Category: MM Curator

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FWA (NY)- NY brings fresh allegations of a for-profit nursing home “pocketing” Medicaid funds

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]: Uri and Efraim are on the NY AG naughty list for $38M in no-nos. Related- the state has been watching these dudes since 2017. But lets not ask why its taken 6 years to get the case to this point.

 
 

Clipped from: https://www.mcknights.com/news/ny-brings-fresh-allegations-of-a-for-profit-nursing-home-pocketing-medicaid-funds/

 
 

 
 

New York’s attorney general wants a state court to force the owners of a Syracuse nursing home to answer questions about “pocketing” $37.6 million in government funding, while the accused’s attorneys say such related-party transactions and other suspect business transactions are common and acceptable. 

Uri Koenig and Efraim Steif, owners of Van Duyn Center for Rehabilitation and Nursing, face numerous allegations of diverting Medicaid funds for their own financial gain, inadequate staffing, and neglect. NY Attorney General Letitia James’ office also alleges that the owners are intentionally “keeping staffing levels low,” according to a June 7 court filing asking the New York Supreme Court order to compel the owners to talk.

The case is the latest in the AG’s quest to spotlight what she considers predatory and illegal financial practices that have in some cases led to reduced staffing and serious patient care concerns. This is at least the fourth case James has pursued against for-profit owners since November of 2022.

In November, James sued the owners and operators of Comprehensive at Orleans LLC, doing business as The Villages of Orleans Health and Rehabilitation Center, a 120-bed nursing home in upstate New York, alleging the illegally diverted $18.6 million in Medicare and Medicaid funds. In December, she filed similar cases against Cold Spring Hills Center for Nursing and Rehabilitation and Fulton Commons Care Center, both located on Long Island.

The most recent Medicaid case demonstrates the lengths some states are going to to rein in regularly used business practices amid an equally aggressive pursuit by federal regulators to bring transparency to the nursing home sector.

“The Attorney General should be permitted to question Respondents about these financial arrangements, which served to siphon government funds from their intended purpose of supporting required resident care,” says a filing the AG’s office shared with McKnight’s Long-Term Care News on Friday.

“The policies that keep staffing levels low and resident census high appear to stem from decisions made by those who control Van Duyn’s operations and business decisions, including Respondent owners,” the filing added. “This is further supported by financial documents demonstrating that Respondent owners diverted money away from resident care and into their pockets by way of disbursements and related company transactions.”

The filing notes that the 513-bed facility has 78 citations from the state Department of Health, including two pertaining to Actual Harm or Immediate Jeopardy. The facility has been a candidate for placement on the Special Focus Facility list, which denotes the poorest performers in the country, since 2018, officials added. The Attorney General’s Medicaid Fraud Control Unit initially opened an investigation into Van Duyne in late 2017, the filing said. 

“[The] investigation has also shown that, during the period of Van Duyn’s poor performance, significant fund transfers out of the nursing home, whereby Respondents funneled millions of dollars paid to Van Duyn by government programs for resident care to themselves and related party companies,” the court document said. “Indeed, a non-profit organization’s analysis found that Van Duyn’s owners routinely engage in related company transactions designed to siphon taxpayer funds away from resident care.”

According to the court document, Koenig and Steif either “own or are strongly affiliated” with related parties that conduct business with the nursing home, including Upstate Services Group, LLC, which provides administrative consulting services to Van Duyn; Fiscal Care, LLC, which provides Van Duyn’s billing services; CFare Foods, LLC, which provides Van Duyn’s food services. Koenig and Steif also control all or part of the company to which the facility pays a “vastly inflated rent,” the document said. 

David R. Ross, an attorney with O’Connell and Aronowitz, however, said the owners intend to provide a response to the Attorney General’s office showing that the way Van Duyn conducts business is in accordance with state regulations. 

“Related party transactions are the norm, as they create economies of scale and resulting cost savings which benefit everyone,” Ross said in a statement to McKnight’s. “These related party transactions are standard practices that are commonplace in New York State and throughout the country, and are characteristic of for-profit and nonprofit nursing homes, as well as hospitals. All related party transactions are fully transparent and are required to be, and have been, reported to the New York State Department of Health in annual cost reports.”

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FWA (OH)- Owner of Eye for Change sentenced in $3.4M 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]: Alfonzo and 20 of his employees used a bogus counseling company to steal $3.4M of your tax dollars. Medicaid members also took kickbacks to help make it all work. They did not say thank you.

 
 

 
 

Clipped from: https://fox8.com/news/3-4m-judgment-in-cleveland-medicaid-fraud-case/

[In the player above, get a breakdown of the top stories on FOX8.com for Tuesday, June 13, 2023.]

