Category: MM Curator

Posted on by

MH/BH- A Look at Substance Use Disorders (SUD) Among Medicaid Enrollees

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]: Medicaid members need help with this.

 
 

 
 

Clipped from: https://www.kff.org/medicaid/issue-brief/a-look-at-substance-use-disorders-sud-among-medicaid-enrollees/

Deaths due to substance use disorder (SUD) have risen sharply during the pandemic, highlighting longstanding gaps—such as under-identification and undertreatment of SUD. Even before the pandemic, SUD contributed to a large and growing share of deaths. For example, alcohol was listed as a contributing factor in 20% of deaths in adults between the ages of 20 and 49 from 2015 to 2019 and drug overdose deaths increased by 35% over the same period. Yet in 2019, only 1 in 10 people (12 and older) with past year SUD received any treatment, including specialty treatment or self-help groups. The Medicaid population may be particularly impacted, as 21% have mild, moderate, or severe SUD, compared to 16% of commercially insured. In its role as a public program and the single largest payer of behavioral health services in the country, Medicaid is particularly positioned to implement policy to improve the delivery, quality, and effectiveness of behavioral health services. The detailed and comprehensive claims data available for Medicaid can help answer questions and inform policy.

Efforts are being made at the state and federal levels to increase SUD awareness, coordination, and treatment access—including some provisions that were recently passed as a part of the Consolidated Appropriations Act enacted in December 2022, such as expanding providers who are able to prescribe buprenorphine for treating OUD. In light of recent efforts to expand access to SUD treatment services, we examine the share of enrollees with SUD using both Medicaid claims and data from the National Survey on Drug Use and Health (NSDUH).

What are the rates and characteristics of Medicaid enrollees with identified SUD?

In 2019, 7.3% of Medicaid enrollees ages 12 to 64 had at least one clinically-identified SUD in Medicaid claims data. Opioid use disorder was identified in 3.3% of Medicaid enrollees; alcohol use disorder in 2.5%; cannabis use disorder in 1.9%; stimulant use disorder (including cocaine or other stimulants) in 1.7%; and 1.7% of Medicaid enrollees had some other type of substance use disorder. These groups were not mutually exclusive, and while we did not look at the share of people with multiple substance use disorders, it is not uncommon for substance use disorders to co-occur. For this analysis, any diagnosis or prescription code that suggests the presence of a SUD is flagged as a “clinically-identified SUD.” This is not a measure of overall prevalence of SUD because not everyone is screened and diagnoses are not always recorded, but it does provide some insight into how often SUD is recognized and possibly treated in clinical settings (Figure 1).

People with clinically-identified SUD are more likely to be male, White, over 25 years old, and qualify for Medicaid based on a disability or through Medicaid expansion. At least one clinically-identified substance use disorder is found in Medicaid claims data for 8.9% of males, 10.0% of White people, and 11.6% of individuals aged 35 to 49. Medicaid beneficiaries who qualify as a result of a disability or through Medicaid expansion have higher rates of clinically-identified SUD than other groups. This pattern holds across most types of SUD, with only a few exceptions. For example, alcohol use disorder is most commonly identified among people aged 50 to 64, while cannabis use disorder is the most commonly identified among people aged 26 to 34. Clinically-identified SUD rates are highest among White people for all substance types except cannabis, where Black people have similar or slightly higher rates (2.4% versus 2.1%, respectively) (Figure 2).

Rates of clinically-identified SUD vary widely by state. Vermont has the highest share of any clinically-identified SUD, with 13.3% of Medicaid enrollees having a clinically-identified SUD, while Arkansas has the lowest rate, with only 3% of Medicaid enrollees having at least one clinically-identified SUD (Figure 3). Rates of clinically-identified SUD vary across states not only because of prevalence, but also because of other factors, such as provider screening behavior and variation in Medicaid coverage of SUD services.

What are implications of findings from claims data?

Other data sources generally suggest that SUD rates from Medicaid claims are undercounts—but even national survey data may undercount SUD for a variety of reasons. National prevalence of SUD is estimated through surveys such as the National Survey of Substance Use and Health (NSDUH), which uses questions based on diagnostic criteria to identify individuals with SUD, including those who haven’t already been diagnosed. We analyzed NSDUH data and found that the prevalence estimates of SUD among Medicaid enrollees is generally higher in national survey data than in Medicaid claims data, and that difference is greatest among adolescents, young adults, and Hispanic people. Even national survey data may undercount SUD due to underreporting of substance use and exclusion of unhoused, incarcerated, and institutionalized people—which are populations where SUD may be more prevalent. Research that adjusts for these undercounts estimates that alcohol and opioid use disorders are at least four times more prevalent than the NSDUH estimates.

National recommendations instruct providers to screen for substance use and conduct brief interventions for adults 18+, yet there may be gaps between SUD screening and referral. Research found that while most patients with an alcohol use disorder were screened for alcohol use, only 14.6% received brief interventions from their providers, and even fewer–about 6%–were referred to treatment.  Despite the serious
health consequences and comorbidity of physical health and SUD conditions, most doctors do not receive much training in substance use disorders. Even within psychiatric residency programs, only 2% of training time is dedicated to substance use disorders. According to fourth-year medical students in Massachusetts, fewer than one-fifth report feeling very prepared to screen for opioid use disorders and/or refer patients with related symptoms to treatment.

