Category Archives: Uncategorized

Hello readers! Today’s post focuses on a topic we’ve touched on a few times in the past – Medicaid drug formularies.

Back in December 2021, the state of Oregon released a draft Medicaid waiver proposal that caught the attention of many stakeholders. In the draft proposal, Oregon stated that it was considering asking CMS for approval to a) adopt a commercial-style closed drug formulary and b) exclude from Medicaid coverage certain drugs approved via the accelerated approval pathway “with limited or inadequate evidence of clinical efficacy.” Oregon proposed to “use its own rigorous review process to determine coverage of new drugs and to prioritize patient access to clinically proven,… More

One of President Biden’s major health care goals is to close the “Medicaid coverage gap” – which refers to those states that have not expanded Medicaid eligibility under the Affordable Care Act (ACA). Until now, the principle strategy to accomplish this goal was to offer the 12 states that have failed to expand Medicaid a “carrot” to incentivize adoption. For example, the American Rescue Plan offered these states a sweetheart of a deal,… More

On January 28th, President Biden issued an “Executive Order on Strengthening Medicaid and the Affordable Care Act.” The E.O. states that the Biden Administration will promote policies that “protect and strengthen Medicaid and the ACA and … make high-quality healthcare accessible and affordable for every American.” To this end, the E.O. makes several important policy changes, including asking the HHS Secretary to establish a Special Enrollment Period for the ACA marketplace,… More

Click here to view Colin Zick’s presentation, New Developments in HIPAA and Related Issues in Health Information Law.  More

Late last year, we noted that the Massachusetts Medicaid program had proposed regulations to address issues related to the prohibition on duplicate discounts in the 340B program.  The Massachusetts solution was relatively straightforward:  for high-cost drugs, Massachusetts Medicaid was going to claim the Medicaid rebate on those drugs itself, meaning that qualifying hospitals could not acquire the drugs under the 340B program.  Little did we know that CMS was also planning to address the same issue,… More

Overview

On November 13, 2018 CMS (as mandated by Congress in the 21st Century cures Act) issued a State Medicaid Director Letter providing states with guidance on both: (1) existing authority for states to provide support for adults with serious mental illness (SMI) and/or children with a serious emotional disturbance (SED); and (2) a new demonstration opportunity  to permit states to offer care for certain individuals with serious mental illness residing in Institutions for Mental Disease (IMDs).… More

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

An appeal recently filed in the United States Court of Appeals for the First Circuit could give further clarity regarding the CMS’s ability to discount Medicaid DSH payments for hospitals that received funds from Medicare and private insurers.

DSH Uncompensated Care Costs and the FAQ Policies

The Medicaid Act requires state Medicaid programs to increase payments to hospitals that treat a disproportionate share of Medicaid and uninsured patients. … More