Category: MM Curator

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REFORM (PROVIDERS)- What Share of Nursing Facilities Would Meet Possible New Staffing Requirements?

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 lot (45%) of nursing home providers would struggle to give residents 3.5 hours of care per day.

 
 

 
 

Clipped from: https://www.kff.org/medicaid/issue-brief/what-share-of-nursing-facilities-would-meet-possible-new-staffing-requirements/

Nursing facilities provided medical and personal care services for nearly 1.2 million Americans across 15,076 Medicare and Medicaid-certified facilities in 2022. While these facilities provide care to an older, frail, and disproportionately female population, there have been long-standing concerns about insufficient staffing in nursing facilities and its impact on quality. A recent report issued by the National Academy of Sciences, Engineering, and Medicine (NASEM) raised concerns about low nursing staff levels in nursing facilities across the country and the impact of inadequate staffing levels on the quality of care for nursing home residents. The high mortality rate in nursing facilities during the COVID-19 pandemic highlighted and intensified the consequences when staffing levels are low and quality suffers. A March 2023 report by GAO cited the need to improve staffing as a priority issue in nursing facilities, finding that inadequate staffing made it difficult for nursing homes to adhere to proper infection prevention and control practices.

In light of these concerns, the Administration issued an executive order in April 2023 directing the Secretary of Health and Human Services to consider actions to promote adequate staffing at nursing homes and reduce staff turnover. The order also directed the Secretary of Labor to take actions that would improve the jobs of long-term care workers. This executive order followed the release of a fact sheet by the Biden Administration in February 2022 announcing forthcoming requirements for minimum nursing facility staffing levels.

This data note explores the current state of nurse staffing levels at nursing facilities in anticipation of the forthcoming proposed rule on staffing regulations. Specifically, we analyze the percentage and characteristics of facilities that would meet higher levels of nursing staff, if required under Medicare and Medicaid. The analysis includes data from 14,575 nursing facilities (97% of all facilities, serving 1.17 million or 98% of all residents) that reported staffing levels in June 2023. Staffing levels and requirements are often specified as direct care hours per resident day (HPRD), which equals the total number of hours worked by each type of nursing staff (nurse aides, registered nurses, and licensed practical nurses) divided by the total number of residents. Key takeaways include:

  • Nearly all facilities would meet a requirement of 2.5 or fewer HPRD and 85% of facilities would meet a requirement of 3.0 HPRD, but close to half (45%) of all nursing facilities would not meet a 3.5 HPRD requirements, and only 29% would meet an HPRD of 4.0.
  • Similarly, when looked at as a share of residents, 83% of residents live in a facility with staffing levels of at least 3.0 HPRD, but 50% of residents live in a facility that meet a 3.5 HRPD and only 23% live in a facility with staffing levels of 4.0 or greater.
  • At any required staffing level above 2.5 HPRD, a lower percentage of for-profit nursing facilities would meet the requirement than non-profit or government nursing facilities.
  • There is wide state variation in the share of facilities that would meet required HPRD levels of 3.0 or higher: At a level of 4 HPRD, the share of facilities meeting the requirement would range from 12% in Texas to 100% in Alaska.

HPRD is a relatively simple measure that does not account for what type of nursing staff are at the facility or the types of patients the facility serves. The measure also does not account for the number of non-nursing staff employed by a facility. The proposed rule is likely to strengthen the HPRD minimum requirement and could potentially include additional nurse staffing requirements. If the proposed rule includes requirements related to the types of nurses facilities must employ (and the hours they must work) or adjusts the number of required nurses based on patient health and frailty, fewer nursing facilities would meet a given requirement than are shown here. The rule may also require nursing facilities to employ additional staff beyond nurses, but such requirements are outside the scope of this analysis.

What are Current Staffing Requirements for Nursing Facilities?

The 1987 Nursing Home Reform Act, established the first federal staffing minimums for nursing facilities. The Obama Administration issued an update to these regulations in 2016. Federal regulations require facilities to provide licensed nursing services 24 hours a day, 7 days a week and to have a registered nurse on duty eight hours per day, seven days per week. Facilities must also appoint a director of nursing, have a full-time registered dietician on staff, and provide services that are “sufficient” to meet residents’ needs. Combined, federal regulations have been interpreted as requiring the equivalent of 0.3 nursing HPRD for a 100-bed facility. Requirements are applied irrespective of facility size or resident census, with two exceptions: In facilities with daily occupancies of 60 or fewer, the director of nursing may serve as a charge nurse; and in facilities with greater than 120 beds, staff must include at least one-time full-time social worker.

For at least 20 years, a number of groups have suggested that federal requirements for nursing staff levels (0.3 HPRD) are below the levels that would ensure patient safety and well-being. For example, in 2001, a report commissioned by the Centers for Medicare and Medicaid Services (CMS) recommended a minimum of 4.1 HPRD. In April 2022, the National Academies of Science, Engineering, and Medicine (NASEM) published a report with staffing recommendations that include: having RN on staff 24/7 with additional RN coverage as needed (current requirement of 8 hours per/day); a full-time social worker (currently this only applies to facilities over 120 beds); and an infection prevention and control specialist (no current requirement). The report also recommended funding research to identify optimum staffing levels for other direct care staff. A KFF June 2022 analysis of state policies on nursing facility staffing minimums found that most states require staffing standards above federal requirements.

What Share of Nursing Facilities Meet Varying Levels of Staffing Requirements That Could Be Included in the Forthcoming Proposed Rule?

As of June 2023, virtually all nursing facilities meet current staffing requirements (0.3 HPRD) and most would meet requirements of up to 3.0 HPRD, but if the new staffing requirements are 4.0 or greater, most facilities would need to hire new staff to comply (Figure 1). Because it is unknown what the new requirements might be, this analysis shows how many nursing facilities would meet required HPRD ranging from 1 to 5. Nearly all facilities would meet a requirement of 2.5 or fewer HPRD and 85% of facilities would meet a requirement of 3.0 HPRD, but close to half (45%) of all nursing facilities would not meet a 3.5 HPRD requirements, and only 29% would meet an HPRD of 4.0. Similarly, when looked at as a share of residents, 83% of residents live in a facility with staffing levels of at least 3.0 HPRD, but 50% of residents live in a facility that would meet a 3.5 HRPD and only 23% live in a facility with staffing levels of 4.0 or greater (Figure 1).

A small share of nursing facilities currently have staffing levels that would meet a requirement higher than 4 HPRD. Only 15% of facilities have staffing levels over 4.5 HPRD and just 8% have levels of 5.0. Only one in ten residents live in a facility with 4.5 or more HPRD and just 5% live in a facility with 5 or more HPRD.

If the required HPRD is adjusted for the health and frailty of residents in a nursing facility (case-mix), about 70% would meet a requirement of 3 HPRD, which is lower than the 85% that would meet an unadjusted requirement of 3 HPRD (Figure 2). Under current requirements, facilities do not have to adjust staffing based on the types of residents that live in the facility. However, federal data include staffing levels for facilities that are adjusted to reflect the health and frailty levels of facility residents. This adjustment is called “case-mix” and accounts for the fact that residents who have more health needs or are frailer are expected to require more assistance from nursing staff. For a given required HPRD, a smaller percentage of facilities would meet a “case-mix” adjusted requirement than would meet an unadjusted requirement.

