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In this newsletter we cover Testimony on ACE Kids, Comments on Medicare Payment Providers, Hep C, Managed Care Rate Development Guide, Delivery System Reform, and ASPE Report on Impact of Medicaid Expansion.

NAMD Update

July 6, 2016
From the NAMD Desk
NAMD Bids Farewell to Darin Gordon in Tennessee, Welcomes Dr. Wendy Long
On June 30, Darin Gordon stepped down as Director of TennCare, Tennessee’s Medicaid program. Darin served as TennCare Director since 2006, making him the longest-serving Medicaid Director in TennCare history. Darin also served as NAMD President and Vice-President and on the NAMD Board. Tennessee Governor Bill Haslam also applauded Darin’s service, saying, “Darin brought much needed stability to the program, guiding it through difficult times, and all of Tennessee is indebted to his incredible service.”


At the same time, NAMD wishes to welcome Dr. Wendy Long, who will serve as the new TennCare Director, as well as the Director of Health Care Finance and Administration for the State of Tennessee, starting July 1. Before becoming Director in 2016, Dr. Long held key executive management positions within the organization including Deputy Director and Chief Medical Officer and provided leadership and direction to all areas of HCFA operations, with particular emphasis on the design and implementation of cost efficient strategies to improve health outcomes. Prior to joining the team at TennCare, Dr. Long was an Assistant Commissioner in the Tennessee Department of Health.
Dr. Long is a Nashville Health Care Council Fellow (class of 2015) and is a past president of the Tennessee Public Health Association. At the national level, she is involved in health policy through the efforts of several organizations including serving as a member of the National Committee for Quality Assurance (NCQA) Standards Committee and the Steering Committee for the Milbank Fund’s Reforming States Group.
NAMD to Testify Before E&C on ACE Kids Act
On Thursday, July 7, NAMD Executive Director Matt Salo will testify before the House Energy and Commerce Committee on the Advance Care for Exceptional Kids Act, or the ACE Kids Act. The hearing will focus on the goals of the proposal and revised legislative language to establish health homes for children with complex medical conditions. The hearing will begin at 10:15 a.m. ET, and a live stream will be available on the E&C website here.


NAMD Responds to Developments in State Coverage Policies for Hepatitis C
Earlier today NAMD issued a statement addressing the states’ evolving Medicaid coverage policies for hepatitis C treatments. NAMD acknowledges the ongoing negotiations between states and manufacturers around access to new treatments. However, the association goes on to state these arrangements do not absolve Congress of addressing the real problem of irrational pricing for drug treatments.


Read the full statement here.


NAMD Comments on CMS Proposed Medicare Payment Programs under MACRA
On June 27, NAMD submitted comments to the Centers for Medicare and Medicaid Services on the proposed rule implementing Medicare’s new provider payment programs: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) program. NAMD’s comments focus on the impact of the new Medicare payment programs on Medicaid payment and delivery system reform. They highlight unique state considerations for CMS, as well as opportunities to further multi-payer alignment.
MIPS and the Advanced APM programs were created under the Medicare Access and CHIP Reauthorization Act of 2015 and replace Medicare’s sustainable growth rate. In particular, the Medicare Advanced APM program has implications for Medicaid delivery system and payment reform. This program makes available a bonus payment to providers who have a certain percentage of their patients or payments through Advanced APMs. Beginning in 2021, participation in qualifying Medicaid APMs can help a provider achieve a Medicare bonus through this program.
For more information on NAMD’s work on this issue, please contact Lindsey Browning.
In This Issue

NAMD Fall Meeting
Nov. 6-8, 2016

Information and registration



Reg Update


CMS IB on 2016 Managed Care Rate Development Guide Addendum
On July 1, the Centers for Medicare and Medicaid Services (CMS) published an informational bulletin detailing provisions of the final Medicaid managed care rule that take effect on July 5, 2016, as well as which requirements states must include in their 2016 rate developments.


