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In the newsletter this week: NAMD blog on Duals; CMS rulemaking on MEQC, PERM; Managed Care; Opioids; Mental Health legislation; MACPAC report

NAMD Update

June 21, 2016
From the NAMD Desk
NAMD Blog Post Highlights Minnesota Duals Demo’s Successes
On June 17, NAMD published a blog post titled “Investment in Integration for the Dual Eligibles Pays Off.” In it, NAMD calls attention to Minnesota’s successful work on integrating care for the Medicare-Medicaid dually eligible population under its Minnesota Senior Health Options program, which was recently disseminated in an HHS report from the Assistant Secretary for Planning and Evaluation (ASPE). NAMD expresses our enthusiasm for the Minnesota model and the lessons learned, and calls for continued focus on duals integration issues and support from the federal government.


More information on the report is available below in the “Reg Update” section of the newsletter. Read the NAMD blog post here.
In This Issue

NAMD Fall Meeting
Nov. 6-8, 2016
Information and registration


Reg Update


Today, the Centers for Medicare and Medicaid Services (CMS) published a notice of proposed rulemaking implementing changes and updates to the Medicaid Eligibility Quality Control (MEQC) and Payment Error Measure Rate (PERM) programs, based on changes to Medicaid and CHIP eligibility under the ACA.


Proposed changes to PERM include:
  • Review Period: ThePERM program will review Medicaid and CHIP payments made by states July through June of a given year. Under the current rule, the PERM program reviews payments made in a Federal FY (October through September).
  • Eligibility Review Responsibility: A federal contractor will conduct PERM eligibility reviews with support from each state. Under the current rule, states are required to conduct eligibility reviews and report the results to CMS.
  • Eligibility Universe: The PERM program will conduct eligibility reviews (in addition to medical and data processing reviews) on FFS and managed care payments sampled for the PERM program. The eligibility review will be conducted on the beneficiary associated with the sampled claim. Under the current rule, states create separate universes of eligible individuals that are sampled for eligibility review.
  • Federal Improper Payments: Improper payments will be cited if the federal share amount is incorrect (even if the total computable amount is correct). Under the current rule, improper payments are only cited on the total computable amount (i.e., federal share + state share).
  • Sample Sizes: A national sample size will be calculated to meet national Medicaid and CHIP improper payment rate precision requirements.The national sample size will then be distributed across states to maximize precision at the state level, and state-specific sample sizes would be based on factors such as each state’s expenditures and previous improper payment rate.  Under the current rule, state-specific sample sizes are calculated based on the state’s previous improper payment rate and state level precision and combined to total the national sample size.
  • Corrective Action: States will continue to implement Corrective Action Plans (CAPs) for all errors and deficiencies; however, there will be more stringent requirements added for states that have consecutive PERM eligibility improper payment rates over the 3% national standard established under section 1903(u) of the Social Security Act (the Act).
  • Payment Reductions/Disallowances: Potential payment reductions/disallowances under section 1903(u) of the Act will be applicable for eligibility reviews conducted during PERM years in cases where a state’s eligibility improper payment rate exceeds 3%. CMS will only pursue disallowances if a state does not demonstrate a good faith effort to meet the national standard, which is defined as meeting PERM CAP and MEQC pilot requirements.
Proposed changes to MEQC include:
  • The MEQC program will be restructured into a pilot program that states must conduct during their off-years from the PERM program to ensure continuous oversight of both Medicaid and CHIP state eligibility determinations.
  • States will be required to review a number of items not fully reviewed through the PERM program (e.g., negative cases).
  • States will have flexibility in different areas to focus pilot reviews; however, should a state have consecutive PERM eligibility improper payment rates over the 3% national standard per section 1903(u) of the Act, the state will lose this flexibility and CMS will provide direction for reviews.
  • States must submit corrective actions for identified errors.
The rule is available for public inspection here. It will be published in the Federal Register on June 23, and comments will be accepted through August 22, 2016.
CMS Publishes Bulletin on FFP for Managed Care EQR
On June 10, the Centers for Medicare and Medicaid Services (CMS) published an informational bulletin addressing the availability of federal financial participation (FFP) for Medicaid managed care external quality review (EQR). The guidance reviews changes to FFP for EQR under the final Medicaid managed care rule and necessary requirements for receiving FFP, including:
  • The application of mandatory EQR activities to prepaid ambulatory health plans (PAHPs) and certain primary care case management (PCCM) entities;
  • FFP for EQR of managed care organizations (MCOs);
  • FFP for EQR of prepaid inpatient health plans (PIHPs), PAHPs, and PCCM entities;
  • Effective dates for FFP for EQR; and
  • Application of EQR to managed care entities in CHIP.
Of particular note is the immediate change of FFP to the regular 50% administrative match for EQR activities conducted for PIHPs, PAHPs, and affected PCCM entities, as well as any EQR activities conducted for fee-for-service delivery systems. This change went into effect on the final rule’s publication date of May 6, 2016.

