Tag: Medicaid Reform

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Tennessee Republicans can’t stop Biden’s Medicaid expansion plan

[ MM Curator Summary] The journos are starting to gloat about being able to force expansion onto non-expansion states.

 
 

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.

 
 

Biden has a plan to expand Medicaid without actually expanding Medicaid. This is how it works.

 
 

A new White House proposal to offer nearly free health insurance to millions of low-income Americans would accomplish the same goal as previous efforts to expand Medicaid in Tennessee but would cut the need for state funding or approval from state lawmakers.

The plan – part of President Joe Biden’s sweeping “Build Back Better” agenda – would subsidize insurance purchased through the Affordable Care Act, commonly known as Obamacare, for impoverished Tennesseans who don’t qualify for TennCare, the state’s Medicaid program.

The proposal has the same aim and impact as Medicaid expansion but would not actually expand TennCare in any way. Instead, it would cover the same low-income population while sidestepping the primary obstacle preventing Medicaid expansion in Tennessee – state Republicans.

“It takes them completely out of the picture. It’s the federal government using federal funds to subsidize health insurance,” said John Graves, an expert on health care reform at Vanderbilt University Medical Center. “There is nothing the legislature can do about this.”

If the Biden proposal survives a divided Congress and is enacted into federal law, it could be transformative for Tennessee and other deep-red states where Medicaid expansion has long been a political non-starter.

But the transformation would be temporary. Biden’s proposal funds the new insurance subsidies for only four years. To extend the subsidies beyond 2025, Biden or his successor would need to secure more funding through a new law.

IN-DEPTH:In Tennessee, the death toll of the delta surge is higher than you think

What is the TennCare ‘coverage gap?’

TennCare, which is jointly funded by the federal and state government, provides health insurance to about one-fifth of Tennesseans, including many children, pregnant people, disabled adults and families who live at or below the poverty line.

But because Tennessee leaders repeatedly rejected Medicaid expansion, TennCare has a significant coverage gap: It does not cover childless adults — no matter how poor they may be — unless they fall into some other eligible category. 

This leaves no affordable insurance option for individuals who make less than $12,880 per year or couples who make less than $17,420, according to federal poverty guidelines. These people are poor enough to conceivably qualify TennCare but are not eligible since they don’t have children or a disability.

This is where the Biden plan kicks in.

The new federal subsidies would cover the entire Obamacare premiums for Tennesseans who live below the poverty line and aren’t eligible for TennCare or some other form of subsidized health insurance. It is estimated that about 120,000 Tennesseans fall into this gap, according to legislative analyses from the Kaiser Family Foundation and the Center for Budget and Policy Priorities.

For people impacted by this law, the subsidized Obamacare coverage would appear largely similar to the low-cost insurance they could have received through Medicaid expansion. Insurance would ultimately come from the same companies, like BlueCross BlueShield of Tennessee, and participants wouldn’t pay premiums but may face some small copays.

To a person on the receiving end of this coverage, the most significant difference would be how you sign up. Instead of joining TennCare under Medicaid expansion, enrollees will instead need to purchase a subsidized insurance plan through Healthcare.gov. 

Mandy Pellegrin, policy director at the Sycamore Institute, a nonpartisan think tank in Nashville, said this additional step may present an obstacle for some Tennesseans, causing a few eligible people to get lost in the process of choosing a coverage plan.

But beyond this small caveat, the proposal brings renewed optimism to efforts to insure the poor in Tennessee, Pellegrin said. Biden’s plan has “excited” advocates for Medicaid expansion who’ve grown exhausted of being stonewalled by lawmakers, she said.

“They are completely removed from this,” Pellegrin said. “It is 100% a workaround.”

Tennessee GOP stopped Medicaid expansion for years

Medicaid expansion, made possible under the Affordable Care Act in 2014, allowed states to grow their Medicaid programs to cover millions of low-income residents who were not previously eligible and unlikely to have insurance. Under the terms of the law, the federal government covered 90% of the cost of insuring these new enrollees.

Most states seized the opportunity to expand Medicaid while a minority rejected expansion, citing cost concerns or political objections to Obamacare in general. Additional states expanded years later due to political shifts or voter initiatives, and today there are just 12 non-expansion states – all of which are controlled by Republicans.

Tennessee is among the most steadfast of these holdouts.

Despite research showing expansion would benefit the poor and rural hospitals, and public polling that most Tennesseans support expansion, the state’s Republican supermajority have trounced every proposal to expand TennCare – even attempts from within their own party.

Former Gov. Bill Haslam presented an expansion-like plan in 2014 but it was promptly killed by lawmakers. Sen. Richard Briggs, R-Knoxville, a doctor, has repeatedly tried and failed to pass expansion bills. Democratic lawmakers fruitlessly push for expansion each year, but don’t wield enough power to advance a bill without Republican allies.

The debate was briefly revived after the election of Biden, who campaigned on a promise to improve Obamacare and woo non-expansion states to finally expand. Biden’s strategy was clear: offer a deal so sweet that no state could turn it down.

It didn’t work.

In a coronavirus relief law passed early this year, Biden offered to pay billions to hold-out states if they finally decided to expand. Tennessee could’ve gained as much as $900 million in two years on top of the federal government covering 90% of the expansion cost.

