Category: Curator

HHS Curator is our free research service published by our team. We read hundreds of Medicaid news items each week and highlight and summarize them for you to save you time.

Posted on by

Medicaid managed care companies take protest to court | NC Health News

Curator, Managed Care, North Carolina

 
 

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.

 
 

 
 

Curator summary

NC managed care now is required to move forward by the legislature by July 2021, though protests/ lawsuits are still pending.

 
 

Clipped from: https://www.northcarolinahealthnews.org/2020/09/29/medicaid-managed-care-companies-take-protest-to-court-again/

 
 

In the middle of a coronavirus pandemic that has tossed up challenge after challenge, the state Department of Health and Human Services also must tend to another enormous project.

Over the next 10 months, the department has been told by the legislature to complete the transformation of its cumbersome Medicaid system.

In the current system, the state pays for each office visit, test and hospitalization for the seniors and children enrolled in Medicaid. By July 1, North Carolina is expected to launch a managed-care system in which private insurance companies get lump-sum payments from the state to pay providers for their overall care of most of the state’s 2.3 million beneficiaries.

North Carolina lags behind the rest of the country in making this switch and the changeover has been touted by Republican legislators as a potential cost-saver for the state.

As DHHS staff tend to the details of the massive switch of how some 1.6 million Medicaid patients will get health care, companies that lost out on bids for a share of the more than $30 billion the state will dole out over the next five years are stepping up their challenges in court.

In late August, an administrative law judge ruled against Aetna, Optima and My Health By Health Providers, companies that argued DHHS unfairly awarded Blue Cross Blue Shield of North Carolina a contract.

My Health By Health Providers, a consortium of major hospital systems in North Carolina, petitioned a Wake County Superior Court judge this week to reverse that decision.

In the court document filed on Sept. 23, the provider-led entity, or PLE,  argued that the contract awarding process gave a weighted bias to traditional insurance companies over the 12 health systems that have joined together as My Health By Health Providers.

They argue that their owners, which already serve more than 1 million Medicaid beneficiaries each year, are in a better position to provide the managed care, in part, because they are in North Carolina and familiar with the health needs already.

They are troubled that the judge issued a ruling in summary judgment, a step that precluded them from presenting their entire body of evidence in a hearing.

Was the process rigged against PLEs?

Lisa Farrell, executive director of My Health By Health Providers, said her organization was only before the administrative law judge for two hours of arguments.

On Monday, she ticked off a few reasons why she thought the DHHS process was rigged against PLEs from the start. She also explained why My Health By Health Providers is continuing its challenge in Wake County Superior Court instead of trying again when the procurement process opens again.

It’s best to be in on the ground-level, she said.

“One of the considerations as you go forward is members will establish themselves,” Farrell said.

Though My Health By Health Providers was the highest PLE scorer in the bidding process, the state argues that it was looking for a regional plan and the conglomeration of health care systems had pitched a statewide plan. The 2015 law mandating the Medicaid switchover stipulates that PLEs can bid for business in a region, or two contiguous regions, but doesn’t say anything about PLEs bidding for all of the state’s regions.

Farrell argues that My Health By Health Providers’ bid also offered regional options.

While explaining why she thinks PLEs are needed in North Carolina to complement and challenge  the managed care that traditional insurance companies provide, Farrell gave an example of a pediatrician in rural North Carolina treating a child with a complex illness.

The health care systems comprising My Health By Health Providers include Atrium Health, Cape Fear Valley Health, CaroMont Health, Cone Health, Duke Health, Mission Health, New Hanover Regional Medical Center, Novant Health, UNC Health, Vidant Health, Wake Forest Baptist Health, and WakeMed Health and Hospitals, some of which are connected to academic research centers.

With that connection, the rural provider could get the patient quickly linked to a health care facility that could provide the more complex care, Farrell argued.

“Providers, because they are providing the care, are really closer to their beneficiaries,” Farrell said.

Conflict of interest contentions

The state’s selections for the coveted managed-care contracts were announced in February 2019. The awards went to four well-established insurance companies: AmeriHealth Caritas, Blue Cross and Blue Shield of North Carolina, UnitedHealthcare and WellCare. Carolina Complete Health, a provider-led group that will be run by Centene, a managed care giant, was the sole provider-led entity selected. The N.C. Medical Society backed that plan.

