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National Medicaid Behavioral Health Quality Lead at Humana

Clipped from: https://humana.talentify.io/job/national-medicaid-behavioral-health-quality-lead—humana-r-293587?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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  • Job Description

 
 

Req#: R-293587

Description

The Behavioral Health Lead will report directly to the National Medicaid Quality Director, and be responsible for the development, maintenance, and execution of Humana Healthy Horizon’s National Improvement strategy and operating model for Behavioral Health Quality, and its integration with Physical Health Quality, within the Medicaid line of business.

Responsibilities

The Behavioral Health Lead exercises independent judgment and decision making on complex issues regarding responsibilities and related tasks, works under minimal supervision, uses independent judgment requiring analysis of variable factors and determining the best course of action. Responsibilities include:

  • Provide direction and oversight of the Behavioral Health Quality management model and improvement strategy for the Medicaid line of business at the national level, and further the integration of Physical Health and Behavioral Health Quality.
  • Develop policy and procedure, and define/improve processes regarding HEDIS and quality measurement data collection and improvement methodology for all Behavioral Health focused measures.
  • Develop educational materials and strategies to engage practicing Behavioral Health clinicians in improving operational process and clinical care quality in an effort to improve member experiences and health outcomes.
  • Establish and improve care coordination processes between outpatient Behavioral Health practices, hospitals, and primary care physicians.
  • Assist in the development of innovative value based payment models for Behavioral Health provider partners.
  • Drive all Behavioral Health Quality related activities during the implementation of new Medicaid markets.
  • Provide ongoing wrap-around support to market Quality teams for Behavioral Health related issues, process improvement, and clinical initiatives.
  • Drive interdepartmental collaboration to achieve business goals

    Required Qualifications

  • Bachelor’s degree in Business, Healthcare, or related field
  • 5+ years of experience in Behavioral Health or Managed Care Quality Management and Improvement
  • 3+ years of experience monitoring and improving behavioral health quality measures (example HEDIS or CAHPS) in a quality operations / quality management or office based practice setting
  • Demonstrated ability to perform moderate to complex data analysis
  • Previous experience working with behavioral health providers on quality and performance improvement activities
  • Strong relationship building skills
  • Excellent written and oral communication skills
  • Comprehensive knowledge of Microsoft Office Word, PowerPoint, Excel

    Preferred Qualifications

  • Clinical Licensure including: Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Counselor (LPCC), Registered Nurse with behavioral health experience
  • Certified Professional in Healthcare Quality (CPHQ)
  • Experience with quality improvement methodology such as plan-do-study-act
  • Advanced degree in business, healthcare, or related field
  • Project management experience
  • Strong business skills, including sales and marketing objectives
  • Previous experience developing provider facing educational materials
  • Detail orientated and comfortable working with tight deadlines in a fast paced environment

    Work at Home Requirements

  • At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
  • Satellite, cellular and microwave connection can be used only if approved by leadership
  • Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
  • Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
  • Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

    #LI-JB2

    Scheduled Weekly Hours

    40

  • About the company

 
 

Humana looks at every facet of your life and works with you to create a path to health that fits your unique needs

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NM- Study: Calls to Medicaid providers are mostly futile

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]: There is no Medicaid provider network in New Mexico. (Practically speaking).

 
 

Clipped from: https://www.abqjournal.com/2557265/study-calls-to-medicaid-providers-are-mostly-futile-ex-only-about-1.html

SANTA FE – A “secret shopper” accountability study shows that medical patients can’t readily schedule appointments by phone through Medicaid providers in New Mexico, even as the state and federal government spend $8.8 billion annually on the health care program that serves nearly half of state residents.

The budget and accountability office of the Legislature presented its findings Tuesday to a panel of lawmakers as evidence of an inadequate network of health care providers.

The agency surveyed private providers of Medicaid health care services as well as providers of mental health and addiction counseling. About 13% of attempts to make an appointment were successful.

“That’s almost 90% of the time – almost all of the time – that they can’t get an appointment,” said Democratic state Sen. Nancy Rodriguez of Santa Fe, responding to the report. “So their health, obviously to me, would get worse in time if they can’t be seen by good medical care or any medical care at all.”

In about half of calls, appointments could not be made because of inaccurate phone listings or voicemails that went unreturned.

When primary health care providers were reached by phone, more than one-quarter were either not accepting new patients or had left the listed medical practice. The study found that patients who were able to connect with Medicaid care providers confronted waiting lists or appointment times that exceeded contractual requirements.

The consumer-protection survey was part of a broader program evaluation indicating that New Mexico residents who are enrolled in Medicaid are not using more services even as enrollment and spending on the program have surged.

