Category: MM Curator

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MCOs- Scan Group Merges with Oregon Managed Medicare and Medicaid Nonprofit

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 2 organizations will a footprint of 800,000 members and a revenue footprint of $7B. And a whole box of toys to play with when it comes to various acquired solutions and provider groups.

 
 

Clipped from: https://labusinessjournal.com/healthcare/medical-center/scan-group-merges-with-oregon-managed-medicare-and-medicaid-nonprofit/

Long Beach-based Scan Group, a senior health care nonprofit, and Portland, Oregon-based CareOregon, a managed care nonprofit, have agreed to merge under the new name HealthRight Group.

The merger, which was announced last month, is intended to give both nonprofits more clout in a marketplace for government-funded health care programs increasingly dominated by for-profit managed care providers such as Long Beach-based Molina Healthcare Inc. and St. Louis, Missouri-based Centene Corp., parent of Woodland Hills managed care provider Health Net. The deal is expected to close sometime this year. Scan Group, which has about 1,600 employees, is the parent company of Scan Health Plan, which had revenue of around $3.6 billion last year. It has about 275,000 members, mostly in California but also in Arizona and Nevada. Later this year, it plans to start enrolling people in Texas, pending approvals.

 
 

Scan Group’s Long Beach headquarters.

CareOregon has been focused on providing managed care for low-income individuals through government subsidy programs, especially Medicaid. It’s similar to Westlake-based L.A. Care, which provides health care for the nearly 25% of Angelenos who meet low-income thresholds. It has about 515,000 members, with nearly 320,000 of those in various Medicaid plans.

Financial terms of the deal were not disclosed. According to the Dec. 14 announcement, the new combined HealthRight Group entity will have revenues of about $6.8 billion and will serve nearly 800,000 health plan members through its Medicare and Medicaid managed care offerings.

While the announcement did not say where HealthRight Group will be headquartered, its designated chief executive, Sachin Jain, and board chair Linda Rosenstock currently hold those same posts with Scan Group in Long Beach. CareOregon Chief Executive Eric Hunter will retain that post and serve as president of HealthRight’s Medicaid Division.

Jain specifically referenced the aim of gaining more clout in the government-funded health care provider space.

“For far too long, America’s not-for-profit managed care organizations have operated at a scale disadvantage to their larger for-profit competitors,” Jain said. “HealthRight aims to bring together two complementary organizations to benefit from greater scale, while maintaining focus on the people and communities they serve.”

In addition to its health plans, HealthRight will operate a diversified business unit comprising assets from both organizations including Welcome Health, a geriatric home-based primary care medical group; Housecall Providers, an in-home primary and palliative care provider; MyPlace Health, a joint venture between Scan Health and Boston-based Commonwealth Care Alliance; Healthcare in Action, a medical group for people experiencing homelessness; and HomeBase Medical, a medical group focused on improving chronic disease management and palliative care for Medicare beneficiaries.

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Tech- Wyoming Receives CMS Certification for Its Medicaid Provider Management System Delivered by HHS Technology Group

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]: Yeah it’s a self-serving press release, but it is interesting to see progress on the decades long path to modularity.

 
 

Clipped from: https://finance.yahoo.com/news/wyoming-receives-cms-certification-medicaid-121100422.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAALMMY3tMR3RhrBoLTCC4IVoMnJqTkqJLK9JvU3K6_47OwWsDqX-MvLdIM-nGFWO39Gv-jR5JqFS5UF0j6GZh55r-5lDL3rrJUfch3b7NXpM7nSCrrZePaXTlrzUbV_EF3nWn5iftRoHCVIcvk4mdCEoLkf12knLVhqBSHzgeCuGg

Discover your Provider® solution streamlines enrollment, screening, and monitoring for Wyoming’s Medicaid providers

FORT LAUDERDALE, Fla., Jan. 3, 2023 /PRNewswire/ — HHS Technology Group, LLC™ (HTG) announced today the Wyoming Department of Health (WDH) received final certification from the Centers for Medicare & Medicaid Services (CMS) for its Provider Enrollment, Screening, and Monitoring (PRESM) system powered by HTG’s Discover your Provider® (DyP®) solution. DyP® offers an advanced online provider portal with electronic and self-service capabilities, such as provider enrollment and license verification, with proven success in improved operational efficiencies, added convenience, and simplified processes, resulting in increased cost savings and a better provider experience.

 
 

HHS Technology Group is a software and solutions company serving the needs of commercial enterprises and government agencies. HHS Tech Group delivers purpose-built, modular software products, solutions, custom development, and integration services for modernization and operation of systems that support a wide spectrum of business and government needs. For more information about HHS Technology Group, visit www.hhstechgroup.com. (PRNewsfoto/HHS Technology Group)

“We are pleased to collaborate with HHS Technology Group to launch the PRESM system,” said Jesse Springer, Medicaid Technology and Business Operations Section Manager, Wyoming Department of Health. “We believe we now have one of the fastest, if not the fastest, Medicaid provider enrollment and re-enrollment systems and processes in the nation.”

A cloud-based, holistic platform, DyP® serves as the system of record for all of Wyoming’s Medicaid, Kid Care CHIP, and WDH provider enrollments. HTG’s contract with Wyoming’s Division of Healthcare Financing includes the operation, maintenance, and enhancement of the PRESM system, which has been in production since April 2021. HTG’s call center also provides critical support and technical assistance to Wyoming Medicaid providers.

“For states to properly administer Medicaid programs that efficiently deliver high-quality medical services to vulnerable populations, it is critical to have clean, accurate, reliable provider data,” said Bradley White, CEO of HTG. “With the launch of PRESM, Wyoming now has an industry-leading solution to optimize all provider management processes, including screening, enrollment, and monitoring.”

