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Third Party Liability claims: What state Medicaid agencies need to know

10.13.21

Read this if you support State Medicaid Program Integrity efforts.

Recently, the Centers for Medicare & Medicaid Services (CMS) released updated guidance on how states should handle their Third Party Liability (TPL) claims and ensuring that all insurances pay prior to the State Medicaid Agency (SMA) paying any claims. Before we get into the updated guidance, let’s discuss the basics of TPL and what your SMA needs to know.

TPL Basics

There are several different types of healthcare liabilities:

  • Health insurers – Coordination of benefits and primary payers; this can be through group insurances or employer/member paid insurance.
  • Government programs – Public health programs, such as the Breast & Cervical Cancer Screening or the Vaccines for Children Program.
  • Other people or entities – Automobile insurance, product liability, or medical malpractice. The main thing to remember is that Medicaid will not pay if someone else is responsible.
  • Awards through courts or casualty/tort claims – This would be if a payment is made in a settlement, Medicaid can claim off of that award for Medicaid covered services that do not exceed what has already been paid out.

Again, the main thing to remember is Medicaid is the payer of last resort! There are few exceptions to this rule, including:

  • Indian Health Services (IHS), where Medicaid pays first and IHS covers the remaining services covered for this population.
  • Members who have Veterans Assistance (VA) coverage. Medicaid is the second payer to VA benefits except for in nursing homes and emergency treatment cases outside of VA facilities.

Agencies have data use agreements that describe how the data will be collected, transmitted, and used. But where does the data come from? 

  • Caseworkers can collect information directly from the member at the time of enrollment or re-enrollment.
  • Eligibility system(s) and the TPL vendor can access both state and federal data exchanges, which can then be shared with the Medicaid Management Information System (MMIS).
  • Medical, dental, vision, and pharmacy claims are a great source of data because this information comes from the provider who collects it from the member.
  • Data exchanges are also an important part of data gathering:
    • State Wage Information Collection Agencies (SWICA) is a state database that shows if a member or family member is employed allowing the state to inquire about additional coverage through the employers insurance.
    • Defense Enrollment Eligibility Reporting System (DEERS) is related to members of current or former military service who have TriCare insurance coverage.
    • State Verification and Eligibility Systems (SVES) and the State Data Exchange (SDX) work together to verify tax information, employment, eligibility, etc.
      • These systems work for more than just TPL through verifying enrollment but TPL is a component. 
      • This is also where the state can reduce duplicate enrollments—having a member with enrollments in Medicaid in several states and reaping the benefits in each state.
  • Motor vehicle administration and worker’s compensation systems can verify if the claim was the result of an automobile accident or occurred on the job. Once verified in the system, an edit can be included to deny so the TPL vendor knows to go back and review the claim.
  • Payers and health plans share the information with each other and with Medicaid. This allows all payer to use the same database.

TPL checkpoints

Throughout the process of developing a claim, there are many opportunities to check TPL coverage. The member is a great source of information since who else knows more about a person, besides themselves. The member enrollment caseworker and the enrollment application can also provide a lot of information that comes directly from the member. Through Medicaid and CHIP work with the Managed Care Organizations (MCO), it is in the MCO’s best interest to ask a member about TPL coverage during each and every encounter with the member. However, it is important to remember that if TPL is involved, Medicaid is the payer of last resort; but for CHIP, if TPL is involved, typically there is no CHIP coverage. 

The TPL vendor, enrollment broker, and providers are also excellent resources for obtaining member information. The TPL vendor conducts data mining within claims to find external causes of conditions that suggest another person or entity is responsible for payment. When a member calls the enrollment broker to choose their MCO, this is an opportunity to ask the member about any TPL coverage. Finally, the providers can share valuable information that was received from the member.

Claims adjudication process

Up to this point, we have discussed the primary payer information, the accident indicator, and a work related indicator, but there are still a couple more steps in the process to discuss. Your SMA’s should set the edits within your MMIS so that the state can process payments correctly up front to reduce overpayments and the expense of recouping that money. The edits within the MMIS should be regularly reviewed to ensure they are in compliance with state policies (including state plans) and federal guidelines.

