Category: MM Curator

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STATE NEWS (AZ)- Arizona seeks to cover traditional Native healing practices under Medicaid

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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]: AZ will try a third time to get CMS to allow federal dollars for Native American health services.

 
 

 
 

Clipped from: https://stateofreform.com/featured/2023/10/arizona-seeks-to-cover-traditional-native-healing-practices-under-medicaid/

 
 

Hannah Saunders | Oct 16, 2023 | Arizona

With traditional Native healing practices being the cornerstone of health and wellbeing of Native communities since time immemorial, the Arizona Health Care Cost Containment System (AHCCCS) is seeking federal approval to cover these services under Medicaid. Arizona would be the first state in the country to do so.

“Title 19 Medicaid dollars cannot be used for traditional healing services as it currently stands, and that’s what we’re trying to change with our 1115 waiver request,” Alex Demyan, assistant director of the Division of Community Advocacy and Intergovernmental Relations at AHCCCS, told State of Reform. 

 
 

 
 

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AHCCCS initially submitted this request in their 1115 waiver in 2015, which the Centers for Medicare and Medicaid Services (CMS) rejected. The agency submitted the request again in 2020 during the current waiver period, but CMS was unable to approve native healing services at the same time they approved other 1115 waiver requests. Demyan said AHCCCS is actively negotiating the coverage of these services, but is uncertain of when it would be approved. 

Christine Holden, tribal liaison for AHCCCS, who is part of the White Mountain Apache Tribe, believes it is crucial to incorporate Native healing services into traditional Western medicine. Native healing services take on a holistic approach, where the medicine man or medicine woman does not separate the physical from the mind or spirit. 

Holden noted this effort represents a new beginning, and that by incorporating traditional Native health into state systems and non-Tribal healthcare systems, Arizona is conveying that it recognizes the importance of Indigenous traditions. 

“Bringing us back to our traditional ways that kept us alive for thousands and thousands of years. So, bringing that back into the western picture really will help from that Native perspective—Native identity and also respecting Tribal sovereignty and the right of Tribes to determine what their healthcare should look like without having to fit in any type of box.”

— Holden

Holden cited Canada and New Zealand, which have incorporated traditional healing practices into Western medicine, which she said has assisted with improving the mental and physical health of patients. Arizona currently has 22 federally recognized tribes. 

“The thing I appreciate about traditional healing is they never look at Western medicine as ‘it doesn’t have a place’ in helping our people heal,” Holden said. “They understand that it complements the traditional piece.” 

Traditional Native healing practices consist of using local roots, plants, and trees as medicine or ailments. Sweat lodges continue to be used as a way of easing an individual’s challenges with mental health. Holden explained how these sweat lodges were historically used during periods of war to treat trauma and post-traumatic stress order for survivors. 

“Native communities recognized this, and how powerful it is to separate the individual that goes to war, from the individual that is a family man, that is a grandfather, that is an uncle,” Holden said. 

Holden explained how prior to going off to fight in wars, Native and Indigenous individuals would visit the medicine man, who would provide the individuals with warrior names.

“The way they kept our warriors from experiencing PTSD or any mental health issues when they came back from those types of situations is they would have a sweat lodge. You pray and ask for forgiveness, and move from that warrior name back to whatever your traditional name was. That gave warriors the tools to be able to separate the things that they did that they weren’t proud of—but had to do to survive—from that person.”

— Holden

Burning of sage and cedar is a historic Native healing method that continues to be used today, including by Holden. She said Natives will light sage and pray, then put the sage on their feet, body, and mind, and waft in the smoke. When saying prayers, Natives believe the smoke will carry those prayers to the creator, and it’s helpful to physically see the prayers being carried. 

“I’ve seen that help, especially younger kids,” Holden said. “They like to see things physically happening, and so when they see that smoke rise for them, that symbolizes okay, my prayers and what I’m asking for is being carried to [the] creator, and that helps them to hold onto that hope.” 

Demyan said the waiver request seeks the maximum amount of discretion to be given to Native and Indigenous communities to establish relevant programs for each community, although CMS will enact minimal federal requirements upon approving the request. Federal requirements may include policy oversight, background checks and verification of training, among others. 

