Category: Curator

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A MO audit found about $7M in managed care payments for out of state patients and another $1M for prisoners not eligible for Medicaid.

 
 

Clipped from: https://www.msn.com/en-us/news/world/audit-finds-dollar8m-in-potential-missouri-medicaid-overpayments/ar-BB1aM1Pl

Missouri overpaid as much as $8 million for Medicaid health care for out-of-state residents and prisoners in recent years, according to a state audit released this week.

 
 

© Madeline Carter/Tribune Nicole Galloway gives her concession speech after losing the Missouri Governor’s race to Governor Mike Parson at the Tiger Hotel on Tuesday evening.

State Auditor Nicole Galloway’s office found the state overspent as much as $6.6 million for 2,600 on health care for patients with out-of-state addresses through the state’s managed care system between July 2017 and June 2019.

Medicaid is a government program that provides health care coverage for low-income adults, children and people with disabilities. Missouri works with managed care companies as middlemen to provide Medicaid care at a lower cost.

The audit also identified $1.7 million in state payments for 500 patients who were incarcerated for at least some of that three-year period.

Missouri law at the time required the state to kick people off Medicaid when they were jailed or imprisoned. Current law requires Medicaid be suspended for those patients so officials can check to see if they qualify for an exemption.

“At a time when every dollar is being stretched to deliver vital services to Missourians, state government must stop wasting resources,” Galloway said in a statement. “The millions in payments for prisoners and non-Missouri residents is unacceptable.”

Missouri’s Department of Social Services, which oversees Medicaid, said problems with the state’s data system required the agency to exempt some recipients from regular eligibility checks to prevent eligible patients from improperly losing coverage. The agency said staff have been working to check those patients’ eligibility now that data system errors have been fixed and cited annual eligibility checks enacted in 2018.

“This audit confirms that the DSS’ action to implement annual renewals in 2018 and 2019 to verify continued eligibility was the correct action,” the agency wrote in a response included in the audit.

Galloway, a Democrat, on Tuesday lost a bid to unseat Republican Gov. Mike Parson. During her campaign, she frequently criticized his administration for dropping close to 90,000 children from the state’s Medicaid health insurance program.

State officials cited a drop in unemployment and improved efforts beginning in 2018 to purge Medicaid rolls of people who were not eligible. Department of Social Services Acting Director Jennifer Tidball has said that about a third of people who lost coverage didn’t answer letters to renew their eligibility.

This article originally appeared on Columbia Daily Tribune: Audit finds $8M in potential Missouri Medicaid overpayments

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Kevin Bagley is the new Nebraska Medicaid Director.

 
 

Clipped from: https://journalstar.com/news/state-and-regional/govt-and-politics/new-nebraska-medicaid-director-named/article_0209133a-843b-58b8-83d4-a6a830d8b32a.html

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A Utah man has been named the new director of the Nebraska Division of Medicaid and Long-Term Care, Gov. Pete Ricketts announced Monday. 

Kevin Bagley, who replaces Matthew Van Patton, who left in February, has worked for the Utah Division of Medicaid since 2011 and is the director of long-term services and supports in the division.

“Kevin’s extensive expertise in Medicaid operations will be especially valuable as Nebraska enhances the Heritage Health Adult Plan and continuously improves customer service,” Ricketts said. 

 
 

Kevin Bagley, director of the Division of Medicaid and Long-Term Care at the Nebraska Department of Health and Human Services.

 
 

Bagley, 37, has collaborated in Utah with community stakeholders; federal, state, and local government agencies; and providers. He has worked with health plans and other community-based organizations to assess and review rate changes, patient access, utilization patterns, clinical standards, provider participation criteria and consumer and provider satisfaction.

He has also worked with the Utah Legislature, provider networks and consumer advocacy groups to design and implement new strategic programs.

During his Utah Division of Medicaid tenure, he has been an actuarial specialist, a process implementation manager and assistant director of authorizations.

He has a Master of Business Administration from Utah State University and a Bachelor of Arts in economics from Brigham Young University.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

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4 years in the making, the Medicaid Managed Care Rule is now fully finalized, with most of the original components in tact.

 
 

Clipped from: https://www.modernhealthcare.com/medicaid/cms-signs-medicaid-managed-care-changes

CMS on Monday wrapped up its long-awaited changes to how states can run their Medicaid and Children’s Health Insurance Program plans.

The final rule gives states more flexibility to set rates for their managed-care plans and ensure plans have adequate provider networks. The Trump administration hopes the changes will encourage private health plans within Medicaid and CHIP, slash regulations and cut federal exposure to healthcare costs.

