Category: MM Curator

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MCOs; IN- New contract for Medicaid operator

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]: MDWise gets another 4 (or 6 with options) to keep running managed care in the state (its been doing it for almost 30 years).

 
 

 
 

Clipped from: https://www.wowo.com/new-contract-for-medicaid-operator/

INDIANAPOLIS (Inside Indiana Business) – The operator of Indiana’s Medicaid program will continue to run the healthcare insurance system for the state. The Family and Social Services Administration has awarded MDwise a four-year contract to provide risk-based managed care services statewide.

MDWise has managed healthcare benefits to low-income residents through Hoosier Healthwise and the Healthy Indiana plan since 1994.

The new contract includes the possibility of two one-year extensions.

Meanwhile, the nonprofit health maintenance organization has hired its first health equity officer. MDwise says Anye Carson will oversee an action plan to reduce health disparities in its coverage.

The organization says Carson will incorporate culturally and linguistically appropriate services for MDwise members.

Carson most recently worked North Carolina-based clinical research organization Parexel. She also previously worked for the IUPUI Extension for Community Health Outcomes Center.

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AK- Average wait time 90 to 120 days for state to process Medicaid applications

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]: Alaska may be pulling a Missouri.

 
 

 
 

Clipped from: https://www.wrangellsentinel.com/story/2023/01/11/news/average-wait-time-90-to-120-days-for-state-to-process-medicaid-applications/11310.html

Alaska has violated state and federal law by failing to process Medicaid applications in a timely manner, according to an Anchorage-based civil rights law firm that settled a class-action lawsuit in federal court with the state three years ago.

The Alaska Department of Health’s figures last week showed that there are 8,987 outstanding Medicaid recertifications and applications to be processed by the state Division of Public Assistance, which is contending with a major backlog in application processing that officials attributed to a staffing shortage and other issues.

“This number includ…

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NMI’s 83 pct. federal match rate for Medicaid is now permanent

MM Curator summary

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

 
 

[MM Curator Summary]: One of the territories now has 87% of its Medicaid costs paid for by federal taxpayers. 4-Eva.

 
 

Clipped from: https://www.saipantribune.com/index.php/nmis-83-pct-federal-match-rate-for-medicaid-is-now-permanent/

 
 

Esther Muña

Thanks to the CNMI’s health partners as well as the efforts of Delegate Gregorio Kilili C. Sablan (D-MP), the federal match rate for the CNMI’s Medicaid program will now permanently remain at the current 83%.

Commonwealth Healthcare Corp. CEO Esther Muña shared the good news during a news briefing yesterday that Sablan recently informed CHCC that the Biden administration has decided to permanently keep the federal match rate for the CNMI’s Medicaid at 83%, meaning the CNMI would only shoulder 17% of Medicaid-related costs.

“I did get a call from Congressman Sablan…that we’re getting the 83% and it’s permanent. That’s obviously great news. It’s been something that we’ve been fighting for—equitable funding financing for the territories,” she said.

Essentially, Muña said, the CNMI government would now only have to shoulder 17% of medical costs accrued by the Medicaid program. Previously, the CNMI was shouldering 50% before it was lowered to 45% and the CNMI still could not afford it.

CHCC hopes that the 17% match will prove more affordable for the CNMI as it would come from the Commonwealth’s general fund.

“The 83% is going to come from the federal [government] and the 17% is going to come from the local funds appropriated for CHCC. The reason why we opted to do this is because, in the past, we’ve always struggled to find the funds to cover our match. It used to be 50%, then our match was lowered to 45% and that obviously was still very difficult. We are hoping that now, the CNMI can afford 17%,” she said.

Muña said this is a great opportunity for CHCC to look at how it can better address health care access with the extra funding it would save with the federal government shouldering 83% of Medicaid costs.

“This is a great opportunity for us to plan better and also to really address the health issues of the CNMI and even for public health,” she said.

According to Saipan Tribune archives, the Marianas’ current 83% federal match rate, technically called the Federal Medical Assistance Percentage, or FMAP, is higher than it is for any state.

The FMAP was set in U.S. Public Law 116-94 in 2019, extended in U.S. Public Law 117-103, in a previous continuing resolution in early 2022, and again in another fiscal 2023 continuing resolution which was passed on Dec. 20, 2022.

The continuing resolution provided appropriators more time to draft an omnibus spending bill to cover the entire fiscal year which has since been passed, permanently keeping the FMAP for the CNMI at 83%.

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WY- Legislators explain Medicaid opposition

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]: A good example of the use of Rule #8 from Alinsky’s Rules for Radicals.

