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This newsletter we cover SUD, children in Medicaid, NPRM Modifying 2018 Exchange Rules, and Hill ACA repeal and replace discussions.

February 28, 2017
From the NAMD Desk

NAMD Responds to Substance Use Disorder Privacy Rule

Last week, NAMD sent a letter to the Substance Abuse and Mental Health Services Administration (SAMHSA) on  a proposed rule addressing the privacy of substance use disorder (SUD) diagnosis and treatment information. The proposed rule would clarify how the SUD privacy requirements apply for purposes of health care payment and operations.

NAMD’s letter reiterates Medicaid Directors’ overarching concerns with separate SUD privacy requirements (42 CFR Part 2). It calls on SAMHSA and Congress to more closely align Part 2 with the requirements governing all other health information. Further, it adds that beneficiaries’ SUD information needs to be available to state Medicaid agencies and their contractors for purposes of care coordination and case management.


Read NAMD’s letter here.
In This Issue

Reg Update


Administration Orders Agencies to Review Existing Regulations

Last week, President Trump issued an Executive Order directing all federal agencies to create a task force to review existing regulations and ” make recommendations […] regarding their repeal, replacement, or modification.” According to the order, each task force must identify regulations that impact job creation, are outdated/ineffective, impose undue costs, and derive from presidential directives that have been rescinded. The Executive Order also directs each task force to seek input from entities affected by the federal regulations, including state governments. Each review entity must make its recommendations within 90 days.

The Executive Order is  available here


CMS Seeking Input on Innovations for Children in Medicaid
Today, CMS released a Request for Information (RFI) that seeks input on approaches to improve the quality and reduce the cost of care for children and youth enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). As part of this RFI, CMS is exploring concepts that encourage pediatric providers to collaborate with health-related social service providers at the state, tribal, and local levels and share accountability for health outcomes for children in Medicaid and CHIP.


CMS is asking interested stakeholders, including state Medicaid agencies, to submit comments on the RFI to by 11:59 PM on March 28, 2017. More information about the RFI is
available here.


CMS Re-Opens CPC+ Model to Additional Payers and Regions
The Centers for Medicare and Medicaid Services (CMS) recently re-opened the Comprehensive Primary Care Plus (CPC+) model for additional payers and regions to participate in the multi-payer model. CMMI is soliciting proposals, from existing and new payers in the 14 current CPC+ regions, as well as payers in up to 10 new regions, to participate in CPC+ Round 2. The Round 2 demonstration is expected to begin in January 2018, and CMS is accepting payer proposals to partner in Round 2 of CPC+ through April 3, 2017.
CPC+ is an advanced primary care medical home model, which CMS announced last spring, that aims to strengthen primary care through regionally-based multi-payer transformation. CPC+ brings together Medicare and other payers, including state Medicaid agencies, to provide financial support for practices to make significant changes in their care delivery.

CMS Issues NPRM Modifying 2018 Exchange Rules

On February 17, the Centers for Medicare and Medicaid Services (CMS) published a notice of proposed rulemaking which would make a variety of changes to the 2018 Exchange requirements. The rule aims to stabilize the individual and small group markets by making changes, such as:

  • Reducing the open enrollment period to last from November 1, 2017 through December 15, 2017 (rather than through January 31, 2018);
  • Expanding the pre-enrollment verification process occurring in special enrollment periods to apply to all individuals enrolling in such a period;
  • Deferring network adequacy reviews to the states; and
  • Reducing the Essential Community Provider (ECP) network requirement to 20 percent of a plan’s network rather than 30 percent, and allows issuers to use a write-in process to verify ECPs.
The NPRM is available on the Federal Register here.


Effective date of SUD Privacy Rule Delayed by 60 days

On February 16, the effective date of the Confidentiality of Substance Use Disorder Patient Records
final rule was delayed from February 17, 2017 to March 21, 2017. The rule sets out to update and modernize 42 CFR part 2 in order to facilitate integration of care and new health care delivery models, while protecting the privacy of patients with a substance use disorder. According to SAMSHA, the 60-day delay is necessary to give Department officials the opportunity for further review and consideration of new regulations. This notice does not impact SAMHSA’s Supplemental Notice of Proposed Rulemaking ( SNPRM) issued on January 18, 2017.


