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Real Time Prescription Cost Avoidance for Payers of Last Resort
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ACCESS TO QUALITY CARE HAS IMPROVED AFTER THE EXPANSION OF MEDICAID

While Medicaid expansion advocates are pleased with the latest developments in Maine and Virginia, there are concerns about access to quality care as the Medicaid population increases. To answer these questions, several studies have been conducted to help assist the states considering expansion and those that are making changes to their current programs.

Medicaid Expansion And Rural Areas
Since most of the rural populations are beneath the poverty line and uninsured, rural areas all over the country depend on community health centers for primary care. The increased federal funding from the Affordable Care Act and Medicaid expansion were believed to be solutions that would improve the access and quality of care for these communities.

In a study from Health Affairs titled, Medicaid Expansion And Community Health Centers: Care Quality And Service Use Increased For Rural Patients, analysts looked into the changes in quality and access between 2011 and 2015. After reviewing community health centers from states that expanded with centers in states that did not, the report indicated that patients covered by Medicaid rose to 13% and uninsured patients decreased by 11%.

Analysts also compared urban centers from areas that expanded Medicaid with urban centers in areas that did not, but the study did not discover any significant changes to the quality of care.

Unlike the urban community health centers, rural centers from states that expanded Medicaid experienced substantial improvement. Researches feel that these improvements may be a result of more affordable pharmaceuticals under Medicaid or perhaps due to the fact that insurance access to care makes visits to health professionals less costly.

Are More Conservative Versions of Medicaid Working?
Health Indiana Plan 2.0 was the outcome of the state expanding Medicaid using the 1115 waiver process. In order to qualify, program enrollees are mandated to contribute to a health savings account. Whenever an enrollee fails to make a payment, their benefits are reduced. Additionally, enrollees that make more than the poverty line are locked out of coverage for 6 months if they miss a payment.

Indiana University researched the effects of the state's decision and compared it to other states that expanded. Using data from the American Community Survey, analysts aimed to see if adults between the ages of 18 and 64 had insurance coverage or Medicaid coverage from 2009 to 2016. According to their analysis, states that expanded their Medicaid programs experienced greater gains in comparison to states that did not. Generally, states that had higher insurance coverage rates before expanding saw more gains. Out of 27 states, Indiana ranked in the middle at 13.

Regardless of Indiana's additional conditions for coverage, the state experienced notable Medicaid coverage gains. Whether the gains could have been larger without the requirements could not be determined. Also, Indiana's cost-sharing requirements could be the cause for the state's underperformance.

A 30,000 Foot View Of Medicaid After Expansion
From the beginning of Medicaid expansion, there have been 77 studies published with 440 unique analyses. Over half of the studies indicate that the effects of Medicaid expansion are in line with the goals of the Affordable Care Act. 35% of the studies showed no significant discoveries and 4% discovered a negative effect after expanding Medicaid.

Up to this point, the studies that have been conducted indicate that the effects of Medicaid expansion have been positive. The lead author of Indiana University's study, The Effects Of Medicaid Expansion Under The ACA: A Systematic Review, Olena Mazurenko says "With dozens of scientific analyses spanning multiple years, the best evidence we currently have suggests that Medicaid expansion greatly improved access to care, generally improved quality of care, and to a lesser degree, positively affected people's health."

#SyrtisSolutions #MedicaidExpansion

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PROTPL SOLUTION ACHIEVES HITRUST CERTIFICATION TO MANAGE RISK AND STRENGTHEN SECURITY

Syrtis Solutions is proud to report that its ProTPL platform has attained certification by the Health Information Trust (HITRUST). Through the inclusion of state and federal standards and incorporating a risk-based approach, the HITRUST CSF helps organizations comply with key regulations and requirements for safeguarding and securing confidential private healthcare information.

" Syrtis Solutions' customers trust our commitment to security. Achieving HITRUST certification for ProTPL's underlying infrastructure is a further extension of our commitment to honoring that trust," said Steve Konsin, CEO of Syrtis Solutions. "Even though we have consistently maintained the highest levels of risk management to protect sensitive healthcare information, we realized how important it was to operate under the HITRUST third-party validation which has become the benchmark certification in the healthcare industry."

THE PROTPL SOLUTION
Most Medicaid beneficiaries do not have any other forms of health insurance; however, there is a part of the population that have a primary payer, like employer-sponsored insurance or Medicare. As a 'payer of last resort' Medicaid must always pay last if other insurance exists. This is identified as third party liability (TPL), with the other payer being the third party that is liable for the insurance coverage.

The difficulty for Medicaid plans to identify primary insurance before claims are paid improperly has been an on going challenge due to antiquated technology, siloed data systems, and network latency. For that reason, inefficient post-payment recovery processes are needed to retrieve the improper claims payments. The method of 'pay and chase' has become normalized with an entire multi-billion dollar industry constructed around it even though cost avoiding payments of claims and directing them to the proper payers is the only way to ensure federal dollars are not paid in error. To address this problem, Syrtis developed ProTPL.