Tennessee’s Republican leadership said in March they would at least consider Biden’s new offer, but to date they have taken no action. In the eight months since Biden’s offer, lawmakers convened for legislative session three times and no serious discussion on expansion has occurred.

None of the other non-expansion states took Biden’s offer either.

Biden’s proposal must get through Congress and past Sen. Joe Manchin

While the Biden proposal completely sidesteps the state lawmakers in Nashville, it does require the approval of Congress in Washington D.C.

The expanded subsidies are part of a $1.85 trillion spending package that also includes universal preschool and large investments in efforts to combat climate change. Republicans balked at the price tag, and the legislation is likely to need votes from every Democrat to pass the Senate.

For now, fate of the proposal appears to hinge on a familiar thorn in Biden’s side – Sen. Joe Manchin.

Manchin, a centrist Democrat from West Virginia who wields significant political power because of his deciding vote, spoke in opposition to the proposal last month. He argued it was unfair for the federal government to pay for subsidies in the 12 non-expansion states when the rest of the country, including West Virginia, shouldered a portion of expansion costs for years.

“For states that held out to be rewarded 100% is not fair,” he said.

Other Democrats have tried to counter this argument. Georgia Sen. Raphael Warnock, who represents a holdout state, stress federal tax dollars collected in Georgia are funding Medicaid programs that low-income Georgians can’t join.

The status quo is not fair to them, Warnock argued. The same argument could be made for Tennesseans.

“People of Georgia are paying taxes for health care that they cannot access while subsidizing health care in West Virginia and in other states,” Warnock said.

The USA TODAY Network contributed to this story.

Brett Kelman is the health care reporter for The Tennessean. He can be reached at 615-259-8287 or at brett.kelman@tennessean.com. 

Clipped from: https://www.oakridger.com/story/news/health/2021/11/16/tennessee-republicans-cant-stop-bidens-medicaid-expansion-plan/6263982001/

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Closing Medicaid coverage gap could widen hospital margins, report says

 
 

 
 

MM Curator summary

 
 

Subsidizing exchange plans in non-expansion states could add $12B to hospital profits.

 
 

 
 

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.

 
 

 
 

If the Build Back Better Act goes into effect, hospital margins in the 12 states that have not expanded their Medicaid programs will increase by an estimated $11.9 billion, according to a Nov. 4 report by USC-Brookings Schaeffer Initiative for Health Policy.

Through the Affordable Care Act, states can extend their Medicaid programs to adults under age 65 with incomes below 138 percent of the federal poverty level, but 12 states have not done so.

In those 12 states, people with incomes below 138 percent of the federal poverty level are mostly ineligible for subsidized coverage. But the current draft of Democrats’ Build Back Better Act wants to fill the coverage gap.

Here are five things to know:

1. The current draft for the Build Back Better Act would fill the Medicaid coverage gap by making people below the poverty line in those 12 states eligible for ACA marketplace coverage. More than that, it would change marketplace coverage by eliminating all premiums and cost-sharing for people with incomes below 138 percent of the federal poverty line. This would add services that are covered by Medicaid but not the marketplace.

2. By making these changes, the report estimates that hospital margins in the 12 states would rise by $11.9 billion if the Build Back Better Act went into effect in 2023. The reason for this improvement is because hospitals would be paid for services they’re delivering anyway but aren’t currently being paid for. Additionally, more patients would be seeking care because of increased coverage, which would raise profits.

3. Hospitals in these states also would have smaller Medicare disproportionate share hospital payments. This is because the payments use a formula that looks at the national uninsured rate and the distribution of uncompensated care across hospitals. Both of these items would change.

4. If policymakers instead chose a federal Medicaid plan, these hospitals would receive smaller increases in margins at $3.6 billion. A federal Medicaid plan would most likely pay hospitals less than marketplace plans, according to the report, leading to hospitals receiving less revenue and less patient volume for uncompensated care.

5. The draft Build Back Better Act could help patients by allowing hospitals to provide care even if they have fewer resources. However, it could also allow hospitals to accept higher profits and increase costs, therefore not helping patients.

 
 

Clipped from: https://www.beckershospitalreview.com/finance/closing-medicaid-coverage-gap-could-widen-hospital-margins-report-says.html

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Illinois’ $16 billion health program is riddled with industry ties and potential conflicts of interest

 
 

 
 

MM Curator summary

 
 

An extensive system of interconnected contracts and agency roles is investigated in this expose.

 
 

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.

 
 

 
 

 
 

DAVID JACKSON Better Government Association

The upper echelon of the state agency charged with overseeing Medicaid is peppered with representatives of the for-profit insurance industry state officials are supposed to be policing, a Better Government Association investigation has found.

An examination of state contracts, salary data, pension statements, court records and internal correspondence identified more than a dozen top-level Medicaid officials in Illinois who have current or recent financial ties to the giant insurance companies now managing the $16 billion per year taxpayers spend to provide medical care to people who cannot afford health coverage.

Officials such as the state deputy administrator who runs Medicaid after a 20-year career as an Aetna senior executive, or the state’s “expert adviser” on Medicaid policy, who is also an Aetna lobbyist, or the consultant who advises state officials while taking fees from the insurance companies.

