Category: MM Curator

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 tells a small group of reporters that it is going after states that are doing RTNO too fast.

 
 

 
 

Clipped from: https://www.modernhealthcare.com/politics-policy/medicaid-unwinding-redeterminations-cms-violations?adobe_mc=MCMID%3D23861661584467735660284450215007065101%7CMCORGID%3D138FFF2554E6E7220A4C98C6%2540AdobeOrg%7CTS%3D1689875606&CSAuthResp=1%3A%3A840741%3A7461%3A24%3Asuccess%3ABC81500C8395D1FB26EE296B90FA68EB

The Centers for Medicare and Medicaid Services is taking action to stem the tide of Medicaid and Children’s Health Insurance Program enrollees losing benefits for procedural reasons as states carry out eligibility redeterminations, federal officials said Wednesday.

So far, at least 3 million Medicaid beneficiaries have lost coverage in 33 states and the District of Columbia since eligibility checks resumed in April, according to data compiled by KFF. The redeterminations process, suspended during the COVID-19 public health emergency, is intended to remove people who no longer qualify for the programs. Yet a significant portion of those disenrolled have lost benefits for other reasons, such as state agencies being unable to contact them, provoking consternation from federal authorities.

“Despite all the preparations and what we know has been a tremendous amount of work at the state level and in the community, we are very concerned about the level of terminations,” Center for Medicaid and CHIP Services Director Daniel Tsai said during a news conference.

The Health and Human Services Department projects that 15 million people will lose Medicaid coverage once redeterminations are complete.

CMS has already ordered several states to pause redeterminations to address their failure to adhere to federal standards and is working with about a half dozen states to correct ongoing violations, Tsai said. The agency has required some states to pause so-called procedural terminations not related to eligibility and to reinstate coverage for those affected by policy, operational or compliance violations, he said. CMS is monitoring an additional dozen states to determine if they are in violation of Medicaid regulations.

One state failed to provide some enrollees with renewal forms, and another didn’t implement required auto-renewal mitigation strategies, according to a CMS fact sheet. The agency continues to monitor states, intervene when necessary and offer technical assistance.

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“We are really asking every state to take up a whole host of policy waivers and strategies that we’ve outlined over the past year and a half, and additional policy waivers we put out over the past month that really will help make the Medicaid eligibility process easier, and help keep eligible people covered,” Tsai said.

States that fail to adhere to federal rules designed to protect eligible beneficiaries could lose federal dollars that support their Medicaid budgets, Tsai said. “Their entire enhanced federal match for the quarter that’s been outlined by statute is at risk, and that’s a significant amount of funding,” he said.

CMS would not disclose what states it has targeted, but CMS Administrator Chiquita Brooks-LaSure said the agency would name them if those states fail to resolve their problems.

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]: The Medicaid Managed Care Task Force has one job.

 
 

 
 

Clipped from: https://idahocapitalsun.com/2023/07/10/idaho-looks-to-restructure-medicaid-funding-but-clear-answers-are-hard-to-find/

State legislative panel hears that dominant Medicaid funding structure has mixed performance evidence

 
 

Idaho’s Medicaid Managed Care Task Force, co-chaired by Rep. John Vander Woude, is considering ways to reduce costs of Idaho’s Medicaid program. (Kyle Pfannenstiel/Idaho Capital Sun)

Idaho is looking at restructuring how it pays for Medicaid, a free health insurance program that insures about 458,000 Idahoans, costing state taxpayers more than $4 billion last fiscal year.

But there’s mixed evidence that the funding structure that’s used by 41 state Medicaid programs, called managed care, leads to less spending on health expenses or better health care outcomes for patients, a panel of Idaho legislators on the Medicaid Managed Care Task Force heard in presentations Monday at the Idaho Statehouse in Boise.

Idaho’s Medicaid program is currently spread out between a mix of funding structures. 

