Category: GB-MC-Quality

Alternative Headline: Indiana’s Pathways Falls Short

[MM Curator Summary]: Indiana’s new managed care program for older Medicaid recipients has exceeded its budget and is widely seen as ineffective. FSSA leader has pointed out the ineffectiveness of said programs, noting that vulnerable population such as the elderly are already going to be covered by Medicaid. 

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The top official at the Indiana Family and Social Services Administration said the state’s new long-term care program for Medicaid members over 60 hasn’t met expectations. The statement contradicts claims the agency made under the previous administration, but aligns with concerns providers have raised.

The Pathways for Aging program shifted Medicaid members over 60 into health plans managed by health insurance companies. FSSA Secretary Mitch Roob said the state will end up paying those companies more than $300 million over budget this year.

Roob said he never would have pursued a program like this because it doesn’t make sense for the population it serves.

"It’s very difficult for managed care companies to manage the care of individuals who are in nursing homes," Roob said. "What is the value—what is the value they can have?"

When he served as FSSA secretary in 2006, Roob said he looked into the possibility of managed care for vulnerable populations like those over the age of 60 or children with disabilities. However, he said when he tried to find a managed care program to see what it would look like, he couldn’t find a private insurance program that had a program for those populations.

"[Managed care] is the way most states have chosen to do care today," Roob said. "It provides them a bit of fiscal—short-term fiscal surety. I could not find a popular, managed care program, in the private sector that dealt with fragile populations. I couldn’t find that because the fragile populations are by definition going to be covered by Medicaid."

Roob said managed care works for pregnant people or people without disabilities because their care is more predictable. But Roob said the previous fee-for-service model used for traditional Medicaid populations, including older Hoosiers, accounts for the ways that their care can be more expensive and less predictable.

"There is a possibility that in the longer term, we will create a better system," Roob said. "In the venture capital world, it’s called the Valley of Death. Getting from here to here has been very difficult. It’s been very painful for everybody involved so far. That pain shows signs of easing, but only signs."

In addition to Roob’s concerns about the program, lawmakers raised additional concerns this year during the legislative session. FSSA was tasked with addressing provider claims processing concerns by the General Assembly before Pathways launched in July 2024. This year, the Indiana legislature also passed legislation targeting similar issues for the second year in a row.

Among other things, House Enrolled Act 1474 set standards for how quickly a managed care organization must pay, deny or suspend a claim from a provider and how much interest is owed if that deadline is not met.

Providers have criticized the claims processing time since the launch of the program.

https://www.wfyi.org/news/articles/fssa-leader-says-he-never-would-have-pursued-pathways-program-more-than-300-million-over-budget

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Alternative Headline: FL Expands IDD Care Access

[MM Curator Summary]: A new Florida law expands Medicaid managed care for people with intellectual disabilities and restores public access to program data, rebuilding trust and accountability. 

enrollment and waitlist data by county.

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Gov. Ron DeSantis on Tuesday signed into law priority legislation for House Speaker Daniel Perez that addresses how people with intellectual and developmental disabilities (IDD) receive health care.

There were fears in the IDD advocacy community that DeSantis was going to veto the bill but he signedHB 1103 into law without any ceremony or a press conference. He acted three days after receiving it and while the House and Senate met in an extended session to craft the next state budget.

Jim DeBeaugrine, a former Agency for Persons with Disabilities (APD) director and now a lobbyist, praised language that requires the agency to make public information about the number of people served in the Medicaid waiver program known as iBudget, plus the number of individuals on the waiting list, broken down by the counties in which they live.

Federal Medicaid law provides coverage for health care services to cure or ameliorate diseases but generally doesn’t cover services that won’t. Specific to IDD, Medicaid covers the costs of institutional care but not of home- and community-based services that, if provided, can help people with IDD live outside of institutions.

Former Gov. Jeb Bush applied for a Medicaid waiver to provide these services to people with IDD. Eligible diagnoses include disorders or syndromes attributable to intellectual disability, cerebral palsy, autism, spina bifida, Down syndrome, Phelan-McDermid syndrome, or Prader-Willi syndrome so long as the disorder manifested itself before the age 18.

But the program is underfunded and has had lengthy waiting lists on which sometimes people have lingered for more than a decade. The Legislature has required APD to provide it with information about the program but while the information was once easily publicly available, the DeSantis administration stopped posting it online.

The bill requires the information to be made public again.