In challenges that started last year in the state Office of Administrative Hearings, My Health By Health Providers, Aetna and Optima Health, another provider-led group linked to Virginia’s Sentara Healthcare, argued that DHHS employees involved in the contract awarding process had conflicts of interest that caused them to favor BCBSNC over their bids.

The state and BCBSNC have disputed those claims, and on Aug. 25, Tenisha Jacobs, an administrative law judge, sided with them, ruling that the contract had been properly awarded.

DHHS issued a statement several days after the decision.

“The NC Department of Health and Human Services (NCDHHS) is pleased to announce that once again court rulings affirm the integrity and fairness of the Departments’ managed care procurement process,” according to the statement.

Jacobs heralded the possibility of such an outcome in a June 2019 ruling before the companies had presented all their evidence. They had asked her to halt the Medicaid system transformation while their court cases remained unresolved.

Though Jacobs ruled against the request, saying the companies seemed unlikely to succeed on the merits of their claims, the transformation was instead put on hold in late 2019 because of a budget standoff between Gov. Roy Cooper and Republicans leading both General Assembly chambers.

July 2021 launch date

The transformation had been scheduled to begin in February of this year, but the General Assembly closed its 2019 session without a budget that dedicated funding to the project.

This summer, the General Assembly set a new deadline. Lawmakers considered penalizing DHHS if the transformation did not occur by July 1, raising the possibility that the department could be charged millions of dollars for each month after that date that the launch did not occur.

Eventually, the bill that passed did not include penalties.

“North Carolina’s approach to managed care has received national recognition and focuses on improving the health of North Carolinians through an innovative, whole-person centered and well-coordinated system of care that addresses both the medical and non-medical drivers of health,” according to the DHHS statement issued in August after the ruling.

Aetna immediately appealed the August ruling in Wake County Superior Court.

“For the past 18 months, Aetna Better Health has dutifully followed the Office of Administrative Hearings’ (OAH) protest process in our protesting the North Carolina Department of Health and Human Services’ (DHHS) awarding of contracts for prepaid health services regarding the state’s Medicaid program on several grounds, including, but not limited to, conflicts of interest between DHHS and certain awarded carriers, changes in the scoring process by DHHS to benefit certain awarded carriers, and DHHS’ attempt to conceal how scores were changed to benefit particular awarded carriers,” Aetna said in a company statement at the time. “After a year and half of protest with little progress, we are left no viable choice procedurally but to pursue our Medicaid protests against DHHS in Superior Court.”

Depositions and 230,000 pages of documents

Dave Richard, deputy DHHS secretary for NC Medicaid, said in an interview last week that while he’s confident in the process used to award the contracts, legal challenges were not unusual.

“I think we’re seeing that across the country that that happens,” Richard said. “No one wants to go through this process. It takes time from people, but we were always prepared that this is a possibility.”

As part of the legal defense, the department produced some 230,000 pages of documents and staff members had to sit through weeks and weeks of depositions.

“The judge ruled in our favor,” Richard said. “We believed she ruled correctly, and we have no reason to believe that there’ll be anything different that happens in the appeal.”

The challengers hope for a different outcome, arguing that they did not get to present all their evidence to the administrative judge.

Could too many lawsuits crash plans?

Matt Salo, executive director of the National Association of Medicaid Directors, said the challenges in North Carolina are not unique, but all that litigation eventually might lead states to reconsider managed care systems.

“I appreciate that this is really important stuff, that this is big business, these are contracts that are very, very meaningful,” Salo said in a telephone interview last week. “But having said that, if we keep going on this trajectory, where everybody who doesn’t like the outcome, just resorts to the courts, and sues and has a bid protest, we’re going to end up in a world where states are just going to throw their hands up and say, ‘You know what, it’s easier if we just go back to fee for service.'”

Salo did not speak specifically about the North Carolina cases, but acknowledged that some companies that lose out on contracts might have legitimate concerns that should be litigated.

