Come see us at AHLA!

On March 21 and 22, two of this blog’s authors will be presenting on two Medicaid topics at the American Health Lawyer’s Association (AHLA) annual Medicare and Medicaid conference in Baltimore, Maryland.

One of the hottest topics in Medicaid right now is the Trump Administration’s policy on granting Medicaid waivers to states, a topic we have posted about here, here and here. … More

MassHealth Leads The Way Towards Addressing Cell and Gene Therapy Reimbursement

Since August, 2017, a new class of transformative therapies referred to as cell therapies or gene therapies have been approved by the US Food and Drug Administration (FDA).  These new cell and gene therapies are typically administered once, as opposed to repeatedly over the course of the patient’s lifetime.

Payers, providers, and manufacturers have been considering how existing payment systems – particularly Medicare and Medicaid – can recognize the value of these new treatments. … More

CMS to Phase Out Designated State Health Program (DSHP) Funding

On December 15, 2017, CMS Director Brian Neale informed State Medicaid Directors of CMS’ intent to phase out funding for Designated State Health Programs (DSHP) in Section 1115 waivers.  CMS will no longer approve waiver requests under Section 1115 for DSHP funding, and will not renew portions of existing waivers that provide DSHP funding.

DSHP funding in Section 1115 waivers developed alongside of CMS’ funding of Delivery System Reform Incentive Payments (“DSRIP”) following the passage of the Affordable Care Act in 2010. … More

Starting Off The New Year With Work: How CMS’ “Work and Community Engagement” Policy Change Could Affect Stakeholders

We hope you enjoyed the holidays and New Year and are getting back into the swing of work.  Speaking of work: Medicaid.  We have previously covered on this blog (here) the Trump Administration’s growing departure from the Obama Administration with respect to the Medicaid program, but now the departure has become increasingly palpable.  On January 11, 2018, CMS announced a new policy supporting states seeking to adopt work and community engagement requirements (together hereinafter referred to as “work requirement”) as part of their Medicaid programs through section 1115 waivers.  … More

Following on the Heels of Massachusetts, Arizona Floats New Medicaid Drug Proposal

On November 17th, Arizona’s state Medicaid agency (the Arizona Health Care Cost Containment System, or AHCCCS) sent a letter to CMS proposing policies that it believes will build on past successes and “leverage[] conservative principles.”

In the letter, AHCCS seeks input from CMS on ideas to “modernize” the prescription drug benefits offered under the state’s Medicaid plan.

(Also, notably, though not the topic of this blog post,… More

Webinar Presentation: The Ambitious MassHealth Shift to ACOs

Partner Tom Barker recently presented a webinar on the MassHealth shift to ACOs. Click here to view the presentation slides.

Webinar Description

The MassHealth program is embarking on a dramatic shift away from fee-for-service Medicaid to a reimbursement model that relies more on value and quality. The Baker Administration hopes to accomplish this through enrolling some MassHealth enrollees into accountable care organizations, or ACOs,… More

Enforcing the Entitlement to Medicaid: The Ongoing Saga

We have written in the past about enforcing the entitlement to Medicaid through the federal court system.  In light of a recent opinion by the United States Court of Appeals for the 8th Circuit, it seems that this judicial saga continues.

The federal Medicaid statute imposes roughly 80 requirements on a state Medicaid plan.  For example, a state Medicaid plan must make medical assistance available “with reasonable promptness.”  Social Security Act § 1902(a)(8). … More

340B Hospitals File Suit in Wake of Hospital Outpatient Cuts

Back in July, my colleague Tom Barker told you about a CMS proposal to institute a fundamental reimbursement methodological change for 340B drugs used in the hospital outpatient setting.  We have noted before the link between the Medicaid prescription drug rebate program and the 340B program.  As a refresher, in order to have its outpatient drugs covered by Medicaid, the manufacturer must agree to three separate requirements.  First,… More

CMS Issues New Guidelines on 1115 Waivers; Signals New Medicaid Objectives

On November 6, 2017 the Centers for Medicare & Medicaid Services (CMS) issued an information bulletin on changes and improvements to the existing Section 1115 waiver process.[1]  Under Section 1115(a) of the Social Security Act, the Secretary of Health and Human Services is permitted to waive compliance with any of the requirements of section 1902 of the Act (which generally sets forth the requirements for state Medicaid programs in order to receive Federal financial assistance) in order to pilot or test projects which,… More

Baker Administration Submits 1115 Waiver Request to CMS, Including Major Change to Drug Coverage

On September 8, 2017, following the mandated 30-day public comment period, the Baker Administration concluded its review of the pending MassHealth Section 1115 Demonstration Amendment Request. The submitted waiver request can be viewed online here.  Once received at CMS, the agency will have to time to review the proposal, and must also solicit additional public feedback, prior to finalizing any waiver.

While the agency made a number of modifications to the waiver based on public feedback,… More