Other factors–such as patient privacy concerns or few healthcare visits–may also play a role in low identification of SUD. Even when providers ask about substance use, patients may feel uncomfortable disclosing their use or may be worried about stigma or legal consequences if they do. Even if a SUD is identified, providers may be hesitant to record it due to concerns about whether recording the SUD violates the privacy rules that add additional protections for people receiving SUD treatment. Other reasons may be population specific. For example, people who are younger and generally healthier may have fewer health care appointments and therefore fewer opportunities for providers to identify SUD. In at least one state, school-based screenings are required for younger populations. Growing drug overdose deaths among adolescents and people of color may suggest disparities in the identification and treatment of SUD.

There is broad variation in Medicaid policy and coverage of SUD services across states. Medicaid coverage of SUD services, as well as utilization management policies, such as prior authorization, can vary widely across states (and even across managed care organizations within states). Although more comprehensive coverage of SUD services has been linked to higher Medicaid acceptance by SUD treatment facilities, as of 2018, only 12 states covered the full continuum of SUD services. People experiencing symptoms of a substance use disorder may find it difficult to navigate this complex landscape, and difficulty accessing treatment is likely exacerbated in areas with workforce shortages.

Looking Ahead

In response to the growing number of overdose deaths and longstanding challenges accessing SUD treatment, state and federal governments have taken action to address ongoing gaps in SUD care—from identification of SUD to treatment. For example, many Medicaid programs have expanded coverage of SUD services and extended benefits to new eligibility groups; increased provider reimbursement rates for SUD services; and/or permanently adopted or continued pandemic-era telehealth expansions for behavioral health services.

At a federal level, HHS has issued notices of proposed rulemaking that may result in improved coordination of SUD services (42 CFR part 2) and expanded access to methadone for opioid use disorder treatment. Congress passed the Consolidated Appropriations Act (CAA) in December 2022, with funding to improve SUD awareness, prevention, treatment, coverage, and increase workforce. For example, the CAA added at least 100 new residency positions dedicated to psychiatry and required that all prescribers of controlled substances undergo training in managing and treating patients with SUD. CAA also lifted some administrative barriers to expand access to medications to treat opioid use disorder including the removal of additional registration requirements for prescribing buprenorphine (X-waiver) and reduced barriers to opioid treatment programs. Recent legislative efforts may lessen some longstanding barriers to SUD care, which could lead to better identification, referral, and treatment of SUD.

Methods

Medicaid Claims (T-MSIS) and State Exclusion Criteria

This analysis uses the following 2019 T-MSIS Research Identifiable claims files: demographic eligibility base (DE) and header and line files from inpatient (IP), long-term care (LT), other services (OT), and prescription (RX) claim files.

We use 48 states and D.C. in the main analysis and 29 states in our analyses that include race and ethnicity. We evaluated states’ claims data using the DQ Atlas criteria and by comparing SUD estimates from T-MSIS to NSDUH. Specific DQ Atlas measures used to determine state data quality include the restricted benefits code, Medicare benefits code, OT claims/encounter volume. We excluded Alabama because the Medicare coverage code was missing for more than 10% of enrollees and the T-MSIS SUD rates were 93 percent lower than NSDUH estimates. We excluded Colorado because the OT file encounter data volume was below 50% of the national median and the T-MSIS SUD rates were 156 percent lower than NSDUH estimates. For analyses involving race/ethnicity, the following states rated as “high concern” or “unusable” data by the DQ Atlas were also excluded:  AL, AZ, AR, CO, CT, DC, HI, IA, KS, LA, MD, MA, MO, MT, NY, OR, RI, SC, TN, UT, WV, WY.

T-MSIS Enrollee Sample Selection

Our sample includes nonelderly Medicaid and CHIP enrollees between the ages of 12 and 64 that have at least one day of enrollment in 2019. Enrollees were excluded if they did not have full or comprehensive Medicaid, had Medicare coverage, or were enrolled for less than one month in 2019. These exclusions are similar to those reported in the CMS SUD data book
technical specifications, but the CMS data book included people with Medicare coverage. After enrollee and data quality exclusions, our main sample includes 46,967,389 enrollees from 48 states and the District of Columbia.

Identification of SUD in T-MSIS

We linked header and line files using MSIS_ID and CLM_ID and linked claims files to the DE file using MSIS_ID (see the T-MSIS User Guide for information on linking variables) for fee-for-service and encounter claims. We identified ICD-9 and ICD-10 diagnosis codes and National Drug Codes (NDCs) from an adapted version of reference codes used in the 2019 CMS SUD data book. Modifications to CMS SUD reference codes include (1) exclusion of tobacco in our definition of “any SUD”; (2) removal of NDC codes primarily used to treat pain rather than opioid use disorder; and (3) removal of methadone NDC codes as these codes are thought to represent pain treatment, rather than opioid use disorder. One or more occurrence of a SUD diagnosis code or NDC code in OT, IP, LT, or RX files is coded as an SUD. Following CMS data book technical specifications, naltrexone—used to treat alcohol use disorder and opioid use disorder—is coded as alcohol use disorder when an alcohol use disorder diagnosis code is present, but coded as opioid use disorder in all other instances. “Any Substance Use Disorder” includes enrollees with at least one opioid, alcohol, cannabis, stimulant, or other SUD. “Other Substance Use Disorder” includes diagnosis codes for sedative, hallucinogen, caffeine, inhalant, unknown, or other SUD.

