State Update

CMS Issues Informational Bulletin on Oral Health

Medicare and Medicaid | Permanent link
On July 10, the Centers for Medicare and Medicaid Services (CMS) released an informational bulletin providing an update on the CMS Oral Health Initiative and other oral health related items.

CMS Launches New Initiative to Help States with Medicaid

Medicare and Medicaid | Permanent link
In a letter to state Medicaid directors dated July 14, the Centers for Medicare and Medicaid Services (CMS) announced the launch of a new collaborative initiative called the Medicaid Innovation Accelerator Program (IAP). The goal of IAP is to improve care and improve health for Medicaid beneficiaries and reduce costs by supporting states in accelerating new payment and service delivery reforms.

Centers for Medicare and Medicaid Services Approves Michigan’s Plan to Expand Medicaid

Medicare and Medicaid | Permanent link

On December 30, the Centers for Medicare and Medicaid Services (CMS) approved Michigan’s Section 1115 waiver to allow its Medicaid program to be expanded to cover more than 300,000 additional residents of Michigan. According to Gov. Rick Snyder (R-MI) the Healthy Michigan Plan will extend health care benefits to 322,000 low-income Michigan residents in spring 2014 and ultimately cover nearly half a million Michiganders. The Medicaid expansion plan will be implemented on April 1. The Michigan plan, unlike the recently approved Arkansas and Iowa plans, does not place new beneficiaries into the health insurance marketplace. However, the Healthy Michigan Plan will establish accounts for the newly eligible beneficiaries that will include some innovative forms of cost-sharing, and beneficiaries that comply with some of the healthy behaviors can see a reduction in these charges. The state has 90 days to submit additional details to CMS regarding how the accounts will work along with more information on what kinds of healthy behaviors will be rewarded. Under the plan, beneficiaries between 100-133% of the federal poverty level will have to pay 2% of their income in premiums into the new accounts though they cannot be denied enrollment for nonpayment. For those under the poverty line in Michigan, individual accounts will be established that reflect a person’s usage of services over the prior six-month period, and beneficiaries will pay the appropriate copay amounts. The copays will not be paid to providers at the time of service but placed into these new accounts on a regular basis. Many details are still to be determined, however, the overall expected payment cannot exceed maximums allowed in Medicaid cost-sharing rules as no waiver was given in this area. Additionally, providers cannot turn people away for failure to pay. Health coverage under the Healthy Michigan Plan includes both federally and state mandated Essential Health Benefits, such as pediatric services, including oral and vision care, and other medically necessary services as needed. To learn more about the Healthy Michigan Plan, click here to view a FAQs document released by the Michigan Department of Community Health.

U.S. Department of Health and Human Services Issues Advisory Opinion on Providing Free Pediatric Dental Care to the Uninsured and Billing Medicaid Patients

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On October 15, the Department of Health and Human Services Office of Inspector General  issued an advisory opinion (No. 13–13) finding that a non-profit community health services organization would not face civil monetary penalties or anti-kickback law sanctions if it began billing Medicaid for dental services provided to its patients, while continuing to provide free dental services to uninsured and underinsured low-income children. 

January 1 Deadline Approaches for 21 States to Shift Children from the Children’s Health Insurance Program to Medicaid

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Beginning January 1, 2014, Medicaid must cover children, ages six to eighteen, with incomes up to 133% of the federal poverty level (FPL) ($31,322 for a family of four in 2013). Today, states must cover children under the age of six in families with incomes of at least 133% of the FPL in Medicaid, while children ages six to eighteen with incomes above 100% of the FPL ($23,550 for a family of four in 2013) may be covered in separate state Children’s Health Insurance Programs or Medicaid at the state’s option. Although many states cover children in Medicaid with income up to 133% of the FPL, due to the change in law, 21 states needed to transition some children from the Children’s Health Insurance Program (CHIP) to Medicaid. This split source of coverage for children is commonly referred to as “stairstep” eligibility, where different aged children in the same family are being enrolled in different coverage programs with different benefits, provider networks, renewal procedures, etc. When the Affordable Care Act (ACA) was enacted 21 states had stairstep eligibility: Alabama, Arizona, California, Colorado, Delaware, Florida, Georgia, Kansas, Mississippi, Nevada, New Hampshire, New York, North Carolina, North Dakota, Oregon, Pennsylvania, Tennessee, Texas, Utah, West Virginia, and Wyoming. The Henry J. Kaiser Family Foundation estimates that 562,103 children will be impacted by the transition, with the largest numbers coming from Texas (131,070 children), Florida (71,329 children), and Georgia (59,435 children). On August 9, the Centers for Medicare and Medicaid Services issued a FAQ document to assist states tackling stairstep eligibility (view the FAQs beginning on question #10). States will continue to discuss whether to continue CHIP in the future, as the ACA extends funding for CHIP only through FY15 and continues the authority for the program through 2019.

