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What’s the Latest?
Hill reports indicate that Congress will pass another Continuing Resolution through December 20.
Extends health center federal grant and workforce program funding.
What’s on Congress’s agenda before the 12/20 deadline?
• Must pass by 12/20:
• 12 Appropriations bills (or another CR)
• Health Care Packages that address health extenders, including CHC funding
• Other issues of note:
• Drug pricing and surprise medical billing
• Border wall, Impeachment, etc.
• Senate HELP Committee in June passed S.1895.• 5 years of level funding for CHCF, NHSC, THCGME
• House E&C Committee in July passed a revised version of H.R. 2328.• 4 years of level funding for CHCF, NHSC, THCGME
Current Options for Long Term Funding
Other CHC Priorities in 116th Congress
• Telehealth package introduced • S. 2741 and H.R. 4932, CONNECT For Health Act of 2019 • Removes the geographic restrictions around originating sites for FQHCs and allows FQHCs/RHCs to be reimbursed in Medicare as distant sites
• Drug Pricing and 340B• Concerning provision that would have excluded 340B from negotiated drugs removed from House bill
• Potential FQHC and physical therapy bill• Working alongside APTA to introduce bill that would allow FQHCs to be reimbursed for physical therapy services under Medicare/Medicaid
Michaela [email protected]
202‐570‐9790
Megan [email protected]
202‐336‐3735
Questions or looking for additional information?
Reach out to:
Long-term, Sustainable Advocacy
Goal: Expand, equip and mobilize grassroots and grasstops for long‐term
promotion and protection of CHCs
Long-term, Sustainable Advocacy
Why?• Funding challenges –
• $22 trillion federal deficit• Divided Congress
• Private competitors
• State and Federal regulatory challenges
• Advocate fatigue
Long-term, Sustainable AdvocacyHow?
• Collective Actions – National Advocacy Calendar
• Skill‐building – Advocacy Media Lounge (LTEs/OpEds)
• Integrating advocacy into operations – ACEs
• Consistent engagement of advocates
• Relationship building in local and state offices
Make Your Presence Known
Online Tips & Tools for Success:
• Visit the Fall Funding Blitz webpage for current advocacy resources
• Make sure to tag your elected officials when posting on social media
• Thank Members of Congress!
• Use #ValueCHCs so HC Advocacy can react and repost
Media Resources
NACHC Social Media GoogleDrivehttps://www.hcadvocacy.org/fallfundingblitz/
National CHC Advocacy Calendar
Coming Up…
2020 is an Election Year & theYear of the Nurse (NACHC campaign)
• February 12 – National Call‐in Day
•March 18 – P&I Hill Day & National Call‐In Day
• April 27 – National Tell Your Story Day (in‐district)
Movement: Sharing Best Practices
Send us your best practices. We want to share with others in the CHC movement.
Let us know how we can best support you!
Susan Burton Kristin St. [email protected] [email protected]
Bethany Hamilton, JDDeputy Director, State [email protected]
Susan SumrellActing Director / Deputy Director, State [email protected]
Kate FriedmanProgram Associate, State [email protected]
State Affairs Team
Hot Topics, but Stay Tuned
For today’s update, we’ll focus on the following hot topics:
• Medicaid – and other breakouts!
• Various Regulatory Actions
• Litigation of High Interest
Medicaid
• States turn to waivers!
• State Focus – CMS “fast tracking” waivers.
• Critical that health centers work with PCAs & Networks to ensure coordinated responses to complex proposals
Medicaid
What happened to expansion?
14 States have not yet adopted Medicaid expansion
States to watch: Georgia and Kansas, at the moment.Issues to watch: How states will leverage ACA Section 1332 waivers to move forward with Medicaid expansion, likely using a SSA Section 1115 waiver. Other states may leverage a “block grant” to provide limited expansions.