ProTPL supplies Medicaid plans with a technology-based solution to prospectively identify TPL on its members to cost avoid claims payments. ProTPL has been adopted by leading Medicaid fee for service and managed care plans in addition to the Department of Defense due to its unique prospective methodology and the rate in which it delivers active and accurate eligibility data. The release of ProTPL has made tremendous strides in reducing improper claims payments for payers of last resort.

syrtissolutions.com/protpl-platform-achieves-hitrust/

#SyrtisSolutions #HITRUST #HIGHTRUSTCSF #ProTPL
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TRUMP ADMINISTRATION SIGNALS POSSIBLE LIMITS TO MEDICAID 1115 WAIVER APPROVALS

From the very beginning of Donald Trump's presidency, he has promised to grant states the flexibility they need to draft their own Medicaid policies. HHS, collaborating with governors and state legislatures, could make dramatic state-by-state modifications to Medicaid utilizing section 1115 waivers allowed under federal law.

Section 1115 waivers grant states the opportunity to waive key provisions of federal Medicaid law. The modifications made possible by Section 1115 waivers are not as dramatic as those contained in the failed bills. As an example, states can not use 1115 waivers to totally restructure Medicaid under block grants or per capita caps, nor can the federal government use them to take away federal reimbursements for Medicaid expansion; nevertheless, they are still significant.

Under the Trump administration, CMS has accepted 1115 waivers that the prior administration continuously rejected. Several states, for instance, have been authorized to make employment a condition for Medicaid enrollment. (The state of Kentucky; however, is presently in court proceedings over the new policy.).

The Trump administration is also permitting Kentucky to require beneficiaries to disclose income changes while Arkansas is disenrolling beneficiaries for the rest of the calendar year if they don't comply with the work requirement.

The list below is what CMS has previously refused, as well as what is still under deliberations:

MEDICAID 1115 WAIVERS ALREADY TURNED DOWN BY CMS
Lifetime limits

In May, CMS rejected an 1115 waiver application from Kansas to set up a three-year time limit for people enrolled in the Medicaid program.

Joan Alker, executive director of the Center for Children and Families at Georgetown University, said in a statement that she was "... pleasantly surprised by that.".

Utah, Wisconsin and Arizona have also handed in similar 1115 waiver applications to CMS for lifetime limits, which Alker expects will also get turned down.

In a statement by Seema Verma regarding Kentucky's attempt to sanction lifetime limits on Medicaid enrollees, she said "We seek to create a pathway out of poverty, but we also understand that people's circumstances change, and we must ensure that our programs are sustainable and available to them when they need and qualify for them.".

Partial expansion

CMS declined Arkansas' bid to reduce the number of people who qualify for the state's Medicaid program. Arkansas was looking to reduce the eligibility requirement from 138 percent of the federal poverty to 100 percent; however, it wasn't a firm denial, instead, CMS pointed out it could not endorse the waiver application "at this time.".

Whenever states vote to expand Medicaid the federal government covers 90 to 100 percent of the program's costs. If Arkansas were allowed to simply cover people up to 100 percent of poverty, the formerly enrolled members who lose their Medicaid coverage would be eligible for federal health insurance subsidies. This would move the liability to pay healthcare expenses from the state to the federal government. This scenario is most likely not attractive to the Trump administration.

OTHER 1115 WAIVERS STILL PENDING
Work requirements for non-expansion states

Apart from the denial of allowing lifetime limits on Medicaid enrollees, another aspect of Kansas' 1115 waiver application is still pending; namely, a work requirement. But unlike Arkansas, Indiana and Kentucky, Kansas didn't expand Medicaid under the Affordable Care Act (ACA); so demanding individuals to retain an employment (minimally 80-hours per week) would probably exclude them for the state's Medicaid program because they would be making too much money.

Oklahoma, Alabama, South Dakota and Mississippi are other states that didn't expand under the ACA exploring work requirements. The Center on Budget and Policy Priorities issued a report that lays out the catch-22 of these proposals.

In the state of Mississippi, as an example, a single parent cannot earn over $370 per month to qualify for Medicaid. Nonetheless, if they obtained 20-hour per week employment at minimum wage, they would earn $580 a month, which is too much income to qualify for Medicaid.

" They will be complying with the work requirement but still lose coverage. You're in this situation that can't be fixed," says Jessica Schubel, a senior policy analyst for the Center on Budget and Policy Priorities.

CMS' Verma has stated that she is concerned about this "subsidy cliff" and wants to identify a "pragmatic and empathetic" approach to work requirements and other new Medicaid initiatives.

Drug testing for Medicaid enrollment

Lastly, in 2017 Wisconsin was the first state to ask for authorization to drug test Medicaid applicants permitting the denial of enrollment if they test positive. Experts say that there is no way to tell where the federal government will decide the issue. Nevertheless, CMS has indicated that they would advocate the use of Medicaid funds to cover neonatal abstinence syndrome (a withdrawal ailment that occurs when an infant is born with an opioid addiction from their mother's consumption during pregnancy). Medicaid experts say it is hypocritical for the federal government to cover babies with drug-related problems but not their parents.

