Category: MM Curator

Posted on by

STATE NEWS (IL) – Expected cost for Illinois’ noncitizen health care program hits $1.1B

 
 

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]: Initial estimates were off by $880M in state only costs compared to the estimate the Good Guvn’r used to originally sell the idea. 30% more noncitizens have already signed up than originally projected.

 
 

 
 

Clipped from: https://www.theintelligencer.com/news/article/expected-cost-illinois-noncitizen-health-care-18083866.php

 
 

SPRINGFIELD  — The estimated cost for Illinois to continue providing health care coverage to noncitizens who are otherwise ineligible for Medicaid benefits has been revised upward to $1.1 billion for the upcoming fiscal year.

As of the end of March, the Illinois Department of Healthcare and Family Services estimated it would cost $990 million to fund the program that provides state-funded health care to individuals age 42 and older who would otherwise qualify for Medicaid if not for their citizenship status.

The new estimate, shared by IDHFS Director Theresa Eagleson in testimony to a Senate appropriations committee on Wednesday, is now $880 million beyond the $220 million estimate included in Gov. J.B. Pritzker’s February budget proposal.

ONLY 25¢: Support Local, Independent Journalism.

ONLY 25¢ FOR ACCESS!

Act Now

IDHFS Chief of Staff Ben Winick told the committee the original estimate relied on the Census Bureau’s American Community Survey data to estimate the eligible population, then assumed a certain percentage would enroll.

But both the cost of providing care and the number of enrollees have far outpaced estimates.

“Because of the unreliability of that data, the projections for enrollment are really just focused on month-over-month growth based on the trends that we’re seeing and not tied to the universe of eligibles,” Winick said. 

10 percent monthly growth

The projections are now based on the program’s current month-over-month growth rate of roughly 10 percent. The number of enrollees is expected to grow to over 120,000 in Fiscal Year 2024. The previous estimate was 98,500 enrollees.

Winick noted the program currently covers about 56,000 individuals while the department oversees health care for about 3.9 million people through its various programs statewide.

State Sen. Dave Syverson, R-Cherry Valley, raised concerns over the fact that no other states offer the same level of health care coverage for noncitizens as Illinois. That, he said, could result in ever-increasing enrollment and upward adjustments to cost estimates.

“As Illinois is the only state in the nation that fully covers health care for undocumenteds from age 42 and older, when they’re crossing the border, and they realize they have health conditions, they know there’s one state to come to if you have health issues,” he said at a Thursday news conference. “Illinois now, because of the policies of this state of being a welcoming state, is now being inundated with every sick individual from around the country that’s coming here.”

The same Senate committee heard a proposal from Sen. Omar Aquino, D-Chicago, that would further expand Medicaid coverage to noncitizens age 19 and older. That would cost another $380 million, per IDHFS estimates.

“We were the first (state) in this country to provide care to populations like this from 42 and above. We are a welcoming state, I say that with a sense of pride,” Aquino said.

He said the expansion means people who were “living in the shadows” are now able to seek care, and the pace of the program’s growth shows the need for it.

“Some of this is highlighting, again, a lot of the untreated medical issues that they have from Type 2 diabetes, cancers and so forth,” he said.

Eagleson noted that the per-patient cost for individuals age 65 and older has been leveling off since that population was first made eligible for the state-run health care program in 2021. The program has since been expanded twice to cover those 42 and older.

“I think it’s important to say that we are seeing people get those diagnostic services and drugs to help them manage chronic conditions and things like that,” Eagleson said. “So on the senior population that started sooner … those costs grew pretty rapidly in the first years, and then they actually decreased and now are just normal inflationary, so they start to level off as people get the treatment.”

Winick said a large portion of the program’s enrollees live in Cook County, and its results have been born out in decreased reliance on the county-run health system.

“A lot of that’s because those conditions are now being managed,” he said. “People are getting proper treatment and now they’re getting more preventive services than the higher-end stuff and they are using their coverage to access a wider variety of providers.” 

Defraying the cost

The department’s all-funds budget request as of February was $37.2 billion, with just over $9 billion from the General Revenue Fund.

The Pritzker administration estimated that the IDHFS budget as proposed could cover about $300 million of the greater-than-expected costs.

