Category: MM Curator

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REFORM- RUSH, CVS Health Launch ACO Targeting Health Equity for Medicaid Members

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

 
 

[MM Curator Summary]: CMS is allowing CA to spend Medicaid dollars on inmates 90 days before release.

 
 

Clipped from: https://www.nhregister.com/news/article/california-prison-inmates-to-get-some-medicaid-17744646.php

 
 

WASHINGTON (AP) — The federal government will allow Medicaid dollars to treat some people in prisons, jails or juvenile detention centers for the first time ever, the Centers for Medicare and Medicaid Services announced Thursday.

CMS will allow California inmates to access limited services, including substance use treatment and mental health diagnoses, 90 days before being released. Since Medicaid was established, federal law has prohibited Medicaid money from being used for people who are in custody, with inmates having access to their health care coverage suspended.

The move will provide more stability for inmates and juvenile detainees as they exit institutions and reenter the outside world, CMS administrator Chiquita Brooks-LaSure said Thursday.

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She said the change will allow the state to “make unprecedented advancements for incarcerated individuals who have long been underserved.”

At least 10 other states have asked CMS for exemptions to use Medicaid dollars to treat inmates before they are being released. California could be a model for those states, especially since the program is new territory for Medicaid and is expected to be a massive undertaking, said Vikki Wachino, who oversees the Health and Reentry Project.

California state officials said Thursday that they hope some inmates will begin accessing services through Medicaid starting in 2024. Incarcerated people will be screened and assessed for eligibility to access the state’s Medicaid program. If eligible, case workers will help them develop a care plan for reentry.

It will take at least two years to roll out the program in all the state’s prisons, said Jacey Cooper, the state’s Medicaid director.

Millions of people are expected to be affected, with California releasing nearly half a million inmates from state prisons or county jails every year and roughly 80% of those people qualifying for Medicaid.

People who are leaving prison, jail or juvenile detention often don’t know where to start with getting medical care, Wachino said.

“Right now, there is an enormous barrier to care when people leave prison and jail,” Wachino said. “As you know, many times when they’re released, they’ve been left to fend for themselves, with very, very few supports.”

___

This story was first published on Jan. 26, 2023. It was updated on Jan. 27, 2023, to delete an incorrect reference to the Health and Reentry Project being at the Commonwealth Fund. The project is not at the Commonwealth Fund.

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REFORM (SD)- Medicaid work requirement proposal passes South Dakota House committee

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]: SD lawmakers are inspired by GA’s recent win.

 
 

Clipped from: https://www.dglobe.com/news/south-dakota/medicaid-work-requirement-proposal-passes-south-dakota-house-committee

A resolution looking to allow the legislature to consider work requirements on the newly expanded Medicaid program is one step closer to the 2024 ballot.

 
 

PIERRE, S.D. — An effort to allow South Dakota to consider work requirements on “able-bodied” members of the newly expanded Medicaid program in the state passed its first legislative hurdle by an 11-2 party-line vote at a House State Affairs hearing on Jan. 30.

While opponents relayed concerns about the implementation of work requirements and the supposed inefficacy of similar experiments in other states, Rep. Tony Venhuizen, a Republican from Sioux Falls, said he brought the amendment as a way to begin a work requirement conversation currently prohibited by the language of the Medicaid constitutional amendment passed by voters last year.

“The costs of administering it would likely be outweighed by the savings we would see by incentivizing work,” he told the committee. “But again, I don’t want to get too far into the detail of how this would be implemented because we are several steps away from that.”

As written, the proposed amendment would make an exception to the Medicaid constitutional language — which says the state “may not impose greater or additional burdens or restrictions” on those newly eligible for the Medicaid expansion program — allowing the legislature to consider imposing work requirements on “any person, under this section, who is able-bodied.”

The proposal to offer voters an opportunity to impose work requirements on able-bodied individuals carries the support of 30 lawmakers.

The legislature can refer ballot measures and amendments to voters with a majority vote in each chamber. Were Venhuizen’s proposal to succeed this session, it would go onto the ballot in the 2024 general election.