“We are asking the permission to reimburse for traditional healing services using Title 19 dollars—that’s the high level,” Demyan said. “We really want to give the maximum amount of discretion to the individual Tribal communities to define what those services look like, what the qualifications for the medicine man or the traditional healing practitioner are. As a state, we don’t view it as our place to define that for the communities.” 

Demyan said the proposal contemplates limiting services to individuals served in the Indian Health Services (IHS) 638 and Urban Indian facilities—for IHS 638 facilities, AHCCCS is contemplating paying the “all-inclusive rate,” that is annually established by the federal government, and is considerate of higher and lower cost services. 

“On the IHS 638 system side, that’s how we’ve backed into a rate that makes sense for the facilities, and our traditional healing workgroup is comfortable, and has been comfortable with that model,” Demyan said. “Urban Indian organizations—those facilities do not get paid the AIR [all-inclusive rate], so we’re still going through the rate setting process there.” 

While waiting for CMS approval, AHCCCS will continue to negotiate terms. If approved, AHCCCS will work with the traditional healing workgroup, and develop and implement policies prior to reimbursement for services. 

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STATE NEWS (CO) – Medicaid audit finds unclear messaging, inaccuracies

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 one example, one family got 48 letters with 460 pages of information in 2 months from the Medicaid agency.

 
 

 
 

Clipped from: https://denvergazette.com/news/state-auditors-office-medicaid-audit-innacuracies-unclear-information/article_9e944fcc-6c59-11ee-a0f1-9f9d7a206300.html

 
 

A state audit released Monday showed that communications from Medicaid to its members is not always accurate, complete or understandable.

The report from the the Office of the State Auditor says that information needs to be more accurate, understandable, informative and clear.

The audit found that of 80 sampled letters sent to Medicaid members, 72 had one or more problems, including duplicated information, contradictory and confusing  messages, unclear guidance and complicated sentences and word choice, according to a news release from the auditor’s office. 

In January and February this year, one family got 48 Medicaid letters with 460 pages. In the same two-month time period, a second family got a 57-page Medicaid letter that repeated the same message 63 times, the audit said.

Letters also contained inaccuracies, such as deadline dates that didn’t comply with state Medicaid requirements, inconsistent response timeframes for the same type of information requests and Spanish-language translations that were unclear. 

“Unclear, inaccurate, and incomplete correspondence can create frustration and confusion for Medicaid members and ultimately lead to barriers with accessing health care, wasted resources, and potential legal issues for the Department,” Kate Shiroff, the audit manager, said in the news release.

As of July, the Department of Health Care Policy and Financing reported about 1.7 million Coloradoans enrolled in Medicaid, which is a federal-state program providing healthcare coverage and services to low-income families. 

Medicaid is administered federally be the Centers for Medicaid and Medicare Services under Title XIX of the Federal Social Security Act and, in Colorado, by the Department of Health Care Policy and Financing.

Colorado’s Medicaid program is called Health First Colorado.

In January and February, the Department of Health Care Policy and Financing sent more than 400,000 letters to members each month out of the Colorado Benefits Management System related to eligibility for Medicaid programs. The department’s vendors also sent over 24,000 prior authorization approval and denial letters to members each month. 

Many of the same issues found in the 2023 audit were also found in work conducted in 2016 by a communications contractor with the Department of Health Care Policy and Financing. Many of them were found again by an audit contractor in 2020.  

“These problems persist because the department has not fully implemented previous recommendations to change its monitoring functions, work processes, guidance to workers, and system design,” the news release says. 

The full audit is available on the OSA website at www.colorado.gov/auditor.

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MCO – Elevance Health Reports $1.3 Billion Profit And Insurer Ups Forecast Once Again

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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]: Elevance profits are down YOY, but revenues from non-Medicaid lines of business are increasing.

Clipped from: https://www.forbes.com/sites/brucejapsen/2023/10/18/elevance-health-reports-13-billion-profit-as-insurer-ups-forecast-once-again/?sh=655338e76c53

Elevance Health reported a third quarter profit of $1.29 billion as the health insurer added health … [+] plan members despite a big dip in Medicaid enrollment due to the end of a pandemic-era coverage provision.