“The governor’s focus remains on investing in priorities he outlined during his budget address,” Pritzker spokesperson Jordan Abudayyeh said in a statement. “His administration is working closely with the General Assembly to ensure that additional priorities fit within a balanced budget framework.”

Department officials noted that they were looking into other ways to defray costs as well.

Because the individuals are not citizens, the federal government does not match the state’s contributions to the program. But Eagleson said the federal Medicaid program “does fund the emergency services for undocumented residents.”

“And so we have already gotten a verbal commitment for – it’s about $67 million in (federal) match for the money that we’ve already spent on the program,” she said of discussions with the federal government. “And then we think the estimate based on the cost…for emergency services will be in the neighborhood of $100 to $120 million going forward.”

The Republican senators also noted that the noncitizens are part of a fee-for-service Medicaid program instead of the Medicaid managed care program in which most other recipients are enrolled.

That managed care system uses private insurance companies known as managed care organizations, or MCOs, to coordinate care for Medicaid recipients. The state releases funds to MCOs at a statute-specified rate. Those MCOs are charged an “assessment,” a type of tax on providers designed to bring more federal funds into the state’s Medicaid program.

Eagleson said putting the noncitizen recipients in the managed care program wouldn’t necessarily decrease costs, but it would subject the recipients to the assessment via the MCO, thereby increasing revenues.

Winick said the reason the noncitizens were not included in managed care was because the department anticipated the group would be much smaller than it has become.

“Obviously now that we’re looking at much higher enrollment numbers, we are considering our options about maybe expediting the rollout of managed care for this population,” he said.

Sen. Chapin Rose, R-Mahomet, pointed out that the money spent on the expansion could have fully funded 20 percent Medicaid base rate expansion for hospitals that has been requested or adequate funding for services provided to individuals with developmental disabilities. 

Posted on by

PHE – Medicaid work requirements may result in 1.7M in coverage losses

 
 

 
 

 
 

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 move to have a national Medicaid work requirement could save federal taxpayers $10.3B, but still let states who want to not have work requirements the ability to pay for them on their own.

 
 

Clipped from: https://www.healthcarefinancenews.com/news/medicaid-work-requirements-may-result-17m-coverage-losses

The requirements would result in federal savings, but would pass costs on to states and cause large coverage losses, data showed.

 
 

Photo: Thomas Barwick/Getty Images

At the tail end of April, Republicans in the House of Representatives passed a debt ceiling bill that includes a stipulation for states to implement work requirements for certain Medicaid enrollees. A new analysis from the Kaiser Family Foundation determined that if the work requirement was fully implemented in 2024 and the rate of Medicaid eligibility loss was as the Congressional Budget Office estimated, then 1.7 million enrollees would not meet work or reporting requirements and potentially face disenrollment.

Data showed that 91% of non-elderly Medicaid enrollees who are not on Supplemental Security Income or Medicare are working or face barriers to work.

States could continue to provide Medicaid to those enrollees but would not receive federal matching funds for doing so. It’s unclear if any states would choose to do it, although the CBO estimated that more than half of enrollees would continue to be covered at the states’ expense.

If states chose to keep all 1.7 million people enrolled, $10.3 billion of Medicaid spending would shift from the federal to state governments in 2024. A small number of states with the largest share of enrollees under the Affordable Care Act Medicaid expansion would account for almost half of the increased state spending or coverage losses.

WHAT’S THE IMPACT

The Medicaid work requirement plan would require that certain enrollees between the ages of 19-55 work or participate in other qualifying activities for at least 80 hours per month. Those could include community service or job training. Those deemed mentally or physically unfit for employment would be exempted, as would pregnant people, those caring for a dependent child or incapacitated person, those in drug or alcohol treatment programs, or people who are in school.

If enrollees fail to meet those requirements for three months or more, the federal government would cease paying the federal share of Medicaid for their expenses. States could disenroll them or continue their coverage but pay 100% of the costs. Eligibility for federal funds could resume at the start of the following calendar year.

The Congressional Budget Office has estimated that if the work requirements are enacted, about 15 million enrollees per year would be subject to the new requirements, and about 1.5 million of them would lose eligibility for federal funding. That would result in federal savings of about $109 billion over a 10-year period, but that cost would shift to states that elected to maintain coverage. About 60% of those who lost federal eligibility would become uninsured because they live in states that did not maintain coverage; for the states that did, costs would increase $65 billion from 2023 to 2033.

