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While Medicaid expansion advocates are encouraged by the most recent developments in Maine and Virginia, there are concerns regarding access to quality care as the Medicaid population expands. To answer these questions, a number of studies have been conducted to help assist the states considering expansion and those that are making adjustments to their current programs.

Medicaid Expansion And Rural Areas
Since the majority of the rural populations are below the poverty line and uninsured, rural areas all over the nation rely on community health centers for primary care. The increased federal funding from the Affordable Care Act and Medicaid expansion were believed to be solutions for improving the access and quality of care for these areas.

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

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

As opposed to the urban community health centers, rural centers from states that expanded Medicaid saw significant improvement. Researches strongly believe that these improvements may be a result of more affordable prescriptions under Medicaid or possibly due to the fact that insurance access to care makes visits to health professionals less expensive.

Are More Conservative Versions of Medicaid Working?
Health Indiana Plan 2.0 was the result 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. In addition, 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. By using data from the American Community Survey, researchers looked to see if adults between the ages of 18 and 64 had insurance coverage or Medicaid coverage from 2009 to 2016. According to their research, 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 mandates could not be determined. Also, Indiana's cost-sharing requirements may be the reason for the state's underperformance.

A 30,000 Foot View Of Medicaid After Expansion
From the beginning of Medicaid expansion, there have been 77 research studies released with 440 unique analyses. More than 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."

#MedicaidExpansion #SyrtisSolutions
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Syrtis Solutions is pleased to report that its ProTPL platform has attained certification by the Health Information Trust (HITRUST). By 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 majority of Medicaid beneficiaries do not have any other forms of health insurance; however, there is a subset of the population that have a primary payer, such as employer-sponsored insurance or Medicare. As a 'payer of last resort' Medicaid should always pay last if additional insurance exists. This is defined as third party liability (TPL), with the other payer being the third party that is responsible for the insurance coverage.

The difficulty for Medicaid plans to detect primary insurance before claims are paid improperly has been an on going challenge due to antiquated technology, siloed data systems, and network latency. Consequently, inefficient post-payment recovery processes are needed to recoup the improper claims payments. The method of 'pay and chase' has become normalized with an entire multi-billion dollar industry built around it despite the fact that cost avoiding payments of claims and routing them to the proper payers is the only way to ensure federal dollars are not paid in error. To resolve this problem, Syrtis created ProTPL.

ProTPL provides Medicaid plans with a technology-based solution to prospectively discover TPL on its members to cost avoid claims payments. ProTPL has been utilized 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 deployment of ProTPL has made tremendous strides in decreasing improper claims payments for payers of last resort.

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

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

Under the Trump's administration, CMS has accepted 1115 waivers that the prior administration consistently rejected. Many states, for example, have been allowed to make employment a requirement for Medicaid enrollment. (The state of Kentucky; however, is presently in court proceedings over the new rule.).

Trump's administration is also permitting Kentucky to require beneficiaries to report 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 rejected, and what is still under deliberations:

Lifetime limits

In May, CMS denied an 1115 waiver request 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 sent similar 1115 waiver applications to CMS for lifetime limits, which Alker expects will also get denied.

In a statement by Seema Verma concerning Kentucky's attempt to sanction lifetime limits on Medicaid enrollees, she stated "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 turned down Arkansas' bid to reduce the number of people who qualify for the state's Medicaid program. Arkansas was looking to decrease the eligibility requirement from 138 percent of the federal poverty to 100 percent; however, it wasn't a firm denial, rather, 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 expenses. If Arkansas were permitted to simply cover people up to 100 percent of poverty, the previously 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 desirable to the Trump administration.

Work requirements for non-expansion states

Apart from the denial of permitting lifetime limits on Medicaid enrollees, one more aspect of Kansas' 1115 waiver application is still pending; specifically, a work requirement. But unlike Arkansas, Indiana and Kentucky, Kansas did not expand Medicaid by way of the Affordable Care Act (ACA); so calling for individuals to maintain an employment (minimally 80-hours per week) would probably exclude them for the state's Medicaid program since they would be earning 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 illustrates the catch-22 of these proposals.

In the state of Mississippi, for instance, a single parent can not earn over $370 per month to get approved for Medicaid. Nevertheless, if they acquired 20-hour per week employment at minimum wage, they would collect $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 troubled about this "subsidy cliff" and wants to find a "pragmatic and empathetic" approach to work requirements and other new Medicaid initiatives.

