INSIDE THE ISSUE

> EOHHS Proposes Waiver Amendment
> Funding Bill Helps Hospitals, Farmers
> State Budget Helps Workforce & BH Care
> New Partnership for Care Transitions
> MassHealth’s Telehealth Bulletin
> Insurer’s Routine Claims Denials
> Transitions

MONDAY REPORT

EOHHS Proposes Waiver Amendment to Expand Coverage

The Executive Office of Health and Human Services (EOHHS) announced it plans to submit an amendment proposal to the 1115 MassHealth Waiver, the state and federal agreement that defines numerous coverage expansions, delivery system reform initiatives, and related funding terms for the state Medicaid program. The current version of the waiver went into effect in late September 2022 and included the historic hospital health equity incentive program, increased funding for safety net hospitals, and investments in primary care practices participating in the MassHealth Accountable Care Organization (ACO) program. Last week, EOHHS announced its intention to propose to the Centers for Medicare and Medicaid Services (CMS) new provisions that will bolster MassHealth coverage and subsidized health insurance programs supported by the waiver.

EOHHS will propose 12 months of continuous eligibility to all adults, which is in alignment with a recent federal law that will provide this same continuous coverage timeline for children effective January 1, 2024. This means MassHealth enrollees will remain covered for at least one year even if their eligibility circumstances change during the year. The amendment will also seek additional federal support for expanded subsidized coverage offered through the Health Connector for those with incomes up to 500% of the federal poverty level. Currently, individuals up to 300% received enhanced state and waiver funded subsidized insurance. To help address hospital throughput challenges and to ensure adequate support for those recovering from hospital care, MassHealth is proposing coverage for up to six months of Short-Term Post-Hospital Housing (medical respite) as a Health-Related Social Needs service.

EOHHS will pursue a long-standing request of MHA and consumer advocates by no longer limiting retroactive coverage for any low-income residents that apply and become eligible for MassHealth. Currently, applicants that are not children or pregnant receive only 10 days of coverage prior to the date they apply for MassHealth coverage, often resulting in provider and patient bad debt for care provided to uninsured patients who are eventually enrolled in MassHealth. EOHHS will seek to end its waiver policy and instead provide the three-month federal Medicaid standard for this lookback coverage.

MHA President and CEO Steve Walsh said, “The MassHealth waiver proposals put forward by the Healey-Driscoll Administration further cements Massachusetts as the leader in health equity and coverage. We commend Governor Healey, EOHHS Secretary Kate Walsh, and Assistant Secretary Michael Levine for working to eliminate coverage gaps while also increasing access to affordable health insurance for more Massachusetts residents.”

Legislature Again Comes Through for Hospitals

The legislature quickly passed, and Governor Healey expeditiously signed, an appropriations bill that directs $180 million to some Massachusetts hospitals, as well as providing $20 million in disaster relief for farmers affected by recent flooding.

The hospital relief had been included in House and Senate supplemental budgets that totaled $693 million and $513 million, respectively. The farmer funding was included in the Senate supplemental budget but not the House’s. As the legislature’s August recess was fast approaching, and as the relief money was sorely needed, House and Senate leaders scrapped conference committee negotiations over the two competing supplemental budgets, placed the stripped-out hospital and farmer funding into a new $200 million bill, and quickly passed it Monday afternoon. The legislation also extends authorization for horse racing and simulcasting. On Tuesday morning, Governor Healey signed the bill into law.

“At a time when many hospitals are still struggling to remain above water, our elected officials have again shown their commitment to helping providers recover and keeping essential care available for patients,” said MHA President & CEO Steve Walsh. “MHA and our members are profoundly grateful for this relief, which will have an immediate effect on healthcare organizations, caregivers, and the communities they serve.”