The BGA disclosures about potential dual loyalties come at a time when struggling health care providers complain the state’s faulty oversight of Medicaid brings record-level profits to insurance companies, even as they deny and delay claims.

The state’s top health care official rejects the suggestion that taxpayer money is being mismanaged or that conflicts of interest are undermining the agency’s objectivity at a time when the COVID-19 pandemic is putting the state’s health care system under stress.

Illinois Department of Healthcare and Family Services Director Theresa Eagleson said all potential conflicts are disclosed and vetted, and officials with dual financial interests are required to recuse themselves from agency decisions that affect their bottom line.

“This is a really big, complex agency, and we’re proud to employ a diverse array of people who bring a lot of experience with Medicaid, with clinical care, with finance, with insurance,” Eagleson said. “We are very careful to follow all the rules.”

HFS officials told the BGA they talk to a wide array of stakeholders, including lawmakers, frontline medical providers and consultants from every industry that is involved in Medicaid. In some cases, they said, state statute requires HFS to talk to industry representatives and their private consultants.

While public records reveal no overt acts where these conflicts led to personal financial gain, ethics experts said a bigger concern centers on how the insurance companies have access at the highest levels of government when Medicaid patients do not.

State ethics laws require a one-year “cooling-off period” before former state employees can procure state contracts. But in general, the walls preventing ethical conflicts or their appearance are flimsy, experts say.

“When the relationships between the government and industry are so cozy, when there are so many financial entanglements, that necessary wall starts to look like Swiss cheese,” said Alisa Kaplan, executive director of the watchdog group Reform for Illinois. “How is the public supposed to look at that and trust that the government is putting their interests first?”

Lawmaker blasts ‘interbreeding’

Revolving doors and conflicts of interest have emerged at virtually every level of American government, from municipal offices to federal agencies. State governments, including Illinois, impose an array of financial disclosure rules and cooling-off periods to stop private interests from co-opting the public sector.

The Illinois Medicaid merry-go-round has been whirling under three successive governors — Democrat Pat Quinn, Republican Bruce Rauner and current Gov. J.B. Pritzker, a Democrat.

“It’s like interbreeding here,” said state Rep. Fred Crespo, a Democrat from Hoffman Estates. “How can they have their hands out to the insurance companies and at the same time be making Medicaid policy?”

In the Illinois Medicaid program, officials and industry executives say they carefully vet potential conflicts through frank, top-level discussions. But the BGA found little public disclosure as program leaders toggle between government appointments and top jobs at the for-profit insurance firms.

“The revolving door and apparent conflicts of interest raise ethical concerns about corruption that damage the public’s support for state government in general and the state’s Medicaid program,” said Kent Redfield, a professor emeritus of political science at the University of Illinois at Springfield, who reviewed the BGA’s findings.

“Clearly, the appearance of bias is there, and that reduces the effectiveness of the Medicaid program,” Redfield said. “The overall picture assembled by the BGA is that the state’s process for managing Medicaid payments is heavily influenced by people and organizations with an insurance industry perspective.”

Consider:

Howard A. Peters III

 
 

Since 2017, Howard A. Peters III has earned $105,000 per year through the state Office of Medicaid Innovation as an “expert adviser” to HFS. He also sits on the HFS Medicaid Advisory Committee, as well as the Illinois Medicaid Telemedicine Task Force.

At the same time, Peters lobbied the agency and lawmakers on behalf of insurance giant Aetna, one of the four companies hired by the state to run the Medicaid program.

His lobbying firm, HAP Inc., which counts Aetna among its handful of clients, also contributed $70,000 to state politicians since Peters joined the state payroll.

Contacted by the BGA, Peters said his dual roles were fully disclosed and discussed with former HFS Director Felicia Norwood and current director Eagleson before he accepted the state job.

“They understood that I had Aetna as a client,” Peters said. “There is no secret here.”

“I wouldn’t say (it was) what you might call a formal process, but it certainly was a very conscious discussion and a conscious decision about how this would work and the importance of not mixing and mingling, if you will — not having conflicts,” Peters said. “The department certainly doesn’t want the very issue that you’re raising, and I don’t, either.”

Peters said he sees no conflict between his dual roles. State officials are scrupulous about guarding against potential conflicts, he said.

“I don’t think there’s a revolving-door concern,” Peters said. “I think that the state has stringent regulations about what you can do when you leave state government. From what I see in terms of how they conduct their business and what I know about the leadership and their character, I don’t have a reason to be concerned as a citizen and as a person who cares about the quality of the government.”

Eagleson, in a separate interview, said Peters is deliberately excluded from discussions involving the four MCOs, including Aetna.

Eagleson said Peters’ longtime involvement in state government, including Cabinet posts, make him “eminently qualified to be a senior adviser” at her agency.

“Everybody is transparent, following the rules,” she said. “He never participates in any meeting that has anything to do with regulating the managed care companies.”

“The work that I advise the department on is not involved with Aetna or the managed care organizations,” Peters said, adding that he advises HFS on a long-term project called health care transformation and on the department’s effort to increase staffing and improve conditions in nursing homes.

Peters said he has not been paid in his roles as current member and former chairman of the Illinois Medicaid Advisory Committee, a panel that includes insurance industry leaders and counsels HFS with respect to Medicaid policy and planning. Rauner in 2018 appointed Peters as the unpaid co-chair of the state’s Medicaid telehealth task force.

