Medicaid | Simon&Co., LLC

Overview of Medicare, Medicaid and Federal Exchange Contractors

Patrick Butler — Thu, 09 Apr 2026 18:32:00 +0000

CMS and states use contractors to perform many tasks in Medicare, Medicaid, the Children’s Health Insurance Programs and the Exchanges. But there is much confusion as to what the contractors specifically do. This paper provides an overview of contractors related to eligibility determinations, data management systems, enrollment choices, program integrity efforts, and the collection and usage of personal information.

Overview of Medicare, Medicaid and Federal Exchange Contractors Download

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Marsha Simon Quoted in MedPage Today on Expanded Coverage Indication for GLP-1s

Patrick Butler — Wed, 31 Dec 2025 18:55:00 +0000

On December 31, MedPage Today released an article titled, “New CMS Demo Aims to Increase Access to GLP-1s Under Medicaid and Part D” that describes the Better Approaches to Lifestyle and Nutrition for Comprehensive Health (BALANCE) demonstration program, designed to increase access to GLP-1 drugs for purposes of “weight management and metabolic health improvement” for Medicare Part D and Medicaid enrollees. The article quoted Marsha Simon’s comments on her interest in the expanded coverage indication for GLP-1s.

From an overall perspective, “it would be very helpful if the administration would address the Part D statutory prohibition on weight-loss drugs,” she wrote in an email. But “I understand the reluctance to take that step unless the basis for Medicare coverage is also addressed which, due to a court decision, prohibits CMS from considering the cost of a service or item, including drugs.”

“Thus, it is the responsibility of Congress to revisit the policy question of whether cost should be a consideration in Medicare coverage,” she said.

However, Simon added, “I would not hold my breath, as Congress has been unable to decide on much simpler issues such as the extension/reform of the [Affordable Care Act] exchange premium subsidies and cost-sharing reductions.”

Simon also was skeptical about the administration’s ability to significantly lower GLP-1 prices. “Even with the rivalry between Lilly and Novo Nordisk for this market, I am not sure that the administration can negotiate a better price than the Part D sponsors — especially as the administration is also negotiating a reduced price for their Trump Rx direct-to-patient drug sales [website] which is $350 per month with no insurance coverage,” she wrote. “Currently, Lilly offers [tirzepatide (Zepbound)] direct to consumers for about $250/month which seems to be the best price the manufacturers are interested in offering.”

Read the full story here

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Duplicate Capitation for Enrollees with Multiple Medicaid ID Numbers

Patrick Butler — Tue, 26 Aug 2025 16:04:57 +0000

While HHS OIG reports of Medicaid capitation payments to managed care plans for deceased beneficiaries or those who have moved out of state have received much attention, few have addressed duplicate capitation payments to managed care plans enrollees with Multiple Medicaid Identification Numbers. Read the Simon&Co. summary of HHS OIG reports on the topic below.

HHS OIG Reports on Capitation Payments for Duplicate Beneficiaries Download

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