Category: MM Curator

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REFORM- CMS Proposes to Implement Changes to Medicaid DSH Calculations

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 annual pretending that we will reform the cash cow that is DSH.

 
 

 
 

Clipped from: https://revcycleintelligence.com/news/cms-proposes-to-implement-changes-to-medicaid-dsh-calculations

The proposed rule would implement changes to Medicaid’s hospital-specific Disproportionate Share Hospital (DSH) cap calculations from the Consolidated Appropriations Act of 2021.

 
 

Source: Centers for Medicare & Medicaid Services/Xtelligent Healthcare Media

 
 

By Jacqueline LaPointe

February 24, 2023 – CMS has proposed a rule to update the regulatory requirements of the Disproportionate Share Hospital (DSH) program in response to the Consolidated Appropriations Act of 2021, including implementing provisions related to including third-party payments for calculating Medicaid hospital-specific DSH caps.

The proposed rule would also clarify regulatory language for the DSH program, including payment and financing definitions, refine administrative procedures for state compliance with federal regulations, and remove regulatory requirements that CMS said have been “difficult to administer and do not further the program’s objectives.”

States must provide DSH payments to qualifying hospitals that serve a disproportionate share of uninsured and Medicaid patients. Which hospitals receive the payments and how much depends on state Medicaid program rules. However, federal law requires hospital-specific limits on DSH payments.

Overall, a hospital cannot receive DSH payments beyond the costs it incurred for providing inpatient and outpatient hospital services during the year to certain Medicaid and uninsured patients, less other payments it received from uninsured patients and under the Social Security Act.

The Consolidated Appropriations Act of 2021 modified the Medicaid portion of the hospital-specific DSH limit calculation to include only costs and payments for services delivered to patients for whom Medicaid is the primary payer for such services.

“Accordingly, the limit excludes costs and payments for services provided to Medicaid beneficiaries with other sources of coverage, including Medicare and commercial insurance),” the proposed rule states.

The updated hospital-specific DSH cap calculation applies to all qualifying hospitals except those in the 97th percentile of all hospitals for inpatient days made up of patients who, for such days, were entitled to benefits from Medicare Part A and supplemental security income. These hospitals will receive a higher hospital-specific limit.

The federal law enacted the changes to the Medicaid DSH program on Oct. 1, 2021. However, CMS said in the proposed rule that data limitations prevented the agency from clarifying which hospitals qualify for the exception for the 97th percentile.

“This rule proposes how CMS would determine which hospitals qualify for this exception,” the proposed rule says.

Hospitals are expecting a significant cut to their Medicaid DSH payments by Oct. 1st if lawmakers do not address it. The Affordable Care Act included an $18 billion reduction to Medicaid DSH payments to be phased in over a couple of years. The cut is to account for policies like Medicaid expansion that were expected to lower uncompensated care for hospitals.

However, 11 states have not expanded Medicaid under the provisions of the ACA. Additionally, one state has adopted Medicaid expansion but has not implemented it.

Congress has delayed the massive cut to the Medicaid DSH program nine times. Without more intervention, the government will reduce Medicaid DSH payments to hospitals by $8 billion between 2024 and 2027.

The proposed rule addresses the cuts by defining the methodology for determining the annual, state-by-state DSH allotment reduction amounts. The amounts will be based on five factors—uninsured factor, Medicaid volume factor, uncompensated care factor, low DSH State factor,  and the budget neutrality factor (BNF)—which are defined in the rule.

The proposed rule also removes administrative inefficiencies from publishing preliminary and final annual DSH allotments and national expenditure targets in the Federal Register.

Comments on the proposed rule are due by April 24th.

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MCOS- Lujan Grisham intervenes in Medicaid procurement process | NM Political Report

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]: Surprise! Er-body gets to do their MCO proposals over again.

 
 

Clipped from: https://nmpoliticalreport.com/2023/03/01/lujan-grisham-intervenes-in-medicaid-procurement-process/

 
 

By Daniel J. Chacón and Robert Nott, The Santa Fe New Mexican

Just as the state Human Services Department was getting ready to announce which insurers had been selected to receive contracts worth billions of dollars to administer its Medicaid program, Gov. Michelle Lujan Grisham stepped in with a last-minute surprise.

She ordered a do-over — a move that has sparked questions and criticism from lawmakers on both sides of the aisle amid shifting explanations from the governor’s administration.

“It just smells wrong,” said Sen. Jerry Ortiz y Pino, an Albuquerque Democrat who chairs the Senate Health and Public Affairs Committee.