Peters’ state salary is paid through the University of Illinois’ Office of Medicaid Innovation, or OMI, an organizational unit within the university that is funded by HFS.

The university office operates under HFS’ direct guidance and through HFS Project Orders, according to records provided to the BGA by the university.

Peters was hired at OMI when it was run by Eagleson, who served as OMI’s $198,000-per-year executive director at the time.

“Theresa was head of the Office of Medicaid Innovations, Director Norwood was director of the Department of Healthcare and Family Services at the time, so they both were aware of my work, and asked me if I was willing to serve them as part-time capacity,” Peters told the BGA.

Peters declined to provide details about his lobbying for Aetna.

“I care about my reputation, and I care about the reputations of the people I’m working with,” Peters told the BGA. “If there’s an issue that remotely looks like I can have an interest that’s not theirs, I’m not involved in that issue.”

Robert Mendonsa Jr.

As deputy administrator at HFS, Robert Mendonsa Jr. has been in charge of managing the state’s Medicaid contracts with the MCOs since 2015. That state appointment came after his 20-year career as a senior executive at the insurance company Aetna.

Mendonsa’s wife, Kelli, is also a senior project coordinator at Blue Cross, and has held similar positions at two other MCOs.

“I’m responsible for managing the MCO contracts,” Mendonsa said in a court deposition last year. “It’s making sure they are complying with the contract, and we are monitoring their performance, and we are driving continual quality improvement.”

Mendonsa was the CEO of Aetna Better Health, the company’s Illinois MCO, until November 2012, records show. Before that, he was president of the company’s 16-state region that included Illinois.

Mendonsa declined comment, but in the deposition, he explained why he left his lucrative corporate job for state government service.

“I was just very intrigued by what I could do working for the state. And I did very well in my prior life, so I was able to not care about the money and do what I really wanted to do,” he testified. “I believe in managed care. And I think that we can improve quality and improve the quality of life and save money at the same time.”

Mendonsa also for several years was president of the board of the Illinois Association of Health Plans, an insurance industry advocacy group.

Mendonsa first joined the state payroll at HFS in March 2013, records show. Two years later, he was appointed to manage the MCO contracts, his current job.

Redfield said Mendonsa’s extensive background with Aetna prior to joining HFS creates the appearance of “a professional bias,” and Mendonsa’s wife working for the MCOs while Mendonsa oversaw the MCO program “would appear to create a personal conflict of interest for Mendonsa.”

HFS officials told the BGA that Mendonsa’s insurance industry tenure gives him unique expertise and helps HFS hold the MCOs accountable for meeting their contract requirements. He disclosed his wife’s current MCO position to the HFS ethics officer, agency officials said, and she does not directly interact with HFS and did not help negotiate the state’s current contracts.

Through an HFS spokesman, Mendonsa told the BGA he emptied his Aetna retirement account before joining the state agency, taking half as a lump sum and placing half in an account unaffected by Aetna’s bottom line. Those funds were later divided with a family member, court records show.

Eagleson told the BGA she was the Medicaid administrator when Mendonsa was hired. “It was my understanding, when Robert was hired, that he had no retirement benefits that were contingent on the performance of Aetna,” she said.

Mendonsa’s 2015 HFS promotion came when Norwood led the agency. Norwood headed Aetna before Rauner appointed her as the HFS director. As the HFS director, Norwood oversaw an acceleration in the privatization of Illinois’ Medicaid program.

A 2017 investigation by the state executive inspector general’s office found Norwood engaged in improper communication with a lobbyist when Norwood ran HFS. Norwood and Norwood’s deputy, Teresa Hursey, discussed a large Medicaid contract sought by one of the lobbyist’s clients, that report states.

Months later, in 2018, Norwood returned to the MCO industry and by last year earned nearly $8 million as executive vice president and president for insurance provider Anthem Inc.’s government business division. Hursey also joined Anthem.

Douglas Elwell

A former Illinois Medicaid administrator, Douglas Elwell remains an unpaid adviser to HFS Director Eagleson, even as he runs the for-profit national consulting firm Health Management Associates (HMA).

Elwell is one of at least 10 top Illinois Medicaid officials who have come from or gone to HMA in recent years.

Emails obtained under the Illinois Freedom of Information Act over a yearlong period reveal more than 50 conversations between Eagleson and Elwell ranging from Medicaid provider billing disputes to policy questions.

As CEO of HMA, Elwell heads one of the blurriest players in the Illinois Medicaid money game: HMA’s clients include the Medicaid MCOs, but it also holds its own state contracts for services to HFS and the state prison system, the BGA found.

The correspondence suggests familiarity and professional trust.

When Eagleson wanted to gather a team of dependable advisers in August 2020, she invited her chief of staff, a state Medicaid deputy and a top state researcher. Eagleson also included Elwell, according to emails obtained by the BGA through an open-records request.

“Doug and I were just talking. Could the five of us spend some socially distanced quality time together for a longer dinner and brainstorming in Springfield next Wednesday or Thursday evening?” Eagleson’s email began.

Eagleson suggested an upscale contemporary American restaurant with a Napa Valley-style tasting room.

