The federal government doled out nearly $100 billion in what it calls “improper” Medicaid payments in 2021 — accounting for approximately one-fifth of all Medicaid payments, according to estimates. The figure represents Washington’s latest accounting of payments that didn’t meet the various requirements for the Medicaid program, which the federal government runs jointly with the states and allows millions of low-income people access to healthcare. The numbers were similarly high in 2020, with around $86.5 billion in Medicaid payments deemed improper, or just over 21%.   read more

4 Tools for Managing Risk in Medicaid Managed Care Organizations   Health Payer Intelligence, March 29 

States have four main tools at their disposal for managing risk in Medicaid managed care organizations, according to a MACPAC issue brief. Medicaid managed care organizations are reimbursed in a capitated manner, meaning they receive a fixed payment on a regular basis for a defined population. Actuaries determine the capitation rate based on projected beneficiary healthcare costs, plan administration expenditures, and other spending items.  read more

Accelerated health spending expected through 2030 as COVID impacts lessen    Fierce Healthcare, March 28 

National health spending is expected to grow 4.9% annually over the next three years and 5.3% from 2025 to 2030, according to the latest estimates from the Centers for Medicare & Medicaid Services (CMS). This is expected to be driven in part by higher drug price growth and new pharmaceutical launches. National health spending growth is expected to be more than 4% for 2021, at $4.3 trillion. That figure compares to nearly 10% growth in 2020, driven by large inflows of government funding related to the pandemic.  read more

Today, the Centers for Medicare & Medicaid Services (CMS) released the 2021-2030 National Health Expenditure (NHE) report, prepared by the CMS Office of the Actuary, that presents health spending and enrollment projections for the coming decade. The report notably shows that despite the increased demand for patient care in 2021, the growth in national health spending is estimated to have slowed to 4.2%, from 9.7% in 2020, as supplemental funding for public health activity and other federal programs, specifically those associated with the COVID-19 pandemic, declined significantly.  read more

A Republican-led effort to overhaul the state’s public benefit system would cost hundreds of millions of dollars to implement and administer, according to an analysis from the Cabinet for Health and Family Services. An initial estimate by the cabinet put the cost at $431 million for additional staff and technology, though that amount is likely lower because of several changes to the lengthy House Bill 7 first introduced March 1.  read more

Why will MCOs be important with PHE unwinding? Medicaid managed care organizations (MCOs) deliver care to more than two-thirds of all Medicaid beneficiaries nationally. Medicaid MCOs (also referred to as managed care plans) may be in contact with enrollees as they provide care coordination and other member services (e.g., health education and promotion, call center support) and may conduct periodic outreach to promote appropriate use of care (e.g., to encourage prevention, wellness, and early intervention).

On March 3, the Centers for Medicare & Medicaid Services (CMS) released a State Health Official (SHO) letter, “Promoting Continuity of Coverage and Distributing Eligibility and Enrollment Workload in Medicaid, the Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) Upon Conclusion of the COVID-19 Public Health Emergency.” The highly anticipated guidance clarifies CMS expectations for state Medicaid and CHIP agencies as they prepare to process outstanding eligibility and enrollment actions when the federal Medicaid continuous coverage requirement ends.  read more

Through proactive efforts, the OIG prevented more than $38.2 million in potentially questionable spending during the first quarter of fiscal year 2022. These savings were achieved in a variety of ways, including front-end claims denials, client disqualifications, Medicaid provider exclusions, the Pharmacy Lock-In Program and WIC vendor monitoring. The OIG recently published a detailed report for the Texas Legislature that describes cost avoidance and waste prevention activities employed by managed care organizations (MCOs) and the OIG’s efforts to combat fraud, waste and abuse (FWA) in Medicaid managed care.   read more

Arizona will soon resume disenrolling state residents no longer eligible for coverage through Medicaid and a related program for children and that many people currently enrolled will need to go through a process to see if they remain eligible, officials said Tuesday. The Arizona Health Care Cost Containment System generally hasn’t disenrolled beneficiaries since the pandemic began in March 2020 unless they moved out of state, voluntarily disenrolled, aged out of the children’s program or died, an agency statement said.

Indy Explains: How Nevada’s new prescription drug savings program works  The Nevada Independent, March 14 

Nevadans will soon be able to save big on prescription drugs after the state joined a coalition that negotiates lower drug costs, according to the Nevada Department of Health and Human Services. Last month, Gov. Steve Sisolak announced that Nevada will join Oregon and Washington in the Northwest Prescription Drug Consortium, a partnership that allows residents to use drug discount cards to purchase prescription drugs at lower costs. The consortium rebranded to ArrayRx in 2021.   read more

Audit flags $2.4B in ‘improper’ Medicaid, CHIP payments; Michigan cries fou    The Detrioit News, March 11 

The state of Michigan is pushing back on audit findings estimating the Department of Health and Human Services made about $2.4 billion in improper payments to Medicaid and Child Health Insurance Program recipients. The state is alleged to have paid out roughly $1.5 billion in improper payments to beneficiaries who weren’t eligible and another more than $800 million to recipients whose case files were missing documentation of eligibility, according to Auditor General Doug Ringler’s office.

The Centers for Medicare & Medicaid Services (CMS) developed the Payment Error Rate Measurement (PERM) program to measure improper payments in Medicaid and the Children’s Health Insurance Program and produce error rates for each program, including a review of the eligibility component of Medicaid. CMS recently made substantive changes to its PERM program, which included hiring a contractor to perform PERM eligibility reviews.

Annual Report Medicaid Audit Unit for March 13, 2021 – March 1, 2022  Mass.gov, March 1 

The Office of the State Auditor (OSA) receives an annual appropriation for the operation of a Medicaid Audit Unit (the Unit) for the purposes of preventing and identifying fraud, waste, and abuse in the MassHealth system and making recommendations for improved operations. The state’s fiscal year 2022 budget (Chapter 227 of the Acts of 2020) requires that OSA submit a report to the House and Senate Committees on Ways and Means by no later than March 12, 2022 that includes:   read more