REGULATORY INTELLIGENCE

YEAR-END REPORT - 2022

Health Policy Tracking Service - Issue Briefs
Medicaid
Federal Medicaid Policy

This Issue Brief was written by Tammy J. Raduege, J.D., a contributing writer and member of the Wisconsin bar.
12/19/2022
I], Background

Created as Title XIX of the Social Security Amendments of 1965, Medicaid is a medical assistance program administered by the states
and funded through federal and state revenues. While the program has evolved over the years, many of the basic objectives and
provisions have remained mostly intact. The federal government sets out and monitors certain requirements, including funding, limits
on cost-sharing, and the scope of medical services. When developing their Medicaid programs, states are allowed to make some of
their own decisions in the areas of eligibility, reimbursement rates, benefits, and delivery of services, as long as they stay within the
federal guidelines. A state must seek a waiver from the federal government to create a program outside the federal guidelines if it
wishes to use federal funds. Because it is a joint program, the federal government and states share Medicaid funding, with the federal
government contributing at least 50 percent to each state for administrative costs. For medical services provided under the program,
the federal medical assistance percentage (FMAP), or matching rate, varies among states. The FMAP is based on per capita income

and ranges from a low of 50% to a high of about 75% percent across the states. [FN2]

In one of his first acts after being inaugurated, President Joseph Biden (D) issued an executive order to strengthen Medicaid and
reopen the Affordable Care Act Marketplace open enrollment. Section 1 of the order cites the positive effect the Affordable Care Act
has had on reducing the uninsured rate in the country, establishing consumer protections, and strengthening the health care system.
He notes, however, that many eligible people still remain uninsured, and he said that his administration views health care as a priority:
'[I]t is the policy of my Administration to protect and strengthen Medicaid and the ACA and to make high-quality healthcare accessible
and affordable for every American," he wrote.

Section 3 of the order directs all agency heads to review their regulations, policies, guidance documents, and other papers to ensure
that they advance the priorities stated in Section 1:

(a) The Secretary of the Treasury, the Secretary of Labor, the Secretary of Health and Human Services, and the heads of all other
executive departments and agencies with authorities and responsibilities related to Medicaid and the ACA (collectively, heads of
agencies) shall, as soon as practicable, review all existing regulations, orders, guidance documents, policies, and any other similar
agency actions (collectively, agency actions) to determine whether such agency actions are inconsistent with the policy set forth in
section 1 of this order. As part of this review, the heads of agencies shall examine the following:

(ii) demonstrations and waivers, as well as demonstration and waiver policies, that may reduce coverage under or otherwise undermine
Medicaid or the ACA;

(iv) policies or practices that may present unnecessary barriers to individuals and families attempting to access Medicaid or ACA
coverage, including for mid-year enrollment; and

(v) policies or practices that may reduce the affordability of coverage or financial assistance for coverage, including for dependents.
[FN3]

 
  

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President Biden remarked that he is "restoring the Affordable Care Act and restoring the Medicaid [program] to the way it was before
Trump became president, which by fiat he changed, made more inaccessible, more expensive and more difficult for people to qualify for

either of those two items." "N41

Il. MEDICAID SPENDING AND ENROLLMENT

As it does each fall, the Kaiser Family Foundation published its report on Medicaid enrollment and spending. This year's report
examines these trends for fiscal years 2022 and 2023. It goes without saying that the pandemic increased both Medicaid enrollment
and spending. Much of these increases were due to the Families First Coronavirus Response Act (Pub. L. 116-127), which offered

states a 6.2 percentage point increase in their FMAPs [FNS] ig they agreed to certain maintenance of effort requirements. One of
those requirements was continuous enrollment. The increased FMAP is to continue until the end of the quarter in which the public
health emergency ends, and the maintenance-of-effort requirements will terminate at the end of the month in which the public health
emergency ends. Briefly, the report's major findings are these:

* From 2017 to 2019, Medicaid enrollment declined. That trend changed when the pandemic hit. In fiscal year 2021, enrollment growth
was 11.2%. Owing to improved economic conditions and improved unemployment rates, states experienced a slower Medicaid
enrollment growth of 8.4% in fiscal year 2022. Anticipating that the public health emergency will end in 2023, states expect enrollment
growth to decrease slightly in fiscal year 2023.

* Of course, when enrollment increases, so does spending. States expect total Medicaid spending (both state and federal) to have
reached its peak in fiscal year 2022, when the growth rate was 12.5%. States expect this figure to fall to 4.2% in fiscal year 2023. The
state spending growth rate was 9.9% in fiscal year 2022, but states expect this figure to increase to 16.3% in fiscal year 2023, owing to

the end of the public health emergency and the temporary increased FMAP. [FN6]

In 2022, the Office of the Actuary released its annual projection of national health care expenditures and enrollment, this one for the
period 2021-2030. According to the report, while health care expenditures soared during the pandemic, they have now started to slow.
The Centers for Medicare and Medicaid Services (CMS) explained in a press release,

The report notably shows that despite the increased demand for patient care in 2021, the growth in national health spending is
estimated to have slowed to 4.2%, from 9.7% in 2020, as supplemental funding for public health activity and other federal programs,

specifically those associated with the COVID-19 pandemic, declined significantly. [FN7]

Going forward, health care expenditures are expected to grow an average of 5.1% annually from now until 2030, the same rate as the
projected rise in the Gross Domestic Product. Supplemental federal funding in response to the pandemic is expected to decrease in the

next three years, bringing the federal share of health care spending down from an all-time high of 51% in 2020 to 46% in 2024. [FN8]

As for Medicaid specifically, enrollment and expenditures were at a high during the pandemic, as discussed above. Once the COVID-19
public health emergency ends, the maintenance-of-effort provisions and the increased FMAPs will end as well, bringing both spending
and enrollment down. Between now and the end of the decade, Medicaid expenditures are expected to rise on average by 5.6%, after
having reached an expected high of 10.4% in 2021. According to CMS,

Average annual growth of 5.6% is projected for Medicaid spending for 2021-2030. Medicaid spending growth is expected to have
accelerated to 10.4% in 2021, associated with rapid gains in enrollment. Over 2022 and 2023, Medicaid spending growth is expected
to slow to 5.7% and 2.7%, respectively, as a result of projected enrollment declines, after the end of the COVID-19 PHE, when the
continuous enrollment condition under the Families First Coronavirus Response Act expires and states begin to disenroll beneficiaries
no longer eligible for Medicaid. Over 2025-2030, spending growth is projected to increase an average 5.6%, in part due to the
expiration of Disproportionate Share Hospital payment cap reductions set for late-2027. Spending is projected to exceed $1 trillion for

the first time in 2028, 'FN®!

A decline in Medicaid enrollment is expected to slow the growth of prescription drug costs as well. IFN10] A link to the report is available
in CMS' press release.

In order to connect more people to coverage, CMS announced that it awarded over $49 million to reduce the uninsured rate and

increase Medicaid and CHIP *""! enrollment. The funds will be awarded to a variety of organizations and entities ? state and local
governments, tribal organizations, federal health safety net organizations, non-profits, schools, and others ? to enable them to identify
eligible individuals and help them enroll in or renew enrollment in Medicaid. Awardees will receive up to $1.5 million in each of three
years to put their plans into action. CMS Administrator Chiquita Brooks-LaSure explained why CMS is committed to this work, which
aligns with the administration's focus on health equity:

'CMS is using every tool available to expand access to coverage and care .. . . The Biden-Harris Administration is committed to
advancing health equity, and encourages organizations that serve children, their parents, and pregnant individuals in diverse and
underserved communities to apply. These organizations play a pivotal role in connecting people to coverage since families and

individuals often seek help from community organizations they know and trust." [FN12]

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CMS lists the types of activities for which the funds are meant:
¢ Engaging schools and other programs serving young people;
* Bridging racial and demographic health coverage disparities by targeting communities with low coverage rates;

¢ Establishing and developing application assistance resources to provide high-quality, reliable enrollment and renewal services in local
communities;

¢ Using social media to conduct virtual outreach and enrollment assistance; and

¢ Using parent mentors and community health workers to assist families with enrolling in Medicaid and CHIP, retaining coverage, and
addressing social determinants of health. [FN13]

Affordable Care Act reforms have led to a dramatic decrease in the number of uninsured African Americans. According to a press
release from CMS, the uninsured rate among African Americans under the age of 65 was 20% in 2011 and is now 12%, a nearly 40%
drop. This is owing to Affordable Care Act reforms such as the Marketplace and the Medicaid expansion. Still, the insured rate for
this population lags that of the White population, whose uninsured rate is 9%, revealing inequity. CMS Administrator Chiquita Brooks-
LaSure explained that health equity is one of her priorities:

'Since the passage of the Affordable Care Act nearly 12 years ago, the law has significantly expanded access to life-saving health
coverage, including for Black communities across the country. . . . Advancing health equity is one of my top priorities, and, in pursuit of
this goal, CMS invested in significant outreach to the Black community during this recent Open Enrollment period. The coverage gains
achieved during Open Enrollment are just a first step ? CMS will continue to advance health equity by expanding coverage access

through Medicaid and the Children's Health Insurance Program, Medicare and the ACA Marketplaces. " [FN14]

The Medicaid expansion has contributed to the decreased uninsured rate among African Americans, but 11 states (Alabama, Florida,
Georgia, Kansas, Mississippi, North Carolina, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming) still have not

implemented the expansion. IFN15] |¢ all of those states adopt the expansion, nearly a million African American adults and children
would gain coverage. Southern states that have not expanded Medicaid have large populations of African Americans and the highest

uninsured rate for all populations. [FN16]
Ill. CMS' strategic plan and the CMS National quality strategy

In September 2021, CMS announced its health strategy, which has six pillars:

* Advance health equity by addressing the health disparities that underlie our health system

¢ Build on the Affordable Care Act and expand access to quality, affordable health coverage, and care

¢ Engage our partners and the communities we serve throughout the policymaking and implementation process
* Drive innovation to tackle our health system challenges and promote value-based, person-centered care

¢ Protect our programs' sustainability for future generations by serving as a responsible steward of public funds

¢ Foster a positive and inclusive workplace and workforce, and promote excellence in all aspects of CMS's operations [FN17]

CMS is made up of several centers and offices, and they will work together to advance that strategy. The initiatives in all of the centers
and offices will focus on the following:

* Engaging stakeholders in decision-making

* Behavioral health

¢ Prescription drug affordability

¢ Maternity care

¢ Benefit expansion

* Rural health

¢ Preparing for the post-pandemic world

* Maintaining coverage to the maximum extent as states unwind from the COVID public health emergency
« Advancing the National Quality Strategy

¢ Nursing home quality and choices for long-term care

« Using data to drive decision-making

¢ Ensuring continuity of care as people transition between Medicare, Medicaid, CHIP, and the Marketplace [FN18]

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In April 2022, CMS laid out its strategy [FN19] for achieving the first pillar, health equity. The agency defines health equity as follows:

[A]ttainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health
regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, and

other factors that affect access to care and health outcomes. !*N24l

The health equity strategy sets out specific goals for each of CMS' centers and offices and a description of what they have done so

far to meet those goals. These centers include the Center for Medicare, the Center for Clinical Standards and Quality, the Center for
Medicare and Medicaid Innovation, the Medicare-Medicaid Coordination Office, the Center for Medicaid and CHIP Services, the Center
for Consumer Information and Insurance Oversight, the Office of Minority Health, and the Office of Information.

CMS set out the following goal for the Center for Medicaid and CHIP Services:

Health equity goal: Closing gaps in coverage, access, and quality of care among people who are Medicaid- and CHIP-eligible or
enrolled, improve data collection and analysis of disparities in coverage and care, support innovation, and orient activities to close gaps.

[FN21]
The strategy points out the actions that this center has already taken to meet its goal, which include:

¢ Rolling back restrictive Medicaid policies, such as work requirements.

¢ Working with states to provide access to a full 12 months of post-partum care.

¢ Working with states to connect justice-involved individuals to home- and-community-based services upon release.

« Issuing Requests for Information to learn more about access to care, enrollment, and maintenance of coverage.

¢ Improving access to home- and community-based services, leveraging the American Rescue Plan's increased federal medical
assistance percentage (FMAP) for these services. [FN22]

The goal for the Center for Medicare and Medicaid Innovation is to 'promote a health system that achieves equitable outcomes through
high-quality, affordable, person-centered care"; and the goal of the Center for Medicare-Medicaid Coordination is to '[close] gaps in
coverage, access, and quality of care among people who are Medicaid- and CHIP-eligible or enrolled, improve data collection and

analysis of disparities in coverage and care, support innovation, and orient activities to close gaps." [FN23]

CMS also invited health care leaders to commit to advancing health equity through their initiatives. [FN24]

In related news, HHS announced that it will award $90 million in American Rescue Plan funds to support data-driven efforts that will
enable HRSA 25! health centers and look-alikes to identify and reduce health disparities. [FN26]

CMS also announced its new CMS National Quality Strategy. The United States government has been concerned with the quality of
care for decades, but modern efforts at prioritizing quality and paying for the quality of care over the quantity of care arose from the

Affordable Care Act. "N27 The first National Quality Strategy was launched in 2011. IFN28] 1, 2022, CMS unveiled its new strategy.
In announcing the strategy, CMS noted that it had developed previous quality strategies, but they and other efforts have not been
sustained or have not acknowledged the importance of equity in a robust quality strategy. According to CMS, 'true quality cannot exist

without equity." [FN29] Notably, the strategy builds on lessons learned during the pandemic. It has eight goals:
¢ Goal 1: Embed Quality into the Care Journey

¢ Goal 2: Advance Health Equity

¢ Goal 3: Promote Safety

* Goal 4: Foster Engagement

¢ Goal 5: Strengthen Resiliency

¢ Goal 6: Embrace the Digital Age

* Goal 7: Incentivize Innovation and Technology Adoption to Drive Care Improvements

* Goal 8: Increasing Alignment [FN30]

The strategy is meant to be a person-oriented approach across the continuum of care during a person's lifetime, and it applies to all
payer types, including Medicaid:

The CMS National Quality Strategy focuses on a person-centric approach from birth to death as individuals journey across the
continuum of care, from home or community-based settings to hospital to post-acute care, and across payer types, including Traditional
Medicare, Medicare Advantage, Medicaid and Children's Health Insurance Program coverage, and Marketplace plans. It builds on

our previous efforts to improve quality across the health care system, incorporates lessons learned from the COVID-19 Public Health
Emergency (PHE), and endeavors to foster and promote the expanded levers used during the pandemic such as interoperability and

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data sharing, data collection specific to social determinants of health and social risk factors, telenealth, emergency preparedness,
leadership, and organizational governance among others. [FNS1]
Please see the blog post for more information.

IV. shifting priorities in medicaid

A. Medicaid Waivers

Section 1115 of the Social Security Act allows the HHS Secretary to waive Medicaid program requirements for experimental, pilot, or
demonstration programs that are likely to promote the objectives of the Medicaid program. Previous administrations have interpreted
this to mean that the waiver program must be designed to expand coverage. Therefore, the government had never before approved
program features like work requirements, which could actually limit coverage. The Trump Administration, however, did not require such
proof. According to a brief from the Kaiser Family Foundation,

revised waiver criteria focus on positive health outcomes, efficiencies to ensure program sustainability, coordinated strategies
to promote upward mobility and independence, incentives that promote responsible beneficiary decision-making, alignment with

commercial health products, and innovative payment and delivery system reforms. [FN32]

President Biden's Administration views waivers much the way that previous administrations had before the Trump Administration. As
discussed below, we are starting to see the Biden Administration's philosophy on waivers taking shape as it seeks to undo policies put
in place under former President Trump.

The Trump Administration's shift in waiver policy was apparent in the way it treated waiver requests approving work requirements in
Medicaid. In January 2018, CMS issued guidance specifically approving such approaches and setting out guidelines for including them

in state Medicaid programs. IFN33] The Trump Administration firmly believed that education, higher income, and employment are all
social determinants of health, so allowing states to impose work/community engagement requirements were all in keeping with sound
Medicaid policy. Opponents said that the requirements would result in a loss of coverage for the people who need it most, owing to their
social circumstances and the bureaucracy around reporting requirements.

Under the Trump Administration's guidance on work requirements, states would not be allowed to impose such requirements on the
elderly, the disabled, or pregnant women. CMS explained the types of activities it would consider 'community engagement," and it
explained that demonstrations should test whether requiring these activities leads to sustained involvement in work or community
engagement and whether they lead to improved health outcomes:

Today, CMS is committing to support state demonstrations that require eligible adult beneficiaries to engage in work or community
engagement activities (e.g., skills training, education, job search, caregiving, volunteer service) in order to determine whether those
requirements assist beneficiaries in obtaining sustainable employment or other productive community engagement and whether
sustained employment or other productive community engagement leads to improved health outcomes. This is a shift from prior agency
policy regarding work and other community engagement as a condition of Medicaid eligibility or coverage, but it is anchored in historic

CMS principles that emphasize work to promote health and well-being. [FNS4]

Additionally, states would need to take into account the needs and limitations of those suffering from addiction and make appropriate
modifications for these people, including counting time in treatment toward the work or community engagement requirement or

exempting these individuals from the requirements altogether. Please see the letter for a full explanation of CMS' intent. [FN35]

States that received waivers for work requirements included Arizona, Georgia, Indiana, Nebraska, Ohio, South Carolina, Utah,
and Wisconsin. Some states (Kentucky, Arkansas, Michigan, and New Hampshire) had approved waivers, but courts had set
aside their work requirements. (New Hampshire had earlier voluntarily suspended its program because so many people were
on track to lose coverage.) When President Trump left office, waivers were pending in Alabama, Idaho, Mississippi, Montana,
Oklahoma, South Dakota, and Tennessee. Virginia had applied for a waiver to add work requirements to its Medicaid expansion

program, but Governor Ralph Northam (D) formally withdrew that request on July 1, 2020. [FN36] When President Biden took
office, he withdrew approval for work requirements; some states withdrew their pending or approved waivers themselves.

[FN37] Please see HPTS' Medicaid Restructuring Brief for a fuller discussion of work requirements.

In the waning days of the Trump Administration, Texas sought a five-year extension of its Section 1115(a) demonstration titled 'Texas
Healthcare Transformation and Quality Improvement Program." The request included significant changes to the waiver. Texas sought
approval of the extension in 2020. It was already authorized until 2022, and the state requested an extension until 2027. The state
indicated that extension of the waiver without notice and comment was necessary to ensure stability for providers and the Medicaid
program in the wake of the COVID-19 emergency period, and it therefore sought an exemption. In early 2021, CMS approved the
request, even approving features that the state had not requested, like an uncompensated care pool and an extension until 2030.
Though the state sought and received an exemption from the federal notice and comment process, it did engage in some state-level
notice and comment procedures, but the notice materials included details about the waiver extension as requested, not as ultimately

granted. [FN38]

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On April 16, 2021, the Biden Administration rescinded the approval, noting that the request did not meet the standard for exemption
from notice and comment:

We have determined that the state's exemption request did not articulate a sufficient basis for us to conclude that approving the

state's emergency request for an exemption from the normal public notice process was needed to address a public health emergency
or other sudden emergency threat to human lives, as required under 42 C.F.R. ? 431.416(g). The state's exemption request in its
application did not establish that the request to extend the demonstration, which was already authorized through September 30, 2022,
was subsiantially related to the public health emergency for COVID-19 or any other sudden emergency threat to human lives, that the
circumstances surrounding the extension request constituted an emergency, or that delay sufficient to complete the public notice and
comment process before approval of the extension request would have undermined or compromised the purpose of the demonstration
or been contrary to the interest of beneficiaries. Rather, the erroneous initial determination to approve an exemption from the normal
public notice and comment requirements was itself contrary to the interest of beneficiaries, as well as of Texas and CMS, because it
deprived beneficiaries and other interested stakeholders of the opportunity to comment on, and potentially influence, the state's request

to extend a complex demonstration ? already authorized through September 30, 2022 ? into the next decade. [FNS8]

Moreover, had the state truly needed to change the waiver to respond to the COVID-19 crisis, it could have used the streamlined
Section 1115 template that CMS had set up for that purpose at the beginning of the emergency period, the agency wrote. It rescinded

approval of the extension and invited the state to resubmit the request after following normal notice and comment processes. [FN40]

At stake are billions of dollars of federal Medicaid funding, which were largely meant to address uncompensated care costs. The state
has so far resisted adopting the Affordable Care Act's Medicaid expansion. IFN41] Because the state has such a high uninsured rate,
[FN42] hospitals suffer significant uncompensated care costs. The Houston Chronicle writes that the state has relied on waivers as a

'cheaper' alternative to expanding Medicaid. [FN43] The federal government is keen on getting the hold-out states to adopt the Medicaid
expansion, and it included in the American Rescue Plan incentives for the states to do so now. According to the paper, the there is no

movement in state government to do so. [FN44]
According to the Houston Chronicle, health advocacy groups and some health policy experts were opposed to CMS approving the
waiver without notice and comment, with one pointing out that the waiver was never meant to be a permanent fix. Several people

opposed to the waiver extension argued that it is time to seriously consider the expansion as a permanent solution. On the other
hand, the president of the Texas Hospital Association expressed his disappointment in the Biden Administration's decision, saying

that it threatens the state's safety net and the ability of hospitals to protect patients. [FN45] Becker's Hospital Review writes that the
government's decision to rescind approval of the waiver extension is 'credit negative" for state hospitals. For large urban hospitals, the
waiver accounts for 10-15% of their revenue. '"N*6l
C. Medicaid Financing

Republicans have always favored block granting Medicaid. The unsuccessful repeal and replace plans of 2017 would have changed
Medicaid financing to block grants or per capita caps. During the Trump Administration, on January 30, 2020, CMS announced its
Healthy Adult Opportunity. States participating in this demonstration could experiment with a block-grant-type arrangement for the
adults in the Medicaid expansion population and other optional groups. CMS explained the population the demonstration targets:

HAO [Healthy Adult Opportunity] is available to all states, with a focus on a limited population ? adults under age 65 who are not eligible
for Medicaid on the basis of disability or their need for long term care services and supports, and who are not eligible under a state
plan. Other very low-income parents, children, pregnant women, elderly adults, and people eligible on the basis of a disability will not be

directly affected ? except from the improvements that result from states reinvesting savings into strengthening their overall programs.
[FN47]

States participating in the demonstration would be granted additional flexibilities as they designed their programs, allowing states to, for
example:

* Adjust cost-sharing requirements to incentivize high value care,

* Align benefits more closely to what is available through a commercial insurance benefit package,

¢ Improve negotiating power to lower drug costs by adopting a closed formulary similar to those provided in the commercial market. . . ,
¢ Make timely programmatic adjustments without additional federal approval,

* Apply additional conditions of eligibility which support the objectives of the program,

* Deliver care through innovative delivery systems, and

¢ Waiving retroactive coverage and hospital presumptive eligibility requirements. [FN48]

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In return, states would need to agree to stay within a certain budget, based either on a total expense or per-enrollee methodology.
Expenses that exceeded the target cost would not be eligible for federal funds, but the demonstration also included the possibility of a

shared savings arrangement between the state and the federal government. [FN48}

[FNSO] 55 well

CMS saw the demonstration as a way for states to deliver better care, achieve better outcomes, and control costs,
as to design a program without undergoing the time and effort that the waiver process requires. [FNS1] Opponents argued that the

demonstration allows states to limit benefits and access to needed drugs. Litigation over the program is expected. [FNS52]

The Kaiser Family Foundation published a brief highlighting the particulars of the demonstration and pointing out the consequences

of the flexibility that the demonstration offers. For example, states that participate in the demonstration may offer less comprehensive
coverage than currently required, establish a closed formulary for prescription drugs, impose premiums and cost-sharing as a condition
of eligibility, and implement other eligibility limitations. If the participating state has adopted the Affordable Care Act's Medicaid
expansion, it is limited in the restrictions it may impose on that population if it wishes to continue receiving enhanced expansion funds.

[FNS3] However, states that have not adopted the expansion may be willing to expand their programs if they can cap expenses and
impose the types of limitations they wish. [FNS4]

Shortly after the Healthy Adult Opportunity demonstration was announced, Oklahoma sought permission to implement the program as
a part of a Medicaid expansion, but the state withdrew the request after voters approved a traditional Medicaid expansion. [FNS]

In the waning days of the Trump Administration, CMS approved a block grant-type waiver for Tennessee, [FNS6] but it was not granted
as a part of the Healthy Adult Opportunity demonstration. Democrats in Tennessee have asked President Biden to rescind the waiver,

[FNS7] and the waiver is being challenged in court. [FNS8] 1, July 2022, CMS formally requested that the state make certain changes to
the waiver, including these, among others:

* removing the expenditure authority for pharmacy and associated pharmacy flexibilities;
* submitting a new financing and budget neutrality model that eliminates the aggregate cap;

¢ requiring CMS an approved demonstration amendment before cutting benefits or coverage that were in place as of December 31,
2021, FNS!

The demonstration was amended in September 2022. [FN6O]

Finally, most states have adopted the Affordable Care Act's Medicaid expansion, which extends eligibility to all individuals earning
up to 138% of the federal poverty level. The federal government pays the lion's share (90%) of the costs for those in the expansion
group. All but eleven states (Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, Tennessee, Texas,

Wisconsin, and Wyoming) have adopted the expansion. [FN61] The states that have not often cite the state's share of the cost as the
reason for not doing so. The American Rescue Plan (ARP) (P.L. 117-2) created an additional incentive for non-adopting states to adopt

and implement the expansion: It offers a two-year five-percentage-point increase in the state's FMAP [FNE2I for its current Medicaid
program plus a permanent 90% FMAP for the newly eligible. According to the Center on Budget and Policy Priorities, the two-year

increased FMAP for the existing Medicaid program would offset states' costs (10%) for the newly insured. [FN63]
V. MEDICAID INNOVATIONS

The Innovation Center

The Affordable Care Act created the Center for Medicare and Medicaid Innovation (the Innovation Center) to improve the health
delivery system by improving the quality of care and keeping costs in check. While the work of the Innovation Center continued
under the Trump Administration, some programs were cancelled or changed and some were made voluntary. Moreover, the Trump

Administration sought public input on changing the direction of the center. IFN64] The Biden Administration has begun to develop its
own vision for the Innovation Center. After more than ten years of experience, CMS believes that it is time to consider a 'refresh" of the
center, and it has published a white paper outlining a new vision for it.

Since its inception, the Innovation Center has launched more than 50 test models, and in the period of 2018-2020, nearly 28 million
patients and more than 528,000 health care providers and plans have participated in them. Of the models, CMS explained,

These models have generated important lessons about how to transition the U.S. health system to value-based care. Models have
been launched in advanced primary care, episode-based care, accountable care, state-based transformation efforts, and for specific
populations, such as Medicare beneficiaries with end-stage renal disease (ESRD), diabetes, heart disease, and in Medicaid for

maternal opioid-use disorders, and populations that experience higher risk for premature births. [FN65]

Leaning on the lessons it has learned after ten years of experience with Innovation Center models, CMS is outlining a new strategy for
the center which will be guided by five objectives:

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¢ driving accountable care;

* advancing health equity;

* supporting innovation;

¢ addressing affordability; and

* partnering to achieve system transformation. [FN66]

The white paper articulates the lessons learned, the issues and challenges of each of those lessons, and the next steps for applying
those lessons and addressing the issues and challenges involved in doing so. CMS identifies the lessons from past experience as
these:

* Health equity should be embedded in each Innovation Center model.

¢ The Innovation Center should pare down its portfolio of models to reduce complexity and overlap.
¢ The Innovation Center must recognize the tools that providers need to assume financial risk.

* Models should be designed to ensure broader provider participation.

* The effectiveness of models may have been hampered by the complexity in financial benchmarks.

¢ Models should encourage lasting delivery transformation after the model ends. [FN67]

Please see the white paper for a fuller discussion of all of these issues.

On a related note, the Innovation Center published its 2020 Report to Congress. (It is required to file a report least every other year.)
The latest report details the activities of the center from October 1, 2018, to September 30, 2020. [FN68]

The CHART Model

Rural health has long been a concern for the government, as those living in rural communities have poorer health outcomes and higher
rates of preventable disease than their urban counterparts, [FN69] ond many rural hospitals have closed or are on the brink of closing.
[FN70] Willions of Medicare and Medicaid participants live in rural areas. To respond to the crisis in a thoughtful and organized fashion,

CMS adopted a Rural Health Strategy [FN71] and has taken several steps to further the strategy. In August 2020, CMS announced a
new model, the Community Health Access and Rural Transformation (CHART) Model, to test innovative solutions to the rural health

crisis. *N'2] The goals of the model are these:

Increase financial stability for rural providers through the use of new ways of reimbursing providers that provide up-front investments
and predictable, capitated payments that pay for quality and patient outcomes;

Remove regulatory burden by providing waivers that increase operational and regulatory flexibility for rural providers; and

Enhance beneficiaries' access to health care services by ensuring rural providers remain financially sustainable for years to come and
can offer additional services such as those that address social determinants of health including food and housing. IFN73]

As originally designed, the model consisted of two tracks, the Community Transformation Track and the Accountable Care
Organization (ACO) Transformation Track. In the Community Transformation Track, CMS announced that it would select up to 15
Lead Organizations, each of which would represent a discrete rural community. CMS gave these examples of entities that could be
lead organizations: state Medicaid agencies, State Offices of Rural Health, local public health departments, Independent Practice
Associations, and Academic Medical Centers, among others. These lead organizations will work with model participants (including, for
example, participant hospitals or a state Medicaid agency) to develop and implement Transformation Plans. CMS explained the role of
Lead Organizations:

The 15 Community Lead Organizations are critical to the success of the Model because they will coordinate efforts across the
community to ensure that access to care is maintained and that the needs of various stakeholders are understood and accounted for
in the transformation plan. Lead Organizations are responsible for managing cooperative agreement funding, recruiting Participant
Hospitals, engaging the state Medicaid agency, establishing relationships with other aligned payers, convening the Advisory Council,
and ensuring compliance with Model requirements. Ultimately, the Lead Organization will oversee the execution and coordination of a

Transformation Plan that outlines the health care delivery redesign strategy for the Community. [FN74]

In the ACO Transformation Track, CMS was to select up to 20 ACOs with a rural focus that will receive advanced shared payments
through the Medicare Shared Savings Program; the ACOs could use these payments to implement value-based payment models to

improve the quality of care and health outcomes in rural communities. IFN75] The request for applications for the ACO Transformation
Track was to be issued in the spring of 2021. However, CMS later announced that it was postponing the RFA release until spring 2022.
In 2022, CMS announced that it removed the ACO Transformation Track from the model. In an email update, CMS explained that it

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remains committed to increasing ACO adoption in rural areas, but it will not be doing so in this model. The agency explained that it is
examining lessons from the ACO Investment Model as it settles on a way to do this.

The application deadline for the Community Transformation Track was extended twice due to the pandemic. However, in September
2021, CMS announced that it awarded funds to four entities to serve as Lead Organizations in that track. The four entities are

the University of Alabama Birmingham, the South Dakota Department of Social Services, the Texas Health and Human Services
Commission, and Washington State Healthcare Authority. These entities will serve, respectively, in the states of Alabama, South
Dakota, Texas, and Washington and they will be responsible to developing and implementing a health care redesign strategy for

communities in which they serve. FN76]
The model is being administered by the Innovation Center.
The Enhancing Oncology Model

When he was the vice-president, now-President Joe Biden (D) spearheaded the Cancer Moonshot Initiative, which was designed to
speed up the progress in the nation's fight against cancer. President Biden has now 'reignited' that initiative, announcing the goal to

decrease cancer deaths by 50% over the next 25 years. [FN77] Taking a step in that direction, the Biden Administration announced a
new model to improve the quality of care for cancer patients while also lowering health care costs. Called The Enhancing Oncology
Model, the model will test strategies for improving cancer care delivery by making it more patient-centered:

CMS' Center for Medicare and Medicaid Innovation (Innovation Center) designed the Enhancing Oncology Model (EOM) to test how to
improve health care providers' ability to deliver care centered around patients, consider patients' unique needs, and deliver cancer care
in a way that will generate the best possible patient outcomes. The model will focus on supporting and learning from cancer patients,
caregivers, and cancer survivors, while addressing inequities and providing patients with treatments that address their unique needs.
[FN78]

According to a press release from CMS, participating providers should expect to deliver patient-focused 'Enhanced Services," such as
24/7 access to care providers, patient navigation services, a detailed care plan, and screening for unmet health-related social needs.
Screening for unmet social needs furthers the administration's focus on equity. Other equity-related program features include:

¢ Offering an additional payment to participating oncology practices that provide Enhanced Services to patients who qualify for both
Medicare and Medicaid,

¢ Requiring participating providers to report patient demographic data (e.g., race, ethnicity, language, gender identity), and

¢ Requiring participating providers to develop plans showing how they will address health equity gaps in their patient population. [FN79}]

The model, which builds on the now-defunct Oncology Care Model, will run for five years, from July 2023 to July 2028. [FN8O] i¢ will
include two risk-based payment options, both of which the administration expects to include as MIPS [FN81] A Iterative Payments
Models in the Quality Payment Program. [FN82] The model was designed for multiple payers, private payers, Medicare Advantage plans,
and state Medicaid agencies. A Fact Sheet is available. [FN83]

Addressing the Social Determinants of Health

In many respects, social needs are related to medical needs. People have to prioritize their concerns, and if they have no home, they
are unlikely to follow a medication regimen, for example. Some make a distinction between social needs and social determinants
of health, arguing that addressing someone's social needs is helpful only to that particular person's health, while addressing social

determinants of health means making systemic changes to improve way people live. [FNE4] Authors in a Health Affairs Blog post argue
that conflating the two may impede efforts to actually make a difference on social determinants of health:

[The referenced articles on social determinants of health] aren't about improving the underlying social and economic conditions in
communities to foster improved health for all ? they're about mediating patients' individual social needs. If this is what addressing the

social determinants of health has come to mean, not only has the definition changed, but it has changed in ways that may impede
efforts to address those conditions that impact the overall health of our country. [FN85]

The authors' observations are well-taken and thoughtful; however, policymakers, writers, and advocates have not widely made a
distinction. For purposes of this discussion, we will use the terms that our sources use.