CLEVELAND (WJW) — The owner of a Cleveland nonprofit offering mental health counseling, which for years defrauded Medicaid by filing fake claims, will spend three years in prison and must repay $3.4 million, a federal judge ruled Tuesday.

Alfonzo Bailey, 40, of Euclid, who founded Eye for Change Youth and Family Services in 2016, pleaded guilty Tuesday to conspiracy to commit healthcare fraud, according to a news release from U.S. Attorney Rebecca Lutzko of Ohio’s Northern District Court.

Suspect flees after armed robbery at University Hospitals

He was sentenced to 36 months in prison and ordered to pay $3,465,643 in restitution for the scheme, in which the nonprofit’s employees conspired to bill the Ohio Department of Medicaid for services that were never rendered according to the U.S. attorney’s office.

The nonprofit Eye for Change offered mental health counseling, case management, job training and supportive housing, among other services, according to the release.

A superseding indictment handed up in May 2021
charged Bailey, the nonprofit and 20 employees with healthcare fraud, money laundering and other related charges in the scheme, which lasted from February 2017 to September 2020.

Prosecutors alleged employees were directed to misdiagnose Medicaid beneficiaries, seeking authorization from the state Medicaid department to offer services at increased rates. Some employees submitted false notes to show proof of the services, according to prosecutors.

Others were accused of paying kickbacks including cash, gift cards and rent or bill payments to those Medicaid beneficiaries, in order to add them to the nonprofit’s clientele, then sending more fraudulent bills to Medicaid.

“These individuals engaged in a scheme to defraud taxpayers by submitting fraudulent billing to a federally funded healthcare program, which is supported by hard-working citizens,” FBI Special Agent in Charge Eric Smith is quoted in a news release from November 2020, when Bailey and eight others were initially indicted.

Growing homeless community causing concern in Cleveland

At the time, Eye for Change was associated with properties in Cleveland, Cleveland Heights and Columbus, according to the 2020 news release.

“There are actually real people out there who are suffering and need help,” Attorney General Dave Yost said at the time.  “You don’t have to make up imaginary patients. A jury of their peers will undoubtedly know some of them. I’m grateful for the state-federal partnership that is bringing these fakes to justice.”

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FWA (NC)- Eastern District of North Carolina | Fayetteville Cardiologist Agrees to Pay Over $5 Million to Resolve Allegedly False Medicare and Medicaid Claims

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]: Hari did lots of unnecessary cardiac procedures to steal $5M of your tax dollars. He did not say thank you.

 
 

 
 

Clipped from: https://www.justice.gov/usao-ednc/pr/fayetteville-cardiologist-agrees-pay-over-5-million-resolve-allegedly-false-medicare

RALEIGH, N.C. – Fayetteville, North Carolina cardiologist Dr. Hari Saini and his current practice, Carolina Heart and Leg Center, P.A., agreed to pay $5,015,554 to the United States and North Carolina to resolve allegedly false Medicare and Medicaid claims. 

“This civil fraud settlement demonstrates our steadfast commitment to protect taxpayer money and guard the integrity of our vital health care programs,” said U.S. Attorney Michael Easley.  “Medical doctors should never bill for unnecessary procedures.  Those who do will be held accountable.  Our office will zealously pursue damages and civil penalties against medical professionals where warranted.”

This settlement arose from whistleblower allegations that Dr. Saini and his cardiology practice performed unnecessary atherectomy procedures to remove minor plaque blockage in leg arteries in patients.  The United States filed a complaint against Dr. Saini, Carolina Heart and Leg Center, and Carolina Cape Fear Medical Group, alleging that Defendants “systematically overstated the stenosis percentage” to justify medically unnecessary atherectomies for the maximum number of procedures for their patients. More specifically, the Government alleged that Dr. Saini—who was one of the highest billing cardiologists in North Carolina for this type of claim—conducted “risky and invasive atherectomy procedures to unnecessarily remove plaque blockage that was, at best, only minimally present, all in blatant disregard for patient safety and Program billing requirements.”  Based upon billing and medical records, Defendants were paid millions from Medicare and Medicaid, which the Government alleged was not supported by the retained medical records for the services provided and billed. 

Ultimately, after six years of discovery and litigation, and with trial looming, Dr. Saini and his practice agreed to pay more than $5 million to resolve the False Claims Act allegations. 

“Physicians cannot perform procedures on patients who don’t need them just to make more money,” said Attorney General Josh Stein. “That’s a waste of taxpayer resources and a fundamental abuse of the trust we put in doctors. My office will hold accountable health care providers when they commit fraud for their own enrichment.”

