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In this issue is the annual 2016 Medicaid Budget Survey; Medicare Part B Premiums; Comment Opportunities on MACRA; Hill News; Prescription Drug Costs.


October 25, 2016
From the NAMD Desk
NAMD’s Fall Meeting Just Two Weeks Away!
The NAMD Fall Conference is scheduled November 6-8 at the Hyatt Regency Crystal City in Arlington, VA. Full conference details, an updated agenda, and registration information can be found here. If you have any questions, please feel free to contact
Tess Moore.


Kaiser Foundation, NAMD Unveil 2016 Medicaid Budget Survey
On October 13, the Kaiser Family Foundation (KFF) and NAMD jointly released KFF’s annual 50-State Medicaid Budget Survey. The survey reviews key trends in Medicaid enrollment and spending, policy changes impacting eligibility and coverage, reimbursement changes, and other hot topics. Alongside the survey report, KFF also published case studies of Medicaid programs in Maryland, Montana, New York, and Oklahoma.


Three Medicaid Directors — John McCarthy of Ohio, Leesa Allen of Pennsylvania, and Calder Lynch of Nebraska – participated in a discussion panel to provide state-specific insights related to the survey findings. The Directors remarks touched on a range of issues including the extensive steps and stakeholder engagement involved in launching a managed long term services and supports program, the overarching goals and drivers for moving away from volume-based systems and their respective roles in setting a vision for modernizing Medicaid information technology and systems.


Read the survey report and related materials here. View the briefing panel event here.


States Facing Cost Shift for Medicare Part B Premiums in 2017
The Social Security Administration recently announced a 0.3% Cost of Living Adjustment (COLA) increase for the Social Security Benefit. Due to statutory requirements governing financing for the Medicare program, the COLA increase will shift additional costs to states for Medicare premiums for the population dually eligible for Medicare and Medicaid. Without specific action from the Congress there will be
no relief for the additional state share of Medicare Part B premiums. CMS is scheduled to announce the final Part B premium amount for 2017 in the coming weeks.


In This Issue

NAMD Fall Meeting
Nov. 6-8, 2016

Information and registration



Reg Update


CMS Offers Comment Opportunity on MACRA Rule’s Multi-Payer Issues
On October 14, the Centers for Medicare and Medicaid Services (CMS) published a final rule implementing the Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) incentive, as required by the Medicare Access and CHIP Reauthorization Act (MACRA). These new models will overhaul Medicare’s physician reimbursements, with implications for Medicaid programs, and are collectively referred to as the Quality Payment Program (QPP).


CMS also provides a comment opportunity for issues relevant to state Medicaid programs, including the following:
  • The possibility of establishing a process to prospectively engage in design and review of payment arrangements to determine if they meet the criteria for being Other Payer Advanced APMs, particularly regarding the assessment of Medicaid APMs. CMS notes that it will continue to communicate its work to the LAN.
  • The creation of an optional pathway for states to seek a determination from CMS on whether a Medicaid payment arrangement is an Other Payer Advanced APM, including the criteria for doing so. We are also seeking additional comments on the overall process for reviewing payment arrangements in order to determine whether they are Other Payer Advanced APMs.
  • Approaches to implementation of cross-cutting measures in future years of the MIPS program that could achieve program goals and be meaningful to MIPS eligible clinicians and the patients they serve.
The rule, which takes effect January 1, 2017, allows for a year-long transition period for providers to become more familiar with QPP goals and requirements, with three options for submitting data to MIPS depending on clinician readiness. More advanced practitioners will be able to begin participating in Advanced APMs during this period. Various modifications from the proposed rule will further ease clinician participation in the QPP. CMS anticipates 2018 will also be a transitional year as the QPP is iterated upon, and will issue additional rules in the future outlining any additional transition period changes.


The rule finalizes the proposed definition of an Alternative Advanced APM, which must meet all of the following:
  • The APM must require participants to use certified electronic health records;
  • The APM provides payment for services based on quality measures comparable to the same MIPS performance category; and
  • The APM must either be a Medicaid Medical Home Model under 1115A(c) of the Social Security Act, or require participating entities to be at risk for non-nominal monetary losses.
Notably, the nominal risk standards for Advanced APMs are modified in the final rule, such that marginal risk and allowable minimum loss rates are no longer part of standards. Instead, Advanced APMs may satisfy the nominal risk requirement by a revenue-based standard, with 8% of the average estimated Medicare Part A and B revenues at risk, or by a benchmark-based standard, with 3% of expected expenditures at risk.


CMS will release a list of initial Advanced APM determinations on or before January 1, 2017. Advanced APM determinations after January 1, 2017 will be announced alongside the first public notice of the APM. CMS anticipates amendments will be made to reopen applications for modifying current APMs, with specific mention of the Maryland All-Payer Model as an example.


The rule also finalizes many of the proposed provisions governing MIPS, including annual selection of quality measures for each of the four statutorily-required performance categories (quality, cost, improvement activities, and advancing care information).