Citing the World Health Organization, the Kaiser Family Foundation sets out these factors as social determinants of health:
¢ Economic stability (employment, income, debt, bills, etc.)

* Neighborhood and physical environment (safety, housing, transportation, recreation, walkability, etc.)

* Education (literacy, language, level of education)

¢ Food (hunger and access to decent food)

¢ Community and social context (social integration, support, involvement in the community, discrimination, etc.)

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Health care system (coverage, access to providers, the level of the provider's cultural competence, etc.) [FN86]

On September 28, 2022, HHS announced that it, through CMS, approved Section 1115 demonstrations in Massachusetts and Oregon
that will allow those states to tests strategies to improve coverage, access to care, and quality of care. Notably, the demonstrations

will also allow those states to test strategies to address social determinants of health. HHS described these new authorities in a press
release:

The initiatives also take steps to address unmet health-related social needs, such as by giving Massachusetts and Oregon new
authority to test coverage for evidenced-based nutritional assistance and medically tailored meals, clinically-tailored housing supports,
and other interventions for certain beneficiaries where there is a clinical need. These efforts coincide with the White House Conference
on Hunger, Nutrition, and Health, where the Biden-Harris Administration released its national strategy to end hunger, improve nutrition

and physical activity, and reduce diet-related diseases and disparities ? all goals supported by the initiatives approved today. [FN87]

Additionally, the initiatives will focus on improving enrollment and continuity of coverage. Oregon will keep children enrolled in
Medicaid until age six. These approvals further several of the Biden Administrations priorities: to address hunger, to improve

health equity, and to strengthen Medicaid and the Affordable Care Act. [FN88]

CMS later approved such a waiver in Arizona as well. The program in Arizona will focus on housing insecurity. In a press release, HHS
explains how Arizona will advance solutions to housing insecurity:

CMS has authorized the state to advance solutions to a key health-related social need: housing insecurity. Through the 'Housing and
Health Opportunities" program, Arizona will provide:

* Services to help more people become and remain stably housed;

¢ Support for community and transitional housing for those with unique clinical needs or transitioning out of institutional care; and

¢ Rent and temporary housing for up to six months for individuals transitioning out of places such as congregate settings, homeless
shelters, the child welfare system, and a range of other options to transition more people out of homelessness. [FN8S]

In addition to testing housing-related interventions, the state will offer case management, outreach, and education to advance those

services, /FN®l

Arkansas is the latest state to receive approval for such a waiver, and CMS Administrator Chiquita Brooks-LaSure applauded the
state's efforts:

'With this demonstration, Arkansas has taken a significant step toward advancing whole-person care for people with health-related
social needs . . . . We are glad to partner with the state to advance services and supports that can expand access to high-quality,
affordable care targeting a person's comprehensive health needs." [FNS1]

The amendment to the state's Arkansas Health and Opportunity for Me (ARHOME) Medicaid demonstration waiver will allow the state
to provide targeted support for health-related social needs. Specifically, the state will cover care coordination and other person-centered
supports provided by 'Life360 HOMEs," which will connect the targeted groups to health services and community supports while also
engaging these enrollees in their own health and well-being. HHS explains that the state will collaborate with hospitals and community
partners to support three types of Life360 HOMEs:

* Rural Life360 HOMEs will support individuals with serious mental illness and/or substance use diagnoses who live in rural areas;
¢ Maternal Life360 HOMEs will support individuals with high-risk pregnancies up to two years postpartum; and

¢ Success Life360 HOMEs will support young adults (ages 19-24) at high-risk for long-term poverty and poor health outcomes due to
prior incarceration, involvement with the foster care system, or involvement with the juvenile justice system, as well as veterans ages

19-30 who are at high risk of homelessness. [FN92]

The state will also be authorized to provide or increase coverage of other related services for Life360 HOMEs participants, including
nutritional services, case management, outreach, and education. [FN93]

Health Homes for Children with Complex Medical Conditions

On August 1, 2022, CMS published a State Medicaid Director Letter giving states guidance on implementing Section 1945A of the
Social Security Act. That section allows states to offer a health home State Plan benefit for Medicaid-eligible children with complex
medical conditions. This benefit affords care coordination, care management, patient and family support, and other services that would
support a family-centered system of care in the hopes of improving health outcomes for these children. The option was added as an
amendment to the Affordable Care Act in the Medicaid Services Investment and Accountability Act of 2019 (Pub. L. 116-16), and it
becomes available on October 1, 2022. To be eligible as a child with a medically complex condition, the child must have:

* One or more chronic conditions that cumulatively affect three or more organ systems and severely reduces cognitive or physical
functioning (such as the ability to eat, drink, or breathe independently) and that also requires the use of medication, durable medical
equipment, therapy, surgery, or other treatments; or

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¢ One life-limiting illness or rare pediatric disease (as defined in Section 529(a)(3) of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 360ff(a)(3)). FN!

Chronic conditions include things such as cystic fibrosis, AIDS/HIV, cerebral palsy, and severe autism spectrum disorder, among

others. 'FN9l

In a press release announcing the guidance, CMS explained how this benefit could be a game changer for families:

Children with medically complex conditions - including serious health concerns like cerebral palsy, cystic fibrosis, blood diseases, and
mental health conditions that can severely impact a child's ability to function - often require tremendous care coordination and highly
specialized treatment. Finding needed services often requires traveling well beyond a family's home, and often care is only available
for these children out-of-state. The new health home services are expected to give these children and their families help in coordinating

and managing care. [FN96]
On September 30, 2022, CMS announced that it issued a notice of funding opportunity for planning grants for states interested in
pursuing this option. Up to $5 million will be awarded; each state approved for the funding may receive up to 100,000. [FNS7]

In related news, CMS released a State Plan Amendment template and implementation guide for states interested in taking up this
;_ [FN98]
option.

VI. MEDICAID AND HOME- AND COMMUNITY-BASED SERVICES

The goal of home- and community-based services (HCBS) is to allow those with physical or cognitive limitations to remain at home
instead of moving into institutional care. The term includes a wide range of services to meet medical needs (such as home health,
durable medical equipment, personal care, etc.) and social needs (such as adult daycare, home-delivered meals, home assessments,

and so forth). IFN®8] For the most part, HCBS are optional benefits in Medicaid, [FN 100] though home health services are mandatory.
[FN101] States offer optional benefits either through the State Plan or through Section 1915 or Section 1115 waivers. IFN102] Vigst people

receive HCBS through optional authorities. [FN103] The Affordable Care Act emphasizes HCBS for Medicaid participants, including the
elderly and persons with physical or cognitive disabilities or mental illness. In 2013, the government reached the point where it is now

spending more on HCBS than on institutional care. IFN104] The preference for home- and community-based services is also evident in
the increasing number of states that are expanding the number of people they serve in the community. According to the Kaiser Family

Foundation's annual budget survey for fiscal years 2019 and 2020, 48 states in 2019 and 47 in 2020 were employing one or more

strategies to increase the number of Medicaid participants served in a home or community setting. [FN105]

CMS has now created its first ever quality measure set for HCBS. As CMS explained in the State Medicaid Director Letter, while

HCBS are optional in Medicaid, the use of such services has increased dramatically in the last couple of decades. However, until now,
there was not a consensus on how to define quality for HCBS. In 2020, CMS issued a Request for Information seeking comment on

a draft set of quality measures. CMS has now created a measure set, and future guidance will advise states on how they can use

the measures as a part of their HCBS quality measurement, reporting, and improvement activities. For now, states may voluntarily
choose to report on the measures, but in time the measures will be built into the reporting requirements for various programs and HCBS
authorities. In the guidance, CMS described the purpose of the measures and how they may actually reduce burdens on states:

The HCBS Quality Measure Set is intended to promote more common and consistent use, within and across states, of nationally
standardized quality measures in HCBS programs, and to create opportunities for CMS and states to have comparative quality data
on HCBS programs. In doing so, it is expected to support states with improving the quality and outcomes of HCBS. It is also intended
to reduce some of the burden that states and others may experience in identifying and using HCBS quality measures. By providing
states and other entities with a set of nationally standardized measures to assess HCBS quality and outcomes and by facilitating

access to information on those measures, CMS may be able to reduce the time and resources expended on identifying, assessing, and

implementing measures for use in HCBS programs. [FN106]

The guidance also explained how the measures can be used to advance equity, a key priority for the Biden Administration. [FN107]

According to CMS, data stratification can be used to identify disparities:

Stratification of data is necessary to use the HCBS Quality Measure Set effectively to identify health disparities experienced by
Medicaid beneficiaries receiving HCBS, and to identify effectively where targeted interventions are needed to reduce inequities.

We strongly recommend and encourage states that implement the measure set to stratify a subset of measures within two years

of implementing the HCBS Quality Measure Set, and to increase meaningfully the number of measures that they stratify over time.
Further, we strongly recommend and encourage states to oversample sufficiently to be able to stratify their data on key demographic
and other beneficiary characteristics, such as race and ethnicity, sex, age, rural/urban, disability, and language. CMS recognizes
that oversampling may be associated with increased cost of implementation and recommends that states consider using part of

the enhanced FFP noted above for system improvements that will enhance their ability to collect the demographic and other data

necessary for stratification. [FN108)

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The measure set is included as an appendix to the guidance.

As indicated, while most HCBS are optional, nearly all states offer them, IFN109] but the offerings vary widely by state. IFN110] Some

decry an 'institutional bias": While nursing home care is a mandatory benefit, HCBS are not. [FN111l There is some effort afoot in
Congress to make HCBS mandatory, which would end the so-called institutional bias and offer services to the 850,000 individuals on
waiting lists for optional HCBS. Still in draft form, the HCBS Access Act would do just that. Sponsors, including Representative Debbie
Dingell (D-Mich.), sought comments on the draft in the spring of 2021. Representative Dingell's press release explained why the bill is
so important:

The proposal seeks to mandate HCBS in Medicaid to provide critical services, creating national, minimum requirements for home and
community-based services, and make it possible to enhance those services and the long-term care workforce. . . .

Under our current long-term care system, too many people cannot access the care they need in their homes and communities even
though these are the environments where most people prefer to receive care. The patchwork system that currently exists through
Medicaid HCBS waivers, where access to services depends on the state in which you live, undermines the much-needed creation of a

durable system. States have been using a waiver process to provide long-term services and supports for almost forty years. [FN112]

To be eligible for reimbursement under Sections 1915(c), 1915(i), and 1915(k), HCBS must be offered in a community-based, non-
institutional setting. In 2014, CMS released its HCBS Settings rule, which set out the requirements for appropriate HCBS settings. Such
settings include these features, generally:

* The setting is integrated in and supports full access to the greater community;
¢ Is selected by the individual from among setting options;
¢ Ensures individual rights of privacy, dignity and respect, and freedom from coercion and restraint;

* Optimizes autonomy and independence in making life choices; and

* Facilitates choice regarding services and who provides them. [FN113]

The final rule "41 for HCBS required states to submit a transition plan to CMS demonstrating that they brought existing HCBS
settings into compliance with the final rule. CMS recognized at that time that the transition would be complex, so it gave states five
years to do so. The original due date was March 17, 2019. In an Informational Bulletin, CMS announced that it would extend the

deadline for another three years, until March 16, 2022. [FN118] GMs then realized that, due to the COVID-19 pandemic, states may need
additional time to fully implement the rule. In a State Medicaid Director Letter, CMS spelled out some of the problems states may be
experiencing during the pandemic:

As states are responding to the Coronavirus Disease 2019 public health emergency (COVID-19 PHE), CMS recognizes that its impact
has necessitated changes to states' ongoing efforts to comply with the HCBS settings criteria. States' stay-at-home and/or safer-at-
home orders and the process of social distancing have made it difficult, if not impossible, for states to accurately evaluate how an
individual is experiencing community integration in current HCBS settings. These necessary directives have seriously impacted not only
the measurement of community integration for individuals, but the intent of the Settings Rule to ensure that individuals with disabilities
and older adults have the opportunity to be active participants in their communities. Lastly, older adults and individuals with disabilities

who receive Medicaid HCBS often have underlying conditions that increase risks to health and welfare associated with COVID-19 that

can further delay a return to integrated activities as they existed prior to the global pandemic. [FN116]

Because of these difficulties, CMS indicated that it will give states an additional year, until March 2023, to fully comply with the rule.

On May 24, 2022, CMS announced a strategy to get states into compliance with the rule in a timely fashion. CMS indicates that the
implementation approach includes these components:

¢ States must receive final Statewide Transition Plan approval by March 17, 2023.

¢ States and providers must be in compliance with all settings criteria not directly impacted by PHE [public health emergency]
disruptions, including PHE-related workforce challenges, by March 17, 2023.

¢ Time-limited corrective action plans (CAPs) will be available to states to authorize additional time to achieve full compliance with

settings criteria that are directly impacted by PHE disruptions, when states document the efforts to meet these requirements to the

fullest extent possible, and are in compliance with all other settings criteria. [FN117]

CMS also indicated that it will be holding multiple meetings with stakeholders to review this information. The agency directs
stakeholders to Medicaid.gov for more information. [FN118)

The American Rescue Plan (P.L. 117-2) provided for a temporary ten-percentage point increase in the federal medical assistance
percentage (FMAP) for certain HCBS during the COVID-19 emergency period. CMS provided guidance for states on implementing that
provision. The bulk of the guidance, which takes the form of a State Medicaid Director Letter, focuses on how to qualify for and claim
the additional federal funds. It addresses these areas:

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* eligible services;

* program requirements;

* ways to enhance, expand, or strengthen HCBS;

* how to report on activities that enhance, expand, or strengthen HCBS; and
* how to claim the increased funding.

Please see the guidance for further details about this new opportunity. IFN119] On June 3, 2022, CMS announced that states will have an
additional year, through March 31, 2025, to use these increased funds:

As a result of the ARP increase in the federal matching rate on activities, states originally had a three-year period - from April 1,
2021 through March 31, 2024 - to use the available state funds, attributable to the ARP's increased FMAP, on activities to enhance,
expand, or strengthen HCBS in Medicaid. The extended timeframe, of an additional year, will help to facilitate high-quality, cost-
effective, person-centered services for people with Medicaid. This will allow Medicaid beneficiaries to remain in the setting of their

choice-whether it is their home or another setting-and remain a valued part of their communities. [FN120]

Children with special needs rely on home- and community-based services and Medicaid is the largest payer for these services.
According to the authors of an Issue Brief from the Kaiser Family Foundation, the pandemic is disproportionately affecting individuals
with disabilities, including children with special needs. The purpose of the brief is to provide context for continuing discussions about the
need to invest in and support HCBS. In short, the brief concludes that, though children with Medicaid have high needs, Medicaid HCBS,
when available, do a good job of serving those needs. Among the key findings are these:

¢ While families of Medicaid/CHIP-only children with special health care needs are more likely to face financial difficulty, they find their
health care more affordable than those with private insurance only due to Medicaid's cost-sharing protections.

* Even though children with special health care needs covered by Medicaid/CHIP-only have greater health care needs, they are more
likely than those with private insurance alone to report that their benefits are always adequate to meet their needs, allow them to see

needed providers, and meet their behavioral health needs, reflecting Medicaid's robust benefit package. [FN121]

These are important considerations when discussing the need to strengthen and support the long-term care system. As indicated,

the American Rescue Plan provided a temporary ten percentage point increase in the federal medical assistance percentage (FMAP)
for HCBS. Whether states can continue with these services and supports when the temporary increased FMAP ends is unclear.
Additionally, many states took emergency action to support long-term care during the COVID-19 public health emergency, but again, it

is unclear whether states can afford to make these changes permanent once the public health emergency ends. [FN122]

There seems to be widespread agreement that the long-term care system needs to be strengthened, but no clear federal commitment
has been made yet for the required funding. The authors of a Kaiser Family Foundation brief note,

Although President Biden earlier this year proposed a $400 billion federal investment over 10 years to expand access to Medicaid
HCBS and strengthen the direct care workforce, it is unclear how much of that funding increase will be approved by Congress as it
considers competing priorities in the budget package and calls among some to reduce the overall spending level. The reconciliation
bill being considered by the House includes $190 billion for HCBS. Increased federal funding for Medicaid HCBS beyond the current
1-year could enable states to support the HCBS provider workforce, offer new or expanded HCBS benefits, and/or serve more HCBS

enrollees, all of which can benefit children with special health care needs. [FN123]

Please see the brief for a much more detailed explanation of the matter and some thoughts for the future. [FN124]

CMS has offered states the opportunity to implement some federally-developed HCBS programs. One such program is the Community
First Choice Option (CFC), which can be approved as a Section 1915 waiver. Under the Affordable Care Act, states choosing this
option receive a 6% bump in their Medicaid federal matching funds to design programs that provide community-based attendant

services and supports to those who would otherwise be institutionalized. [FN125] Services that fall under the CFC program include such
things as attendant services to help with daily living activities (e.g., eating, toileting, grooming, dressing, and bathing), instrumental
activities of daily living (e.g., meal preparation, managing finances, and transportation); and health-related tasks, (e.g., catheterization,
range of motion exercises, and medication administration). Other personal services, plus the cost of moving patients back into the

community from an institution, may also be covered. IFN126] Currently, only five states have an approved State Plan Amendment for a
CFC program. [FN127]

PACE is both a Medicare and Medicaid program. To be eligible, one must be 55 or older, live in the service area of a PACE
organization, be eligible for nursing home care, and be able to live safely in the community instead of in a nursing facility. PACE is an

optional Medicaid benefit, and not every state offers it. [FN 128] According to Medicaid.gov, PACE,

provides comprehensive medical and social services to certain frail, community-dwelling elderly individuals, most of whom are
dually eligible for Medicare and Medicaid benefits. An interdisciplinary team of health professionals provides PACE participants with

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coordinated care. For most participants, the comprehensive service package enables them to remain in the community rather than
receive care in a nursing home. Financing for the program is capped, which allows providers to deliver all services participants need
rather than only those reimbursable under Medicare and Medicaid fee-for-service plans. PACE is a program under Medicare, and
states can elect to provide PACE services to Medicaid beneficiaries as an optional Medicaid benefit. The PACE program becomes the

sole source of Medicaid and Medicare benefits for PACE participants. [FN129]

The Money Follows the Person demonstration is a Medicaid home- and community-based program that supports people moving out of
institutions and back into their homes or the community. According to a CMS press release, HHS has already awarded over $4 billion to
support people in these moves. HHS has now issued a funding opportunity offering awards of up to $5 million to each of the 20 states
and territories that are not yet participating in the demonstration. The funds are meant for the planning process to allow states to get
these programs up and running. They can be used, for example, for:

¢ Establishing partnerships with community stakeholders, including those representing diverse and underserved populations, Tribal
entities and governments, key state and local agencies (such as state and local public housing authorities), and community-based
organizations;

¢ Conducting system assessments to better understand how HCBS support local residents;
¢ Developing programs for the types of community transitions MFP supports;
* Establishing or enhancing Medicaid HCBS quality improvement programs;

¢ Recruiting HCBS providers as well as expert providers for transition coordination and technical assistance; and

¢ Conducting a range of planning activities deemed necessary by the award recipients and approved by CMS. [FN130]

Additionally, for states that already participate in Money Follows the Person, HHS will provide additional funding for 'supplemental
services":

For states already participating in MFP, CMS also announced that the agency is increasing the reimbursement rate for MFP
'supplemental services." These services will now be 100% federally funded with no state share. Further, CMS is expanding the
definition of supplemental services to include additional services that can support an individual's transition from an institution to the
community, including short-term housing and food assistance. These changes will help further address critical barriers to community

living for eligible individuals, as well as increase community transition rates and the effectiveness of the MFP demonstration overall.
[FN131]

Vil. MEDICAID AND BEHAVIORAL HEALTH

While the definition of the term 'behavioral health' has changed over time, it is now widely used to encompasses mental health

and substance use disorder (drugs or alcohol), among other things. IFN'132] Medicaid is the single largest payer of mental health
services, and the program is an increasingly larger payer for substance use disorder services. [FN133] Some mental health services
are mandatory, but many are optional. [FN134] As an essential benefit, mental health and addiction services are required for the newly
eligible in states that implement the Medicaid expansion, but only 39 states (including the District of Columbia) have done so. [FN135]
In 2022, the Biden Administration announced its Behavioral Health Strategy. The strategy has five goals:

¢ Strengthen equity and quality in behavioral health care;

¢ Improve access to substance use disorders prevention, treatment and recovery services;

¢ Ensure effective pain treatment and management;

¢ Improve access to and quality of mental health care and services; and

* Utilize data to inform effective actions and measure impact on behavioral health. [FN136]

Please see CMS' Behavioral Health Strategy page for more information. [FN137]

The pandemic has exacerbated the problems with mental health and substance abuse, and CMS hoping that mobile crisis intervention
units will help. In September 2021, CMS announced that it awarded $15 million in planning grants to 20 states for Medicaid mobile
crisis intervention services. These units provide around-the-clock services 365 days per year for individuals in crisis due to mental
health or substance abuse problems. CMS believes that these services could save lives and avoid unnecessary incarceration of people
in crisis. In announcing the funds, HHS Secretary Xavier Becerra noted that the pandemic has detrimentally affected mental and
behavioral health, particularly in underserved communities:

'The pandemic has taken a serious toll on the mental health of Americans, especially in underserved communities . . . . Through these
awards, the Biden-Harris Administration is making a bold investment to highlight the importance of behavioral health and ensure states

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can provide vital services to those hardest hit by the pandemic. This funding from the American Rescue Plan will expand access to
crisis care for everyone-and reach people where they are. " [FN 138]
The grants may be used for a variety of purposes:

The planning grants provide funding to develop, prepare for, and implement qualifying community-based mobile crisis intervention
services under the Medicaid program. Grant funds can be used to support states' assessments of their current services; strengthen
capacity and information systems; ensure that services can be accessed 24 hours a day, every day of the year; provide behavioral
health care training for multi-disciplinary teams; or seek technical assistance to develop State Plan Amendments (SPAs), demonstration

applications, and waiver program requests under the Medicaid program. FN139]

The funds, which are provided through the American Rescue Plan (P.L. 117-2), run for one year. Beginning on April 1, 2022, states
became temporarily eligible for an enhanced federal match rate for mobile crisis intervention services. IFN140] Biease see CMS" press
release for a link to the list of the 20 states that will be receiving the funds.

In late 2021, CMS published a State Health Official Letter explaining more about the option. CMS explained in the letter why these
services are crucial for behavioral health care:

Community-based mobile crisis intervention services are a key element of an effective behavioral health crisis continuum of care.

The main objectives of community-based mobile crisis intervention services are to provide rapid response, individual assessment

and crisis resolution by trained mental health and substance use treatment professionals and paraprofessionals in situations that
involve individuals who are presumed or known to have a mental health condition and/or SUD. With the provision of these intervention
services, individuals can be linked to needed services, such that psychiatric hospitalizations, including hospitalizations that follow
psychiatric emergency department (ED) admissions, can be reduced. Additionally, mobile crisis teams can respond to situations that

require their services rather than those of law enforcement. [FN141]

States with approval to provide these services will qualify for an 85% FMAP (federal medical assistance percentage) for the first 12
fiscal quarters of the five-year period. Briefly, to qualify for payment, the services:

¢ must be rendered outside of a hospital to an individual who is eligible for Medicaid, either through a waiver or the State Plan, who is
experiencing a mental health or substance use disorder crisis; and

* must be rendered by a multi-disciplinary team that meets the requirements of the statute (at least one behavioral health care
professional qualified to conduct assessments and other professionals or paraprofessionals with expertise in behavioral health or
mental health crisis intervention services, including, for example, nurses or social workers).

Additionally, states must require that the mobile crisis team be able to provide 'screening and assessment, stabilization and de-
escalation, and coordination with and referrals to health, social and other services and supports, as needed, and health services as
needed." The services may be provided through a fee-for-service or managed care delivery system. Please see the letter for much

more information about this new state option. [FN142]

In September 2022, CMS approved Oregon as the first state to take up this option. CMS encourages other states to take up the option
[FN143]
as well.

Substance Use Disorder

One huge concern in the area of behavioral health is the opioid abuse crisis. Deaths from overdose doubled from 2007 to 2017; in
2017, 47,600 individuals died from overdose. IFN144] The pandemic exacerbated the problem. According to the CDC, in the 12 months
preceding April 2021, over 100,000 American died of an overdose, an increase of about 28% over the previous year. [FN145] According

to the Kaiser Family Foundation, Medicaid and CHIP cover about 40% of individuals with an opioid addiction. IFN146] tn a blog post,
CMS explained why it is so concerned about this epidemic: the drugs can cause fatal harm to the central nervous and respiratory
systems; opioid misuse can lead to other drug addictions and hence illnesses such as Hepatitis C and HIV, which are common among
intravenous drug users; accidental overdose is not uncommon; and the number of prescriptions for opioid drugs has quadrupled in less

than 20 years, even though people are not reporting more pain than they were 20 years ago. [FN147]
In 2022, CMS published its National Drug Control Strategy, which the Biden Administration calls a 'whole-of-government approach to

beat the overdose epidemic." The plan includes targeted actions to expand access to evidence-based prevention, to reduce harm, and
to expand treatment and recovery services. Notably, it also includes targeted actions to reduce the flow of dangerous drugs such as

fentanyl. IFN148] « Fact Sheet about the strategy is available. [FN149]

The Medicaid exclusion for services provided in an 'institution for mental diseases' with over 16 beds has been a stumbling block to
treatment for substance use disorder. The exclusion is a vestige of the original Medicaid law in 1965 that was meant to encourage
treatment in smaller, community-based settings instead of large inpatient institutions. However, it has taken away an important option

in the fight against opioid abuse. [FN150] Policymakers have been battling for several years to change the provision in order to open
up this option. In the meantime, the federal government has been granting waivers to states to develop pilot programs for inpatient

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substance abuse treatment at facilities with more than 16 beds, and several states are offering, or are seeking to offer such programs.

[FN151] Section 5052 of the SUPPORT Act created a limited exception to the IMD exclusion. CMS released a State Medicaid Director
Letter offering guidance to states that wish to implement this new State Plan option. Section 5052 enacted a new section of the Social
Security Act, Section 1915(I), which created an exception to allow states, at their option, to cover IMD services from October 1, 2019
to September 30, 2023, for individuals aged 19-64 with at least one substance use disorder diagnosis. Among other things, the letter

specifically defines which individuals and IMDs are eligible under the exception. IFN152]

In a letter to Chiquita Brooks-LaSure, the CMS Administrator, a group of bipartisan senators, Senators Chuck Grassley (R-lowa), Bill
Cassidy (R-La.), Alex Padilla (D-Calif.), Catherine Cortez Masto (D-Nev.), and John Cornyn (R-Texas) have asked CMS for clarification
on whether mental health crisis stabilization centers are considered Institutions for Mental Diseases under Medicaid payment rules.

[FN153] The letter spells out the potential problem:

Crisis stabilization programs offer access to mental health and substance use care to communities and are distinct from longer-term
treatment facilities. They accept all patients that walk-in, or arrive by ambulance, fire, or police drop-offs. The maximum length of stay
for these programs is 23 to 72 hours, and their primary goal is to keep patients in mental health crises out of inappropriate settings
like homeless shelters and county jails. Such programs rely on the availability of federal Medicaid funds to offer sustainable access to
patients of limited means. . . . Without clarifying guidance from CMS, we are concerned that states may feel compelled to apply the
IMD exclusion to crisis stabilization programs, which would limit the availability of these programs significantly and leave vulnerable

individuals experiencing mental health crises without access to necessary crisis support services. [FN154]

The letter notes that the new 988 Suicide Prevention Lifeline may greatly increase the need for crisis stabilization, which is one reason
why the senators believe that clarification is crucial.

Mental Health

In November 2018, CMS announced an opportunity for states to participate in a new demonstration program for adults with a serious
mental illness (SMI) or children with a serious emotional disturbance (SED); this demonstration also tests a limited exception to the IMD
exclusion. CMS described the opportunity in a State Medicaid Director Letter:

This SMI/SED demonstration opportunity will allow states, upon CMS approval of their demonstrations, to receive [federal financial
participation] for services furnished to Medicaid beneficiaries during short term stays for acute care in psychiatric hospitals or residential
treatment settings that qualify as IMDs if those states are also taking action, through these demonstrations, to ensure good quality

of care in IMDs and to improve access to community-based services as described below. This SMI/SED demonstration opportunity

is comparable to the recent section 1115(a) demonstration opportunity to improve treatment for [substance use disorders], including
opioid use disorder (OUD). However, through these demonstrations, states will focus on demonstrating improved care for individuals
with serious mental health conditions in inpatient or residential settings that qualify as IMDs as well as through improvements to

community-based mental health care. [FN155]
CMS announced that it approved such a demonstration program submitted by the District of Columbia. At the same time, CMS
approved the district's plan to implement a similar demonstration for individuals diagnosed with a substance use disorder. According

to CMS's press release, the district has been particularly affected by the opioid crisis and has experienced a 236% increase in fatal
opioid-related overdoses from 2014 to 2017. Often, individuals with a substance use disorder also suffer from a serious menial illness,

so CMS and the district see the potential for saving thousands of lives. [FN156] According to CMS, as of November 2022, the District
of Columbia and ten states (Alabama, Idaho, Indiana, Maryland, Michigan, New Hampshire, Oklahoma, Utah, Vermont, and

Washington) have SMI/SED waivers, and five states (Massachusetts, New Jersey, New Mexico, Washington, and West Virginia)

have such a waiver pending. IFN197]

Xill. maternal health

According to a Fact Sheet from the White House, hundreds of women die in this country from complications of pregnancy or delivery
or complications during the post-partum period. Unfortunately, women of color and women in rural communities are disproportionately

impacted; they have 'significantly' higher mortality and morbidity rates than white urban women. IFN158] As we discuss below, the
American Rescue Plan (Pub. L. 117-2) included an option for states to extend post-partum coverage to one year on a temporary basis

(up to five years), [FN159] but the administration is calling on Congress to make this extended coverage permanent. [FN 160] However,

the administration recognizes that immediate actions need to be taken. Due to the urgency of the situation, the Biden Administration
worked with over a dozen federal agencies to write the Blueprint for Addressing the Maternal Health Crisis. The blueprint is a call for the
government to work in five priority areas:

- Increasing access to and coverage of comprehensive high-quality maternal health services, including behavioral health services.
- Ensuring women giving birth are heard and are decisionmakers in accountable systems of care.
- Advancing data collection, standardization, harmonization, transparency, and research[.]

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- Expanding and diversifying the perinatal workforce.

- Strengthening economic and social supports for people before, during, and after pregnancy. [FN161]

According to the Fact Sheet from the White House, the actions in the blueprint would afford the following for women:

(1) post-partum coverage for 12 months;

(2) investments in rural maternal care;

(3) a 24-hour, toll-free maternal mental health hotline;

(4) better access to substance use disorder services;

(5) elimination of certain unexpected medical bills (as provided for in the No Surprises Act, which is being implemented by rulemaking)
(6) provider training to ensure culturally sensitive and linguistically appropriate care;

(7) better use of data to better understand health outcomes;

(8) a more diverse health care workforce;

(9) better access to doulas and midwives;

(10) expanded availability of social supports; and

(11) better workplace protections for mothers. [FN162]

The blueprint is available on the White House web site. [FN163]

To improve maternal and infant care, CMS launched the Maternal and Infant Health Initiative in 2014. Initially, the focus of the initiative
was to increase and improve postpartum visits and to increase the use of effective contraception. Five years into the initiative, with
maternal and infant mortality and morbidity increasing, CMS reevaluated the program's progress and its future. The agency convened
an expert workgroup, which identified priority focus areas for which Medicaid and CHIP programs could provide technical assistance.
Those focus areas are:

1. Increase the use and quality of postpartum care visits;

2. Increase the use and quality of well-child visits; and

3. Decrease the rates of cesarean section births in low-risk pregnancies, defined as nulliparous (first-time pregnancies), term (37 or
more weeks gestation), singleton (one fetus), vertex (head facing down in the birth canal) or 'NTSV births." [FN164]

CMS has now announced a new phase of the initiative, and it summarized the plan on Medicaid.gov:

Over the course of 2021, CMS will roll out new technical assistance opportunities for states addressing the three focus areas
recommended by the MIH Expert Workgroup and will include: (1) the Postpartum Care Learning Collaborative; (2) the Infant Well-Child
Visits Learning Collaborative, and (3) the NTSV Learning Collaborative. Each learning collaborative will offer TA [technical assistance]
to state Medicaid and CHIP agencies and their partners using two strategies: (1) a webinar series open to all states, including a webinar

that will address payment reform strategies to incentivize improvement, and (2) an affinity group for states interested in developing and

implementing a quality improvement project. N18!

The new plan is meant to support states as they work on the three focus areas that the workgroup prioritized.

As a part of the Maternal and Infant Health Initiative, CMS has launched the Maternal Health by Reducing Low-Risk Cesarean Delivery
(LRCD) Learning Collaborative. When it announced the LRCD, CMS noted that cesarean births place both the birthing individual and
the child at higher risk for poorer outcomes. Still, cesarean births account for over one-quarter of all births nationwide, and the rate for
African Americans is even higher. The program seeks to reduce cesarean births for those at low risk with a vaginal birth. It will consist
of two parts: a webinar series and an affinity group. CMS invited the following entities to join in the webinar series, which were held over
the course of 2022: state Medicaid and CHIP agencies, Medicaid hospital and maternity care providers, Medicaid and CHIP managed
care plans, and other quality improvement partners. Each episode of the three-part webinar series focused on how Medicaid can play a

role in reducing low-risk cesarean deliveries. [FN166]

CMS, through its Innovation Center, is also administering the Maternal Opioid Misuse (MOM) Model. In that model, CMS hopes
to improve the quality of care for pregnant and post-partum individuals and their babies and to reduce the cost of caring for these
individuals. CMS explained how the model is designed to achieve these goals:

Fostering coordinated and integrated care delivery: Support the delivery of coordinated and integrated physical health care,
behavioral health care, and critical wrap-around services.

