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In the newsletter: New guidance on community engagement; Kentucky work requirement waiver approved; MedPAC & MACPAC, Beneficiaries Dually Eligible for Medicare and Medicaid.

January 23, 2018
From the NAMD Desk
In This Issue

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November 12-14, 2018
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Reg Update


State Medicaid Director Letter: CMS Announces New Guidance on Community Engagement
In mid January, the Centers for Medicare & Medicaid Services (CMS) sent a letter to state Medicaid Directors announcing a new policy designed to assist states in their efforts to improve Medicaid enrollee health and well-being through incentivizing community engagement among non-elderly, non-pregnant adult Medicaid beneficiaries who are eligible for Medicaid on a basis other than disability. The policy responds to numerous state requests to test programs through Medicaid demonstration projects under which work or participation in other community engagement activities – including skills training, education, job search, volunteering or caregiving-would be a condition for Medicaid eligibility for able-bodied, working-age adults.
The new policy guidance sent to states is intended to help them design demonstration projects that promote the objectives of the Medicaid program and are consistent with federal statutory requirements. To achieve the objectives of Medicaid, state programs should be designed to promote better physical and mental health.


To date, CMS has received demonstration project proposals from 10 states that include employment and community engagement initiatives: Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin.


“Medicaid needs to be more flexible so that states can best address the needs of this population. Our fundamental goal is to make a positive and lasting difference in the health and wellness of our beneficiaries, and today’s announcement is a step in that direction,” said Seema Verma, CMS Administrator.


To read the letter, please click here. For FAQ’s, please click here.


Kentucky Is First to Receive CMS Approval for Medicaid Work Requirements

On Friday, January 12th, CMS approved Kentucky’s 1115waiver request to impose work requirements for certain state’s Medicaid recipients. The approval is precedent-setting as the first state to gain approval under guidance from CMS (see above) intended to encourage states to apply for waivers mandating Medicaid work requirements. Key components of the waiver include the following:

  • What is the requirement? The waiver requires specified populations of poor adults to work up to 20 hours a week in “community engagement” positions in order to retain Medicaid benefits.
  • What will qualify? Qualifying hours include those spent in work positions, education settings, community service, or job training.
  • What else does the waiver stipulate? The waiver allows Kentucky to add premiums for specified enrollees and disenrollment penalties if set rules are not followed.
Kentucky was one of ten states – including Arizona, Arkansas, Indiana, Kansas, Maine, New Hampshire, North Carolina, Utah and Wisconsin – seeking waivers from CMS to impose Medicaid work requirements in exchange for continued eligibility.


According to state officials, Kentucky’s Medicaid waiver is projected to save the state $2 billion over the course of five-years and will result in 95,000 fewer people on Medicaid.


BCPI Advanced: CMS Announces New Demonstration for Bundled Payments for Care Improvement
CMS has announced a voluntary Bundled Payments for Care Improvement Advanced demonstration (BCPI Advanced) that requires participants to take on financial risk and includes outpatient and inpatient episodes of care. Specifically, BCPI Advanced will test a new iteration of bundled payments for 32 Clinical Episodes and aim to align incentives among participating health care providers for reducing expenditures and improving quality of care for Medicare beneficiaries. This comes after the agency canceled the mandatory Episode Payment Models and the Cardiac Rehabilitation Incentive pay model and shrunk the Comprehensive Care for Joint Replacement demonstration in late November.


The first cohort of Participants will start participation in the Model on October 1, 2018, and the Model Period Performance will run through December 31, 2023. CMS will provide a second application opportunity in January 2020.


To learn more, please click here. Partner Workgroup
The CMCS team invites you to participate in an ongoing forum for states and other partners to provide feedback on key changes, updates, and content and functionality enhancements to States and other partners are a key target audience of, and your participation will help us make the site better meet your needs. If you’d like to sign up before the next scheduled meeting (January 25th), please email Ashley Lewis at
Some Frequently Asked Questions are as follows:
1. What’s involved?
  • Standing quarterly webinar meetings; and
  • Email or offline communication between meetings as needed.

2. What kind of feedback or participation is helpful?

  • Feedback on recent changes, especially the usefulness and relevance of information;
  • Feedback on future changes (i.e., content or functionality); and
  • Usability testing.

3.  Will this be a forum to discuss policy questions or issues?

  • No, this group is limited exclusively to the design and maintenance of the website.