AlabamaFloridaGeorgiaKansas
MississippiMissouri
North Carolina
OklahomaSouth CarolinaSouth DakotaTennessee
TexasWisconsinWyoming
State Waiver Activity
Blockbuster Medicaid (1115) waivers:• AZ – work requirements pulled back• DC – behavioral health transformation approved
• GA – expansion; work requirements• IN – postponed work requirements• MN – IMD for SUD/OUD care; CCBHCs• NE – IMD for SUD/OUD care• OH –mental health and SUD services • TN – partial block grant, work requirements
• UT – per capita caps
Blockbuster Medicaid (1115) waivers:• AZ – work requirements pulled back• DC – behavioral health transformation approved
• GA – expansion; work requirements• IN – postponed work requirements• MN – IMD for SUD/OUD care; CCBHCs• NE – IMD for SUD/OUD care• OH –mental health and SUD services • TN – partial block grant, work requirements
• UT – per capita caps
ACA Marketplace (1332) Waivers:• ID – reinsurance and choice between expansion coverage or Marketplace coverage; rejected by CMS as incomplete
• KS – state bill under development to consider expansion but 1332 waiver similar to Idaho or Utah
• AK, CO, DE, HA, ME MD, MN, MT, NJ, ND, OR, RI, WI – All were approved state‐based reinsurance programs
ACA Marketplace (1332) Waivers:• ID – reinsurance and choice between expansion coverage or Marketplace coverage; rejected by CMS as incomplete
• KS – state bill under development to consider expansion but 1332 waiver similar to Idaho or Utah
• AK, CO, DE, HA, ME MD, MN, MT, NJ, ND, OR, RI, WI – All were approved state‐based reinsurance programs
We know it’s on your mind, and you can’t be in three places at the same time. Maybe two, but not three.
Medicaid Block Grant /Per Capita Cap Guidance
June 2019, CMS submitted a draft State Medicaid Director letter (guidance) to the Office of Management and Budget (OMB) called “Medicaid Value and Accountability Demonstration Opportunity.” Releaseis expected soon.
Pending guidance will invite states to submit Medicaid block grant waiver proposals, we are working to raise awareness within the administration regarding our concerns.
Medicaid Block Grant /Per Capita Cap GuidanceNACHC’s engagement on this issue aims to protect health centers, the communities they serve, and the integrity of the Medicaid program as a safety net.
NACHC Action:• Working with TNPCA on Section 1115
• Monitoring and preparing for OMB’s release of CMS guidance
• Met with OMB about safety net and express concerns
• Identify other high risk states and will be working directly with those PCAs
• Coordinating with other local and national organizations and allies
Medicare & Medicaid: Recent Federal & State Regulatory Activity
Federal Agency Action• New! Medicaid Fiscal Accountability Regulation – Under Review
• CMS and ONC Interoperability Rules – NACHC Commented
• Section 1557 Proposed Rule – NACHC Commented
• 42 CFR Part 2 – NACHC Commented
• Medicaid Access Monitoring Recession Proposed Rule – NACHC Commented
• USDA’s NPRM “Revision of Categorical Eligibility in the Supplemental Nutrition Assistance Program (SNAP)” – NACHC Commented
• Medicare Physician Fee Schedule Proposed Rule – NACHC Commented
Federal Agency Action• New! Medicaid Fiscal Accountability Regulation – Under Review
• CMS and ONC Interoperability Rules – NACHC Commented
• Section 1557 Proposed Rule – NACHC Commented
• 42 CFR Part 2 – NACHC Commented
• Medicaid Access Monitoring Recession Proposed Rule – NACHC Commented
• USDA’s NPRM “Revision of Categorical Eligibility in the Supplemental Nutrition Assistance Program (SNAP)” – NACHC Commented
• Medicare Physician Fee Schedule Proposed Rule – NACHC Commented
State Action on Medicaid and ACA in the Courts
In the Courts• Texas v. Azar – constitutionality of the entire ACA• Franciscan Alliance v. Azar – ACA Section 1557 antidiscrimination• Arizona Health Centers Sue AHCCCS – suit to enforce 9th Circuit decision re reimbursement for FQHC Medicaid services
• Various work requirement waiver lawsuits Kentucky Arkansas New Hampshire Indiana
In the Courts• Texas v. Azar – constitutionality of the entire ACA• Franciscan Alliance v. Azar – ACA Section 1557 antidiscrimination• Arizona Health Centers Sue AHCCCS – suit to enforce 9th Circuit decision re reimbursement for FQHC Medicaid services
• Various work requirement waiver lawsuits Kentucky Arkansas New Hampshire Indiana
Resources and Tools Medicaid Resources – Updated!
• PPS Checklist• Emerging Issues in PPS• Change in Scope • Medicaid Wraparound Issues• Trackers and templates are
coming back!
340B• State Legislative Toolkit • Monthly Pharmacy Office Hours
3rd Thursdays at 2PM ET
Telehealth • Monthly Office Hours at 2PM ET
PCA Assessment• Raw data released!• Chartbook (Data Atlas) coming
soon!
Payment and Delivery Reform • APM Academy, Round 2 coming
soon!
Outreach and Enrollment• New case studies available!