“The era of prescriptive regulations has failed. The government should identify expected outcomes, results, and standards—not micromanage processes,” CMS Administrator Seema Verma said in a statement.

Most of the rule changes take effect next month.

Health plans sparred with provider and consumer groups over the rule’s relaxed network adequacy standards, which allow states to set their standards—like provider-to-enrollee ratios—instead of using minimum time-and-distance standards. Insurers claimed the change would help states and plans take up telehealth and other innovations. But critics argued the move could make it harder for beneficiaries to access care.

Providers and Medicaid managed-care plans also asked CMS to allow states switching to managed care to require plans to make pass-through payments to providers for up to five years instead of three years.

“We continue to view pass-through payments as problematic and not consistent with our regulatory standards for actuarially sound rates because they do not tie provider payments with the provision of services,” the final rule states. CMS claimed three years is “a reasonable amount of time to integrate pass-through payment arrangements into allowable payment structures.”

The rule doesn’t affect an Obama-era requiring insurers to spend at least 85% of their Medicaid revenue on medical care and other activities to improve quality, even though that requirement is the biggest concern for plans and states.

According to CMS, comprehensive managed-care plans covered more than 55 million people enrolled in Medicaid in 2018.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

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Oklahomans voted for Medicaid expansion, but they don’t want to pay for it using tobacco settlement funds.

 
 

Clipped from: https://www.enidnews.com/news/state/voters-reject-tapping-of-tset-for-medicaid-expansion/article_4cc44f8b-22f0-57c3-a5e6-07cca8eaf482.html

OKLAHOMA CITY — Voters decided Tuesday that they don’t want lawmakers to pay for Medicaid expansion by tapping the state’s constitutionally protected tobacco settlement funds.

Nearly 60% voted against the ballot measure. Garfield County voters rejected the measure by 61.21%.

The resounding rejection of State Question 814 dealt a blow to legislators. Lawmakers had proposed reducing the amount of the annual payment that flows into the Tobacco Settlement Endowment Trust (TSET) by 50% to offset some of the expense of the upcoming Medicaid expansion approved by voters earlier this year.

“I hate that it didn’t pass because our options on how to fund Medicaid expansion are really limited at this point, and none of the options that are left on the table are options that people are going to like,” said state Sen. Greg McCortney, R-Ada.

He said the Legislature is constitutionally mandated to balance the budget. If income is down and expenses are up, lawmakers will have to cut spending somewhere, and there are only so many options on the table.

McCortney said he’s heard some Oklahomans suggest tax increases to pay for expansion, but suspects many of Tuesday’s legislative winners ran on pledges to keep taxes low.

“So increasing taxes to pay for Medicaid expansion is clearly not what the people of Oklahoma are looking for the Legislature to do,” he said.

Had the measure passed, lawmakers would have received about $49.7 million — or 75% — of the state’s share of the annual payment from “big tobacco.” The measure required lawmakers to use the TSET funds to help pay the state’s 10% Medicaid expansion share. The federal government is responsible for paying the remaining 90%.

The voter-mandated Medicaid expansion is expected to shore up struggling hospitals and insure as many as 200,000 more Oklahomans. However, it comes amid a worsening state budget situation and doesn’t provide lawmakers any guidance on how to pay the estimated $164 million to $246 million price tag next year.

“Today’s outcome is an enormous win for Oklahomans who clearly prioritize their health,” said Matt Glanville, Oklahoma government relations director for the American Cancer Society Cancer Action Network.

He is part of the Vote No — 814 is Not OK coalition.

“We are grateful that voters recognize they don’t have to sacrifice tobacco control and cancer research grants to expand Medicaid,” Glanville said. “The Legislature knows how to fund Medicaid expansion while maintaining the integrity of the TSET trust, and they simply need to implement those measures.”

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

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340 B covered entities are opposed to moving drugs to FFS only in NY (carving rx out of managed care).

 
 

Clipped from: https://www.nydailynews.com/news/politics/new-york-elections-government/ny-medicaid-prescription-drugs-funding-change-20201111-njbe3len6fgwbn2khxxykwxoxi-story.html

ALBANY — A growing coalition of health care groups and providers are outraged over an impending change to Medicaid funding for prescription drugs in the Empire State.

The groups are pleading with the Department of Health to not follow through on changes to the 340B drug discount program, which allows safety net hospitals catering to underserved and low-income communities to purchase deeply discounted prescription drugs.

A provision tucked into the budget this year, based on a recommendation by the state’s Medicaid Redesign Team, would “carve out” the discount and shift payment to a fee-for-service reimbursement starting next April.