Please find the notice delaying the rule’s effective date


CMS releases 2016-2025 Projections of National Health Expenditures Data
On February 15, CMS released its 2016-2025 Projections of National Health Expenditures Data Report, revealing that total health spending as of 2016 has reached nearly $3.4 trillion, a 4.8-percent increase from 2015. The report also predicts that national health expenditure growth will average 5.6 percent annually over 2016-2025, outpacing GDP by 1.2 percentage points. This spending growth, CMS purports, will be largely attributable to increasing medical prices (compared to recent historically low growth).


In addition to addressing national health expenditures writ large, the report includes analysis specific to spending on Medicare, Medicaid, and private health insurance, as well as prescription drug spending and medical price inflation.


Please find report here.


Hill Update


House GOP ACA Repeal and Replace Legislation Leaked; Senate Path Appears Difficult
Late last week, media outlets obtained a leaked discussion draft of a House GOP ACA repeal-and-replace proposal which aligns with House leadership’s policy document circulated earlier this month. The draft legislation, which is likely to change as debate continues, would significantly alter the Medicaid program by:
Repealing Medicaid Expansion
  • Codifies the optional nature of the expansion in statute, consistent with the Supreme Court’s ruling on the matter;
  • Effective January 1, 2020, ends states’ ability to expand this group beyond 138% FPL;
  • Continues the enhanced match for the expansion population through January 1, 2020. After this date, the match will continue only for individuals who qualified as newly eligible under the ACA, were enrolled prior to January 1, 2020, and do not have a break in coverage for more than a month after 2020.
Converting Medicaid into a Per Capita Cap System
  • Converts the Medicaid program into a per-capita cap system beginning in FY 2020, based on Medicaid eligibility categories of:
    • Individuals aged 65 and over;
    • Blind or disabled individuals;
    • Children under 19 who are ineligible for CHIP;
    • Individuals who qualified as newly eligible under the ACA; and
    • Other adults not included in the above groups.
  • In FY 2021 and beyond, states which spend above their per capita cap allotments will have their FMAPs reduced on a quarterly basis to total the amount of the previous year’s overage.
  • Per capita caps for each of the eligibility group will be set at a FY 2019 baseline, using FY 2016 per capita spending data, and adjusted based on the medical care portion of the Consumer Price Index for Urban Consumers (CPI-U) plus one percentage point.
  • Allowable supplemental payments not attributed to an individual beneficiary or service will be calculated separately as a percentage of total expenditures, distributed across all population groups, for purposes of calculating per capita caps.
  • States will receive 100% FMAP for MMIS and eligibility system design, implementation, installation, operations, and maintenance in FY 2018 and 2019 to meet necessary reporting requirements.
  • State administrative match will be increased by 10%, to a total of 60%, for expenses directly related to implementing new data requirements.
Other Medicaid Provisions
  • Excludes certain providers from the Medicaid program, if they meet the following criteria:
    • Are a 501(c)(3) organization;
    • Are an essential community provider under the ACA primarily engaged in family planning services, reproductive health, and related care;
    • Provide abortions that are not due to rape, incest, or a life-threatening condition to the mother; and
    • Received more than $350 million from Medicaid programs in FY 2014 throughout all affiliates and subsidiaries.
    • Eliminates the enhanced FMAP for 1915(k) Community First Choice programs starting January 1, 2020;
    • Starting January 1, 2020, ends the requirement for states to allow hospitals to make Medicaid presumptive eligibility determinations;
    • Starting January 1, 2020, removes the requirement for Medicaid Alternative Benefit Plans (ABPs) to include the ACA’s Essential Health Benefits.
State Innovation Fund
The legislation would create a state innovation fund and allocate $100 billion for the fund for nine years, beginning in FY 2018. The fund would provide grants to states to stabilize insurance markets and create high-risk pools, promote access to preventive care and dental and/or vision services, and reduce out-of-pocket spending. The grants will be initially calculated based on the number of individuals eligible for ACA tax credits and the amount the state’s average Exchange premium costs exceeded the national average. Beginning in FY 2020, states will be required to provide a 7% match for grant funds, with the match amount increasing by 7% each year until a maximum of 50% in FY 2026.

