Category: MM Curator

Posted on by

STATE NEWS (TX)- Governor explains why Medicaid coverage of doulas was vetoed from budget

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]: Because reasons. Not very confident the reasons given mean much.

 
 

 
 

Clipped from: https://www.news5cleveland.com/news/local-news/governor-explains-why-medicaid-coverage-of-doulas-was-vetoed-from-budget-backers-of-the-program-react

 
 

COLUMBUS — Ohio Governor Mike DeWine made dozens of line-item vetoes before signing the state’s $191 billion budget on Monday.

One of those line items dealt with being able to use Medicaid funding to cover doulas for expectant mothers.

News 5 Evening Anchor Courtney Gousman dug into the issue to find out why the governor nixed the issue and how those backing the bill feel about it.

That line item was originally introduced in the state house by former State Representative Erica Crawley from Columbus.

Crawley, who authored the bill, which was introduced in 2019, would create a program that would allow doulas for pregnant women to be covered by Medicaid funding.

Doulas are trained professionals who serve as social and emotional support for pregnant women, as well as advocates during pre and postnatal care.

Studies show when doulas are involved, maternal and infant mortality rates dramatically decrease, saving lives.

Crawley told Courtney Medicaid pays for 51% of the births in the state, and it makes sense for Medicaid to pay for doula coverage for pregnant women.

Crawley is now a Franklin County Commissioner and is actively advocating for this piece of legislation, which she tells Courtney, has bipartisan support.

“The funding has not been there. If it was, then you wouldn’t hear me trying to push legislation asking for more funding to be available through Medicaid, and so I think this continues to be smoke and mirrors to continue to kick the can down the road,” Crawley said.

Courtney reached out to the governor’s office to find out why he chose to remove the item from the state budget. She was told it was a technical amendment due to the bill’s language.

DeWine, along with the state’s Medicaid Director, Maureen Corcoran, addressed the issue during Wednesday’s budget briefing.

“We’re very much in favor of doulas; in fact, we provide that for that and intended to provide that for that. I’ll let the director take the rationale, but the policy is we understand doulas can be very helpful, very effective. We’re for that,” DeWine said.

Corcoran said it was a technical amendment.

“Governor, so you got it right on the nose. It was a technical amendment. It finally establishes for us a regular framework so we can expand the coverage and the ability to utilize doulas that we’re already using on a smaller scale in Medicaid,” Corcoran said.

Corcoran said the state is still working to implement a doula program statewide that would be covered by Medicaid, and they are still working to piece together the framework with the nursing board.

The hope is to have something by January or soon thereafter, Corcoran said.

Watch live and local news any time:

Good Morning Cleveland at 5

Download the News 5 Cleveland app
now for more stories from us, plus alerts on major news, the latest weather forecast, traffic information and much more. Download now on your Apple device here, and your Android device here.

You can also catch News 5 Cleveland on Roku, Apple TV,
Amazon Fire TV, YouTube TV, DIRECTV NOW, Hulu Live and more. We’re also on Amazon Alexa devices. Learn more about our streaming options here.

Posted on by

STATE NEWS (OR) – Search launches for new head of Oregon Health Authority

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]: Kinda a weird way to go about it.

 
 

 
 

Clipped from: https://www.thelundreport.org/content/search-launches-new-head-oregon-health-authority

Image

 
 

The state is asking for the public’s input as it searches for a new director of the Oregon Health Authority.

The agency, which employs roughly 5,000 people, has gone without a permanent director since March after the last one, James Schroeder, lasted only seven weeks in the job.

The firm hired to conduct the search for a new director, Motus Executive Search, will host three “listening sessions” to “gather the perspectives of community partners to identify the key attributes and skills you would like to see in the next OHA director,” according to a press release the health authority issued.

The state posted the job opening early this month.

The position is considered one of the more challenging ones in Oregon government. The director before Schroeder, Patrick Allen, resigned as Gov. Tina Kotek took office. She’d vowed to fire him during the campaign.

Schroeder, who formerly headed Health Share of Oregon, an insurance contractor serving the Medicaid-funded Oregon Health Plan, had taken office vowing to be collaborative and build relationships with providers and communities.

But he faced challenges, offered his resignation, and later said some longtime staffers at the agency are resistant to change.

Posted on by

STATE NEWS (NC) – Officials give update on tailored Medicaid plans

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]: Expect another delay.