Utilizing Innovation Center authorities and state flexibility: Leverage the use of existing Medicaid flexibility to pay for sustainable
care for the model population.

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Strengthening capacity and infrastructure: Invest in institutional and organizational capacity to address key challenges in the
provision of coordinated and integrated care, "67!

CMS has entered into cooperative agreements with eight states (Colorado, Indiana, Maine, Maryland, New Hampshire, Tennessee,

Texas, and West Virginia) that have agreed to work with one or more community care delivery partners. IFN168] The model is to be
implemented over five years, with Year 1 being the pre-implementation phase, Year 2 being the transition phase (when care delivery
is to begin), and Years 3-5 being the full implementation phase. The pre-implementation phase was to end by January 2021, when the
states were to have screened and enrolled the participants. Due to the COVID-19 pandemic, this deadline was postponed until July

2021 IFN169]

The pre-implementation phase has ended, and CMS has published an evaluation report for that period. The report describes each
state's program ? the population (urban or rural) they will be working with, the type of care delivery partner they will be working with
(a managed care organization or a health care facility, like a hospital or a federally-qualified health center), the expected enrollment

(ranging from 30 to 1,500), and the type of intervention on which the state is focused (like case management, service integration and
coordination, or information sharing). CMS identifies these as key takeaways of the pre-implementation period:

¢ MOM Model awardees and their partners hope to relieve physical and psychosocial barriers to OUD treatment for pregnant and
postpartum people
* Barriers to treatment include transportation, childcare issues, and stigma

* MOM Model enrollment began in July 2021 for six of eightawardees [FN170]

Please see the report for more information.

According to HHS, the post-partum period is crucial to a new mother's health: More than one-half of pregnancy-related deaths occur
within one year of childbirth, and 12% percent occur after six weeks postpartum. [FN171] However, under current law, states are only
required to provide post-partum coverage for 60 days after childbirth. IFN'172] Medicaid is the single largest payer for births in this

country, [FN173] covering more than 40% of all births in the U.S. IFN174] as mentioned above, the American Rescue Plan provided states
with an option to cover post-partum women through the State Plan for one full year after childbirth. Before the American Rescue Plan,

states wishing to extend post-partum coverage had to do so through a waiver. IFN175] The new option began on April 1, 2022, and

in a press release on that day, HHS indicated that 720,000 individuals could be eligible for the extended coverage. [FN176] CMS is
encouraging states to take up this option. CMS Administrator Chiquita Brooks-LaSure explained why this coverage is a priority for the
Biden Administration:

'No mother should have to fight for her coverage or care during pregnancy or while caring for a newbom. CMS is doing everything we
can to support the health of new parents and families, and to advance health equity across the country . . . . Across the Biden-Harris
Administration, we are committed to advancing equitable, high-quality maternity care, and reducing unnecessary postpartum illnesses

and deaths that disproportionately harm people of color." [FN177]

CMS announced in the spring and summer of 2022 that it had approved several states to take up the option. They include California,
Connecticut, the District of Columbia, Florida, Hawaii, Illinois, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts,
Michigan, Minnesota, New Jersey, New Mexico, Ohio, Oregon, South Carolina, Tennessee, Virginia, and Washington. These

approvals afford extended coverage to 318,000 people. [FN178] 9 press release from CMS explained why this coverage is so important:

Medicaid covers 42% of all births in the nation. But for too long, families have been left behind by a health care system that breaks
connections to care when they are needed most. More than half of pregnancy-related deaths in the United States occur in the 12-month
postpartum period; 12 percent occur after six weeks postpartum.

This new option for states to extend Medicaid and CHIP postpartum coverage is part of the ongoing efforts of HHS and the Biden-Harris
Administration to address disparities in maternal health outcomes by opening the door to postpartum care for hundreds of thousands

of individuals. It offers states an opportunity to provide life-saving care that can reduce pregnancy-related deaths and severe maternal
morbidity, as well as improve continuity of care for chronic conditions such as diabetes, hypertension, cardiac conditions, substance

use disorder, and depression-particularly for underserved communities. [FN179]
In fall 2022, CMS added Indiana, and West Virginia to the growing list of states expanding post-partum coverage. In Indiana, the

extended coverage is expected to benefit 12,000 individuals, and in West Virginia, 3,000 are expected to benefit. [FN180] just weeks
later, the agency announced that it had approved North Carolina for the extended coverage as well.

Equity is a concern with post-partum coverage as about one-half of childbearing Medicaid participants are Black, Hispanic, or American
Indian/Alaskan Native individuals; [FN181]
die from a pregnancy-related complication, deaths that are often preventable.

and Black and American Indian /Alaskan Native individuals are about five times more likely to
[FN182]

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A brief from the Assistant Secretary for Planning and Evaluation's Office of Health Policy in HHS explained the benefits of extending
post-partum coverage to one year. Some of the key findings include these:

¢ If all states extended post-partum benefits to 12 months, the proportion of pregnant individuals who would be covered for the full year
would rise from 52% to 100%, and would include roughly 720,000 women each year.

¢ Pregnant individuals from non-expansion states and states with more restrictive eligibility limits for parents would benefit the most from
the extended coverage, with eligibility rising by 65 percentage points in non-expansion states (covering about 350,000 individuals) and
38 percentage points in non-expansion states (covering about 370,000 individuals).

¢ Gains in eligibility would be largest for individuals earning between 138% and 250% of the federal poverty level, as these individuals

do not qualify as parents in most states. N18]

Additionally, CMS has issued guidance on this option as well as other opportunities to improve maternal health. [FN184]

Finally, the Kaiser Family Foundation keeps track of state actions to increase post-partum coverage. As of November 2022, 34 states
(including the District of Columbia) have either extended coverage to 12 months or have plans to. Please see the tracker for more

information. '"N*85

IX. PREPARING FOR THE END OF THE COVID-19 PUBLIC HEALTH EMERGENCY

One of the first pieces of legislation Congress passed to ameliorate the impact of the COVID-19 pandemic was the Families First
Coronavirus Response Act (P.L. 116-127). That act affected Medicaid in a variety of ways; perhaps most importantly, it increased
the federal medical assistance percentage (FMAP) by 6.2 percentage points for states that complied with certain maintenance of

effort requirements. Generally, states were required to maintain continuous enrollment in order earn the increased FMAP. [FN186]
Unfortunately, the increased FMAP will only be available until the end of the public health emergency, which is ongoing.
As Kaiser Health News points out, Medicaid enrollment swelled to unprecedented levels during the public health emergency: As of

July 2021, 76.7 million people were enrolled, [FN187] nearly 25% of the entire population. [FN188] When the public health emergency
ends, millions of people could be determined ineligible for Medicaid or could lose it for not responding to redetermination information
requests. Sorting it out will be a Herculean task for states, which will take time and money. According to Kaiser Health News, the Biden
Administration will give states a year to reevaluate their Medicaid rolls, but many states feel pressured to do it sooner because the
increased federal funds will end shortly after the public health emergency does. As an example, the author points to the work ahead of
officials in Colorado:

In Colorado, officials expect they'll need to review the eligibility of more than 500,000 people, with 30% of them at risk of losing benefits
because they haven't responded to requests for information and 40% not qualifying based on income. [FN189]

This spells trouble for low-income people. This population tends to be in poorer health to begin with, and any interruption in coverage,
even if only temporary, could be devastating. Moreover, COVID vaccination rates are lower for Medicaid enrollees, leaving them

vulnerable to serious illness if they become infected. [FN190]

According to the article, the Biden Administration has vowed to give states 60 days' notice before the public health emergency ends,
and the increased federal funds will expire at the end of the quarter in which the public health emergency ends. [FN191]

To ease the redetermination process, HHS and CMS requested an opinion from the Federal Communications Commission (FCC) on
using telephone services for this process. Specifically, HHS and CMS asked for an opinion on,

whether text messages and automated pre-recorded telephone calls to individuals' cell phones with reminders to update their contact
information, return their renewal forms, and follow up with the Marketplace if their enrollment needs to transition, are permissible under
the Telephone Consumer Protection Act (TCPA). With Medicaid and CHIP enrollment rising to over 86 million enrollees, as of January

2022, it is important to ensure state agencies have the tools and guidance that they will need to communicate effectively with enrollees.
[FN192]

CMS also created several tools to help states unwind from the public health emergency. The first tool gives advice on fair hearings.

CMS believes that during this process, states will have increased demand for fair hearings. [FN193] The second tool summarizes some
of the state unwinding plans that CMS deems the best and most promising. CMS gathered information on states' plans during a series
of calls with the states in December 2021. The agency identifies these common themes in the plans: renewals and determinations,

updating enrollee contact information, workforce capacity, and outreach and partnerships. IFN194] CIS has also released a tool detailing
existing federal requirements for renewals, verifications, applications, and oversight of their programs. According to CMS, compliance
with these existing requirements will be 'critical to ensuring that timely and accurate eligibility determinations are completed and that

eligible individuals remain enrolled or are transferred seamlessly to other coverage." [FN195] jp, May 2022, CMS released a resource

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detailing ten fundamental actions that states should take to prepare for the unwinding. [FN196] That document also points states to
additional resources on its Medicaid Unwinding page. [FN197]

In a March 3, 2022 State Health Official Letter, CMS gave guidance to states as they plan for this period. In the letter, CMS indicated
that it would grant temporary waivers to states to facilitate this process, and it set out some strategies for promoting continuity of
coverage and avoiding churn during the unwinding period. IFN198] The letter outlined these strategies:

Renewal for Individuals Based on Supplemental Nutritional Assistance Program (SNAP) Eligibility (Targeted SNAP Renewal)
Ex Parte Renewal for Individuals with No Income and No Data Returned (Beneficiaries with No Income Renewal)

Facilitating Renewal for Individuals with no Asset Verification System (AVS) Data Returned within a Reasonable Timeframe
(Streamlined Asset Verification)

Partnering with Managed Care Plans to Update Beneficiary Contact Information (MCO Beneficiary Contact Updates)

Use of the National Change of Address Database (NCOA) and United States Postal Service (USPS) Returned Mail to Update
Beneficiary Contact Information (NCOA and/or USPS Contact Updates)

Extending Automatic Reenrollment into Medicaid Managed Care Plans up to 120 Days (MCO Plan Auto-Reenrollment)

Extended Timeframe to Take Final Administrative Action on Fair Hearing Requests (Fair Hearing Timeframe Extension)

Delaying the Resumption of Premiums Until a Full Redetermination is Completed (Premium Resumption Delay) [FN199]

In the interest of transparency, in August 2022 CMS released a chart showing which states have received waivers for which strategies.
As of August 5, 2022, 20 states had received a waiver for at least one of the strategies outlined in the March letter. [FN200]

In related news, the Biden Administration indicated that it will add a new 'call to action button" to Medicaid.gov to assist enrollees
through the redetermination process. The notice explains that this option will automatically direct enrollees to a new 'Renew Your
Medicaid and CHIP Coverage" page that provides information on renewals, including updating contact information, checking their mail
for correspondence, and completing a renewal form, if needed. The page also provides an interactive map that can take enrollees

directly to their state Medicaid program. [FN201]

At the beginning of the pandemic, CMS advised states of the option to expand Medicaid eligibility by adding a category for uninsured
individuals needing COVID-19 care. The option extends until the end of the public health emergency. In anticipation of the public health
emergency ending and the unwinding from it, CMS provided a new resource for the states that took up the option. States will need

to redetermine eligibility by ensuring that no other eligibility category fits these individuals, and if none is available, states will need

to disenroll them after providing a 10-day notice. However, if the state needs additional information to redetermine eligibility, it must
provide an opportunity for the enrollee to provide such information. The disenrollment process may trigger requests for fair hearings.
CMS stresses that the end of the federal authority itself is not grounds for seeking a fair hearing, but enrollees may request one if they

believe they were disenrolled in error. The resource provides strategies for providing notice and redetermining eligibility. [FN202]

In related news, CMS released a new series of FAQs for states as they plan how to unwind from the policies set out for the duration of

the public health emergency. [FN203] CMS also released a new resource discussing the use of ex parte renewals during the unwinding
process. These types of renewals, also called administrative or auto-renewals, are renewals that rely on existing data instead of

requiring additional information from the enrollee. According to CMS, they can ease the state's burden during the unwinding process.
[FN204]

X. selected Legislative Activity

« In Congress, 2021 FD H.B. 56 (NS) would ensure coverage of medically necessary medical food in Medicaid and other insurance
programs. Generally, medical food is defined as food that is prescribed for a disease or condition that it taken enterally. The bill is
sponsored by Representative Andy Biggs (R-Ariz.).

* House Bill 124 (2021 FD H.B. 124 (NS)) would enact the Byron Nash Renal Medullary Carcinoma Awareness Act of 2021, which
would establish financial incentives for states to provide education on renal medullary carcinoma to Medicaid participants with Sickle
Cell Disease. The sponsor is Representative Al Green (D-Tex.).

«In the Senate, 2021 FD S.B. 151 (NS), which would enact the COVID HCBS Relief Act of 2021, would temporarily increase by 10
percentage points state FMAPs for home- and community-based services upon approval of an application. The FMAP would be added
to the already increased FMAP set by the Family First Coronavirus Relief Act (P.L. 116-127) and would be effective from October 1,
2020, to September 30, 2022. The bill defines home- and community-based services as follows:

(C) Home and community-based services. The term 'home and community-based services' means home health care services
authorized under paragraph (7) of section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)), behavioral health services
authorized under paragraph (13) of such section, personal care services authorized under paragraph (24) of such section, PACE

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services authorized under paragraph (26) of such section, services authorized under subsections (b), (c), (i), (j), and (k) of section 1915
of such Act (42 U.S.C. 1396n), such services authorized under a waiver under section 1115 of such Act (42 U.S.C. 1315), and such
other services specified by the Secretary.

The Senate Special Committee on Aging issued a press release about the bill, summarizing how the COVID HCBS Relief Act would
invest in home- and community-based services:

Earlier this year, Senator [Bob] Casey introduced the COVID HCBS Relief Act of 2021, which would provide a 10 percent Federal
Medical Assistance Percentages (FMAP) increase to states to be used to enhance HCBS; funds can be used to support front-line
workers with increased pay, paid sick and family medical leave and personal protective equipment, among other essential supports.
Since March 2020, Senator Casey has also introduced three other bills to invest in HCBS. Seniors and people with disabilities are
uniquely vulnerable to the COVID-19 virus; people with developmental disabilities have died from COVID-19 at a rate of three times

higher than the general population. Currently, more than 800,000 people nationwide are waiting to receive HCBS, with nearly 16,000 in
Pennsylvania. [FN205]

The companion bill in the House is 2021 FD H.B. 525 (NS). In addition to sponsoring the Senate bill, Senator Bob Casey (D-Pa.) and
others sent a letter to President Joseph Biden (D) urging further investment in home- and community-based services as a way to
strengthen the long-term care workforce, particularly for those who choose home or community care over institutional care. As the letter
writers aptly point out, our aging population will require a robust long-term care system, and these investments would help ensure such

a system. Such investments would also bolster the economy, which has been battered by the COVID-19 pandemic. [FN206]

¢ Senate Bill 274 (2021 FD S.B. 274 (NS)) would enact the Stronger Medicaid Response to the COVID-19 Pandemic Act. That act
would allow states, at their option, to provide Medicaid coverage for COVID-19 vaccines and treatment for uninsured individuals.
Senator Michael Bennet (D-Colo.), one of the bill's sponsors, explains what the bill would do:

The Stronger Medicaid Response to the COVID-19 Pandemic Act increases support for expanding health care needs resulting from the
current public health crisis. The legislation would allow Medicaid programs to pay for treatment and prevention, hospitalization, drugs,
vaccines, and other related services for individuals with COVID-19 who are uninsured. This builds on the Families First Coronavirus

Response Act which provided Medicaid coverage for COVID-19 testing for uninsured individuals. [FN207]

¢ Representative Jamaal Bowman (D-N.Y.) and Senator Elizabeth Warren (D-Mass.) introduced a resolution calling for a nationwide
commitment to strengthen all aspects of the care economy, including, for example, child care, health care, and adult care. The House
bill is 2021 FD H.R. 180 (NS) and the Senate Bill is 2021 FD S.R. 85 (NS). The lengthy findings supplied with the bill note, among many
other things, that:

¢ nearly 20 million adults have long-term care needs stemming from age or disability;

* the average cost of a private room in a nursing facility exceeds $100,000 a year;

* Medicaid covers long-term care but with strict income and resource limitations;

¢ Medicaid mandates coverage of institutional long-term care while home- and community-based care services are optional and more
limited;

¢ Medicare does not generally cover long-term care;

* only 7% of Americans over 50 have private long-term care insurance because of the expense;

* nearly 30,000,000 Americans are uninsured, many of them people of color;

¢ the COVID-19 pandemic has highlighted the essential nature of care work, including health care and child care;

¢ 135 rural hospitals have closed since 2010, and the rate of closure is accelerating; and

* adults in institutional long-term care represent just 1% of the population but have accounted for nearly one-third of the nation's
COVID-19 deaths.

The resolution asserts that the federal government has the duty to dramatically strengthen the care economy, and this duty can only be
met by the government redressing the wrongs of history and acknowledging the oppression and exclusion of care workers, particularly
immigrants and those of color. In a press release, Representative Bowman sums up why the bill is important:

Just as our physical infrastructure is crumbling, the United States today suffers from a lack of care infrastructure. Millions are struggling
to access child care, health care, long-term supports and services, and paid family and medical leave. Growing numbers of care
workers, disproportionately women of color and immigrants, face poverty wages and exploitation; along with education, social
assistance, and other essential workers, they are on the frontlines of multiple crises in our society. Investing in care work and programs
can boost the economy, meet people's fundamental needs, and help us face the challenges of the 21st century and beyond.

The resolution calls for far-reaching public investments to guarantee the care people need at all stages of life, and to ensure caregivers
and care workers are treated with the dignity they deserve. That must include raising pay, benefits, protections, and standards for all

care workers, ensuring pathways to unionization, and creating millions of new care jobs over the next decade. [FN206]

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¢ Sponsored by Senator Tammy Baldwin (D-Wis.) and others, 2021 FD S.B. 285 (NS) would make Medicaid available to inmates in the
final 30 days of the sentence.

¢ In the House, 2021 FD H.B. 581 (NS) would make payment for certain Medicaid family planning services contingent on the state
submitting specified data on abortion to the Centers for Disease Control and Prevention. The findings supplied with the bill note that
state reporting of abortion data is inconsistent, incomplete, and/or non-existent.

« In Congress, 2021 FD H.B. 469 (NS) calls for Medicaid coverage of reconstructive breast surgery following breast cancer.

¢ Senator Jeanne Shaheen (D-NJ) and others introduced 2021 FD S.B. 274 (NS), which would enact the Stronger Medicaid Response
to the COVID?19 Pandemic Act. Senate Bill 274 would allow states to provide to the uninsured Medicaid coverage without cost-sharing
for COVID-19 prevention and treatment, and for coverage of preventive services and treatment for conditions that may complicate

COVID-19 treatment. The option would be open for the duration of the public health emergency. [FN209] Earlier in the pandemic,
the Families First Coronavirus Response Act gave states the option to offer Medicaid coverage of COVID-19 testing for uninsured

individuals. However, fewer than one-half of the states have taken up the option. IFN210] Since Senator Shaheen's bill was introduced,
Congress passed and President Joseph Biden (D) signed the American Rescue Plan. That bill allows states, at their option, to provide
Medicaid coverage to uninsured individuals for the cost of COVID-19 vaccinations and treatment for COVID-19 for the duration of the
public health emergency. The companion bill in the House is 2021 FD H.B. 918 (NS).

« Also in the Senate, 2021 FD S.B. 439 (NS), which was introduced on February 25, 2021, would enact the Coronavirus Medicaid

Response Act. That act would increase state Medicaid FMAPs [FN211] during times of economic downturn. The bill defines 'economic
downturn' in relation to a state's unemployment rate. A press release from Senator Michael Bennet (D-Colo.), one of the bill's sponsors,
explained how the process would work:

This legislation would respond to the increased need for health care during the public health and economic crisis by creating a quicker
and more responsive process for supporting state Medicaid programs. It would address fluctuating demand in states for Medicaid by
automatically connecting the Medicaid Federal Medical Assistance Percentage (FMAP) to state unemployment levels, so that additional

federal aid would ebb and flow with a state's economy. [FN212]

¢ Senate Bill 408 (2021 FD S.B. 408 (NS)) would direct the HHS Secretary to publish guidance for states setting out strategies that
Medicaid maternal care providers can use to reduce maternal mortality and morbidity. The bill provides, in pertinent part,

Subject to the availability of appropriations, not later than 36 months after the date of enactment of this Act, the Secretary shall publish
on a public website of the Centers for Medicare & Medicaid Services guidance for States on resources and strategies for hospitals,
freestanding birth centers (as defined in section 1905(I)(3)(B) of the Social Security Act (42 U.S.C. 1396d(I)(3)(B))), and other maternal
care providers as determined by the Secretary for reducing maternal mortality and severe morbidity in individuals who are eligible for
and receiving medical assistance under Medicaid or CHIP.

Senator Pat Toomey (R-Pa.), one of the bill's sponsors, explained in a press release why this bill is important to him:

'Hundreds of women in the United States die each year as a result of complications from pregnancy and childbirth, but as many as
two-thirds of these deaths are believed to be preventable . . . . By bolstering information and resources to better monitor and treat
at-risk pregnancies, this legislation will help improve health outcomes for pregnant women and mothers enrolled in Medicaid. | am
glad Senator Brown and | are continuing this important effort, and am hopeful our colleagues on both sides of the aisle will join us in

reducing maternal deaths." [FN213]

¢ Another Senate Bill, 2021 FD S.B. 411 (NS), also seeks to improve maternal outcomes. The findings supplied with the bill note

that each year in the United States, approximately 700 women die from complications associated with pregnancy or childbirth, and
another 700,000 suffer near fatal pregnancy-related complications. Sixty percent of these deaths are preventable, according to the
bill. The findings also point out the racial disparities in maternal outcomes, and the fact that Medicaid programs are only required to
provide coverage for 60 days after the birth of a child. If passed, the bill would enact the Mothers and Offspring Mortality and Morbidity
Awareness (''MOMMA'S) Act, which would, among other things, expand Medicaid and CHIP coverage for pregnant and post-partum
women and extend eligibility for one year instead of 60 days. It would also provide for an increased FMAP for this extended coverage.
The Senate Bill is sponsored by Senators Dick Durbin (D-IIl.) and Tammy Duckworth (D-III.).

* As a way to make prescription drugs more affordable for seniors, 2021 FD H.B. 1167 (NS) would automatically enroll certain seniors
who have aged out of Medicaid for Medicare Part D subsidies. The bill is sponsored by Representatives Chris Pappas (D-NY) and Paul
Tonko (D-NY). Representative Pappas' press release explained,

Medicare Part D was created to help low-income seniors afford their prescription drugs despite sky-rocketing costs. However, current
law does not automatically enroll eligible seniors who previously qualified under Medicaid Expansion, leaving thousands of eligible
seniors struggling to access life-saving prescription drugs unaware they are eligible for assistance. This legislation remedies this by

helping seniors cut through the red tape and automatically enrolling individuals who aged out of Medicaid Expansion and into Medicare.
[FN214]

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« Introduced by Senator Cory Booker (D-N.J.) and others, 2021 FD S.B. 346 (NS) would enact the Black Maternal Health Momnibus Act
of 2021. This multifocal bill aims to end preventable maternal mortality and severe morbidity and address racial disparities in maternal
outcomes. As it related to Medicaid, the bill would, among other things:

¢ call for a task force to address of health in maternal care. The report of that task force would include recommendations for expanding
social service coverage to address social determinants of maternal health under Medicaid managed care organizations and State
Medicaid programs;

* require HHS to report on maternal health data collection processes and quality measures, including the strengths and weaknesses of
maternal care quality measures in Medicaid;

* require a report from MACPAC on the implications of pregnant and postpartum incarcerated individuals being ineligible for Medicaid
under a State plan;

¢ call for a demonstration project, to be known as the Perinatal Care Alternative Payment Model Demonstration Project, to test payment
models for maternity care under Medicaid State Plans.

Please see the bill for other Medicaid provisions.

* Senate Bill 620 (2021 FD S.B. 620 (NS)) would direct the HHS Secretary, in consultation with the Administrator of CMS, to prepare a
report for Congress setting out the changes that HHS has made during the COVID-19 emergency period to expand access to telehealth
in Medicare, Medicaid, and CHIP (the Children's Health Insurance Program). The bill, which would enact the Knowing the Efficiency
and Efficacy of Permanent (KEEP) Telehealth Options Act of 2021, was reintroduced for this session by Senator Deb Fischer (R-Neb.)
and Jackie Rosen (D-Nev.). In a press release, Senator Fischer said of the bill,

'Millions of Americans, including many Nebraskans, have benefited from telehealth services during this pandemic. This bipartisan
legislation will provide us with valuable information on how to improve and expand this technology to save more lives... ." [FN215]

¢ If passed 2021 FD S.B. 646 (NS) would provide for 12-month continuous enrollment in Medicaid and the Children's Health Insurance
Program (CHIP). The bill is sponsored by Senators Sherrod Brown (D-Ohio), Tammy Baldwin (D-Wis.), Elizabeth Warren (D-Mass.)}
and Sheldon Whitehouse (D-R.I.).

* Senate Bill 701 (2021 FD S.B. 701 (NS)) would provide for equal coverage of in vitro specific IgE allergy tests and percutaneous
allergy tests in the Medicare and Medicaid programs. The bill, which was introduced on March 11, 2021, is sponsored by Senator Jerry
Moran (R-Kan.) and others. The findings supplied with the bill note the importance of diagnosing allergies to prevent serious health
problems or the exacerbation of other illnesses. They also note that, despite recommendations from the National Institutes of Health
that these two diagnostic tools are equally effective at detecting allergies, some Medicare and Medicaid plans deny equal access to
them.

* House Bill 1439 (2021 FD H.B. 1439 (NS)) would enact the Expanded Genetic Screening Act of 2021, which would ensure Medicaid
coverage of non-invasive prenatal genetic screening for pregnant women of all ages. A press release from Representative Jackie
Speier (D-Calif.), one of the bill's co-sponsors, explained that the non-invasive prenatal test (NIPT) is more accurate than the
commonly-used maternal serum screening (MSS):

During pregnancy, expectant mothers may decide to undergo prenatal screenings related to genetic conditions. For decades, the
primary screening test has been maternal serum screening (MSS), but new technology has led to the development of more accurate

screening options like NIPT. MSS has a false positivity rate of 5.6 percent compared to a 0.09 percent false positivity rate for NIPT.
[FN216]

Representative Speier calls NIPT the 'gold standard" for genetic screening tests, and she believes that every woman should have
access to it.

¢ Senators John Barrasso (R-Wyo.) and Tom Cotton (R-Ark.) are sponsoring 2021 FD S.B. 918 (NS), which calls for a supplemental
appropriation of $12 billion to the Provider Relief Fund. The funds would be available for,

building or construction of temporary structures, leasing of properties, medical supplies and equipment including personal protective
equipment and testing supplies, increased workforce and trainings, emergency operation centers, retrofitting facilities, and surge
capacity.

Those entities eligible for funds include,

public entities, Medicare or Medicaid enrolled suppliers and providers, and such for-profit entities and not-for-profit entities not
otherwise described in this paragraph as the Secretary may specify, within the United States (including territories), that provide
diagnoses, testing, or care for individuals with possible or actual cases of COVID-19.

« In the Senate, 2021 FD S.B. 983 (NS) would amend the Affordable Care Act to create a public option for health insurance. Providers
and suppliers participating in Medicaid and Medicare would be providers in this option, unless they opt out. The Secretary of HHS
would establish a process to admit other providers to the program. The bill, which is bicameral, is sponsored by Senator Sheldon

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Whitehouse (D-R.I.) and Sherrod Brown (D-Ohio), and Representative Jan Schakowsky (D-III.). It has been introduced in previous
Congressional sessions, and was introduced in the Senate this session on March 25, 2021.

¢ Also in the Senate, Senator Bob Casey (D-Pa.) is sponsoring 2021 FD S.B. 1162 (NS), which would enact the Program of All-Inclusive
Care for the Elderly Plus Act (or the PACE Plus Act). According to a press release from the Senate Special Committee on Aging, the
act would strengthen and expand the PACE program in these ways:

¢ Increase the number of PACE programs nationally by making it easier for states to adopt PACE as a model of care and provide grants
to organizations to start PACE centers or expand existing PACE centers;

¢ Expand the number of seniors and people with disabilities eligible to receive PACE services by ensuring individuals with a high level of
care need are eligible for PACE and incentivize states to grow their PACE programs; and

¢ Reduce the administrative burden on PACE programs through improved technical assistance and streamlined application processes.
[FN217]

* If passed, 2021 FD S.B. 1114 (NS) would direct CMS to issue guidance to states on increasing vaccination rates for pregnant women
in Medicaid and CHIP. The vaccinations that the bill is concerned with include,

Advisory Committee on Immunization Practices recommended vaccines among pregnant women, particularly with respect to the
influenza, diphtheria, tetanus, and whooping cough (pertussis) vaccines|[.]

The guidance would also advise states on securing federal matching funds to implement the recommendations. Additionally, the bill
would direct the Secretary HHS to consult with stakeholders and consider adding vaccination rates for pregnant women as a measure
in the Child Health Quality Measures or the Adult Health Quality Measures.

¢ In the House, 2021 FD H.B. 1677 (NS) would direct the HHS Secretary, the Medicare Payment Advisory Commission, and the
Medicaid and CHIP Payment and Access Commission to conduct studies and prepare a report to Congress on the actions taken to
expand access to telehealth services under the Medicare and Medicaid programs and CHIP (the Children's Health Insurance Program)
during the COVID-19 emergency period.

* Sponsored by Senator Bernie Sanders (D-Vt.), 2021 FD S.B. 1228 (NS) seeks equity for the U.S. Territories. Several provisions
relate to Medicaid. Among other things, the bill would eliminate the general Medicaid funding limits (or caps) for the territories, eliminate
the specific FMAPs allotted to territories, temporarily increase the FMAP for Puerto Rico and the Virgin Islands to 100%, grant
Medicaid waiver authority to the territories, and allow Medicaid disproportionate share hospital payments for the territories. The bill is
co-sponsored by Senators Elizabeth Warren (D-Mass.) and Ed Markey (D-Mass. ).

« Among other things, 2021 FD S.B. 1234 (NS) would award grants to states to create Pregnancy Medical Home Demonstration
Projects. The findings supplied with the bill note the high incidence of maternal mortality and morbidity in the United States relative to
other developed countries, and they note that many of these incidents are avoidable. Moreover, women of color are disproportionately
affected by maternal mortality and morbidity. The findings also highlight a successful Pregnancy Medical Home program in North
Carolina:

(10) North Carolina has established a statewide Pregnancy Medical Home (PMH) program, which aims to reduce adverse maternal
health outcomes and maternal deaths by incentivizing maternal health care providers to provide integral health care services to
pregnant women and new mothers. According to the North Carolina Department of Health and Human Services Center for Health
Statistics, the pregnancy-related mortality rate for Black women was approximately 5.1 times higher than that of White women in 2004.
Almost a decade later, in 2013, the pregnancy-related mortality rates for Black women and White women were 24.3 and 24.2 deaths
per 100,000 live births, respectively. The PMH program has been credited with the convergence in pregnancy-related mortality rates
because the program partners each high-risk pregnant and postpartum woman that is covered under Medicaid with a pregnancy care
manager.

The bill would allow grants for other states to establish such demonstrations. To be eligible, a state must, among other things, commit
to working with state and local Medicaid agencies, and the program must prioritize women enrolled in a Medicaid state plan or waiver
program. The bill is sponsored by Senator Kristen Gillibrand (D-N.Y.).

¢ In the House, 2021 FD H.B. 2007 (NS) seeks research into uterine fibroid tumors. The findings supplied with the bill note the
prevalence of these tumors; the toll it takes on sufferers, including pain, stress, and reproductive problems; the personal and societal
costs associated with such tumors, including health care costs and lost labor costs; the disproportionate impact of such health problems
on women of color; and the lack of funding for research on uterine fibroid tumors. The bill proposes several areas of research into this

health problem, including Medicaid and CHIP IFN218] coverage of services to treat uterine fibroids.

«In the Senate, 2021 FD S.B. 1675 (NS) seeks to improve the health of pregnant and perinatal women and their infants. Among other
things, the bill would authorize grants for states, Indian tribes, or tribal organizations to establish innovative programs of integrated care
for pregnant or post-partum women:

(a) In General. The Secretary may award grants for the purpose of establishing or operating evidence-based or innovative, evidence-
informed programs to deliver integrated health care services to pregnant and postpartum women to optimize the health of women and

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their infants, including to reduce adverse maternal health outcomes, pregnancy-related deaths, and related health disparities (including
such disparities associated with racial and ethnic minority populations), and, as appropriate, by addressing issues researched under
subsection (b)(2) of section 317K.

To be eligible for such a grant, states, tribes, or tribal organizations must commit to working with relevant stakeholders, including state,
local, or tribal agencies responsible for Medicaid and home- and community-based service providers.

¢ Senators Bernie Sanders (D-Vt.) and Kristen Gillibrand (D-N.Y.) are sponsoring 2021 FD S.B. 1283 (NS), which would create a tax on
certain trading transactions. Revenue from the tax could be used for, among other things, expanding and strengthening Medicare and
Medicaid.