 
 

Clipped from: https://www.thesheridanpress.com/news/local/legislators-explain-medicaid-opposition/article_8995bad2-8e0d-11ed-a768-fbdd0e82c10e.html

 
 

SHERIDAN — Three Sheridan County state legislators explained their opposition to Medicaid expansion during a pre-legislative luncheon hosted by Sheridan County Chamber of Commerce Wednesday. 

Sen. Dave Kinskey, R-Sheridan; Rep. Cyrus Western, R-Big Horn; and Rep. Ken Penderraft, R-Sheridan; were the three legislators present out of the full Sheridan County delegation. Sheridanite Cathi Kindt asked legislators, “If there were a solid business case for Medicaid expansion, would you support it?”

All three legislators said no, but for varying reasons. 

“This thing has been brought up like eight times in the last couple of years,” Pendergraft said. “The answer to your question, ma’am is no. Even if he could show me that it would make Wyoming a great deal of money, I’m opposed. And the reason that I’m opposed is also philosophical. With liberty comes responsibility. If I cede responsibility, I give up some of that liberty, and on that philosophical basis, I would be opposed.”

Pendergraft believes there’s already too much governmental involvement in health care already and believes there should not be more. 

Western said he also does not prescribe to Medicaid expansion for philosophical reasons. 

“Are people fundamentally entitled, at a constitutional rights level, to free health care?” Western posed. “I understand the the reasoning and the rationale behind it, I really do, to the extent that it makes sense, but everything costs something. And so given how expensive it is, given how much money we’d have in debt. Those are my biggest concerns. It’s not that I can’t appreciate the benefits that it brings.”

Kinskey said other states reported costs well beyond what was budgeted and the federal government not coming through with its promises to help pay for expansion. 

“They end up being a budget buster everywhere it’s adopted,” Kinskey said. “…So if we adopted Medicaid expansion and the Feds did not keep their word and they went to spend to paying half like they do on all the other Medicaid, that difference is equal to the maintenance on every school in the state of Wyoming for a year.”

“Budget-wise, I just don’t think that this case can be made (for Medicaid expansion),” Kinskey said. 

Four bills are currently listed that address aspects of Medicaid: Medicaid twelve month postpartum coverage; medical treatment opportunity act-Medicaid reform; Medicaid coverage-licensed pharmacists; and podiatry medical services-Medicaid. To read the bills, see wyoleg.gov. 

The general session begins Jan. 10 in Cheyenne. 

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REGs; Prior Auth- CMS Proposed Rule Seeks to Provide Transparency and Efficiency in Preauthorization Process

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 details on the proposed rule to increase what payers (mostly plans) need to do around prior auth.

 
 

 
 

Clipped from: https://www.jdsupra.com/legalnews/cms-proposed-rule-seeks-to-provide-1575175/

 
 

Introduction

On 13 December 2022, the Centers for Medicare and Medicaid Services (CMS) published CMS-0057-P (the Rule),1 a proposed rule that, if adopted, will place new requirements on a number of entities, including Medicare Advantage (MA) organizations, state Medicaid fee-for-service programs, Medicaid managed care plans, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges.2 The rule is an effort by CMS to “improve the electronic exchange of healthcare data and streamline processes related to prior authorization, while continuing CMS’ drive toward interoperability in the healthcare market.”3 CMS envisions that the proposed rule will “play a key role in reducing overall payer and provider burden and improving patient access to health information.”4 The comment period for the proposed rule closes on 13 March 2023. If adopted, the key components of the Rule would go into effect in 2026.5

Improved Prior-Authorization Processes

Of particular relevance to hospital and physician provider clients, the Rule seeks to improve prior- authorization processes to streamline prior-authorization submissions and decisions between providers and payers. The prior-authorization process allows providers to request approval from payers for coverage of specific medical treatment, including elective surgeries and inpatient-level-of-care admissions, in advance of the treatment. Payers typically require health care providers to obtain prior authorization for elective treatment and inpatient hospital treatment to confirm that the treatment is both covered by the payer and medically necessary. However, the prior- authorization process is often burdensome, requiring providers to determine whether specific services require preauthorization and the requirements of that process across varying systems. The requirements for each payer are also often different. For example, one payer might require submission of documents via fax where another requires medical records sent via CD. These document submission requirements often involve repeated follow-up by providers to confirm receipt or, if documents do not reach the intended recipient, resubmissions. As CMS’ own guidance explains, requiring health care providers to undertake onerous prior-preauthorization procedures can risk patient health when inefficiencies cause a delay in care.6 It also forces providers to expend their thin resources parsing varying documentation, submission, and approval requirements. These inefficiencies can result in unnecessary out-of-pocket payments from patients, or even abandonment of treatment if prior-authorization delays persist. Through the proposed rule, CMS hopes to “alleviate some of the burden of prior authorization processes and to improve the patient experience” in order to provide efficiency and transparency to the prior-authorization process.7

