Medicaid Story Archives - Page 2 of 17 - West Virginia Public Broadcasting

Supreme Court May Decide If W.Va. Medicaid Must Cover Gender-Affirming Surgeries

The U.S. Supreme Court may decide if West Virginia Medicaid is required to cover gender-affirming surgeries.

Updated on Friday, July 26, 2024 at 4 p.m.

The fight over whether West Virginia is legally required to cover gender-affirming surgeries under Medicaid is headed to the U.S. Supreme Court.

The original lawsuit, filed on November 19, 2020, by Lambda Legal, a civil rights organization focused on LGBTQ and HIV/AIDS rights, alleged West Virginia’s Medicaid and state employee health plans unlawfully denied coverage for gender-affirming care for two transgender residents.

On September 23, 2021, Lambda Legal announced that plaintiffs had been added to the suit, two transgender West Virginia women, Shaunte Anderson and Leanne James.

The suit argued the state is violating the Affordable Care Act and Medicaid law by not covering treatments for gender dysphoria.

West Virginia banned gender-affirming surgeries due to gender dysphoria from Medicaid coverage in 2004. Medicaid covers pubertal modulating and hormone therapy.

On April 29, 2024, the U.S. Court of Appeals for the Fourth Circuit ruled in Anderson’s favor that West Virginia could not deny Medicaid coverage for gender reassignment surgeries.

In an 8-6 decision, the appeals judges concluded that West Virginia discriminates unfairly against transgender people because the state’s policies allow coverage for the same procedures to other people for different medical reasons.

West Virginia Attorney General Patrick Morrisey announced Thursday he filed a petition with the U.S. Supreme Court to challenge the decision of the lower court.

“This is a case that we think should be heard by the U.S. Supreme Court, because it’s interpreting a major federal law, the Medicaid act, and it presents a nationally important constitutional question, whether Medicaid, or any state related insurance program, must cover all transgender care,” Morrisey said.

Morrisey told reporters at a press conference that he believed the state’s Medicaid program made “a reasonable decision to reserve scarce funding” and that the state is entitled to have priorities in the operation of its Medicaid program.

“The state’s Medicaid program is saying no to the transsexual surgery,” Morrisey said. “And it’s a state that’s trying to help ensure that we’re covering people with heart disease, with diabetes and all sorts of medical conditions. We’re not a rich state, we can’t afford to do everything.”

In a statement, Lambda Legal Senior Counsel, Tara Borelli, attorney in the Anderson v. Crouch lawsuit, said she is confident the court’s decision will stand.

“Everyone, including transgender people, deserves access to life saving and medically necessary health care,” Borelli said. “This appeal to the U.S. Supreme Court serves no purpose other than to deny equal treatment and urgently needed care to Medicaid participants except to put lives at risk. The U.S. district court and the Fourth Circuit both reviewed the evidence and found that targeting transgender people for discrimination is unconstitutional.”

**Editor’s Note: This story was updated to include Lambda Legal’s Response to West Virginia’s Appeal to the Supreme Court.

House Funds Waiver Programs In Final Hours Of Special Session

An extraordinary legislative session ended with tensions high among lawmakers who wanted more transparency in spending from the Department of Health and Department of Human Services.

The West Virginia House of Delegates refused to concur with the state Senate’s amendment to Senate Bill 1001 in a late-night session Monday.

Instead of restoring the budget line items cut from the state budget passed on the last night of session, Senate Bill 1001 appropriates money to a new reserve fund of $183 million. Lawmakers hope the cabinet secretaries of the departments will spend on underfunded line items. The secretary has the ability to move only 5 percent of any money from one existing account to another. This fund is new and it will expire March 31, 2025. It is not encumbered so the cabinet secretaries are not required to spend the money on specific items.

On Tuesday, the Senate took no action on Senate Bill 1001 and sent the bill back to the House.

Emotions were high in the House after the Senate adjourned Sine Die without addressing the House’s version of the bill.

The House’s version would have required rate pay increases for those who work with individuals with intellectual and developmental disabilities, otherwise known as those served by the IDD waiver program.