Elevance Health

Elevance Health reported a third quarter profit of $1.29 billion as the health insurer added new customers despite a big dip in Medicaid enrollment due to the end of a pandemic-era coverage provision.

Elevance, which sells government and commercial health insurance including Blue Cross and Blue Shield plans in 14 states, Wednesday reported third quarter profits decreased nearly 20% to $1.29 billion compared to $1.6 billion in the year-ago quarter. The dip in net income was due largely to an “operating loss of $741 million in the company’s “corporate & other segment” executives said was driven by “business optimization charges.”

“In the third quarter, we completed a strategic review of our operations, assets, and investments to enhance operating efficiency, refine the focus of our investments in innovation and optimize our physical footprint,” the company said in its earnings report. “This resulted in a net charge of $697 million, comprised of the write-off of certain information technology assets and contract exit costs, a reduction in staff including the relocation of certain job functions, and the impairment of assets associated with the closure or partial closure of data centers and offices.”

Still, revenue jumped 7% to $42.8 billion as overall health plan enrollment grew and the company’s Carelon health services business performed well.

Elevance’s membership grew by 42,000, or 0.1%, to 47.3 million as of September 30, 2023 compared to a year ago.

The growth was driven primarily by “growth in BlueCard, Affordable Care Act health plans, and Medicare Advantage membership, partially offset by attrition in Medicaid due to the resumption of eligibility redeterminations and a new entrant into one of our state Medicaid programs in the third quarter, as well as declines in our Employer Group risk-based business,” Elevance said in its third quarter earnings report.

The end of the U.S. Public Health Emergency in May after three years of the Covid-19 pandemic is impacting health insurers that have a significant business administering Medicaid coverage for states, which are conducting so-called “Medicaid redeterminations.” Medicaid redetermination, also described as Medicaid renewal or Medicaid recertification, is essentially when people are asked to show they are qualified for such coverage.

“During the third quarter of 2023, medical membership decreased by 664 thousand driven by attrition in Medicaid due to the aforementioned dynamics,” Elevance said in its report.

Still, Elevance’s profits and continued growth are figured in the company’s forecast for increased profits with adjusted net income now expected to be “greater than $33.00 per share.” That is more than an earlier forecast for adjusted net income of company “greater than $32.85” per share.

“Elevance Health delivered another quarter of solid performance reflecting the strength and balance of our diversified portfolio of businesses, our continued investments in innovation and growth, and our relentless focus on affordability, simplicity, and customer experience,” said Elevance Health president and chief executive Gail K. Boudreaux. “With affordability a paramount concern for all payors and a more uncertain forward-looking operating environment, we took action during the third quarter that will enhance our ability to act nimbly and operate efficiently.”

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MCO- Medicaid Managed Care Organizations face scrutiny over prior authorization denials

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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 scrutiny on MCO denials and prior auths continues.

 
 

 
 

Clipped from: https://thetimesweekly.com/medicaid-managed-care-organizations-face-scrutiny-over-prior-authorization-denials/

 
 

A recent review of Medicaid Managed Care Organizations (MCOs) has revealed concerning trends in approving prior authorization requests for services. In 2019, MCOs denied one out of every eight requests for prior authorization of services, according to a report by the Office of the Inspector General (OIG).

Among the 115 MCOs examined in the review, 12 exhibited denial rates for prior authorization requests that exceeded 25 percent—twice the overall rate. This discrepancy in approval rates highlights potential disparities in access to essential healthcare services for Medicaid enrollees.

Despite the high number of denials, many state Medicaid agencies reported that they did not routinely review the appropriateness of MCO denials. Additionally, many still needed to have mechanisms in place to collect and monitor data on these decisions. More robust oversight is required, potentially allowing inappropriate denials to go undetected within the Medicaid-managed care system.

The OIG has recommended measures to improve enrollee protections and state oversight of prior authorization denials in Medicaid-managed care in response to these findings. These include:

• States must regularly review the appropriateness of a sample of MCO prior authorization denials.

• Mandating States to collect data on MCO prior authorization decisions.

• Issuing guidance to states on utilizing MCO prior authorization data for oversight.

• States must implement automatic external medical reviews of upheld MCO prior authorization denials.