The Medicaid program, as it currently stands in the state, is a federal-state cost-share health care program available to children, low-income families and disabled adults.

However, upon the successful expansion of Medicaid last election, the eligible population grew, raising the eligible income levels for low-income families and allowing any adult under 138.5% of the federal poverty line to access the program.

Unlike the populations that Medicaid traditionally serves, Venhuizen argued, many in the expanded population are able to work.

Still, opponents to the proposal, many of them representing health care organizations in the state, expressed concern that the definition of “able-bodied” in the relatively general amendment offered by Venhuizen could have negative consequences.

“I think the lack of definition around the word able bodied [is a concern.] We saw this in North Dakota actually a lot when I was spending some time up there with the legislature, folks that deal with mental health issues,” said Tim Rave, the executive director of the South Dakota Association of Healthcare Organizations. “They’re probably physically able to work if that was the definition, but the challenges that they’re having with their mental health problems could be prohibiting them from being active in employment.“

Other opposing arguments cited research from Arkansas that work requirements created “substantial coverage loss” among expanded populations and the infeasibility of implementation due to federal opposition.

While the Biden administration has struck down work requirements in every case — as Medicaid is a program with federal oversight and states must seek approval to change certain rules — Venhuizen noted that 13 states imposed these requirements under the Trump administration, and nine more, including South Dakota, pending approval.

“I do think it’s fair to assume that, if there’s a change in administration, this could be back on the table,” he said.

Venhuizen and the members of the committee in favor of moving the proposal to the House floor argued that several of the points brought up by the opposition were well-founded; however, he argued that giving the legislature the option to discuss the proposal would be the better venue for discussing the specifics.

“I thought that line of argument raised an important concern,” Venhuizen said, specifically referencing a point raised about the seasonal nature of parts of the state economy. “I can see arguments on both sides, but that’s exactly the kind of thing we should be thinking about [as a legislature.] It’s a little concerning to me that the Medicaid amendment in its current form makes that decision for us.”

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REFORM (IA)- House panel advances bill to change who qualifies for SNAP, Medicaid

MM Curator summary

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

 
 

[MM Curator Summary]: Indiana lawmakers are positioning to tighten up SNAP spending.

 
 

Clipped from: https://www.iowapublicradio.org/state-government-news/2023-01-26/iowa-house-panel-advances-snap-bill-medicaid

 
 

Republicans on a House panel advanced a bill Thursday that would change who can qualify for food and medical assistance in Iowa.

It would establish new limits on assets Iowans could hold while receiving food assistance, known as SNAP. Under the bill, the state would also ask the federal government for permission to enforce work requirements for some Medicaid recipients. And the bill would direct the state to do additional verification of Iowans’ eligibility for SNAP and Medicaid.

Republicans on the panel said the House Health and Human Services Committee would be working on changes to the bill in the coming weeks, which would include seeking federal permission to ban the use of SNAP benefits to buy candy and soda.

Supporters of the bill say it will ensure taxpayer dollars are only spent on people who truly need the help.

A wide range of groups that advocate for low-income Iowans, people with disabilities, children, and health care organizations oppose the bill. They say people who need help with food and medical care could lose their benefits if the bill becomes law.

Journey Berzett of Urbandale told lawmakers she has a disability and relies on SNAP to buy food. She asked them to consider people like her.

“To you, I’m a stranger. You think people like me are probably the one exception who is worthy of these entitlement programs,” Berzett said. “Or maybe you don’t. Maybe you think the right to life, liberty and the pursuit of happiness only applies to those who can afford it. What I do know is that community is about coming together and helping each other, and this bill does not do that.”

Tyler Raygor, a lobbyist for Americans for Prosperity, said he supports the bill because public assistance should be narrowly tailored.

“We think it’s important to remember we’re dealing with finite taxpayer dollars,” Raygor said. “When you have folks on these programs who don’t need them, that puts these programs in jeopardy for folks who truly do need them, like folks that we’ve heard from today.”