In 2023, the previous West Virginia Department of Health and Human Resources (DHHR), Bureau for Medical Services contracted with Myers and Staffer, an actuary firm, to conduct a “rates” study of the Aged and Disabled Waiver, and Personal Care Services programs.

The study recommended a $6.5 million rate increase for the IDD waiver program to hire and retain direct care professionals.

“We the House feel it is very important to include these rate increases for providers because we are very short on providers,” Del. Amy Summers, R-Taylor, said. “And it is our job as the legislature to make sure this infrastructure is there.”

Del. Mike Pushkin, D-Kanawha, said he believes there will be no rate increases since the House’s amendment was not passed.

“I trust when they said under oath that they had absolutely no intention of increasing the rates,” Pushkin said. “That’s what they told us when they were under oath, there was not their intention to increase these reimbursement rates.”

One House amendment that was included in the final version of the bill is a line protecting the IDD Waiver line from any moving of monies within the department.

These concerns stem from a line of questioning during an interim meeting in April where Human Services Secretary Cynthia Persily testified that the department used funds from the IDD waiver program to pay for contract nurses and COVID-19 testing.

“I think the one issue that we did come to fix was the IDD issue in the stealing of money that was occurring out of that line item,” Del. Adam Burkhammer, R-Lewis, said. “I believe that this legislation stops that. It ensures that $97 million is going to IDD.”

By taking no action, the Senate left the House to jump through hoops to get Senate Bill 1001 back on the floor and up for consideration.

Procedurally, the House had to move backward in order to take the bill back up. They had to vote to undo their Monday night actions, then vote to concur with the Senate, lest the bill die and the funding be left incomplete.

“The position that the House is in right now, is they need to recede from what they did yesterday, or the bill is dead,” Sen. Eric Tarr, R-Putnam told reporters after the Senate adjourned Tuesday.

Tarr said the bill was the product of months of negotiation among the House, Senate and governor’s office to go through and set up a mechanism for transparency.

“We don’t believe there’s a cash flow shortfall anywhere, and that’s coming up on us anytime soon,” Tarr said. “However, if there would be then there’s a reserve fund that has incredible transparency to it, that the secretary has to sign off individually on transferring those funds and the report to the joint committee on which line it went into, and why.”

Many lawmakers in the House expressed a desire for the cabinet secretaries to have to ask permission to spend, instead of reporting the expenditure after the fact.

“We can’t control where the money goes, specifically, but we can at least be told where it’s going to be spent,” Del. J.B. Akers, R-Kanawha said. “And pardon my language, I would hope that if it’s not spent the way that we intended, there’s hell to pay next year.”

In the Senate, only one Senator voted against this version of Senate Bill 1001 — Sen. Mike Woelfel D-Cabell. The House passed the bill nearly unanimously. It now heads to the governor’s desk for his signature.

Lawmakers Volley Over Best Means Of Medicaid Funding Transparency

Lawmakers said they did not think they could trust the secretaries of the Department of Health and the Department of Human Services to spend the money accordingly, without the line items.

The West Virginia House of Delegates refused to concur with the state Senate’s amendment to Senate Bill 1001 in a late-night session Monday.

Senate Bill 1001 and its counterpart, House Bill 101, aim to restore funding to the Department of Health and the Department of Human Services, focused on the state’s Medicaid and Title IX waiver programs.

Clawback Cuts

According to the West Virginia Center on Budget and Policy, the Fiscal Year 2025 budget the legislature passed earlier this year underfunded the state’s Medicaid program by about $150 million.

This included a more than $10 million decrease in the line item in the state’s budget for the intellectual and developmental disabilities waivers, commonly called IDD waivers program.

The program allows people with disabilities to live outside hospitals and institutions by connecting them with resources like home health care workers and financial support.

In response to the cuts, advocates and providers alike have been sounding the alarm after the budget was passed in March.

Gov. Jim Justice said during a press briefing April 17 that he is not to blame for the budget cuts and said he would check and see if there was any way that it could be funded, without bloating the budget.