U.S. Court of Appeals for the Ninth Circuit Rules California Illegally Halted Medicaid Coverage, Including Adult Dental Coverage, in 2009

Medicare and Medicaid | Permanent link

On July 5, the United States Court of Appeals for the Ninth Circuit struck down California’s 2009 Medicaid cuts, which were made to save the state money as it battled a budget crisis. The state of California argued that coverage of adult dental, podiatry, optometry and chiropractic services for low-income people in rural and underserved areas is not mandatory, but optional, under the Medicaid Act. Specifically, according to the opinion, California read the Medicaid Act as permitting it to reimburse rural health clinics (RHCs) and federally-qualified health centers (FQHCs) for only those ’physicians’ services‘ performed by doctors of medicine and osteopathy. Further, California interpreted the Medicaid Act as stating physicians’ services provided by other types of physicians, including dentists, podiatrists, optometrists and chiropractors are not covered. The Centers for Medicare and Medicaid Services, the federal agency that works with states to administer Medicaid, agreed with the state, and permitted California’s cuts via the approval of its state plan amendment. The question the Ninth Circuit was tasked with answering was whether Congress has defined unambiguously the scope of physicians’ services for which the RHCs and FQHCs must be reimbursed. The court held that Medicaid imposes an obligation on participating states to cover RHC and FQHC services, and that Medicaid imports the Medicare definition of those terms. Specifically, the court stated that the RHC and FQHC services that Medicaid requires states to cover are coequal to those services as they are defined in portions of the Medicare statute. In other words, whatever meaning the Medicare statute gives to those terms, they bear the same meaning in the Medicaid statute. The Medicare Act (see PDF, page 7) defines the term physician to include five categories of professionals: doctors of medicine and osteopathy, doctors of dental surgery or dental medicine, doctors of podiatry, doctors of optometry, and chiropractors. Thus, Medicare unambiguously defines the RHC and FGHC services to include services performed by dentists, podiatrists, optometrists and chiropractors, in addition to services provided by doctors of medicine and osteopathy. The Ninth Circuit reversed and remanded the decision of the district court stating that California’s legislation, which eliminated coverage for certain health care services, was in conflict with the Medicaid Act and as a result, was invalid. The California Department of Health Care Services is currently considering whether to appeal the Ninth Circuit decision.

U.S. Court of Appeals for the Ninth Circuit Rules on Certain Dental Procedures Under Medicare

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On May 31, the U.S. Court of Appeals for the Ninth Circuit affirmed that Medicare's broad dental services exclusion does not permit coverage of extensive dental services necessitated by the medical conditions of Medicare beneficiaries (Fournier v. Sebelius, 9th Cir., No. 12-15478). The Ninth Circuit affirmed the district court’s judgment affirming the decision by the Secretary of the U.S. Department of Health and Human Services (HHS) denying plaintiffs’ claims for Medicare coverage for dental services. In Fournier v. Sebelius, the plaintiffs are Medicare beneficiaries who suffer from medical conditions that caused significant dental problems, and they received dental services to correct those problems. According to the Court’s ruling, the decision by the Secretary of HHS to deny coverage for the Medicare beneficiaries' medically necessary dental procedures was reasonable, given that the Secretary has consistently interpreted the Medicare Act as excluding coverage for such procedures. According to the final ruling by the Secretary of HHS these dental treatments would be covered by Medicare only if they were furnished along with a covered procedure that was performed by the dentist on the same occasion. In addition, the Ninth Circuit held that the secretary’s denial of coverage did not violate the plaintiffs’ equal protection rights under the Fifth Amendment of the U.S. Constitution.

Centers for Medicare & Medicaid Services Releases a Condensed Health Insurance Marketplace Application

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The Centers for Medicare & Medicaid Services (CMS) has released a shortened health insurance exchange application for uninsured Americans.

Colorado Expands Medicaid Under the Affordable Care Act and Passes Oral Health Legislation

Medicare and Medicaid | Permanent link
Gov. John Hickenlooper (D-CO) signed S.B. 200 into law on May 13. The new law expands Medicaid under the Affordable Care Act.

Centers for Medicare & Medicaid Services Offers States Easier Medicaid Enrollment Options

Medicare and Medicaid | Permanent link
The Centers for Medicare & Medicaid Services issued a letter to state Medicaid directors and health officials on May 17, offering states the option of using targeted strategies to identify and enroll low-income adults newly eligible for Medicaid under the Medicaid expansion provision of the Affordable Care Act.