Tag: Medicaid Managed Care

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UHC is among the plans who recently won in MN after the state ended the 40+ year ban on for-profit MCOs.

 
 

 
 

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.

 
 

 
 

Jim Mone, Associated Press

UnitedHealth Group, based in Minnetonka, operates Optum and UnitedHealthcare, the nation’s largest health insurer.

Minnesota’s health insurance program for lower-income residents is adding UnitedHealthcare as an option next year, a contract award announced Monday that makes the health insurance giant the first for-profit HMO in the managed care program.

The Legislature in 2017 passed a law allowing for-profit competition in the market for Medicaid health plans, which for 40 years had been reserved for Minnesota’s nonprofit health insurers.

With state contracts that cover just the seven-county metro announced Monday, beneficiaries across the Twin Cities area will be able to select Minnetonka-based UnitedHealthcare among multiple health plan options to provide their state-funded benefits. Health maintenance organizations (HMOs) are a type of health insurance.

“Minnesota was one of the last — if not the last — states in the nation to allow for for-profit health care plans,” Jodi Harpstead, the state’s Human Services commissioner, said in an interview.

“Interesting that UnitedHealth is a for-profit health plan that’s actually headquartered in the state of Minnesota, so [the company] certainly understands Minnesota in a lot of ways,” Harpstead said. “They’re very large. With that comes all kinds of data and other capacities, which could be beneficial.”

UnitedHealthcare has been making a push since 2017 to do more business in its home state. The company, which is the health benefits division of UnitedHealth Group, started by introducing its Medicare Advantage health plans and selling more types of coverage for employer groups.

“We are honored to have received a contract from the state of Minnesota, which will allow us to serve more people in our home state, many of whom are our friends and neighbors,” Victor Fields, the chief executive of UnitedHealthcare Community Plan of Minnesota, said in a statement.

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UnitedHealthcare will now have access to another portion of Minnesota’s health insurance market — one that was famously reserved for nonprofits. Before the 2017 law, for-profit insurance companies could not get an HMO license in Minnesota, and only HMOs could bid on the state’s managed-care business in Medicaid.

The state-federal Medicaid program primarily covers low-income people under age 65, although others can qualify in certain circumstances. At UnitedHealthcare, Medicaid enrollment has grown by about 30% over the past five years to just over 7.5 million people at the end of September.

Harpstead said the state Department of Human Services, in conjunction with leaders from seven metro counties, scored all bids submitted by HMOs to select winners. Health plans were asked, in particular, to described how their services could help eliminate disparities while increasing equitable health outcomes. UnitedHealthcare scored high enough through that process, she said, to become an option throughout the region.

Nonprofit carriers Blue Cross and Blue Shield of Minnesota, HealthPartners, Hennepin Health, Medica and UCare also were awarded contracts for anywhere from one to seven counties. Beneficiaries can select from at least three HMO options in each county.

“When a new player enters the field, normally they would be picking up new enrollees — not having people change,” Harpstead said. “People are allowed to change, and United is free to make the case that they should consider that, but most people don’t change their health plans.”

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In Hennepin County, Minnetonka-based Medica also will be a new option for 2022. In Ramsey and Scott counties, the HMO from Eagan-based Blue Cross will no longer be an option. That means about 75,000 people in those counties need to pick a new health plan, or they automatically will be enrolled in an HMO.

Altogether, the state in 2022 will pay the companies $3.87 billion, which they will use to cover medical expenses for some 600,000 adults and children in the program.

Minnesota’s ban on for-profit HMOs was adopted in the early 1970s and driven by consumer protection concerns. Lawmakers worried the profit motive would prompt companies to skimp on health care, and some DFLers raised those concerns again in 2017.

But Republicans in the Legislature argued for-profit competition would expand options in the state’s health insurance market. The ban was repealed at the time as part of a bill to create a state-funded reinsurance program to combat runaway premiums on health plans sold to individuals.

“If they’ve not experienced a for-profit health plan, some people are nervous about what that might mean,” Harpstead said on Monday. “I think it all remains to be seen as we get started here.”

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In 2018, Minnesota was one of 39 states that was hiring health insurers to manage care for Medicaid beneficiaries, according to Kaiser Family Foundation. The California-based group estimated that UnitedHealthcare at the time was the second-largest of six Fortune 500 companies in the Medicaid HMO market.

The contracts announced Monday cover the state’s MinnesotaCare and a large share of Minnesota’s Medicaid program, which is called Medical Assistance. Overall expenses in what’s known as the Prepaid Medical Assistance Program will grow by 9.7% next year, Harpstead said, due to a combination of growing health care costs and new benefits for enrollees.

 
 

Clipped from: https://www.startribune.com/unitedhealthcare-to-become-first-for-profit-health-insurer-in-minnesotas-medicaid-program/600112067/

 
 

 
 

MM Curator summary

A recent state audit claims that MCOs deny services at a much higher rate than FFS.

 
 

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.

 
 

DES MOINES, Iowa — Iowa’s privatized Medicaid system has illegally denied services or care to program recipients, and both private insurance companies managing the system have violated terms of their contracts with the state, according to a state audit released Wednesday.

Auditor Rob Sand released a report from his investigation that examined a six-year period from 2013 through 2019. He said his investigators found a massive increase in illegal denials of care by managed care organizations, or MCOs, under privatized Medicaid.

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“What this means is that privatized Medicaid is less likely to treat Iowans in accordance with the law. It means that the Medicaid MCO’s that we have contracted with are not upholding their end of the bargain,” Sand said.

The head of Iowa’s Medicaid program responded within minutes of the audit’s release, rejecting its conclusions and arguing Sand was making an “apples to oranges comparison” that mischaracterized the current program.