National Survey on Drug Use and Health. The National Survey of Drug Use and Health (NSDUH) asks respondents 12 and older about substance use and symptoms of substance use disorders, and those who exceed certain thresholds are classified as having a SUD. This analysis uses 2018/19 NSDUH data and includes Medicaid enrollees between the ages of 12 and 64. Although the NSDUH collects nationally representative data and asks each respondent about their substance use and symptoms, it may still underestimate SUD prevalence. NSDUH only collects data from people with an address–excluding those who are unhoused, institutionalized, or incarcerated – which is relevant because these populations may have higher rates of substance use disorders.

This work was supported in part by Well Being Trust. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

Posted on by

PHE- More than 60% of Adults Unaware of Medicaid Eligibility Redetermination

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]: Most er-body that’s gonna get redetermin’d don’t know they’re gonna get redetermin’d.

 
 

 
 

Clipped from: https://www.healthleadersmedia.com/payer/more-60-adults-unaware-medicaid-eligibility-redetermination

The impending renewal process could mean enrollees are left without coverage.

KEY TAKEAWAYS

A survey from the Urban Institute finds that 64% of adults in a Medicaid-enrolled family have no idea that they may lose coverage with the return to regular Medicaid renewal processes.

There has been almost no change in awareness since the previous survey results from June 2022, when 62% of enrollees said they were unaware.

States and the federal government can raise awareness to alleviate potential mass coverage loss.

Most adults in a Medicaid-enrolled family lack awareness of the upcoming Medicaid eligibility redetermination, according to analysis from the Urban Institute, funded by the Robert Wood Johnson Foundation.

April 1 is the deadline for states to start redetermining eligibility of Medicaid beneficiaries and the survey by the Urban Institute finds 64.3% of enrollees have heard nothing about the return to regular Medicaid renewal processes as of December 2022.

That’s virtually no change when compared to survey results from June 2022, when 62% of beneficiaries reported being unaware of redeterminations.

The most recent survey uncovers that 16% of adults have heard only a little about the return to regular renewal processes, while 13.9% have heard some, and 5.1% have heard a lot.

Get the latest on healthcare leadership in your inbox.

Subscribe

Regardless of geographical location, awareness remains low. Lack of awareness was 66.5% in the Northeast, 67.6% in the Midwest, 63.4% in the South, and 61.3% in the West.

Whether respondents were in a state that has expanded Medicaid eligibility made no difference either. Lack of awareness was 64.5% in Medicaid expansion states and 63.7% in non-expansion states.

“The end of the public health emergency’s continuous coverage requirement means millions of people are at risk of losing continuous coverage in Medicaid, which they have relied upon for nearly three years,” Gina R. Hijjawi, senior program officer at the Robert Wood Johnson Foundation, said in a statement.

 
 

“States and the federal government must quickly raise awareness that many families will soon need to take steps to maintain or find new health coverage.”

As many as 18 million people could lose Medicaid coverage with the COVID-19 public health emergency ending, the Urban Institute states.

States and the federal government can do their part to offset coverage loss by raising awareness that families will have to take steps to maintain or find new coverage on the Affordable Care Act marketplace.

Posted on by

MCOs- CareSource, HAP’s joint venture to expand Medicaid coverage

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 two MCOs will team up in the Michigan market, with HAP getting help on the exchange and CareSource getting HAP’s 2% of the local Medicaid lives as a starting point.

 
 

 
 

Clipped from: https://www.modernhealthcare.com/medicaid/caresource-hap-joint-venture-medicaid-henry-ford-health?adobe_mc=MCMID%3D51072139927741433197045149676155828835%7CMCORGID%3D138FFF2554E6E7220A4C98C6%2540AdobeOrg%7CTS%3D1677142257&CSAuthResp=1%3A%3A840741%3A7461%3A24%3Asuccess%3ABC81500C8395D1FB26EE296B90FA68EB

Health Alliance Plan, the integrated insurer of Henry Ford Health, signed a letter of intent to create a joint venture with Dayton, Ohio-based CareSource to expand its Medicaid coverage and re-enter the public health care exchange program.

HAP currently provides Medicaid coverage to fewer than 40,000 in Michigan, exclusively in the thumb region and in Oakland, Macomb and Wayne counties. CareSource, one of the nation’s largest managed Medicaid providers, has 2.3 million members across seven states. Besides Medicaid, it offers marketplace and Medicare Advantage plans.

Related: Henry Ford Health’s $2.2B redevelopment to transform Detroit campus

Currently, HAP insures less than 2 percent of the statewide Medicaid population, but hopes to grow its Medicaid membership to 100,000 through the expansion, Dr. Michael Genord, president and CEO of HAP, told Crain’s.

“This joint venture brings national scale and innovation to our Medicaid line,” Genord said. “Leveraging CareSource’s abilities just makes sense … and drives forward the Henry Ford mission of caring for the most at-risk Michiganders and really drives this health equity mindset and delivers value.”