Nicole Comeaux, director of the state’s Medicaid program, told legislators that satisfaction surveys of Medicaid participants have shown consistent improvements since 2019 – though about 7% of respondents reported an absence of medical providers.

She outlined initiatives aimed at shoring up networks of medical providers, including requirements that 90% of Medicaid spending go toward medical care and not administrative costs.

Enrollment in Medicaid has climbed by 16% since 2019, according to program evaluators for the Legislature. Spending is up 56% over the same period. But per-patient use of certain Medicaid physical care services declined or remained steady. Program evaluators for the Legislature say pandemic-related curtailments in medical services could be partly to blame.

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Managed care organizations, which manage the delivery and payment of health care services for people using Medicaid insurance, are required to conduct their own secret-shopper surveys. A review of those surveys found there was no standard methodology and that some overbooked medical providers were exempt from participation.

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Report criticizes counties that continue to claw back Medicaid birth costs

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 thinks fathers that can pay should pay.

 
 

Clipped from: https://wisconsinexaminer.com/2022/12/14/report-criticizes-counties-that-continue-to-claw-back-medicaid-birth-costs/

 
 

(Kelly Sikkema | Unsplash)

Despite campaigns to end the practice, Wisconsin counties continue to take some unmarried parents to court to repay the cost of their children’s births covered by Medicaid, according to a new report published Wednesday.

The report, produced by ABC for Health, states that altogether Wisconsin counties have won legal judgments declaring that unmarried parents owed $106 million to repay the mother’s childbirth hospital bills that Medicaid had paid for. 

The judgments are part of a policy called birth cost recovery. The policy focuses on unmarried parents of newborn children whose mothers are enrolled in Medicaid while a child’s other parent has resources to pay some or all of those costs. 

The architects and supporters of the policy view it as another form of child support, ensuring that parents, typically fathers, take financial responsibility for their children regardless of their relationship with the mother. 

The authors of the new ABC for Health report dispute that premise, however. ABC for Health is a Madison nonprofit that helps low-income Wisconsin residents obtain health care coverage and works to combat medical debt. The organization has for years opposed birth cost recovery policies — dubbing the concept “the birth tax.”

Birth cost recovery claims are pursued when the parents of a child are unmarried and are assumed to be living apart. The policy sends a message that “if you’re married, we’re not going to be worried about it,” says Bobby Peterson, executive director for ABC for Health, who wrote the report along with Brynne McBride, the organization’s CEO. “If you aren’t married, we’re coming after you.”

To write the new report, “Merchants of Debt: Wisconsin Counties & The Birth Tax,” ABC for Health conducted an open records request of the state Department of Health Services for the total number of judgments on file demanding repayment from families with a child whose birth was covered by Medicaid. 

The data, which includes cases going back decades, showed 78,549 such judgments, totaling $106 million across the state. 

In 2020, when there were 58,872 births, 52% of them, or 30,703, were covered by Medicaid, according to the report. Two-thirds of the Medicaid births were to unmarried parents, making them potentially subject to birth cost recovery judgments. 

The report notes that among Black Medicaid patients giving birth, 88% were unmarried and therefore potentially likely to be the subject of a birth cost recovery judgment. Among American Indian and Alaskan Native births covered by Medicaid, 85% involved unmarried parents, while 58% of white Medicaid births involved unmarried parents.

County child support agencies pursue birth cost recovery suits and report the information to the state Department of Health Services (DHS). 

The report contends that outside Wisconsin, birth cost recovery has become less frequent. 

“Wisconsin is one of the few states that pursues this policy and is by far the most aggressive,” the report states. “Most states in the nation have abandoned this practice, concluding that it is not in the best interest of infants, parents, and families.”

While the money is collected by child support agencies, ABC for Health argues that the money should not be considered child support, “as none of the money collected supports the direct care or protection of the child.” 

Birth cost recovery “drives families further into poverty and discourages unmarried fathers from playing an important, supportive role in their child’s life.”

Peterson says ABC for Health has worked with clients who were inappropriately targeted for a clawback of Medicaid dollars in birth cost recovery because authorities wrongly perceived them as uninvolved in the child’s life when personal circumstances such as a job or other responsibilities kept them away from home for long periods.

He contrasted the state’s projected $6.5 billion surplus with “going after these families that have very little money.”

The report finds that Milwaukee County has collected $69.2 million in Medicaid birth cost recovery judgements and Dane County $6.8 million.