Only two other groups publicly support the bill. One is the Opportunity Solutions Project, a group associated with a conservative think tank based in Florida called the Foundation for Government Accountability. The organization has been pushing for public assistance asset tests and Medicaid work requirements in Iowa for years. The other is Iowans for Tax Relief.

Lina Tucker Reinders, the executive director of the Iowa Public Health Association, said she is very concerned about the proposed asset test. She said SNAP is a tool people can use to pull themselves out of poverty.

“When people are using the other tools available to them to do things like save for a down payment for a home to move to a neighborhood for their children, to save money in a 529 plan for their kids’ college—things that we know are effective in breaking generational poverty—it creates a cliff effect,” she said. “And so they’re punished for doing those things that they’re told are the right things to do to break the cycle of poverty.”

Other opponents of the bill say it could put SNAP benefits at risk for some Iowa families that have more than one car. They also raised concerns about how much it would cost the state to hire more people and get a new computer system to make more eligibility checks possible.
 

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RX- Medicaid commission calls for flexibility in drug coverage

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

 
 

[MM Curator Summary]: MEDPAC thinks Medicaid programs should be able to have their own rx coverage process other than “well I guess if it made it through the p*ss poor FDA process, we have to pay for it.”

 
 

Clipped from: https://www.axios.com/pro/health-care-policy/2023/01/27/medicaid-commission-drug-coverage-flexibility

Illustration: Megan Robinson/Axios

The Medicaid and CHIP Payment and Access Commission voted Friday to ask Congress to let states restrict Medicaid coverage of a drug when Medicare only covers it in clinical trials and while other data is collected on effectiveness.

Why it matters: Unlike Medicare, Medicaid has to fully cover FDA approved drugs regardless of their cost or how much real-world evidence exists on the drug’s effectiveness — which has the potential to wreak havoc on state budgets.

  • The commission wants Congress to level the playing field between Medicaid and other insurers and give states the option for more flexibility.

Reality check: Lawmakers on both sides of the aisle support making it harder for Medicare to limit coverage of FDA-approved drugs — so it would be an uphill battle to get Congress to expand the coverage pathway to Medicaid.

  • Regardless, the vote indicates this is a difficult issue that Medicaid stakeholders aren’t likely to drop anytime soon.

Driving the news: Last year, regulators decided Medicare will cover the controversial Alzheimer’s drug Aduhelm only for patients enrolled in randomized clinical trials.

  • The National Association of Medicaid Directors said in a February letter that limiting Medicare coverage would shift costs onto state Medicaid programs, since Medicaid programs don’t have the same option to restrict coverage.

Giving Medicaid the ability to cover drugs only in clinical trial settings could take some financial pressure off of states to cover expensive but questionably effective drugs, according to MACPAC.

  • The policy could also encourage drug manufacturers to move through traditional FDA approval and show adequate clinical benefit, the commission said.

 
 

  • But MACPAC noted during Thursday’s meeting that limiting Medicaid coverage of drugs can reduce beneficiaries’ access to therapeutics and create more administrative work for prescribing providers.

What they’re saying: “To me, the key issue here is that we’re talking about medications that have potential benefit, but we don’t actually know if it’s an actual benefit yet,” MACPAC Commissioner Angelo Giardino said during the commission’s Thursday meeting.

  • Commissioner Heidi Allen was the lone member to vote against the recommendation.
  • “I think [this flexibility] has equity and access implications, and it’s hard for us to look into the future to say what those would be,” Allen, a social work professor at Columbia University, said during the Thursday meeting.
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TECH- CMS Improves Medicaid Reimbursement for Digital Health Consults

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]: Now specialists can bill for telehealth so we can stop gaming what the PCPs are getting paid to cover the specialists costs.

 
 

Clipped from: https://www.healthleadersmedia.com/technology/cms-improves-medicaid-reimbursement-digital-health-consults

The Centers for Medicare & Medicaid Services has issued guidance changing Medicaid and CHIP coverage for eConsults, or provider-to-provider specialty consults conducted via digital health or telehealth. The  ruling could expand the service, which helps primary care providers keep more of their patients and boosts access to care for underserved patients.