Drug testing for Medicaid enrollment

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

#medicaidexpansion #medicaidlifetimelimits #medicaidworkrequirements #section1115waivers #syrtissolutions
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The Center for Medicare and Medicaid Services recently released a Medicaid Scorecard to improve transparency and accountability. The scorecard includes care quality data from 2015 statistics given by participating states, as well as federally reported information. By consolidating this data, CMS and the states look to analyze the performance of Medicaid plans, the program's administration, and outcomes. Any effort to improve efficiencies within the Medicaid program is met with unanimous support across the country; however, industry experts are concerned with the quality of the data utilized and the underlying purpose of the Medicaid Scorecard.

CMS's preliminary Medicaid scorecard aims to improve state and federal alignment, beneficiary health outcomes, and program administration. It functions to determine how effectively states are delivering health services to their beneficiaries; in addition, it reviews the timespan it takes for the federal government to accept waiver requests from the states. The Medicaid Scorecard focuses 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, regards the scorecard as a means of improved accessibility to Medicaid data and the program's care outcomes. Verma mentioned, "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 can be made from it. In their point of view, the data itself is out of date, rendering it an unreliable source to determine 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 recognizes inconsistencies. The groups CEO, Margaret Murray, sees 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 released their Medicaid Scorecard with hopes to improve state and federal alignment, beneficiary health outcomes, and program administration; however, Industry experts are questioning its methodology.

#medicaid #medicaidscorecard #syrtissolutions
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After months of deliberation among Republican representatives in both the House and Senate, lawmakers in Virginia voted in support of Medicaid expansion under the ACA on May 30th, 2018. The provision to expand the state's Medicaid program to over 400,000 Virginia residents was featured 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 opposition to Medicaid expansion. Second, Virginia's increasing uninsured population is a strain on the state's capacity to supply healthcare to its citizens. Ever Since the Affordable Care Act was introduced, the uninsured population has expanded because of increasing costs for coverage. Supporters think that Medicaid expansion will strengthen Virginia's health care system and benefit both program members and individuals 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 supporters of other states around the country looking to expand their programs. At the moment, there are four states debating the issue.

Utah - Despite support from legislators for a partial expansion, activists in Utah collected the required number of signatures to have a full expansion of Medicaid on the state's November ballot. Currently, polls indicate that more than half of the state's voters back expansion.

Idaho - According to healthcare advocates, activists in Idaho have accumulated the required signatures for a ballot initiative. The initiative would allow residents to vote in November on a expansion of the states Medicaid program. At the time of this post, the signatures have been sent 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 gathering 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 calling for 25,000 signatures has been authorized by the Secretary of State. Unlike other efforts, Montana proposes an increase on taxing tobacco by $2.00 a pack alongside a 33% increase of the wholesale price for tobacco products. Presently, supporters are promoting the initiative and securing signatures.

As Virginia neared its very first government shutdown, last week legislatures finalized a state budget that included Medicaid expansion. 400,000 residents will now be eligible to enroll in the program. The choice to expand the program, despite resistance from Republican leadership, could be a good indicator as to what will occur in other states aiming to expand this year.

#medicaid #medicaidexpansion #syrtissolutions
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The repeal of the Affordable Care Act with its existing provisions for Medicaid did not materialize at the federal level in 2017; however, states are looking into reform independently with the use of Medicaid 1115 waivers. These waivers focus on priorities within the states and allow local governments the flexibility to test coverage models that do not reflect program rules of the federal government.

Medicaid 1115 waivers provide states the opportunity to waive key provisions of federal law. The changes made possible by Section 1115 waivers are not as dramatic as those contained in the failed bills-- for instance, states can't use these waivers to completely restructure Medicaid under block grants or per capita caps, neither can the federal government use them to take away federal reimbursements for Medicaid expansion-- but they are still significant.

In an initiative 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. In addition to work requirements, states are also looking into provisions such as eligibility time limits, drug testing, and premiums. Because of this, these waivers are controversial and have brought up policy issues throughout the country.

At the moment, a number of states have submitted waivers for approval from the federal government. Here is some of the highlighting waiver activity within the states.

New Hampshire was the fourth state to be approved 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 be involved 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 said, "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 concerned that its ramifications will not support the original goals of the Medicaid program. A number of Democratic legislators are in opposition to the work requirements, thinking that they undermine access to the healthcare program. Advocates of the waiver view it as means of safeguarding the program's sustainability. They assert that Medicaid should be reserved for the country's most vulnerable and low-income individuals and families.

Support for Medicaid expansion in Kansas came to a halt in February regardless of initiatives 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 among five states, including Utah, Maine, Arizona, and Wisconsin, to ask for lifetime limits from CMS. This would have allowed the state to limit coverage to three years/36 months for a portion 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 declaring, "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."

