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In the newsletter we cover Opioids, Access Rule guidance, Medicare Part D, NASBO expenditure report and state job opportunities.

November 28, 2017
From the NAMD Desk
In This Issue

Save the Date
NAMD Fall Meeting
November 12-14, 2018
Washington Hilton, Washington, D.C.



Reg Update


Opioid Costs Could Have Been Massively Underestimated, Says White House
Last Monday (November 20th), the White House Council of Economic Advisors (CEA) released a new report suggesting that the U.S. government has significantly underestimated the cost of the opioid crisis. In adjusting for underreporting of opioids in overdose deaths, including heroin-related fatalities, and incorporating nonfatal costs of opioid misuse, CEA finds that in 2015 the economic cost of the opioid crisis was $504 billion. This is over six times more than the most recently estimated cost of the epidemic.


To read the CEA’s full report, please click here.


President Trump Picks Alex Azar to Lead Health and Human Services
President Trump announced two weeks ago that he was nominating Alex Azar as Secretary for Health and Human Services (HHS), a role vacated by Tom Price. Mr. Azar worked as deputy secretary of HHS under the George W. Bush administration before serving as president of an Eli Lily & Co. affiliate. According to former HHS Secretary Mike Leavitt under Bush, Azar is a strong choice, as he “understands the process and he knows the levers and how you make it work and where the potential roadblocks are.”


CMS Informational Bulletin: 2018 Updates to Child Core Set and Adult Core Set
Two weeks ago, the Centers for Medicare & Medicaid Services (CMS) released an informational bulletin (IB) that describes the 2018 updates to the core set of children’s health care quality measures for Medicaid and the Children’s Health Insurance Program (CHIP) (the Child Core Set) and the core set of health care quality measures for adults enrolled in Medicaid (the Adult Core Set).
Please find the IB here.
For more information on Quality of Care Performance Measures, visit here.
CMS Releases Guidance on Access Rule
On November 16, the Centers for Medicare and Medicaid Services (CMS) issued a State Medicaid Director letter providing guidance on the application of the Medicaid fee-for-service access monitoring rule. The guidance specifically aims to clarify how CMS intends to interpret the rule’s requirements for reduced or restructured rates which may result in diminished access.
In the guidance, CMS identifies situations which will not trigger the access monitoring rule’s provisions, including:
  • Reductions to implement other federal Medicaid payment requirements, but only when the state is not or cannot exercise discretion in how the federal requirement is implemented.
  • Reductions which create payment rates that are still at or above Medicare and/or commercial rates.
  • Reductions resulting from changes to the Medicare fee schedule, when a state’s rate methodology is tied to the Medicare methodology.
CMS also identifies situations which may result in reduced access, and advises states to rely on the public notice and comment process to identify access issues. If none are identified or the state takes actions to address concerns raised in the public comment period, the access rule’s provisions will not be triggered. CMS does encourage states to monitor beneficiary and provider feedback in these instances. Examples of these situations include:
  • Reductions agreed to between the state and provider groups;
  • Reductions targeted to a subset of service codes within a category, but which do not reduce the overall net payments within the category by more than four percent;
  • Nominal single-year rate freezes or inflationary updates resulting in less than anticipated rate increases for providers;
  • Rate changes to address program and fiscal integrity or incentivize more efficient care;
  • Reductions for services primarily delivered through managed care, with individuals in FFS either not utilizing the services or only utilize the services prior to transitioning into managed care coverage.
Lastly, CMS clarifies that states with significant managed care enrollment are generally exempted from the access rule’s requirements. The rule applies only to services carved out of managed care, and managed care states should develop access monitoring review plans only for those services and individuals enrolled in FFS beyond a retroactive eligibility or transition period.