For example, the rule would require payers to set up new software systems specific to prior authorizations. The previously finalized Interoperability and Patient Access Rule, 85 Fed. Reg. 25510 (codified at 42 C.F.R. 406), required impacted payers to implement a Patient Access Application Programing Interface (API). Building off of the Patient Access API, the proposed rule would require payers to build and maintain a Prior Authorization Requirements, Documentation and Decision (PARDD) API, create efficiencies through automation of the processes for providers to determine whether a prior authorization is required, easily ascertain any documentation requirements for the prior authorization, and enable the interchange of prior authorization requests and decisions between a provider’s electronic health records system and the PARDD API.8 All providers would be able to electronically submit requests for prior authorization to impacted payers. Notably, covered entities under the Health Insurance Portability and Accountability Act must use a specifically adopted, current standard for prior authorization transactions. The proposed rule would not modify or impact that standard.9

Importantly, to better facilitate payer and provider transparency, the rule would require payers to identify a specific reason when denying a prior authorization request.10 Payers would also have to publicly report some prior authorization metrics by publishing them annually on the payer’s website.11 This data would be “compiled from multiple sources, on multiple measures and individuals,” in the hopes that the data’s availability would further promote consumer transparency.12 Among other categories, the rule would require payers to report a complete list of all items and services requiring preauthorization, the approval and denial percentages of standard and expedited prior-authorization requests aggregated by item and service, the percentage of approvals after appeal, and the average time between submission and determination.13 These requirements should help foster greater efficiency in the claim appeal process and also provide benchmarks for analysis of appropriate documentation required by providers in order to support medical necessity and avoid denials for certain medical services.

The rule would also set timeframes for certain payers to provide prior authorization decisions. Payers would have 72 hours to render a decision on an urgent submission, and seven calendar days for nonurgent requests.14 Though these timeframes are proposed under the rule, CMS is also currently seeking comment on shorter timeframes (e.g., 48 hours for expedited requests and five calendar days for standard requests).15

In addition to creating preauthorization efficiencies, the Rule also seeks to impose a series of varying requirements for patient data sharing of patient health information among payers to decrease the burdens of patient data submissions by patients and providers throughout a patient’s health care journey. For examples, the rule, if adopted, will require payers to electronically transfer a patient’s health data, with permission, to that patient’s new health plan as a patient changes plans and require payers to share quarterly patient data where patients have concurrent coverage with two or more payers.16

Conclusion

While the comment period closes in March of 2023, the proposed rule, if adopted, would not take effect until early 2026. Though the date may seem distant, the rule has the potential to simplify and modernize some otherwise archaic and onerous prior-authorization procedures. Providers will no longer have to guess whether certain services require preauthorization, will be able to better determine medical necessity of services, and more efficiently and, hopefully, effectively engage in the claims denial appeals process with payers. Time will tell whether this rule will yield the transparency and efficiency it seeks to promote.

1 Advancing Interoperability and Improving Prior Authorization Processes for MA Organizations and Medicaid Managed Care Plans, State Medicaid Agencies, State CHIP Agencies, CHIP Managed Care Entities, and Issuers of QHPs in the Federally-Facilitated Exchanges, 87 Fed. Reg. 76238 (Dec.13, 2022).

2 Ctr. for Medicare & Medicaid Servs., Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule CMS-0057-P: Fact Sheet (Dec. 2022), https://www.cms.gov/newsroom/fact-sheets/advancing-interoperability-and-improving-prior-authorization-processes-proposed-rule-cms-0057-p-fact.

3
Id.

4
Id.

5 Advancing Interoperability and Improving Prior Authorization Processes for MA Organizations and Medicaid Managed Care Plans, State Medicaid Agencies, State CHIP Agencies, CHIP Managed Care Entities, and Issuers of QHPs in the Federally-Facilitated Exchanges, 87 Fed. Reg. at 72329.

6
Id.

7
Id.

8
Id.

9
Id.

10
Id.

11 Id.

12 Id. at 76304.

13
Id. at 76305.

14 Ctr. for Medicare & Medicaid Servs., supra note 2.

15
Id.

16
Id.

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Op-Ed- California should accept the federal government’s invitation to trim Medi-Cal rolls

MM Curator summary

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

 
 

[MM Curator Summary]: In which the op-ed writer suggests the un-thinkable.

 
 

Clipped from: https://www.ocregister.com/2023/01/11/california-should-accept-the-federal-governments-invitation-to-trim-medi-cal-rolls/

 
 

California should accept the federal government’s invitation to trim Medi-Cal rolls

Despite tougher fiscal conditions, Governor Newsom’s January budget proposal for California misses an opportunity to take advantage of a large cost-saving opportunity other states will be leveraging in the coming months.