Some other areas that should be reviewed to check for TPL coverage is the member age and diagnosis codes. If the member is 65 years of age or older, Medicare should be considered as a source of coverage. Also, diagnosis codes can be an indicator of an automobile accident or injury on the job. Following each of these steps, can prevent the state from overpaying a claim or making a payment in error.

Potential TPL indicators in information received on a claim can vary. For example, CMS and dental codes use the same field names, while the uniform billing (UB) form has defined codes to identify the primary liability. 

CMS-1500     UB-04     Dental
Other Insurance Condition Code Other Insurance
Accident Date Occurrence Code Accident Date
Work Related Injury Diagnosis Code Work Related Injury
Diagnosis Codes Diagnosis Code

Data relationships

The relationship between data sources varies across programs. Medicaid feeds into and/or receives information from all data sources, including CHIP, MCOs, TPL vendor, data warehouse, federal databases, and state databases (such as department of motor vehicles and worker’s compensation). CHIP interacts with Medicaid, MCOs, TPL vendor, and the data warehouse. The TPL vendor exchanges information with Medicaid, CHIP, MCOs, data warehouse, and state databases. The MCOs have a relationship with Medicaid, CHIP, TPL vendor, and the data warehouse. Working together, these programs have access to all of the different data sources; however, sometimes the relationship is indirect and takes multiple steps to complete the transaction. This is why the sharing of data is so important!

TPL data sharing

Working together is the best way to ensure all entities have access to the same and as much information as possible. There typically needs to be a contract relationship between your SMA and all entities that send or receive data. It is a good idea for the SMA to have a data use agreement with each agency that defines how the data will be collected, transmitted, and used. The data can be transmitted in any way, as long as it is secure, and can be stored in the data warehouse which allows all entities that will use the data to have access to the same information.

MCO contracting

The MCO contract between the SMA or the CHIP Agency and the MCO requires the MCOs to conduct TPL activity. In addition, your state should consider including a finder’s keepers clause in their contract with the MCO, which allows the state to collect on overpayments that the MCO chooses not to collect. For example: the MCO can decide that it will cost more to recoup the overpayment than the money recouped so the MCO can choose not to pursue in which case the state can pursue. The state would keep all the money collected.

The contract between your SMA and TPL vendor should include the state and federal data searches as required by regulation. This contract should also include sharing of data with the MCOs that reduces the risk of duplicate expenses for the SMA and the MCOs.

TPL policy

It is key for your SMA to align all policies to both state and federal regulations but the more the policies are aligned across programs within your state, the better.

Many TPL policy references can provide all information regarding the federal regulations.

  • Title 42, Chapter IV, Subchapter C, Part 433 – State Fiscal Administration, Subpart D – Third-Party Liability
  • Medicaid Bipartisan Budget Act (BBA) of 2018, Section 53102, Third Party Liability in Medicaid and CHIP
  • Deficit Reduction Act of 2005 (DRA)
  • Coordination of Benefits and Third Party Liability (COB/TPL) in Medicaid 2020 Handbook
    • This comprehensive resource includes all of the references as well as guidance for your SMA.
  • Medicaid.gov TPL 
    • Good resource for updated information in addition to resources and guidance for states.

Now that we have covered the basics of TPL, let’s review some of the updated guidance recently released by CMS.

TPL policy changes

Medicaid BBA of 2018

  • CMS updated the pay and chase guidelines and removed some of the requirements.
    • SMAs are no longer required to pay and chase pregnancy claims. These can now be rejected up front.
  • CMS updated medical support enforcement claims payment to extend the timely filing period.
    • The timely filing period was 30 days but has now been extended up to 100 days.

DRA of 2005

  • The updated regulations clarified that third-parties include:

    • Health insurance
    • Medicare
    • Employer sponsored health insurance
    • Settlements from liability insurer
    • Workers compensation
    • Long-term care insurance
    • State and federal programs unless specifically excluded by statute
  • The updated regulations also specified that health insurers should provide the SMA with eligibility data, honor assignment of right to payment, and refrain from procedural denial of Medicaid claims.

COB/TPL in Medicaid 2020 Handbook

  • CMS updated the guidelines to include the pay and chase requirement for Medical Support Enforcement and Preventive Pediatric Services.

On August 27, 2021, CMS released guidance directing SMAs to ensure their state plans are updated and in compliance with federal guidelines by December 31, 2021. 

