Category: MM Curator

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STATE NEWS (CA)- This is reform? California wants to let its billionaires go on Medicaid

MM Curator summary

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.

 
 

[MM Curator Summary]: There are very few limits on the wealth you can have and still get on Medicaid in CA if you are over 65.

 
 

Clipped from: https://thehill.com/opinion/healthcare/4138033-this-is-reform-california-wants-to-let-its-billionaires-go-on-medicaid/

Politicians and investigative journalists have long complained about the billionaires that have no taxable income and pay no taxes despite their wealth. In response, politicians have advanced many constitutionally dubious proposals to tax wealth on grounds of equity and fairness.

It is odd, then, that there has been so little attention paid or protest given to the pending proposal in California — phase II of its 2021 reform — to strike all asset testing for those above age 65 in determining eligibility for long-term care benefits from Medicaid.

Lest anyone dismiss this as another crazy California idea that will never be enacted, like universal state government health insurance and racial reparations, this Medicaid expansion proposal is well on its way to approval, part of a series of incremental steps over the last several years that have already loosened Medicaid eligibility standards.

And this one offers a dangerous precedent for other states. Because Medicaid is jointly financed by the federal government, at fifty cents on the dollar or more, non-California taxpayers, including many middle-income workers living in states with stricter Medicaid rules, will actually end up paying a huge chunk of this costly California policy’s billion-dollar annual price tag.

Medicaid was designed as a jointly financed federal-state program to provide health care for the poor. It also pays for nursing-home care and increasingly for home healthcare for individuals, especially the disabled and elderly who spend down their assets before becoming eligible. Eligibility for various types of long-term care benefits is determined by medical need and a set of income and asset tests, which differ by state and have changed over time, but are within a federal framework.

California has long played loose with eligibility, benefits and other rules, even beyond the allowable leniencies in federal law. For example, under “Phase I” of the state’s 2021 reform legislation, its asset-test maximum for Medicaid eligibility is $130,000 (compared to just $2,000 in most states) for individuals and $195,000 (compared to $3,000) for couples.

Also, the “look-back” period to identify and disallow strategic transfers of assets to gain Medicaid eligibility is only 30 months, whereas federal law calls for 60 months. California’s look-back also does not apply if the applicant is not in a nursing home at the time of application. Federal law penalizes such strategic transfers, regardless of whether the person is institutionalized. California also turns a blind eye to as much as $12,000 in daily transfers of wealth to relatives per day, meaning that the wealthy can strategically shift as much as $4.4 million per year in order to pass the asset test.

California also completely disregards applicants’ net housing equity, which most states start to count as an asset after exempting the first $688,000 to $1,033,000. Retirement assets, including spousal retirement assets, are also disregarded, unlike in most other states.

Estate recovery from deceased recipients only applies to assets going through probate, thus bypassing retirement and insurance assets entirely. Unlike in some states, no liens are placed on housing. Despite the great wealth held in California, with home values averaging $750,000, the Medicaid program’s estate recovery efforts have lagged over the years, falling from $72 million collected in 2015 to $17 million in 2020.

Many of these leniencies directly contradict federal law, yet they were somehow approved by federal regulators at the Center for Medicare and Medicaid Services (CMS), without request for public comments, through a series of state plan amendments. Today, Phase II of California’s pending proposal — the total elimination of asset testing — is before CMS.

California officials told CMS that the total disregard of assets would annually cost the federal government only $115 million. Their own budget showed an increase of 37,000 newly eligible individuals and a $400 million total cost.

This is low compared to the approximately $35 billion that California spends on long-term care benefits through Medicaid. My own rough calculation, based on data from the Health and Retirement Study on asset holdings and another survey on long-term care needs, is that the annual additional cost to Medicaid from California’s disregard of assets will actually be at least $1.2 billion, with over 100,000 newly-eligible individuals.

Roughly half of this bill will be picked up by the federal government, not just by California taxpayers.

Even more concerning than the bad policy — which is contrary to the financial self-reliance of those who can afford it — is the poor precedent this circumvention of federal law would set for other states in designing their own Medicaid programs. Also, the complete lack of democratic process and bureaucratic transparency at a time of massive federal budget deficits is profoundly disturbing.

It is not too late for CMS and Congress to call these harmful actions into question and stop them.

Mark J. Warshawsky is a senior fellow at the American Enterprise Institute. He served as Vice-Chair on the federal Commission on Long-Term Care in 2013.

Tags California Medicaid

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REFORM- Home Visits With A Registered Nurse Did Not Affect Prenatal Care In A Low-Income Pregnant Population

MM Curator summary

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.

 
 

[MM Curator Summary]: Sending a nurse in the home didn’t help.

