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HHS RESCINDS MEDICAID REGULATIONS!

MEDICAID NEWS
FOR IMMEDIATE RELEASE CONTACT:

CMS Media Affairs Office
Monday, June 29, 2009
(202) 690-6145

Department of Health and Human Services (HHS) Secretary Kathleen Sebelius today announced that the administration will rescind all or part of three Medicaid regulations that were previously issued and delay
the enforcement of a fourth regulation. Each of these rules, in whole or in part, had been subject to Congressional moratoria set to expire on July 1, 2009.
　
"These regulations, if left in place would have potentially adverse consequences for Medicaid beneficiaries, some of our nation’s most vulnerable people," said Secretary Sebelius. "By rescinding these rules, we can expect that children will continue receiving services through their schools, beneficiaries will be able to access all available case management resources to help them better manage their health care, and outpatient hospital and clinic services can continue to
be covered in the most efficient manner."
　
"The actions we are taking today are necessary to ensure that the states have the flexibility they need to fully serve Medicaid-eligible individuals," said Secretary Sebelius.
　
The Centers for Medicare & Medicaid Services (CMS) and HHS today are:
　
・ Rescinding a final rule, published December 28, 2007, that
would have eliminated reimbursement for school-based administrative
costs and costs of transportation to and from schools. The rescission
reflects concern that the rule could limit the Medicaid administrative
outreach activities of schools, and that the overall budgetary impact on
schools could potentially impact their ability to offer Medicaid
services to students.
　
　
・ Rescinding a rule, published November 7, 2008, that would have
limited the outpatient hospital and clinic service benefit for Medicaid
beneficiaries to the scope of services recognized as an outpatient
hospital service under Medicare. This rule was rescinded because CMS
became aware that coverage beyond that scope could not be easily moved
to other benefit categories, resulting in great impact than previously
anticipated.
　
　
・ Rescinding provisions of an interim final rule published
December 4, 2007, which would have restricted beneficiary access to case
management services. These provisions appeared to, in practice, restrict
beneficiary access to needed covered case management services, and limit
state flexibility in determining efficient and effective delivery
systems for case management services.
　
　
・ Delaying until June 30, 2010, the enforcement of portions of a
regulation that clarified limitations on health care related tax
programs so that CMS could determine whether states need additional
clarification or guidance. CMS may also further review the potential
impact of the regulation, and give additional consideration to
alternative approaches.

San Francisco Unified School District Sues State of California Over Free Care

May 29, 2009

Click here for the School District press release and copy of the pleadings.  Click here for the correspondence from CMS that is the basis for the State's action.

What a Difference a Day Election Makes!

Center for Children and Families Director Mann Appointed

by Obama Administration to
Direct Medicaid and CHIP
 

May 29, 2009
 

Secretary of Health and Human Services Kathleen Sebelius announced today that Georgetown University Center for Children and Families Director Cindy Mann has been appointed Director of the Center for Medicaid and State Operations at the U.S. Department of Health and Human Services (CMSO). CMSO oversees Medicaid and the Children’s Health Insurance Program (CHIP) at the federal level. Mann will assume her new position on June 8. CCF is an independent, nonpartisan policy center based at Georgetown University’s Health Policy Institute whose mission is to expand and improve health coverage for America’s children and families.

Mann was an original cofounder of CCF along with Deputy Directors Joan Alker and Jocelyn Guyer. In the four years since CCF began, it has become a nationally recognized and respected voice on issues related to health coverage for children and families at both the federal and state levels. Accomplishments include serving as a key resource to policymakers, state and national organizations, and the media during the reauthorization of CHIP and advising state-level policymakers, program administrators and advocates on coverage and enrollment policies.

Cindy Mann, J.D., is a research professor at Georgetown University, Health Policy Institute and the executive director of the Center for Children and Families at the Institute. Her work focuses on health coverage, financing, and access issues affecting low-income populations. She has written extensively on these issues -- and on how they relate to the Medicaid and CHIP, in particular -- and has worked closely with state and federal policymakers and program administrators on the design and implementation of Medicaid and CHIP. From 1999-2001, Ms. Mann was the director of the Family and Children's Health Program Group at the Health Care Financing Administration (HCFA), now the Centers for Medicare & Medicaid Services. In that capacity, she directed, at the federal level, the implementation and oversight of the Medicaid program with respect to families, children, and pregnant women, and oversaw the implementation of CHIP. Prior to her work at HCFA, Ms. Mann led the Center on Budget and Policy Priorities' federal and state health policy work. She also has extensive state-level experience, having worked on health care, welfare, and public finance issues in Massachusetts, Rhode Island, and New York. She holds a law degree from New York University School of Law.

Secretary Duncan outlines school reform agenda

May 22, 2009

Click here for the full report

Farewell, 2287

May 1, 2009

On May 1, 2009, the Federal Register contained the following posting regarding a proposed new final rule:

This rule proposes to rescind the December 28, 2007 final rule entitled “Elimination of Reimbursement Under Medicaid for School Administration Expenditures and Costs Related to Transportation of School-Age Children Between Home and

School”; the November 7, 2008 final rule entitled “Clarification of Outpatient Hospital Facility (Including Outpatient Hospital Clinic) Services Definition”; and certain provisions of the December 4, 2007 interim final rule with comment period entitled

“Optional State Plan Case Management Services.”

In plain language, this new rule would rescind CMS-2287-P2, the regulation that would have eliminated Medicaid reimbursement for school-based administrative and transportation services; portions of the Targeted Case Management regulation [CMS 2237-P]; and the regulation dealing with hospital outpatient services [CMS-2213-P2].  And, since it only calls for a thirty day public comment period, it would go into effect before the June 30 expiration of the current moratorium.  For those of you in the school community, that means that reimbursement for administrative and transportation services will continue.

The regulation also solicits public comment.  Please consider submitting comments of your own or those of your organization, pro or con.

Take that, Dreadful Dennis!

Call to Action: Live Webcast with CDF* President Marian Wright Edelman

May 1, 2009

Momentum is building—the next few weeks provide our nation with an unprecedented opportunity to make critical changes to our broken health care system. Our goal is to provide affordable, comprehensive health coverage to everyone this year—especially children.

Join CDF President Marian Wright Edelman and other child advocates for a live webcast and learn how you can step up and take action at this crucial time for our nation. Mrs. Edelman's speaking engagements are powerful experiences that change lives. Don't miss this exciting event!

May 12 at 3:00 p.m. EST/12:00 p.m. PST
RSVP today and submit a question for
Mrs. Edelman to answer during the webcast.

*The Children's Defense Fund's Leave No Child Behind® mission is to ensure every child a Healthy Start, a Head Start, a Fair Start, a Safe Start, and a Moral Start in life and successful passage to adulthood with the help of caring families and communities.

Sebelius, Napolitano, Besser to Host Webcast on Swine
Flu, Answers Questions from the American People

April 29, 2009
 

Health and Human Services Secretary Kathleen Sebelius, Homeland Security Secretary Janet Napolitano and Acting Director of the Centers for Disease Control and Prevention, Dr. Rich Besser will host a Webcast to answer questions and provide information directly to the American people regarding the 2009 H1N1 flu on Thursday at 1:00 p.m. EDT. The Webcast
can be viewed at www.hhs.gov and www.cdc.gov.

"At times like this, clear accurate information is one of the most powerful tools we have and we look forward to answering questions and speaking directly to the American people," said Secretary Sebelius. "Our administration believes in using new methods to engage the American people and ensure they can speak directly to their public officials. This Webcast is an important part of that effort."