“The timing of this decision is certainly suspect given the fact that the respondents to the RFP (request for proposals) had already been scored,” Senate Minority Leader Greg Baca of Belen said in a statement. “I fully support the bipartisan calls for the governor to explain this unexpected action.”

Last September, the department issued a request for proposals from health insurance companies to deliver services to the nearly 1 million New Mexicans on Medicaid, a state-managed federal health care program targeted at low-income residents.

In December, a seven-member evaluation committee comprised of bureau chiefs and directors reviewed and scored the five proposals the department received.

At the start of the year, Procurement Manager Charles Canada recommended the department “select/proceed with an intent to award” contracts to four of the five respondents — a recommendation endorsed by the department’s former Medicaid director, Nicole Comeaux, and chief procurement officer, Gary Chavez, according to documents obtained by The New Mexican.

Western Sky Community Care, one of the department’s existing Medicaid providers, didn’t make the cut.

Western Sky is a subsidiary of St. Louis-based Centene Corp., which reached a $13.7 million settlement with the state Attorney General’s Office in 2022. At the time, the AG’s Office said Centene failed to pass on discounts to the state’s Medicaid program, among other things. A separate news release issued by the state Superintendent of Insurance pegged the settlement at more than $17 million to resolve claims the company had violated consumer protection laws in connection with its spread pricing practices.

Centene has paid millions of dollars to settle Medicaid overpayment allegations in other states, according to published reports.

Canada wrote the insurers recommended for “selection/intent to award” — Blue Cross and Blue Shield of New Mexico, UnitedHealthcare, Molina Healthcare of New Mexico, Inc., and Presbyterian Health Plan — earned the highest point totals in the evaluation and offered proposals “deemed most advantageous to the State.”

Lujan Grisham’s communications director, Maddy Hayden, wrote in an email the governor and her staff “shared concerns” with former Human Services Department Secretary David Scrase and acting Secretary Kari Armijo “about the providers’ ability to provide adequate care and continuity of services during a changeover in providers.”

“Following these discussions,” Hayden wrote, “it was decided to cancel the procurement, review the deliverables and issue a new RFP to procure the best services for New Mexicans. This decision was based solely on protecting the best interests of the nearly 1 million New Mexicans covered by Medicaid.”

The Human Services Department initially had said it was scrapping the original RFP so the agency’s new leadership “can assess the design of the procurement” given the looming departures of Scrase and Comeaux, the former Medicaid director.

The decision has come under withering criticism, with House Minority Leader Ryan Lane, R-Aztec, calling for more transparency in the governor’s decision to intervene in the procurement process.

“New Mexicans deserve transparency, and I think that’s the issue right now, is there’s a lot of questions out there,” he said.

“We’re talking about multimillion-dollar corporations that submit responses to these kinds of RFPs,” Lane added. “We’re not talking about mom and pops that aren’t sophisticated, so I think people would typically think that these are well-defined responses and complete responses because of the level of sophistication. That’s why I think we need to have some transparency about why the RFP responses were not accepted.”

Ortiz y Pino indicated the governor had tainted the process.

“It just reinforces to me how critical it is that we not let politics enter into these decisions,” he said. “Keep the Governor’s Office out of it. Let the department do its own work. But no, they always have to get involved.”

Ortiz y Pino noted billions of dollars are at stake.

“This is not an insignificant thing,” he said. “When you factor in the federal money,” it’s about $8 billion to run the state’s Medicaid program.

Ortiz y Pino said the health insurance companies that answered the department’s request for proposals “spent a fortune” developing responses to the state.

“They’ve had to do enormous amounts of work and at the 11th hour — no, 11th hour, 59th minute — cancel them for no good reason given, absolutely no reason given, just we’re going to start all over now. That just does not feel right,” he said. “I don’t have any evidence at all that there’s something nefarious going on, but it just feels wrong.” 

The state’s contracts with its existing providers — Blue Cross and Blue Shield of New Mexico, Presbyterian Health Plan, and Western Sky Community Care — are set to expire at the end of this year.

“With over eighty percent of New Mexico’s Medicaid population receiving care through the managed care delivery system it is essential to select managed care partners that provide access to quality, cost-effective health care — and that can help transform the health care system to deliver measurably improved outcomes to New Mexicans,” Scrase, the former Cabinet secretary, said in a statement at the time.

The state decided to cancel the procurement Jan. 27, the same day the Governor’s Office announced Scrase’s plan to retire, according to the Albuquerque Journal, which first reported the story.

The request for proposals increased accountability for the state’s managed care partners, Comeaux, the state’s former Medicaid director, said in a statement when the department announced it was going out to bid.