Notably, for states that already have approved 2016 rates or completed their rate development processes prior to the publication of the final rule, CMS does not intend to review and assess already-approved rates for compliance with the rule’s provisions. These states will be expected to be in compliance by their next rating period. States with rates developed for rating periods starting before October 1, 2016 will not be required to redevelop their rates to reflect provisions effective July 5, 2016. For states otherwise fully compliant with the 2016 rate development guide but not fully compliant with the new regulations, CMS will pursue corrective action plans requiring compliance by the next rating period.


Read the bulletin here.


CMS Issues Statement on Expansion of Hepatitis C Drug Coverage in Massachusetts
On June 30, CMS released a statement identifying Massachusetts as the most recent state to implement/announce plans to increase Medicaid patients’ access to Hepatitis C medications. Despite this development, CMS still emphasizes the role of manufacturers, pharmacy benefit managers, and other stakeholders to ensure the access and affordability of Hepatitis C medications (the cost of which can be prohibitively high). To this end, CMS will continue to closely monitor state efforts to assure access to Hepatitis C treatment in accord with guidance released last November.
Read the press release here.
CMS Releases Pair of LTSS Spending Reports
Recently, the Centers for Medicare and Medicaid Services (CMS) published a pair of reports on Medicaid long-term services and supports expenditures.
  • On April 15th, CMS published a report on federal and state spending on Medicaid long-term services and support (LTSS), valued at $152 billion in FY2014 – a 4% increase from FY2013. In the report, CMS finds that recent growth in LTSS spending has fallen behind historical averages, with expenditures increasing by more than 5% from FY1996 to FY2010. That said, Medicaid LTSS provided through managed care organizations (MCOs) increased by a very significant margin (55%) from FY2013 ($14.5 billion) to FY2014 ($22.5 billion), representing 55% of total LTSS spending in FY2014. Importantly, CMS also finds in the report that the percentage of Medicaid LTSS devoted to home- and community-based services (HCBS) increased slightly to 53.1% in FY2014; HCBS constituted the vast majority (75%) of spending for individuals with development disabilities, compared to only 41% of spending for other large population groups (older people, people with physical disabilities, people with serious mental illness, etc.).
  • In another report (published June 3rd), CMS explores the evolution of Medicaid LTSS spending from FY1981 to FY2014 in conjunction with various delivery implications.  The report summarizes Medicaid LTSS’s policy and spending evolution since Medicaid’s inception, presenting LTSS spending by service, target population group, and state (with particular emphasis on the states with the highest portion of spending for HCBS in FY2014.
CMS Publishes QEP Final Rule
On July 1, the Centers for Medicare and Medicaid Services (CMS) published a final rule making modifications to the Qualified Entity Program (QEP), as required by the Medicare Access and CHIP Reauthorization Act (MACRA). The rule allows qualified entities to confidentially share or sell analyses of Medicare and private sector claims data to providers, employers, and other groups, who can use the data to support improved care. The rule outlines mandatory privacy protections that must be in place for any such data that is shared or sold.


Read a CMS press release on the rule here.


Supreme Court Declines to Hear Appeal on DOL Home Care Worker FLSA Rule
On June 27, the United States Supreme Court declined to hear a challenge to the Department of Labor (DOL)’s final rule applying minimum wage and overtime protections to home care workers under the Fair Labor Standards Act (FLSA). DOL is now in a period where it expects full compliance with the rule.


Additional information about the home care rule is available on DOL’s website here.


CMCS Reiterates Public Notice Requirements for Medicaid Rate Changes
On June 24, the Center for Medicaid and CHIP Services (CMCS) issued an informational bulletin discussing federal public notice and public process requirements for changes to Medicaid payment rates. The bulletin both reiterates longstanding CMCS policy and outlines new requirements under the final Medicaid access monitoring rule in the following areas:
  • Public notice policies that pertain to all proposed changes to provider rates or methodologies;
  • Public input process policies, which apply when states reduce rates or restructure payments, and are designed to obtain input related access to care; and
  • Public input process policies that are specific to changes to institutional provider payment rates.
The bulletin also provides requirements states must meet if they seek to use a single mechanism to meet the above-outlined requirements.


Access the bulletin.


