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Medicaid, work and community engagement

This column was originally published in The Journal Record on November 27, 2019.


Introducing Becky-Pasternik-Ikard

Rebecca “Becky” Pasternik-Ikard is a lawyer, a nurse and a Medicaid program director who brings decades of experience to assist Phillips Murrah healthcare clients in copy with reimbursement, including negotiating payments, audits and appeals, and other regulatory issues related to governmental payments of providers.

By Phillips Murrah Of Counsel Attorney Becky Pasternik-Ikard

Physicians, hospitals and other health care providers continue to experience not only shrinking reimbursement rates, but also an increasingly formidable regulatory presence. A recent controversial Centers for Medicare and Medicaid Services policy reform permits states to require certain Medicaid beneficiaries to engage in meaningful work or in volunteer activities as a condition for continued eligibility.

This policy is a fundamental shift in Medicaid eligibility, eliciting criticism from the health care community that employment should not be a condition for coverage and access to medical treatment.

Although overall Medicaid enrollment has declined over the past two years, Medicaid enrollment has increased since the Affordable Care Act, driven primarily by newly eligible adults gaining coverage under Medicaid expansion, with the highest enrollment increases seen in Medicaid expansion states. This increase includes not only the Medicaid expansion population, but also those individuals who were currently eligible, but not enrolled. These people learned of coverage due to extensive outreach efforts by expansion states.

In its Jan. 11, 2018 State Medicaid Director letter entitled Opportunities to Promote Work and Community Engagement among Medicaid Beneficiaries, CMS announced the new policy and clarified that states could predicate continued Medicaid eligibility on participation in work requirements, including community service, caregiving, education, job training, and substance use disorder treatment. The basis for this policy is Section 1901 of the Social Security Act. Divisive reactions have opponents characterizing it as inconsistent with Medicaid’s objective of health coverage and an impermissible Medicaid enrollment reduction strategy.

Eighteen states have sought approval to implement work requirements. Although CMS has approved all requests submitted by Medicaid expansion states, the implementation of three, Arkansas, Kentucky and New Hampshire, has been interrupted or stopped due to legal challenge.

Kentucky, a Medicaid expansion state, received CMS approval the day after the new policy was announced. Kentucky had submitted a Section 1115 waiver authority request in 2017 incorporating work requirements. Shortly after Kentucky’s January 2018 approval, a legal challenge was filed. Kentucky’s implementation has been blocked twice by a federal district court judge and is under appeal. Kentucky Gov.-elect Andy Beshear has declared plans to rescind Medicaid work requirements.

In July 2017, Indiana submitted its request to CMS proposing work requirements for its Medicaid expansion enrollees. Although Indiana received CMS approval in February 2018, implementation did not begin until January 2019. In September 2019, a lawsuit was filed challenging Indiana’s program. Indiana has suspended its work requirements pending the outcome of the litigation.

In March 2018, CMS approved Arkansas’ June 2017 request to amend its Section 1115 waiver to implement work requirements. Implementation began in June 2018. In August 2018, a lawsuit was filed challenging Arkansas’ approval. A year after approval, the federal district court set it aside. The matter is under appeal.

In May 2018, New Hampshire became the fourth state to win approval for work requirements, with implementation scheduled in March, but it was postponed due to a lawsuit filed the same month. Consistent with the rulings for Kentucky and Arkansas, in July 2019, the same federal district court judge set aside the approval for New Hampshire.

State leadership and Medicaid programs nationwide await the outcome following the Oct. 11 oral arguments related to the appeals for Arkansas and Kentucky. Oklahoma, a non-expansion state, has a pending waiver request to impose work requirements on certain Medicaid beneficiaries. If approved, this would add barriers to access and continuity of care, which are likely to place additional administrative and financial burdens on hospitals, physicians and other health care providers.

Becky Pasternik-Ikard is the former CEO of the Oklahoma Health Care Authority and former state Medicaid director. She currently practices Of Counsel for Phillips Murrah law firm in Oklahoma City.

NewsOK Q&A: Oklahoma Medicaid plans offer solution for costly prescription drugs

In this article, Oklahoma City healthcare attorney Mary Holloway Richard discusses steps Oklahoma has taken to lower prescription drug costs for consumers.

oklahoma city health care attorney mary richard

Mary Richard is recognized as one of pioneers in Oklahoma healthcare law. She has represented institutional and non-institutional providers of health services, as well as patients and their families. She also has significant experience in representing providers in regulatory matters.

Q: Oklahoma recently has been recognized by Secretary Alex Azar, of the U.S. Department of Health and Human Services, for innovations in its Medicaid prescription drug program designed to lower drug costs to the state. How was the state able to accomplish this feat?

A: Medicaid is a federal program that’s administered by the states. In Oklahoma, it’s administered by the Oklahoma Health Care Authority. So, while the state receives some federal funding, a good portion of Medicaid funds are supplied by the state. In order to reduce costs related to prescription drugs, Oklahoma applied to the Centers for Medicare & Medicaid Services (CMS) and was granted an amendment to the Oklahoma State Plan that facilitates prescription drug cost savings. The plan links the payment of a drug to its effectiveness and outcomes. This is essentially what we refer to as “value-based” prescription drug purchasing. CMS reports that “(t)he state plan amendment proposal submitted by Oklahoma will be the first state plan amendment permitting a state to pursue CMS-authorized supplemental rebate agreements involving value-based purchasing arrangements with drug manufacturers.” This program is part of the Trump administration’s “American Patients First” blueprint, designed to address rising drug prices.

Q: How will the amendment work in Oklahoma?

A: The amendment to the state plan, as approved by CMS, now allows Oklahoma to negotiate and enter into valued-based contracts with drug manufacturers. This means that, through identifying the most effective medications, the state can tailor its negotiations with manufacturers to drugs that have demonstrated the most success in treating patients, thereby achieving cost savings and efficiencies in treatment. Negotiating value-based contracts will supplement Oklahoma’s ability to control drug prices under its current participation in the Sovereign States Drug Consortium. The Consortium negotiates supplemental rebates on behalf of states. Oklahoma is free to accept or reject rebate offers.

Q: Are there other cost saving initiatives related to decreasing prescription drug costs?

A: Currently, certain drugs have a preferred status if they’re listed on the Medicaid State Supplemental Rebate Agreement. Almost every state Medicaid plan, including Oklahoma’s, gives the state the authority to negotiate supplemental rebate agreements with drug manufacturers. These agreements allow for rebates to be given to the state by manufacturers as least as large as those provided in the Medicaid national drug rebate agreement. Importantly, two other parts of the Trump administration’s plan to decrease drug costs include giving Medicare insurance plans greater ability to negotiate for the Medicare Program (Part B and prescription drugs) and to make drug prices transparent for consumers. The latter part of the president’s plan would require drugmakers to disclose list prices in public advertising.

 

Published: 7/10/18; by Paula Burkes
Original article: https://newsok.com/article/5600913/oklahoma-medicaid-plans-offer-solution-for-costly-prescription-drugs