Update on Grassley Amendment

By  Hansine Fisher 

We have it on report that the Grassley amendment was defeated.  A new amendment has been introduced by Senator Allard (R-Colorado).  (See Allard 4159).    An amendment to the war bill has been introduced in the Senate by John Dingell (D-MI) and Tim Murphy (R-PA).   See HR5613. There is also a “Sense of the Senate Amendment”  More to follow.

THE THREATENED IMPACT OF RECENT FEDERAL REGULATIONS

By  Hansine Fisher

WHAT IS THE MEDICAID ADMINISTRATIVE MATCH PROGRAM? §         Medicaid Administrative Match, sometimes called “MAM” or “AdMatch” by local health jurisdictions, covers a range of federally-approved activities that assist state Medicaid agencies such as the State Department of Social and Health Services (DSHS) to carry out their administrative functions more efficiently.   §         Each state must obtain federal approval to claim reimbursement for these activities.   §         A longstanding agreement between the State’s Medicaid agency (within DSHS) and local health jurisdictions ensures that Medicaid-eligible individuals and families will have better access to health care through improved outreach, linkage, interagency coordination, and systems development efforts around Medicaid services.   §         The agreement between DSHS and the Center for Medicare and Medicaid Services (CMS) states the terms by which federal matching funds (also referred to as Federal Financial Participation or FFP) under Medicaid available to local health jurisdictions for the cost of administrative activities that directly support efforts to identify and enroll potential eligibles into Medicaid, to bring them into services covered by Medicaid, to remove barriers to accessing Medicaid services and to reduce gaps in Medicaid services.

HOW DOES IT WORK? §         The Department of Social and Health Services has for many years used agreements with local health jurisdictions to expand its outreach efforts.  §         These agreements increase the opportunities to inform the State’s poorest and most vulnerable residents about the Medicaid program, what it offers, how to apply, and to assist them in accessing needed care and treatment.   §         The activities which form the basis of these agreements have been approved by the federal Center for Medicare and Medicaid Services (CMS), and are the key to federal reimbursements earned by local health jurisdictions.  (Statewide, local health jurisdictions are earning about $17 million annually through Medicaid administrative claiming.) §         The agreements expand the capacity of the Medicaid program in another way.   §         Federal regulations require that the costs of the outreach and linkage activities covered by the agreement be shared proportionately by the State (and its partners) and the federal government.  The agreements require that the local health jurisdictions contribute the “non-federal” share of the cost, rather than the State.  This enables the State to expand its Medicaid outreach and follow along activities without additional legislative appropriations.

WHAT CMS HAS DONE §         CMS, the federal Medicaid agency, has historically used published laws, regulations, policy, and other written guidance as the basis for approving plans covering the delivery of Medicaid services and administrative activities within a state.§         The Deficit Reduction Act of 2005 required changes to the Medicaid Targeted Case Management (TCM) program. §         CMS needed to change the Code of Federal Regulations so that it complied with the language of the Deficit Reduction Act. §         However, when it published the new rule for TCM (2237-F) in the Federal Register on December 4, 2007, CMS included language that was not in the Deficit Reduction Act. §         One section of the “new” language in the regulations is being interpreted by CMS to mean that most, if not all, of the federally-reimbursable Medicaid linkage activities now performed by local health jurisdictions through their agreements with DSHS will no longer be allowed.  §         There is no basis in current law or  standing regulations for this interpretation, and CMS itself has gone on record over the years saying that activities which connect individuals to Medicaid services can be claimed as a Medicaid administrative cost (MAM in Washington) or as a Medicaid service such as TCM. The new rule is being interpreted to mean that linkage may only occur when it is a Medicaid service.  §         Within the mission of public health, referral activity is a critical component of outreach program and clearly distinct from case management as defined in the new TCM regulations. §         In public health programs, the types of referral activities now reimbursed as Medicaid administrative costs serve two purposes: to ensure that outreach programs to at-risk/vulnerable populations (e.g., pregnant women at risk because of their young age, lack of social supports, or other medical conditions; homeless individuals and families; individuals with a diagnosis of HIV/AIDS) result in timely and appropriate referrals for prenatal care, medical evaluations, and chronic conditions, and to determine the type of medical care needed by special populations and facilitate linkage to such care.  Much of the public health activity focuses on the “front door” – identifying persons at risk, steering them toward ongoing care and care management of their medical needs, and following up to make sure the care is adequate to the person’s needs. §         Local health jurisdictions have estimated that as much as 65% of the federal reimbursements they are now earning through the Medicaid Administrative Match program will be lost (or about $11 million annually).