“The new contract reflects our intent to require our managed care organizations and their subcontractors to work with providers and community partners to improve access, advance health equity, reduce disparities, and deliver comprehensive quality care that results in positive outcomes for New Mexicans,” she said.

Campaign finance reports filed with the New Mexico Secretary of State’s Office show Western Sky Community Care contributed $10,400 to Lujan Grisham’s campaign on April 4, 2022, during the primary election reporting period. The documents show a refund was issued the same day, though it doesn’t explain why.

At least three other insurers bidding on the Medicaid contracts — Blue Cross and Blue Shield, Molina and UnitedHealthcare — also contributed to the governor’s reelection campaign, documents show. Molina was at the top with $20,800 in donations.

Follow Daniel J. Chacón on Twitter @danieljchacon.

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MCOs- CareSource partnering with Walmart on new benefits for CareSource Medicaid members

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]: CareSource will join UHC on Walmart’s dance card.

 
 

 
 

Clipped from: https://www.daytondailynews.com/local/caresource-partnering-with-walmart-on-new-benefits-for-some-on-medicaid/J3OLSBZLIRCDDLOV5VJSQBAECA/

 
 

Dayton-based insurer CareSource on Tuesday announced a three-year partnership with Walmart to provide certain members of CareSource’s Medicaid plan access to health benefits and food through Walmart as part of an effort to address racial health inequities.

The partnership will begin in Ohio sometime within July or August of this year, with a focus on cardiometabolic conditions, such as heart disease, stroke, diabetes, or hypertension. Walmart will have community health workers complete state-approved health risk and social needs assessments. Those health workers will then connect select CareSource Medicaid members to community resources, life skills support, and health literacy education.

ExploreCareSource partnering with Michigan nonprofit, seeks to expand into ninth state

“Our goal is to utilize our combined assets to create healthier individuals and communities,” said Warren Moore, Walmart’s vice president of social determinants of health. “We’re trying to close the gaps in care and promote positive health behavior change through holistic, culturally sustaining, and high-quality health and wellness solutions. CareSource is the ideal partner to help bring this vision to life.”

Eligible CareSource members will receive monthly funds to spend on food, a Walmart-plus membership for no cost delivery, and access to tele-nutrition services to aid in improving their health outcomes. CareSource members also will be able to take part in CareSource Life Services, which includes CareSource JobConnect, to provide a path to financial tools and improve both economic mobility and health outcomes.

ExploreCareSource seeks to provide clinical services to the military

“This partnership will address the major needs our members face, which are difficulty with transportation, access to healthy food, access to care and assistance with care coordination,” said Dr. David Williams, CareSource’s executive vice president and chief medical officer. “We know providing additional support, such as an in-store community health worker, will create another access point to ensure our members have the resources they need, within a location they frequent. As a result of this relationship, we expect an immediate, positive impact in the lives of our members.”

CareSource and Walmart will also work together on a maternal and child health program to improve health outcomes for mothers and children in Georgia, providing similar access to community health workers and monthly stipends for food and health services.

 
 

From <https://www.daytondailynews.com/local/caresource-partnering-with-walmart-on-new-benefits-for-some-on-medicaid/J3OLSBZLIRCDDLOV5VJSQBAECA/>

 
 

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STATE NEWS- State plan to shift Medicaid expenses would cost St. Lawrence County taxpayers $3.8 million

MM Curator summary

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

 
 

[MM Curator Summary]: The fight between the state Medicaid money financing masters and the local counties just trying to survive continues. Shorthand – NYC vs Albany.

 
 

 
 

 
 

Clipped from: https://www.northcountrynow.com/news/st-lawrence-county-lawmakers-adamantly-oppose-gov-hochuk-medicaid-proposal-0335816

BY JIMMY LAWTON
North Country This Week

CANTON –A proposal by Gov. Kathy Hochul could push $3.8 million in Medicaid expenses back to St. Lawrence County taxpayers, but legislators across the state are rallying to halt the move.

Offsetting the cost in St. Lawrence County would require a 6% hike in county taxes, which would push the county well over the state-imposed 2% cap.

A resolution passed by the St. Lawrence County Finance Committee calls on state officials and the governor to reconsider the plan.

“St. Lawrence County strongly disagrees with the need to cut county funding so deeply when the executive budget proposes to fully fund its own reserves two years ahead of schedule by depositing $5.4 billion into reserves before the end of state fiscal year 2023, while also projecting a general fund surplus of $35 billion by the end of state fiscal year 2024,” the resolution reads.