Since 2020, the federal government has prevented states from removing no-longer-eligible Medicaid beneficiaries from the program’s rolls. Now that this pandemic emergency measure was eliminated by the omnibus budget bill Congress passed last month. California should join other states in enforcing eligibility requirements for those receiving healthcare benefits.

Of the $297 billion in state revenues Newsom expects to spend in 2023-2024, the largest share – $102 billion – is devoted to Health and Human Services. Most of the spending in this category will take the form of provider reimbursements by the state’s Medicaid program, known as Medi-Cal.

Normally, the federal government covers 50% of Medi-Cal reimbursements for most beneficiaries. But during the COVID-19 pandemic, Congress increased the federal percentage to 56.2%, as long as the state maintained continuous coverage for everyone using the program as of early 2020 or added to the program thereafter. Now, the federal share will gradually fall back to 50% in early 2024, and the continuous coverage mandate will be removed.

According to federal data, California’s population of Medicaid beneficiaries grew from 10.3 million at the beginning of the pandemic to 12.6 million in September 2022 (the last month that data was available). An additional, 1.3 million young people are enrolled in the Children’s Health Insurance Plan, meaning that over one third of the state’s population is now covered by federal/state health programs that do not require participant contributions.

Many states plan to respond to the federal policy change by systematically reviewing all Medicaid beneficiaries to see whether they still qualify for benefits. For example, Texas has identified a cohort of 1.4 million beneficiaries that are most likely to be deemed ineligible because they have reached the age of 65 (and should instead use Medicare) or no longer have an eligible dependent child in their household. Once the state is allowed to begin disenrollments in April 2023, it plans to run electronic data matching algorithms on this cohort to determine who should be removed from the program.

California appears to have no such plan. The governor’s budget summary projects a large increase in General Fund Medi-Cal spending due to the “loss of increased federal funding consistent with the end of the federal Public Health Emergency while costs for caseload persist through the year.”

This is unfortunate because the state expects to have a $22.5 billion budget shortfall in the next fiscal year and further deficits thereafter. Rather than make meaningful cuts to balance the budget, many of Newsom’s budget balancing measures involve taking on more long term debt and shifting resources between funds.

In California, where political leaders have emphasized the need for universal health coverage, the idea of disenrolling Medi-Cal beneficiaries may seem anathema. But it is necessary to minimize wasteful and fraudulent spending. Right now, Medi-Cal is covering highly skilled workers who, after being temporarily unemployed, got high paying jobs as the economy bounced back. These individuals can afford to pay for their company’s insurance coverage. Other beneficiaries may have moved out of state or stopped participating in the program for other reasons. Unless their names are removed from the rolls, unscrupulous providers could file claims under their names.

Medi-Cal beneficiaries who are now self-employed or who hold jobs at employers that do not provide healthcare benefits are eligible to buy policies on Covered California, often with large federal insurance subsidies. So, rather than contribute nothing to the cost of their care, they might expect to pay a relatively small amount for healthcare coverage.

While enforcing eligibility rules may seem cruel, it is necessary to ensure that state resources are available for the truly needy without bankrupting taxpayers or driving them out of the state. The previous Democratic-controlled Congress has invited all states to trim their Medicaid rolls; this is an invitation that California should accept.

Marc Joffe is a federalism and state policy analyst at the Cato Institute.

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Abortion- Montana DPHHS proposes new regulations on Medicaid-reimbursed abortions

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 state is looking to ensure its existing rules around payment for abortion are actually followed.

 
 

Clipped from: https://www.ktvh.com/news/montana-dphhs-proposes-new-regulations-on-medicaid-reimbursed-abortions

 
 

HELENA — This week, state regulators will hold a hearing on a proposed rule change that would add more requirements in order for an abortion to be covered by Medicaid.

The Montana Department of Public Health and Human Services announced the proposal, which would require prior authorization before Medicaid pays for abortion services. DPHHS leaders said additional documentation is needed to ensure that the state Medicaid program is only covering abortions that are medically necessary. However, some advocates say the change would be an unnecessary barrier to accessing an abortion.

The federal government’s Hyde Amendment prohibits Medicaid funding for abortions, except in cases of rape and incest and when the mother’s life is endangered. Montana, though, has a different standard. After a 1995 court ruling, the state has used its own general funds to cover abortions that have been determined to be “medically necessary,” even if the mother’s life isn’t endangered.

DPHHS leaders say, after a contractor reviewed Medicaid-reimbursed abortions, they concluded most claims lacked sufficient documentation to confirm medical necessity.