It singles out Dane County for particular criticism, noting that County Executive Joe Parisi declared in late 2019 that the county would not file new birth cost recovery cases. 

Peterson said that in conducting the study ABC for Health found that the county has continued to pursue cases that were already underway, however. During the COVID-19 pandemic, the county intercepted stimulus checks and supplemental unemployment pay as part of satisfying judgments awarded to the county.

In September 2020, after the Milwaukee County Board appeared to be on the verge of ending birth cost recovery, the board reversed direction. The county’s child support director, Jim Sullivan, argued at the time that birth cost recovery judgments were only pursued against absent fathers who had sufficient income and should be held financially responsible for their children.

Peterson says that argument has not persuaded him. The claim that fathers who were ordered by courts to pay back Medicaid costs for their children’s births had higher incomes has been “exaggerat[ed] way out of proportion,” he says.

“We have always said that at some point, if the child support agencies are applying prosecutorial discretion correctly, there may be cases that you pursue,” Peterson says. “But the vast majority of these cases are poor or working class folks that don’t have the resources to show up [in court].”  

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REFORM- Cessation of Medicaid funding for neonatal circumcision examined in new study

MM Curator summary

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

 
 

[MM Curator Summary]: Families made decisions against their own preferences and their doctor’s opinions when CA non-covered the $215 procedure.

 
 

Clipped from: http://today.ku.edu/2022/12/14/cessation-medicaid-funding-neonatal-circumcision-examined-new-study

 
 

LAWRENCE — Although it is both a religious rite and cultural practice, male circumcision is primarily done in the United States as a means of preventative health care. Yet Medicaid funding for this neonatal procedure has been decreasing for decades.

 
 

A new article in the journal AIDS and Behavior titled “The 1982 Medicaid Funding Cessation for Circumcision in California and Circumcision Rates”2 investigates the state’s decision to stop subsidizing Medicaid neonatal circumcision. The research finds that such funding coverage affects circumcision rates, which could magnify health care disparities such as lower rates of sexually transmitted infections, including HIV and urinary tract infections.

“California’s 1982 decision to defund Medicaid male neonatal circumcision was associated with a 25 to 31 percentage point decrease in West-Medicaid circumcision rates compared to the changes for other groups and other states in this time period,” said David Slusky, professor of economics at the University of Kansas. “Overall this shows that insurance funding decisions have a key impact on families’ health care decisions.”

Co-written by KU economics alumnus Ryan Wendling (who worked on the project as an undergraduate research assistant) and infectious disease physician Rebecca Linfield of Stanford University, this research is the first to use the California case as a natural experiment to see how a defunding policy change affects contemporaneous circumcision rates.

The potential medical benefits of circumcision are well-known: This includes decrease of HIV (up to 60% in clinical trials in multiple countries in Africa), sexually transmitted infections, rates of urinary tract infections and rates of penile cancer.

“Male neonatal circumcision is quite inexpensive relative to other procedures — about $215 per procedure — and therefore a cost-effective way to prevent disease,” Slusky said.

According to his research, Medicaid now pays for anywhere from 30% to 70% of all U.S. births across states. In 1990, only California (1982) and North Dakota (1986) had ended Medicaid coverage of neonatal circumcision. By 2011, a total of 17 additional states had adopted similar policies, with only Colorado reversing its decision in 2017. California cut Medicaid neonatal circumcision funding in 1982 primarily for budgetary reasons.

While this result has affected people based on their income, it also does so based on race.

“Medicaid insures those with lower incomes, which unfortunately in our country is a disproportionately larger share of Black and Hispanic populations than of other populations,” he said. “Newborn males from these groups were therefore more likely to be covered by Medicaid and thus more likely to be affected by defunding Medicaid male neonatal circumcision.” 

A KU faculty member since 2015, Slusky specializes in health economics and labor economics. He has conducted research on a variety of topics, including the Flint water crisis3, COVID-19 restrictions4 and abortion care5.

“Our results are another example that financial nudges matter. There was no change in circumcision availability, let alone mandates or cultural norms. And there will always both be families that will circumcise their sons regardless of cost and families that won’t even if it’s free. But we show that for a substantial number of low-income families, the financial cost makes a difference,” Slusky said.

“State policymakers need to keep that in mind when they decide what is and is not covered by Medicaid.”

Top photo: iStock

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SD- Gov. Kristi Noem, state departments begin process to implement ‘will of the voters’ in Medicaid expansion

MM Curator summary

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

 
 

[MM Curator Summary]: SD officials grudgingly begin to implement the expansion approved by the 3rd estate.