In summary, “under those requirements, federal costs would decrease, the number of people without health insurance would increase, the employment status of and hours worked by Medicaid recipients would be unchanged, and state costs would increase,” the CBO said.

KFF estimated 16.7 million enrollees in the expansion group would be between ages 19 and 55 in May 2024 using the age distribution of expansion adults in administrative data. This estimate includes some parents of dependent children, who would be exempt from the work requirement but still potentially subject to reporting requirements. If 10% fail to meet the work or reporting requirements, as CBO assumed, 1.7 million enrollees could lose eligibility for federal matching funds in 2024.

THE LARGER TREND

The Biden administration first began taking steps to roll back Medicaid work requirements in 2021, citing the economic and health impacts of the COVID-19 pandemic, which it said could make it more difficult for Medicaid recipients to fulfill the requirements.

“Uncertainty regarding the current crisis and the pandemic’s aftermath, and the potential impact on economic opportunities (including job skills training and other activities used to satisfy community engagement requirements, i.e., work and other similar activities), access to transportation and to affordable child care have greatly increased the risk that implementation of the community engagement requirement approved in this demonstration will result in unintended coverage loss,” CMS said in letters to states at the time.

Hospitals in states that implement Medicaid work requirements could see their Medicaid revenues decrease by as much as 21%, their uncompensated care costs increase as much as 133% and their operating margins fall by upward of 2%, according to estimates by The Commonwealth Fund.

Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com

Posted on by

PROVIDERS (VA)- Judge scraps federal assent to Virginia Medicaid rule

 
 

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 a US circuit judge tells a federal HHS agency how to interpret the Social Security Act.

 
 

Clipped from: https://godanriver.com/news/state-and-regional/govt-and-politics/judge-vacates-federal-ok-for-virginia-medicaid-rule/article_643accec-3cf9-5df4-bf5e-162a4cb765be.html

The General Assembly’s 2020 bid to slow the overuse of emergency rooms got a quick thumbs up from the U.S. Centers for Medicare and Medicaid Services – but in the end it was too quick and a federal judge ruled that approval should be vacated.

It could mean doctors and hospitals are paid more for caring for Medicaid recipients whose visits to ERs and hospitals could have been avoided, and might boost Medicaid spending in Virginia by 0.2%.  

The case, filed by the Virginia Hospital and Healthcare Association, the Medical Society of Virginia and the College of Emergency Physicians, turned on language in the state budget. It said Medicaid’s payment for an ER visit that ended with a diagnosis that the visit was avoidable should be based on the final diagnosis instead of the usually much more costly rate for an ER services.

In addition, the associations said budget language saying claims for patients readmitted to a hospital within 30 days of discharge would be deemed to be potentially preventable and would therefore be paid at only half the usual rate.

The hospitals and doctors groups said the measure’s effect was “to bilk of tens of millions of dollars [from] those hospitals and physicia

ns who treat Medicaid patients.”

Since the state runs Virginia’s Medicaid program, but  it is jointly funded by the state and federal government, the Centers for Medicare and Medicaid Services need to approve changes in the way a state administers the program, which the federal agency did.

But Judge Henry E. Hudson, of the U.S. District Court in Richmond ruled that the federal agency did not follow the federal Medicaid law when approving the Virginia changes because it treated payment for care of people with similar symptoms differently for different patients.

“Although services for those with similar presenting symptom but different final diagnoses will be comparable, it is indisputable that reimbursement for those services will be different if the final diagnoses are deemed ‘preventable,'” Hudson ruled.

Thus, he ruled, because the Downcoding Provision conflicts with other requirements within the Medicaid Act, CMS’ approval of the Downcoding Provision was not in accordance with law.

He found that the federal agency acted arbitrarily in approving the Virginia changes.

CMS’ approval of the amendment [to Virginia’s Medicaid plan] did not provide any explanation or justification,” Hudson ruled.

He said the lack of any analysis or explanation in response to doctors’ and hospitals’ objections to the changes “renders its approval” of the provision “arbitrary and capricious.”

Hudson dismissed claims that the measures violated the 5th Amendment’s ban on government taking property without due process.

