Weekly Health Care Policy Update – November 14, 2022

November 21, 2022

In this update: 

  • Administration Updates
    • Biden Administration Indicates PHE Will Continue Past January
  • Federal Agencies
    • CMMI to Host Specialty Care Strategy Listening Session
    • HHS Proposes Rule to Update Standards for Electronic Drug Transactions
    • GAO Issues Study on Private Health Insurance Market Concentration
  • Other Updates
    • SCOTUS Hears Oral Arguments in Nursing Home Case
    • Voters Approve Ballot Measures on Abortion, Medicaid, and Medical Debt
  • New York State Updates
    • Governor Hochul Extends Statewide Polio Emergency; Ends Monkeypox Emergency
    • DOH Provides Updates on ABA Services, Releases Updated Fee Schedule and Policy Manual
    • DOH Provides Update on Coordination of Benefits Submissions for Medicaid FFS Pharmacy Billing
  • Funding Opportunities
    • DOH Releases RFA for Hepatitis C Navigation and Care Coordination in High-Risk Settings
    • OMH Announces Community Mental Health Loan Repayment Program
    • ACL Releases Funding Opportunity for Chronic Disease Self-Management Education Programs
    • AmeriCorps Releases Funding Opportunity for 2023 Seniors Workforce Development Program

Administration Updates

Biden Administration Indicates PHE Will Continue Past January
Last week, the deadline for the Department of Health and Human Services (HHS) to provide 60 days’ notice before expiration of the Covid-19 public health emergency (PHE) passed. Reuters reported that Biden administration officials confirmed the PHE would be extended further, with the possibility of a winter surge and the need for additional time to prepare for the unwinding contributing to the decision. An HHS spokeperson reaffirmed that HHS would provide 60 days’ notice before the PHE’s expiration.
 
HHS may now choose to extend the PHE another full 90 days, to April 11th, or to another date. It is also possible for Congress to set a specific end date through legislation in the end-of-year spending package.
 
The Reuters report is available here.

Federal Agencies

CMMI to Host Specialty Care Strategy Listening Session
On December 1st from 1pm to 2pm ET, the Center for Medicare and Medicaid Innovation (CMMI) will be hosting a listening session on its Specialty Care Strategy. CMMI posted two blog posts in recent months discussing its plan for greater integration of specialty care into its models.  The webinar will specifically cover: 

  • An overview of the Innovation Center’s specialty care models;
  • The rationale for focusing on specialty care integration;
  • An overview of the specialty care strategy; and
  • Feedback on the specialty care strategy from a guest panel.

Registration is available here. Attendees may submit written comments or questions in advance through the registration link. The two CMMI blog posts on specialty care are available here (November post) and here(June post).
 
HHS Proposes Rule to Update Standards for Electronic Drug Transactions
On November 7th, HHS released a proposed rule to adopt updated versions of Health Insurance Portability and Accountability Act (HIPAA) electronic transactions involving retail pharmacy benefits. These rules are intended to allow health information to be transferred more efficiently and with greater uniformity. If finalized, the proposed rule would modify current standards for retail pharmacy transactions such as health care claims or eligibility for a health plan. Most HIPAA-covered entities would be required to be compliant with the regulations 24 months after the effective date. Specifically, the proposals would adopt the National Council for Prescription Drug Programs (NCPDP) Telecommunication Standard Implementation Guide and the Equivalent NCPDP Batch Standard Implementation Guide Version 15.
 
The proposed rule is available here and will remain open for comment for 60 days.
 
GAO Issues Study on Private Health Insurance Market Concentration
On November 7th, the Government Accountability Office (GAO) released a study on health insurance market concentration. Overall, GAO found that concentration in the individual, small group, and large group markets continued to increase in 2019 and 2020, continuing a trend of increasing market concentration from 2010 to 2018 previously reported by GAO in a 2020 report.
 
GAO defines an insurance market as concentrated if three or fewer issuers hold at least 80% of the market. By this definition, each of the three markets in 2020 was concentrated in at least 42 states. The individual and small group markets became more concentrated in recent years, with the median market share of the top three issuers in each market increasing by 12 and 10 percentage points, respectively, to at least 97% in both markets by 2020. GAO found that individual market exchanges were concentrated in all states in 2020.
 
The study is available here.

Other Updates

SCOTUS Hears Oral Arguments in Nursing Home Case
On November 8th, the Supreme Court heard oral arguments in Health and Hospital Corporation of Marion County, Indiana v. Talevski,a case which will decide whether people who depend on government-funded programs such as Medicaid are allowed to sue states when they believe their rights have been violated.