That means hospitals that care for large numbers of people with Medicare, Medicaid or those without insurance would lose out on the savings and the state would instead capture the rebate, a move that could decimate essential services for communities hardest hit by the coronavirus pandemic, opponents argue.

“It’s essential to maintain the safety net for our state’s most vulnerable populations,” said Guillermo Chacon, president of the Latino Commission on AIDS and founder of the Hispanic Health Network. “The State’s budget changes to ‘carve-out’ Medicaid prescription drugs will devastate the 340B drug discount program for the poorest New Yorkers in need of health services.”

Sen. Gustavo Rivera (D-Bronx) and Assemblyman Dick Gottfried (D-Manhattan), the health chairs in both the Senate and Assembly, have proposed a bill that would delay the transition for three years.

As per the current law, the state Department of Health has convened an advisory group, which is exploring the impact of the change. The work group has met three times and is scheduled to reconvene soon, according to agency spokesman Jonah Bruno.

Bruno said the proposal “saves taxpayers millions of dollars by increasing transparency, ensuring Medicaid pays the best price for medications, and eliminating unnecessary administrative costs to health plans, all while ensuring that consumers continue to have access to needed medications.”

More than 35 groups have so far joined the Save NY’s Safety Net: 340B Saves Lives coalition, including the Drug Policy Alliance, the Alcoholism & Substance Abuse Providers of New York State, and Community Healthcare Network, a non-profit network of 14 federally-qualified health centers serving 85,000 patients annually in the five boroughs.

“We provide high-quality, affordable primary care and specialty support services, regardless of patient ability to pay,” said Robert Hayes, president and CEO of the the health care provider. “The 340B carve-out threatens our most essential programs. The carve-out is reverse Robin Hood, taking efficient, life and health preserving care from New Yorkers most in need.”

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

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OH will scrap the PBMs chosen by the MCOs and replace them with a single pharmacy operational support vendor (POSV) chosen by the state.

 
 

 
 

Clipped from: https://www.dispatch.com/story/news/2020/11/06/medicaid-stepping-up-oversight-pharmacy-benefit-program-saving-taxpayers-money-due-pbm-abuses/6181248002/

 
 

The Ohio Department of Medicaid on Thursday started the process of hiring a private administrator to oversee its $3 billion pharmacy benefit program.

The department requested proposals for a pharmacy operational support vendor to help design its program and provide financial oversight once it’s up and running.

Medicaid created the new post as part of a broader overhaul of its managed care program. In addition to rebidding contracts with private managed care organizations that oversee the program, the state agency is also replacing five pharmacy benefit managers hired by those private organizations to process claims with one company hired by the state and monitored by the administrator.

“The POSV (pharmacy operational support vendor) will ensure monetary incentives are properly and fairly aligned, eliminate self-dealing and steering, and monitor and close potential pricing or rebate loopholes,” said Medicaid Director Maureen Corcoran.

“In short, the POSV ensures that the fox is no longer guarding the chicken coop.”

The administer will operate independently from the pharmacy benefit manager, providing oversight and ensuring pharmacists are paid accurately for the prescriptions they fill.

The added oversight comes after a report showed PBMs billed the state far more than they paid pharmacists and kept the difference, allowing them to receive $224 million in one year — an amount generated by PBMs charging three to six times the standard rate, according to an independent analysis.

Ohio Pharmacists Association Executive Director Ernie Boyd applauded state officials “for taking this important step in Ohio’s cleansing of the PBM problem.”

“The proposal would position Ohio as a national leader in rooting out dysfunction in the drug supply chain. With proper execution of implementation of this vision, provider access can be stabilized, incentives can become better aligned, and taxpayer dollars can be deployed more effectively and efficiently,” Boyd said.

“One thing that’s extremely noteworthy in the RFP is that ODM has effectively stripped PBMs of their price-setting capabilities. That is a major marketplace shift, and is a complete rebuke of what PBMs have been doing. Essentially, the text of the RFP is ODM’s way — through action — to completely pull the rug out from under the many shell games that PBMs were engaging in. Pretty incredible 180 from where we were.”

The tax-funded health insurance program provides coverage to more than 3 million poor and disabled Ohioans.

ccandisky@dispatch.com

@ccandisky

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

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NC has launched an enrollment website for the new managed care program, and members can enroll from March to May of 2021.

 
 

 
 

Clipped from: https://www.wnct.com/news/north-carolina/nc-medicaid-launches-website-for-beneficiaries-to-learn-more-about-medicaid-managed-care/

 
 

RALEIGH, N.C. (WNCT) The North Carolina Department of Health and Human Services announced the launch of NC Medicaid’s managed care enrollment website in preparation for the launch of Medicaid Managed Care scheduled for July 1, 2021.