¢ In the House, 2021 FD H.B. 2114 (NS) would enact the Essential Caregivers Act of 2021. That act would require Medicare and
Medicaid skilled nursing facilities, nursing facilities, and intermediate care facilities for the intellectually disabled to allow certain
essential caregiver visitors to visit a resident during a public health emergency. Essential caregivers are those who agree to follow
specified safety protocols and who:

(i) furnished care to such resident prior to the first day of the emergency period described in section 1135(g)(1)(B);

(ii) will provide activities of daily living (as determined appropriate by the facility) or emotional support to such resident, in accordance
with the care plan of such resident;

(iii) the facility approves to furnish such activities or support[.]

« In the Senate, 2021 FD S.B. 1190 (NS) would provide enhanced federal Medicaid matching payments for direct support worker
training programs. Such programs would include:

(A) training in the core training competencies for personal or home care aides described in section 2008(b)(3)(A); and
(B) opportunities for education, training, and career advancement.

The bill aims to support workers such as personal or home care aides, direct support workers, home health aides, nursing assistants,
and other specified direct support professionals.

¢ In Congress, 2021 FD H.B. 2972 (NS) would enact the Helping Ensure Life-and Limb-Saving Access to Podiatric Physicians
(HELLPP) Act, which would recognize doctors of podiatric medicine as physicians in the Medicaid program. The bill was introduced on
May 4, 2021.

¢ Senator Sherrod Brown (D-Ohio) and others are sponsoring 2021 FD S.B. 1833 (NS), which would renew the provision ensuring the
Medicare rate floor for Medicaid primary care services and would which would apply this rate to additional providers of primary care
services.

¢ Sponsored by Representative Karen Bass (D-Calif.) and other lawmakers, 2021 FD H.B. 1794 (NS) would enact the Foster Youth
Dental Act of 2021. The bill seeks to improve access to dental care to foster youth and former foster youth. Representative Bass' press
release explains how the bill would accomplish this. The bill would:

1. Expand Medicaid oral health coverage by increasing the eligibility age from 21 years old to 25 years of age for former youth who are
eligible for the foster youth Medicaid pathway.

2. Provide incentives for dental providers by:

¢ Making the Medicaid reimbursement rate for oral health services provided to eligible patients equal to state's median private sector
dental payment rate.

¢ Allowing states to submit to CMS their median private sector dental payment rates.
* Applying the higher of the state-submitted median private sector dental rate and the national median private sector dental rate.

3. Enhance outreach efforts to enroll former foster youth in Medicaid by having states establish an outreach and enrollment program
in coordination with the State Title IV-E (foster care) and any other appropriate or interested agencies. States would also be required
to establish an outreach program to dental health providers practicing in such State to increase the number of providers available to

eligible patients.

4. Protect existing coverage for foster youth by ensuring that foster youth who move between states don't lose their Medicaid dental
health insurance. 219]
The bill has bipartisan sponsorship.

«In the Senate, 2021 FD S.B. 1798 (NS) would direct the Secretary of HHS to issue guidance on how to increase access to telehealth
in Medicaid and CHIP. The guidance would include technical assistance and best practices on the issues specified in the bill (delivery,
billing, existing strategies, examples from states, and so forth). The bill would also direct the Medicaid and CHIP Payment and Access
Commission to conduct a study in at least ten states in different geographic regions of the country on how telehealth impacts 'health
care access, utilization, cost, and outcomes, broken down by race, ethnicity, sex, age, disability status, and zip codef[.]"

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¢ Senate Bill 1773 (2021 FD S.B. 1773 (NS)) would call for the Secretary of HHS to create a publicly available dashboard showing
spending for and utilization of prescription drugs and biologicals in the Medicaid and Medicare programs. The bill provides, in part,

(a) In General. Beginning not later than January 1, 2022, the Secretary shall establish, and annually update, intemet website-based
dashboards, through which beneficiaries, clinicians, researchers, and the public can review information on spending for, and utilization
of, prescription drugs and biologicals (and related supplies and mechanisms of delivery) covered under each of parts B and D of title
XVIII and under a State program under title XIX, including information on trends of such spending and utilization over time.

* Representative Claudia Tenney (R-N.Y.) and others are sponsoring 2021 FD H.B. 3733 (NS), which would enact the Essential
Caregivers Act of 2021. That act would require skilled nursing facilities, nursing facilities, intermediate care facilities for the intellectually
disabled, and inpatient rehabilitation facilities that participate in Medicaid or Medicare to permit residents access to two self-designated
essential caregivers during any public health emergency declared by HHS.

¢ Senator Marco Rubio (R-Fla.) introduced the State Accountability, Flexibility, and Equity for Hospitals Act of 2021 (the SAFE for
Hospitals Act) on June 10, 2021. The bill would reform how states' allotments for Medicaid disproportionate share hospital payments
are calculated. In a press release, Senator Rubio explained what the bill (2021 FD S.B. 2021 (NS)) would do:

¢ Gradually change the DSH allocation formula so states' allocations are based on the number of low-income earners living in the state,
as a percentage of the total U.S. population earning less than 100 percent of the Federal Poverty Level (FPL).

¢ Prioritize DSH funding to hospitals providing the most care to vulnerable patients, while providing states with the necessary flexibility
to address the unique needs of hospitals in each state.

¢ Expand the definition of uncompensated care to include costs incurred by hospitals to provide certain outpatient physician and clinical
services, which is a change recommended by MACPAC.

* Allow states to reserve some of their DSH funding allocations to be used in future years in order to give hospitals more certainty or
consistency in the amount of DSH funding they can expect when planning for the future. [FN220]

¢ In the House, 2021 FD H.B. 3337 (NS) would enact the Birth Access Benefiting Improved Essential Facility Services (BABIES) Act.
That act would require HHS to create a Medicaid demonstration program testing innovative payment models for freestanding birth
center services for women with a low-risk pregnancy. The bill aims to increase access to these services and to improve the quality and
scope of such services.

« In the Senate, 2021 FD S.B. 2022 (NS) would create a state option for states to cover whole genome sequencing clinical services for
certain children. Those eligible for such services would include any individual:

(A) who is eligible for medical assistance under the State plan (or a waiver of such plan);

(B) who is under the age of 21 (or, at the option of the State, under the age of 20, 19, or 18 as the State may choose), or in the case of
an individual described in section 1902(a)(10)(A)(i)(IX), under the age of 26; and

(C) who-

(i) has been referred or admitted to an intensive care unit, or has been seen by at least 1 medical specialist, for a suspected genetic or
undiagnosed disease; or

(ii) is suspected by at least 1 medical specialist to have a neonatal- or pediatric-onset genetic disease.

¢ In the House, Representative Glenn Grothman (R-Wis.) is sponsoring a resolution that, if passed, would express the sense of the
House of Representatives that 'welfare" programs discourage marriage and hurt the institution of the family. According to the text of the
resolution, means-tested programs such as Medicaid determine eligibility by counting all individuals in the household related by birth,
adoption, or marriage, which discourages marriage. The resolution then states that the House of Representatives:

(1) recognizes that welfare programs discourage marriage and hurt the institution of the family in the United States;

(2) believes that the Federal Government should treat everyone equally and that it is wrong to discriminate against parents who choose
to get married before having children;

(3) supports action to review any Government program, tax credit, or policy that puts financial penalties on married couples as opposed
to their unmarried peers; and

(4) supports action to change benefits or end programs in order to eliminate these penalties.
The resolution is 2021 FD H.R. 513 (NS).

* Representative Ann McLane Kuster (D-N.H.) and others are sponsoring 2021 FD H.B. 3514 (NS), which would eliminate what is
known as the Medicaid Inmate Exclusion. This exclusion terminates Medicaid for incarcerated individuals. Representative Kuster
explained in a press release why this bill is important to her:

'The Medicaid Inmate Exclusion (MIE) is an outdated, flawed policy which contributes to a vicious cycle of addiction, incarceration,
and recidivism that devastates families and communities, and drains state and local budgets while harming public health and our

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economy . . . . The Humane Correctional Health Care Act would help break the cycle by investing in adequate treatment and ensuring
individuals who are involved in the justice system have the opportunity to heal, recover, and make valuable contributions to our
communities. States should not be on the hook for billions in health care spending on incarcerated Americans who should have
Medicaid coverage. I'm pleased to reintroduce this bipartisan, common-sense measure alongside my Bipartisan Addiction and Mental
Health Task Force co-chair, Rep. Brian Fitzpatrick, and | urge leadership in both the Senate and the House to consider this legislation."
[FN221]

* Congresswoman Stacey Plaskett (D-V.I.) and others are sponsoring 2021 FD H.B. 3434 (NS), which seeks to improve the way
the territories are treated under the Medicaid and Medicare programs. As it relates to Medicaid, the bill would eliminate the general
Medicaid funding caps, eliminate the specific FMAPs for territories, and permit Medicaid disproportionate share hospital payments for

the territories, 'FN222] According to Congresswoman Plaskett, the territories are treated unfairly when it comes to Medicare and Medicaid
funding:

'People in the territories should have just as much access to health care as anyone else. With federal attention focused on how health
care disparities have contributed to the financial crisis in the territories, we believe that this is an opportune time to press the issue of
Medicaid and Medicare. The inequities in federal funding provided to the territories for Medicaid and Medicare has placed a significant
financial burden on local governments, including in the U.S. Virgin Islands, and has further exacerbated their respective financial
situations. It has also put access to affordable health care out of reach for too many Virgin Islanders, making our hospitals' emergency
rooms the primary health care provider for the one-third of our population without health insurance, which contributes to unmanageable

costs in uncompensated care [,]" N29

¢ Representative Robin Kelly (D-Ill.) and others are sponsoring 2021 FD H.B. 3345 (NS), which would enact the Helping Medicaid Offer
Maternity Services (MOMS) Act of 2021. That act would strengthen the provision in the American Rescue Plan that offers states the
option to provide post-partum services for one year after the birth of a child. In her press release announcing the bill, Representative
Kelly noted that 70% of women experience some complication in the one year following the birth of a child, so she believes it is crucial
that they are covered during this entire period. Her press release explained what the bill would do:

The Helping MOMS Act of 2021 would amend the American Rescue Plan to eliminate the time limit on the state option to elect
extended postpartum Medicaid coverage, allowing states a permanent option to extend coverage. The bill would also increase the
Federal Medical Assistance Percentage (FMAP) rate 5 [percentage points] for pregnancy-related services in the first year states adopt

extended postpartum coverage. FN?4l

«In the Senate, 2021 FD S.B. 2013 (NS) would ensure coverage Medicaid coverage of medically necessary food, vitamins, and
individual amino acids for digestive and inherited metabolic disorders. It would also require such coverage in Medicare, CHIP, and
private health plans.

¢ House Bill 3407 (2021 FD H.B. 3407 (NS)) would enact the Mothers and Offspring Mortality and Morbidity Awareness (MOMMA'S)
Act. The bill is a multifaceted attempt to improve maternal health care in the United States. Among other things, the bill would ensure
oral health services for pregnant and post-partum women, and it would ensure post-partum coverage for one year after birth. The bill
would grant states enhanced federal funding for such coverage, but a maintenance-of-effort requirement would be enforced. The bill is
sponsored by Representative Robin Kelly (D-Ill.) and others.

« Representative Bonnie Watson Coleman (D-N.J.) and others are sponsoring 2021 FD H.B. 3126 (NS). Among other things, the bill
would require 12 months of coverage for post-partum care.

* Sponsored by Senator Bob Casey (D-Pa.), 2021 FD S.B. 1977 (NS) aims to improve care for pregnant and post-partum women.
Among other things, the bill would extend Medicaid to all pregnant or post-partum individuals, extend eligibility for such individuals
to 365 days post-partum, and require Medicaid coverage for doulas, lactation consultants, and midwives. Additionally, the bill would

require a 100% FMAP for any services mandated by the bill. IFN225]

¢ In the House, Representative Paul Tonko (D-N.Y.) and others are sponsoring 2021 FD H.B. 3450 (NS), which would enact the
Medicaid Bump Act. That act would increase the FMAP to 90% for certain new mental health and behavioral health services. The
companion bill in the Senate is 2021 FD S.B. 1727 (NS).

¢ Also in the House, 2021 FD H.B. 3219 (NS) would provide additional payments for 'high Medicaid providers" for services and lost
revenue related to COVID-19. The bill sets out which providers would be eligible for the funds (a total of $10 billion) upon approval of an
application:

(1) Eligible high medicaid health care provider. The term 'eligible high Medicaid health care provider' means a provider of supplier that-
(A) is enrolled with a State Medicaid plan under title XIX (or a waiver of such plan);

(B) provides diagnoses, testing, or care for individuals with possible or actual cases of COVID-19; and

(C) is either-

(i) a disproportionate share hospitals described in Section 1923(b) of the Social Security Act;

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(ii) a children's hospitals described in Section 1886(d)(1)(B)(iii) of the Social Security Act and Section 340E of the Public Health Service
Act;

(iii) a physician or other practitioner described Section 1903(t)(2) of the Social Security Act (42 U.S.C. 1396b(t)(2)(A)); or

(iv) such other providers and suppliers as the Secretary determines should be appropriately considered to be included based on high
caseloads of patients eligible under title XIX of the Social Security Act.

¢ In the House, 2021 FD H.B. 3894 (NS), which would enact the Collecting and Analyzing Resources Integral and Necessary for
Guidance (CARING) for Social Determinants Act of 2021 passed the House on December 8, 2021. That act would direct the HHS
Secretary to regularly issue guidance to states to clarify strategies for addressing social determinants of health in the Medicaid and
CHIP programs.

¢ Texas is one of 12 states that have not yet adopted the Affordable Care Act's Medicaid expansion. [FN226] fy bill sponsored by
Representative Lloyd Doggett (D-Tex.) and dozens of other lawmakers calls for a demonstration project that would allow political
subdivisions within a state to bypass state government and implement the expansion on their own. The bill is 2021 FD H.B. 3961 (NS).

¢ Senator Bob Casey (D-Penn.) and others are sponsoring 2021 FD S.B. 2210 (NS), which would enact the Better Care Better Jobs
Act. The bill would make significant investments in home- and community-based services by increasing access to such care and
ensuring a well-compensated health care workforce. Among other things, the bill calls for state planning grants to strengthen and
expand home- and community-based services, make permanent the state option to provide community spouses protection against
spousal impoverishment, and make the Money Follows the Person program permanent. In a news release, Senator Casey explained
why this bill is important:

'For millions of families, and especially for women, home and community-based services are a bridge to work and a bridge to economic
security. The Better Care Better Jobs Act would not only enable more older adults and people with disabilities to remain in their homes,
stay active in their communities and lead independent lives, it would also create jobs and lead to higher wages for care workers, who

are predominantly women and people of color. This legislation is critical to advancing equity, spurring economic recovery and improving

quality of life for older adults and people with disabilities[.]* "N22"!

¢ Senate Bill 197 (2021 FD S.B. 2197 (NS)) seeks to expand access to telehealth in rural and frontier states. The bill, which would enact
the Rural and Frontier Telehealth Expansion Act, has bipartisan sponsorship. A press release explains what the bill would do:

This bipartisan bill would increase federal FMAP for telehealth services, including audio-only telehealth, by 5 percentage points if the
state covers telehealth services under Medicaid and is a frontier state (Nevada, Alaska, Montana, North Dakota, South Dakota, and
Wyoming) or a state "where less than 90% of the total population has access to fixed terrestrial broadband service of at least has fixed

25 Megabits per second (Mbps) download and 3 Mbps upload according to the annual Broadband Deployment Report of the Federal

Communications Commission. 'FN228l

The press release stresses the importance of telehealth services in caring for individuals who do not have easy access to in-person
care. Several of the sponsors noted that the pandemic highlighted how critical telehealth is to our health care system, and they
indicated that they want to incentivize states to continue offering such services.

¢ In Congress, Representatives Guy Bilirakis (R-Fla.) and Darren Soto (D-Fla.) are sponsoring 2021 FD H.B. 4036 (NS), which seeks to
expand Medicaid reimbursement for telehealth mental and behavioral health services. Representative Bilirakis' press release explained
why the bill is needed:

There has been widespread agreement that telehealth has been successfully used throughout the pandemic to increase access to
quality behavioral healthcare, adding enhanced safety and convenience. Prior to the pandemic, Medicare's coverage of telehealth
services was limited to treatments associated with opioid addiction. At the end of last year, Bilirakis and Soto championed a provision
put into law that would expand access by allowing Medicare and Medicaid to reimburse for all behavioral health services for children,

seniors and those on disability. However, there are some restrictions in place that limit full access. The EASE Act, co-authored by

Bilirakis and Soto would permanently remove those remaining restrictions. [FN229]

The findings supplied with the bill note the increasing demand for mental health services and the shrinking psychiatric workforce. The
companion bill in the Senate is 2021 FD S.B. 2112 (NS), sponsored by Senator John Kennedy (R-La.).

¢ Sponsored by Senator Raphael Warnock (D-Ga.) and others, 2021 FD S.B. 2315 (NS) would enact the Medicaid Saves Lives Act.
That act would create a fallback federal program to provide Medicaid coverage for individuals in non-expansion states who earn up
to 138% of the federal poverty level. Additionally, the bill would dramatically increase the financial incentives for expansion in the
American Rescue Plan by increasing the FMAP from 5 percentage points in the American Rescue Plan to 10 percentage points
and increasing the duration of these from funds from eight quarters to 40 quarters. Senator Tammy Baldwin (D-Wis.) one of the co-
sponsors, who represents a non-expansion state, explained what the bill would do:

The Medicaid Saves Lives Act would provide health insurance to Americans with low incomes in the 12 states that have refused to
fully expand their state Medicaid programs under the Affordable Care Act. By closing the coverage gap in these states and providing
free and affordable health insurance to millions of Americans, the Medicaid Saves Lives Act would also provide access to preventative

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health care services; improve health outcomes and prevent premature deaths; lower costs for uncompensated care, which would in turn
reduce hospital and provider closures; and improve economic mobility for Americans with low-incomes by enabling them to work. [FN230]

Senator Baldwin also explained what her state's refusal to expand Medicaid means for her constituents: 91,000 individuals in the state
that would qualify for coverage if the state expanded Medicaid have been denied coverage, and the state is foregoing $1.6 billion in

federal funds for the expansion. /FN231]

The Commonwealth Fund published a post demonstrating how the proposed increase in the American Rescue Plan's incentives
would benefit the non-expanding states. In Wisconsin, for example, the state is missing out on nearly $1.1 billion in American Rescue
Plan funds by not expanding Medicaid. Under the Medicaid Saves Lives Act, the state would be forfeiting about $14 billion. The post

provides the same analysis for all non-expanding states. [FN232]

¢ Among other things, 2021 FD H.B. 3963 (NS) would extend Medicaid eligibility for the last 30 days of incarceration if the incarcerated
individual is otherwise eligible for Medicaid coverage.

¢ In the House, 2021 FD H.B. 4158 (NS) would enact the Insulin Access for All Act of 2021, which would eliminate cost-sharing for
insulin as a covered Medicaid outpatient drug. Upon introducing the bill, the main sponsor, Representative Bobby Rush (D-IIl.) pointed
out the high cost of insulin and the choices that patients must make just to afford it:

'One in ten Americans have diabetes, and yet, the price of insulin has soared to a point that many are left making heart-wrenching
and desperate decisions to afford a drug that is increasingly out of reach. There is no reason, in the richest country in the world, that
individuals should be left without meaningful access to medication they need to survive . . . . | am proud to introduce this legislation,

with significant support from my House colleagues, to tackle this issue head-on by making insulin completely free for individuals

enrolled in Medicare or Medicaid, who represent some of the most vulnerable populations of diabetics." [FN233]

¢ Senate Bill 2352 (2021 FD S.B. 2352 (NS)) would ensure health insurance coverage, including Medicaid coverage without cost-
sharing, for the treatment of infertility and the prevention of iatrogenic infertility. The bill is sponsored by Senators Cory Booker (D-N.J.),
Kristen Gillibrand (D-N.Y.), and Robert Menendez (D-N.J.).

¢ In the House, 2021 FD H.B. 5007 (NS) would require Medicare and Medicaid providers to be vaccinated against COVID-19 once the
vaccine receives full federal approval. Exceptions for medical or religious reasons would apply. In Medicaid, the bill would require states
to amend their State Plans to require providers to be vaccinated.

«In the Senate, 2021 FD S.B. 2646 (NS) would require states to provide Medicaid coverage for survivors of a disaster or emergency, as
defined in the bill. Income thresholds would apply, and the bill would allow for more lenient eligibility and enrollment requirements, like
presumptive eligibility, continuous eligibility, and simplified verification. The bill would create an option for states to provide home- and
community-based services under these circumstances, regardless of the level of care.

* During the COVID-19 emergency period, states have been allowing the use of telehealth to a much greater degree. CMS allowed
flexibilities for using this delivery method, and many states changed their programs in response to that and to the higher demand for
safe health care delivery. House Bill 4770 (2021 FD H.B. 4770 (NS)) would require the HHS Secretary to report on the changes states
made to telehealth benefits. In pertinent part, the bill provides,

(1) Interim report. Not later than 1 year after the last day of the emergency period described in subsection (a), the Secretary shall
submit to Congress an interim report that-

(A) details any changes made to the provision or availability of telenealth benefits (such as eligibility, coverage, or payment changes)
under State plans (or waivers of such plan) under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) during such emergency
period[.]

* Senators Tom Carper (D-Del.) and Susan Collins (D-Me.) are sponsoring 2021 FD S.B. 2622 (NS), which would enact the Quit
Because of COVID-19 Act. That act would require Medicaid state plans to cover tobacco cessation services without cost-sharing and
would temporarily provide a 100% FMAP for these services. In a press release, Senator Carper highlights the health risks of tobacco
use and points out that Medicaid participants use tobacco at twice the rate of individuals with private insurance. The press release sets
out the major provisions of the rule:

Specifically, the Quit Because of COVID-19 Act would:

¢ Require state Medicaid and CHIP programs to cover evidence-based tobacco cessation treatments ? seven FDA-approved tobacco
cessation medications as well as individual, group, and phone-based counseling ? with no cost-sharing for all enrollees;

¢ Prohibit use of prior authorization requirements for tobacco cessation treatments in Medicaid and CHIP programs;

* Require state outreach campaigns to educate health care providers and Medicaid and CHIP enrollees about the tobacco cessation
coverage; and

¢ Provide 100% federal reimbursement of the cost of the tobacco cessation coverage and outreach campaign for the duration of the
COVID-19 public health emergency plus an additional two years. [FN234]

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The companion bill in the House is 2021 FD H.B. 2125 (NS).

¢ Senate Bill 2618 (2021 FD S.B8. 2618 (NS)) would increase the FMAP for oral health services, vision services, and hearing services to
90%.

¢ In the House, 2021 FD H.B. 4670 (NS) would enact the Advanced Safe Testing at Residence Telehealth (A-START) Act of 2021,
which calls for three demonstration programs to test innovative telehealth technology. One of the demonstrations would be in Medicaid.
The bill's sponsor, Representative David Schweikert (R-Ariz.) explained in a press release that the bill builds on the successful use of
telehealth during the COVID-19 pandemic:

'This legislation is an important step in expanding patient and provider access to healthcare innovation to promote high quality, 21st
century technology-based care. The COVID-19 pandemic revealed just how valuable access to health care technology can be, and |
am proud to build upon its advancements. The A-START Act would accelerate the enormous achievements recently made in expanding

telehealth, diagnostics, screening, wearables, and patient monitoring technology. Patients deserve access to the best information and

data that modern technology can provide, to make informed decisions about their health." [FN235]

¢ In the House, 2021 FD H.B. 5015 (NS) would enact the Medicaid DSH Payment Adjustment Fairness Act of 2021. That act would
expand the hospitals that are eligible for Medicaid Disproportionate Share Hospital payment adjustments. The bill is sponsored by
Representatives Brian Higgins (D-N.Y.) and John Katko (R-N.Y.).

¢ Without a doubt, nursing facilities were particularly hard hit by the COVID-19 pandemic. Deaths of residents and staff in nursing
facilities accounted for one-third of all COVID-19 deaths in this country, despite reporting only 5% of all COVID cases nationwide.

[FN236] A Senate bill (2021 FD S.B. 2694 (NS)) seeks to make needed changes in both Medicare skilled nursing facilities and Medicaid
nursing homes to ensure that these facilities are better prepared should any similar emergency arise in the future. The bill seeks to
make improvements in accountability, transparency, and staffing, and it calls for a demonstration program to test building modification
and investment in nursing facility staff.

« Representative Pramila Jayapal (D-Wash.) and others are sponsoring 2021 FD H.B. 5227 (NS), which would amend the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 to relax rules about non-citizens' eligibility for certain public benefits. As
it relates to Medicaid, it would eliminate the five-year waiting period for lawfully present immigrants. In a press release announcing the
bill, Representative Jayapal remarked on her own immigrant roots:

'As an immigrant who came to this country alone at the age of 16, | am proud to introduce legislation that finally eliminates senseless,
harmful, and xenophobic barriers to health care, nutrition assistance, and other life-changing public benefits for immigrant families . . . .
As COVID-19 disproportionately impacts immigrants who are heroically serving on the frontlines of this crisis, the LIFT the BAR Act is
an urgent, necessary, and just step towards ensuring they have access to the care, relief, and support they need and deserve - during

a pandemic and beyond." [FN237]

* Companion bills in the House (2021 FD H.B. 5169 (NS)) and Senate (2021 FD S.B. 2694 (NS)) would enact the Nursing Home
Improvement and Accountability Act of 2021. That act seeks to improve care in Medicare skilled nursing facilities and Medicaid nursing
facilities and better support the workers at those sites. A Senate press release announcing the Senate bill noted the terrible toll that the
pandemic has had on these facilities and the deficiencies that currently exist in them. According to Senator Ron Wyden (D-Ore.), these
failings have caused families to lose faith in the ability of nursing facilities to provide safe, high-quality care. The Senate's press release
sums up what the act would accomplish:

The bill would require nursing homes to meet minimum staffing standards, ensure a Registered Nurse (RN) is available 24 hours a
day, require a full-time infection control and prevention specialist and provide additional resources through Medicaid to support these
care and staffing improvements and raise wages. The bill also takes a number of steps to increase transparency and accountability by

improving data collection, providing better information to residents and their families and enhancing the effectiveness of state surveys.
[FN238]

¢ In the House of Representatives, 2021 FD H.B. 5260 (NS) seeks to reduce the price of prescription drugs in Medicare and Medicaid.
As it relates to Medicaid, the bill would, among other things, create a state option to pay for covered outpatient drugs through risk-
sharing value-based agreements.

« Representatives G.K. Butterfield (D-N.C.) and Gus Bilirakis (R-Fla.) are sponsoring 2021 FD H.B. 5377 (NS), which would enact the
Cancer Patient Equity Act. The bill would ensure Medicare, Medicaid, and CHIP coverage of cancer molecular diagnostics, analysis,
and testing. In a press release, Representative Butterfield explains what the act would accomplish:

'The Cancer Patient Equity Act will give patients access to cutting-edge, next-generation molecular diagnostic tests that can help
identify an individual's specific type of cancer and can inform treatment protocols. Determining whether a patient's cancer is rare or
whether it has traits that make it more or less responsive to available treatments can be a game-changer for patients. Too often patients
do not have access to these tests unless their cancer reoccurs, at which point it may be too late. My bill will help ensure that patients

and their physicians are empowered with actionable information from the beginning of their treatment[.]* [FN239]

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¢ Representatives Gus Bilirakis (R-Fla.) and Kathy Castor (D-Fla.) are sponsoring 2021 FD H.B. 5414 (NS), which would enact the
Ensuring Medicaid Continuity for Children in Foster Care Act of 2021. That act would exempt foster children in a qualified residential
treatment program from the Medicaid IMD (institution for mental disease) exclusion.

¢ Bills in the House (2021 FD H.B. 5546 (NS)) and Senate (2021 FD S.B. 2974 (NS)) would enact the Preventing Opportunities for Teen
E?Cigarette and Tobacco Addiction Act (the PROTECT Act), which aim to reduce youth addiction to tobacco products, including e-
cigarettes. Representative Debbie Wasserman-Schultz (D-Fla.) explained why she was motivated to sponsor the House bill:

'The profit-driven, predatory assault to hook America's young people on e-cigarettes and tobacco products demands an aggressive
counterattack, and this bill would arm parents, healthcare providers, schools, and policy makers with the vital tools we need to defeat
the perils young people face with this ongoing epidemic . . . . Through research, guidance, and messaging this legislation would
develop promising strategies to aggressively address the dangers caused by e-cigarettes. At all costs, we need to ensure our young
people do not become addicted to these harmful products. | am eager to collaborate with Senator Blumenthal on this important

legislation that takes a bold step toward addressing this urgent public health issue." [FN240]

Among other things, the bill calls for continued funding through the Centers for Disease Control and Prevention's National Tobacco
Control Program to improve access to and delivery of tobacco cessation services in Medicaid and CHIP (the Children's Health
Insurance Program).

¢ In Congress, 2021 FD H.B. 5450 (NS) would enact the Blocking Joseph Robinette Biden's Overreaching Vaccine Mandates Act.

It would prohibit any federal funds to implement a COVID-19 vaccination mandate. It would also prohibit HHS from: (1) requiring

health care providers, as a condition of participation in the Medicare and Medicaid programs, to mandate that their employees be
vaccinated for COVID-19; or (2) penalizing providers in any other way for failing to require this of their employees. The bill is sponsored
by Representative Diana Harshbarger (R-Tenn.) and others. Representative Harshbarger explained on her web site,

I'm all for fighting COVID and keeping Americans healthy and safe, and we should use all scientific clinical tools and protections
available. But authoritarian vaccine mandates and threatening jobs based on COVID vaccine status - that could have devastating
impacts to our health care and first responder workforce and other parts of our economy - are not the answer. " [FN241]

« In Congress, 2021 FD H.B. 5627 (NS) would prohibit the Secretary of HHS from imposing a vaccine mandate as a condition of
participation in Medicare or Medicaid. As it relates to Medicaid, the bill would provide as follows:

(tt) Limitation. Notwithstanding any other provision of this title, the Secretary may not require, as a condition to provide services under
a State plan under this title (or waiver of such plan) or to be eligible to receive payment, reimbursement, or a contract under such State
plan (or waiver), an individual or entity to mandate COVID-19 vaccinations for the employees or contractors of such individual or entity
unless before implementing such requirement, with respect to individuals and entities, the Secretary certifies that such requirement
would not result in any staffing shortages for such individuals and entities.

The bill is sponsored by Representative Bob Latta (R-Ohio).

¢ Introduced on February 8, 2022, 2021 FD S.B. 3593 (NS) would, among other things, call for a study of the effects of changes to
telehealth policy in Medicare and Medicaid during the COVID-19 pandemic. The bill would provide grants to states that provided
telehealth services during the pandemic to study and report on changes made to the provision or availability of telehealth during this
period.

* If passed, 2021 FD H.B. 6636 (NS) would amend the Medicaid Inmate Exclusion Policy to allow Medicaid coverage through pre-
trial detainment, at the states' option. Currently, the policy excludes Medicaid coverage any time a person is incarcerated. In a press
release, Representative David Trone (D-Md.), one of the bill sponsors, explained why the bill is important:

'Seizing Medicaid coverage from pre-trial detainees, who experience higher rates of mental health and substance use disorders, is
destabilizing and counterproductive . . . . Not only does this policy hurt these vulnerable populations, but it also disproportionately
affects low-income folks who are unable to pay bonds. This bill would bridge those inequities and allow for a more humane, more just

pre-trial health care system." [FN242]

« Introduced in the House, 2021 FD H.B. 6612 (NS) would provide for an increased FMAP for states that increase spending for maternal
health services. The bill defines maternal health services as:

(I) Prenatal, labor and delivery, and postpartum health care services that are furnished in a licensed and accredited hospital, birth
center, midwifery practice, or other health care practice that provides prenatal services, labor and delivery services, and postpartum
services.

(Il) Telehealth services during the prenatal and postpartum periods.

(III) Home visiting services during the prenatal and postpartum periods.

(IV) Mental or behavioral health care services for individuals during the prenatal and postpartum periods.

A press release from Representative Kathy Manning (D-N.C.), one of the bill's sponsors, explains why the bill is needed:

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Today, Congresswoman Kathy Manning (NC-06) is introducing new legislation to expand access to vital health services during and
after pregnancy for people with Medicaid coverage, to advance reproductive and maternal health justice, and to save lives. The
Advancing Maternal Health Equity Under Medicaid Act would increase the federal reimbursement rate for states that increase their
spending on matemal health services under Medicaid. The United States has the highest maternal mortality rate among developed
nations, disproportionately impacting Black women, Native women, women in rural communities, and people with low incomes. And yet,

60 percent of all pregnancy-related deaths are preventable, according to the Centers for Disease Control and Prevention (CDC). [FN243]

¢ In the Senate, 2021 FD S.B. 3500 (NS) would enact the Ensuring Accurate and Complete Abortion Data Reporting Act. That bill

would require states to submit abortion data as a condition of receiving certain federal Medicaid family planning funds. Its companion

in the House, 2021 FD H.B. 581 (NS) was introduced in January 2021. Reporting abortion data to the Center for Disease Control and
Prevention is optional, and according to Joni Ernst (R-la.), one of the bill's sponsors, only a handful full of states record and report it ina

'in a comprehensive and verifiably accurate way." IFN244]

* Representatives Debra Dingell (D-Mich.) and Earl Blumenauer (D-Ore.) are sponsoring 2021 FD H.B. 6770 (NS), which would enact
the Program of All-Inclusive Care for the Elderly Plus Act (or PACE Plus Act). That act seeks to improve access to PACE by awarding
grants to PACE providers to open pilot sites in rural areas or urban underserved areas. An individual grant could be up to $1 million,
and up to 30 awards could be made.

¢ Aresolution (2021 FD S.J.R. 32 (NS)) would express disapproval of the Biden Administration's rule requiring that staff in Medicaid-
and Medicare-participating facilities be vaccinated against COVID-19. The resolution, which was introduced in late 2021, passed the
Senate on March 2, 2022.