4. How will this help me?

  • If you use, your feedback will help make it a better site and easier to use;
  • You’ll get to preview new functionality and tell us what you think;
  • Your perspective is important to us. You may have thoughts or feedback we haven’t considered. Feedback from this forum has already substantively impacted content and functionality of; and
  • If you work on your organization’s website, this is a good chance to collaborate, learn how we manage, and identify ways for our sites to work better together.

Hill Update


Brief Government Shutdown Ends with Senate, House Votes
This weekend saw dramatic headlines as the federal government briefly shut down, after the Senate’s failure Friday evening to pass a continuing resolution (CR) to fund the government. Negotiations continued throughout the weekend and into Monday. On Monday afternoon, the Senate cleared a procedural vote, 81 – 18, to end the shutdown, after Democrats received verbal assurances from Senate Majority Leader Mitch McConnell (R-KY) to hold a vote on immigration within the next month. The House quickly approved the measure and President Trump signed it Monday night.


The Senate package was identical to last week’s House-passed CR in all respects except the timing of the next funding showdown – the Senate set that date at February 8, as opposed to the House’s February 16. Other features – including a six-year extension of CHIP and temporary delays of some ACA taxes – remain in place.


Congress Amps Up Scrutiny of 340B Program with Legislation, E&C Report
Congressional policymakers are turning an increasingly critical eye on the 340B drug discount program, as legislation introduced in both the House and Senate aims to enhance program reporting, transparency, and limit new 340B entities for two years.


The legislative push follows a House Energy and Commerce Committee (E&C) report which takes issue with the inability of Congress to track how savings from the 340B program are spent by program covered entities, as well as a lack of sufficient regulatory authority at the Health Resources and Services Administration (HRSA) to oversee the program. Notably, among the report’s recommendations is a call for minimizing duplicate discounts across 340B and Medicaid.


SFC Advances Alex Azar’s HHS Secretary Nomination
On January 17, the Senate Finance Committee voted 15 – 12 to advance HHS Secretary nominee Alex Azar to the full Senate for consideration. The vote was primarily along party lines, though Democratic Sen. Tom Carper (D-DE) joined the Committee’s Republicans in the vote to advance. Azar’s nomination is expected to clear the Senate when it is considered.


RECAP: Senate Homeland Security and Government Oversight Committee Analyzes Potential Linkages Between Medicaid and the Opioid Crisis
On January 17, the Senate Homeland Security and Government Oversight Committee held a hearing titled “Unintended Consequences: Medicaid and the Opioid Epidemic.” A witness list, submitted witness testimony, and a recording of the hearing is available here.


The hearing focused on whether the Medicaid program, and specifically Medicaid expansion, has inadvertently worsened the ongoing opioid crisis. While state witnesses from Maine and Indiana suggested that their work shows correlations between Medicaid coverage and opioid abuse or diversion, academic testimony stated that evidence showed Medicaid coverage promoted access to opioid treatment, rather than diversion or abuse.


RECAP: HELP Hearing Assesses Causes of Opioid Crisis and Path Forward
On January 9, the Senate Health, Education, Labor, and Pensions (HELP) Committee held a hearing titled “The Opioid Crisis: An Examination of How We Got Here and How We Move Forward.” The hearing featured testimony from Dreamland author Sam Quinones. Submitted witness testimony and a full recording of the hearing is available on the HELP website here.


Discussion at the hearing focused on the need to use federal funding to empower local communities to address opioid addiction, though there was a partisan divide on the applicability of Medicaid expansion as a tool towards this goal.


In the News


Bloomberg: “Wal-Mart to Offer Pill-Disposal Product to Curb Opioid Abuse”
Seeking to curb opioid abuse, Wal-Mart Stores will offer its pharmacy customers a product that disposes of unwanted or expired prescription drugs. As reported by Bloomberg, customers filling a new Class II opioid prescription at any of Wal-Mart’s 4,700 U.S. pharmacies will now receive a packet of DisposeRx, a powder that – when mixed into a pill bottle with warm water – creates a safe, biodegradable gel; those with refillable opioid prescriptions, moreover, will get a free sachet every six months, and customers can request a free packet at any time. Wal-Mart touted the DisposeRx offering as the “first of its kind” because it allows patients to dispose of unwanted or expired pills at home: “The best part is that patients don’t have to take the drugs back to a location,” Marybeth Hays, Wal-Mart’s head of consumables and health and wellness in the U.S., said in an interview. “It can all happen at home.”