"It's imperative that the American people know exactly what their government is doing, and exactly what they can do themselves to mitigate the spread of this virus," said Secretary Napolitano. "Everyone has a part to play in this, and it's important that the lines of communications are open."

Questions for the officials can be submitted by emailing hhsstudio@hhs.gov. Additional information regarding the Webcast is
included below.

WHAT:      Webcast regarding 2009 H1N1 flu virus

WHEN:      Thursday, April 30, 2009
                1:00 p.m. EDT

WHERE:    Watch the Webcast live at www.hhs.gov or www.cdc.gov. Submit questions for the Webcast by emailing hhsstudio@hhs.gov. Registration for the Webcast is not required.

Please note, you will need Flash (http://www.adobe.com) installed on your computer in order to view the live video stream.  You can test your ability to view the Flash video stream starting at 10 a.m. EDT on Thursday by visiting www.hhs.gov or www.cdc.gov.

NOTE:   Networks can access the Webcast via outbound fiber from VYVX:100355

Sebelius Confirmed as HHS Secretary

April 28, 2009

The Senate approved the nomination of Kathleen Sebelius to head the Department of Health and Human Services, filling the final seat in President Obama's Cabinet on the eve of his 100th day in office.

Democrats had sought a quick vote on the Kansas governor as Congress moves ahead with health-care reform this summer, but Republicans slowed Sebelius's advancement because of her record in favor of abortion rights. GOP procedural objections faded with the recent outbreak of swine flu and the threat of a global pandemic. Sebelius was confirmed by a 65-31 vote this afternoon.

April 27, 2099

The official FMAP increases are available in the Federal Register.  See second and third pages.

Lewin Group Study of Impact of CMS Regulations Begins

April 22, 2009

Last year, as part of Congressional action on the seven regulations proposed by CMS, the agency was required to contract with an independent company to produce a report on the fiscal impact and utilization of several of those regulations.  That report was to be presented to Congress in April, 2009.  The Lewin Group was selected to complete the study, and that process has just begun.  A copy of the draft questionnaire being used by Lewin is attached.  More on this story to follow.

Sebelius Confirmation Could Occur as Early as Tuesday

April 22, 2009

The Senate could vote as early as Tuesday on the nomination of Kansas Gov. Kathleen Sebelius to be Secretary of Health and Human services.  Senate Majority Leader Harry Reid announced that up to eight hours of debate on her nomination is scheduled to begin at 10 a.m. Tuesday. She will need 60 votes for confirmation.

At the urging of conservative religious groups, some Senate Republicans have opposed Sebelius because of her support for abortion rights. However, one of her strongest supporters has been fellow Kansan, Republican Sen. Pat Roberts, who is an ardent opponent of abortion. The Senate Finance Committee endorsed her selection on a vote of 15-8.

If the Senate approves her nomination, Sebelius will become the final member of President Obama's cabinet to be confirmed. The lack of an HHS Secretary has slowed progress filling several other critical posts, including Director of the Centers for Medicare and Medicaid Services.

Obama Selects Kansas Governor Sebelius for Secretary of HHS

March 2, 2009

WASHINGTON - Making it official, President Barack Obama says he has chosen Kansas Gov. Kathleen Sebelius for health and human services secretary.  He also has picked Nancy-Ann DeParle as the director of the White House Office for Health Reform.  The president's announcement comes just days before he holds a White House summit on health care.  Lawmakers from both parties and representatives of major interest groups, from insurers to drug companies to consumers, will attend.

For more on the nominee, click here.

Obama Sending States $15 billion for Medicaid

February 23, 2009

President Barack Obama said that his administration would move more than $15 billion in federal Medicaid dollars to states on Wednesday, a move meant to help stem a healthcare crisis in the face of rising unemployment and growing ranks of uninsured people.

“That means by the time most of you get home, money will be waiting to help 20 million vulnerable Americans in your states keep their healthcare coverage,” Obama told governors in Washington today at the National Governors Association annual winter meeting.

In his White House speech, the president reiterated that the funding—part of the much larger economic stimulus package—“is not a blank check.” Obama said that the dollars are “intended to go directly toward helping struggling Americans keep their healthcare coverage.” Several of the nation’s governors have said that the infusion of federal money into their Medicaid coffers, more than $87 billion over the next three years, could free up state dollars previously marked for the program to instead go to other programs outside of the healthcare arena.

FMAP State Allocations In the ARRA*

February 22, 2009

The Federal Medical Assistance Percentages (FMAPs) are used in determining the amount of Federal matching funds for State expenditures for assistance payments for certain social services, and State medical and medical insurance expenditures. The Social Security Act requires the Secretary of Health and Human Services to calculate and publish the FMAPs each year.

State by state details can be found here.

*American Recovery and Reinvestment Act (PL 111-5)

American Recovery and Reinvestment Act

Summary of Health and Income Support Provisions in Conference Agreement

February 11, 2009

 See the bottom of page two for extension of moratoria language

New Administration Halts Pending Bush Regulations

January 20, 2009

You [may have] Heard It Here First

January 15, 2009

A number of credible sources reported today that the House version of the new economic stimulus legislation contains language extending the moratoria on the six CMS regulations from April 1, 2009, to October 1, 2009.  Official confirmation/language will be posted here as soon as it is available.

Updated 1/16/09 - Click here for the official news release from the House and here for the first official printing of the House version.  You will not find the moratoria extension language in this version, as it is not in final form.

CMS Provides Written Answers to Questions From the NAME Conference

January 5, 2009

At the National Alliance for Medicaid in Education, Inc. (NAME) 2008 Annual Conference, the Centers for Medicare and Medicaid Services (CMS) conducted a panel presentation regarding Medicaid services provided in schools.  Conference participants submitted both written and oral questions to the CMS panel.  Due to time constraints, CMS was unable to answer all of those questions.  NAME recently received written answers from CMS and they are posted on the NAME site.

You can obtain further information about NAME and the benefits of membership by clicking here.

Reaching Out on Health Care

Daschle Visits Indiana for Grass-Roots Forum

December 31, 2009

Even before taking office or introducing concrete policy proposals, the administration-in-waiting is moving to build public support around the broad notion that the U.S. health system needs an overhaul. To Washington veterans, the approach may seem backward, or even naive, but Obama is betting that the energetic, technology-savvy supporters who fueled his candidacy will act as a potent counterbalance to the traditionally powerful special interests that have defeated similar reform efforts.  Full story here.

CDF Releases State of America's Children 2008® Report

December 25, 2008

The Children’s Defense Fund recently released its State of America's Children 2008 report, a compilation of the most recent and reliable national and state-by-state data on poverty, health, child welfare, youth at risk, early childhood development, education, nutrition and housing. The report provides a statistical compendium of key child data showing epidemic numbers of children at risk: the number of poor children has increased nearly 500,000 to 13.3 million, with 5.8 million of them living in extreme poverty, and nearly 9 million children lack health coverage, with both numbers likely to increase during the recession. The number of children and teens killed by firearms also increased after years of decline.

Learn more and download the report.