 
 

 
 

Clipped from: https://www.northcarolinahealthnews.org/2023/06/27/nc-officials-give-update-on-delayed-rollout-of-tailored-medicaid-plans/

 
 

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

North Carolina’s Medicaid program “transformed” in the summer of 2021, moving more than a million children, some of their parents and pregnant women off of the long-standing way of paying for every test, visit and hospital stay and moving them into managed care, where private insurance companies receive a set monthly fee for each patient and then set about keeping them healthy.

But some groups of Medicaid beneficiaries remained in the traditional fee-for-service system: 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.

During a conference for health care professionals in Raleigh earlier this month, officials from the N.C. Department of Health and Human Services gave an update on the twice-delayed launch of an experimental managed care program for Medicaid enrollees with complex needs.

The program will create specialized health plans tailored to those complex beneficiaries.  The tailored plans are expected to provide “enhanced behavioral health services” that are not available through standard plans, according to the N.C. Medicaid ombudsman’s office. 

DHHS originally hoped to move eligible enrollees to tailored plans in December, but a lack of buy-in by service providers forced the agency to postpone. The launch was delayed to April before being pushed back again to Oct. 1, the current planned rollout date.

Jay Ludlam, deputy secretary for N.C. Medicaid, addressed the delays during a June 14 symposium organized by the i2i Center for Integrative Health. He said as many as 7,000 beneficiaries would have been forced to find new primary care providers — and in some cases, entirely new health care teams — had the state not extended its timeline. 

“That was really disconcerting to us at the department,” Ludlam said. “Imagine an individual with intellectual developmental disabilities, who has seen the same care team for the whole 10 years of her life, now needing to establish new relationships and assemble a new care team.”

He added: “That felt wrong. That felt like that was not what we were trying to design.”

 
 

Kristen Dubay, left, and Loul Alvarez of DHHS give a presentation on tailored plans for Medicaid enrollees. Credit: Jaymie Baxley/NC Health News

Still, Ludlam acknowledged that DHHS “waited too long” before announcing the most recent delay in February, which “left only about 35 days for members to readjust their plans” ahead of the then-anticipated April launch. 

Enrollees will receive more notice this time around, he said, with the state set to make a “go-or-no-go decision” on the October rollout by mid-July.

Another delay?

About 150,000 people, or 5 percent of the state’s Medicaid participants, are expected to transition to tailored plans. These people also are some of the most expensive patients, who have complicated — often multiple — diagnoses, and who need a lot of support. 

Their care will be coordinated by one of six behavioral health organizations that serve different regions of the state: was

 
 

Map showing the regions served by the different behavioral health organizations. Credit: NC Medicaid

The organizations are meant to act as intermediaries to connect eligible enrollees with health care providers who will be reimbursed through tailored-plan contracts. 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. 

Federal law requires that Medicaid beneficiaries have networks that are adequate to address their needs, but that doesn’t always happen.

Ludlam said a review of statewide data at the beginning of the year found that a large number of tailored-plan enrollees would be forced to “drive 100 miles each way” from their homes to receive care. The situation has improved in recent months, he said, but one major provider has yet to sign on.

“There are continued gaps in contracting,” Ludlam said. “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.”

DHHS declined to say if the launch would be delayed again if the holdout system did not contract with the regional organizations.

“The Department will always push for what is best for the people of North Carolina and will continue to work to improve access and strengthen the services available to them,” the agency said in a statement to NC Health News on June 20. “We are currently evaluating Tailored Plan network readiness and remain focused on providing the best care possible for the nearly 150,000 people that will benefit.”

In February, The News & Observer of Raleigh reported that the organizations were having difficulty contracting with Atrium Health. A spokesperson for the Charlotte-based system told the newspaper that Atrium needed time to “validate the plans are prepared for their responsibilities to fully and adequately serve the needs of their constituents.” 

The spokesperson added that the state, in its first delay of implementing the tailored plans, had “concluded there are numerable challenges in the submission, processing and payment of claims — which has been a historical challenge with these plans,” according to The N&O.

A new model

The stage was set for tailored plans when the state switched Medicaid systems.

North Carolina had for decades paid providers directly for Medicaid-covered services, paying separately for every test, doctor visit and hospital stay. That changed after the state transitioned to a managed care model, which essentially privatized Medicaid by routing payments through a cadre of insurance companies, in 2021.

Ludlam said the changeover — mandated by the General Assembly in 2015 — was driven by Mandy Cohen, the former DHHS secretary who was recently tapped by the Biden administration to serve as director of the Centers for Disease Control and Prevention.

“Secretary Cohen really challenged us to develop a model of whole-person care that focused on buying health,” he said. “Buying health requires that we think about preventative health and emergent health, but also social determinants of health. It requires us to also think about a whole person, and how we integrate those different treatments or different interventions to support the health of members and develop that program.”

