA set forth aggregate reductions to state Medicaid DSH allotments annually from fiscal year (FY) 2014 through FY 2020, and subsequent legislation delayed the start of these reductions until FY 2018. Under current law, these reductions will run through FY 2025.
The NPRM delineates the DSH Health Reform Methodology (DHRM) to implement the allotment reductions set to begin FY 2018. According to CMS, it accounts for relevant data that was unavailable to CMS during prior rulemaking for DSH allotment reductions originally set to take place for FY 2014 and FY 2015. As revealed in the NPRM, in order to implement DHS cuts starting in FY 2018, CMS will calculate each state’s unreduced DSH allotment under the current formula to serve as the base amount to which the state-specific DSH allotment reduction amount will apply annually. CMS proposes to then apply the DHRM to the unreduced DSH allotment amount on an annual basis to calculate the final allotment reductions.
 To access the proposed rule, please click here.
CMS Releases Pediatric Measure Set, Part of the Core Quality Measures Collaborative 
Last Friday, CMS announced the release of a Pediatric measure set as part of the Core Quality Measures Collaborative (CQMC). This release marks the next step forward for alignment of quality measures between public and private payers. Seven of the nine measures in this Pediatric set of quality measures are harmonized with existing state-level measures in the Medicaid and CHIP Child Core Set.
As a reminder, the CQMC core measure sets are intended for practitioner (e.g., physician/clinician) or group practice level accountability. The initial seven core sets, released in February 2016, were in the following areas: Accountable Care Organizations (ACOs)/ Patient Centered Medical Homes (PCMHs)/primary care, OB/GYN, Cardiology, HIV/Hepatitis C, Gastroenterology, Oncology and Orthopedics.
For more information, please click here.
The CMS Medicaid Prevention Learning Network will offer a new affinity group to state Medicaid agencies on Medicaid and school-based health services delivery
The CMS Medicaid Prevention Learning Network plans to offer a new affinity group to state Medicaid agencies on Medicaid and school-based health services delivery. The affinity group will explore ways to partner with schools to improve health outcomes, using the Child Quality Measures Core Set to evaluate progress. The 12-month group will provide expert moderated webinars on a broad range of topics based on the needs of participating states, one-on-one consultation and group opportunities, and a forum to interact with peers to share learnings and experiences. Learn more about the new affinity group with this fact sheet!

CMS asks that interested states send completed Expression of Interest forms or any questions about participating to:  by
August 23, 2017. Six to eight states will be chosen to participate. All interested states who submit the EOI will be given the opportunity to join the group expert webinars.
Informational Bulletin: Medicaid and CHIP Managed Medical Loss Ratio (MLR) Credibility Adjustments
CMS issued an IB providing the required MLR credibility adjustments for Medicaid and CHIP managed care plans with rating periods beginning July 1, 2017 or later.  This bulletin also contains OACT’s methodology for developing the credibility adjustments as required in the final rule and examples of how states should apply the MLR credibility adjustments.  In alignment with MLR requirements for health plans operating in the private market and Medicare Advantage, the Medicaid and CHIP managed care rule provides a credibility adjustment to account for the potential variation in smaller managed care plans.  The credibility adjustment is used to account for random statistical variation related to the number of enrollees in a managed care plan. CMS will publish MLR credibility adjustment factors on an annual basis.
The IB can be accessed here.
New Toolkit for Promoting Access in Medicaid and CHIP Managed Care: Strategies for Ensuring Provider Network Adequacy and Service Availability
CMS released a toolkit to assist states in developing their network adequacy and service availability standards for Medicaid and CHIP managed care.  To develop this toolkit, CMS formed a working group of states to discuss common access challenges and goals, as well as to create a forum for states to present their successful techniques for establishing and monitoring network adequacy in their programs.  The product of this group’s efforts is a compilation of effective and promising network adequacy and service availability strategies and analysis techniques, as well as valuable data sources that states are using to develop and assess the availability of providers and services in their states.
The toolkit can be accessed here.
Washington Dual Demos Report
Last week, the
Washington Final Demonstration Year 1 and Preliminary Demonstration Year 2 Medicare Savings Report was released. The report contains Medicare savings results of the Washington Health Home Managed Fee-for-Service model demonstration under the Medicare-Medicaid Financial Alignment Initiative. Launched in 2013, the demonstration has leveraged Medicaid health homes to integrate care for high-cost, high-risk, full-benefit Medicare-Medicaid beneficiaries. In January 2016, CMS released a preliminary estimate of Medicare Parts A and B savings for the Washington Health Home demonstration for Demonstration Year 1 (Jul. 2013 – Dec. 2014) as part of an issue brief on early findings in Washington. The results presented in the report released last week update the Demonstration Year 1 results, providing a final estimate of Medicare savings for Demonstration Year 1 and a preliminary estimate of Medicare savings for Demonstration Year 2 (Jan. – Dec. 2015). It reveals that: total gross Medicare savings were nearly $35 million in Year 1, and that preliminary saving results for Demonstration Year 2 are around $32 million (for a total of $67 million).
To read the report, please click here. For more information about the Washington demonstration, please click here.
CMS “Back-to-School” Toolkit Now Available
CMS’s new “back-to-school” Toolkit – Connecting Kids to Coverage National Campaign’s School-Based Outreach and Enrollment – includes essential resources linked to partnering with schools, connecting with members of the school community (i.e., superintendents and counselors), and including enrollment into existing school activities. The Toolkit features ready-to-use materials like message guides, templates, resource links, and offers social media graphics for Facebook and Twitter.
Please find the toolkit here, or visit for additional Back-to-School resources.
CMS New Card Project to Tackle Fraud
CMS readying a fraud prevention initiative that will remove Social Security numbers from Medicare cards to help combat identity theft and safeguard taxpayer dollars. CMS will begin mailing new Medicare cards in April 2018 and complete this mailing by April 2019.
For the latest updates regarding this initiative, please click here.
Market Saturation and Utilization Data Tool
CMS has developed a Market Saturation and Utilization Data Tool that includes interactive maps and a dataset that shows national-, state-, and county-level provider services and utilization data for selected health service areas. The fifth release of the data tool includes a quarterly update of the data to the ten health services areas from release 4, and also includes Long-Term Care Hospitals and Chiropractic Services data. Release 5 will therefore include five, twelve-month reference periods and the following health service areas: Home Health, Ambulance (Emergency, Non-Emergency, Emergency & Non-Emergency), Independent Diagnostic Testing Facilities (Part A and Part B), Skilled Nursing Facilities, Hospice, Physical and Occupational Therapy, Clinical Laboratory (Billing Independently), Long-Term Care Hospitals, and Chiropractic Services.
To access the tool, please click here.