President-Elect's Transition Website can be found here.  Policy updates, legislative goals, introduction of appointees, etc. Your one-stop shop for the new administration

December 15, 2008

They're At It Again

December 6, 2008

From an Email originating from CMS:

From: Johnson, Donald N. (CMS/OL)

Sent: Friday, December 05, 2008 5:30 PM

Subject: HHS Releases Final Report to Congress on the Medicaid Regulations under Section 7001(c)(1) of the Supplemental Appropriations Act of 2008

Importance: High

I am pleased to inform you of the release of the attached Department of Health and Human Services report, “Final Report to Congress on the Medicaid Regulations under Section 7001(c)(1) of the Supplemental Appropriations Act of 2008”. This report was transmitted to the House Energy and Commerce and the Senate Finance committees on December 3, 2008.

Required under Section 7001(c)(1) of the Supplemental Appropriations Act, 2008 (P.L. 110-252), this report discusses in detail the problems the Medicaid regulations fully under moratoria were intended to address, how the design of the regulations were intended to address these specific problems, and the Centers for Medicare & Medicaid Services (CMS’) legal authority for each regulation. The following four rules are addressed in this report:

·        Proposed rule, published January 18, 2007 – Medicaid Program; Cost Limit for Providers Operated by Units of Government and Provisions to Ensure the Integrity of Federal-State Partnership (CMS-2258-P)

·        Proposed rule, published May 23, 2007 – Medicaid Program; Graduate Medical Education (CMS-2279-P)

·        Final rule, published December 28, 2007 – Medicaid Program; Elimination of Reimbursement Under Medicaid for School Administration Expenditures and Costs Related to Transportation of School-Age Children Between Home and School (CMS-2287-F)

·        Proposed rule, published August 13, 2007 – Medicaid Program; Coverage for Rehabilitative Services (CMS-2261-P)

A copy of the report in .pdf format can be download here.  With regard to 2287, notice that CMS uses the same tired old GAO and OIG reports of waste and abuse in school-based administrative and transportation services that they always drag out to try to make their point.  It is good to note that the dates they use are the dates of the reports, not the dates of the alleged events, many of which occurred before the 2003 MAC Guide, some as long ago as the late 1990's.  Apparently CMS would have us believe that, once having been told they are not in compliance, school districts continue their non-compliant behavior.

The report also makes reference to the 1997 Technical Assistance Guide, which mysteriously disappeared from the CMS site nearly two years ago

Some Useful Links as We Enter the Obama Years

December 2, 2008

More on The Baucus Proposal

November 13, 2008

Some of the provisions in the Baucus proposal with the most important implications for children and their families are:

      1.     Expanding SCHIP Coverage.  The Baucus plan proposes a notable expansion of SCHIP by creating a new requirement that all states cover children at least to 250 percent of the federal poverty level (FPL). As of October 2008, twenty-six states have enacted eligibility levels at or above 250 percent of the FPL.

o      States currently below 250 percent of the FPL.  The plan would require all states that have not yet expanded coverage to 250 percent of the FPL to do so.  If they wanted to expand further up the income scale than 250 percent of the FPL, they would continue to have the option to do so.

o      States already at or above 250 percent of the FPL.  States that already cover children above 250 percent of the FPL could continue to do so.

o      Possible changes to SCHIP Financing.  The plan acknowledges that SCHIP’s capped financing structure can cause states to cut back or freeze enrollment, and that this is a potential problem in a world in which everyone must enroll in coverage.  It suggests that changes will be made to SCHIP’s financing structure to address this issue, as well as the increased need for funds created by expansions to 250 percent of the FPL and beyond, but does not provide any details.

2.  Strengthening Medicaid A central part of the Baucus proposal is to strengthen and expand Medicaid, which has long been a cornerstone of the health care system.  It already serves more than 50 million Americans and will play an even more important role in the months ahead as  unemployment rises and more and more families lose their only access to affordable healthcare coverage.

o      Expansion of Medicaid to 100 percent of the FPL.  While not directly aimed at children, the Baucus plan includes a proposal to expand coverage to all people below 100 percent of the federal poverty level.  If adopted it would not only offer help to millions of adults, but also would ensure that children living in poverty can enroll in the same source of coverage as their parents.   When children are covered through the same source of insurance as their parents, they are more likely to enroll in coverage and to secure necessary care. .

o      Ensuring Medicaid’s stability during difficult economic times.  With the proposed health care system relying heavily on Medicaid, the Baucus plan acknowledges the importance of ensuring that Medicaid remains stable and strong, including during difficult economic times.  To that end, the Baucus plan calls for increasing the federal Medicaid matching rates of states when an economic downturn occurs.  It notes a variety of options that could be used to determine when additional federal matching funds should be made available, but does not offer a detailed proposal.

White Paper on Health Care Reform

November 12, 2008

This morning Senate Finance Committee Chairman Max Baucus released an executive summary of his white paper on health care reform.  The 100-plus page white paper will be released later this week. Click here for the executive summary.

Here is a quick summary of the parts affecting Medicaid and SCHIP:

Medicaid

·     Recommends setting a national minimum Medicaid eligibility level at 100 percent of the poverty level, essentially eliminating categorical eligibility below this level. Senator Baucus estimates that this would cover an additional 7.1 million people.

-      States that already offer Medicaid coverage above 100 percent of poverty would be required to continue to do so and would continue to receive the same federal financial participation for those groups.

-     The plan does not specify how the expanded coverage below 100 percent of poverty would be financed, but says that it would “invest new Federal resources to help states, and is committed to findings ways for the Federal government and the states to share responsibility for the costs associated with increased Medicaid enrollment.”

-      No individuals currently eligible for Medicaid coverage would lose eligibility under the plan.

·     Recommends developing simplified, uniform enrollment and renewal processes, updating eligibility systems, and additional federal support for outreach efforts.

·     Recommends establishing a new, permanent counter-cyclical Medicaid financing mechanism that would trigger an automatic increase in the federal match rate for Medicaid during times of economic downturn. This would alleviate the need for Congress to pass legislation to increase the FMAP each time the nation faces an economic crisis.

·     Recommends eliminating the five-year ban on legal immigrants’ eligibility for Medicaid and CHIP.

·     Encourages efforts to improve quality and access in Medicaid and CHIP.

CHIP (the Children’s Health Insurance Program)

·     Recommends setting a mandatory minimum CHIP eligibility level at 250 percent of poverty (29 states currently have CHIP eligibility levels lower than that and have no expansions pending).

-      States that already offer CHIP coverage above 250 percent of poverty would continue to receive the same federal financial participation they receive today.

·     Calls attention to the insufficiency of CHIP allotments in the past, and calls for the federal government to help states with the costs associated with increased CHIP enrollment. The plan does not provide details, but cites the CHIP reauthorization bills of 2007 as examples of how this might be done.

Financing

·     The plan does not list specific sources of financing for the plan, but includes a discussion of the savings that could be derived from:

-         Reducing fraud, waste, and abuse;

-         Increasing transparency;

-         Reforming medical malpractice;

-         Extracting savings from Medicare Advantage plans;

-         Increasing efficiency in long term care; and

-         Making changes to the current tax treatment of health care.

·    Overall, the plan also envisions achieving savings by covering all Americans, increasing wellness and prevention, and investing in quality improvement efforts.

The Orphan Regulation - The One With No Moratorium Protection

November 10, 2008

 On Friday CMS published the final rule on the Medicaid outpatient reimbursement. The rule can be found here.  <p><strong>><a href='http://projects.washingtonpost.com/2008/pick-your-president/'>2008 Election Contest: Pick Your President</a></strong> - Predict the winner of the 2008 presidential election.</p>

 State Budget Woes Hit Schools Hard

October 7, 2008

As an increasing number of states suffer severe financial problems, budget cuts have reached schools.  A recent report from the Center on Budget and Policy Priorities notes that . . . "at least 14 states have implemented or are considering cuts that will affect low-income children’s or families’ eligibility for health insurance or reduce their access to health care services. Programs for the elderly and disabled are also being cut. At least 11 states are cutting medical, rehabilitative, home care, or other services needed by low-income people who are elderly or have disabilities, or significantly increasing the cost of these services.  At least 13 states are cutting or proposing to cut K-12 and early education; several of them are also reducing access to child care and early education, and at least 17 states have implemented or proposed cuts to public colleges and universities."