CMS Issues Guidance on APDs for MMIS, E&E Systems
On June 27, the Centers for Medicare and Medicaid Services (CMS) issued a State Medicaid Director letter providing guidance around Advance Planning Document (APD) requirements necessary to receive enhanced 90% match for systems work related to Medicaid eligibility and enrollment (E&E) and Medicaid Management Information Systems (MMIS) under a December 2015 final rule. The guidance indicates that state ADPs must:
  • Describe how plans comply with 2016 Interoperability Standards Advisory, including how the system will support seamless coordination with the Federal Data Services Hub and the Marketplace (either state-based or federal), a requirement expanded upon in the rule;
  • A new condition requiring that E&E systems be able to process MAGI-based Medicaid applications;
  • A new condition requiring mitigation plans to reduce problems arising from missing major project milestones;
  • A new condition requiring states to identify key IT personnel, their project roles, and time dedicated to the project;
  • A new condition requiring documentation of software such that it may be operated by contractors and other users; and
  • A new condition requiring states strategize to reduce operational costs and difficulties from using software on alternate hardware or operating systems.
The letter indicates additional guidance will outline the formal process for determining additional APD conditions.


Access the letter here.


SAMHSA Finalizes CCBHC Measure Technical Specifications
Recently, the Substance Abuse and Mental Health Services Administration (SAMHSA) finalized a technical specifications manual for the 32 quality measures listed in the certification criteria for the Certified Community Behavioral Health Center (CCBHC) demonstration. These specifications provide detailed guidance on collecting and reporting each CCBHC quality measure.


Access the specifications here.

Hill Update


House Poised to Vote on Mental Health Legislation
Today the House of Representatives is set to vote on an amended version of H.R. 2646, the Helping Families in Mental Health Crisis Act, which will be considered under a suspension of the rules – a move designed to head off the introduction of controversial provisions on the floor. The bill was approved earlier this month by the House Energy and Commerce Committee. The Senate has not yet scheduled time for a vote on its comprehensive mental health proposal.


Zika Funding Remains in Limbo
Congressional efforts to provide funding to tackle the growing threat of the Zika virus are currently locked in a partisan battle over funding for Planned Parenthood. Legislation for $1.1 billion in funding put forward by Senate Republicans included several policies stirring Democratic opposition, foremost among them the defunding of Planned Parenthood. It is unclear how the parties intend to resolve these differences.
Legislation Introduced to Reduce Biologic Exclusivity Period
Recently, Rep. Janice Schakowsky (D-IL) introduced
legislation in the House which would reduce the manufacturer patent exclusivity period for biologic drugs to 7 years from the current 12. Companion legislation is anticipated to be introduced in the Senate by Sens. John McCain (R-AZ) and Sherrod Brown (D-OH). This policy was proposed in the President’s FY 2017 budget, and was estimated in that document to generate $6.9 billion in Medicare savings over the next decade.
Senate Passes Bill Accelerating Medicaid DME Requirements; House Plans to Pair it with Medicaid PI Provisions
On June 21, the Senate unanimously passed
S. 2736, the Patient Access to Durable Medical Equipment (DME) Act of 2016. The bill would delay a second scheduled Medicare cut to DME reimbursement rates in its non-DME bid areas for one year, lock future bid ceilings at the July 1 bid rates, and most relevant for the Medicaid program,
move up the timeline for Medicaid DME reimbursement rates to match Medicare competitive bid rates from January 2019 to October 2018.
The House has not yet held a vote on its own bill aimed at delaying the Medicare DME cuts. This version has an alternate timeline for delaying the cuts, and also features previous legislation passed unanimously by the House – the Ensuring Access to Quality Medicaid Providers Act. That legislation would require states to create FFS provider directories, notify a federal database of providers terminated for cause, and require states to disenroll providers terminated for cause in another state.
It is unclear if the Senate and House versions of the Medicare DME legislation will be easily reconciled, though observers note that both chambers agree that the Medicare DME reimbursement cuts must be addressed.