While managed care is not unique to North Carolina, the state’s system differs from conventional models by including tailored plans for Medicaid beneficiaries with complex needs. 

At the Raleigh symposium, Shannon Dowler, chief medical officer for N.C. Medicaid, said the model born from Cohen’s vision has “not been done anywhere else in the country.” She believes the state will receive “national attention as the data starts coming in and we see the outcomes and the impact on our members.”

 
 

 
 

 
 

Not everyone is convinced of the effectiveness of the tailored-plan approach. Some health care advocates worry that the plans will create more barriers to care for individuals who already have limited options. 

“The big fear is, will a very, very vulnerable population — people with profound disabilities — lose access to care that they really need?” Doug Sea, an attorney with the Charlotte Center for Legal Advocacy, asked in a September 2022 interview with NC Health News. “The fact is that the General Assembly set this up in a way that directly discriminates against people on the basis of these profound disabilities.”

Barring any further delays, the implementation of tailored plans could coincide with a transformative moment for the state’s Medicaid program. 

 
 

Shannon Dowler, chief medical officer for N.C. Medicaid, speaks during a symposium organized by the i2i Center for Integrative Health. Credit: Jaymie Baxley/NC Health News

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.

 
 

 
 

 
 

 
 

 
 

Republish our articles for free, online or in print, under a Creative Commons license.

Posted on by

STATE NEWS (MT) – OPI to use Medicaid data for school meal programs

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]: MT will start robo-enrolling Medicaid covered kids in fee/reduced lunch programs.

 
 

Clipped from: https://montanafreepress.org/2023/06/27/opi-to-use-medicaid-data-for-school-meal-programs/

 
 

Montana’s Office of Public Instruction will next week begin using state Medicaid data to automatically certify public school students for free or reduced-price meals — part of an ongoing pilot program the U.S. Department of Agriculture has tested in 27 other states since 2012.

Federal assistance in school lunchrooms has been a mainstay of the USDA’s National School Food Program for more than half a century, offering tens of millions of students reduced- or no-cost meals on the basis of family income. Typically, Montana parents submit an application for enrollment detailing their qualifications, and OPI already uses several metrics to determine eligibility, including homelessness and participation in two other federal food assistance programs, SNAP and TANF. During the past school year, nearly 40% of Montana students qualified for free or reduced-price meals.

In a statement this month, state Superintendent Elsie Arntzen said adding data about a family’s income eligibility for Medicaid to the list of determining factors would help “streamline” the process. Arntzen clarified that OPI will use information about income from the Department of Public Health and Human Services’ database, rather than a family’s enrollment status in Medicaid, to make the new determinations. Montana’s participation in the pilot program — one of 14 states doing so this year — runs through the 2023-24 school year. 

As Montana Free Press reported last week, the Medicaid status of millions of people nationwide is in extreme flux after the federal government lifted a three-year pandemic freeze on states disenrolling individuals from the public insurance rolls who were no longer eligible. More than one million Medicaid enrollees nationwide reportedly lost coverage in the weeks following the April decision. In Montana, the first round of reevaluations two months ago resulted in a loss of coverage for more than 15,000 people, the vast majority of whom were removed from the program because they failed to return required paperwork. DPHHS expects to conclude its redetermination process in January.

RELATED

 
 

Almost half of Medicaid recipients reviewed in April lost coverage


Nearly half of Montanans whose Medicaid eligibility was reviewed in April lost coverage, according to new information published Tuesday by the state health department. The summary is the first publicly available glimpse into how Montana is fairing during the national ‘Medicaid unwinding’ — the mass reevaluation process for millions of people since the federal emergency response to the pandemic froze public insurance rolls in place three years ago.

by Mara Silvers 06.20.202306.23.2023

Asked how the ongoing review of Medicaid eligibility in Montana might affect the state’s school pilot plan, both OPI and DPHHS indicated they anticipate no impact. DPHHS spokesperson Jon Ebelt said via email that once a student is certified for free or reduced-price meals, their status will not change during the school year “regardless of a change of circumstance for the family or Medicaid enrollment status.” OPI spokesperson Brian O’Leary reiterated that assurance, adding that the ongoing Medicaid redeterminations are “not impacting” OPI’s participation in the pilot.

“DPHHS has informed the OPI that eligibility for Medicaid will be changing,” O’Leary wrote in an email. “The OPI and DPHHS are proceeding with the original plan to use Medicaid as a source for direct certification.”

