INSIDE THE ISSUE

> The Section 1115 Waiver
> Schemers & Gougers
> Important Legislation
> Prior Authorization
> Coordinating Behavioral Health
> The Compassionate Caregiver Award

MONDAY REPORT

MHA Endorses EOHHS’ Waiver Proposal

MHA sent a letter last week to the administrator of the federal Centers for Medicare and Medicaid Services (CMS), expressing the association’s “strong support” for the MassHealth 1115 waiver application from the state.

The waiver proposal is the main agreement between Massachusetts and the federal government, outlining how the Medicaid program will be administered in the commonwealth. Key aspects of the plan’s funding are supported by a direct assessments on hospitals that MHA and its membership was instrumental in constructing in collaboration with the Executive Office of Health and Human Services (EOHHS). If approved by CMS, the waiver will govern numerous spending and coverage MassHealth provisions for the next five years. The current five-year waiver expires in June.

In the letter to Administrator Chiquita Brooks-LaSure, MHA’s President & CEO Steve Walsh noted that the waiver proposal from EOHHS “includes provisions that are essential to ensuring that the progress made in our innovative ACO program can be sustained into the next waiver period. It also calls for increased investments in primary care, behavioral health, safety net providers, and health-related housing and nutrition services.”

A key factor included throughout the proposed waiver’s components is the focus on healthcare inequities. Financing to support hospital efforts – over and beyond traditional funding for disproportionate share hospitals – is tied to mechanisms to hold hospitals accountable for their equity efforts.

“While tremendous gains have been made in expanding access, reducing the number of uninsured individuals, and providing high-quality care to all residing in Massachusetts regardless of color or income, much more needs to be done to address existing health inequities,” Walsh wrote. He added that the waiver will not only hold hospitals accountable for their ability to address healthcare inequities, but also overall healthcare outcomes measured under the innovative MassHealth accountable care organization program.

The proposed waiver also requests significant new funding support for safety net providers; it recognizes the increasing cost pressures on safety net hospitals and the growing number of hospitals serving large percentages of MassHealth patients. With the support of the hospital assessment and through the 1115 waiver, the commonwealth is seeking to increase its support of these hospitals, which collectively serve the greatest number of MassHealth patients.

“Without the financial support and administrative flexibilities from the federal government, healthcare providers would be unable to provide the high-quality care their communities deserve,” Walsh wrote.

Pandemic Brings Out the Worst in Many

Non-functioning test kits, recalled hand sanitizer, marked up K95 masks, and more – the pandemic has brought out the worst in scammers and price gougers. Last week, a U.S. Senate subcommittee held a hearing entitled Stopping COVID-19 Fraud and Price Gouging that featured testimony from, among others the Federal Trade Commission and the U.S. Public Interest Research Group (U.S. PIRG).

While all Senators agreed that a crack-down on the schemers is needed, Subcommittee Democrats urged the FTC to take stronger, more punitive action against companies and businesses engaging in price gouging and sales of counterfeit products. Subcommittee Republicans emphasized the importance of industry and state partnerships in combating fraudulent or price-gouging products.

Massachusetts Senator Ed Markey noted that when the CDC updated its masking guidance to encourage use of higher quality masks against COVID-19, online marketplaces became rife with counterfeit and fraudulent masks and have done little to prevent them from being sold. Markey suggested creating a national ranking standard to help consumers understand how much protection they receive from each type of mask.

U.S. PIRG’s Teresa Murray (not to be confused with former State Senate President Therese Murray) told the Subcommittee on Consumer Protection, Product Safety, and Data Security that since July 2020, the Food and Drug Administration (FDA) has recalled 273 different brands of hand sanitizer products. Most recently there has been a surge in counterfeit masks, with the FDA and the Customs and Border Patrol (CBP) seized 34 million counterfeit masks in 2020 and 2021. Murray also noted the prevalence of fake COVID-19 test sites, in which Americans are charged for a free test or their identity is stolen. She added that there is a surge in unauthorized at-home COVID-19 rapid tests, and an ongoing problem of price gouging on products that has been prevalent in many sectors of the market since the pandemic began.

MHA-Backed Bills Move Through Legislature

Last week, the state legislature acted on numerous bills in advance of the House and Senate’s deadline for most committees to make determinations on the legislation before them – known as Joint Rule 10. While many committees adopted extension orders to allow for further deliberation, several bills in MHA’s legislative package were granted a favorable report by the Joint Committee on Financial Services and will continue through the legislative process. They are:

H.1061, An Act to Strengthen and expand access to behavioral healthcare

Filed by Rep. Marjorie Decker (D-Cambridge), H.1061 seeks to strengthen the behavioral health system by addressing workforce development, ensuring equitable reimbursement and coverage of behavioral health services, and furthering other patient and administrative needs. Reimbursement and coverage provisions include prohibition of medical necessity denials due to administrative or technical defect in a claim; creation of a Behavioral Health Rate Task Force to, among other charges, evaluate ways to ensure the financial stability of inpatient behavioral health units and facilities; and requiring coverage without prior authorization of all medically necessary mental health services across MassHealth, the Group Insurance Commission (GIC), and commercial insurers. The bill would reinitiate Medicaid Graduate Medical Education funding for child psychiatrists; necessitate timely physician licensure; and require coverage of mental health clinicians working towards licensure while practicing under the supervision of a licensed professional. Other care delivery and administrative changes include expanding the Department of Mental Health Expedited Psychiatric Inpatient Admissions (EPIA) policy to psychiatric boarders with a primary medical diagnosis, and easing Determination of Need requirements for psychiatric units in acute care hospitals.