The federal and state False Claims Acts mandate that the Governments recover triple the money falsely obtained, plus substantial penalties for each false claim submitted, and attorneys’ fees and costs to the whistleblower.  It should be noted that the civil claims resolved by settlement here are allegations only, and that there has been no judicial determination or admission of liability.  Dr. Saini and his practice deny these fraud allegations.

This matter was handled in partnership between the United States Attorney’s Office of the Eastern District of North Carolina and the Medicaid Investigations Division of the North Carolina Attorney General’s Office.  Assistant United States Attorney Neal Fowler and North Carolina Senior Deputy Attorney General Eddie Kirby represented the United States and State of North Carolina in this civil action.  The investigation was conducted by the HHS Office of Inspector General, including Special Agent Craig Schiffbauer, and the North Carolina Medicaid Investigations Division.

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MCOs (ID) – Idaho looks at farming out Medicaid

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: The Medicaid Managed Care Task Force has one job- make sure the state moves to managed care.

 
 

 
 

Clipped from: https://dnews.com/local/idaho-looks-at-farming-out-medicaid/article_64391e68-9b3e-56e5-b87e-728794eb58f0.html

Task force mulls using third party to administer benefits in hopes of cutting costs

 
 

Julie VanOrden

 
 

FILE – Health and Human Services Secretary Xavier Becerra speaks during a meeting with a task force on reproductive health care access in the Roosevelt Room of the White House, April 12, 2023, in Washington.

Evan Vucci

BOISE — The Idaho Legislature’s Medicaid Managed Care Task Force discussed the program’s growing budget, how it could contract with a managed care organization, and challenges faced by the division at its first meeting Monday.

The task force was created to look at how potentially implementing managed care — or contracting with a third party to administer and oversee Medicaid benefits — could reduce costs in the program. The group is required to report its findings by Jan. 31, 2024, with potential policy recommendations.

One of the dominating debates of the 2023 legislative session was the ballooning price tag of Medicaid over the last couple of years; this year’s budget came in at $4.5 billion, which some lawmakers were concerned wouldn’t fully pay some of the bills.

The task force, which met in the state Capitol on Monday morning, is co-chaired by the House and Senate Health and Welfare Committee chairpersons, Rep. John Vander Woude, R–Nampa; and Sen. Julie VanOrden, R-Pingree. Its Senate members are Sens. Mark Harris, R-Soda Springs; Kevin Cook, R-Idaho Falls; Glenneda Zuiderveld, R-Twin Falls; and Senate Minority Leader Melissa Wintrow, D-Boise.

The task force’s House members are Reps. Dori Healey, R-Boise; Jordan Redman, R-Coeur d’Alene; Josh Tanner, R-Eagle; and Rep. Nate Roberts, D-Pocatello.

“I think it’s one of the major projects we’re going to deal with this summer,” Vander Woude said.

One of the ideas that came up repeatedly in discussions over the course of the session involved switching to managed care for more Medicaid patients. Managed care is a system meant to manage cost, utilization and quality of care, according to Medicaid.gov.

MANAGED CARE ORGANIZATIONS

If Idaho’s Division of Medicaid were to move forward with implementing managed care for more of its patients — Medicaid dental care is currently provided through a managed care plan — it would need to seek a contractor to deliver these services.

State Purchasing Manager Chelsea Robilard provided task force members with a detailed explanation of the procurement requirements for finding and contracting with a managed care organization.

Because of the size of the program and its complexity, the process would likely take a long time and the Division of Purchasing would probably need one more full-time employee, she said. Division of Medicaid Administrator Juliet Charron estimated it would take around two years to complete if the Legislature decided to switch from its current system, which is called value-based care and is a reimbursement system that ties payments made to providers to the quality of the care provided and incentivizes efficiency and effectiveness, according to the Department of Health and Welfare website.

MEDICAID BUDGET

Division of Financial Management Administrator Alex Adams provided information about Medicaid’s impact on the state budget, which is significant. Medicaid costs make up the majority of total spending in every state, he said.

This hasn’t always been the case, and nationally and in Idaho, the spending for the program has raised steadily since 2018, driven by more people becoming eligible when states opted into Medicaid expansion and higher costs of services.

Idaho Medicaid is paid primarily through federal funds. In the $4.5 billion fiscal year 2024 appropriation for the program, around $3 million were federal funds. The budget included about $856 million in state general funds and nearly $676 million in dedicated funds.

When looking at all state spending — general, dedicated and federal included — Medicaid makes up 34% of the budget, and public schools, the next largest expenditure, is 24% of spending, Adams said.