“You know, APD has gotten hundreds and hundreds of millions of dollars over the last several years. And I think it’ll help to hold the agency accountable. And it’s good for the public, particularly the advocacy community, to understand what happens with those dollars, how many people we’re funding, whether the dollars are being spent for services,” DeBeaugrine told the Florida Phoenix Tuesday.

“You know, the rub on all of this is that the agency used to publish that data without the law telling them to. But since they stopped, I believe this is a positive step towards re-establishing accountability and transparency.”

The law also involves a Medicaid managed-care pilot program launched at the behest of then-House Speaker-Designate, now speaker, Perez in 2023. The pilot was designed to care for up to 600 individuals and was approved forMedicaid regions D and I, which serve Hillsborough, Polk, Manatee, Hardee, Highlands, Miami-Dade, and Monroe counties.

The state received federal approval for the pilot in February 2024. The Agency for Health Care Administration (AHCA) issued a competitive procurement for the pilot with two vendors, Florida Community Care and Simply Healthcare Plans Inc., vying for the contract. AHCA eventually awarded the contract to Florida Community Care.

Three hundred and fifty eight people were enrolled in the pilot program as of May 5. During testimony before the House Health and Human Services Committee in February, Carol Gormley, vice president for government affairs for Independent Living Systems, attributed the slow start-up to administrative barriers on APD’s part. Independent Living Systems is the parent company of Florida Community Care.

The new law lifts the 600-person cap on the pilot program on Oct. 1, expanding enrollment statewide for qualifying disabled people on the Medicaid iBudget wait list. There are 21,000 plus people on the waitlist, according to a legislative analysis.

In a statement to the Florida Phoenix Tuesday, Gormley lauded DeSantis and the Legislature for their “commitment to expanding and improving services for persons with disabilities.

“We look forward to the opportunity to extend the comprehensive benefits offered through the pilot program to families who choose to participate,” she said.

https://floridaphoenix.com/2025/06/10/new-law-brings-managed-care-to-people-with-intellectual-disabilities/

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Alternative Headline: Skyline Fights Medicaid Cuts

[MM Curator Summary]: Skyline Health CEO Matt Kollman is leading bipartisan advocacy to protect rural hospitals from harmful Medicaid cuts.

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WHITE SALMON — Skyline Health is taking a leadership role in the national conversation surrounding some proposed Medicaid cuts that could devastate rural healthcare systems. CEO Matt Kollman has emerged as a prominent voice advocating for sound Medicaid policy that balances the sustainability of the Medicaid program with stable funding for hospitals and appropriate access to services for patients.Kollman’s advocacy has gained significant attention at both state and federal levels. He was recently featured in U.S. Sen. Maria Cantwell’s February 2025 Medicaid Snapshot Report, where he emphasized that unwise funding cuts “will undoubtedly result in reduction of services, reduction of access or worse — hospital closures.” This statement underscores the critical role Medicaid plays in sustaining rural hospitals like Skyline Health.Recently, Kollman travelled to Washington, D.C., and met with both Sen. Cantwell and Rep. Newhouse. He discussed Medicaid policy options and impacts and presented a letter signed by local health leaders, as well as several elected officials from both parties that emphasized bipartisan interest in approaching Medicaid policy with the proper care and concern. The letter was well received by both Federal legislators.Nationwide, more than 300 rural hospitals are at immediate risk of closure if certain cuts proceed. The potential loss of these facilities would not only impact healthcare access but also the economic stability of rural communities.ADVERTISING

Skyline Health remains committed to advocating for sound Medicaid policies that ensure the sustainability of rural healthcare services. Kollman’s efforts reflect the organization’s dedication to protecting the health and well-being of the Columbia River Gorge community and similar rural areas nationwide.

https://www.columbiagorgenews.com/free_news/skyline-health-advocates-for-sound-medicaid-policy/article_b14a81ac-38b4-4b97-9581-802b21e0d95c.html

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Alternative Headline: Medicaid Cuts Threaten Disability Care

[MM Curator Summary]: Virginia families fear devastating effects from upcoming Medicaid cuts, which may strip away essential disability and caregiver support services.

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RICHMOND, Va. (WRIC) — The founder of a Virginia nonprofit that supports families with disabilities is speaking out about her fears and frustrations over recent Medicaid cuts — and what they could mean for some of the state’s most vulnerable communities.