KEY TAKEAWAYS

The Centers for Medicare & Medicaid Services has issued new guidance on Medicaid and CHIP coverage for eConsults, or interprofessional consultations between a primary care provider and a specialist on treatment for a specific patient.

Under the new guidance, specialists are able to bill Medicaid for eConsults rather than primary care providers, who would often have to bill higher rates so that they could reimburse specialists for their services.

The platform is popular with primary care providers who want to keep more of their patients and specialists who want to expand their reach, while it improves access to care for underserved populations who can’t afford or won;t travel to see a specialist.

Federal officials have expanded coverage for specialty consults between care providers via digital health for Medicaid and Children’s Health Insurance Program (CHIP) members.

In guidance issued earlier this month, the Centers for Medicare & Medicaid Services (CMS) announced that interprofessional consultations, or instances when a care provider seeks the advice of a specialist for a patient’s treatment, via eConsults can be covered by state Medicaid or CHIP programs even when the patient is not present, as long as the consult is focused on that patient.

eConsults are clinical consults usually conducted via telemedicine (including the telephone) or digital health. They enable primary care providers to expand care management options for their own patients without having to send those patients off to a specialist. And they improve access to care for patients who might not want to travel to see a specialist due to a variety of reasons, including distance and cost.

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Alongside helping primary care providers retain more of their patients, the platform is popular with federally qualified health centers (FQHCs) and community health centers who treat underserved populations and in rural areas where access to specialists is scarce. It also helps specialists expand their reach and treat more patients in need of their services.

“Timely access to specialty providers can improve the quality of care and treatment outcomes for both physical and behavioral health,” CMS wrote in its guidance. “While access to specialty care has been a challenge across a range of specialties, access to specialty care for mental health and substance use disorders has been a particular challenge.”

The ruling changes the payment model so that the consulting provider, or the specialist, can bill for the treatment. Previously, CMS allowed the treating provider to bill Medicaid, which in many case forced the program to pay higher rates to the treating provider so that he/she could reimburse the specialist for consulting services.

To qualify eConsult coverage, both care providers must be enrolled in the Medicaid program in the state where the patient is located, though the consultant can be located in another state.

“Given the potential for improving access to specialty care, a number of states have obtained authority through state legislation for or expressed interest in covering eConsults,” the Los Angeles-based Manatt, Phelps & Phelps law firm wrote in a recent blog. “States that choose to cover eConsult codes must submit a state plan amendment to CMS to add a payment methodology for the qualifying service, and should consider broadly communicating any related policy changes to their enrolled provider community.”

 
 

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MCOS- Human Services Department to cancel procurement process for the selection of managed care organizations to deliver Medicaid services

MM Curator summary

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

 
 

[MM Curator Summary]: Maybe next year.

 
 

Clipped from: https://www.hsd.state.nm.us/2023/01/30/human-services-department-to-cancel-procurement-process-for-the-selection-of-managed-care-organizations-to-deliver-medicaid-services/

Current contracts to remain in place, no disruption in services  

SANTA FE – The New Mexico Human Services Department (HSD) announced today it will cancel the procurement process for the selection of managed care organizations to deliver services to the state’s 800,465 Medicaid Centennial Care members. 

The current contracts in place will continue until a new, expedited request for proposals (RFP) is issued, so there will be no disruption in services being provided. The contracts for those companies are set to expire at the end of 2023.  

The original RFP is being terminated so that the agency’s new leadership, given the planned departures of both Secretary David Scrase and the Medicaid Director Nicole Comeaux, can assess the design of the procurement.  

Since 2019, the Medicaid program has worked to improve program benefits, provider payments, and access to care. HSD has invested over $800 million in increased provider rates, extended postpartum coverage to 12 months, worked to eliminate the developmentally disabled waitlist for services, removed asset tests that create barriers for older adults, implemented home visiting programs for pregnant women, processed 6,534 Medicaid Provider enrollment applications, and added reimbursement of Adult Accredited Residential Treatment Center services. 

