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Over the last year and continuing with the President’s new FY 2009 budget proposals, the Administration has proposed or issued regulations that will force states to make significant changes to Medicaid, that would total over $13 billion over 5 years. These changes would threaten access to health care for millions of our most vulnerable citizens and result in new pressures on state and local governments, when the fiscal downturn is already straining their ability to maintain critical education, public health, and social services. On February 22, 2008, the Centers for Medicare & Medicaid (CMS) of the U.S. Dept. of Health & Human Services (HHS) issued new rules that would provide for prior determination of “reasonable and necessary” services, which are subject to Medicare reimbursement, and allow states greater flexibility in designing their Medicaid benefit packages and sharing Medicaid costs with enrollees. Prior Determinations for Medicare Services A new final rule will give Medicare healthcare providers and patients the ability to obtain prior determination of whether a Medicare contractor considers a particular service or procedure to be "reasonable and necessary" - and therefore subject to reimbursement. Effective March 24, Medicare contractors must respond within 45 days to such requests, taking into account the patient’s physical condition and urgency of treatment, and the supporting documentation. Previously, there was no process to reliably determine whether a procedure or service would be considered "reasonable and necessary." Healthcare providers could only offer patients an "advance beneficiary notice" if they thought this was a possibility. Increased State Flexibility & Cost Sharing Under Medicaid Proposed Medicaid regulations would significantly increase states' "flexibility" to design their own Medicaid programs, align benefit packages more closely with beneficiary needs, and allow cost sharing by enrollees. These measures coincide with the Bush administration’s "goals of aligning Medicaid more closely with private market insurance and giving states more control over their Medicaid benefits packages," and implement provisions of the Deficit Reduction Act of 2005 and the Tax Relief and Health Care Act of 2006. Public comments are due March 24. States could require enrollment in one or more "benchmark" plans, similar to options under SCHIP (State Children's Health Insurance Program). Benchmark plans could provide health benefits at the level of: the standard PPO plan for federal government workers; the state employee plan; plans offered by the state's largest HMO; or coverage proposed by the state and approved by HHS. States could furnish benchmark coverage through a fee-for-service delivery system, with or without primary care case-management; a managed care delivery system; or through premium assistance. When an employee cannot afford health insurance offered by an employer, the state could contribute to the cost of those premiums. States could also tailor benefit packages to particular populations, providing "wrap-around" and additional benefits, including dental care. Cost sharing proposals would permit states to change their current Medicaid premiums and cost sharing structures, similar to SCHIP rules. Those with family incomes of 100-150% of the federal poverty level (FPL) could share some costs, and those with greater income levels could be charged monthly premiums. As with SCHIP, all cost sharing would be limited to no more than 5% of a family's income. The 2008 FPL for a family of four is $21,200. State plans could not impose premiums upon several vulnerable groups, including women who are pregnant or under treatment for breast or cervical cancer, patients receiving hospice care, and children who are disabled or in foster care. States could also exempt additional classes of patients from premiums. According to the National Governors Association (NGA), these new regulations "will shift an estimated 13 billion in federal costs to the states" at a time when the fiscal situation of the states is very difficult. ANA has signed on to a letter urging Congress to take action to both enact and extend legislative moratoria to prevent serious harm to vulnerable Medicaid beneficiaries, especially children and people with disabilities, children in foster care, and our nation's health care system, in particular its health care safety net. Over the last year the Administration has proposed or issued a series of Medicaid regulations that, if implemented, will have a devastating impact on beneficiaries, providers, states and localities |