Pam Mines, founder of the JP JumPers Foundation, said she’s worried the new policies will force caregivers back into the workforce and leave their loved ones without proper support.

“The biggest concern is how it’s going to affect those families,” Mines said. “There are several families who the loved ones who are caring for these individuals are possibly not working because they need to provide care. And Medicaid pays for that.”

“Without the—with these Medicaid cuts, a lot of those individuals are going to say that, well, you know, because you’re [an] able-bodied person, you need to go to work,” she added. “But if that—that leaves their loved one, who’s going to care for them?”

While Donald Trump’s administration claims people with disabilities won’t be impacted by the “big, beautiful” bill, Mines called that “a contradiction.”

“How do you even determine, like, what is the qualifications for someone with the disability?” she asked.

“It sounds like it’s able-bodied,” she said. “So, unless you’re like in a wheelchair…”

Mines said the uncertainty is the hardest part.

“Right now, there are just so many unanswered questions,” she said. “And people are very scared.”

Her son, JP, has been stuck on a Medicaid waiver waiting list since he was 4 years old. He’s 21 now and still waiting to get off it.

“We’ve been on a waiting list since he was 4 years old. So we’ve been waiting all this time,” Mines said. “Right now JP is not affected by Medicaid, but he’s on our insurance right now. However, when he ages out and he can no longer be on our—on our—he’s going to have to get his own insurance.”

She’s worried what will happen when that day comes.

“They’re going to say, okay, he’s an able-bodied person and he can work,” she said. “But will he be able to work full time? Will his mental capacity be able to handle him working a full-time job and being able to get insurance?”

Mines said the potential for harm extends far beyond her own household. “It’s not only impacting the person with special needs, but those who care for them.”

And while she couldn’t name every cut in the legislation, she argued that many supports people don’t even realize exist could be stripped away.

“There are a lot of things that I don’t even know about that are going into the care for someone with special needs, that they are going to get cut because they don’t think that it’s important—but it is,” she said.

Beyond the medical concerns, Mines is worried about food insecurity and mental health support.

“You’re no longer going to get a check because, you know, you’re no longer covered and we can no longer pay for you to watch or take care of your child, or you no longer going to get SNAP benefits,” she said. “So that special food that you can eat or that special food that your loved one—that’s all they eat—you can no longer SNAP benefits to be able to get the food.”

As a mother, Mines said the emotional toll is just as severe.

“I don’t understand how this even was a thought,” she said. “It’s just heartbreaking that this community was—wasn’t considered the one that we should protect the most. It was the one that we went after first.”

She said the disability community is one that anyone can join—through an accident, a diagnosis, or aging. “This community is one that continues to evolve because of circumstances,” Mines said. “So in one minute, one day, you cannot be a part of it and have no empathy. And then the next day you’re in it and now you want people to consider you.”

Despite her fears, she remains determined to share support for the special needs community regardless of the bill’s impact.

“We’re going to stand together and we’re going to be strong and we’re going to build together and we’re going to support each other because that’s what we do,” she said. “The special needs community is a community. We are a community. And that’s not going to change because of this bill.”

These cuts to Medicaid will start next year but the full impact will stretch over a decade.

https://www.wric.com/news/virginia-news/special-needs-advocate-speaks-on-medicaid-cuts/

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Alternative Headline: UHC Under Federal Probe

[MM Curator Summary]: UnitedHealthcare is under federal investigation over potential Medicaid billing misconduct and is cooperating with the DOJ.

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UnitedHealthcare Group has announced its cooperation with federal criminal investigators from the Department of Justice regarding its Medicaid business. This cooperation began earlier this year after a Wall Street Journal report highlighted the investigation.

The investigation focuses on billing practices within Medicaid. UnitedHealthcare has faced challenges over the past few quarters due to rising healthcare costs.

The company stated, "We are cooperating with the Department of Justice as they investigate our Medicaid business practices."

https://www.khq.com/national/unitedhealthcare-cooperates-with-doj-investigation-into-medicaid-billing/article_1af8d293-7cba-4b0b-81dd-8ee1073ba02d.html

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Alternative Headline: NY Medicaid Mental Health Gains

[MM Curator Summary]: New York Medicaid plans show improved compliance with mental health coverage rules, contrasting with federal regulatory rollbacks.