Former Republican Gov. Terry Branstad in 2016 abruptly shifted Iowa’s Medicaid program from management by the Iowa Department of Human Services to private insurers. His successor, current GOP Gov. Kim Reynolds, has continued to support privatization amid complaints that service has suffered, payments to service providers have been delayed at times and promised savings never materialized.

Such privatization became a popular idea among GOP politicians, who argued private companies would more efficiently manage Medicaid than a state government agency. Currently, the private Medicaid managers provide health care for more than 781,000 poor and disabled Iowans.

Sand said after privatization, there was an 891% increase in the number of cases in which a judge restored services to a Medicaid participant, concluding services were unlawfully denied by the private insurers managing the program.

He promised after being elected in 2018 that he would do a compliance report on Medicaid after service providers and recipients complained about the new system failing to provide comparable care and payment.

“This has been a long-time coming. It has taken a lot of work. We’ve reviewed tens of thousands of documents and at the end of the day what this is, is a statement of facts,” Sand said. “It’s telling Iowans what’s going on in the state. We’re doing our job. It’s about the people.”

Sand also reported that the two companies managing the Medicaid program, Amerigroup and Centene Corp., operating as Iowa Total Care, violated provisions of the contract established with the DHS.

He said Amerigroup failed to comply with one provision of the contract, and Iowa Total Care failed to comply with numerous provisions of the contract. For example, in multiple documented instances, both companies failed to comply with the contract clause requiring Home and Community Based Services providers to continue providing services to a member switching from one provider to another.

“This has resulted in members going without services, such as bathing and wound care, thus violating the contract and state and federal law, while the company still receives payment for their care,” Sand said in the report.

In her statement responding to the report, Medicaid Director Elizabeth Matney called the audit “an incorrect and flawed report.”

Matney said the report inaccurately compares the previous “fee-for-service” system with a managed care approach in which appeals can be resolved without going before an administrative law judge. Such judges then can focus on more complex cases.

“We worked with the Auditor of State’s team to explain why this was an apples to oranges comparison,” Matney said. “The process is not the same, so making a comparison without factoring in the improvements we built into the MCO appeals process prior to ever seeing an administrative law judge is just wrong.”

She said much more information would be needed to substantiate the claims in the auditor report.

She said the department is reviewing the allegations of contract violations and offered to meet with Sand to discuss in further detail agreeing that “contract compliance is something that requires diligent oversight.”

 
 

Clipped from: https://www.nwaonline.com/news/2021/oct/25/auditor-iowas-privatized-medicaid-illegally/

 
 

 
 

 
 

MM Curator summary

 
 

More details released from the PA court case against Aetna suggest an extensive issue of assigning kids to PCPs known to not be in network.

 
 

 
 

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.

 
 

 
 

The following article was originally published in the Ohio Capital Journal and published on News5Cleveland.com under a content-sharing agreement.

COLUMBUS, Ohio—In a case that could have implications for Ohio, a Pennsylvania whistleblower is accusing Aetna of making it impossible for the parents of some kids on Medicaid to find doctors. The insurer then pocketed money from the state for services not rendered, the suit alleges.

Aetna denies the charges.

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The case is relevant here because the Ohio Department of Medicaid in April awarded a $1 billion contract to Aetna to implement OhioRISE, an ambitious new program meant to coordinate care for 60,000 children with complex behavioral needs.

The Pennsylvania allegations, which were unsealed last month in federal court in Pittsburgh, might cast doubt on whether the company will live up to its promises in the OhioRISE program.

The allegations also add to questions of conflict and bias concerning Ohio’s procurement this year of the OhioRISE contract and six others for $22 billion worth of Medicaid managed care. Together, the contracts are meant to reshape the way the Ohio Medicaid department delivers care to 3 million people.

The Ohio Department of Medicaid was asked to comment on the Pennsylvania suit a week ago. As of Tuesday, it hadn’t responded other than to acknowledge that it had been asked for comment.

For its part, Aetna parent company CVS Health denies the accusations.

“Aetna places the highest priority on the health and wellbeing of its members, and we provide access to quality care through a comprehensive provider network, including in Pennsylvania,” spokesman Bob Joyce said in an email. “Plaintiff’s allegation that Aetna has network adequacy deficiencies across the country is irresponsible and unrelated to the (U.S. Justice Department’s) investigation.

“Aetna denies the allegations in the complaint, and intends to vigorously defend itself should (the whistleblower) choose to move forward with her non-intervened complaint. Aetna is pleased that after reviewing all of the evidence, the government chose not to participate in the lawsuit.”

The case was filed under the False Claims Act, which encourages people with knowledge of government rip-offs to blow the whistle by giving them a portion of the money recovered.

While it’s accurate that the federal government declined to intervene in the suit, the federal government is said to intervene — or take over — in only about 20% of such cases.

And in an Aug. 25 filing, the Justice Department notified the court that the federal government would continue to be listed as a plaintiff and pointed out that the case can only be dismissed if Attorney General Merrick Garland consents to it. The filing also asked U.S. Magistrate Judge Cynthia Reed Eddy to unseal the complaint, which she did the following month.

Serious claims

The Pennsylvania whistleblower, Carol Wessner, accused Aetna Better Health of Pennsylvania of shrinking its network of doctors for kids on Medicaid and then lying to the Pennsylvania Department of Health about it.

Aetna hired Wessner as a “quality management nurse consultant” in 2013. Her primary task was to investigate why such a high percentage of Aetna’s child patients were missing their Early and Periodic Screening, Diagnostic and Treatment appointments. The doctor visits, required by Medicaid since 1967, are intended to catch developmental and other health issues as early as possible.