H.1148/S.688, An Act to prevent inappropriate denials by insurers for medically necessary services

Filed by Rep. Liz Malia (D-Boston) and Sen. John Keenan (D-Quincy), H.1148/S.688 would ensure healthcare providers are reimbursed for the delivery of medically necessary services that health insurers cover. It would prohibit health plans from denying payment for services solely on the basis of an administrative or technical defect in a claim. It would also require insurers to provide clarification of the reasons for claim denials and allow providers sufficient time to re-submit curative claims. Among other action, the bill would establish a 30-day timeframe for insurers to respond to provider appeals for retrospective reviews of medically necessary services.

H.1199/S.695, An Act relative to specialty medications and patient safety

Filed by Rep. Jon Santiago (D-Boston) and Sen. Jason Lewis (D-Winchester), H.1199/S.695 is based on a 2019 Health Policy Commission report about so-called “white bagging” and “brown bagging” of certain medications. The legislation would prohibit insurers, including the GIC, MassHealth, and commercial carriers, from requiring a third-party specialty pharmacy to dispense a medication directly to a patient with the intention that the patient will transport the medication to a healthcare provider for administration (brown bagging). It would also disallow insurers from requiring the use of a home infusion pharmacy to dispense sterile intravenous (IV) drugs ordered by physicians to patients in their homes or the use of an infusion site external to a patient’s provider office or clinic. If an insurer were to mandate the distribution of medication from a third-party specialty pharmacy to a healthcare facility for administration (white bagging), the bill would establish requirements around the mandate, including 60 days’ notice, same-day delivery of the medication, and the provision of logistics to ensure that a medication remains at the appropriate temperature at all stages of supply and storage.

Insurer white and brown bagging has long been opposed by providers, who have cautioned about the significant clinical, operational, care access, safety and financial challenges, both for patients and providers. H.1199/S.695 would ensure that clinicians – not insurance companies – determine the appropriate setting and method of delivery for their patients who need these medications.

Do You Have an Opinion on Prior Authorizations?

In January, CMS released proposed regulations for the 2023 Medicare Advantage and Part D plan year. The proposal includes a number of changes to increase agency oversight of health plans, including provisions to better monitor provider networks and compliance with the medical loss ratio requirements, as well as stronger oversight of third parties that help beneficiaries choose and enroll in Medicare Advantage and Part D plans.

The proposed regulations also include an RFI related to Medicare Advantage prior authorization policies and their effect on patient access to care and health system capacity during a public health emergency. Throughout the pandemic, hospitals have struggled with prior auth requirements that have resulted in patients remaining in acute care hospitals far longer than necessary, coverage denials not based on medical necessity, and inadequate post-acute care networks. MHA will be reaching out to members for specific input, but hospitals and healthcare systems are also encouraged to submit comments directly to CMS. The specific questions from the Federal Register are here. Comments are due March 7 and may be submitted electronically.

RFP for New Community Behavioral Health Centers

As part of the commonwealth’s Roadmap for Behavioral Health Reform, EOHHS is developing a statewide network of Community Behavioral Health Centers (CBHCs) that will expand access to mental health and addiction treatment in communities.

The Massachusetts Behavioral Health Partnership (MBHP), EOHHS’ behavioral health managed care vendor, has released an RFP to procure CBHCs on EOHHS’ behalf. Interested providers have until Wednesday, April 13, 2022, to apply. A bidders’ conference will be held via Zoom on Friday, February 18, 2022, from 11 a.m. – 12:30 p.m. See details in the above link.

CBHCs will serve as hubs of coordinated and integrated mental health and substance use disorder treatment for MassHealth members of all ages and will provide routine and urgent outpatient services, crisis services for adults and youth, and community crisis stabilization services for adults and youth. The current Adult Community-Based Mobile Crisis Intervention (AMCI) program, also known as the Emergency Services Program (ESP), and Youth Community-Based Mobile Crisis Intervention (YMCI), also known as Mobile Crisis Intervention (MCI), will be integrated into the CBHC network.

Schwartz Center Opens Nomination for Caregiver Award

Nominations are open for the Schwartz Center’s National Compassionate Caregivers of the Year Award, which recognizes “extraordinary healthcare professionals from across the country who embody the characteristics of compassionate care, and whose professional achievements have helped to create healing healthcare environments for patients, families, colleagues, and communities.” The nomination deadline is March 15, 2022, and the application form is here.

Up to six award recipients will be chosen by a national review committee. Nominees may include healthcare professionals and interdisciplinary teams of healthcare professionals. Nominations for clinical and nonclinical providers, administrators, educators, and others who provide direct or indirect care to patients, families, and/or healthcare staff.

John LoDico, Editor