CMS’ Jonathan Blum Looks at Medicaid, Medicare Advantage Reform

The Centers for Medicare and Medicaid Services is increasing its focus, and has recently taken several steps to strengthen state Medicaid programs, increase oversight of Medicaid Advantage programs, and boost health equity efforts.

The agency’s Principal Deputy Administrator and Chief Operating Officer Jonathan Blum discussed these priorities with Moderna Healthcare while he was in Chicago this week for the 2023 Healthcare Information and Management Systems Society conference.

Here’s what to know.

Rescheduling Will Strengthen Medicaid

Blum said a moratorium on states removing individuals from Medicaid during the COVID-19 pandemic in exchange for increased federal funding would strengthen the public benefit program. States have invested in technology and improved their existing entitlement systems as they resume eligibility check First time in two and a half years.

“The process has forced the states to build better structures which will last longer than the process itself,” he said. “The eligibility process has always been a big challenge for the states. We’ll have a stronger Medicaid program once we’re finished.”

At the federal level, CMS enhanced to automatically populate user information from their Medicaid file into an Exchange application. By better linking technology systems between Medicaid and the exchange plans, Blum said he hopes to avoid consumer gaps in coverage.

States should follow Illinois’ lead

Blum said more states should follow Illinois’ lead and enact amendments that allow public schools to bill Medicaid for health services.

CMS this week approved a state plan amendment for Illinois additional Medicaid funding to pay for behavioral health, physical therapy, preventive care and other health services for all students enrolled in Medicaid or the Children’s Health Insurance Program, not just one For students with individualized education programs. , CMS has made similar modifications to the Medicaid programs of 11 other states.

Blum said the state plan revision also strengthens the relationship between the Medicaid program and schools as rescheduling begins again.

“Schools have more accurate address, location data than insurance companies,” he said. “It will help with other policy goals we have. It is a really good development.

CMS ready to crack down with ‘corrective action’

CMS will also watch for outliers among states that process Medicaid eligibility applications too quickly or slowly, as well as those where there are large numbers of individuals who are not eligible for other coverage, where consumers experience long call center wait times. Report more. in those cases, Blum said the agency can and will block states’ ability to remove individuals from Medicaid until they refine their procedures.

“Our teams are ready and prepared to use that authority if necessary,” he said.

more inspections coming

One of the primary goals of CMS with its program integrity procedures is to reflect the reality that most individuals are enrolled in managed care settings through Medicaid or Medicare Advantage plans. “Our oversight needs to shift toward managed care, whereas historically we’ve been doing this through a traditional, fee-for-service system,” Blum said.

It is this perspective that inspired the finalization of CMS Medicare Advantage Risk-Adjustment Data Verification Rule, which allows the agency to compensate insurers for past overpayments. It also inspired CMS Reshape its Medicare Advantage risk-adjustment program, although the changes will be phased in over three years.

“We do not disagree,” Blum said in response to criticism that CMS’s final Medicare Advantage rules do not go far enough in curbing insurers’ excessive profits. “But we also understand that changes need to be carefully calibrated so that plans can accommodate, so we don’t disrupt premiums and cut benefits too quickly.”

Revamped star rating will boost health equity

CMS re-tooling Medicare Advantage Star Rating Program Incentivizing insurers to bridge the health equity gap. The agency removed the “reward factor” that used to give insurers a large bonus if they performed consistently well over time. Instead of this, CMS this month finalized a plan Establish a health equity index to encourage plans to create better access to services in healthcare sectors and offer policies to disadvantaged areas in an effort to improve the health of the population.

“I would challenge anyone to provide definitive proof that more enrollment in managed care organizations, more enrollment in the Medicare Advantage program, leads to better savings, better outcomes and better quality of care,” Blum said. “It may happen at an individual level, but I would challenge anyone to provide definitive evidence that it happens at an absolute, population level.”

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