The Department is dedicated to continuing to provide robust and comprehensive services to Medicaid customers.      

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We talk, interpret and smile in all languages.  We provide written information to our customers in both English and Spanish and interpretation services are available in 58 languages through our provider, CTS Language Link. For our hearing, and speech impaired customers, we utilize Relay New Mexico, a free 24-hour service that ensures equal communication access via the telephone to individuals who are deaf, hard of hearing, deaf-blind or speech disabled. 

The Human Services Department provides services and benefits to 1,076,746 New Mexicans through several programs including: the Medicaid Program, Temporary Assistance for Needy Families (TANF) Program, Supplemental Nutrition Assistance Program (SNAP), Child Support Program, and several Behavioral Health Services.

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Town Hall Ventures’ Andy Slavitt on how to invest in Medicaid

 
 

MM Curator summary

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

 
 

[MM Curator Summary]: Andy’s got some ideas on how to make money in Medicaid.

 
 

Clipped from: https://www.statnews.com/2023/01/31/town-hall-ventures-medicaid-slavitt-health-tech/

 
 

SAN FRANCISCO — Part of Andy Slavitt’s core mission at Town Hall Ventures is proving that health tech companies can make a viable business out of reaching low-income people who also face social challenges, like a lack of housing or nutritious food options. It’s a bold assertion that hasn’t been proven out yet, though a handful of Town Hall Ventures’ portfolio companies — including Unite Us and Alphabet spinout Cityblock  — have already achieved valuations over $1 billion.

The stakes are growing steadily higher, especially for the millions who signed up for Medicaid coverage during the public health emergency and who risk losing it as temporary expansions end. And by investing in teams they trust to embed in vulnerable communities, build culturally sensitive products, and develop sophisticated analytics to assess social needs, Slavitt and his team are hoping to set an example for other venture funds who have historically avoided Medicaid.

“The clinical answers are not so hard. I can’t emphasize that enough,” Slavitt said. Though the diagnoses affecting low-income patients are largely the same as the ones affecting those with commercial insurance, the health care system isn’t set up to accommodate homeless people, or medically complex pediatric patients in health care deserts, he said. 

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“What’s different largely speaking is that being poor really sucks and being miles away from anyone who can really care for you really sucks and needing to fill out 10 forms to get housing or child care or any of these other things is a big deterrent to getting care,” he said. “A system that doesn’t welcome you, doesn’t recognize where you live, really doesn’t work.” 

From an investment perspective, he said, there’s potential for a “decent margin — not a huge margin” in helping the country’s roughly 90 million Medicaid patients get better preventive health care, avoiding more expensive treatment in the future. “There’s no bigger market than Medicaid,” he said. 

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STAT spoke with Slavitt in San Francisco, where he and other investors and health care executives descended earlier this month for the J.P. Morgan Health Care Conference. This conversation has been edited for length and clarity. 

What types of companies do you think are best equipped to solve these problems?

The good news is there’s an awakening that the most needed area of investment is also investable space. Not everyone has figured it out.

There’s two types of ways of thinking about investing. One starts with how do I find a market opportunity and make a lot of money? And the other starts with is there a really big problem that I can figure out how to solve? Not every problem in health care will be solved with innovation. But some can, and the ones that can are the ones where you’ve got a clinical, social, behavioral model that addresses the need of a specific population where there’s also some payment model that allows you to meet those needs.

If you look across Medicaid, you can follow the journey from moms to babies, pregnant moms to pediatrics, complex pediatrics, then school-based programs, justice and teen mental health programs, disability, all the way up to [dual Medicare and Medicaid eligibles and eldercare]. We have activities in all those buckets. We have investments in most of those buckets. 

Finding people who really understand these problems at a really operational finite level [is important]. Take a company like Cityblock Health. There are several thousand available housing units in New York that don’t get used for homeless people because they’re only available for people with a psych diagnosis. And in order to get a psych diagnosis, you’ve got to go find a psychiatrist in New York, then make it to the appointment, then it gets rejected. … They’ve got a team of psychiatrists that do that, nothing but that, and they get people into housing. 

