It seems like every week, there are multiple new developments in the 340B program.  While it has just been a few weeks since my last 340B blog post, since that time we have had another Senate hearing, a new GAO Report, a new House hearing, and introduction of more than a dozen new bills in Congress.  But why, despite all these developments, does it feels like little has actually changed in the 340B world since January?  Continue Reading July 2018: Where Are We Now With 340B?

Congress is in session this week with six important health care hearings, including hearings on Medicare fraud, mental health, and Stark reform. Meanwhile, the Administration continues to put forth new proposed rules and guidance that will impact many stakeholders between now and the end of the year. We cover this and more in this week’s health care preview, which you can find by clicking here.

State Medicaid Agencies have historically engaged in an epic balancing act.  Federal law requires State Medicaid Agencies to ensure beneficiaries have access to medically necessary services.  Federal law also requires State Medicaid Agencies to safeguard their Medicaid Programs against fraud, waste or abuse in billing for Medicaid services.  Balancing those competing requirements has long proven challenging.

Indeed, that very challenge is why federal law also requires State Medicaid Fraud Control Units (MFCUs) be housed outside of the State Medicaid Agencies, and that the State Medicaid Agencies have no authority over which cases the individual MFCUs investigate or prosecute under applicable civil or criminal statutes.  Concerns over access to care should not factor into prosecution judgments in the face of allegations of Medicaid fraud.

No state is more emblematic of the challenges presented by that balancing act than Texas.  But Texas may also be a case study in why use of private Medicaid Management and Medicaid Managed Care companies is no panacea for those challenges.  Moreover, Texas may be a case study in the importance of private Medicaid Management and Medicaid Managed Care companies understanding the depth of those challenges and the need to fully assess what the company may be taking on, before contracting to provide Medicaid services in a particular state. Continue Reading Texas:  A Cautionary Tale for Medicaid Management and Managed Care Companies

This week, focus turns to the Senate as the House overwhelmingly passed its opioid package known as H.R. 6 last week (see our previous coverage here). The Senate will look to combine its various proposals into one package for floor consideration and what passes will provide a timeline for reconciling the House and Senate packages. In other news, the Senate will spend time in the HELP and Finance Committee on drug pricing. With Secretary Azar set to testify, we look for signals that the Administration is moving forward with any aspect of its drug pricing blueprint. We cover this and more in this week’s preview, which you can find here.

The government is focusing on opioids.  Whether it be program policies, enforcement, or legislation, combating the opioid epidemic continues to be a major focus for government officials.  It is also a major piece of the health care legislation moving in both the House and the Senate.

In the Senate, the Judiciary Committee advanced five bills relating to the opioid crisis, and the HELP Committee advanced the “Opioid Crisis Response Act of 2018,” which has over 40 measures relating to opioids. Most recently (6/12), the Senate Finance Committee unanimously approved the Helping To End Addiction And Lessen (HEAL) Substance Use Disorders Act Of 2018.  That Act includes the expansion of the Physician Payment Sunshine Act to include payments to mid-level providers, as we previously blogged about here.  Click here for a summary of all Senate bills.

On the House side, over the last two weeks, the House passed over 50 bills to combat the opioid crisis and have received bipartisan support. Additional opioid related bills have been introduced and passed out of committee. On June 20, the House voted and passed three additional opioid bills (HR 5925, HR 9797, and HR 6082). Two of these bills were considered controversial. H.R. 5797, The IMD CARE Act, repeals the Medicaid IMD exclusion for individuals with opioid use disorders. H.R. 6082, The Overdose Prevention and Patient Safety Act, amends 42 CFR Part 2 confidentiality protections pertaining to substance use disorder patient records.  Continue Reading Opioids Have Our Attention

It has been a few weeks since the publication of the Trump Administration’s Blueprint to Lower Drug Prices, and Secretary Azar’s  Request for Information (RFI) on the Blueprint.  We previously posted about the Blueprint’s focus on the 340B Drug Discount Program.

Many have speculated about the possible changes in store for Medicare under the Blueprint, especially the potential changes to Medicare Parts B and D.  But what about Medicaid?  Unlike Medicare, the federal government does not have exclusive authority to impose operational changes in Medicaid, because of the role of the individual states (and DC) in administering their own Medicaid Programs.  What do the Blueprint and RFI say about Medicaid, and what are the potential implications? Continue Reading A Deeper Dive: What the Trump Administration Blueprint to Lower Drug Prices Might Mean for Medicaid

This week the Senate Finance Committee will mark up its opioid package. Additionally, the HELP Committee will hear from Secretary Azar on the Administration’s effort to lower prescription drug prices. For our complete review and what else to watch for this week, click here.

To date, 34 states (including D.C.) have adopted Medicaid expansion. Of the remaining 17 states, some are considering expanding Medicaid. States with recent activity relating to Medicaid expansion include Florida, Idaho, Maine, Missouri, Nebraska, New Hampshire, North Carolina, Utah, and Virginia.  Last week, Virginia became the latest state to expand Medicaid and also tied a Medicaid work requirement to the expansion. California is also exploring expanding Medicaid to undocumented adults.

Below we have highlighted recent state grassroots, legislative, and executive action to expand Medicaid. Continue Reading A Rundown of Recent State Action Relating to Medicaid Expansion

In a previous blog, we reviewed pending and approved 1115 waivers in 11 states. These reviews provide an overview of 1115 waiver applications, including a focus on work requirements, lock-outs, changes in coverage structures, repealing the Medicaid IMD exclusion, and other behavioral health initiatives.  As we continue to monitor these applications, we’ve created a new site to track 115 waivers and will be continuing to update this site with additional state waiver requests and approvals.

On April 30, 2018, Ohio became the latest state to submit an 1115 waiver to include work requirements for certain Medicaid beneficiaries. The waiver application requires individuals in the Group VIII category – those with income level of 0-138% of the federal poverty level (FPL) – to meet the Work and Community Engagement requirement to maintain their Medicaid eligibility. These requirements will closely mirror existing SNAP and Able-Bodied Adults without Dependents (ABAWD) requirements. There are at least fifteen exemptions to the work requirements outlined in the 1115 waiver request.

If the individual is not exempt, they will need to work or participate in a community engagement activity for a minimum of 20 hours per week, or 80 hours averaged monthly. These activities include education and training activities, job search or readiness programs, or the Work Experience Program, which supports beneficiaries in meeting work activity requirements through private or government entities.

Lastly, Ohio is requesting a federal match for supportive services such as transportation to help eligible beneficiaries in meeting the work and community engagement goals. If there is no federal match, the State would consider granting beneficiaries a good cause exemption. To date, Ohio is the only state with a submitted 1115 waiver including work requirements that is pursuing federal match for supportive services to help beneficiaries meet the work requirement.

A complete summary of the Ohio 1115 waiver application is found here.

You can view our complete waiver summary and links to state-by-state summaries by clicking here.