The “budget proposal would end the Affordable Care Act enhanced Federal Medical Assistance Percentage federal pass-thru to counties and New York City,” the resolution says.

The Governor is proposing to keep all of these federal savings going forward and use them to cover further expansion of Medicaid eligibility and benefits and to increase payments to health care providers, according to the resolution.

The county estimates the shift will cost the state’s 57 counties to spend an additional $280 million and approximately $1 billion when New York City is included.

The figures shared by the county match estimates my by the New York State Association of Counties.

New York State is one of the few states that pushes Medicaid expenses on to local taxpayers, in most states the expense isn’t passed down.

“It’s been a long held understanding that Congress intended these federal savings to be shared with counties promotion to the amount they contribute toward non federal Medicaid match,” the resolution. “Since 2003 New York State has shared the funds proportionally based on analysis of savings received during periods when an enhanced federal Medicaid match was enacted by congress.”

County legislators aren’t alone in their calls. Similar concerns have been raised by county legislators across the state including a unified call from NYSAC.

“In 2011, the State made a deal with local governments that said, ‘You can’t raise property taxes more than 2% a year, but to make that possible, we’ll cover any increases in the cost of Medicaid,’” said NYSAC Executive Director Stephen Acquario. “Counties kept our end of the bargain and held property tax increases in check, but now the state is shifting billions of dollars of new Medicaid costs onto counties over the next several years. New York taxpayers are already grappling with increasing costs to rent, housing, food, and utilities and can’t afford to bear the burden of rising Medicaid costs.”

State lawmakers representing the North Country are also opposing the plan.

On Tuesday Assemblyman Scott Gray (R-Watertown) joined members of The New York State Association of Counties to push against Gov. Hochul’s proposal within the Executive Budget that would withhold federal Medicaid funding from counties.

“After serving 21 years in the Jefferson County Legislature, I understand the importance of federal fund allocations,” said Gray.

Gray said that with Medicaid coverage expanding since the passage of the Affordable Care Act, counties have been setting their budgets with the funding in mind.

“New York state has increasingly relied on county revenue intercepts to disguise and support its wayward spending habits. The state has previously intercepted sales tax revenue, aid meant for distressed hospitals, passed AIM payment responsibilities onto the counties and now wants to intercept Medicaid payments intended for county-level services,” he said. “Gov. Hochul must recognize the seriousness of this issue and release these Medicaid funds to the counties as the U.S. Congress intended.”

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STATE NEWS- Insider named director of Medicaid, which serves nearly 1.5 million Oregonians

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]: Welcome to Dana! Her role as the Oregon Medicaid Director is now official.

 
 

 
 

Clipped from: https://oregoncapitalchronicle.com/2023/02/23/insider-named-director-of-medicaid-which-serves-nearly-1-5-million-oregonians/

Dana Hittle, interim director for the past two years, oversees the Oregon Health Plan, the free health insurance plan for about one in three Oregonians

 
 

Dana Hittle has been appointed permanent director of the Oregon Health Authority’s Medicaid program, which serves nearly 1.5 million Oregonians. (Oregon Health Authority)

Dana Hittle has secured a role in Gov. Tina Kotek’s administration as the permanent Medicaid director at the Oregon Health Authority. 

Hittle has been the interim Medicaid director for the last two years, leading a system – also called the Oregon Health Plan – that provides free health care coverage to nearly 1.5 million low-income Oregonians, or about one in three residents. 

Hittle’s career spans more than 22 years with the health authority and Oregon Department of Human Services.

Her appointment, announced Thursday, comes in the midst of a transition for the Oregon Health Plan that will impact who gets covered – and who loses their coverage. In April, the Oregon Health Authority will start to examine Medicaid rolls to determine who still meets the low income requirements. 

 
 

Dana Hittle, Oregon Health Authority Medicaid director. (Oregon Health Authority)

That work is unfolding across the nation. When the pandemic started in 2020, the federal government gave enhanced Medicaid benefits to states that kept people enrolled in the program regardless even if their income rose. Oregon’s Medicaid enrollment increased by hundreds of thousands.

Hittle oversaw much of the expansion, and now she will manage a reduction in those receiving benefits. Medicaid covers health, behavioral health, dental and visual treatment. 

To qualify, residents can earn up to 138% of the federal poverty level. For a single person, that’s a gross salary of up to $18,075 a year, or a maximum of $36,908 a year for a family of four. The Oregon Health Authority, which manages the Oregon Health Plan, expects that 300,000 people who earn more than the ceiling will no longer qualify. But up to 65,000 of them are likely to retain insurance.