At any required staffing level above 2.5 HPRD, a lower percentage of for-profit nursing facilities would meet proposed staffing levels than non-profit or government nursing facilities (Figure 3). If the level were set at 3 HPRD, 81% of for-profit nursing facilities would meet the requirement compared with 94% of non-profit facilities and 90% of government facilities. At 3.5 HPRD, differences by ownership type widen: a smaller share (47%) of all for-profit nursing facilities would meet requirements than non-profit facilities (75%) or government facilities (68%). At 4.0 HPRD, just 20% of for-profit nursing facilities would meet requirements compared with about half of non-profit (52%) and government facilities (47%). About 72% of all facilities are for-profit (home to 74% of residents), 22% are non-profit (home to 20% of residents), and 6% are government-owned, (home to 6% of residents).

Differences by ownership status are smaller when using an HPRD adjusted for resident health and frailty. When using this adjusted HPRD, only about 12% of for-profit facilities, 8% of non-profit, and 8% of government facilities would meet a requirement of 3.5 HPRD. There is nearly no difference by ownership type in the percentage of facilities that would meet a case-mix adjusted requirement of 4 HPRD or higher.

If required staff levels exceed 3 HPRD, there would be wide variation across states in the share of facilities that would meet the requirements (Figure 4). There is minimal state variation across the states if the new requirements are 2 HPRD or fewer because over 90% of facilities would meet a required level of 2 HPRD in all states (Figure 4). If the requirement is 3 HPRD, the share of facilities in compliance would range from 58% in Missouri to 100% in five states and, if set at a level of 4 HPRD, the share of facilities in compliance would range from 12% in Texas to 100% in Alaska. Results are similar when looking at the percentage of nursing facility residents who live in a facility that would meet various staffing requirements (Appendix Table 1).

Staffing levels also vary within states, though some states generally have lower levels of staffing than others. For example, in Alaska, staffing levels range from 4.7 to 12.7 while in New Mexico, facilities range from 2.3 to 5.6 (Appendix Table 2).

What Happens to Nursing Facilities When They Do Not Meet Required Staffing Levels?

For facilities determined out of compliance with federal staffing requirements, penalties vary depending on a deficiency’s severity and how long it takes for a nursing facility to reach substantial compliance.
Substantial compliance is a level of compliance with the requirements such the deficiency no longer poses a substantial risk to resident health or safety. For deficiencies that do not result in immediate jeopardy, facilities are given up to six months to correct deficiencies. If a facility does not come into substantial compliance within three months, Medicare and Medicaid will not pay the costs for individuals admitted after the deficiency finding date. If a facility that does not come into substantial compliance within six months, Medicare and Medicaid will not pay the costs for any individuals in the facility. For deficiencies that result in immediate jeopardy, CMS or the State Medicaid Agency may either: 1) appoint temporary management to oversee operations while deficiencies are corrected or 2) end the facility’s participation in the Medicare and/or Medicaid programs and transition residents to another facility or community setting.

Between July 2021 and July 2022, about 19% of nursing facilities received deficiencies for “Nursing Services“, meaning that they failed to have “sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety”. This grouping of deficiencies captures more than just failing to meet the 0.3 HPRD requirement and includes other deficiencies such as the failure to ensure proper training for nurse aides. The vast majority of these deficiencies were not associated with harm to patients.

What are Key Issues to Watch?

Looking ahead, if a proposed rule is issued and finalized, many nursing facilities may need to hire new staff to meet the proposed staffing levels, but the extent of the challenge will depend on the specifics of the new requirements. Key considerations for evaluating new requirements, beyond the level of the minimum staffing requirement, include the following.

  • How long do nursing facilities have to comply with the new requirements and are they phased in over time? Implementation periods of several years and phased-in requirements give nursing facilities more time to come into compliance.
  • Do the new requirements include a total number of HPRD or do they include specific requirements for different types of nursing staff? Requirements for overall staffing levels will be easier for nursing facilities to meet than requirements that are specific to each type of nursing staff.
  • Do the new requirements include requirements for non-nursing staff such as social workers, nutritionists, and infection control specialists? Requirements for non-nursing staff could make it harder for some facilities to comply.
  • Are the new requirements adjusted for patients’ characteristics such that facilities with higher-risk residents need to have more staff or more highly trained staff? It may be more difficult for nursing facilities to meet requirements that vary based on patient characteristics.

Compounding the compliance challenge are workforce shortages in the long-term services and supports (LTSS) sector, which reflect demanding working conditions and relatively low wages. The COVID-19 pandemic affected health care workers in all settings but particularly for direct care workers who provide LTSS. As of December 2022, employment levels were still over 13% below pre-pandemic levels for nursing care facilities and 7% below pre-pandemic levels for community care facilities for the elderly. Immigrants could help fill some of those positions, but a backlog of green card petitions is expected to further exacerbate nursing shortages across both health and long-term care sectors. Nationwide, there is “a growing crisis of unfilled job openings and high staff turnover” in the long-term care sector. Recognizing these shortages, most states have moved forward to increase Medicaid payment rates to LTSS providers. In a recent survey of Medicaid directors, 44 states reported increasing Medicaid rates for nursing facilities in 2022, and a survey of HCBS programs found that 48 states increased rates for home- and community based LTSS providers. Despite those pay increases, workforce shortages persist.

Potential increases in nursing home staffing requirements could increase costs, which may be difficult for some states’ Medicaid programs to absorb without additional federal funding. The American Health Care Association, a group representing both for-profit and not-for-profit long-term care facilities, commissioned a study in anticipation of the proposed rule and estimated that a minimum staffing requirement could cost anywhere from 3 billion to 10 billion dollars in a single year and require hiring more than 187,000 nurses and nurse aides. It is not clear how these costs will be financed, but they are likely to be passed on to public and private payers for nursing facility services, including residents and their family members who paid $45 billion in out-of-pocket costs for care in nursing homes and other institutional LTSS settings in 2020. Medicaid spent nearly $53 billion dollars in that year, about twice the amount ($26 billion) that traditional Medicare spent on skilled nursing facilities (SNFs) in 2020. Medicaid financing is shared by the states and the federal government. However, unlike the federal government, states must meet balanced budget requirements, and therefore, may need to cut other spending or raise taxes to pay for the state share of additional nursing home costs.

In addition to potential costs to meet nursing facility staffing requirements, a recent proposed rule on Medicaid access would require states to demonstrate that their payment rates for home and community-based LTSS are “adequate to ensure a sufficient direct care workforce to meet the needs of beneficiaries and provide access to services in the amount, duration, and scope specified in the person-centered plan” Together these rules could require significant Medicaid investments in LTSS.

