NAMD Director on CMS regulations at MHPA conference

We are excited to share the first edition of our new 5 Slide Mini-Series, which focuses on Medicaid Unwinding and Redeterminations. This initial edition provides an overview of Medicaid eligibility and enrollment trends during and after the COVID-19 public health emergency (PHE). Some key points from this edition include: 1. During the COVID-19 PHE, Medicaid enrollment increased by 31.3%, from approximately 71.7 million in March 2020 to a peak of 94.1 million in March 2023. 2. As states resumed regular eligibility reviews and disenrollment processes starting in April 2023, Medicaid enrollment dropped to 79.4 million by August 2024, representing a 15.6% decline from the above peak. Southern states experienced the largest regional reduction in Medicaid enrollment during the Redetermination Period, with a 21.6% drop from March 2023 to August 2024 (excluding NC, which implemented Medicaid Expansion in Dec 2023). 3. Overall, national enrollment remains higher than pre-COVID levels, growing by over 8 million persons from January 2020 to August 2024. Over 1.8 million of this net growth (22.6%) occurred in the seven states that implemented Medicaid expansion during this timeframe (ID, MO, NC, NE, OK, SD, UT). 

Florida health systems are waiting for Medicaid hospital-at-home reimbursement to kick in as the state joins a growing group reimbursing for such services, though other states remain cautious about paying for a program with an uncertain future. Approximately 330 hospitals across 37 states offer at-home acute care services through a waiver the Centers for Medicare and Medicaid Services created during the COVID-19 pandemic for Medicare and fee-for-service Medicaid. The waiver lets hospitals provide acute-level care at home through in-person visits, telehealth and remote patient monitoring at the same reimbursement rate as a hospital stay. But the waiver expires at the end of this year, leaving the program's future in question even as support builds in Congress to extend it. Still, hospitals are lobbying more states to cover the program under Medicaid. https://lnkd.in/ekhWRxVY

While conversations on the state and federal level surrounding Medicaid policy have rightfully focused on coverage issues and benefit expansion, ensuring access to care during enrollment is equally crucial. This recently published JAMA article sheds light on key access challenges and policy considerations within the Medicaid landscape. As regulations continue to evolve, so must the ways we accurately and effectively measure our provider networks, and most importantly, our enrollees access to care. Ensuring that we are taking into account the acute needs of our specific member populations when measuring and monitoring networks allows for truly representative assessment of network capacity. Key Insights: ·     Extending Medicaid coverage improves access to care, yielding positive health and economic outcomes. ·     Measuring access in Medicaid is complex; traditional metrics may not capture patients' experiences accurately. ·     Meaningful metrics, such as appointment availability and wait times, offer patient-centered insights. Link to Full Article: https://lnkd.in/g6qZx23U

🚨 New Medicaid policy to increase footing of plans to parity of commercial plans and improve access to care and health services Bottom line: This is an enormous shift and would undermine the long-standing narrative of Medicaid as a poor payer and incentivizes more holistic care delivery to Medicaid patients. 1. CMS requires both states and Medicaid managed care plans to report and analyze access to services and payment rates 💠 If access issues are identified, the plans will be required to make timely changes, such as by enrolling new providers, increasing rates to providers, expanding telehealth, or addressing other barriers. 💠 They will enforce with corrective action plans within 12 mos. 💠 Managed Care wait times will be monitored using set standard wait times and secret shoppers. On or after July 9, 2027, Medicaid managed care must hold primary care and OB/GYN routine appts w/in 15 business days of requests, and w/in 10 days for routine mental health or substance use disorder services. Compliance= rate of appointment availability of at least 90% by “secret shoppers” evaluation. 💡 A heavy lift but these are “indicators of core population health” and may prevent urgent or emergent issues. 💠 New floor for fee-for-service Medicaid rates, requiring them to = 80% of the comparable Medicare rate. 2. CMS permits states to increase Medicaid managed care reimbursement to achieve parity with commercial plans, 💡 groundbreaking 💠 Helps plans to compete with commercial plans for providers to participate in their network, so that they can furnish comparable access to care. 💠 Funding for the directed payments will need to be paid as an adjustment to monthly capitation rates that are based on plan enrollment to increase transparency 💠 Inclusion of out-of-network providers 3. CMS continues authority for Medicaid plans to cover alternative services and settings to address health-related social needs 💠 In-lieu of service include payment for sobering centers, medically tailored meals, supportive housing assistance, or personal care services, etc with a 5% aggregate cap 4. Minimum reimbursement is defined for home-and-community-based service direct care workers #Medicaidreform #access #parity #populationhealth #healthcareonlinked https://lnkd.in/ggkwTJGn

