The following is the latest health policy news from the federal government for August 11-24.  Some of the language used below is taken directly from government documents.

Centers for Medicare & Medicaid Services

• After suspending the No Surprises Act-created Independent Dispute Resolution process in the wake of a court ruling striking down a recent increase in fees for that process, CMS has established a new rate structure for initiating the adjudication of payment disagreements between providers and payers.  It explains the new rate structure in this new FAQ, which nevertheless notes that despite the creation of new rates, the Independent Dispute Resolution process remains suspended until further notice.
• CMS has updated the ICD-10 MS-DRG grouper version 41 with changes that will take effect on October 1.  Go here for further information, additional resources, and links to downloads.
• CMS has posted a brief animated explainer video, “Social Determinants of Health Items:  Determining When a Proxy Response is Allowed,” to help home health, hospice, and long-term-care hospitals determine when the use of a proxy response is permitted for the following social determinants of health items:  A1005 – ethnicity; A1010 – race; A1110 – language; A1250 – transportation; B1300 – health literacy;

Medicaid managed care plans may be shortchanging their members on care – or so suggests a new review by the Department of Health and Human Services’ Office of the Inspector General.

According to the OIG, the Medicaid managed care plans it audited in 37 states rejected one out of every eight requests for prior authorization, with more than ten percent of the audited plans denying prior authorization requests more than 25 percent of the time.

Such findings, the OIG concluded, “…raise(s) concerns about health equity and access to care for Medicaid managed care enrollees.”

To address this problem, the OIG recommends that the Centers for Medicare & Medicaid Services

(1) require States to review the appropriateness of a sample of MCO prior authorization denials regularly, (2) require States to collect data on MCO prior authorization decisions, (3) issue guidance to States on the use of MCO prior authorization data for oversight, (4) require States to implement automatic external medical reviews of upheld MCO prior authorization denials, and (5) work with States on actions to identify and address MCOs that may be issuing inappropriate prior authorization denials.

Learn more from the OIG report “High Rates of Prior Authorization Denials by …

In 2016, the Centers for Medicare & Medicaid Services authorized states to direct Medicaid managed care organizations to pay providers according to specific rates or methods.  Typically, states use these arrangements, often referred to as state directed payments, to establish minimum payments for certain types of providers or to require participation in value-based payment arrangements.  A few states, though, use state directed payments to require Medicaid managed care organizations to make large, additional payments to providers similar to supplemental payments their Medicaid fee-for-service programs.

In a new issue brief, the Medicaid and CHIP Payment and Access Commission describes the history of Medicaid state directed payment policy and examines the use of these payments by the states.  Learn more from the MACPAC report “Directed Payments in Medicaid Managed Care.”…

The following is the latest health policy news from the federal government for April 28 – May 4.  Some of the language used below is taken directly from government documents.

End of the COVID-19 Public Health Emergency

• DeBrunner & Associates has prepared a summary of the status of selected government health care waivers and flexibilities upon the expiration of the COVID-19 public health emergency on May 11. The DeBrunner summary covers telehealth, COVID-19 treatment and coverage, flexible hospital operations, long-term-care hospitals, inpatient rehabilitation facilities and units, patient cost-sharing, and state Medicaid waivers.  Find the summary here.
• The COVID-19 public health emergency led to the temporary creation of a number of flexibilities in the delivery of health care, including one issued by the Drug Enforcement Agency (DEA) that made possible prescribing controlled medications via telehealth.  With the coming end of the public health emergency on May 11, and with it the expiration of some but not all COVID-related flexibilities, the DEA has announced that it is temporarily extending this flexibility while continuing to evaluate the situation.  It has submitted a draft regulation to the Office of Management and Budget to this effect but will provide no further information about it

The following is the latest health policy news from the federal government for March 6-10.  Some of the language used below is taken directly from government documents.

White House FY 2024 Budget Proposal

The Biden administration this week released its proposed FY 2024 federal budget.  Among its many proposals are measures to extend the life of the Medicare hospital trust fund and reduce Medicare beneficiaries’ health care costs; to reduce prescription drug costs for consumers, Medicare, and Medicaid; to return high Medicaid managed care organization profits to the federal government; to make behavioral health care more affordable for seniors; to expand the health care workforce; to improve access to care in rural areas and among underserved communities; to improve HIV/AIDS and hepatitis C prevention and treatment for Medicaid participants; and more.  Learn more about the health care aspects of the administration’s budget proposal from this White House fact sheet on its Medicare proposal; additional White House fact sheets; this HHS news release outlining the budget’s health care highlights; and the budget document itself, where the Department of Health and Human Services section begins on page 75.

Centers for Medicare & Medicaid Services

• CMS has posted anticipated 2023 state