Read the bulletin.


CMS Bulletin Surveys State Options for Enrolling and Retaining Eligible Children in Medicaid, CHIP
On June 13, the Centers for Medicare and Medicaid Services (CMS) published an informational bulletin highlighting strategies, options, and authorities available to states to identify, enroll, and retain eligible children in Medicaid and/or CHIP coverage. Identified strategies include:
  • Express lane eligibility;
  • Presumptive eligibility;
  • Continuous eligibility;
  • Lawfully residing immigrant children and pregnant women authorities;
  • Expanding Medicaid to previously uncovered adult populations;
  • Expanding CHIP coverage to dependents of state employees; and
  • Ensuring seamless transitions for young adults.
Read the bulletin.


CMS Publishes Letter on Medicaid Family Planning Services
On June 14, the Centers for Medicare and Medicaid Services (CMS) published a State Health Official (SHO) letter clarifying its guidance on the delivery of family planning services and supplies to all Medicaid beneficiaries. The letter specifically addresses family planning services in FFS and managed care delivery systems; clarifies the purposes of family planning visits; offers strategies for reducing barriers to family planning services; and suggests ways to increase access to contraceptives.


Read the letter.


CMS Issues RFI on Medicaid IT Enterprise Modularity, Pre-Certification
On June 14, the Centers for Medicare and Medicaid Services (CMS) issued a Request for Information (RFI) on Medicaid information technology enterprise modularity and pre-certification of modular solutions. As part of its ongoing strategy to promote modular systems architectures and solutions for Medicaid IT, CMS is seeking public input on the current availability of modular solutions – specifically for clinical data warehouses and identity management.


The RFI is available here.

CMS NPRM Updates Hospitals’ Medicare, Medicaid Conditions of Participation
On June 13, the Centers for Medicare and Medicaid Services (CMS) published a notice of proposed rulemaking (NPRM) which updates the conditions of participation in Medicare and Medicaid for hospitals, including specific changes for critical access hospitals (CAHs). The NPRM’s proposed changes focus primarily on reducing hospital readmission rates, incidences of hospital-acquired conditions, and improving antibiotic usage. Other changes include addressing workforce shortages, reducing barriers to care, and improving patient protections.


A fact sheet providing more detailed analysis of the NPRM is available here.


CMS Blog Hails Positive Results from Minnesota Duals Demonstration
On June 16, senior staff from the Centers for Medicare and Medicaid Services, including CMS Deputy Administrator and Center for Medicare Director Sean Cavanaugh, Medicare-Medicaid Coordination Office Director Tim Engelhardt, and CMS Deputy Administrator and Center for Medicaid and CHIP Services Vikki Wachino wrote a blog entry highlighting the successful outcomes of Minnesota’s duals demonstration initiative, the Minnesota Senior Health Options (MSHO) program. The blog draws on findings from an HHS Assistant Secretary for Planning and Evaluation (ASPE) report, which found MHSO enrollees were:
  • 48 percent less likely to have a hospital stay, and those who were hospitalized had 26 percent fewer stays;
  • 6 percent less likely to have an outpatient emergency department visit, and those who did visit an emergency department had 38 percent fewer visits; and
  • 13 percent more likely to receive home and community-based long term care services.
The blog indicates CMS hopes to use these findings to continue development, testing, and scaling up of successful models for integrating dually eligible populations.


Read the blog and the ASPE report.

CMS Enhances State-Specific Information
Recently, the Centers for Medicare and Medicaid Services (CMS) added additional information to the “By State” section. The section’s state profiles now include a new organizational system and are streamlined to highlight state-specific data rather than national or aggregate data. This information includes information from the adult and child core quality measures reports, as well as updates to state Medicaid eligibility levels.