The JV product will operate as a separate entity and be headquartered in Detroit, said Erhardt Preitauer, president and CEO of CareSource. Terms of the deal are not finalized, both executives said, and will require approval from state and federal regulators.

Daily Dose Newsletter: Sign up to receive a late afternoon weekday roundup of that day’s breaking news and developments in healthcare.

Email Address

The JV will offer a new product line that will “capitalize on the (HAP) brand and name in the market,” Preitauer said.

The deal is expected to receive regulatory approval by the end of the first quarter this year, with expansion coming thereafter, Genord said.

HAP will also benefit from CareSource’s public marketplace product line. The Health Insurance Marketplace is a federally-operated insurance marketplace for citizens not offered insurance through an employer.

The new healthcare marketplace comes at a critical time. Medicaid coverage for hundreds of thousands of Michiganders could end in the next few months as the feds plan to roll back the pandemic health care emergency.

The state’s Medicaid population grew by approximately 700,000 during the pandemic thanks to the federal Families First Coronavirus Response Act, signed by President Donald Trump on March 18, 2020, which required states to continue enrollment of Medicaid beneficiaries for as long as the government declared the pandemic a public health emergency.

Not a Modern Healthcare subscriber? Sign up today.

That directive will end as part of the 2023 budget bill signed by President Joe Biden late last year. Beginning in April, states will have to start to re-establish their redetermination process, which assesses whether an individual receiving Medicaid benefits continues to be eligible.

“A lot of people will be leaving a Medicaid plan,” said Genord. That’s where our long-term vision for the marketplace comes in. We’ll have a value differentiation (from competitors).”

Genord did not provide details on how it plans to differentiate.

It’s unclear how the potential Medicaid purge will impact the new joint venture’s Medicaid line.

This story first appeared in Crain’s Detroit Business.
  

Posted on by

RX- Medicaid, with planned payment pilot, girds for influx of pricey gene therapies

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]: Pharma guys are totally on board with the CMS plan to “centralize” the way payment happes for these new drugs, so we should feel good about this not turning into another MDRP-style total spending game/cluster.

 
 

 
 

Clipped from: https://www.biopharmadive.com/news/gene-therapy-medicaid-payment-model-outcomes/643102/

An article from

 
 

The proposed model could help state Medicaid agencies explore outcomes-based payment schemes, but may come too late for a looming test.

 
 

The Centers for Medicare and Medicaid Services is planning a payment model around cell and gene therapies that would centralize use of outcomes-based agreements. Getty / Edited by BioPharma Dive

People with the blood disorder sickle cell are anticipating the arrival of two gene therapies that could dramatically reshape their disease, potentially offering something approaching a cure.

Insurers, too, are preparing for the treatments, which are expected to carry price tags in the seven figures. While five other expensive gene therapies are already available in the U.S., sickle cell is far more prevalent than the inherited diseases they treat, affecting an estimated 100,000 people in the country. Many are covered through Medicaid, the federal insurance plan for people with limited income.

An experimental model proposed by the Centers for Medicare and Medicaid Services last week could help state agencies better afford those medicines, as well as offer a testing ground for payment schemes that could apply to other pricey gene therapies. Yet the timeline for its implementation might mean it comes after the first sickle cell gene therapies reach market.

“Sickle cell is a call to action,” said Michael Sherman, chief medical officer of Point32 Health, the parent company of Harvard Pilgrim Health Care and Tufts Health Plan.

“Without these kinds of models, we’re going to see access issues,” he added. “The Medicaid state agencies, like other parts of the financing system, were never designed with this sort of upfront shock.”

The gene therapy model is one of three pilot programs CMS will test in the coming years in response to an executive order from President Joe Biden directing the agency to find further ways to lower prescription drug costs. Administration officials described these programs as building on last year’s Inflation Reduction Act, which gave Medicare the authority to negotiate prices for a limited number of drugs.

Under the gene therapy model, state Medicaid agencies could delegate authority to CMS to coordinate multistate frameworks to pay for gene therapies based on how much patients benefit from treatment. In sickle cell, for example, payment could be contingent on whether patients remain free of the pain crises they regularly experience.

These types of payment schemes, typically known as outcomes-based arrangements, are already used in some cases for the currently available gene therapies. But budget limitations and federal price reporting requirements have limited their use within Medicaid, indirectly shaping how they’re designed for private insurers, too.

edcines cleared by the FDA’s main review office since 2015 have been cancer drugs, a tally that reflects the advent of cancer immunotherapy as well as continued progress in matching treatment to genetics.

“There’s a lot of benefit, I think, to having both more of a centralized purchaser or negotiator across Medicaid programs … and having more centralized data collection,” said Stacie Dusetzina, a professor of health policy at Vanderbilt University Medical Center. “I think it also gives CMS a little bit of an upper hand at the negotiating table.”

Jeff Marrazzo, the former CEO of gene therapy developer Spark Therapeutics, agrees that a centralized approach in Medicaid could help.

“What I’ve observed is that state Medicaid agencies … generally have experienced more challenges with providing access to cell and gene therapies,” he wrote in an email. “This is due in part to the cost density of cell and gene therapies, but also because these organizations lack the infrastructure required to implement alternative pricing, reimbursement, and access models.”

Marrazzo cited data collection as one example, noting that some state agencies might lack the ability to appropriately track clinical outcomes for patients treated with a gene therapy.