O’Leary added that OPI will begin checking Medicaid data and certifying eligible families on July 1. Once enrolled, he said, students will not have their free or reduced-price meal status revoked, meaning if they’re certified on July 1 but their Medicaid coverage changes July 2, their meal status will not change. O’Leary noted that families can still submit paper applications for free or reduced-price enrollment.

Tammy Wham, incoming president-elect of the Montana School Nutrition Association, told MTFP Tuesday that her organization doesn’t yet have enough information to be sure how the ongoing Medicaid review might affect the meal certification pilot.

According to O’Leary, OPI doesn’t directly deal with family notifications of school meal eligibility. That task, he said, falls to local school districts. OPI does maintain a collection of meal eligibility forms on its website, as well as an online application portal for families in certain school districts.

O’Leary further stated that, based on past pilot data from other states, OPI anticipates the program will result in an increase in Montana students eligible for school food assistance. Jan Rhodes, a regional public affairs officer for the USDA, said more than one million students across 15 pilot states were certified for free meals using Medicaid data in 2017-18, with an additional 258,893 certified for reduced-priced meals. In 2019-20 — the last school year with available data — the USDA determined more than 1.2 million students were certified for free meals across three states, and another 240,000 were certified for reduced-price meals.

Last fall marked the first time since the start of the COVID-19 pandemic that families were required to apply for free or reduced-price meals in Montana. During the two school years prior, all students received school meals at no cost regardless of family income as part of the federal government’s response to the global crisis.

Posted on by

STATE NEWS (AZ/TRIBAL NATIONS)- Navajo Nation declares widespread Medicaid scam in Arizona a public health state of emergency

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 giant humanitarian crisis has been created by fraudsters in AZ.

 
 

 
 

Clipped from: https://abcnews.go.com/Health/wireStory/navajo-nation-declares-widespread-medicaid-scam-arizona-public-100293149

A widespread Arizona Medicaid scam that has left an unknown number of Native Americans homeless on the streets of metro Phoenix is being declared a public health state of emergency by the Navajo Nation as fraudulent sober living homes lose their fundin…

 
 

A billboard is seen in Scottsdale, Ariz., Saturday, June 10, 2023, near the health care facility of the Salt River Pima-Maricopa Indian Community, which has been affected by a gigantic Medicaid fraud scheme involving sober living homes that promised hel…

The Associated Press

PHOENIX — A widespread Arizona Medicaid scam that has left an unknown number of Native Americans homeless on the streets of metro Phoenix is being declared a public health state of emergency by the Navajo Nation as fraudulent sober living homes lose their funding and turn former residents out onto the streets.

The emergency declaration was issued late last week by the Navajo Nation Commission on Emergency Management and signed this week by Navajo Nation President Buu Nygren, according to documents posted on the Facebook page of the tribe’s Operation Rainbow Bridge, which was created to deal with the scam’s effects on its enrolled members.

“There are significant concerns about the impacts to Navajo Nation lives from abrupt displacement that have affected an estimated 5,000 to 8,000 Navajo individuals, particularly in the exacerbation of medical, and public health risks associated with lack of immediate intervention and preventive services,” the declaration reads.

The declaration allows the tribe to add more personnel, travel resources, medical supplies, funding and other means of support to address the ongoing problem.

Navajo Nation Attorney General Ethel Branch said earlier this month that the tribe’s law enforcement teams over the course of several weeks made contact with more than 270 Native Americans released onto the streets of metro Phoenix by sober living homes that have been targeted by a state crackdown on fraudulent billing.

Navajos account for most Native Americans grappling with addictions who have been affected by the scam and subsequent crackdown.

The Salt River Pima-Maricopa Indian Community has also warned its members about the deceptive providers with billboards outside its reservation in Scottsdale, Arizona.

The Arizona Health Care Cost Containment system, the agency that manages Medicaid payments for the state, this week announced several more changes that aim to stop payments to deceptive organizations that have been billing for services that are not provided, not appropriate, or unnecessary.

The agency’s website says a six-month moratorium is being placed on new enrollments for certain types of residential and outpatient behavioral health providers and non-emergency transportation services. Some providers will now be required to have background checks and site visits.

Providers also can no longer bill the state for Medicaid money on behalf of others, and certain kinds of claims are now being flagged.

Payments have been cut off to more than 100 of providers suspected of fraudulent billing.

Arizona officials announced in May they were investigating a huge Medicaid funding scam that potentially affected thousands of people, most of them believed to be Native Americans.

State officials believe the fake homes have defrauded Arizona out of hundreds of millions of its share of federal Medicaid dollars. Arizona authorities so far have seized $75 million and have issued 45 indictments in the investigation that also includes the FBI and the U.S. Attorney General’s Office.