How will you know you’ve been successful?

If we’re massively successful, [Town Hall] will invest a few billion dollars over our life into these communities. We need hundreds of billions of dollars invested, and there’s all this capital that sits there trapped [in the health care industry] … or is repatriated to shareholders because these are incredibly profitable companies. And they come into these communities and they take the profits out. Money needs to be reinvested back into these communities. 

Do the communities you’re focused on use technology any differently than wealthier ones?

SMS is less expensive to use than a browser. There are subtleties. I went out to the field with a Cityblock community health partner and I said, “What’s your favorite part of your job?” And she said, “My iPad.” I don’t hear that a lot in health care, but she said, “I bring this into someone’s apartment and I can build access to the whole world for them. I can connect them to the thing they need, I can order something for them on the spot and they can see action. I can communicate with their daughter who is a big user of technology.” 

Amazon has a lot to teach us in coming into health care because they know how to deploy technology in ways that don’t feel like technology. 

How are the metrics you use to evaluate companies different from other markets?

It’s imperfect and it’s a little bit of a moving target. We started in earnest on it probably a year ago. We got more resources on our team to be able to collect the information from our companies. It was always part of the process but if you’d asked me the question for each one how are they doing, I wouldn’t have been able to give you a great answer. 

One easy tell, when I talk to a company, is, “Tell me what it is.” Plume, which is a trans health company, they’re like, “we have to reduce anxiety and depression scores very fast.” So they measure that like crazy. If I look at Eleanor Health, which is focused on addiction and recovery treatment, what they basically want to get to is lower craving levels. They don’t measure urine tests [as much] … they’ve learned that the frequency of touch points with people at various stages of their addiction recovery is really important, so they’ll measure that.

There’s a set of consistent metrics, but you’ve got to respect them to tell their own story. At some level they’re going to know their business better. 

If I don’t hear that they’re measuring Net Promoter Score rabidly in the right way, it tells me, OK there’s some other way you’re getting paid than doing your job. 

There’s questions we ask every company like diversity on your management team, diversity on your board, diversity at each level, diversity of promotions. There’s usually other investors at the table, and I’m pretty sure they’re going to ask the question about “how’s your sales acquisition doing?” But my first questions will always be what I think is important. You have to hire diversity, particularly in the early stages, and then their networks will come in. But you have to force it. 

This story, part of a series on health tech for underserved populations, was supported by USC Annenberg Center for Health Journalism’s national fellowship.

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DENTAL- Utah bill proposes expanding dental care coverage to adults under Medicaid

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

 
 

[MM Curator Summary]: A local university is willing to foot the state’s share of the bill.

 
 

Clipped from: https://stateofreform.com/featured/2023/01/utah-bill-proposes-expanding-dental-care-coverage-to-adults-under-medicaid/

 
 

Senate Bill 19, a measure that would extend dental benefits under Medicaid to adults 21 years of age and older, advanced to the House after passage in the Senate by a vote of 19 to 0 with 10 abstentions Monday. 

 
 

 
 

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Sponsored by Sen. Evan Vickers (R – Cedar City), the measure passed with bi-partisan support and has the backing of the Utah Dental Association (UDA). 

Under current state law, only members who are pregnant, disabled, blind, age 65 or older, enrolled in Targeted Adult Medicaid (TAM) receiving treatment for substance use disorder, or children receiving Early Periodic Screening, Diagnostic and Treatment (EPSDT) have access to dental benefits through Medicaid. 

In partnership with the Utah Department of Health and Human Services (DHHS), the University of Utah School of Dentistry (UUSOD) administers dental care to these individuals through the school’s clinics and affiliated providers in over 150 locations throughout the state. 

“Back in 2008, the state eliminated all dental benefits for adults and the University of Utah School of Dentistry subsequently went to the legislature and said we’d like to partner and provide this care, and there are federal programs available that allow for that,” said James H. Bekker, Associate Dean for Professional and Community Partnerships at UUSOD. 