You can learn more about the updated guidance here

MCO claims

  • MCO encounter claims need to be in the state’s data warehouse to ensure:
    • TPL services are tracked in the data warehouse
    • TPL and MCO paid claims can be differentiated
    • All services are reported within the warehouse

Next steps

There are several things you can do to help ensure your SMA is getting the most out of your TPL data. You can review the following:

  • Medicaid, CHIP, and MCO TPL policies
  • TPL vendor business processes and policies
  • MCO contracts for TPL language
  • TPL vendor contract
  • Claim edits in the MMIS

If you have any questions, please contact our Medicaid consulting team. We're here to help.

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Read this if you are a member of a State Medicaid Agency’s leadership team or Program Integrity (PI) unit. 

In March 2020, the Centers for Medicare and Medicaid Services (CMS) suspended PERM cycle activities in response to Secretary Azar’s public health emergency (PHE) declaration. The suspension of the PERM cycle activities provided states with an opportunity to direct resources to the state’s PHE response. In August 2020, CMS released the suspension of PERM cycle activities to allow CMS and states to complete the PERM cycles that were either in progress or in the process of starting up.

While the PERM cycle suspension was in place, CMS released an updated PERM Manual in May 2020. You can access the updated PERM Manual here. The update primarily consists of the addition of guidelines related to the return of the eligibility reviews to the PERM cycle, as defined in the PERM Final Rule published by CMS in July 2017. The manual updates include adding regulation on the CMS Eligibility Review Contractor (ERC) to perform the eligibility reviews. 

Another topic receiving significant updates in the manual was the sample guidelines. Some of the updates included:

  • Sampling units related to Third-Party Liability (TPL)
  • CMS and its contractors must be granted systems access for the review process
  • Sampling timeframes updated for each cycle

There are more updates in the manual, which states will not want to miss. BerryDunn has prepared a summary of the updates included in CMS’ May 2020 release of the PERM manual. View the summary.

While state resources are busy addressing the current PHE, the states should be tracking and documenting waiver activity, as many of the flexibilities provided by waivers will expire at the end of the PHE or soon after. Provider claims for services rendered during the PHE are eligible for the PERM cycle review, and states will need to give the PERM reviewers the flexibilities honored by the state. 

For questions or to find out more information about the PERM Cycle, contact Dawn Webb

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Keeping the PERM Manual update in focus during the PHE

Read this if you are at a state agency looking to implement or improve your 988 Suicide & Crisis Lifeline. 

Between 2015 and 2020, one in four fatal police shootings involved a person with a mental illness, and an estimated 44% of people incarcerated in jail and 37% of people incarcerated in prison had a mental health condition. In addition, the recent COVID-19 pandemic has adversely impacted the mental health situation in the country. 

Many people experiencing mental health distress call 911 because it is a widely known emergency number and easy to use. Recent data has shown that people using 911 to get help with serious mental illness do not get the right care at the right time and some even end up in law enforcement custody, rather than being seen by a mental health professional.

The 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) is the new three-digit, nationwide phone number that is locally operated and offers 24/7 access via call, text, and chat to trained crisis counselors who can help individuals experiencing mental health-related distress. Mental health-related distress can include substance use crisis, suicidal thoughts, depression, or any emotional distress. The 988 Suicide & Crisis Lifeline is also available for individuals worried about a loved one who might need crisis support services. Its goal is to provide accessible and immediate crisis intervention and support to every individual in need. 

988 state implementation and top challenges

As of August 2022, 23 states have passed legislation to facilitate the implementation of the 988 Suicide & Crisis Lifeline. Colorado, Nevada, and Washington enacted legislation with user fees to support 988 operations and provide financial sustainability for the system. Several states have established advisory groups or planning committees with representatives from state agencies, health providers, law enforcement, emergency medical services, and other partners to better coordinate the system and identify policy levers. 

Implementing a three-digit number for behavioral health emergencies in every state and providing 24/7 primary coverage through in-state call centers have presented certain challenges to states across the nation. As states prepare to launch the 988 hotlines, they have encountered key issues around infrastructure, workforce, 911 integration, readiness of the crisis care continuum, cultural competence, and performance management.  