Hill Update


Senate Fails to Pass Health Reform; Next Steps Unclear as House Goes to Recess
Topping off a week full of dramatic developments, the early hours of Friday morning saw the Senate’s attempts to advance health reform falter at the final moment. Senators Lisa Murkowski (R-AK), Susan Collins (R-ME), and in a surprise development, John McCain (R-AZ), alongside all Senate Democrats, voted down the Health Care Freedom Act (HCFA). HCFA was a so-called “skinny” repeal package, focused on repealing the individual and employer mandates and certain taxes under the Affordable Care Act (ACA), with the intention of allowing the Senate to enter into a conferencing process with the House to pass more substantial legislation. Prior to this vote, the Senate voted down both the Better Care Reconciliation Act, 43 – 57, and a straight repeal of the Affordable Care Act, 45 – 55.
While 2017 reconciliation instructions remain in effect, there does not appear to be a short-term path to 50 votes for Senate Republicans to achieve ACA repeal. Next steps are not immediately clear, though reports indicate conversations are occurring between Senators Bill Cassidy (R-LA) and Lindsey Graham (R-SC) on a proposal to block grant ACA funding to states, with state option to maintain ACA insurance regulations. That said, the Senate will be turning its attention in the next two weeks to other business, including confirming several Presidential appointees and addressing a defense spending bill.


Given the Senate’s failure to advance a health reform package, the House will be going into August recess. The Senate will follow into recess in two weeks.
RECAP: House E&C Hearing Explores D-SNP Reauthorization
On July 26, the House Energy and Commerce Committee (E&C) Subcommittee on Health held a hearing titled “Examining the Extension of Special Needs Plans.” A recording of the hearing, witness list, and submitted witness testimony is available on E&C’s website here.
The hearing focused on assessing legislative language in the Senate’s CHRONIC Care Act and approved by the House Committee on Ways and Means. Committee members acknowledged the role played by Medicare Advantage Special Needs Plans (SNPs) in promoting care integration for the dually eligible Medicare-Medicaid population. One witness recommended that Congress permanently reauthorize the SNP program, rather than extend authorization by five years as contemplated in the draft legislative language. Another witness recommended that Congress allow Medicare funding to provide home and community-based services for at-risk beneficiaries who are about to achieve dual eligible status.