In Louisiana, contracts worth billions of dollars were thrown out in January after the state’s chief procurement officer determined the health department had mishandled the bidding process.

Two losing bidders helped reveal the problems in challenges filed by Louisiana Healthcare Connections and Aetna Better Health, which banded together to complain of conflicts of interest, a skewed process and improprieties.

“There can be a role for a protest, you know, if something serious has gone wrong, if there was a serious mistake that was made, and sometimes that happens,” Salo said. “You know, it’s important to have an outlet. …There are legitimate protests. And if that’s the case, you should do it.

“What I’m worried about is the trend where it’s just, it’s just a knee jerk reaction of ‘I didn’t like the option. So, I’m escalating to the next step.'”

 
 

Posted on by

Coronavirus pandemic complicates Medicaid expansion efforts in Oklahoma


Coronavirus pandemic complicates Medicaid expansion efforts in Oklahoma

Published: Mon, April 27, 2020 5:00 AM
When Oklahoma expands Medicaid on July 1, legislators still haven't decided how to pay for the state’s share of the expansion. [Bryan Terry, The Oklahoman]
Oklahoma is on track to expand Medicaid on July 1, but legislators still don’t know how to pay for the state’s share of the expansion.
And the COVID-19 pandemic has complicated the situation.
Skyrocketing unemployment claims mean the expansion, and costs for the state’s current Medicaid program, could be about $100 million more than previously anticipated.
Altogether, the $250 million would amount to about 3% of the current state budget, but the state is projected to have a $1.3 billion revenue shortfall in the budget year that begins July 1.
In other words, extra cash will be hard to find next year.
Gov. Kevin Stitt said he’s still aiming to pay for the state’s 10% share of Medicaid expansion by increasing a hospital fee. The federal government will cover 90% of expansion costs.
“I maintain I will not raise taxes on Oklahomans,” Stitt said. “This is going to have to be a provider tax, and the Legislature’s still kicking around how to fund that.”
The provider fee is the Supplemental Hospital Offset Payment Program, enacted in 2011. So-called SHOPP assesses a fee of up to 4% of annual net patient revenue at 65 Oklahoma hospitals. The fee, which is adjusted annually, currently sits at 2.3%.
The fee was never intended to fully cover the cost of expansion, so the state will have to find more money from somewhere to cover the rest, said Sen. Greg McCortney, R-Ada.
Already a hard sell to a Republican-controlled Legislature, the state’s financial outlook has some lawmakers questioning the timing of the expansion. Stitt wants to expand Medicaid on July 1 as part of his SoonerCare 2.0 plan, which he devised as an alternative to State Question 802.
SQ 802 asks voters to enshrine Medicaid expansion in the state’s constitution, and it would have to take effect by July 1, 2021.
“Between not knowing how much (Medicaid expansion) costs now and not really having an opportunity to thoroughly vet exactly what the long term plan is, I’m personally in favoring of slowing down and kind of putting the brakes on it right now,” McCortney said.
But in the months since negotiations started, the COVID-19 crisis has dramatically changed the financial picture for Oklahoma hospitals.
Following an executive order from Stitt, hospitals had to put elective surgeries and minor medical procedures on hold for about a month to be able to free up hospital beds for an anticipated flood of coronavirus patients.
“The budget downturn related to the COVID-19 virus certainly puts financial strains not only on the state but also our hospital members,” Oklahoma Hospital Association President Patti Davis said in a statement. “As hospitals have scaled back elective surgeries and procedures in preparation for a surge of COVID-19 patients, the financial situation for most hospitals has changed significantly over the past month.
(Story continued below…)
“At the same time, expanding Medicaid would bring back $9 into the Oklahoma economy for every $1 investment by Oklahoma. This infusion of federal funds into Oklahoma in this downturn is something that must be considered seriously.”
Stitt allowed some elective surgeries to resume last week, and all will be able to resume Friday.
But the hospital association has warned patients there could still be delays with some elective surgeries and minor medical procedures as hospitals seek additional personal protective equipment for health care workers.
“The hospitals, they definitely want it,” said Rep. Marcus McEntire, R-Duncan. “That hasn’t changed, and with this pandemic, it may have accelerated their desire to get it going because expansion could really help them with their cash flow.”
“Our job at the Health Care Authority, at this time, is to make sure we’re ready operationally and ready to serve,” he said.
Corbett appeared before the Senate Health and Human Services Committee, chaired by McCortney, as the Senate vets his appointment to the Health Care Authority.
There’s still not an agreement on SoonerCare 2.0 or funding for the plan, Senate Pro Tem Greg Treat, R-Oklahoma City, told reporters Thursday.
“There’s no agreement to that end yet,” he said. ”I know the governor is still pursuing the state plan amendment with the federal administration, but we have not committed to getting the money there yet.”
The agency recently submitted an application for a Healthy Adult Opportunity waiver that would allow the state to impose work requirements and charge premiums for newly eligible Medicaid recipients.
With the vote on SQ 802 set for June 30, it’s unclear if Stitt might be willing to delay implementation of his expansion plan.
“It seems this governor gets laser-focused on something and he wants to see it through to the end, and he may be that on this issue,” McEntire said.
Carmen Forman
Carmen Forman covers the state Capitol and governor's office for The Oklahoman. A Norman native and graduate of the University of Oklahoma, she previously covered state politics in Virginia and Arizona before returning to Oklahoma. Read more ›