NGA Calls for Federal Investment to Combat Opioid Epidemic
On June 21, the National Governors Association (NGA)’s Health and Human Services Committee leadership sent a letter to party leaders in the House and Senate urging Congress to provide sufficient federal funding to support state efforts in curbing the ongoing opioid abuse epidemic. The letter reiterates previous NGA requests on this issue, including expanding medication-assisted treatment and eliminating the Medicaid institutions for mental disease (IMD) exclusion.


Read the letter here, and NGA’s previous recommendations to address the opioid epidemic here.


House Speaker Outlines Vision of Restructured Medicaid Program
Recently, Speaker of the House Paul Ryan (R-WI) released a health reform proposal under his “A Better Way” Initiative. The plan represents the consensus views of the House Republican and outlines the party’s vision for a healthcare system that would replace the ACA and significantly alter Medicare and Medicaid.


The plan’s Medicaid proposals would allow states to choose between a block grant or a per capita cap approach for receiving their federal share of Medicaid funding. The per capita caps would apply to Medicaid’s four major beneficiary categories – aged, blind and disabled, children, and adults – and would be set to grow at a rate slower than under current law. States would be permitted to set employment, job seeking, or job training requirements for beneficiaries, set premiums or require premium assistance programs for non-disabled adults, and receive permanent authorizations of managed care waiver programs that have been renewed twice or more or meet current “fast track” renewal requirements.


In the News


Modern Healthcare reports on Surgeon General’s opioid addiction initiative
While visiting a substance abuse treatment center in the Bronx on Thursday, Surgeon General Vivek Murthy said the ultimate solution to fighting widespread opioid addiction in the United States will require a re-approach to the way the country thinks about addiction. In doing so, Murthy stressed that policymakers, healthcare providers, and the public need to treat substance abuse the same as chronic illnesses, like diabetes and heart disease.


Read the article here.


Oregon Medicaid Director Discusses State’s Coordinated Care Organizations
Last week, Lori Coyner sat down with State of Reform to discuss her agency’s newly released metrics report, revealing various measures surrounding Oregon’s CCOs’s pay-for-performance program. Marking its third year, the program rewards CCOs that satisfy at least 12 of 17 state incentive measures and enroll at least 60% of members in Patient-Centered Primary Care Homes.


Coming at a particularly opportune time as Oregon undergoes its 1115 Medicaid waiver renewal process, the analysis of the program captures several significant findings, including that CCOs have: 1) Increased enrollment in Patient-Centered Primary Care Homes to about 80%, even in the face of a doubling in Medicaid enrollment overall (650,000 to 1.1 million); 2) Increased preventive screenings; and 3) Decreased emergency department use. Once the upcoming 1115 waiver has been renewed, Coyner plans to situate Patient-Centered Primary Care enrollment at her agency’s core while making standards more rigorous. She will also work to prioritize care transitions from institutional settings to supportive housing to prevent homelessness and foster greater collaboration between CCOs and hospitals to ensure that patients are receiving adequate follow-up (particularly in terms of mental and behavioral health).


Please read the article here.

Take Note


New Report on Medicaid Delivery System Reform
In June, the California Health Care Foundation/Manatt Health released a report on the future of Medi-Cal, which currently serves over a third of Californians. Conducting a landscape review and in-depth interviews with a diverse array of over 50 Medi-Cal stakeholders and thought leaders, the report provides an overview of Medi-Cal, assesses key challenges and opportunities, establishes a vision for delivery system reform, and articulates a path to achieve that vision. Key findings include:
  • Overall, there is strong agreement with a vision for Medi-Cal, as expressed in the Medi-Cal 20/20 waiver, to foster “shared accountability among all providers to achieve high-value, high-quality, and whole-person care.”
  • Key barriers to achieving this vision include fragmented administration and delivery of care, fragmented financing, uneven access to providers, workforce challenges, lack of transparency and effective accountability mechanisms, and under-resourced program management.
  • There are near-term reforms that can be started now, including reforming how capitation rates are set for Medi-Cal managed care plans, intensifying efforts to coordinate care for people with serious mental illness, addressing workforce shortages, and more.
  • In parallel to these important initiatives, a far more ambitious, longer-term agenda is needed to restructure and transform the underlying Medi-Cal delivery and payment system. 
Please read the report here.