 
 

 
 

Clipped from: https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2022.01517?journalCode=hlthaff

Abstract

There is an urgent need to improve maternal and neonatal health outcomes and decrease their racial disparities in the US. Prenatal nurse home visiting programs could help achieve this by increasing the use and quality of prenatal care and facilitating healthy behaviors during pregnancy. We conducted a randomized controlled trial of 5,670 Medicaid-eligible pregnant people in South Carolina to evaluate how a nurse home visiting program affected prenatal health care and health outcomes. We compared outcomes between the treatment and control groups and found little evidence of statistically significant differences in the intensity of prenatal care use, receipt of guideline-based prenatal care services, other health care use, or gestational weight gain. Nor did we find treatment effects in subgroup analyses of socially vulnerable participants (46.9 percent of the sample) or non-Hispanic Black participants (52.0 percent of the sample). Compared with the broader Medicaid population, our trial participants had more health and social risk factors, more engagement with prenatal care, and similar pregnancy outcomes. Delivering intensive nurse home visiting programs to the general Medicaid population might not be an efficient method to improve prenatal care for those who need the most support during pregnancy.

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RX- Medicaid Drug Proposal Sets Up Likely Constitutional Challenge

MM Curator summary

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.

 
 

[MM Curator Summary]: Pharma will argue that asking them to explain how the calculate their prices to CMS is stealing their private property under the 5th amendment.

 
 

Clipped from: https://news.bloomberglaw.com/health-law-and-business/medicaid-drug-proposal-sets-up-likely-constitutional-challenge

Provisions in a proposed HHS policy aimed at driving down drug costs to the Medicaid program overstep the agency’s authority and are likely to face a constitutional challenge, attorneys say.

The proposed rule (RIN: 0938-AU28), issued in May, aims to prevent the misclassification of drugs, particularly when brand-name drugs are inaccurately labeled as generic, which can result in lower rebate payments for states.

Lawyers representing drugmakers say the proposal would rewrite the rules of engagement for drug companies looking to do business with the Medicaid Drug Rebate Program, a partnership that allows drug makers access to the nation’s 94 million Medicaid and CHIP beneficiaries in exchange for offering Medicaid agencies the lowest possible price for prescription drugs.

They pointed to a move by the department’s Centers for Medicare & Medicaid Services to clarify ambiguous terminology that allowed drugmakers to avoid paying higher rebates to Medicaid. They also criticized a requirement that manufacturers of between three and 10 of the costliest drugs in the drug rebate program complete surveys detailing proprietary information such as production expenses, research costs, and international pricing.

The agency’s tightening grip on drug prices comes as costs associated with covering expensive specialty drugs like gene and cell therapies continue to spiral.

A report from the Magellan Rx Management, one of the nation’s largest Medicaid pharmacy benefit managers, found six drugs with an average cost per patient in 2021 of over $100,000. Two drugs, Novartis’ Zolgensma and Sarepta Therapeutics’ Exondys, used to treat muscular dystrophy, topped out at over $1 million per patient.


An earlier report by the Health and Human Services Office of Inspector General said that, without greater government oversight to control spending, the per-enrollee rates that state Medicaid agencies must pay to managed care organizations would continue to rise dramatically as more and more high-cost drugs enter the market.

The proposed rule’s reporting requirement would try to rectify this by requiring manufacturers to offer medicines priced within the top 5% to negotiate significant rebates either directly with CMS or with 50% of state Medicaid agencies.

Those that don’t would have to send CMS details of their proprietary pricing information. Manufacturers that fail to comply with the information requests within 90 days would be imposed fines of up to $100,000.

Takings Clause

William A. Sarraille, attorney at Sidley Austin LLP, a law firm that represents pharmaceutical companies including Pfizer and AstraZeneca, said that the CMS’s new drug price reporting rules violate legal protections for trade secrets. He also said mandating that companies share financially sensitive proprietary data breaches the takings clause of the Fifth Amendment, which bars taking private property for public use without just compensation.

“What the [drug companies] are saying is that since the statute doesn’t authorize the scope of the survey information that’s being mandated—and there’s concern regarding trade secret information being disclosed to the public and therefore the value of the trade secret being undermined—that this amounts to a regulatory taking without just compensation,” Sarraille said.

Edwin Park, a research professor at the Georgetown Center for Children and Families, pushed back against claims that the CMS lacks authority to require drugmaker surveys. Park said Section 1927(b)(3)(B) of the Social Security Act has allowed the CMS to survey manufacturers since the Medicaid Drug Rebate Program began in 1991. However, the CMS has refrained from exercising this power until now.

The act permits the CMS to “survey wholesalers and manufacturers that directly distribute their covered outpatient drugs, when necessary, to verify manufacturer prices,” Park said.

The takings clause argument echoes that made by several drugmakers challenging the Medicare drug pricing provisions of the Inflation Reduction Act. Merck & Co. and Bristol-Myers Squibb Co. argue in their lawsuits that patented drugs are “protected from uncompensated takings” under the takings clause. Johnson & Johnson and Astellas Pharma Inc. also cited the takings clause in their litigation against the IRA.

Top courts have stuck down such claims in challenges to other federal programs, including the Affordable Care Act, the No Surprises Act, and the 340B drug pricing program.

Park argues that the CMS survey, while not ideal for drug companies, would give state Medicaid agencies the information they need to negotiate fairer drug prices with manufacturers. That’s a better option than the alternative, where states looking to lower spending on drugs could implement a closed Medicaid formulary that would cover just one drug per class, excluding high-cost drugs based on price alone, he said.