Wessner claims that she discerned a pattern. Aetna officials contended that kids were missing appointments because providers were discriminating against them, but she found that time and again, those providers weren’t in Aetna’s network.

Wessner “never encountered an (Aetna pediatric doctor) who discriminated against children on (Aetna) Medicaid,” the suit says. “Rather, many of the (doctors) to whom children were assigned (i) were not contracted with (Aetna); (ii) were dead; (iii) were out of state; or (iv) did not see children at all.”

Many of the physicians to whom Aetna claimed to assign children wouldn’t be likely to pass even superficial scrutiny, Wessner said.

“… children, including two-year-old boys, were assigned to gynecologists, hospitalists and vascular surgeons,” the lawsuit says, referring to a provider group that Aetna listed as in its pediatric network. Aetna “also had wrong addresses, phone numbers and affiliations for the (primary care providers) at this site.”

Wessner also provided possible evidence that Aetna was deliberately shrinking its network while telling a different story to Pennsylvania Medicaid officials.

She said that on May 7, 2014, she was in a meeting with a Philadelphia public health official when the official was handed a note from Aetna. The company was notifying the city’s department of health that it was terminating its contracts with all eight of the agency’s City Health Centers, the suit says.

Yet by “February 2015 — almost a year later — (Aetna) still had 491 children enrolled with the department,” the lawsuit says. “Some were enrolled as recently as Feb. 1, 2015.”

Wessner claims that Philadelphia was far from the only agency in which Aetna terminated contracts with providers while continuing to tell state Medicaid officials that its child clients were enrolled with the agencies’ doctors. Her lawsuit says Aetna took similar actions with at least six other health systems, in some cases assigning children to doctors within the systems even after terminating their contracts.

In the case of the Reading Health Physicians Network, the lawsuit claims that in September 2016 — almost two years after Aetna had terminated its contract — the company still assigned 1,127 of its child clients to doctors there. Seven hundred thirty six of them hadn’t had their federally required diagnostic exams in at least a year, it said.

The lawsuit says money was the motive for all this.

Aetna “misrepresented its network adequacy by including providers (Aetna) knew were inaccessible in order to gain new Medicaid enrollees that would increase (Aetna’s) per-member/per-month payment from Medicaid.”

Payback?

Wessner claims she was retaliated against for repeatedly flagging problems to her superiors, including Aetna Better Health of Pennsylvania CEO Jason Rottman.

She said her supervisor, Alice Jefferson, in 2015 told her to stop sending written reports and make them verbally instead. In 2016, Wessner was removed from her job investigating kids’ missed checkups. Then in 2018, she was terminated.

Regardless of the outcome of the case, it adds to questions about the companies hired as part of Ohio’s Medicaid reforms this year.

Aetna’s parent company, CVS, has long been accused of gouging Ohio Medicaid for prescription drugs — a charge the corporation denies. UnitedHealth has faced similar accusations and is being sued over fraud claims by Attorney General Dave Yost. Yet it was one of six giant corporations to be awarded huge managed-care contracts in this year’s procurement.

Yost in March sued another of those corporations, Centene, and it paid out $88 million in June to settle them.

When the Ohio Medicaid department undertook its procurement process, it set it up in a way that didn’t allow evaluators to consider previous bad acts by the companies applying. Now Mercer, the consultant that facilitated the process, won’t say whether any of the successful bidders are also its clients.
 

 
 

Clipped from: https://www.news5cleveland.com/news/state/aetna-an-ohio-medicaid-contractor-accused-of-denying-kids-care-in-pennsylvania

By Clarissa Donnelly-DeRoven

MM Curator summary

 
 

Speech therapists in NC continue to struggle to adapt to the new managed care model.

 
 

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.

 
 

Three months into North Carolina’s Medicaid transition, some small health providers say they’re struggling to navigate the new system. They describe spending hours more on new administrative tasks, trying to ensure their patients don’t experience lapses in care and that they get paid for the services they provide.

“I want to help everybody, and this is preventing me from doing that,” said Rebecca Rowe, a speech language pathologist who runs her own practice in Charlotte. Rowe and other small medical practice owners worry that the added administrative costs may make it untenable for them to serve as many Medicaid patients in the future. 

“When you’re talking about a small business, you have to maximize the time, right? Maximize the time spent one-on-one with clients,” Rowe said. “It’s hurting children first and foremost, but it’s also hurting small businesses and I don’t think that’s something that the North Carolina government understood.”

Dave Richard, the deputy secretary for North Carolina’s Medicaid system, said the agency is aware of these problems and working to address them through weekly conversations with the CEOs of each of the managed care organizations. Still, he said, some of the issues are just a function of the new system. 

“Managed care is managed care and there’ll be some of these changes that just are inevitable because of the way that managed care organizations have to work,” he said.

From public to private

On July 1, North Carolina’s Medicaid program transitioned from a system run and managed primarily by the state, to a system run and managed by five different private insurance companies, called managed care organizations or MCOs. About 1.6 million low-income North Carolinians had their coverage switched from state managed to MCO managed. Three quarters of those people — 1.2 million — are under 21 years old. 

Some 900,000 people who have more intense health care needs, ranging from developmental disabilities to chronic mental health issues, remain on state-run Medicaid and will see their plans turned over to the MCOs in 2022. 

Nationwide, about 70 percent of people on Medicaid receive coverage from a managed care entity, according to the Kaiser Family Foundation. Before the transition, North Carolina was the largest state in the country without a significant presence of corporate managed care organizations in its Medicaid system. 

The transition from state run to MCO run occurred by and large to save money and provide more budget predictability. 