Legislature Passes $56.2 Billion FY2024 State Budget

The Massachusetts legislature approved the long-awaited FY2024 state budget last Monday night. The $56.2 billion budget includes a House-supported initiative to allow all school meals free of charge to all students, and a Senate proposal to allow students without legal immigration status to qualify for in-state tuition rates and financial aid in public higher education institutions if they attended high school in the commonwealth for three years or earned their GED here. The budget also includes $50 million to support free community college across all campuses by the fall of 2024, as well as $38 million for free community college programs for students 25 and older pursuing nursing degrees, starting this fall.

The budget continues the legislature’s commitment to behavioral health (BH) through several line items and initiatives. Of particular note, the budget appropriates $192 million from the Behavioral Health Trust Fund toward behavioral health workforce initiatives, including $100 million to replenish the existing BH loan repayment program. The program expands what members of the BH workforce are eligible for the program; now included are any behavioral health positions in an acute care hospital and not just those working in psychiatric units, in line with MHA recommendations.

Twenty-five million is also appropriated for a scholarship program for BH providers in high-need settings. The final budget also includes two MHA-supported provisions: 1) a requirement that the Department of Children and Families (DCF) and the Office of the Child Advocate develop a plan by September 15, 2023, for a pilot program to use evidence-based program models in DCF congregate care provider programs for youth that are experiencing an intensive BH crisis or BH and medical crisis, are being housed in emergency departments or inpatient units, and cannot safely receive treatment in the existing congregate programs; and 2) creation of a task force to study and make recommendations to address geriatric psychiatric patients who are ready to be discharged from acute care in a geriatric psychiatric unit to a nursing home.

On the insurance coverage front, the final budget includes language to expand ConnectorCare eligibility for individuals earning up to $73,000 per year under a two-year pilot program, estimated to reach somewhere between 47,000 and 70,000 residents. It also includes a measure to allow state employees to be enrolled in healthcare coverage on their start date or on the first day of the full month they are employed.

New Partnerships Aimed at Easing Patient Transitions

PointClickCare also entered into an agreement last week to join MHA’s Strategic Business Partner (SBP) program, which identifies and connects member hospitals and health systems with sector-leading firms that can meet the facilities’ pressing needs. Specifically, PointClickCare will help acute care providers address the needs of patients with mental health and substance use disorders, equipping them to follow up with behavioral health patients in need of continued care. Care teams across Massachusetts can receive notifications directly within established workflows when patients of concern register in the emergency department (ED). By improving the ED experience, caregivers can more effectively provide continued care for patients who need it most, while continuing to close communication gaps across care settings to streamline transitions, support high-risk patients, reduce costs, improve coordination, and reduce readmissions.

PointClickCare, through its agreement with the state, will provide a Behavioral Health Treatment and Referral Platform (BH TRP) to facilitate admission to the next appropriate steps of care for patients in the commonwealth, who are awaiting disposition in emergency departments related to behavioral health. The platform will be used by acute and psychiatric hospitals, health insurance carriers, and state agencies, including the Department of Mental Health and MassHealth, the Massachusetts Medicaid program.

“We’re grateful for the bold steps the state is taking to create a more coordinated behavioral health system for patients and healthcare organizations across Massachusetts,” said Jason Tracy, M.D., chair, emergency medicine, South Shore Health. “Given the magnitude of the boarding crisis, collaboration between healthcare providers and the adoption of new, innovative solutions has never been more critical. We look forward to helping set this solution in motion as our focus on expanding access to behavioral healthcare across the commonwealth continues.”

MassHealth Delivers Solid Win for Telehealth Patients

MassHealth has issued an important bulletin that allows providers to continue delivering a broad range of MassHealth-covered services via telehealth, and to be reimbursed for those services at parity with their in-person caregiving counterparts.

Through the bulletin, MassHealth is also allowing an eligible distant-site provider delivering covered services via telehealth to bill a facility fee if such fee is allowed under the provider’s governing regulations or contracts.

Providers have long advocated for parity payments, arguing that it is important to pay for the services being provided, regardless of the method used to provide them. Paying providers for telehealth services on-par with in-person visits increases access to care for patients, including those in communities where public transportation to care facilities is lacking. Parity also gives financial predictability to caregivers, who are increasingly providing care in a hybrid environment where both in-person and telehealth visits are offered.

