Weekly Health Care Policy Update – April 19, 2024

April 26, 2024

In this update: 

  • Federal Agencies
    • CMMI to Host Webinar on Primary Care AHEAD
    • Administration Launches Site to Receive Complaints of Anticompetitive Behavior in Health Care
    • HHS Issues Final Rule on Administrative Dispute Resolution Process
    • ARPA-H Announces LIGHT Program
  • Other Updates
    • CBO Publishes Report on Medicare ACOs
    • MedPAC Holds April 2024 Meeting
    • MACPAC Holds April 2024 Meeting
    • KFF Releases Survey on Recent Disenrollments from Medicaid
    • Commonwealth Fund Publishes Report on Racial Disparities in Health Care
  • New York State Updates
    • Governor Hochul Announces FY 2025 Budget Agreement; Legislation to Pass Shortly
    • OMH Issues Memorandum Outlining Proposed Changes to PROS Program
    • OMH and OASAS Issue Memorandum on APG Rate Changes for Group Psychotherapy and Peer Support Services
    • DOH Seeks Public Comment on Heightened Scrutiny Evidence Packets for SADC Sites

Federal Agencies

CMMI to Host Webinar on Primary Care AHEAD
On May 9th at 1pm, the Centers for Medicare & Medicaid Services (CMS) will host a webinar on the role of the Primary Care AHEAD program within the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Program. The webinar will cover how CMS views primary care informing the overall goals of the AHEAD Model, the role that primary care practices play in the success of the AHEAD Model, opportunities for participating State Medicaid Agencies to boost participation in the Primary Care AHEAD program and increase statewide primary care investment, and the relationship between hospital global budgets and primary care components of the AHEAD Model.
 
The registration for the webinar is available here.
 
Administration Launches Site to Receive Complaints of Anticompetitive Behavior in Health Care
On April 18th, the Federal Trade Commission (FTC), the Department of Justice (DOJ), and the Department of Health and Human Services (HHS) launched HealthyCompetition.Gov, an online portal that allows the public to submit reports anti-competitive behavior in health care.
 
Any individual who believes they have evidence of a potential violation may use HealthyCompetition.gov to submit their complaint to DOJ and the FTC. The complaint will undergo preliminary review and then further investigation or the opening of a formal investigation, if appropriate. The goal of the portal is to “help create more competitive health care markets that are fairer to patients, providers, payers, and workers.”
 
More information is available here.
 
HHS Issues Final Rule on Administrative Dispute Resolution Process
On April 18th, HHS issued a final rule on the administrative dispute resolution (ADR) process for the 340B Prescription Drug program. The final rule establishes an ADR process, as required under the Affordable Care Act, allowing all 340B covered entities to address disputed claims with pharmaceutical companies without the outlay of significant financial resources or legal expertise. The rule allows covered entities to bring claims when they believe they have been overcharged or where access to 340B pricing has been denied, includes a timeline for when ADR decisions must be made, and includes an opportunity for reconsideration when parties are dissatisfied with the initial decision.
 
The final rule is available here.
 
ARPA-H Announces LIGHT Program 
On April 11th, the Advanced Research Projects Agency for Health (ARPA-H) announced the Lymphatic Imaging, Genomics, and pHenotyping Technologies (LIGHT) program. This new program will invest in comprehensive diagnostic tools for lymphatic dysfunction. Though over 10 million Americans suffer from lymphedema, a type of lymphatic dysfunction, diagnostic imaging is lacking. Under this program, multiple awards are anticipated across three technical areas: diagnosis and monitoring through biomarker diversity; imaging technologies; and prevention, prediction, and diagnosis confirmation.
 
The announcement is available here.

Other Updates

CBO Publishes Report on Medicare ACOs
On April 18th, the Congressional Budget Office (CBO) published a report entitled “Medicare Accountable Care Organizations: Past Performance and Future Directions.” The report summarizes research findings as well as conversations with experts about the factors that have contributed to the relative success or failure of Medicare Accountable Care Organizations (ACOs). The report draws several key conclusions: 

  • ACOs led by independent physician groups and those with a larger proportion of primary care providers are associated with greater savings;
  • ACOs whose initial baseline spending was higher than the regional average are associated with greater savings;
  • ACOs with weak incentives to reduce spending are associated with more limited savings;
  • ACOs that lack resources necessary for providers to participate are associated with more limited savings;
  • ACOs where providers could selectively enter and exit the program on the basis of their anticipated financial benefit or loss are associated with more limited savings.

CBO makes several recommendations to increase net savings achieved by ACOs. These include various mechanisms to increase providers’ incentives to participate and to reduce spending, as well as mechanisms to increase the awareness and engagement of beneficiaries.

The full report is available here.