CMS has prepared a variety of informational resources to assist in reviewing the rule’s provisions. They include:
CMS Publishes TA Resources for Core Measure: Antipsychotic Use in Children
Recently, the Centers for Medicare and Medicaid Services (CMS) made available a variety of technical assistance resources to support states in calculating and reporting a new measure in the Child Core Set – “Use of Multiple Concurrent Antipsychotics in Children and Adolescents.” The measure is a high priority for CMS for 2016. The following resources are available:
  • Resources from the TA webinar, “Calculating the Multiple Concurrent Antipsychotics Measure in the Child Core Set,” are available here.
  • Information on Pennsylvania and Wyoming’s experience:
CMS Announces Second Round of CPC Initiative Savings
Recently, the Centers for Medicare and Medicaid Services (CMS) announced a second round of savings from the Comprehensive Primary Care (CPC) initiative, with 95% of participating practices meeting quality requirements. Four of the seven CPC regions met requirements for shared savings, as well, with a total of $55.7 million Medicare Part A and B savings. In addition to the savings, participating practices saw favorable quality scores on hospital admission and readmission rates and patient experience measures.


Read the CMS blog post accompanying the announcement here.


Hill Update


SFC Ranking Member Promises Action to Address Part B Premium Increase
In light of the Social Security Administration’s
recent announcement of a 0.3% Cost of Living Adjustment (COLA) increase for the Social Security Benefit, Senate Finance Committee Ranking Member Ron Wyden (D-OR) released a statement saying “Seniors in Medicare expect their health costs to be affordable and stable, and I’ll be looking at every option in the days ahead to make sure that remains the case.”


The COLA increase means that Medicare Part B premiums will not significantly increase for the 70% of Medicare Part B beneficiaries who use their monthly Social Security benefits to pay their premiums. Federal law prohibits premiums from increasing beyond the COLA for these beneficiaries, leaving the remaining 30% of beneficiaries to shoulder the remainder of the increase. This includes dually eligible Medicare-Medicaid beneficiaries who have their Part B premiums paid by Medicaid programs. A similar scenario last year was halted by Congress, but the legislative fix is not applicable for this year’s situation.


In the News


CMS Approves Washington’s 1115 Medicaid Transformation Waiver
Recently, the Washington State Health Care Authority announced an agreement with CMS to continue its 1115 waiver implementing the Healthier Washington plan. The waiver will bring up to $1.5 billion in federal dollars to support Washington’s activities around regional care transformation via Accountable Communities of Health, long-term services and supports, and providing supportive housing and supported employment to vulnerable populations in the state. CMS and Washington will continue to negotiate special terms and conditions under the waiver in the coming months.


Learn more about the Washington initiative here.


Stateline Covers Pew’s Review of Medicaid MAT Coverage for Addiction
On October 14, Stateline published an article titled “In some states, Medicaid rules make it more difficult to treat addiction.” The article reviews the varying state policies governing coverage of buprenorphine, the most common opioid addiction medication, which include prior authorization, dosage and duration limits, and “fail-first” requirements for alternative treatments. The findings are drawn from a recent study conducted by IMS Institute for Healthcare Informatics on behalf of Advocates for Opioid Recovery.


State officials note that building capacity to treat opioid addiction is not a simple or quick process. NAMD Executive Director Matt Salo is quoted in the article, stating that the opioid epidemic “is an extraordinarily complex and multifaceted problem that involves far more than simply paying for buprenorphine prescriptions. There are no quick fixes.”


Read the article here.


Experts Explore Outstanding Issues with Mylan-DOJ EpiPen Announcement
On October 14, the firm Mintz Levin published a blog post titled “Five Things to Know about the Mylan EpiPen ‘Settlement’ – What It Is and What It Isn’t.” The post is grounded in a legal analysis of Mylan’s announcement of a settlement with the U.S. Department of Justice regarding rebates owed to the federal government and the states due to a misclassification of the EpiPen product as a generic for purposes of the Medicaid drug rebate program (MDRP). This misclassification allowed Mylan to avoid paying higher branded drug rebates or mandatory rebates on price increases outpacing inflation.


The authors discuss ways in which Mylan’s announcement, which indicates a $465 million settlement with DOJ providing resolution of all potential rebate liability claims by federal and state governments, differs from past settlements related to False Claims Act settlements pertaining to the MDRP. Included in the analysis is the possibility for additional action by the U.S. Health and Human Services Office of the Inspector General, and for state Attorneys General to opt out of a “global” settlement to pursue their own settlements.


Read the blog post here.


Morning Consult Reports on New Research Linking Medicaid Coverage to Higher ER Utilization
Morning Consult reported on a study recently published by the New England Journal of Medicine which expanded upon an earlier analysis of data from Oregon’s 2008 lottery for Medicaid coverage. The new analysis covers the 2007-2010 period. The researchers reported that newly covered individuals increased their emergency department utilization by 40 percent in the first 15 months of coverage. They write that one possible reason for this finding is that the type of people who use more care when they gain Medicaid coverage are likely to increase use across multiple settings, including both the emergency room and the physician’s office. Another possible reason they cite is that by increasing the use of primary care, Medicaid coverage may end up driving greater use of emergency care.