¢ In Congress, 2021 FD H.B. 7156 (NS) would enact the Medicaid Coverage for Addiction Recovery Expansion (CARE) Act. That act
would give states the option to extend Medicaid coverage for adults who receive services in a residential addiction treatment facility,
as long as the services are a part of a full continuum of evidence-based treatment services provided under the State plan. The bill has
bipartisan sponsorship. One the bill's sponsors, Representative Bill Foster (D-Ill.) indicated in a press release that the bill would allow
'countless" Medicaid enrollees access to comprehensive intensive inpatient treatment for substance use and addiction. Representative
Foster said,

'An outdated Medicaid policy is preventing people from accessing much-needed substance use disorder treatment .. . . If we are
serious about fighting the opioid epidemic, we need to align our policies with our present-day understanding of addiction as a treatable
medical condition, not a moral failing. The Medicaid CARE Act would do just that and get comprehensive substance use disorder

treatment to the patients who need it the most. " [FN245]

¢ Senate Bill 3791 (2021 FD S.B. 3791 (NS)) and House Bill 7051 (2021 FD H.B. 7051 (NS)) would provide for Medicaid coverage
of prescription digital therapeutics. In a press release, Senator Shelley Moore Capito (R-W.V.), one of the Senate bill's sponsors,
explained what prescription digital therapeutics (PDTs) are:

[They] are software-based disease treatments designed to directly treat disease, tested for safety and efficacy in randomized clinical
trials, evaluated by the U.S. Food and Drug Administration (FDA), and prescribed by health care providers. PDTs are designed and
tested much like traditional prescription drugs but rather than swallowing a pill or taking an injection, patients receive cognitive therapy

through software. [FN246]

* Citing 'rampant' Medicaid fraud, "47! senator James Inhofe (R-Okla.) and others are sponsoring 2021 FD S.B. 3917 (NS), which
would impose an asset verification test for all Medicaid enrollees and applicants. In a press release, the bill's sponsors expressed their
wish that fraud be reined in so that those who need Medicaid the most can access it:

This bill helps ensure that Medicaid dollars are preserved for those in need and taxpayer dollars are wisely stewarded by requiring
states to apply asset verification services (AVS) to the entire population of Medicaid applicants. In its current state, AVS only applies
to the Aged, Blind, and Disabled (ABD) population. This bill would create parity between the ABD and non-ABD populations, thereby
ensuring that Medicaid dollars are going to those in need by preventing ineligible individuals from receiving Medicaid and promoting

fiscal responsibility. [FN248]

¢ In the House, 2021 FD H.B. 7233 (NS) would add requirements under Medicaid State plans for health screenings and referrals for
certain eligible juveniles leaving public institutions. It would also require the HHS Secretary to issue guidance under the Medicaid
program and CHIP (the Children's Health Insurance Program) to improve the delivery of health care services, including mental health
services, in elementary and secondary schools and school-based health centers. The bill has bipartisan sponsorship.

¢ Senator Tina Smith (D-Minn.) and others are sponsoring 2021 FD S.B. 3991 (NS), which would enact the American Made
Pharmaceuticals Act of 2022. That act would call for a demonstration program that gives preferential treatment in the Medicare and
Medicaid programs and CHIP for pharmaceuticals manufactured in the United States. The bill has bipartisan sponsorship. A press
release announcing the bill explains why the sponsors believe the act is necessary:

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The pandemic has exposed our nation's dependence on other countries for essential prescription drugs. Seventy-two percent of key
pharmaceutical ingredients come from overseas, threatening the security of the supply chain and leading to shortages of essential
prescription drugs. In fact, 29 of the 40 critical drugs for COVID-19 patients were in shortage at the start of the pandemic.

The American Made Pharmaceuticals Act would reduce our dependence on foreign countries for these pharmaceuticals by boosting
production here at home. The legislation would create federal incentives to onshore manufacturing of essential medicine, while taking

steps to shore up links in the supply chain. IFN249]
The bill's companion in the House is 2021 FD H.B. 7400 (NS).

«In the Senate, 2021 FD S.B. 4039 (NS) would enact the Medicaid Ensuring Necessary Telehealth is Available Long-term (MENTAL)
Health for Kids and Underserved Act. That act would direct the HHS Secretary to provide guidance to states on reimbursement for
behavioral health services provided by telehealth in the Medicaid program and CHIP (the Children's Health Insurance Program). In a
press release announcing the bill, the bipartisan group of sponsors explained what the bill would do:

The MENTAL Health for Kids and Underserved Act would require CMS to provide guidance to states on how they can increase access
to mental and behavioral health services and treatment via telehealth under Medicaid and CHIP. Additionally, it would request guidance

on how states can furnish behavioral services and treatments in school-based settings and best practices for integration. The bill

focuses on those most at risk including underserved Americans and school-aged children. [FN250]

¢ Senator Cory Booker (D-N.J.} and others are sponsoring 2021 FD S.B. 4067 (NS), which would enact the John Lewis Equality in
Medicare and Medicaid Treatment (EMMT) Act of 2022. Its companion in the House is 2021 FD H.B. 7755 (NS). The EMMT Act would
require the Center for Medicare and Medicaid Innovation (CMMI) to consider health equity in developing new models. A press release
from Senator Booker's office explains that CMMI is currently not required to do this:

Established by the Affordable Care Act, CMMI works to develop, test, and implement new value-based payment models. Under
current law, however, CMMI is not required to consider social determinants of health - such as a patient's environment, education, and
economic status - when implementing and testing new payment models. The current status quo incentivizes health providers to pick
patients who will produce favorable clinical outcomes, which leaves women, people in rural communities, and Black and Brown people

sidelined in the development of payment models. [FN251]
Among other things, the bill would require CMMI to:
* Consider a model's impact on access to care for people of color, women, and people in rural areas, in addition to cost and quality.

* Include experts in health disparities and social determinants of health during the evaluation and review process for new payment
models.

* [Create] a Social Determinants of Health Model that focuses on health conditions of those dually eligible for Medicaid and Medicare,
behavioral health, and maternal mortality. [FN262]

¢ Representative Anna Eshoo (D-Calif.) and others are sponsoring 2021 FD H.B. 7236 (NS), which would enact the Strengthen Kids'
Mental Health Now Act of 2022. The bill aims to improve mental health care for youth. According to Representative Eshoo's press
release, one in five children in the United States suffers from a mental, emotional, or behavioral disorder, but only 20% of them receive
specialized mental health care. The press release explains what the bill would do:

The Strengthen Kids' Mental Health Now Act will foster improvements across the full continuum of pediatric mental health and
substance use disorder care. The bill extends support to communities, schools, and health care providers by matching Medicaid
payment rates with Medicare payment rates for pediatric behavioral health services, provide guidance to states to expand access to
mental health services, including through telehealth, and provide competitive awards to strengthen and improve the mental health

system infrastructure and workforce. [FN253]

«In the Senate, 2021 FD S.B. 4100 (NS) would enact the Mammas First Act. The findings supplied with the bill note the disparity in
maternal mortality between White and women of color. They recite these facts:

(1) According to the Centers for Disease Control and Prevention, the maternal mortality rate varies drastically for women by race and
ethnicity. On average, there are 12.7 deaths per 100,000 live births for White women, 43.5 deaths per 100,000 live births for African-
American women, 32.5 deaths for American Indian and Alaskan Native women, and 14.4 deaths per 100,000 live births for women
of other ethnicities. While maternal mortality disparately impacts African-American women and indigenous women, this urgent public
health crisis traverses race, ethnicity, socioeconomic status, educational background, and geography.

The findings also cite the benefits of having doulas and midwives involved in maternal care. If passed, the Mammas First Act would
ensure Medicaid payment for care rendered by doulas, midwives, and tribal midwives in a variety of settings using in-person or
telehealth services. The bill is sponsored by Senator Elizabeth Warren (D-Mass.) and others.

¢ In the House on May 6, 2022, 2021 FD H.B. 7666 (NS) would, among other things, reauthorize several programs relating to mental
health and substance abuse. It would also direct the HHS Secretary to establish a behavioral health crisis coordinating office to
coordinate the work that HHS agencies and offices are doing to address mental health and substance abuse. This would include,

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for example, the Substance Abuse and Mental Health Services Administration, CMS, and the Health Resources and Services
Administration, as well as external stakeholders. An amended version of the bill passed the House on June 22, 2022.

¢ In the Senate, 2021 FD S.B. 4170 (NS) would enact the Mental Health Reform Reauthorization Act of 2022. Among other things,
the act would reauthorize certain mental health and substance use disorder programs. As it relates to Medicaid, it would require
the Substance Abuse and Mental Health Services Administration (SAMHSA) to coordinate with CMS to improve mental health and
substance use disorder care in state Medicaid programs. Specifically, the bill would direct SAMHSA to,

promote coverage of evidence-based prevention and treatment services, improve quality of care, and identify opportunities for State
Medicaid agencies and State mental health and substance use disorder agencies to collaborate, including through the braiding of
funds, demonstration programs, waivers, amendments to State plans under section 1912, other State flexibilities, and agency guidance
for all populations enrolled in Medicaid programs.

The bill would also call for a study and report to address adherence to the standard of care for treatment of individuals with serious
mental illness and children with serious emotional disturbance under Medicare and Medicaid. Senate Bill 4170, which was introduced
on May 10, 2022, is sponsored by Senators Bill Cassidy (R-La.) and Chris Murphey (D-Conn.).

¢ Representative Carolyn Maloney (D-N.Y.) is sponsoring 2021 FD H.B. 7803 (NS), which would repeal the IMD exclusion. Generally,
Medicaid does not pay for mental health services rendered in an IMD (institution for mental disease) with more than 16 beds. The bill
would enact the Michelle Alyissa Go Act; Representative Maloney explained in a press release that the bill is named for a woman who
was killed outside a subway station by an individual suffering from mental illness who was unable to access adequate health care.
Representative Maloney's press release explained the problem that this bill seeks to remedy:

Under current federal law, Medicaid is prohibited from covering stays for patients between the ages of 21 and 64 who are receiving
mental health or substance abuse treatment in a facility with more than 16 beds. This prohibition, also known as the Institution for
Mental Disease (IMD) exclusion, has been in effect since Medicaid was created in 1965 and has resulted in people like the individual

who killed Ms. Go not being able to access care, as they do not have the money to cover these services out of their own pockets. [FN254]

« In Congress, the current version of 2021 FD H.B. 7233 (NS) would, among other things, require Medicaid State Plans and to ensure
that Medicaid-eligible juveniles leaving incarceration have the screenings they are due according to the schedule set out for EPSDT

IFN255] services. The bill would also direct HHS to provide guidance to state Medicaid agencies and CHIP on how to reduce barriers
to school-based services. HHS would also be directed to provide guidance on expanding mental, emotional, and behavioral health
services covered under State Plans or waivers, including best practices for:

(1) effective programs for the provision of such services;

(2) provision of such services to underserved communities;

(3) flexibilities for children's hospitals and other providers to expand access to such services while ensuring high quality and safety; and
(4) recruitment and retention of providers of such services.

Additionally, HHS would be directed to regularly update guidance on expanding access to Medicaid telehealth. The bill was introduced
in March 2022 and reported in House committees in June 2022.

¢ In the House, 2021 FD H.B. 8014 (NS) would enact the Jobs and Opportunities for Medicaid Act. That act would require Medicaid
enrollees to work or volunteer 20 hours a week as a condition of eligibility for Medicaid. In a press release, one of the bill's sponsor,
Jake LaTurmer (R-Kan.) explained why he believes this bill is important:

'The key to growing our economy is getting more Americans back to work. We have countless employers looking for workers right now
in Kansas and the ongoing labor shortage is making it difficult for small businesses to stay afloat... . | am proud to introduce the Jobs
and Opportunities for Medicaid Act because | believe the best welfare program is a job. This legislation will help able-bodied adults get

back into the workforce and end their reliance on taxpayer-funded government assistance." [FN256]

As we discuss in our Medicaid Restructuring Issue Brief, a Trump-era policy allowed states to seek approval for similar work
requirements, and a handful of states received approval. The requirements were challenged in court and did not fare well. Upon taking
office, President Joe Biden (D) withdrew approval for the requirements. That decision is being challenged in court as well.

¢ Representatives Jaime Herrera Beutler (R-Wash.) and Lisa Rochester Blunt (D-Del.) are sponsoring 2021 FD H.B. 8181 (NS), which
would enact the Optimizing Postpartum Outcomes Act of 2022. That act would direct the Health and Human Services Secretary to
issue guidance on Medicaid coverage for health services rendered during the post-partum period. The guidance would need to include:

(1) best practices from States with respect to innovative or evidenced-based payment models to increase access to covered pelvic
health services;

(2) recommendations for States on available financing options under [Medicaid and the Children's Health Insurance Program];

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(3) guidance and technical assistance to State agencies responsible for administering State plans (or waivers of such plans) under the
Medicaid program . . . regarding additional flexibilities and incentives related to screening and referral for, and access to, covered pelvic
health services; and

(4) guidance regarding suggested terminology and diagnosis codes, such as the International Classification of Diseases code set, to
identify women with pelvic floor dysfunction and disorders.

The bill also calls for a report to Congress on gaps in coverage for:

(1) covered pelvic health services under State plans (or waivers of such plans) under the Medicaid program under title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.) for postpartum women; and

(2) other services for postpartum women who received medical assistance under a State plan (or a waiver of such plan) under the
Medicaid program under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) during their pregnancy.

¢ An appropriations bill in the House, 2021 FD H.B. 8295 (NS), includes appropriations for CMS, including grants to states for Medicaid
as follows:

For carrying out, except as otherwise provided, titles XI and XIX of the Social Security Act, $367,357,090,000, to remain available until
expended.

In addition, for carrying out such titles after May 31, 2023, for the last quarter of fiscal year 2023 for unanticipated costs incurred for the
current fiscal year, such sums as may be necessary, to remain available until expended.

In addition, for carrying out such titles for the first quarter of fiscal year 2024, $197,580,474,000, to remain available until expended.
Payment under such title XIX may be made for any quarter with respect to a State plan or plan amendment in effect during such
quarter, if submitted in or prior to such quarter and approved in that or any subsequent quarter.

Additionally, the bill includes an appropriation for CMS program integrity activities. The bill was reported in the House on July 5, 2022.

¢ Senators Bob Casey (D-Pa.) Bill Cassidy (R-La.) and others are sponsoring a bipartisan bill to increase capacity for pediatric mental
health services. Senate Bill 4472 (2021 FD S.B. 4472 (NS)) would enact the Health Care Capacity for Pediatric Mental Health Act of
2022. That act is meant to support children and teenagers needing services for mental health and substance use disorder. In a press
release, Senator Casey summed up the importance of the act:

'For many young people navigating mental health or substance use disorders, the pandemic exacerbated the everyday challenges
they face. It has never been more clear-we need to fill in the many gaps in mental health care for kids. This legislation would ramp up

efforts to expand the workforce that provides this crucial care while improving resources for kids who need care in their communities[.]"
[FN257]

The act would create grant programs to improve behavioral health integration, improve coordination of physical and mental health
services as well as community-based resources, and support data collection on behavioral health care needs. It also seeks to

modernize and improve mental health services through telehealth and through other care sites. [FN256] Additionally, the bill calls for
workforce training grants to train workers who can offer these services. The grants would be administered through the Secretary of the
Department of Health and Human Services (HHS), in coordination with the Assistant Secretary for Mental Health and Substance Use
and the Administrator of CMS.

¢ Senator Casey is also sponsoring 2021 FD S.B. 4498 (NS), which seeks to expand access to Medicaid mental, emotional, and
behavioral health services. Among other things, it would direct the HHS Secretary to issue guidance to states on how to expand the
availability of mental, emotional, and behavioral health services covered by State Plans or waivers. The guidance would need to
include best practices for effective programs, how to best provide these services in underserved communities, how to recruit and retain
providers, and how to support the delivery of these services in schools and other community settings. The bill was introduced on June
23, 2022.

* Representatives Buddy Carter (R-Ga.) and Elise Stefanik (R-N.Y.) are sponsoring 2021 FD H.B. 8354 (NS), which would enact the
Defunding Abortion Transportation Act. That act would prohibit Medicaid funding for non-emergency transportation to services for which
federal financial participation is not allowed. Representative Carter explained why he is sponsoring the bill:

'The Biden administration is gearing up to fund interstate travel for people seeking abortions. That is wrong. The Defunding Abortion
Transportation Act will put guardrails in place to prevent the federal government from subsidizing the death of unborn children.
Democrats' abortion agenda, which allows for taxpayer-funded, elective abortions up until the moment of birth, is extreme and must be

reined in[.]° [FN259]

¢ In the Senate, Senators Rob Portman (R-Ohio) and Bob Casey (D-Pa.) are sponsoring 2021 FD S.B. 4747 (NS), which would enact
the Investing in Kids' Mental Health Now Act of 2022. That act seeks to expand access to mental, emotional, and behavioral health care
for children in the wake of the pandemic. A press release from Senator Portman's office explains how the bill would achieve that:

To help address the severe toll that the COVID-19 pandemic has had on children's mental health, the bill provides pediatric mental
health care providers with additional resources ? a one-year Medicaid funding increase through an enhanced Federal Medical

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Assistance Percentages (FMAP). Pediatric mental, emotional, and behavioral health care providers serving Medicaid patients in

participating states will have access to this funding. [FN260]

Additionally, the bill would direct HHS to issue guidance to states on how to expand mental, emotional, and behavioral telehealth
services and on best practices for supporting children in crisis or in need of intensive mental, emotional, or behavioral services. [FN261]

* Representative Buddy Carter (R-Ga.) and others are sponsoring a bipartisan bill to improve access to and payment for non-
emergency transportation to recurring appointments, such as dialysis services. The bill, 2021 FD H.B. 8841 (NS), would enact the
Access to Critical Non-Emergency Transportation Services Act, and Representative Carter's press release explains what that act would
accomplish:

Currently, Medicare beneficiaries must obtain prior authorization before accessing ambulance rides to dialysis or diabetes wound

care services, threatening patients' access to regularly scheduled health care services critical to their health. This bill will require the
Secretary of Health and Human Services to coordinate with states to ensure low-income Medicare patients dually enrolled in Medicaid
and Medicare who are denied ambulance NEMT are able to access Medicaid NEMT with appropriate modes of transportation. It would

also make sure Medicare beneficiaries that qualify as partial dual-eligible beneficiaries are given assistance to enroll in Medicaid and

have access to Medicaid transportation benefits. [FN262]

* Agroup of Democratic representatives are sponsoring 2021 FD H.B. 8862 (NS), which would enact the Providing Real Opportunities
and Lifelong Investments for Everyone ('PRO-LIFE") Act of 2022. In a press release, Representative Rosa DeLauro, one of the bill's co-
sponsors, explained why this bill is important:

'Congressional Republicans are making their end goal crystal clear: to strip away a woman's fundamental right to make her own
healthcare decisions and ban abortion nationwide . . . . They claim to be pro-life and pro-family, and then they enact policies that go
against science, hurt the health of American women, and gut programs that help families deal with rising costs and stagnant wages. Let
me be clear, if Republicans were true to their claims, they would fight for policies that actually support the lives of working Americans.

With introduction of the PRO-LIFE Act, which includes a number of priorities that will support American families, including the Child Tax

Credit and paid family and medical leave, we will re-establish what it truly means to be pro-life. " [FN263]

As it relates to Medicaid, the bill would, among other things, create a task force to make recommendations for expanding Medicaid
coverage of social services that address social determinants of maternal health. It would also direct the HHS Secretary to create a
demonstration project called the Perinatal Care Alternative Payment Model Demonstration Project in which states would test payment
models under their State Plans for maternity care provided to Medicaid-enrolled pregnant and postpartum individuals. Notably, the bill
would also establish an option for states to increase Medicaid eligibility for children and would extend post-partum coverage to one
year.

¢ Senator Bob Casey (D-Pa.) is sponsoring 2021 FD S.B. 5008 (NS), which would enact the Maximizing Opioid Recovery Emergency
(MORE) Savings Act. That act would ensure better coverage of and access to medication-assisted therapy for substance use disorder.
Among other things, the bill would temporarily increase the federal medical assistance percentage (FMAP) to 90% for medication-
assisted therapy. It would also amend the definition of 'medication-assisted therapy" to add the following:

(C) at the option of a State, includes recovery support services, such as peer counseling and transportation, that are provided to an

individual in conjunction with the provision of such drugs and biological products to support the individual in maintaining a healthy
lifestyle following opioid misuse treatment.

¢ Senator Tom Carper (D-Del.) and others are sponsoring 2021 FD S.B. 5011 (NS), a bipartisan, bicameral measure to improve
coordination of physical and mental health services for children. (The House bill is 2021 FD H.B. 9037 (NS).) The bill's sponsors
recognize the children's mental health crisis and acknowledge that, in 2021, the U.S. Surgeon General issued a public health advisory

calling for a comprehensive and coordinated response to that crisis. [FN264] ] The bill calls for the federal government to develop a
Medicaid Whole Child Health Care model. In a press release, Senator Carper summarizes what the bill would accomplish:

Specifically, the KIDS Health Act of 2022 would:

* Authorize a $125 million demonstration program to help states improve coordination between mental health and community health
care providers, which will better support children's needs through a holistic approach;

* Allow states to establish or enhance payment models that reward doctors for providing higher-quality care that helps children stay
healthier and invest in workforce recruitment and training;

¢ Allow participating states to design and implement a delivery model in which health care providers partner with community
organizations and government agencies to coordinate services across multiple sectors;

¢ Require GAO to issue a report, evaluating the individual, financial, and systems-level impacts associated with whole child health
models implemented under the demonstration project; and
* Require the Secretary of Health and Human Services to issue guidance on combining federal and non-federal funds to address social

determinants of health in low-income populations. [FN265]

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¢ Inthe Senate, Senator Chuck Grassley (R-lowa) is sponsoring 2021 FD S.B. 5015 (NS), which would enact the Healthy Moms

and Babies Act. That act would include several varied measures to improve maternal and child health in Medicaid and CHIP [FN266] ,
including, among other things:

* requiring state Medicaid programs to report on adult health care quality measures of maternal and perinatal health;

¢ establishing Medicaid quality improvement measures to decrease caesarean births;

¢ creating a state Medicaid health home option to provide coordinated maternal and post-partum care;

¢ directing the Health and Human Services Secretary (HHS) to release guidance on care coordination to improve maternal health;

* calling for a MACPAC [FN267] study on doulas and community health workers;

* directing CMS to study coverage of remote patient monitoring and its impact on maternal and child health outcomes;

¢ developing guidance for Medicaid maternal care providers on reducing maternal mortality and morbidity;

¢ directing the HHS Secretary to submit a report to Congress on social determinants of health for Medicaid and CHIP enrollees;

* directing the HHS Secretary to submit a report to Congress on payment methodologies for transferring pregnant individuals between
facilities before, during, and after delivery;

* requiring the HHS Secretary to provide guidance to states on state options for addressing social determinants of health; and
¢ directing the CMS Administrator to conduct payment error rate audits on state Medicaid agencies every two years.

¢ Aresolution in Congress, 2021 FD H.R. 9233 (NS), seeks to improve the public's perceptions of and interactions with federal
agencies. It would direct specified agencies to take certain actions. Among other things, it would direct the Secretary of the Department
of Health and Human Services to:

(ii) strengthen requirements for maternal health quality measurement, including-
(I) measuring perinatal quality and patient care experiences; and
(Il) evaluating the measurements by race and ethnicity to better identify inequities in maternal health care delivery and outcomes;

(iii) to the maximum extent permitted by law, support coordination between the Medicare program under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.), the Medicaid program under title XIX of such Act (42 U.S.C. 1396 et seq.), the Children's Health
Insurance Program under title XXI of such Act (42 U.S.C. 1397aa et seq.);

(iv) to the maximum extent permitted by law, propose ways to streamline State benefit program enrollment and renewal processes
in order to reduce administrative burden on customers and remove barriers to enrollment and renewal, including by eliminating face-
to-face interview requirements and requiring prepopulated electronic renewal forms, to ensure eligible individuals are automatically
enrolled in and retain access to such benefit programs;

(v) develop guidance for covered entities and business associates of such entities as such terms are defined in section 160.103 of title
45, Code of Federal Regulations, on providing telehealth in compliance with HIPAA privacy regulation (as defined in section 1180(b)(3)
of the Social Security Act) to improve patient experience and convenience following the end of the COVID-19 public health emergency;
and

(vi) test methods to automate patient access to electronic prenatal, birth, and postpartum health records (including laboratory results,
genetic tests, ultrasound images, and clinical notes) to improve patient experiences in maternity care and health outcomesj[.]

XI. SELECTED Administrative Activity

¢ CMS published an emergency regulation requiring that staff at health care facilities participating in the Medicare or Medicaid programs
be vaccinated against COVID-19. CMS Administrator Chiquita Brooks-LaSure explained why the agency believes the rule is necessary:

'Ensuring patient safety and protection from COVID-19 has been the focus of our efforts in combatting the pandemic and the constantly
evolving challenges we're seeing . . . . Today's action addresses the risk of unvaccinated health care staff to patient safety and provides

stability and uniformity across the nation's health care system to strengthen the health of people and the providers who care for them."
[FN268]

The regulation applies to ambulatory surgical centers, hospices, Programs of All-Inclusive Care for the Elderly, hospitals, long term care
facilities, psychiatric residential treatment facilities, intermediate care facilities for individuals with intellectual disabilities, home health

agencies, comprehensive outpatient rehabilitation facilities, critical access hospitals, specified clinics, community mental health centers,

home infusion therapy suppliers, rural health clinics/Federally Qualified Health Centers, and end-stage renal disease facilities. [FN269]

All workers at these facilities were to receive the first dose of a two-dose vaccine or one dose of the Johnson & Johnson vaccine by
December 5, 2021, and before providing any care or treatment to patients. All workers were to be fully vaccinated by January 4, 2022.

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Exceptions would be allowed for recognized medical conditions or religious beliefs, observances, or practices. The regulation, which is
published at 86 F.R. 61555-01 (Nov. 5, 2021), was to take effect on November 5, 2021. A list of FAQs is available. N27"!

The rule was issued without notice and comment after the Secretary determined that good cause existed to forego these requirements
due to the urgent nature of the matter. Subsequently, two groups of states challenged the requirements in court, and district courts in

Louisiana and Missouri each filed decisions preliminarily enjoining enforcement. Courts of Appeals denied a stay. [FN271]

In a per curiam decision, the Supreme Court held, among other things, that HHS was within its statutory authority in issuing the rule,
that the rule was not arbitrary or capricious, and that the HHS Secretary had good cause to forego the notice and comment procedures.

[FN272] The Court's decision merely stays enforcement of the preliminary injunctions while the lower court cases wend their way through
the court system. The Supreme Court's decision affects the 24 states that had joined in the two lawsuits. Enforcement in the remaining

states is ongoing, on the schedule set out in the interim final rule. [FN273]
Upon learning of the Court's decision, Chiquita Brooks-LaSure, CMS Administrator, remarked,

'The Centers for Medicare & Medicaid Services (CMS) is extremely pleased the Supreme Court recognized CMS' authority to set a
consistent COVID-19 vaccination standard for workers in facilities that participate in Medicare and Medicaid. CMS' vaccine rule will
cover 10.4 million health care workers at 76,000 medical facilities. Giving patients assurance on the safety of their care is a critical
responsibility of CMS and a key to combatting the pandemic.

'Vaccines are proven to reduce the risk of severe disease. The prevalence of the virus and its ever-evolving variants in health care
settings continues to increase the risk of staff contracting and transmitting COVID-19, putting their patients, families, and our broader
communities at risk. And health care staff being unable to work because of illness or exposure to COVID-19 further strains the health

care system and limits patient access to safe and essential care." [FN274]

According to The New York Times, hospitals must now contend with the realities that accompany the Court's decision. There are
a good number of states that heretofore did not have a vaccine mandate for health care workers. In states that did, hospitals lost
employees that did not want to be vaccinated, exacerbating existing staff shortages. The paper cites this data about state vaccine
mandates for health care workers:

While 21 states and the District of Columbia have already mandated vaccines for health care workers, six - Texas, Montana,
Arkansas, Indiana, Tennessee and Georgia - implemented bans that prohibited some employers from requiring vaccines.
Eighteen states had no requirement for health care workers, while five, including Utah, Arizona and Michigan, exempted health care

organizations from bans on vaccine requirements. [FN275]
Nursing facilities are especially concerned about losing staff at this critical point in the pandemic, and administrators at some have

urged the administration to allow them to test their employees instead of requiring a vaccine. Currently, about 83% of nursing
home employees are vaccinated, but with the recent Omicron surge, infections among staff and residents have risen dramatically.
Administrators in those facilities fear the loss of even more staff due to the vaccine mandate. "N'6l administrators at smaller hospitals

have the same concern. !FN277]

¢ In February 2022, HHS announced that it distributed $560 million in Phase 4 general distribution funds to more than 4,000 providers
across the country. After this latest round of distributions, HHS has awarded roughly $11.5 billion in Phase 4 funds to about 78,000
providers. Currently, approximately 86% of the applications for Phase 4 have been processed, and the remaining funds will be awarded

throughout the year. [FN276]
According to HHS' news release, Phase 4 distributions have been awarded with an eye toward equity:

Phase 4 payments have an increased focus on equity, including reimbursing a higher percentage of losses for smaller providers

and incorporating bonus payments for providers who serve Medicaid, Children's Health Insurance Program (CHIP), and Medicare
beneficiaries, '"N27®l

¢ In 2013, CMS released a Health Home Core Set of quality measures to ensure that people with chronic conditions receiving care in a

health home are getting high quality care with positive outcomes. CMS reviews the set annually. In February 2022, CMS advised that it
made a 2022 update to the set, in which it added these two new measures:

Follow-Up After Emergency Department (ED) Visit for Mental Illness (FUM), NQF #3489 which measures the percentage of ED visits
for beneficiaries age six and older with a principal diagnosis of mental illness or intentional self-harm and who had a follow-up visit

for mental illness. Two rates are reported for this measure: (1) the percentage of ED visits for mental illness for which the beneficiary
received follow-up within 30 days of the ED visit; and (2) the percentage of ED visits for mental illness for which the beneficiary received
follow-up within 7 days of the ED visit.

Colorectal Cancer Screening (COL), NQF# 0034 which measures the percentage of patients 50 to 75 years of age who had appropriate

screening for colorectal cancer. "N28°!

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CMS reports that 21 states and the District of Columbia have health home programs. [FN281]

* As a part of its continuing effort to advance health equity, HHS issued a request for information (RFI) [F282] on February 17, 2022,
seeking information about access to care and coverage in the Medicaid program and CHIP (the Children's Health Insurance Program).
Specifically, HHS is hoping that stakeholders will shed light on these topics: health care access (such as enrolling in and maintaining

coverage), accessing services and supports, and provider payment adequacy. [FN283] ~ news release about the RFI explains what HHS
hopes to gain with the information it receives:

Feedback obtained from the RFI announced today will aid in CMS' understanding of enrollees' barriers to enrolling in and maintaining
coverage and accessing needed health care services and support through Medicaid and CHIP. This information will help inform future
polices, monitoring, and regulatory actions, helping ensure beneficiaries have equitable access to high-quality and appropriate care
across all Medicaid and CHIP payment and delivery systems, including fee-for-service, managed care, and alternative payment models.
The RFI submissions will also inform CMS' work to ensure timely access to critical services, such as behavioral health care and home

and community-based services. [FN284]

¢ CMS gave notice that it approved an application from the American Association for Accreditation of Ambulatory Surgery Facilities
for continued recognition as a national Accrediting organization for Rural Health Clinics that participate in the Medicare or Medicaid
programs. The notice is published at 87 F.R. 16003-02 (Mar. 21, 2022).

* CMS also gave notice of final and preliminary Medicaid federal share disproportionate share hospital (DSH) allotments and limitations
on the aggregate amounts states may make to institutions of mental disease (IMDs). The rule's summary reads as follows:

This notice announces the final Federal share (FS) disproportionate share hospital (DSH) allotments for Federal fiscal year (FY) 2018
and FY 2019, and the preliminary FS DSH allotments for FY 2020 and FY 2021. This notice also announces the final FY 2018 and FY
2019 and the preliminary FY 2020 and FY 2021 limitations on aggregate DSH payments that States may make to institutions for mental
disease and other mental health facilities. In addition, this notice includes background information describing the methodology for

determining the amounts of States' FY DSH allotments. N78!

* CMS gave notice of its final decision to approve an application from the Joint Commission for continued recognition as an accrediting
organization for hospitals that participate in Medicare and Medicaid. The notice is published at 87 F.R. 25642-01 (May 2, 2022).

* CMS finalized a rule on reassignment of provider payments. The rule, which is published at 87 F.R. 29675 (May 16, 2022),
reinterprets the general rule that states must make provider payments directly to the provider in most cases. The summary of the rule
reads as follows:

This final rule reinterprets the scope of the general requirement that State payments for Medicaid services under a State plan must
generally be made directly to the individual practitioner or institution providing services or to the beneficiary, in the case of a class of
practitioners for which the Medicaid program is the primary source of revenue. Specifically, this final rule explicitly authorizes States to
make payments to third parties on behalf of individual practitioners, for individual practitioners' health insurance and welfare benefits,
skills training, and other benefits customary for employees, if the individual practitioner consents to such payments on their behalf.

This is a departure from the Trump Administration's interpretation of the rule.

* CMS gave notice that it is extending the deadline to file a final rule for the proposed rule titled, 'Medicare and Medicaid Program:
Requirements for Long-Term Care Facilities: Regulatory Provisions to Promote Efficiency, and Transparency Final Rule", published at
84 F.R. 34737 (July 18, 2019). Normally, final Medicare rules must be filed within three years of the date the proposed rule published.
The deadline for this final rule would have been July 18, 2022, but CMS has extended it to July 18, 2023. Please see 87 F.R. 42137-01
(July 14, 2022).