Adams highlighted the potential challenges in setting the fiscal year 2025 budget, including that federal pandemic relief funds will wear off and the state will go back to covering a larger share as it traditionally had, and that federal matching percentages are set to decrease because of growth in Idaho’s per capita income. Adams also said the state isn’t likely to end the year with a surplus, as it has the past couple of years, because the property tax legislation passed this session directs most surplus revenue toward property tax relief.

The Medicaid budget also comes with its own unique challenges, Adams said. Because of the nature of the program, if someone is eligible for care and receives it, the state is legally obligated to pay the bill; this makes controlling costs difficult. There are also competing interests between containing costs and providing access to quality care.

“It’s too easy to look at issues only through the lens of the budget and at the expense of patient outcomes,” Adams said.

CHALLENGES IN THE DIVISION

Ryan Langrill from the state Office of Performance Evaluations (OPE) provided an overview of challenges the office found in past evaluations of Idaho’s Medicaid.

Lawmakers have tasked the office with looking into a number of programs within the division, including related to rate setting, delays in claims processing, the Idaho behavioral health plan and its non-emergency transportation.

These reports, all of which are available at legislature.idaho.gov/ope, identified weaknesses within the department such as with contract management. For instance, in regard to the state’s non-emergency medical transportation contract that failed, OPE found that the division made two significant errors: The data that it made available to contractors through the request for proposals process wasn’t complete and didn’t allow them to submit a bid that reasonably reflected the services they would need to provide, and it set a spending cap that wasn’t actuarially sound and wouldn’t cover the cost of providing the services, Langrill said.

The office also has determined over the years the division struggled with benefit management and design, measuring performance adequately, adapting knowledge and skills to new policies or systems, stewardship and a shortage of staff to adequately manage programs.

One of the reports found the department wasn’t asking for enough funding to cover the rates to provide services, Langrill said.

“This led to a lot of frustration from the budget committee, where they were paying for rate increases that the Division of Medicaid told them were necessary for the program, but the rate increases were not actually sufficient to make providers whole,” Langrill said.

Wintrow said, “different ideologies about the program create tensions and budget deficits that they (the department) may not be responsible for, and some of that is on us as a Legislature.”

The office and an outside consultant hired by the state to create Medicaid cost-containment recommendations both noted that the Division of Medicaid has a “lean” staff, which can create issues.

The task force is scheduled to meet again July 10 and it will go over the long-term cost-saving measures recommended in the second report from the consultant, the firm Sellers and Dorsey. The first set of short-term recommendations were presented to lawmakers in February.

The next meetings are slated for July 25, Aug. 9 and Aug. 31.

Guido covers Idaho politics for the Lewiston Tribune, Moscow-Pullman Daily News and Idaho Press of Nampa. She may be contacted at lguido@idahopress.com and can be found on Twitter @EyeOnBoiseGuido.

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MCOs (OK)- OHCA Selects Organizations to Assist in Serving Oklahoma Medicaid

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: We have winners in the Sooner State (Aetna, Humana, Centene). Not sure we have one that is exactly “provider-led” as was intended by the do-over effort, but hey. Potato, Potato.

 
 

Clipped from: https://oklahoma.gov/ohca/about/newsroom/2023/june/ohca-selects-organizations-to-assist-in-serving-oklahoma-medicaid.html

Oklahoma City, OK – The Oklahoma Health Care Authority has selected three qualified and experienced contracted entities to assist in executing OHCA’s comprehensive health care model, SoonerSelect, for certain SoonerCare members.    

The selected contracted entities serving the medical plans are Aetna Better Health of Oklahoma, Humana Healthy Horizons of Oklahoma and Oklahoma Complete Health, a subsidiary of Centene Corporation. The selected contracted entity serving the children’s specialty program is Oklahoma Complete Health. Each of the contracted entities meets the statutory requirements of a provider-led entity and must also contract with local Oklahoma provider organizations. 

“By moving away from a fee-for-service model toward this new delivery system, we can increase the effectiveness of SoonerCare while achieving better health outcomes,” said Kevin Corbett, OHCA CEO. “SoonerSelect places a strong emphasis on quality of service and health outcomes while maintaining fiscal responsibility for Oklahoma taxpayers.”   

SoonerSelect will allow OHCA to incentivize health outcomes while maintaining oversight and authority over Oklahoma’s Medicaid program and the program funding. OHCA is committed to improving the health and lives of SoonerCare members and will hold its SoonerSelect partners to the highest standards through stringent accountability measures.   

By contracting with provider-led entities, OHCA will strengthen the voice of local providers and leverage their expertise and familiarity with Oklahoma communities in delivering health care services to SoonerCare members.  

