Highlights from the 2022 National Association of Medicaid Program Integrity Conference; Advancing Medicaid Program Integrity – Chris Richter
Several members of Public Consulting Group’s (PCGs) Health Payer Services team recently attended and presented at the 2022 NAMPI conference in Baltimore this past month. There were approximately 500 in-person attendees and another 500 virtual, with representation from 43 US states and territories, in addition to several federal agency attendees (with numerous participants and session speakers coming from CMS, OIG, and HHS).
There was a tremendous emphasis on state/federal partnerships to identify and prosecute fraud, though there seems to be some difference in priorities—with state agencies focused on the public health emergency (PHE) unwinding and managed care organization (MCO) oversight, while the federal agencies continue to fight COVID-19 fraud and nursing home issues.
The major program integrity themes across this year’s conference and vendor breakout sessions included:
- Planning for PHE Unwinding
- MCO Oversight Issues
- Continual COVID-19 fraud schemes
- Behavioral Health and Hospice Audits
- Drug and Genetic Testing Schemes
- Nursing Home Care Quality
PCG was once again a proud sponsor of this year’s event. PCG’s Peter Cheesman presented in a vendor breakout session on August 9th, discussing the powerful insights that a Data Broker model can bring to eligibility decision support, also identifying both member fraud and providing datapoints and evidential information that can assist fraud investigators in their investigations. This messaging was timely, with the imminent PHE unwinding and the policy changes that will likely impact Medicaid eligibility requirements in most states.
2022 National Conference of State Legislators Summit – Margot Thistle
In early August 2022, members of the Health Policy News team exhibited and attended the legislative summit of the National Conference of State Legislators (NSCL) in Denver. Our team was excited to be back in person and connect with many of the state policy leaders in person that we have been collaborating with throughout the pandemic. NCSL included panels on many relevant health issues facing states and legislatures. This included the Public Health Emergency wind-down and new developments in state and federal Medicaid law, as well as reflection on the past two years of the pandemic and ways states should continue to enhance public health programs in the future.
One panel included Supreme Court scholars who presented a recap of the 2021-2022 term of the Supreme Court including a few cases that impact Medicaid agencies and providers. These cases included ruling on assignment of third-party recovery payments, disproportionate share hospital reimbursement, and 340B drug cost formulas. We have included a quick highlight of some case law that may be useful for readers:
Medicaid/Medicare Law Developments
- Medicaid Third Party Assignment Requirements: Under Title XIX of the Social Security Act, states must require that Medicaid beneficiaries assign the state rights to payments recovered from third parties. States are permitted to retain funds necessary to reimburse medical assistance payments made on behalf of an individual. This provision was challenged at the state level in Florida and was brought before the Supreme Court this past session in Gallardo v Marstiller. The challenge to the Act focused on whether the assignment of settlement payments applied to past medical care costs could include future medical care costs too. Although federal law requires assignment, Florida had further regulated this provision to include caps on the amount the State could recover from settlements for medical costs. The Plaintiff argued that this cap precluded the state from recovering more than the max amount set forth in Florida law, and limited recovery to past medical expenses. The Supreme Court ruled that the Act did not limit a beneficiary’s assignment to payments for past “medical care” already paid for by Medicaid, but that the grant of “any rights to payment for medical care” covers “not only rights to payment for past medical expenses, but also rights to payment for future medical expenses.”
- Disproportionate share calculations for disproportionate share hospitals (DSH): In Becerra v Empire Health Foundation the Supreme Court ruled that patients Medicare insures, but does not pay for on a given day, are counted for purposes of calculating the hospitals’ disproportionate patient population. Hospitals use the Medicare fraction calculation to measure their low-income senior population and the Medicaid calculation to measure their low-income non-senior population. This ruling may result in lower DSH payments, as the court found that eligibility means patients admitted days are included for the purpose of DSH calculation payments, even if the patient is not yet receiving Medicare thus bringing down the total reimbursable amount.
- 340B Reimbursement: The 340B program is a federal drug pricing program requiring drug manufacturers to provide outpatient drugs at a reduced price to certain eligible entities, which could include public or community health centers and hospitals. In American Hospital Association v Becerra the Supreme Court held that the Department of Health and Human Services (HHS) must conduct a survey of hospitals drug acquisition costs if HHS wants to reimburse Section 340B hospitals for certain Medicare outpatient drugs at a different rate than other hospitals. Under the Medicare Prescription Drug Improvement and Modernization Act of 2003, there are two approaches for HHS to set Medicare drug cost reimbursement rates, and the Court opined that HHS is unable to vary the reimbursement rate without the annual survey since reimbursement is based on average drug costs. The Court also held that the rates are subject to judicial review due to the statutory formula outlined in the Act.