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REFORM (PROVIDERS)- Provider group seeks 2-year moratorium on HCBS settings rule enforcement

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]: In which the nursing home lobby asks for more time to remedy abysmal member care. 2 more years, to be exact.

 
 

Clipped from: https://www.mcknightsseniorliving.com/home/news/provider-group-seeks-2-year-moratorium-on-hcbs-settings-rule-enforcement/

 
 

 
 

(Credit: Ijubaphoto / Getty Images)

A new white paper from LeadingAge recommends a two-year enforcement moratorium on the federal government’s home- and community-based services settings final rule, saying that it is flawed policy.

The final rule from the Centers for Medicare & Medicaid Services, originally proposed in 2014 and in effect since March, creates “significant challenges” and “pain points” as it fails to ensure access to person-centered care and creates obstacles to assisted living and other providers trying to deliver services, according to the paper.

The white paper, titled “Home and Community-Based Settings Rule: How Regulation Intended to Ensure Access to Medicaid Funded Services Falls Short, and Changes Needed to Fix It,” was released Wednesday. 

LeadingAge President and CEO Katie Smith Sloan said in a statement that although the intent of the HCBS settings final rule is “laudable,” it is problematic in practical application. The association recommends the two-year enforcement moratorium for HCBS providers while the Biden administration develops specific guidance for them.

“When applied to certain types of care settings, including assisted living and adult day services, the rules’ requirements could potentially harm an older adult,” Sloan said. “As a result of these issues, the rule is limiting older adult Medicaid beneficiaries’ access to HCBS — the opposite of its intent.”

Providers could leave Medicaid

The sentiments echo a letter Sloan sent to leaders of the Senate Special Committee on Aging and Senate Committee on Health, Education, Labor and Pensions last month. States had until March 17 to comply with most of the rule’s provisions. Assisted living communities providing HCBS to their residents through Medicaid waivers are among those affected.

The white paper presents examples demonstrating how the settings rule affects assisted living and some other providers — for instance in the areas of employment counseling, kitchen access and lockable door requirements for assisted living residents living with dementia. As a result, LeadingAge said, the rule could “chill access” to services, with many assisted living and adult day providers declining to accept Medicaid payments.

Currently, 18% of assisted living residents rely on Medicaid to pay for daily services, and 61% of all assisted living communities are Medicaid-certified, according to the National
Center for Assisted Living.

“Additional costs for staffing to complete lengthy person-centered service planning templates with inapplicable questions, coupled with renovations and policy changes, do not make financial sense in a system already struggling with low Medicaid reimbursement rates and a staffing crisis,” the paper stated. “These pressures have pushed — and will push — providers out of the Medicaid provider space, further limiting options for low-income older adults, and forcing more individuals to go without care, or pushing them into their only remaining option — a nursing home — quite the opposite of the intent of the settings rule.”

Thirty-four percent of assisted living residents are living with diagnosed dementia, according to the Centers for Disease Control and Prevention’s National Center for Health Statistics. Eighteen percent of assisted living communities have dedicated dementia care wings or floors, and 11% serve only adults who are living with dementia, according to NCAL.

More feedback recommended

Along with a two-year moratorium on the settings rule, LeadingAge is proposing that CMS treat services for older adults differently than those for working-aged individuals with disabilities. The association also recommended soliciting feedback from aging services experts, providers and state officials on the settings rule, to better define compliance parameters for the population being served.

“By better defining parameters for compliance in settings where the settings rule doesn’t fit the population being served, settings rule compliance efforts can focus more directly on services to individuals for which the rule was intended,” the paper concluded.

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REFORM- DACA recipients’ Medicaid eligibility slammed by U.S. House Republicans

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]: In which an administrative redefinition of 2 words could add whole new permanent Medicaid eligibility category.

 
 

Clipped from: https://iowacapitaldispatch.com/2023/07/18/daca-recipients-medicaid-eligibility-slammed-by-u-s-house-republicans/

 
 

Supporters of the DACA program rally outside the U.S. Supreme Court in November 2019. (Photo by Robin Bravender/States Newsroom)

WASHINGTON — A panel on the U.S. House Oversight and Accountability Committee on Tuesday grilled a Biden administration official about the White House’s decision to allow undocumented people in the Deferred Action for Childhood Arrivals program to enroll in Medicaid or private insurance provided under the Affordable Care Act.

The chair of the subcommittee, Republican Rep. Lisa McClain of Michigan, argued that the policy decision to allow those under DACA to gain access to health care coverage is “rewarding illegal immigrants at the expense of (the) American citizen.” 

“The proposal will incentivize further illegal immigration,” she said.

The hearing comes after the Biden administration in April announced rulemaking that would change the definition of “lawful presence” to include DACA recipients in Medicaid and Affordable Care Act coverage. Medicaid is a joint federal-state program that provides health coverage to low-income Americans and people with disabilities.

Democrats on the panel argued that the hearing was an attack on DACA recipients and an opportunity for Republicans to criticize the Biden administration’s immigration policy.

“Somehow, letting people who legally live in the United States buy health care is going to create a border crisis,” the top Democrat on the committee, Rep. Katie Porter of California, said. “It’d be funny to watch this bad argument fall apart if it weren’t such a waste of time.” 

The sole witness was Ellen Montz, the deputy administrator and director of the Center for Consumer Information and Insurance Oversight at the Centers for Medicare and Medicaid Services, which is part of the U.S. Department of Health and Human Services.

Montz said the proposed rule would allow about 129,000 DACA recipients to access coverage for Health Insurance Marketplaces, the Basic Health Program and some Medicaid and Children’s Health Insurance Programs. If finalized, the rule would go into effect Nov. 1.

“The COVID–19 public health emergency further highlighted the need for this population to have access to high-quality, affordable health coverage,” she said.

Montz said about 200,000 DACA recipients were considered essential workers during the early stages of the pandemic.

“During the height of the pandemic, essential workers were disproportionately likely to contract COVID-19,” she said. “These factors emphasize how increasing access to affordable health insurance would improve the health and well-being of many DACA recipients currently without coverage.”

There are about 600,000 DACA recipients, and they are protected from deportation and deemed lawfully present in the U.S.

Applications for the DACA program have been halted since 2021 following an injunction by a Texas judge, who will also determine whether the program is legal. 

Even if applications could be accepted, immigration advocates have criticized that thousands of undocumented youth are not eligible for the program, some because they were not even born yet. To qualify, an undocumented youth needs to have continuingly resided in the U.S. since 2007.

Immigration policy

Republicans on the panel argued that because of the Texas decision, DACA is considered unlawful, and therefore health care should not be extended to those recipients.

The program has not been deemed unlawful — the Texas judge found the Obama administration memorandum that created the program illegal, so the Biden administration went through the formal rulemaking process that now is before the Texas judge. 

That decision is expected in the coming months and if DACA is deemed unlawful, the case is expected to go to the U.S. Supreme Court in 2024. 

McClain took issue with HHS rewriting immigration policy. She said immigration reform should be up to Congress.

