STATES CAN START MEDICAID ELIGIBILITY REDETERMINATIONS APRIL 1, 2023

 

Over the last three years, the Coronavirus public health emergency was extended numerous times. The PHE and the Families First Coronavirus Response Act adjusted Medicaid eligibility, and consequently, Medicaid enrollment increased dramatically during the course of the pandemic. Between February 2020 and July 2022, 82 million people enrolled in the Medicaid program, but millions are expected to lose coverage in 2023.

Recently, Congress released H.R. 2617 and within the $1.7 trillion bill was a requirement for states to start Medicaid eligibility redeterminations by April 1. States have been expecting eligibility redeterminations, but up until this point, it was not clear when they would occur because of the PHE extensions.

Due to the April deadline, they will need to review their Medicaid budgets as federal funding decreases and maintenance of eligibility requirements (MOE) expire. States expect the eligibility redeterminations to take at least a year to complete. During that time, it will be critical for states to communicate the change and updated eligibility statuses to program recipients.

In the course of the pandemic, Congress passed the FFCRA to expand Medicaid coverage and deliver additional fiscal aid to states by increasing the federal medical assistance percentage (FMAP) by 6.2 percent. Under the legislation, states were restricted from changing eligibility or removing members from the program. In recent months, states have requested a 120-day notice to prepare for the end of the PHE, but H.R. 2617 only allows for 3 months.

Along with eligibility redeterminations, the bill also features a gradual phase-down of the 6.2 percent FMAP over the next year. Rather than an instant reduction, the FMAP will decrease to 5 percent between April and June and slowly drop to 1.5 percent by the end of December.

States will need to generate monthly reports and make various efforts to correspond with plan members before they disenroll them to qualify for the FMAP step-down. For instance, states can not disenroll a member because their mail was returned. Plans will need to follow up with beneficiaries using other methods, such as email. These efforts will help to reduce the number of beneficiaries that lose coverage.

According to Medicaid.gov, this will be the "single largest health coverage transition event since the first open enrollment period of the Affordable Care Act." DHHS released a report in August predicting that approximately 15 million people would lose coverage based on historical patterns of coverage loss.

Now that states have a deadline to redetermine Medicaid eligibility, coordinating benefits to ensure eligible beneficiaries continue receiving coverage will be crucial. Some members will be eligible for additional benefits. Others may enroll in employer-sponsored healthcare or find coverage on the ACA exchange. While eligibility redeterminations will be a challenging task for Medicaid plans, it will also present an opportunity to ensure that vulnerable populations receive benefits and that program resources are preserved.

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OCTOBER MEDICAID NEWS ROUNDUP

 

Syrtis Solutions delivers a monthly Medicaid news recap to help you stay up-to-date. The monthly roundup highlights developments, research, and legislation that pertains to Medicaid program integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Below is a list of last month's important Medicaid news.

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SEPTEMBER MEDICAID NEWS

Syrtis Solutions distributes a monthly Medicaid news roundup to help you stay informed. The monthly roundup concentrates on developments, research, and legislation that relates to Medicaid integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Below is a list of last month's significant Medicaid developments.

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NYRx PHARMACY BENEFIT CARVE OUT

 

Changes in how pharmacy benefits are supplied under New York's Medicaid program are coming. Earlier this year, the state reported that to lower prescription drug costs, it would carve out its Medicaid pharmacy benefits and transition to a fee for service delivery model. On April 1, 2023, Medicaid members will start receiving their pharmacy benefits under the state's new delivery model, NYRx.

New York's carve out strategy is designed to decrease pharmaceutical drug costs by consolidating the state's purchasing power. In addition to lowering costs, the carve out is also geared to improve access to care and reduce restrictions by introducing a single drug formulary.

The decision to carve out, however, has not gone unnoticed. Over the past year, there has been a growing amount of criticism directed at the state's decision. The advocacy organization, Save NY's Safety Net, wrote the state's governor earlier this month and requested that she reverse the decision. They are concerned over its impact on the delivery of healthcare to the state's most vulnerable populations. They also warned the governor that the carve out would negatively affect the Medicaid program's provider network. According to the coalition, "many existing facilities will be forced to close completely, and hundreds of frontline community healthcare workers will lose their jobs."

Advocates of the carve out, like New York state Assemblyman John McDonald, disagree with the advocacy groups. He strongly believes that the shift will help more program recipients than it hurts.

According to the New York State Department of Health, "moving all Medicaid consumers under the FFS Pharmacy Program allows for a single, uniform list of covered drugs and standardized, consistent rules and regulations. Thus, New York State is able to offer an improved, simplified process for Medicaid consumers to get the medicines and supplies they need."

Each year prescription drug spend accounts for a larger percentage of state budgets. To reduce these costs, some states like New York have chosen to transition to fee for service models and carve out pharmacy benefits. While this is one approach to try and reduce costs, states should also identify opportunities to improve efficiency and cost avoid in their Medicaid plans.

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AUGUST MEDICAID NEWS RECAP

 

Syrtis Solutions delivers a monthly Medicaid news recap to help you stay up-to-date. The monthly recap focuses on developments, analysis, and legislation that relates to Medicaid integrity, cost avoidance, coordination of benefits, improper payments, fraud, waste, and abuse. Here is a recap of last month's noteworthy Medicaid news.

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MEDICAID NEWS IN JULY

Syrtis Solutions sends out a monthly Medicaid news roundup to help you stay informed. The monthly roundup highlights developments, analysis, and legislation that pertains to Medicaid program integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Below is a summary of last month's significant Medicaid news.

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JUNE MEDICAID RECAP

Syrtis Solutions sends out a monthly Medicaid news roundup to help you stay informed. The monthly recap focuses on developments, analysis, and legislation that pertains to Medicaid integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Here is a summary of last month's important Medicaid news.

See the news here.