Posted on by

NC passes coronavirus recovery bill to spend stimulus | Charlotte Observer


NC passes coronavirus recovery bill to spend stimulus

NC legislature passes COVID-19 relief, without expanding jobless benefits or Medicaid

May 02, 2020 10:45 AM, Updated May 02, 2020 02:53 PM
Paper artist Fritzi Huber gives a tutorial on how to make a paper cup. In the weeks ahead, we will share first-person accounts of how the coronavirus is affecting the lives of North Carolinians through video diaries, photos & essays. By Bobby Huber
RALEIGH
The North Carolina legislature came back Tuesday for its 2020 session with a tall order: decide how to handle $3.5 billion in new federal money for COVID-19 relief.
On Saturday, the House and Senate passed their plan unanimously, sending it to the governor.
Leaders from both chambers reached a deal late Friday night on a $1.57 billion spending plan containing millions in funding for education, health care, small business loans, food banks, medical research, testing and $50 million for personal protective equipment.
Rep. Donny Lambeth, a Forsyth County Republican, called it a “really good compromise.” He said lawmakers would work on a second phase of how to spend the federal money when they return to session later this month.
Not all House members were in the chamber. Several voted by proxy, with party leaders announcing their votes. Most were wearing masks.
While the House didn’t get the temporary Medicaid expansion for coronavirus patients it wanted, the chambers agreed to increased funding in rural health and small business loans.
“The federal government through its power has actually already said they’re going to cover 100% of the treatment of COVID-19,” House Speaker Tim Moore, a Kings Mountain Republican, told reporters after the final vote. “We didn’t need to do it because the federal government is already taking that up.”
Lawmakers did not increase the maximum amount of unemployment weekly benefits to $400, as the Senate had wanted.
And a call to allow restaurants and bars to serve mixed drinks as take-out and delivery orders were nixed in the final bill.
In an emailed statement Saturday, Democratic Gov. Roy Cooper said he applauds the General Assembly for working quickly to pass legislation to fight COVID-19, without committing to signing the bill.
“These bills were developed collaboratively, and although it’s just a first step, they are the product of a consensus approach that I hope can continue. I will be reviewing them closely and look forward to taking action on them soon,” Cooper said.

Resolving differences

Lawmakers also had disagreed over what to do with the state’s current mandate for schools to reduce class size in kindergarten through third grade. Schools must continue to change staffing and buildings to reduce class sizes. The House wanted to waive that requirement for a year. In the end, they dropped the delay, but Rep. David Lewis said lawmakers can take up the issue when they return.
The same goes for a provision dealing with the salaries of school principals, Lewis said.
“This is a good bill. It provides common sense, tangible, much needed and urgent relief,” said Lewis, a Harnett County Republican.
Sen. Jeff Jackson, a Mecklenburg County Democrat, tweeted a video of himself saying the House and Senate “came together and compromised to produce a joint bill that makes a good first step.” Jackson is a Mecklenburg County Democrat.
The House has spent a month in public COVID-19 committee meetings drafting smaller bills that were rolled into one comprehensive bill. The Senate did not reveal any of its plans until this week.
The Senate passed its original $1.36 billion COVID-19 response bill on Wednesday night, and the House passed its first, $1.7 billion version Thursday. Cooper had laid out his own plan to spend $1.4 billion of the federal money.

