RISE summarizes the latest regulatory headlines that impact Medicare, Medicare Advantage (MA), and Medicaid.

CMS takes enforcement action against UnitedHealth, Anthem MA plans

The Centers for Medicare & Medicaid Services (CMS) has suspended three UnitedHealthcare MA plans and one Anthem MA plan from enrolling new members due to their failure to meet medical loss ratio requirements and spend 85 percent of their premium income on medical care. MA plans are required to maintain a medical loss ratio of at least 85 percent. When an organization fails to meet this threshold for three consecutive years, CMS is required by law to suspect its ability to accept new enrollments in plans offered for the contract year following submission of the report. The suspended plans include UnitedHealthcare of the Midwest, Inc., UnitedHealthcare of New Mexico, Inc., UnitedHealthcare of Arkansas, Inc., and MMM Healthcare, LLC – Puerto Rico, an MA health plan acquired by Anthem three months ago. The plans can resume enrollment of new members in 2023 if they demonstrate to CMS that they have met the 85 percent threshold.

CMS delays enforcement of payer-to-payer interoperability rule

CMS has announced it will delay enforcement action against payers for the payer-to-payer exchange provision of the May 2020 Interoperability and Patient Access final rule until future rulemaking is finalized. The provision was expected to take effect on Jan. 1, 2022. However, CMS said the delay doesn’t affect other regulatory requirements and implementation timelines outlined in the final rule.

Two of the policies from the final rule are already in effect. Hospitals with certain EHR capabilities must send admission, discharge, and transfer notifications to other providers. In July, CMS began to enforce requirements for certain payers to support Patient Access and Provider Director APIs.

Feds extend ACA open enrollment period, expand health coverage access initiatives

To make it easier for American consumers to sign up for quality, affordable health care coverage, CMS announced that consumers will have an extra 30 days to choose health plans through open enrollment, which will run from November 1, 2021 through January 15, 2022 on HealthCare.gov.

CMS also said it is expanding services provided by federally-facilitated navigators to help consumers enroll in coverage and help reduce health disparities. It will also relaunch its “Champions for Coverage” program, which includes more than 1,000 local organizations that provide outreach and education about the health insurance marketplace.

The expansion of services was announced in the third part of the 2022 Payment Notice. Navigators will now provide consumers with information on certain post-enrollment topics, such as marketplace eligibility appeals process and marketplace-related components of premium tax credit reconciliation. The Champions for Coverage program will help spread the word about open enrollment with educational resources and “event-in-a-box” materials.

CMS has also established a new monthly special enrollment period targeting certain low-income individuals in marketplaces through HealthCare.gov. This will provide most consumers with one or more options to enroll in free or low-cost plans. In addition, state partners now have new flexibilities. State marketplaces with their own eligibility and enrollment platforms will be able to set their own open enrollment period end dates, so long as the dates are on or after Dec. 15.

OIG urges state Medicaid programs to evaluate quality of telehealth for behavioral health services

A new federal report on Medicaid programs in 37 states found states need to do a better job evaluating whether telehealth improves access and quality of care. And, despite concerns about fraud, waste, and abuse, many state Medicaid programs do not conduct monitoring and oversight specific to telehealth, according to the Office of Inspector General (OIG) report. The OIG didn’t identify the states in the reports.

Among the key findings:

  • Three of the 37 states were unable to identify which services were provided via telehealth. As a result, they can’t do an analysis on the effects of telehealth or perform basic monitoring and oversight specific to telehealth services.
  • Only two states evaluated the effects of telehealth specifically on access to behavioral health services for Medicaid enrollees.
  • Only one state evaluated the effects of telehealth specifically on cost. The state found that prior to the pandemic, telehealth produced savings of $8,600 in emergency room avoidance for one managed care plan, as well as $484,000 in reduced transportation costs for another managed care plan.
  • No state has evaluated the effects of telehealth specifically on the quality of behavioral health services. For example, no state reported looking at the effects of telehealth on continuity of care or patient safety.
  • Although states are responsible for monitoring their Medicaid programs and are the first line of defense against fraud, only 11 states conduct monitoring and oversight to detect fraud, waste, and abuse that is specific to telehealth.

“Given the increased use of telehealth during the COVID-19 pandemic, it is important that states evaluate the effects of telehealth specifically,” OIG said in the report. “Such analyses could help states ensure the effective use of telehealth and improve health outcomes for different populations.”

OIG recommended that CMS work with the three states unable to identify which services are provided via telehealth to ensure they use indicators that allow them to distinguish services provided via telehealth from those delivered in-person. CMS should also conduct evaluations of the impact of telehealth on access, cost, and quality of behavioral health services for Medicaid enrollees. Finally, OIG recommended that CMS conduct monitoring for fraud, waste, and abuse. CMS concurred with the first recommendation but did not indicate whether it concurred with the other two recommendations.