In addition to facilitating and promoting greater provider participation, DyP® leverages a modular design for increased functionality and leading-edge technology to streamline once-seemingly cumbersome and time-consuming processes significantly. The significant value delivered by DyP® to states and providers includes:

  • Reduced enrollment time for new providers from over one month to under five days.
  • Significantly reduced state and contractor burden and time (approximately 2 FTEs) from the previous manual process for new applications, renewals, and licensing updates.
  • A fully integrated pharmacy provider enrollment process with streamlined monitoring.
  • A 100% electronic provider agreement process, including signatures.

Notably, DyP® is one of six certified Medicaid Management Information System (MMIS) provider solutions, and HTG is among the few companies to obtain certification for multiple modules, as evaluated and awarded by the National Association of State Procurement Officials NASPO) ValuePoint contracting arm. Most recently, HTG’s Recover your Liability® (RyL®) solution, which automates third-party liability functions and integrates with other MMIS modules, earned NASPO ValuePoint certification.

To learn more about HTG’s Discover your Provider® platform and its proven success, visit HHS Technology Group online.

About HHS Technology Group, LLC

HHS Technology Group (HTG) is a software and solutions company serving the needs of commercial enterprises and government agencies. HTG delivers modular software solutions, custom development, and integration services for the modernization and operation of systems supporting a broad spectrum of business and government needs. For more information about HHS Technology Group, visit www.hhstechgroup.com.

Media Contact: 
Janet Mordecai
Amendola Communications (for HHS Technology Group)
jmordecai@acmarketingpr.com

 
 


Cision

View original content to download multimedia:https://www.prnewswire.com/news-releases/wyoming-receives-cms-certification-for-its-medicaid-provider-management-system-delivered-by-hhs-technology-group-301712112.html

SOURCE HHS Technology Group

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Fraud/Waste- Medicaid: Improper Payments Caused by Mismanagement, Broken Priorities

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 author says things we don’t want to hear.

Clipped from: https://www.nationalreview.com/2022/12/medicaids-improper-payments/

 
 

(digicomphoto/Getty Images)

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Progressive health policy over the past decade has centered on expanding Medicaid. Unfortunately, this drive has undermined the original purpose of Medicaid and compromised the program’s integrity. Improper payments have spiraled out of control even as the government has systematically undercounted them.

The Centers for Medicare and Medicaid Services (CMS) recently released a report estimating $132 billion in annual improper payments in federal health-care programs. Over 60 percent of reported improper payments are from Medicaid, and CMS estimates that about 16 percent of Medicaid payments don’t follow program rules.

The operative word is “reported.” That’s because the actual level of improper payments is much higher than what the government is counting.

Efforts to uncover problems with eligibility have been notably lacking, even though eligibility problems are the primary reason for Medicaid’s improper payments. Since Medicaid is a welfare program only lawfully available to low-income Americans, verifying eligibility is vital.

From 2014 to 2017, as Obamacare’s expansion of the program began, the Obama administration halted Medicaid-eligibility reviews. In 2018, those reviews restarted, and the reported improper-payment rate soared. But CMS only did meaningful reviews for two years.

Between April and August 2020, it entirely halted improper-payment assessments. CMS has cited “COVID-19 flexibilities,” such as postponed eligibility determinations, as a factor in the decrease of reported improper payments from $99 billion in last year’s report (22 percent of all Medicaid payments) to $81 billion this year.

In short, Medicaid has become prone to improper payments while the government refuses to measure them accurately.

The government’s failure to confirm Medicaid eligibility before enrollment is egregious, particularly since expanded eligibility over the past decade has transformed the program. Medicaid was originally designed to assist the most vulnerable Americans: low-income pregnant women, children, seniors, and individuals with disabilities. However, Obamacare offered states generous financial incentives to expand Medicaid to able-bodied, working-age adults. These incentives resulted in massive increases in Medicaid enrollment and spending in states that adopted the Obamacare expansion — accompanied by a significant increase in improper payments.

Covid-19 policies have caused the program to swell further. Congress explicitly forbade states from updating their eligibility criteria or removing ineligible Medicaid enrollees during the Covid-19 public-health emergency. Once again, it deployed federal subsidies to entice them to comply. Even though the pandemic is over, the Biden administration has refused to end the official emergency; Medicaid rolls continue to swell, with one-in-four Americans on this welfare program.

Just from the Obamacare expansion, Medicaid already had a flood of spending on ineligible individuals. An Inspector General audit from 2014 to 2015 estimated that just two states (California and New York) made more than $6 billion in Medicaid payments for 5.4 million enrollees who were either ineligible or did not have their eligibility adequately reviewed. And the problem is much worse today.

This disregard for taxpayer dollars is particularly scandalous as the country grapples with ballooning deficits and 40-year high inflation. But it isn’t just a matter of dollars and cents.

Medicaid expansion has devoted more resources to able-bodied working-age adults rather than the neediest people for whom Medicaid was originally intended. In a program where long wait times are nothing new, this means a further deterioration in quality. The combination of improper payments and deficient audits point to deep programmatic mismanagement, not to mention broken policy priorities.

There is much to fix in Medicaid, and the task is so much more arduous when the federal government downplays the problem. Eligible recipients, as well as taxpayers footing the bill for Medicaid, deserve better than this mismanagement and careless spending. The new Republican House majority should investigate the Biden administration’s policies that have contributed to improper payments and the steps taken to downplay the problem.

Brian Blase, who served as a special assistant to President Trump at the National Economic Council, is president of Paragon Health Institute. Joe Albanese is a policy analyst at Paragon Health Institute.