This transition in health care delivery will allow OHCA to achieve the following payment and delivery system reform goals:   

  • Improve health outcomes for Oklahomans   
  • Move toward value-based payment   

 
 

  • Improve SoonerCare member satisfaction   
  • Contain costs by investing in preventive and primary care   
  • Increase cost predictability to the State    

“The selected organizations are the best at what they do and their established partnerships with Oklahoma providers is vital to the success of the program,” said State Medicaid Director Traylor Rains. “I am confident in their ability to assist us in providing high-quality services to our SoonerCare members.”    

Oklahoma joins 40 other states in engaging third-party organizations to administer certain Medicaid benefits. States have reported positive outcomes by investing in primary care, preventive services and effective quality improvement strategies, such as addressing maternal health outcomes, obesity and smoking rates, and reduced emergency room utilization. 

It is common for these contracted organizations to be heavily invested in infrastructure, including technology, staffing, and research on best practices to coordinate care for members. The selected organizations must have an Oklahoma presence, including key staff and call center operations.   

The contracts were competitively bid and were selected after a technical evaluation and oral presentations. The contracts are for an initial term through June 30, 2025 with five renewal options. OHCA staff will spend the next several months working with the contracted entities to ensure a smooth transition for SoonerCare members and will continue to oversee the plans to ensure a high level of care for members.   

Subject to approval by the Centers for Medicare and Medicaid Services, OHCA expects to launch the medical and children’s specialty plans in April 2024. The SoonerSelect dental plans which were previously announced are expected to launch in February 2024.  

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STATE NEWS (TN) Tennessee to be the first to offer diapers through Medicaid: Here’s what to know

 

 
 

 
 

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]: One of the early benefits of TN’s innovative block grants- diapers.

 
 

Nashville Tennessean

Tennessee could soon be the first state in the nation to cover part of the cost of diapers for babies on the state’s Medicaid program, TennCare.

With $30 million in funding approved last month by the state legislature, TennCare is working to get federal approval and implement a benefit offering half of the diapers a baby needs for the first two years of life. The benefit is expected to be in place by January.

“We are the first state that provides relief for the cost of diapers for mothers for the first two years,” Gov. Bill Lee told reporters during a recent news conference. “I think we’re in a really unique spot in Tennessee, we have the only Medicaid waiver in the country that is this modified block grant.”

 
 

Tennessee has not expanded Medicaid under the Affordable Care Act, and Democrats have criticized Lee and legislative Republicans for not doing so. The expansion would expand coverage to as many as 200,000 additional Tennesseans.

Instead, the Lee administration pursued a modified block grant approach to TennCare, with the goal of using savings to add additional benefits.

A burden lifted:Tennessee to offer first-of-its-kind Medicaid diaper benefit

“This is a model for other states potentially to… expand the number of people that can be served, expand the services that we can provide to Medicaid recipients, and to do so, not only without additional cost to the state, but in a way that actually incentivizes lowering the cost of health care to those who receive it,” Lee said. 

Here’s what to know about the new benefit:

Why diapers?

Unlike food, diapers are not targeted by any in-kind federal assistance program – no food stamps, or WIC benefits cover them. About one in three families in Middle Tennessee struggle to provide the diapers their infants need. 

Without enough diapers to keep a baby clean and dry, infants are at higher risk for diaper dermatitis and urinary tract infections. Most daycare facilities require parents to provide a day’s worth of diapers for their child – which poses a significant burden to families facing financial insecurity. 

Lee proposed the benefit during his first State of the State address since the overturning of Roe v. Wade as a “pro-life” and “pro-family” use for savings realized in the state’s new Medicaid block grant funding structure. 

When will the benefit be available?

Implementation of the new benefit now depends on approval from the federal Centers for Medicare and Medicaid Services. CMS approval involves a formal proposal by TennCare, followed by an open comment period for the public to respond.

“This is a first-of-its-kind Medicaid benefit,” TennCare Communications Director Amy Lawrence told The Tennessean. “No other state has done this, so it might take a little bit more time for CMS to approve it, but we’re hopeful that they will.” 

If CMS moves quickly to approve the plan, the benefit could become available to families on TennCare by January 2024. 

How many diapers are covered?

TennCare will provide half of the total average number of diapers needed by an infant each month for each child eligible for the benefit. TennCare is working to calculate the quantity of diapers the benefit will provide each month.

Who is eligible?

Any child who is a TennCare member under 2 years of age at that time will be eligible for diapers until they turn 2 regardless of when they enrolled into TennCare, Lawrence said. Mothers, parents and caretakers are not required to be TennCare participants to obtain the diaper benefit for their child.

Where does the money come from?