Dental care, mental health care and substance abuse treatment are under a managed care structure, where a business contracts with the state to manage patient treatment. Under that system, the state pays a managed care organization a per member, per month fee for all people anticipated to receive Medicaid by the state that financial specialists predict before as a contract is negotiated. 

That contrasts from a fee for service program, which can involve the state health department directly managing patient care, approving individual fees for individual health care services. But experts note that systems with these titles can vary.

What are the differences between managed care and fee for service programs?

One key difference between those systems is who has the risk if health care becomes more expensive. 

Idaho Medicaid Division Director Juliet Charron told the task force  a managed care system shifts risk from the state to a contractor which, in turn, can help make budgets more predictable.

“Managed care is not the silver bullet for cost containment,” Charron said.

She added that a managed care system that involves an outside organization being paid a per member, per rate month for a contract term — called a capitation model — gives the state a better idea of what Medicaid expenses. That service, she said, involves budgeting the costs out up front to pay another organization, rather than the state paying each individual health care bill, like it does under the fee for service model.

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Another option for funding Medicaid payment is having a value care organization, such as a group of doctors or clinics, network together to manage patient care, still operating under a per-member, per-month system. Idaho Medicaid has some care contracted through value care organizations started recently, but Charron said data on whether those contracts have saved costs are still preliminary. She said she expects to have that data in August or September.

Information on cost savings, budget predictability, health care quality and accessibility from managed care is mixed, Kathryn Costanza, program principal for the National Conference of State Legislators, told the task force.

“When you’ve seen one Medicaid program, you’ve seen one Medicaid program,” Costanza said, underscoring the difficulty of comparing the ways states structure their programs. 

Does managed care save costs?

A report commissioned by the state from Sellers Dorsey, a research firm based in Pennsylvania, recommended Idaho pursue a managed care organization to run its Medicaid program, suggesting that it would save money over time. The final report was released in April and presented at the meeting Monday.

Sellers Dorsey Director Michael Heifetz, answering questions from lawmakers, said cost savings usually take several years after switching to a managed care organization. 

Rep. Josh Tanner, R-Eagle, said he didn’t see actual data in the report that showed cost savings, and that “the article alludes to a lot of different things.”

“How are we going to reduce costs? What mechanisms have you seen that do that?” Tanner asked.

Heifetz agreed with Charron, saying “there’s no silver bullet.”

“There isn’t one, or else we would have used that a long time ago,” Heifetz said. “… But managed care is still the better mechanism to look inside the curtain.” 

“Managed care at its basic function is still looking at what is and what isn’t working,” he said.

Heifetz also said that a managed care program “is largely meant to inherit the risk on the financial side, while also being responsible on the (care) quality side.”

Charron said she frequently tells people that with Idaho Medicaid’s limited staff resources spread across handling different funding structures, that “we are masters of none.”

Idaho’s costs for Medicaid have ballooned since the state’s Medicaid program expanded to allow more of the working poor to access free health insurance, which began in January 2020. State lawmakers voted earlier this year to create a special working group of legislators called the Medicaid Managed Care Task Force. The group is tasked with studying existing managed care programs in Idaho and other states to find the “most successful and cost effective means of implementing managed care.”

The panel meets next July 25 and in August, when the committee plans to host roundtable discussions with people and organizations. Idahoans can submit public comment to committee secretary Grace King at gking@lso.idaho.gov. 

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]: We would like a new set of numbers to better help support our ask for more money, please.

 
 

 
 

Clipped from: https://www.tdmr.org/ada-report-comparing-state-medicaid-reimbursement-rates-with-private-insurance-is-flawed/

 
 

On June 27, we reported that the Legislature would not be increasing the Medicaid fee schedule for dentists despite the overwhelming need and the record abundance of funds in the state coffers this legislative session.

The reason cited was that Texas HHS (HHSC) would not agree to such an increase because Texas was still paying a higher reimbursement rate than some other states.

The only research we could find on this was a 2020 ADA Health Policy Institute report entitled “Reimbursement Rates for Child and Adult Dental Services in Medicaid by State” which showed this and is included as a PDF in that article.

