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Administrative/Regulatory Initiatives. The staff of the Centers for Medicare and Medicaid Services (CMS) are making significant policy changes without amending the Medicaid statute or changing existing or proposing new regulations. There appears to be a growing number of individual negotiations involving intergovernmental transfers, provider taxes and donations and waivers that are limited to state executive branch staff. This approach permits CMS staff to, without the guidance of Congress or public comment through the regulatory review process, impose new costs and administrative complexity on state Medicaid programs. This approach also makes it more difficult for state legislatures to carryout necessary program oversight since many of these negotiations are limited to discussions with executive branch personnel. NCSL urges CMS to pursue legislative changes, propose regulations, or issue detailed written guidelines regarding policy related to intergovernmental transfers, provider taxes and donations, and waivers. Any such changes in law, regulation or guidelines should be prospective and in conjunction with the renewal date of any waivers and not retroactive. Furthermore, any CMS audit of any state Medicaid programs should include an opportunity for appeal and reconciliation if requested by the respective states. Whatever approach is taken should include briefings for state legislatures and an opportunity for state legislatures to provide feedback.
Mental Health Managed Care Waivers. CMS has recently reversed a significant policy by denying previously granted Medicaid managed care waivers. These waivers allowed states to utilize the savings from managed care to serve non-Medicaid eligible residents. NCSL urges CMS to facilitate innovation in delivery models rather than undermine current working systems by reversing their previous decisions.
Long Term Care Partnership Program. The development of a comprehensive long term care program is critical to the future of the Medicaid program. Without the development of such a program, long term care expenditures will continue to overwhelm the program, limiting needed expenditures for primary and preventive health care. The renewed interest in reinstating the Long Term Care Partnership Program is exciting and NCSL believes that the enactment of legislation to reinstate this program would be an important first step toward reform. NCSL urges Congress to repeal the provision in the Omnibus Budget Reconciliation Act of 1993, that restricts the ability of states to develop programs that provide limited asset protection within the Medicaid program to individuals who purchase long term care insurance.
Family Opportunity Act. NCSL supports the options provided to states through the Family Opportunity Act to expand Medicaid coverage to certain disabled children. NCSL opposes efforts to offset the cost of this new option or any new option with reductions in the existing Medicaid program. NCSL is particularly concerned about efforts to change targeted case management from a service to an administrative procedure without the benefit of hearings to discuss and evaluate the impact of such a change.
Unspent Disproportionate Share Hospital (DSH) Funds. Shortly some unspent DSH funds will revert to the federal treasury. NCSL urges the Congress to consider legislation that would redistribute these funds to states to provide assistance to uninsured and low-income people.
Implementation of the Medicare Modernization Act
The National Conference of State Legislatures supports the establishment of a prescription drug program within Medicare and is particularly supportive of the subsidies for low income Medicare beneficiaries. NCSL is pleased with many provisions of the MMA, but does have a number of concerns about the specifics of the new law and the implementation of the new Medicare Part D prescription drug benefit.
Individuals Eligible for Medicaid and Medicare (Dual-Eligibles). In 1988, the Congress included a provision in the Medicare Catastrophic Coverage Act that required states to pay the premiums, copayments and deductibles for certain low-income individuals who were eligible for both Medicare and Medicaid. NCSL believed then, and continues to believe that the cost of Medicare coverage should be borne by the federal government and program beneficiaries. NCSL believes that the costs associated with providing prescription drug coverage, to low-income individuals made eligible for the new Medicare Part D program, should be 100 percent federally funded.
State Maintenance of Effort Payments (Claw Back). NCSL opposes the provision in the MMA that requires states to make maintenance of effort or “claw back” payments to the federal government based on 2003 prescription drug expenditures for dual-eligibles. NCSL urges the Congress to include this among the issues to receive further review in the next Congress. States should have the ability to administratively appeal errors in calculating the claw back so they do not have to litigate such issues.
Enhanced Federal Matching Payments or Additional Federal Funds for Administrative Costs. The MMA requires states, as a condition of receive federal Medicaid matching payments (FMAP) to conduct eligibility determinations for the new Medicare Part D prescription drug program. During Congressional consideration of the legislation, NCSL urged Congress to provide enhanced matching funds to states for these mandated administrative functions. No additional funds were provided. NCSL urges Congress to provide states with additional funds to provide pay for computer hardware and software improvements, staff training and educational materials that will be necessary to fulfill this mandate.
State Flexibility-Enrollment of Dual-Eligibles in Medicare Part D. NCSL is concerned about the number of frail dual-eligibles that may fail to enroll in the new Medicare Part D program, thereby becoming uninsured for prescription drug coverage. NCSL urges Congress to consider changes in the Medicare Part D program that would provide states with more flexibility to ensure that these vulnerable individuals retain prescription drug coverage during the transition from Medicaid coverage to Medicare Part D coverage.
State Pharmaceutical Assistance Programs. NCSL is pleased that the new law requires the new plans to coordinate with existing State Pharmaceutical Assistance Programs (SPAPs) and that the law authorizes grants to states to assist with the transition.
State Retiree Health Benefits. The Medicare Modernization Act provides incentives to employers to continue to provide prescription drug coverage to retired employees through employer-based retiree health benefit plans. NCSL is pleased that Congress included incentives for state and local government sponsored retiree health benefit plans.
Nursing Home Reforms. NCSL is committed to continued vigilance in the protection of our vulnerable citizens in nursing facilities and those receiving long term care services in other venues, including their homes. The Medicare Modernization Act establishes a pilot program to evaluate the use of background checks for long term care service workers in nursing facilities, home health agencies, hospices and similar settings. NCSL believes that this is an important pilot program and looks forward to working with the Administration and Congress to assure the safety of people who receive the broad range of long term care services.
Federal Assistance to States for the Cost of Providing Emergency Health Care Services to Undocumented Immigrants. NCSL supports the program established in the Medicare Modernization Act that provides federal assistance to states for the costs of providing emergency health care services to undocumented immigrants. NCSL urges the U.S. Department of Health and Human Services to make certain that all impacted hospitals, whether urban or rural, large or small, are eligible to receive funds under this provision.
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