He also dismissed the hospitals’ and doctors’ claims against the state Medicaid agency and its director, on the grounds that they incorrectly argued that the federal Medicaid law gave them a private right of action against the state.

Virginia’s Medicaid agency had said the downcoding provision would save $40 million a year while the readmission rule would save $15 million.

Video Player is loading.

Current Time 0:00

/

Duration 3:15

Loaded: 0%

0:00

Stream Type LIVE

Remaining Time -3:15

 
 

1x

  • Chapters

 
 

  • descriptions off, selected

 
 

  • captions settings, opens captions settings dialog
  • captions off, selected

 
 

  • default, selected

This is a modal window.

Beginning of dialog window. Escape will cancel and close the window.

TextColorTransparencyBackgroundColorTransparencyWindowColorTransparency

Font SizeText Edge StyleFont Family

End of dialog window.

One third of Americans don’t have access to primary care providers in their communities, according to a study from the National Association of Community Health Centers published last month.

Posted on by

RX- Lilly ordered to pay millions more in False Claims Act case

 
 

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]: Lilly appealed and the bill keeps going up.

 
 

Clipped from: https://www.fiercepharma.com/pharma/lilly-damages-tripled-183m-long-running-false-claims-case

 
 

When a federal jury last year ordered Eli Lilly to pay $61 million for skimping out on Medicaid rebates, the company vowed to fight the verdict. But instead of the result Lilly wanted, the award has been tripled to more than $183 million.

On Tuesday, Illinois federal judge Harry Leinenweber ruled that Eli Lilly owes triple damages from last year’s award after whistleblower Ronald Streck convinced a jury that the company violated the False Claims Act and short-changed Medicaid on rebate payments.

Since the case falls under the False Claims Act, the award was eligible for “trebled” damages, according to court filings.

The case dates to 2014, when whistleblower Streck—a pharmacist and lawyer—sued Eli Lilly for allegedly launching retroactive price increases and failing to pay Medicaid rebates based on the higher prices.

Streck and his attorneys moved forward with litigation in 2018 after the U.S. government declined to intervene in the case, Streck’s law firm said last year.

In the order Tuesday, Leneinweber pointed out that Lilly “changed its practices years before the trial.” In court, Lilly argued its corrective actions weighed in favor of “minimal, if any, penalties,” according to the document.

Still, Leneinweber decided that the company indeed owes $183.69 million under the “trebled” damages rules in the False Claims Act. The judge ultimately noted that “while Lilly could have, of course, behaved better, it could have acted far worse.”

Lilly, for its part, said it’s “committed to upholding high standards of corporate conduct in our business dealings.” The company is “disappointed” with the outcome, but it plans to appeal and is “confident that the Seventh Circuit will reverse,” a spokesperson said over email.

Streck also filed a False Claims Act whistleblower suits against Bristol Myers Squibb and other companies in 2013 but later withdrew his claims against the other defendants. BMS ultimately settled for $75 million in 2021 while Astellas Pharma’s U.S. unit resolved its case for $18 million that same year.

Editor’s note: This story has been updated with comments from Eli Lilly. 

Posted on by

FWA (CT)- Connecticut Psychologist Pays $658K to Settle Allegations She Received Payments from Medicare and Medicaid for Services Not Provided

 
 

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]: Husband and wife psychiatrists sole $658k of your tax dollars with a Medicaid scam. They did not say thank you.

 
 

 
 

Clipped from: https://www.justice.gov/usao-ct/pr/connecticut-psychologist-pays-658k-settle-allegations-she-received-payments-medicare-and

Vanessa Roberts Avery, United States Attorney for the District of Connecticut, and William Tong, Connecticut Attorney General, today announced that Dr. EVELYN LLEWELLYN has entered into a civil settlement agreement with the federal and state governments in which she will pay $658,294 to settle allegations that she received payments from the Medicare and Medicaid programs for psychology services that were not provided.

Llewellyn is a psychologist licensed by the State of Connecticut.  She is married to Dr. Michael Lonski, PhD, who is also a psychologist licensed by the State of Connecticut.  Llewellyn and Lonski maintained separate medical practices in psychology operated out of their home offices in Greenwich.  Lonski was responsible for submitting claims for reimbursement to insurance programs, including Medicare and Medicaid, for the psychology services allegedly performed by Lewellyn and Lonski.