These facts are powerful arguments for protection of federal reimbursement for school based administrative and transportation services, and must be addressed by the new Congress before the current moratorium protecting those programs is lifted on April 1.

Senator Stabenow (D-MI) Introduces Bill to

Protect Rehab and Case Management

October 7, 2008

On September 26 Senator Debbie Stabenow of Michigan introduced S. 3611, a bill to To amend title XIX of the Social Security Act to improve the provision of rehabilitation services and case management and targeted case management
services under the Medicaid program, and for other purposes.  Full text here in .pdf format.  You can track the bill at www.thomas.gov

Names Being Mentioned as Potential Appointees for HHS Secretary

October 7, 2008

For McCain

Mike Huckabee, former governor of Arkansas

Mark McClellan, former administrator of Centers for Medicare and Medicaid Services

Bobby Jindal, Louisiana governor

For Obama

Rosa DeLauro, Connecticut congresswoman

Howard Dean, Democratic National Committee chairman

Kathleen Sebelius, Kansas governor

September 29, 2008

Congress overrides Medicare payment bill veto

July 15, 2008

Congress on Tuesday rejected President Bush's veto of legislation protecting doctors from a 10.6 percent cut in their reimbursement rates when treating Medicare patients (H.R. 6331, the Medicare Improvements for Patients and Providers Act of 2008).  The override vote in the House was a lopsided 383-41, easily meeting the two-thirds threshold needed to nullify the president's veto. About an hour later, the Senate voted to override, 70-26.

The bill also extends protection to the Departmental Appeals Board, which had been the subject of a disemboweling by CMS late last year. Details to follow.

The Fat Lady Finally Sang!

I'm writing to tell you that it's official

June 30, 2008

Over the weekend the President signed the War Supplemental funding bill with moratoria on six Medicaid regulations.  Congratulations to all of you who worked on the campaign to move Congress.  It shows you what a lot of will, determination and team effort can accomplish. You should never forget what you accomplished and should be very happy.  I am proud to be a small  part of your team.

Thank You!

Who Knows What Evil Lurks in the Hearts of Men?

June 1, 2008

That reference is from a radio show called “The Shadow,” which few of you will remember since it went off the air in 1954.  Unfortunately for us, it is also a question we should be asking about the Centers for Medicare and Medicaid Services.

Let me explain.  On December 28, 2007, CMS published the final version of CMS-2287, which eliminates federal reimbursement for school-based administrative services and most school-based transportation services.  Normally this rule would have been implemented sixty days after publication, or February 28, 2008.  A six month moratorium was imposed on the rule, however, which would have made the implementation date August 28, or thereabouts (60 days + 6 months).  Over the course of the months of March and April, however, CMS sent a variety of messages that established the implementation date as June 30, 2008; September 30, 2008, September 1, 2008, the first day of the 2008/2009 school year, [another moving target] and, if you believe the State of Georgia, February 28.

After a series of increasingly confusing messages from CMS, they seemed to settle on June 30 as the last day of the current reimbursement program, and that is the date LEAs and Congress have been using.  CMS has had ample opportunity to advise both if the date was something other than June 30 but has not done so. Last week, several states were notified in writing by their CMS regional offices that the implementation date is now September 1, 2008, not June 30.

Attempts have been made by several interested parties, including Congressional staff, to obtain clarification from CMS regarding this most recent shift.  The only response from CMS – and most inquires have met with stony silence – has shed no light on the subject and mimicked this email from CMS on February 8, 2008 (emphasis added) 

"The publication of the final school-based rule (CMS-2287-F) on December 28, 2007 does not affect the ability of States to submit claims for costs incurred prior to the effective date of the rule; the rule will be applied prospectively. However, as you know, there's a six-month moratorium on CMS' ability to enforce the rule, due to legislation recently signed into law. This moratorium is scheduled to end June 30, 2008.

Final regulations are typically effective 60 days after publication; however, due to the moratorium, that 60 day period starts once the moratorium ends. As a result, the implementation date for the rule will technically be September 1, 2008. CMS never intended States and Schools to be in compliance with the final rule prior to the start of the 2008-2009 school year, so the moratorium really has no effect on that timeline  . . . . Finally, although I indicated [in an earlier email] that CMS was considering developing some sort of additional guidance to address questions surrounding implementation of CMS-2287-F, there are no official plans to do so at the current time and no format specified for any guidance that may ultimately be issued.

Hope this helps. Let me know if you have additional questions.
Thank you.

Sharon Brown|
Administrative Claiming Team,
Division of Reimbursement and State Financing | Financial Management Group |
Centers for Medicare& Medicaid Services | (: 410-786-0673 | *: sharon.brown@cms.hhs.gov"

Because that communication was not entirely clear, I made contact with Ms. Brown shortly after her February email.  She was kind enough to respond by phone.  She left a message on my voice mail.  Here it is in its entirety.  (You will probably have to download it to play it.)

And if this date confusion weren’t enough, there is a second issue.  This one is far more troublesome.

• ·         Regardless of the implementation date, the only thing the moratorium really does is allow LEAs to continue to claim FFP for services delivered before that date
• ·         CMS will certainly retain the right to review those claims
• ·         CMS has repeatedly demonstrated, in previous audits, that it will audit administrative service programs for years prior to the May, 2003 Medicaid Administrative Claiming Guide rule changes even though the audits have been conducted in the years after the 2003 guide.  In some cases, they have gone as far back as the 1990s to disallow claims
• ·         If you follow this twisted logic, CMS could review claims made for services delivered between December 8 and the date of the moratorium and impose the conditions set out in 2287; e.g., disallowing most transportation claims.

Stay tuned  If you want to try for clarification on your own, the CMS contact for public information inquiries is Jeff Nelligan, Director of Media Affairs, Central Phone: 202-690-6145, Central Fax: 202-690-7159, E-mail: OEABox@CMS.HHS.GOV  If that doesn’t work, you can find contact information for your Member of Congress by clicking here.  Maybe she/he can find out.

Updated Chart on the State of CMS Cuts and Moratoria

May 29, 2008

Click here for an updated chart on the Medicaid Regulations that reflect recent action by the U.S. District Court for the District of Columbia.

Desperate People do Desperate Things

 May 21, 2008

Fearful that a federal Judge was going to act on Friday to declare 2258 to be in violation of existing moratorium,  which would then require the Administration to give a 60 day comment period before the regulation could be effective, the Administration issued the following statement.  This announcement is to make it look like Administration is in control and at same time is give Republican Senators an excuse to vote against the domestic amendment (which includes the moratoria) on the Senate floor tomorrow. After all, "we have 60 days to negotiate.”

----------------------------------

May 21, 2008

To:  Republican Health Policy Staff

Fr: Andy Chasin

Re:  Voluntary Extension of Moratorium on IGT and GME Rules

The Administration today announced that they would voluntarily extend for 60 days the moratorium on Medicaid rules related to intergovernmental transfers (IGT) and graduate medical education (GME).  The Administration has previously indicated that it would consider staying its rules on intergovernmental transfers and graduate medical education funding while negotiating changes to these rules with lawmakers.  Those rules represent $885 million of the $1.65 billion at issue for the seven Medicaid rules.  Without further action the IGT and GME rules will now go into effect August 1st instead of May 25th.