“The consistent lack of documentation, coupled with the conditions routinely provided on the MA-037 forms as the basis for medical necessity, lead the department to reasonably believe that the Medicaid program is paying for abortions that are not actually medically necessary, but are, in fact, elective, nontherapeutic abortions,” the rule proposal said.

The proposal would require a claim for Medicaid reimbursement to include a number of supporting documents, including a medical history, the results of a physical exam, and confirmation of a medical professional’s diagnosis. It would also say Medicaid reimbursement can only be made when a physician performs an abortion — not a physician assistant or advanced practice registered nurse.

In a statement to MTN, DPHHS director Charlie Brereton again argued the change was necessary.

“DPHHS must ensure that abortions paid for by Montana taxpayers under Medicaid are truly medically necessary, in accordance with the law,” he said. “We welcome comment on the proposed rule and look forward to further protecting the integrity of our Medicaid program through its finalization and implementation.”

But opponents of the change are expressing concerns about the impact it would have on those seeking an abortion.

“It’s functionally an abortion ban for low-income families,” said Aileen Gleizer, a communications consultant with Blue Mountain Clinic. “If individuals have private health insurance, they don’t have to go through these hoops.”

Gleizer says about half of the clinic’s abortion patients are covered by Medicaid, and that other clinics have seen similar numbers.

“Abortions are a time-sensitive service, so the mandatory prior authorization is particularly harmful,” she said. “It would delay abortions later in pregnancy, it would make them more expensive, more invasive, require a longer recovery.”

Gleizer also serves as a board member for the Susan Wicklund Fund, which provides financial support for people seeking an abortion. She said, since the vast majority of Montana counties do not have abortion providers, many of the patients they work with are traveling hundreds of miles. She said the additional requirements – especially the need for a physical exam, which she said could prevent approval by telemedicine – would hit those patients especially hard.

“Adding additional preauthorization, additional appointments, would delay,” said Gleizer. “And we don’t know what that process looks like, and what rejection looks like.”

DPHHS will hold a public hearing on this rule change Thursday, Jan. 12, at 1 p.m., via remote conferencing. The department will accept public comment through Jan. 20.

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Expansion- NC may be the last state to expand Medicaid for a while

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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]: Another good example of the use of Rule #8 from Alinsky’s Rules for Radicals.

 
 

 
 

Clipped from: https://www.northcarolinahealthnews.org/2023/01/11/this-state-could-be-the-last-one-for-a-while-anyway-to-expand-medicaid/

Stateline/ Pew Trusts

For years, state Sen. Phil Berger says, there was nobody in North Carolina who opposed Medicaid expansion under the Affordable Care Act more vehemently than he did.

“If there was somebody in the state of North Carolina that had spoken out publicly in opposition to Medicaid expansion more than me, I’d like to talk to that person,” Berger said in an interview last month. From the time the ACA passed in 2010 until last spring, “my attitude was Medicaid expansion was wrong for North Carolina,” he said.

Berger, a Republican, is president pro tempore of the North Carolina Senate, the most powerful position in the chamber, so his opposition virtually guaranteed that the legislature would not expand the joint federal/state program to include an additional 600,000 adults with low incomes.

That’s why Berger’s recent conversion from opponent to proponent has shot North Carolina to the top of the list of the states that are most likely to break ranks with the other 10 that have refused to expand Medicaid.

But it’s hard to imagine the other states doing the same anytime soon, which means that an estimated 6 million Americans will continue to be denied coverage.

In November, South Dakota became the 39th state to approve expansion under the ACA, but it did so by a citizen-initiated ballot measure over the opposition of the state’s GOP governor and legislative leaders. Six other states also have expanded Medicaid that way. But among the holdouts, only Florida allows that option, and the pathway is so arduous there that proponents recently postponed their campaign for two years.

“We’re pretty close to the end” of expansion by way of citizen initiatives, said Kelly Hall, executive director of The Fairness Project, a national organization created to promote Medicaid expansion and other progressive goals through ballot initiatives.

Of course, it’s possible that GOP leaders in the remaining states, the largest of which is Texas, could have a change of heart like Berger did.

The North Carolinian said he had three objections to expansion: He feared that extending Medicaid coverage might discourage people from seeking work; he worried that the federal government could one day renege on its pledge to cover 90% of the cost of expansion, leaving states holding the bag; and he was concerned about adding to the unpredictability of North Carolina’s wildly fluctuating Medicaid expenses.

That last issue was resolved in 2021 with North Carolina’s transition to a Medicaid managed care system, which Berger says has made expenditures much more predictable. He abandoned his first objection, he said, after coming to realize that most of the younger, nondisabled adults who would be covered under expansion have jobs, are caregivers or are students.