When North Carolina ran its own Medicaid program, state employees were responsible for authorizing claims and allocating the funds to pay doctor bills. The cost of the program came in at $14.8 billion in 2019 and $16.8 billion in 2020. The federal government pays for the majority of Medicaid costs; over that two year period, North Carolina’s share came out to about $3.8 billion. 

The cost savings is expected to come from the shifting payment structure. The state-run Medicaid program operated using a fee-for-service model, where the state reimbursed health care providers for each visit, test and service. The model used by managed care organizations pays providers a set payment per patient. Under the new model, patient health outcomes will be one of the key benchmarks for measuring how well providers are doing.

The MCOs are for-profit entities. In the past, they made money by denying services and cutting reimbursement rates. Richard said there are accountability measures in place to prevent this kind of nefarious behavior, specifically through something called a Medical Loss Ratio.

The Affordable Care Act requires private health insurance companies to submit data on how they spend their money. The standard under the Medical Loss Ratio requires the companies to spend between 80 and 85 percent of the money they take in from premiums on actual health care services. If they don’t do that, and instead spend customer payments on things like executive compensation and advertising, they have to issue rebates. 

The rule extends to the MCOs working with North Carolina’s Medicaid program.

Division of Mental Health director Dave Richard speaks to reporters at the WakeBrook event Thursday. Photo credit: Rose Hoban

“They have to spend 88 percent of what we pay them on services,” Richard said. “It can’t be that they’re spending 80 percent, then they’re pocketing the rest. So there’s this real tight part in our managed care plan that I think holds them accountable at that level.”

With managed care, more logistics to deal with

Before the transition, service providers submitted requests for authorizations and claims directly to the state’s Medicaid program through the NCTracks online portal. Now they have to navigate the systems of multiple managed care companies. This, they say, is one of the most time consuming parts of the transition. 

Lakajai Harris, a speech language pathologist, runs her own practice and works with children in rural Beaufort County. About 95 percent of her patients are now on managed care plans. She is in-network with four of the five managed care plans and said navigating them has presented huge logistical burdens.

“It seems like all of these insurance companies, they have one site that you need to go on to submit claims and one site to submit payments,” she said. “That means that we’ve gone from NCTracks to eight different sites.”

Stacy Kozlowski, an occupational therapist who also runs her own practice, said the same. She operates primarily in Johnston County and is in-network with all of the managed care companies.

“Small businesses like myself that provide services in the more rural areas, rural areas that big hospital systems don’t go to.” she said. “We don’t have the overhead or the administrative ability to manage seven or eight different entities with different systems.”

Providers say the MCOs are allotting them shorter authorization periods for service than the state-run Medicaid program did, which adds to their administrative work. 

Rowe, the Charlotte speech therapist, said Carolina Complete Healthcare recently authorized her to see an existing patient for just one month. 

Rebecca Rowe is a speech language pathologist who runs her own therapy practice in Charlotte. She’s struggled to handle the added administrative burdens of the new Medicaid system. Photo courtesy of Rebecca Rowe.

“That was down from six months that this child was receiving before, so that equates into extra manpower for our staff, for our front desk to continually do these authorizations,” she said. “Let’s say your practice sees 50 to 100 kids under these managed care companies. So you think about an hour every month getting a new authorization, right? That’s a lot of time and a lot of money.”

Harris said the time it takes the MCOs to authorize claims is slower than it was under the state-run system. In the past, she said it took about two weeks for her to receive a signature from their doctor and authorization from Medicaid before she could start services. Now, that timeline has doubled.

Since Harris knows when an existing client’s authorization will run out, she tries to submit the paperwork early enough that their new authorization for services will start immediately after their old one runs out, meaning the new waiting period primarily impacts new clients. 

Sometimes, though, existing patients get sucked in. She told the story of one boy whose authorization expired and his mother couldn’t make an appointment for a few days. By the time the boy’s doctor sent back the signed form to Harris and she submitted it to the child’s insurance, two weeks had passed. 

Harris said Blue Cross Blue and Shield of North Carolina, which runs HealthyBlue, requires 15 days to approve services. She said she called to see if they might be able to expedite the approval, but she had no luck. 

“This child has gone almost a month without services because I had to wait those 15 days to get approval,” Harris said. “I basically feel that I will have to start all over with him.”

Harris said BCBS of NC’s timeline for authorization feels especially arbitrary because some of the other entities, like AmeriHealth, approve authorizations in as little as two to three days.

More paperwork

Kozlowski said one MCO plan is asking her to send updated care plans every 30 days, which she said in her professional opinion is not necessary. 

“This is not like adult outpatient therapy where they’re progressing within six to eight weeks,” she said. “These are kids with chronic conditions that take greater periods of time to make progress.”

Sending an updated plan of care every 30 days means the therapist working with a child has to take daily notes, write up the new plan, and then Kozlowski’s office will fax it to the child’s pediatrician, wait for the pediatrician to sign and return it, and then submit it for authorization to the insurer. 

“We have to allow at least a month so that there’s no lapse in service,” she said. Kozlowski has hired additional staff to deal with the added administrative work that’s come from juggling five new insurance programs. 

Harris, who does her own billing, said she doesn’t know how sustainable a system like this is for a one-woman business. She only just received payment for services she provided in July, after a long hassle with one of the MCOs. The entity kept denying her claims, saying she wasn’t in-network, which she said wasn’t true. Eventually, she learned it was because the MCO entered her biographical information incorrectly into their system. But, it wasn’t easy to figure out.