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Texas, red states consider expanding Medicaid after abortion restrictions

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]: Pro-lifers are becoming an ally in maternal health. Or maybe its just that their detractors are starting to realize they always were..

 
 

Clipped from: https://www.washingtonpost.com/nation/2022/12/29/abortion-medicaid-texas/

 
 

A previous version of this article misidentified a woman as Yolanda Jackson in the photo caption for the second photo. She is Yolanda Washington. This version has been corrected.

Makayla Robinson is seven months pregnant, unemployed, living at a Dallas maternity home and relying on health care from Medicaid that could end next spring.

In Texas, Medicaid covers new mothers for two months after they give birth. For now, Robinson, 22, and others have extended coverage because of the federal pandemic public health emergency that the Biden administration has thus far approved through April.

Robinson worried what would happen after that.

“I wouldn’t be able to go to the doctor,” she said. ” … I’m having financial problems. The Medicaid really helped.”

The limits on Robinson’s Medicaid coverage after the emergency insurance lapses hinge on Texas’s long-standing rejection of the Affordable Care Act, which included provisions for expanded Medicaid. And it has set up an uncomfortable dynamic: While Texas and nearly a dozen other red states have resisted expanding Medicaid for those who are pregnant, many of them have also restricted access to abortion, leading to more new mothers needing coverage.

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Now Republican lawmakers in Texas, Mississippi, Wyoming and other red states face a choice: focus exclusively on further restricting abortion, or join antiabortion groups and Democrats lobbying to expand postpartum Medicaid coverage.

“There’s a discussion among Republicans and those who are anti-choice about what should we be doing to support mothers?” said Usha Ranji, associate director for women’s health policy at the Kaiser Family Foundation.

Some national antiabortion groups that support postpartum Medicaid expansion have proposed other legislation to expand funding for those who are pregnant, in the wake of new state curbs on abortion after the Supreme Court’s Dobbs decision erased the protections of Roe v. Wade.

“On our side, there is an awareness and a very strong move after Roe’s overturn toward caring for women,” said Steve Aden, general counsel and chief legal officer for Washington-based Americans United for Life. “I think the whole movement is looking for ways to implement policy on the state level to support the increasing number of women who will have children.”

Republicans have long controlled both chambers of the Texas legislature, which allowed them to pass one of the strictest abortion laws in the country last year ahead of the Supreme Court’s decision. Last year, the Texas House also passed a measure that would have expanded postpartum Medicaid for a year. But the Texas Senate — including Sen. Bryan Hughes (R), author of the state’s restrictive abortion law — halved postpartum Medicaid to six months. Gov. Greg Abbott (R) signed the bill, but because it didn’t cover those who had had abortions, the Biden administration refused the extension.

Now Texas Right to Life and other antiabortion groups are lobbying for passage of a year-long postpartum Medicaid extension at the next legislative session that starts in January.

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“This policy fits into a bigger collage of pro-life policies we can pass to promote a pro-life Texas,” said John Seago, president of Texas Right to Life. “We want Texas to be abortion-free, but we also want Texas to be pro-life. We want these mothers to be healthy and to have access to the care they need.”

The conservative Austin-based Texas Public Policy Foundation is also backing expanded postpartum Medicaid, arguing that it can save the state money through preventive care.

“With many complications that come up, there’s a cost that comes back around for the state with many uninsured. It’s much better to make sure these moms are healthy so they can take care of the children,”
said
David Balat, director of the foundation’s Right on Healthcare initiative and a former hospital executive.

Robinson was homeless when she arrived at the
nonprofit Viola’s House maternity home soon after moving to Dallas from Memphis, unaware that Tennessee lawmakers had just agreed to extend Medicaid postpartum up to a year starting this spring. She said she fled a “toxic environment” of neighborhood violence, leaving her partner behind in search of a better quality of life in Texas for her son, whom she plans to name Uriah.

Robinson had graduated high school but not college. She initially worked as a hotel housekeeper but soon had to quit, unable to stand all day. She applied for front-desk and restaurant positions, she said, but, “Most jobs don’t want to hire me, seeing the belly sticking out.”

Viola’s House serves five homeless pregnant women ages 18 to 24 at a time, providing housing, coordinating medical care and offering other support. Most arrive already enrolled in Medicaid, according to Yolanda Washington, the residential services manager who helps them arrange health care.

She said extended Medicaid coverage during the pandemic has helped residents get back on their feet.

“It makes a difference. It takes that long for a woman to do her six weeks rest, breastfeeding with the baby, start to get up and get insurance from a job,” Washington said.

She said many of the women at the maternity home don’t know their Medicaid benefits will expire. Her granddaughter found out the hard way when she went to a doctor three years ago and was told she no longer had coverage.

Without Medicaid coverage, Washington said, “It stops them from going and getting preventive care, because they say, ‘How am I going to pay for a Pap smear? Or birth control?’ The only way they go is the emergency room.”

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Viola’s House founder and executive director, Thana Hickman-Simmons, said it gets funding from the state as well as from those on both sides of the abortion issue, so she tries to stay out of politics. But she was troubled to see many pandemic benefits ending, potentially postpartum Medicaid.

“Can the government do more for mothers who are facing an unplanned pregnancy? Absolutely. They’re making rules and not doing enough for the rules that they’re making,” Hickman-Simmons said. “You’ve got to fund all the services it takes to support life.”

Seago’s lobbying for postpartum coverage — “Don’t call it Medicaid expansion, just ensuring insurance for moms up to a year after birth” — has won support in the Texas House, including Republican House Speaker Dade Phelan, who helped pass the measure last year and is still committed, staff said.

But for the law to pass in the upcoming session, Phelan has to convince fiscal conservatives in the Texas Senate, including hard-right Lt. Gov. Dan Patrick, that the measure saves money in the long run and should be a priority over other antiabortion proposals by Hughes and others, such as barring out-of-state travel for abortions or requiring men to pay child support from conception.