CMS envisions testing several different types of outcomes-based arrangements, including an annuity model where continued payment is based on continued benefit. (To date, gene therapy developers have favored a rebate-based approach, where a certain percentage of their treatment’s cost is returned to the insurer if a specific outcome is not achieved.)

Five years ago, Spark proposed a similar annuity-based idea to help insurers pay for its then newly approved gene therapy Luxturna, for a type of childhood blindness. Spark priced the treatment at $425,000 per eye and sought to offer an installment payment plan, proposing the CMS run a demonstration project around Luxturna.

Keep up with the story. Subscribe to the BioPharma Dive free daily newsletter

Email:

  • Select Newsletter: Daily Dive M-F
  • Select Newsletter: Commercialization Weekly Every Wednesday
  • Select Newsletter: Gene Therapy Weekly Every Thursday
  • Select Newsletter: Emerging Biotech Weekly Every Tuesday
  • Select user consent: By signing up to receive our newsletter, you agree to our Terms of Use and Privacy Policy. You can unsubscribe at anytime.

Its ability to do so was limited by Medicaid rules requiring drugmakers give the program the “best price” they offer on their products. In the event a patient didn’t benefit from treatment, and an insurer therefore didn’t owe the remaining installment payments, Spark would have had to report that fractional cost as its best price.

CMS recently tweaked its policy, allowing drugmakers to report multiple “best prices” in the context of outcomes-based arrangements. “This was an important first step,” Marrazzo wrote. “Along with the [recent] policy change, I do believe CMS providing a more centralized approach could lead to more annuity models being taken up, particularly by Medicaid plans.”

The agency plans to focus the model on a specific disease, and indicated sickle cell as a likely candidate. Behind the advancing sickle cell treatments is a growing pipeline of other gene therapies in development.

“Our concern has been that, for some of these more rare diseases, we haven’t seen the access that we would like to see. Sickle cell is one of them,” said CMS Administrator Chiquita Brooks-LaSure on a call with reporters last week. “One of the reasons we’re so excited about this model is because we think states need some assistance from us to really be effective in the space.”

But CMS doesn’t envision launching the gene therapy model until 2026 at the earliest, years after the two gene therapies now nearing market are expected to be approved. Their developers — Bluebird bio and partners Vertex Pharmaceuticals and CRISPR Therapeutics — are currently preparing approval applications that they expect to finish filing with the FDA this quarter.

The latest developments in oncology research


More than one quarter of the medcines cleared by the FDA’s main review office since 2015 have been cancer drugs, a tally that reflects the advent of cancer immunotherapy as well as continued progress in matching treatment to genetics.

Under current timelines, CMS would begin developing the model this year and announce model specifications in 2024 and 2025, with implementation following the year after. The agency would then track metrics like gene therapy spending, use and change in access over time to evaluate its success.

To some, earlier would be better. “Being in a business, I don’t understand why it takes two years to announce model specifications,” Sherman said.

The planned model is also voluntary, so CMS would need to rely on participation from both state Medicaid agencies and from drugmakers. The latter group, CMS argued in its report, would be enticed by the prospect of simpler market access.

That access could come with some tradeoffs, however. “It may be a little bit less attractive because of the inability to command the highest possible price, especially if there is a large population that’s going to be treated and many Medicaid programs are interested in joining together into this kind of one model,” Dusetzina said.

Posted on by

FWA- Stacey Hayes Arrested for 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]: Another member stole more money using NEMT. This is getting to be a thing.

 
 

 
 

Clipped from: https://www.doj.nh.gov/news/2023/20230217-hayes-medicaid-fraud.htm

Concord, NH – Attorney General John M. Formella announces that Stacey Hayes, age 49, of Hudson, New Hampshire, has been indicted for theft and Medicaid fraud in connection with fraudulent claims for non-emergency medical transportation services.

On February 15, 2023, the Merrimack County Grand Jury indicted Hayes on charges of Theft by Deception, Medicaid Fraud – False Claims, and Medicaid Fraud – False Records. The indictments allege that between September 1, 2020, and September 30, 2021, Hayes, pursuant to one scheme or course of conduct, created false records that were kept as documentation of expenses for Medicaid services, which caused false claims for payment of Medicaid services to be filed, resulting in Hayes obtaining more than $1,500.00 in Medicaid funds. During that timeframe, Hayes allegedly submitted fraudulent mileage reimbursement forms for 337 non-emergency medical appointments that did not exist, which resulted in her receiving $7,232.18 for reimbursement of mileage expenses that she did not incur.

The maximum penalty on the Theft by Deception charge, a class A felony, is 7½ to 15 years in the New Hampshire State Prison. The maximum penalty for the False Claims and False Records charges, both class B felonies, are each 3½ to 7 years in the New Hampshire State Prison.

Hayes is next scheduled to appear in Merrimack County Superior Court at 8:30 a.m. on February 27, 2023. The charges and allegations are merely accusations, and Hayes is presumed innocent unless and until proven guilty.

Senior Assistant Attorney General Thomas T. Worboys and Attorney Andrew Yourell of the Attorney General’s Medicaid Fraud Control Unit are prosecuting this case. Investigator Eric Shirley, also of the Attorney General’s Medicaid Fraud Control Unit, investigated the matter based on a referral from the New Hampshire Department of Health and Human Services’ Program Integrity Unit and AmeriHealth Caritas New Hampshire’s Special Investigations Unit.