Solutions for state agencies

To address these key issues, states should consider the following to aid in the successful implementation of the 988 Suicide & Crisis Lifeline:

Assess the states’ needs to successfully implement the 988 Suicide & Crisis Lifeline

Despite meeting baseline requirements for the implementation of the 988 Suicide & Crisis Lifeline, state agencies are struggling to implement the 988 Suicide & Crisis Lifeline. 

By performing a structured needs assessment, state agencies can evaluate their infrastructure, policies and procedures, funding, and workforce needs to better understand their readiness to implement and capability to sustain the 988 Suicide & Crisis Lifeline. This assessment provides insight for state agencies to understand their strengths, challenges, and areas of opportunity, and it should evaluate: 

  • State infrastructure
    Behavioral health leaders acknowledge that infrastructure supports are necessary to make the 988 Suicide & Crisis Lifeline work across the continuum of care. It is important to assess the infrastructure across the crisis care continuum to help ensure a smooth transition for individuals who need care quickly. Successful implementation should take certain considerations into account during the planning process, such as including all the interested parties representing diverse populations.
  • Workforce
    In the current labor market, workforce availability and retention are top concerns for sustainable and effective 988 Suicide & Crisis Lifeline operations. States are struggling to hire the extra staff needed to launch the 988 Suicide & Crisis Lifeline as well as to recruit qualified persons. To realistically implement the system, innovative workforce development and supporting wages to recruit and retain a specialized workforce are critical considerations for the states. Critical components to include in the assessment should include, but are not limited to:
    • Training
      Staff training and proper supervision will be crucial to effectively manage the 988 Suicide & Crisis Lifeline, and states need best practices models for how to best train crisis responders and the call center staff. States should assess the existing training infrastructure to identify ways early on to support the mental health of their 988 Suicide & Crisis Lifeline counselors to reduce the risk for burnout and post-traumatic stress disorder. 
    • Capacity
      Adequate capacity is a key factor to workforce. The assessment should identify the number of qualified workforce available for in-person staffing. In the current labor market, it will also be important to consider including the identification of the number of qualified staff able to work remotely. If states would like to consider remote capabilities for the call centers, it will also be important to assess the available technology necessary, as well as the development of standards and expectations, including strong communication. 
  • Readiness of the crisis care continuum
    Apprehension about the readiness of the crisis care continuum (e.g., mobile crisis teams through diversion services and lower levels of care) exist. Federal officials have stated they expect up to 12 million calls/texts/chats in the first year of the 988 Suicide & Crisis Lifeline, and research suggests approximately 20% of those calls/texts/chats will require some level of in-person response. States are questioning whether mobile crisis teams are prepared for the increased demand while also identifying connections and access to upstream services. In addition, states can consider the needs and experiences of the system’s end users to help address equity. The assessment can help to assess the readiness of the various components across the crisis care continuum.

Establish a strategic plan of action to implement the 988 Suicide & Crisis Lifeline 

With the implementation of the 988 Suicide & Crisis Lifeline, state agencies have an opportunity to strengthen crisis care. The best way to begin strengthening crisis care is to develop and implement strategic plans that optimize the 988 Suicide & Crisis Lifeline and the following services. Building on the strengths and opportunities identified in the needs assessment and the associated recommendations, strategic plans can establish priorities and identify sustainable solutions that build capacity, promote equitable access to care, and promote continuous quality improvement. Collaborating with key stakeholders to develop a strategic plan can help identify a roadmap for how the state should approach the implementation, maintenance, and sustainability of the 988 Suicide & Crisis Lifeline, including, but not limited to, the following areas:

  • Data and performance management
  • Stakeholder engagement
  • Health equity
  • Voice of the customer
  • Financial sustainability

Maximize available funding streams

Historically, behavioral health has not had sufficient funding to adequately address mental health and substance use disorder prevention, treatment, and recovery services across the continuum of care. The COVID-19 pandemic exacerbated behavioral health challenges for many individuals struggling and highlighted the challenges with the infrastructure and workforce. In the last couple of years, the federal administration has continued to allocate additional funding to supplement existing and ongoing federal funding. States should begin by evaluating the existing federal funding opportunities to support the implementation of the 988 Suicide & Crisis Lifeline. According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) 988 Convening Playbook for States, Territories, and Tribes, below are a few examples of funding sources that can be leveraged for the implementation of the 988 Suicide & Crisis Lifeline. 