In their official response, the Centers for Medicare & Medicaid Services (CMS) did not indicate concurrence with the first four recommendations. However, they agreed with the recommendation to collaborate with States to identify and address MCOs that may be issuing inappropriate prior authorization denials.

Senator Robert Casey (D-Pa.), who chairs the Senate Special Committee on Aging and U.S. Representative Frank Pallone, Jr. (D-N.J.), Energy and Commerce Committee ranking member, has voiced concerns about the potential prioritization of MCOs’ financial interests over the needs of patients seeking care. “I’m deeply troubled by reports that Medicaid managed care plans denied an average of one out of every eight requests for treatment, more than double the rate of service denials in Medicare Advantage,” Pallone said in an earlier statement.

“Medicaid is a lifeline for over 80 million people, including children, people with disabilities, seniors, and hardworking families,” he continued. “This report strongly suggests that some private insurance plans, which states have contracted with to provide health care coverage to their residents, may be improperly denying access to critical services to maximize their profits.”

In a letter to the OIG, Casey emphasized the role of insurance companies in administering Medicaid benefits through MCOs, which receive fixed fees known as “capitated payments.”

Casey noted that independent watchdogs have consistently raised concerns about the MCO model, which may incentivize insurers to limit payments and deny coverage. He highlighted that MCOs have expanded significantly, becoming the “dominant delivery system” for Medicaid, providing coverage to over 67 million Americans, or 84 percent of Medicaid enrollees.

The senator noted that the OIG’s national evaluation of Medicaid MCOs, published in July, examined 115 plans with a minimum of 10,000 enrollees operating across 37 states and managed by seven companies. For example, the report found that, on average, MCOs denied 12.5 percent of requests for prior authorization in 2019, with notable variations from state to state and among different companies and plans.

Casey said one insurer in 13 states exhibited denial rates ranging from 5 percent to 29 percent. In California, denial rates for various MCOs ranged from 7 percent to 29 percent. The OIG report also identified 2.7 million individuals enrolled in MCOs with 25 percent or higher denial rates. Notably, one Illinois plan had a denial rate of 41 percent, while two other plans in Georgia and Texas denied one-third of claims.

Casey has called for a thorough examination of the MCO system to ensure that patients enrolled in Medicaid have unfettered access to the services they are entitled to. Additionally, he has urged the CMS to provide robust oversight to safeguard the interests of enrollees in receiving the care they need.

“When patients are denied coverage of medically necessary services, they often face tight timelines to file actionable appeals,” Casey said. “Assuming such appeals are filed in a timely manner, the process can be complicated and time-consuming, creating barriers that can make it difficult for Medicaid enrollees to seek recourse.”

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PHE (FL)- State Fights Medicaid Eligibility Allegations

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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]: FL Medicaid agency says it has given sufficient notice in several ways to members.

 
 

 
 

Clipped from: https://www.law.com/dailybusinessreview/2023/10/11/state-fights-medicaid-eligibility-allegations/?slreturn=20230918101434

 
 

Credit: Tada Images/Adobe Stock

A potential class-action lawsuit alleges the state has not provided adequate information to Medicaid beneficiaries before dropping them from the health-care program.

Gov. Ron DeSantis’ administration is trying to fend off a potential class-action lawsuit that alleges the state has not provided adequate information to Medicaid beneficiaries before dropping them from the health-care program.

Attorneys for the state Agency for Health Care Administration and the Department of Children and Families on Friday filed court documents arguing that a federal judge should reject requests to issue a preliminary injunction and to make the lawsuit a class action.

The lawsuit, filed in August in Jacksonville, stems from a process that the state started this spring to determine whether more than 5 million people enrolled in Medicaid remained eligible for benefits. The process was a result of the end of a federal COVID-19 public-health emergency.

One of the documents filed Friday said the state since April has conducted about 2.5 million “redeterminations,” with more than 1.7 million people found eligible and nearly 830,000 found ineligible. The redetermination process is expected to continue for months.

The plaintiffs’ lawyers argue that the state has violated due-process rights and a federal Medicaid law because it has not provided adequate notice about reasons for terminating people’s benefits and about opportunities for hearings before termination. They are seeking an injunction that would require reinstating coverage to people and ending additional terminations until adequate information is provided.