The case originated in 2019 when Susie Talevski sued the Health and Hospitals Corporation of Marion County, an Indiana public agency that owns the nursing facility where her father was a resident. The suit claimed that Gorgi Talevski had his rights violated by the nursing home and that substandard care contributed to his rapid decline. This right has been considered precedent as established in Wright v. Roanoke Redevelopment and Housing Authority (1987) and Wilder v. Virginia Hospital Association (1990). However, more recent opinions (including Planned Parenthood of Greater Texas v. Smith and Gee v. Planned Parenthood of Gulf Cost Inc.)have ruled against Medicaid enrollees, concluding that they do not have the right to challenge decisions of a state Medicaid program.

The case may also have implications beyond Medicaid, since the Court is examining its longstanding position about the rights of Americans relying on any program under the Spending Clause. Given this broad reach, over 25 amicus briefs have been filed in the case, including many from federal officials, advocacy groups, and provider groups. A ruling is expected by the end of the term in June 2023.

Voters Approve Ballot Measures on Abortion, Medicaid, and Medical Debt
On November 8th, voters across the country approved ballot measures on abortion, Medicaid expansion, and medical debt. Five states voted to protect abortion rights in the wake of the Supreme Court’s Dobbsdecision earlier this year, which reversed Roe v. Wadeand overturned a constitutional right to abortion. Voters in California, Michigan, and Vermont affirmed abortion rights through their state constitutions, while voters in Kentucky and Montana rejected efforts to further limit access to the procedure. In Kentucky, voters rejected an amendment that would have completely removed the right to an abortion at the state level (though the procedure remains banned statewide). In Montana, voters rejected a “born alive” ballot initiative that would have required medical interventions to save infants of any gestational age.

Voters in South Dakota voted 56% to 44% to expand Medicaid to roughly 42,500 residents in their state who make less than roughly $19,000 per year, beginning in mid-2023. South Dakota’s vote marks the seventh successful effort to expand Medicaid in Republican-led states via ballot measures, including Maine, Missouri, Oklahoma, Idaho, Nebraska, and Utah. South Dakota is expected to receive an additional $328 million in federal funds through expansion.

Voters in Arizona voted 72% to 28% to cap the interest rate on medical debt at 3% and limit wage garnishment for medical debt to a maximum of 30% of earnings. The measure also increased the value of primary residence and cars protected from medical debt collectors to $400,000 and $15,000, an increase from $250,000 and $6,000.

New York State Updates

Governor Hochul Extends Statewide Polio Emergency; Ends Monkeypox Emergency
On November 8th, Governor Hochul issued Executive Order 21.2, which extends the State Disaster Emergency due to the emerging poliovirus outbreak through December 8th. The statewide disaster emergency declared due to the monkeypox virus expired on October 27th.
 
Executive Order 21.2 is available here.
 
DOH Provides Updates on ABA Services, Releases Updated Fee Schedule and Policy Manual
In the October Medicaid Update, the New York State Department of Health (DOH) announced the following updates regarding Medicaid coverage of Applied Behavior Analysis (ABA) services: 

  • Effective January 1, 2023, Medicaid Managed Care (MMC) plans will cover ABA services for enrollees. ABA providers should contact the relevant MMC plans for coverage, billing, and reimbursement guidance.
  • Effective April 1, 2022, the fee-for-service (FFS) reimbursement for ABA services increased from $7.25 per 15-minute unit ($29 per hour) to $19.07 per 15-minute unit ($76.28 per hour). Claims submitted on or after April 1, 2022 will be automatically reprocessed to reflect this increased fee.
  • NYS Medicaid FFS has removed the 60-minute per date of service minimum requirement for billing ABA services.
  • NYS Medicaid FFS has added two new CPT codes to the ABA fee schedule: 
    • CPT Code 97156 – Family Adaptive Behavior Treatment Guidance; and
    • CPT Code 97158 – Group Adaptive Behavior Treatment (up to eight individuals).

Additional details are available in the October Medicaid Update here. DOH also released an updated fee schedule (available here) and a policy manual for ABA providers (here).
 
DOH Provides Update on Coordination of Benefits Submissions for Medicaid FFS Pharmacy Billing
In the October Medicaid Update, DOH announced the following updates on Coordination of Benefits (COB) submissions for Medicaid FFS pharmacy billing, effective November 1, 2022: 

  • DOH has strengthened current system editing to further ensure appropriate submission of NYS Medicaid FFS pharmacy claims when the patient has other third-party coverage. Changes will recognize all values in specified fields and will reject or approve, per program policy, when other patient responsibility amounts are accepted and other third-party insurance billing is validated when the claim is not covered.
  • Medicaid FFS will not accept a combination of the Other Coverage Code of “3” in National Council for Prescription Drug Program (NCPDP) Field 308-C8 with any reject code in 472-6E when another third-party is responsible for payment. The provider must work with the primary insurance to obtain coverage for the member.