Lawmakers said the budget cuts were necessary due to a possible federal government clawback of $465 million in COVID-19 relief funding for schools.

Justice announced in April that West Virginia will not face that clawback.

Pressing Costs

Lawmakers said they did not think they could trust the secretaries of the Department of Health and the Department of Human Services to spend the money accordingly, without the line items.

Before and during the pandemic, Persily testified that the previous Department of Health and Human Resources (DHHR) administration would use leftover funds to fund what she called “pressing costs.” According to Persily, this was common practice in the department before it was split into three separate departments by an act of the legislature last year.

Lawmakers and Justice now agree, the funding must be restored. Senate Bill 1001 allocates more than $5 million to the Department of Health and $183,437,463 to the Department of Human Services.

These monies would be placed in reserve funds that can be accessed by the agency secretaries when or if the money is needed. However, each chamber wants its own form of oversight over how these additional funds are spent.

An Extraordinary Session

Del. Amy Summers, R-Taylor, amended the bill in the House Finance Committee to require increasing reimbursement rates for companies and their employees providing services for people with disabilities.

“We all know that if we don’t have the workers to take care of individuals in these settings then we will take care of these individuals in state psych hospitals,” Summers said in committee Monday.

The House sent that version over to the Senate where Summers’ amendment was stripped and the Senate reverted it to their plans – Sen. Eric Tarr’s, R-Putnam, original amendment.

“That reserve fund is there so that the quarterly disbursements, if they aren’t enough for any given line that has been cut, they can make a transfer, but the Secretary has to sign off on it,” Tarr told West Virginia Public Broadcasting. “She has to report on the transfers monthly to the joint committee.”

Tarr’s amendment also includes language that requires the unexpended reserve funds be returned to the Treasury by March 31, 2025.

House language to prohibit any funds from being transferred out of the home and community based waiver programs was retained in this version.

When the bill arrived back in the House, delegates from both sides of the aisle expressed outrage at the Senate’s actions.

“So let me get this straight,” Summers said. “Our bill went over, where we had the rates in there, the rate increases for IDD, for TBI, for aged and disabled waiver, for personal care services that went over there. They didn’t like that. But then they made sure they stuck in the amendment that they wanted about, ‘We want all this money to expire to general revenue on March 31.’ And now we’re supposed to take that?”

Del. Michael Hite, R-Berkeley, said the House’s amendments were meant to restore money and direct it to specific funds and services.

“Not just to leave it up to the Department of Human Services, again, to do the right thing,” Hite said. “That was the purpose of our amendments. That’s what we voted on in here. To make sure that they did the right thing, because they have proven over and over again that they don’t do the right thing.”

Del. Joey Garcia, D-Marion, said this was the time to fight, and encouraged his fellow lawmakers to reject the Senate’s amendments.

“The lady from the 73rd, offered a great amendment,” Garcia said. “And I talked to somebody from the Senate here a second ago and asked, and they said, ‘Well, that should be up to the discretion of the secretary, whether or not they have the ability to do these provider rate increases, right?’ Well, they haven’t done it. We as a body have the ability to set that policy and say, ‘Yes, you will take that money, and you will fund those, because otherwise, what are we doing here, but trying to find an illusory solution?”

Del. Mark Zatezalo, R-Hancock, said it is the lawmaker’s responsibility to keep promises to their constituents, and by rejecting the Senate’s amendments, they’d be keeping their promises.

“I agree with my colleagues here, we need to stick with our position on this and make sure it gets to where it goes so that we basically are telling people the truth,” Zatezalo said.

Del. Eric Householder, R-Berkeley, disagreed with his colleagues. He said Senate Bill 1001 fulfilled their promise to the people of West Virginia, and lawmakers were putting that at risk.

“I can’t give you any guarantees, whether or not they’re going to recede or not,” Householder said. “You’re gonna put that at risk by having a conference committee, that it’s an unknown. I’m saying that if this bill restores the cuts, we’re better off to concur with the Senate amendment and move on.”

The House voted nearly unanimously to reject the Senate’s amendment and refused to concur, requesting the Senate to recede.