To read the full article, please click here.


Kaiser Health News: “When Food Stamps Pass as Tickets to Better Health”
With a $3.4 million grant from the U.S. Department of Agriculture, the University of California-San Diego administers a program, Más Fresco or “More Fresh,” which rewards food stamp beneficiaries for buying more fresh produce (the USDA has funded similar efforts in other states, including Illinois, Georgia, Pennsylvania, Minnesota and New Mexico). Más Fresco is open to Southern Californians in Los Angeles, Orange and San Diego counties who are enrolled in the Supplemental Nutrition Assistance Program, or SNAP – the official name for food stamp benefits. The goal of the four-year program, like that of its counterparts in other states, is to improve diets and overall health by making fresh produce more affordable. “We know food insecurity and, unfortunately, chronic disease go hand in hand,” said Joe Prickitt, a UC-San Diego dietitian who is senior director of Más Fresco. “For SNAP participants, there’s a real cost barrier to buying fruits and vegetables. They say they’re just too expensive.”


To read the full article and learn more about Más Fresco, please click here.


The Washington Post: “Feds Approve Extension of Maryland’s ‘All Payer’ Hospital Model”
Federal health officials have authorized Maryland to continue its unique “all payer” health-care model for hospitals through 2019, while the state seeks approval to apply a similar plan to outpatient service providers such as doctors, skilled nurses, and rehabilitation centers. Officials say expanding the program, which regulates how much hospitals can charge in exchange for having the federal government cover a larger share of Medicare costs than it does in other states, is “one of the strongest steps Maryland can take to fulfill a federal requirement to lower its annual Medicare costs by $330 million.”


To read the full article, please click here.


Modern Healthcare: “CMS Considering First Revisions to Lab Rules in 26 Years”
According to Modern Healthcare, CMS is taking a “hard look at whether regulations governing clinical laboratories need to be updated.” Last week, CMS posted a RFI asking for input from industry leaders, expressing interest in whether personnel requirements, testing standards, and industry fee structures need to be modified. The notice comes as the CMS is implementing a new policy to pay labs the same rate for tests as private payers. Prior to the new payment rule kicking in Jan.1, Medicare’s fee schedule for lab tests had been largely unchanged since it was established in 1984.


“The CLIA regulations have not been meaningfully updated for about a quarter of a century,” said Rodney Rohde, chair and professor of clinical laboratory science at Texas State University. “This notice will be the beginning of a process, that we hope, will create a regulatory environment that improves patient care and gives laboratory professionals an opportunity to have a growing impact on the efficacy of diagnostic decision-making and treatment.”


To read the full article, please click here.


Modern Healthcare “Changes to Medicaid Could Accelerate Hospital Closures”
Authors of a new study published Monday in Health Affairs say any changes that undermine coverage gains made through the Affordable Care Act’s Medicaid expansion could lead to more hospital closures due to financial strain stemming from shrinking Medicaid revenue. In the study, researchers examined CMS data on hospital closures and their financial performance between 2008 and 2016, finding that hospital closure rates were the same from 2010 to 2012 among states that eventually expanded Medicaid versus states that opted not to expand. Beginning in 2013, a year after the U.S. Supreme Court ruled states had the option to expand Medicaid to cover all adults earning up to 138% of the federal poverty level, however, closure rates between expansion and non-expansion states began to diverge: States that did not expand Medicaid had a total increase of 0.43 closures per 100 hospitals between 2008 and 2016 while states that opted to expand saw their closure rate decrease by 0.33 per 100 hospitals during the same period.


To read the full article, please click here.


Health Affairs: “Where Multiple Modes of Medication-Assisted Treatment Are Available”
The opioid epidemic has touched nearly every corner of the United States. Public health officials, lawmakers, and others have recommended a vast scale-up in the capacity of substance abuse treatment in response, especially evidence-backed medication-assisted treatment (MAT). There are currently three drugs used for the treatment of opioid use disorder (OUD): methadone, buprenorphine, and naltrexone. While all three are demonstrated to be effective in treating OUD, not all drugs are appropriate for all patients.  As such, writes Health Affairs, it is not only imperative that treatment facilities and providers offer MAT, but also that multiple treatment options be made available to increase treatment uptake and success.


