CMS issues guidance on SUPPPORT Act; Electronic Visit Verification; Kaiser report on community engagement and work requirements; job postings.

Bi-Weekly Update
August 13, 2019
In This Issue

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November 11-13
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Regulatory Update


CMS Issues Guidance on SUPPORT Act’s DUR Requirements
On August 5, the Center for Medicaid and CHIP Services (CMCS) issued an Informational Bulletin describing drug utilization review (DUR) provisions states must implement under the SUPPORT Act. Notably, states must have these changes in place by October 1, 2019. For FFS pharmacy benefits, states may submit necessary State Plan Amendments (SPAs) by December 31, 2019; for states carving in the pharmacy benefit into managed care, these DUR requirements must be in their managed care contracts on October 1.
CMS interprets the SUPPORT Act’s language to implement “safety edits” and “claims review automated processes” as requiring prospective and retrospective DUR activities, respectively. These include:
  • Safety edits, including early fill, duplicate fill, and quantity limit alerts;
  • Maximum daily morphine equivalent (MME) safety edits; and
  • Concurrent utilization alerts for beneficiaries concurrently prescribed opioids and benzodiazepines and/or antipsychotics.
States are also required to produce an annual DUR report on antipsychotic prescribing in children under age 18, with specific focus on children in foster care.
Lastly, the guidance provides a review of necessary components of the SPA submission and reminds states of the potential availability of enhanced systems match funding to implement these provisions.
CMS Issues Additional FAQs on EVV Requirements
On August 8, the Center for Medicaid and CHIP Services (CMCS) published a set of Frequently Asked Questions (FAQs) providing additional information on the 21st Century Cures Act’s requirement for electronic visit verification (EVV) in Medicaid personal care services and home health care services. These FAQs are intended to clarify questions from states and stakeholders that have emerged over the past year. Topics addressed include:


    • EVV requirements in instances of individuals receiving services from a live-in caregiver;
    • Whether EVV requirements apply for service components that authorize provision of medical supplies and equipment;
    • Options for implementing EVV when a service is provided in both the home and the community during the same visit; and
    • Whether web-based timesheets with dual verification satisfy the EVV requirement.

CMS Publishes Guidance on New Options for Creating Alternative Benefit Plans
On August 8, the Center for Medicaid and CHIP Services (CMCS) published an Informational Bulletin detailing new options for states in selecting benchmark plans for the purposes of defining Essential Health Benefits (EHBs) in an Alternative Benefit Plan (ABP). Notably, the guidance indicates that states may grandfather existing ABPs with selections from previous EHB benchmarks, but states seeking to modify an ABP with new benchmarks or create a new ABP must use one of these new options beginning January 1, 2020. They are:

  • Select an EHB benchmark from another state;
  • Replace an EHB category or categories with categories from another state’s EHB benchmark; or
  • Propose a set of benefits.
The guidance reminds states of their obligation to actuarially certify that their ABP’s EHB benchmark plan meets regulatory requirements around coverage and scope of benefits standards, as well as comply with State Plan Amendment (SPA) submission and public notice processes.

CMMI Guidance Highlights Opportunities for Medicaid Participation in Medicare Emergency Transportation Demonstration
On August 8, the Center for Medicare and Medicaid Innovation (CMMI) and the Center for Medicaid and CHIP Services (CMCS) issued a
Joint Informational Bulletin on a new Medicare fee-for-service demonstration with opportunities for Medicaid participation. The demonstration, called the Emergency Triage, Treat, and Transport (ET3) model, is focused on providing flexibilities in Medicare to encourage the use of telehealth, treatment in place, and ambulance transport to non-emergency department settings. The model includes a multi-payer component, and this guidance provides states with details on the model’s Medicare financing, eligible services, and how states can leverage Medicaid authorities to align their own programs with this model. Also included is a literature review of similar models already existing across the country, providing real-world reference points for states to mirror.


On the Hill
Congress is in August recess and will return to session on September 9.


Reports & Publications


KFF: Understanding the Intersection of Medicaid and Work: What Does the Data Say?
Last week, the Kaiser Family Foundation released a brief providing state data on Medicaid community engagement and work requirements. The analysis finds that 63 percent of the 23.5 million adults with Medicaid coverage in the U.S. who are not dually eligible for Medicare and Medicaid and do not receive federal disability payments, are already working full- or part-time. Most of those who are not working report that they do not work because they have caregiving responsibilities, attend school, or have an illness or disability.


The report concludes that those most likely to be targeted by states’ new work requirements are the 7 percent of adult Medicaid enrollees who report that they are retired, unable to find work, or are not working for another reason. The analysis also finds that most adults in Medicaid who work are in low-wage jobs in industries with low rates of employer-sponsored insurance, such as food service and construction. And it show that some people who remain eligible for Medicaid could lose coverage due to failure to navigate the red tape of the new work and reporting requirements.


The full report is available here.


In the News


KFF: Coordinating Care of Mind and Body Might Help Medicaid Save Money and Lives
In this article, Kaiser Family Foundation highlights efforts in Tennessee incentive care coordination for Medicaid patients with physical and mental health needs. TennCare’s Tennessee Health Link program provides bonuses to mental health providers who guide patients in care related to their physical health.&nbsp
TennCare evaluates care coordinator’s performance, measuring patient’s inpatient hospital and psychiatric admissions as well as visits to emergency rooms, and allows providers to share savings.
The full article is available here.
Modern Healthcare: Trump finalizes rule penalizing legal immigrants for using Medicaid, SNAP
The Trump administrative has finalized the controversial “public charge rule”, allowing federal immigration officials to consider legal immigrants’ use of public health insurance, including Medicaid, nutrition, housing and other programs as a strongly negative factor in their applications for permanent legal residency. The rule will take effect on October 15 and is not retroactive for participation in public benefit programs before that date.
The full article is available here.

Job Postings


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