THE RESPONSE §         CMS wrote the TCM regulations so they would go into effect on March 4, 2008. §         CMS employees in the Seattle regional office have verbally informed the State Medicaid agency that Medicaid referral activities now claimed by local health jurisdictions will no longer be allowed.  §         The TCM rule is one of seven rules promulgated by CMS in 2007 whose combined effect is expected to result in a $50 billion reduction in Medicaid payments to the States over the next five years, according to a reported recently issues by the US House of Representatives’ Oversight Committee on Oversight and Government Reform. §         The National Governors’ Association, with 100% support from all its members, wrote a letter to Congress on February 25^th urging Congress to take immediate action to delay the implementation of all seven regulations.    §         Several governors, including Governor Gregoire, also testified before Congress at this time on the impact of these cuts. §         Following the receipt of the governors’ letter, and their testimony, both houses of Congress have begun to look at all the CMS regulations promulgated in 2007 and what might be done to stop their implementation in the context of the FY09 federal budget.   §         The Senate Budget and Finance Committees, of which Senators Murray (Budget) and Cantwell (Finance) are members, are playing a critical role in this discussion.   §         Legislation is being considered that would place a moratorium on all CMS regulations is under discussion and should be introduced soon.   §         The moratorium language would most likely need to be in “must pass” legislation – the continuing resolution on the budget, funding for the wars in Iraq and Afghanistan, the alternative minimum tax, or the fix in Medicare to prevent the 10% reduction for physician services – in order to avoid a Presidential veto. §         On another front, the State of Maine has just recently filed a federal lawsuit on the TCM regulations on the grounds that they exceed the language in the Deficit Reduction Act and violate the federal Administrative Procedures Act.  Maine has been joined in this lawsuit by three other states – Maryland, New Jersey and Oklahoma.  Any action coming out this lawsuit will impact all states. 

WHAT CAN BE DONE §         The Congressional delegation is expected to be in Washington State during the two week March recess, which begins March 15^th, so it is a great time to speak to your Congressional representatives about how this issue will impact the people in your jurisdiction and your agency.   §         Members of the Washington State Congressional delegation are Senators Maria Caldwell and Patty Murray, Representatives Brian Baird, Norm Dicks, Richard (Doc) Hastings, Jay Inslee, Rick Larsen, Jim McDermott, Cathy McMorris Rodgers, Dave Reichert, and Adam Smith. §         Ask them to support a moratorium on implementing the TCM regulation (CMS 2237-IFC) and let them know that you understand and appreciate efforts already underway to place a moratorium on all 7 regulations promulgated by CMS in 2007.  

March 12, 2008 Grassley Amendment to Budget Bill Threatens Possible Moratoria on CMS Regulations

By Hansine Fisher

Multiple amendments to the budget are rumored at this point that may impact children’s access to care under Medicaid and SCHIP.  Attached are a couple of documents that may be of help in our efforts to defeat them.  As background, the budget already includes a reserve fund for SCHIP reauthorization, as well as a reserve fund to extend moratoria to damaging Medicaid regulations.  See http://budget.senate.gov/democratic/documents/BudRes09CHAIRMAN’SMARK030508FINAL.pdf <http://budget.senate.gov/democratic/documents/BudRes09CHAIRMAN’SMARK030508FINAL.pdf> and scroll to page 28.

1) Grassley Amendment – please call your senators and urge them to OPPOSE the Grassley amendment.
 