‘Best Price’ Debate

Another contentious aspect of the proposed rule is the CMS’s move to redefine and clarify established terms within the Medicaid statute, lawyers say.

According to Sarraille, a provision within the proposed rule would fundamentally alter how drug manufacturers calculate Medicaid rebates by modifying the regulatory definition of “best price” to require manufacturers to stack, or aggregate, all discounts and rebates across the pharmaceutical supply chain when determining the lowest net price for a drug.

“Best price has historically been understood [by drugmakers] as the best price offered to any one included purchaser within the statute. So if there’s a 40% discount to a particular managed care entity, that would be one potential best price point. And then if there’s a 10% discount to a retail pharmacy chain that would be another potential best price point,” Sarraille said.

“What CMS is proposing to do is not to consider those different potential price points, but to say, if the pill goes through the retail pharmacy, and is ultimately paid by the managed care entity, then the best price is not the higher of 40 or 10% off. It’s both 40% plus 10% off,” he said.

Legal challenges by drug manufacturers argue the existing regulations are vague on whether stacking is required.

The US Supreme Court recently ordered the US Court of Appeals for the Fourth Circuit to rehear an appeal of a lower court’s decision in U.S. ex rel. Sheldon v. Allergan. The lower court dismissed a complaint alleging the drugmaker violated the False Claims Act because it chose not to stack discounts provided to separate entities.

The district court had ruled in favor of the manufacturer, finding the company’s interpretation against stacking was “objectively reasonable” since CMS regulations hadn’t explicitly required it.

To assuage any doubt over the agency’s intentions, the CMS proposed rule added explicit language to its regulatory statement that “manufacturer[s] must adjust the best price for a covered outpatient drug for a rebate period if cumulative discounts, rebates or other arrangements to best price eligible entities subsequently adjust the price available from the manufacturer for the drug.”

Need for Negotiation

Peter Pitts, president and co-founder of the Center for Medicine in the Public Interest and a former associate commissioner of the Food and Drug Administration under President George W. Bush, said it’s going to take negotiation on both sides in order to avoid litigation.

Pitts was critical of the CMS’s approach, saying it wasn’t “collegial.” Of the proposed rule, he said, “all they change is CMS’s ability to—not clarify the rules, but change the rules as they see fit.”

“The problem right now is that both sides aren’t negotiating in good faith,” he said.

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CMS Issues Proposed Rule Regarding Medicaid Drug Rebate Program

MM Curator summary

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.

 
 

[MM Curator Summary]: CMS pushes forward with the rule that will survey manufacturers on how they set prices AND penalize ones that incorrectly misclassify drugs in order to pay less rebates.

 
 

 
 

Clipped from: https://www.policymed.com/2023/08/cms-issues-proposed-rule-regarding-medicaid-drug-rebate-program.html

In late-May, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule entitled Misclassification of Drugs, Program Administration and Program Integrity Updates Under the Medicaid Drug Rebate Program (MDRP). The proposed rule addresses drug misclassification and drug pricing and product data misreporting by pharmaceutical manufacturers. Also important for manufacturers, the rules propose program integrity and program administration changes, including limiting the time within which a manufacturer can initiate an audit of a State Medicaid Program’s drug utilization for purposes of Medicaid rebate obligations; clarifying requirements to accumulate or “stack” price concessions when a manufacturer determines best price; and providing for drug price verification and transparency through data collection.

“With today’s proposed rule, we are advancing unprecedented efforts to increase transparency in prescription drug costs, being good stewards of the Medicaid program, and protecting its financial integrity. This proposed rule will save both states and the federal government money,” Department of Health and Human Services Secretary Xavier Becerra said in a statement.

Some Important Parts of Proposed Rule

CMS is proposing to verify certain drug prices reported by manufacturers through an annual Medicaid Drug Price Verification Survey. According to CMS, verifying drug prices and publishing non-proprietary information about drug prices will increase public transparency for high-cost drugs allowing state Medicaid agencies to negotiate covered outpatient drug (“COD”) prices more effectively with manufacturers.

Only a select number of manufacturers of single-source CODs would be surveyed. CMS would develop a list of high-priced CODs which it estimates would be approximately 160 drug products or 200 national drug codes (“NDCs”). It would then narrow the list to between three and 10 NDCs by excluding CODs for which a manufacturer participates in certain CMS drug pricing programs or pays a significant amount in supplemental rebates to at least 50 percent of states. The manufacturers of the three to 10 NDCs selected would receive a Medicaid Drug Price Verification Survey.

Additionally, the proposed rules also seek to address situations in which manufacturers incorrectly report or misclassify their drugs in the MDRP. Misclassifying a brand-name drug as a generic drug reduces a manufacturer’s Medicaid rebate payments. CMS intends to define the situations in which it would consider a drug misclassified for the purposes of the MDRP, as well as other situations in which a manufacturer is paying rebates to states that are different from the rebates that are supported by the drug data being reported. CMS also would develop a process and timeline to notify manufacturers that it has determined that a misclassification of a COD has occurred, and the process for correcting the misclassification.