The Oregon Health Authority is seeking a waiver with the federal Centers for Medicare and Medicaid Services to increase the income ceiling to 200% of the federal poverty level during the redetermination process. If the agency approves, a single person earning $29,160 a year or a family of four earning $60,000 annually will still qualify for Oregon Health Plan benefits. That new income ceiling is expected to start April 1, the same day that redeterminations will begin.The Medicaid budget is $22.6 billion for the current two-year budget cycle, and nearly three-quarters of it is paid by the federal government.

The Oregon Health Authority is also implementing its new Medicaid waiver, which will provide coverage for short-term housing benefits and nutrition support.

“Especially with all of the challenges Oregonians have faced over the last few years, I’m really focused on how we can implement programs that extend health-related supports to those in need,” Hittle said in a statement. “I’m honored to work in this role and to serve the state.”  

Hittle’s boss will be interim James Schroeder, the interim health authority director. Kotek hired Schroeder to lead the health authority, and he replaced Patrick Allen.

“At a time when we’re working hard to protect and expand health coverage in Oregon, it’s paramount that OHA has an experienced leader like Dana to successfully guide our state’s Medicaid initiatives,” Schroeder said in a statement. “I look forward to working with her on the transformative projects we have ahead of us.” 

The agency did not immediately respond to a question about her salary.

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STATE NEWS (PA)- Despite major Medicaid boost, lack of staff still limits nursing home admissions

 
 

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]: How much of a rate increase is needed to deal with nursing facility challenges in PA? The answer is not 17%.

 
 

 
 

Clipped from: https://www.mcknights.com/news/despite-major-medicaid-boost-lack-of-staff-still-limits-nursing-home-admissions/

 
 

Tine Hansen-Turton, president and CEO of the Woods in Pennsylvania, discusses workforce solutions at a summit Tuesday. Credit: PHCA

Months after a 17% Medicaid increase kicked in, hundreds of Pennsylvania nursing home beds remain empty because facilities can’t hire enough staff to provide care, a new survey finds.

The Pennsylvania Health Care Association released its 2023 State of Nursing Facilities Report Tuesday showing that 57% of responding members have beds they cannot fill due to a lack of staff.

Thirty-one percent of respondents said they have 21 or more direct care positions open but cannot find certified nurse aides, licensed practical nurses or registered nurses to fill them.

The association held a Long-Term Care Policy Summit Tuesday in the state capital to bring together lawmakers, providers and others to brainstorm and share workforce solutions.

The PHCA survey showed:

  • The average facility denied 17 admissions because of a lack of staff between November 2022 and February 2023.
  • 81% of respondents are using staffing agencies to fill open positions.
  • 93% of respondents anticipate either needing to use or increasing their use of agency
  • Facility labor costs increased an average of 20% from 2019 to 2022.
  • 93% of respondents anticipate either needing to use or increasing their use of agency workers to meet the new state staffing minimum that will begin in July.

In related news, LeadingAge Pennsylvania on Wednesday sent a letter to US Sen. Bob Casey Jr. (D-PA) outlining members’ concerns about the looming federal staffing requirement.

“We must recognize that providers are in crisis and residents’ access to care is at risk, due in large part to historic underfunding and a workforce crisis that predated the pandemic,” wrote President and CEO Garry Pezzano. “As we get back on our feet after the pandemic, we need to [give] common sense approaches a chance to make an impact before jumping to arbitrary staffing mandates on a national level. Common themes worthy of support include efficient and accessible training and competency programs, workforce immigration pipelines, faster turnaround times for staff licensing and test center coordination, and developing and incentivizing modern career pathways.”

New resources haven’t turned tide yet

Pennsylvania increased its Medicaid reimbursement rates by 17.5% last year after nearly a decade with little to no increases. That boosted rates by approximately $35 per resident per day. Association President and CEO Zach Shamberg said survey respondents “overwhelmingly” plan to use those extra funds to recruit and retain staff.

Despite that, nursing homes in the state continue to struggle.

“The problem is, we’ve made a promise to [aging] Pennsylvanians that we will care for them and that care, the availability of that care, and the accessibility to that care is very much at jeopardy today,” Shamberg said in opening remarks at the summit. “There are providers … who are having real difficulty keeping that promise.”

Pennsylvania has relied heavily on temporary nurse aides during the pandemic, giving frontline staff key training opportunities even as the state saw significant certification delays.

Joseph DeMattos, president and CEO of Health Facilities Association of Maryland, also attending the summit and said the tens of thousands of temporary nurse aides in his state during the pandemic played an “incredibly critical role” in caring for residents.