Florida's Medicaid Contracts: A New Era Begins The recent awarding of three statewide Medicaid contracts to Humana, Centene, and Elevance Health marks a significant shift in Florida's healthcare landscape. This development promises the winners extensive access to a substantial segment of the state's 4.8 million Medicaid members. The CY25 Final Rule from CMS, which aims to increase the number of dually eligible managed care enrollees receiving Medicare and Medicaid services from the same organization, suggests that Humana, Centene, and Elevance could see an increase in Medicare Advantage members. This change is poised to set new precedents in healthcare service standards and competition across Florida. Equally noteworthy is the exclusion of former contract holders such as UnitedHealthcare and Molina Healthcare, fundamentally altering the Medicaid and Medicare Advantage landscape in the state. This reshuffle reflects the dynamic and competitive nature of the healthcare industry in Florida. Further detail below from Noah Tong #florida #medicaid #medicare

The latest national Medicaid managed care enrollment data (from 2021) show 74% of Medicaid beneficiaries were enrolled in comprehensive managed care organizations (MCOs). The vast majority of states that contract with MCOs report that the pharmacy benefit is carved into managed care (32 of 41), eight states report that pharmacy benefits are carved out of MCO contracts as of July 2023

Federal Transit Administration and Centers for Medicare & Medicaid Services Announce Medicaid Transportation Coordination Fact Sheet - https://lnkd.in/eNB8tprr Medicaid is a health coverage program for low-income people, funded jointly by states and the federal government, and administered by states. Medicaid non-emergency medical transportation (NEMT) is an important benefit for beneficiaries who need to get to and from medical services but have no means of transportation. The Federal Transit Administration (FTA) and the Centers for Medicare & Medicaid Services (CMS) released the Medicaid Transportation Coordination Fact Sheet, which encourages partnerships between the State DOTs and state Medicaid agencies to improve the accessibility and efficiency of NEMT for low-income individuals, people with disabilities, and older adults. Building from CMS’s Medicaid Transportation Coverage Guide issued in 2023, this fact sheet helps clarify and encourage partnership at the state level and includes commonly asked questions and relevant resources. Stakeholders, such as State DOT staff, provided input into the document. Many FTA public transit grantees offer NEMT, providing vital access to health care for low-income Medicaid beneficiaries, particularly in rural areas. By improving federal and state coordination of public transit and NEMT, we improve access to critical health care services for people who have been underserved in the past. Working together, state Medicaid agencies and State DOTs can: - Improve access to care; - Help meet Federal requirements; - Maximize funding by using Federal fund “braiding” opportunities; - Save health care dollars by reducing missed appointments; and, - Improve the experiences of consumers and transportation providers. CMS and FTA are celebrating 20 years of partnership on the federal interagency Coordinating Council on Access and Mobility (CCAM). CMS and FTA invite communities to take advantage of a newly announced joint national technical assistance (TA) center that will launch in early 2025 and provide NEMT related resources, trainings, case studies of promising practices, and a grant program that offers funding for multisector planning and pilot projects to develop and test innovative transportation solutions.

The word "Medicaid" gets thrown around a lot. Did you know there are 2 primary types of Medicaid? 1. Long-term Care Medicaid (what we primarily deal with at #PathFinderLawGroup) 2. Community Medicaid Knowing the difference is important - especially if you're going to require Medicaid services in the near future. Read our article to learn more about the differences between Long-Term Care Medicaid and Community Medicaid: https://lnkd.in/eFrrdYjw

Dual eligible individuals represent a heterogeneous population with complex needs. D-SNP programs can be tailored to support these diverse needs across states through State Medicaid Agency Contracts (SMACs). States are increasingly leveraging D-SNPs to promote coordinated and integrated care, achieving meaningful incremental improvements with minimal investment. Medicaid experts Brianna Ensslin Janoski, Allison Rizer, and Thomas Betlach recently hosted a discussion on opportunities for states to advance D-SNP program reform. Read their insights: https://lnkd.in/e8HHGmPK #Medicaid #Medicare #DualEligible #DSNP #HealthPolicy #HealthcareInnovation #State

For the last few weeks I have been working a lot with Medicaid billing. I decided to write this to help others that may also benefit from what I have learned. Navigating Medicaid Billing: A Guide for Healthcare Providers Medicaid billing can be a complex and daunting process for healthcare providers, but mastering it is essential for ensuring proper reimbursement and financial sustainability. Understanding the intricacies of Medicaid billing is crucial for providers who serve Medicaid beneficiaries, as it enables them to effectively navigate the system and deliver quality care while maintaining financial viability. First and foremost, healthcare providers must familiarize themselves with the Medicaid program's rules and regulations governing billing procedures. Each state administers its Medicaid program, so providers need to be aware of the specific guidelines and requirements applicable to their state. This includes knowing which services are covered, eligible beneficiaries, documentation standards, and billing codes. Accurate documentation is paramount when billing Medicaid. Providers must maintain detailed records of the services rendered, including patient demographics, diagnosis codes, treatment plans, and progress notes. Thorough documentation not only ensures compliance with Medicaid regulations but also facilitates timely reimbursement by providing clear evidence of the care provided. Selecting the appropriate billing codes is another critical aspect of Medicaid billing. Healthcare providers must use Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes that accurately reflect the services provided. These codes determine the reimbursement amount, so choosing the correct codes is essential for maximizing revenue and avoiding claim denials. #Billing #Substanceabuse #Behavioralhealth #EMR #Mentalhealth