The proposed rules would codify a manufacturer’s obligation to pay unpaid rebate amounts to states due to the misclassification(s) and describe actions CMS may take if a manufacturer fails to correct a misclassification, including CMS correcting the misclassification, suspension of the drug and/or its manufacturer from the MDRP, exclusion of the misclassified drug from being eligible for Medicaid reimbursement, and potential civil monetary penalties.

Further, CMS proposes to revise the rules governing the determination of best price, to require that “[c]umulative discounts, rebates or other arrangements must be stacked to generate a final price realized by the manufacturer for a covered outpatient drug, including discounts, rebates or other arrangements provided to different best price eligible entities”. CMS notes, as an example, that, “if a manufacturer provides a discount to a wholesaler, then a rebate to the provider who dispensed the drug unit, and then another rebate to the insurer who covered that drug unit, CMS has concluded that ‘best price’ must include (or ‘stack’) all the discounts and rebates associated with the final price, even if the entity did not buy the drug directly from the manufacturer.”

Among many other proposals, CMS is proposing to require Medicaid managed care plans that cover CODs “to structure any contract with any subcontractor [(e.g., PBMs)] for the delivery or administration of the COD benefit [to] require the subcontractor to report separately the amounts related to the incurred claims,” including amounts related to “reimbursement for . . . CODs, payments for other patient services, and the dispensing or administering providers fees, and subcontractor administrative fees.” CMS believes this information would improve the calculation and reporting of the Medicaid Loss Ratio and would also require PBMs to report to plans on the spread between reimbursement paid to pharmacies and amounts charged to Medicaid managed care plans.

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PHE- Biden administration warns states as millions lose Medicaid

MM Curator summary

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.

 
 

[MM Curator Summary]: More on the CMS effort to get faster states to slow down their RTNO. Including links to the letters they sent August 9 to all 50 states.

 
 

 
 

Clipped from: https://www.politico.com/news/2023/08/10/biden-administration-states-medicaid-00110686

More than 4 million people have had their Medicaid benefits terminated in the last four months, including nearly three-quarters who have lost coverage because of paperwork problems.

 
 

The criteria don’t reflect all potential challenges with states’ unwinding processes, the letters are only based on data reported by states in May and some states are missing data.

Still, CMS’ decision to make the letters available online represents a sharp about-face for an agency that has refused for months to single out any state it believes may be violating federal law — or even name specific criteria that would trigger stronger action against states — for fear of damaging its relationships with them.

“It looks like this is certainly part of the paper trail to move to more explicit and hopefully rigorous enforcement activities,” said Joan Alker, executive director and co-founder of Georgetown University’s Center for Children and Families. “It’s a positive sign that CMS is becoming more transparent about their enforcement activities.”

It also comes as the agency faces increasing pressure both from Congress and state-level advocates who are alarmed by the high rates of coverage losses and have called on the agency to take more forceful action for noncompliant states, like yanking federal funding.

More than 4 million people have had their Medicaid benefits terminated in the last four months, including nearly three-quarters who have lost coverage because of paperwork problems.

More than half of states were flagged by CMS as having high rates of people who lost their Medicaid benefits for procedural reasons, meaning the state was unable to make a determination about whether the person was or was not eligible for coverage.

CMS said the data indicate people may not be receiving renewal notices, are unable to understand them or are running into challenges submitting renewal forms — in short, eligible people may be losing coverage. The agency noted that federal regulations require it to continue to provide Medicaid to eligible individuals until they are found ineligible.

Sixteen states were flagged for having long call center wait times and high call abandonment rates, which CMS said are “impeding equitable access” to Medicaid coverage and may indicate potential noncompliance with federal requirements under the Social Security Act.

Sixteen states were also singled out because a large number of Medicaid applications based on income were not processed within the 45-day window required by regulation.

Jim Beardsworth, a spokesperson for Rhode Island’s Department of Human Services, said the state has a “rigorous quality control program” to review procedural terminations and has delayed ending coverage for families and children until the beginning of 2024.

He added that the state has plans to soon increase its call center support through a cross-agency partnership, and is working with federal officials to build additional capacity, and that the state had reduced its application processing times to meet federal guidelines as of Aug. 1.

The four other states flagged for all three criteria did not respond to requests for comment on Thursday, nor did CMS.

While much attention has been paid to Republican-led states that have prioritized removing ineligible people from their Medicaid rolls as quickly as possible and have, as a result, seen high rates of coverage losses, the letters suggest significant problems in blue states, which are by and large taking their time with the unwinding process.

New Mexico and Rhode Island, two of the states flagged for all three criteria, are run by Democrats. And four more blue states were identified as falling short on two of the criteria.

“They need to apply these criteria across the board, and they’re doing that, and that’s good,” Alker said.

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Feds Say Hospitals That Redistribute Medicaid Money Violate Law | California Healthline

MM Curator summary

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.