No extra unemployment benefits

The North Carolina Chamber of Commerce, which represents businesses around the state, worked closely with lawmakers on several provisions that made it into the final version of the bill, including $125 million in funding for small business loans through the Golden LEAF Foundation.
The nonprofit group launched an initial round of small business loans in March and almost immediately ran out of money due to the high demand. Ray Starling, the chamber’s general counsel, said this extra $125 million will supplement other loans and grants coming in from the federal government.
”That’s going to be very helpful for small businesses,” he said.
The chamber opposed the proposal to expand the state’s maximum unemployment benefits by $50 a week, Starling said.
Starling said the way that proposal had been written, it wasn’t clear if the extra money would go to everyone receiving unemployment, or only people receiving the maximum amount. And without a financial estimate of how much it would cost, he said, many businesses were wary of potentially having to pay more into the unemployment system in the future.
Cooper issued an executive order in March that businesses wouldn’t have to pay into the unemployment system during coronavirus, but usually they have to supplement the state funding.
North Carolina has among the lowest unemployment benefits in the nation. Starling said the chamber wouldn’t necessarily oppose efforts to expand those benefits in the future. He said it just couldn’t support anything now, with details lacking about the cost of the program, and “about where the economy is going to be later this year and how many people are still going to be on unemployment.”

Deadline to spend the rest of the stimulus money

Lambeth said the compromise includes tens of millions of dollars in various forms to help hospitals, particularly rural hospitals and teaching hospitals attached to universities.
Lambeth said he would’ve liked to see more money for hospitals but noted that the legislature will still have around $2 billion from the federal government that will have to be spent by December.
“That’s a nice problem to have,” he said.
Moore said that over the next two weeks, the House COVID-19 committee would continue to meet and that the House would return on May 18 for a “normal” session. He said proxy voting would end, which means more House members would be in the chamber at once.
Moore said rules about access to the Legislative Building would be reassessed at that point. This week only lawmakers, staff and credentialed press were allowed inside.
Rep. John Bell, a Wayne County Republican, called the package passed Saturday the first step in a long process to provide COVID-19 relief.
House Democratic Minority Leader Darren Jackson said in an emailed statement after the vote that the bills will help North Carolina “battle the COVID-19 disease and help our workers and small businesses with the damage caused by the disease.”
“There is much more work to do, particularly with protecting front-line workers, strengthening the unemployment safety net, broadband investment, and expanding health care coverage and lowering health care costs for all North Carolinians,” Jackson said.
Senate Minority Whip Jay Chaudhuri, a Wake County Democrat, highlighted the package’s spending on school nutrition, PPE, local governments, rural and underserved communities, child care, food banks and $25 million for “testing, tracing and trends,” which the governor has repeated is necessary for lifting statewide restrictions.

Reopening pressure

Moore told reporters on Thursday that during the time lawmakers are gone, they’ll see how things go with the state reopening and people going back to work.
Cooper extended his statewide stay-at-home order from April 29 through May 8, with a few of the restrictions scheduled to start to lift after that under what Cooper described as a “modified” stay-at-home order. The stay-at-home order wouldn’t lift until the second phase, which would likely be the end of May.
Most lawmakers from both parties have been supportive of Cooper’s order, though they have started to question the slow-phased opening.
Six Republican House members in the conservative American Legislative Exchange Council, including Appropriations Chair Rep. Jason Saine, signed a letter calling on states to safely reopen the economy, though their letter doesn’t say exactly how.
On Tuesday, lawmakers arrived for the session to protesters who want the governor to lift restrictions sooner.
A monitor fills the desk space next to Rep. Darren Jackson, showing a video call with other members of the House as they finalize versions of a bill allocating federal money for COVID-19 relief, on Saturday, May 2, 2020, in the North Carolina General Assembly building in Raleigh, N.C. Casey Toth ctoth@newsobserver.com
Dawn Baumgartner Vaughan covers North Carolina state government and politics at The News & Observer. She previously covered Durham, and has received 10 North Carolina Press Association awards, including an award for investigative reporting and the McClatchy President’s Award.
Will Doran reports on North Carolina politics, with a focus on state employees and agencies. In 2016 he started The News & Observer’s fact-checking partnership, PolitiFact NC, and before that he reported on local governments around the Triangle. Contact him at wdoran@newsobserver.com or (919) 836-2858.