Hughes and Patrick did not respond to requests for comment on the proposal.

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“It’s really a question of when are you paying for this care: preventive or after she gives birth and ends up in the emergency department? From our point of view, this is a wise investment, both financially and morally,” Seago said.

Texas Alliance for Life, the state’s other large antiabortion group, had not taken a position on postpartum Medicaid expansion, but its board was still considering the measure, said spokeswoman Amy O’Donnell.

Seago is
pushing a revamped version of last year’s bill sponsored by state Rep. Toni Rose (D).

“She’s a pro-abortion Democrat, but this is an area where pro-lifers are supporting her and this agenda,” he said.

Rose said it made sense that antiabortion groups would support the measure.

“It’s a pro-life bill. We want to save lives,” she said. ” … As I’ve stated to my colleagues, if you’re pro-life you should be able to get behind this.”

Rose said Texas Senate leaders have to consider the fallout from their abortion posture: “If we want women to carry the baby, let’s give them the resources they need to do that.”

The American College of Obstetricians and Gynecologists supports postpartum Medicaid extensions, noting in a statement that while maternal mortality is increasing nationwide, “a growing body of evidence shows that many of these deaths, particularly from preventable causes such as overdose and suicide, occur after pregnancy-related Medicaid coverage ends.”

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Pregnant Texans are more likely to be uninsured and less likely to seek prenatal care than those in the rest of the country, and the state has high rates of maternal mortality and morbidity, especially among Black women. At least 52 pregnancy-related deaths were reported in 2019, 27 percent occurring 43 days to a year after pregnancy, according to a report released in December by the state Department of State Health Services. Severe medical complications from pregnancy and childbirth also increased significantly between 2018 and 2020, from 58.2 to 72.7 cases per 10,000 deliveries in Texas, according to the report.

Among the committee’s top recommendations: expanding postpartum health-care coverage to a year.

“People are quickly falling off the pregnancy-related coverage and not getting coverage because the income eligibility threshold is quite low in Texas, and they are not getting private coverage and reporting health concerns they either address in the emergency room or don’t address,” said Kari White, lead investigator with the Texas Policy Evaluation Project at the University of Texas at Austin.

Without extended coverage, she said, “pregnant Texans are really going to fall through gaping holes in the safety net.”

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Enrollment- UPDATED: ACA enrollment increases 18% over last year, fueled by Inflation Reduction Act tax credits

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]: Exchange enrollment is up.

Clipped from: https://www.healthcarefinancenews.com/news/aca-enrollment-increases-18-over-last-year-fueled-inflation-reduction-act-tax-credit-subsidies

The ACA is seen as an alternative for Medicaid coverage as states begin the redetermination process starting April 1.


Photo: HealthCare.gov

Affordable Care Act marketplace enrollment continues to outpace previous years, with nearly 11.5 million people selecting a health plan nationwide as of Dec. 15, the deadline for coverage starting Jan. 1, 2023, according to the Department of Health and Human Services. 

About 1.8 million more people have signed up for health insurance, or an 18% increase, from this time last year, HHS said.

In 2022, the number of those signing up through the federal marketplace on HealthCare.gov totaled 10.2 million. Final 2022 enrollment numbers recorded 14.5 million consumers signing up for coverage in all states, with 3 million being new consumers, according to the Centers for Medicare and Medicaid Services snapshot.

The HealthCare.gov Marketplace Open Enrollment remains open until Jan. 15, 2023, for coverage beginning Feb. 1, 2023.

The next snapshot of national plan selections, including state-based marketplaces, will be released Jan. 11, 2023.

WHY THIS MATTERS

HHS credits investment in the Inflation Reduction Act for tax credits that have allowed four out of five HealthCare.gov consumers to find a health plan for $10 a month or less.

“Unprecedented investments lead to unprecedented results,” HHS Secretary Xavier Becerra said. “Under President Biden’s leadership, we have strengthened the Affordable Care Act Marketplace with continued record affordability, robust competition, and historic outreach efforts – and today’s enrollment numbers reflect that.”
 
Ninety-two percent of HealthCare.gov enrollees will have access to options from three or more insurance companies when they shop for benefits, HHS said. Consumers can compare and select options by creating standardized plans that offer many of the same benefits at the same cost.
 
THE LARGER TREND

The national uninsured rate reached an all-time low earlier this year, according to HHS.

This means less uncompensated care for hospitals.

One concern that could increase the number of uninsured is the end of the Medicaid continuous enrollment requirement that was put in place under the public health emergency. An estimated 18 million Medicaid beneficiaries could lose their health insurance as states go through the redetermination process for coverage.

With passage of the $1.7 trillion omnibus spending package, states may start processing Medicaid determinations on April 1, whether the PHE is still in place or not.

The ACA is seen as an alternative for beneficiaries who no longer qualify for Medicaid coverage.

Whether those no longer qualifying for Medicaid could immediately jump onto ACA coverage under a Special Enrollment Period is not clear. What is clear is that passage of the omnibus bill severs Medicaid redeterminations from the end of the PHE.

CMS did not comment on the issue but a spokesman there said, “There’s a lot of work ahead for us to do.”

Special Enrollment Period coverage is generally available to those who have had a life event, such as a marriage, divorce, or having or adopting a child. HealthCare.gov directs consumers who have had a life event, other than a loss of coverage, more than 60 days ago and who missed the Special Enrollment Period to contact the Marketplace Call Center at 1-800-318-2596. But COVID-19 is also considered a qualifying reason.