CMS Releases Proposed Rule Addressing 2019 Policy and Technical Changes for Medicare Advantage and Part D Plans
CMS has released a highly anticipated proposed rule addressing Contract Year (CY) 2019 Policy and Technical Changes for Medicare Advantage (MA) and Part D plans.
The regulation proposes:
  • Lock-in policies for beneficiaries prescribed opioid medications in Part D, implementing a key part of the Comprehensive Addiction and Recovery Act (CARA);
  • Greater flexibility on MA plan design through elimination of meaningful difference standards and a revised interpretation of the uniformity requirement that would allow cost-sharing and benefits to vary if beneficiaries meet medical criteria; and
  • The ability of Part D plans to substitute new generics via mid-year formulary changes without notice, and proposes to treat biosimilars as generics for Part D’s low-income subsidy (LIS) and catastrophic cost-sharing.
The NPRM also contains several proposals relevant to the Medicaid program, including:
  • MA Default Enrollment: CMS proposes to revise its regulations and permit “default enrollment only for Medicaid managed care enrollees who are newly eligible for Medicare and who are enrolled into a D-SNP administered by an MA organization under the same parent organization as the organization that operates the Medicaid managed care plan in which the individual remains enrolled.” CMS also proposes to “limit these default enrollments to situations where the state has actively facilitated and approved the MA organization’s use of this enrollment process and articulates this in the agreement with the MA organization offering the D-SNP, as well as providing necessary identifying information to the MA organization.” See p. 131.
  • Passive Enrollment of Duals: CMS proposes a “limited expansion of its regulatory authority in circumstances when beneficiary enrollment would be disrupted by changes in health plan participation.” Specifically, it would allow “passive enrollment for full-benefit dually eligible beneficiaries from a non-renewing integrated D-SNP to another comparable plan.” See p. 140.
Comments on the proposed rule are due by 5 p.m. on Jan. 16, 2018.

To read the rule, click here.The corresponding factsheet is available here.


CMS recently circulated an announcement reminding states of the availability of free technical assistance resources to enhance Medicaid home and community-based services (HCBS) waiver programs. Topics for TA include supported employment, person-centered planning, service design, needs-based criteria, conflict of interest requirements, individual budgeting, and community integration supports.


States can request TA at


Hill Update


Congress Returns from Recess to Crowded Agenda of Tax Reform; Federal Government Financing
After a week in recess for Thanksgiving, the House and Senate will return to DC this week with a full agenda for the year’s 12 remaining legislative days. The upper chamber continues its work to advance a tax reform package under reconciliation rules, with the current bill including a repeal of the ACA’s individual mandate. The political dynamics remain up in the air, with concerns being voiced by fiscal conservatives over potential increases to the federal deficit and key moderate Republicans expressing skepticism over the inclusion of health provisions. However, only one Senator – Ron Johnson (R-WI) – has stated outright opposition to the package.


In an additional wrinkle, a Congressional Budget Office analysis indicates that the budget resolutions authorizing $1.5 trillion in deficit spending for tax reform would trigger sequestration rules, requiring $135 billion in other FY 2018 mandatory and discretionary spending reductions – including $25 billion from Medicare. A bipartisan 60-vote threshold in the Senate would be required to lift the sequestration caps.


Further complicating the legislative calendar is the December 8 expiration of a continuing resolution funding the federal government, which many observers expect will be extended through the holidays to allow more time for negotiations between Republicans and Democrats on a number of other issues. Foremost among these is reauthorization of CHIP, as well as potential action to stabilize the individual market.


In the News


Kaiser Health News: “Kaiser Health News: Massachusetts Grabs Spotlight by Proposing New Twist on Medicaid Drug Coverage”
Massachusetts’ state Medicaid program hopes to road-test a new approach to Medicaid drug coverage by which it would negotiate discounts for the drugs it purchases and exclude drugs with limited treatment value. Currently, state Medicaid programs are required to cover almost all drugs that have received Food and Drug Administration approval; in exchange, manufacturers must discount those drugs – typically based on a set percentage of the list price, specified by federal law. Yet, as drug prices soar, states argue that those fractional rebates no longer suffice to defray the burden of rising costs, reports Kaiser. Under Massachusetts’ corresponding remedy, the state says (if approved) it would be able to pick which drugs it covers based on most beneficiaries’ medical needs and which medicines demonstrate the highest rates of cost effectiveness.
If CMS approves Massachusetts’s plan, others will likely take similar action. With Medicaid spending on prescription drugs having increased about 25 percent in 2014 and nearly 14 percent in 2015,”this is absolutely something a lot of other states are looking very closely at,” said Matt Salo, executive director of the National Association of Medicaid Directors (NAMD).


To read the full article, please click here.


Modern Health Care: “HHS concerned about Medicare’s long-term sustainability”
In a report issued last week, HHS said the Medicare trust fund “is not projected to be sustainable over the long term with the projected tax rates and expenditure levels.” Specifically, the agency estimates that the ratio of workers paying taxes to beneficiaries eligible for Medicare will drop from 3:1 in 2016 to 2:1 by 2091. With healthcare costs continuing to rise faster than the taxable wages used to support the program, the shortfall is meanwhile expected to reach $3.3 trillion over the next 75 years. To ameliorate this problem, HHS says it will need to significantly increase its revenue or reduce Medicare benefits to balance its budget; the department argues that while Medicare providers are increasingly adopting value-based approaches to care, the shift isn’t happening quickly enough.