To read the full article, please click here.

Take Note


MedPAC & MACPAC, Beneficiaries Dually Eligible for Medicare and Medicaid
MACPAC and MedPAC are pleased to issue the fifth edition of their joint data book: Beneficiaries Dually Eligible for Medicare and Medicaid. This book is an ongoing effort on the part of both commissions to create a common understanding of people enrolled in both programs.


Dually eligible beneficiaries receive both Medicare and Medicaid benefits by virtue of age or disability and low income. A majority of them are people with multiple chronic conditions, physical disabilities, or cognitive impairments, but the group also includes individuals who are relatively healthy. Numbering 10.7 million, they make up a relatively small share of beneficiaries in each program but they account for a disproportionate share of each program’s spending. Medicare pays for their primary, acute, and post-acute care services. Medicaid provides assistance with Medicare premiums and cost sharing and covers services that Medicare does not, such as long-term services and supports.


Beneficiaries Dually Eligible for Medicare and Medicaid provides demographic information on the dually eligible population, their use of services, and expenditures on their behalf in 2013 (the most recent year for which data is available). Key statistics from the new 2018 edition of the data book include:
  • Dually eligible beneficiaries accounted for 15 percent of all Medicaid enrollees but 32 percent of all Medicaid spending. Overall, most were female (61 percent), white (57 percent), and lived in an urban area (76 percent).
  • Medicaid spent $118.9 billion compared to Medicare’s $193.5 billion on dually eligible beneficiaries in 2013. Medicaid spending’s cumulative growth was 8 percent and average annual growth was 1.9 percent from 2009 to 2013, compared to Medicare spending growth at 19.5 percent and 4.5 percent, respectively.
  • Although the majority of dually eligible beneficiaries were still in Medicare and Medicaid fee for service, enrollment in managed care was increasing. From 2009 to 2013 enrollment in Medicare Advantage and comprehensive Medicaid managed care rose about 5 percentage points, while enrollment in fee for service declined.
  • The majority (58 percent) of dually eligible beneficiaries were age 65 and older. They were more likely than people under age 65 to qualify for Medicaid due to high medical costs or because they required an institutional level of care.
  • Most dually eligible beneficiaries (72 percent) were eligible for full Medicaid benefits. Almost all Medicaid spending (98 percent) on dually eligible beneficiaries was for these individuals, as opposed to those whose Medicaid coverage was limited to assistance with Medicare premiums and cost sharing.
To read the full data book, please click here.


Bipartisan Policy Center: Reinventing Rural Health Care: A Case Study of Seven Upper Midwest States
In 2017, the Bipartisan Policy Center and the Center for Outcomes Research and Education (CORE) spoke with over 90 national thought leaders and stakeholders about the current state of rural health care in the Upper Midwest region, including Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, and Wyoming. BPC and CORE used these discussions to determine the real-world implications of existing federal policies, understand ongoing care challenges, and identify opportunities for improvement in rural health care access and delivery. A new paper reports these findings, highlighting key takeaways from the roundtables and interviews and identifying four specific areas for developing recommendations:
  1. Rightsizing Health Care Services to Fit Community Needs: Not every rural community needs to have a Critical Access Hospital; communities should tailor available services to the needs of the community, which for many rural areas are driven by changing demographics.
  2. Creating Rural Funding Mechanisms: Once the right system and services have been identified for a community, funding mechanisms and payment models should reflect the specific challenges that rural areas face-such as small population.
  3. Building and Supporting the Primary Care Physician Workforce: With the appropriate services and funding, rural communities can build sustainable and diverse workforces.
  4. Expanding Telemedicine Services: Health professionals working in rural areas need the right tools for success.
To read the full report, please click here.


Joint Report: Ensuring Beneficiary Health and Safety in Group Homes
In a new report, the U.S. Department of Health and Human Services Office of the Inspector General (OIG), the Administration for Community Living, and Office, and the Office for Civil Rights provides suggest model practices to the Centers for Medicare and Medicaid Services (CMS) and states for comprehensive compliance oversight of group homes to help ensure better health and safety outcomes. The report is a response to evidence unearthed by OIG that health and safety procedures were not being followed. The suggested model practices involve four key compliance oversight components:
  1.  Reliable incident management and investigation processes;
  2. Audit protocols that ensure compliance with reporting, review, and response requirements;
  3. Effective mortality reviews of unexpected deaths; and
  4. Quality assurance mechanisms that ensure the delivery and fiscal integrity of appropriate community-based services.
To read the report and learn more, please click here.