 
 

Clipped from: https://www.mitchellrepublic.com/news/south-dakota/gov-kristi-noem-state-departments-begin-process-to-implement-will-of-the-voters-in-medicaid-expansion

After passing with 56% of the vote, offering Medicaid benefits to an expanded population is now a part of the state constitution. Here’s what state officials have to do to meet the July 1 deadline.

 
 

House Speaker Hugh Bartels stands to applaud during Gov. Kristi Noem’s budget address on Dec. 6. Part of the new spending in Noem’s budget was $13 million this year to begin implementing the Medicaid expansion passed by the voters on Nov. 8, 2022.

Jason Harward / Forum News Service

SIOUX FALLS, S.D. — With language now etched into the South Dakota State Constitution requiring the state to provide Medicaid benefits to an expanded eligibility group, Gov. Kristi Noem and the state legislature are indicating they will implement the amendment as written.

“The legislature’s hands are tied,” said Rep. Kevin Jensen, who will chair the House Health and Human Services Committee this coming session. “Because of the constitutional amendment, we can’t do anything to change or restrict it other than pass another amendment. So the legislature, as far as I can see, our only role will be to either vote for the funding bill at the end of the year or vote against it.”

Timeline requires enrollments by July

The language of Initiated Amendment D, which passed with 56% of the vote on Nov. 8, makes clear the general process ahead of the Department of Social Services, which will oversee the expansion of Medicaid to adults between the ages of 18 and 64 with incomes below 138.5% of the federal poverty line.

By March 1, 2023, the department must submit an amended state plan to the federal divisions that oversee Medicaid. In a statement to Forum News Service, Laurie Gil, the secretary of the state Department of Social Services (DSS), said these amendments “will establish eligibility, benefits, and the delivery system for the expansion population.”

The amendment then requires that the program begin accepting applications and conferring these benefits on July 1, 2023.

“DSS currently anticipates accepting applications in July 2023, and we plan to communicate a more specific date for accepting applications in late spring 2023,” Gil wrote in the statement.

As currently constructed, the federal government covers 90% of health care costs incurred by those in the expansion population — according to the Bureau of Finance and Management,
52,000 South Dakotans are expected to be eligible for the program.

During the first two years of expansion, the federal government offers states a boost in funding as an incentive; these incentives are estimated to total $53 million in the first year.

On top of these incentives meant to offset parts of the initial cost, Noem during her budget address on Dec. 6 proposed an appropriation of just under $13 million in the first year of expansion.

South Dakota

Gov. Kristi Noem delivers South Dakota budget address, headlined by grocery tax cut, strong revenues

The budget, which features a topline dollar figure of $7.2 billion, makes investments in state employees, providers and the state’s correctional infrastructure. Noem will look to push her proposals through the legislature, which has final say on all spending matters.

December 06, 2022 03:55 PM

 · 

By  Jason Harward

The Bureau of Finance and Management says this will cover an additional 68 full-time DSS employees to administer expansion and “includes additional contingency funding on both healthcare cost and projected enrollment.”

Opposition could inform legislative actions

Even in appropriating those dollars, Noem continued to make clear her opposition to the program itself.

“Make no mistake, the expansion of Medicaid — as passed on the November ballot by the people of this state — is an expansion of a government program that will give free healthcare to a population of the state that the majority are able-bodied, single males,” Noem said.

While this statement is generally true when looking at state-level data (in Maine, for example, more than 86% of enrollees as of Oct. 1 are childless adults, 54% of whom are male), some legislators think that the economics of the program still make sense for the state.

“From a practical standpoint, these folks are the working poor,” said Sen. Sydney Davis, who will serve as the vice chair of the Senate Health and Human Services committee this session. “They have no resources for preventative health care, so they end up in the emergency room, with conditions that could have easily been prevented, and that is likely to now be more costly.”

Noem disagrees, saying during her speech that “costs exceeded their expectations” in every other state that has expanded Medicaid, a point that several legislators concur with. Noem estimated that, in the fifth year of implementation, the state would bear a cost of $80 million.

“A lot of people fear it could lead to a state income tax because at some point it’s going to cost us $100 million per year,” Rep. Kevin Jensen said.

Although enrollment does often exceed expectations, several states report savings in other areas of the general fund that make up for part of these overruns. In Montana, for example, direct savings from Medicaid expansion in 2021 totaled $27 million, largely from new federal dollars covering other state expenses

South Dakota’s Legislative Research Council estimated these savings at around $11 million per year, with the offsets mainly coming from “correctional healthcare, behavioral healthcare, and Indian Health services.”