 
 

[MM Curator Summary]: CMS is looking into secondary, private agreements that providers use to further game “provider tax” schemes.

 
 

 
 

Clipped from: https://californiahealthline.org/news/article/feds-cms-hospitals-redistribute-medicaid-money-hold-harmless/

 
 

(Moment / Getty Images)

The Biden administration wants to crack down on private arrangements among some hospitals to reimburse themselves for taxes that help fund coverage for low-income people. It contends the practice violates federal law.

Federal regulators say these arrangements “appear designed to” redirect Medicaid dollars away from facilities that treat the poorest patients to those that “provide fewer, or even no, Medicaid-covered services,” according to a proposed enforcement plan released May 3 by the Centers for Medicare & Medicaid Services.

The practice is typically orchestrated by the lobbying groups that represent hospitals in state capitals — and is often kept secret. Not even federal regulators know how widespread it is, although programs operate in at least a few states, including California and Missouri. It’s also the subject of a Texas lawsuit that could block the federal government’s proposal.

“It does seem like these associations are finding a way to distribute the money in a really weird way,” said Joshua Gordon, the director of health policy for the Committee for a Responsible Federal Budget in Washington, D.C. “But without the transparency, we don’t exactly know what’s going on.”

Previous efforts to block these payback arrangements have gone nowhere in the face of opposition from the powerful health care industry and state health officials who fear that clamping down could result in less money for Medicaid, the joint state-federal health insurance program for low-income people. Several Medicaid experts predicted the latest proposal could meet the same fate, or face immediate court challenges if adopted.

The federal government’s sweeping and contentious proposal would require states to police hospitals, nursing homes, and other health care providers to ensure they made no private agreements to redistribute Medicaid dollars.

Public and private hospitals argue CMS has no jurisdiction to regulate private transactions and has overstepped its legal authority. Together with state health officials from around the country, they warn the move could strip billions of federal dollars from Medicaid and threaten safety-net coverage for 94 million low-income people. Texas alone could lose $6 billion a year, according to Texas Health and Human Services.

California Healthline attempted to interview state health leaders and hospital association officials around the country, but they declined to comment or did not respond to repeated calls and emails.

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The federal government’s proposal is part of a broader Medicaid financing package, and it resurrects a long-standing effort by administrations of both parties over the years to rein in Medicaid spending — which ballooned to $734 billion in 2021.

In this case, regulators are targeting what are known as provider taxes, which states are increasingly imposing on hospitals, nursing homes, and other health care providers to help states pay for their share of the Medicaid program. The more provider taxes states levy, the more money they can also get in federal funding.

These taxes are a critical source of revenue that all states except Alaska rely on for their Medicaid programs — and to get federal matching Medicaid dollars. They account for 17% of state Medicaid funding in 2018, according to a 2020 report by the Government Accountability Office, which called for more transparency in how the money is collected and spent.

In California, hospitals have redistributed provider tax funds since 2009. Here’s how it works: Hospitals with a significant share of low-income patients get more Medicaid funding back than they pay in the tax, so they donate a small portion of their Medicaid funding to a charity run by the leadership of the California Hospital Association, a statewide lobbying organization. The charity awards grants to the hospitals that treat a smaller share of low-income patients and don’t receive as much funding back as they paid in taxes.

For instance, Cedars-Sinai in Los Angeles, one of the country’s richest hospitals, paid nearly $172 million in provider taxes in 2022, eclipsing the $151 million it got back in Medicaid dollars. Then, it received nearly $28 million from the hospital association’s charity — earning about $6.9 million from the program, the hospital’s audited financial statements show.

Meanwhile, faith-based Adventist Health, which serves a larger share of poor people and operates roughly two dozen hospitals in California, Oregon, and Hawaii, paid $148 million in taxes in 2022 and reaped $401 million in Medicaid dollars through the program, according to its independently audited financial statements. It then contributed $3 million of that Medicaid money to the charity.

Federal law sets stringent rules for provider taxes: They must be broad-based and apply to all providers within a certain category, like hospitals; providers within a state must be taxed at the same rate; and taxes can’t be returned directly or indirectly to providers as part of a “hold harmless” agreement.

It’s that last clause that has spurred the feds to act.

Regulators say some health care providers, to gain the needed support within their ranks for the tax, are moving the tax money — and the federal revenue it draws to states — among themselves.

“We believe providers with relatively higher Medicaid volume agree to redistribute some of their Medicaid payments to ensure broad support for the tax program,” they wrote in their proposal.

These agreements “undermine the fiscal integrity” of the Medicaid program, they wrote.

It’s unclear how widespread such agreements are because hospitals don’t make them public. CMS said it has identified “instances” of Medicaid redistribution payments, but spokesperson Greg Myers declined to elaborate.

Jonathan Williams, vice president of government affairs at Sutter Health, which operates about 20 hospitals across Northern California, argued in a June 30 letter to the federal agency that these arrangements help hospitals expand “care networks and afford necessary incentives to ensure that providers can continue caring for Medicaid beneficiaries with unique and specific care needs.”