The government alleges that Llewellyn received payment for claims submitted by Lonski to the Medicare and Medicaid programs for psychology services allegedly provided by Llewellyn to Medicare and Medicaid beneficiaries that were, in fact, not provided.

To resolve the governments’ allegations, Llewellyn has agreed to pay $658,294, which covers the time-period from November 11, 2014, through and including February 5, 2020.

On December 12, 2022, Lonski pleaded guilty in Hartford federal court to health care fraud.  He is scheduled to be sentenced on June 12.

This matter was investigated by the Office of Inspector General for the Department of Health and Human Services and the Federal Bureau of Investigation.  The case is being prosecuted by Assistant U.S. Attorneys Richard M. Molot and Susan L. Wines, and by Assistant Attorney General Joshua Jackson of the Connecticut Office of the Attorney General.

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

Posted on by

FWA (CT) Hartford Woman Charged With Stealing Medicaid Benefits

 
 

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]: Ebony Mayo stole a Medicaid member ID to not have to pay for her own costs of care with her commercial insurance copays. You paid $16k for her to be able to do that.

 
 

Clipped from: https://patch.com/connecticut/hartford/hartford-woman-charged-stealing-medicaid-benefits-state

Crime & Safety


Connecticut’s chief state’s attorney charges the 42-year-old with using someone else’s identity to get Medicaid coverage.

 
 

Posted Fri, May 5, 2023 at 9:28 am ET|Updated Fri, May 5, 2023 at 9:30 am ET

 
 

State authorities have charged a Hartford woman with illegally obtaining Medicaid benefits for medical services so as to avoid co-pays with her regular medical insurance provider. (Shutterstock)

HARTFORD, CT — A Hartford woman has been charged this week with illegally obtaining Medicaid benefits when she wasn’t eligible.

Ebony Mayo, 42, of Hartford, was charged Wednesday with improperly using the identity of a Medicaid recipient and using that recipient’s identification to get medical goods and services for herself.

She was charged by inspectors from the Medicaid Fraud Control Unit in the Office of the Chief State’s Attorney.

Find out what’s happening in Greater Hartfordwith free, real-time updates from Patch.

Mayo was charged with one count each of first-degree larceny by defrauding a public community, health insurance fraud and first-degree identity theft.

According to the arrest warrant affidavit, from March 2021 through October 2021, Mayo utilized the Medicaid number and personal identification of another party to acquire medical treatment and services for herself.

Find out what’s happening in Greater Hartfordwith free, real-time updates from Patch.

State officials said Mayo admitted to using the identity and Medicaid card of another to pay for her own medical visits and medications, even though she had her own insurance, in order to avoid co-payments.

The investigation revealed that by Mayo causing the fraudulent claims, Medicaid paid 93 claims for service amounting to a loss of $15,778, according to authorities.

Mayo was released on a $20,000 non-surety bond and is scheduled to appear in Hartford Superior Court May 16.

Each of the charges, according to state officials, are class B felonies punishable by up to 20 years in prison.

Anyone with knowledge of suspected fraud and abuse in the public health care system is asked to contact the Medicaid Fraud Control Unit at the Chief State’s Attorney’s Office at 860-258-5838.

For the full announcement of the charges, click on this link.

Get more local news delivered straight to your inbox. Sign up for free Patch newsletters and alerts.

Posted on by

FWA (KY) – Kentucky companies pay $1.7M to settle fraud 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]: 2 labs in KY ran a lab scheme tied to court-ordered drug tests.

 
 

 
 

Clipped from: https://www.kentucky.com/news/local/crime/article275259571.html


Two Kentucky-based businesses have agreed to collectively pay about $1.7 million to resolve allegations they illegally billed Medicaid and Medicare for court-ordered drug testing.

One of the accused companies was Blue Waters Assessment and Testing Services, LLC, which is based in Lexington and provides services related to urine drug testing, including tests for individuals ordered by the Fayette County family courts as part of their cases.

The Lexington company sent the specimens to VerraLab JA, LLC, a clinical laboratory based in Louisville that does business under the name BioTap Medical, according to the U.S. Attorney’s Office. BioTap performed the urine drug tests and billed them to Kentucky Medicaid and Medicare.