Read the article here and access the study itself here.


Take Note


NASHP Report Analyzes State Options to Address Prescription Drug Costs
In its new report, the National Academy of State Health Policy (NASHP) explores approaches to limiting drugs prices, reflecting on the inherent value of the pharmaceutical industry alongside the unsustainably high costs of drugs, especially drugs that have been newly launched or are exclusively positioned. Without such thoughtful reform, NASHP notes, states could be forced to abandon drug coverage in order to balance and safeguard their budgets. The report emphasizes that in order to prevent this, states must play an active role in incentivizing industry players to make their products more affordable, while keeping forces like market entry barriers, generic competition, and scientific innovation in mind. In doing so, NASHP identifies a range of policy options for states to consider – from regulatory interventions to more market-oriented approaches – to tackle rising drug prices.


Read the report here.


MACPAC Publishes New MACSTATS Demographic Information
Last week, MACPAC updated its MACSTATS database, which presents data and information on Medicaid and CHIP that can be difficult to find or require looking across multiple data sources. Of particular note are
four tables exhibiting age-aggregated and disaggregated demographic characteristics of Medicaid beneficiaries, including gender, race, education, marital status, income, and health status.


The full package of materials can be found here.


Diverse Stakeholder Group Announces Launch of Modern Medicaid Alliance
The Modern Medicaid Alliance (MMA) represents a new coalition of more than two dozen national advocacy groups, dozens of state and regional organizations, and grassroots supporters committed to educating policymakers and the public about the benefits of Medicaid. Advocating on behalf of more than 70 million beneficiaries who receive benefits under the Medicaid program, the MMA plans to highlight how innovative health solutions in Medicaid improve outcomes and lower costs, leading to better coordination, prevention, and improved financial security.
More on the MMA can be found here.
Report Examines Progress on IT/ICT for Individuals with Disabilities
Recently, the National Council on Disability Policy published its annual report, as required by statute. This year’s report focuses on the state of information and communication technology (ICT) and its use by individuals with disabilities. The report reviews how technology can empower people with disabilities to live fuller lives, describes common barriers to these individuals to use ICT, and analyzes future trends in ICT and their relationship to people with disabilities. The report also offers recommendations including calling on Congress to pass a Technology Bill of Rights for People with Disabilities.


Read the report here.


GAO Report Calls for Improved HHS Measure Alignment
On October 13, the Government Accountability Office (GAO) published a report titled “HHS Should Set Priorities and Comprehensively Plan Its Efforts to Better Align Health Quality Measures.” GAO notes in the report that misalignment of measures can burden providers and impede quality of care improvement efforts. To better understand the degree of measure misalignment across programs, GAO reviewed three studies and found few common measures in use across public and private payers. It supplemented this work with interviews with HHS staff and outside experts, and identified three key factors which drive measure misalignment:
  1. Dispersed decision making across public and private entities;
  2. Variation in data collection and reporting systems; and
  3. Few meaningful measures, despite the numerous measures developed by various stakeholders.
To address these factors, GAO recommends and HHS agrees that HHS should:
  • Prioritize development of electronic quality measures and related data elements for the core measures it and private payers have agreed to use; and
  • Comprehensively plan, including setting timelines for, its efforts to develop more meaningful quality measures.
Read the report here.


Assisted Living Group Raises Concerns with HCBS Rule; Publishes State AL Reg Tracker
On October 11, the National Center for Assisted Living (NCAL) sent a letter to CMS raising concerns with implementation of the home and community-based services (HCBS) settings rule. Specifically, NCAL contends that the rule’s HCBS waiver requirements may exclude assisted living communities from Medicaid HCBS programs, leading individuals in these settings to seek institutional care, contrary to the intent of the rule.


Separately, NCAL recently released the 2016 edition of its annual Assisted Living State Regulatory Review. The review focuses on state requirements for assisted living licensure or certification, and also provides a high-level state-by-state snapshot of Medicaid coverage for assisted living services. The 2016 review can be accessed here.



Arizona Looking for Intergovernmental Relations Assistant Director

The Office of the Director (OOD) is seeking a collaborative and experienced professional to join our team as Assistant Director in the Office of Intergovernmental Affairs (OIR). This position determines and publicly advocates substantive AHCCCS program policy.


The position reports directly to the AHCCCS Director and is responsible for developing and overseeing the implementation of the strategic communications with the Centers for Medicare and Medicaid Services (CMS), the media, federal and state legislators, representatives of tribal governments and Indian Health Services.


Please see full posting and application here.


DC Health Care has Two Openings

The D.C. Department of Health Care Finance has two positions open. A Supervisory Nurse Specialist, JO-1610-6897 and a Supervisory Policy Analyst, JO-1610-6896. The closing date for both positions is October 26. Please visit to see full descriptions and apply.



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