#medicaidexpansion #section1115waivers #medicaidworkrequirements #medicaidlifetimelimits#syrtissolutions

http://syrtissolutions.com/cms-limits-medicaid-1115-waivers
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MEDICAID SCORECARD PUBLISHED BY CMS TO ASSESS PROGRAM'S ADMINISTRATION

The Center for Medicare and Medicaid Services recently issued a Medicaid Scorecard to promote transparency and accountability. The scorecard features care quality data from 2015 statistics given by participating states, in conjunction with federally reported information. By combining this data, CMS and the states look to analyze the performance of Medicaid plans, the program's administration, and outcomes. Any step to improve efficiencies within the Medicaid program is met with unanimous support across the country; however, industry specialists are concerned with the quality of the data utilized and the underlying intent of the Medicaid Scorecard.

CMS's preliminary Medicaid scorecard strives to improve state and federal alignment, beneficiary health outcomes, and program administration. It functions to assess how effectively states are delivering health services to their beneficiaries; at the same time, it reviews the timespan it takes for the federal government to authorize waiver requests from the states. The Medicaid Scorecard concentrates on three particular areas of measurement:

• State Health System Performance measures "how states serve Medicaid and CHIP beneficiaries across key domains."

• State Administrative Accountability provides "insight into how states and the federal government work together to administer Medicaid and the Children's Health Insurance Program (CHIP)."

• Federal Administrative Accountability provides "insight into how the federal government and states work together to administer Medicaid and the Children's Health Insurance Program (CHIP)."

The Chief of CMS, Seema Verma, considers the scorecard as a means of improved access to Medicaid data and the program's care outcomes. Verma stated, "This is about bringing a level of transparency and accountability to the Medicaid program that we have never had before." Over time, CMS says it will make updates to the Medicaid Scorecard enabling it to address additional issues.

The National Association of Medicaid Directors (NAMD) has raised concerns. According to NAMD, "There are significant methodological issues with the underlying data, including completeness, timeliness, and quality." They dispute the quality of the data and what conclusions could be made from it. In their point of view, the data itself is out of date, rendering it an inaccurate source to identify a state's performance. Furthermore, they point out that any determinations made from the scorecard will be problematic since it compares states with significantly different Medicaid structures.

The Association for Community Affiliated Plans (ACAP) is encouraged by the introduction of a Medicaid Scorecard but also sees inconsistencies. The groups CEO, Margaret Murray, views CMS's effort as a good start. Murray shared, "we agree with Administrator Verma's note that this is a beginning in terms of how we talk about quality, rather than an endpoint. For one thing, the draft scorecard brings into sharp relief the need for more uniform, consistent data reporting across the Medicaid program."

CMS has recently introduced their Medicaid Scorecard with the desire to improve state and federal alignment, beneficiary health outcomes, and program administration; however, Industry specialists are questioning its methodology.

http://syrtissolutions.com/cms-releases-medicaid-scorecard

#medicaid #medicaidscorecard #syrtissolutions
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VIRGINIA APPROVES MEDICAID EXPANSION, NOW EYES TURN TO UTAH, IDAHO, NEBRASKA AND MONTANA

After months of debate amongst Republican representatives in both the House and Senate, legislators in Virginia voted in support of Medicaid expansion under the ACA on May 30th, 2018. The plan to expand the state's Medicaid program to over 400,000 Virginia citizens was included in the General Assembly's approved budget. Democratic Governor, Ralph Northam endorsed the bill at the state's capital on June 7th. Virginia will finance the expansion with the assistance of a 90% funding from the federal government. According to The Commonwealth Institute, "The new Medicaid coverage would require state contributions totaling $1.02 billion over eight years, resulting in a net savings to the state of $1.06 billion."

The decision to expand was motivated by two contributing factors. First and foremost, last November, the Republicans were at risk of losing their majority rule due to their resistance to Medicaid expansion. Second, Virginia's increasing uninsured population is a strain on the state's ability to supply healthcare to its citizens. Since the Affordable Care Act was introduced, the uninsured population has grown because of the increasing costs for coverage. Advocates believe that Medicaid expansion will strengthen Virginia's health care system and benefit both program members and people with private insurance. On the other hand, critics are worried about the related costs and sustainability of expanding the program.

The vote for Medicaid expansion in Virginia is encouraging news for advocates of other states around the country seeking to expand their programs. Currently, there are four states debating the issue.

Utah - Despite support from lawmakers for a partial expansion, activists in Utah pulled together the required number of signatures to have a full expansion of Medicaid on the state's November ballot. Currently, polls indicate that over half of the state's voters support expansion.

Idaho - According to healthcare advocates, activists in Idaho have accumulated the required signatures for a ballot initiative. The initiative would make it possible for residents to vote in November on a expansion of the states Medicaid program. At the time of this post, the signatures have been submitted to county clerk's for confirmation by June 30th.