Secretary Michael Leavitt released the following statement today:

"I reiterate the Administration's willingness to work with Congress and Governors to discuss their concerns before the rules go into effect", Secretary Leavitt said.  "We will voluntarily refrain from making these rules effective until August 1, 2008, more than 60 days after the moratorium expires.  I invite interested parties to sit down with me and my staff in the coming weeks to ensure that we meet our mutual commitments to protect health care for low-income individuals."

The two rules at issue are:

·         Graduate Medical Education - CMS 2279 - proposed rule published on May 23, 2007.  Cost:  $115 million for the moratorium. For permanent repeal, $800 million over 5 years, and $1.9 billion over 10 years.

·         Cost limit for Providers Operated by Units of Government and Provisions to Ensure the Integrity of Federal-State Financial Partnership - CMS 2259-FC- final rule with comment period, published on May 29, 2007.  Cost:  $770 million for the moratorium.  For a permanent repeal, $9.0 billion over five years and $22.0 billion over 10 years.

FINANCE BRINGS UNEMPLOYMENT INSURANCE, MEDICAID SAFEGUARDS
TO 2008 SENATE SUPPLEMENTAL FUNDING BILL

For Immediate Release Contact: Dan Virkstis
May 21, 2008 (202) 224-4515

Baucus urges passage of bipartisan provisions for America

as funding bill moves to Senate floor

Washington, DC – Senate Finance Committee Chairman Max Baucus (D-Mont.) today urged passage of key Finance provisions in the domestic spending portion of the 2008 supplemental funding bill, including measures that would extend unemployment insurance (UI) for America’s workers and that would safeguard Medicaid services for millions of low-income Americans. The Senate Finance Committee put forward similar UI provisions in late January as part of the economic stimulus package, and Baucus has been vocal in his opposition to stringent Medicaid regulations issued by the Department of Health and Human Services (HHS) to reduce federal funding to the Medicaid program.

“These provisions in the supplemental spending bill target some of today’s most urgent domestic issues by providing additional assistance to those Americans who have lost their jobs during this tough economic time, and by protecting Medicaid coverage for millions who face being shut out of our health care system,” said Baucus. “I urge my colleagues in the Senate to do what’s right for America’s working families, and move these provisions in our supplemental funding bill.”

The UI provision would make 13 weeks of additional UI benefits available to jobless Americans through the end of March 2009. Americans in high unemployment states – with total unemployment rates of six percent or higher – would have 13 additional weeks of eligibility for a total of 26 additional weeks. Individuals who have begun to receive either 13-week extension of benefits by the end of March would be eligible to receive benefits for the remainder of that 13 weeks.

One provision related to Medicaid would suspend until April 1, 2009, seven regulations issued by HHS to reduce federal funding to the Medicaid program by nearly $20 billion, cutting millions of vulnerable Americans out of the health care system. Specifically, the proposed rules would force cuts in school-based, rehabilitation, and case management services, and limit the ability of states to impose taxes on health care providers. They would also change the definition of public provider, the definition of outpatient services, the policy on intergovernmental transfers, and eliminate payment for graduate medical education. These rules would shift millions of dollars in health care costs to state and local governments at a time when they are already under tremendous financial pressure. The National Governors’ Association has asked Congress to block these proposed regulations.
 

Cost Estimate for Protecting the Medicaid Safety Net Act of 2008,

Congressional Budget Office:

April 25, 2008

The CBO cost estimate examines legislation (HR 5613) that would place a one-year moratorium on seven new Medicaid regulations for services supplied by public providers; graduate medical education, school-based administration and transportation services; and rehabilitation services. CBO estimates that the increases in spending under the bill would cost $1.8 billion between 2008 and 2013, and the decreases in spending under the bill would save $1.9 billion between 2008 and 2018, largely due to the required delays in implementing the regulations. According to CBO, the legislation would not affect federal revenues or discretionary spending (CBO cost estimate, 4/22).

The Governors Weigh In

April 24, 2008

Floor Statement of U.S. Senator Chuck Grassley of Iowa
Ranking Member of the Committee on Finance
Medicaid Moratoriums Bill Moving in the House
Wednesday, April 16, 2008
 

Today the House Energy & Commerce Committee is taking up consideration of HR5613. This bill seeks to place a moratorium on seven Medicaid regulations until the next Administration. I know some people have concerns with the CMS Medicaid regulations.

Let me be clear: I’m not here to argue the regulations are perfect. I have issues with some of them I’d like to see addressed. However, the regulations do address areas where there are real problems in Medicaid.

Mr. President, Medicaid is a federal-state partnership that provides a crucial health care safety net for some very vulnerable populations – low-income seniors, the disabled, pregnant women, and children. They depend on Medicaid, and it does generally serve them well.

Medicaid is also a program with a checkered history of financial challenges. That’s the gentle way of putting it. A more severe way of putting it would be that Medicaid has a history of states abusively pushing the limits of what should be allowed to maximize federal dollars sent to them.

I’m not going to devote time in my remarks today to issues of fraud and abuse in Medicaid. I’ll probably be back to do more on that later. Instead, I want to focus on a very simple concept: Medicaid program integrity depends on CMS and the states and providers and ultimately, beneficiaries having a clear understanding of the rules of the road. When states don’t have clear guidance, they could be inappropriately spending taxpayer dollars. Improper payments and wasteful spending only increase the financial pressure on the safety net.

Mr. President, the Medicaid regulations HR5613 attempts to halt are efforts by CMS to provide clearer rules of the road in critical areas where there have been well documented problems. During the recent debate on the budget resolution, I entered into the record a CRS memo that showed some of the issues that exist under current law. I’m not going to go into them in detail today, but when CMS doesn’t know how a state is billing for a service and states don’t have clear guidance for how they should bill, neither Medicaid beneficiaries nor the taxpayers are well served.

We should be talking about fixing the regulations so they better address real problems in Medicaid, but instead the House is trying to kick the can to next year.

So what does that mean for the taxpayer? HR5613 spends $1.7 billion to place moratoriums on the regulations. This is only to delay the regulations until the end of March of next year. I know supporters hope that the next administration will completely cancel the regulations. What would it cost if we tried to completely prevent these regulations from ever taking effect? Not $1.7 billion that’s for sure. It would actually cost the taxpayers almost $20 billion over the next five years and almost $50 billion over the next ten years.

It is an absolute farce for anyone to argue that all of those dollars are being appropriately spent and that Congress ought to just walk away from these issues. But that’s what HR5613 does. Now I know supporters of that bill will say they just need more time. They say they haven’t had enough time to study the regulations and respond.

That argument is starting to strain credibility. The public provider rule was proposed well over a year ago. The rehabilitation services rule was proposed nine months ago. Supporters of the bill have had plenty of time, if they wanted to make new policy. But it is obvious by their actions, their only real interest is making the regulations go away. This is unfortunate Mr. President, because finding solutions is what we should be doing. When we start talking about the integrity of the Medicaid program, clarity is what is most needed between CMS and the states. If you don’t like the rules, fine. But there are ten of billions of taxpayer dollars involved. Roll up your sleeves and get to work solving the problems the regulations try to solve.

Mr. President, that’s what we should be doing for the taxpayers. Putting moratoriums on all of the Medicaid regulations issues by CMS is not the right answer.