Shamberg said Pennsylvania facilities that used temporary aides each converted an average of eight into full time CNAs over the last few months, which has resulted in approximately 4,500 new, full-time workers.

But Centers for Medicare & Medicaid Services TNA waivers in all remaining states expire along with the public health emergency on May 11.

“The pandemic may be over but if we don’t get on the right track — if we don’t start addressing this today, then the challenges will be long lasting,” Shamberg said, noting that the association plans to make approval of nursing home medication aides a legislative priority this year.

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STATE NEWS (MT)- House Human Services advances bill to fully fund Medicaid rates in Guidehouse study

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 legislature decided to just do exactly what the consultants said this time.

 
 

Clipped from: https://dailymontanan.com/2023/03/01/house-human-services-advances-bill-to-fully-fund-medicaid-rates-in-guidehouse-study/

 
 

The House Human Services Committee on Tuesday passed a bill to fully fund Medicaid reimbursement rates recommended in an in-depth study by a national consultant — plus the cost of inflation.

House Bill 649 passed 17-4 with bipartisan support following a lengthy hearing Friday where an onslaught of providers from across the health care and medical community spoke in support.

Levi Anderson, with the Western Montana Mental Health Center, said he had just sent a letter one week earlier notifying partners across the state the center was closing 31 community-based mental health crisis stabilization beds, which represent 65% of state capacity.

“That is a direct result of a lack of funding for those services,” Anderson said.

At the meeting Tuesday, Rep. SJ Howell, D-Missoula, said all the other bills the committee would deal with rest on HB 649. In other words, if legislators are to truly address the continuum of care, they need to address “deeply underfunded providers.”

“I think this might be the most important bill this committee is going to grapple with this session,” Howell said.

Howell joined all other Democrats on the committee and a majority of Republicans in voting in favor of the bill, sponsored by Rep. Mary Caferro, D-Helena.

“It is critical that we fully fund healthcare services before another nursing home closes and more Montanans are left to sleep the night in their wheelchairs,” Caferro said in an email Wednesday. “We have the data that proves Medicaid providers are underpaid. We have the money. Let’s solve the problem.”

The bill notes inadequate rates have resulted in the closure of 11 nursing homes and loss of 857 skilled nursing facility beds in the state. It is expected to be on the House floor Thursday.

In the last session, the legislature authorized the Department of Public Health and Human Services to spend $2.75 million to pay for an analysis of provider rates in the state.

The review by national consulting firm Guidehouse showed Montana was underfunding businesses that provide support and services for people who rely on Medicaid.

Republican Gov. Greg Gianforte proposed an increase to reimbursement rates, and a legislative subcommittee approved even higher rates.

Pointing to estimates from the Health Department that showed the work the subcommittee did pushed many rates close to 100% of the recommended benchmarks, Chair Rep. Bob Keenan, R-Bigfork, said, “I think we’ve solved the problem.”

At the hearing on HB 649, Caferro, a member of the subcommittee, agreed the group worked hard and got close to benchmarks — “but not quite.” She and other sponsors proposed to close the rest of the gap.

“If we don’t fully fund the Medicaid rate, then we will continue to see a decline in people’s health and well-being to the point of death,” Caferro said.

She pointed to one woman with Alzheimer’s who had been moved to three different nursing homes because of closures and couldn’t be with loved ones: “Well, then that lady passed away.”

Caferro characterized the effects of underfunding in Montana as “tragic and unnecessary.”

She pointed to waiting lists for in-home care for seniors, for children and adults who have physical disabilities, and for children and adults who have developmental disabilities. She said community crisis centers are sitting empty and children are being sent out of state for care.

“Medicaid provides health care in every corner of the state and all parts in between,” she said. “The problem is we are running out of providers due to a long history of underfunding.”

The bill would cost $12 million a year in state funding, she said. It would translate into more money for services because the federal government matches the money the state contributes.

Caferro earlier estimated the match as at least $3 of federal money to $1 of Montana money, and in some cases as much as $9 in federal money: “It’s a good bang for the buck.”

At the hearing, she said the estimated $2.5 billion surplus includes at least $150 million saved by the state because of an enhanced federal Medicaid match, and she believes that portion should go to fund services.

In response to a question at the hearing, Mary Windecker, with the Behavioral Health Alliance of Montana, said the last couple of years, more and more people have been leaving the health care industry in the wake of rising housing costs and inflation.

Vacancies are hitting 20% to 30% across all the sectors that were studied, she said.

“We do believe that there are people out there who would very much love to work in the industry again, but they have to be able to put a roof over their head and food on the table,” Windecker said.