Success raising rates in other states

A few days after publishing the article, TDMR was contacted by a source in the dental insurance industry who was involved in efforts in other states outside of Texas to raise dental reimbursement rates. There has been success in doing so in a number of states including Louisiana, Georgia, and Kansas over the last year (see below).

They were interested in what happened in Texas.

Complaints on accuracy of ADA report

When the ADA report was mentioned, they said dentists in other states had complained to the ADA about the accuracy of the report because there was no way Kentucky was paying Medicaid dentists almost 105% of private insurance rates.

Because of the complaints, we were told that Marko Vujicic, the chief economist and vice president of the ADA’s Health Policy Institute, admitted the report wasn’t fully accurate.

HPI chief economist admits complaints valid

To back this up, there was an email written on June 28, the day after the publishing of our article, by Dr. Vujicic PHD and circulating around with his permission.

We were forwarded a copy and reproduce the relevant text here:

Re: KY, look, we are pretty open about our shortcomings with MCO data and also transparent on what we compare Medicaid rates to. The data are not perfect, each update we try to do better and rest assured, we are about to get new data in the coming weeks and will address some of the methodology challenges. Do I wish this happened quicker, yes, but we are at the mercy of outside data agencies too. We are not going to get MCO Medicaid data, it is just going to be the FFS Medicaid rates. Again, that is all the data we have. I would love it if MCOs had to disclose their data but they don’t. We will be using dentist charges this go around in the denominator, as that will be a better comparison vs. paid amounts. And I assure you we will look to make things even clearer in the write up.

Feel free to pass this along. I appreciate the feedback, we are not ignoring it, trust me.

Did the ADA’s petard hoist us here in Texas? We simply don’t know.  We don’t have all the rates to compare ourselves and determine their accuracy.  But clearly, an ADA report has authority and we would hope it to be accurate.

Medicaid Gains in Other States

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]: Also not Medicaid. Also 100% state funded. But this journo does a good job of pointing this out.

 
 

 
 

Clipped from: https://oregoncapitalchronicle.com/2023/07/06/oregon-expands-free-health-insurance-for-low-income-oregonians-regardless-of-immigration-status/

The move coincides with debates in other states this year on expanding Medicaid coverage to undocumented immigrants

 
 

Oregon has a program for undocumented immigrants that mirrors Medicaid. (Getty Images)

UPDATED at 6:05 p.m. with more information from the Oregon Health Authority.

Oregon has expanded free health insurance that mirrors Medicaid to all residents who qualify, regardless of their immigration status. 

The move took effect July 1. It marks an expansion of a Medicaid-type program for immigrants last year for residents who don’t qualify for the Oregon Health Plan because of their immigration status. The program, Healthier Oregon, covered those 19-24 and 55 and older who met low-income and other qualifications and was funded by a $100 million allocation by the Legislature in 2021.

The expansion this month to all immigrants who qualify follows a two-year allocation of $460 million for the program in the recently ended legislative session. The Oregon Health Authority said that 40,000 immigrants who had received state-funded emergency health coverage were switched to the program on July 1. 

An authority spokeswoman, Amy Bacher, said the agency estimates that 55,000 people will be covered through the program.

“When it comes to health, we’re all connected,” Dave Baden, interim director of Oregon Health Authority, said in a statement. “Expanded health coverage through the full implementation of Healthier Oregon will keep more people and families healthy, which will reduce health costs and risks for every community.”

Baden said the expansion sets a new standard for other states. It comes amid a debate this spring in some states, including Connecticut, Minnesota and Nevada, about expanding Medicaid to undocumented immigrants, Politico reported. Similar efforts in New York and Maryland failed, however, with Democrats balking about the price tag.

Medicaid is funded largely through the federal government, which pays about two-thirds, with the rest provided by the state. Healthier Oregon receives some federal funding for emergency and pregnancy-related services but the state pays for most of the benefits.