"Apres moi, le deluge”

Let us Hope Not

Dennis Smith will be leaving CMS tomorrow. Herb Kuhn will be appointed as the Acting Center Director.  Mr. Kuhn is currently the Deputy Administrator under Kerry Weems.  More on Mr. Kuhn.

An Editorial

April 10, 2008

“He who lives by the sword dies by the sword.”

Dennis Smith was a good soldier.  Time and time again he carried the Administration’s water on the spate of regulations affecting reductions in health care coverage for pregnant women, low-income children, nursing home residents and other groups.  

From time to time, good soldiers are asked to fall on their swords.  Smith, described by the Wall Street Journal as the “architect of the rules,” did so.

Over the course of the past two years or so, Mr. Smith increasingly lost credibility with both parties in Congress.  It was almost painful to watch him testify before the various committees, where he was often asked valid questions to which there were no reasonable answers.  Reports demanded by Congress and promised by Smith were almost always tardy or ignored, with excuses no better than a child’s “The dog ate my homework.”

Smith’s sword was sharpened by the Administration’s abject miscalculation of the furor the seven regulations (and the evisceration of the DAB) would have.  The battle is not over, by any means, but Smith has already had to pay the price.  We will see him again, perhaps on the staff of a Member of Congress already troubled by the moratoria.  Unfortunately for Dennis, his reputation as the Administration’s voice will travel with him.

This is neither the time nor the place for an ad hominem attack on Mr. Smith, but those who have worked with him in the past, including during his tenure as Director of the Department of Medical Assistance Services for the Commonwealth of Virginia, seem to believe that his personality and his mission too often merged. 

Dennis Smith was a good soldier.  Let us hope for his sake - and for our own - that he is not asked again to fall on his sword.

Interested in the Energy and Commerce Health Subcommittee

Hearing This Morning?

April 9, 2008

H.R. 5613, the “Protecting the Medicaid Safety Net Act of 2008”
Read the Committee Action Sheet
View the Archived Webcast or Download

Did You Miss the Energy and Commerce Health Subcommittee Hearing Last Week?

Connect to the Archived Video Webcast of this Hearing or Download

Be sure to listen to Mr. Dingell's opening remarks

The House Energy and Commerce Subcommittee on Health

Hearing on H.R. 5613

April 3, 2008

Full details will be posted here soon, including a link to the recorded video.  Here is the link to the written testimony of the witnesses.  Markup of the bill is next week, with a floor vote the next week. Stay tuned.

H.R. 5613 Cosponsor List as of April 3, 2008

Congressional Research Service Report on 2258

March 26, 2008

The Congressional Research Service March 25 released a report that outlines how a controversial Centers for Medicare & Medicaid Services final rule would affect states' use of intergovernmental transfers to fund their Medicaid costs.

The report, Medicaid Regulation of Governmental Providers, explains that intergovernmental transfers (IGTs) allow states to help fund their share of Medicaid costs through contributions from local governments or other governments entities. Some states have interpreted the term "public agency," which is included in the lists of entities eligible to contribute to state costs, to include providers that are not governmental but have a "public-oriented mission," such as not-for-profit hospitals, according to the report.

However, the rule would tighten the definition of a government entity, eliminating the term public agency and making some hospitals ineligible to contribute to state Medicaid costs.

CMS contends that the rule is necessary because arrangements in which hospitals participate in IGTs are "often repaid through Medicaid disproportionate share hospital payments or through inflated Medicaid payment rates for which federal matching amounts are claimed," according to the report.

In addition, states can make Medicaid payments to hospitals or another provider which are then transferred back to the state through an IGT. The net effect, according to the report is to "effectively raise the federal matching rate in the state to levels beyond those specified in law."

The rule also would limit payments to governmentally operated providers to amounts that do not exceed costs, although the limit would not apply to Indian Health Services facilities, tribal facilities, or disproportionate share hospital payments, according to the report. Another provision of the rule would require government entities to document that they are making a certified public expenditure when they contribute to state Medicaid costs.

The May 2007 rule (72 Fed. Reg. 29748) has drawn criticism from Congress, states, provider groups and advocacy organizations who say its reduction in payments to the states would be detrimental to Medicaid beneficiaries.

Congress enacted a moratorium prohibiting implementation of the rule until May 25, 2008, and pending legislation would extend it further. In addition, a coalition of provider groups, which together represent most of the nation's hospitals, have filed a lawsuit seeking a preliminary injunction prohibiting implementation of the rule ((No. 48 HCDR 3/12/08) ..

See link to new CRS report on IGTs and the Medicaid Public Provider Cost Limit Rule.

BNA
Volume 13 Number 59
Thursday, March 27, 2008
ISSN 1091-4021
 

Good News from The Hill

March 25, 2008

Senator Jay Rockefeller (D-WV), Chair of the Senate Finance Health Subcommittee, is about to introduce legislation that would delay implementation of the seven offensive CMS Regulations until April 2009. His bill will look like Representative Dingell’s H.R. 5613, the Protecting the Medicaid Safety Net Act , but may also address an August 17 directive from CMS that attempts to limit eligibility and expansion of SCHIP.  That directive requires states to confirm that the state children’s health insurance program (SCHIP) is serving 95 percent of eligible Medicaid beneficiaries in families earning less than 200 percent of the federal poverty level (FPL) before allowing coverage expansions to families earning more than that. 

Legislation imposing moratoria on CMS regulations has faced problems with cost (CMS claims significant cost savings in the first year for most of its proposed regs) but both the House and Senate budget resolutions include budget-neutral reserve funds for moratorium legislation.

Both House and Senate bills would put off for one year the recent CMS regulations affecting intergovernmental transfers; coverage of rehabilitation services for people with disabilities; outreach and enrollment in schools; specialized medical transportation to schools for children covered by Medicaid; graduate medical education payments; outpatient hospital services; targeted case management services; state provider tax limits, and appeals filed through the HHS Departmental Appeals Board.

As Mr. Dingell pointed out in a press statement accompanying introduction of his bill, “If the Administration’s proposed cuts move forward, those most in need will pay the highest price. The restrictions the Administration is imposing on Medicaid are harmful and will undoubtedly put the health of thousands of our most vulnerable children at unnecessary, indefensible risk.”

Two recent reports indicate that, if implemented, the rules would have a disastrous effect on states’ economies and their ability to provide services to the most vulnerable beneficiaries.

House Oversight Committee Chairman Henry Waxman conducted a survey of State Medicaid officials who estimated state losses could top $50 billion over five years in reduced federal payments due to the regulations.  This is nearly three times CMS’ original estimate.   

A recent report commissioned by First Focus, a children’s advocacy group, and produced by Professor and attorney Sara Rosenbaum of George Washington University’s School of Public Health, found that the rules would especially harm low-income children with special needs and may violate a Medicaid provision requiring access to the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program.

Bruce Lesley, President of First Focus, points out that as states battle to counteract the current economic downturn, the CMS regulations shift of Medicaid costs to the states could saddle children most in need of health care with the burden of paying for it themselves or going without treatment.  The regs would also cut billions of dollars from the budgets of public schools, which would then be faced with the decisions to reduce funding for education and health services or raise state and local taxes to pay for the reduction in federal support.

Senator Charles Grassley (R-IA), meanwhile, warns that while the Medicaid regs may be imperfect, ignoring the problems they are intended to solve would be bad public policy.   Senator Grassley would like Senate Finance to review all the rules and replace them with “sound policy.”