Missouri’s hospital association also runs a “pooling arrangement,” in which hospitals that get more Medicaid money than they paid in taxes can donate funds to the hospitals that didn’t.

“Missouri providers have had various private agreements to redistribute funds among themselves for decades, with the full knowledge and approval of CMS,” according to an unsigned and undated letter to the agency from the MO HealthNet Division, which runs the state’s Medicaid program.

In 2002, Missouri got federal approval for its redistribution program by pledging to use the funds for Medicaid services, whereas California has not received approval.

The federal government’s plan would require states to get health care providers to attest that they don’t participate in any arrangement that violates federal law. State officials described the proposal as an impractical administrative burden that could dissuade hospitals, nursing homes, and other providers from participating in Medicaid altogether. “Imposing additional requirements on providers that participate in Medicaid managed care networks would only serve to further dissuade network participation, which will have a negative impact on member access to care,” Mike Levine, the assistant secretary for MassHealth, Massachusetts’ Medicaid program, wrote to CMS on July 3.

Texas, which has long tangled with the federal agency over how it funds its Medicaid program, sued in federal court earlier this year after the agency declared in a separate letter to states that these types of arrangements aren’t allowed and must be reported. The letter was sent in February, before the agency issued its formal proposal.

In June, a federal judge handed Texas and its health care industry a victory, temporarily delaying the reporting requirement that regulators had outlined in their February letter. The judge agreed with Texas that the agency had exceeded its legal authority and couldn’t regulate private agreements.

State health officials and hospital leaders are pointing to the Texas court case as evidence that the agency’s May proposal to crack down on the redistribution of Medicaid funds is a “widely controversial interpretation” of the law, as the Tennessee Hospital Association put it in a July 3 letter to CMS.

Federal regulators have not said if or when they will implement their plan. The last time the agency issued a sweeping Medicaid financing proposal, it withdrew it almost a year later.

Mark McClellan, who served as head of the Centers for Medicare & Medicaid Services for two years during the George W. Bush administration, predicted states and Congress would push back hard if the new proposal moved forward.

“Medicaid is a huge component of state spending and keeps getting bigger,” McClellan said. “So, sudden CMS changes or clamping down is going to be disruptive for state coverage.”

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Human Services Department Announces Intent to Award Medicaid Contracts

MM Curator summary

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.

 
 

[MM Curator Summary]: Winners – BCBS, Presby, UHC and Molina.

 
 

 
 

Clipped from: https://www.hsd.state.nm.us/2023/08/11/human-services-department-announces-intent-to-award-medicaid-contracts/

SANTA FE – Today, the New Mexico Human Services Department (HSD) announced its intention to award Medicaid managed care organization (MCO) contracts to four health plans for Turquoise Care, the state’s Medicaid managed care program. The state will negotiate contracts with BlueCross BlueShield, Presbyterian Health Plan, United Health Plan, and Molina Health Plan with a start date of July 1, 2024. The state announced that it does not intend to negotiate a Medicaid contract with current MCO Western Sky Community Care. 

The Human Services Department also announced a decision to rescind the cancellation of the Turquoise Care Request for Proposals (RFP), which was made on January 30, 2023, to allow agency leadership an opportunity to assess the design of the procurement.  

“HSD spent the past several months reviewing the MCO contracts in depth and making improvements that focus on advancing and incentivizing health plan performance and ensuring that Medicaid customers have access to this information when they pick their health plan,” said HSD Acting Secretary Kari Armijo. “We will be negotiating contracts that reflect these improvements with the expectation of achieving better health outcomes for Medicaid customers.”  

HSD has engaged with a consultant to make recommendations for improving MCO contract enforcement and compliance, and the agency is making several contract improvements with the existing health plans that will go into effect September 2023. 

The new go-live date for the MCO contracts is July 1, 2024, a change from the original planned go-live date of January 1, 2024. The extension will allow HSD to complete the Medicaid unwinding, which requires a full recertification of every Medicaid customer over a 12-month period that extends through March 2024. This process was suspended during the COVID-19 Public Health Emergency. Open enrollment for the new MCO contracts will begin in April 2024 after the unwinding is complete. 

“The new contract go-live date will minimize disruption for Medicaid customers by allowing HSD to focus on the important work of recertifying eligibility for the 934,305 customers who are enrolled in the program,” said Armijo. “We want all Medicaid customers to be watching for their turquoise envelopes and submitting the required paperwork to make sure they stay covered if eligible and to help them transition to other health insurance coverage if they no longer qualify for Medicaid.” 

Medicaid customers can learn more about how to renew their Medicaid coverage by visiting HSD’s Renew New Mexico! website at renew.hsd.nm.gov or by calling HSD at 1-800-283-4465. 

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We talk, interpret and smile in all languages.  We provide written information to our customers in both English and Spanish and interpretation services are available in 58 languages through our provider, CTS Language Link. For our hearing, and speech impaired customers, we utilize Relay New Mexico, a free 24-hour service that ensures equal communication access via the telephone to individuals who are deaf, hard of hearing, deaf-blind or speech disabled. 