The Medicaid Fraud Control Unit investigates and prosecutes fraud by healthcare providers who treat Medicaid beneficiaries. Healthcare providers include, but are not limited to, hospitals, nursing homes, doctors, dentists, pharmacies, ambulance companies, and anyone else who is paid for providing healthcare services to Medicaid beneficiaries. If you would like to report a case of provider fraud, please contact the Medicaid Fraud Control Unit at (603) 271-1246.

Posted on by

FWA- Detroit man, 47, gets 2-20 years in prison for 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]: We reported on this several months back, and now the sentencing has happened. Dewan gets between 2 and 20 years for the giant identity theft scam he ran to steal $11M of your tax dollars.

A Detroit man accused of stealing personal information from thousands of people to commit Medicaid fraud has been sentenced to two to 20 years in prison, Attorney General Dana Nessel said Tuesday.

Dewan Williams, 47, of Detroit, was charged with several crimes in October and pleaded guilty in January to conducting a criminal enterprise, a 20-year felony, and identity theft, a five-year felony, according to court records.

Initially, Williams was also charged with three counts of using a computer to commit a crime, each a seven-year felony, and three counts of welfare fraud over $500, each a four-year felony.

Wayne County Circuit Court Judge Mariam Bazzi handed down the sentence last week and ordered Williams to pay restitution. Williams is required to turn himself in at an adjourned sentencing date of June 29, according to Nessel’s office.   

Authorities said Williams bought Social Security numbers of identity theft victims on the dark web and used the information to obtain free cellphones under a federal Medicaid program. After he received the phones, he would sell them for a profit.

An investigation into Williams’ scheme began after the Michigan Department of Health and Human Services – Office of Inspector General received complaints from multiple victims about their identities being used to fraudulently apply for government aid. The department contacted the Attorney General’s Office, which turned to the Michigan State Police.

A joint investigation between the health department and state police uncovered the scheme and led to a search of Williams’ house. Investigators found 150 new and pre-packaged cell phones as well as the stolen personal information of about 7,000 identity theft victims.

“Identity theft is on the rise in Michigan,” said Department of Health and Human Services Inspector General Alan Kimichik said in a statement. ” … The OIG is committed to protecting the integrity of public assistance programs and ensuring the appropriate use of available public resources.”

Get the COVID-19 Update newsletter in your inbox.

Updates on how the coronavirus is affecting your community and the nation

Delivery: Varies

Your Email

Officials said Williams’ operation cost the state $11 million in unnecessary payments. After the accounts were determined to be fraudulent, the state shut them down and recouped its money, they said.

“The threat of identity theft is real,” Nessel said in a statement, “and I urge Michigan residents to educate and protect themselves against potential victimization.”

From <https://www.detroitnews.com/story/news/local/detroit-city/2023/02/21/detroit-man-47-gets-2-20-years-for-medicaid-fraud/69927817007/>

Posted on by

FWA (NY)- Show me the money. Years later, NYS Medicaid overpayments still not recovered

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]: They “fixed” it all except for that last little bit about actually recovering the money.

 
 

 
 

Clipped from: https://cbs6albany.com/news/you-paid-for-it/show-me-the-money-years-later-nys-medicaid-overpayments-still-not-recovered-you-paid-for-it-comptroller-dinapoli-department-of-health

 
 

 
 

ALBANY, N.Y. (WRGB) — Medicaid overpayments that were discovered by the New York State Comptroller’s Office more than two years ago have still not been recovered — and you paid for it.

The overpayments involved those who were dual eligible for both Medicaid and Medicare

According to the comptroller, “A prior audit report, issued in December 2020, identified about $50 million in actual and potential Medicaid overpayments, cost-savings opportunities, and questionable payments for services provided to recipients enrolled in Medicare-covered hospice care. The follow-up found that the Department of Health made some progress in addressing the problems identified, but more actions were needed. Namely, the Office of the Medicaid Inspector General had yet to materially recover the overpayments.”

MORE: NY Assembly rule now allows votes, without even showing up to the floor

Among the things the health department has done in the wake of the audit was implement a tracking system to identify those so called dual eligibles in hospice care.

Of the initial report’s nine audit recommendations, three had been implemented, five had been partially implemented, and one had not yet been implemented.

The full audit report can be found here: Department of Health: Improper Medicaid Payments for Individuals Receiving Hospice Services Covered by Medicare (Follow-Up) (state.ny.us)

Posted on by

PHE; STATE NEWS (NH)- Fiscal Committee Votes to Accept $51.5M in Federal Medicaid Money

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 the details of planning for the dwindling extra PHE FMAP looks like in one state.

 
 

 
 

Clipped from: https://indepthnh.org/2023/02/17/fiscal-committee-votes-to-accept-51-5m-in-federal-medicaid-money/

 
 

Health and Human Services Medicaid Director Harry Lipman, left, and chief financial officer, Nathan White, discuss accepting $51.5 million in federal money to cover the cost of about 100,000 Medicaid recipients who may no longer qualify after the federal health emergency declaration ends March 31.