The transition of New York’s Medicaid MMC pharmacy claims to FFS is currently planned for April 1, 2023, unless modified by legislation in the meantime. Additional details on the new COB submissions are available in the October Medicaid Update here. Questions may be submitted to NYRx@health.ny.gov.

Funding Opportunities

DOH Releases RFA for Hepatitis C Navigation and Care Coordination in High-Risk Settings
On November 9th, the DOH AIDS Institute released a Request for Applications (RFA) for hepatitis C virus (HCV) navigation and care coordination in high-risk settings. There are two funding components, as follows: 

  • Component A: Over $1 million in total annual funding across seven awardees to support HCV linkage and navigation services for clients in high-risk settings. Annual awards will not exceed $150,000 per awardee.
  • Component B: A total of $1.6 million in annual funding across eight awardees to support nurse-led care coordination services in Opioid Treatment Programs (OTPs). Annual awards will not exceed $200,000 per awardee.

Applicants may submit separate applications for each component. For Component A, eligible applicants are not-for-profit health care organizations licensed under Article 28 that have at least two years of experience treating HCV. For Component B, eligible applicants are not-for-profit OTPs certified by the Office of Addiction Services and Supports (OASAS) under Article 32 that have at least two years of experience providing HCV treatment onsite (or applicants must provide HCV treatment via telehealth in partnership with an HCV provider that has the relevant experience). Contracts will last for five years.
 
The RFA is available here. Applications are due on January 11, 2023. Questions should be submitted to Colleen Flanigan at hepatabc@health.nyc.gov through November 30th.
 
OMH Announces Community Mental Health Loan Repayment Program
On November 10th, the New York State Office of Mental Health (OMH) announced a new program to support licensed community mental health programs with recruiting and retaining psychiatrists and psychiatric nurse practitioners (PNPs). The OMH Community Mental Health Loan Repayment Program (OMH CMHLRP) will award $9 million in total annual funding through State Aid grants for loan repayment across a minimum of 360 awards (180 psychiatrists/180 PNPs). Loan repayments may be awarded for both existing and newly hired staff, as follows: 

  • Up to $120,000 in loan repayment over a three-year period for psychiatrists; and
  • Up to $30,000 in loan repayment over a three-year period for PNPs.

The following providers may apply on behalf of eligible staff: 

  • Inpatient/CPEP: Article 28 hospital inpatient psychiatric units, Article 31 freestanding inpatient hospital programs, and Comprehensive Psychiatric Emergency Programs (CPEPs).
  • Outpatient: Article 31 outpatient programs, including Assertive Community Treatment (ACT) teams, Continuing Day Treatment (CDT), Children’s Day Treatment, Partial Hospitalization (PH), Personalized Recovery Oriented Services (PROS), and Mental Health Outpatient Treatment and Rehabilitative Services (MHOTRS) clinics.

Additional details are available here and SPG’s summary of the opportunity is available here. Applications may be submitted to OMH.CMHLRP@omh.ny.gov and will be accepted on a first-come, first-serve basis until funds are exhausted.
 
ACL Releases Funding Opportunity for Chronic Disease Self-Management Education Programs
On November 3rd, the HHS Administration for Community Living (ACL) released a funding opportunity entitled “2023 Empowering Communities to Deliver and Sustain Evidence-Based Chronic Disease Self-Management Education Programs.” Through this program, ACL will award $5.9 million in total funding across 7-8 awardees who will propose to develop capacity , deliver, and sustain evidence-based self-management education and support programs for older adults with disabilities. Individual awards will range from $500,000 to 600,000. Project periods will last for four years.
 
Eligible applicants include not-for-profit 501(c)(3) organizations and community-based organizations.
Applicants should target individuals with significant social determinants of health needs in areas where programs do not exist, as well as underserved areas and populations defined by the federal Executive Order on Advancing Racial Equity and Support for Underserved Communities.
 
Additional details are available here. Applications are due on January 11, 2023.
 
AmeriCorps Releases Funding Opportunity for 2023 Seniors Workforce Development Program
On November 4th, AmeriCorps Seniors released a funding opportunity for the 2023 Seniors Workforce Development Senior Demonstration Program. This program supports projects that help older adults seek secure employment in professional, skilled labor, or para-professional careers. AmeriCorps Seniors is partnering with Public Health AmeriCorps on this opportunity, which seeks to support projects that address the public health needs of local communities, advance health equity, and create pathways to public health careers for older adults. Applicants that propose public health careers programming should apply via the Public Health Careers Track.
 
AmeriCorps will award $5 million in total annual funding during the three-year program period. Applicants are required to match funds equal to 10 percent of their total requested three-year program budget. Eligible applicants include not-for-profit organizations with or without 501(c)(3) status. Contracts will start on July 1, 2023.
 
Additional information is available here. Applications are due on February 1, 2023.