As to the federal government backing out of its commitment on the federal match, Berger noted that it hasn’t done so under Democratic or Republican presidents, or with either party in control of Congress. “It ain’t going to happen,” he said.

Inducements for expansion

When former President Barack Obama signed the Affordable Care Act in 2010, it included a requirement that states expand Medicaid to enable all adults with low incomes to enroll in the program. In 2012, however, the U.S. Supreme Court ruled that Medicaid expansion was optional for states. Nearly half the states and Washington, D.C., expanded in 2014, as soon as the new law allowed, and more followed.

States that rejected expansion turned down substantial inducements. In the original Medicaid program, the federal government pays anywhere from 50% to nearly 78% in matching funds depending on a state’s per capita income. (Congress temporarily raised that federal match rate during the COVID-19 public health emergency.) But under the ACA, the federal match to cover the Medicaid expansion population is 90% for every state.

States that expanded Medicaid experienced job growth, particularly in the health care sector, as a result of the federal largesse. Expansion also reduced the amount hospitals needed to pay for uncompensated care, which was particularly helpful for financially strapped rural hospitals, many of which have closed in the past two decades.

In 2021, in response to the pandemic, the Biden administration added another inducement for the holdout states: a 5 percentage point bump in their federal match under traditional Medicaid for two years. That amounts to hundreds of millions of dollars in extra funding for those remaining states. Florida, for example, would pocket nearly $4 billion of extra federal money if it expanded, according to an analysis by Manatt Health, a research, legal and consulting organization. Mississippi would get $739 million.

“We’re losing money [in Mississippi] every minute we don’t expand, not to mention the human cost,” said Brandon Jones, campaign manager for the Southern Poverty Law Center, which supports Medicaid expansion.

Among the holdouts, only Florida allows for a ballot initiative process that could be used to expand Medicaid. (Wyoming’s law does not allow initiatives involving revenue or appropriations, as a Medicaid expansion would.) But even in Florida, the legislature has made qualifying for a ballot initiative so difficult that backers of Medicaid expansion recently decided to try to get on the ballot in 2026 rather than 2024 as they initially had intended.

“Given the complexities we have here in Florida that you don’t see in other states, even though the will of the people of Florida is there for expansion, but we need time to gather the funds to run a successful campaign,” said Jake Flaherty, campaign director of Florida Decides Healthcare, which is leading the expansion effort.

Flaherty acknowledged that hostility toward expansion from Republican Gov. Ron DeSantis and GOP leaders in the legislature make it virtually unthinkable that an expansion bill could pass. The same is true in many of the other holdout states, including Texas, where recently reelected Republican Gov. Greg Abbott and Lt. Gov. Dan Patrick remain staunchly opposed. Even if privately sympathetic to expansion, GOP lawmakers in Texas are unlikely to cross their party’s state leaders.

Ballot foreclosed in Mississippi

Until recently, Mississippi seemed to be fertile ground for a successful ballot campaign. In fact, several years ago, proponents of expansion launched an initiative campaign with an eye toward getting on the ballot in 2022. But in 2021, the state Supreme Court threw out the state’s ballot initiative process. The ruling pertained to an initiative concerning medical marijuana, but it scuttled the Medicaid expansion ballot campaign.

There have been proposals in the Mississippi legislature to devise a new initiative process that can withstand legal challenge. But for now, proponents of expansion say they don’t see a pathway, and passage in the legislature would have to overcome the steadfast opposition of Republican Gov. Tate Reeves and state House Speaker Philip Gunn.

The state’s GOP leaders remain opposed despite the fact that a majority of Mississippians want to see Medicaid expanded, according to polls. Jones, of the Southern Poverty Law Center, who is a former Mississippi House member, says his private conversations with Republican lawmakers have convinced him that they largely feel the same way. But, he said, they are fearful of crossing their leaders on the issue.

With Gunn’s announcement that he will not run again for his seat, Jones said he believes the legislature will eventually pass expansion.

“Do we do it this year? Probably not. It’s an election year, and we still have a speaker and a governor who are opposed,” Jones said. “But anything big we’ve ever done in Mississippi seems to happen real quickly … that’s what happened with changing the state flag. So, this could be the year it happens with Medicaid expansion.”

Reeves’ office didn’t respond to a request for comment, and Gunn’s office said he wasn’t available for an interview.

In Wyoming, proponents drew encouragement from state House passage of a Medicaid expansion bill for the first time in 2021, but the measure ran aground in the Senate that year.

Proponents in Kansas also have been heartened by newly reelected Democratic Gov. Laura Kelly’s plan to make another run at expansion next year. Polls there too indicate strong support for passage, with more than 70% in favor. Kansas is surrounded by states that have expanded. (Kansas does not have a citizen ballot initiative process. Last August’s referendum in which Kansas voters chose to keep abortion protections in the state constitution was placed on the ballot by the legislature.)