State Affairs Staff• Call or email with any questions
Auto-HPSAs: Where Are We?
• The “national update” of all auto‐HPSA scores officially occurred in August. • Relative to other auto‐HPSA providers, health centers became more competitive overall.
• However, across health centers, the changes in competitiveness are significant.
• PCOs and FQHCs may be able to “tweak” individual scores this fall.
• The new scores go into effect on February 1, 2020.
A Rural Disadvantage?
• The states whose health centers were most negatively impacted by the update were predominantly rural.• There appears to be a bias inherent in the statute and regs & the national update made it more apparent.
• The aggregate figure for each state can “mask” significant shifts within the state.• E.g., PA had a net gain of 10% more auto‐HPSA scores being competitive. But 23% of its scores dropped below the competitive cut‐off, while 33% rose above it.
What Next?1. Expand involvement in non‐NHSC programs that
address Workforce needs.
2. Work to eliminate any inherent biases in the HPSA scoring system.• Will be a Workgroup focusing on this with HRSA starting next year
• Much easier said than done.
3. “Grow the pie” by expanding the NHSC Loan Repayment Program – particularly for Primary Care Providers.
340B: Regulatory Updates
But this doesn’t mean we can let down our guard on:• Compliance • Being able to show how we use savings to
expand access• Fighting back on discriminatory
contracting.
Please contact me if a health center gets an OSV condition about SFS at contract pharmacies.
HRSA is presently “lying low” on audits and compliance activity.
Opioid Lawsuits
• NACHC Leadership and Legal Counsel are currently studying the opioid litigation, to determine the most appropriate role for NACHC and the larger health center community.
• More information coming soon.
Immigration & Public Benefits
Policy Status
Public Charge Regulation NOT in effect, litigation proceeding
Requirement that all new immigrants have health insurance within 30 days
NOT in effect, litigation proceeding
Chilling Effect Very much IN EFFECT
Public Charge: NOW WHAT?
• Lawsuits are still working their way through the courts, so the situation may evolve.
• Keep educating staff and patients. See: • NACHC webpage• Additional resources available through the National Health Center Immigration Workgroup.• These include free monthly webinars on the FIRST Wednesday of each month at 3:00 ET. Contact nvu@cpca to get on the mailing list.
Title X – Recommended Actions
2. Subrecipients should review their new subrecipient agreements carefully, to ensure that they – and the grantee ‐‐ are complying with all new requirements.
3. See the NACHC Women’s Health webpage for more resources, including FAQs and compliance documents.
1. All health centers that currently receive Title X funding – either as grantees or subrecipients – should update their Women’s Health P&P ASAP to reflect the new rules.
‐ A revised template is on the NACHC website.
“Conscience Protections” - NOT IN EFFECT
• In May, HHS finalized new rules expanding the rights of health care workers to refuse to provide or participate in certain activities if they cite a religious or moral objection.• Health centers were a likely enforcement target.
• The rules were to take effect in on November 22, but two courts issued national injunctions.
• Next steps unclear – but underlying laws remain in place.
Other Regulatory Updates
ABORTION: For every health center audit, HRSA now requires auditors to submit their “working papers” documenting how they determined:
• Whether the health center performs abortions
• if so, whether it has P&Ps in place to ensure compliance.
FCC RURAL HEALTH CARE PROGRAM:
• The FCC recently announced that FQHCs and other safety net providers will receive priority for full funding.
• If your rural health centers aren’t participating, they should look into it.
Summary of Regulatory Take-Aways1. The “national update” of auto‐HPSA scores is complete, and the system appears to have
an underlying bias against rural sites.2. The most effective response to the auto‐HPSA changes is to expand funding for the NHSC.3. While HRSA is currently lying low on 340B compliance issues, it is still very important to
ensure compliance and show how 340B savings expand access. 4. NACHC is researching a potential role in the opioid litigation. 5. Courts have blocked the implementation of the public charge regulation and the
requirement that new immigrants have health insurance. However, the chilling effect of these proposals remains strong, and education is the best response.
6. The new Title X reg is in effect, while the conscience protection reg has been blocked by the courts.
7. Rural FQHCs centers should consider participating in the FCC’s Rural Health Care Program, as funding is now stable.
Online Resources
State and Congressional District Maps, State Fact Sheets
NACHC WebpageNACHC Blog
For these and other materials, go to www.nachc.org/focus‐areas/policy‐matters
NACHC Policy Papers
NACHC Fact Sheets
Questions? Comments? Concerns?
