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Medicaid funding bill coming down to the wire

The deadline for the Medicaid appropriations bill and its counterpart tech bill are quickly approaching and the House and Senate remain apart during negotiations.

The appropriations bill remains in limbo and if it is not passed by the deadline, the department could be taken over by the Governor’s office. Currently, one of the most polarizing portions of the bill has to do with managed care in Mississippi hospitals. This program enlists the services of three out-of-state companies to save money for the Medicaid program by deciding on types of treatment and other healthcare cost related decisions. These companies are all out-of-state after a coalition of 60 Mississippi hospitals called “Mississippi True” did not receive a contract last summer.

The contracts for these services last three years and they are currently in the first year of those deals. The Senate is aiming to re-bid those contracts, but the House is standing firm that they will not re-bid the contracts. Tim Moore, CEO of The Mississippi Hospital Association says that the program needs to be funded if they hope to continue providing adequate care to Mississippians.

“We just need a fair approach to deliver healthcare and providers to be a part of that,” Moore said. “The House’s bill was very structured toward providers; putting in protections for providers and we’re not seeing that on the Senate side.”

Moore said that one of the main differences was language that would allow managed care companies to pay less than Medicaid pays.

Part of the problem for the legislature is the lack of negotiations up until this point. While the deadline may be today, negotiators were just named last night for the Senate. Negotiations will continue throughout the day, and Hob Bryan noted that while it is not uncommon for last minute deals to take place, there is still much to be discussed.

“Historically, it would be unthinkable that there would not be a public conference committee meeting, but we now have a process where the Speaker and the Lt. Governor expect to make pronouncements and have everybody else just fall in line,” Bryan said. “That is dysfunctional, I think.”

Bryan said that it was determined that this bill would go to the committee stage earlier this month, and this last-minute negotiation session could have been avoided.

“If there had been a conference committee meeting for a couple weeks in public, with six people actually talking to each other, and six people who actually had control of the legislation, they could work something out. This is everyday business. This is people with different perspectives, getting together and resolving things someway, somehow,” Bryan said. “I don’t believe that process is happening because you have all of this ‘cloak and dagger business’.”

While the budget may get all the attention, equally as important is the tech bill, which Bryan says is the supplement to the appropriation bill.

“We have a law that says that we have a Medicaid program, and then we have the technical amendment bill that says that ‘the Medicaid program has to do the following things, and it is prohibited from doing the following things.’ If you have the appropriation bill without tech bill, there’s money with which to run the dept. of Medicaid, but there are no restrictions,” Bryan said.

A breakdown of the two sides’ original bills can be seen below:

Summary of SB 2836 – Senate Medicaid Bill 2018.

  • Lifts cap on physician visits, allows DOM to determine.
  • Reimburses primary care, pediatric, OB/GYN, internal medicine and vaccine codes at 100% Medicare rate and requires MCOs to reimburse for these same services in the same manner.
  • Removes 25 visit cap on home health.
  • Removes the cap on prescription drugs, allows DOM to determine and sets reimbursement for pharmacy providers at rates no less than the maximum rate approved by CMS.
  • Increases payments for dental fees removes the repealer on dental services
  • Requires that each hospital receives no less than its OBRA; unless Medicaid, in consultation with MHA and all affected providers, develops and agree upon a fair and equitable alternative payment amount.
  • Requires PEER review of the NET program by 1/1/19 and every two years thereafter.
  • Deletes population health program in (42).
  • provides for coverage of treatment of substance abuse disorders, tobacco cessation, alcohol and chemical dependency and opioid addictions, – not more than 30 days of inpatient treatment per year and clinic treatments for such shall not count against any limits
  • Physician administered drugs shall be billed and reimbursed as either a medical claim or pharmacy point of sale to allow greater access to care.
  • Allows children between ages of 10 and 18 to receive vaccines through a pharmacy venue.
  • Adds reimbursement for 17P without PA requirements.
  • DOM may contract with a health information technology company with experience in population health management to develop a pop health and data analytics program for Medicaid enrollees provided the cost for the contract remains less than $10 million per year over the duration of the contract.
  • Adds inpatient coverage for inmates; suspends rather than terminates their eligibility and provide for disenrollment for an MCO upon incarceration expect for the inpatient services.
  • Medical Care Advisory Committee does the following and reports by 1/1/19: develops a study and advises the division with respect to the effect of any 5% rate reduction; and, compares provider reimbursement rates to those applicable in other states in order to establish a fair and equitable reimbursement structure which encourages provider participation.
  • Allows Medicaid flexibility to adjust rates, quantity of services and types of care available to beneficiaries by deleting the language prohibiting Medicaid from making such changes without legislative approval.
  • Allows more flexibility to address deficits including reducing or eliminating any or all optional services; reducing reimbursement rates; any other cost containment measures deemed appropriate by the Governor. This removes the hospital protections regarding rate reductions by hospitals funding the state share through additional assessments.
  • Requires all providers to keep records which document cost report information for three years after the date of submission of the cost report.
  • Deletes requirement that MCOs reimburse no less than the Medicaid rates
  • Prohibits expansion of Medicaid managed care program without enabling legislation. Establishes a commission to study expansion to all beneficiaries. Commission shall consist of: Chairmen of Senate/House Medicaid, Approps and one other Senator/Rep; DOM executive Director; MID Commissioner; hospital rep of a hospital operated in Mississippi appointed by Speaker; doctor appointed by Lt. Gov; pharmacist appointed by the Governor; mental health professional appointed by the Governor; findings shall be reported by 12/1/18.
  • Extends repealer to 6/30/2021 on both 43-13-117 and 43-13-145.
  • Adds a reverse repealer

