Washington, DC Update 10/6/23

Congress avoided a government shutdown last Saturday by passing a temporary 45-day continuing resolution until November 17, 2023.

Congress Launches MCO Investigation: House Energy and Commerce Committee Ranking Member Frank Pallone, Jr. (D-NJ) and Senate Finance Committee Chair Ron Wyden (D-OR) today sent a series of letters to the largest Medicaid Managed Care Organizations (MCOs) across the country as part of a new investigation seeking answers following reports of high rates of prior authorization denials for patients.

An alarming report by the Department of Health and Human Services (HHS) Inspector General found that numerous Medicaid MCOs had staggeringly high rates of denial of health services for patients. Over 70 million low-income Americans are enrolled in Medicaid MCOs, which are responsible for ensuring that people struggling to make ends meet can access the critical treatment and care they need and to which they are legally entitled.

The HHS Inspector General report found that MCOs denied, on average, one out of every eight prior authorization requests for service—a denial rate of 12.5 percent, which is more than double the denial rate in Medicare Advantage.

“These findings raise serious concerns that Medicaid MCOs are systematically and improperly denying necessary care which they are required by law to provide,” Pallone and Wyden continued. “Low-income children and families, seniors, and people with disabilities rely on these plans for access to critical health care services, and prior authorization denials prevent them from receiving these services, which can lead to worse health outcomes.”

Over three-quarters of Medicaid beneficiaries are enrolled in a comprehensive managed care plan operated by an MCO. States pay MCOs a specified amount per member per month that is designed to cover the expected costs of care for each enrolled beneficiary. Pallone and Wyden voice concern about whether this may be creating a financial incentive for MCOs to increase profits by denying requests for care.

As the Democratic leaders of the Committees with jurisdiction over the Medicaid program, Pallone and Wyden requested documentation and answers to a series of questions, including:

1. Does a company require prior authorization for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services across any of its subsidiary health plans?
2. A description of all algorithms, including machine learning and artificial intelligence algorithms, that a company used in prior authorization decisions separated by approvals, partial denials, and full denials for 2018-2022 for any and all MCOs that a company operated within that time frame.
3. Information on the rate of appeals by level of appeal and the outcome for Medicaid MCOs and for its Medicare Advantage products.

Letters were sent to Aetna, AmeriHealth Caritas, CareSource, Centene, Elevance, Molina and United Healthcare.

Unwinding Resources to Reach and Support College Students

End of the Public Health Emergency and Impact on Affordable Health Coverage for College Students (ed.gov)

The University of Utah: What To Do If You Lose Medicaid Coverage https://attheu.utah.edu/facultystaff/what-to-do-if-you-lose-medicaid-coverage/

University of Southern Florida Single Stop Partnership

https://www.usf.edu/undergrad/students/single-stop.aspx

Young Invincibles has a toolkit that includes materials that can be used and/or adapted for outreach.

Georgetown CCF and AAP Outreach Materials

Georgetown University CCF teamed up with its long-standing partner, the American Academy of Pediatrics (AAP), to develop outreach materials and get them into the hands of trusted messengers such as pediatricians. Together with GMMB, our communications partner, we created consumer-facing flyers with state-specific information in Spanish and English.

CMS Fillable Outreach Materials

Postcard for Kids with Medicaid or CHIP (English and Spanish): Use this postcard to help families keep coverage for their kids. 

Fillable Postcard for Kids with Medicaid or CHIP (English and Spanish): Customize this postcard with state Medicaid information to help families keep coverage for their kids.

Postcard for Renewing Kids’ Medicaid or CHIP (English and Spanish): Use this small postcard to help families take steps to keep health coverage. You can also get a tribal-focused version of this postcard.

Fillable Postcard for Renewing Kids’ Medicaid or CHIP (English and Spanish): Customize this postcard with state Medicaid information to help families take steps to keep health coverage. You can also get a tribal-focused version of this postcard.

State Health and Value Strategies: Unwinding Updates

This SHVS publication offers a walk-through state by state actions in the last month.

CMS: 12-Month Continuous Medicaid Coverage

The Department of Health and Human Services, through the Centers for Medicare & Medicaid Services (CMS), sent a letter to state health officials reinforcing that states must provide 12 months of continuous coverage for children under the age of 19 on Medicaid and the Children’s Health Insurance Program (CHIP) beginning January 1, 2024. This action will help to ensure that eligible children enrolled in Medicaid and CHIP have uninterrupted coverage over the course of a year, helping children maintain access to the health care services they need to thrive.

The letter provides background on the importance of continuous coverage in preventing interruptions that impede access to health coverage to support better short- and long-term health outcomes, and describes policies related to implementing continuous coverage for children as required by the Consolidated Appropriations Act of 2023. The letter also reminds states that they may request section 1115 demonstration authority under the Social Security Act to extend the continuous coverage period for children beyond 12 months, and to adopt continuous coverage for adults eligible for Medicaid.