The BioTap group received payments from medicaid and medicare which they were not entitled to and agreed to pay nearly $1.5 million as part of a settlement against the false claims. Blue Waters Assessment and Testing and its owner, David Waters, agreed to pay an additional $250,000 for roles in submitting the claims, according to the U.S. Attorney’s Office.

The government said billing these tests to state Medicaid and Medicare violated the False Claims Act, which prohibits fraudulent claims being submitted.

 
 

“Submitting false claims to Medicare or Medicaid wastes taxpayer dollars and undermines the integrity of those programs,” said Tamala E. Miles, special agent in charge at the Department of Health and Human Services, Office of Inspector General.

As federally-funded health insurance, Medicaid and Medicare do not pay for tests given to satisfy a court order.

Medicaid and Medicare only pay for laboratory tests used for medical diagnosis or treatment, according to the U.S. Attorney’s Office.

“In fact, Medicaid’s regulations explicitly prohibit reimbursement for laboratory tests, such as urine drug tests, that were ordered by a court,” the United States Attorney’s Office said.

“The federal Medicaid and Medicare programs are designed – and funded – to provide health care benefits to eligible individuals with a medical necessity,” Carlton S. Shier, IV, U.S. attorney for the Eastern District of Kentucky, said in a press release. “These lab tests were not medically necessary and were improperly billed to these programs.

“It is important to all of us that steps are taken to return such misapplied funds to their appropriate purpose – providing medical care.”

Posted on by

MCOs (VA)- Virginia Premier Medicaid members shifting to Optima Health

 
 

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]: Sentara is moving around some of its covered lives. Not sure why yet, but will try to find out.

 
 

Clipped from: https://www.beckerspayer.com/payer/virginia-premier-medicaid-members-shifting-to-optima-health.html

Virginia Premier will move its 300,000 Medicaid members to Optima Health on July 1.

Both are owned by Sentara Health and collectively support nearly 750,000 Virginia Medicaid members, according to a May 10 news release from the Norfolk, Va.-based health system. 

“Bringing the Virginia Premier Medicaid membership over to Optima Health will enable us to continue to provide a superior customer experience for our Medicaid membership — while also creating efficiencies that support lower costs for the state and reduced administrative burden on healthcare providers,” Sentara Health Plans President Colin Drozdowski said in the release. 

Virginia Premier Medicaid members enrolled as of June 30 will keep their same coverage and benefits but will become Optima Health members. Virginia Premier D-SNP will continue to operate under the Virginia Premier name, and there will be no changes in benefits and services, the release said.

Subscribe to the following topics: virginia premiermedicaidoptima healthsentara healthvirginia

Posted on by

PROVIDERS (NC)-Medicaid expensive for free clinics

 
 

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]: NC providers say Medicaid is too much of a hassle. I got 99 problems and Medicaid billing rules ain’t one of em’.

 
 

Clipped from: https://www.northcarolinahealthnews.org/2023/05/09/medicaid-is-an-expensive-proposition-for-free-clinics/

 
 

Tony Price is CEO of Moore Free and Charitable Clinic in Southern Pines, N.C. Price, who also chairs the North Carolina Association of Free and Charitable Clinics, said facilities like his would need to make major changes to accept Medicaid. || Photograph by Jaymie Baxley/North Carolina Health News (Southern Pines, N.C., May 2, 2023)

For nearly 20 years, uninsured people in the Sandhills have turned to Moore Free and Charitable Clinic for medical services.

Operating in a converted warehouse at the end of an unassuming road near Pinehurst in Moore County, the clinic provides free or low-cost care to patients with diabetes, hypertension and other chronic illnesses. Construction is underway to add a dental treatment area to the facility.

Moore Free and Charitable serves hundreds of patients, some of whom may soon become eligible for Medicaid under the expansion signed into law in March by Gov. Roy Cooper. But Tony Price, CEO of Moore Free and Charitable, said his clinic does not plan on participating in Medicaid — at least not for the time being.

“Medicaid is a complex process,” he said. “There’s a whole lot of compliance issues that we don’t have to deal with today that you do when you take Medicaid.”

One issue is billing. Unlike traditional providers, the clinic does not have a billing system in place to streamline the claims process for Medicaid. Price said Moore Free and Charitable tracks the estimated value of every service it provides, but those records are for “internal use only.”