Posted on by

FWA (CT)- Brookfield Counselor Sentenced to 30 Months in Federal Prison for Defrauding Medicaid of More than $1 Million

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]: Mr. Banks stole 1M with bogus counseling claims. We have seen this movie before.

 
 

 
 

Clipped from: https://www.justice.gov/usao-ct/pr/brookfield-counselor-sentenced-30-months-federal-prison-defrauding-medicaid-more-1

Vanessa Roberts Avery, United States Attorney for the District of Connecticut, announced that GREGORY C. BANKS, 50, of Brookfield, was sentenced today by U.S. District Judge Michael P. Shea in Hartford to 30 months of imprisonment, followed by three years of supervised release, for health care fraud.

According to court documents and statements made in court, Banks owned and operated North East Counseling & Trauma Services and Gregory Banks Counseling, LLC.  North East Counseling & Trauma Services, which had an office in Danbury, provided counseling services to individual patients, including those with mental health and trauma issues.  Banks was enrolled individually as a Behavioral Health Clinician provider in the Connecticut Medicaid Program (“Medicaid”), but North East Counseling & Trauma Services and Gregory Banks Counseling LLC were never enrolled as providers in Medicaid.

Between January 2018 and July 2022, Banks submitted and caused to be submitted fraudulent claims to Medicaid for counseling services that were purportedly provided to Medicaid clients.  Specifically, Banks submitted claims for dates of service when no services of any kind had been provided to the Medicaid clients identified in the claims. 

In October 2020, the Connecticut Department of Social Services (DSS) audited Banks and his businesses and requested documentation from Banks for six sample clients.  In response, Banks made multiple false statements for the purpose of delaying the progress of DSS’s audit and to conceal his offense.  For example, in February 2021, Banks sent an email to DSS in which he falsely represented that one of the files DSS requested was destroyed by a water leak above his office when, in fact, no such water leak had occurred.

Through this scheme, Banks defrauded Medicaid of $1,044,387.08.  Judge Shea ordered Banks to pay full restitution.

Banks, who is released on a $100,000 bond, is required to report to prison on September 8.

This investigation was conducted by the U.S. Department of Health and Human Services, Office of the Inspector General (HHS-OIG) and the Federal Bureau of Investigation.  U.S. Attorney Avery acknowledged the valuable cooperation of the Connecticut Department of Social Services in the investigation.

This case was prosecuted by Assistant U.S. Attorney David T. Huang.

People who suspect health care fraud are encouraged to report it by calling 1-800-HHS-TIPS.

Posted on by

FWA (PA) Former physician’s assistant from Altoona charged with $40k Medicaid 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]: Ms Batrus stole $40k and lots of members did not get the med management oversight needed for quality care.

 
 

 
 

Clipped from: https://www.wtaj.com/news/local-news/former-physicians-assistant-from-altoona-charged-with-40k-medicaid-fraud/

HUNTINGDON COUNTY, Pa. (WTAJ) — An Altoona woman is facing charges for racking up more than $40,000 in Medicaid payments when she was employed as a physician’s assistant, the Office of the Attorney General (OAG) reported.

Jennifer Batrus, 50, of Altoona, is accused of using the guise of the pandemic to submit payments from Medicaid for patients she never saw in person nor talked to on the phone during the COVID-19 pandemic.

According to the OAG, Batrus was employed as a physician’s assistant with American Family Psychiatry since March 2016. Through the investigation, it was learned that she would often travel between the Huntingdon and State College offices and see roughly 30 patients a day, four days a week.

The OAG said they were alerted by a Medicaid management company that there may be fraud taking place.

Partial building collapse in Blair County may be the end of a 1930s theater

Investigators spoke to employees and patients, as well as executed search warrants at both offices before speaking with Batrus, the criminal complaint reads.

It was discovered that Batrus stopped going to the office when the COVID pandemic struck. The company began to do appointments by phone, stressing it was important to at least speak with the patients on the phone before sending their medicine every month, the documents filed in court show.

Investigators found that many patients were getting prescriptions filled though never getting a phone call from Batrus, who still allegedly billed Medicaid for office visits.

When interviewed, Batrus allegedly claimed she did it for the money after her husband’s restaurant was closed due to COVID, investigators noted.

Forensic analysis showed that Batrus’ non-existent office visits between March and December 2020, 517 of them, totaled over $40,000 that was paid out by Medicaid.

Batrus is now facing multiple felony charges for fraud, theft and submitting claims with false info and no services rendered.

Stay up to date with news that matters to you with the WTAJ app on iPhone and Android by clicking here.

The Office of the Attorney General noted that Batrus’ license to practice medicine expired in Dec. 2022.