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org

 
 
 

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Reform- MassHealth Selects Community Partners for Medicaid ACOs

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]: MA is bolting on a slew community partners to its Medicaid ACO model. Or making it more official, rather.

Clipped from: https://www.hcinnovationgroup.com/policy-value-based-care/medicare-medicaid/news/21291392/masshealth-selects-community-partners-for-medicaid-acos

After seeing promising results in the first three years of the program, the Commonwealth of Massachusetts has selected 20 community partners to work with the 17 accountable care organizations (ACOs) in the state’s Medicaid program called MassHealth.

Massachusetts recently received federal approval through its 1115 demonstration to refine the ACOs and Community Partners programs over the next five years.

Community Partners work with ACOs to support MassHealth members with significant behavioral health and complex long-term services and supports needs.

Over the last three years, the Community Partners program has shown a reduction in ER visits by 21 percent, a reduction in behavioral health admissions by 30 percent, and a reduction in risk-adjusted total cost of care by 20 percent. The Behavioral Health Community Partners program complements the Commonwealth’s Roadmap for Behavioral Health Reform, which significantly expands access to mental health and addiction treatment.

“Integrating the full healthcare needs of MassHealth members with complex health conditions remains a primary goal in the next phase of the Commonwealth’s healthcare delivery restructuring,” said Secretary for Health and Human Services Marylou Sudders, in a recent statement. “Community Partners play an essential role in delivering coordinated care for MassHealth members, including individuals with disabilities, mental illness, substance misuse disorders and co-occurring disorders.”

The goals of the Community Partners program for the next five years include:

  • Re-affirming MassHealth’s commitment to community-based outreach and care coordination for the highest-risk members, leveraging the expertise of community-based organizations;
  • Continuing to incentivize integration of care across physical health, behavioral health, long-term services and supports, and health-related social needs;
  • Strengthening Community Partners’ accountability for outcomes and standardizing expectations for the delivery of care coordination supports; and
  • Simplifying and streamlining the relationships between Community Partners and ACOs.

The announcement includes the selection of 12 Behavioral Health and eight Long-Term Services and Supports Community Partner organizations. MassHealth ACOs and managed care organizations will contract directly with Community Partner organizations, with the goal of improving integration and care coordination for MassHealth members.

The selected Long-Term Services and Supports Community Partners are:

  • Behavioral Health Network, Inc.
  • Boston Medical Center Corp.
  • Center for Human Development 
  • Community Care Partners, LLC 
  • Family Service Association of Greater Fall River, Inc 
  • Greater Lynn Senior Services 
  • Open Sky Community Services    
  • Seven Hills Family Services 

The selected Behavioral Health Community Partners are:

  • Behavioral Health Network, Inc.
  • Behavioral Health Partners of MetroWest 
  • Boston Health Care for the Homeless Program, Inc. 
  • The Brien Center 
  • Center for Human Development 
  • Clinical and Support Options, Inc. 
  • Community Care Partners, LLC 
  • Community Counseling of Bristol County 
  • Eliot Community Human Services, Inc 
  • Open Sky Community Services 
  • Riverside Community Care, Inc 
  • Stanley Street Treatment and Resources, Inc.

 
 

 
 

 
 

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Fin/Budget/Reform- Federal Budget Bill Permanently Increases Medicaid Funding For US Pacific Territories

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]: Reminder- there’s more than 50 Medicaid programs.

Clipped from: https://www.civilbeat.org/2022/12/federal-budget-bill-permanently-increases-medicaid-funding-for-us-pacific-territories/

The Covid-19 pandemic in U.S. Pacific territories drove up unemployment, halted tourism economies and prevented families from going home. But it also brought a much-needed influx of federal funding that local officials say helped island governments provide more health care services.

Now, some of that funding will be permanent. On Thursday, President Joe Biden signed the $1.7 trillion budget bill.

The bill preserves a federal Medicaid funding match of 83% for all three U.S. Pacific island territories — Guam, American Samoa and the Northern Mariana Islands — as well as the U.S. Virgin Islands, and extends Puerto Rico’s 76% rate for another five years.

It’s a critical victory for lawmakers and advocates who have been pushing to preserve higher Medicaid funding rates that Congress enacted during the first two years of the pandemic. One American Samoan official said she expects the funding will allow the territory to expand cancer treatment options for patients.

 
 

The Medicaid office in the Northern Mariana Islands posts signs to manage the crowds of people who have signed up for the public health insurance program. Carlo Domingo/Civil Beat/2022

Medicaid is a public health insurance program that serves low-income individuals and families. It provides valuable health care coverage for people who may not get access to health insurance through work or wouldn’t otherwise be able to pay for their own premiums on the insurance marketplace.

That includes a large swath of people who live in U.S. territories, where health care infrastructure is limited and health care staff shortages are the norm. Families often find themselves flying to Hawaii or other places for health care they can’t get at home.

“We want to reduce our reliance on off-island care,” said Sandra King Young, who leads Medicaid services in American Samoa,. “We want to build our local capacity to care for our people. It’s better for our families, they don’t have to be displaced to get medical treatment off island.”

Territory Funding Caps

King Young thinks the prior arrangement effectively treated U.S. territories like much wealthier states.

In U.S. states, the federal matching percentage for Medicaid changes according to the state’s per capita income, according to analysis by the Kaiser Family Foundation. U.S. territories, however, were treated differently and subject to the fixed federal match of 55% and statutory funding caps.

That’s despite relatively high poverty rates in U.S. territories. In 2019 when the 55% matching rate for U.S. territories was in place, Hawaii’s federal matching percentage for Medicaid funds was about 54%. That year, 6.4% of Hawaii families lived below the federal poverty level according to the American Community Survey.

