The Centers for Medicare and Medicaid Services (CMS) has released corrected clarificaitions to recently-published rules for hospitals and “primary roads” for determination of Critical Access Hospital (CAH) eligibility.

• Medicare Program; Updates to Face-to Face Encounter and Written Order Prior to Delivery List – Final Rule published 1/17/23; effective 4/17/23
• Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Organ Acquisition; etc.; Correction – Rule published 1/4/2023; Effective date 1/1/2023
  
• Medicare Program; Implementing Certain Provisions of the Consolidated Appropriations Act, 2021 and Other Revisions to Medicare Enrollment and Eligibility Rules; Correction – Rule published 12/30/2022; Effective 12/30/2022
  
• Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, and End-Stage Renal Disease Treatment Choices Model; Correction – Rule published 12/30/22; Effective 1/1/2023
  
• Medicare Program:  Hospital Inpatient Prospective Payment Systems; Correction – Final Rule published 12/13/2022; effective date 12/12/2022
  

In December, our Board of Directors approved our biennial policy roadmap that aligns with our organizational mission to improve the health, education and well-being of children and youth in the commonwealth.

Learn more about our five policy areas, including data points, policy priorities, and legislative or other significant actions:

• Child Welfare: Ensure each child in Pennsylvania lives in a home where they are safe and protected from abuse and neglect.
• Early Care and Education: Ensure each child in Pennsylvania can participate in affordable and accessible high-quality early care and education, including infant and toddler child care and pre-kindergarten education.
• Home Visiting: Ensure each child in Pennsylvania can grow up in a stable and healthy home environment.
• K-12 Education: Ensure each child in Pennsylvania has the opportunity for an adequate and equitable high-quality public education.
• Perinatal and Child Health: Ensure each birthing person and child in Pennsylvania can access affordable, quality health care.

PPC is committed to policy choices that improve maternal and child well-being, advance racial equity and support economically disadvantaged families.

Our work to advance equitable policy solutions is critical in our long-term vision because we can’t achieve our goals if any child is left behind.

Explore the policies we work on to build better futures within the 2023-24 Policy Roadmap.

Also new this year is our revamped State of the Child, which serves as a data companion to the roadmap. View a variety of data points pertaining to Pennsylvania’s children and their well-being

In late December, President Biden signed a sprawling appropriations package (HR 2617) which sets the federal budget for Fiscal Year 2023. Many elements of the omnibus budget prioritized kids and families including reauthorizing the MIECHV program, increasing child care funding, and enhancing CHIP and Medicaid programs across the country.

The omnibus contained language from the Jackie Walorski Maternal and Child Home Visiting Reauthorization Act of 2022, which passed the House in November and included:

1. Reauthorization of the MIECHV program through 2027
2. An initial increase in funding of $100 million, bringing the program’s full appropriation to $500 million
3. Subsequent funding increases of $50 million annually (except for a $150 million increase in 2027)
4. Establishing a publicly available dashboard that reports program outcomes
5. Requiring activities to reduce unnecessary data collection, reporting, and other administrative requirements of the program
6. Allowing for virtual home visits

In a victory for the child care sector, the budget contained a 30.1% increase for the Child Care Development Block Grant (CCDBG) to over $8 billion. Pennsylvania will get about $56.3 million more in 2023 compared to 2022. It also contained increases for Head Start and the Individuals with Disabilities in Education Act (IDEA).

The omnibus also contained multiple provisions related to Medicaid and CHIP. First, it delinked the Medicaid continuous coverage requirement from the COVID-19 public health emergency and set the gradual decrease of the federal match for Medicaid to begin on March 31, 2023. In an exciting win for advocates, the law now requires all states to provide 12 months of continuous eligibility for children in both Medicaid and CHIP (previously only available for children up to age 4 in Medicaid, but all children in CHIP). Funding and authorization for the CHIP program extended two years to 2029, and the 12-month postpartum coverage option for CHIP and Medicaid was made permanent (this provision was initially supposed to sunset after five years). If you’d like to read more about the health care provisions of the omnibus, please check out SayAhhh!, the blog by our partners at the Georgetown University Center for Children and Families.

From The American Prospect, December 27, 2022

Insurer UPMC and its new pharmacy benefit manager Express Scripts are squeezing local independent pharmacies, with residents caught in the crossfire.

In late November, at a strip mall in the rural Pennsylvania town of Bedford, Stephanie Over worked behind the Fisher’s Pharmacy counter, filling prescriptions into translucent orange pill bottles and administering shots. As strip mall pharmacies go, Fisher’s stands out. A recently restored art deco facade juts out, and the store’s name runs down vertically in Broadway font. The store is a local fixture in Bedford, population under 3,000, and has been around for almost 100 years, of which Stephanie has worked nearly 30.

Stephanie was about to check out for her lunch break when the letters flooded in. Regulars at Fisher’s began marching up to the counter, clutching notices from the University of Pittsburgh Medical Center (UPMC), a leading health insurer in Western Pennsylvania, and Express Scripts, the pharmacy benefit manager for UPMC.

