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Federal Medicaid match matters to state’s healthcare providers

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.

In this article, Oklahoma City Attorney Rebecca Pasternik-Ikard answers questions about state and federal government’s role in funding Oklahoma’s Medicaid program.

What is the Federal Medical Assistance Percentage (FMAP)?

The Federal Medical Assistance Percentage is the federal government’s share of the expenditures for medical services and administrative costs for a state Medicaid program and is often called the “federal match.”

Why does it matter to Oklahoma’s healthcare providers?

FMAP matters because each state’s Medicaid program is funded jointly by state and federal dollars. Generally, states receiving a higher FMAP for medical services need fewer state dollars. But a state must have state dollars to leverage federal matching dollars. On a quarterly basis, a state submits to the federal government its Medicaid expenditures paid by state dollars seeking to “draw down” the federal matching dollars.

How often does the FMAP change?

The FMAP for medical services for all states is calculated annually by U.S. Department of Health and Human Services (HHS), based on a formula in the Social Security Act, and is effective from Oct. 1 through Sept. 30 of each year. The FMAP varies from state to state; it can be no lower than 50% and no higher than 83%. So, for every $1 states spend on Medicaid, states can “draw down” at least $1 from the federal government. However, the FMAP for a state’s Medicaid administrative costs is fixed, generally at 50% FMAP. States do receive enhanced FMAP for certain populations, services and a variety of administrative functions.

How does the FMAP specifically impact physicians, hospitals and other healthcare providers?

Fluctuations in the FMAP for medical services can have significant impact on all healthcare providers. Significant increases often allow a state to restore, increase or add benefits compensable under the Medicaid program, as well as adjust upward the rates paid to providers. Conversely, depending on a state’s ability to offset the loss of federal funds, a decrease in the FMAP can trigger the elimination or reduction in certain benefits provided to Medicaid enrollees, as well as a decrease in provider rates.

How is the FMAP for medical services calculated?

The FMAP is based on a rolling three-year average of the per capita income of each state as compared to the national average per capita income. However, there is a lag in the data used. For instance, for FY 2019 (effective Oct 1, 2018-Sept. 30, 2019) the FMAP calculation for states was based on state per capita personal income data for 2014, 2015 and 2016. Generally, what this means is that for states with lower per capita incomes relative to the national average, the federal government contributes more to the Medicaid program. Conversely, the federal government contributes less to the Medicaid program in those states with higher per capita incomes. However, the formula is not responsive quickly when a state experiences an economic downturn.

How does the FMAP work in Oklahoma?

With the exception of the FY 2014 FMAP of 64.02%, Oklahoma’s FMAP declined overall from 64.00% in FY 2013 to 58.57% in FY 2018. Oklahoma experienced the largest cumulative FMAP decrease in the nation over this period. This significant loss of federal dollars prompted the Oklahoma Health Care Authority (OHCA) to implement administrative and operational strategies to continue to operate the Medicaid program, resulting in physician and other provider rate reductions of 7.75% in July 2015 and 3% in January 2016. From FY 2018 to FY 2019, Oklahoma had the greatest FMAP increase of any state of 3.81%, from 58.57% ($1.43 in federal dollars for every state dollar spent in medical services) to 62.38% ($1.66 in federal dollars for every state dollar spent in medical services). This influx of federal matching dollars and OHCA’s management of its administrative and program budgets allowed OHCA to restore the last provider rate reduction of 3%. From FY 2019 to FY 2020, Oklahoma experienced another significant FMAP increase of 3.64% from 62.38% ($1.66 in federal dollars for every state dollar spent in medical services) to 66.02% ($1.94 in federal dollars for every state dollar spent in medical services). Once again, provider rates were increased. The good news is that, due to Oklahoma’s experience with shifting FMAPs, a Rate Preservation Fund of $29.4 million was created this year, to help offset future FMAP decreases and mitigate potential provider rate reductions.

Rebecca Pasternik-Ikard is an attorney at Phillips Murrah.

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.