By comparison in American Samoa 50% of all families lived under the poverty level that year. In the Northern Mariana Islands, it was 33%, and on Guam, the family poverty rate was 16.8%. King Young says the 83% Medicaid fund match, the maximum permitted under statute, brings American Samoa more in line with mainland states like Mississippi that similarly have above average poverty rates.

The bill also requires territorial governments to submit a four-year strategic plan to the federal government by the end of September and includes funding to improve Medicaid data systems in the Northern Mariana Islands, Guam, U.S. Virgin Islands and American Samoa.

More Money for Cancer Treatment

Gov. Lou Leon Guerrero from Guam said in a press release that the money will help Guam treat more Medicaid recipients and expand Medicaid services.

“This bill will help us provide greater access to health care and critical health services to those in our community most in-need,” she said.

In American Samoa, King Young says that cancer patients in particular will benefit from the increased funding. Right now, Medicaid patients who need cancer treatment must pay their own way to get care, often requiring a flight to New Zealand.

The territory can sometimes cover diagnostic work for cancer or pay to send a Medicaid patient to New Zealand for diagnosis but if it turns out they have cancer, “then we stop the coverage,” Young said. “Then the patient is on their own.”

King Young thinks that will change with the higher federal matching percentage.

“We intend to start covering cancer treatment and cancer patients,” she said. The Northern Mariana Islands has also used the increase in federal funding during the pandemic to establish oncology services in the island’s only hospital where about 70% of patients rely on Medicaid.

U.S. Rep. Gregorio Sablan from the Northern Marianas said in his e-newsletter that increasing the federal Medicaid match has been a goal of his since taking office more than a decade ago.

“Without today’s spending bill the federal share would drop to 55%, costing the Commonwealth an estimated $40 million and threatening services at the Commonwealth Healthcare Corporation, which depends on Medicaid for 37% of revenue,” he said.

King Young from American Samoa noted that improving local access to oncology services is a long-term investment that will require planning and staffing resources.

“It’s not going to be fixed by just getting money,” she said.

 
 

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Reform- Ga. only state to require work for 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]: David beat Goliath; Goliath whines after the loss.

Clipped from: https://www.valdostadailytimes.com/news/ga_fl_news/ga-only-state-to-require-work-for-medicaid/article_8e290454-86e3-11ed-8101-b3ae7ea4b3a6.html

ATLANTA – After years of legal wrangling, the countdown to the July 1, 2023, launch date of Georgia’s Medicaid work requirements program is underway.

The new plan – officially called Pathways to Coverage – will require enrollees to complete 80 hours of work, education, job training, or community service per month to get Medicaid health insurance. Many will also have to pay a monthly premium.

Once the program begins, Georgia will be the sole state with work requirements for Medicaid. Adults between ages 18 and 64 who earn less than 100% of the federal poverty level – and who are not otherwise eligible for Medicaid – are the targeted group. For 2022, the federal poverty level was $13,590 for a single person and $27,750 for a family of four.

Though exact numbers are difficult to calculate, it’s expected that the Pathways program will provide insurance to only a small percentage of the 1.3 million Georgians without health insurance.

State officials estimate around 345,000 Georgians would be eligible for the new program. Back in 2020, they said they expected only about 64,000 people to actually enroll in the program.

Now that the program is becoming a reality, the Georgia Department of Community Health (DCH), the state Medicaid agency, has requested funds to cover up to 100,000 people in the upcoming budget, said spokesman David Graves. That’s 29% of those who will be eligible.

“Georgia leadership has put in place barriers that they know, that they have calculated, will prevent … people from enrolling,” said Leonardo Cuello, research professor at Georgetown University’s Center for Children and Families, about the discrepancy between the number of eligible people and the number expected to enroll.

Critics of Pathways contend the program will cover far fewer Georgians and cost more than a full expansion of Medicaid, as 39 states have done.

Leah Chan, senior health analyst at the Georgia Budget and Policy Institute, a left-leaning think tank in Atlanta, said the new program will cost around $2,420 per enrollee while it would cost only $496 per enrollee if the state fully expanded Medicaid.

“New financial incentives under the American Rescue Plan sweeten the deal [for full Medicaid expansion] and more than offset the state cost of expansion for at least the first two years,” Chan said.

Enrollees in Georgia Pathways will need to certify their employment each month. Those who earn more than 50% of the federal poverty level will also be required to pay a monthly premium ranging from $7 to $11, with an additional surcharge for people who use tobacco products.

The program will provide a two-month grace period for people who do not pay their premiums.

But after three months of non-payment, they will lose the insurance. They can be reinstated if they make at least one monthly payment within 90 days.

The state plans to use the existing benefits portal, Georgia Gateway, for program applicants to manage their work-requirement reporting, said Graves, the DCH spokesperson. He said Georgians can expect to learn more about the details of the program over the coming months.

Critics say the machinery necessary to track enrollee work records and payments will dramatically increase bureaucratic burdens both for Medicaid recipients and the state.

“When you think about working families in Georgia, they are busy with their jobs, getting kids to school and the doctor, paying the stack of bills that come in every month, and the last thing they need is additional red tape … every month just to keep their health insurance from getting terminated,” Cuello said.

Cuello said the state will have to develop “expensive administrative processes” to ensure compliance with the work requirements. The [congressional Government Accountability Office] and states have estimated costs ranging from $70 million to $270 million a year to implement and run this type of program, he said.

DCH has not yet decided whether it will need to hire additional staff to help run the program, Graves said.

The Pathways program allows some exceptions to the work-requirement rules. Enrollees will be allowed 120 hours of “non-compliance,” that is of not meeting the work requirements, in every 12-month period.

But routine child care is not on the list of exceptions.

Other states that previously attempted work requirements ensured that caring for young children was a valid reason for not meeting the requirements and would not result in losing insurance.