Another concern for legislators is the potential for the federal government to change its end of the 90-10 cost share, which would not change South Dakota’s constitutional mandate and would simply increase the cost borne by the state.

Sen. Jean Hunhoff, the chair of the appropriations committee in the Senate, told Forum News Service in November that it might be wise for the state to save some of the federal dollar incentives coming into the state during the first two years to cover this potential risk.

“We would have to pick up all that extra that [federal dollars] were no longer picking up,” Hunhoff said. “I think we have to see how we can manage those dollars that are coming in and make sure those dollars go into a fund that is to cover a Medicaid expansion group.”

An additional ancillary appropriation that could increase enrollment would be some amount of one-time funding for outreach and education. While Shelly Ten Napel, the executive director of the Community HealthCare Association of the Dakotas, said efforts like these have had “really significant impacts” on enrollment rates in other states, the stomach for this sort of appropriation might be lacking.

“I really don’t see an appetite for it in the state legislature,” Davis said. “I think my colleagues will see that as a cost in addition to something that is already costing money.”

Though related appropriations are still speculative, Rep. Greg Jamison, a Republican who was a vocal proponent of expanding Medicaid, is certain that the legislature will at the very least appropriate the $13 million requested by the governor.

“There are a lot of my Republican friends who are not happy with it, and they may think that they could stop it or defund it or something, but they’ll realize that that’s not possible,” Jamison said. “The governor seemed a little bit begrudging but she played it pretty safe and did say it’s the will of the voters, so she definitely understands that.”

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Opinion | What Comes Next for the War on Drugs? The Beginning of the End

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]: 2 key pieces of legislation (1 of them Medicaid-specific) are on the table to impact access to life saving substance abuse treatment medications.

 
 

Clipped from: https://www.nytimes.com/2022/12/12/opinion/drug-crisis-addiction.html

 
 

By The Editorial Board

The editorial board is a group of opinion journalists whose views are informed by expertise, research, debate and certain longstanding
values. It is separate from the newsroom.

There are three bills floating through Congress right now that could not only save lives and money but also help to finally dismantle the nation’s failed war on drugs. The Medicaid Re-entry Act, the EQUAL (Eliminating a Quantifiably Unjust Application of the Law) Act and the MAT (Mainstreaming Addiction Treatment) Act all have bipartisan support and could be passed during the lame duck session of Congress. Lawmakers should act on them without delay.

The MAT Act would eliminate the special Drug Enforcement Administration waiver that doctors must apply for in order to prescribe buprenorphine (a medication that helps reduce the craving for opioids). It would enable community health aides to dispense this medication as long as it’s prescribed by a doctor through telemedicine. And it would give the Substance Abuse and Mental Health Services Administration responsibility to start a national campaign to educate health care practitioners about medications for opioid use disorder. Reams of data have shown and addiction specialists agree that these medications offer some of the best options for preventing overdoses and helping people into recovery. But a 2019 report from the National Academies of Sciences, Engineering and Medicine found that fewer than 20 percent of people who could benefit have access to them.

There are several reasons for that, including stigma and a lack of understanding about how medications for opioid use disorder work. The biggest problem is that so few doctors are willing to treat addiction in the first place. Dropping the D.E.A. waiver will not be enough to alleviate that shortage; lawmakers will also have to find ways to ensure that addiction treatment enjoys the same robust reimbursement rates as other chronic conditions. But eliminating the waiver would still be a crucial step in the right direction. The prescription drugs that caused the current epidemic should not be easier to access than the medications that could help alleviate it.

The MAT Act, which was written by Representative Paul Tonko of New York, boasts some 248 co-sponsors and has already passed the House as part of a broader mental health package.

 
 

The Medicaid Re-entry Act would allow states to reactivate Medicaid for inmates up to one month before their scheduled release from prison. Those benefits are normally suspended (or in some states terminated) during incarceration because current law prohibits jail and prison inmates from receiving federal health insurance. Reinstating them after incarceration takes time and resources that people who have just been released from jail or prison don’t necessarily have. The resulting disruptions in medical care can be dire: America’s prison population suffers disproportionately from a range of serious ailments, including mental illness, heart disease and opioid use disorder. Among other risks, former prisoners are 50 to 150 times as likely to die of an overdose in the first two weeks after their release.

Closing the post-incarceration treatment gap would go a long way toward reducing such deaths. The Rhode Island Department of Corrections reduced its post-incarceration overdose fatalities by 60 percent by ensuring that inmates could access methadone and buprenorphine both during incarceration and after release, without disruption. “It was basically a slam dunk,” says Keith Humphreys, an addiction expert at Stanford University and a former senior adviser to President Barack Obama on drug policy. “Instead of sending them off with a brochure, you connect them to treatment.”