“Medicaid enrollees must be given timely and adequate notice detailing the reasons for a proposed termination and how they can challenge the action, and they must be given an opportunity to make their case before an impartial decision-maker prior to termination of their Medicaid coverage,” the lawsuit said.

But attorneys for the Agency for Health Care Administration and Department of Children and Families on Friday disputed that the state had violated beneficiaries’ rights and said U.S. District Judge Marcia Morales Howard should deny the requests for a class action and an injunction.

“Plaintiffs’ requested injunction upsets the apple cart with respect to millions of people: those who were found ineligible for full Medicaid whom plaintiffs demand be reinstated, and those for whom eligibility re-determinations would be halted during the pendency of this litigation,” one of the documents said. “DCF’s [the Department of Children and Families’] administration of a multibillion-dollar program cannot simply pivot overnight to accommodate chaos of that magnitude.”

The judge has scheduled a hearing Oct. 30 on the issues. The Senate Health and Human Services Appropriations Committee also is slated Wednesday to receive presentations about the redetermination process.

The process has drawn close scrutiny, and criticism from Democratic lawmakers and groups advocating for beneficiaries, for months.

The federal government declared the public-health emergency in 2020 as the COVID-19 pandemic began. Medicaid is jointly funded by the federal and state governments. As part of the emergency, Washington agreed to pick up more of the tab for the program.

But there was a catch: In exchange for the extra money, states had to agree that they wouldn’t drop people from the Medicaid rolls during the emergency. Florida’s program grew from about 3.8 million beneficiaries in January 2020 to nearly 5.8 million in April of this year, at least in part because people who might not otherwise be eligible for coverage could not be dropped.

With the end of the emergency, the state began redetermination, and the Medicaid rolls had dropped to about 5.25 million in August, according to data on the Agency for Health Care Administration website.

The Agency for Health Care Administration runs most of the Medicaid program, though the Department of Children and Families is heading the redetermination process.

The plaintiffs in the lawsuit are a mother and daughter from Jacksonville and a mother and daughter from Miami-Dade County. Both of the children and one of the mothers lost Medicaid coverage. Their full names are not included in the lawsuit.

The lawsuit alleges that the plaintiffs and potential class members “are losing Medicaid coverage without meaningful and adequate notice, leaving them unable to understand the agency’s decision, properly decide whether and how to contest their loss of Medicaid coverage or plan for a smooth transition of coverage that minimizes disruptions in necessary care. Without Medicaid coverage, plaintiffs are unable to obtain care they need, including prescription drugs, children’s vaccinations and postpartum care.”

But in the filings Friday, the state’s lawyers disputed the allegations.

“Even if technical violations exist on a case-by-case basis, plaintiffs cannot demonstrate that these technical violations cause a classwide risk harm justifying a preliminary injunction against the state,” one of the documents said. “DCF sends multiple communications and notices to recipients regarding eligibility redeterminations and the termination of benefits. Those communications contain a host of information, from the reason for termination, to phone numbers and websites to access for more information, to apprising the recipient of hearing rights, to advising recipients where they can receive free legal advice, to identifying additional programs and services and more. DCF maintains a robust website with information about benefits eligibility, fair hearing processes, and other available resources and programs.”

Jim Saunders reports for the News Service of Florida.

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PHE (TX)- Texas extends Medicaid redetermination deadlines

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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]: TX gives members a little more time.

 
 

 
 

Clipped from: https://www.beckerspayer.com/payer/texas-extends-medicaid-redetermination-deadlines.html

Texas is granting some Medicaid beneficiaries an extra month to complete renewal paperwork. 

In an Oct. 10 news release, the Texas Health and Human Services Commision said additional time is being granted to those most likely to still be eligible for the program, including older adults and adults with disabilities. 

The agency has initiated redeterminations for 3.5 million people, or 59 percent of the state’s Medicaid population, according to the news release. The department is now focused on a targeted outreach campaign for Medicaid recipients with disabilities, school-aged children and the aging population. 

As of Oct. 2, 73 percent of those disenrolled from Medicaid in Texas had their coverage terminated for procedural reasons, rather than being determined ineligible for the program, according to KFF. 