“I honestly haven’t dined out inside yet but am willing to try to find the right place,” Eagleson wrote.

Elwell has been back and forth through Illinois’ revolving door. He spent 12 years as a principal, managing principal and interim CFO of HMA. Then Elwell led the Cook County Health and Hospital System from November 2014 through early 2019. He came to HFS for one year as state Medicaid administrator, then in February 2020 rejoined HMA, first as COO and now as CEO of the consulting firm.

HMA does not publicly disclose its industry clients, but the BGA found it has included some of the top MCOs operating in Illinois and nationally: Centene Corp., Blue Cross, Aetna Health and, in recent years, Molina Health.

In state contract filings, HMA reported that 45% of its corporate stock is owned by funds connected to the Chicago private equity firm Beecken Petty O’Keefe — also called BPOC — which offers health-care-focused investment funds. In Illinois contract disclosures HMA listed 2019 sales revenue of $94.7 million from all sources nationwide.

While serving for-profit clients and investors, HMA also wins government contracts in Illinois and numerous other states, as well as in Cook County. HMA since 2018 has held state of Illinois consulting contracts worth $1.3 million with HFS, the Department of Corrections and the Department of Human Services.

Redfield called it a “troublesome economic conflict of interest” that HMA had contracts with state MCO regulators and also with the individual MCOs.

Elwell told the BGA that HMA had a “very elaborate firewall system” to avoid ethical conflicts. “We basically train all of our people, we test them, and we are very transparent with the managed care companies, as well as with the Medicaid agencies,” Elwell said.

“We care very deeply about our reputation, and we care very deeply about the reputations of people who work with us. So I understand the appearance, but I can tell you, in fact, we spend a lot of time and a lot of money to make sure we’re avoiding that conflict and are very transparent.”

Elwell said HMA has a contract to help Illinois establish its health information exchange and simultaneously advises the MCOs on unrelated issues, such as how to meet quality assurance standards in Illinois or how to team up with local organizations that assist Medicaid patients.

“I don’t feel I have special status, other than as part of a sounding board,” he said. “These are pretty independent people. They’re good at it without me.”

“I care what happens to Medicaid in Illinois, and I’m always going to care, and sometimes I am sure I am giving them my advice when it’s not wanted and not followed,” Elwell said. “But I care enough that, when asked, I am going to give them my best idea.”

 
 

Clipped from: https://pantagraph.com/news/state-and-regional/illinois-16-billion-health-program-is-riddled-with-industry-ties-and-potential-conflicts-of-interest/article_66a01162-9b0f-5753-803e-ab6d34fe1180.html

 
 

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Arkansas- Governor expects federal waiver approval for continuation of Medicaid expansion program

MM Curator summary

 
 

The revised AR expansion waiver has back-pedaled its original design to include no requirements related to work, but still has different benefits for members who do not engage in their own health.

 
 

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.

 
 

 
 

HUTCHINSON (file photo) Asa Hutchinson

Governor Hutchinson said Tuesday at his press conference that he anticipates that the federal government will approve the state’s request to renew its Medicaid expansion program, with some revisions, prior to the end of the year, when the state’s current Medicaid expansion agreement expires.

The Medicaid expansion, authorized by the federal Affordable Care Act, covers adults who make less than 138 percent of the federal poverty level (an annual income of $17,774 for an individual or $36,570 for a family of four). The program in Arkansas, first enacted in 2014, uniquely uses Medicaid funds to pay for private health insurance to cover most beneficiaries. Once nicknamed the “private option” and now known as “Arkansas Works,” it was implemented under a series of agreements with the federal government, known as waivers because the feds waive certain Medicaid rules. The latest request, submitted this summer, renames the program ARHOME.

“We’ve been assured that they would act on that in sufficient time so the waiver doesn’t expire — which is the end of the year,” Hutchinson said. “So our [Department of Human Services] is working diligently with them on that. I don’t anticipate any issue in getting the new waiver granted. But that specific timeframe is undetermined.”

The new waiver request maintains the use of private health insurance to cover beneficiaries, but would route people who are “inactive” to the regular Medicaid program rather than the private plan. Under the state’s waiver request, it doesn’t take much to stay “active” — if beneficiaries simply choose their own plan as opposed to being auto-assigned, or if they go to the doctor for a checkup, they are considered active, even if they don’t participate in other incentive programs the state is planning (participating in one of those programs, which includes incentives to encourage employment, would also count). So long as they interact with the plan in some way — completing a health assessment, say, or any use of a medical service, etc. — they can stay in the private plan. In very early talks with lawmakers, the idea was floated of making incentives around work or education/training part of the requirement to keep a private plan. But the final framework only designates someone as inactive if they don’t do anything at all related to their health care plan. 