BMJ, Postsurgical Prescriptions for Opioid Naive Patients and Association with Overdose and Misuse: Retrospective Cohort Study
According to a new study in BMJ (formerly the British Medical Journal), the duration of opioid use, rather than dosage, is more likely to lead to misuse. Specifically, the study, which tracked opioid prescription refills of half a million patients, shows that each opioid refill was associated with a 44 percent increase in misuse and each additional week of opioid use was associated with a 20 percent increase in misuse. Meanwhile, higher doses of opioids were linked to only a mild increase in the risk of misuse.


To read the study, please click here.


NCHS Releases 2016 Data on Opioid Overdose Deaths
CDC’s National Center for Health Statistics has released their
Data Brief: Drug Overdose Deaths in the United States, 1999-2016. These data come from the National Vital Statistics System (NVSS), showing that deaths from drug overdose are an increasing public health burden in the United States. Some key findings include:
  • More than 63,600 Americans died from a drug overdose in 2016.
  • The age-adjusted rate of drug overdose deaths increased by 21% from 2015 to 2016.
  • Drug overdose deaths were highest among adults aged 25-54, at around 35 deaths per 100,000 Americans.
  • West Virginia, Ohio, New Hampshire, the District of Columbia, and Pennsylvania had the highest observed age-adjusted drug overdose death rates in 2016.
  • The drug overdose deaths involving synthetic opioids other than methadone (drugs such as fentanyl, fentanyl analogs, and tramadol) doubled between 2015 and 2016.
To read the brief, please click here.

Missouri Posting for HealthNet Division Director
The Missouri Department of Social Services is searching for a Director for our MO HealthNet Division. The MO HealthNet Division is the division within the Medicaid single state agency that administers Missouri’s medical assistance programs that purchase and monitor health care services for low income and vulnerable citizens of Missouri.


Below is a full job description for the position, as well as information about Jefferson City. The deadline to apply is January 26, 2018.



Indiana Posting for Pharmacy and Clinical Outcomes Director
The mission of Indiana’s Family and Social Services Administration is to develop, finance, and compassionately administer programs to provide healthcare and other social services to Hoosiers in need in order to enable them to achieve healthy, self-sufficient, and productive lives. As part of the Family and Social Services Administration, the Indiana Office of Medicaid Policy and Planning (OMPP) receives around 13 percent of the state’s budget to ensure vital healthcare coverage for approximately 1 in 5 Hoosiers. This position is responsible for:
  • Effectively administering the state’s pharmacy benefits for 1.4 million Medicaid members;
  • Coordinating population health strategies and integrating novel programmatic interventions that will help contain the cost of drugs and improve member health outcomes;
  • Helping OMPP achieve its mission by effectively promoting population health improvements that have long-term cost containment benefits, which ensures sustainability of the program and longer, healthier lives for vulnerable Hoosiers.
Applications are due by February 15, 2018.



North Carolina Posting for Chief Medical Officer
The North Carolina Division of Medical Assistance (DMA) manages health care services for the most vulnerable North Carolina residents.  With a budget of nearly $14 billion, DMA serves about 2 million low-income parents, children, seniors, and people with disabilities through the NC Medicaid and NC Health Choice for Children programs.


The North Carolina Division of Medical Assistance is seeking a Chief Medical Officer (CMO). This position functions as a key member of the Division Executive Team, providing input into policy decisions and medical leadership to all Medicaid sections and initiatives, with the goal of promoting the delivery of high quality services within a sustainable budget.  The position will also have management responsibilities.  The CMO will interact on a regular basis with Pre-Paid Health Plans (PHP) and Local Management Entities/Managed Care Organizations (LME/MCO) medical directors and clinical and non-clinical staff in other state agencies including the Division of Public Health, Division of Mental Health, Intellectual & Developmental Disabilities, and Substance Abuse, and others as needed. Other key responsibilities include analysis of proposed legislation and testimony at legislative committee meetings, input on state-related payment reform, leadership on Social Determinants, and serving as a liaison to the healthcare provider community.



For more job opportunities, please check out
NAMD’s State Jobs page!



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