Other states have extended deadlines for beneficiaries to return required paperwork, a flexibility HHS granted states during the redeterminations process. In Michigan, a 30-day extension resulted in 15,000 additional renewals. 

Subscribe to the following topics: texasmedicaidbeneficiariesextra monthrenewal paperwork

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As Hospitals Consolidate, Medicaid Patients Have Fewer Options

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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]: When hospitals acquire other hospitals to increase revenues and profits, somehow Medicaid member access gets even worse. Wonders never cease.

 
 

 
 

Clipped from: https://revcycleintelligence.com/news/as-hospitals-consolidate-medicaid-patients-have-fewer-options

A new research brief finds Medicaid admissions decline as hospital markets get more concentrated, but hospitals question the analysis.

 
 

Source: Getty Images

September 28, 2023 – Access to care for Medicaid patients declines as hospital markets become more concentrated following mergers and acquisitions, a new research brief from the National Institute for Health Care Management (NIHCM) Foundation suggests.

The research brief finds the average hospital reduced admissions for Medicaid patients when markets became more concentrated. The finding indicates potential limitations on access to care for lower-income individuals, says lead researcher and health economist Sunita Desai, PhD, of the New York University School of Medicine.

Desai analyzed data between 2006 and 2012 from the Healthcare Cost and Utilization Project State Inpatient Databases for New York State, the American Hospital Association Annual Survey, and data on hospital mergers.

The average hospital’s measure of market concentration increased by 7 percent during that time, Desai reports. With every 1 percent increase in a hospital-specific measure of concentration, there was a 0.59 percent decline in all Medicaid admissions and, specifically, a 1.3 percent decline in birth admissions. The study analyzes births separately, as they account for the most frequent Medicaid admissions.

“Policymakers and regulators should consider potential impacts on care and access for Medicaid patients when reviewing mergers or developing policy responses to hospital concentration,” Desai writes. “Moreover, given Medicaid patients are more likely to go to public hospitals, investments in the public hospital systems may be warranted in response to growing market concentration.”

Non-profit hospitals are particularly impacted by hospital market concentration with greater consolidation associated with a decline in Medicaid volume for non-profit organizations. Meanwhile, Medicaid volume increased for public hospitals, according to the research brief.

The finding suggests that non-profit hospitals are not necessarily investing increased profits they receive from higher commercial reimbursement rates into care for low-income populations that require a safety net, the research brief explains. Hospitals generally receive 90 cents for every dollar they spend on treating Medicaid patients, significantly less than what they receive for treating commercially insured patients.

The American Hospital Association (AHA), however, claims the research brief is a “bias-riddled ‘study'” that deflects from the effects payer concentration has on access to care.

“Instead of continuing to myopically focus on the hospital field, researchers should look at broader factors, like how commercial health insurers dominate every market in the U.S. and use that market power for their own enrichment,” Melinda Hatton, AHA’s general counsel and secretary, says in a statement.

“This market domination often comes at the expense of patients. Government reports confirm that some commercial health insurers leverage their market power to put in place policies that delay or deny patient care, inappropriately withhold reimbursement to providers and burn out doctors and nurses,” Hatton continues.

AHA-published research has linked hospital mergers and acqusitions to increased access to high-quality care.

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Arizona’s Medicaid program isn’t giving suspected fraudsters due process, critics say

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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]: Some providers are getting caught in the crossfire as the state tries to deal with the humanitarian crisis / fallout from the sober homes fraud last year.

 
 

Stephanie Innes

Arizona Republic

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The number of people publicly criticizing Arizona’s Medicaid fraud crackdown appears to be growing and protesters say they won’t stop until state leaders address their concerns.

About 60 people, carrying signs with slogans such as “All Tribes Lives Matter” and “Our Struggle Is Real,” gathered Tuesday in front of the Arizona Health Care Cost Containment System offices at 801 E. Jefferson St. in Phoenix on to criticize the way the agency has responded to rampant fraud involving its American Indian Health Program.

A much smaller group of protesters gathered a week ago in front of the state health department.

State officials have said the fraud involved fake behavioral health clinics billing the state for services they never provided and that the clinics preyed on Indigenous people struggling with substance use disorder.

In some cases, clinics in the Valley were using white vans to kidnap people from indigenous reservations and take them to bogus treatment facilities, sometimes holding them against their will, investigators have said.