 
 

Reinstating Medicaid before release would be another, even more robust way to accomplish the same goal. Several states have already applied for federal waivers that would allow them to do so on a trial basis. The Biden administration should approve those waivers without delay. But Congress should also pass the Medicaid Re-entry Act so that the benefit of seamless care isn’t determined by where an inmate is incarcerated.

The bill, which was also written by Mr. Tonko, has bipartisan backing in both chambers and support from a wide range of groups, including the National Alliance on Mental Illness and the National Sheriffs Association. Experts on addiction believe it could save both lives and money. “It would open up a world of possibilities for taking care of people who are newly released,” Mr. Humphreys says. “There is really no reason not to do it.”

The EQUAL Act would eliminate the federal sentencing disparity between drug offenses involving crack cocaine and powder cocaine. That disparity was created by a 1986 law that equated 50 grams of crack with 5,000 grams of powder cocaine and subjected possession of either to a minimum sentence of 10 years in prison.

Editors’ Picks

 
 

The law was based on the now disproved idea that crack cocaine is far more addictive than powder cocaine. It resulted in disproportionately harsher penalties and far more prison time for drug offenders in communities of color: While two-thirds of people who smoke crack are white, 80 percent of people who have been convicted of crack offenses are Black.

In 2010, Congress reduced the crack-to-powder ratio from 100:1 to 18:1. The EQUAL Act would finally eliminate it altogether. If passed, approximately 7,600 people who are serving excessive crack-related sentences could be released an average of six years earlier, according to an estimate from the U.S. Sentencing Commission. That comes out to some 46,500 fewer prison years.

EQUAL, which was written by Representative Hakeem Jeffries of New York, who was recently elected leader of the House Democrats, passed the House last year with overwhelming bipartisan support. We urge the Senate to pass it. Lawmakers should get this long overdue bill across the finish line now, before House investigations and other political battles take priority in the next session.

The nation’s five-decade war on drugs has been a dismal failure. Overdose deaths have reached — and then surpassed — extreme levels in recent years, and the number of people who are still in prison for drug offenses remains stubbornly and egregiously high. Still, it is hard to agree on what comes next. What has been shown to work is not always politically feasible, and what’s politically popular often doesn’t make for sound public health. The MAT, EQUAL and Medicaid Re-entry Acts meet both requirements. Congress should pass all three now.

 
 

 
 

 
 

 
 

 
 

 
 

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TECH- Inconsistent Medicaid coverage for remote patient monitoring hampers adoption

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]: RPM is taking off in some areas, but needs more money.

 
 

Clipped from: https://www.insiderintelligence.com/content/scattershot-medicaid-coverage-remote-patient-monitoring-hampers-adoption

The trend: Remote patient monitoring (RPM) interventions can help low-income individuals get healthier. But more consistent state Medicaid coverage will be necessary for these programs to scale up.

What’s driving the trend? Providers and patients are more bullish on using technology to manage their conditions. So, health systems are using more RPM programs and investors are pouring money into RPM-focused tech startups.

Reimbursement roadblocks: Providers have struggled to capture complete reimbursement from insurers for their RPM programs. Many organizations rely on grants or donations to jumpstart an intervention.

The Centers for Medicare & Medicaid Services recently increased the types of remote monitoring services it will cover for Medicare patients, but Medicaid is a different story.

The opportunity: States are proceeding with caution when it comes to covering RPM services, mostly because they want to see more evidence proving that remotely monitoring patients will be cost efficient for Medicaid and clinically valuable for patients.

Health systems have an opportunity to validate the effectiveness of their RPM interventions, particularly for vulnerable populations.
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MCOs- HHS IG Issues Audit Report on Documentation of Medicaid Managed Care Payment Review Determinations Made Under Payment Error Rate Measurement Program

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]: Meh.

 
 

Clipped from: https://insurancenewsnet.com/oarticle/hhs-ig-issues-audit-report-on-documentation-of-medicaid-managed-care-payment-review-determinations-made-under-payment-error-rate-measurement-program

WASHINGTON, Dec. 14 — The U.S. Department of Health & Human Services’ Office of Inspector General issued the following audit report summary for the Centers for Medicare and Medicaid Services:

* * *

Why OIG Did This Audit

The Centers for Medicare & Medicaid Services (CMS) is responsible for overseeing States’ design and operation of their Medicaid programs and ensuring that Federal funds are appropriately spent. CMS developed the Payment Error Rate Measurement (PERM) program to measure improper payments in Medicaid and the Children’s Health Insurance Program (CHIP). This is the third in a series of three OIG audits that assessed the adequacy of the PERM program by reviewing the accuracy of determinations for each of its three components.