Kentucky was the very first state to be given 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 launch the overhaul of the state's Medicaid program on July 1, 2018. It will begin in Campbell County and reach throughout the state over a duration of six months. These changes will primarily affect able-bodied beneficiaries with incomes up to 138% of the federal poverty level that obtained coverage during the program's expansion in 2014. Due to the overhaul, it's approximated that Kentucky and the federal government will save $2.2 billion over five years. Additionally, the Center On Budget and Policy Priorities expects 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 sees the Trump administration's approval as a violation of several federal laws and a risk to the lives of tens of thousands of low-income families.

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

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

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

Arizona is looking to modernize 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 currently has lifetime limits. In regards to the decision to postpone the lifetime limit request, Deputy Director of AHCCCS, Jami Snyder said, "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.

Regardless of the federal government's inability to reform Medicaid, states are now taking the initiative to carry it out themselves by submitting 1115 waiver requests to CMS. Across the nation, local governments are now considering provisions such as work requirements, drug testing, lifetime limits, and premiums. Some states have received approval while others are encountering strong resistance. Although reform through Medicaid 1115 waivers is supported by many state legislators, the way in which they are carried out will be vital to ensuring the future of the Medicaid program.

#syrtissolutions #medicaidreform #medicaid1115waivers #section1115waivers
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Throughout the 2016 Presidential campaign and shortly 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 supervisor of The Centers for Medicare and Medicaid Services (CMS), Seema Verma, are now considering waivers to the Medicaid program that the previous administration denied. In spite of the Trump administrations unsuccessful efforts to reform Medicaid on the federal level, a number of states are making attempts to expand their programs. Below is a summary of states in varying stages of expansion discussions.

Nebraska: Over the past six years, any efforts to expand Nebraska's Medicaid program have failed as a result of Republican leadership. Republican Governors, Pete Ricketts and his predecessor Dave Heineman both argued that the state could not afford to expand Medicaid. Furthermore, they think that expanding Medicaid would favor able-bodied citizens as opposed to low-income residents, for whom the program was intended.

Nevertheless, that may all change this November at the voting booths. Presently, there are several 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 noticed the success of Maine's ballot initiative, supporters 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 needed by July 6, 2018. According to Insure the Good Life organizers, residents have been receptive to the idea of expanding Medicaid.

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

In order to get on the November 6th ballot, advocacy groups needed to obtain a minimum of 56,192 signatures from 18 districts across the state by May 1, 2018. The advocacy groups filed the signatures before the deadline and claim they have the required threshold needed to secure a place on November's ballot. At this point, the signatures will need to be confirmed by county clerks before June 30th, in order for the expansion proposal to be voted on.

While expectations are high among advocates, implementation of expansion will fall on the governor and state lawmakers; additionally, they have the power to reverse voter-passed initiatives. Republican candidate, Rep. Raul Labrador will resist the expansion initiative 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 resistance from the state legislature in Utah to prevent any expansion momentum. Supporters of expanding Medicaid in Utah pushed back by passing a ballot initiative much like Maine's.

Governor Herbert also endorsed the HB472 bill. The bill seeks approval from the federal government to expand his states Medicaid program to 100% of the federal poverty level (FPL) while also 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 submitted a 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 unlikely that CMS will back the governor's bill since the federal government has only approved these types of requests under the condition that states expand to 138% of the FPL.

While the governor's administration would like to receive 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 coupled with work requirements for enrollees. However, Virginia's Senate budget didn't include arrangements for expansion. Due to the divided support for Medicaid expansion, the Virginia legislature was unable to settle a budget. As a result, the implementation of Medicaid expansion and Virginia's FY 2019 budget are presently deadlocked. It has been nearly two months since Virginia's General Assembly adjourned without consensus.

On May 14th, the Senate met for a special session to discuss a spending plan and the Senate Finance Committee will proceed with 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 administrators cannot come to an agreement by June 30th, the state will experience its first government shutdown.

Maine's Medicaid program, MainCare, was authorized for expansion last November through a ballot initiative. Voters advocated the expansion by 59%. However, 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 due to 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 asserts that the cost of the expansion is twice the amount estimated by the state legislature and refuses to execute the plan unless his stipulations are met.

LePage's terms consist of:

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

As a result of Governor LePage's resistance, Maine Equal Justice Partners (MEJP) has submitted a lawsuit against DHHS for failure to act. MEJP says that the administration is denying residents coverage that is required by law. They fear that an estimated 70,000 low-income residents looking for 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. Even so, she did permit LePage's request to seek outside counsel for representation in the case.