The purpose of the enrollment website is to help Medicaid beneficiaries learn more about Medicaid Managed Care.

In 2015, the NC General Assembly enacted legislation directing NCDHHS to transition Medicaid and NC Health Choice from a primarily fee-for-service delivery system to managed care.

Under managed care, the state contracts with insurance companies, which are paid a predetermined set rate per enrolled person to provide all services.

The enrollment website provides information about who will have to choose a health plan, who will stay in the traditional Medicaid program (NC Medicaid Direct), and who can choose between the two.

It will also share the basic medical and behavioral health benefits that are offered. There will be a list of frequently asked questions and answers to help beneficiaries understand the changes.

A small number of people will not need to choose a Medicaid Managed Care health plan because of the type of health services they need. They will stay enrolled in NC Medicaid Direct.

To learn more, beneficiaries can visit the NC Medicaid Direct services page on the enrollment website.

RALEIGH — The North Carolina Department of Health and Human Services today announced the launch of NC Medicaid’s managed care enrollment website, www.ncmedicaidplans.gov, in preparation for the launch of Medicaid Managed Care scheduled for July 1, 2021.
 
The purpose of the enrollment website is to help Medicaid beneficiaries learn more about Medicaid Managed Care. In 2015, the NC General Assembly enacted legislation directing NCDHHS to transition Medicaid and NC Health Choice from a primarily fee-for-service delivery system to managed care. Under managed care, the state contracts with insurance companies, which are paid a predetermined set rate per enrolled person to provide all services.
 
The enrollment website provides information about who will have to choose a health plan, who will stay in the traditional Medicaid program (NC Medicaid Direct) and who can choose between the two. It will also share the basic medical and behavioral health benefits that are offered. There will be a list of frequently asked questions and answers to help beneficiaries understand the changes.

Most people currently receiving Medicaid benefits will need to enroll in Medicaid Managed Care. Open enrollment will begin March 15, 2021, and will continue through May 14, 2021. Medicaid beneficiaries will be able to choose from five health plans — WellCare, United HealthCare, Healthy Blue, AmeriHealth Caritas and Carolina Complete Health (serving regions 3, 4 and 5). Those who are federally recognized tribal members or qualify for Indian Health Services are exempt from managed care. Those who live in Cherokee, Graham, Haywood, Jackson or Swain counties or in a neighboring county may choose to enroll in the Eastern Band of Cherokee Indians (EBCI) Tribal Option.
 

Features that will be added to the Medicaid Managed Care enrollment website in January 2021 include:

• Medicaid and NC Health Choice Provider and Health Plan Lookup Tool members can use to find and select the best primary care provider for their families.
• Choice Guide members can use to view health plans and select those with the best features for their needs

To learn more about North Carolina’s transformation to Medicaid Managed Care, visit the Medicaid Transformation webpage.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

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The new OH MCO contract awards will focus on population health measures, and are expected to be announced January 2021.

 
 

Clipped from: https://www.limaohio.com/wire/state-wire/435620/why-ohio-is-overhauling-medicaid

The overhaul of Ohio’s Medicaid program has farther reaching consequences than CareSource.

The health insurance program for 3 million Ohioans with low incomes and disabilities is a major policy tool. It’s a key source of health care for the Dayton region, which is older and less affluent than the state as a whole, and also a source of funding for hospitals, doctors and other providers.

The change is designed to improve the care of the 2.7 million Ohioans who get their care get their Medicaid benefits through a system called Medicaid managed care where an insurance company that manages the plan and pays out the claims. Five insurance plans manage these policies in Ohio.

“We’re in a fairly unique group of states who have made a pretty near comprehensive commitment to manage care. So we want to keep pushing the envelope in terms of getting the best outcomes for people that we support,” State Medicaid Director Maureen Corcoran, in an interview after the procurement was publicly posted in October.

Some of the outcomes that the overhaul aims to improve have been documented in state and federal reports.

Loren Anthes, Medicaid researcher with Cleveland-based Center for Community Solutions, reported that the state had a “secret shopper” program that found trying to learn more about Medicaid member consumer experiences, the ability to schedule an appointment for routine care was less than 70%; the ability to schedule an appointment as a new patient was around 75%; on average, patients had to wait 27 days for an appointment; and only 7 in 10 contracted physicians accepted new patients.