Justice Finalizing Special Session Plans

Gov. Jim Justice said he will make a decision early next week when he’ll call a special legislative session. In a Wednesday media briefing, he said he was hopeful the session would happen in May.

Justice has committed to reversing the Medicaid cuts made in a scaled-down budget passed on the last day, in the last hour, of the regular legislative session.

“I don’t know why we did this,” Justice said. “We stripped money out of the budget that was in my budget, that really and truly was there to help, whether it be Medicaid or whatever. There’s so many people that are in need in this state. We’ll put it back for sure.”

The Legislature passed a so-called skinny budget due to fears over a possible $465 million federal “clawback” regarding federal education funding spent during the pandemic. The U.S. Department of Education eventually granted a waiver, dismissing the “clawback.” Justice said he told everybody all along the waiver would come.

“Lo and behold, the sky didn’t fall, did it,” Justice said. “Now all we’ve done is bring a tremendous amount of anxiety and issues to those that are absolutely hurting the most.”

When pressed to name some specific issues he might include in the call, Justice instead listed generalities.

“I want to see that we take care of our kids, we take care of our seniors, we take care of our vets, we’ll absolutely take care of issues like childcare,” Justice said.

The last special session called in August 2023 was in response to a Department of Corrections staffing crisis and concerns over first responder funding. Justice however, included 44 proposed bills in that special session call.

A finalized state budget for fiscal year 2025 must be completed by June 30.

Appeals Court: Medicaid Program Must Cover Gender-Affirming Care

The Fourth U.S. Circuit Court of Appeals in Richmond, Virginia, upheld a lower court ruling Monday on a vote of 8 to 6 that the state’s Medicaid exclusion violated federal law.

A federal appeals court has ruled that West Virginia’s Medicaid program must cover gender-affirming surgeries.

The Fourth U.S. Circuit Court of Appeals in Richmond, Virginia, upheld a lower court ruling Monday on a vote of 8 to 6 that the state’s Medicaid exclusion violated federal law.

The Fourth Circuit ruling also applies to North Carolina’s health insurance program for state employees.

The states had argued that cost, rather than bias against transgender beneficiaries, was behind excluding gender-affirming surgeries. West Virginia’s Medicaid program does cover hormone therapy, office visits, counseling and lab work.

The court’s majority found that the states’ exclusion did not apply to the same procedures, such as mastectomies or breast reductions, for patients with cancer or excess breast tissue who are not transgender.

Attorney General Patrick Morrisey, a candidate for governor in the state’s Republican primary, said he’d appeal the case to the U.S. Supreme Court.

“Our state should have the ability to determine how to spend our resources to care for the vital medical needs of our citizens,” Morrisey said in a statement.

The West Virginia lawsuit, filed in 2020 in the U.S. District Court for the Southern District of West Virginia, named the former Department of Health and Human Resources and its former secretary, Bill Crouch, as defendants.

The suit also covered PEIA, the state employees’ health insurance program.

District Judge Robert Chambers ruled against the exclusions in 2022. Morrisey appealed to the Fourth Circuit.

Advocates, Lawmakers Worry For Future Of Medicaid In W.Va.

Health care services for nearly 30 percent of West Virginia’s population may be difficult to access if lawmakers don’t fully fund the Medicaid program in an expected special session.

Medicaid provides free or low-cost health coverage to low-income people, families and children, pregnant women, the elderly and people with disabilities.

According to the Kaiser Family Foundation (KFF), West Virginia has the highest percentage of Medicaid enrollment in the U.S., with more than 564,000 people enrolled, or 29 percent of the state’s population in 2017.

According to the West Virginia Center on Budget and Policy, the Fiscal Year 2025 budget the legislature passed this year underfunded the state’s Medicaid program by about $150 million.

The budget Gov. Jim Justice originally proposed fully funded Medicaid, according to Kelly Allen, executive director of the West Virginia Center on Budget and Policy.

“By our analysis, it was underfunded by about $150 million relative to the governor’s proposed budget, which would have fully essentially funded Medicaid according to what Medicaid agency officials were saying that they needed to keep current levels of services,” Allen said.