Hill Update


Senate Moves Forward to Conference with House on Opioid Bills
Last week, the Senate voted 95-1 to go to conference with the House on opioid legislation in an effort to send a final bill to the president’s desk before Congress goes to recess in mid-July. Among the senators who will serve on the conference committee alongside 35 House members include: Sens. Chuck Grassley (R-IA), Lamar Alexander (R-TN), Orrin Hatch (R-UT), Jeff Sessions (R-AL), Patrick Leahy (D-VT), Patty Murray (D-WA) and Ron Wyden (D-OR). Sen. Mike Lee (R-UT) was the only senator to vote against the motion. Notably, Sens. Sheldon Whitehouse (D-RI) and Rob Portman (R-OH), primary sponsors of the Senate-passed Comprehensive Addiction and Recovery Act (S. 524), were not among the Senate’s list of conferees as they are not members of the committee’s jurisdiction over the bill.


Meanwhile, Democrats in both chambers continue to push funding for the bill, which isn’t provided in either chamber’s packages. Republicans have responded that they will provide new funding to fight opioid abuse through the regular appropriations process. A final package on opioids has been viewed by some lawmakers as a way to advance mental health or medical innovation legislation if they are ready to move forward. However, Sen. Alexander – chair of the Senate HELP Committee which has been working on legislation regarding both issues – has said he would have to speak with other conference members about that. “I hope we can get done by mid-July,” he said. “Because it’s an issue that both Democrats and Republicans see as a crisis issue and one that we’d like to deal with.” Meanwhile, Sen. Hatch, chairman of the Senate Finance Committee, has projected that the bill would ultimately pass. “It will put some responsible money trying to resolve that problem, so hopefully it’ll be helpful,” he said.


E&C Unanimously Passes Mental Health Bill
On June 15, the House Energy and Commerce Committee (E&C) unanimously voted to advance H.R. 2646, the Helping Families in Mental Health Crisis Act of 2016, to the full House. Amendments to include gun violence provisions were kept from the legislation, along with further negotiations around more controversial provisions included in initial drafts. Timing for introducing the bill to the House floor is currently uncertain, with E&C Chairman Fred Upton (R-MI) anticipating such a step being taken in the fall.

In the News


Los Angeles Times Reports on Prospects of Nonexpanding States’ Fight Against Opioid Addiction Epidemic
The deepening heroin and prescription opioid crisis has shed light on the thousands of poor patients with addiction who cannot get treatment in states where political leaders have opposed the Affordable Care Act. One such state is Missouri, whose State Medicaid Director Joe Parks purports that “the best way to get treatment if you’re addicted to drugs…is to get pregnant.” Missouri had the 16 th highest rate of opioid overdose deaths in 2014, caused by widespread abuse of prescription painkillers and inexpensive heroin. Without Medicaid coverage, it has become virtually impossible for low-income individuals to get the help they need, with a year of treatment running as high as $10,000. While lawmakers in the House and the Senate have recognized this problem and are working on legislation that would ameliorate these prohibitive costs, it is expected that it will serve as mere “window dressing” for Missouri and other states that haven’t expanded Medicaid.


Read the article here.


Delaware Takes Steps to Address HCV Costs While Ensuring Medicaid Beneficiaries Qualify for Treatments, Newsworks reports
In 2015, Delaware spent $13.5 million to treat 141 people suffering from hepatitis C, representing less than 9% of the state’s total identified HCV patient population. To control these exorbitant costs, Delaware recently took steps to restrict Hepatitis C drugs to only those who have serious liver disease, echoing the actions of New Jersey and several other states. But facing pressure from lawyers, patients and doctors, Delaware Medicaid Director Stephen Groff decided to phase out any disease criteria in order for Medicaid beneficiaries to qualify for treatment – a “huge step,” according to advocates. In his own words, Groff is “happy we’re moving forward, so we’re insuring all of our members who need treatment are able to access that treatment.”
Read the article here.
Billings Gazette Reports on Implications of Montana Medicaid Copay Increases
On June 1, planned increases in Montana Medicaid copayments went into effect, carrying implications for a number of medical services covered for state Medicaid members, both above and below the federal poverty line (FPL). Spurred by a provision in the recent Montana Medicaid expansion (HELP Act), the increases for individuals with a household income below 100% of the FPL range from $1 to $4 per visit or service, while a handful of services for this population (e.g., generic drugs, approved preventative services, etc.) no longer require co-payments. On the other hand, those whose income is
above 100% of the FPL will pay a 10% co-payment of the amount reimbursed to a provider for a Medicaid-covered service. For individuals on both sides of the 100% FPL benchmark, however, total co-payments will not exceed 5% of the total household quarterly income; in addition, providers will not be able to turn away people who are below the 100% of the FPL and unable to pay the co-payments. Yet even with these “individualized” provisions, it is feared that the increases will have devastating ramifications for Medicaid beneficiaries in the state, especially the poor and most vulnerable.