It was wonderful to connect with our legislative colleagues and policy counterparts at the state level in person and discuss ways PCG could help states with post-pandemic planning and American Rescue Plan Act program management.
Insights from the NASHP Annual Conference – Health Policy News Team
Members of the Health Policy team joined hundreds of state health policy leaders in Seattle earlier this month for the National Academy of State Health Policy (NASHP) Annual Conference: “Forecast for State Health Policy.” PCG team members attended the sessions and exhibited at the conference. The conference touched on timely health policy issues across the spectrum of public health, health care delivery, public programs, and private industry.
As has been the case for the last several years, states shared their efforts to develop and leverage innovative payment models to address rising costs, workforce shortages, and increasing healthcare complexities. Megan Renfrew, Associate Director of External Affairs at the Maryland Health Services Cost Review Commission, shared that recent data demonstrates that Maryland’s All-Payer Model has reduced both total expenditures and total hospital expenditures for Medicare beneficiaries without shifting costs to other parts of the health care system outside of the global budgets.
On the topic of Medicaid innovations, Daniel Tsai, Director of the Center for Medicaid and Children’s Health Insurance Program (CHIP) Services at the Centers for Medicare and Medicaid Services (CMS), shared trends the agency is seeing in Section 1115 Waivers. He highlighted state efforts to leverage waivers to address social determinants of health, substance use disorders, and workforce challenges.
Some of the most prominent topics in this year’s NASHP conference, however, looked toward a post-pandemic world and addressing the ongoing challenges with behavioral health care. We share highlights on those topics below.
Planning for the End of the Public Health Emergency
While acknowledging that the timeline is unclear, representatives from California, Utah, Pennsylvania, and Arkansas shared the work their Medicaid programs (sometimes in partnership with state Exchanges) are undertaking in preparation for the end of the COVID-19 Public Health Emergency. In a session titled “The Long Unwinding Road: Ending the Public Health Emergency (PHE)”, panelists shared how they are preparing for the expected large influx of work on their already taxed staff when they need to reinitiate eligibility redeterminations, such as:
- Working to collect updated contact information
- Launching coordinated outreach and communications campaigns, including leveraging social media and coordinating with other trusted sources (other agencies, community organizations and managed care organizations)
- Marking and/or tracking cases that are being kept open to easily identify when they need to begin processing redeterminations, and/or beginning to process redeterminations in their systems without moving forward with eligibility changes
- Training new staff that may have never processed redeterminations
- Streamlining procedures, including via waivers
- Spacing out the timing of redeterminations for a more consistent workflow and holding likely eligible cases for later in the timeline when any kinks in the process are more likely to have been addressed
- Assigning client outreach leads and going door-to-door to process redeterminations on-site
All panelists acknowledged that they expect to lose Medicaid members for “administrative reasons” in addition to due to eligibility changes. They hope their efforts will minimize those losses as much as possible.
PCG is assisting states to prepare for the end of the PHE. For more information about the services PCG is providing to state agencies, click here to see the PCG Public Health Emergency Unwinding Services.
Focus on Behavioral Health
The conference included a deep dive into the timely issue of behavioral health care with a series of panels on the topic. These panels focused on state efforts to support children’s mental health, address the substance use disorder (SUD) epidemic, decriminalize serious mental illness (SMI), and build rural crisis systems. At the same time that behavioral health care needs have expanded during the COVID-19 pandemic, the pandemic has exacerbated the behavioral health workforce shortage, undermining progress made in preventing opioid overdose deaths and worsening the mental health crisis among the country’s youth. The conference featured a broad spectrum of state innovations that provide insight into how to invest future dollars and allocate resources effectively to tackle the behavioral health crisis facing states across the nation:
- Increasing access to mental health services for youth: State policy leaders shared how they have repurposed CDC Reopening Schools Grant funds and leveraged behavioral health coaches to support school-based mental health services. Because schools offer a convenient setting for and critical access to behavioral health care services for children and youth, states are increasingly investing in the infrastructure to provide services in the school setting.
- Reducing harm and increasing access to treatment for SUD: Substance use treatment policy experts shared innovations to support people in recovery, including embedding medication for addiction treatment within hospital Emergency Departments, opening recovery community centers that can connect people in recovery with employment, housing, and peer support, and offering methadone through Mobile Medication Units.
- Decriminalizing mental illness: State executive, legislative and program leaders presented an overview of the Sequential Intercept Model and discussed the importance of investments in community-based interventions and programs that engage people with serious mental illnesses in care and treatment before they interact with the criminal legal system or end up in emergency rooms.
- Supporting access to crisis services in rural and frontier areas: State mental health crisis policy experts highlighted the importance of putting secure tablets in the hands of law enforcement to virtually connect providers and clients to mitigate time and distance issues that create barriers to access.