The objective of this audit was to assess the adequacy of the PERM program by determining whether CMS’s contractor conducted Medicaid Managed Care (MMC) payment reviews that were in accordance with Federal requirements.

How OIG Did This Audit

Our audit covered 407 PERM MMC payments reviewed by CMS’s PERM contractor, totaling $476,065 ($291,356 Federal share), included in the MMC component of the Reporting Year (RY) 2019 PERM program for 3 States. We judgmentally selected these States based on the total amount of the MMC payments and the number of MMC payments reviewed by CMS’s review contractor. We reviewed a random sample of 100 PERM MMC payments for the 3 States.

 
 

What OIG Found

CMS’s review contractor conducted the majority of its MMC payment reviews in accordance with Federal requirements. Of the 100 sampled MMC payments we reviewed, 60 were correctly determined. However, we were not able to determine whether the remaining 40 payment review determinations were correct because the payment reviews were not documented and therefore may be incorrect. Based on the sample results, we estimated 40 percent of the sampled MMC payment determinations made by CMS’s review contractor may not have been correct. We also estimated the total amount related to these 40 claims to be $229,435 ($123,520 Federal share) during our audit period.

CMS’s review contractor did not maintain documentation of its payment review determinations because CMS did not include specific contract and statement of work language requiring its review contractor to maintain all documentation to support its MMC payment review determinations for non-errors.

We are not making recommendations because CMS took action to address the deficiencies we identified. Specifically, after our audit period, for RY 2020, 2021 and 2022 PERM cycles, CMS exercised an optional task for the contract with the review contractor, which added language requiring the review contractor to maintain relevant documentation for non-error (i.e., correct) payments. In its contract renewal occurring in March 2021, CMS replaced the optional task with a permanent requirement for the review contractor to maintain relevant documentation for non-error payments.

* * *

The report is posted at: https://oig.hhs.gov/oas/reports/region4/42109003.pdf

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MCOs- CNC stock slips as Bank of America downgrades on Medicaid risk (NYSE:CNC)

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]: Analysts understand what the end of the PHE means to plans with big Medicaid books of business.

 
 

Clipped from: https://seekingalpha.com/news/3916633-cnc-stock-slips-as-bank-of-america-downgrades-on-medicaid-risk

 
 

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Centene Corporation (NYSE:CNC) dropped as much as 5% on Tuesday after Bank of America downgraded the health insurer to Underperform from Neutral, citing its concerns about the potential for Medicaid redeterminations starting next year.

Centene’s (CNC) rivals in the Medicaid market include Elevance Health (ELV) and Molina Healthcare (MOH).

“We are downgrading CNC to underperform from Neutral and upgrading MOH from underperform to Neutral on what we see as a better risk/ reward at MOH between the two Medicaid MCOs,” the analyst Kevin Fischbeck wrote, lowering the price target on CNC to $85 from $100 per share.

Millions of Americans are at risk of losing insurance coverage as Medicaid continuous enrollment requirement, under which Medicaid programs received federal funding to keep people continuously enrolled through the pandemic, is set to expire with the end of the COVID emergency.

However, in November, the Biden administration did not indicate any plans to end the emergency status when it expires in January, signaling that the declaration could extend until spring.

Wall Street has remained bullish on Centene (CNC) stock, with an average rating of Buy from analysts in line with Seeking Alpha Author ratings. However, Seeking Alpha’s Quant System, which consistently beats the market, rated CNC as a Hold.

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OR- Kotek names interim director for the Oregon Health Authority

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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]: Welcome to Oregon’s new Medicaid Director!

 
 

Clipped from: https://oregoncapitalchronicle.com/2022/12/13/kotek-names-interim-director-for-the-oregon-health-authority/

James Schroeder, CEO of Health Share of Oregon, has 20 years of clinical and executive health care experience


James Schroeder, CEO of Health Share of Oregon, the state’s largest Medicaid insurer, will become the interim director of the Oregon Health Authority on Jan. 10. (Courtesy of Gov.-elect Tina Kotek’s office)

Gov.-elect Tina Kotek will appoint a 20-year health care veteran to lead the Oregon Health Authority in early January, at least temporarily.

In a statement on Tuesday, she said that James Schroeder, currently the CEO of the state’s largest Medicaid insurer, Health Share of Oregon, will serve as interim director.