Read the article  here.

Take Note


MACPAC Releases June 2016 Report to Congress
Earlier this month, the Medicaid and CHIP Payment and Access Commission (MACPAC) published its June 2016 report to Congress. The report’s chapters cover:
  • Trends in Medicaid Spending: The Commission discusses the growing share of federal and state spending on the Medicaid program, but notes that compared to other payers, the Medicaid program’s per beneficiary spending is growing at a comparable or slower rate since the early 1990s. Two-thirds of the program’s spending growth is attributable to increased enrollment, with the remainder attributable to increased spending per beneficiary. 2014 Medicaid spending was impacted by a 20% increase in prescription drug expenditures, driven primarily by hepatitis C therapies and other high-cost drugs. The Commission expects Medicaid spending growth in the drug space to decline in future years, and for overall Medicaid spending to increase by 6% annually over the next decade.
  • State Tools to Manage Medicaid Spending: The Commission analyzes policy levers states possess to control Medicaid spending, including eligibility and enrollment changes, altering provider reimbursements, program integrity initiatives, and delivery system reform. While acknowledging that many drivers of spending growth are beyond states’ control, the Commissioners found that states are focusing on tying payments to quality and outcomes rather than resorting to flat benefit and payment reductions.
  • Medicaid Financing Alternatives: The Commission analyzes a selection of proposed reforms to Medicaid financing, including block grants, capped allotments, per capita caps, and shared savings. This topic remains on the Commission’s research agenda for the coming year.
  • Functional Assessment Tools for Medicaid LTSS: The Commission reports on its survey of 124 identified tools states use to conduct functional assessments for long-term services and supports (LTSS) eligibility, and in some cases, care planning. The chapter analyzes pros and cons of transitioning to a single national assessment tool, concluding that doing so at this time would be premature in light of ongoing LTSS delivery reforms and federal work around LTSS measure development.
MedPAC Releases June 2016 Report to Congress
In its June 2016 Report to Congress, the Medicare Payment Advisory Commission (MedPAC) suggests a wide range of changes to Medicare. With particular relevance to Medicaid, MedPAC:
  • Recommends that Congress should change Part D’s low-income subsidy for beneficiaries with incomes at or below 135% of the FPL to encourage use of generic drugs, preferred multisource drugs, or biosimilars (for which cost-sharing should be reduced or eliminated);
  • Offers principles for MACRA-driven implements of APMs, through which clinicians may receive initial 5% bonuses and later differential Medicare payment updates if the payment entities are controlling cost, improving quality, and bearing financial risk;
  • Addresses lessons learned to informed MACRA’s Merit-based Incentive Program (MIPs) and encourages the use of quality measures to emphasize population-based outcomes;
  • Suggests employment of risk-based payment models (such as Medicare advantage and ACOs) until more is known about the efficacy and costs of telehealth; and
  • Provides a status report on CMS’s Financial Alignment demonstration, an initiative to test new models of care for dual eligibles in 13 states.
Read the new report and corresponding fact sheet.


