NAMD Releases Statement on the Senate’s Better Care Reconciliation Act of 2017 (BCRA)
On Monday, June 26th, NAMD released a statement addressing the Senate’s health reform proposal, the Better Care Reconciliation Act (BCRA). The statement, approved by the NAMD Board, discusses the following points:
The value and strength of the Medicaid program;
Medicaid Directors’ ongoing commitment to targeted reforms to improve the program;
Challenges with the envisioned federal financing changes; and
The need to prioritize stabilization of the individual market before returning to measured, deliberate Medicaid reforms.
CMS Releases MACRA Year Two NPRM; Comments Due August 21
On June 20, the Centers for Medicare and Medicaid Services released a public inspection version of a Notice of Proposed Rulemaking (NPRM) on the second year of the Quality Payment Program (QPP) established by the Medicare Access and CHIP Reauthorization Act (MACRA). The Federal Register version will be published on June 30, and comments must be submitted by August 21.
The NPRM envisions iterating on the first year of the QPP, with more support for small practices. Of relevance for Medicaid Directors is the rule’s provisions on All Payer Combination Advanced Alternative Purchasing Models (APMs), which include:
Adding a revenue-based nominal amount standard of 8 percent in addition to the benchmark-based nominal amount standard. CMS says this standard would be applicable only to payment arrangements in which risk is expressly defined in terms of revenue, and would not replace or supersede the expenditure-based standard previously finalized.
Proposing to conduct all Qualifying Participants (QP) determinations under the All-Payer Combination Option at the individual eligible clinician level. All-Payer Combination Option QP determinations would be made based on 2 periods: January 1 – March 31 or January 1 – June 30.
Creating a separate All-Payer QP Determination Period lasting from January 1 – June 30 of the performance year.
Modifying the information required to make determinations of Other Payer Advanced APMs after the All-Payer QP Performance Period, as well as the information required to perform QP determinations under the All-Payer Combination Option.
Beginning in performance year 2019, creating a process for payers to submit certain authorized payment arrangements before the relevant All Payer QP performance period, which would allow certain other payers to request that CMS determine whether their other payer arrangements are Other Payer Advanced APMs. The authorized payment arrangements would be those authorized under Title XIX, Medicare Health Plan payment arrangements, and payment arrangements in CMS Multi-Payer Models.
CMS Solicits Letters of Intent for the Second Round Medicare-Medicaid Accountable Care Organization Models
The Medicare-Medicaid ACO (MMACO) Model initiative is designed to improve the quality of care and lower costs for dually eligible beneficiaries. Through MMACO, the Centers for Medicare & Medicaid Services (CMS) is partnering with interested states to offer new and existing Medicare Shared Savings Program ACOs the opportunity to take on accountability for the Medicaid costs for their assigned Medicare-Medicaid enrollees. The MMACO model is open to all states and the District of Columbia that have a sufficient number of Medicare-Medicaid enrollees in fee-for-service. CMS will enter into Participation Agreements with up to six states, with preference given to states with low Medicare ACO saturation.
The deadline for states to submit letters of intent for the one-year performance period starting January 1, 2019 is August 4, 2017. The first round of models was announced in December 2016, and a third round of models will start January 1, 2020. ACOs in a state can apply to participate in the model after a state is selected by CMS. Interested states may want to focus first on the nine-page CMS Frequently Asked Questions document, and then review the 34-page Request for Letters of Intent for more details. Additional information is available on CMS’ website.
Balancing Incentive Program State Case Studies
To learn more about how states are transforming their long-term services and supports (LTSS) systems under the Balancing Incentive Program (authorized by Section 10202 of the Affordable Care Act), CMS and its technical assistance provider, Mission Analytics, selected five Program states that implemented structural changes successfully and used Program funds innovatively to expand access to community LTSS: Mississippi, Texas, New Hampshire, Massachusetts and New Jersey. To access these case studies, please visit this link.
Adult and Child Core Set Data Products and Tools
The Center for Medicaid and CHIP Services (CMCS) is pleased to announce the release of FFY 2015 Adult and Child Core Set data and additional resources. Additionally, both the 2014 and the 2015 performance data is now available as a dataset on data.medicaid.gov. Please see the links below for the full set of Adult and Child Core Set Measure reporting resources:
In addition, the FFY 2017 Technical Specifications and Resource Manuals for the Adult Core Set, the Child Core Set, and the Maternal and Infant Health (MIH) Initiative are now available. There are additional resources to help states calculate and report the measures: Summary of Changes, Data Quality Checklists, and Measurement Period Tables. Please see the links below for the full set of Core Set measure resources:
For Technical Assistance related to the Adult and Child Core Set measures, as well as the Health Home Core Set and MIH Initiative measure, please contact MACqualityTA@cms.hhs.gov.