The Human Services Department provides services and benefits to 1,046,816 New Mexicans through several programs including: the Medicaid Program, Temporary Assistance for Needy Families (TANF) Program, Supplemental Nutrition Assistance Program (SNAP), Child Support Program, and several Behavioral Health Services.

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Carter, Dunn introduce Medicaid Staffing Flexibility and Protection Act

MM Curator summary

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.

 
 

[MM Curator Summary]: States can (and do) already contract for help with this. So this must be aimed at letting the contractors do more than they are currently authorized to do.

 
 

 
 

Clipped from: https://buddycarter.house.gov/news/documentsingle.aspx?DocumentID=11368

Washington, D.C. — Reps. Earl L. “Buddy” Carter (R-GA) and Neal Dunn (R-FL) this week introduced the Medicaid Staffing Flexibility and Protection Act, which alleviates staffing shortages at state Medicaid agencies so that beneficiaries do not lose their coverage due to procedural or staffing issues.

During the pandemic, states were required to continuously enroll people into Medicaid for the duration of the public health emergency, regardless of changes to the enrollee’s eligibility. Four months after this program ended, some states are still struggling to work through redetermining the eligibility for the nearly 95 million Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries, which has already caused eligible Americans to lose their coverage. With 229,000 local government jobs and 133,000 state government jobs yet to be recovered since February 2020, some states do not have the workforce to handle this massive task.

This bill provides states the flexibility and resources they need by allowing them the option to hire outside contractors to help work through this backlog, ensuring that those who need these essential health care benefits receive them.

“This common-sense solution allows states to meet their obligations to Medicaid and CHIP enrollees,” said Rep. Carter. “I’ve heard from Georgians who are concerned that their family will lose access to necessary, life-saving care, for no reason other than workforce and staffing challenges. This bill will equip states with the tools they need to review these applications and give beneficiaries the coverage and peace of mind they need.”


“As states work diligently to protect taxpayer dollars and maintain the integrity of their Medicaid programs, it is important that they have the options they need to efficiently execute the redetermination process. The Medicaid Staffing Flexibility and Protection Act will give states the freedom to contract out certain services related to the necessary redetermination process to private partners if they choose to. States may choose to do so due to workforce shortages which are being felt acutely across the nation,” said Rep. Dunn.


Read the full bill text here.

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STATE NEWS (NC)- Medicaid gives NC district free school meals

MM Curator summary

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.

 
 

[MM Curator Summary]: A look at how some school districts are bridging the gap from when COVID paid for all school meals to now.

 
 

Clipped from: https://www.ednc.org/medicaid-data-is-helping-students-in-this-n-c-county-eat-for-free/

 
 

Graham County Schools Nutrition Director Denise Moody walks into an office at Robbinsville Elementary School. Alli Lindenberg/EducationNC

There are 1,100 students enrolled in Graham County Schools. Thanks to a pilot program through the U.S. Department of Agriculture (USDA), all of those students will receive free school meals starting in the 2023-24 school year. 

The USDA’s Food and Nutrition Service approved 12 new states to participate in the Direct Certification with Medicaid Demonstration Project for the 2023-24 school year. North Carolina is one of those states.

The data associated with Medicaid caused Graham County School district’s identified student percentage (ISP) to jump from 43% to 66% across all three schools in the county. Identified students are students who qualify for free meals without a household application. This additional data from Medicaid allowed for the automatic enrollment of lower income, and potentially hungry, students. 

A school’s ISP is also what determines their ability to enroll in the Certified Eligibility Provision (CEP). The purpose of CEP is to provide meals “at no cost” to students in high poverty areas. It allows schools and districts to offer free school meals to all students if a certain percentage of the student body qualifies for free-and-reduced lunch.

“We’ve got a lot of people living below the poverty level, and then we have a lot of families that just barely made that cut off,” said Denise Moody, director of nutrition for Graham County Schools.
 

 
 

A summer school student works on her lesson at Robbinsville Elementary School in June 2023. Alli Lindenberg/EducationNC

Moody has been with the school system for 12 years. She started out as a teacher, both in first and third grade. Her degree is in nutrition, so when the previous nutrition director retired, she was a natural choice for the role.

Out of the 1,100 students in Graham county, 310 belong to families that receive Supplemental Nutrition Assistance Program (SNAP) benefits. An additional 300 students are in families that qualify for Medicaid.

“Before, we were only able to count our food stamp kids and homeless or runaway and foster kids, so we didn’t have that data,” said Moody.

Even though Graham County Schools previously had an ISP of 43%, which made them eligible for CEP, it wouldn’t have been financially worth it.

CEP works by reimbursing schools and districts. According to the CEP agreement with the federal government, the school system has to pick up any cost for the nutrition department that is above and beyond whatever reimbursement they receive from CEP. 

If Graham had enrolled in CEP last year, Moody said, they would have received a $4.43 reimbursement per meal for the majority of the children but $0.87 cents for the remaining children that ate meals.

