CMS’ Jonathan Blum units sights on Medicaid, Medicare Benefit reform

The Facilities for Medicare and Medicaid Companies is sharpening its focus, and has lately taken a number of steps to make state Medicaid packages stronger, improve its oversight of Medicaid Benefit packages and increase well being fairness efforts.

Jonathan Blum, the company’s principal deputy administrator and chief working officer, mentioned these priorities with Fashionable Healthcare whereas he was in Chicago this week for the 2023 Healthcare Info and Administration Methods Society convention.

This is what to know.

Redeterminations will strengthen Medicaid

States’ pause on eradicating people from Medicaid through the COVID-19 pandemic in change for elevated federal funding will make the general public advantages program stronger, Blum mentioned. States have invested in  expertise and fine-tuned their current eligibility programs, as they resume eligibility checks for the primary time in two-and-a-half years.

“The method has compelled states to construct higher buildings that may final for much longer than this course of,” Blum mentioned. “Eligibility processes have at all times been an enormous problem for states. We could have stronger Medicaid packages as soon as we end.”

On the federal stage, CMS fine-tuned Healthcare.gov to robotically populate a consumer’s info from their Medicaid file to an change utility. By higher connecting expertise programs between Medicaid and change plans, Blum mentioned he hopes to keep away from shopper gaps in protection.

States ought to observe Illinois’ lead

Extra states ought to observe Illinois’ lead and pursue amendments that permit public faculties to invoice Medicaid for well being companies, Blum mentioned.

CMS this week authorized a state plan modification to award Illinois further Medicaid funding to pay for behavioral well being, bodily remedy, preventative care and different well being companies for all college students enrolled in Medicaid or the Youngsters’s Well being Insurance coverage Program, not simply these with an Individualized Schooling Program. CMS has granted comparable amendments to 11 different states’ Medicaid packages.

The state plan modification additionally strengthens ties between the Medicaid program and faculties as redeterminations resume, Blum mentioned.

“Faculties have rather more correct deal with, location information than insurance coverage corporations,” he mentioned. “It is going to assist with different coverage objectives now we have. It’s a very cool growth.”

CMS is able to crack down with ‘corrective motion’

CMS may also be awaiting outliers amongst states that course of Medicaid eligibility functions too rapidly or slowly, the place there are massive quantity of people who don’t qualify for different protection, the place customers report lengthy name heart wait instances and extra. In these circumstances, the company can, and can, pause states’ potential to take away people from Medicaid till they refine their processes, Blum mentioned.

“Our groups are poised and able to use that authority if crucial,” he mentioned.

Extra oversight is coming

Considered one of CMS’ major objectives is to tinker with its program integrity processes to mirror the fact that almost all of people are enrolled in managed care preparations, both by way of Medicaid or Medicare Benefit plans. “Our oversight must be shifting in direction of managed care when traditionally we’ve been doing that by way of a conventional, fee-for-service system,” Blum mentioned.

That’s the angle that led CMS to finalize the Medicare Advantage risk-adjustment data validation rulewhich permits the company to recoup earlier overpayments to insurers. It is what additionally led CMS to revamp its Medicare Advantage risk-adjustment program, though the modifications might be phased in over three years.

“We don’t disagree,” Blum mentioned, in response to criticism that CMS’ closing Medicare Benefit guidelines don’t go far sufficient in curbing insurers’ extreme income.  “However we additionally perceive modifications have to be rigorously calibrated so plans can regulate, so we don’t disrupt premiums and minimize advantages quickly.”

Revamped star scores will increase well being fairness

CMS retooled the Medicare Advantage star ratings program to incentivize insurers to bridge well being fairness gaps. The company eliminated the “reward issue” that gave insurers an even bigger bonus in the event that they persistently carried out effectively over time. As a substitute, CMS this month finalized a plan to ascertain a well being fairness index to incentivize plans to construct higher entry to companies in healthcare deserts, and supply insurance policies in deprived areas in an effort to enhance inhabitants well being.

“I’d problem anyone to offer definitive proof that extra enrollment in managed care organizations, extra enrollment within the Medicare Benefit program, drives higher financial savings, higher outcomes and higher high quality of care,” Blum mentioned. “It might occur at a person stage, however I’d problem anybody to offer definitive proof it occurs on the full, inhabitants stage.”