 Montz said that the agency was not crafting immigration policy and has the authority to set definitions. 

“Do we owe a legal duty to provide health care to DACA recipients over American citizens?” McClain asked Montz.

Montz said that DACA recipients are considered lawfully present in the country and therefore the Affordable Care Act would be extended to them.

“What this rule does is extend eligibility, it does not restrict eligibility for any other category,” Montz said.

Democratic Reps. Alexandria Ocasio-Cortez of New York and Greg Casar of Texas said they found the hearing inappropriate, coming off the news of a joint investigation by the Houston Chronicle and the San Antonio Express-News that reported Republican Texas Gov. Greg Abbott directed border troopers to push migrant children into the Rio Grande and deny migrants water. Wire running along the water was also installed and it led to many migrants being injured.  

“We are having this hearing on the heels of Gov. Abbott in Texas issuing an order to Texas troopers to push children and infants into the Rio Grande River. And now we’re having a hearing today about why we should push people brought here as children off health care coverage,” Ocasio-Cortez said.

Ocasio-Cortez said that DACA recipients pay about $9 billion in taxes each year.

“I do not know a group of people that oftentimes are more patriotic to this country than DACA recipients,” she said. “They give and they give and they give to a country that does not love them back.” 

Republican Reps. Glenn Grothman of Wisconsin and Eric Burlison of Missouri said the new rule would be too costly.

“At the end of the day, health care costs a lot of money,” Burlison said. “And this nation is nearly broke.”

 
 

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REFORM (MT)- A plan to cut Montana’s Medicaid waiting list was met with bipartisan cheers. Then a veto.

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]: Montana was ok with expanding Medicaid for thousands of Chad the 27 year old otherwise healthy bartendesr in 2016. Not OK with clearing the waiting list for 160 members with intense healthcare needs on a waiting list for services.

 
 

 
 

Clipped from: https://www.news-medical.net/news/20230714/A-plan-to-cut-Montanae28099s-Medicaid-waiting-list-was-met-with-bipartisan-cheers-Then-a-veto.aspx

Montana state Sen. Becky Beard thought she’d found a fix for a shortage of assisted living care options for Montanans who can’t afford to pay for it themselves — a shortage she became aware of while searching for a suitable place for her mother to live.

Beard, a Republican from the rural town of Elliston, ushered a bill through the GOP-controlled legislature this spring. The proposal would have moved more than 200 people off waiting lists for government-supported care and saved the state money by accessing more federal Medicaid money to cover their costs and the cost of those already in assisted living.

The bill had broad support from assisted living facility owners whose facilities eventually would accept more of these patients covered by Medicaid, the state-federal program that pays medical and other health-related bills for low-income and disabled people. In Montana, the federal government pays about 65% of the cost of most Medicaid-covered services, and the state pays for the rest.

But Republican Gov. Greg Gianforte vetoed the measure May 18, two weeks after the legislature adjourned. A post-session vote in June by Montana’s 150 lawmakers to override the veto failed by 10 votes.

Gianforte’s veto disappointed and mystified the bill’s supporters.

“I don’t see where there is any negative impact, financially for the state, for the residents, or to us as providers,” said Mike White, who co-owns seven assisted living facilities across Montana. “I thought, of all the bills out there, this would be the last one to get vetoed.”

Gianforte said the bill, by creating another Medicaid entitlement program, could have ended up costing the state much more in the long run. He also said it would have restricted the state’s ability to serve Medicaid-funded residents “in a community setting.”

Supporters of the bill said that the governor is simply wrong — and that Montana missed an opportunity to tackle a long-standing problem: the lengthy waiting lists for people on Medicaid who need assisted living or in-home care, to keep them out of more expensive nursing homes.

An analysis by Gianforte’s own budget office said the bill would have saved the state $1 million during its first two years by using more federal money. Some supporters also pointed to the state’s $2.4 billion surplus, saying the state could certainly afford this small change to its Medicaid plan, if it ended up costing the state.

“This administration has shown that they don’t care about poor people, about people who are struggling,” said state Rep. Mary Caferro, a Democrat. “They simply don’t care, because we had the money to do it.”

The Gianforte administration insisted that there is no accurate way to estimate the long-term costs of placing assisted living under a Medicaid option called Community First Choice, and that doing so would complicate management of in-home and assisted living services.

Beard’s Senate Bill 296 would have required the state to place Medicaid funding for assisted living under Community First Choice starting in 2026, instead of a “waiver” program, where it’s been for many years.

States must ask the feds for Medicaid waivers to offer services or cover populations not covered under federal law. Like many other states, Montana asked for a waiver decades ago to cover nonmedical services that help keep older or disabled people out of nursing homes or other institutional settings. About 2,700 Montanans use these waiver-covered services each year, including about 900 in assisted living facilities.

But funding for Montana’s Big Sky Waiver program is capped by the legislature, so it has a waiting list for covered services. As of this spring, about 160 people who’d qualified for Medicaid coverage were on the waiting list for an assisted living spot.

An additional 150 people were waiting for other Medicaid services, such as in-home care that helps with daily chores like eating, dressing, and bathing. Those spots open only if lawmakers approve more funding or if a person getting the services dies or no longer qualifies for Medicaid.

Community First Choice, however, has no waiting list because it’s an entitlement, with no funding cap. A person who qualifies for Medicaid gets whatever services are covered under the program.

CFC was created as a state Medicaid option by the 2010 Affordable Care Act, in hopes of expanding coverage of services that help older and disabled people who have little income and few assets live independently, staying out of pricey facilities.

To encourage states to incorporate CFC into their Medicaid plans, the Affordable Care Act offered a higher federal match, of 6 additional percentage points.

Only nine states, however, have adopted CFC, and only three — Washington, Oregon, and California — have chosen to cover assisted living under the program.

Montana is one of the nine states that applied for the program, 11 years ago under Democratic Gov. Brian Schweitzer. But the state did not include assisted living as a covered service under CFC.

Rose Hughes, executive director of the Montana Health Care Association, which represents nursing homes and assisted living facilities, said states apparently worry that making these services an entitlement will increase their Medicaid budgets.

But she argued that expanding assisted living coverage under Medicaid saves states money because it can keep people out of more expensive nursing homes and, in some cases, costs less than in-home care.

Assisted living “is an extremely cost-effective service, and it’s one that seniors like,” Hughes said.

She also noted that anyone who qualifies for assisted living under CFC or the waiver is eligible for nursing home-level care.

“The day they get put on a waitlist, they could go to a nursing home, and the state would pay for that,” Hughes said.

And getting rid of the waiting list simply is the humane thing to do, bill supporters said.

The waiting list, managed by the state, rates people’s level of need and can seem incredibly arbitrary, bill supporters said. There are separate waiting lists for different locales; if you’re on the list in one town and move elsewhere, you must get on another waiting list.

“These systems are designed to protect people when they run out of resources. These people did their part, and we owe it to them,” said Michael Coe, director of operations for Caslen Living Centers, the company co-owned by White.