Posted on by

Trump administration skimps on coronavirus aid for Medicaid providers


Trump administration skimps on coronavirus aid for Medicaid providers

WASHINGTON — The Trump administration’s program to aid hospitals and doctors on the front lines of the coronavirus crisis is leaving behind the nation’s Medicaid safety net — the pediatricians, mental health providers and hospitals that serve the poorest patients.

That result is likely to deepen inequalities in America’s healthcare system as tens of billions of dollars of federal assistance go primarily to large medical systems that serve higher-income patients with Medicare or private health insurance.
State leaders — Republicans and Democrats alike — are expressing alarm, warning that the federal coronavirus response is critically weakening Medicaid. The threat — which follows three years of largely unsuccessful efforts by President Donald Trump and his congressional allies to slash the healthcare safety net — comes at the very moment that tens of millions of Americans are losing jobs and will probably need the government health plan.
“States have spent years building networks of providers to serve the very complex needs of patients who rely on Medicaid,” said former Arizona Medicaid director Tom Betlach, who is currently helping the state’s Republican governor run Arizona’s swamped social service programs.
“Now, states are struggling to figure out how they can keep these providers afloat without more assistance,” Betlach added. “There’s a lot of concern out there.”
Medicaid, the half-century-old health insurance program for the poor, together with the related Children’s Health Insurance Program, provide coverage to more than 70 million Americans, including nearly half of the nation’s children.
State Medicaid directors this week warned Health and Human Services Secretary Alex Azar that his department’s coronavirus response is inadequate, and called for more aid “in the next two weeks” to avoid widespread disruptions.
“This engagement with states must occur as soon as possible,” wrote Florida Medicaid director Beth Kidder and Arizona Medicaid director Jami Snyder, the president and president-elect, respectively, of the National Association of Medicaid Directors.
A coalition of leading mental health advocacy groups, including the National Alliance on Mental Illness and the National Council for Behavioral Health, sent Azar a similar warning, telling him that more than 60% of mental health providers have already been forced to close one or more programs.
And the American Academy of Family Physicians, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists pleaded with Azar this week for assistance. “If our member physicians cannot access urgently needed financial relief, their practices may close and patients will lose access to critical care,” the groups warned.
There is growing evidence this is already happening.
In South Carolina, Spartanburg Pediatric Health Center — one of the only pediatricians’ offices in the area that doesn’t restrict how many poor patients with Medicaid coverage it takes — is set to close in July. Dr. Shana Egge, one of the center’s pediatricians, said the health system that owns it concluded it could no longer afford to keep it open.
“I don’t know what will happen to the kids we care for,” Egge said. More than 70% of the clinic’s patients come from low-income families.
Hospitals, clinics and physicians’ offices across the country have seen a steep drop-off in business during the coronavirus outbreak as medical centers limit nonessential procedures and patients stay away, fearful of getting ill.
That prompted Congress to earmark $100 billion in emergency assistance for medical providers in the most recent aid package. But it left the distribution of this funding to the Department of Health and Human Services.
The department initially allocated money based on providers’ Medicare revenues, a calculation that favored hospitals and physicians that care for large numbers of elderly patients.
Last week, Azar announced yet another formula, which would allot additional aid largely based on medical providers’ total revenues. This tipped the scales even more toward hospitals, physicians and other providers that care for patients with commercial health insurance, which typically pays them much higher rates than either Medicare or Medicaid, the two main government health plans.
Particularly disadvantaged are medical providers that focus on poor patients. These practices, medical centers, nursing homes, mental health providers and other home- and community-based providers typically have lower revenues and fewer reserves to weather crises like a pandemic.
“The bigger your Medicaid business, the worse you do,” said North Carolina health Secretary Mandy Cohen. She said state leaders there are particularly concerned about rural hospitals and physicians’ offices that may not make it without immediate relief.
A spokesperson for the U.S. Department of Health and Human Services said the agency is trying to distribute money fairly. “There are some providers who will receive further, separate funding, including skilled nursing facilities, dentists and providers that solely take Medicaid,” the spokesperson said.
But in doctors’ offices and medical centers across the country, clinicians working with poor patients say they are running out of time.
Dr. Jennifer Sanderford, a pediatrician in Crested Butte, Colo., hasn’t paid herself in a month and was forced to put vaccines she ordered for her patients on a credit card. “There is just money being hemorrhaged with nothing coming in,” she said. Nearly a third of her patients are on Medicaid.
Cambridge Health Alliance, a large safety-net provider in Massachusetts, has been caring for hundreds of low-income workers in the Boston area diagnosed with COVID-19, the illness caused by the coronavirus. It has projected $90 million in losses this year, said Dr. Assaad Sayah, the chief executive, yet anticipates receiving only $6.7 million in new aid from the federal government.
Some of Cambridge Health Alliance’s work — such as helping to establish a shelter for homeless patients with the coronavirus — won’t even be factored into the aid formula, Sayah said.
“I don’t want to point fingers, but it seems like it’s the big players are the ones who got listened to,” he said.
“Who is sitting at the table when decisions are being made? I know it’s not me. It’s not organizations like us.”
———