  • SAMHSA 
    • Transformation Transfer Initiative
    • Community Mental Health Services Block Grant
    • Substance Abuse and Treatment Block Grant
    • Mental Health Block Grant Set-aside
    • State Opioid Response Grant
    • Tribal Opioid Response Grants
  • American Rescue Plan Act (ARPA) of 2021—for Mobile Crisis and Crisis Line Services
  • Medicaid
    • Early, Periodic, Screening, Diagnosis, and Treatment (known as EPSDT)
    • 1915(a) waivers
    • 1915(b) waivers
    • 1115 SMI/SED Service Delivery Waiver

The implementation of the 988 Suicide & Crisis Lifeline is critical to supporting the community and meeting their needs at a time where they need community support the most. If you have any questions, please contact BerryDunn’s behavioral health consulting team. We’re here to help.

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Components of successful implementation of the 988 Suicide & Crisis Lifeline

Read this if you are at a state Medicaid agency.

The uncertainty surrounding the end date of the COVID-19 Public Health Emergency (PHE) has made it difficult for state Medicaid agencies to plan and prepare to transition to pre-pandemic operations. Upon the federal declaration of the PHE, states and territories were forced to react quickly to reduce the impact on the Medicaid program and its enrollees. Many states and territories took advantage of the emergency authorities through the Centers for Medicare and Medicaid Services (CMS) to implement temporary policy changes such as the removal of prior authorization requirements, increased payments to providers, removal of cost-sharing, and the expansion of telehealth services. 

While many of the emergency authorities will terminate on or around the end of the PHE, states and territories may elect to make those temporary changes permanent due to the positive impact for both enrollees and providers. Take telehealth, for example. The broad flexibilities allowed during the PHE permitted providers to meet the healthcare needs of enrollees in a time where in-person visits were not recommended, nor available. To increase access to testing and vaccinations in pharmacies, pharmacy technicians and interns were permitted to administer COVID-19 vaccinations when supervised by an immunizing pharmacist.

So what comes next for states and territories once the PHE ends? Taking a proactive approach to plan out next steps will assist states and territories to be better prepared upon conclusion of the PHE. The US Department of Health and Human Services (HHS) has committed to providing at least a 60-day notice prior to the official end date of the PHE. CMS encourages states and territories to communicate changes to enrollees, managed care plans, counties, providers, and other stakeholders.

As we await the declared end date of the PHE or notification of another extension, states and territories can begin taking actions to prepare for the resumption of normal operations. We have learned new ways to prevent disruptions in meeting the needs of enrollees, developed enhanced methods of communication to stay in touch, and used technology to its fullest capacity. While our new normal is very different than pre-pandemic times, we can all use what we have learned to strengthen our tactics for any future PHEs. BerryDunn is here to assist and support states and territories as they prepare for the eventual end of the PHE.

If you have questions or would like to discuss further, please contact the Medicaid consulting team. We're here to help. You can also read more BerryDunn articles on the PHE unwinding here.

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Looking beyond the Public Health Emergency: What's next for states

Read this if you are a Medicaid agency or attended MESC 2022.

As I depart Charlotte and fly home and MESC 2022 closes out, I understand why Charlotte is referenced as the Queen City. The people make it so, as we were welcomed with open arms in this beautiful place. Our appreciation and gratitude go out not only to Charlotte, but also to NESCSO for providing us with a place to meet, share ideas, get inspired, and deepen our relationships.

In the coming months, our team can sift through what we learned during our four days at MESC. It will be up to us to transform the ideas spawned from presentations and conversations into tangible action, and grow the new relationships we developed. Here are my key takeaways and themes from the conference that I will continue to ponder:

  • The conference is in full swing on the other side of the pandemic. MESC was sold out, as 1,700 people attended.
    • MESC established a new annual award for collaboration. This year the award went to the Public Sector Technology Group's (PSTG) Medicaid Information Technology Architecture (MITA) workgroup. CMS is optimistic that the MITA workgroup's efforts will help improve Medicaid and that the resulting toolkit will be the future of MITA. Thank you to this group, and congratulations on a well-deserved award!
  • Modernization efforts:
    • The reality of managing modernization efforts is settling in. States and territories are beginning to get clear on their approach, acknowledging that each has unique needs, and consequently, can customize their approach. It will be a long haul requiring good upfront strategizing, planning and execution.
    • Many states and territories recognize a need to examine and adjust their internal structures to manage multiple procurements and strategies.
    • Data and data governance is foundational to the modularization and modernization effort.
  • Unwinding is weighing on everyone's mind, but participants discussed other forward-looking topics. 
  • CMS continues to solicit input from states, territories, and vendors
    • This was CMS' first in-person conference since the pandemic's start—it was so great to have their energy and participation.
    • It was fantastic to be in sessions where CMS asked: How can they do better? 
    • Efforts on outcomes, streamlining certification, consistency, and accountability continue to be CMS themes
    • Brent Weaver, CMS' new Data and Systems Group Director, outlined four of CMS' goals at MESC:
      • Strengthen state and territory partnerships
      • Get input from vendors on unwinding
      • Identify ways to improve data quality
      • Find ways that will help CMS become better partners
  • Ensuring health equity and leveraging social determinants for health is a priority for states and territories.
  • New solution vendors are coming into the Medicaid space, and want to learn about Medicaid and the broader enterprise as they look for ways to adapt their systems.  
  • There continues to be mergers and re-shuffling of the more established vendors as they look to adapt to and serve the needs in the Medicaid space.
    • This was BerryDunn's 17th conference. We have broadened our services and maintained our values. I'm grateful that BerryDunn continues to have a stable presence at the conference.  
  • Our Medicaid Practice Group mission statement (see below) aligns with the CMS Data and Systems Group Director's reason for being in his role. 

Additional thoughts: Asking "why," change, and education

I also appreciated conversations within our Medicaid community based on the “why": Why are we doing what we do? Why focus on modernization? Health equity? Social determinants of health? 
The "why" drives what we do by providing us with our North Star, helping us with strategy, and giving us our roadmaps for proceeding. By starting with the purpose and outcome we strive for, we can align the changes we need to make.  

Change can be a source of fear, and there is a risk of venturing into the unknown. Medicaid leaders understand that the work they are responsible for is critical to their members, providers, and taxpayers. Lives depend upon our work, and the potential of "change" can have positive or negative consequences. Effective planning can mitigate the risks and help alleviate staff, member, and provider fears about change. 

Education also plays a big part in the mitigation equation. After tying the purpose to the vision, roadmap, and phased plans to modernize our programs, there needs to be an education plan to bring everyone up to speed and build confidence in those who will be impacted.

Conclusion

I am grateful that the BerryDunn Medicaid Practice Group's mission complements the goals of CMS and the direction in which states and territories are moving. We are honored to participate in this vital work and join all in the Medicaid community as we work on the initiatives before us. I leave you with our mission statement and invite you to share your organization's mission with us.

BerryDunn's Medicaid Practice Group helps Medicaid agencies improve the health and lives of individuals by empowering, inspiring, and partnering with our clients—we innovate, share deep expertise, and provide an independent perspective to resolve challenges. We are the success partner for Medicaid agencies, building healthier communities and stronger futures.

I look forward to seeing you all again next time in Denver! Let's make it a great year!

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MESC 2022: Reflections from 30,000 feet

Read this if you are at a state Medicaid agency.

The COVID-19 PHE has raised many questions for Medicaid programs across the country. The Centers for Medicare & Medicaid Services (CMS) and other healthcare organizations have been providing guidance on how to best manage the PHE since it began. In particular, CMS has provided recommendations on how Medicaid programs can implement new processes and rules into their Medicaid Enterprise Systems (MES) for individuals to remain under continuous enrollment until the end of the PHE. 