“They kept just giving me the runaround, like, ‘Well, submit a claim, see what happens, and then we can go from there.’ And it would take a week or two before I get some type of response back,” she said. “I finally told the rep, if I wasn’t going to get paid soon — by the month of October — I would have to close down because I was not receiving payments. I’m still seeing these children, and I’m not getting paid for these children.”

Harris said her issue was only resolved after she submitted a complaint to the North Carolina Medical Society, an organization that serves as an intermediary between the MCOs and health care providers. 

“This managed care,” she said, “I don’t know how small businesses like me are going to survive.”

State expected some bumps

Richard, the head of North Carolina’s Medicaid program, said the agency was “preparing for the worst” during the first few days of the transition, such as a total crash of the program’s online systems. 

“But honestly, the big stuff went well. We’ve had what I call serious issues for people, but not the catastrophic problems that I think people were concerned would happen,” Richard told a virtual audience gathered during an October conference for the state chapter of the National Alliance on Mental Illness.

Some of the serious, but not catastrophic, issues included problems with non-emergency medical transport, a program that is supposed to help people get transportation to and from their medical appointments.

Kelly Zyablov, a mom with two children on the new managed care plans, told her children’s speech therapist — Rowe — that she couldn’t afford gas for the 45-minute trips back and forth between her house in Union County and the office in Charlotte. 

Rowe looked at a brochure, created by the N.C. Department of Health and Human Services, that describes the different services available to those on the new managed care plans. The services are designed to address social determinants of health. 

Under the “Other” section, Rowe noted the bullet point: “$20 in Uber or Lyft gift cards for college students for grocery stores, local events.” She told Zyablov to call the insurance company and see if they could give her that benefit, or something similar, so she could drive her son to therapy. 

That sounded like great news for Zyablov. She called the number and said: “My kids have therapy, we need to get back and forth. Do you offer gas cards? They said no, but if your children are obese, we can give you a food card.” No thanks, she said and hung up. 

Without the extra gas money, Zyablov can only take her son, who has a brain disorder called apraxia, to speech therapy once a week — and sometimes even that is a stretch. 

Richard said there must’ve been a miscommunication. Though non-emergency medical transport is not exactly the system designed to help someone in Zyablov’s situation, there are a handful of “value-added services” attached to each managed care plan that are designed to address social determinants of health, such as not being able to afford gas to and from appointments. 

What might managed care look like in years to come?

“We know that there’ll be some disruption right? Because as you make this change, managed care principles take place,” Richard said, “And we’ll see a few rocky moments.”

Providers are worried about what those “managed care principles” might look like in practice. Many look to states that have recently switched over to managed care plans. Iowa, for example, moved from state-run Medicaid to a system operated by managed care organizations in April 2016. 

Over the last five years, providers have complained about declining reimbursements for care, while patients say they’ve been denied critical coverage. Two of the managed care companies, UnitedHealthcare and AmeriHealth Caritas, abruptly left the program just a few years in. UnitedHealthcare said it left because Iowa underfunded its Medicaid program, but Iowa officials said the insurance company left because it didn’t want to comply with oversight mechanisms. 

The possibility that the MCOs will cut reimbursement rates is what worries many providers the most, including Rowe. 

“These plans typically cut rates and cut services, right? That’s what they do to try to save money,” she said. “What will happen is, it’s all downstream. So these kids will go without services, they will get to their public school, they will be behind.”

Richard said that, hopefully, won’t be the case.

“If the health plans do their job, and if our community based care management does its job, the way health plans are going to make money is by people being healthier,” he said. “And that’s really the goal that we have, is that healthier people will use less of the more intensive services, which then allows for those health plans to make their margins.”

 
 

Clipped from: https://www.northcarolinahealthnews.org/2021/10/19/three-months-into-medicaid-transformation-providers-say-the-new-administrative-burdens-are-crushing/

 
 

MM Curator summary

 
 

CMS is expected to release guidance on its new vaccine mandates for nursing homes and hospitals receiving federal funds.

 
 

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.

 
 

The Centers for Medicare & Medicaid Services (CMS) revealed last week that it was in the rulemaking stage of a collaboration with the Occupational Safety and Health Administration (OSHA) on the establishment of a federal vaccine mandate.

Last Monday, Dr. Lee Fleisher, CMS’ chief medical officer and director of the Center for Clinical Standards and Quality (CCSQ), confirmed that the agency is slated to release its guidelines in late October. Fleisher did so while appearing at the National Association for the Support of Long-Term Care’s (NASL) annual meeting.

This means that Medicare-certified home health providers should expect CMS to release guidance any day now.

 
 

“CMS will soon issue the emergency regulation requiring staff vaccinations within the nation’s more than 15,000 Medicare and Medicaid-participating nursing homes and Medicare and Medicaid-certified health care providers that are regulated under CMS regulations, but we cannot comment on the specifics of the pending regulations as we are in the active rulemaking process,” a CMS spokesperson told Home Health Care News in an email. “There will be a 60-day comment period that will begin when the regulation is published in the Federal Register for the public to share their feedback with CMS.”

The journey to a federal vaccine mandate officially began last month after President Joe Biden announced a six-pronged approach to his administration’s COVID-19 strategy, with plans explicitly mentioning home health providers. The approach also pushed for American workers to get vaccinated and called for increased COVID-19 testing.

At the time, CMS confirmed that vaccinations would be a condition for participating in the Medicare and Medicaid programs.

 
 

“The staff vaccination requirement would only apply to Medicare and Medicaid-certified provider and supplier types that are regulated under the Conditions of Participation,” the agency said. “If an entity is not regulated under the CoPs, then this requirement would not apply.”

For now, providers can only speculate on the potential details of the mandate and if any exceptions will be taken into consideration. When one comes out, CMS will need to keep several considerations in mind, according to National Association for Home Care & Hospice (NAHC) President William A. Dombi.