Even if it had a billing system, the clinic would need to hire staff to prepare claims and submit them to the state. This work is time-consuming and requires a fastidious eye, according to Price. A claim could get kicked back or rejected if the person filing it accidentally enters the wrong code. (Codes signify what a patient’s diagnosis is and what care they received.)

Price chairs the North Carolina Association of Free and Charitable Clinics, an organization made up of more than 70 clinics that cater to the uninsured. The association’s members saw a combined 82,480 patients in 2021, the most recent year for which data is available.

Price’s misgivings about accepting Medicaid are shared by other members of the association, many of which lack the money and manpower needed to overhaul their clinic operations to accommodate Medicaid patients. All of the state’s free clinics rely primarily on donations and grants to stay afloat, and the facilities themselves are staffed mostly by volunteer physicians, nurses and other medical staff.

“The infrastructure will have to change in the clinics, and that’s an expensive proposition,” Price said.

Clinical contrast

April Cook, CEO of the North Carolina Association of Free and Charitable Clinics, said only eight of the organization’s members accept Medicaid. 

They mainly do so, she said, to deal with the “churn” of patients who receive Medicaid for a few months before being dropped from the program. Medicaid enrollees make up only 5 percent of the total number of patients served by the association’s member clinics.

Cook said the handful of free clinics that do take Medicaid are reimbursed at a lower rate than at community health clinics, officially known as Federally Qualified Health Centers. They also have far fewer employees. 

“Typically, an FQHC has two to three times the number of staff members as free and charitable clinics, and the biggest reason is Medicaid and Medicare,” Cook said. “It takes so many more individuals to dot all the i’s and cross the t’s when you’re dealing with these federal programs.” 

 
 

A member of Moore Free and Charitable Clinic’s staff confers with a patient in Southern Pines. Data from the N.C. Association of Free and Charitable Clinics showed that free clinics had an average of only eight full-time staff members in 2021. || Photograph by Jaymie Baxley/North Carolina Health News

While the centers and clinics both focus on underserved populations, they are not always in the same communities. Price’s county, for example, is home to FirstHealth Moore Regional Hospital but does not have a federally qualified health center listed with the N.C. Department of Health and Human Services.

“Here’s the bottom line: there’s not enough FQHCs to address all of the folks that have Medicaid,” Cook said. “So if you’re in a rural area where there’s already not an FQHC or there’s a primary care shortage, there’s not a whole lot of options for patients. 

“Medicaid doesn’t necessarily mean access, which is unfortunate.”

Filling gaps

Over 600,000 people are expected to benefit from Medicaid expansion in North Carolina, but only if they are U.S. citizens or lawfully present non-citizens who have “qualified” immigration status. 

Undocumented immigrants will remain ineligible for coverage, forcing an untold number of individuals to seek care through other channels. Free clinics are among the few available options for undocumented patients who have little or no income.

Cook said that while the association does not “want to condone people coming in illegally,” she believes it is “to everybody’s benefit to treat …  where you can.”

“There are people that are on both sides of the fence here, but it’s about understanding the implications of not serving someone that is undocumented,” she said, adding that undocumented individuals with easily treatable issues may turn to emergency rooms for service if they cannot be seen elsewhere. “I think part of free and charitable clinics’ mission is to help drive down health care costs and take care of people preventively before they reach a condition that requires them to be hospitalized.”

 
 

 
 

 
 

Medicaid will not be officially expanded in North Carolina until a state budget is approved. Before that happens, many North Carolinians are expected to lose their existing coverage through the unwinding of a federal provision that prevented states from removing enrollees from the program during the COVID-19 pandemic. 

This process, known as redetermination, will likely create a new coverage gap for free clinics to help fill. 

“There’s been some talk that if [the General Assembly] can get the budget passed in June then they would try to expand Medicaid by October, which would be very fast, because of the unwinding,” Cook said. “They don’t want people that have been treated to feel like they’re out in the cold. I’m here to say they won’t be out in the cold because we have 70 free and charitable clinics in North Carolina that are there ready to help lead the way.”