Kaiser Foundation Brief Examines Policy Issues with Medicaid Hospital Payments
On June 9, the Kaiser Family Foundation published a brief on the impact of expanded coverage under the ACA (as well as recent changes to Medicaid supplemental payments) on Medicaid hospital payments. Overall, it reveals that hospitals have financially benefited from the ACA coverage expansions and increases in Medicaid payments, especially in states that have expanded Medicaid (between 2013 and 2014, uncompensated care decreased from $34.9 billion to $28.9 billion nationwide, 95% of which was driven by expanding states). While hospitals certainly expect to benefit from these decreases in uncompensated care, it is also anticipated that lowered costs may be offset by volume-generated increases in Medicaid payments. It is also expected that other changes to Medicaid payment policy (such as required reductions to DSH payments and policy changes to limit the use of other supplemental payments) are likely to have a
more substantial effect on Medicaid hospital payment and overall hospital financial performance in the future.
Read the issue brief here.
The Commonwealth Fund Examines Issues in States Not Expanding Medicaid
On June 16, the Commonwealth Fund issued a brief analyzing a sample of silver plans offered in the largest markets in 18 states that use the federal website for marketplace enrollment and have not expanded Medicaid eligibility as a comparison to Medicaid protections. Using the example of a 40-year-old, nonsmoking man who earns $13,000 a year (about 110% of poverty), the brief finds that enrollees in most silver plans analyzed are at risk of incurring premium and out-of-pocket costs that are higher than what they would pay under Medicaid. The premium and out-of-pocket costs in the marketplace plans in these 18 states average at $510, ranging from $324 (Texas) to $764 (Kansas). Medicaid beneficiaries, on the other hand, do not pay anything for premiums; have an enhanced set of essential benefits; and enjoy smaller out-of-pocket limits.


This research incorporated five Medicaid expansion states (Arkansas, Indiana, Iowa, Michigan, and Montana) that are allowed under Section 1115 authority to charge premiums of 2% of income, or flat fees that range from $10 to $25 per month, to enrollees with incomes between 100-138% of poverty.

Read the brief here.


CDC Launches Webinar Series on Revised Opioid Prescribing Guidelines
The Centers for Disease Control and Prevention (CDC) recently announced a webinar series to explore in detail its recently-released opioid prescribing guidelines. More information about these webinars can be found on CDC’s website here. Below are the first four scheduled webinar topics and dates in the series.
  • June 22 – Webinar 1: Overview of the CDC Guideline for Prescribing Opioids for Chronic Pain (Addressing Recommendations 1-12)
  • July 27 – Webinar 2: Non-opioid treatments (Addressing Recommendation 1)
  • August 3 – Webinar 3: Assessing benefits and harms of opioid therapy (Addressing Recommendations 1, 2, 7, 8)
  • August 17 – Webinar 4: Dosing and titration of opioids (Addressing Recommendations 4, 5, 7)
Please visit the following page for more information about this webinar series:



Nebraska has 2 Positions Open – Deputy Director of Finance and Program Integrity and Financial and Business Operations Administrator
First, the Nebraska Department of Health and Human Services’ Division of Medicaid and Long-term Care (MLTC) is undergoing a period of significant transformation through the implementation of an integrated managed care program for nearly all enrollees, the redesign of the long-term supports and services system, implementation of a modern eligibility & enrollment system, and procurement of a state-of-the-art data management & analytics system to better support business and operational needs.


There is now an exciting opportunity for a highly motivated and energetic individual to join the executive leadership team as one the division’s four deputy directors to help lead and sustain this transformation by overseeing the Division’s financial and program integrity operations, including budget and planning, rates and reimbursement, managed care finance, program financial and operational analyses, provider enrollment, and fraud detection and prevention activities.


Second, the Nebraska Department of Health and Human Services, Division of Medicaid and Long-term Care (MLTC), is seeking an innovative, business minded individual to join an exceptional team of highly motivated and skilled professionals as the Financial and Business Operations Administrator. MLTC is responsible for the provision of health care benefits, largely administered through contracted managed care organizations (MCOs), totaling over $2 billion annually. This position performs highly responsible professional work facilitating the Division’s financial and business activities including business operations, budgeting, rates and reimbursement, forecasting, contractor financial performance analysis, and other financial management analyses. The position reports to and works closely with the Deputy Director of Finance and Program Integrity, and ensures compliance with appropriate legislative, regulatory, accounting, and auditing standards. The successful candidate will be a hands-on working manager who is capable of building and leading a team of dedicated staff.

To view full job descriptions and and application process, please visit state jobs.


South Carolina Seeking Program Managed for Health Programs Operations
The South Carolina Department of Health and Human Services (the Department) is seeking a program manager for Health Programs Operations that is highly motivated and performs well under pressure.  The program manager must be able to communicate/interface with Information Technology resources to ensure transformation of complex business requirements.  The Health Programs team focuses on health outcomes, quality patient care, contract management and the development of innovative programs and policies that improve the overall health of our beneficiaries and the citizens of South Carolina.  The program manager is responsible for the day-to-day operation and implementation of policies of the managed care program that provide Medicaid benefits to recipients in South Carolina.

To view full description and and application process, please visit
state jobs.


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