Beard eventually found her 82-year-old mother a spot at a Helena senior living facility that her mother pays for herself, without help from Medicaid.

Beard said the experience drove home the difficulty many Montanans face in finding such services if they can’t afford to pay.

She said she shares the concerns of her fellow conservatives about the state budget, but on this issue, she thinks paying for more assisted living slots is both fiscally sound and the right thing to do — and she’ll pursue it again in the 2025 legislature.

“This is a real need, and we’re not done with it,” Beard said. “I’m not giving up on this.”

 
 

This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

 

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FWA (NY)- Pharmacy owner and manager accused of stealing millions from 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]: Poveda and Burbano paid Medicaid members bribes so they could steal $2.9M of your tax dollars.

 
 

 
 

Clipped from: https://brooklyneagle.com/articles/2023/07/12/pharmacy-owner-and-manager-accused-of-stealing-millions-from-medicaid/

 
 

Attorney General Letitia James announced on Tuesday the indictment, arrest, and arraignment of Juan Poveda, the owner, and Javier Burbano, the manager, of a Queens-based pharmacy for allegedly partaking in a scheme that saw millions stolen from Medicaid.

Poveda, 32, and Burbano, 32, who both run Santiago Pharmacy under CSE Drug Corp., are accused of paying kickbacks to Medicaid recipients for filling their HIV prescriptions at their pharmacy. They also allegedly submitted fraudulent claims for HIV drugs like Biktarvy, which were either illicitly acquired or never actually purchased.

In addition to Grand Larceny in the First Degree and Health Care Fraud in the Second Degree, the defendants face charges for allegedly paying unlawful kickbacks to Medicaid beneficiaries, a violation of New York Social Services Law. The charges brought against them include Money Laundering in the First Degree and in the Second Degree for purportedly conducting financial transactions intended to disguise the illegally procured funds.

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According to the Attorney General’s Office, search warrants were executed at Corona Chemist Pharmacy in Corona and Mi Botica Pharmacy in Flushing, Queens as part of the ongoing investigation. If convicted, the accused face a maximum of 25 years in prison for class B felonies like Grand Larceny and Money Laundering in the First Degree, and up to 15 years for class C felonies like Health Care Fraud in the Second Degree.

Attorney General James expressed her disappointment in the situation, stating, “We trust pharmacies to attend to the needs and welfare of their patients, not to take advantage of our most vulnerable neighbors to line their own pockets. Stealing from Medicaid is a reprehensible crime, and New Yorkers can count on my office to hold these bad actors accountable.”

Allegedly, the defendants paid cash kickbacks to Medicaid recipients to incentivize them to fill their HIV prescriptions at Santiago Pharmacy, subsequently billing Medicaid and receiving millions of dollars for those prescriptions. The court papers claim that Poveda and Burbano stole more than $2.9 million from Amida Care, a Medicaid-funded managed care organization, by billing for drugs that were either not legally obtained or never existed. The fraudulent funds were then supposedly concealed by routing the criminal proceeds through pass-through bank accounts without any apparent business operations.

It is essential to note that the charges filed in this case are accusations. The defendants are presumed innocent until proven guilty in a court of law.

The Attorney General thanked the New York State Department of Health, the Office of the Medicaid Inspector General, and the United States Department of Health and Human Services Office of the Inspector General for their assistance in this investigation. She also acknowledged the cooperation of Medicaid MCOs Amida Care and VNS Choice, pharmacy benefit managers Express Scripts and Med Impact, pharmacy services administrative organization AlignRx, and pharmaceutical wholesaler AmerisourceBergen.

This ongoing investigation involves a team of investigators and prosecutors led by Attorney General Thomas O’Hanlon. The Office of the Medicaid Fraud Control Unit, which oversees this case, is funded with a federal grant from the U.S. Department of Health and Human Services and supplemented by New York State. The office regularly recovers more in law enforcement actions than it receives in state funding.

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FWA (MD) -Owner of Health Care Company Pleads Guilty to Federal Charge for Conspiracy to Commit Health Care Fraud

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]: Kabiwa et al paid Medicaid members and providers bribes so they could steal $3.3M of your tax dollars.

 
 

 
 

Clipped from: https://www.justice.gov/usao-md/pr/owner-health-care-company-pleads-guilty-federal-charge-conspiracy-commit-health-care

Baltimore, Maryland – Mboutchock Kabiwa a/k/a Eugenie Bakari or Eugenie Kabiwa, age 45, of Silver Spring, Maryland, pleaded guilty yesterday to conspiracy to commit health care fraud in connection with a scheme to pay bribes and kickbacks to Medicaid beneficiaries to induce the beneficiaries to visit her company Holy Health Care Services, LLC (“Holy Health”), a mental health services provider with locations in Washington, D.C.

The guilty plea was announced by United States Attorney for the District of Maryland Erek L. Barron; Acting Special Agent in Charge of the FBI Washington Field Office’s Criminal and Cyber Division, Emily Odom; Special Agent in Charge Maureen Dixon, Office of Investigations, Office of Inspector General of the Department of Health and Human Services (“HHS OIG”); and Daniel W. Lucas, Inspector General for the District of Columbia.

According to her plea agreement, Kabiwa and a co-conspirator owned and operated Holy Health.  Holy Health entered into Medicaid Provider Agreements with the District of Columbia’s Department of Health Care Finance (“DHCF”), to provide healthcare services to D.C. Medicaid recipients.  Holy Health was certified by the District of Columbia’s Department of Behavioral Health (“DBH”) to provide mental health services as a freestanding clinic and as a Mental Health and Rehabilitation Services (“MHRS”) provider.  As a certified MHRS provider, Holy Health had authority to provide and bill for a variety of mental health services including “community support” – a service for which community support workers (“CSWs”) provide rehabilitative and educational support to mental health patients both in clinical settings and in the community.  Holy Health documented the services provided to patients utilizing an electronic healthcare system called the Integrated Care Management System (“ICAMS”), then submitted invoices for those services to DHCF, which processed the invoices and paid Holy Health.  

As detailed in the plea agreement, Kabiwa and her co-conspirators paid bribes and kickbacks to Medicaid beneficiaries to induce the beneficiaries to visit Holy Health, and paid bribes and kickbacks to others in exchange for referring Medicaid beneficiaries to Holy Health for mental health services.  The co-conspirators caused Medicaid beneficiaries to be transported, often by van, to Holy Health’s North Capitol location.  Medicaid beneficiaries who visited Holy Health were required to sign in and received a cash bribe – generally $5 or $10 – in exchange for visiting Holy Health.  To conceal the nature of these payments, Kabiwa directed Holy Health employees to falsely describe these payments as a transportation stipend, even when Holy Health transported the beneficiaries or when beneficiaries were not incurring transportation expenses.  At other times during the conspiracy, Kabiwa and her co-conspirators attempted to conceal the illegal bribe payments to beneficiaries as payments from the Agatha Foundation, a nonprofit that Kabiwa founded.  Kabiwa provided front-desk employees of Holy Health with sign-in sheets containing Agatha Foundation letterhead to create the false appearance that Agatha was making the payments.  Kabiwa admitted that she and a co-conspirator provided funds to Holy Health employees to fund the kickback and bribe payments. 