MedPAC Holds April 2024 Meeting
On April 11th and 12th, the Medicare Payment Advisory Commission (MedPAC) met for its April public meeting. Topics discussed in this session included: 

  • Telehealth: Commissioners expressed disapproval of a recent CMS policy that requires beneficiaries to receive an in-person physician visit prior to receiving telehealth services.  
  • PFS Rates: The Commissioners also discussed potential reforms to physician fee schedule (PFS) rate-setting, alongside policies to address site-of-service payment differentials.
  • Health Care Consolidation: MedPAC intends to continue a conversation about health care consolidation’s impact on prices, particularly for generic drugs.
  • 340B: The Commissioners also discussed opportunities for 340B reform.

The slides from the meeting are available here.

MACPAC Holds April 2024 Meeting
On April 11th and 12th, the Medicaid and CHIP Payment and Access Commission (MACPAC) met for its April public meeting. The Commissioners considered recommendations to improve financial transparency in Medicaid and CHIP programs, principally through more regular, comprehensive state reports on financing methods. The Commissioners expressed support for efforts to strengthen oversight of State Medicaid Agency Contracts (SMACs) particularly for dual eligible special needs plans (D-SNPs). In an ongoing conversation, Commissioners will continue to review recent research on the implications of the Medicaid unwinding. Lastly, the Commissioners discussed presumptive eligibility for home- and community-based services (HCBS) and future collaboration with children’s hospitals.

The slides from the meeting are available here.

KFF Releases Survey on Recent Disenrollments from Medicaid
On April 12th, the Kaiser Family Foundation (KFF) released results from a survey exploring the consequences of the ongoing Medicaid unwinding. The survey found that nearly 1 in 4 adults who were disenrolled in the past year report being uninsured. Nearly half of respondents successfully re-enrolled in Medicaid, while 28% found insurance through their employer, Medicare, the ACA marketplaces, or the military. The majority of adults (7 in 10) reported being at least temporarily uninsured following the loss of their Medicaid coverage.

The announcement is available here.

Commonwealth Fund Publishes Report on Racial Disparities in Health Care
On April 18th, the Commonwealth Fund released their 2024 State Health Disparities Report. The report shows that substantial health and health care disparities exist between white and Black, Hispanic, and American Indian and Alaska Native (AIAN) communities in nearly all states, even in states that have otherwise high-performing health systems with considerable access to care. Overall, Massachusetts, Rhode Island, and Connecticut show relatively high performance for all racial and ethnic groups, while Oklahoma, West Virginia, and Mississippi performed most poorly. New York ranked 17th overall, with relatively high performance across 25 indicators of health system performance for white and Asian American, Native Hawaiian, and Pacific Islander New Yorkers, but far lower performance for Black and Hispanic New Yorkers. 

The announcement is available here.

New York State Updates

Governor Hochul Announces FY 2025 Budget Agreement; Legislation to Pass Shortly
On April 15th, Governor Kathy Hochul announced the “parameters of a conceptual agreement” on the New York State Enacted Budget for Fiscal Year (FY) 2025, which runs from April 1, 2024 to March 31, 2025. The Legislature began releasing final budget bills yesterday (April 18th) and is expected to finish shortly. Notable health care policy items in the budget include: 

  • Medicaid
    • An aggregate increase in Medicaid reimbursement for hospitals ($525 million all funds), nursing homes ($285 million all funds), and Assisted Living Programs ($15 million all funds).
    • Authority for the Department of Health (DOH) to seek approval for a managed care tax to raise additional revenue to fund Medicaid and the health care system. The amount of funds to be raised is unspecified and will depend on discussions with the federal government. Funds would be placed in a new Healthcare Stability Fund and would not be immediately allocated to a specific purpose.
    • A Cost of Living Adjustment (COLA) for human services agencies of 2.84% (up from the Executive’s proposed 1.5%), with the additional provision that salaries for frontline staff must increase by at least 1.7%. As in the Executive Budget, the same entities are eligible who received last year’s COLA, except for Care Coordination Organizations (CCOs).
    • Telehealth payment parity requirements are extended by two years, through 2026 (up from one year in the Executive proposal).
  • Long-Term Care
    • The establishment of a single Statewide Fiscal Intermediary (FI) in the Consumer Directed Personal Assistance Services (CDPAS) program. The Statewide FI must be an entity that is currently serving as statewide FI for another state. It will employ several subcontractors, including at least one per rate-setting region, which must be entities with existing FI experience. Other than these entities, no other FIs will be allowed to continue operating after April 2025.
  • Safety Net
    • The Governor’s Healthcare Safety Net Transformation program for partnerships to stabilize distressed safety net hospitals, with an anticipated $300 million in funding.
    • Creation of a Community Advisory Board for SUNY Downstate and postponement of any reduction in capacity there until at least April 2025.
    • Most of the Governor’s proposed consumer protections, including:
      • An expanded, mandatory uniform hospital financial assistance policy, with a new clarification that immigration status may not be considered in the process.
      • Requirement that separate patient consent must be obtained for treatment and payment.
      • Limits on medical financial products, such as medical credit cards.