For more information and to read the letter to state health officials, please visit https://www.medicaid.gov/sites/default/files/2023-09/sho23004.pdf - PDF

CMS: Medicaid Transportation Coverage Guide

The Centers for Medicare & Medicaid Services (CMS) is issuing this guidance, the Medicaid Transportation Coverage Guide, to serve as a consolidated and comprehensive compilation of both current and new Medicaid transportation policy, providing a one-stop source of guidance on federal requirements and state flexibilities. This Medicaid Transportation Coverage Guide addresses the transportation assurance requirement in section 1902(a)(4)(A) of the Social Security Act (the Act) and includes new guidance to improve access to necessary transportation services in more complex scenarios, including where beneficiaries may encounter extended wait times and need to make long-distance trips.

The guidance also provides references and greater context on certain overlapping requirements, so states are better able to navigate complex issues and consider impacts across their Medicaid programs. Medicaid transportation is a critical service that assists beneficiaries with accessing covered Medicaid services and has a direct impact on health outcomes. CMS encourages states to consider how to fully operationalize the transportation assurance and to ensure it is regularly monitored and considered for improvements.

All references to the Medicaid program in this letter and the accompanying Medicaid Transportation Coverage Guide encompass Medicaid expansion Children’s Health Insurance Programs (CHIP).

CMS: Sickle Cell Action Plan

Centers for Medicare & Medicaid Services (CMS) continues to recognize the challenges faced by members of the Sickle Cell Disease (SCD) community and is releasing a new Sickle Cell Disease Action Plan (and accompanying Infographic on the Action Plan) to address and eliminate barriers within CMS programs. The actions in this plan are designed to improve health outcomes and reduce health disparities for individuals living with SCD.

The burden of this disease, particularly for people enrolled in CMS programs, underscores the importance for CMS to use existing levers to take action on opportunities and solutions. The Action Plan builds on the Health Equity pillar of the CMS Strategic Plan and the goals under the CMS Framework for Health Equity. It also aligns with the mission and vision of the CMS National Quality Strategy and the CMS Behavioral Health Strategy’s goal to ensure effective pain treatment and management.

For more information about Sickle Cell Disease and related work that is happening across the agency, check out this recent blog from CMS Administrator Chiquita Brooks-LaSure and Acting CMS OMH Director Dr. Aditi Mallick.

Watch Sickle Cell Disease video, created by OMH, to learn more about common health complications faced by individuals with SCD, in addition to disparities, symptoms, and treatment options.

NSCH: New 2022 National Survey Children’s Health Data

CAHMI is thrilled to announce the release of new data findings from the 2022 National Survey of Children’s Health (NSCH). Search CAHMI’s National Data Resource Center for Child and Adolescent Health (DRC) online interactive data query to get national, state and child subgroups level results on Title V National Performance Measures (NPMs) and National Outcome Measures (NOMs). The 2022 NSCH marks the seventh edition of this survey since its redesign in 2016, providing population-based and representative national, regional and state level data about child and youth health and the family, community, school and health systems experiences that influence their well-being.

ACL: Webinars on Partnering to Address Health-Related Social Needs

Health care entities and social services providers are increasingly recognizing the importance of partnerships among historically siloed sectors to address health-related social needs. While the number of community-based organizations (CBOs) and community care hubs (CCHs) pursuing contracting relationships with health care organizations is increasing, challenges persist. 

Join the Partnership to Align Social Care, the Aging and Disability Business Institute, and Camden Coalition for a webinar series offering a deep dive into leading contracting practices to effectively and efficiently address health-related social needs.

Register today for "Contracting to Align Health and Social Care Ecosystems: A Webinar Series Sharing Leading Practices," taking place on the second Tuesday of each month during October, November, and December. 

• Designing the Payment Structure: A Health Plan’s Guide to Paying CBOs and CCHs for Social Care
• October 10, 2023, 2:00-3:00 PM ET
• Defining Core Activities: Developing an Effective Scope of Work for Contracted Partners
• November 14, 2023, 12:00-1:00 PM ET 
• Operationalizing Contracts: Improving Contracting Implementation and Collaboration
• ​​​​​​​ December 12, 2023, 12:00-1:00 PM ET

Each webinar will focus on the essential elements of contracting between health care and community partners, feature leading practices from the field, and highlight key findings from a four-part toolkit, "Healthcare Guide to Contracting with CBOs," co-designed by CBO, CCH, health plan, and health system representatives.

Register here.

KFF: Pandemic-Era Changes to Medicaid Home- and Community-Based Services (HCBS) 

This issue brief provides the results of a 50-state survey conducted by the Kaiser Family Foundation and describes how the Public Health Emergency authorities allowed states to strengthen their HCBS programs. The authors look at the changes made as the PHE ended and at the family caregiver's role in providing HCBS. The brief discusses key take-aways including the role of respite. Forty-nine states offer respite care in their HCBS programs. Respite care was the most frequently reported support offered and caregiver counseling or support groups was the least. The survey also found that In 11 states, payments to family caregivers who are legally responsible for the person they are caring for will be ending and payments to other types of family caregivers will end in 5 states. Read the report. 

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Family Voices is a national organization and grassroots network of families and friends of children and youth with special health care needs and disabilities that promotes partnership with families--including those of cultural, linguistic and geographic diversity--in order to improve healthcare services and policies for children.