“James brings over 20 years of management, leadership and health care delivery experience and a deep respect for the work of the OHA,” Kotek said. “Addressing the cracks in our mental health and addiction services systems will be a top priority for my administration, and I am confident that James has the experience and determination to get results for Oregonians.”

Schroeder will start Jan. 10, the day after Kotek takes office. He will replace Patrick Allen, who announced last month that he will step down Jan. 9. Steve Allen, the health authority’s behavioral health director, will leave the same day. Kotek said during her campaign she would replace both Allens, who are not related.

Patrick Allen brought to the agency years of government leadership experience, including as director of the Department of Consumer and Business Services, which oversees most insurance companies. Schroeder has clinical and administrative health care experience. He was trained as a physician’s assistant, a role that includes prescribing medications, and has worked in clinical and managerial roles. 

For the past two years, he’s led Health Share, which insures 426,000 Medicaid patients in the Portland area. Before that he held several top positions at Kaiser Permanente, including as vice president of safety net transformation and medical director of Medicaid. And since 2013, he’s served as medical officer in the Oregon Air National Guard, according to his LinkedIn page.

Schroeder also has worked as a clinician and executive in medical clinics that serve many Medicaid patients, founding and serving as CEO of the Neighborhood Health Center in the Portland area.

A leading Portland advocate, Kevin Fitts, executive director at Oregon Mental Health Consumers Association, welcomed Schroeder’s medical background. Fitts said his experience working with patients and ethical training to “do no harm” will be crucial for the state’s work in Medicaid and behavioral health.

Andrea Cooper, Kotek’s chief of staff, told health authority employees in an email on Tuesday that they will likely see Schroeder in the office before he assumes the interim role, working with Allen on the transition. She urged them to support him in the new role.

Multi-billion dollar budget

The health authority is one of the biggest agencies in Oregon in terms of budget – more than $17 billion a year in the current budget cycle – and it has 4,770 employees. The agency is responsible for most of the state’s health care programs, including behavioral health, public health and Medicaid, which covers one in three Oregonians.

When the federal health care emergency ends, which could happen in mid-January, the agency will need to audit the 1.4 million Oregonians covered by Medicaid to weed out those who no longer qualify because they make too much money. The agency also needs to bolster the state’s mental health services. For years, Oregon has ranked in national surveys as having the highest or among the highest share of people suffering with mental health and addiction problems and a lack of treatment options.

The Legislature has allocated $1 billion to create behavioral health and addiction treatment and social service networks, but Fitts said the behavioral health system continues to languish. He said the next director will need to ask tough questions and look for solutions that go beyond the system as it is now, he said.

Schroeder acknowledged that challenge in a statement.

“Our state is at a critical turning point, especially when it comes to the delivery of mental health and addiction services. I am honored by this appointment, and I want Oregonians across the state to know that I take this responsibility very seriously,” Schroeder said in a statement. “I will work tirelessly to ensure that the OHA team produces results for our communities.”

Focus on equity

Allen said he’s worked closely with Schroeder for years, saying he’s well qualified. The two have been in contact more frequently in recent weeks as it became clear that Schroeder would succeed him, at least on an interim basis. 

Besides working on behavioral health issues and homelessness, two of Kotek’s priorities, Schroeder will face a big challenge trying to make health care more equitable, Allen said. He set an agency goal of achieving equity by 2030. Allen said the agency’s culture has changed since he took the helm to emphasize equity. He said that needs to be a part of all of the agency’s programs for the state to advance.

“If you’ve got big chunks of the population that are disconnected from all of that and you don’t pay attention to health equity, you’re really not serving the need that you need to serve,” Allen said. “That’s a big cultural change that took a long time to begin to get to.”

Allen said keeping a focus on equity has been one of the most difficult parts of the job because the agency is frequently grappling with a crisis, such as a disease outbreak. For much of the past three years, it’s been focused on the pandemic. Allen said it’s human nature to focus on the immediate crisis but that can mean that health inequities continue to dog the state.

“For any director of OHA, that part is harder. And it’s often the part that gets left behind because because the rest of the problem is so urgent.” 

It’s not clear whether Kotek plans to appoint Schroeder to serve as the permanent director or will consider him. A spokeswoman, Katie Wertheimer, did not immediately respond to a request for comment about that.

Allen said that when he was appointed to lead the agency by Gov. Kate Brown in 2017 it was initially on an interim basis.

Fitts said he’s optimistic that Schroeder will be able to bring needed change to the health authority.

“The status quo is unacceptable,” Fitts said. “I think we need a visionary and we need somebody to have the courage to be above board and talk about these issues.”

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