Navajo Nation President Buu Nygren on June 20 declared the fraud a humanitarian crisis on the Operation Rainbow Bridge Facebook page. The fraud reportedly spread to tribes in other states, including Montana, where the Blackfeet Nation in August declared an emergency over the scam, the Associated Press reported.

The Navajo Nation launched Operation Rainbow Bridge to help people who were caught up in the scams get home or find the services they need.

 
 

But critics say that the state’s effort to punish fraudsters and prevent more theft of taxpayer dollars has caused an increase in homelessness and unemployment, and left some people without the treatment they need. At least 102 providers were suspended from the AHCCCS program in May, and others have since been suspended in connection with the alleged fraud.

Patients are suffering and in some cases are dying because they aren’t getting the help they need, said Ashley Adams, an attorney who attended the protest. She said she is representing some of the providers who have either been suspended or otherwise harmed by the state crackdown.

“The bad actors set the tone for everyone else,” Adams said. “Anyone who got into this business at a certain time is assumed to be bad … (AHCCCS) is not doing investigations, they are not interviewing employees or looking at records. They are making assumptions.”

A big part of the problem, Adams said, is that much of the fraud began during the height of the COVID-19 pandemic, when demand for behavioral health and substance use disorder treatment was increasing and the health system in general was trying to improve access for patients.

But the state’s response after discovering the scam clinics and money loss was to have a “knee-jerk reaction” and now all providers of services through the American Indian Health Program are assumed to be fraudulent, she said.

 
 

“There are solutions to be found aside from suspending everybody,” she said. “They are suspending providers that were doing good work.”

Protest organizer André Miller, a pastor, mayoral candidate and behavioral health provider from Mesa, said his group is trying to meet with Arizona Gov. Katie Hobbs to outline its concerns but that so far they’ve bene unable to to secure any of her time. Hobbs’ office did not respond Tuesday to a request for comment. Miller said his group will continue its public protests until state leaders respond.

Hobbs’ office issued a statement last week when the protesters were outside the Arizona Department of Health Services that said her administration “has worked relentlessly to crack down on fraud, protect taxpayer dollars and end the humanitarian crisis created by fraudulent sober living homes that have endangered some of Arizona’s most vulnerable.”

The statement emailed by Hobbs spokesperson Christian Slater said the administration has been working to get resources for those affected, “providing 13,700 nights of temporary lodging and transportation for over 750 people affected, and directly serving over 4,000 individuals.”

Investigators have said the scam primarily targeted indigenous Arizonans through the AHCCCS American Indian Health program, which allows providers to bill AHCCCS directly as fee-for-service rather than to managed care organizations, which is how most of the agency’s billing is handled.

Miller and some other providers say they they’ve been forced to fire employees, not because they were suspended, but because payments from AHCCCS are delayed because of extra checks and balances the agency put in place to prevent more fraud.

Audit faults state agency for poor foster care oversightDeveloper acquires 1,800 acres in this Arizona cityPhoenix Diocese establishes Arizona’s first, full-fledged seminaryTrump ally wrote subpoenas of Maricopa Co. election data

 
 

AHCCCS was allegedly bilked for “hundreds of millions of dollars,” Arizona Attorney General Kris Mayes announced in May at a multi-agency news conference led by Hobbs. The scam was a “stunning failure of government,” Mayes said at the time.

Newfound Hope Wellness & Detox Center in Tempe, which serves primarily indigenous patients, was suspended from AHCCCS payments in February because of suspected fraud, though the owners, who attended Tuesday’s protest, say there’s no evidence any fraud occurred.

Tara Sutherland is living at a facility operated by Newfound Hope with her four children and is fearful that if the organization doesn’t get its provider suspension lifted soon, she’ll be without a place to live. Sutherland, 50, is Navajo and is getting help for substance use disorder involving drugs and alcohol. She and her children were homeless for two months in the spring after a sober living home where they were residing closed.

“We were living in my van and my car. We were parking here and there, maybe staying overnight at friends’ houses, it was hard,” Sutherland said. “Now they are starting in new schools and I don’t want them to keep transferring.”