Strategies for MES

BerryDunn has been working with many states and territories to develop strategic plans to comply with specific rules and requirements throughout the PHE. Some of these strategies involve changes to the original designs of the MES. Examples include:

  • Updating system rules to maintain individuals enrolled in continuous coverage throughout the PHE
  • Retesting system rules to confirm systems are working properly once PHE rules are removed
  • Revamping system notifications so reminders keep individuals informed about ongoing changes
  • Training staff on the new system updates so they can manage calls and orient individuals on changes regarding their eligibility

CMS continues to release updated guidance on how Medicaid programs can best prepare for the end of the PHE in order to resume normal operations. These recommendations indicate that Medicaid programs adopt strategies to maintain coverage of eligible individuals as the continuous enrollment requirements come to an end, following the conclusion of the PHE, while allowing coverage for ineligible individuals to terminate. Medicaid programs must ensure their systems are prepared for the transition, but some of these updates and changes to the systems may pose greater challenges: 

  • Since there are no precedents to compare with the current PHE unwinding event, Medicaid programs will need to execute changes within a limited timeline and work with the issues that may arise as they execute unwinding
  • For some Medicaid programs, system rules, both current and updated ones, are not able to run simultaneously
  • Medicaid programs may need to hire additional staff, train new employees, and retrain or cross train current employees within a small window of time
  • Medicaid programs will need to perform additional MES testing to confirm those systems are working as required
  • Medicaid programs will incur additional costs to cover additional operational efforts
  • System vendors will incur extra work that may affect project timelines and other priorities

If you have any questions or would like to learn more about how BerryDunn can assist you with the PHE unwinding efforts, please contact the Medicaid consulting team.

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Design, Development, and Implementation (DDI) and project impacts resulting from the Public Health Emergency (PHE)

Read this if you are at a state Medicaid agency.

The Covid-19 Public Health Emergency (PHE) placed US state and territory Medicaid programs on the front line of reorganizing what healthcare looks like for millions of Medicaid enrollees. Each Medicaid program shifted automation and manual procedures in order to comply with and benefit from the increased federal funding in early 2020. With the PHE winding down, every Medicaid program must look at how to return to regular operations and unwind, or undo, the continuous coverage requirement temporarily put in place by the Centers for Medicare and Medicaid Service (CMS). BerryDunn has collaborated with Medicaid programs to identify best practices and consider new opportunities to implement rollback methods in an effort to lower risk during the unwinding period and beyond. 

New learning programs considered

Administrators who have been assessing their staff and operational readiness to support the expected influx of renewals, policy changes, and staffing changes are considering launching learning programs ahead of the unwinding efforts. Using this time to engage with staff has uncovered the need to redeploy fundamental learning programs to prepare for the anticipated high volume of two-years of renewals. Administrators have also begun to engage with community leaders and health plan organizations in ways that provide coordinated and complete communication to beneficiaries. Many programs have looked at expanding benefits within the guidelines of CMS, such as extending post-partum coverage to a full 12 months and increasing reasonable compatibility to a larger percentage, recognizing the economy has evolved since 2020.

Other outreach efforts

During the pandemic, many beneficiaries moved without notifying the Medicaid program of the address change. Proactive Medicaid programs are working directly with health programs and medical facilities to ensure the most updated addresses are captured, and are using public transportation advertisements, online website reminders, and email notifications to encourage beneficiaries to update addresses.

In other locations with a high rate of unemployment in specific industries, Medicaid programs are working with identified outreach partners like unions and industry associations to communicate messaging of Medicaid benefits. Thousands of employees may have lost full-time employment during the pandemic and have returned to work with reduced hours and less benefits. As a sign of changing times, some programs are employing social media campaigns to connect with existing and new enrollees. 

Medicaid programs across the states and territories are finding creative ways to reach impacted communities. Program administrators are organizing staff and systems to be well positioned to undo the effects of the temporary policies. The dismantling of the two-plus years of PHE is expected to be performed within a 12-month period. As administrators eagerly anticipate the announcement of an extension or the pending PHE unwinding start date, one thing is certain: US states and territories are preparing to support an extensive population of Medicaid beneficiaries post pandemic.

BerryDunn is partnering with many states and territories to help ensure a successful unwind of temporary services and return to normal operations. If you would like to discuss how BerryDunn can support your needs, contact the Medicaid consulting team.
 

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How Medicaid programs are preparing for the operational challenges of the PHE unwinding

Read this if you are at a state Medicaid agency. 

As the end of the Public Health Emergency becomes more likely, much attention has been paid to the looming coverage cliff as state Medicaid agencies re-determine eligibility for their programs. The impacts can be mitigated in part by planning and taking proactive steps.