“This is a tremendously important action by MassHealth that will further advance the use and promise of telehealth,” said Adam Delmolino, MHA’s senior director, Virtual Care & Clinical Affairs. “Since the beginning of the pandemic, MassHealth has been at the forefront of the rapidly evolving virtual care environment, outpacing commercial insurers in its recognition of the increased access and convenience for patients that telehealth provides. MHA and the members of the tMED Coalition are grateful to MassHealth for the recognition of telehealth as a vitally useful tool for our healthcare system.”

Labor Department: United Health Subsidiary Just Routinely Denied Claims

The U.S. Department of Labor (DOL) has filed a suit against UMR, Inc., a third party administrator owned by UnitedHealth Group, for routinely rejecting claims without conducting required medically necessary reviews. UMP provides services to at least 2,136 self-funded ERISA plans across the U.S.

DOL says that since 2015 UMR has incorrectly ruled on claims relating to emergency services and urinary drug screenings (UDS). “UMR was required to apply a standard of ‘medical necessity’ to determine whether a UDS claim was medically necessary,” DOL wrote. “Specifically, UMR violated ERISA by denying UDS Claims because it applied no standard and simply denied all claims.” UMR also routinely refused to pay claims that did not include specific T10 or T11 codes, indicating “True ER” or “Sudden and Severe” diagnoses, respectively. And when it denied claims, it did not send the claimant enough information to determine why the claim was rejected. That is, the explanation of benefits did not indicate if the claim was denied due to a lack of proper documentation and did not describe what additional information was needed to make the claim valid.

The Labor Department asked the court to force UMR to halt and reform its practices and re-adjudicate all denied claims.

Transitions

Mark Keroack, M.D., the president & CEO of Baystate Health and a former chair of the MHA Board of Trustees, announced his retirement from Baystate, effective July 2024. Keroack has led the system for 10 years. Keroack was MHA Board Chair from June 2018 to June 2019, and oversaw the creation of a “Caring for the Caregiver” initiative that focused the healthcare community on ensuring its workforce is recognized for its efforts, and that its safety and wellbeing is protected. He was also very involved during his board tenure in advancing the healthcare community’s response to the opioid crisis, and was a key member of the board’s executive committee that helped guide the state’s response to the COVID-19 pandemic. “Mark leads with a focus on mission; even though the financial environment has been challenging, his decisions always prioritize local health needs,” said Harriet DeVerry, Baystate’s board chair. His friends and admirers at MHA wish Dr. Keroack all the best in his 2024 retirement, and look forward to working with him in the coming months.

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Glenn Focht, M.D. is the new president of Anna Jaques Hospital, effective September 4. Since 2021, he has served as chief medical officer (CMO) and senior vice president (SVP) of Anna Jaques as well as chief operating officer of Seacoast Affiliated Group Practice, an Anna Jaques-employed physician practice. Prior to joining Anna Jaques Hospital, Focht served for four years as president of the Connecticut Children’s Specialty Group at Connecticut Children’s Hospital. He served for five years as CMO for the Pediatric Physicians’ Organization at Boston Children’s Hospital, and held SVP of medical affairs and CMO roles at Cooley Dickinson Hospital and Milford Regional Hospital for many years. Focht received his medical degree from the University of Pennsylvania Medical School and completed his internship and residency at the University of Massachusetts Medical Center. Interim President Jeffrey Brickman will continue in his role until September 4.

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Justin Precourt has been named the interim president of UMass Medical Center. The previous president, Dr. Michael Gustafson, had announced that he would step down from the position on July 28. Precourt has been the CNO and V.P. of Patient Care Services since April 2019. He has a BSN in nursing from Northeastern University, an MSN in nursing administration from Saint Joseph’s College, and a DNP from Rush University.

John LoDico, Editor