AHCCCS officials on Tuesday did not have any comment other than to reiterate what they said last week, which is that the agency continues to investigate and suspend behavioral health providers for credible allegations of fraudulent billing, and that its top priority is the health and safety of enrolled members.

Reach health care reporter Stephanie Innes at stephanie.innes@gannett.com or at 480-313-3775. Follow her on X, formerly known as Twitter @stephanieinnes.

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From <https://www.azcentral.com/story/news/local/arizona-health/2023/10/03/criticism-of-arizonas-medicaid-fraud-crackdown-is-growing/71051357007/>

 
 

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Molina loses anticipated Indiana Medicaid contract Dive

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]: Molina has a surprise Medicaid RFP loss due to challenges meeting DSNP requirements.

 
 

 
 

Clipped from: https://www.healthcaredive.com/news/molina-indiana-medicaid-contract-loss/695442/

An article from

 
 

The health insurer expected to be offered a contract to manage the care of Medicaid seniors in a new long-term services and supports program, but wasn’t able to stand up products in time.

 
 

Molina’s contract loss in Indiana is not expected to change the payer’s financial outlook. Gerenme via Getty Images

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Dive Brief:

  • Molina will not be offered a Medicaid contract from Indiana that the payer expected to receive, after it was tied up in regulatory red tape, Molina disclosed on Monday in a filing with the Securities and Exchange Commission.
  • Indiana’s long-term services and supports contract required the health insurer to have a dual-eligible special needs plan available for 2024, but Molina wasn’t able to stand the product up in time because of CMS administrative requirements, according to the filing.
  • The regulatory requirements shouldn’t affect any of Molina’s other current or pending Medicaid contracts, the payer said. Molina still expects to bring in 2024 premium revenue around $38 billion.
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Indiana’s Pathways for Aging is a new program meant to help seniors on Medicaid receive long-term care in a home and community-based setting. Long-term services and supports programs offer a variety of medical and social services to people who need help with daily activities because of age, disability or chronic illness.

The state is awarding contracts to managed care organizations before Pathways launches in 2024. Molina, along with Elevance, Humana and UnitedHealthcare, was supposed to receive a contract to manage beneficiaries’ care in the new program.

However, the Indiana Family and Social Services Administration notified Molina in late September that it wouldn’t receive the contract to participate in Pathways. Molina said it would have had a DSNP product available by 2025, but Indiana already determined that Molina hadn’t met readiness review requirements.

The contract was expected to run for four years, with the potential for two one-year renewal terms. Pathways, when launched, will cover roughly 100,000 qualifying Hoosiers.

“Indiana is the only state in its portfolio in which a Medicaid contract, whether actual or expected, has been affected by the CMS administrative proceeding,” Molina said in the filing, adding that the contract loss would not be material to the payer’s financials.

Molina did not respond to a request for comment on what CMS requirements held up its DSNP launch.

The contract loss comes after recent Medicaid wins for Molina in California, Iowa and Nebraska, which should collectively add more than $4 billion in annual premium revenue for Molina and offset the worst of member losses from Medicaid redeterminations, according to management.

“While the Indiana development is slightly disappointing, we remain bullish on [Molina] given the substantial amount of new business won over the last year,” JP Morgan analyst Calvin Sternick wrote in a note Monday.

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New Hampshire seeking Medicaid contract bids

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 Granite State fires up the MCO RFP machine, with contracts going live in September 2024.

 
 

 
 

Clipped from: https://www.beckerspayer.com/contracting/new-hampshire-seeking-medicaid-contract-bids.html

New Hampshire is looking for payers to administer its Medicaid managed care program starting next year.

The state said in early September it expects to select three insurers to administer benefits starting Sept. 1, 2024 through Aug. 31, 2029.

Those selected will administer Medicaid benefits to up to 190,000 enrollees under the age of 65, including acute care, behavioral health and pharmacy services.

“Respondents are expected to identify ways in which they will meet or exceed MCM Program

requirements and goals by offering innovative strategies for building on authentic patient/provider relationships with an emphasis on primary care prevention and provider-delivered care coordination to effectively reduce future illness burden and improve population health in every county of the state,” the state wrote.

The state expects discussions with selected bidders to begin in late November, with final approval expected in January.

 

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