Assuming the Budget is officially enacted into law, SPG will release a full Enacted Budget summary on Monday.

OMH Issues Memorandum Outlining Proposed Changes to PROS Program
On April 16th, the NYS Office of Mental Health (OMH) issued a memorandum to Mainstream Medicaid Managed Care Plans (MMCPs), Health and Recovery Plans (HARPs), HIV Special Needs Plans (HIV SNPs), Medicaid Advantage Plus (MAP) plans, and Personalized Recovery Oriented Services (PROS) providers that provides an overview of forthcoming billing and reimbursement changes to the PROS program. On December 28, 2023, NYS submitted a State Plan Amendment (SPA) to CMS to implement these changes, which is currently pending approval. The intent of this memorandum is to allow plans and PROS providers time to plan and implement the necessary system configurations and adjustments necessary to accommodate the changes.

Proposed changes include: 

  • Simplifying the reimbursement model by redefining the PROS unit, eliminating the concept of program participation time, and reducing the number of monthly base rate tiers from five (5) to three (3);
  • Adding Complex Care Management and Peer Support to the menu of services under the Community Rehabilitation and Support (CRS) component;
  • Streamlining multiple CRS services into a single Psychosocial Rehabilitation Service;
  • Moving Cognitive Remediation from the CRS component to the Intensive Rehabilitation (IR) component;
  • Adding Licensed Occupational Therapists to the list of qualified Licensed Practitioners of the Healing Arts (LPHA);
  • Adding Certified Psychiatric Rehabilitation Practitioners (CPRP) to the list of qualified professional staff; and
  • Expanding the definition of Ongoing Rehabilitation and Support (ORS) to include support for individuals in educational programs.

The memorandum is available here. The SPA is available here. Pending CMS approval, the proposed effective data of the SPA is on or after July 1, 2024.

OMH and OASAS Issue Memorandum on APG Rate Changes for Group Psychotherapy and Peer Support Services 
On April 18th, OMH and the Office of Addiction Services and Supports (OASAS) issued a memorandum to MMCPs, HARPs, HIV SNPs, and MAP plans regarding Ambulatory Patient Group (APG) rate changes for psychotherapy (group and family group) and peer support services.

Effective January 1, 2024, rate updates for OMH Mental Health Outpatient Treatment and Rehabilitative Services (MHOTRS) Programs include: 

  • Group Psychotherapy (1 hour): service weight temporarily increased by 50%
  • Family Group Psychotherapy (1 hour): service weight increased by 50%
  • Self-help/Peer Group Services (15 minutes): service weight increased by 50%

Effective July 1, 2024, the following rate updates will occur for MHOTRS and OASAS programs: 

  • Group Psychotherapy (1 hour): the service weight will increase by 30% for OASAS programs and will be adjusted from the temporary 50% to 30% of the original weight
  • Family Group Psychotherapy (1 hour): service weight will increase by 50% for OASAS programs and will continue for MHOTRS programs
  • Self-help/Peer Group Services (15 minutes): service weight continues to receive the 50% increase for MHOTRS programs only (not applicable to OASAS programs)
  • For both OMH and OASAS programs: Billing group and family group psychotherapy with modifiers AF (psychiatrist), AG (physician), or SA (psychiatric nurse practitioner) will continue to increase the weight for the group service by an additional 20%
  • For OASAS programs only: The provider will be required to code one of the three modifiers listed above or one of the following three modifiers; AH (clinical psychologist), AJ (clinical social worker), or HO (master’s level), when submitting claims group and family group psychotherapy in order to receive the enhancements mentioned above

The memorandum is available here. Questions may be submitted to BHO@omh.ny.gov.

DOH Seeks Public Comment on Heightened Scrutiny Evidence Packets for SADC Sites
On April 17th, DOH issued a request for public comment on the Heightened Scrutiny evidence packets for Social Adult Day Care (SADC) sites. DOH is required to publish for public comment the evidence packets for SADC sites that deliver Home and Community-Based Services (HCBS) that were identified as Heightened Scrutiny. Settings that fall into one of two categories that define qualities of an institution and are subject to a Heightened Scrutiny review by CMS are as follows: 

  • Prong 1: Setting is in a publicly or privately operated facility that provides inpatient institutional treatment
  • Prong 2: Setting is in a building on the grounds of, or adjacent to, a public institution.

The evidence packets will be submitted to the federal government to establish that the identified SADC sites have overcome the regulatory presumption that these settings are institutional (i.e., non-eligible for HCBS funding) due to their location. CMS, based on evidence submitted by the State, will confirm whether a setting is not institutional in nature and does have the qualities of home and community-based settings.

Additional details are available here. Public comment may be submitted to HCBSSADCSiteAssessments@health.ny.gov with the subject line “Public Comment” through May 17th.