Opposition to the CMS regs has come from a variety of sources, including some that may not have been foreseen by the Administration.  For example, former Republican National Committee Chairman and current Mississippi Governor Haley Barbour testified at the February 26th Waxman hearings that the regulations banning intergovernmental transfers and graduate medical education payments under Medicaid would devastate a number of providers in Mississippi and cost the state upwards of one hundred million dollars.

Stay tuned.  It’s just beginning to get interesting.

Hospitals File Lawsuit Over Medicaid

Groups representing most of the nation's hospitals announced Tuesday they were suing federal health officials to block the enactment of regulations that some hospitals claim threaten their survival.  The regulations would restrict federal Medicaid payments so they don't exceed the cost of providing care. But hospital officials said the rules would make it harder to offset the expense of treating the uninsured.  Find the full story here.

Participants in the lawsuit include the American Medical Association, the National Association of Public Hospitals and Health Systems, and the Association of American Medical Colleges.

Federal action "sneaky, mean, shortsighted"

[yes, I know I originally posted this back in February, but it is fun to read again, isn't it?]

February 13, 2008

Hey, I didn't say that.  The Bakersfield Californian did.  Read the whole column here.

You Had Your Chance, CMS

March 5, 2008

In response to a series of reports presented Monday by Representative Henry A. Waxman, Chairman of the Oversight and Government Reform Committee, showing the terrible fiscal impact of the CMS regulatory cuts, CMS spokesman Jeff Nelligan said that the committee's report is "not credible."  According to Mr. Nelligan, "The committee paper fails to provide any reliable information such as the assumptions, expenditure reports, the knowledge of how states will respond, and budget forecasts necessary to substantiate any of the numbers contained in the paper."

Mr. Waxman asked for this information weeks ago and CMS would not or could not make it available to him.  He then went directly to the states and got responses from more than forty of them.  Is CMS suggesting that the states were all lying or inept?

(The complete reports from Mr. Waxman's Committee can be found below)

It Had To Happen - TCM Rule Goes To Court

NEWS RELEASE

February 29, 2008


Today, Maine Attorney General Steve Rowe announced the filing of a lawsuit against the United States Department of Health and Human Services (US DHHS) and Michael Leavitt in his capacity as Secretary of US DHHS. The Complaint, filed in the United States District Court for the District of Columbia, challenges a certain agency rule that would adversely impact many of Maine's Medicaid recipients and cost the State's general fund more than 16 million dollars in fiscal years 2008 and 2009.  Maine joins with Maryland, New Jersey, and Oklahoma in this litigation. The states allege that portions of the revised rules violate the 2005 Deficit Reduction Act and parts of the Social Security Act.

The US DHHS promulgated an Interim Medicaid Program Final Rule on December 4, 2007 relating to Medicaid case management and targeted case management.

In the complaint, Maine and three other states allege that portions of the Interim Final Rule promulgated by the US DHHS are arbitrary, capricious, an abuse of discretion and not in accordance with the 2005 Deficit Reduction Act or any of the provisions of Title XIX of the Social Security Act. The complaint also alleges that the US DHHS violated the rule making requirements of the federal Administrative Procedure Act (APA) and that the Interim Final Rule does not provide a reasonable transition period for Maine to modify its case management programs.

Rowe said that many of the provisions in the Interim Final Rule will jeopardize the health and safety of Medicaid beneficiaries, limit the state's flexibility to provide case management in the most effective and efficient manner and result in a substantial reduction in federal funds for Medicaid case management services.

"This federal rule will abruptly cut off funding that helps protect the health and safety of our state's most vulnerable citizens. The rule is not only unfair to States and Medicaid beneficiaries, it is also illegal. We are confident that the federal court will find that the Secretary of Health and Human Services exceeded the authority given to him by Congress." Rowe said. "States derive no pleasure from suing the federal government. However, in this case, we must do so to protect the health and safety of our citizens."

Joining Maine in this lawsuit are Maryland, New Jersey and Oklahoma.

This suit seeks injunctive relief, which is a court-ordered act or prohibition against an act or condition which has been requested, and sometimes granted, in a petition to the court for an injunction. Such an act is the use of judicial (court) authority to handle a problem, and is not a judgment for money. Whether the relief will be granted is usually argued by both sides in a hearing rather than in a full-scale trial, and the overall process is much quicker that a trial.  There are normally three stages in this form of injunctive relief; first, a temporary restraining order, which is intended to prevent immediate harm; second, a preliminary injunction, which could be granted after arguments are heard by the Court; and finally, a permanent injunction, which is just what it sounds like.

If You Were Waiting for Mr. Waxman's Next Step . . .

March 3, 2008

Today Representative Henry A. Waxman, Chairman of the Oversight and Government Reform Committee of the House released a new report: The Administration’s Medicaid Regulations: State-by-State Impacts.

Click here for an interactive map showing how the proposed regulations would impact each state.

The report details the state-by-state impacts of seven regulations issued by the Centers for Medicare & Medicaid Service (CMS) that would make major, wide-ranging changes in Medicaid, the nation’s largest low-income health care program.

“As the economy tips into recession, the last thing we should be doing is taking federal funds from states, especially funds that are supposed to help people with their health and medical expenses,” said Chairman Waxman. “The Bush Administration has proposed drastic changes in the Medicaid program, without even attempting to understand the financial impact on states, localities, and the people they serve. The Governors have opposed these proposals on a bipartisan basis. With this report, we can really see why. I hope that the Administration will reconsider these misguided regulations.”

Although Medicaid is the largest health care program operated by the states, the Administration has failed to provide any estimates of the state-specific impacts of its regulations. After several unsuccessful attempts by the Committee to obtain these important state estimates from CMS, the Committee requested an analysis from Medicaid State Directors on the impact of the CMS regulations on their state.

The report finds that the state estimates of the fiscal impact of the CMS regulations are significantly higher than the $15 billion impact projected by the Administration for next five years. States estimated that the regulations would reduce federal payments to them by nearly $50 billion over the next five years, more than three times the Administration’s estimate.

The large discrepancy between the state estimates and the CMS estimates is evidence that the regulations are likely to have a much larger fiscal and programmatic impact on state Medicaid programs and state budgets than people realize.

The report also finds:

• The combined effect of the reductions in federal funds from all seven regulations represents a major fiscal blow for many states;
• The regulations will reduce federal spending by shifting costs, not through greater efficiencies;
• The regulations will disrupt existing systems of care for fragile populations; and
• The regulations threaten the financial stability of the hospitals, emergency rooms, and clinics that treat Americans without health insurance.

Documents and Links

•  Press Release (102 KB)
•  Feature: The Administration's Medicaid Regulations: State-By-State Impacts
•  Report: The Administration's Medicaid Regulations: State-By-State Impacts (305 KB)
•  Summaries of State Responses (179 KB)

Progress in Saving School Services Reimbursement:

Medicaid Moratorium Could Be Extended

March 3, 2008

The Senate Budget Committee has set aside enough money to keep the school-based Medicaid reimbursement program in operation well into 2009.  For the funds to become available, however, the authorizing committees which oversee the Health & Human Services Department must approve a change in the law.

Members of Congress with control over HHS are well aware of and sympathetic to concerns on the Medicaid reimbursement program’s proposed termination by the Centers for Medicare & Medicaid Services in HHS.  As a result, expect a bill to be introduced in each chamber next week to extend -- into March of 2009 -- the current moratorium, which expires June 30.  There has been pressure from Members of the Senate and a number of Governors to continue this moratorium, as well as others affecting a variety of Medicaid programs.