The ARHOME waiver also proposes an increase in premiums charged to most beneficiaries who make more than the poverty level. Beneficiaries would not lose coverage for failure to pay, but would incur a debt to the insurance companies (currently, those who fail to pay premiums incur a debt to the state, which can be withheld from tax refunds). Currently, most beneficiaries who make more than the poverty line are charged a flat $13 per month. The ARHOME waiver proposes bumping that up, depending on income:


Co-payments would also be higher, and would be applied to more beneficiaries. Currently, co-payments are only charged to beneficiaries who make more than the poverty line, and are capped at $60 per quarter. Under ARHOME, they would be charged at most income levels and the caps would be bumped up (see chart below). Failure to pay would incur a debt to the provider. No one would lose coverage for failure to pay. According to the waiver request, “A provider cannot refuse to provide service for non-payment at the first occurrence but can refuse to provide a future service due to non-payment.” Here are the proposed maximum annual allowable amounts on the co-pays by income:


 
 

Here are the co-pays that will be in place in 2022, according to the waiver proposal:


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The total of both co-pays and premiums will be capped at 5 percent of household income per quarter.

Those deemed medically frail — and those routed in a new program for people with serious mental illness or substance use disorder — will not be charged premiums or co-pays.

The ARHOME program also includes new initiatives for rural health, maternal and infant health, behavioral health and certain at-risk populations. State officials focused on these initiatives when they unveiled the waiver request last summer.

ARHOME also includes wellness incentives programs, along with the work and education incentives programs, as well as mechanisms to contain cost growth and to establish quality performance targets for the private plans.

If the feds approve the ARHOME waiver, it could still come with minor variations to the framework not described in the request: Certain terms and conditions may apply that will provide more details about just how that framework will function in practice.

 
 

Clipped from: https://arktimes.com/arkansas-blog/2021/11/02/governor-expects-federal-waiver-approval-for-continuation-of-medicaid-expansion-program

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Maryland Department of Health announces new Medicaid rate increases

MM Curator summary

 
 

MD will spend the ARPA money it got for HCBS on rate increases for 3 provider types.

 
 

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.

 
 

 
 

Baltimore, MD – Today, the Maryland Department of Health (MDH) announced Medicaid rate increases for home and community-based services (HCBS) providers. Increased Medicaid rates will enable HCBS providers to strengthen service delivery.

“These rate increases will prove instrumental in further serving our Medicaid recipient population,” said MDH Secretary Dennis R. Schrader. “The new rates are the result of working closely with Medicaid providers and stakeholders, and they will help Marylanders who need assistance the most.”

The American Rescue Plan Act (ARPA), which became law on March 11, supports Medicaid HCBS providers during the COVID-19 pandemic by providing a 10 percent enhanced federal medical assistance percentage (eFMAP). The law requires states to use these funds to enhance, expand or strengthen HCBS.

During the most recent legislative session, the Maryland General Assembly passed HB 588, the state’s FY2022 budget bill, which directs Medicaid to spend at least 75 percent of federal ARPA reinvestment dollars for a one-time-only provider rate increase. As such, Maryland is implementing the following rate increases:

  • A 5.5 percent rate increase for most HCBS developmental disability providers
  • A 5.4 percent rate increase for most HCBS behavioral health and Applied Behavior Analysis (ABA) providers
  • A 5.2 percent rate increase for community-based long-term services and support providers

The provider rate increases target providers and services that are eligible for the enhanced federal match. Additionally, the provider increases vary slightly based on the amount of reinvestment monies generated within the long-term care, behavioral health, and developmental-disabilities programs. 

For more detailed information, including the methodology used to determine the estimated fiscal impact and rate increases, please see MDH’s initial HCBS Spending Plan, submitted to The Centers for Medicare and Medicaid Services.

Impacted Medicaid providers have received alerts and public notices detailing the services to which rate increases apply, the services that are excluded, and other related information. Providers may submit questions via the form at https://health.maryland.gov/pages/contactus.aspx.

 
 

 
 

 
 

Clipped from: https://southernmarylandchronicle.com/2021/11/02/maryland-department-of-health-announces-new-medicaid-rate-increases/

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LETTER: Proposed Medicaid assessment changes would jeopardize care

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AAAs are unhappy the state is handing over their scope to Maximus.

 
 

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.

 
 

We, as former Area Agency on Aging (AAA) administrators in the Southwestern Pennsylvania region, are writing to express our deep concern over a change being executed by the Pennsylvania Department of Human Services (DHS) that will eliminate the local Area Agencies on Aging from the Medicaid assessment/eligibility process for older adults and people with disabilities.

For over 30 years, the 52 Area Agencies on Aging, serving all 67 counties in Pennsylvania, have been performing the assessment/clinical eligibility determination for seniors and persons with disabilities who are seeking to access Medicaid-funded services and supports.

Local Area Agencies on Aging have been trusted community resources that have assisted individuals and their families/caregivers with navigating through a complex, multi-faceted and often confusing Medicaid enrollment process. Nothing can replace the highly specialized and personalized assistance provided by the trained and experienced Area Agencies on Aging staff who excel at understanding the unique needs of vulnerable populations. These Area Agencies on Aging have consistently achieved an impressive 99.75% on-time completion rate for assessments.

So, what is the issue?

The Pennsylvania Department of Human Services is currently preparing for negotiations with Maximus US Services Inc. (Maximus) to expand its scope of work for the DHS as the Independent Enrollment Broker to include the assessment responsibility.

Maximus has a history of poor performance as an enrollment broker in Pennsylvania and in other states. According to the Office of Long-Term Living (June 8, 2021), the Long-Term Services and Supports Subcommittee reports that Maximus failed to meet its contractual performance obligation for timely completion of enrollments within the 90-day timeframe for 17 consecutive quarters!