Nebraska - Promoters of expansion in Nebraska have been gathering signatures since April for the Insure the Good Life petition. They will need 85,000 signatures from registered voters by July 5th in order to vote on the matter in November's general election. According to groups collecting signatures, momentum is on the side of Medicaid expansion for Nebraska.

Montana - Montana's Medicaid program is planning to extend their expansion since it is scheduled to expire in 2019. In order to finance the expansion, a ballot initiative requiring 25,000 signatures has been authorized by the Secretary of State. Unlike other initiatives, Montana proposes an increase on taxing tobacco by $2.00 a pack alongside a 33% increase of the wholesale price for tobacco products. Currently, supporters are promoting the initiative and securing signatures.

As Virginia neared its first government shutdown, recently legislatures finalized a state budget that included Medicaid expansion. 400,000 residents will now be eligible to enroll in the program. The decision to expand the program, despite resistance from Republican leadership, could be a good sign as to what will take place in other states looking to expand this year.

#medicaid #medicaidexpansion #syrtissolutions

http://syrtissolutions.com/medicaid-expansion-approved-virginia/
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STATES SEEK TO USE MEDICAID 1115 WAIVERS TO WAIVE KEY PROVISIONS OF THE PROGRAM

The repeal of the Affordable Care Act with its existing provisions for Medicaid did not materialize at the national level in 2017; nevertheless, states are exploring reform independently by way of Medicaid 1115 waivers. The waivers focus on priorities within the states and permit local governments the flexibility to test coverage models that do not reflect program rules of the federal government.

Medicaid 1115 waivers give states the opportunity to waive key provisions of federal law. The changes made possible by Section 1115 waivers aren't as dramatic as those included in the failed bills-- as an example, states can't use these waivers to fully restructure Medicaid under block grants or per capita caps, nor can the federal government use them to take away federal reimbursements for Medicaid expansion-- yet they are still significant.

In an effort to "support states helping Medicaid beneficiaries improve well-being and achieve self-sufficiency", CMS released new guidance for waivers that introduced work requirements on January 11, 2018. Along with work requirements, states are also considering provisions such as eligibility time limits, drug testing, and premiums. Consequently, these waivers are controversial and have brought up policy issues throughout the country.

Presently, a number of states have sent waivers for authorization from the federal government. Here is some of the highlighting waiver activity within the states.

NEW HAMPSHIRE'S MEDICAID 1115 WAIVER FOR WORK REQUIREMENTS
New Hampshire was the fourth state to be permitted by the Trump administration for Medicaid work requirements. Under the state's Medicaid 1115 waiver, able-bodied adults will either need to work, develop job skills, or engage in community service for them to receive premium assistance and program benefits from the state's Medicaid expansion.

Chief of CMS, Seema Verma congratulated the state and pointed out, "the Trump Administration has helped create one of the strongest job markets in our nation's history and we want to make sure able-bodied, working-age adults receive the necessary skills to join our growing workforce."

Governor Chris Sununu (R-- NH) stated, "Work requirements help lift able-bodied individuals out of poverty by empowering them with the dignity of work and self-reliability while also allowing states to control the costs of their Medicaid programs."

Critics of the waiver are worried that its ramifications will not support the original goals of the Medicaid program. A number of Democratic representatives are in opposition to the work requirements, thinking that they threaten access to the healthcare program. Advocates of the waiver view it as means of safeguarding the program's sustainability. They argue that Medicaid should be reserved for the country's most vulnerable and low-income individuals and families.

KANSAS' REQUEST FOR LIFETIME LIMITS IS DENIED
Support for Medicaid expansion in Kansas came to a halt in February despite efforts from the Senate Public Health and Welfare Committee and House Democrats. Kansas Governor, Sam Brownback (R) vetoed the bill. Had it been signed off on, an estimated 150,000 residents would have been eligible.

While expansion failed, Kansas is one of five states, including Utah, Maine, Arizona, and Wisconsin, to request lifetime limits from CMS. This would have made it possible for the state to restrict coverage to three years/36 months for some of its beneficiaries. CMS has turned down the request making Kansas the first of the five states requesting lifetime limits to be denied.

Chief of CMS, Seema Verma, defended the outcome saying, "we seek to create a pathway out of poverty, but we also understand that people's circumstances change, and we must ensure that our programs are sustainable and available to them when they need and qualify for them."

MEDICAID REFORM IN KENTUCKY
Kentucky was the very first state to receive approval from CMS for an 1115 waiver (January 12, 2017). The waiver will implement work requirements, monthly premiums for low-income parents and expansion adults, dis-enrollment and coverage lockouts, the elimination of retroactive eligibility, the addition of deductible and incentive accounts, and waiving non-emergency medical transportation.

Kentucky's governor, Matt Bevin (R), intends to start the overhaul of the state's Medicaid program on July 1, 2018. It will start in Campbell County and reach throughout the state over a duration of six months. These changes will largely affect able-bodied beneficiaries with incomes up to 138% of the federal poverty level that acquired coverage during the program's expansion in 2014. Due to the overhaul, it's predicted that Kentucky and the federal government will save $2.2 billion over five years. Furthermore, the Center On Budget and Policy Priorities estimates that over the duration there will be a 15 percent drop in adult Medicaid enrollment.