To read the full article, please click here. To access HHS’s new report, please click here.


Reuters: “Counting the costs: U.S. hospitals feeling the pain of physician burnout”
It is estimated that some 54% of doctors nationwide are affected by physician burnout, a syndrome marked by emotional exhaustion, cynicism, and decreased effectiveness. Many burned-out doctors cut back their work to cope, says Reuters, and an alarmingly high number commit suicide. Increasingly high rates of physician burnout are bad not just for doctors and other medical professionals, but also for patients and hospital business. Physician burnout, to be sure, erodes job performance, increases medical errors, and leads doctors to leave a profession they once loved; furthermore, experts estimate that it can cost more than a $1 million to recruit and train a replacement for a doctor who leaves because of burnout. Some leading healthcare executives say the way medicine is practiced in the United States is to blame, fueled in part by growing clerical demands that have doctors spending two hours on the computer for every one hour they spend seeing patients. In the words of Dr. Christine Sinsky, vice president of professional satisfaction at the American Medical Association, “We have to recognize the exacting toll that the first generation of electronic health records has had on physicians.”


To read the full article, please click here.


Modern Health Care, “Unintended consequences: CMS’ readmissions program might be harming patients”
CMS’s Hospital Reduction Readmission Program, established under the Affordable Care Act, has effectively motivated hospitals to change wasteful care practices and better manage populations. Readmissions have fallen as hospitals respond to penalties that can dock up to 3% of their Medicare payments. Yet, as reported in a new JAMA study, the tactics hospitals have adopted to avoid a penalty might not always be in the best interest of patients. “This program has gotten hospitals to focus on readmissions and a lot less on everything else,” said Dr. Ashish Jha, a professor of health policy at the Harvard School of Public Health. “The big penalty for readmission rates has meant hospitals put less attention on reducing complications and on reducing mortality.”


To read the full article and learn more about the JAMA study, please click here.


Stateline: “New App Maps Overdose Epidemic in Real Time” 
A year ago, the Drug Enforcement Administration (DEA)’s Washington/Baltimore High Intensity Drug Trafficking Area (HIDTA) team developed a smart phone application that could be used by first responders to record the time and location of opioid overdoses and transmit the information to a regional mapping database. Today, that tool, known as ODMAP, is used by more than 250 law enforcement, first responder, and public health agencies in 27 states. While cities and states have begun collecting data on drug seizures, arrests, overdose deaths and other collateral effects of the opioid epidemic, ODMAP is the only tool designed to track drug overdoses, both fatal and non-fatal, by location, as they happen. Furthermore, because the same application can be used by all state and local authorities, the resulting database is the first to support a nationwide map.
So far, ODMAP has been adopted in parts of Alabama, California, Delaware, Florida, Georgia, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Michigan, Montana, New Mexico, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Texas, Virginia, Washington, Wisconsin and West Virginia.
To read the full article and learn more about ODMAP, please click
Morning Consult: “Look to Pharmacists to Fight Antibiotic Resistance, Too” 
A recent study by the Johns Hopkins Center for Health Security has identified opportunities for pharmacies to be relied on even more to meet growing public health needs. While the study’s recommendations about opioid abuse epidemic solutions may generate the most attention, its urging regarding another emerging issue, antibiotic resistance, deserves attention before “another growing threat reaches epidemic proportions.” Antimicrobial resistance is indeed a grave concern, and it is getting worse: CDC estimates that more than 2 million people are infected with antibiotic-resistant bacteria every year, and that these bacteria are directly responsible for more than 23,000 deaths annually. As the study recommends, pharmacies can play an important role in providing patient education, performing tests to correctly identify infections so that antibiotic use is appropriate, and helping sufferers manage disease symptoms. All of these strategies will help to lessen the pressure for inappropriate, unnecessary, and ineffective antibiotic use.
To learn more about the study, please click here.


Take Note


NASDDDS Health and Wellness Review Report 
In a new report, the National Association of State Directors of Developmental Disability Services (NASDDDS) reviews incident management systems and mortality reporting in select state intellectual/developmental disability systems, identifying strong practices that are replicable in State I/DD programs across the country. NASDDDs finds that states use multiple approaches towards protecting, preventing, and continuously monitoring for indicators of abuse, neglect, or mistreatment of their citizens with intellectual and developmental disabilities.  The report provides highlights of the activities of twelve states as well as a self-assessment tool for states interested in assessing the thoroughness of both the design and execution of the system in place for identifying, reporting, intervening, preventing, and responding to critical incidents.