According to the plea agreement, Kabiwa and her co-conspirators caused claims to be submitted by Holy Health to Medicaid for services, including community support services, purportedly provided to Medicaid beneficiaries procured through bribes and kickbacks.  Medicaid would not have paid the claims had it known they were procured through bribes and kickbacks.  Kabiwa also became aware that co-conspirators entered false notes into ICAMS for CSW services that were not rendered and were not provided as billed to Medicaid, but took no action to stop or correct the fraudulent claims.  Based on the amount that Medicaid paid to Holy Health for community support services that were not delivered or procured through bribes and kickbacks, the actual loss to Medicaid was at least approximately $3,343,781.

Finally, Kabiwa admitted that she fraudulently obtained an Economic Injury Disaster Loan (“EIDL”) of $150,000 for Holy Health.  The EIDL program was part of the Coronavirus Aid, Relief, and Economic Security Act (“CARES Act”) and was intended to help small businesses meet necessary financial obligations that could have been met had the COVID-19 pandemic not occurred.  After a $1,000 handling charge, EIDL loan proceeds of $149,900 were transferred into a Holy Health bank account on May 26, 2020.  Within a few days, Kabiwa
transferred $120,000 of the EIDL proceeds from the Holy Health bank account to her personal bank account.  Kabiwa
used the EIDL funds for personal purposes including to purchase two vehicles—one of which was a Porsche Cayenne.  Kabiwa
titled both vehicles in the name of her non-profit, the Agatha Foundation.  Kabiwa also transferred more than $40,000 in EIDL funds overseas, including $37,821 to Cameroon, even though Holy Health had no operations outside of the United States. 

Kabiwa faces a maximum sentence of 10 years in federal prison for the health care fraud conspiracy.  As part of her plea agreement, Kabiwa will be required to forfeit and pay restitution in the full amount of the loss, which the parties agree is at least $3,493,681.  U.S. District Judge Paula Xinis has scheduled sentencing for November 21, 2023 at 10:00 a.m.

The District of Maryland Strike Force is one of three strike forces established throughout the United States by the U.S. Department of Justice to investigate and prosecute COVID-19 fraud, including fraud relating to the Coronavirus Aid, Relief, and Economic Security (“CARES”) Act.  The CARES Act was designed to provide emergency financial assistance to Americans suffering the economic effects caused by the COVID-19 pandemic.  The strike forces focus on large-scale, multi-state pandemic relief fraud perpetrated by criminal organizations and transnational actors.  The strike forces are interagency law enforcement efforts, using prosecutor-led and data analyst-driven teams designed to identify and bring to justice those who stole pandemic relief funds. 

For more information on the Department’s response to the pandemic, please visit https://www.justice.gov/coronavirus.  Anyone with information about allegations of attempted fraud involving COVID-19 can report it by calling the Department of Justice’s National Center for Disaster Fraud (NCDF) Hotline at 866-720-5721 or via the NCDF Web Complaint Form at: https://www.justice.gov/disaster-fraud/ncdf-disaster-complaint-form.

United States Attorney Erek L. Barron commended the FBI, the HHS OIG, and the District of Columbia Office of Inspector General’s Medicaid Fraud Control Unit for their work in the investigation.  Mr. Barron thanked Assistant U.S. Attorneys Jessica C. Collins, Christopher M. Sarma, and Megan S. McKoy, who are prosecuting the case.

For more information on the Maryland U.S. Attorney’s Office, its priorities, and resources available to help the community, please visit www.justice.gov/usao/md.

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STATE NEWS (WA)- CMS approves Washington’s Medicaid Transformation Project waiver extension request for five more years

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]: Another 5 years of the normal stuff, plus some new stuff.

 
 

 
 

Clipped from: https://stateofreform.com/featured/2023/07/cms-approves-washingtons-medicaid-transformation-project-waiver-extension-request-for-five-more-years/

 
 

Shane Ersland | Jul 14, 2023 | Washington

The Centers for Medicare & Medicaid Services (CMS) recently approved Washington’s request to extend and amend its Section 1115 Medicaid Transformation Project waiver. 

 
 

 
 

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The extension will allow Washington to implement new policies and use federal Medicaid funds to improve Apple Health, the state’s Medicaid program. The waiver ended on June 30th, and the extension runs through June 30th, 2028.

Washington Medicaid Director Charissa Fotinos, MD, said the extension will allow the state to test the effectiveness of innovative practices aimed at promoting consistently high-quality, evidence-based, coordinated, and integrated care in a statement following CMS’ approval of the state’s request.

“With this extension, Washington is also introducing new initiatives and investments to assist the state in improving health coverage, access, and consistent provision of high-quality services for Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries, all while advancing health equity among its beneficiary populations. 

Overall, the goal of the demonstration is to provide medical assistance and improve the health of communities and populations. This extension will lead to additional populations being served by Medicaid, as well as additional services being furnished to Medicaid and CHIP beneficiaries.”

— Fotinos

The extension permits the state to continue its Medicaid Alternative Care and Tailored Supports for Older Adults programs by adding covered services and increasing TSAO eligibility standards. The programs expand care options for older residents so they can stay in their homes, and delay or avoid more intensive situations, such as the need to move into a nursing facility. It also assists unpaid family caregivers. 

CMS also approved the state’s request for contingency management, an evidence-based tool used in treating substance abuse disorder (SUD). It includes a series of incentives for meeting treatment goals, and has been effective in increasing rates of drug abstinence for a range of SUDs, including stimulants, cannabis, alcohol, and tobacco.

The extension also allows the state to provide full Medicaid benefits to postpartum individuals with incomes up to 193 percent of the federal poverty level who apply for Medicaid or CHIP during their postpartum period, but who were not previously enrolled in Medicaid or CHIP during their pregnancy, until 12 months after their pregnancy ends.

Additional newly approved programs include:

  • Re-entry coverage for individuals leaving a prison, jail, or youth correctional facility
  • Program innovations that support older adults, including expanded eligibility and presumptive eligibility to support access and enrollment
  • Continuous Apple Health enrollment for children through age five
  • Programs that address health-related social needs (HRSN), including community-based payment through community/Native hubs, rental subsidies for up to six months, and HRSN services for nutrition, housing, medical respite, and transportation

CMS denied Washington’s request to cover postpartum care for non-citizens. The state therefore cannot use waiver funds to support the initiative, but plans to use other funding resources to provide postpartum care for non-citizens.

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MCOs- Elevance (Anthem) Earnings: 2023 Outlook Increased Despite Utilization and Medicaid Redetermination Trends

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]: Anthem tells shareholders they will get through the PHE wind-down just fine. Largely because those people kicked off of Medicaid are going to go back to getting commercial coverage from their employers (which Anthem will sell to them).