Funding for the benefit comes from the $330 million in savings the state realized by restructuring how the state receives Medicaid funding from the federal government in a new system known as a modified block grant.

Lawmakers approved $30 million in funding last month specifically for the diaper benefit, which will first become available when the state budget goes into effect on July 1. 

Where will families be able to get diapers through TennCare?

Right now, TennCare is planning to run the benefit through participating pharmacies, similar to how the department handles over-the-counter drugs.

“We would get participating pharmacies to code it, bill it to us and then people could go through their pharmacy to get diapers,” Lawrence said. 

A variety of diaper brands will be covered by the benefit to allow parents to choose the best fit for their child, and account for skin sensitivities and other needs. Approved brands are still being determined. 

 
 

From <https://www.tennessean.com/story/news/politics/2023/05/18/tennessee-will-be-the-first-state-to-offer-diapers-through-medicaid-heres-what-to-know/70223132007/>

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PHE- Early numbers show nearly 70% of Oregonians keep Oregon Health Plan benefits in first round of renewals

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]: Oregon shows that the wind-down can be done without everyone losing their minds. This is the way.

 
 

Clipped from: https://ktvz.com/news/government-politics/2023/05/23/early-numbers-show-nearly-70-of-oregonians-keep-oregon-health-plan-benefits-in-first-round-of-renewals/

 
 

Oregon Health Authority

SALEM, Ore. (KTVZ) – The Oregon Health Authority and Oregon Department of Human Services are committed to transparency and will be sending monthly information about medical coverage among Oregonians as the agencies continue to track the state’s progress in determining eligibility for medical programs.

Background

When the COVID-19 pandemic began, the federal government allowed states to keep people on Medicaid once they became eligible and did not require annual eligibility renewals. During this historic health emergency, the Oregon Health Plan (OHP), Oregon’s Medicaid program, grew to nearly 1.5 million people.

In April, Oregon began the process of redetermining eligibility for everyone on OHP.  While most people will continue to qualify for existing benefits, OHA is required to review eligibility for all OHP and Medicare Savings Program (MSP) members by mid-2024.

OHP redeterminations started in April

In April, Oregon began processing eligibility redeterminations for all 1.5 million members receiving OHP and other Medicaid-funded services and supports. The federal government requires Oregon to disenroll any members who are no longer eligible or fail to respond to renewal notices.

All OHP households will receive a renewal notice over the next 10 months. People are encouraged to check that their contact information is up to date so that they can be contacted by the state and receive renewal notices.

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Oregon will be able to process many renewals automatically. This means that every OHP member will receive a renewal notice, and the notice will explain whether the member needs to provide additional information or take action to keep their coverage.

OHP members encouraged to respond quickly

Although the state has taken many steps to prepare, the large number of OHP redeterminations, along with renewals of long-term services and supports, is expected to cause greater wait times, delays, and possible interruptions to people’s OHP benefits. OHP members are encouraged to respond as quickly as possible after they receive a request for information to avoid any possible delays. The fastest way members can provide an update is by going to benefits.oregon.gov and logging into their ONE account.

Members losing OHP coverage have other coverage options and will receive at least 60 days advance notice. Many people will be eligible to enroll in health plans through the Oregon Health Insurance Marketplace (OHIM) with financial help. Other people may be eligible for Medicare or employer coverage.

April OHP redeterminations data

  • April was the first month Oregon began processing medical renewals, during this reporting period: 133,232 individuals, or 75,436 cases have had their OHP renewed.
  • 46,894 individuals, or 29,072 cases needed to provide more information to complete the process.
  • 13,208 required individuals to review, sign and send back their renewal packet.
  • 8,394 people were ineligible and received a 60-day notice of termination of coverage. When people are ineligible, they are referred to the Oregon Health Insurance Marketplace for other options for health care coverage.

Early data for May shows 66% of people will retain benefits.

Members losing coverage should report changes to their income or household information immediately if any of the information used to make the decision is inaccurate. They also should apply for other health coverage as soon as they know their coverage ending date to prevent a gap in coverage.

Data dashboards in place for tracking progress

Two new dashboards became available in April for the public to track Oregon’s progress.

  • Medical Redeterminations Dashboard for tracking the state’s progress in determining eligibility for medical programs. This dashboard is updated daily. The types of data in this dashboard will expand over the next few months.
  • ONE Customer Service Center Dashboard for monitoring the customer service experience for people calling the ONE Customer Service Center to apply for or ask for help with medical, food, cash and child care benefits. The ONE Customer Service Center Dashboard is updated every day.