When looking at the Healthcare Effectiveness Data and Information Set, which is a widely used set of performance measures in the Medicaid managed care industry, only 52% of Ohio children get their health checks completed, fewer than 2 in 3 children get regular vaccinations, and fewer than half of children have annual dental appointments.

Ohio is trying to create a new set of rules that gets better results. Gov. Mike DeWine’s office announced the request for proposals as part of a new vision for Ohio’s Medicaid program that focuses on people — not just the business of managed care.

“Since coming into office in January of 2019, my administration has been evaluating our Medicaid program to develop a vision of a better, healthier, and more productive state,” DeWine had said. “With input from Ohioans covered by Medicaid, physicians, hospitals, health care providers, and managed care plans, this will be the first major overhaul of Medicaid in 15 years.”

The overhaul has so far been a massive effort.

For the past 18 months, the DeWine administration has been doing the leg work leading up to this bid. This includes getting feedback from 1,100 different people and organizations.

Ohio Medicaid will let the winning bids know with award letters Jan. 25, 2021. The goal is for the newly rebid system to go live Jan. 5, 2022.

Some of the new conditions that Ohio Medicaid wants for insurance companies it contracts with include making the system easier to use, adding population health measures to keep people healthy, and the new conditions also add new accountability measures.

The method that will be used to score applicants like CareSource includes different points for different categories, with a total 1,000 points as the highest possible score.

The scoring method puts the highest emphasis on population health measures, where companies can earn up to 395 points. Qualifications and experience is the lowest weighted category, worth up to 85 points.

Some of the aspects of the bid includes that insurance companies are asked to describe how they will identify and address the need for reliable transportation to services, and they must submit a plan for how they will invest a portion of profits back into the community. The system also comes with a range of penalties for non-compliance, such as an insurance company getting an enrollment freeze until they fix the particular issue.

The new system is also supposed to make it easier for doctors and other providers to work with the system, such as having a single point for filing claims instead of the current system of working with up to five different plans.

“The thing I noticed in particular is there’s a big shift away from the interests of the managed care companies to the interests of patients and providers,” Anthes said.

 
 

https://www.limaohio.com/wp-content/uploads/sites/54/2020/11/web1_Ohio-15.jpg

By Kaitlin Schroeder

Dayton Daily News, Ohio (TNS)

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OH Medicaid will have MCOs offer companionship-focused calls to nursing home residents.

 
 

 
 

Clipped from: https://www.modernhealthcare.com/post-acute-care/ohio-medicaid-launches-program-curb-long-term-care-loneliness

The Ohio Department of Medicaid is introducing a “friendly caller” program to reduce loneliness among residents in long-term care facilities.

Through the holidays, Ohio Medicaid, Ohio’s five Medicaid managed care organizations and the state’s Area Agencies on Aging will work together to pair residents with volunteers for 30-minute informal calls twice a week.

The Area Agencies on Aging will train volunteers on how to provide companionship over the phone. Volunteers also will be trained on the UCLA Loneliness Scale to identify residents who made need more intervention. The program will be open to any nursing home or assisted living facility with at least 50 residents receiving services through Ohio Medicaid managed care programs.

“Research shows us that the holidays are an emotionally challenging time for those residing in shared living facilities, a reality exacerbated by months of social distancing and limited interaction with loved ones,” Ohio Medicaid Director Maureen Corcoran said in a prepared statement. “We also know that depression can accelerate physical deterioration. This initiative gets to the heart of the matter by offering consistent, caring and highly interpersonal connections that are needed now and throughout the holidays ahead.”

Heading into the holiday season, the isolation necessary to protect long-term care residents from community spread will make the pandemic more challenging, long-term care leaders said. Families won’t be able to visit residents, group meals among residents won’t happen and volunteers won’t be able to come in to celebrate, they said. Instead, staff will turn to virtual visits and, in some cases, outdoor visits, said Katie Smith Sloan, president and CEO of LeadingAge, a national association of aging services providers.

“Older adults are living at Ground Zero in the worst pandemic in a century,” Smith Sloan said. She and other long-term care leaders are calling on government officials and all Americans to help stop the spread of COVID-19.

Since April 15, about 21,000 residents in Ohio’s long-term care facilities have contracted COVID-19, about 3,100 of whom have died, according to Ohio’s COVID-19 dashboard. In Ohio, more than half of the deaths from the virus have been among long-term care residents. On Tuesday, Ohio saw its second highest daily number of total deaths – 98 – from COVID-19.

Nationwide, positive cases for nursing home residents rose 21% from the first week of November to the second, according to the American Health Care Association and National Center for Assisted Living, which represents nursing homes and assisted living communities. In the U.S., there were 12,429 resident cases the week of Nov. 8.