Other Provisions
As discussed in the House GOP leadership’s policy document, the draft legislation would repeal the ACA’s premium tax credits for purchasing subsidized insurance on the Exchange and replace them with an age-adjusted tax credit, ranging from $2000 to $4000. The ACA’s taxes and fees would also be repealed.

The outlook for this legislation is currently unclear, as formal hearings and discussion have not yet begun. However, announcements in the Senate suggest that Republicans in that chamber may face a more challenging road to reform. Last week, Senator Lisa Murkowski (R-AK) stated she would not support repeal of the Medicaid expansion or the de-funding of Planned Parenthood, both of which are elements of the House discussion draft.


RECAP: SFC Holds Confirmation Hearing for CMS Nominee
On February 16, the Senate Finance Committee (SFC) held a hearing to consider the nomination of Seema Verma as Administrator of the Center for Medicare and Medicaid Services (CMS). A recording of the hearing is available on the SFC website here.


Republicans on the Committee noted Verma’s experience working with states and CMS to secure federal approvals for Medicaid demonstrations, while Democrats sought to assess how Verma would approach ACA repeal, Medicaid reform, and other topics. She declined to outline policy positions on some such proposals, noting that as CMS Administrator she would be responsible for implementing Congressional reforms.
Of note for Medicaid Directors, Verma stated that her primary goals for Medicaid are to promote state accountability and to improve beneficiary health outcomes. She stated that Medicaid, as currently structured, does not do enough to promote these goals, requiring burdensome federal approvals that pose barriers for state innovation. She specifically mentioned the Medicaid managed care rule as an example of regulatory burden that does not necessarily achieve these aims. She also stated that any policy option that did promote these goals should be considered, but did not explicitly support block grants or per capita caps for Medicaid. Finally, Verma expressed support for a timely reauthorization of CHIP for at least eight years.


In the News


Washington Post Examines ER Doctors’ Impact on Long-term Opioid Use
The Washington Post recently highlighted a Harvard study connecting the prescribing habits of hospital emergency-room doctors with extended use of narcotic painkillers. Examining nearly 380,000 Medicare patients who visited emergency departments across the U.S. between 2008 and 2011, the study reveals that individuals seen by a frequent opioid prescriber are about 30 percent more likely to take them for at least six more months over the ensuing year. As the article clarifies, long-term use of opioids does not necessarily mean addiction or physical dependence on the drug; however, data show that one-third of Americans who take prescription opioids for at least two months reportedly become addicted to, or physically dependent on, the powerful painkillers.


Please find article here.


Stateline Looks at the Effect of ACA Repeal on Addiction Services
As lawmakers discuss the future of the ACA, this article explores how governors, health care professionals, and advocates are cautioning that cuts in federal funding for addiction treatment could impact addiction services.
Stateline notes that since 2014, an estimated 1.6 million uninsured people with addictions have gained Medicaid coverage in the 31 states (plus the District of Columbia) that opted to expand. It also notes that the ACA has also provided financial incentives for states to test new models for treatment.


Please find article here.


Take Note


Commonwealth Provides an Overview of Arkansas’s Medicaid Expansion Experience
In this report, the Commonwealth Fund describes the key features of Arkansas’s “private option” as an alternative to conventional Medicaid expansion. The first state to receive approval to expand Medicaid under the ACA through a Section 1115 waiver, Arkansas deploys Medicaid funds to purchase private health plans on the state’s marketplace with the aim of promoting market competition, continuity of coverage, and greater access to care. Using data from 2013-2015 that assessed health insurance coverage, access to care, utilization, and self-reported health among low-income adults in Arkansas compared to adults in two other states, Commonwealth concludes that Arkansas’s private option improved access to primary care and prescription medications, reduced reliance on the emergency department, increased use of preventive care, and improved perceptions of quality and health among low-income adults in the state, compared to Texas, which did not expand Medicaid.