Still, Cook acknowledged that funding is a persistent challenge for free clinics. The association, she said, has asked lawmakers to earmark $15 million in the state’s budget for recurring appropriations that will allow the clinics to hire additional staff and provide more services to patients. The budget passed by the House of Representatives last month contains only $5.5 million in annual funding for the free clinics, and the amount in the final budget passed by the legislature is likely to be less than what the association has asked for.

“We will not benefit financially from Medicaid expansion,” Cook said. “We are hoping that the General Assembly won’t forget about us and it realizes the critical part that we play as a safety-net provider.”

Looking ahead

Cook stressed that the free clinics represented by the association are “fully in support” of Medicaid expansion.

“We’re very happy for our patients that will be eligible,” she said. “However, that being said, [expansion is] going to extend coverage to 500,000 to 600,000 uninsured in North Carolina, with a remaining 700,000 that will not qualify for Medicaid and will remain uninsured. We are primarily focused on those individuals.”

 
 

Christina Sanford is an enrollment specialist at Moore Free and Charitable Clinic in Southern Pines. Many of the state’s free clinics are bracing for an uptick in new patients as a result of Medicaid redetermination. || Photograph by Jaymie Baxley/North Carolina Health News

While none of the association’s members have immediate plans to begin accepting Medicaid, the prospect is not entirely off the table. Cook said there is a possibility that some free clinics may adjust their operations to serve enrollees who continue to lack access to traditional  providers. 

“If two years down the road we’re hearing over and over that patients that we had are suffering because they can’t find primary care for their Medicaid, then we may have to pivot,” she said.

Price, the association chair and clinic CEO in Moore County, said it is too early to tell what the future might hold for Medicaid in free clinics.

“How many patients are we apt to lose? How many might we get back from [redetermination]? How many undocumented patients do we have out there that weren’t counted in the first place?” he asked. “We’re gonna try to pull together data to better help us make a decision about how to proceed.”

Correction: A previous version of this article stated that only U.S. citizens will benefit from Medicaid expansion in North Carolina. Non-citizens who have “qualified” immigration status will also be eligible for coverage.

 
 

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

Posted on by

STATE NEWS (FL)- Florida will reject Medicaid coverage for immigrants

 
 

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]: Florida says not to the Dem’s latest Medicaid expansion strategy. And asks for more data on how much taxpayers are paying for non-citizens…

 
 

Clipped from: https://floridapolitics.com/archives/611373-florida-will-reject-medicaid-coverage-for-immigrants/

 
 

The Biden administration is making Medicaid available for nearly 580,000 people who came to the United States as children but can’t otherwise qualify for Medicaid because of their immigration status.

But Florida won’t be taking advantage of the option that was announced in April. In fact, Gov. Ron DeSantis’ administration is doubling down on its opposition.

DeSantis made clear at a Jacksonville news conference Wednesday he has no intention of tapping into the program. He made the comments after signing SB 1718, a sweeping immigration bill that requires private employers with 25 or more employees to use the E-Verify system for new employees and essentially bans Florida counties from issuing identification cards or other documents to individuals who do not provide proof of lawful presence in the United States.

The new law also aims to understand undocumented immigrants’ health care costs better because, as the Governor noted: “You show up to an emergency room, they treat you; it doesn’t matter if you are illegal or legal.”

According to DeSantis, Florida emergency rooms provided about $340 million in care to undocumented immigrants in the state fiscal year ending July 1, 2022.

 
 

“And taxpayers were on the hook for two-thirds of those costs,” DeSantis said. “The Biden administration is trying to increase those costs. They want to actually use Medicaid to cover illegal aliens, which we don’t support and won’t do in Florida. But that’s their vision in terms of what they want to do,” DeSantis said.

The Governor said he thinks the $340 million figure captures just “some” of the health care costs, saying, “We think that there’s more.”

To that end, SB 1718 requires hospitals that receive Medicaid funding to ask patients whether they are United States citizens, lawfully present in the United States, or unlawfully present in the United States.

The new law requires hospitals to submit quarterly reports to the state detailing the number of emergency department visits or admissions and how the patients responded to the question.

“The public deserves an honest accounting of how much this is costing us in terms of services, and health care is probably No. 1,” he said.

The health care provision was one of the more controversial elements of the immigration bill as opponents contended that it would dissuade undocumented immigrants from seeking health care.

Post Views: 0