Summary of HB 898 – House Medicaid Bill 2018

  • Hospitals may (not shall) receive additional payment for baclofen pump.
  • Authorizes DOM to adjust APR-DRGs by DOM or MCOs.
  • Requires DOM to develop and implement a hospital readmission education program designed to reduce potentially preventable readmissions and may work with any MCO to operate the program.
  • Authorizes Medicaid, but does not require it, to give rural hospitals the option to opt out of APC methodology in favor of 101% rate established by Medicare.
  • Reduces nursing home bed-hold days from 52 to 42.
  • Removes physician office visit cap and allows 100% Medicare rate for OB-GYN for certain primary care services
  • Allows DOM to determine reimbursement rates for Emergency transportation services (currently set at 70% Medicare).
  • Removes the cap on prescription drugs.
  • Allows physician-administered drugs to be billed and reimbursed as either medical claims or pharmacy point of sale.
  • Allows DOM to determine dental and orthodontic reimbursement.
  • Reduces ICF-ID bed hold days from 84 to 63.
  • Certain services by a psychiatrist may be reimbursed at up to 100% of the Medicare rate.
  • Authorizes DOM to develop and implement an alternative fee for service UPL to preserve supplemental funding (this protects residual UPL).
  • Removes fall back protection of UPL program if MHAP isn’t approved.
  • Requires that FQHCs be reimbursed under PPS as approved by CMS.
  • Study NET program by 1/1/19 and every two years thereafter.
  • Deletes requirement for a targeted case management program.
  • Authorizes medication-assisted comprehensive treatment services for opioid substance use disorder to be provided through outpatient, residential, hospital or a certified opiate treatment program.
  • Allows children between ages of 10 and 18 to receive vaccines through a pharmacy venue.
  • Removes the 5% withholding on outpatient hospital services( unless the division projects a deficit for any fiscal year)
  • Allows Medicaid flexibility to adjust rates, the quantity of services and types of care available to beneficiaries by deleting the language prohibiting Medicaid from making such changes without legislative approval.
  • Allows more flexibility to adjust deficits including reducing or eliminating any or all optional services; reducing reimbursement rates; imposing additional assessments; any other cost containment measures deemed appropriate by the Governor. This removes the hospital protections regarding rate reductions by hospitals funding the state share through additional assessments.
  • Maintains that the MCOs pay at least what Medicaid pays.
  • Subjects the MCOs to audits with specific measurable directives.
  • Requires the MCOs to recognize the credentialing of providers by the Division of Medicaid and not require providers to be credentialed separately by the MCO in order to receive payments.
  • Medicaid may establish a pilot program to begin on or before January 1, 2020, and operate for three years to evaluate an alternative managed care payment model for medically complex children.

If the legislative body were to leave the Capitol without a bill passed, Bryan says that the uncertainty could lead to issues for hospitals, doctors, nurses, and patients. He says that doctors’ offices, nursing homes, clinics and other healthcare facilities depend on Medicaid funding to provide care especially in rural areas across the state.

“If there is uncertainty about whether you’ll be paid, how much you’ll be paid; it affects the decisions that doctors, dentists, nurses, hospitals, and nursing homes make about how they’ll operate in the coming year, so it affects healthcare availability,” he said.

A midnight deadline is set for the bill. No bills can be passed five days before the end of the session which is on Sunday, so the session can be extended if the bill is not passed tonight. A special session could also be called if no bill is passed before the session adjourns.

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