GAO Report Analyzes Early Autism Identification and Treatment
On June 20, the GAO released a report describing 1) How federal agencies encourage early autism identification and interventions; 2) The intervention services provided by federal education and health care programs; and 3) The steps taken by HHS and federal agencies to improve research coordination. The report finds that from FY2012-FY2015, approximately $395 million was awarded by the Departments of Defense (DOD), Education, and Health and Human Services (HHS) for research on these matters nationally. Narrowing in on five states, GAO finds that children enrolled in federal health care programs – Medicaid, CHIP, or TRICARE – received a variety of autism interventions, with speech, language, and audiology identified as the most frequently administered service (32.7%) followed by physical and occupational therapy (22%), behavioral therapy (18.5%), home care and skills training (17.1%), and evaluation and management (9.8%). It also reveals how HSS has taken action required by the 2014 Autism CARES Act that could help coordinate federal autism research and further drive GAO’s recommendations.


Please read the report here.


CHCS Brief Explores Duals Demo Plans’ Lessons Learned
In 2011, the Centers for Medicare & Medicaid Services (CMS) created the Financial Alignment Initiative to test new models to integrate Medicare and Medicaid for this population. Under the initiative’s capitated model demonstrations, CMS and states contract with Medicare-Medicaid Plans, which are responsible for the full range of covered services for dually eligible beneficiaries.


A new report, prepared by the Center for Health Care Strategies (CHCS) for the Association for Community Affiliated Plans (ACAP), examines the experiences of 14 plans that are participating in the demonstrations. The report identifies innovations advanced under the demonstrations, as well as lessons/recommendations for designing effective and replicable strategies to improve care for dually eligible individuals in the future. The lessons identified include the following:
  • Investing in relationships with states and providers – before, during, and following program implementation – is essential to program success;
  • Implementing extensive care management activities requires significant time and resources from both plans and providers;
  • Coordinating physical and behavioral health services necessitates that MMPs focus on promoting collaboration and information sharing across primary care and specialty behavioral health settings; and
  • Simplifying and fine-tuning administrative and related processes are key to demonstration success, but this takes time.
The report is posted  here.


PEW Issue Brief Explores Medicaid Efforts to Address Prescription Drug Abuse
A recent PEW Charitable Trusts issue brief presents the results of a nationwide survey of Medicaid patient review and restriction (PRR) programs, providing an overview of the ways in which public and private insurance plans use PRR programs to encourage the safe use of opioids and other controlled substances. In the 43 states analyzed, PEW finds substantial variation in the number of beneficiaries enrolled in Medicaid PRR programs; the criteria used to identify patients for enrollment; the ways in which providers are assigned; the structure of patients’ appeal rights; and the timeframe of enrollment. While variable in these regards, PEW also finds that more than 40% of responding states view the inability to review cash transactions as the “greatest barrier” to operating PRR programs; despite this, only 58% of Medicaid PRRs have access to enabling tools like the prescription drug monitoring programs, or PDMPs.


Please read the issue brief here.


ASPE Report Reviews Impact of Medicaid Expansion
A recent Health and Human Services Assistant Secretary for Planning and Evaluation (ASPE) report provides a literature review of the impacts of the ACA’s Medicaid expansion in 2014 and 2015 on health access, affordability, and quality of care. It finds that in Medicaid expansion states between 2014 and 2015:
  • The number of uninsured adults decreased by 9.2 percentage-points (compared to a 7.2 percentage point reduction in non-expansion states);
  • Access to primary care, prescription medication use, and the rate of diagnosis for chronic conditions for new enrollees all increased;
  • Unmet healthcare among low-income adults declined by 10.5 percentage points, coupled by an equivalent reduction in the portion of low-income adults reporting problems with paying medical bills; and
  • Nearly two-thirds (61%) of adults with Medicaid expansion coverage considered themselves to be “better off now than they were before” enrolling in Medicaid, 93% of adults were very or somewhat satisfied with their Medicaid health plans, and 92% were very or somewhat satisfied with their plan doctors.
Please read the issue brief here.


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