 
 

 
 

Clipped from: https://www.morningstar.com/stocks/elevance-earnings-2023-outlook-increased-despite-utilization-medicaid-redetermination-trends

 
 

 
 

Elevance Health’s ELV strong second-quarter results contributed to a mild 2023 outlook increase and caused the shares to rise closer to our $520 fair value estimate in early trading July 19. Our expectations for the year remain in line with the new target, and we’re keeping our fair value estimate intact. The firm’s narrow moat looks solid, built on local scale leadership that helps it offer lower prices than most competitors.

In the second quarter, Elevance turned in 13% revenue, 12% operating profit, and 13% adjusted EPS growth, including recent share repurchases. Despite increasing medical utilization trends and the resumption of Medicaid redetermination activities after the public health emergency, the medical insurance segment led the way, increasing revenue 11% and operating profits 21%. Medical membership grew 2% year over year, including strong growth in the individual business (18%) and decent growth in Medicare Advantage (6%) and Medicaid (5%). Sequentially, Medicaid membership started to decline a bit (down 1%) after the resumption of redetermination efforts in the quarter to ensure only qualified individuals are covered. Eventually, we suspect there will be a membership mix shift from Medicaid to higher-margin employer-sponsored or individual plans, but redeterminations create a near-term risk to profits, especially if there is a coverage gap during this transition.

Overall, though, Elevance turned in a solid quarter that appeared to relieve investors worried about medical utilization trends recently highlighted by key managed-care organization peers. Management said Elevance already tried to price for such trends in 2023 and even mildly raised its 2023 adjusted EPS outlook to at least $32.85 while largely maintaining its margin assumptions, including for its medical loss ratio. Our 2023 EPS forecast remains roughly in line with the firm’s new goal, and we do not anticipate making significant changes to our assumptions based on this announcement.

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STATE NEWS (NC)- State officials delay rollout of specialty Medicaid plans — again

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]: Reminder- NC still can’t figure out how to help members with intense behavioral health needs get a better delivery system after 20 years of trying. NC politicos do seem able to keep a frothy panic going on whether Medicaid expansion happens to meet the needs of Chad (the 27 year old otherwise healthy bartender), tho.

 
 

 
 

Clipped from: https://www.cityviewnc.com/stories/state-officials-delay-rollout-of-specialty-medicaid-plans-again,49606

For the 3rd time, tailored plans for complex patients are being postponed

 
 

Our team has worked very hard on this, and we believe in the whole-person vision that is core to the design of the tailored plans.”

Kody Kinsley, N.C. secretary of health and human services

By Jaymie Baxley | NC Health News

The repeatedly delayed rollout of specialized health care plans for tens of thousands of Medicaid beneficiaries — those with complex, often behavioral health needs — has been postponed indefinitely, the N.C. Department of Health and Human Services announced Tuesday. 

This marks the third time the state has pushed back the launch of so-called tailored plans for individuals who require more extensive care and support than average Medicaid enrollees. Some of the groups expected to eventually transition to tailored plans include people with intellectual or developmental disabilities; people with substance use disorders and traumatic brain injuries; low-income seniors living in nursing homes; and many people with severe mental health problems.

DHHS originally said these groups would be moved to tailored plans in December 2022 before delaying the launch to this April and then again to October. In a news release announcing the latest postponement, the agency said it is “not able to announce a certain go-forward date at this time.”

“The department has been working collaboratively with the legislature to achieve the necessary tools to administer the tailored plans on par with other managed care plans, but they are still a work in progress,” the release said. “Further, uncertainty with the state budget, which will fund transformation costs and rebase for the Medicaid program, creates additional needs for launching tailored plans.”

Another issue, the agency suggested, is a lack of readiness among the six behavioral health organizations that will coordinate care for tailored plan enrollees across the state. Those state-supported managed care agencies, known as LME-MCOs, are Alliance Health, Eastpointe, Partners Health Management, Sandhills Center, Trillium Health Resources and Vaya Health. The department statement said “progress has been made” in ensuring that those organizations have the “technical capabilities” needed to implement the tailored plans. 

The LME-MCOs are meant to act as intermediaries, connecting eligible enrollees with health care providers who will be reimbursed through tailored-plan contracts. But some providers have been reluctant to accept this arrangement, making it difficult for the organizations, all of which serve multiple counties, to ensure that eligible beneficiaries have access to care where they live.

Continued gaps

In its announcement last Tuesday, DHHS acknowledged that “gaps remain in provider networks” — echoing comments made by Jay Ludlum, deputy secretary for N.C. Medicaid, during a June 14 symposium in Raleigh organized by the i2i Center for Integrative Health. 

“There are continued gaps in contracting,” he said at the time. “We are seeing that it’s primarily around one system that is not contracting, and I’m not going to mention them by name. We are trying to encourage them to engage in that contracting. I think that that’s really important.”

While Ludlum did not identify the holdout, Rhett Melton, CEO of Partners Health Management, in March said his organization was having difficulty contracting with Atrium Health. The Charlotte-based provider, which is the country’s eighth-largest hospital system, has about 2,700 acute care beds in North Carolina, nearly 150 of which are for patients with mental health needs.

“Atrium has the health care market, if you will, for us in (our region),” Melton said during a meeting of the Joint House and Senate Appropriations Committee on Health and Human Services. “When we don’t have the contract with Atrium, that displaces about 25% of our members.”

Atrium, in turn, appeared to take a swipe at the behavioral health organizations in a statement to NC Health News, referencing the ongoing capability challenges described by DHHS.

“Our intent is to be contracted with each of the payors in this space to support this vulnerable patient population and its growing needs,” a spokesperson for the system said in an email. “As the state has noted publicly, there are gaps in the technological capabilities and operational readiness of the tailored plans. We look forward to being able to move forward when the department and the plans have resolved these issues.”

‘Key issues outstanding’

Tailored plans have been a work in progress ever since North Carolina switched to a managed-care Medicaid system in 2021. While managed care is not unique to the state, North Carolina’s system differs from the traditional model by including plans tailored to the needs of some of the state’s most expensive patients, many of whom have complicated — often multiple — diagnoses and who need a lot of support. 

DHHS has said about 150,000 people, or 5% of the state’s Medicaid participants, are expected to move to tailored plans when the plans eventually go live, but it is not yet clear if that can happen without Atrium’s participation. It also remains to be seen when the behavioral health organizations will be fully prepared for the plans’ rollout.

Anthony Ward, CEO of Sandhills Center, said his organization “values the integrated, whole-person approach included in the tailored plan design.” 

“We are committed to continuing our work with the North Carolina Department of Health and Human Services on our preparation for the tailored plan launch when announced,” he said in an email to NC Health News. “We share NC DHHS’ focus on minimizing disruption for the members served by the tailored plans and have been working actively with community providers currently serving our members, including primary care physicians, to contract with us in advance of the tailored plan launch.”

State Health and Human Services Secretary Kody Kinsley echoed Ward’s comments in texts to NC Health News. 

“Our team has worked very hard on this, and we believe in the whole-person vision that is core to the design of the tailored plans,” he said. “However, as I said before the joint oversight committee in March, we have key issues outstanding we need resolved.”