A preliminary hearing is scheduled for July 5.

Posted on by

EXPANSION (SD)- Medicaid expansion in South Dakota begins July 1

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]: After a year or so of drama, shiny new Medicaid cards will be issued starting tomorrow.

 
 

 
 

Clipped from: https://www.capjournal.com/news/medicaid-expansion-in-south-dakota-begins-july-1/article_29483796-1435-11ee-a809-6f4a7861ec6b.html

 
 

Medicaid expansion begins in South Dakota on July 1, a move sparked by a successful ballot initiative last November in which 56% of South Dakotans voted for the expansion.

That means, according to the South Dakota Department of Social Services website, that “an estimated 52,000 new individuals” will qualify for Medicaid.

The expansion of Medicaid, which has rolled out on a state-by-state basis since the Affordable Care Act, was originally part of the ACA, with the federal government financing the expansion at 100% initially, and at 90% by 2020. But in 2012, when the U.S. Supreme Court upheld the constitutionality of the Affordable Care Act, the Court also limited the federal government’s ability to enforce a Medicaid expansion provision, according to the Kaiser Family Foundation and other sources.

That left the decision to expand Medicaid up to the states.

“I expect more preventive care will be able to be received,” said Michaela Seiber, CEO of South Dakota Urban Indian Health. Seiber said that expansion could be especially helpful for people who need to follow up initial appointments with additional care.

 
 

Michaela Seiber

Courtesy photo

The DSS website notes that South Dakota applicants must be between 19 and 64 years old, must live in South Dakota, must be “a U.S. citizen or qualified immigrant,” and must either possess or have applied for a Social Security Number.

With the expansion, adults with incomes of up to 138% of the Federal Poverty Level will be eligible for Medicaid. That means single adults making up to about $20,120 per year will be eligible, and a family of four earning up to $41,400 will be eligible.

Applications for the expanded program began on June 1, and people who are already receiving Medicaid do not need to reapply.

Shelly Ten Napel, CEO of Community Healthcare Association of the Dakotas, said the expansion of Medicaid falls closely in line with its mission of serving underserved populations.

 
 

Shelly Ten Napel

Courtesy photo

“Our mission for over 40 years has been access to high-quality healthcare for all Dakotans,” she said. “This moment is a big one for us because adding another piece to the coverage puzzle is going to have an impact on the healthcare system in our state, on people’s lives, and it’s going to save lives.

The Community HealthCare Association of the Dakotas, as its website states, “is a non-profit membership organization that serves as the primary care association for North Dakota and South Dakota.”

Penny Kelley, outreach and enrollment services program manager for CHAD, also noted that the expansion could help patients obtain preventive care.

 
 

Penny Kelley

Courtesy photo

“For someone not able to get preventive care, oftentimes that can lead to a small problem being a big problem,” she said.

Kelley said the presence of health insurance creates “a ripple effect through the entire community,” preventing serious illnesses by allowing medical professionals to treat patients early.

“They’re not having to go to the ER because they were able to take care of (the problem) with their doctor ahead of time,” she said.

Seiber, with South Dakota Urban Indian Health, noted that federally qualified health centers offer sliding scales for people who don’t have insurance. The problems can surface, though, when those initial visits reveal conditions that require specialists.

“If they have something that’s more complex than we can provide for, they get referred out,” Seiber said. That sort of specialized care, along with the medications, may not be accessible on a sliding scale, she said.

Kelley stressed the importance of spreading the word about Medicaid expansion.

“There’s continued work to be done in order to let people know that they may be eligible,” she said. “They have received letters from the DSS letting them know, but that doesn’t always get someone’s attention. So we have been trying to do a lot of outreach.”

Kelley said, too, that efforts to reach people to tell them about Medicaid expansion can also create avenues to inform them about other areas of health.

“If they’re not eligible for Medicaid expansion, they could potentially be eligible for low-cost healthcare on Healthcare.gov,” she said.

Seiber noted that there’s a navigator working at South Dakota Urban Indian Health in Pierre who can help people with applications and other administrative tasks – such as applying for Medicaid. The position is funded by a federal grant received by the Community HealthCare Association of the Dakotas and applied to SDUIH’s navigator position.

The South Dakota Department of Social Services’ website notes that “90% of the cost of providing healthcare to the Medicaid expansion population will be funded by the federal government ($512,587,699)” – a provision of the Affordable Care Act – “and the state is required to pay for the remaining 10% ($66,385,019).” The American Rescue Plan provides additional funding.