 **    The Grassley amendment to the budget resolution’s Medicaid regs reserve fund places new restrictive conditions on the use of the reserve fund.  The underlying reserve allows the Congress to address the concerns related to the regulations listed in the reserve fund in a number of ways.
**    Under Grassley’s approach, however, the reserve fund would only be available for legislation that amends underlying Medicaid law to clarify “…allowable uses of federal funds paid to public providers, the appropriate methodologies states can use to bill the federal government for graduate medical education, the appropriate use of rehabilitation services by states, and the appropriate billing methodologies for school-based administration, school-based transportation, and case-management services.”   This effectively means the reserve fund would not give the Finance committee any flexibility.  Instead, the Committee’s hands would be tied and it would not have the time it needs to consider the underlying policies. It would require legislative changes be made concurrent with delaying the offending regulations.
**    Nothing in the existing reserve fund in the budget resolution stops the Congress from modifying Medicaid policy to address these issues.  If Congress can agree to change the law that’s fine, but if it cannot reach bipartisan agreement this year, it should still be able to block the Administration’s proposed policy changes to protect beneficiaries and the states. Grassley’s approach means the administration’s regulations stand until and unless the Congress can agree on specific revisions to Medicaid law dealing with these complex issues.
**    The amendment needs to be soundly rejected to help protect states and Medicaid beneficiaries from the harmful impact of the Medicaid regs we’ve all been working on this year.

2) Other Rumored SCHIP Amendments
 
Rumors about SCHIP amendments to the Senate budget resolution have also been swirling.  Amendments could be along the lines of budget amendments offered last year:
·      proposing restrictions on adult/parent coverage (like last year’s Chambliss No. 536.  A YEA vote would have limited state flexibility to cover parents and childless adults and create an option to cover mental and dental health for children. (The option to provide mental and dental health coverage already exists under current law.) This amendment was defeated 44-55.
·      restricting coverage in SCHIP over 200% (like last year?s Cornyn No. 511.  A YEA vote would limit states’ flexibility to cover children above 200% FPL and parents. This amendment was defeated 38-59).

Attached is a chart that CCF did to summarize last year’s budget amendments (see last page for brief descriptions) – the Chambliss and Cornyn amendments seem most likely to be repeated in some form, another Bunning EPSDT amendment would obviously be bad too.
 
Please let folks know on Capitol Hill that these amendments should not be supported and thanks so much for your advocacy on behalf of children

Capitol Hill Watch | Congress Might Be Unable To Block New Medicaid Rules That Would Shift More Costs to States

Select the link below to read this article from the Kaiser Daily Health Policy Report

http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=50370

Threat to Medicaid Admin Match Claiming

By Kathy Carson

The Centers for Medicare and Medicaid Services (CMS) issued a regulation December 4, 2007 entitled MEDICAID DEFINITION OF COVERED CASE MANAGEMENT SERVICES CLARIFIED. Washington and other states have been notified by CMS that they are interpreting this regulation to mean that linking Medicaid-covered individuals to Medicaid-covered services belongs in targeted case management and should not be reimbursed through Administrative Match. Its provisions will become effective on March 3, 2008, but HRSA has said that they will implement it in the next contract period, which begins January 1, 2009.

Within the mission of public health, referral activity is crucial to assurance and clearly distinct from case management. In public health programs, the types of referral activities now reimbursed as Medicaid administrative costs serve two purposes: to ensure that outreach programs to at-risk/vulnerable populations result in timely and appropriate referrals for medical care, and to determine the type of medical care needed by special populations and facilitate linkage to such care. Much of public health activity focuses on the “front door” – identifying persons at risk, steering them toward ongoing care and care management of their medical needs, and following up to make sure the care is adequate to the person’s needs.

What can we do?

Comments on the TCM regulations are accepted until February 4. To submit comments, click on this link and select MEDICAID DEFINITION OF COVERED CASE MANAGEMENT SERVICES CLARIFIED. At the bottom of the fact sheet is a link that says Submit Feedback. Clicking that link takes you to a screen where you can enter your comments. http://www.cms.hhs.gov/apps/media/fact_sheets.asp
Urge your Congressional representatives to sign on to Senate Bill 2280 or House Bill 3940, sponsored by the Minnesota delegation, to extend the comment period and delay implementation of these regulations.

TCM Changes and Public Health Programs

Proposed regulations for TCM are likely to impact public health programs now earning Medicaid administrative match (MAC, MAM, MAA, etc.) for activities that link vulnerable populations to needed medical care.

Use this site to find out about the proposed regulations, what’s being done at the local, state, and federal level. Review of resource documents. Please also feel free to post comments below.