“The School of Dentistry participates in creating that pathway. And so we opened up gradually to first the TAM patients that have substance abuse disorder and then we added to that blind and disabled patients. And then we added to that elderly. So it’s just been something that’s happened gradually and we’ve been able to do well.”

SB 19 would allow the state to pursue federal Medicaid waivers that extend dental care to all adults 21 years of age and over who are eligible for Medicaid. The bill, like previous ones that expanded dental coverage eligibility, contains a zero fiscal note because UUSOD pays the state’s portion to receive federal matching funds to provide care. 

Should SB 19 pass, the number of Medicaid members eligible for dental coverage could grow from 70,000 to over 200,000, according to UUSOD estimates. 

“This program allows [dentists] to see the patients and be compensated at a much better rate,” Bekker said. “It’s clear that with [currently eligible] Medicaid patients, that’s about 70,000 patients throughout the state, the School of Dentistry can’t possibly see all those patients at our clinics.

And so we have created an associated provider opportunity so any dentist in the state of Utah can become associated with the School of Dentistry and thereby treat these populations in their own office. They bill directly to Medicaid, they’re reimbursed directly [by] Medicaid. It’s just that association that they need with a state entity in order to be able to qualify.”

As the legislative liaison to the UDA and its past president, Bekker says dentists in the state are supporting the proposal. 

General dentists had previously been reluctant to join the program and serve Medicaid patients because of low reimbursements rates, Becker noted. He has been working to change the perception that Medicaid does not pay adequately and recruit more dentists to participate and meet the potentially increased demand. 

“We’re doing what we can to educate dentists out there to understand that it’s different than it was,” Bekker said. “The compensation rates are better and this is a wonderful opportunity to enhance your practice and provide care to underserved populations.”

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PROV- Without 20 percent Medicaid boost, state’s providers say bed reductions will continue

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]: More NY nursing homes are closing beds unless they get their 20% bump this year.

 
 

Clipped from: https://www.mcknights.com/news/without-20-percent-medicaid-boost-states-providers-say-bed-reductions-will-continue/

 
 

 
 

New York state nursing home advocates want a 20% Medicaid boost to pay rates, a demand struggling for traction while the governor’s budget framework puts money into home-based care instead. 

The demand was delivered officially to Gov. Kathy Hochul (D) Friday in a letter signed by the heads of five organizations representing nursing home providers and healthcare workers. Her budget proposal is scheduled to be released Wednesday. Without changes, more beds will be taken out of service and some facilities could close, providers warned.

“New York has underfunded nursing home care for the last 15 years,” said Stephen B. Hanse, president and CEO of New York State Health Facilities Association/New York State Center for Assisted Living, adding that New York was the only state to cut Medicaid to nursing homes during the pandemic.

Hanse’s organization represents 400 skilled nursing providers whose more than 60,000 employees care for more than 65,000 nursing home residents and assisted living clients. 

The statewide average Medicaid reimbursement is $211 per resident per day, Hanse said. Divide that by the 24-hour care that is required and it equates to the state paying providers $8.79 per hour to care for each resident, he noted in an email to McKnights Long-Term Care News.

“This is unacceptable … and is a driving factor why New York has a long-term care staffing crisis as nursing homes cannot compete in the labor market for desperately needed workers,” he explained. 

In addition to Hanse’s group, the letter was signed by: LeadingAge New York; Greater New York Health Care Facilities Association; 1199 SEIU, United Healthcare Workers East; and Southern New York Association Inc., which represents more than 60 nursing homes encompassing 16,000 beds in southern New York, Westchester, and Long Island.

New York requires nursing homes to provide a minimum of 3.5 hours of care per resident per day. Facilities are also required to spend at least 70% of revenue on resident care with 40% of that amount patient facing. 