Extending health coverage

To get help, people can also:

Get help finding other health coverage at OregonHealthCare.gov/GetHelp

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STATE NEWS (CNMI)- CNMI Medicaid to limit, reduce, or suspend 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]: This is what it looks like when you can’t exceed your funded Medicaid amount.

 
 

Clipped from: https://www.mvariety.com/news/cnmi-medicaid-to-limit-reduce-or-suspend-services/article_e89dd87e-f86c-11ed-ac03-bb8a65cd4d59.html

 
 

(Office of the Governor) — Under the waiver authority of Section 1902(j) of the Social Security Act, the Commonwealth Medicaid Agency will limit, reduce, or suspend services due to financial constraints and cost-cutting measures.

In an effort to sustain the program and ensure medically necessary services are not disrupted, temporary limitations, restrictions, or suspensions will be implemented and taken into effect on June 1, 2023, and end no later than September 30, 2023.

The affected services are:

Suspended

Dental Services

Outpatient Physical Therapy and Related Services

Home Health Physical Therapy, Home Health Aide, or Medical Social Worker services 

Prosthetic Devices

Vision Services

Children ages 0-20 years may be excluded from the limitations, reductions, or suspensions of services for the purposes of Early and Periodic Screening, Diagnostic, and Treatment services through prior authorization. Prior Authorization requests must accompany physician certification of medical necessity.

Limited

Home Health Services* – Skilled Nursing Services only

Durable Medical Equipment will be restricted to monthly rental only

Accessories required for the use of a DME and Medical supplies will be restricted to critical cases

Prescribed Drugs**

Transportation**

*Children ages 0-20 years may be excluded from the limitations, reductions, or suspensions of services for the purposes of Early and Periodic Screening, Diagnostic, and Treatment services through prior authorization. Prior Authorization requests must accompany physician certification of medical necessity.

**Prescribed Drugs will be limited to generics only. Prescribers and pharmacists are required to make good faith efforts in ensuring first-line therapies are available in generic.

**Transportation: Air transportation will be reimbursed for medically necessary and emergency purposes and shall be enforced by the Health Network Program. Ground non-emergency transportation must accompany a Physician’s Certification Statement of necessity.

Restricted to

The Commonwealth Healthcare Corporation, Tinian Health Center, Rota Health Center, or a Federally Qualified Health Center or FQHC:

Outpatient Hospital Services

Laboratory and X-Ray Services

Family Planning and Pregnancy-Related Services

Physician, licensed practitioner, and any other medical care services

Clinic Services

Exceptions may be made if CHCC or the FQHC is unable to provide the services in a timely manner by a written authorization signed by the designated staff. The Service Provider Exception Authorization Form must be completely filled and signed by the two entities.

Exclusions

Dialysis Services will remain available at any of Medicaid’s approved provider networks in the CNMI.

For more information, please contact the Commonwealth Medicaid Agency:

Saipan

Gov’t Bldg 1252, Capital Hill

Monday – Thursday

Closed on Fridays & Holidays

7:30 a.m. – 1 p.m.

Contact no.

(670) 664-4880/4882

Tinian

Tinian Health Center

Monday – Friday

7:30 a.m. – 4:30 p.m.

Contact no.

(670) 433-9263/33

Rota

Rota Health Center

Monday – Friday

7:30 a.m. – 4:30 p.m.

Contact no.

(670) 532-9461/62

Posted on by

RX- Biden-Harris Administration Announces Proposal to Advance Prescription Drug Transparency in Medicaid

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: In which CMS will dive deeper on exactly how RX manus set prices. Or will try to, anyway.

 
 

Clipped from: https://www.hhs.gov/about/news/2023/05/23/biden-harris-administration-announces-proposal-advance-prescription-drug-transparency-medicaid.html

New HHS proposal would shed light on cost of prescription drugs and save states and federal government money in Medicaid

The Biden-Harris Administration has made lowering prescription drug costs in America a key priority — and President Biden is continuing to deliver results. Today, the U.S. Department of Health and Human Services, through the Centers for Medicare & Medicaid Services (CMS), is proposing steps to further drive down prescription drug costs in Medicaid and build on President Biden’s executive order to lower prescription drug costs for Americans. CMS’ latest notice of proposed rulemaking (NPRM) would shed light on the actual cost of drugs covered by Medicaid. Under this proposal, Medicaid would have increased ability to hold drug manufacturers accountable for what Medicaid programs pay for drugs.

“President Biden is not only committed to protecting Medicaid, but continues to take bold actions to strengthen the program,” said HHS Secretary Xavier Becerra. “With today’s proposed rule, we are advancing unprecedented efforts to increase transparency in prescription drug costs, being good stewards of the Medicaid program, and protecting its financial integrity. This proposed rule will save both states and the federal government money.”