On January 24, sixteen Kentucky Medicaid recipients took legal action and sued the federal government over the waivers provisions. The group observes the Trump administration's approval as a violation of several federal laws and a danger to the lives of tens of thousands of low-income families.

HEALTHY INDIANA 2.0 CLAMPS DOWN ON ENROLLMENT AND ELIGIBILITY
CMS approved the amended extension of Healthy Indiana 2.0 on February 1. Initially, the state's waiver expanded the program under the Affordable Care Act (ACA) from February 2015 through January 2018 by changing the states pre-ACA limited coverage expansion waiver, Healthy Indiana Program 1.0. While other states waivers focus on adults enrolled during expansion, Indiana's also includes changes to the terms of coverage for non-expansion adults. This encompasses low-income parents and those eligible for transitional medical assistance.

Healthy Indiana Program 2.0 includes provisions such as: increasing premiums by 50% for tobacco using members starting the second year of enrollment, eligibility work requirements for most adults in 2019, dis-enrollment and coverage lockouts, setting up a tiered premium structure, and restricting transitional medical assistance eligibility to between 139% and 185% of the federal poverty level.

While there are a number of exemptions in place to help beneficiaries acquire and retain coverage, the launch of these provisions will undoubtedly alter program eligibility. Now that the state has received approval for their provisions, Indiana faces the task of implementing them.

ARIZONA'S FOUR 1115 WAIVERS UNDER REVIEW Arizona is looking to update and reform their Medicaid program, Arizona Health Care Cost Containment System (AHCCCS). At the moment, the state has pending Medicaid 1115 waivers with CMS. The amendments include a retroactive eligibility request, an Institution for Mental Disease (IMD) waiver, work requirements, and an uncompensated care payment model.

Initially, Arizona also sought for authorization of a 5-year lifetime time limit on Medicaid enrollment. However, this was recently taken out from the state's requests after CMS rejected Kansas's similar request for a 3-year time limit. No other state at this time has lifetime limits. In regards to the decision to delay the lifetime limit request, Deputy Director of AHCCCS, Jami Snyder stated, "We have removed the lifetime limit from the waiver request, really for the purpose of expediting approval of the work requirements request." Right now, Arizona is still in discussions with CMS.

Despite the federal government's inability to reform Medicaid, states are now taking action to do it themselves through submitting 1115 waiver requests to CMS. Around the nation, local governments are now taking into consideration provisions such as work requirements, drug testing, lifetime limits, and premiums. Some states have received approval while others are dealing with strong resistance. Although reform through Medicaid 1115 waivers is welcomed by many state lawmakers, the way in which they are implemented will be vital to ensuring the future of the Medicaid program.

#medicaidreform #syrtissolutions #medicaid1115waivers #section1115waivers

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A MEDICAID EXPANSION ROUND-UP

Throughout the 2016 Presidential campaign and not long after assuming office, President Trump was adamant about repealing the ACA's provisions for Medicaid expansion. As a matter of fact, President Trump and the administrator of The Centers for Medicare and Medicaid Services (CMS), Seema Verma, are presently taking into consideration waivers to the Medicaid program that the prior administration rejected. Regardless of the Trump administrations unsuccessful efforts to reform Medicaid on the federal level, a number of states are making attempts to expand their programs. Here is a summary of states in varying stages of expansion discussions.

STATES CONSIDERING MEDICAID EXPANSION
Nebraska: Over the last six years, any attempts to expand Nebraska's Medicaid program have failed as a result of Republican leadership. Republican Governors, Pete Ricketts and his predecessor Dave Heineman each argued that the state could not afford to expand Medicaid. In addition, they believe that expanding Medicaid would favor able-bodied citizens as opposed to low-income residents, for whom the program was intended.

However, that may all change this November at the voting booths. Right now, there are a number of healthcare associations and advocacy groups in the process of gathering signatures from locals to secure a proposal under the Insure the Good Life Petition. Having seen the effectiveness of Maine's ballot initiative, advocates in Nebraska are gaining confidence that they will generate a similar result. In order for the proposal to be included on the ballot, a total of 85,000 signatures from registered voters are required by July 6, 2018. According to Insure the Good Life coordinators, residents have been receptive to the idea of expanding Medicaid.

Idaho: Even with resistance from the Republican-leaning legislature, Idaho Medicaid expansion activists are looking to expand their Medicaid program to 78,000 residents under the ACA through a ballot initiative. Expanding the program would serve to cover Idahoans who fall into a coverage gap because they make too much money to be eligible for Medicaid but not enough to receive subsidized health insurance in the exchange.

In order to get on the November 6th ballot, advocacy groups had to secure at least 56,192 signatures from 18 districts around the state by May 1, 2018. The advocacy groups submitted the signatures before the deadline and say they have the required threshold needed to land a place on November's ballot. Now, the signatures will need to be authenticated by county clerks before June 30th, in order for the expansion proposal to be voted on.