South Dakota is among 40 states, along with Washington, D.C., that have expanded Medicaid. According to the Center on Budget and Policy Priorities, “Expansion has produced net savings for many states. That’s because the federal government pays the vast majority of the cost of expansion coverage, while expansion generates offsetting savings and, in many states, raises more revenue from the taxes that some states impose on health plans and providers.”

More information from the South Dakota Department of Social Services is available at https://dss.sd.gov/economicassistance/medical_eligibility.aspx, and people can contact the office in Pierre, at 912 E. Sioux Ave., with a phone number of 605-773-3612.

Kelley said people with questions about Medicaid expansion can also call the 211 helpline.

Posted on by

STATE NEWS- California poised to spend $19 billion on Medicaid and other health care programs

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]: CA might be spending a chunk of the health insurance tax on, well, healthcare.

 
 

 
 

Clipped from: https://www.politico.com/news/2023/06/24/california-strikes-huge-deal-unlocking-billions-for-health-care-00103476

Months of negotiations among the state’s top health care players have ended in a plan to pump billions into Medicaid and struggling hospitals.

 
 

The complex agreement, reported by POLITICO for the first time, resolves a sticking point in budget talks that lawmakers and Gov. Gavin Newsom have been working to resolve by June 30. | Justin Sullivan/Getty Images

 
 

SACRAMENTO, Calif. — Major players in California’s health care field have reached a deal on how they want the state to spend $19 billion in proceeds of a renewed tax on insurance plans plus the federal funds that go with it — a development that followed months of private negotiations between bitter industry rivals, state lawmakers and the governor’s office.

The complex agreement, reported here for the first time, resolves a sticking point in budget talks that lawmakers and Gov. Gavin Newsom have been working to resolve by June 30. It would impose a tax on health care plans in what those involved described as a once-in-a-generation investment into a system that serves nearly 16 million Californians. It’s a massive victory for the health care industry that came about through an alliance of powerful interests that are often avowed enemies in the statehouse.

The last three times California levied this tax on health plans, it used the money to balance the budget during economic downturns. Now, for the first time, much of the revenue will be spent to improve the state’s publicly subsidized health care system — and in a year when the state faces a $32 billion budget deficit.

Posted on by

PHE- The $74,000 Question: Cancer, Medicaid and the Urge to Purge the Rolls

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]: New treatments but not for Medicaid members. Example 1,478 of how Medicaid “provider networks” are a flimsy, convenient, mirage.

 
 

 
 

Clipped from: https://www.governing.com/health/the-74-000-question-cancer-medicaid-and-the-urge-to-purge-the-rolls

The costs of treating cancer are soaring, just at a time when some states are moving to save money by cutting Medicaid enrollment. It’s sure to worsen health-care inequality.

 
 

The soaring cost of treating people with cancer is a major problem for all health insurance programs, but it poses especially big problems for Medicaid. Cancer drugs, in particular, raise a huge specter for the future of the state-federal program.

As cancer drugs go, platinum-based carboplatin is relatively inexpensive. Used to treat ovarian and other cancers, it’s a generic, and online coupons can bring it down to less than $15 per month. But carboplatin is often administered as part of an intravenous cocktail, which can push costs into the tens of thousands of dollars for cancer patients. Tivdak, used to treat cervical cancer, cost $529,000 a year in 2021.

Then there’s a new class of drugs in which blood is taken from a patient, processed genetically to fine-tune its effectiveness against a cancer, and then is injected back into the patient. These individually tailored drugs are very effective — and very expensive. One of them, developed to treat leukemia in children, is estimated to cost $1 million per year. More drug cocktails manufactured to meet an individual’s particular case are on the way.
 

Meanwhile, the standard treatment for advanced prostate cancer costs nearly $74,000 per year. It’s an easy drug to administer, with just a quick injection on a typical three-month schedule. Insurance companies typically negotiate down that price, but patients often still get stuck with a bill running into the thousands. It’s quite literally a real pain in the butt, but there’s an alternative: a daily pill that costs $32,000 a year.

These cancer drugs are a matter of life or death. All are expensive. Even some generics are in very short supply. The list price is beyond the means of almost everyone.

Of course, no one really pays list price. How much they do pay depends on the insurance they have. For lower-income Americans, that insurance is typically Medicaid — or nothing. How much lower-income Americans pay for such cancer treatments hangs on two things: whether they qualify for Medicaid, and what Medicaid pays for in their state.
 

Across the country, Medicaid is the largest item in state budgets — 27 percent in 2021 — and it’s the fastest-growing part as well. The state share of Medicaid spending — the states split the cost with the federal government — rose by 9.9 percent in 2022 and is projected to jump 16.3 percent in 2023.