“This proposed rule prioritizes CMS’ role as a good steward of Medicaid dollars while also strengthening program integrity and the management of pharmacy benefits for people with Medicaid coverage,” said CMS Administrator Chiquita Brooks-LaSure. “We’re committed to preserving access to life-saving treatments and securing fiscal sustainability for the Medicaid program, which remains a lifeline for millions of people.”

Today’s proposed rule to improve the Medicaid Drug Rebate Program follows the Biden-Harris Administration’s historic creation of the Medicare Prescription Drug Inflation Rebate Program. As part of President Biden’s new prescription drug law, for the first time ever, drug companies must now pay rebates to Medicare when their prescription drug prices increase faster than the rate of inflation for certain drugs dispensed to people with Medicare.

Increase Transparency of Prescription Drug Costs

This rule would allow CMS to have more insight into what the most expensive drugs on the market today actually cost to manufacture and distribute. The proposed regulation would give CMS and states additional tools, like a drug price verification survey, which would result in greater transparency into manufacturers’ drug prices. This survey would verify drug prices to increase transparency about why certain drug prices are expensive for Medicaid and help states better negotiate what the Medicaid program pays for high-cost drugs. With this information, state Medicaid agencies would be able to operate their pharmacy programs more effectively while helping more people get vital drug treatments. This increased transparency under Medicaid would advance the Biden-Harris Administration’s efforts to complement the Inflation Reduction Act and further drive down prescription drug costs without impacting coverage of drugs for Medicaid beneficiaries. For additional information on the drug price verification survey, visit Medicaid.gov.

Increase Transparency of Managed Care Plans

Another proposed provision aims to enhance transparency into the costs of administering drug benefits in Medicaid-managed care plans. Managed care plans cover more than 75% of Medicaid beneficiaries. Managed care plan pharmacy benefit managers (PBMs) often negotiate and administer the pharmacy benefit, though there has been a lack of transparency into the amount plans have paid to PBMs for administering the drug benefit and the amount pharmacies have been paid for the drugs. This lack of transparency has raised concerns about PBMs using spread pricing arrangements to increase their profit margins by charging an MCO more for a drug than the amount a PBM pays a pharmacy. To address this issue, CMS is proposing that contracts between states, Medicaid-managed care plans, and third-party contractors, such as PBMs, reflect transparent reporting of drug payment information among third-party contractors. This proposal will help ensure that taxpayer dollars are actually going to pay for drugs and not increased profits.

Increased Transparency in Drug Classifications

The NPRM also focuses on the potential misclassification of drugs as brand name or generic. The proposed rule includes provisions to ensure states would receive the appropriate rebates to which they are entitled, since states receive a higher percentage of rebate dollars for brand-name drugs compared to generics. With increased transparency, states would be able to determine if manufacturers appropriately classified their covered outpatient drugs, and if they did not, give CMS the ability to take action to correct the misclassification.

For additional information on these and other provisions in the NPRM, please visit Federal Register. CMS looks forward to accepting public comment on the NPRM through July 25, 2023.

Posted on by

FWA (GA) Atlanta man, healthcare provider indicted on 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]: “Atlanta man” did something. In 2018, and in 2020.

 
 

Clipped from: https://www.11alive.com/article/news/local/atlanta-man-medicaid-fraud-indictment-2018-claims/85-2f605799-d190-41e8-afd3-90ccf8b5da90

 
 

 
 

ATLANTA — An Atlanta healthcare provider has been indicted on 26 counts of Medicaid fraud and three counts of felony forgery after he allegedly submitted fraudulent claims, according Georgia Attorney General Chris Carr’s office. 

The 55-year-old man was indicted last Monday after the Attorney General’s Office Medicaid Fraud Division presented evidence to a Fulton County Grand Jury.

“We are working each day to protect taxpayer dollars by putting a stop to Medicaid fraud in our state,” Attorney General Carr said.

He allegedly submitted the claims for fake services he didn’t provide under his company to get a reimbursement payment from the government program in 2018. 

He was a licensed healthcare provider in Georgia, according a court document.

Court documents also show that the 55-year-old also forged a few documents in 2020, the indictment stated. 

“Ensuring the integrity of providers and services is a key part of our efforts. Georgia’s Medicaid program is meant to care for our most vulnerable, and we will not tolerate those who would abuse this public trust,” Carr added.

The indictment comes after Georgia received it’s own Medicaid fraud division which receives majority of its funding from the U.S. Department of Health.

If convicted, the man could pay up to a fine of three times what the government program lost and $11,000 for each fraudulent claim, according to the U.S. Department of Health and Human Services.

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