Reflections on 2023, Predictions for 2024
Unwinding the Public Health Emergency
Much of 2023 was spent planning for and implementing the end of the COVID-19 Public Health Emergency (PHE), while also making policy decisions on continuation of certain COVID-19 era flexibilities. A top priority for states, of course, was undertaking the immense tasks related to processing Medicaid redeterminations for the first time in three years. At the same time, they also looked to the future, considering flexibilities that could expand beyond the pandemic, including related to telehealth.
Through a series of articles, HPN outlined activities as states began undertaking the necessary process of unwinding the Continuous Coverage Requirement (CCR), which had required states to maintain enrollment of nearly all Medicaid enrollees throughout the pandemic. HPN also shared an overview of lessons learned from the end of continuous enrollment and current Medicaid re-eligibility efforts. Also related to the end of the PHE, we assessed the impact on vaccine and Covid-19 testing costs.
Finally, we offered a preview of the implications of the end of the PHE for the national telehealth landscape. HPN did a deep dive into proposed federal telehealth rules that would have affected access to medications for opioid use disorder (OUD) had they gone into effect as written. We also provided an update on those proposed rules, which are still under revision while the Drug Enforcement Agency (DEA) and Department of Health and Human Services (HHS) consider an unprecedented volume of public comments.
As we look forward, it will be important to watch how CMS uses its enforcement authority with respect to the unwinding process. The agency has already intervened in states that it identified as erroneously disenrolling individuals, as well as states that self-identified as making similar mistakes. Stakeholders interested in providing feedback about the redetermination process to CMS should consider responding to the interim final regulation the agency published in December, which codifies reporting requirements and enforcement authority and offers insight into the agency’s enforcement discretion. The public comment period closes February 2, 2024.
In the meantime, COVID-era telemedicine prescribing flexibilities remain in effect until 2024 but future rulemaking is expected. Based on the public feedback received thus far, it would not be surprising if the in-person visit requirements and 30-day prescribing limits included in the proposed rule were removed or significantly amended in the final version. DEA and HHS have indicated that they will host additional public comment periods to collect further stakeholder input. HPN will continue following the trajectory of these rules into the new year.
Approval and Implementation of Justice-Involved Waivers
In January 2023, the Centers for Medicare and Medicaid Services (CMS) approved the country’s first Section 1115 Re-Entry Demonstration Waiver in California. HPN provided an overview of California’s approved waiver, as well as a synopsis of pre-release and post-release services proposed for inclusion in the 14 state waivers that are still pending approval. We also summarized guidance published by HHS for states pursuing Re-Entry Section 1115 Demonstration Waivers.
As we move into 2024, California’s implementation of its demonstration waiver continues, providing a roadmap and opportunities to learn from best practices and lessons learned for other states. In October, the California Department of Health Care Services (DHCS) released the Policy and Operational Guide for Planning and Implementing the CalAIM Justice Involved Initiatives. The guidance specifically covers topics including pre-release service readiness planning, provider enrollment and payment, and reentry planning, among others. DHCS has also developed a comprehensive website that includes resources to support implementation of the justice-involved initiatives, such as an overview of the initiative, webinar recordings and announcements, and resources for providers and correctional facilities. Additional activity is expected in other states as well. Fourteen other states (Arizona, Kentucky, Massachusetts, Montana, New Hampshire, New Jersey, New Mexico, New York, Oregon, Rhode Island, Utah, Vermont, Washington state, and West Virginia) continue to await CMS determination on their waiver, with additional states considering waiver submission.
Federal Health Policy Rule-Making
Impactful federal health policy rule-making activity happened on both the Medicaid and the commercial plan side in 2023, with additional activity expected in 2024.
On the Medicaid side, HPN experts provided tools to states considering two notices of proposed rulemaking released by CMS in April 2023 and aimed at transforming the delivery of, access to, and payment for Medicaid programs: Ensuring Access to Medicaid Services (Access NPRM) and Managed Care Access, Finance, and Quality (Managed Care NPRM). Ensuring beneficiaries can access covered services is a critical function of Medicaid programs and a top priority of CMS. To assist states, HPN produced resources that highlighted the main policy changes included in the proposed rules, as well as flagged areas for state comment. We have included links to the facts sheet for those who wish to refresh their memory:
Although the comment period ended in June 2023, CMS has yet to issue the final guidance. HPN will continue to monitor the rules which could have far reaching implications on Medicaid funding, and operations. Â
On the commercial side, HPN provided an overview of key changes in the recently-released draft 2024 Notice of Benefit and Payment Parameter for 2024 and the draft 2024 Letter to Issuers in the Federally-facilitated Exchanges. Most notably, the overview featured changes proposed related to State-based Exchanges (SBEs) and network adequacy.
With comments on the guidance due at the beginning of the 2024, states will be awaiting the final NBPP and Letter in the first few months of 2024 to confirm what changes will in fact go into effect for 2025. On the network adequacy side, states with SBEs will likely need to begin considering the network adequacy time and distance standards they will adopt, ensuring they are at least as stringent as the federal standards. Any state considering transitioning to a SBE may need to amend their plans to build in a transition period as a SBE on the federal platform.
Focus on Caregiving Series
HPN featured a special fall 2023 Focus on Caregiving Series, which examined the role of caregivers in our healthcare system and state-level support and policy actions related to caregiving. We highlighted an Executive Order on increasing access to high-quality care across the U.S. and supporting caregivers, which was signed on April 18, 2023. The Executive Order acknowledged the important contributions of caregivers and the fact that they often deliver essential care without receiving adequate support, with actions aiming to address this concern. We also explored respite care, the emergency or planned temporary care relief for primary caregivers. Respite care offers a critical break for caregivers, and our focus was the expansion of respite programs and innovative approaches to respite care in states including Kentucky and Utah.
As we continue the fall Focus on Caregiving Series in 2024, HPN will look to New York, which provides respite services to family caregivers. Using state general funds and funding under federal and state-funded programs, the state provides this important service through community-based respite programs (State Respite), the National Family Caregiver Support Program (NFCSP), and Expanded In-Home Services for the Elderly Program (EISEP). The state is looking to establish a pilot medical respite program, with regulations pending. HPN will continue to track this into 2024 and provide updates for other states that may be seeking to replicate the efforts underway in NY.