In preparation for the bills, the House Oversight and Government Reform Committee will be releasing a report on  Monday, March 3, on the impact that reimbursement termination would have on each of 41 states surveyed.

Who Do They Think They are Kidding?

February 25, 2008

In its attempts to explain the effective date for 2287 (administrative and transportation services reimbursement), something it has yet to accomplish with any clarity, CMS has repeatedly claimed that it is trying to “avoid disruption to the 08/09 school year.”  At best, the agency is being disingenuous.  The disruption has already occurred, as LEAs attempt to cope with the budget cuts 2287 will cause.  As one example, most states require school districts to notify teachers no later than March 15th if they will not be reemployed in the fall.  Pink slips will be falling like autumn leaves.  No, wait.  A better metaphor would be that they will descend like a late and especially bitter snowstorm. 

Current Status of the CMS Regulations

February 25, 2008

With sincere thanks to Judy Chesser, New York City Health and Hospitals Corporation.  This document says it won't print within the margins, but it does.

Critics Say New Medicaid Rules Will Hurt States During Economic Downturn

Feb 20, 2008

Critics of Medicaid regulations [TCM] that will begin to take effect on March 3 contend that implementing the rules during an economic downturn "will only worsen the fiscal situation for already strapped state budgets," CQ HealthBeat reports. Speaking at a forum sponsored by the Alliance for Health Reform and the Kaiser Family Foundation's Commission on Medicaid and the Uninsured, Barbara Edwards of the National Association of State Medicaid Directors said that as the economy weakens, more workers are becoming unemployed and some are enrolling in Medicaid because they have no alternatives for coverage. At the same time, state revenues are declining, and states are faced with more demands for Medicaid services and fewer resources, Edwards said, adding that the timing "almost couldn't be worse for states for many reasons."

However, Dennis Smith, director of CMS' Center for Medicaid and State Operations, at the forum said that timing is not the only consideration. "In good times people say, 'Don't rock the boat.' In tougher times they say, 'Oh no, not now,'" adding, "We think that these are good regulations that help preserve the integrity of the program" (Johnson, CQ HealthBeat, 2/19).

[Excerpted from the Kaiser Family Foundation Report of this date]

American Public Human Services Association Analysis of TCM Regulation

February 21, 2008

The American Public Human Services Association and its affiliates, the National Association of State Medicaid Directors and the National Association of Public Child Welfare Administrators has assembled an excellent side-by-side comparison of the Deficit Reduction Act provisions covering TCM and the CMS proposed CMS regulation on the same issue.  You can find it here, along with their cover letter.

Federal action sneaky, mean, shortsighted

February 13, 2008

Hey, I didn't say that.  The Bakersfield Californian did.  Read the whole column here.

It isn't June 30th, it's September 1

(Or Maybe it isn't.  Standby.  More CMS Memos are Flying)

February 8, 2008

From an email from CMS regarding CMS-2287:

"The publication of the final school-based rule (CMS-2287-F) on December 28, 2007 does not affect the ability of States to submit claims for costs incurred prior to the effective date of the rule; the rule will be applied prospectively. However, as you know, there's a six-month moratorium on CMS' ability to enforce the rule, due to legislation recently signed into law. This moratorium is scheduled to end June 30, 2008.

Final regulations are typically effective 60 days after publication; however, due to the moratorium, that 60 day period starts once the moratorium ends. As a result, the implementation date for the rule will technically be September 1, 2008. CMS never intended States and Schools to be in compliance with the final rule prior to the start of the 2008-2009 school year, so the moratorium really has no effect on that timeline.

With respect to claims for prior periods, all such claims must meet the timeliness requirements specified at 45 Code of Federal Regulations (CFR) 95.7. In addition, Section 1132(a) of the Social Security Act requires that a claim for federal financial participation (FFP) must Be filed within a two-year period that begins on the first day of the calendar quarter immediately following the quarter in which the expenditure was made. The implementing regulations for timely filing
Are at 45 CFR Subpart A and provide specific guidelines for determining when an expenditure is said to have been made, so as to initiate the two-year filing period.

Finally, although I indicated that CMS was considering developing some sort of additional guidance to address questions surrounding implementation of CMS-2287-F, there are no official plans to do so at the current time and no format specified for any guidance that may ultimately be issued.

Hope this helps. Let me know if you have additional questions.
Thank you.

Sharon Brown|
Administrative Claiming Team,
Division of Reimbursement and State Financing | Financial Management Group |
Centers for Medicare& Medicaid Services | (: 410-786-0673 | *: sharon.brown@cms.hhs.gov"

OK, so here is what I think this all means - the rule (CMS2287) goes into effect the last day of the current (07/08) school year.  CMS is trying to make the case that this is October 1, 2008.  That might be true if your state uses the federal fiscal year.  Most don't, but rather end their fiscal year on June 30.  That would then become the operative date for 2287.  Confused?  Stand by for more, including some serious attempts to extend the moratorium.  Don't stop keeping your time sheets.  This is FAR from over. Hell, she hasn't even come onstage yet.

Help on the CMS Regs from the Kaiser Family Foundation

February 7, 2008

If you are confused by the multiple CMS regulations of the past nine months, you will appreciate this analysis done by the Kaiser Family Foundation.

The Evisceration of the Departmental Appeals Board

January 28, 2008

.

Supreme Court Case Law Library

There are a number of Supreme Court cases that directly affect the issues of FAPE and "related services."  They are now posted on this site in the Case Law Library.  I will soon post a brief summary of each case for your convenience.  The cases currently in the library are BROWN v. BOARD OF EDUCATION; BOARD OF EDUCATION OF THE HENDRICK HUDSON CENTRAL SCHOOL DISTRICT; WESTCHESTER COUNTY v. ROWLEY; IRVING INDEPENDENT SCHOOL DIST. v. TATRO;  and CEDAR RAPIDS COMMUNITY SCHOOL DISTRICT v. GARRET F.  I especially recommend that you read the last two.

To gain access to any of the documents in the left hand margin, click on the document title.  Some of these documents are in Adobe format, and will require Adobe Reader to open.  If you do not have a copy of this program, you can download one for free by clicking on the link above.

To submit questions, comments or suggestions for the website, click on the e-mail address below:

greg8355@gmail.com

If you ever need a reminder of why we are in this fight, check this one out 

The History of IDEA from the US DOE.

Please feel free to use the information posted here in your efforts to expand access to Federal Medicaid funding for special education.

Any summary or analysis of any state or federal law or regulation is transmitted for informational purposes only and not for legal advice. Users should not act upon this information without seeking the professional advice of a lawyer in the applicable jurisdiction. An effort has been made to provide useful information, but the information is not necessarily complete, may be inaccurate, and may not reflect current legal developments. The provider does not warrant that the information is complete or accurate and disclaims all liability to any person for any loss caused by errors or omissions in any summary.

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Welcome:  This site was originally intended as a place for me to post materials that were handouts for a national presentation I made in Boston nearly two years ago.  Since that time I have expanded the site to include a library of important government documents (and this site is searchable by key word, by the way), a library of relevant Supreme Court cases, regular (well, maybe not so regular, as I try to keep up with the news as it happens) news updates, and the occasional editorial.  The site also has a new threaded discussion feature.  Most of the links you will need are in the left margin.  Enjoy, use and reproduce materials,  and refer freely.  Email me with questions, requests, etc.

Gregory Morris