Nevertheless, April Holman, executive director of Alliance for a Healthy Kansas, a coalition of 128 Kansas organizations working toward expansion, said the Republican legislature and its leaders have proved impervious to popular opinion — though pressure is rising.

“For me, I’m always hopeful or I wouldn’t be able to do this work,” Holman said. “But it requires building a movement that is too large and too loud to ignore and that’s what we’ve been trying to do.”

Neither the new Republican House speaker in Kansas, Daniel Hawkins, nor Republican Senate President Ty Masterson responded to Stateline requests for comment.

That leaves North Carolina as the most likely domino to fall next. And if it does, Berger will be one of the key players toppling it.

Berger single-handedly changed the political landscape for expansion by announcing his support last year, putting himself alongside Democratic Gov. Roy Cooper, who has long advocated for expansion. The Senate passed expansion overwhelmingly in its 2022 session, but the bill failed to pass in the House, not because of objections to expansion itself but because of a provision that would have made it easier to create new health facilities or services in the state, which the hospital industry opposed.

Last year’s legislative session was the shorter one in its two-year cycle. As a result, Berger said, the House and Senate didn’t have time to negotiate their differences on the bill. This year, lawmakers will have more time, and Berger said he is optimistic about reaching a different result.

“I have told folks that I felt like by the time the two-year session is over, North Carolina will have expanded Medicaid,” he said. “There’s a deal in there somewhere.”

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This state could be the last one (for a while, anyway) to expand Medicaid

by Pew Trusts, North Carolina Health News
January 11, 2023

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Supervisory Health Insurance Specialist. | Centers for Medicare & Medicaid Services

Clipped from: https://www.linkedin.com/jobs/view/supervisory-health-insurance-specialist-at-centers-for-medicare-medicaid-services-3436495899/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Duties

 
 

  • Directs the work of a diverse staff of employees who develop business, technical and system requirements and manage information systems to operationalize Part B and Part D drug negotiation and inflation rebates.
  • Manages and directs the development of processes and systems to collect manufacturer agreements and manufacturer data and to support the inflation rebate and negotiation processes.
  • Manages the development of and review of technical briefing papers, talking points, testimony drafts, and presentations
  • Represents the division in consultations in consultations with the local, state, and U.S. government officials, and the public regarding system requirements to operationalize Part B and Part D drug negotiations.
  • Attend meetings and conferences with CMS staff and serve as a source of background data on the basis of research performed in preparation for the meetings and conferences.

 
 

Requirements

 
 

Conditions of Employment

 
 

  • You must be a U.S. Citizen or National to apply for this position.
  • You will be subject to a background and suitability investigation.
  • This is a remote position; however, the position reports to a CMS Office on a periodic basis. Requirements to report to the office will vary and can be discussed at the time of interview.

 
 

Qualifications

 
 

ALL QUALIFICATION REQUIREMENTS MUST BE MET BY THE CLOSING DATE OF THIS ANNOUNCEMENT.


Your resume must include detailed information as it relates to the responsibilities and specialized experience for this position. Evidence of copying and pasting directly from the vacancy announcement without clearly documenting supplemental information to describe your experience will result in an ineligible rating. This will prevent you from receiving further consideration.


In order to qualify for the GS-15, you must meet the following: You must demonstrate in your resume at least one year (52 weeks) of qualifying specialized experience equivalent to the GS-14 grade level in the Federal government, obtained in either the private or public sector, to include: (1) Directing or leading the development of business requirements for data management systems; (2) Directing or leading the development of policies, regulations, or procedures for health care programs; and (3) Overseeing the work of subordinate employees or team members.


Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religious; spiritual; community, student, social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.


Click The Following Link To View The Occupational Questionnaire


Education


This job does not have an education qualification requirement.


Additional information


Bargaining Unit Position: No


Tour of Duty: Flexible


Recruitment/Relocation Incentive: Not Authorized


Financial Disclosure: Not required


This position will be in direct support of the Inflation Reduction Act of 2022. This Act increases healthcare spending by nearly $100 billion, mainly by extending the American Rescue Plan’s temporarily-expanded Affordable Care Act (ACA) premium tax credits for an additional three years, through 2025. The bill will also allow Medicare to negotiate prescription drug prices, implement improvements to Medicare Part D including a benefit redesign and new manufacturer discount program, impose inflation rebates for Part B and Part D drugs, and other miscellaneous changes in Part B and Part D to improve the affordability of prescription drugs.