By GARRY RAYNO, InDepthNH.org

CONCORD — The state will have $51.5 million in additional federal funds to support Medicaid recipients who qualified under relaxed guidelines due to the COVID-19 pandemic.

The Joint Legislative Fiscal Committee Friday approved accepting the federal enhancement money as the state begins the process of determining if about 100,000 people who were added to the Medicaid rolls due to the pandemic qualify for the program under normal eligibility requirements.

After the federal COVID-19 Emergency Declaration ends March 31, the state will begin the process and have up to a year to complete it.

Under the emergency declaration, those on Medicaid, the state-federal health insurance program, were automatically re-enrolled.

During the pandemic the federal Medicaid match was increased by 6.2 percent, which ends March 31, and then is 5 percent through June, 2.5 percent through October and 1 percent until the end of the year.

The $51.5 million is what the state expects to receive from the federal enhancement through this calendar year.

At the fiscal meeting, Harry Lipman, state Medicaid Director, said his agency anticipates it will need almost all of the federal money to cover the additional people added to the Medicaid rolls during the pandemic.

“We are carrying 102,000 people who would not be on the program under normal circumstances,” he said, “and this allows us to cover this extra (enrollees).”

He noted the state has one of the lowest bases in the country.

Both Lipman and Nathan White, the Health and Human Services Chief Financial Officer told the committee the agency has never attempted an “unwinding” like this before and they are unsure how it will go.

Lipman noted the federal poverty level changed recently and that added 1,700 people who will now qualify under normal eligibility for Medicaid.

White noted the agency will work in phases to disenroll thousands of people.

“You don’t know how many will appeal,” he said, “and if they do, they stay on Medicaid until it’s resolved. It’s a big unknown.”

The agency has been contacting people who are on Medicaid under the emergency declaration to set up appointments to see if they qualify under the normal requirements.

According to information given to the committee, “the department is diligently developing an unwind plan with the goal of ensuring that there are no gaps in medical coverage, whether that coverage is continued Medicaid or other sources of private or Marketplace coverage, and which is consistent with the budget in managing coverage transfer or disenrollment within a three-to-four-month timeframe.”

Committee member state Sen. Cindy Rosenwald, D-Nashua, noted the department lapsed federal Medicaid funds last year and wanted to know if they would be doing the same thing with this money.

Lapse is money appropriated, but not spent by the end of the fiscal year.

Lipman said last year the agency thought the federal government might end the declaration in October, and carrying the money forward has allowed the department to cover the additional Medicaid costs through March 3 of this year through the continuous enrollment provision.

He said if everything goes perfectly as they unwind the additional recipients, there could be a small lapse, “but if there is some bumpiness, we’ll need the money to cover people.”
The pandemic emergency resulted in an increase of income- based eligibility that was highest in Rockingham County at 29.3 percent and lowest in Belknap County at 20.3 percent.

Increase in Medicaid covering the disabled, elderly and foster care was highest in Rockingham County at 18.8 percent and lowest in Coos County at 10.4 percent according to information distributed to the fiscal committee.

Winter Maintenance

The committee also approved the transfer of $3.6 million from the Highway Fund Surplus Account to cover winter maintenance of the highway system.

The biggest increases department officials told the committee are the price of salt and overtime and leased and contracted services to plow and treat the roads, due to a workforce shortage.

The money will cover the remaining winter season for the department.

Garry Rayno may be reached at garry.rayno@yahoo.com.

Posted on by

STATE NEWS (FL)- Senate panel Ok’s bill exempting Medicaid patients with mental health disorders from ‘step therapy’

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 is moving towards relaxing prior auth for those with SMI.

 
 

 
 

Clipped from: https://floridapolitics.com/archives/589626-senate-panel-oks-bill-exempting-medicaid-patients-with-mental-health-disorders-from-step-therapy/

 
 

A Senate panel approved a measure allowing Medicaid beneficiaries with serious mental illness to bypass “fail first” procedures, which require people to try less expensive options before “stepping up” to drugs that cost more.

The Senate Health Policy Committee on Monday passed SB 112 unanimously. Its counterpart (HB 183) has been referenced to the House Healthcare Regulation Subcommittee.

The bill defines serious mental illness as “psychiatric disorders as bipolar disorders, including hypomanic, manic, depressive, and mixed-feature episodes; depression in childhood or adolescence; and major depressive disorders, including single and recurrent depressive episodes.”

Before agreeing to pass the bill, the Senate health panel agreed to tag on an amendment that requires the state to take the policy change into effect when setting the next round of Medicaid managed care rates for the traditional managed medical assistance program, as well as the long-term care program.

While the Legislature has been more willing to embrace access to mental health services and drugs, there has been an uphill battle getting bills passed. So much so that the bills currently only apply to the state’s Medicaid managed care plans and not to commercial health policies or policies sold in the state group insurance program.

 
 

SB 112 builds off a 2022 law that allows recipients with schizophrenia to bypass step therapy. The 2023 bill broadens the existing law to apply to Medicaid beneficiaries with serious mental illness. The Legislature in 2022 passed a law that requires Medicaid to allow recipients with schizophrenia to bypass.

SB 112 had broad support from the health care industry — from the Florida Hospital Association to AARP Florida to the Florida Medical and Florida Osteopathic Medical Association — among others.