“First, any mandate must provide sufficient time for reasonable compliance,” Dombi told HHCN in an email. “That matters primarily because there is a high risk of interruption of patient services resulting from lost clinical staff. The vaccine mandates in health care settings that already have occurred have demonstrated that some staff leave their jobs. In home care and hospice, there is a current staff shortage such that even the loss of one staff member can cause difficulties in continuing to serve existing patients as well as taking on new patients.”

Secondly, a CMS mandate must provide for exceptions with clear standards for applying those exceptions, he noted.

Additionally, “to the extent possible,” a CMS vaccine mandate should be evenly applied across the health care sector, NAHC’s leader advised. On top of that, CMS should also consider the costs of a vaccine mandate, especially on newer home health and home care agencies.

“A vaccine mandate presents a variety of new costs for home care companies,” Dombi said. “Appropriate compensation for such costs is a reasonable expectation as these costs are not built into today’s payment rates.”

On the state level, New York rolled out its own vaccine mandate back in August. The regulation mandates the vaccination of home health and personal care workers in the state, with the requirement that the first dose be administered by Oct. 7.

Since then, the rate for New York home-based care workers checked in at about 86% partially vaccinated and 71% fully vaccinated. About 34,000 caregivers have not begun the process at all, according to reports from The New York Times.

The state has received pushback from organizations such as the Home Care Association of New York State (HCA-NYS).

“We have been saying to our governor and our state health department, from the beginning, if you’re going to apply the mandate … you need to do it in a way that doesn’t cause a dislocation of care service for patients and a loss of workforce,” Al Cardillo, president of HCA-NYS, previously told HHCN.

Another East Coast state, Massachusetts, announced plans to require vaccinations for all staff at rest homes, assisted living residences, hospice programs, as well as home-based care workers.

Along these lines, individual home-based care providers have also taken a leap and implemented vaccine mandates within their organizations.

In August, Empath Health announced a policy that requires its staff, volunteers and vendors to be fully vaccinated against COVID-19 by Nov. 1.

“This was not a decision that was made lightly or quickly,” Dr. Neville Sarkari, chief medical officer at Tidewell Hospice, previously told HHCN. “We spent a great deal of time debating this internally. The vaccines are effective and safe, so we felt it was the right thing to do to protect our patients and our colleagues.”

Tidewell Hospice is one of Empath Health’s hospice subsidiaries.

CommonSpirit Health and its home-based care arm, CommonSpirit Health at Home, also announced that it would require its employees to be fully vaccinated by Nov. 1.

“As health care providers, we have a responsibility to help end this pandemic and protect our patients, our colleagues, and those in our communities – including the most vulnerable among us,” Lloyd H. Dean, CEO of CommonSpirit, said in a press statement. “An abundance of evidence shows that the vaccines are safe and highly effective. Throughout the pandemic, we have made data-driven decisions that will help us best fulfill our healing mission, and requiring vaccination is critical to maintaining a safe care environment.”

OSHA has already submitted its rulemaking on COVID-19 vaccination and testing requirements for private sector businesses of more than 100 employees.

“NAHC remains highly supportive of vaccinations,” Dombi continued. “We appreciate the efforts of the administration to get as many people vaccinated as possible and as quickly as possible. However, we must proceed with plans to address all the likely consequences of a mandate in order to ensure continuity in patient care and access to health care at home.”

Additional reporting by Jordyn Reiland

 
 

Clipped from: https://homehealthcarenews.com/2021/10/cms-getting-closer-to-vaccination-guidance-for-home-health-agencies-other-medicare-medicaid-providers/

 
 

Oregon’s proposed five-year Medicaid plan has lofty goals and concepts. They include expanding members’ access to care, making the health care system more equitable and increasing flexibility in how money can go toward quality of life needs that can influence overall health, like housing and green spaces.

Heavyweights in the health care industry, including coordinated care organizations, support much of it, especially the plan’s focus on equity in health care. But the industry is pushing for more answers and has some concerns about the state’s draft Medicaid plan for 2022-2027, records show. In particular, they question where the money will come from to fund new programs and staffing.

Coordinated care organizations — the entities that insure Medicaid members — behavioral health providers and hospitals have weighed in on the initial concepts in Oregon’s proposed five-year Medicaid plan, also called a waiver. In 53 pages of feedback, health care companies, advocacy groups and industry representatives provide a candid assessment of where Oregon’s health care industry needs to go — and potential blind spots in the proposed plan for the state’s roughly 1.34 million Medicaid members. The Lund Report obtained the health care industry’s feedback on the state’s Medicaid proposal concepts through a public records request. 

Earlier this year, the Oregon Association of Hospitals and Health Care Systems prodded the state for more details. 

“Throughout these concept papers, whether around the global budget or the health equity zones, there is a lack of detail, which makes it difficult to interpret how (Oregon Health Authority) is viewing this policy and creates challenges for hospitals and others in providing meaningful feedback,” the hospital industry’s trade group wrote to the health authority.

Oregon officials are still working on the five-year plan and will release another draft with more details in early November. From there, they will negotiate its terms with the federal Centers for Medicare & Medicaid Services before Oregon’s existing waiver expires in June 2022. 

Lori Coyner, the state’s senior Medicaid waiver advisor, said the health authority has “actively solicited input” from a range of people. 

“We have considered all the input that we received,” Coyner said in a statement. “We have made adjustments where it was appropriate, especially if the adjustment furthered our goal of using the waiver renewal to create a more equitable system of health. During upcoming public comment on the application, we will solicit and consider still more input, and we look forward to more engagement with interested parties, community members and Oregon Health Plan members.”