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

#medicaidexpansion #syrtissolutions #utahmedicaidexpansion #nebraskamedicaidexpansion #mainemedicaidexpansion #idahomedicaidexpansion #virginiamedicaidexpansion
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Last month, President Trump postponed presenting his strategy to resolve the skyrocketing costs of prescription drugs. Inspite of 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 decreasing the price its Medicaid program is willing to pay Vertex Pharmaceuticals for the company's cystic fibrosis drug.

The federal government's aversion to cut down drug prices for the Medicaid program is the primary driver of rising costs. Private health insurance companies can make their own formularies and negotiate pricing. Medicaid has even more negotiating power because of its massive membership, but by rule, is barred from doing the same.

The Centers for Medicare & Medicaid Services (CMS) is estimating that prescription drug costs will be the fastest growing category of health spending over the following ten years. 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%." In addition, 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."

The Trump Administration, the Center for Medicare and Medicaid Services, and other government authorities are aggressively evaluating the situation and looking for a remedy. One course of action is proposed in President Trump's 2019 budget. The recommendation is to put into place a pilot program that would allow state Medicaid programs to test drug formularies that would encourage more competitive drug pricing.

Medicaid's lack of ability to negotiate with drug companies is one factor leading to soaring drug prices. In Massachusetts alone, drug prices have doubled in the last 5 years. MassHealth's drug spending is extending the state's budget as drug costs have increased to over $2 billion a year. In response to the rising costs, Massachusetts's Governor, Charlie Baker, has submitted a waiver to the Trump administration to create a selective drug formulary that would permit the state to negotiate pricing and eliminate ineffective medications. State authorities are certain that by reducing the number of drugs in the formulary and by limiting the amount of drug manufacturing companies who supply them, it will establish the negotiating power needed to decrease costs.

While health-care policy specialists and CMS advocate the plan, the state's proposal to eliminate drugs from the formulary could be problematic. Consumer groups argue that the people benefiting from the program may need a number of drugs for their conditions. Depending upon what drugs authorities deem ineffective, patients could likely lose access to needed care. Critics of the plan suggest that it does nothing to address drug costs and it will in fact hurt people that rely on the program. In fact, there is a strong potential that drug manufacturers will increase drug prices as their competition decreases.

Assuming the governor's plan is signed off on, MassHealth will need to set up an appeal process for doctors to prescribe drugs absent on the formulary so patients can access the medications they need. If states considering this model can prove 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 representatives also see the advantage of having the option to negotiate drug prices. In an effort to deal with climbing 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%, the board can ask for discounts to a more reasonable price.

The initial test will be conducted 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 brought down to $83,000. That equates to a 67% discount.

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

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

#medicaid #medicaiddrugcosts #syrtissolutions
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Medicaid is losing billions of dollars from improper payments. According to HHS Agency Financial Reports, improper Medicaid payments reached $30 billion in 2015 and increased to nearly $37 billion in 2017. The vast majority of these improper payments were found out to be improper claims payments caused by data errors.

The federal government frequently points out such substantial figures as evidence of prevalent fraud, waste, and abuse that purportedly 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, mundane issues, involving the "eligibility errors" that occur when a patient relocates from one state to another and doesn't provide Medicaid with a change of address. Fraud in the Medicaid program may well still be a dramatic problem, but when "improper payments" are the result of such "eligibility errors" rather than fraud, the true scope of the challenge can better be realized.

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 increase in improper payments can be contributed to the sheer size of the program and weak oversight. Director Yocom testified that Medicaid has been on the list of high-risk programs going back to 2003 and that its oversight is insufficient. She mentioned, "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 defines 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 include:

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 time span, improper Medicaid payments have surged by $8 billion dollars. It is obvious that the program lacks adequate oversight. To preserve the vital federal-state health insurance program and protect taxpayer dollars, the issues that develop from poor eligibility data within the Medicaid program must be resolved.

#syrtissolutions #medicaid #medicaidfraudwasteandabuse #medicaidimproperpayments
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Lawmakers in Virginia were not able to approve the Commonwealth's biennial spending plan previously this year; which included provisions for Medicaid Expansion. Because of a split in Republican support within the House and Senate, the lawmakers agreed to reconvene for a special session, which took place Wednesday. Proceeding 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 realizes the concerns of conservatives but also appreciates 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 previously been against expansion is Senate Majority Leader Thomas K. Norment Jr. (R). His willingness to support expansion is dependent on a more conservative approach and it would need to be created collaboratively. In an interview with WCVE radio, Norment stated, "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 drafted 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 mainly on procedural moves. The next step will be to attend to Governor Ralph Northam's (D) newly proposed budget bill that he presented 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 required 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 approximately $421 million. The House would like to see funds invested into education, raises for teachers, and other areas so they predict the savings from expansion to be closer to $307 million as a result of varying start dates.

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