So why give Maximus the additional assessment responsibility when the quality of enrollment work is so poor?

Why would the Commonwealth of Pennsylvania/Department of Human Services consider awarding an even larger contract to a private company that has repeatedly failed to meet critical performance standards? Why would the state strip away from the local Area Agencies on Aging the assessment responsibility when they have a proven record of performance and reliability?

Seniors and people with disabilities are waiting for an answer.

We strongly urge the Commonwealth of Pennsylvania/Department of Human Services to withdraw the Request for Application and to continue to allow our Pennsylvania residents access to the local community-based Area Agencies on Aging. The Area Agencies on Aging have proven their ability to provide consistent and reliable assessment service.

Katherine Johnson

Former administrator, Westmoreland County Area Agency on Aging

Mildred Morrison

Former administrator, Allegheny County Department of Human Services, Area Agency on Aging

Robert Willison

Former Executive Director, Southwestern Pennsylvania Area Agency on Aging Inc., serving Fayette, Greene and Washington counties

 
 

Clipped from: https://observer-reporter.com/opinion/letters/letter-proposed-medicaid-assessment-changes-would-jeopardize-care/article_9b9dc18c-372b-11ec-a787-cfb4329e279e.html

 
 

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CMS Innovation Center Publishes Vision for Next 10 Years

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A review of the dozens of models pushed by the center the last 10 years shows limited success.

 
 

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.

 
 

On October 20, 2021, the Centers for Medicare and Medicaid (“CMS“) Innovation Center (“Innovation Center“) published a white paper detailing its vision for the next ten years: a health system that achieves equitable outcomes through high quality, affordable, person-centered care.  The white paper first recounts the last ten years of testing and learning that laid the foundation for the Innovation Center’s future strategy.  The future strategy is organized around five strategic objectives that will guide the Innovation’s Center’s models and priorities for the next ten years.  The five strategic objectives for advancing this systemwide transformation include (1) Drive Accountable Care, (2) Advance Health Equity, (3) Support Innovation, (4) Address Affordability, and (5) Partner to Achieve System Transformation.  These strategic objectives aim to guide the Innovation Center’s models which will seek to reduce program costs and improve quality and outcomes for Medicare and Medicaid beneficiaries.  Finally, the white paper emphasizes its approach to measuring the progress of each of these objectives and assessing the impact the objectives have on beneficiaries, providers, and the market as a whole.

CMS Innovation Center’s First Decade: Foundation for Strategy Refresh

The Innovation Center, established in 2010 as part of the Affordable Care Act, began as an initiative to transition the health system to value-based care by developing, testing and evaluating new payment and service delivery models in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).  In short, the Innovation Center’s mandate was, and is, to develop healthcare payment models to decrease health care spending and improve health care quality.

In its first decade of operation, the Innovation Center launched over fifty model tests, and from 2018 to 2020 alone, the models have reached nearly 28 million patients and over 528,000 health care providers and plans.  To develop the strategy for the next decade of models, the Innovation Center conducted an internal review of its portfolio of models.  In addition to the model-generated data, CMS Innovation Center staff examined policy and operational lessons from other model tests, performed an extensive literature review, conducted interviews with experts and stakeholders, and convened focus groups with agency leaders.

As described in a previous Healthcare Law Blog article, “Evaluation of Innovation Center Models,” the Innovation Center’s scorecard over the last ten years shows mixed results.  Only six out of more than fifty models launched generated statistically significant savings to taxpayers and Medicare: ACO Investment Model; Home Health Value-Based Purchasing Model; Medicare Care Choices Model; Maryland All-Payer Model; Pioneer ACO Model; and Repetitive, Prior Authorization of Repetitive, Schedule Non-Emergent Ambulance Transport Model.  In addition, only four models met the requirements to be expanded in duration and scope: Home Health Value-Based Purchasing Model; Pioneer ACO Model; Repetitive, Prior Authorization of Repetitive, Schedule Non-Emergent Ambulance Transport Model; and Medicare Diabetes Prevention Program Expanded Model.

Based on its review and collection of data, the CMS Innovation Center identified important lessons learned in order to accelerate the movement to value-based care and drive broader system transformation.  First, the white paper summarizes the key lessons learned from each model, the issues and challenges faced within each of arena, and the next steps needed to address such issues and challenges.  As summarized in the August 12, 2021 Health Affairs article, the new Administrator of CMS Chiquita Brooks-LaSure described the six key takeaways from the Innovation’s first decade:

  • The Innovation Center should make equity a centerpiece of every model;
  • Offering too many models is overly complex, particularly when models overlap;
  • The Innovation Center must re-evaluate how it designs financial incentives in its models to ensure meaningful provider participation;
  • Providers find it challenging to accept downside risk if they do not have tools to enable and empower changes in care delivery;
  • Challenges in setting financial benchmarks have undermined our models’ effectiveness; and
  • Innovation Center models can define success as encouraging lasting transformation and a broader array of quality investments, rather than focusing solely on each individual model’s cost and quality improvements.