Legislation passed in March made North Carolina the 40th state to expand access to Medicaid. The expansion, which will not officially take effect until a state budget is approved, will provide coverage to about 600,000 people who currently lack health insurance. At the same time, an estimated 300,000 existing beneficiaries are expected to lose coverage through the unwinding of a federal mandate that prevented states from kicking people off the rolls during the COVID-19 pandemic.

DHHS has confirmed that many of these individuals will become eligible for Medicaid again under expansion, once that takes effect.

Jaymie Baxley reports on rural health and Medicaid for NC Health News. Before joining the team in May, he covered public safety, county government and the COVID-19 pandemic for The Pilot newspaper in Moore County. Reach him at jbaxley at northcarolinahealthnews.org.

The CityView News Fund is a nonprofit organization that supports CityView’s newsgathering operation. Will you help us with a tax-deductible donation?

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STATE NEWS (MS) Presley announces health care plan, takes shot at Medicaid chief

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]: Dem Governor promises expansion and casts shade at outgoing Medicaid Director. Classy.

 
 

 
 

Clipped from: https://magnoliatribune.com/2023/07/12/presley-announces-health-care-plan-takes-shot-at-medicaid-chief/

 
 

Brandon Presley holds a press conference on July 10, 2023 (Photo from Presley’s Twitter)

Democratic gubernatorial candidate Brandon Presley re-upped his commitment to Medicaid expansion this week while taking aim at Medicaid Executive Director Drew Snyder who he called a “career political hack.” Presley, 45, has held elected office for the last 22 years.

On Monday, Democratic gubernatorial candidate Brandon Presley formally rolled out his health care plan for Mississippi. Drum roll: it’s Medicaid expansion.

Following the reannouncement of his months-long support for expansion, Presley took to Twitter saying he would implement the policy on “Day 1” if elected. Presumably, the Democratic candidate understands that the supermajority Republican Legislature would have a say in the matter.

Presley also used Twitter to launch a missile at Division of Medicaid Executive Director Drew Snyder. The would-be governor called the sitting Medicaid chief a “career political hack.”

Presley, 45, has held elected office for the last 22 years.

It is unclear what, if anything, provoked the shot on Snyder. Conservative leaders, including Snyder’s boss and Presley’s political opponent–incumbent Governor Tate Reeves, a Republican– have resisted pressure to expand the taxpayer-funded welfare program. Snyder, to his credit, has never taken a public position in favor or opposition to the policy.

Medicaid expansion first came into play under the Affordable Care Act, sometimes referred to as “Obamacare.” Critics of expansion, like former Trump White House Health Care Adviser Brian Blase, frequently cite concerns over the scope and cost of expansion, along with doubt over whether it really solves the problems identified by proponents of the policy.

READ MORE: Brian Blase – Lawmakers Should Reject Calls to Expand Medicaid


Blase says Medicaid expansion states “experienced much greater enrollment and spending than they projected.”

He also argues that the results are less than promising. “Medicaid enrollees typically have worse health outcomes than those with private insurance or the uninsured, even after controlling for a variety of other factors that affect health.”

Nearly One-Third of Mississippians Already on Medicaid

Even without formal expansion, Mississippi’s Medicaid rolls are quite large. In June, there were over 900,000 Mississippians enrolled with some form of Medicaid benefits. That is roughly one-third of the state’s population.

As first reported by Magnolia Tribune, Mississippi’s Medicaid population ballooned by over 187,000 over the last three years. The de facto expansion was a byproduct of a federal prohibition on checking income eligibility during the declared COVID public health emergency. Total Medicaid expenditures in Mississippi, which include both state and federal funds, increased nearly $1.3 billion, from $5.92 billion in Fiscal Year 2019 to an estimated $7.2 billion in Fiscal Year 2023.

For the Hospitals

Presley has argued that expansion would result in 220,000 more Mississippians being added to the taxpayer-funded program, and that it would help struggling rural hospitals across the state. A cavalcade of Democratic Party officials, sympathetic media outlets, and a now deeply fractured Mississippi Hospital Association have joined in bolstering the claims.

RELATED: More Hospitals Drop Out of Mississippi Hospital Association


The truth about the causes of the current hospital dilemma, and the likelihood that expansion would solve the dilemma, is more nuanced and frequently minimized. Proponents often overlook changing dynamics in communities served by hospitals, including large population losses in certain parts of the state and the shift of health care delivery away from in-patient care.

According to a recent report from the Center for Healthcare Quality and Payment Reform (CHQPR), Mississippi has 27 rural hospitals that are labeled “at-risk.” This marks a 29 percent decline from the number reported as recently as October of 2022, and puts Mississippi in 37th place nationally for the percentage of at-risk rural hospitals.

RELATED: Number of At-Risk Mississippi Hospitals Falls by 29 Percent


States in worse shape–with higher percentages of rural hospitals in danger–include Medicaid expansion states Arkansas, Connecticut, Hawaii, Massachusetts, Nevada, New York, Oklahoma, and Vermont. To put a fine point on it: among the 13 states performing worse than Mississippi, eight of them have expanded Medicaid.

Lt. Governor Delbert Hosemann, a Republican who has come under fire from primary challenger State Senator Chris McDaniel for allegedly supporting Medicaid expansion, said in a recent interview with WJTV that expansion would not solve every funding problem in Mississippi hospitals, adding that it is “not the answer.”

“Not one hospital administrator I’ve talked to said that expansion would cover all my problems. Not one, and I’ve been just about everywhere in Mississippi. And so, that’s not the answer. The answer is to start with what we need and fund to that,” Hosemann said. “I haven’t had a hospital administrator yet say it would, it may help them, but it wouldn’t be the answer. Not the long-term answer. And what’ll happen is we’ll be right back here five years from now having poured more money in it and not have an answer.”

Taking Aim at the Medicaid Chief

Presley said if elected governor, he will remove Snyder, who he called a “career political hack.”

“One of the easiest things I’ll do to improve healthcare in Mississippi is to appoint a Director of Medicaid that is an actual career healthcare professional and not a career political hack,” Presley tweeted, adding, “Tate Reeves wants his pals in top jobs and I want professionals.”

Lost in the politics is the fact that the Executive Director of the Division of Medicaid is not a job that requires the ability to treat medical maladies. It is, first, an administrative job that requires management and business skills.

Snyder brings to bear a law degree from the University of Virginia, a business administration degree from the University of Mississippi, private sector health care law experience, and public policy experience under both then-Secretary of State Delbert Hosemann and former Governor Phil Bryant.

During Snyder’s tenure under two governors, the Division of Medicaid has gone from regularly operating with deficits to consistent balanced budgets.

Governor Reeves’ Deputy Chief of Staff for External Affairs, Cory Custer, told Magnolia Tribune on Tuesday that Snyder is doing a great job.

“Drew is doing a great job and we are grateful for his service to Mississippi,” Custer said. “Thankfully, Brandon Presley will never be governor, so this is really a non-issue.”