* CMS also gave notice that it received an application from the Center for Improvement in Healthcare Quality for continued approval as
an accrediting organization for hospitals that participate in Medicare and Medicaid. CMS is inviting comments on the application. Please
see 87 F.R. 43525-01 (July 21, 2022).

¢ Under the public charge rule, federal officials may make unfavorable immigration decisions for a person they deem to be a 'public

charge," that is, someone who is likely to be dependent on the government for subsistence. IFN286] The Department of Homeland
Security has now finalized a rule clarifying that it will not consider someone a public charge due to their acceptance of public health
benefits (like Medicaid) to which they are legally entitled. CMS explained the import of the rule:

The final rule applies to noncitizens requesting admission to the U.S. or applying for lawful permanent residence (a 'green card") from
within the U.S. When assessing whether a noncitizen is 'likely to become primarily dependent on the government for subsistence,"
DHS will not penalize individuals who choose to access the vast majority of health-related benefits and other supplemental government
services available to them, including most Medicaid benefits (except for long-term institutionalization ? such as residing in nursing

home ? at government expense) and the Children's Health Insurance Program (CHIP). [FN287]

Similarly, the Department of Homeland Security will not consider someone a public charge due to their acceptance of other non-
cash programs, such as SNAP. Certain cash benefits may be considered under the new 'totality of the circumstances' rule. In a

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press release announcing the rule, CMS Administrator Chiquita Brooks-LaSure commented that the rule reinforces one of the Biden
Administration's core principles: that health care is a right and not a privilege. [FN288] The rule reverses the Trump Administration's
interpretation of the public charge rule. '"?®°l The final rule is published at 87 F.R. 55472 (Sept. 9, 2022).

* CMS gave notice that it gave final approval to Det Norske Veritas to continue as an accrediting organization for hospitals that
participate in the Medicare and Medicaid programs. The notice is published at 87 F.R. 54510 (Sept. 6, 2022).

* CMS gave notice that it received an application from the Joint Commission for continuing recognition as an accrediting organization
for psychiatric hospitals that participate in Medicaid and Medicare. The agency is soliciting comments on the application. Please see 87
F.R. 59435 (Sept. 30, 2022).

¢ CMS is seeking comments on the Accreditation Commission for Health Care's application for continuing recognition as an accrediting
organization for end-stage renal disease facilities that participate in Medicare and Medicaid. The notice is published at 87 F.R. 60171
(Oct. 4, 2022).

¢ CMS announced that it approved the National Dialysis Accreditation Commission's application for continuing approval as an
accrediting organization for end-stage renal disease facilities that participate in Medicare and Medicaid. Please see 87 F.R. 60173 (Oct.
4, 2022).

* In early 2020, at the start of the COVID-19 pandemic, the Families First Coronavirus Response Act (Pub. L. 116-127) provided for a

6.2 percentage point increase in states' FMAPs [FN290] t ease the financial strains that states were experiencing. The increase is to end
when the COVID-19 public health emergency ends. To qualify for the increased FMAP, states had to comply with certain maintenance-

of-effort requirements, including continuous coverage. In an interim final rule that requested comments, IFN291] CMS set out specific
requirements for continuous coverage. It is now seeking comment on those requirements and is reopening the comment period for the
interim final rule. CMS wrote:

On November 6, 2020, CMS published an interim final rule with request for comments (IFR) entitled ??Additional Policy and Regulatory
Revisions in Response to the COVID-19 Public Health Emergency." The IFR set forth certain requirements in CMS regulations that
States must follow in order to claim a temporary increase in Federal matching funds for their Medicaid programs under the Families
First Coronavirus Response Act (FFCRA). In light of the possibility of changed circumstances since publication of the IFR and other

policy considerations, CMS is considering modifying those requirements. CMS is soliciting additional information from the public on any

issues that may be pertinent to these potential modifications by reopening the public comment period for an additional 30 days. [FN292]

XIl. selected federal guidance

¢ States are required to file Medicaid Access Monitoring Review Plans to document that their fee-for-service payment rates are
sufficient to enlist enough providers to ensure that care and services are available under the State Plan to the extent that they are

available to the general population in that geographic area. [FN283] Qn March 31, 2022, CMS gave notice in a CMCS Informational
Bulletin that it is exercising enforcement discretion in reviewing these plans during the COVID-19 public health emergency. These plans
must be updated once every three years, and the next update would be October 1, 2022. However, CMS will delay enforcement until
October 1, 2024:

CMS is delaying enforcement of the requirement for states to submit updated AMRPs that otherwise would be due by October 1, 2022,
until October 1, 2024. In the interim, as discussed in more detail below, CMS will continue to require states to demonstrate that they are
meeting the statutory obligation to ensure Medicaid rates are consistent with section 1902(a)(30)(A) of the Social Security Act (the Act).
Strengthening and expanding access to care is a CMS priority. This includes a broad view of access that ensures enrollment in and
maintenance of coverage and that, once people are enrolled, covered services are provided in a timely, equitable, high-quality manner,

regardless of delivery system. [FN204]
Please see the Informational Bulletin for a fuller discussion.

¢ Earlier in the pandemic, CMS released a toolkit titled, 'Coverage and Reimbursement of COVID-19 Vaccines, Vaccine Administration,
and Cost-Sharing under Medicaid, the Children's Health Insurance Program, and Basic Health Program," and the agency updates the
toolkit periodically. On May 6, 2022, CMS announced a new update. Sections that were updated include Recommended COVID-19

Vaccines and COVID-19 Vaccine Distribution, and Medicaid and CHIP Reporting Requirements and Implications. The updated toolkit is

available from CMS. FN2951

¢ CMS defines stand-alone vaccine counseling as medical counseling about a vaccine when the patient does not actually receive the
vaccine on the same day. In a State Health Official Letter on May 12, 2022, CMS gave guidance to states about coverage for these
services. According to CMS, the Medicaid Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit provides for
coverage of stand-alone vaccine counseling to those under the age of 21 who are eligible for the benefit. Additionally, the American
Rescue Plan (ARP) (Pub. L. 117-2) temporarily provides for full coverage without cost-sharing and a 100% FMAP for stand-alone
COVID-19 vaccine counseling. CMS interprets these two provisions to require full coverage of these services with a 100% FMAP for

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those eligible for EPSDT who qualify under the American Rescue Plan. States may still cover stand-alone counseling for vaccines,
including COVID-19, for those not eligible for EPSDT, but they would do so at the state's regular FMAP:

State expenditures on stand-alone COVID-19 vaccine counseling are federally matched at 100 percent under the ARP only when

this counseling is provided to Medicaid beneficiaries who are eligible both for EPSDT and the COVID-19 vaccination coverage
required under the ARP. States have the option to cover stand-alone vaccine counseling for Medicaid beneficiaries who are not
eligible for EPSDT. State expenditures on stand-alone COVID-19 vaccine counseling for beneficiaries not eligible for EPSDT, and
state expenditures on stand-alone vaccine counseling related to vaccines other than COVID-19 vaccines, are federally matched at the

otherwise applicable FMAP, not at the ARP 100 percent FMAP. [FN296]

The guidance also advises states on stand-alone vaccine counseling under CHIP (the Children's Health Insurance Program). Please
see the letter for more details.

¢ In 2016, CMS published a final rule for the Medicare and Medicaid programs titled, 'Reform of Requirements for Long-Term Care
Facilities." "9"! tn late June 2022, CMS released updated guidance on the minimum standards for long-term care facilities that

participate in Medicare and Medicaid; the guidance further implements the 2016 rule. IFN288] One area of concern is staffing levels

in these facilities. Earlier in 2022, CMS issued a Request for Information seeking feedback on revising staffing levels. While the
rulemaking process progresses, CMS added requirements for compliance surveyors to use Payroll Based Journal staffing data in their
inspections to ensure compliance with current staffing requirements. The guidance also addresses infection control, timely inspections,

mental health and substance use disorder, and room crowding, among other things. IFN299] CMS made changes to Chapter 5 of the
State Operations Manual to address the timeliness of state investigations as well. [FN300] The updated guidance furthers President
Biden's initiative to improve health and the quality of care in nursing homes. [FN301I | Fact Sheet is available. !*N202]

+ Ina June 2021 CMCS !FN3°3] Informational Bulletin (CIB), IFN304] Crs provided tools for states and CMS to use to improve monitoring

and oversight of Medicaid and CHIP [FN305] managed care programs. The 2021 CIB announced an upcoming web-based reporting
portal for states to use to report required managed care information, and it included various toolkits, among other things. On July 6,
2022, in a new CIB, CMS provided an update on the development of the web-based portal, and it included templates, including one for
reporting on the Medicaid loss ratio and one for the Network Adequacy and Assurances Report. Please see the newest CIB for more

information. '*N3°6]

« CMS has issued guidance on health coverage options for Ukrainians who enter the United States after fleeing the war in their country.
The document gives guidance on Medicaid and CHIP coverage and Marketplace coverage with financial assistance. As for Medicaid,
the coverage for non-citizens depends on their immigration status, and the document discusses coverage for those in parolee status or
temporary protected status, and for those classified as refugees. The guidance also supplies details on the requirements for eligibility
for these individuals, including state residency requirements, applications for those moving between states, and presumptive eligibility.

CMS is offering technical assistance to states as they sort out these issues. [FNSO7]

« CMS released guidance to states that are considering transitioning Medicaid nursing facility payments from the Resource Utilization
Groups (RUGs) to the Patient-Driven Payment Model (PDPM) and using the PDPM as the basis for nursing facility upper payment limit

demonstrations, [F938]

¢ CMS released 2023 and 2024 updates the child and adult core set of quality measures. [FN309]

Xill. Additional Resources

The Substance Use?Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities
Act (P.L. 115-271) requires CMS to release each year the Transformed Medicaid Statistical Information System (T-MSIS) Substance
Use Disorder (SUD) Data Book. The book is meant to detail the number of Medicaid participants with SUD and the services they
received. In late January 2022, CMS announced the publication of its latest book, which covers calendar year 2019. The report
revealed that the number of persons suffering with an SUD or an opioid use disorder increased slightly from the previous year;
however, the number receiving medication-assisted therapy increased more significantly, and the number needing emergency care
decreased 2.6%. The number receiving care in an inpatient setting decreased slightly from the previous year and the number who
received services in a residential or outpatient setting increased slightly. In all, 4.7 million Medicaid enrollees were treated for an SUD
in 2019, and 1.6 million were treated for an opioid use disorder. Please see the Data Book for a thorough discussion of Medicaid SUD

services for 2019. /FN9101

CMS published a resource to help states, nursing facilities, and other providers better understand the sources of coverage for
COVID-19 testing costs. The resource includes: (1) a flow chart explaining Medicare payment for these services in nursing facilities and
skilled nursing facilities; and (2) one-page summaries of testing coverage in Medicare, Medicaid (including for the uninsured), private

coverage, and coverage from other sources. [FNS11]

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CMS and HHS' Administration for Children and Families (ACF) jointly issued a toolkit explaining the value of data sharing between child
welfare agencies (under Title IV-E of the Social Security Act) and Medicaid agencies and providing technical assistance for doing so.
The agencies explained in the toolkit why data sharing is so important for children in foster care:

Timely, effective data sharing provided within the parameters of federal law helps to ensure this vulnerable population of children
and youth receive the health care services and care coordination they need. Children in foster care have higher rates of physical
and behavioral health care needs compared with children without a history of foster care involvement. To meet the often-complex
health care needs of children and youth entering foster care, they must receive timely initial health assessments and be connected
to necessary services. Timely access to health services can lead to improved health outcomes for youth during and beyond their

placement. [FNS12]

The resource provides background on children under the care of Title IV-E agencies, and discusses legal consideration for this type of
data sharing, what kind of data can be shared, exchange models and methods, and cost allocation and claiming. Several appendices
are attached with sample documents and more information. [FNS13]

In June 2022, CMS released 2020 Medicaid managed care data. One of the releases is an enrollment report that includes plan-specific
data and national and regional data, IFN314] ond the other contains profiles of state programs and their program features. [FNS15]

CMS announced that it published the 2022 Medicaid and CHIP beneficiary profile. This document supplies detailed information in the
following domains:

* Medicaid and CHIP Enrollment
¢ Beneficiary Expenditures

¢ Beneficiary Characteristics

¢ Beneficiary Health Status

¢ Beneficiary Experience

¢ Special Topic: Oral Health [FNS16]
As of February 2022, 87,384,715 individuals were enrolled in Medicaid. Based on 2020 data, 8,040,486 Medicaid enrollees are dually
eligible (eligible for both Medicaid and Medicare), and 19,586,992 are women of reproductive age. [FNS17]

CMS released a report titled, 'Medicaid Beneficiaries Who Use Long-Term Services and Supports: 2019." [FNS18]

For many, Medicaid eligibility is based on their modified adjusted gross income (MAGI). CMS typically releases an annual report setting
out the time it takes for states to determine MAGI eligibility. CMS just released a report, and it announced that now, because of the
pandemic and the eventual unwinding from pandemic-related policies, it will be reporting on these processing times quarterly. The
newest report is for the period January ? March 2022. The key findings were these:

Of the 47 states that reported Medicaid MAGI application processing time data to CMS's specifications for the January ? March 2022
period:

* More than half (52 percent) of all MAGI determinations at application were processed in under 24 hours;

¢ About two-thirds of all MAGI determinations at application were processed within seven days;

¢ ln 21 states, more than 60 percent of MAGI determinations at application were processed within seven days;

¢ In 14 states, 40 percent or less of MAGI determinations at application were processed within seven days; and

¢ The determinations made in more than 45 days varied by month: 7 percent (January 2022), 9 percent (February 2022), and 11
percent (March 2022) of all MAGI determinations at application were conducted in over 45 days. [FNS19]

Please see the report for more details.

CMS published a report on Medicaid drug review and utilization, as required by the SUPPORT Act (Pub. L. 115-271). The report covers
the 2020 fiscal year. [FNS20]

XIV. Conclusion

The transition from the Obama Administration to the Trump Administration significantly affected health care and health care policy,
including Medicaid policy. Legislative attempts to repeal the Affordable Care Act were largely unsuccessful, particularly where Medicaid
is concerned. After the latest Supreme Court decision, it appears the law is here to stay for some time to come. With the election of

President Joseph Biden (D), Medicaid is undergoing another transition. The President's January 2021 executive order [FN321] affirmed
his administration's commitment to Medicaid, and he asked agencies to identify policies that limit Medicaid coverage or provide barriers

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to securing Medicaid. As agencies identify those policies, we are sure to see more changes in Medicaid. President Biden has already
taken action rescinding waivers issued under the previous administration.

The COVID-19 pandemic has required many temporary changes to Medicaid policy. We will continue to report on those as they are
issued, and when the emergency period ends, we will report on the transition to pre-COVID-19 policy.

© Copyright Thomson/West - NETSCAN's Health Policy Tracking Service

 

[FN2]

The FMAPs for fiscal year 2021 are published at: 'Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier,'
Kaiser Family Foundation, available at: https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#. For more information on how the FMAP is calculated, please
see Alison Mitchell, "Medicaid's Federal Medical Assistance Percentage," Apr. 25, 2018, available at: https://fas.org/sgp/crs/misc/
R43847.pdf.

[FN3]

"Executive Order on Strengthening Medicaid and the Affordable Care Act," The Whitehouse, Jan. 28, 2021, available at: https://
www.whitehouse.gov/briefing-room/presidential-actions/202 1/01/28/executive-order-on-strengthening-medicaid-and-the-affordable-
care-act/.

[FN4]

Melissa Quinn, "Biden Signs Executive Actions on Abortion Policy, Health Care Access," CBS News, Jan. 29, 2021, available at: https://
www.cbsnews.com/news/biden-signs-health-care-access-executive-orders/.

[FN5]
FMAP is the federal medical assistance percentage, or match rate.

[FN6]

Elizabeth Williams, "Medicaid Enrollment & Spending Growth: FY 2022 & 2023," Kaiser Family Foundation, Oct. 25, 2022, available at:
https:/Avww.kff.org/medicaid/issue-brief/medicaid-enrollment-spending-growth-fy-2022-2023/.

[FN7]

Press Release, "CMS Office of the Actuary Releases 2021-2030 Projections of National Health Expenditures," CMS, Mar. 28, 2022,
available at: https:/Awww.cms.gov/newsroom/press-releases/cms-office-actuary-releases-202 1-2030-projections-national-health-
expenditures.

[FN8]

Press Release, "CMS Office of the Actuary Releases 2021-2030 Projections of National Health Expenditures," CMS, Mar. 28, 2022,
available at: https:/Awww.cms.gov/newsroom/press-releases/cms-office-actuary-releases-202 1-2030-projections-national-health-
expenditures.

[FN]

Press Release, "CMS Office of the Actuary Releases 2021-2030 Projections of National Health Expenditures," CMS, Mar. 28, 2022,
available at: https:/Awww.cms.gov/newsroom/press-releases/cms-office-actuary-releases-202 1-2030-projections-national-health-
expenditures.

[FN10]

Press Release, "CMS Office of the Actuary Releases 2021-2030 Projections of National Health Expenditures," CMS, Mar. 28, 2022,
available at: https:/Awww.cms.gov/newsroom/press-releases/cms-office-actuary-releases-202 1-2030-projections-national-health-
expenditures.

[FN11]
CHIP is the Children's Health Insurance Program.

[FN12]

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Press Release, "CMS Commits Over $49 Million to Reduce Uninsured Rate Among Children and Boost Medicaid Enrollment Among
Parents, Pregnant People," CMS, Jan. 27, 2022, available at: https://(www.cms.gov/newsroom/press-releases/cms-commits-over-49-
million-reduce-uninsured-rate-among-children-and-boost-medicaid-enrollment-among.

[FN13]

Press Release, "CMS Commits Over $49 Million to Reduce Uninsured Rate Among Children and Boost Medicaid Enrollment Among
Parents, Pregnant People," CMS, Jan. 27, 2022, available at: https:/Awww.cms.gov/newsroom/press-releases/cms-commits-over-49-
million-reduce-uninsured-rate-among-children-and-boost-medicaid-enrollment-among.

[FN14]

News Release, "New HHS Report Highlights 40 Percent Decline in Uninsured Rate Among Black Americans Since Implementation of
the Affordable Care Act," HHS, Feb. 23, 2022, available at: https://Awww.hhs.gov/about/news/2022/02/23/new-hhs-report-highlights-40-
percent-decline-in-uninsured-rate-among-black-americans-since-implementation-affordable-care-act.html.

[FN15]

"Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated Nov. 9, 2022, available at:
https:/Avww.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN16]

News Release, "New HHS Report Highlights 40 Percent Decline in Uninsured Rate Among Black Americans Since Implementation of
the Affordable Care Act," HHS, Feb. 23, 2022, available at: https:/Awww.hhs.gov/about/news/2022/02/23/new-hhs-report-highlights-40-
percent-decline-in-uninsured-rate-among-black-americans-since-implementation-affordable-care-act.html.

[FN17]

Chiquita Brooks-LaSure, CMS Administrator, "My First 100 Days and Where We Go from Here: A Strategic Vision for CMS," CMS Blog,
Sept. 9, 2021, available at: https:/Avww.cms.gov/blog/my-first-100-days-and-where-we-go-here-strategic-vision-cms#:? :text=Engage
our partners and the,responsible steward of public funds.

[FN18]

Strategic Plan Cross-Cutting Initiatives, CMS, available at: https:/Avwww.cms.gov/sites/default/files/2022-04/13_ CCI Fact_sheet_4_12
Final-508.pdf.

[FN19]

Pillar: Health Equity, CMS, available at: https:/Avww.cms.gov/sites/default/files/2022-04/Health Equity Pillar Fact Sheet_1.pdf; see, also,
Press Release, "CMS Outlines Strategy to Advance Health Equity, Challenges Industry Leaders to Address Systemic Inequities," CMS,
Apr. 20, 2022, available at: https:/Avww.cms.gov/newsroom/press-releases/cms-outlines-strategy-advance-health-equity-challenges-
industry-leaders-address-systemic-inequities#:?:text=In effort to address systemic,outcomes experienced by people who.

[FN20]
Pillar: Health Equity, CMS, available at: https:/Avww.cms.gov/sites/default/files/2022-04/Health Equity Pillar Fact Sheet_1.pdf.
[FN21]
Pillar: Health Equity, CMS, available at: https:/Avww.cms.gov/sites/default/files/2022-04/Health Equity Pillar Fact Sheet_1.pdf.
[FN22]
Pillar: Health Equity, CMS, available at: https:/Avww.cms.gov/sites/default/files/2022-04/Health Equity Pillar Fact Sheet_1.pdf.
[FN23]

Pillar: Health Equity, CMS, available at: https:/Avww.cms.gov/sites/default/files/2022-04/Health Equity Pillar Fact Sheet_1.pdf.

[FN24]

Press Release, "CMS Outlines Strategy to Advance Health Equity, Challenges Industry Leaders to Address Systemic Inequities," CMS,
Apr. 20, 2022, available at: https:/Avww.cms.gov/newsroom/press-releases/cms-outlines-strategy-advance-health-equity-challenges-
industry-leaders-address-systemic-inequities#:?:text=In effort to address systemic,outcomes experienced by people who.

[FN25]
HRSA is the Health Resources and Services Administration.

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[FN26]

News Release, "HHS Announces $90 Million to Support New Data-Driven Approaches for Health Centers to Identify and
Reduce Health Disparities," HHS, Apr. 21, 2022, available at: https:/Avww.hhs.gov/about/news/2022/04/21/hhs-announces-90-
million-support-new-data-driven-approaches-health-centers-identify-reduce-health-disparities.htmI?utm_source=news-releases-
email&utm_medium=email&utm_campaign=april-24-2022.

[FN27]

Youssra Marjoua and Kevin J. Bozic, "Brief History of Quality mMvement in US healthcare," National Library of Medicine, Sept. 9, 2012,
available at: https:/Awww.ncbi.nim.nih.gov/pme/articles/PMC3702754/#.

[FN28]

See, e.g., "Report to Congress: National Strategy for Quality Improvement in Health Care," CMS, Mar. 2011, available at: https://
www.cms.gov/CClIIO/Resources/Forms-Reports-and-Other-Resources/qualityO321201 1a.

[FN29]

Michelle Schreiber, et a/., "The CMS National Quality Strategy: A Person-Centered Approach to Improving Quality," CMS Blog, June 6,
2022, available at: https://content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/3 1afec9.

[FN30]

Michelle Schreiber, ef al., "The CMS National Quality Strategy: A Person-Centered Approach to Improving Quality," CMS Blog, June 6,
2022, available at: https://content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/3 1afec9.

[FN31]

Michelle Schreiber, et al., "The CMS National Quality Strategy: A Person-Centered Approach to Improving Quality," CMS Blog, June 6,
2022, available at: https://content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/3 1afec9.

[FN32]

MaryBeth Musumeci, "Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers,"
Kaiser Family Foundation, Sept. 20, 2018, available at: https:/Avww.kff.org/medicaid/issue-brief/section-1 115-medicaid-demonstration-
waivers-the-current-landscape-of-approved-and-pending-waivers/?utm_campaign =KFF-2018-The-Latest&utm_source=.

[FN33]

Press Release, "CMS Announces New Policy Guidance for States to Test Community Engagement for Able-Bodied Adults,"

CMS, Jan. 11, 2018, available at: https:/Awww.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/201 8-Press-releases-
items/2018-01-11.html; State Medicaid Director Letter, SMD #18-002, Jan. 11, 2018, available at: https:/Awww.medicaid.gov/federal-
policy-guidance/downloads/smd18002.pdf.

[FN34]

State Medicaid Director Letter, SMD #18-002, Jan. 11, 2018, available at: https:/Avww.medicaid.gov/federal-policy-guidance/
downloads/smd18002.pdf.

[FN35]

State Medicaid Director Letter, SMD #18-002, Jan. 11, 2018, available at: https:/Avww.medicaid.gov/federal-policy-guidance/
downloads/smd18002.pdf.

[FN36]

"Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State," Kaiser Family Foundation, updated Aug. 19, 2022,
available at: https:/Awww.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1 1 15-waivers-by-state/.

[FN37]

"Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State," Kaiser Family Foundation, updated Aug. 19, 2022,
available at: https:/Awww.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1 1 15-waivers-by-state/.

[FN38]

Letter from HHS to Texas Medicaid Director, Apr. 16, 2021, available at: https:/Awww.medicaid.gov/medicaid/section-1 115-
demonstrations/downloads/tx-healthcare-transformation-ca. pdf.

[FN39]

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Letter from HHS to Texas Medicaid Director, Apr. 16, 2021, available at: https:/Avww.medicaid.gov/medicaid/section-1 115-
demonstrations/downloads/tx-healthcare-transformation-ca.pdf.
[FN40]

Letter from HHS to Texas Medicaid Director, Apr. 16, 2021, available at: https:/Awww.medicaid.gov/medicaid/section-1 115-
demonstrations/downloads/tx-healthcare-transformation-ca. pdf.

[FN41]

Texas is one of just 12 states that have not adopted the Medicaid expansion. See "Status of State Action on the Medicaid Expansion
Decision," Kaiser Family Foundation, updated June 9, 2022, available at: https://www.kff.org/health-reform/state-indicator/state-activity-
around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=#c#olld:#L#ocation #s#ort:#asc'#.

[FN42]

Sources name Texas as the state with the highest, or one of the highest, uninsured rates in the country, at roughly 29%.
See, e.g., Ayla Ellison, "States Ranked by Uninsured Rates," Becker's Hospital Review, July 15, 2020, available at: https://
www.beckershospitalreview.com/rankings-and-ratings/states-ranked-by-uninsured-rates.html.

[FN43]

Jeremy Blackman, "Biden Administration Rescinds Billions in Medicaid Funding for Texas," Houston Chronicle, Apr. 16, 2021, available
at: https:/Awww.houstonchronicle.com/politics/texas/article/Biden-administration-rescinds-billions-in-16107275.php.

[FN44]

Jeremy Blackman, "Biden Administration Rescinds Billions in Medicaid Funding for Texas," Houston Chronicle, Apr. 16, 2021, available
at: https:/Avww.houstonchronicle.com/politics/texas/article/Biden-administration-rescinds-billions-in-16107275.php.

[FN45]

Jeremy Blackman, "Biden Administration Rescinds Billions in Medicaid Funding for Texas," Houston Chronicle, Apr. 16, 2021, available
at: https:/Awww.houstonchronicle.com/politics/texas/article/Biden-administration-rescinds-billions-in-16107275.php.

[FN46]

Morgan Haefner, "Revoked Texas Medicaid Waiver Credit Negative for Hospitals," Becker's Hospital Review, Apr. 27, 2021, available
at: https:/Awww.beckershospitalreview.com/finance/revoked-texas-medicaid-waiver-credit-negative-for-hospitals.html.

[FN47]

Fact Sheet, "Health Adult Opportunity Fact Sheet," CMS, Jan. 30, 2020, available at: https:/Avww.cms.gov/newsroom/fact-sheets/
healthy-adult-opportunity.

[FN48]

Fact Sheet, "Health Adult Opportunity Fact Sheet," CMS, Jan. 30, 2020, available at: https:/Avww.cms.gov/newsroom/fact-sheets/
healthy-adult-opportunity.

[FN49]

Fact Sheet, "Health Adult Opportunity Fact Sheet," CMS, Jan. 30, 2020, available at: https:/Avww.cms.gov/newsroom/fact-sheets/
healthy-adult-opportunity; State Medicaid Director Letter, Healthy Adult Opportunity, SMD #20-001, Jan. 30, 2020, available at: https://
www.medicaid.gov/sites/default/files/F ederal-Policy-Guidance/Downloads/smd20001.pdf.

[FN50]

Press Release, "Trump Administration Announces Transformative Medicaid Healthy Adult Opportunity," CMS, Jan. 30, 2020, available
at: https:/Avww.cms.gov/newsroom/press-releases/trum-administration-announces-transformative-medicaid-healthy-adult-opportunity.

[FN51]

Dan Diamond and Rachel Roubein, "Block Grants' No More: Trump's Medicaid Overhaul has New Name, Same Goals," Politico, Jan.
29, 2020, available at: https:/Avww. politico.com/news/2020/01/29/trump-medicaid-overhaul-block-grants-108882.

[FN52]

Dan Diamond and Rachel Roubein, "Block Grants' No More: Trump's Medicaid Overhaul has New Name, Same Goals," Politico, Jan.
29, 2020, available at: https:/Avww. politico.com/news/2020/0 1/29/trump-medicaid-overhaul-block-grants-108882.

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[FN53]

Robin Rudowitz, et al., "Implications of CMS's New "Healthy Adult Opportunity" Demonstrations for Medicaid," Kaiser Family
Foundation, Feb. 5, 2020, available at: https:/Avww.kff.org/medicaid/issue-brief/implications-of-cmss-new-healthy-adult-opportunity-
demonstrations-for-medicaid/.

[FN54]

Gregory Craig, "Medicaid Healthy Adult Opportunity ? or Block Grants by Another Name," American Nurse's Association's Capitol Beat,
Feb. 27, 2020, available at: https://anacapitolbeat.org/2020/02/27/medicaid-healthy-adult-opportunity-or-block-grants-by-another-name/.

[FN55]

Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated June 9, 2022, available at: https://
www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe
=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc#

[FN56]

Ross Margulies, "CMS Approves Tennessee "Block Grant" Waiver: A Summary and Analysis from your Editors," JDSupra, Jan. 11.
2021, available at: https:/Avww.jdsupra.com/legalnews/cms-approves-tennessee-block-grant-8012077/.

[FN57]

Vivian Jones, "Tennessee Democrats ask Biden Administration to Reverse Medicaid Block Grant Waiver," The Center Square, Jan. 25,
2021, available at: https:/Avww.thecentersquare.com/tennessee/tennessee-democrats-ask-biden-administration-to-reverse-medicaid-
block-grant-waiver/article_dc344406-5162-1 1eb-a41e-7b0e2ac974d2.html.

[FN58]

John Styf, "Tennessee's Medicaid Block Grant Waiver Challenged in Court," The Center Square, May 10, 2021, available at:
https:/Avww.thecentersquare.com/tennessee/tennessees-medicaid-block-grant-waiver-challenged-in-court/article_9b6f9b9e-
b1d5-11eb-9724-9f3426968b75.html.

[FN59]

CMS letter to TennCare Director, June 30, 2022, available at: https:/Awww.medicaid.gov/medicaid/section-1 1 15-demonstrations/
downloads/tn-tenncare-iii-cms-ltr-06302022. pdf.

[FN60]

CMS letter to TennCare Director, Sept. 22, 2022, available at: https:/Awww.tn.gov/content/dam/tn/tenncare/documents/
tenncarewaiver.pdf.

[FN61]

"Status of State Action on Medicaid Expansion Decision," Kaiser Family Foundation, updated July 9, 2021, available at: https://
www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe
=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN62]
FMAP is the Federal Medical Assistance Percentage, or the match rate.

[FN63]

Tara Straw, et al., "Health Provisions in American Rescue Plan Act Improve Access to Health Coverage During COVID Crisis," Center
on Budget and Policy Priorities, Mar. 11, 2021, available at: https:/Awww.cbpp.org/research/health/health-provisions-in-american-
rescue-plan-act-improve-access-to-health-coverage.

[FN64]

See, e.g., "What is CMMI?' and 11 other FAQs about the CMS Innovation Center, Kaiser Family Foundation, Feb. 27, 2018, available
at: https:/Avww.kff.org/medicare/fact-sheet/what-is-cmmi-and-1 1-other-faqs-about-the-cms-innovation-center/.

[FN65]
"Innovation Center Strategy Refresh," CMS, available at: https://innovation.cms.gov/strategic-direction-whitepaper.

[FN66"inno]

ation Center Strategy Refresh," CMS, available at: https://innovation.cms.gov/strategic-direction-whitepaper.

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[FN67]
"Innovation Center Strategy Refresh," CMS, available at: https://innovation.cms.gov/strategic-direction-whitepaper.

[FN68]

2020 Report to Congress, Center for Medicare and Medicaid Innovation, available at: https://innovation.cms.gov/data-and-reports/2021/
rtc-2020.

[FN69]

"CMS Community Health Access and Rural Transformation (CHART) Model," Medicaid.gov, available at: https://www.medicaid.gov/
about-us/messages/101126.

[FN70]

Press Release, "Trump Administration Announces Initiative to Transform Rural Health," CMS, Aug. 11, 2020, available at: https://
www.cms.gov/newsroom/press-releases/trump-administration-announces-initiative-transform-rural-health.

[FN71]

"CMS Rural Health Strategy," available at: https:/Avww.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Rural-
Strategy-2018.pdf.

[FN72]

Press Release, "Trump Administration Announces Initiative to Transform Rural Health," CMS, Aug. 11, 2020, available at: https://
www.cms.gov/newsroom/press-releases/trump-administration-announces-initiative-transform-rural-health.

[FN73]
CHART Model, Center for Medicare and Medicaid Innovations, available at: https://innovation.cms.gov/innovation-models/chart-model.

[FN74]
CHART Model, Center for Medicare and Medicaid Innovations, available at: https://innovation.cms.gov/innovation-models/chart-model.

[FN75]
CHART Model, Center for Medicare and Medicaid Innovations, available at: https://innovation.cms.gov/innovation-models/chart-model.

[FN76]
CHART Model, Center for Medicare and Medicaid Innovations, available at: https://innovation.cms.gov/innovation-models/chart-model.

[FN77]
"Cancer Moonshot," The White House, available at: https:/Avww.whitehouse.gov/cancermoonshot/.

[FN78]

Press Release, "Biden Administration Announces New Model to Improve Cancer Care for Medicare Patients," CMS, June 27, 2022,
available at: https:/Awww.cms.gov/newsroom/press-releases/biden-administration-announces-new-model-improve-cancer-care-
medicare-patients.