Senate Leadership Releases Health Reform Package; Aiming for Vote This Week
On June 22, Senate Republican leadership publicly unveiled the results of weeks of closed-door negotiations to repeal and replace the ACA. The legislative package, called the Better Care Reconciliation Act (BCRA), uses the House-passed American Health Care Act as a starting point, but includes changes to the individual market and to the House’s Medicaid provisions. A brief synopsis of the Medicaid provisions are below.
Requires CMS to coordinate with state Medicaid Directors and their Association prior to issuing Medicaid rulemaking.
Allows grandfathering of managed care 1115 waivers under certain conditions.
Grants states the option to provide Institutions for Mental Disease (IMD) services for adults aged 21 – 65 for no more than 30 consecutive days per admission and 90 days per year.
Converts federal Medicaid financing to a per capita cap system. States choose the base period by selecting eight consecutive calendar quarters between Q1 2014 and Q3 2017. The caps will grow at CPI-medical or CPI-medical plus one percentage point, depending on the population in question, through FY 2024. Starting FY 2025, the caps grow at CPI-U for all populations. Caps will be adjusted up to 2% for the highest and lowest-spending states.
Maintains Medicaid expansion through 2019. No new expansions can take place starting in CY 2020. For states expanding under the ACA, enhanced FMAP is maintained through 2019, then begins phasing down the enhanced expansion FMAP starting FY 2020 – 2023 before eliminating the enhanced FMAP by 2024. States expanding Medicaid after March 1, 2017 receive no enhanced FMAP.
Non-expansion states are exempted from the ACA’s DSH cuts. Non-expansion states below the FY 2016 national ratio of DSH allotments to Medicaid enrollees will have their FY 2020 allotments adjusted such that they would meet the FY 2016 average.
Creates a safety net funding pool for non-expansion states, available from FY 2018 – 2022.
Allows states to impose work requirements on certain adult populations.
Allows states to select a block grant option for Medicaid.
Eliminates the 1915(k) Community First Choice enhanced FMAP in CY 2020.
Gradually reduces the allowable provider tax percentage from 6% to 5% from FY 2021 – 2025.
RECAP: E&C Health Subcommittee Hearing on Safety Net Program Funding
On June 23, the House Energy and Commerce Committee (E&C) Subcommittee on Health held a hearing titled “Examining the Extension of Safety Net Health Programs.” A recording of the hearing, full witness list (including Texas Medicaid Director Jami Snyder), and submitted witness testimony is available on E&C’s website here.
The hearing explored issues around extending funding for federally qualified community health centers (FQHCs) and the Children’s Health Insurance Program (CHIP). Republicans on the committee noted their desire to see FQHCs maximize the impact of existing funds, as well as questioned the sustainability of the 23% enhanced FMAP for CHIP. Democrats focused on the Senate BCRA, released the day prior to the hearing, and noted links between Medicaid, FQHCs, and CHIP.
Witnesses focused on the importance of funding both FQHCs and CHIP, noting the enhanced flexibilities states have for administering CHIP, and the timing of state budget cycles which should expedite Congress’s decisions on funding.
In the News
Celebrating Montana Medicaid Director Mary Dalton’s 30 years of service
In this piece in the Missoulian, Montana Department of Public Health and Human Services Director Sheila Hogan honors her colleague Mary Dalton’s “tremendous and influential role to improve healthcare access for Montana residents.” With Mary Dalton’s retirement from the Medicaid agency, says Hogan, endures “a legacy that will impact generations to come.”
Click here to learn about the incredible work Dalton has done as Medicaid Director to advance programs like Healthy Montana Kids and the HELP Plan, as well as an initiative focusing on tribal-led health promotion and disease prevention.
With an Obamacare repeal, some fear opioid deaths will rise, reports the Los Angeles Times
Along the front lines of the drug epidemic, there is growing fear that the rush to repeal and replace Obamacare could aggravate the opioid crisis that last year claimed more than 50,000 lives. In recent years, reports the Los Angeles Times, Medicaid has emerged as one of the most important tools in the opioid crisis, with Obamacare funding allowing Medicaid coverage for poor, working-age adults, a population traditionally not eligible for coverage. In Ohio, for example, more than a third of the approximately 700,000 people who enrolled in Medicaid after the expansion began in 2014 reported some drug or alcohol dependence, according to a recent study. Before expansion, many of these individuals had to rely on a patchwork system of treatment programs that was as poorly coordinated as it was unpredictably funded, discouraging some patients from even seeking care. Now, nearly three-quarters of new Ohio Medicaid enrollees with a substance abuse disorder report better access to care. In the eyes of many, the Affordable Health Care Act (AHCA) will threaten this progress. According to Dr. Shawn Ryan, president of BrightView Health, a network of drug treatment clinics in Cincinnati, “It would essentially write off a generation…It would be catastrophic.”