The waiver is key because it lets states use federal Medicaid funding in ways that go outside the scope of the federal cookie-cutter model of Medicaid. For example, in 2012, Oregon’s Medicaid waiver allowed the state to set up coordinated care organizations. 

About 1.34 million Oregonians are on Medicaid, a program that provides medical coverage to people if their income falls below certain thresholds. That’s about 30% of Oregonians.

Many commenters questioned whether the state has the money to fulfill its expanded goals for Medicaid. About three-quarters of the roughly $8 billion the state spends annually on insuring Medicaid members comes from federal coffers; the rest comes from the state.

Here’s a look at the feedback from the health care industry:

Behavioral Health Care 

PacificSource, a Springfield-based CCO, reminded Oregon Health Authority officials of a 2020 Secretary of State’s audit that found the children’s behavioral health care system is fragmented and siloed.

“While providing care for all members of the Oregon Health Plan is paramount, we believe that earlier interventions and care coordination for our youth could serve as a central strategy for meeting the

administration’s goal of eliminating health inequities,” the CCO wrote in its letter to the authority. 

PacificSource, echoing concerns throughout the industry, said worker shortages pose a threat to goals of providing adequate mental health care for children. This comes in the context of a state proposal to keep children enrolled in Medicaid for five uninterrupted years. 

“We share in the belief that children must receive appropriate mental health care,” the group wrote. “We would ask how this idea works with the proposal to maintain enrollment for children uninterrupted for five years.”

The group added that “without ensuring that the Oregon Health Plan can accept dramatically more patients,” the proposal may not ensure children rapidly receive care. 

“Oregon needs a concerted effort to invest in workforce recruitment, retention and development,” the group wrote. 

AllCare Health, a Grants Pass-based CCO, raised concerns about how Oregon will fulfill its stated goal of increasing access, including pharmacy services for people with behavioral health conditions.

That step, AllCare wrote, “generated concern among stakeholders because increased access to services assumes adequate and culturally appropriate mental health providers. However, in many communities available resources are inadequate to handle current crisis caseloads.”

AllCare said the state’s description of that goal, called Step 3, “does not include a plan for providing or funding much needed workforce development. Step Three also troubled stakeholders because it offers no solution for programs that are too often failing, and places an unreasonable burden on CCOs alone.”

Other aspects of behavioral health care proposals drew praise. The Oregon Council for Behavioral Health in its letter, said it supports the state’s goal of a consistent, reliable funding stream for peer support services through the waiver. Peers in the behavioral health workforce can work closely with clients and offer them perspectives and advice based on their life experiences, such as overcoming addiction. 

They are already utilized in Oregon, but funding them can be difficult. 

“A reliable funding source would sustain and support the development of equitable access to peer services across the state, and provide the opportunity to support equitable living wages for this critical and diverse workforce,” the council wrote in its letter to the state.

Cost Growth Target Concerns 

PacificSource also wants nuance added to the state’s draft paper, saying it “seems to imply an inevitable reduction in the rate of growth (of spending on Medicaid) to 3%.”

That’s tied to the state’s cost-growth target reduction efforts, which have the goal of curbing per-capita health care spending to 3.4% annually and then to 3% after 2026. 

State officials hope to negotiate with the federal government for a formula that will provide Oregon with some of the savings the federal government would receive through efforts to limit the growth of Oregon health care costs.

The state hopes that providers and health care insurers will be able to meet the cost-growth limits in part by rooting out waste and inefficiencies.

PacificSource reminded state officials that at this point, the long-term 3% growth rate is aspirational and not a formal state recommendation. 

“We believe that the concept paper (and the plan) must take into account the real possibility that the 3% target is not a given, and unforeseen events may influence whether or not a future successor committee will recommend that particular target,” PacificSource wrote. “Because this number seems important to determining the amount of savings recaptured for community investment purposes, we ask that the concept paper be amended to reflect this important nuance.”

High Drug Costs Eyed

The Coalition for a Healthy Oregon asked the state to consider, for an unspecified period of time, not counting high-cost pharmaceuticals under the 3.4% rate of growth cap. The coalition represents several CCOs and providers, including  Advanced Health, AllCare Health, Cascade Health Alliance, InterCommunity Health Network CCO, Trillium Community Health Plan, Umpqua Health Alliance and Yamhill Community Care.

“Given the effect of pharmaceutical drug prices on cost growth in the Medicaid system, we need a way to deal with this, especially as a safeguard to protect the global budgets concept,” the group wrote.

CCO Oregon, another group that represents CCOs, urged a similar action for high-cost drugs, usually those that don’t yet have a generic equivalent on the market.

“Achieving approval for a true global budget at 3.4% rate of growth is a goal for the OHA, CCOs, and our provider partners,” the group said. “High-cost pharmaceuticals and therapeutics can skew the overall cost and rate of growth for the OHP and CCOs.”

The group said its goal is quality care without being penalized for high-cost drugs.

Health Equity Zones Scrapped 

Oregon Health Authority officials have backed away from an earlier initial concept that would have put so-called “health equity zones” in place for communities to determine funding priorities.

Instead, the authority is moving forward with a central focus on equity. 

Coordinated care organizations, which are assigned to regions, voiced strong concerns that “health equity zones” would create silos and bureaucracy. 

The Coalition for a Healthy Oregon said its members “are concerned about creating equity zones as described in OHA’s draft concept.”

“We understand communities want greater input in health equity investments,” the group said. “This can be done successfully within the CCO model without creating parallel structures. A parallel track could lead to a divergence of spending priorities, whereas community investments should be aligned in pursuing health equity.”