Medicaid is a joint federal and state program, which means for every dollar the state allocates toward the program, the federal government matches those funds through the Federal Medicaid Assistance Percentage (FMAP).

Each state’s FMAP is based on a formula in the federal Medicaid statute that is based on state per capita income. The lower a state’s per capita income, the higher the state’s FMAP, or federal Medicaid matching rate will be. These rates vary from 50 percent to 74 percent.

West Virginia’s Fiscal Year (FY) 2025 FMAP percentage is 73.84 percent with a multiplier of 2.8 percent.

“Because Medicaid is a matching program,” Allen said. “For every dollar of state funding that we spend, we pull down almost $3 in federal funds, that can actually total over $600 million in potential cuts to Medicaid, which is about 12 percent of the entire program.”

The governor’s proposed budget allocated about $517 million to Medicaid, whereas the enacted budget allocated $438 million.

Justice said during a press briefing on April 17 that he is not to blame for the budget cuts and said he would check and see if there was any way that it could be funded, without bloating the budget.

“Why did we do this? Why in the world did we do this? Why did we strip $100 million out of something that we didn’t have to do and absolutely we knew it was going to really hurt people,” Justice said.

Lawmakers said the budget cuts were necessary due to possible federal government clawback of $465 million in COVID-19 relief funding for schools.

Justice announced Friday that West Virginia will not face that clawback.

“I don’t think that argument ever carried a lot of water because I don’t think that was a reason to underfund the budget itself, I think that was a reason to hold on to surplus dollars, those one time dollars that they didn’t allocate,” Allen said.

Allen said before the pandemic, the state was spending more on Medicaid than it is now. That is because during the pandemic, a public health emergency allowed additional federal funds to be distributed to programs like Medicaid.

“One factor that allowed the state to have a flat budget for all of these years was, we didn’t, we weren’t really able to reduce our state spending on Medicaid, because we were getting all this extra federal Medicaid money due to the pandemic,” Allen said.

In 2023, federal spending stopped with the end of the public health emergency and the passage of the Consolidated Appropriations Act.

“This isn’t really an issue of Medicaid spending being out of control or a big spike in Medicaid spending,” Allen said. “It’s really just that that federal, extra match expired, which we always knew it was going to. And the state’s responsibility now is essentially to go back to its pre-pandemic levels of Medicaid funding.”

If lawmakers don’t amend the budget in an expected May special session, there are a few ways that Medicaid costs could be reduced including a reduction in eligibility.

Currently, single adults who make about $20,000 a year, or a family of four earning around $40,000 annually qualify for Medicaid. The program also covers insurance for children and people with disabilities.

Cynthia Persily, secretary of the West Virginia Department of Human Services, testified in front of the Joint Health Committee on April 15 that services could be cut if the program is not fully funded.

“Whenever there’s a shortage in Medicaid dollars, there are several things that we can do, right,” Persily said. “We can decrease enrollment in Medicaid, we can decrease services, or we can decrease the reimbursement rate. And so there would have to be some sort of combination of those three pieces in order for us to make Medicaid whole.”

Allen said there are many services the federal government considers optional.

“But I don’t think you and I and most West Virginians would think they’re optional,” Allen said. “That’s things like prescription drugs, substance use treatment, physical and occupational therapy, things like waiver programs, intellectual and developmental disability programs. These are all programs that are optional for states to offer, but they’re really, really important to people.”

A representative from the Department of Human Services, Whitney Wetzel said in an email statement to West Virginia Public Broadcasting that the department is hopeful the budget will be restored in a special legislative session. However, if cuts are sustained, the DoHS’s Bureau for Medical Services (BMS) will review optional services and rates.

Wetzel further explained that Medicaid eligibility rules are mandated by the Centers for Medicare and Medicaid Services (CMS).

“There are currently no plans that would impact members’ eligibility,” Wetzel wrote.

Appalachia Health News is a project of West Virginia Public Broadcasting with support from Marshall Health.