Stand down, draw down
Section 1115 funding initiatives approved under prior administrations will not be extended or renewed if they’re not “directly tied to healthcare services.”
It’s Day 87 of the Trump administration, and state Medicaid programs will no longer be able to draw down federal Medicaid matching funds for designated state health programs (DSHP) or designated state investment programs (DSIP) through their 1115 waivers. States won’t need to end their programs early, but they’ll need to figure out how to replace the federal funding when it’s gone after their waivers are renewed.
In Ambiguous Guidance, CMS Suggests Restrictions on Medicaid Coverage of Gender-Affirming Care for Youth
On April 11, the Centers for Medicare & Medicaid Services (CMS) issued guidance to state Medicaid directors implying that Medicaid programs may no longer cover gender-affirming medications and surgeries for youth. It’s the latest step by the Department of Health & Human Services (HHS) to implement President Trump’s January 28 executive order (EO), which directed agencies to prohibit access to gender-affirming care for transgender individuals under the age of 19.
The guidance does not expressly define any new mandates or prohibitions, but in an accompanying statement, CMS Administrator Dr. Mehmet Oz declared that “Medicaid dollars are not to be used for gender reassignment surgeries or hormone treatments in minors.” CMS has rarely defined concrete coverage exclusions without express statutory authorization.
As with prior HHS letters, CMS’ new guidance describes the Trump administration’s position that gender-affirming medications and surgery “lack reliable evidence of long-term benefits for minors, and for some children, these interventions are now known to cause long-term and irreparable harm.”
A significant minority of states cover gender-affirming care for youth. Faced with ambiguous CMS guidance, these states may choose to continue covering these services while awaiting additional clarity as to whether CMS intends to disallow federal payments (and if so, starting when and as to what age group of Medicaid enrollees) — or they may choose to challenge CMS’ guidance in court.
Keep reading at The 80 Million.
ICYMI: Cell and Gene Therapy in Medicaid
We are living at the leading edge of cell and gene therapies (CGT) rapidly proliferating in the health care system including some one-time, durable treatments for rare and severe genetic conditions like cancers and sickle cell disease (SCD). The advances in science that make these therapies work are incredible and the therapies themselves are transforming medicine and lives, in some cases curing pernicious and terminal illnesses. The pace of FDA approval of CGT is rapidly increasing, and the clinical pipeline is robust:
21 gene therapies have been approved in the US (including genetically modified cell therapies) since 2015.
Two-thirds of those were approved between 2022 and 2024.
Over 4,000 CGTs are in clinical development; oncology is the most targeted therapeutic area.
In December 2023, the U.S. Food and Drug Administration approved two new gene therapies to treat SCD, landing Medicaid squarely in the thick of the CGT coverage and access challenges. SCD is a debilitating and costly genetic disorder that predominantly impacts Black and African American people. Half of the roughly 100,000 patients with SCD in the United States are enrolled in Medicaid, and many observers note that SCD CGTs are “the tip of the iceberg” for Medicaid as CGTs proliferate.
Keep reading at The 80 Million.
Arkansas submitted a request to establish “work and community engagement requirements” for its Medicaid expansion population. The federal public comment period will be open through May 9.
North Carolina Gov. Josh Stein touted that 650,000+ residents have received health care from the state’s December 2023 Medicaid expansion. About a third of those enrollees live in rural communities, previously making access more elusive.
Oregon submitted a request to continue its substance use disorder program and seek new authority to provide contingency-management incentives as a medical intervention to enrollees under its Section 1115 demonstration.
Manatt is hosting a webinar with Dr. Monica Soni, chief medical officer of Covered California, on population health April 28. Register here.
USDA is fast-tracking requests to yank soda from food-stamps program – The Wall Street Journal
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