[FN79]

Press Release, "Biden Administration Announces New Model to Improve Cancer Care for Medicare Patients," CMS, June 27, 2022,
available at: https:/Awww.cms.gov/newsroom/press-releases/biden-administration-announces-new-model-improve-cancer-care-
medicare-patients.

[FN80]

Press Release, "Biden Administration Announces New Model to Improve Cancer Care for Medicare Patients," CMS, June 27, 2022,
available at: https:/Awww.cms.gov/newsroom/press-releases/biden-administration-announces-new-model-improve-cancer-care-
medicare-patients.

[FN81]
MIPS is the Merit-based Incentive Payment System.

[FN82]

Fact Sheet, "Enhancing Oncology Model," CMS, available at: https:/Awww.cms.gov/newsroom/fact-sheets/enhancing-oncology-model.

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[FN83]
Fact Sheet, "Enhancing Oncology Model," CMS, available at: https://www.cms.gov/newsroom/fact-sheets/enhancing-oncology-model.

[FN84]

See, Brian Castrucci and John Auerbach, "Meeting Individual Social Needs Falls Short of Addressing Social Determinants of Health,"
the Health Affairs blog, January 16, 2019, available at: https:/Avww.healthaffairs.org/do/10.1377/hblog201901 15.234942/full/; "Study
Calls for Clarity on SDOH, Related Terminology," American Academy of Family Physicians," June 10, 2019, available at: https://
www.aafp.org/news/practice-professional-issues/20190610sdohterms.html.

[FN85]

Brian Castrucci and John Auerbach, "Meeting Individual Social Needs Falls Short of Addressing Social Determinants of Health," the
Health Affairs blog, January 16, 2019, available at: https:/Avww.healthaffairs.org/do/10.1377/hblog20190115.234942/full/

[FN86]

Samantha Artiga and Elizabeth Hinton, "Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity,"
Kaiser Family Foundation, May 10, 2018, available at: https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-
social-determinants-in-promoting-health-and-health-equity/.

[FN87]

News Release, "HHS Approves Groundbreaking Medicaid Initiatives in Massachusetts and Oregon," HHS, Sept. 28, 2022, available at:
https:/Avww.hhs.gov/about/news/2022/09/28/hhs-approves-groundbreaking-medicaid-initiatives-in-massachusetts-and-oregon.html.

[FN88]

News Release, "HHS Approves Groundbreaking Medicaid Initiatives in Massachusetts and Oregon," HHS, Sept. 28, 2022, available at:
https:/Avww.hhs.gov/about/news/2022/09/28/hhs-approves-groundbreaking-medicaid-initiatives-in-massachusetts-and-oregon.html.

[FN89]

News Release, "HHS Approves Arizona's Medicaid Interventions to Target Health-Related Social Needs," HHS, Oct. 14, 2022,
available at: https:/Awww.hhs.gov/about/news/2022/10/14/hhs-approves-arizonas-medicaid-interventions-target-health-related-social-
needs.html.

[FN90]

News Release, "HHS Approves Arizona's Medicaid Interventions to Target Health-Related Social Needs," HHS, Oct. 14, 2022,
available at: https:/Awww.hhs.gov/about/news/2022/10/14/hhs-approves-arizonas-medicaid-interventions-target-health-related-social-
needs.html.

[FN91]

"HHS Approves Arkansas' Medicaid Waiver to Provide Medically Necessary Housing and Nutrition Support Services," Medicaid.gov,
Nov. 1, 2022, available at: https://content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/33582a5.

[FN92]

"HHS Approves Arkansas' Medicaid Waiver to Provide Medically Necessary Housing and Nutrition Support Services," Medicaid.gov,
Nov. 1, 2022, available at: https://content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/33582a5.

[FN93]

"HHS Approves Arkansas' Medicaid Waiver to Provide Medically Necessary Housing and Nutrition Support Services," Medicaid.gov,
Nov. 1, 2022, available at: https://content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/33582a5.

[FN94]

State Medicaid Director Letter, #22-004, "Health Homes for Children with Medically Complex Conditions," CMS, Aug. 1, 2022, available
at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/smd22004. pdf.

[FN95]

State Medicaid Director Letter, #22-004, "Health Homes for Children with Medically Complex Conditions," CMS, Aug. 1, 2022, available
at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/smd22004. pdf.

[FN96]

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Press Release, "CMS Offers Roadmap for States to Help Connect Children with Complex Medical Conditions to Critical Medicaid
Services," CMS, Aug. 1, 2022, available at: https:/Avww.cms.gov/newsroom/press-releases/cms-offers-roadmap-states-help-connect-
children-complex-medical-conditions-critical-medicaid.

[FN97]

"Health Home for Children with Medically Complex Conditions Notice of Funding Opportunity," CMS, Sept. 30, 2022, available at:
https://content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/32fd9e0. The funding opportunity notice is available at: https://
www.grants.gov/web/grants/view-opportunity.html?oppld=343826.

[FN98]

"CMS Releases Medicaid Health Home State Plan Option State Plan Amendment Template and Implementation Guide," CMS, Sept.
26, 2022, available at: https://content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/32efd07.

[FN99]

LTSS Models, CMS, available at: https:/Avww.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/LTSS-TA-Center/
info/hebs.

[FN100]

"Home- and Community-Based Services," MACPAC, available at: https:/Avww.macpac.gov/subtopic/home-and-community-based-
services/.

[FN101]

"Mandatory and Optional Benefits," Medicaid.gov, available at: https:/Awww.medicaid.gov/medicaid/benefits/mandatory-optional-
medicaid-benefits/index.html.

[FN102]
See, e.g., "Waivers," MACPAC, available at: https:/Awww.macpac.gov/medicaid-101 /waivers/.

[FN103]

Molly O'Malley Watts, ef a/., "Medicaid Home and Community-Based Services Enrollment and Spending," Kaiser Family Foundation,
Feb. 4, 2020, available at: hitps:/Avww.kff.org/medicaid/issue-brief/medicaid-home-and-community-based-services-enrollment-and-
spending/.

[FN104]

State Medicaid Director Letter, 'Community First Choice State Plan Option,' SMD #16-011, Dec. 30, 2016, available at: https://
www.medicaid.gov/federal-policy-guidance/downloads/smd1601 1.pdf.

[FN105]

Kathleen Gifford, et al., "A View from the States: Key Medicaid Policy Changes: Results from a 50-State Medicaid Budget Survey for
State Fiscal Years 2019 and 2020," Kaiser Family Foundation, Oct. 2019, available at: https://www.kff.org/medicaid/report/a-view-from-
the-states-key-medicaid-policy-changes-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-201 9-and-2020/.

[FN106]

State Medicaid Director Letter #22-003, "Home and Community-Based Services Quality Measure Set," CMS, July 21, 2022, available
at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/smd22003.pdf.

[FN107]

See, e.g. "Executive Order on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government,"
The White House, Jan. 20, 2021, available at: https:/Avww.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-
order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/.

[FN108]

State Medicaid Director Letter #22-003, "Home and Community-Based Services Quality Measure Set," CMS, July 21, 2022, available
at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/smd22003.pdf.

[FN109]

"Home- and Community-Based Services 1915(c)," Medicaid.gov, available at: https:/Avww.medicaid.gov/medicaid/home-community-
based-services/home-community-based-services-authorities/home-community-based-services-1915c/index.html.

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[FN110]

MaryBeth Musumeci, et a/., "Key State Policy Choices about Medicaid Home and Community-Based Services," Kaiser Family
Foundation, Feb. 4, 2021, available at: https:/Avww.kff.org/medicaid/issue-brief/key-state-policy-choices-about-medicaid-home-and-
community-based-services/.

[FN111]

"Bill to Expand Medicaid Home and Community Based Services Introduced in Congress," National Health Law Program, Mar. 16, 2021,
available at: https://healthlaw.org/news/bill-to-expand-medicaid-home-and-community-based-services-introduced-in-congress/.

[FN112]

Press Release, "Dingell, Hassan, Casey, Brown Release Draft Proposal for HCBS Access Act," Rep. Dingell's web site, Mar. 16, 2021,
available at: https://debbiedingell.house.gov/news/documentsingle.aspx? DocumentID=2932.

[FN113]

"Fact Sheet: Summary of Key Provisions of the Home and Community-Based Services (HCBS) Settings Final Rule (CMS 2249-F/2296-
F)," CMS, Jan. 10, 2014, available at: https://www.medicaid.gov/sites/default/files/201 9-12/hcbs-setting-fact-sheet. pdf.

[FN114]
79 F.R. 2948-01 (Jan. 16, 2014).

[FN115]

CMCS Informational Bulletin, 'Extension of Transition Period for Compliance with Home and Community-Based Settings Criteria,' May
9, 2017, available at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/cib050917.pdf.

[FN116]

State Medicaid Director Letter #20-003, "Home and Community-Based Settings Regulation ? Implementation Timeline Extension
and Revised Frequently Asked Questions," CMS, July 14, 2020, available at: https:/Avwww.medicaid.gov/Federal-Policy-Guidance/
Downloads/smd20003.pdf.

[FN117]

"Home and Community-Based Services Final Rule Update: Final Statewide Transition Plan Submissions, Settings Criteria Not
Impacted by the COVID-19 PHE, and Requests from States for Corrective Action Plans," Medicaid.gov, May 24, 2022, available at:
https://content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/3193d28.

[FN118]

"Home and Community-Based Services Final Rule Update: Final Statewide Transition Plan Submissions, Settings Criteria Not
Impacted by the COVID-19 PHE, and Requests from States for Corrective Action Plans," Medicaid.gov, May 24, 2022, available at:
https://content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/3193d28.

[FN119]
Dear Medicaid Director Letter, "Implementation of American Rescue Plan Act of 2021 Section 9817: Additional

Support for Medicaid Home and Community-Based Services during the COVID-19 Emergency," #21-003, May 13, 2021, available at:
https:/Avww.medicaid.gov/federal-policy-guidance/downloads/smd21003.pdf.

[FN120]

Press Release, "HHS Extends American Rescue Plan Spending Deadline for States to Expand and Enhance Home- and Community-
Based Services for People with Medicaid," CMS, June 3, 2022, available at: https:/Avww.cms.gov/newsroom/press-releases/hhs-
extends-american-rescue-plan-spending-deadline-states-expand-and-enhance-home-and-community.

[FN121]

Elizabeth Williams and MaryBeth Musumeci, "Children with Special Health Care Needs: Coverage, Affordability, and HCBS Access,"
Kaiser Family Foundation, Oct. 4, 2021, available at: https:/Awww.kff.org/medicaid/issue-brief/children-with-special-health-care-needs-
coverage-affordability-and-hcbs-access/?utm_.

[FN122]

MaryBeth Musumeci, et a/., "State Actions to Sustain Medicaid Long-Term Services and Supports During COVID-19," Aug. 26, 2020,
available at: https:/Awww.kff.org/medicaid/issue-brief/state-actions-to-sustain-medicaid-long-term-services-and-supports-during-
covid-19/.

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[FN123]

Elizabeth Williams and MaryBeth Musumeci, "Children with Special Health Care Needs: Coverage, Affordability, and HCBS Access,"
Kaiser Family Foundation, Oct. 4, 2021, available at: https:/Awww.kff.org/medicaid/issue-brief/children-with-special-health-care-needs-
coverage-affordability-and-hcbs-access/?utm_.

[FN124]

Elizabeth Williams and MaryBeth Musumeci, "Children with Special Health Care Needs: Coverage, Affordability, and HCBS Access,"
Kaiser Family Foundation, Oct. 4, 2021, available at: https:/Avww.kff.org/medicaid/issue-brief/children-with-special-health-care-needs-
coverage-affordability-and-hcbs-access/?utm_.

[FN125]

News Release, 'HHS Announces new Affordable Care Act Options for Community-Based Care,' Apr. 26, 2012, available at: http://
www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2012-Press-Releases-ltems/2012-04-26.html.

[FN126]

Report to Congress, Community First Choice: Interim Report to Congress by HHS Secretary Kathleen Sebelius, 2014, available at:
http://www. medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Home-and-Community-
Based-Services/Downloads/Community-First-Choice-Interim-Report-to-Congress. pdf.

[FN127]

'Community First Choice (CFC) 1915(k)," Medicaid.gov, available at: https:/Avww.medicaid.gov/medicaid/hcbs/downloads/community-
first-choice-interim-report-to-congress. pdf.

[FN128]

Program of All-Inclusive Care for the Elderly, CMS, available at: https:/Awww.medicaid.gov/medicaid/ltss/pace/index.html.

[FN129]
Program of All-Inclusive Care for the Elderly, CMS, available at: https:/Awww.medicaid.gov/medicaid/Itss/pace/index.html.

[FN130]

Press Release, "HHS to Provide $110 Million to Strengthen Safety Net for Seniors and People with Disabilities," CMS, Mar. 31, 2022,
available at: https:/Awww.cms.gov/newsroom/press-releases/hhs-provide-1 10-million-strengthen-safety-net-seniors-and-people-
disabilities.

[FN131]

Press Release, "HHS to Provide $110 Million to Strengthen Safety Net for Seniors and People with Disabilities," CMS, Mar. 31, 2022,
available at: https:/Awww.cms.gov/newsroom/press-releases/hhs-provide-1 10-million-strengthen-safety-net-seniors-and-people-
disabilities.

[FN132]

"Behavioral Health Integration," SAMHSA, available at: https:/Avww.samhsa.gov/sites/default/files/samhsa-behavioral-health-
integration.pdf.

[FN133]
'Behavioral Health Services,' Medicaid.gov, available at: https:/Awww.medicaid.gov/medicaid/benefits/bhs/index.html.

[FN134]

Julia Zur, et al., "Medicaid's Role in Financing Behavioral Health Services for Low-Income Individuals," Kaiser Family Foundation, June
29, 2017, available at: https:/Avww.kff.org/medicaid/issue-brief/medicaids-role-in-financing-behavioral-health-services-for-low-income-
individuals/.

[FN135]

"Status of State Medicaid Expansion Decisions: Interactive Map," Kaiser Family Foundation, updated June 9, 2022, available at: https://
www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/.

[FN136]

"CMS Outlines Strategy to Strengthen Behavioral Health Care," Medicaid.gov, June 1, 2022, available at: https://
content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/31a5df1.

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[FN137]
"CMS Behavioral Health Strategy," CMS, available at: https:/Awww.cms.gov/cms-behavioral-health-strategy.

[FN138]

Press Release, "Biden-Harris Administration Awards $15 Million to 20 States for Mobile Crisis Intervention," CMS, Sept. 7, 2021,
available at: https:/Awww.cms.gov/newsroom/press-releases/biden-harris-administration-awards-15-million-20-states-mobile-crisis-
intervention.

[FN139]

Press Release, "Biden-Harris Administration Awards $15 Million to 20 States for Mobile Crisis Intervention," CMS, Sept. 7, 2021,
available at: https:/Awww.cms.gov/newsroom/press-releases/biden-harris-administration-awards-15-million-20-states-mobile-crisis-
intervention.

[FN140]

Press Release, "Biden-Harris Administration Awards $15 Million to 20 States for Mobile Crisis Intervention," CMS, Sept. 7, 2021,
available at: https:/Awww.cms.gov/newsroom/press-releases/biden-harris-administration-awards-15-million-20-states-mobile-crisis-
intervention.

[FN141]

State Health Official Letter, #21-008, "Medicaid Guidance on the Scope of and Payments for Qualifying Community-Based Mobile Crisis
Intervention Services," CMS, Dec. 28, 2021, available at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/sho21 008. pdf.

[FN142]

State Health Official Letter, #21-008, "Medicaid Guidance on the Scope of and Payments for Qualifying Community-Based Mobile Crisis
Intervention Services," CMS, Dec. 28, 2021, available at: https://www.medicaid.gov/federal-policy-guidance/downloads/sho21 008. pdf.

[FN143]

Press Release, "HHS Approves Nation's First Medicaid Mobile Crisis Intervention Services Program, To Be Launched in Oregon,"
CMS, Sept. 12, 2022, available at: https:/Avww.cms.gov/newsroom/press-releases/hhs-approves-nations-first-medicaid-mobile-crisis-
intervention-services-program-be-launched-oregon.

[FN144]

'Medicaid's Role in Addressing the Opioid Epidemic,' Kaiser Family Foundation, updated June 3, 2019, available at: http:/Avww.kff.org/
infographic/medicaids-role-in-addressing-opioid-epidemic/.

[FN145]

"Drug Overdose Deaths in the U.S. Top 100,000 Annually," CDC, Nov. 17, 2021, available at: https:/Avww.cdc.gov/nchs/pressroom/
nchs_press_releases/2021/20211117.htm.

[FN146]

'Medicaid's Role in Addressing the Opioid Epidemic,' Kaiser Family Foundation, updated June 3, 2019, available at: http:/Avww.kff.org/
infographic/medicaids-role-in-addressing-opioid-epidemic/.

[FN147]

CMS Opioid Misuse Strategy 2016, CMS, Jan. 5, 2017, available at: https:/Avww.cms.gov/Outreach-and-Education/Outreach/
Partnerships/Downloads/CMS-Opioid-Misuse-Strategy-2016.pdf.

[FN148]

Press Release, "President Biden Releases National Drug Control Strategy to Save Lives, Expand Treatment, and Disrupt Trafficking,"

The White House, Apr. 21, 2022, available at: https:/Avww.whitehouse.gov/ondep/briefing-room/2022/04/2 1/president-biden-releases-

national-drug-control-strategy-to-save-lives-expand-treatment-and-disrupt-trafficking/. The strategy is "National Drug Control Strategy,"
The White House, available at: https:/Avww.whitehouse.gov/wp-content/uploads/2022/04/National-Drug-Control-2022Strategy.pdf.

[FN149]

"FACT SHEET: White House Releases 2022 National Drug Control Strategy that Outlines Comprehensive Path Forward to Address
Addiction and the Overdose Epidemic," The White House, Apr. 21, 2022, available at: https:/Awww.whitehouse.gov/briefing-room/
statements-releases/2022/04/21/fact-sheet-white-house-releases-2022-national-drug-control-strategy-that-outlines-comprehensive-
path-forward-to-address-addiction-and-the-overdose-epidemic/.

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[FN150}

Christine Vestal, 'This Obscure Medicaid Waiver Opens up More Beds for Opioid Treatment,' PBS, Stateline, Apr. 5, 2017, available at:
http://www.pbs.org/newshour/rundown/obscure-medicaid-waiver-opens-beds-opioid-treatment/.

[FN151]

According to the Kaiser Family Foundation, 33 states currently have such waivers and three states (Arizona, Massachusetts, and
Tennessee) have such a waiver pending. Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State, Kaiser
Family Foundation, updated June 9, 2021, available at: https://Awww.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-
pending-section-1115-waivers-by-state/.

[FN152]

State Medicaid Director Letter, "Implementation of Section 5052 of the SUPPORT for Patients and Communities Act ? State Plan
Option under Section 1915(l) of the Social Security Act," SMD #19-003, Nov. 6, 2019, available at: https:/Awww.medicaid.gov/federal-
policy-guidance/downloads/smd19003.pdf.

[FN153]

Press Release, "Grassley Joins Bipartisan Push to Ensure Federal Medicaid Funds Can Be Used in Mental Health Crisis Stabilization
Centers," web site of Sen. Grassley, Oct. 3, 2022, available at: https://(www.grassley.senate.gov/news/news-releases/grassley-joins-
bipartisan-push-to-ensure-federal-medicaid-funds-can-be-used-in-mental-health-crisis-stabilization-centers; the Sept. 30 letter is found
at: https:/Avww.grassley.senate.gov/imo/media/doc/grassley_et_altocmscrisisstabilizationcenters. pdf.

[FN154]

Letter to Administrator Brooks-LaSure, Sept. 30, 2022, available at: https:/Awww.grassley.senate.gov/imo/media/doc/
grassley_et_altocmscrisisstabilizationcenters.pdf.

[FN155]

State Medicaid Director Letter, "Opportunities to Design Innovative Service Delivery Systems for Adults with a Serious Mental Illness or
Children with a Serious Emotional Disturbance," SMD #18-011, Nov. 13, 2018, available at: https:/Awww.medicaid.gov/federal-policy-
guidance/downloads/smd 1801 1.pdf.

[FN156]

Press Release, "CMS Announces Approval of Groundbreaking Demonstration to Expand Access to Behavioral Health Treatment,"
CMS, Nov. 6, 2019, available at: https:/Avww.cms.gov/newsroom/press-releases/cms-announces-approval-groundbreaking-
demonstration-expand-access-behavioral-health-treatment.

[FN157]

"Section 1115 Demonstrations: Substance Use Disorders, Serious Mental Illness, and Serious Emotional Disturbance," Medicaid.gov,
available at: https:/Awww.medicaid.gov/medicaid/section-1 115-demonstrations/1 115-substance-use-disorder-demonstrations/
section-1115-demonstrations-substance-use-disorders-serious-mental-illness-and-serious-emotional-disturbance/index.html.

[FN158]

Fact Sheet, "President Biden's Maternal Health Blueprint Delivers for Women, Mothers, and Families," The White House, June 24,
2022, available at: https:/Avww.whitehouse.gov/briefing-room/statements-releases/2022/06/24/fact-sheet-president-bidens-maternal-
health-blueprint-delivers-for-women-mothers-and-families/.

[FN159]

Usah Ranji, ef a/., "Postpartum Coverage Extension in the American Rescue Plan Act of 2021," Kaiser Family Foundation, Mar. 18,
2021, available at: https:/Awww.kff.org/policy-watch/postpartum-coverage-extension-in-the-american-rescue-plan-act-of-2021/.

[FN160]

Fact Sheet, "President Biden's Maternal Health Blueprint Delivers for Women, Mothers, and Families," The White House, June 24,
2022, available at: https:/Avww.whitehouse.gov/briefing-room/statements-releases/2022/06/24/fact-sheet-president-bidens-maternal-
health-blueprint-delivers-for-women-mothers-and-families/.

[FN161]

Fact Sheet, "President Biden's Maternal Health Blueprint Delivers for Women, Mothers, and Families," The White House, June 24,
2022, available at: https:/Avww.whitehouse.gov/briefing-room/statements-releases/2022/06/24/fact-sheet-president-bidens-maternal-
health-blueprint-delivers-for-women-mothers-and-families/.

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[FN162]

Fact Sheet, "President Biden's Maternal Health Blueprint Delivers for Women, Mothers, and Families," The White House, June 24,
2022, available at: https:/Avww.whitehouse.gov/briefing-room/statements-releases/2022/06/24/fact-sheet-president-bidens-maternal-
health-blueprint-delivers-for-women-mothers-and-families/.

[FN163]

"White House Blueprint for Addressing the Maternal Health Crisis," The White House, June 2022, available at: https://
www.whitehouse.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint. pdf.

[FN164]

"Maternal & Infant Health Care Quality," Medicaid.gov, available at: https:/Awww.medicaid.gov/medicaid/quality-of-care/improvement-
initiatives/maternal-infant-health-care-quality/index.html.

[FN165]

Maternal & Infant Health Care Quality," Medicaid.gov, available at: https:/Awww.medicaid.gov/medicaid/quality-of-care/improvement-
initiatives/maternal-infant-health-care-quality/index.html.

[FN166]

"Low Risk Cesarean Delivery," Medicaid.gov, available at: https:/Awww.medicaid.gov/medicaid/quality-of-care/improvement-initiatives/
maternal-infant-health/quality-improvement/Low-Risk-Cesarean-Delivery/index.html.

[FN167]

"Maternal Opioid Misuse (MOM) Model," CMS, available at: https://innovation.cms.gov/innovation-models/maternal-opioid-misuse-
model#:?:text=The model addresses fragmentation in,system surrounding this vulnerable population (emphasis in original).

[FN168]

"Maternal Opioid Misuse (MOM) Model Evaluation of Pre-implementation Period (January 2020?July 2021)," CMS, available at: https://
innovation.cms.gov/data-and-reports/2022/mom-preimp-report-aag.

[FN169]

"Maternal Opioid Misuse (MOM) Model," CMS, available at: hitps://innovation.cms.gov/innovation-models/maternal-opioid-misuse-
model#:?:text=The model addresses fragmentation in,system surrounding this vulnerable population.

[FN170]

"Maternal Opioid Misuse (MOM) Model Evaluation of Pre-implementation Period (January 2020?July 2021)," CMS, available at: https://
innovation.cms.gov/data-and-reports/2022/mom-preimp-report-aag.

[FN171]

State Health Official Letter, #21-007, "Improving Maternal Health and Extending Postpartum Coverage in Medicaid and the Children's
Health Insurance Program (CHIP)," Dec. 7, 2021, available at: https:/Avww.medicaid.gov/federal-policy-guidance/downloads/
sho21007.pdf.

[FN172]

See, e.g., "Medicaid Postpartum Coverage Extension Tracker," Kaiser Family Foundation, Dec. 16, 2021, available at: https://
www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/.

[FN173]

"Prenatal and Postpartum Care: Postpartum Care," Medicaid.gov, available at: https:/Awww.medicaid.gov/state-overviews/scorecard/
postpartum-care/index.html.

[FN174]

Sarah Gordon, et al., "Medicaid after Pregnancy: State-Level Implications of Extending Postpartum Coverage," ASPE, Dec. 7, 2021,
available at: https://aspe.hhs.gov/sites/default/files/documents/cf9a7 15be16234b80054f14e9c9c0d 13/medicaid-postpartum-coverage-
ib .pdf.

[FN175]

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See, e.g., Edwin Park, "House-Passed American Rescue Plan Act Would Spur Medicaid Expansion and Promote Maternal Health,"
Say Ahhh Blog, Georgetown University Health Policy Institute, Mar. 1, 2021, available at: https://ccf.georgetown.edu/2021/03/01/house-
passed-american-rescue-plan-act-would-spur-medicaid-expansion-and-promote-maternal-health/.

[FN176]

Press Release, "Thousands More People with Medicaid and CHIP Coverage Now Eligible to Access Critical Postpartum Coverage
Thanks to the American Rescue Plan," HHS, Apr. 1, 2022, available at: https:/Awww.hhs.gov/about/news/2022/04/01/thousands-
more-people-with-medicaid-and-chip-coverage-now-eligible-to-access-critical-postpartum-coverage-thanks-to-the-american-rescue-
plan.html#:?:text=The Biden#Harris Administration is,American Rescue Plan (ARP).

[FN177]

News Release, "HHS Announces Efforts to Help Expand Nationwide Access and Coverage for High-quality Maternal Health Services,"
HHS, Dec. 7, 2021, available at: https:/Avww.hhs.gov/about/news/2021/12/07/hhs-announces-efforts-help-expand-nationwide-access-
coverage-high-quality-maternal-health-services.html.

[FN178]

News Release, "HHS Approves 12-month Extension of Postpartum Medicaid and CHIP Coverage in Hawaii, Maryland, and Ohio,"
HHS, Aug. 16, 2022, available at: https:/Avwww.hhs.gov/about/news/2022/08/1 6/hhs-approves-12-month-extension-of-postpartum-
medicaid-and-chip-coverage-in-hawaii-maryland-and-ohio.html#:? :text=Hawaii# Maryland# and Ohio are,X" IllinoisX" KansasX"
KentuckyX" .

[FN179]

Press Release, "During the Biden-Harris Administration, Nearly 253,000 Americans in 14 States and D.C. Have Gained Access
to 12 Months of Postpartum Coverage Through Medicaid and CHIP Extensions," CMS, Medicaid.gov, available at: https://
content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/31¢c74c0.

[FN180]

Press Release, "HHS Approves 12-Month Extension of Postpartum Medicaid and CHIP Coverage in Indiana and West Virginia," CMS,
Sept. 8, 2022, available at: https:/Avww.cms.gov/newsroom/press-releases/hhs-approves-12-month-extension-postpartum-medicaid-
and-chip-coverage-indiana-and-west-virginia.

[FN181]

News Release, "HHS Announces Efforts to Help Expand Nationwide Access and Coverage for High-quality Maternal Health Services,"
HHS, Dec. 7, 2021, available at: https:/Avww.hhs.gov/about/news/2021/12/07/hhs-announces-efforts-help-expand-nationwide-access-
coverage-high-quality-maternal-health-services.html.

[FN182]

State Health Official Letter, #21-007, "Improving Maternal Health and Extending Postpartum Coverage in Medicaid and the Children's
Health Insurance Program (CHIP)," Dec. 7, 2021, available at: https:/Avww.medicaid.gov/federal-policy-guidance/downloads/
sho21007.pdf.

[FN183]

Sarah Gordon, et al., "Medicaid after Pregnancy: State-Level Implications of Extending Postpartum Coverage," ASPE, Dec. 7, 2021,
available at: https://aspe.hhs.gov/sites/default/files/documents/cf98a7 15be16234b80054f14e9c9c0d 13/medicaid-postpartum-coverage-
ib .pdf.

[FN184]

State Health Official Letter, #21-007, "Improving Maternal Health and Extending Postpartum Coverage in Medicaid and the Children's
Health Insurance Program (CHIP)," Dec. 7, 2021, available at: https:/Avww.medicaid.gov/federal-policy-guidance/downloads/
sho21007.pdf.

[FN185]
"Medicaid Postpartum Coverage Extension Tracker," Kaiser Family Foundation, updated Nov. 17, 2022, available at: https://
www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/.

[FN186]

See, e.g., Rachel Dolan, et a/., "Medicaid Maintenance of Eligibility (MOE) Requirements: Issues to Watch," Kaiser Family Foundation,
Dec. 17, 2020, available at: https:/Avww.kff.org/medicaid/issue-brief/medicaid-maintenance-of-eligibility-moe-requirements-issues-to-
watch/.

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[FN187]

"July 2021 Medicaid & CHIP Enrollment Data Highlights," CMS, July 2021, available at: https:/Awww.medicaid.gov/medicaid/program-
information/medicaid-and-chip-enrollment-data/report-highlights/index.html.

[FN188]

Rachana Pradhan, "Why Millions on Medicaid Are at Risk of Losing Coverage in the Months Ahead," Kaiser Health News, Feb.
14, 2022, available at: https://khn.org/news/article/why-millions-on-medicaid-are-at-risk-of-losing-coverage-in-the-months-ahead/?
utm_campaign=KFF-2022-The-Latest&utm.

[FN189]

Rachana Pradhan, "Why Millions on Medicaid Are at Risk of Losing Coverage in the Months Ahead," Kaiser Health News, Feb.
14, 2022, available at: https://khn.org/news/article/why-millions-on-medicaid-are-at-risk-of-losing-coverage-in-the-months-ahead/?
utm_campaign=KFF-2022-The-Latest&utm.

[FN190]

Rachana Pradhan, "Why Millions on Medicaid Are at Risk of Losing Coverage in the Months Ahead," Kaiser Health News, Feb.
14, 2022, available at: https://khn.org/news/article/why-millions-on-medicaid-are-at-risk-of-losing-coverage-in-the-months-ahead/?
utm_campaign=KFF-2022-The-Latest&utm.

[FN191]

Rachana Pradhan, "Why Millions on Medicaid Are at Risk of Losing Coverage in the Months Ahead," Kaiser Health News, Feb.
14, 2022, available at: https://khn.org/news/article/why-millions-on-medicaid-are-at-risk-of-losing-coverage-in-the-months-ahead/?
utm_campaign=KFF-2022-The-Latest&utm.

[FN192]

"HHS and CMS requests FCC Opinion on the Telephone Consumer Protection Act to Assist States with the Eventual Return to
Normal Eligibility Determination Operations," Medicaid.gov, May 6, 2022, available at: https://content.govdelivery.com/accounts/
USCMSMEDICAID/bulletins/316609a.

[FN193]

The tool is, "Strategic Approaches to Support State Fair Hearings as States Resume Normal Eligibility and Enrollment Operations
After the COVID-19 PHE," Apr. 2022, available at: https:/Awww.medicaid.gov/resources-for-states/downloads/strat-apps-state-fair-
hearings.pdf.

[FN194]

The tool is, "Medicaid and CHIP Unwinding Planning Efforts Summary of Best & Promising State Practices from CMS/State
Discussions," CMS, Apr. 2022, available at: https://Awww.medicaid.gov/resources-for-states/downloads/state-unwinding-best-
practices.pdf.

[FN195]

"Eligibility & Enrollment Processing for Medicaid, CHIP, and BHP During COVID-19 Public Health Emergency Unwinding Key
Requirements for Compliance," CMS, May 17, 2022, available at: https:/Awww.medicaid.gov/resources-for-states/downloads/eligibility-
enrollment-rules.pdf.

[FN196]

"Top 10 Fundamental Actions to Prepare for Unwinding and Resources to Support State Efforts," available at: https://
www.medicaid.gov/resources-for-states/downloads/top- 1 0-fundamental-actions-to-prepare-for-unwinding-and-resources-to-support-
state-efforts.pdf.

[FN197]
www.Medicaid.gov/unwinding.

[FN198]

State Health Official Letter, "Promoting Continuity of Coverage and Distributing Eligibility and Enrollment Workload in Medicaid, the
Children's Health Insurance Program (CHIP), and Basic Health Program (BHP) Upon

Conclusion of the COVID-19 Public Health Emergency," CMS, Mar. 3, 2022, available at: https:/Awww.medicaid.gov/federal-policy-
guidance/downloads/sho22001 .pdf.

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[FN199]

State Health Official Letter, "Promoting Continuity of Coverage and Distributing Eligibility and Enrollment Workload in Medicaid, the
Children's Health Insurance Program (CHIP), and Basic Health Program (BHP) Upon

Conclusion of the COVID-19 Public Health Emergency," CMS, Mar. 3, 2022, available at: https:/Avww.medicaid.gov/federal-policy-
guidance/downloads/sho22001 .pdf.

[FN200]

"COVID-19 PHE Unwinding Section 1902(e)(14)(A) Waiver Approvals," CMS, Medicaid.gov, available at: https:/Awww.medicaid.gov/
covid-19-phe-unwinding-section-1902e14a-waiver-approvals/index.html.