The Child Nutrition Department at Graham County Schools is a self-sustaining budget. The magic number for the 100% free reimbursement rate is 63% for Graham County Schools, which they were finally able to reach because of Medicaid data. Last year was the first year the school was able to use that data, because of the pilot program through USDA. With a 63% ISP, the meals will be fully covered because they are able to reach that higher rate of reimbursement.

Paying down debt

During the first two years of the COVID-19 pandemic, all public school students were able to eat school meals for free, regardless of income. That flexibility ended during the last school year, although North Carolina’s legislature extended a provision allowing students who qualify for reduced lunch to receive free lunch.

“When everybody was eating for free, more kids did eat,” said Moody. “During those two years, during the pandemic, we had more participation.”

The more students that eat free meals, the more money Moody receives in the form of reimbursement. According to her calculations, if participation is as high as she is hoping for this upcoming school year, she could get $200,000 back. Not only does that help provide meals to students, but it also allows the department to cover rising costs of food due to inflation.

“You used to be able to get a case of fruit cocktail for $26. Now it’s like $66. Some of this stuff has doubled in price,” said Moody.

In the future, Moody hopes she can purchase some new equipment for her kitchens.

“I have a steamer that needs to be replaced. I have a refrigerator that needs to be replaced. We have some equipment that is 20 years old,” said Moody.

The new steamer costs $46,000. A new industrial fridge would cost about $5,000. In addition to kitchen equipment, the schools could use some new dining tables and chairs, she said.

Other food programs

In addition to the free meals, there are other resources available for families in the district that are experiencing food insecurity. The MANNA FoodBank, based out of Asheville, delivers 50 food boxes to the district’s central office every two weeks. These boxes include shelf-stable items and items that students can make themselves, like microwavable mac and cheese. Sometimes the boxes will also include fresh produce, like apples or oranges. 

Boxes of produce for the summer feeding program at Graham County Schools. Alli Lindenberg/EducationNC

Parents can sign up to receive boxes at the office or contact Denise Moody directly. There is also a soup kitchen in Robbinsville that MANNA supplies. They hand out bags of food on Wednesday nights. Families can drive up and pick up the bags.

While families wait for school to resume this fall, students can eat free breakfast and lunch at Robbinsville High School. The summer feeding program began on June 12 and will continue through July 31. Breakfast is served from 7:30 to 8:30 a.m. Monday through Friday. Lunch is served from 11:00 a.m. to 12:00 p.m. Monday through Friday.

Any child 18 and under is welcome.

Correction: An earlier version of this article stated that the free lunch Graham County Schools will provide in the 2023-24 school year was due to data available because of Medicaid expansion. It has been updated to reflect that these free meals are due to Medicaid data from the USDA’s Direct Certification with Medicaid Demonstration Project.

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FWA (AK)- Anchorage assisted-living home operator charged in Medicaid fraud case

MM Curator summary

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.

 
 

[MM Curator Summary]: Abdoulie Lowe stole about $800k of your tax dollars using bogus Medicaid claims.

 
 

 
 

Clipped from: https://alaskapublic.org/2023/08/04/anchorage-assisted-living-home-operator-charged-in-medicaid-fraud-case/

 
 

A sign directs visitors to either the Nesbett Courthouse or Boney Courthouse in downtown Anchorage. (Valerie Kern/ Alaska Public Media)

An Anchorage man is accused of fraudulently collecting nearly $800,000 in Medicaid payments over the past two years, state officials said Thursday.

According to a statement from the Alaska Department of Law, a grand jury indicted 47-year-old Abdoulie Lowe for receiving reimbursements for work which wasn’t documented as required by law. He also allegedly submitted another $7,000 in claims for services he claimed to provide to people in his care “when he was actually working elsewhere,” the statement said. 

An initial indictment in the case listed offenses spanning from October 2021 through April of this year. Lowe – who did business as Apapa Assisted Living Home – allegedly submitted more than $328,000 in fraudulent claims for care of a single patient, plus more than $248,000, $185,000 and $32,000 for three others.

Maeve Kendall, the assistant attorney general with the state Medicaid Fraud Control Unit prosecuting the case against Lowe, declined to discuss the developing case in detail Friday. She said none of the money has been recovered yet, in what she called one of the unit’s larger cases.

“A six-figure fraud is certainly a significant matter for our unit, and especially in Alaska,” Kendall said.

According to Kendall, Apapa had been providing care at an East Anchorage apartment, an arrangement she said was relatively common for small assisted-living facilities in Alaska.

“At the arraignment yesterday, Mr. Lowe did confirm with the court that he is no longer operating as a Medicaid provider,” Kendall said. “So he does not have clients in his care at this point.”

Lowe could not be reached for comment Friday. Court records didn’t list a lawyer for him.  A phone number for Apapa Assisted Living had been disconnected.

Lowe is charged with six felony counts of medical assistance fraud and one felony count of second-degree theft, plus failing to maintain workers’ compensation for his employees.

According to the Department of Law, the most severe charges against Lowe carry penalties of up to 10 years in prison, a $100,000 fine and payment of restitution to the state.

“A conviction on any of these charges can lead to Mr. Lowe’s exclusion from the Medicaid program,” prosecutors wrote.