In 2021, New York gave a Medicaid boost of 1%, but operating costs have surged 42%, according to the Alliance for Senior Care. A letter to the editor in the Rochester Beacon from the seven members of that group said that more than 6,700 beds in the state are “off-line” and coalition members in western New York are limiting admissions due to staffing challenges. The head of Gurwin Healthcare System told Spectrum News that its two nursing homes, which operate a total of 580 beds on Long Island, are similarly limiting admissions and “temporarily closing beds.”

Hochul’s budget priorities released earlier this month did not include any mention of a Medicaid increase for long-term care, instead making investments into teams that would care for low-income adults in their homes, reported WSHU. A Hochul spokesman said the governor is “committed to ensuring that all New Yorkers can age with dignity and independence in the community of their choosing.” 

Hanse and other nursing home advocates will be ready to scour the budget to see what kind of legislative fight they will have on their hands.

“Home-based care is not an alternative to skilled nursing care, given the fact that residents of nursing homes are unable to be cared for in the community given their acuity levels and co-morbidities,” Hanse said.

 
 

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MEDICARE- CMS Issues Final Rule to Protect Medicare, Strengthen Medicare Advantage, and Hold Insurers Accountable

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]: But will they recover the overpayments tho

 
 

Clipped from: https://www.cms.gov/newsroom/press-releases/cms-issues-final-rule-protect-medicare-strengthen-medicare-advantage-and-hold-insurers-accountable

Risk Adjustment Data Validation (RADV) final rule strengthens Medicare Advantage and restores payment oversight program

Today, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), finalized the policies for the Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program, which is CMS’s primary audit and oversight tool of MA program payments. Under this program, CMS identifies improper risk adjustment payments made to Medicare Advantage Organizations (MAOs) in instances where medical diagnoses submitted for payment were not supported in the beneficiary’s medical record. The commonsense policies finalized in the RADV final rule (CMS-4185-F) will help CMS ensure that people with Medicare are able to access the benefits and services they need, including in Medicare Advantage, while responsibly protecting the fiscal sustainability of Medicare and aligning CMS’s oversight of the Traditional Medicare and MA programs.

As required by law, CMS’ payments to MAOs are adjusted based on the health status of enrollees, as determined through medical diagnoses reported by MAOs. Studies and audits done separately by CMS and the HHS Office of Inspector General (OIG) have shown that Medicare Advantage enrollees’ medical records do not always support the diagnoses reported by MAOs, which leads to billions of dollars in overpayments to plans and increased costs to the Medicare program as well as taxpayers. Despite this, no risk adjustment overpayments have been collected from MAOs since Payment Year (PY) 2007. 

“Protecting Medicare is one of my highest responsibilities as Secretary, and this commonsense rule is a critical accountability measure that strengthens the Medicare Advantage program. CMS has a responsibility to recover overpayments across all of its programs, and improper payments made to Medicare Advantage plans are no exception,” said HHS Secretary Xavier Becerra. “For years, federal watchdogs and outside experts have identified the Medicare Advantage program as one of the top management and performance challenges facing HHS, and today we are taking long overdue steps to conduct audits and recoup funds. These steps will make Medicare and the Medicare Advantage program stronger.”

“CMS is committed to protecting people with Medicare and being a responsible steward of taxpayer dollars,” said CMS Administrator Chiquita Brooks-LaSure. “By establishing our approach to RADV audits through this regulation, we are protecting access to Medicare both now and for future generations. We have considered significant stakeholder feedback and developed a balanced approach to ensure appropriate oversight of the Medicare Advantage program that aligns with our oversight of Traditional Medicare.” 

The RADV final rule reflects CMS’s consideration of extensive public comments and robust stakeholder engagement after the release of the 2018 Notice of Proposed Rulemaking. The finalized policies will also allow CMS to continue to focus its audits on those MAOs identified as being at the highest risk for improper payments.  

The RADV final rule can be accessed at the Federal Register at  https://www.federalregister.gov/public-inspection/current.

View the fact sheet on the final rule here: https://www.cms.gov/newsroom/fact-sheets/medicare-advantage-risk-adjustment-data-validation-final-rule-cms-4185-f2-fact-sheet.