“A stay-at-home parent taking care of two young kids in a family that lives at half of the poverty level … can’t afford child care, and they can’t just leave two young kids at home alone,” Cuello said. “Georgia’s plan makes no exceptions for these parents, and they will be denied health insurance.”

The plan has federal approval to operate until Sept. 30, 2025.

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Director Actuarial Services (Medicaid)

Clipped from: https://www.adzuna.com/details/3774541772?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

UPMC offers a premier benefits package, designed to care for your total well-being — physically, emotionally, and financially — paired with endless opportunities for career advancement and educational growth. Kickstart a rewarding career with UPMC!

Responsibilities:

  • Consultant within UPMC Health System; Act as an Actuarial Consultant within the UPMC Health System and perform various activities, Including IBNR calculations, Data Analysis.
  • Ensure that the departmental work products meet the highest standards of quality.
  • Reserving: Works with the financial reporting department to develop reserve amounts for IBNR claims, active claims and premium deficiency reserves on a regular or as-needed basis.
  • Benefits and Product Development: To provide appropriate UPMC management personnel with actuarial valuations of the Impact of any proposed benefit changes or new product designs on an as-needed basis.
  • Underwriting: Works closely with the underwriting department to:Provide pricing tools to enable underwriting personnel to produce accurate price quotes on request from Sales and Marketing staff in a timely basis, together with whatever appropriate supportive documents may be needed by sales staff to facilitate sales.
  • Provider Relations/contracting: To provide reports for the purpose of evaluating and advising UPMC HP management on the financial impact of proposed provider agreements or changes to existing agreements on an as-needed basis.
  • Manage Actuarial Department: Supervise Actuarial department and various entities within UPMC Health Plan as needed to ensure department goals and objectives are met.
  • Pricing: To develop product pricing levels, factors and methods to ensure premium and revenue flow adequate to cover medical and administrative costs and profit margins for the various product lines consistent with corporate strategic goals. Also, to advise UPMC Health Plan senior management on the financial impact of any special pricing or contract arrangements which may affect health plan financial profitability.
  • Work with the UPMC HP Appointed Actuary to ensure satisfactory filings of annual Statements of Actuarial Opinion and associated memoranda.
  • Direct the development and assessment of underwriting methods and tools in order to enhance the ability of underwriting staff to accurately identity and quantify risk, and so produce price quotes which appropriately match premium to risk.
  • Supervise Actuarial department personnel to ensure that departmental objective and goals are achieved in a timely manner
  • Forecasting: To provide UPMC HP senior management with regular and ad hoc reports which communicate current and future near- and long-term projections of financial performance of the various health product lines in order to facilitate corporate decision and the development of corporate strategies and goals.
  • Compliance: Ensure that all required statutory rate filings are submitted appropriately, and that all rates, factors and methods are in compliance with applicable state and federal regulations. Ascertain and comply with filing and actuarial requirements for participation in government-sponsored health plans as appropriate.
  • Additional Business: Ability to learn new lines of business to help UPMC Health Systems to expand into different arenas such as Slop Loss Insurance or Workers Compensation.

Qualifications

  • Minimum Bachelors degree in mathematics, statistics, actuarial science, economics or related field.
  • Advanced degree preferred.
  • 8 plus years of experience in progressively more responsible actuarial work in health insurance/managed care or equivalent training/education.
  • Experience with both commercial and government health programs preferred, specific involvement with the new MMA regulation; in-depth understanding of health insurance market dynamics.
  • Excellent problem-solving and analytical skills.
  • Good oral and written communication skills.Strong PC skills.
  • Data retrieval skills and relational database experience.
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Medicaid Rebate Program Specialist (Work-Flex) | Purdue Pharma

Clipped from: https://www.linkedin.com/jobs/view/medicaid-rebate-program-specialist-work-flex-at-purdue-pharma-l-p-3402185699/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Purdue Pharma L.P. and its subsidiaries develop, manufacture and market medications and consumer health products to meet the evolving needs of healthcare professionals, patients, and caregivers. We were founded by physicians, and we are currently led by a physician. Beyond our efforts to provide quality medications, Purdue is committed to supporting national, regional and local collaborations to drive innovations in patient care. Privately held, Purdue is pursuing a pipeline of new medications through internal research & development and strategic industry partnerships.

 
 

For close to two decades Purdue has engaged in many initiatives to stem prescription opioid abuse. We are committed to bringing lifesaving relief to communities and individuals suffering from substance use disorder and overdose. We are currently developing or supporting the development of two essential life-saving opioid overdose reversal medications and have the capability to manufacture others for medication assisted treatment. Providing these medicines has the potential to improve and save countless lives.

 
 

We are driven by our purpose: Compassion for patients and excellence for science inspire our pursuit of new medicines.

 
 

We are building an exciting path forward, and we are committed to recruiting a dedicated team of professionals who advance our expertise through a commitment to Purdue’s Values: Integrity and Courage , underpinned by Innovation , and always in Collaboration with each other.

 
 

At Purdue Pharma and our subsidiaries, you have a unique career opportunity to work differently, uncover and seize new opportunities, and take a hands-on, ownership approach to your work. We go beyond traditional roles and find creative ways to extend our skills and interests, challenging ourselves to contribute in different, meaningful ways. We strive to create an environment where you can bring your best to work each day. We welcome the opportunity to have you on our team!

 
 

We respect diversity and accordingly are an equal opportunity and an affirmative action employer. Qualified applicants will receive consideration without regard to: actual or perceived race, sex or gender (including pregnancy, childbirth, lactation and related medical conditions), national origin, ancestry, citizenship status, religion, color, age, creed, sexual orientation, marital status, gender identity or gender expression (including transgender status), protected medical condition as defined by applicable state or local law, genetic information, physical or mental disability, veteran status and military service, or any other characteristic protected by local, state, or federal laws and ordinance.