[FN201]

"New Enhancement to Medicaid.gov to Assist Beneficiaries Preparing for Medicaid & CHIP Eligibility Renewals," Medicaid.gov, May 24,
2022, available at: https://content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/3192c59.

[FN202]

"Ending Coverage in the Optional COVID-19 Group: Preparing States for the End of the Public Health Emergency," CMS, Oct. 2022,
available at: https://(www.medicaid.gov/resources-for-states/downloads/ending-covrg-optnl-covid-grp-guidance.pdf.

[FN203]

"COVID-19 Public Health Emergency Unwinding Frequently Asked Questions for State Medicaid and CHIP Agencies," CMS, Oct. 17,
2022, available at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/covid-19-unwinding-faqs-oct-2022. pdf.

[FN204]

"Ex Parte Renewal: Strategies to Maximize Automation, Increase Renewal Rates, and Support Unwinding Efforts," CMS, Oct. 20, 2022,
available at: https:/Awww.medicaid.gov/resources-for-states/downloads/ex-parte-renewal-102022. pdf.

[FN205]

Press Release, "Casey, Booker and Colleagues Urge Administration to Push Forward with Investments in Home and Community-
Based Services," Senate Committee on Aging, Feb. 5, 2021, available at: https:/Avww.aging.senate.gov/press-releases/casey-booker-
and-colleagues-urge-administration-to-push-forward-with-investments-in-home-and-community-based-services.

[FN206]

Letter to Pres. Joseph Biden signed by Sen. Bob Casey and 30 other senators, Feb. 5, 2021, available at: https://
www.aging.senate.gov/imo/media/doc/Casey-Booker HCBS Letter to Pres Biden.pdf.

[FN207]

Press Release, "Bennet, Colleagues Introduce Bicameral Legislation to Expand Medicaid Coverage for COVID-19 Treatment,
Vaccines," web site of Sen. Bennet, Feb. 8, 2021, available at: https:/Avww.bennet.senate.gov/public/index.cfm/2021/2/bennet-
colleagues-introduce-bicameral-legislation-to-expand-medicaid-coverage-for-covid-1 9-treatment-vaccines.

[FN208]

Press Release, "Bowman, Warren Introduce Care for All Agenda to Expand and Revitalize the Care Economy," web site of Rep.
Bowman, Mar. 1, 2021, available at: https://oowman.house.gov/press-releases?ID=6F768584-ED84-4209-A7CF-5CC724DC771F.

[FN209]

"US S 274 Stronger Medicaid Response to the COVID?19 Pandemic Act," bill summary by Bill Track 50, available at: https://
www .billtrack50.com/BillDetail/1306308.

[FN210]

Akeeisa Coleman, "How Will the American Rescue Plan's Medicaid Funding Help States?" The Commonwealth Fund Blog, Mar. 29,
2021, available at: https:/Avwww.commonwealthfund.org/blog/202 1/how-will-american-rescue-plans-medicaid-funding-help-states.

[FN211]
The FMAP is the Federal Medical Assistance Percentage, or match rate, from the federal government.

[FN212]

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Press Release, "Bennet, Colleagues, Introduce Bill to Support State Medicaid Programs During an Economic Crisis," web site of
Sen. Bennet, Feb. 26, 2021, available at: https:/Awww.bennet.senate.gov/public/index.cfm/2021/2/bennet-colleagues-introduce-bill-to-
support-state-medicaid-programs-during-an-economic-crisis.

[FN213]

Press Release, "Toomey and Brown Introduce Legislation to Reduce Maternal Deaths and Improve Health Outcomes for Mothers,"
web site of Sen. Toomey, Feb. 24, 2021, available at: https:/Awww.toomey.senate.gov/newsroom/press-releases/toomey-and-brown-
introduce-legislation-to-reduce-maternal-deaths-and-improve-health-outcomes-for-mothers.

[FN214]

Press Release, "Pappas and Tonko Introduce Legislation to Expand Low-Income Seniors' Access to Prescription Drugs," web site of
Rep. Pappas, Feb. 17, 2021, available at: https://pappas.house.gov/media/press-releases/pappas-and-tonko-introduce-legislation-
expand-low-income-seniors-access.

[FN215]

Press Release, "Senator Fischer Reintroduces Telehealth Legislation," Senator Fischer's web site, Mar. 9, 2021, available at: https://
www.fischer.senate.gov/public/index.cfm/news?|D=37E247B4-C1 17-4EB1-91DA-AC3F400DF20F.

[FN216]

Press Release, "Speier and Cole Introduce Legislation to Expand Access to Genetic Screening Tests for Medicaid Recipients," web site
of Rep. Speier, Feb. 26, 2021, available at: https://speier._house.gov/press-releases?ID=1 1B171C4-AF 13-4A1D-A1FA-9E3DE3C4F2E6.

[FN217]

Press Release, "Amid the Pandemic, Casey Introduces Bill to Expand Supportive Services to Help Low-Income Americans Remain in
Their Homes," Senate Special Committee on Aging, Apr. 15, 2021, available at: https:/Avww.aging.senate.gov/press-releases/amid-the-
pandemic-casey-introduces-bill-to-expand-supportive-services-to-help-low-income-americans-remain-in-their-homes.

[FN218]

CHIP is the Children's Health Insurance Program.

[FN219]

Press Release, "Rep. Bass Introduces Bipartisan Foster Youth Dental Act of 2021," Rep. Bass' web site, Mar. 11, 2021, available at:
https://bass.house.gov/media-center/press-releases/rep-bass-introduces-bipartisan-foster-youth-dental-act-2021.

[FN220]

Press Release, "Rubio Reintroduces Bill to Modemize Medicaid DSH, Help Hospitals Providing Care to Low-Income
Patients," Sen. Rubio's web site, June 11, 2021, available at: https:/Awww.rubio.senate.gov/public/index.cfm/press-releases?
ID=97766731-179C-44AC-8ED4-07075F88DCC7.

[FN221]

Press Release, "Kuster, Fitzpatrick, Booker Introduce Bipartisan Legislation to End Outdated Policy that Prevents Incarcerated
Individuals from Accessing Medicaid," Rep. Kuster's web page, May 25, 2021, available at: https://kuster.house.gov/news/
documentsingle.aspx? DocumentID=3626.

[FN222]

For more information on federal Medicaid funding for the territories, please see Fact Sheet, "Medicaid and CHIP in the Territories,"
MACPAC, Feb. 2021, available at: https:/Awww.macpac.gov/wp-content/uploads/2019/07/Medicaid-and-CHIP-in-the-Territories. pdf;
"Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier," Kaiser Family Foundation, Fiscal Year 2022,
available at: https://Awww.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/?currentTimeframe=0&sortModel
=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN223]

Press Release, "Plaskett Introduces Legislation to Improve Medicaid and Medicare in U.S. Territories," web site of Rep. Plaskett, May
15, 2021, available at: https://plaskett.house.gov/news/documentsingle.aspx?DocumentID =188.

[FN224]

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Press Release, "Rep. Kelly and Rep. Herrera Beutler Introduce Bipartisan Helping MOMS Act," Rep. Kelly's web site, May 19, 2021,
available at: https://robinkelly.house.gov/media-center/press-releases/rep-kelly-and-rep-herrera-beutler-introduce-bipartisan-helping-
moms-act.

[FN225]

Please see Sen. Casey's press release for the bill. Press Release, "An Estimated 50,000 Women each Year Experience Severe
Maternal Morbidity or Severe Complications after Giving Birth," Sen. Casey's web site, June 15, 2021, available at: https://
www.casey.senate.gov/news/releases/casey-introduces-legislation-to-expand-medicaid-for-pregnant-postpartum-women.

[FN226]

"Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated June 9, 2022, available at: https://
www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe
=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN227]

"Casey, Colleagues Unveil Key Legislation from President Biden's American Jobs Plan to Make Historic Investment in Care Economy,"
Sen. Casey's web site, June 24, 2021, available at: https:/Awww.casey.senate.gov/news/releases/casey-colleagues-unveil-key-
legislation-from-president-bidens-american-jobs-plan-to-make-historic-investment-in-care-economy.

[FN228]

Press Release, "Rosen Leads Bipartisan Group of Senators to Introduce Bipartisan Legislation to Expand Access to Telehealth
Services," web site of Sen. Jacky Rosen, June 24, 2021, available at: https:/Avww.rosen.senate.gov/rosen-leads-bipartisan-group-
senators-introduce-bipartisan-legislation-expand-access-telehealth.

[FN229]

"Bilirakis, Soto and Kennedy Reintroduce Bill to Improve Access to Mental Health Treatment," Rep. Bilirakis'' web site, June 23, 2021,
available at: https://bilirakis.house.gov/media/press-releases/bilirakis-soto-and-kennedy-reintroduce-bill-improve-access-mental-health.

[FN230]

Press Release, "Senators Baldwin, Reverend Warnock, Ossoff Introduce New Legislation to Expand Quality, Affordable Health Care
Coverage," web site of Sen. Tammy Baldwin, July 12, 2021, available at: https:/Awww.baldwin.senate.gov/press-releases/medicaid-
saves-lives-act.

[FN231]

Press Release, "Senators Baldwin, Reverend Warnock, Ossoff Introduce New Legislation to Expand Quality, Affordable Health Care
Coverage," web site of Sen. Tammy Baldwin, July 12, 2021, available at: https:/Awww.baldwin.senate.gov/press-releases/medicaid-
saves-lives-act.

[FN232]

Sara Rosenbaum, et al., "How the Medicaid Saves Lives Act and Other Federal Options Can Ensure All Americans Have Access to
Affordable Coverage," The Commonwealth Fund Blog, Aug. 5, 2021, available at: https:/Avwww.commonwealthfund.org/blog/2021/how-
medicaid-saves-lives-act-and-other-federal-options-can-ensure-all-americans-have?. The American Rescue Plan is P.L. 117-2. FMAP
is a state's federal medical assistance percentage.

[FN233]

Press Release, "Rush Introduces Insulin Access for All Act to Eliminate Cost Sharing for Insulin Under Medicare and Medicaid," web
site of Rep. Rush, July 2, 2021, available at: https://rush.house.gov/media-center/press-releases/rush-introduces-insulin-access-for-all-
act-to-eliminate-cost-sharing-for.

[FN234]

Press Release, "Carper, Collins Introduce Bill to Expand Affordable Access to Tobacco Cessation Treatments," web site of Sen.
Carper, Aug. 6, 2021, available at: https:/Avww.carper.senate.gov/public/index.cfm/pressreleases?id=A7D9F301-4692-45B0-
BE80-941AD6D0EC1E.

[FN235]

Press Release, "Congressman Schweikert Introduces Legislation to Expand Patient Access to Innovative Technologies in their Home,"
July 22, 2021, available at: https://schweikert.house.gov/media-center/press-releases/congressman-schweikert-introduces-legislation-
expand-patient-access.

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[FN236]

"The Nursing Home Improvement and Accountability Act of 2021," Senate Finance Committee, available at: https://
www.finance.senate.gov/imo/media/doc/Nursing Home Improvement and Accountability Act_One-Pager_Final.pdf.

[FN237]

Press Release, "Jayapal and C?rdenas Introduce Bill to Expand Health Care, Nutrition Assistance, and Other Support Programs to
Immigrants," Rep. Jayapal's web site, Sept. 10, 2021, available at: https://jayapal.house.gov/2021/09/1 O/lift-the-bar-act/.

[FN238]

Press Release, "Wyden, Casey Unveil Comprehensive Bill to Improve Nursing Homes for Residents and Workers," Senate Finance
Committee, Aug. 10, 2021, available at: https:/Avww.finance.senate.gov/chairmans-news/wyden-casey-unveil-comprehensive-bill-to-
improve-nursing-homes-for-residents-and-workers.

[FN239]

Press Release, "Butterfield Introduces Bipartisan Bill to Cover Cancer Molecular Testing and Educate on Genetic Counseling," Rep.
Butterfield's web site, Sept. 30, 2021, available at: https://butterfield.house.gov/media-center/press-releases/butterfield-introduces-
bipartisan-bill-to-cover-cancer-molecular-testing.

[FN240]

Press Release, "Wasserman Schultz, Blumenthal Introduce Legislation to Curb Youth E-Cigarette, Tobacco Use," Rep. Wasserman
Schultz's web site, Oct. 8, 2021, available at: https:/Avassermanschultz.house.gov/news/documentsingle.aspx?DocumentID=2750.

[FN241]

Press Release, "Congresswoman Diana Harshbarger Introduces Bill to Prohibit the Federal Government from Requiring COVID-19
Vaccines," web site of Rep. Harshbarger, Oct. 1, 2021, available at: https://harshbarger.house.gov/media/press-releases/
congresswoman-diana-harshbarger-introduces-bill-prohibit-federal-government.

[FN242]

Press Release, "Trone, Emmer, Turner, Tonko Introduce Legislation to Allow Medicaid to Cover Pre-Trial Detainees," web site of Rep.
Trone, Feb. 7, 2022, available at: https://trone.house.gov/2022/02/07/continuity-of-care/.

[FN243]

Press Release, "The Advancing Maternal Health Equity Under Medicaid Act Will Address the Maternal Mortality Crisis in the United
States," Rep. Manning's web site, Feb. 7, 2022, available at: https://manning.house.gov/media/press-releases/congresswoman-
manning-introduces-new-bill-expand-access-maternal-health-care.

[FN244]

Press Release, "Ernst Leads Effort to Ensure Abortion Data Is Reported Accurately, Completely," web site of Sen. Joni Ernst, Jan.
21, 2022, available at: https:/Avww.emst.senate.gov/public/index.cfm/2022/1/ernst-leads-effort-to-ensure-abortion-data-is-reported-
accurately-completely/

[FN245]

Press Release, "Foster Introduces Bipartisan Medicaid CARE Act to Expand Access to Substance Use Disorder Treatment Under
Medicaid," Rep. Foster's web site, Mar. 22, 2022, available at: https://foster.house.gov/media/press-releases/foster-introduces-
bipartisan-medicaid-care-act-to-expand-access-to-substance.

[FN246]

Press Release, "Sens. Capito, Shaheen, Reps. Mckinley, Thompson Introduce Bipartisan Access to Prescription Digital Therapeutics
Act," Sen. Capito's web site, Mar. 10, 2022, available at: https:/Avww.capito.senate.gov/news/press-releases/sens-capito-shaheen-reps-
mckinley-thompson-introduce-bipartisan-access-to-prescription_digital-therapeutics-act.

[FN247]

Press Release, "Inhofe, Lankford, Braun, Blackburn, Kennedy, Paul, R. Scott Introduce Protecting Medicaid Beneficiaries Act,"
Sen. Inhofe's web site, Mar. 24, 2022, available at: https://www.inhofe.senate.gov/newsroom/press-releases/inhofe-lankford-braun-
blackburn-kennedy-paul-r-scott-introduce-protecting-medicaid-beneficiaries-act.

[FN248]

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Press Release, "Inhofe, Lankford, Braun, Blackburn, Kennedy, Paul, R. Scott Introduce Protecting Medicaid Beneficiaries Act,"
Sen. Inhofe's web site, Mar. 24, 2022, available at: https://www.inhofe.senate.gov/newsroom/press-releases/inhofe-lankford-braun-
blackburn-kennedy-paul-r-scott-introduce-protecting-medicaid-beneficiaries-act.

[FN249]

Press Release, "Bill Would Help Relieve Essential Prescription Drug Shortages, Reduce Dependence on Foreign Manufacturing,"
web site of Sen. Smith, Apr. 5, 2022, available at: https:/Avww.smith.senate.gov/sens-smith-cotton-and-reps-craig-mullin-introduce-
bipartisan-legislation-boost-us-pharmaceutical.

[FN250]

Press Release, "Thune, Brown, Cardin Introduce Legislation to Expand Access to Mental Health Services," web site of Sen. John
Thune (R-S.C.), Apr. 7, 2022, available at: https:/Awww.thune.senate.gov/public/index.cfm/press-releases?ID=ODDAD78D-5EB8-455E-
ABO00-8DC60665CE3A.

[FN251]

Press Release, "Booker, Sewell Introduce Legislation to Advance Health Equity and Access to Care," Sen. Booker's web page, Apr.
13, 2022, available at: https://www.booker.senate.gov/news/press/booker-sewell-introduce-legislation-to-advance-health-equity-and-
access-to-care.

[FN252]

Press Release, "Booker, Sewell Introduce Legislation to Advance Health Equity and Access to Care," Sen. Booker's web page, Apr.
13, 2022, available at: https://www.booker.senate.gov/news/press/booker-sewell-introduce-legislation-to-advance-health-equity-and-
access-to-care.

[FN253]

Press Release, "Eshoo, Blunt Rochester, Fitzpatrick Introduce Major Bipartisan Bill to Strengthen Children's Mental Health," Rep.
Eshoo's web site, Mar. 29, 2022, available at: https://eshoo.house.gov/media/press-releases/eshoo-blunt-rochester-fitzpatrick-
introduce-major-bipartisan-bill-strengthen.

[FN254]

Press Release, "Rep. Maloney Introduces the Michelle Go Act to Improve Medicaid Coverage of Mental Health Services," Rep.
Maloney's web site, May 21, 2022, available at: https://maloney.house.gov/media-center/press-releases/rep-maloney-introduces-the-
michelle-go-act-to-improve-medicaid-coverage.

[FN255]

EPSDT stands for Early and Periodic Screening, Diagnostic, and Treatment Services.

[FN256]

Press Release, "Rep. LaTurner Introduces the Jobs and Opportunities for Medicaid Act," Rep. Tumer's web site, June 9, 2022,
available at: https://laturner.house.gov/media/press-releases/rep-laturner-introduces-jobs-and-opportunities-medicaid-act.

[FN257]

Press Release, "Casey, Cassidy Introduce Bill to Improve Mental Health Care Access for Kids," web site of Sen. Casey, June 23, 2022,
available at: https:/Awww.casey.senate.gov/news/releases/casey-cassidy-introduce-bill-to-improve-mental-health-care-access-for-kids.

[FN258]

Press Release, "Casey, Cassidy Introduce Bill to Improve Mental Health Care Access for Kids," web site of Sen. Casey, June 23, 2022,
available at: https:/Awww.casey.senate.gov/news/releases/casey-cassidy-introduce-bill-to-improve-mental-health-care-access-for-kids.

[FN259]

"ICYMI: Reps. Carter, Stefanik Introduce Legislation to Prevent Federal Funding for Abortion Transportation," Rep. Carter's Web Site,
July 15, 2022, Available At: https://buddycarter.house.gov/news/documentsingle.aspx?DocumentID=10414.

[FN260]

Press Release, "Portman, Casey Introduce Bipartisan Legislation to Invest in Children's Mental Health," Sen. Portman's web site, Aug.
3, 2022, available at: https://www.portman.senate.gov/newsroom/press-releases/portman-casey-introduce-bipartisan-legislation-invest-
childrens-mental.

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[FN261]

Press Release, "Portman, Casey Introduce Bipartisan Legislation to Invest in Children's Mental Health," Sen. Portman's web site, Aug.
3, 2022, available at: https://Awww.portman.senate.gov/newsroom/press-releases/portman-casey-introduce-bipartisan-legislation-invest-
childrens-mental.

[FN262]

Press Release, "Carter Introduces Bipartisan Access to Critical Non-Emergency Medical Transportation Services Act," Rep. Carter's
web site, Sept. 15, 2022, available at: https://buddycarter.house.gov/news/documentsingle.aspx?DocumentID=10585.

[FN263]

Press Release, "Phillips Leads House Democrats in Introducing the Pro-Life Act," web site of Rep. Dean Phillips, Sept. 15, 2022,
available at: https://phillips.house.gov/news/documentsingle.aspx?DocumentID=854.

[FN264]

Press Release, "Carper, Sullivan Lead Colleagues to Introduce Bipartisan, Bicameral Bill to Implement Holistic Approach to Children's
Health Care," Sen. Carper's web site, Sept. 29, 2022, available at: https:/Avww.carper.senate.gov/public/index.cfm/pressreleases?
ID=AE4525E0-EB0A-4589-AB99-2247F57ACFC2.

[FN265]

Press Release, "Carper, Sullivan Lead Colleagues to Introduce Bipartisan, Bicameral Bill to Implement Holistic Approach to Children's
Health Care," Sen. Carper's web site, Sept. 29, 2022, available at: https:/Avww.carper.senate.gov/public/index.cim/pressreleases?
ID=AE4525E0-EB0A-4589-AB99-2247F57ACFC2.

[FN266]

CHIP is the Children's Health Insurance Program.

[FN267]
MACPAC is the Medicaid and CHIP Payment and Access Commission.

[FN268]

Press Release, "Biden-Harris Administration Issues Emergency Regulation Requiring COVID-19 Vaccination for Health Care Workers,"
CMS, Nov. 4, 2021, available at: https:/Avww.cms.gov/newsroom/press-releases/biden-harris-administration-issues-emergency-
regulation-requiring-covid-1 9-vaccination-health-care.

[FN269]

Press Release, "Biden-Harris Administration Issues Emergency Regulation Requiring COVID-19 Vaccination for Health Care Workers,"
CMS, Nov. 4, 2021, available at: https:/Avww.cms.gov/newsroom/press-releases/biden-harris-administration-issues-emergency-
regulation-requiring-covid-19-vaccination-health-care.

[FN270]

"CMS Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule," CMS, available at: https:/Awww.cms.gov/files/document/
cms-omnibus-staff-vax-requirements-2021 .pdf.

[FN271]
Biden v. Missouri, U.S. Supreme Court, Nos. 21A240 and 21A241, Jan. 13, 2021, 2022 WL 120950.

[FN272]
Biden v. Missouri, U.S. Supreme Court, Nos. 21A240 and 21A241, Jan. 13, 2021, 2022 WL 120950.

[FN273]

Press Release, "Statement by CMS Administrator Chiquita Brooks-LaSure on the U.S. Supreme Court's Decision on Vaccine
Requirements," CMS, Jan. 13, 2022, available at: https:/Avwww.cms.gov/newsroom/press-releases/statement-cms-administrator-
chiquita-brooks-lasure-us-supreme-courts-decision-vaccine-requirements.

[FN274]

Press Release, "Statement by CMS Administrator Chiquita Brooks-LaSure on the U.S. Supreme Court's Decision on Vaccine
Requirements," CMS, Jan. 13, 2022, available at: https:/Avww.cms.gov/newsroom/press-releases/statement-cms-administrator-
chiquita-brooks-lasure-us-supreme-courts-decision-vaccine-requirements.

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[FN275]

Audra D.S. Burch and Reed Abelson, "Hospitals Confront the Fallout from Supreme Court Ruling on Vaccine Mandate," The New York
Times, Jan. 15, 2022, available at: https:/Avww.nytimes.com/2022/01/15/us/healthcare-workers-vaccine-mandate.html.

[FN276]

Audra D.S. Burch and Reed Abelson, "Hospitals Confront the Fallout from Supreme Court Ruling on Vaccine Mandate," The New York
Times, Jan. 15, 2022, available at: https:/Avww.nytimes.com/2022/01/15/us/healthcare-workers-vaccine-mandate.html.

[FN277]

Audra D.S. Burch and Reed Abelson, "Hospitals Confront the Fallout from Supreme Court Ruling on Vaccine Mandate," The New York
Times, Jan. 15, 2022, available at: https:/Avww.nytimes.com/2022/01/15/us/healthcare-workers-vaccine-mandate.html.

[FN278]

News Release, "HHS Distributing $560 Million in Provider Relief Fund Payments to Health Care Providers Affected by the COVID-19
Pandemic," HHS, Feb. 24, 2022, available at: https:/Avww.hhs.gov/about/news/2022/02/24/hhs-distributing-560-million-provider-relief-
fund-payments-health-care-providers-affected-covid-19-pandemic.html?utm.

[FN279]

News Release, "HHS Distributing $560 Million in Provider Relief Fund Payments to Health Care Providers Affected by the COVID-19
Pandemic," HHS, Feb. 24, 2022, available at: https:/Avww.hhs.gov/about/news/2022/02/24/hhs-distributing-560-million-provider-relief-
fund-payments-health-care-providers-affected-covid-19-pandemic.html?utm.

[FN280]

CMCS Informational Bulletin, "2022 Updates to the Health Home Core Health Care Quality Measurement Sets," CMS, Feb. 16, 2022,
available at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/cib02162022.pdf (emphasis in original, footnotes omitted).

[FN281]

CMCS Informational Bulletin, "2022 Updates to the Health Home Core Health Care Quality Measurement Sets," CMS, Feb. 16, 2022,
available at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/cib02162022 pdf.

[FN282]

"Request for Information 2022 Access to Coverage and Care in Medicaid and CHIP," Medicaid.gov, available at: https://
cmsmedicaidaccessrfi.gov1 .qualtrics.com/jfe/form/SV_6EYj9eLS9b74Npk.

[FN283]

News Release, "Biden-Harris Administration Announces Request for Information on Access to Care and Coverage for People
Enrolled in Medicaid and CHIP," Feb. 17, 2022, available at: https:/Awww.hhs.gov/about/news/2022/02/1 7/biden-harris-administration-
announces-request-for-information-on-access-to-care-and-coverage-for-people-enrolled-in-medicaid-and-chip.html.

[FN284]

News Release, "Biden-Harris Administration Announces Request for Information on Access to Care and Coverage for People
Enrolled in Medicaid and CHIP," Feb. 17, 2022, available at: https:/Awww.hhs.gov/about/news/2022/02/1 7/biden-harris-administration-
announces-request-for-information-on-access-to-care-and-coverage-for-people-enrolled-in-medicaid-and-chip.html.

[FN285]
The notice is published at 87 F.R. 14858 (Mar. 16, 2022).

[FN286]

Drishti Pallai and Samantha Artiga, "2022 Changes to the Public Charge Inadmissibility Rule and the Implications for Health Care,"
Kaiser Family Foundation, May 5, 2022, available at: https:/Awww.kff.org/racial-equity-and-health-policy/issue-brief/2022-changes-to-
the-public-charge-inadmissibility-rule-and-the-implications-for-health-care/.

[FN287]

Press Release, "New Rule Makes Clear that Noncitizens Who Receive Health or Other Benefits to which they are Entitled Will Not
Suffer Harmful Immigration Consequences," CMS, Sept. 8, 2022, available at: https:/Awww.cms.gov/newsroom/press-releases/new-
rule-makes-clear-noncitizens-who-receive-health-or-other-benefits-which-they-are-entitled-will.

[FN288]

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Press Release, "New Rule Makes Clear that Noncitizens Who Receive Health or Other Benefits to which they are Entitled Will Not
Suffer Harmful Immigration Consequences," CMS, Sept. 8, 2022, available at: https:/Awww.cms.gov/newsroom/press-releases/new-
rule-makes-clear-noncitizens-who-receive-health-or-other-benefits-which-they-are-entitled-will.

[FN289]

Drishti Pallai and Samantha Artiga, "2022 Changes to the Public Charge Inadmissibility Rule and the Implications for Health Care,"
Kaiser Family Foundation, May 5, 2022, available at: https:/Awww.kff.org/racial-equity-and-health-policy/issue-brief/2022-changes-to-
the-public-charge-inadmissibility-rule-and-the-implications-for-health-care/.

[FN290]

FMAP is the federal medical assistance percentage, or the match rate.

[FN291]
The interim final rule is published at 85 F.R. 71142-01 (Nov. 6, 2020).

[FN292]
The request for comment is published at 87 F.R. 58456 (Sept. 27, 2022).

[FN293]

"Access Monitoring Review Plans," Medicaid.gov, available at: https:/Awww.medicaid.gov/medicaid/access-care/access-monitoring-
review-plans/index.html.

[FN294]

CMCS Informational Bulletin, "CMS Enforcement Discretion ? Medicaid Access Monitoring Review Plans," CMS, Mar. 31, 2022,
available at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/cib03312022 pdf.

[FN295]
"Coverage and Reimbursement of COVID-19

Vaccines, Vaccine Administration, and Cost-Sharing under Medicaid, the Children's Health Insurance Program, and Basic Health
Program," CMS, available at: https://www.medicaid.gov/state-resource-center/downloads/covid-19-vaccine-toolkit. pdf.

[FN296]

State Health Official Letter, SHO #22-002, "Medicaid and CHIP Coverage of Stand-Alone Vaccine Counseling," CMS, May 12, 2022,
available at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/sho22002.pdf.

[FN297]
81 F.R. 68688-01 (Oct. 4, 2016).

[FN298]

Fact Sheet, "Updated Guidance for Nursing Home Resident Health and Safety," CMS, June 29, 2022, available at: https://
www.cms.gov/newsroom/fact-sheets/updated-guidance-nursing-home-resident-health-and-safety.

[FN299]

Press Release, "CMS Issues Significant Updates to Improve the Safety and Quality Care for Long-Term Care Residents and Calls for
Reducing Room Crowding," CMS, June 29, 2022, available at: https:/Awww.cms.gov/newsroom/press-releases/cms-issues-significant-
updates-improve-safety-and-quality-care-long-term-care-residents-and-calls.

[FN300]

Fact Sheet, "Updated Guidance for Nursing Home Resident Health and Safety," CMS, June 29, 2022, available at: https://
www.cms.gov/newsroom/fact-sheets/updated-guidance-nursing-home-resident-health-and-safety.

[FN301]

Fact Sheet, "Protecting Seniors by Improving Safety and Quality of Care in the Nation's Nursing Homes," The White House, Feb.
28, 2022, available at: https:/Avww.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-
people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/.

[FN302]

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Fact Sheet, "Updated Guidance for Nursing Home Resident Health and Safety," CMS, June 29, 2022, available at: https://
www.cms.gov/newsroom/fact-sheets/updated-guidance-nursing-home-resident-health-and-safety.

[FN303]
CMCS is the Center for Medicaid and CHIP Services in CMS.

[FN304]

"Medicaid and CHIP Managed Care Monitoring and Oversight Tools," CMS, June 28, 2021, available at: https:/Avww.medicaid.gov/
federal-policy-guidance/downloads/cib06282021.pdf.

[FN305]
CHIP is the Children's Health Insurance Program.

[FN306]

"Medicaid and CHIP Managed Care Monitoring and Oversight Tools," CMS, July 6, 2022, available at: https:/Awww.medicaid.gov/
federal-policy-guidance/downloads/cib07062022. pdf.

[FN307]

"Health Coverage Options for Certain Ukrainian Nationals," CMS, July 13, 2022, available at: https://www.medicaid.gov/medicaid/
eligibility/downloads/hith-cov-opt-fr-cer-ukrainian-natnls.pdf.

[FN308]

State Medicaid Director Letter, #22-005, "Guidance on Nursing Facility State Plan Payment and Upper Payment Limit Approaches
in Medicaid Relying on the Medicare Patient-Driven Payment Model," CMS, Sept. 21, 2022, available at: https:/Avwww.medicaid.gov/
federal-policy-guidance/downloads/smd22005.pdf.

[FN309]
CMCS Informational Bulletin, "2023 and 2024 Updates to the Child and Adult Core Health Care Quality
Measurement Sets," CMS, Nov. 15, 2022, available at: https://www.medicaid.gov/federal-policy-guidance/downloads/cib1 11522. pdf.

[FN310]

"Report to Congress T-MSIS Substance Use Disorder (SUD) Data Book Treatment of SUD in Medicaid, 2019," CMS, Jan. 1, 2022,
available at: https:/Awww.medicaid.gov/medicaid/data-systems/downloads/2019-sud-data-book.pdf.

[FN311]
The resource is available at: https://edit.cms.gov/files/document/covid-medicare-payment-covid-1 9-viral-testing-flow-chart.pdf.

[FN312]

"Toolkit: Data Sharing for Child Welfare Agencies and Medicaid," ACF and CMS, available at: https:/Avww.acf.hhs.gov/sites/default/
files/documents/cb/data-sharing-and-medicaid-toolkit. pdf.

[FN313]

"Toolkit: Data Sharing for Child Welfare Agencies and Medicaid," ACF and CMS, available at: https:/Avww.acf.hhs.gov/sites/default/
files/documents/cb/data-sharing-and-medicaid-toolkit.pdf.

[FN314]
"Enrollment Report," Medicaid.gov, available at: https://www.medicaid.gov/medicaid/managed-care/enrollment-report/index.html.

[FN315]

"Profiles and Program Features," Medicaid.gov, available at: https:/Avww.medicaid.gov/medicaid/managed-care/profiles-program-
features/index.html.

[FN316]

"2022 Medicaid and CHIP Beneficiary Profile: Enrollment, Expenditures, Characteristics, Health Status, and Experience," CMS, July
2022, available at: https:/Avwww.medicaid.gov/medicaid/quality-of-care/downloads/beneficiary-profile-2022. pdf.

[FN317]

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"2022 Medicaid and CHIP Beneficiaries at a Glance," CMS, July 2022, available at: https:/Avww.medicaid.gov/medicaid/quality-of-care/
downloads/beneficiary-ataglance-2022. pdf.

[FN318]

Min-Young Kim, et al., "Medicaid Beneficiaries Who Use Long-Term Services and Supports: 2019," July 22, 2022, available at: https://
www.medicaid.gov/medicaid/long-term-services-supports/downloads/ltss-user-brief-2019.pdf.

[FN319]

MAGI Application Processing Time Snapshot Report: January - March 2022, CMCS, Sept. 1, 2022, available at: https://
www. medicaid.gov/state-overviews/downloads/magi-app-process-time-snapshot-rpt-jan-mar-2022. pdf.

[FN320]

Report to Congress, "Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities
Act: Section 1004 Medicaid Drug Review and Utilization," CMS, available at: https:/Awww.medicaid.gov/medicaid/downloads/sud-prev-
medicaid-drug-rev-util.pdf.

[FN321]

"Executive Order on Strengthening Medicaid and the Affordable Care Act," The Whitehouse, Jan. 28, 2021, available at: https://
www.whitehouse.gov/briefing-room/presidential-actions/202 1/01/28/executive-order-on-strengthening-medicaid-and-the-affordable-
care-act/.

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