Posted on by

Gov. Kemp, DCH Announce Approval of 1135 Medicaid and PeachCare for Kids® Waiver | Governor Brian P. Kemp Office of the Governor

GA made a number of changes to relax requirements on providers, prior authorization and assessment criteria across multiple programs as part of its COVID-19 response

Gov. Kemp, DCH Announce Approval of 1135 Medicaid and PeachCare for Kids® Waiver

April 02, 2020

Atlanta, GA – Governor Brian P. Kemp and the Georgia Department of Community Health (DCH) today announced that the Centers for Medicare and Medicaid Services (CMS) approved Georgia’s section 1135 waiver request on the temporary checklist, granting the state a number of flexibilities for Medicaid and PeachCare for Kids® providers and members to combat the COVID-19 public health emergency. To read the approval letter, click HERE.

“We want to thank CMS for granting this waiver to provide the resources and flexibility for our health care systems and heroic health care workers to fight COVID-19,” said Governor Kemp. “The safety of Georgians is my top priority, and this measure helps ensure access to health care for some of our state’s most vulnerable citizens during this unprecedented time.”

“The Department of Community Health is grateful to our federal partners for moving so quickly to provide regulatory relief and support to our health care systems,” said DCH Commissioner Frank Berry. “We also greatly appreciate the work of our providers in helping us to explore creative avenues to ensure the best care to our citizens.”

Included in the approval of template checklist flexibilities under the 1135 waiver are:

Temporary suspension of Medicaid fee-for-service prior authorization requirements for particular benefits

Extension of pre-existing prior authorizations

Suspension of Pre-Admission Screening and Annual Resident Review (PASRR) Level I and Level II assessments for 30 days

Extension of state fair hearing requests and appeal timelines

Authorization for Georgia Medicaid to provisionally, temporarily enroll out-of-state providers who are enrolled in another state’s Medicaid program or Medicare

Waiver of application fees, criminal background checks, site visits and in-state licensure requirements for providers not already enrolled in another state’s Medicaid program or Medicare

Authorization for Georgia Medicaid to temporarily cease re-validation of providers

Authorization for the provision of services in alternative settings

The approval of these temporary flexibilities is effective retroactively to March 1, 2020 and ends upon termination of the public health emergency, including any extensions, according to CMS.

Additional provisions requested in Georgia’s 1135 waiver are still pending CMS review and approval. Updates will be provided on those pending items as more information becomes available.