May 20 Update

In This Week’s Update:

  • CMS Issues Guidance on Calculating Spread Pricing in Medicaid
  • Department of Labor Issues Guidance on AHP Court Decision
  • State Updates: MD, MT, NV, NH, NM, OR & WA
  • Webinar: Strategies for Connecting Justice-Involved Populations to Medicaid
  • Case Study: NY’s Surprise Billing Law
  • Webinar: Addressing Transportation to Improve Community Health
  • Behavioral Health Coverage in Medicaid Managed Care

CMS Issues Guidance on Calculating Spread Pricing in Medicaid

Last week, the Centers for Medicare and Medicaid Services (CMS) issued new guidance for Medicaid managed care plans and children’s health insurance plans clarifying how current regulations require spread pricing to be accounted for in the calculation of medical loss ratios (MLR). The guidance is meant to help ensure that health plans monitor spread pricing in Medicaid appropriately to avoid inflated profits for pharmacy benefit managers. In the guidance, CMS clarifies the definition of “prescription drug rebates” and provides examples of what these could include.

Department of Labor Issues Guidance on AHP Court Decision

Also last week the Department of Labor issued new guidance in response to a recent court decision invalidating its recent rule on association health plans (AHPs). The guidance confirms that AHPs operating under the new rule cannot market to or enroll new members, and that existing AHPs (that predated the latest rule) can continue to operate. For a brief overview of the new guidance, see this Health Affairs blog post.

State Updates: MD, MT, NV, NH, NM, OR & WA

  • Maryland – Governor Larry Hogan signed legislation enacting the Maryland Easy Enrollment Health Insurance Program. The new program will offer uninsured Marylanders the option of checking a box on their state income tax return, allowing the Maryland Health Benefits Exchange, the state’s official health insurance marketplace, to determine their eligibility for benefits under the Affordable Care Act (ACA).
  • Montana – Governor Steve Bullock signed into law a package of nine health care bills, including the reauthorization of Medicaid expansion and a bill authorizing the state to pursue a Section 1332 waiver to implement a reinsurance program. As a reminder, State Health and Value Strategies is tracking all state activity on Section 1332 waivers via this map.
  • Nevada – Governor Steve Sisolak signed into law AB 469 which limits the amount insured patients can be charged for emergency services when they receive care from an out-of-network provider. The Governor also signed AB170 which codifies the Affordable Care Act’s protections for pre-existing conditions into state law.
  • New Hampshire – The New Hampshire Insurance Department issued an alert advising consumers that Aliera, which markets itself as a health care sharing ministry, may be operating illegally in New Hampshire.
  • New Mexico – The state’s official health insurance marketplace, beWellnm, held a board meeting last week. On the agenda were several motions related to the marketplace’s transition to a state-based exchange.
  • Oregon – The Health Evidence Review Commission voted unanimously to update Oregon Health Plan coverage for neck and back pain by removing requirements for opioid tapering. The change will be effective October 1.
  • Washington
    • Governor Jay Inslee signed into law two significant health care bills last week. One bill creates a public option health care plan, called Cascade Care, the first such legislation to become law in a state. That legislation also authorizes standardized plans on the marketplace and subsidies up to 500 percent of the federal poverty level. The second bill creates a long-term care benefit for which Washington workers will pay into a trust through a payroll tax and, once eligible, will have access to assistance for a range of daily tasks related to self-care.
    • Insurance Commissioner Mike Kreidler ordered Aliera Healthcare, Inc. and Trinity Healthshare, Inc., both of Delaware, to immediately stop selling plans in Washington state and engaging in deceptive business practices.

Upcoming Webinar–Emerging Strategies for Connecting Justice-Involved Populations to Medicaid Coverage and Care

Tuesday, June 18 from 1:00 to 2:00 p.m. ET

State Health and Value Strategies, in partnership with Manatt Health, is hosting a webinar for states that provides an overview of the opportunities available to connect justice-involved populations to Medicaid coverage and care. States are exploring opportunities to engage justice-involved populations–including juveniles and adults–in Medicaid coverage, case management and health care both immediately prior to and following their release from prison or jail. States’ interests are motivated by the high needs and high related health costs of these individuals–who are often eligible for Medicaid upon release, especially in states that have expanded Medicaid. Despite the current prohibition on drawing down federal Medicaid financing to fund health care for people while they are incarcerated, there are a number of strategies states can deploy to meaningfully connect justice-involved populations to critical coverage as well as medication and physical and behavioral health care services when re-entering the community. The webinar will provide an overview of Medicaid enrollment and suspension processes to make sure an individual has active Medicaid coverage and “in-reach” planning pre-release that helps with engagement and care management post-release.

Registration (required) at the following link:

Case Study Examining New York’s Law to Protect Consumers from Surprise Out-of-Network Bills

In a new report supported by the Robert Wood Johnson Foundation, researchers at Georgetown University’s Center on Health Insurance Reforms (CHIR) share findings from a case study assessing New York’s experience with its surprise billing law, five years after implementation. The report is based on a review of New York’s law, implementing regulations, and published reports and analyses about the state’s experience to date. In addition, the authors conducted ten structured interviews with state regulators, consumer advocates, insurance company representatives, physician and hospital representatives, and expert observers. The findings include lessons learned during the legislative process and stakeholder engagement, as well as gaps that remain in consumer protections.

Addressing Transportation to Improve Community Health

All In: Data for Community Health is hosting a webinar on June 5 that will feature projects addressing transportation with a multi-sector data component. Presenters include a representative from FLOURISH: St. Louis, who will talk about how they are using data to address infant mortality through transportation in St. Louis, and a representative from the Baltimore City Health Department, who will share experiences related to the Baltimore Rideshare program. Both presenters will showcase what is possible through multisector partnerships, using data, to improve transportation and health in communities.

Behavioral Health Coverage in Medicaid Managed Care

A recent report by the Institute for Medicaid Innovation highlights findings from the organization’s annual Medicaid managed care survey that is specific to behavioral health and examines trends in prevalence and disparities. The report includes a brief historical overview of behavioral health care in the United States; examines the top policy, network, and operational barriers faced by Medicaid managed care organizations; and highlights state variation in financing models for behavioral health coverage. The authors also outline opportunities to address research, clinical, and policy priorities for behavioral health.