To ensure compliance with an applicable preliminary nationwide injunction, which may be supplemented, modified, or vacated, depending on the course of ongoing litigation, the Federal Government will take no action to implement or enforce Executive Order 14043 Requiring Coronavirus Disease 2019 Vaccination for Federal Employees. Therefore, to the extent a federal job announcement includes the requirement to be fully vaccinated against COVID-19 pursuant to Executive Order 14043, that requirement does not currently apply. Positions with vaccination requirements under authority(ies) separate and distinct from Executive Order 14043 will be clearly identified. HHS may continue to require documentation of proof of vaccination to ensure compliance with those policies. Health and safety protocols remain in effect, in accordance with CDC guidance and the Safer Federal Workforce Task force. Consistent with current guidance, workplace safety protocols will no longer vary based on vaccination status or otherwise depend on the availability of vaccination information. Therefore, to the extent a job announcement states that HHS may request information regarding the vaccination status of selected applicants for the purposes of implementing workplace safety protocols, this statement does not currently apply.


Remote-Out Positions at CMS: This is a remote position; however, the position reports to a CMS Office on a periodic basis (e.g. 1-2 times per year). Requirements to report to the office will vary and can be discussed at the time of interview. As such, your pay will be based on your home address. For more information on locality and pay scales, please


The Interagency Career Transition Assistance Plan (ICTAP) and Career Transition Assistance Plan (CTAP) provide eligible displaced federal employees with selection priority over other candidates for competitive service vacancies. To be qualified you must submit the required documentation and be rated well-qualified for this vacancy.


  • A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding.


Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.

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Medicaid Certification Consultant | Public Consulting Group

Clipped from: https://www.linkedin.com/jobs/view/medicaid-certification-consultant-at-public-consulting-group-3434195048/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Overview

 
 

About Public Consulting Group

 
 

Public Consulting Group LLC (PCG) is a leading public sector solutions implementation and operations improvement firm that partners with health, education, technology, and human services agencies to improve lives. Founded in 1986 and headquartered in Boston, Massachusetts, PCG employs approximately 2,000 professionals worldwide—all committed to delivering solutions that change lives for the better. The firm has extensive experience in all 50 states, Canada, and a growing practice in Europe. PCG offers clients a multidisciplinary approach to meet challenges, pursue opportunities, and serve constituents across the public sector. To learn more, visit www.publicconsultinggroup.com.

 
 

Responsibilities

 
 

The Medicaid marketplace is changing, and PCG is at the forefront. We are looking for an experienced Medicaid Consultant to join our team and help lead our growth efforts. Deep Medicaid experience is critical, as well as experience working with the Centers for Medicare and Medicaid Services (CMS) and the new streamlined modular certification (SMC) and outcomes-based certification (OBC). Our ideal Medicaid Consultant will provide oversight and direction for scope, schedule, , quality, , communications, risk, and , stakeholder management activities, all while adding deep Medicaid and Medicaid Enterprise Systems (MES) experience and thought leadership

 
 

Specific Responsibilities

 
 

  • Demonstrated understanding and knowledge of Medicaid, CMS, SMC/OBC, and MES
  • Conduct Medicaid System Assessments
  • Help states plan for and execute SMC/OBC activities
  • Help lead and provide expert level guidance on various projects
  • Ensure planned results are achieved on time
  • Work with clients, vendors, team members to establish and achieve project goals
  • Address problems through risk management and contingency planning
  • Plan, organize, execute, and monitor and control project activities
  • Perform project assessments and report on project progress
  • Facilitate meetings and present project information
  • Identify, document, and/or escalate issues to appropriate levels

 
 

Required Skills/Experience

 
 

Qualifications

 
 

  • Bachelor’s degree or equivalent university degree
  • 5+ years experience performing project oversight and assessments for a large enterprise grade information technology initiative
  • 4+ years experience performing performance metrics measurements and reporting to management and executive level staff.
  • Demonstrated experience working with SMC/OBC
  • Demonstrated written and verbal communications skills
  • Ability to influence internal and external stakeholders
  • Ability to lead/manage others in a matrixed environment
  • Proficiency in Microsoft applications (Outlook, Word, Excel, PowerPoint, Visio, Project) and project management tools

 
 

#D-PCG

 
 

Compensation

 
 

Compensation for roles at Public Consulting Group varies depending on a wide array of factors including, but not limited to, the specific office location, role, skill set, and level of experience. As required by applicable law, PCG provides the following reasonable range of compensation for this role: $110,000-$140,000

 
 

EEO Statement

 
 

Public Consulting Group is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PCG, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PCG will not tolerate discrimination or harassment based on any of these characteristics. PCG believes in health, equality, and prosperity for everyone so we can succeed in changing the ways the public sector, including health, education, technology and human services industries, work.