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ALBANY | Gov. Hochul has announced that all Medicaid managed care plans operating in New York State have improved compliance with rules for fair access to mental health and substance use disorder services, even as the Trump Administration rolls back enforcement of these critical protections. Among the plans reviewed by the New York State Office of Mental Health (OMH), the Capital District Physicians’ Health Plan, Inc., and Excellus BlueCross BlueShield were found to be 100 percent compliant with all regulations.

“While the Trump Administration sleeps on regulations aimed at ensuring access to critical behavioral health services, New York State has achieved landmark reforms and is holding insurance companies accountable so that all New Yorkers can get coverage for this critical care,” Gov. Hochul said. “The gains in compliance we’re seeing today reflect our steadfast commitment to ensuring these carriers cover critical mental health services and don’t restrict access to care.”

Last month, the Trump Administration indicated in a federal court filing that it does not intend to enforce certain mental health parity regulations, including rules requiring insurance companies apply fair standards for behavioral health services. These regulations prevent insurers from imposing additional barriers — such as prior authorization requirements or restrictive provider networks — making it harder for patients to access mental health and substance use care as compared to physical health services.

In contrast, New York State has been actively taking steps to ensure Medicaid managed care plans are complying with regulations and providing New Yorkers with the coverage they are entitled to receive under law. The State Office of Mental Health reviewed six nonquantitative treatment limitations — provisions that are sometimes manipulated by these plans to restrict access to necessary behavioral health care — and found all carriers in compliance.

In addition, OMH’s comprehensive and rigorous examination also determined that both the Capital District Physicians’ Health Plan, Inc., and Excellus BlueCross BlueShield were fully compliant with all 19 nonquantitative treatment limitations.

OMH, however, also found that most managed care plans did not fully demonstrate compliance with other provisions with the Mental Health Parity and Addiction Equity Act. Some continually applied a different rate-setting process for behavioral health services and reimbursing providers for less than they would for medical and surgical services.

New York State has worked to hold managed care plans accountable for these violations. During a similar review of behavioral health claims filed between 2018 to 2020, OMH uncovered high levels of inappropriate denials for specialty services claims, including $39 million between December 2017 and May 2018. New York State took enforcement action on all 15 Medicaid managed care plans, issuing a total of 95 citations between 2019 and 2021, resulting in fines to 11 carriers totaling more than $1 million.

Resulting fines were used to fund the Community Health Access to Addiction and Mental Healthcare Project, also known as CHAMP. This program is the State’s independent health insurance ombudsman program for behavioral health care, which helps New Yorkers access treatment and insurance coverage for substance use and mental health treatment.

New York State Department of Health Commissioner Dr. James McDonald said, “Access to harm reduction and mental health services saves lives and the measures taken under Governor Hochul’s leadership ensures Medicaid managed care plans are complying with the regulations and are creating no limitations to care for New Yorkers who rely on these services. Access to affordable coverage is a matter of health equity and the State Department of Health will continue to work with our state and local partners to expand access to harm reduction and mental health services and eliminate health disparities in New York State.”

OMH monitors managed care organizations on an ongoing basis to ensure they are properly providing behavioral health services to their members. The agency works in partnership with the Department of Health, which has the legal authority to apply fines and enforce compliance in the Medicaid program.

New York is leading the nation in requiring health insurers to cover behavioral health services and continues to develop tools to ensure these companies are following all applicable laws. New York State’s new network adequacy standards will go into effect starting in July, entitling New Yorkers to an initial appointment for behavioral health care within 10 business days of the request, or seven calendar days following hospital discharge. Insurers unable to meet these timeframes will have to offer out-of-network mental health or substance use disorder coverage without increasing the cost for the consumer.

The state now also requires commercial insurers to reimburse covered outpatient mental health and substance use disorder services provided by in-network OMH and Office of Addiction Services and Supports facilities at no less than the Medicaid rate. In the FY 2026 Enacted State Budget, Governor Hochul also secured $1 million to ensure that insurers are providing the mental health care coverage policyholders deserve including new resources to strengthen compliance oversight, educating consumers and providers, and investigating and mediating complaints.

Gov. Hochul also helped secure a state Medicaid waiver to cover social determinants of health, required commercial and Medicaid health plans to use transparent, nonprofit clinical guidelines and cover all medically necessary treatments.

https://suncommunitynews.com/news/118836/states-medicaid-managed-care-plan-compliance-improving/

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Alternative Headline: EIR Program Targets Rural Care

[MM Curator Summary]:  Mission Mobile Medical launches an Executive-in-Residence program to improve Medicaid quality metrics and expand scalable care access in underserved rural areas.