Caferro said those people should not be asked to sacrifice their own economic well-being. She also said she appreciated the support for health care initiatives from a wide spectrum of groups.

“I’ve never been in a legislative session where the human service issues have been so prominent, and the sponsors and people bringing the issues are so diverse, and that makes me really happy,” Caferro said.

Proponents for her bill included representatives from the Montana Medical Association, the Montana Hospital Association, St. John’s United retirement community, the Human Resource Development Councils, the Montana Association of Counties, the Montana Coalition to Solve Homelessness, the Behavioral Health Alliance of Montana, the Centers for Independent Living, the Montana Health Care Association, Montana Women Vote, and many others.

Before approving the bill, the committee adopted an amendment that Rep. Laura Smith, D-Helena, said aligned Caferro’s bill with House Bill 2, the big budget bill.

Rep. Alice Buckley, D-Bozeman, said the bill offered legislators the opportunity to support their constituents and communities across the state.

“We were elected here to do the people’s work,” Buckley said.

In addition to Howell, Smith and Buckley, the following Democratic representatives voted “yes” on HB 649: Donavon Hawk of Butte; Ed Stafman of Bozeman; Minority Leader Kim Abbott of Helena; and Zooey Zephyr of Missoula.

The following Republican representatives also supported the bill: Lola Sheldon-Galloway, of Great Falls; Jodee Etchart of Billings; George Nikolakakos of Great Falls; Tom Welch of Dillon; Gregory Frazer of Deer Lodge; Mike Yakawich of Billings; Wayne Rusk of Corvallis; Greg Oblander of Billings; Ed Buttrey of Great Falls; and Jennifer Carlson of Churchill.

Voting “no” were Republican representatives Amy Regier of Kalispell, Caleb Hinkle of Belgrade, Ron Marshall of Hamilton, and Nelly Nicol of Billings.

Daily Montanan reporter Nicole Girten contributed to this story.

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FWA- CT psychologist who submitted false Medicaid bills totaling over $148K gets prison

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]: Jennifer stole $148k using a services-not-provided scheme she ran out of her counseling business.

 
 

 
 

Clipped from: https://www.courant.com/2023/02/28/ct-psychologist-who-submitted-false-medicaid-bills-totaling-over-148k-gets-prison/

 
 

Dreamstime/Dreamstime/TNS

A Colebrook psychologist was sentenced to nine months in prison after pleading guilty to submitting false Medicaid bills totaling $148,102.80.

A Colebrook psychologist was sentenced to nine months in prison after pleading guilty to submitting false Medicaid bills following an investigation by the Medicaid Fraud Control Unit at the Office of the Chief State’s Attorney, authorities said.

Jennifer Lefebre-McGevna, 46, received a prison sentence of five years, suspended after nine months served, followed by five years of probation. She pleaded guilty in Hartford Superior Court on Jan. 10 to one count of first-degree larceny by defrauding a public community and one count of health insurance fraud.

Lefebre-McGevna was enrolled as a provider in the Connecticut Medicaid program. She was also the owner of Healing the Child from Within, LLC and enrolled in the Connecticut Medicaid Assistance Program as a private practice that performed psychotherapy services, according to state authorities.

From April 2017 through December 2020, Lefebre-McGevna reportedly submitted Medicaid claims for counseling services when no services were rendered, according to court records. There were over 1,000 claims submitted for unperformed services totaling $118,028.96. She utilized unlicensed people to perform services and submitted billings as if she performed them for bills totaling $24,961.66, court records said, and also submitted billings for canceled and missed appointments, totaling $5,112.19. The overall amount of fraudulent bills totaled $148,102.80, according to court records.

After paying $30,000 upon sentencing, she was ordered to pay the remaining restitution during her probationary period. She was also ordered to not act as a provider in the Medicaid program, according to state officials.

Anyone with knowledge of suspected fraud or abuse in the public healthcare system is asked to contact the Medicaid Fraud Control Unit at the Chief State’s Attorney’s Office at 860-258-5986.

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FWA- Man from Oklahoma pleads guilty to 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]: Harvey caused a mountain of destruction with his pill mill. And stole $118k of your tax dollars in the process.

 
 

 
 

Clipped from: https://newstalkkzrg.com/2023/02/27/man-from-oklahoma-pleads-guilty-to-medicaid-fraud/

 
 

OKLAHOMA CITY – A former Oklahoma City physician, charged in 2016 with 29 felony counts and one misdemeanor, pleaded guilty last week to Medicaid fraud and multiple drug offenses. Harvey Jenkins operated Aria Orthopedics in south Oklahoma City, where he prescribed large volumes of opioids and other narcotics from January 2010 to February 2015.