So did other providers.

“Providence appreciates the intent behind this concept but has concerns about the duplication of existing efforts and the potential to create more silos,” Providence Health & Services wrote to the authority. 

CCOs all already have community advisory committees whose purpose is to give community members a voice in CCO policy.

More Dental Access Encouraged 

Dental providers urged Oregon state officials to look for ways to invest in oral health and make it equitable across the state. Oregon Health Plan members can access dental care already. But it can be a struggle to access care or find providers. 

Providence Health & Services wrote: “There is a notable absence of oral health in the concept papers. Oral health is a critical component

of healthcare and should be considered throughout the policies, much as health equity and behavioral health has been considered.”

In an email, Manu Chaudhry, dental director for Capitol Dental Care, a major provider of care for Medicaid members, urged Oregon Health Authority officials to consider the big-picture needs like workforce and the infrastructure as it plans its waiver. This includes coordinating care across physical, behavioral and oral health needs, Chaudhry wrote.

“Addressing issues that impede the ability of those eligible to receive care needs to be a part of Oregon’s ongoing focus to ensure the continuing success of Oregon’s coordinated model and CCOs,” he wrote.

 
 

https://www.thelundreport.org/content/health-care-industry-voices-concerns-over-state%E2%80%99s-medicaid-plan

 

 
 

A Toledo company that’s trying to stop a group of contracts worth billions from going forward on Wednesday focused on what it saw as inconsistencies in the way the Ohio Department of Medicaid procured them. And it again hinted at possible improprieties by Medicaid Director Maureen Corcoran.

It was the second day in a trial considering whether to stop implementation of five-year Medicaid managed-care contracts worth a combined $22 billion — the largest government procurement in state history.

A longstanding Medicaid managed-care company, Paramount Advantage, was not among the six selected earlier this year even though it had been a provider since the start of the state’s managed-care program and it had gotten good ratings.

It says being locked out of the program would result in more than 600 layoffs at Paramount and its parent company, Toledo-based ProMedica.

But if it’s successful in stopping implementation of the contracts, that would at least delay a major overhaul of Ohio’s $30 billion-a-year Medicaid program. The reforms are meant to focus care on individual clients, provide a continuum of service to 60,000 kids with complex behavioral needs and bring transparency to the way it spends billions on prescription drugs.

While the process by which companies were selected was intended to be competitive, it involved many more ambiguities than when state officials take bids for items like asphalt or police cars. Through two days of testimony, Paramount attorney Kirsten R. Fraser has focused on ambiguities and inconsistencies as she tries to make the case that her client was improperly passed over.

Managed-care providers contract with the state to sign up clients, create networks of providers such as doctors and hospitals, help determine what care is covered and see that providers are paid. Managed-care companies are paid a set amount each month for each client they have.

One of the vagaries in the procurement process that Fraser has pointed out is that interested companies were told they’d be evaluated according to three criteria: “method of approach,” “capability” and “experience.” But when she questioned six of the seven Medicaid officials who evaluated proposals, none could point to written definitions of those terms — either in the instructions to submit a proposal, or during the evaluation process.

Paramount contends that the process was biased in favor of huge, out-of-state companies, including Centene, a successful bidder that this year agreed to pay $88 million to settle claims that it ripped off Ohio taxpayers.

Ohio Medicaid Director Maureen Corcoran. Official photo.

 
 

Despite Paramount’s long experience in Ohio, evaluators rated it a weakness that the relatively small company hadn’t operated out of state. Fraser asked Medicaid Deputy Director Patrick Beatty if that didn’t conflict with Corcoran’s claim to a Senate committee that the procurement process would favor companies with deep experience in Ohio. Beatty responded that Corcoran didn’t serve on the panel that evaluated applications.

Even so, Corcoran had the final say in who won contracts.

Corcoran’s role in the procurement is under scrutiny for other reasons.

All of the evaluators who have testified so far said they had to file forms disclosing whether they held a financial interest in the companies trying to win contracts. 

Corcoran has refused to say whether she filed such disclosures even though it appears to be required by law. Documents filed under a separate law show that at least as of last year, Corcoran held stock in two of the companies that were awarded managed-care contracts and in the company that got the contract to create a system of services for kids with complex behavioral problems.

Corcoran also won’t say how much stock in those companies she owns. The law under which she disclosed her ownership only requires officials to say whether they own at least $1,000 worth of stock in a company.

When Fraser asked Beatty if he knew about Corcoran’s holdings, lawyers for the Medicaid department objected and Franklin County Common Pleas Judge Julie M. Lynch sustained the objection.

Fraser also asked Beatty if Corcoran violated the “blackout period” by communicating or having her staff communicate with companies while their proposals were under consideration. Beatty said he knew of no such improper communications.

Several times in her presentation Wednesday, Fraser pointed out that as recently as last year, Paramount scored well ahead on parts of Medicaid’s annual report card than UnitedHealth. That company, the nation’s fifth-largest, was successful in this year’s procurement and Corcoran owned its stock at least from 2018 through 2020.

But the Medicaid evaluators testified that they had strict instructions not to consider their past experiences with companies; they were only to consider what was in the companies’ applications.

Mary Applegate, the department’s medical director, said the point was to re-envision the program and bring about better health outcomes, such as reduced infant mortality. She said that in their application and their oral presentation, Paramount officials explained how they would do things under the current system.

“We wanted resourcefulness,” Applegate said. “We wanted patient-centeredness. We wanted a new paradigm of what ‘managed care’ means.”

The trial will resume Nov. 8.

 
 

https://ohiocapitaljournal.com/2021/10/14/disappointed-medicaid-bidder-focuses-on-inconsistencies/