While hopes are high among advocates, implementation of expansion will fall on the governor and state administrators; moreover, they have the authority to reverse voter-passed initiatives. Republican candidate, Rep. Raul Labrador will resist the expansion effort if he is elected. According to Labrador," I think that they need to be informed about what Medicaid expansion would do for the state. If you look at every single state that has expanded Medicaid, they're spending more money than they expected to spend ... and that's taking away money from all the other needs."

Utah: Even with the available federal funding and the states Republican Governor, Gary Herbert's (R - UT) support of Medicaid expansion, there has been enough opposition from the state legislature in Utah to prevent any expansion momentum. Supporters of expanding Medicaid in Utah pushed back by passing a ballot initiative similar to Maine's.

In addition, Governor Herbert also endorsed the HB472 bill. The bill seeks authorization from the federal government to expand his states Medicaid program to 100% of the federal poverty level (FPL) while at the same time implementing work requirements in order to eliminate the coverage gap. Expanding that states program to 100% of the FPL would extend coverage to 72,000 residents by 2020 rather than 150,000 under 138% FPL. If the bill successfully passes, Utah's out of pocket costs would be far less than if their program expanded to 138% FPL.

Arkansas proposed a very similar plan that would have capped eligibility at poverty level instead of 138% of the FPL. CMS did not sign off on the request and it is not likely that CMS will endorse the governor's bill since the federal government has only approved these types of requests under the stipulation that states expand to 138% of the FPL.

While the governor's administration would like to get approval for the bill, Utah voters will also have a chance to weigh in at the ballot boxes in November to fully expand Medicaid to the 138% FPL.

Virginia: In February, The Virginia House of Delegates voted and approved a budget adopting ACA Medicaid expansion in conjunction with work requirements for enrollees. However, Virginia's Senate budget plan didn't include arrangements for expansion. Due to the divided support for Medicaid expansion, the Virginia legislature was not able to complete a budget. Because of this, the implementation of Medicaid expansion and Virginia's FY 2019 budget are currently deadlocked. It has been almost two months since Virginia's General Assembly adjourned without consensus.

On May 14th, the Senate met for a special session to talk about a spending plan and the Senate Finance Committee will continue work on the budget today. The entire Senate will reconvene on May 22. In order for Virginia to expand its Medicaid program, there will need to be a majority vote in both the House and Senate. If Virginia representatives can not come to an agreement by June 30th, the state will experience its first government shutdown.

MAINE HAS ADOPTED MEDICAID EXPANSION BUT IS IN LEGISLATIVE DEADLOCK
Maine's Medicaid program, MainCare, was approved for expansion last November through a ballot initiative. Voters advocated the expansion by 59%. Nevertheless, for 80,000 low-income citizens who would have been eligible for coverage, the state missed the state plan amendment submission deadline to CMS (April 3, 2018). The legislature is currently facing a deadlock as a result of Governor LePage's (R) resistance to expansion.

After the vote, the governor stated, "this fiscally irresponsible Medicaid expansion will be ruinous to Maine's budget."

Under the law, it is estimated that Maine would spend $55,000,000 yearly on the program and the federal government would cover at least 90% of the cost of MainCare's new enrollees. LePage contends that the cost of the expansion is double the amount estimated by the state legislature and refuses to implement the plan unless his demands are met.

LePage's terms include:

• That taxes won't increase
• Stabilization money funds won't be utilized
• The funding mechanism will be ongoing
• Wait lists for the disabled and elderly are fulfilled prior to Medicaid eligibility
expansion.

Due to Governor LePage's resistance, Maine Equal Justice Partners (MEJP) has submitted a lawsuit against DHHS for failure to act. MEJP argues that the administration is refusing residents coverage that is mandated by law. They fear that an estimated 70,000 low-income residents seeking coverage will not be able to enroll by the next deadline, July 2, 2018. Maine's State Attorney General, Janet Mills, declined to represent the governor in the lawsuit. However, she did permit LePage's request to seek outside counsel for representation in the case.

The landscape of Medicaid is changing as reformists file waivers and implement work requirements. Additionally, Republican leadership across the country is resisting Medicaid expansion, strongly believing that it goes against the programs original objective. Regardless of the GOP's opposition, there is a tremendous amount of activity amongst expansion supporters to expand their state's Medicaid programs. By way of ballot initiatives, voters are stepping out in front of their legislatures to voice their support for expansion at the polls this fall.

http://www.syrtissolutions.com/medicaid-expansion-roundup

#syrtissolutions #medicaidexpansion #utahmedicaidexpansion #mainemedicaidexpansion #nebraskamedicaidexpansion #idahomedicaidexpansion #virginiamedicaidexpansion
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THE SOARING COST OF DRUGS FOR THE MEDICAID PROGRAM

Last month, President Trump postponed introducing his plan to deal with the skyrocketing costs of prescription drugs. Despite the delay, New York's Medicaid Drug Utilization Review Board (DURB) took it upon themselves to negotiate with drug manufacturers. DURB voted in favor of reducing the price its Medicaid program is willing to pay Vertex Pharmaceuticals for the company's cystic fibrosis drug.