The letter told them that under a new policy, UPMC’s insurance plan would not cover prescriptions at Fisher’s anymore. Instead, UPMC’s beneficiaries would be encouraged to go to other pharmacies in the health plan network for their own “convenience,” which meant national chains like Rite Aid, Walmart, or Giant Eagle, a regional grocery chain. Bedford is a remote town, 100 miles from both Harrisburg and Pittsburgh. Residents, many of whom had gone to Fisher’s for decades, would have to drive several towns over, maybe 30 or 40 minutes, just to get their prescriptions filled. Fisher’s knew them, their families, and medical history, a personal touch that would be lost at a chain.

“Why should our people have to drive through 20 signal lights to get a prescription filled when they could just call us and we’d have it ready,” said Over.

The letter offered no explanation for the policy change. Stephanie called the owner, Jennifer Leibfreid, who had not been notified by UPMC. Fisher’s tried calling other local pharmacies and associations to piece together whether other independents were receiving the same letters from customers.

Most had. In an overnight purge, UPMC, the third-largest insurer in the state and the most powerful hospital network, dropped over 1,200 pharmacies from its health plan, around half of the stores it previously carried. Most were independents. The decision impacted tens of thousands of individuals who bought their insurance on the state health insurance exchange, known as Pennie, as well as company plans for businesses with fewer than 50 employees. Patients covered by Medicare and Medicaid are not affected by the change.

The UPMC kill-off will have devastating consequences for pharmacies and patients across rural Pennsylvania. Fisher’s estimates that it might lose 20 percent of its customers, some of whom need prescriptions filled every other day. They’ll have to decide whether to drive several towns over or pay out of pocket at Fisher’s for generic drugs.

Thirty miles south of Bedford, Potomac Valley Pharmacy in Hyndman was another retailer cut out from UPMC’s plan. Pharmacist Dan Iseminger doesn’t know how much business he’ll lose because “frankly, I’ve been too scared to look.” In that area, as in many other rural parts of the state, UPMC is often the only health plan locals can afford.

Read the full article here.

ARC announced our first-ever Appalachian Regional Initiative for Stronger Economies (ARISE) award! Connect Humanity will help 50 underserved communities in Appalachia plan for broadband growth.

The Connect Humanity team will work with local partners across 12 Appalachian states to help communities develop tailored digital equity plans, secure funding for high-speed internet expansion, provide digital literacy and broadband job training, and more.

“Broadband access is essential for Appalachia to thrive and compete in a global economy; without this support, our most rural communities may be left further behind. I commend our states and community partners in every Appalachian subregion for coming together in order to fully participate in our digitalized world,” said ARC Federal Co-Chair Gayle Manchin.

The details on the funding are:

• Location: 50 underserved communities across every subregion of Appalachia (TBA)
• Local Partners: Center on Rural Innovation, Empire State Development, Enterprise Center, Fair Count, Generation WV, Mississippi Alliance of Nonprofits & Philanthropy, NC State University Institute for Emerging Issues, SOAR, Student Freedom Initiative, Center for Strategic Partnerships at the Pennsylvania Department of Community & Economic Development, Virginia Funders Network
• Community Need: Helping underserved communities in Appalachia compete for some of the $45 billion from the Broadband Equity, Access, and Deployment and Digital Equity Act funding, driving large-scale transformation around broadband access.
• Solution: Connect Humanity will help communities develop tailored digital equity plans designed to ensure high-speed and affordable internet, device access, and digital literacy training.
• Grants Received: $6.3 million ARC ARISE grant

Appalachian communities can get involved at connecthumanity.fund/arise.

CMS released a State Health Official (SHO) letter that provides guidance to states on policy for Medicaid and the Children’s Health Insurance Program (CHIP) to allow one provider to discuss a Medicaid or CHIP beneficiary’s case with a specialist, with or without the beneficiary present, and to pay the specialist for their services directly. The current policy only allows payment in this circumstance if the provider who is seeking the consultation is paid for the consulted provider’s services and then pays the consulted provider directly. This change more directly “links” routine care with specialty care, allowing more people to benefit from practitioners with specialized knowledge.

For more, read the full letter https://www.medicaid.gov/federal-policy-guidance/downloads/sho23001.pdf

CMS issued an informational bulletin on the provisions included in the Consolidated Appropriations Act, 2023 (CAA, 2023) related to the Medicaid continuous enrollment condition.

The CAA, 2023 updates various Medicaid and CHIP provisions, including significant changes to the continuous enrollment condition of the Families First Coronavirus Response Act. Under the CAA, 2023, expiration of the continuous enrollment condition will no longer be linked to the public health emergency (PHE) and instead the condition will end on March 31, 2023. Following the end of the condition, states will have up to 12 months to initiate, and 14 months to complete, a renewal for all individuals enrolled in Medicaid, the Children’s Health Insurance Program, and the Basic Health Program. As of January 2023, the PHE is still in effect.

Read the Informational Bulletin for more detail.