In the News


TIME: These are the Faces with pre-existing onditions
In a recent piece,
TIME presents moving personal profiles of individuals with pre-existing medical conditions, defined as health issues that pre-date new health insurance coverage. Facing such conditions as cerebral palsy, muscular dystrophy, and Marfan syndrome, these individuals are “terrified” of what the possible repeal of the Affordable Care Act (ACA) could mean for their access to health care, as both the House- and Senate-proposed replacements will allow insurers to charge people with pre-existing conditions significantly more for comprehensive coverage in the individual market than they currently pay. As reported by TIME, this would force many to forego coverage or become financially destitute, precipitating intense fear and anxiety. With “the uncertainty with health care that we’re experiencing right now,” I cannot say “‘Oh, I’ll be ok,'” says Jean Shenk, one of the individuals profiled in the article.
To read Jean Shenk’s story and those others with pre-existing conditions, please click here.
A New Way to Fulfill the Single Biggest Need of Poor Patients: Teeth, reports The Washington Post
Over the past few years, a group of Virginia dentists has developed a new denture-making process which enables them to serve nearly 10 times as many people at Remote Area Medical, a weekend clinic in Appalachia. “When I started, we were doing dentures in the conventional way,” said Scott Miller, a dentist from Bristol, VA. Yet over time, he and his colleagues were able to invent a thermoplastic acrylic that holds its shape after being heated. Now, the dentists have pre-made dentures in six sizes, large to small, that they can mold to a patient’s mouth in a little over a day. Where they used to supply eight set of dentures a year to patients, now the dentists create 50 full and about 30 partial sets, fulfilling the health needs of many more individuals.
To learn more, please click here.


Take Note


Journal of American Medicine: Incidence, Risks, and Types of Infections in Pediatric Long-term Care Facilities
In the United States, more than 26,000 infants, children, and adolescents are discharged annually from acute care hospitals into post-acute care facilities. Infections are a significant cause of morbidity and mortality in this population, but few recent data describe their incidence and effects. In a new study in the Journal of American Medicine, researchers investigated the types of infections diagnosed in residents of pediatric long-term care facilities, calculated infection rates, and identified risk factors for respiratory tract infections (RTIs). They found that RTIs were the most common infections diagnosed, but modifiable risk factors for RTIs were not identified. The researchers recommended that future work should focus on optimizing infection prevention and control strategies to reduce infections, particularly RTIs, in the pediatric long-term care population.
To read the study, please click here.
New England Journal of Medicine: The Role of Science in Addressing the Opioid Crisis
Opioid misuse and addiction is an ongoing and rapidly evolving public health crisis, requiring innovative scientific solutions. In response, and because no existing medication is ideal for every patient, the National Institutes of Health (NIH) is joining with private partners to launch an initiative in three scientific areas:
  • Developing better overdose-reversal and prevention interventions to reduce mortality, saving lives for future treatment and recovery;
  • Finding new, innovative medications and technologies to treat opioid addiction; and
  • Finding safe, effective, nonaddictive interventions to manage chronic pain.
Each of these areas requires a range of short-, intermediate-, and long-term research strategies. Read this article to learn more about the initiative and the NIH’s unique work with private partners. “With our partners,” says the NIH’s Nora Volkow and Francis Collins, we “will take an ‘all hands-on deck’ approach to developing and delivering the scientific tools that will help end this crisis and prevent it from reemerging in the future.”
MACPAC: Four New Issue Briefs
The Medicaid and CHIP Payment and Access Commission (MACPAC) recently released four updated or new issue briefs analyzing key aspects of Medicaid policy in light of the ACA repeal and replace legislation that has been pending before Congress; namely, the House of Representative’s American Health Care Act (AHCA) and the Senate’s Better Care Reconciliation Act (BCRA). The publications include:
  • Medicaid DSH Allotments: How Could Funding for Safety-Net Hospitals Change in 2018 and Beyond?– This issue brief summarizes MACPAC’s projections of fiscal year (FY) 2018 state disproportionate share hospital (DSH) allotments under current law, previously described in MACPAC’s March 2017 Report to Congress on Medicaid and CHIP, and provides new projections of changes in DSH allotments under the AHCA, as passed by the House on May 4, 2017, and the BCRA discussion draft, as released in the Senate on July 13, 2017. Additionally, MACPAC has published a spreadsheet compendium, containing state-by-state projections of federal DSH allotments and safety-net payments under current law as well as under the AHCA and BCRA.
  • Design Issues in Medicaid Per Capita Caps: An Update – This issue brief revisits the design considerations first described in MACPAC’s June 2016 report chapter, Alternative Approaches to Federal Medicaid Financing and subsequently discussed by MACPAC at its January, March, and April 2017 public meetings. It also describes the design choices made under the AHCA as passed in the House on May 4, 2017, and the Senate’s BCRA discussion draft, as made public on June 22, 2017.
  • Medicaid per Person Spending: Historical and Projected Trends Compared to Growth Factors in Per Capita Cap Proposals – This brief looks at historical and projected spending for Medicaid and other payers, and how these compare to common measures of inflation and income. The brief compares projected Medicaid spending growth by enrollee group to the growth factors included in the House-passed AHCA and the Senate’s draft BCRA.
  • The Impact of State Approaches to Medicaid Financing on Federal Medicaid Spending – This issue brief looks at the effect that state approaches to raising the non-federal share have had on federal funding to states. The analysis finds that when state use of legally permissible sources other than general revenue is taken into account, federal share increases nationally by about 5 percentage points. MACPAC writes, the effect at the state level likely varies from the national estimate due to variations in financing arrangements with providers and the allocation of taxing and financing responsibilities between the state and local governments.


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