The increase in the states’ share is especially large this year because of the end of the program’s “continuous enrollment” requirement. The states got a big payout from the federal government at the beginning of the COVID-19 pandemic, and the program required that no one on Medicaid could be taken off the program until after the federally declared public health emergency was terminated. The emergency officially ended on May 11. That not only triggered the phaseout of the continuous enrollment requirement but also ended additional federal Medicaid funding as of the end of 2023.

For cancer patients, that brings big implications. Medicaid tends to be relatively generous in covering the costs for cancer patients who meet eligibility guidelines. It’s one thing to have Medicaid coverage, though, and another thing to find a treatment facility that accepts Medicaid. A Yale study, for example, found that only two-thirds of cancer facilities accepted new Medicaid patients with four common cancers.

There’s a big difference between states as well. Among facilities in states that had expanded Medicaid under the Affordable Care Act, 71 percent of new cancer patients were accepted. In states that had not expanded Medicaid, it was just 60 percent. So Medicaid recipients can find themselves in a double bind: hoping that the state they live in covers them, and then hoping that they can find a facility in the state that accepts that coverage.

 

‘The Path of Dependency’

Facing soaring Medicaid costs, an eagerness to cut social welfare programs and the end of the public health emergency’s enrollment mandates, some states have raced to purge their Medicaid rolls. Arkansas, for example, aggressively trimmed the number of eligible Medicaid recipients in half the time that the federal government required.

Calling the purge a way to get the state’s Medicaid program “back to normal,” Gov. Sarah Huckabee Sanders said it was time to get many Arkansans “off the path of dependency.” The state wasn’t cutting Medicaid coverage, she asserted in a Wall Street Journal op-ed. Instead, “we’re simply removing ineligible participants from the program to reserve resources for those who need them and follow the law.”

That’s not the whole story, though. Seven of every 10 people who were removed from Medicaid in Arkansas were cut for administrative reasons, such as failing to fill out the right forms or provide all of the information required to continue their coverage. Relatively few cutoff decisions came from a determination that the individuals weren’t income-eligible for the program. The state said it’s contacting cancer patients so they can keep their treatments, but worries spread throughout the state that it was primarily the administrative burden of the process that was responsible for pushing people off the program, not their eligibility.

That’s a step that many more lower-income Americans are going to face this year. Medicaid enrollment was already rising sharply before the pandemic, up 10 percent from 2015 to 2020 due solely to growth in the Medicaid-eligible population. With the onset of COVID-19, that surge turned into a skyrocket: Medicaid enrollment grew by 23.3 million from February 2020 to the end of March 2023, an increase of more than 30 percent. With many Medicaid recipients sure to be squeezed out of the program now, they’ll be facing ballooning costs with disappearing insurance coverage.

 

A Federal Warning

States are in the very uncomfortable middle of all of these questions. Almost all of the factors driving their Medicaid spending are beyond their control, and almost all of them are projected to continue to spiral upward for the very long term.

Except for one factor, that is: The states do have control over the number of people eligible for the program and in how aggressively they police their Medicaid paperwork to manage the number of people who are admitted into the program or are dropped from it. Along with Arkansas, Arizona, Idaho, New Hampshire and South Dakota are working quickly to prune their rolls.

Earlier this month, U.S. Health and Human Services Secretary Xavier Becerra sent the governors a letter warning them to exercise caution. “I am deeply concerned with the number of people unnecessarily losing coverage, especially those who appear to have lost coverage for avoidable reasons that state Medicaid offices have the power to prevent or mitigate,” he wrote. But that has scarcely slowed down the states intent on cutting their Medicaid spending by reducing the number of the program’s recipients.

This battle isn’t targeted specifically at lower-income cancer patients. But they represent the patients needing some of the most serious and most expensive treatments, and without Medicaid most could not afford the drugs that could improve — or save — their lives.

The pressures the states face with lower-income cancer patients are just the leading edge of a much broader, quickly emerging crisis. The health care that some of society’s sickest and most vulnerable individuals will receive will depend increasingly on Medicaid. Some of the most effective treatments are quickly rising in price. Meanwhile, the states are facing less control over the fastest-growing item in their budgets. Efforts to grab the only lever over Medicaid spending that they have will inevitably squeeze out a lot of the patients, who have nowhere else to turn.

That’s the inescapable result of the peculiar system of health insurance that’s grown up in America since Medicaid’s enactment in 1965. And it’s sure to worsen the already staggering levels of health-care inequality plaguing the nation.

Governing‘s opinion columns reflect the views of their authors and not necessarily those of Governing‘s editors or management.