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Accelerating the improvement in Quality measures for Medicaid populations for managed care organizations (MCOs), Mission Mobile Medical Group announced today the appointment of the first member of the Executive-in-Residence (EIR) Team, embedding national healthcare leadership directly into frontline strategy and operations.

David B. Vliet, BHA, MBA, a respected healthcare executive and innovation leader, has joined as the first member of the cohort. This is another signal that Mission Mobile Medical Group is driving bold, outcomes-based change in some of the country’s most underserved regions.

“Most organizations hire board members to help put more dollars in their pockets; we are recruiting a team of value-aligned leaders to help us in making a greater difference in the world,” said Dawn Berg, Vice President of Community Health Alliances at Mission Mobile Medical. “This team knows how to execute; they have built scalable systems of care and understand the realities of vulnerable populations. David is a tremendous leader, and his presence will accelerate our mission to deliver care to every corner of the country.”

David Vliet previously led LifeLong Medical Care, one of California’s largest Federally Qualified Health Centers (FQHCs), where he advanced systemwide innovation in care delivery, operations, and community engagement. He is known for pioneering the nation’s first Firehouse Clinic, bringing primary care services into trusted community spaces to address entrenched access barriers.

Vliet also serves as CEO of VlietHealth, a healthcare consulting firm that focuses on infrastructure development and operational transformation in both domestic and international markets. He recently founded Mobile Health Strategies: Guatemala, a nonprofit organization dedicated to expanding mobile healthcare in Central America. Vliet is a nationally recognized advocate for healthcare equity and operational excellence, and he is the namesake of the David B. Vliet Changemaker Award, established by Advocates for Community Health.

“Healthcare innovation must be grounded in reality; it has to be actionable, scalable, and serve the communities that have been left behind,” said David Vliet. “Mission Mobile Medical is proving that flexible, high-performing care models can move the needle where traditional systems have failed. I’m honored to join this mission and help drive an operational blueprint that delivers results.”

By leveraging AI-driven analyses of claims and EHR data, Mission Mobile Medical pinpoints high-need communities and deploys Satellite Clinics in trusted local settings. The Networks aggregate sparse populations and provide comprehensive primary, preventive, and behavioral care, addressing long-standing challenges such as transportation barriers, provider shortages, and the rising burden of chronic disease.

"Securing leaders of David’s caliber reflects both the seriousness of our mission and the maturity of our model,” said Amanda LeFever, President and CFO of Mission Mobile Medical Group. “We continue to prove that Satellite Primary Care clinic networks deliver results, and that this care model can be scaled systematically and sustainably. David brings unmatched insight into how to operationalize complex care systems, and his leadership will strengthen every facet of what we do."

As the inaugural member of the Executive in Residence cohort, Vliet will advise on strategic initiatives, mentor emerging leaders within Mission Mobile Medical, and help design delivery frameworks that translate into high-engagement, high-performance networks across the country.

The EIR team will continue to expand with additional leaders with deep experience in Medicaid and Medicare operations, FQHC transformation, rural health innovation, and value-based care, playing a critical role in shaping the future of its data-informed, decentralized, and outcomes-driven delivery network.

Vliet added, "This is a moment of great urgency and great potential in healthcare. The work we do through Mission Mobile Medical can help redefine how we serve rural and vulnerable populations, not just in pockets of innovation, but at scale. I look forward to working alongside the Mission Mobile Medical team to advance that vision."

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About Mission Mobile Medical Group

Mission Mobile Medical Group supports the world’s largest network of mobile healthcare programs (250 operational sites in 42 states, Puerto Rico, and Canada). As a B-Corp, the company partners with MCOs frustrated with efforts to implement scalable care delivery programs to rural and underserved populations. The model improves rural network adequacy and equips and empowers local providers to assist MCOs in enhancing engagement with beneficiaries. The results are rapid, significant, and sustainable improvements in key Quality measures, including reductions in unnecessary Emergency Department visits, improved Controlled Blood Pressure and Controlled Diabetes, prenatal and postnatal Care, and Behavioral Health screenings and treatments. www.missionmobilemed.com.

https://fox5sandiego.com/business/press-releases/ein-presswire/830161696/mission-mobile-medical-group-launches-executive-in-residence-program-david-b-vliet-named-to-inaugural-cohort/

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