The federal government's aversion to lower drug prices for the Medicaid program is the prime driver of soaring costs. Private health insurance companies can create their own formularies and negotiate pricing. Medicaid has much more negotiating capability as a result of its massive membership, but by rule, is limited from doing the same.

The Centers for Medicare & Medicaid Services (CMS) is forecasting that prescription drug costs will be the fastest growing category of health spending over the next decade. CMS is well aware of the situation and according to the Chief of CMS, Seema Verma, "the bottom line is that insurance premiums have skyrocketed and there's a number of people that just can't afford to pay."

Pharmacy Benefits Consultants investigated wholesale drug prices from the beginning of 2017 to 2018 and discovered that "twenty prescription drugs saw their prices rise by more than 200%." Additionally, The Senate Homeland Security and Governmental Affairs Committee Minority (HSGAC) performed a review and found that "prices for each of the 20 most-prescribed brand-name drugs for seniors have increased dramatically every year for the past five years." That rate is "approximately ten times higher than the average annual rate of inflation." Moreover, from 2012 to 2017, "twelve out of the 20 most commonly prescribed brand-name drugs for seniors had their prices increased by over 50 percent."

President Trump's administration, the Center for Medicare and Medicaid Services, and other government administrators are aggressively evaluating the situation and searching for a resolution. One strategy is proposed in President Trump's 2019 budget plan. The recommendation is to put into place a pilot program that would permit state Medicaid programs to test drug formularies that would encourage more competitive drug pricing.

MASSACHUSETTS MEDICAID: THE MEDICAL HUB AND HEALTHCARE LEADER
Medicaid's lack of ability to negotiate with drug companies is one element leading to soaring drug prices. In Massachusetts alone, drug prices have doubled in the last 5 years. MassHealth's drug spending is stretching the state's spending plan as drug costs have grown to over $2 billion a year. In response to the climbing costs, Massachusetts's Governor, Charlie Baker, has proposed a waiver to the Trump administration developing a selective drug formulary that would allow the state to negotiate pricing and eliminate ineffective medications. State officials are certain that by controlling the quantity of drugs in the formulary and by limiting the number of drug manufacturing companies who supply them, it will establish the negotiating power needed to decrease costs.

While health-care policy specialists and CMS back the plan, the state's proposition to remove drugs from the formulary could be problematic. Consumer groups assert that the people benefiting from the program may need several drugs for their conditions. Depending on what drugs officials deem ineffective, patients could potentially lose access to needed care. Critics of the proposal suggest that it does nothing to deal with drug costs and it will in fact hurt people that rely on the program. In reality, there is a high potential that drug manufacturers will increase drug prices as their competition decreases.

Assuming the governor's plan is approved, MassHealth will need to develop an appeal process for doctors to prescribe medications not present on the formulary so patients can access the medications they need. If states considering this model can show that patient's access to needed drugs is intact and their programs can save funds, it may be an answer to rising drug prices across the nation. For the moment, President Trump's 2019 budget would permit five states to try what Massachusetts is proposing.

NEW YORK'S SOLUTION TO REASONABLE MEDICAID DRUG PRICES
New York officials also see the advantage of having the opportunity to negotiate drug prices. In an effort to combat increasing drug costs, New York's state Medicaid program's DURB voted to pass a law that uses supplemental rebates to manage drug costs. The law concentrates on drugs that are "priced disproportionately to their therapeutic benefits." When the state experiences a drug spending surge of 2.4% to 15.1%, DURB can ask for discounts to a more reasonable price.

The first test will be carried out with Vertex Pharmaceutical's cystic fibrosis drug, Orkambi. In the past, the drug cost $250,000 a year for patients, the proposed cost has been lowered to $83,000. That amounts to a 67% discount.

On a world-wide scale, pharmaceutical manufacturers rarely, if ever, entertain demands for discounts. These companies believe that competition is the solution to managing drug pricing. They argue that drugs like Orkambi have no competitors and that $250,000 yearly is reasonable. They also claim that high prices support their ability to study and create new drugs. This claim does not ring true considering that nine out of the ten largest pharmaceutical companies spend more on marketing than on creating new drugs.

Drug prices continuously rise and it is leaving patients access to care at risk. Therefore, government officials are making efforts to decrease the costs and obtain fair prices. Ultimately, the existing reality of hyper-inflated drug prices cannot be sustained, not only for public programs like Medicaid and Medicare but for everyone.

#medicaid #medicaiddrugcosts #syrtissolutions

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BILLIONS LOST DUE TO IMPROPER MEDICAID PAYMENTS

Medicaid is losing billions of dollars from improper payments. According to HHS Agency Financial Reports, improper Medicaid payments reached $30 billion in 2015 and grew to nearly $37 billion in 2017. The vast majority of these improper payments were found out to be improper claims payments as a result of data errors.