In the unsettling initial days of the COVID-19 Public Health Emergency (PHE), the Centers for Medicare and Medicaid Service (CMS) temporarily increased federal matching funds for state Medicaid programs. In exchange, states would suspend redeterminations of enrollees’ eligibility for the duration of the PHE. 

For Medicaid, states were in effect prohibited from disenrolling an individual from Medicaid programs. The result, according to CMS data, is 14.8 million more people were enrolled in Medicaid as of late 2021 than before the pandemic, reaching a total of nearly 79 million Medicaid enrollees.  According to one estimate, the end of the PHE could bring a decline in the number of Medicaid enrollees by as many as 15 million. This number includes an estimated 8.7 million adults and 5.9 million children. 

Local and state government eligibility staff will need to review the submitted documents and determine if these members qualify for continued Medicaid coverage. The potential exists for members to lose coverage, due to factors such as having moved, not realizing their circumstances have otherwise changed, or being unable or unaware to return the required paperwork within appropriate timeframes.

State Medicaid agencies strive to maintain an equitable program while remaining trusted stewards of public funds. With a large base of beneficiaries, this change is expected to impact the community and the healthcare market, with broad implications for public health. Similarly, the federal requirement for continuous health coverage has also helped state Medicaid agencies by easing the strain on organizations during pandemic-related disruptions. 

For these reasons state Medicaid agencies may search for routes to limit the loss of coverage. This can be accomplished through finding policy levers to retain members, establishing routes to alternative forms of insurance, and mitigating the risk of coverage loss for members. 

Mitigating the likelihood of becoming uninsured

State Medicaid agencies can reduce the risk that members lose their coverage and become uninsured through a number of steps. 

  • Designing comprehensive, multi-pronged, and targeted communication strategies. States can help Medicaid members understand the requirements and timelines required to maintain their coverage.
  • Updating systems to automate and reduce administrative burden. Maximizing ex parte renewals through the use of existing data that is stored in integrated systems.
  • Making key decisions early. States can minimize coverage loss by carefully planning the unwinding process and their approach to resuming Medicaid eligibility renewals.
  • Coordinating with other forms of coverage. Confirm or design user-friendly pathways by which a member is transferred or referred to other alternatives like the Marketplace or CHIP.
  • Leveraging their health plans. Particularly when it comes to coordinating outreach and updating member information. Managed care plans are also able to refer members who are losing coverage to other qualified health plans.

Policy levers for retaining members

States may consider reviewing emergency state plan amendments and appendix k amendments completed during the PHE to determine what flexibilities are possible to continue under existing authorities. At the same time, states should consider what other policy options may help retain coverage for existing members- for example:

  • Adopt 12 months continuous eligibility. This can be done for children via a State Plan Amendment (SPA), for adults through an 1115 waiver, and for individuals enrolled in BHP (via BHP Blueprint revision) 
  • Establish 12 months of postpartum coverage. This can be done through several paths, including SPAs 
  • Review operational policy for efficiencies. For example, a State could consider modifying the frequency of periodic data matching 

Next steps

The US Department of Health and Human Service has previously indicated its intention to provide notification to states of the end of the PHE 60 days before its scheduled end. The PHE was renewed in April 2022, and as of this writing will last until mid-July, meaning enrollees could lose Medicaid coverage as soon as August 1. The enhanced FMAP and the Maintenance of Eligibility (MOE) requirements are in place until the end of the quarter in which the PHE ends. In the case of a July 2022 end date to the PHE, the enhanced FMAP would last through September 30, 2022. 

Regardless, Medicaid agencies will need to begin reviewing all enrollees’ eligibility, performing outreach, and designing system updates this summer. In terms of next steps, states should consider the following:

  • Evaluate your program and identify initiatives to prioritize in the coming year. Ask your CMS contact about the latest applicable guidance. 
  • Develop Advanced Planning Documents (APDs) to help fund technology needs for initiatives, along with training your SMA team and providers. 
  • Implement a communications management approach to engage stakeholders, and inform affected Medicaid members.
  • Marshal project management resources and develop a realistic and achievable roadmap to success.  
  • Explore agency contracting vehicles, cooperative contracts, and other procurements tools. 

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the Medicaid consulting team.

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Medicaid coverage gap: Tools and strategies for Medicaid agencies to help retain members