Please click here to read the report and learn more.


Manatt Health, Medicaid at a Crossroads: What’s at Stake for the Nation’s Largest Health Insurer
As proposals are being considered by Congress and the new administration to repeal the Affordable Care Act’s (ACA) Medicaid expansion and implement limits on federal Medicaid funding through block grants and per capita caps, this Manatt Health issue brief considers how much Medicaid has changed over the last 50 years, evolving from a small welfare program into an integral part of the nation’s health insurance system.
Specifically, the brief reviews what states have accomplished to drive value in and through their Medicaid programs, and what states stand to lose in terms of progress and innovation in their Medicaid programs and health care delivery systems if federal support for Medicaid is reduced.
Please find brief here.


Kaiser Family Foundation, Coverage Changes for People with HIV Under the ACA
This brief provides national estimates of changes in insurance coverage among people with HIV since the implementation of the ACA. Based on analysis of data from the Centers for Disease Control and Prevention (CDC), it finds there was a nationwide increase in coverage for people with HIV from 36 percent in 2012 to 42 percent in 2014. In the Medicaid expansion states sampled, Medicaid coverage rose from 39 percent in 2012 to 51 percent in 2014.


Please find analysis here.


National Academy of Sciences Report on Children’s Behavioral Health
A recent report from the National Academy of Sciences considers how changes in the healthcare landscape are impacting children’s behavioral health, including the ACA’s coverage expansion, the movement towards value-based payment, and the focus on population health strategies. The paper also highlights ways for the children’s behavioral health community to engage with stakeholders to advance child and family health and development.


Please find link to report here.


Kaiser Family Foundation: New Tool on ACA Repeal and Replace Proposals
A new interactive tool from the Kaiser Family Foundation enables users to create side-by-side comparisons of major ACA alternative plans, including Sen. Rand Paul’s Obamacare Replacement Act (2017); Sen. Bill Cassidy’s Patient Freedom Act (2017); House Speaker Paul Ryan’s A Better Way: Our Vision for a More Confident America (2016); and Empowering Patients First Act (2015), introduced by Rep. Tom Price before he became Secretary of Health and Human Services. With the tool, users can compare the plans’ approaches to more than a dozen key areas of health policy, including individual insurance market rules, requirements and provisions for employers, benefit design, Medicaid, and Medicare.


Please find it here.


ASHP Publishes Controlled Substances Diversion Prevention Guidelines
Late last year, the American Society of Health-System Pharmacists (ASHP) published national guidelines to help healthcare organizations devise strategies to prevent the diversion of controlled substances. In particular, the guidelines include a framework for creating a comprehensive controlled substances diversion prevention program (CSDPP).


The guidelines can be found here.


SHVS Toolkit: Data Points to Assess Federal Medicaid Proposals
To assist states in assessing the potential implications of federal Medicaid proposals, the State Health and Value Strategies Program and Manatt Health have developed a toolkit providing state-by-state data on Medicaid enrollment and expenditure trends-factors that are central to establishing the amount each state would be allocated under various capped funding proposals.
In addition to this resource (download here), a memo explaining its content is available here. The release of these materials was also accompanied by a webinar presented by SHVS and Manatt, and this presentation is available


Nevada – Multiple Job Openings
The Division of Health Care Financing and Policy (DHCFP) is seeking qualified applicants for the position of  Deputy Administrator of the Division.


The mission of DHCFP is to purchase and provide quality health care services to low-income Nevadans in the most efficient manner; promote equal access to health care at an affordable cost to the taxpayers of Nevada; restrain the growth of health care costs; and review Medicaid and other state health care programs to maximize potential federal revenue.


There are also numerous Health Care Coordinator positions within the department.

All job postings can be accessed  here.



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