“We don’t get any help from the federal government because the folks who are on it don’t have papers,” Rep. Rob Nosse, D-Portland, told the Capital Chronicle. 

Nosse was among the Democrats in the Legislature who backed the expansion of Healthier Oregon. It’s part of the state’s goal to ensure all Oregonians have health care coverage. 

During the pandemic, nearly 1.5 million Oregonians, or one in three residents, were on Medicaid, which offers free dental, mental and physical health care. That expansion ended in April. The state is now going through a redetermination process and informing those who no longer qualify that they will lose coverage in 60 days.

State officials have informed about 25,000 people they will lose coverage, according to a statement released by the Oregon Health Authority and the Department of Human Services on June 20. It estimated in that release that seven in 10 people will retain their benefits under the Oregon Health Plan, the state’s version of Medicaid.

To qualify for the program, most residents can earn up to 138% of the federal poverty level, or about $20,000 a year for an individual or about $41,500 for a family of four. Oregon also has opened up benefits to those earning up to 200% of the federal poverty level to reduce the so-called churn population who fall off and on Medicaid, depending on their income. That means that individuals earning up to about $29,000 a year or a family of four earning up to $60,000 a year will receive the free coverage. The state estimated that would add about 25,000 more people to the Medicaid program. 

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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]: It ain’t Medicaid. Its 100pct funded by the state.

 
 

 
 

Clipped from: https://www.baltimoresun.com/health/bs-hs-maryland-medicaid-expansion-20230705-d2gcmu27tvhu7m4nwxrhiyq2iu-story.html

Maryland Medicaid will start paying for some community violence prevention services, peer recovery support services in certain settings, and pregnancy and postpartum care for people whether or not they’re a U.S. citizen under benefits expansions announced earlier this week.

“These new benefits will help improve the well-being of Maryland Medicaid participants and contribute to the overall health of Maryland communities,” Gov. Wes Moore said in a news release announcing the expansion. “The new benefits mark a significant milestone in Medicaid’s ongoing efforts to ensure accessible and inclusive health care for all Marylanders.”

One part of the expansion, the Healthy Babies initiative, launched Saturday. It aims to reduce the number of maternal deaths in the state, according to the news release.

The program provides health care to people who are pregnant or have recently given birth, live in Maryland, and meet specific income requirements, regardless of whether they are U.S. citizens. If eligible, non-citizens who otherwise meet the requirements will receive the same Medicaid benefits available to other pregnant people, including physical and behavioral health services and dental and prescription drug coverage without copays.

Maryland Medicaid also will cover four months of postpartum care for people eligible for the program. The plan may help pay for pregnancy and postpartum care the patient received three months before they applied to the program.

As of Saturday, Maryland Medicaid also will provide reimbursement for some community violence prevention services, including mentorship, conflict mediation, crisis intervention, referrals to licensed health care professionals or social services providers, patient education and screening services for victims of violence.

Certified peer recovery specialists who work at Federally Qualified Health Centers, opioid treatment programs or community-based substance use disorder programs licensed by the Behavioral Health Administration also may be reimbursed by Medicaid for their services.

“These expanded benefits will work to improve population health, providing individuals with enhanced access to vital health care services and support,” said Ryan Moran, the state’s deputy secretary of health care financing and Medicaid director, in the release. “We encourage Marylanders to reach out and take advantage of these services.”

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]: Wonders never cease.

 
 

 
 

Clipped from: https://www.northcarolinahealthnews.org/2023/07/12/state-officials-delay-the-rollout-of-specialty-medicaid-plans-again/

 
 

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 issues.

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 departmental 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 on 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.”

 
 

Jay Ludlam, deputy secretary of Medicaid for N.C. DHHS, speaks at the Hilton Raleigh North Hills hotel on June 14, 2023. Credit: Jaymie Baxley/NC Health News

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 percent 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 Tuesday. “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 percent 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.

 
 

 
 

 
 

 
 

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