To read the report, please click here.


The Commonwealth Fund Examines Potential Impact of a Medicare LTSS Benefit
A new Commonwealth Fund report explores whether providing public support of LTSS in Medicare would replace care currently provided for free by family caregivers. In analyzing 2015 data from the National Health and Aging Trends Study, the report finds that Medicare beneficiaries predominantly rely on unpaid care for LTSS. It also finds that hours of unpaid care are not substantially lower when paid care is also received. The authors suggest that this means that public financing of LTSS would not replace, but rather supplement, the contribution of family and unpaid caregivers to support individuals living in the community.


The analysis is available here.
NASBO State Expenditure Report
Last week, the National Association of State Budget Officers (NASBO) released their latest State Expenditure Report, which provides state-by-state data on estimated fiscal 2017 total state spending, as well as updated fiscal 2016 and fiscal 2015 data. It breaks down spending by program area, including Medicaid spending.
Key findings from the report include:
  • Estimated total state spending increased 5.2 percent in fiscal 2017, following an increase of 2.2 percent in fiscal 2016.
  • Federal funds to states are estimated to have increased 5.3 percent in fiscal 2017, partly driven by Medicaid. But in the last five years, federal funds to states have seen a slight decline when excluding Medicaid.
  • Medicaid continued to increase as a share of total state spending (including all state and federal funds), representing 29.0 percent of all state spending in fiscal 2017.
Read the report here.
KFF Brief Looks at Section 1115 Behavioral Health Waivers
This Kaiser Family Foundation (KFF) issue brief explores recently approved and proposed Section 1115 waivers that address behavioral health care in Medicaid. It categorizes these waivers into four buckets: using Medicaid funds to pay for substance use and/or mental health services in institutions for mental disease, expanding community-based behavioral health benefits, expanding Medicaid eligibility to cover additional people with behavioral health needs, and financing delivery system reforms. The document examines each bucket of behavioral health waiver, highlighting key issues for states within each.


The brief is  available here.

North Carolina Posting for Chief Medical Officer
The 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.
Missouri Posting for HealthNet Finance Director
The Missouri Department of Social Services (DSS) is seeking a MO HealthNet Finance Director as part of the senior leadership team. This position offers the unique opportunity to be an integral part of developing and sustaining innovative financial systems to support the state’s Medicaid program for low-income Missourians.
This position is responsible for MO HealthNet Budget forecasting, development and expenditure control and financial reporting; institutional reimbursement; rate setting; financial services and payment models.
The successful candidate will be a hands-on leader capable of building and leading a team of dedicated financial staff. This position, located in Jefferson City, Missouri, reports to the department’s Chief Financial Officer and takes daily direction from the MO HealthNet Division Director. For additional information about our department, visit
Oregon Posting for Medicaid Director
The Oregon Health Authority is looking for a passionate leader who is eager to influence and advance health system transformation in Oregon, to join the innovative team as the State Medicaid Director.
This key position is a catalyst in building strong collaborative relationships with public health, behavioral and oral health champions throughout the state. The State Medicaid Director provides overall leadership and direction for strategic program development, health policy and program implementations for the Oregon Health Plan, with an enrollment of over one million individuals.


Oregon invites you to view additional details about this opportunity in this electronic brochure.


Nebraska Posting for Policy and Communications Deputy Director
The Nebraska Department of Health and Human Services (DHHS) has an exciting opportunity for a Policy and Communications Deputy Director to join our team within the Division of Developmental Disabilities. The Deputy Director will be responsible for overall policy formulation for the Division. Successful candidates will have policy development experience, strong interpersonal skills, and share in our mission of “helping people live better lives.”
The Deputy Director will be responsible for all the administration and management of planning, coordinating, and implementing the overall policy formulation for the Division of Developmental Disabilities with delegated authority to provide communication for the Division; interacting with stakeholders on behalf of the Division Director to promote system reform and transparency; monitoring and communicating Division objectives, activities, and potential areas of concern regarding policy or precedent as well as proposed remedies to the Director and other members of the leadership team; and play a key role in efforts of internal reorganization, management of the state’s newly redesigned Medicaid home and community-based waiver programs for people to lead healthy, independent, and active lives in communities throughout Nebraska.
If you are interested in joining our team and have a desire to fulfill our mission to “help people live better lives,” please submit a Resume/CV and letter of interest to Human Resources at
For more job opportunities, please check out NAMD’s State Jobs page!


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