The federal government often points out such substantial figures as evidence of prevalent fraud, waste, and abuse that allegedly exists in federal government health care programs. Yet in point of fact, a 2013 HHS-OIG report provides some much needed perspective, revealing that 57 percent of the "improper" Medicaid payments come from more commonplace, routine issues, involving the "eligibility errors" that occur when a patient moves from one state to another and does not provide Medicaid with a change of address. Fraud in the Medicaid program may well still be a dramatic issue, but when "improper payments" are the result of such "eligibility errors" as opposed to fraud, the true scope of the challenge can better be recognized.

With the increased awareness that government officials have paid to the need for accurate Medicaid claims information within federal government healthcare systems, one may have expected that now, nearly five years since an inspector general testified that much of the data used to identify improper payments and fraud is not "current, available, complete, [or] accurate", the issues would certainly be tended to and the federal government's records rendered more reliable.

In a statement to the House Oversight and Government Reform Committee, Carolyn Yocom, GAO Health Care Director pointed out, "despite efforts to reduce improper payments in the Medicaid program by the Centers for Medicare & Medicaid Services, which oversees the program, overall improper payments continue to increase."

The climb in improper payments can be contributed to the sheer size of the program and inadequate oversight. Director Yocom testified that Medicaid has been on the list of high-risk programs dating back to 2003 and that its oversight is insufficient. She said, "the size and complexity of Medicaid make the program particularly vulnerable to improper payments-- including payments made for people not eligible for Medicaid or made for services not actually provided."

The GAO characterizes an improper payment as "any payment that should not have been made or that was made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements. Reducing improper payments-- such as payments to ineligible recipients or duplicate payments-- is critical to safeguarding federal funds, but the federal government has consistently been unable to determine the full extent of improper payments and whether its actions to reduce them are appropriate."

Improper payments also involve:

Any payment made in error when the payment was the liability of a third party
Any payment to an ineligible recipient
Any payment for an ineligible service
Any duplicative payment
Payment for services not received (except where authorized by law).
Any payment that does not account for credit for applicable discounts.

In a two-year period, improper Medicaid payments have increased by $8 billion dollars. This is a very clear sign the program does not have the needed oversight. In order to preserve the vital federal-state health insurance program and safeguard taxpayer dollars, the issues that develop from poor eligibility data within the Medicaid program must be resolved.

http://www.syrtissolutions.com/medicaid-improper-payments

#syrtissolutions #medicaid #medicaidfraudwasteandabuse #medicaidimproperpayments
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AN UPDATE ON THE VIRGINIA MEDICAID EXPANSION DEBATE

Legislators in Virginia were unable to approve the Commonwealth's biennial spending plan previously this year; which included provisions for Medicaid Expansion. Due to a divide in Republican support within the House and Senate, the legislators agreed to reconvene for a special session, which occurred Wednesday. Leading up to the session, in an attempt to persuade Republican Senate support for Medicaid expansion, House Speaker M. Kirkland Cox (R) proposed strictly enforcing work requirements. He recognizes the concerns of conservatives but also realizes the need for healthcare for the 400,000 uninsured Virginians. Concerning the work requirements, Kirkland said, "We're going to look at that and try to, you know, strengthen that somewhat. I think among conservatives that's something that's very important."

In spite of the split support in the last regular session, some legislators that had opposed expansion are now reevaluating supporting it. One of those who had formerly been against expansion is Senate Majority Leader Thomas K. Norment Jr. (R). His willingness to support expansion is contingent on a more conservative approach and it would need to be developed collaboratively. In an interview with WCVE radio, Norment said, "if, in fact, there is going to be a fiscally responsible and conservative Medicaid expansion plan, it has got to be developed on a more collaborative basis. One person can't develop that plan, come in and drop it down in front of 21 Republican senators and say, 'Here it is.' That is not going to work."

In order to approve a budget and expand Medicaid, lawmakers will need to have their plan prepared by July 1 or the state will experience its first government shutdown.

Senate Minority Leader Richard L. Saslaw (D) says, "This is something that should have been done three or four years ago, but better late than never. Between 350,000 and 400,000 Virginians will get the health care that's needed."

This week's two-hour special session focused primarily on procedural moves. The next step will be to attend to Governor Ralph Northam's (D) newly proposed budget bill that he revealed in between the sessions. It will make its way through the House and Senate finance committees and then onto the chambers for voting. Finally, a conference will be held to sort any standing details between the House and Senate. It will need two Republicans to pass Medicaid expansion within the Senate; however, just one vote from Republicans is necessary to pass it in the form of a budget amendment.

According to Governor Northam's estimations, savings as a result of Medicaid expansion will be about $421 million. The House would like to see funds invested into education, raises for teachers, and other areas so they estimate the savings from expansion to be closer to $307 million as a result of varying start dates.

In the past, Virginia's Republican representatives have not advocated Medicaid expansion, but in recent months it's beginning to look like that will change. Even Though the Republican Senate did not hold elections last year, the chamber almost lost its majority to Democrats in November. As a result of the approaching elections and the need for support from voters to retain control of the House, Republicans are now making efforts to convert Republican opposition to back Medicaid expansion.
#medicaid #medicaidexpansion #syrtissolutions #virginia

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