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Efforts under way to roll back MOE requirements
The Centers for Medicare & Medicaid Services (CMS) and Congress will be under significant political pressure to roll back the maintenance of effort (MOE) requirements included in the Patient Protection and Affordable Care Act (PPACA), according to Michael Miller, director of policy at Community Catalyst in Boston, "either wholesale, or via individual waiver applications such as that filed by Arizona."
First, says Mr. Miller, CMS and Congress need to consider the harm that a change in the MOE requirements would do to beneficiaries. "Then, they need to look at the extent to which states have availed themselves of less harmful alternatives," he says.
Political vs. fiscal
CMS should consider whether, in some cases, a state's claim of inability to sustain its Medicaid program represents merely a political preference of the state leadership rather than a true inability to afford the program, argues Mr. Miller. "It's important for CMS to at least distinguish 'can't' from 'don't want to,'" he says.
The PPACA established both a new national eligibility policy for Medicaid and a set of interim rules, notes Mr. Miller, ensuring that Medicaid will cover up to 133% of the Federal Poverty Level, and states can't go backward.
"The MOE is just as much a part of the PPACA as the 2014 coverage expansion. It is integral to it," says Mr. Miller. Since MOE requirements don't stop states from eliminating optional benefits, Mr. Miller says he expects to see additional cuts in services such as adult dental, therapies, and even prescription drugs.
In addition, says Mr. Miller, states are likely to consider expanding managed care to new populations such as people with disabilities, and implementing provider rate freezes or cuts.
As all governors, CMS, and Congress are aware, and as a Feb. 3, 2011, letter from HHS Secretary Kathleen Sebelius makes clear, says Mr. Miller, efforts to roll back the MOE are not primarily about giving states the tools to better afford their Medicaid program.
"States already have multiple tools at their disposal," says Mr. Miller. "These efforts are about re-litigating and trying to overturn the coverage expansion in the PPACA, and in so doing, undermine the entire law."
Secretary Sebelius' letter was an effort to address many of the recent questions posed by states, says Mr. Miller. "It would, I think, be enormously helpful to states to have HHS further clarify their willingness to entertain waiver requests relating to care coordination for Medicare and Medicaid dual eligibles," he says.
This would allow states to share Medicare as well as Medicaid savings, Mr. Miller explains. "There are other areas where additional clarification or further policy development would help states," he adds. "For example, in light of better information and tools to control drug spending, will CMS recalculate Part D 'clawback' payments?"
Going forward, Mr. Miller says we are likely to see more states come in with requests for MOE waivers. "We are virtually certain to see congressional hearings on the MOE," he says. "We will very likely see legislation to eliminate the MOE."
This could come either as stand-alone legislation or it may be connected to another bill, says Mr. Miller. "Unfortunately, we are all too likely to see many states taking the well-worn, but ultimately dead-end path of cuts to benefits, instead of putting their Medicaid programs on the path of sustained improvements in cost effectiveness," he says.
Contact Mr. Miller at firstname.lastname@example.org.