OBGYN Dr. Sujatha Prabhakaran said the bill will go a long way to help women with postpartum depression. A member of the Florida Chapter of the American College of OBGYNs, she traveled to Tallahassee from Sarasota to lobby in support of the bill on behalf of her patients. But she said she also appeared before the committee as a mother and a daughter.

“I also am a mother who knows how difficult pregnancy and motherhood can be without mental illness, so I want to do everything I can to help my fellow mothers who are struggling with mental illness get the care their physicians and caregivers know they need,” she said, fighting back tears.

“And finally, I stand here before you today as a woman who was once a child who lost her own mother to untreated postpartum depression. Deaths like my mother’s are tragic in so many ways, but especially because we know that with timely and appropriately prescribed treatment, these deaths are so preventable.”

 
 

Prabhakaran was one of two physicians to testify on behalf of the bill Monday. Orange Park psychiatrist Ted Bosi also spoke in support of the proposal. 

“Individual patients need individual treatments. That’s why I support SB 112,” Bosi said.

Post Views: 0

Posted on by

STATE NEWS (OH)- Ohio Home Care Agencies to Seek Boost in Medicaid Reimbursement Rates in Biennial State Budget

MM Curator summary

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

 
 

[MM Curator Summary]: Home care agencies in Ohio are claiming they lose about $800 every time they start helping a Medicaid member.

 
 

 
 

Clipped from: https://www.businesswire.com/news/home/20230220005022/en/Ohio-Home-Care-Agencies-to-Seek-Boost-in-Medicaid-Reimbursement-Rates-in-Biennial-State-Budget

Rates still at Y2K levels; Home care for older and disabled Ohioans in crisis

COLUMBUS, Ohio–(BUSINESS WIRE)–Ohio’s outdated Medicaid reimbursement model for home-based care has reached a crisis point, collapsing as reimbursement rates no longer cover the cost of providing care and preventing agencies from paying a competitive wage for the important work caregivers perform.

“We lose about $800 per patient every time we admit a Medicaid patient. Over a two-year period, we lost hundreds of thousands of dollars providing care for Medicaid patients”

Tweet this

As such, the Ohio Council for Home Care and Hospice today announced that the association would be seeking long overdue and critically needed Medicaid rate increases to address the severe worker shortage and cover the cost of these critical health services.

While receiving health care at home is less costly and can be more effective than institutional care, state residents on Medicaid are increasingly added to waiting lists and go without proper care as the industry experiences an exodus of workers. As a result:

  • Home health agencies have closed, can’t hire workers and many no longer accept Medicaid patients – the state’s most vulnerable residents, with the worst impact being felt in underserved and rural communities.
  • Thousands of Ohioans are on waiting lists for home care services because there are not enough providers. These individuals are getting no care, inadequate care or use more costly emergency rooms or nursing homes, where they pay a further price in lost quality of life, independence, social interaction and well-being.

“This issue isn’t going away,” said Joe Russell, Executive Director of the Ohio Council for Home Care and Hospice (OCHCH). “Within the next two decades, the population of those 60 and older is expected to grow more than four times faster than the state’s overall population. If we want to care for the influx of older adults to allow them to age in place, and to help others who are struggling with disabilities, chronic illness or recovering from surgery, we need to address the worker shortage and cover the costs of these services.”

Lisa Von Lehmden-Zidek, Cleveland-based chair of the OCHCH board, said Medicaid reimbursement rates today are essentially the same as they were in 2000, a time period during which inflation rose more than 75 percent. For context, one agency could not take 1,693 Medicaid referrals in a single month last year due to staffing difficulties.

“The cost of home care greatly exceeds what Medicaid covers, and it makes no sense because receiving home care is significantly less costly than institutional care. If this continues, home care will be untenable and the costs for all Ohioans will increase with institutional care and more hospitalizations,” she said.

The statistics are alarming. Almost 144,000 Ohioans on Medicaid were enrolled in a home or community-based program as of August 2022, with thousands more on waiting lists. Older Ohioans are waiting from months to two years for supportive personal care services so they can live independently in their communities.

Greg Davis, a founder and co-owner of Patriot at Home, one of the largest providers of skilled home care in the Youngstown market, said at his agency, Medicare is subsidizing Medicaid. “We lose about $800 per patient every time we admit a Medicaid patient. Over a two-year period, we lost hundreds of thousands of dollars providing care for Medicaid patients,” he said.

Russell said the problem can be addressed in the State’s biennial budget.

“We should value the health and safety of Ohio’s most vulnerable in a way that’s on par with Medicare and private pay. Ohio Medicare payments can be more than 300% what Ohio Medicaid pays for the exact same service. Our goal is for state Medicaid reimbursements to cover the actual costs for care,” he said.

Advocates are seeking reasonable increases to achieve average market wages for the profession to both increase the wages and help cover overhead costs. The chart above reflects both wages and overhead, but the rate increases would allow agencies to pay RNs the market wage of $35 per hour (currently $22.20/hour) and pay aides the market rate of $20 per hour (currently only $10.10/hour).

About the Ohio Council of Home Care and Hospice

OCHCH represents over 600 home care and hospice and palliative care agencies from across the state of Ohio. Our members care for medically fragile children; those recovering at home from surgeries, and mental health and addiction treatment; older Ohioans who wish to age in place and many more.