Bloomberg: “Opioids Given to Almost 1 in 4 Medicaid patients”
According to new analysis by Express Scripts Holding Company, one of the largest managers of Medicaid plans’ drug benefits for the past two decades, 6 percent of all prescriptions in Medicaid have been for pain pills over the past two decades. Nearly one in four people on Medicaid, moreover, received powerful and addictive opioid pain medicines in 2015. Analyzing 1.8 million opioid prescriptions written for 3.1 million Express Scripts Medicaid members across 14 states in 2015 at a total cost of $90.1 million, the report also found that among the Express Scripts Medicaid members prescribed the pain pills, 28.5 percent received more than a month’s worth of the drugs.
National Governors Association, Shared Priorities from the Governors’ Bipartisan Health Reform Learning Network
In early June, the National Governors Association Center for Best Practices’ (NGA) Governors’ Bipartisan Health Reform Learning Network (Network) convened to discuss state-based ideas on how to continue to improve the U.S. health care system. Please click here for an overview of the Network’s key takeaways in the following areas:
Strengthening the state federal partnership (i.e., establishing an adequate transition period for federal legislative and regulatory changes, balancing cost-sharing between state and federal government, etc.);
Private health insurance priorities, including stabilization of the private health insurance market, achieving state authority and flexibility, and maintaining the affordability and accessibility of health insurance;
Medicaid priorities, including providing states the flexibility to innovate and tailor solutions, investing in delivery system and payment reform, and addressing the cost drivers in health care; and
Public health priorities, including maternal and child health and the opioid crisis.
NASBO 2017 Fiscal Survey of States Examines Medicaid Cost Growth
The National Association of State Budget Officers (NASBO) recently released their Spring 2017 fiscal survey of states, which examines the landscape of state revenues and expenditures. In particular, it explores Medicaid spending growth in FY2016 and projections for FY2017 and FY2018. It finds that:
Medicaid general fund spending growth continues to exceed general fund revenue growth. The median general fund revenue growth is projected to be 3.1 percent in FY2018 and Medicaid spending growth from general fund is expected to be 4.8 percent in FY2018.
In FY2016, Medicaid spending grew by 5 percent and in FY2017 Medicaid spending is estimated to increase by 5.3 percent.
Governors’ recommended budgets for FY2018 assume a median growth rate of total Medicaid spending of 3.5 percent.
More states are proposing restricting provider rates and benefits in FY2018 than in the previous few years. In FY2018 proposed budgets, 20 states propose restricting provider rates and 12 states propose restricting benefits.
About half of Medicaid expansion states indicated savings in state-funded behavioral health and correction programs, and about two-thirds of expansion states reported savings in state uncompensated care expenses.
Kaiser Family Foundation: 5 Options to Respond to Per Capita Caps
Congress is debating the Affordable Health Care Act (AHCA) that would end the enhanced matching funds for the Affordable Care Act (ACA) Medicaid expansion and would also end the program-wide guarantee for federal Medicaid matching dollars by setting a limit on federal funding through a block grant or per capita cap. In a new brief, the Kaiser Family Foundation discusses five key measures states could use to manage their budgets and the associated challenges under a per capita cap:
1). Raise taxes or make budget cuts;
2). Reduce benefits not required by statute;
3). Limit coverage of high-cost enrollees;
4). Reduce provider rates or implement delivery system reforms; and
5). Implement policies to promote personal responsibility.
Urban Institute, Medicaid and CHIP for Children – Trends in Coverage, Affordability, and Provider Access
Using data from the National Health Interview Survey (NHIS), this report from the Urban Institute assesses changes in Medicaid and CHIP coverage for children between 2008 and 2015. It finds that:
The share of children with Medicaid/CHIP coverage increased by 8.9 percentage points between 2008 and 2018, amounting to an estimated 6.8 million children.
Financial barriers declined over this period for children covered by Medicaid/CHIP, leading to significant decreases in the share of children who did not receive or who delayed care because of cost, as well as the share of children in families that had problems paying medical bills.
Nearly all children covered by Medicaid/CHIP had a usual source of care, and just over one in ten saw a specialist, but these figures did not change substantially over time.
Between 2008 and 2015, the share of children who delayed care for reasons other than cost decreased from 14.2 to 11.5 percent. This decrease was driven by declines in care delays related to long waits at the doctor’s office, inconvenient doctor’s office hours, and difficulty reaching the doctor’s office by phone.
The Director of Medical Services works under administrative direction of the Department of Human Services (DHS) Director for the Division of Medical Services (DMS), and is responsible for directing operations of the State Medicaid programs by developing and establishing work priorities, standards of performance, reviewing and approving managerial decisions, and monitoring budgetary needs and expenditures for the Division. The Director of Medical Services is the State Medicaid Director as recognized by the federal financing agency, the Centers for Medicare and Medicaid Services (CMS), and is the primary liaison with CMS, the Legislature, the Governor’s Office, approximately 27,000 Medicaid providers, provider associations, professional associations, as well as other State Medicaid Directors.