His plea is the result of an investigation conducted by the Oklahoma Attorney General’s Medicaid Fraud Control Unit.

“Our investigation ended Harvey Jenkins’ reckless medical practice and brought justice for the patients he endangered and the taxpayers he defrauded,” said Attorney General Gentner Drummond. “I appreciate the work that the attorneys and others in the Medicaid fraud unit put into this investigation to bring about a successful resolution.”

The investigation revealed that Jenkins cared for approximately 90 patients a day, most of whom were insured through Medicaid. In addition to the prescriptions he wrote, Jenkins also used another doctor’s signature to write prescriptions without her permission.

Jenkins’ plea agreement includes a 20-year suspended prison sentence, probation and fines, investigative costs and restitution in the amount of $181,474. He agreed to make an initial payment of $60,000 within 30 days and to make monthly payments of at least $600, beginning in May, for the remaining balance. Jenkins also agreed to surrender his medical license and never to seek employment relating to the practice of medicine or caring for children or vulnerable adults.

The counts he pleaded guilty to include:

  • Eleven counts of illegal possession, distribution, dispensing, prescribing controlled dangerous substances within 2,000 feet of a public park.
  • One count of conspiracy to illegally possess, distribute, dispense, prescribe controlled dangerous substances within 2,000 feet of a public park.
  • One count of maintaining a place, building where controlled dangerous substances are kept.
  • One count of conspiracy to defraud the state by making or causing to be made false claims under the Oklahoma Medicaid program.
  • Six counts of making or causing to be made false claims under the Oklahoma Medicaid program.
  • One count of conspiracy to fraudulently obtain the personal identity of another person.
  • Four counts of fraudulently obtaining the personal identity of other persons.
  • One count of conspiracy to practice medicine without a license.
  • Four counts of illegally practicing medicine without a license.

Several agencies aided the investigation, including the Oklahoma Bureau of Narcotics and Dangerous Drugs Control, Oklahoma Board of Medical Licensure and Supervision, Oklahoma City Police Department, City of Oklahoma City’s Public Works Administration and the Oklahoma State Board of Pharmacy.

The Oklahoma Attorney General’s Office Medicaid Fraud Control Unit receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $4,381,834.00 for Federal fiscal year (FY) 2023. The remaining 25 percent, totaling $1,095,458.00 for FY 2023, is funded by the State of Oklahoma. The federal fiscal year 2023 is defined as October 1, 2022, through September 30, 2023.

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FWA- Investigation by Paxton’s Medicaid Fraud Unit Results in $1.1M in Restitution to Health Care Programs

 
 

MM Curator summary

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

 
 

[MM Curator Summary]: These two yahoos stole $907k from Medicare and $218k from Medicaid- but really they stole the full $1.1M from you, the taxpayer.

 
 

Clipped from: https://www.texasattorneygeneral.gov/news/releases/investigation-paxtons-medicaid-fraud-unit-results-11m-restitution-health-care-programs

An investigation by Attorney General Paxton’s Medicaid Fraud Control Unit has led to the sentencing for health care fraud of two individuals in federal court in Del Rio, Texas.  

Melody Ann Villarreal and Oscar Gutierrez, Jr. were both found guilty of submitting fraudulent run sheets for ambulance transports that did not occur and submitting them to both Medicare and Medicaid for payment.  

Villarreal and Gutierrez were ordered to pay $907,376.41 in restitution to Medicare and $218,651.23 to Medicaid. Villarreal was sentenced to 48 months of incarceration, followed by three years of supervised release, and Gutierrez was sentenced to 60 months of incarceration, also followed by three years of supervised release. 

“My office will continue to crack down on those who commit fraud, drive up the cost of health care for Texans, and try to compromise the integrity of our health care system,” said Attorney General Paxton. “I’m proud to say that the hard work of my Medicaid Fraud Control Unit and our law enforcement partners has ensured that justice was done in this case and that Texas taxpayer funds were recovered.” 

The case was investigated by Lieutenant Jeff Winney, Investigative Auditor Michael Youngs, and Captain Raúl González of the Medicaid Fraud Control Unit, in cooperation with the Department of Health and Human Services’ Office of the Inspector General and the FBI. The case was prosecuted by Assistant United States Attorney Rex Beasley out of the Western District of Texas. 

The Texas Medicaid Fraud Control Unit is responsible for investigating and prosecuting Medicaid fraud and patient neglect and abuse. If you suspect Medicaid fraud or abuse, or patient neglect, please report it by calling (512) 371-4700 or visiting the Texas Attorney General’s website.