 
 

For more information about your rights under Equal Employment Opportunity, visit:

 
 

  • EEOC Know Your Rights
  • EEOC Know Your Rights (Spanish )
  • USERRA Rights
  • Family and Medical Leave Act (FMLA)
  • Employee Polygraph Protection Act (EPPA)
  • E-Verify (English and Spanish)
  • Right to Work (English and Spanish)
  • Pay Transparency Nondiscrimination Provision (English)
  • Pay Transparency Nondiscrimination Provision (Spanish)

 
 

We strive to make our Career opportunities website accessible to all users. If you need an accommodation to participate in the application process, please email: careers@pharma.com
. This email is not for general employment inquiries or vendors; rather it is strictly for applicants who require assistance accessing our careers website .

 
 

Job Summary

 
 

The Medicaid Program Specialist will be responsible for coordinating the day-to-day operations of Purdue’s Medicaid drug rebate payment program obligations governed by Purdue’s master service agreement with the Center for Medicare and Medicaid Services (CMS) Medicaid Drug Rebate Program and governing regulations.

 
 

Primary Responsibilities

 
 

  • Collaborate with Purdue’s third-party Medicaid processing vendor to validate all state Medicaid rebate invoices in accordance with industry best practices and within their respective payment deadlines and coordinate payments to the States.
  • Validate Medicaid payment packages for accuracy.
  • Manage state Medicaid invoice identification of disputes, and implement and monitor dispute tracking log, and liaise with States and Purdue’s third-party Medicaid processing vendor on dispute identification and resolution.
  • Build and maintain strong State and Pharmacy Benefit Administrator relationships and manage the relationships with state Medicaid agencies.
  • Manage the Medicaid dispute resolution process to maintain current and accurate books between Purdue and state Medicaid agencies.
  • Perform trending analysis and invoice reconciliation to identify utilization disparities, and abnormal trends, and research trends with states.
  • Calculate and validate state supplemental rebate and State Pharmaceutical Assistance Program (SPAP) invoice amounts.
  • Have an understanding of Purdue’s Revitas Flex Medicaid system, train other users on software.
  • Support Purdue’s third-party Medicaid processing vendor with testing of new software due to government pricing systems upgrades and/or changes in pricing methodology.
  • Ensure all invoice data is properly archived and maintained in order to comply with all Federal guidelines and audit requirements.
  • Perform financial modeling to aide in financial accruals process related to Medicaid rebate liability, and to support inquiries from other company stakeholders.
  • Update and maintain SOPs as appropriate.
  • Depending on skill set, provide back up support to government pricing functions for the calculation of Average Manufacturer Price (AMP), Best Price (BP), and potentially other government price reporting obligations.

 
 

Education And Experience Requirements

 
 

  • Minimum 3-5 years of industry experience in healthcare, pharmaceutical and/or medical device industry preferred
  • Minimum 2 years of experience working in the areas of, Medicaid, government pricing, rebate adjudication, contract management process/systems, document control, etc.
  • Bachelor’s degree

 
 

Necessary Knowledge, Skills, And Abilities

 
 

  • Technical Skills: Proficient in Outlook, MS Excel and MS Word. Knowledge of SAP and Revitas Flex Medicaid / Contract Sphere or other pharmaceutical contract/rebate/membership systems a plus. Must possess technical skills sufficient to learn new systems, understand system functionality well, and test systems when required.
  • Market understanding – Good understanding of the Medicaid Drug Rebate Program, and general understanding of government price calculations such as Average Manufacturer Price (AMP), Medicaid Best Price (BP) and reporting processes. Understanding of the involvement of legal/regulatory and compliance in the government market. Proven understanding of current health care environment, regulations, and health care reform laws.
  • Contract Interpretation – Ability to understand and interpret contract language related to government price calculations.
  • Organization skills – Must possess good capability of organizational skills and ability to manage multiple projects at one time. Ability to adjust to changing needs within the organization and flexibility to change priorities as needed. Must be able to work under strict deadlines.
  • Communication – Must possess strong written and verbal communication skills to interact with external and internal customers.
  • Analytics: must be good with numbers, able to analyze data and trends and data discrepancies, good critical reasoning skills. Strong analytical skills and attention to detail with the capability to appropriately define issues, questions data; to comprehend qualitative and quantitative methods to perform accurate analysis. Ability to creatively think about different problems and devise pragmatic solutions.
  • Strong interpersonal skills with demonstrated ability to work well with others, manage work with counterpart(s) at Purdue and drive towards consensus.
  • Attention to detail and deadlines, a strong work ethic, and a history of adherence to policies and procedures are critical.

 
 

Physical And Environmental Requirements

 
 

  • Perform job functions in various positions that may require sitting, stooping, balancing, kneeling, crouching, twisting, and/or reaching. While sitting for an extended period of time on a routine basis, incumbent may use the following equipment: Personal computer, telephone/ other voice communication devices, copier, fax, scanners, or other specialized equipment used in an office setting.

 
 

Additional Information

 
 

  • Work-flex roles can be performed through a combination of on-site and remote-based work.
  • Employee should be located in the following states: CT, NJ, NY
  • Relocation assistance not provided.

 
 

Minimum required education, experience, knowledge, skills and abilities are included in the posting. The position will be filled at the level commensurate with the successful candidate’s education, experience, knowledge, skills, and abilities.

 
 

The job description is not an exhaustive list of all functions that the employee may be required to perform, and the employee may be required to perform additional functions. Additionally, the company may revise the job description at any time.

 
 

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