Roadmap for Achieving the Vision: Strategic Objectives, Measuring Progress and Next Steps:

The white paper summarizes the overarching goal for the Innovation Center’s next decade: the “health system must recognize and meet people’s medical needs by considering their preferences, values, and circumstances, should strive to keep people healthy and independent, and help providers coordinate care seamlessly and holistically across settings in a manner that puts people at the center of their own care.”  To this end, the Innovation Center promises to work more closely with external stakeholders and providers most directly affected by the models in order to facilitate a more intentional focus on addressing health disparities and ensuring equitable access, quality, and outcomes.  This includes collaborating across the life cycle of models – from design to evaluation and potentially expansion – and in the implementation of each of the five objectives of the strategic refresh.

For each of Innovation Center’s strategic objectives, CMS set forth the goal of each strategic objective, the method of measuring progress each objective, and a research-backed explanation of each objective, as described in more detail below.

  • Strategic Objective 1: Drive Accountable Care. The National Academy of Medicine reported that high-quality primary care forms the foundation of a high-functioning health system and is key to improving the experience of patients and care teams, as well as population health, and reducing costs.[1] Therefore, CMS’ first strategic objective, “Drive Accountable Care,” aims to increase the number of people in a care relationship with accountability for quality and total cost of care.  The goal is for all Medicare beneficiaries with Parts A and B to be in a care relationship with accountability for quality and total cost of care by 2030 and the vast majority of Medicaid beneficiaries to have the same.

 
 

  • Strategic Objective 2: Advance Health Equity. Healthy People 2030 defined health equality as “the attainment of the highest level of health for all people.”[2]  However, evaluations from the Next Generation ACO model showed that aligned Medicare beneficiaries were more likely to be white and less likely to be either dually eligible or to live in rural areas relative to other fee-for-service beneficiaries in the same market areas.  Therefore, the second strategic objective, “Advance Health Equity,” aims to embed health equity in every aspect of the Innovation Center’s models and increase focus on underserved populations.  To do so, all new models will require participants to collect and report the demographic data of their beneficiaries and, as appropriate, data on social needs and determinants of social health.  All new models must also include patients from historically underserved populations and safety net providers, such as community health centers and disproportionate share hospitals.  Finally, CMS will identify areas for reducing inequities at the population level, such as avoidable admissions, and set targets for reducing those inequities.

 
 

  • Strategic Objective 3: Support Care Innovations. CMS found that accountable care models, especially those that include total cost of care approaches, will need payment incentives to support the delivery of integrated, equitable person-centered care.  Thus, the third strategic objective, “Support Care Innovations,” will leverage a range of supports that enable integrated, person-centered care such as actionable, practice-specific data, technology, dissemination of best practices, peer-to-peer learning collaboratives, and payment flexibilities.  To accomplish this goal, CMS will set targets to improve performance of models on patient experience measures, such as health and functional status, or as a subset of Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures that assess health promotion and education, share decision-making and care coordination.  All models will consider or include patient-report outcomes as part of the performance measurement strategy.

 
 

  • Strategic Objective 4: Improve Access by Addressing Affordability. While national health spending growth slowed between 2010 and 2019 compared to the previous decade, costs continue to rise at unsustainable rates for both state and federal governments as well as households.  Therefore, making health care affordable is an important consideration to driving broad system transformation.  Under its fourth objective, “Improve Access by Addressing Affordability,” CMS will pursue strategies to address health care prices, affordability, and reduce unnecessary or duplicative care.  This includes setting targets to reduce the percentage of beneficiaries that forgo care due to cost by 2030 and ensuring all models consider and include opportunities to improve affordability of high-value care by beneficiaries.

 
 

  • Strategic Objective 5: Partner to Achieve System Transformation. Achieving broad health system transformation requires collaboration with employers, health plans and states, as well as patients, caregivers, providers and community organizations.  Therefore, the final strategic objective, “Partner to Achieve System Transformation” aims to align the Innovation Center’s priorities and policies across CMS and beyond, aggressively engaging payers, purchasers, providers, states and beneficiaries to improve quality, to achieve equitable outcomes, and to reduce health care costs.  To this end, where applicable, all new models will make multi-payer alignment available by 2030, and all new models will collect and integrate patient perspectives across the life cycle.

For the strategic objectives set forth above, the Innovation Center will assess the impact in each area according to three categories: (1) Beneficiary Impacts (including patient experience, functional status improvements, population level metrics, quality of care transitions, access to follow-up care, coordination across providers, access to home- and community-based care, access to telehealth services, disparities in outcomes by demographic characteristics, and beneficiary costs); (2) Provider Impacts (including care transformation, impact on administrative burden, level of alignment on models across payers, sustainability of participation in models, and access to actionable data); and (3) Market Impacts (including level of consolidation, new linkages or relationships between providers, spread of model elements to other payers, scalability of model to other regions or payors, and generalizability of impacts to other populations).

CMS Innovation Center Strategy – Moving to Implementation

The Innovation Center outlined a proposed timeline to take place to implement its mission to drive value-based payment and transformation across the health system.  The next three to six months are characterized by stakeholder engagement, including listening sessions with beneficiaries, health equity experts, primary care, safety net, specialty providers, states and payers.  The Innovation Center also identified an existing model that informs the strategy and transformation.  Beginning in early 2022, stakeholder engagement will shift to include outreach to communicate and share the strategies via conferences, podcasts, and events.  CMS will launch stakeholder engagement strategies across the life cycle of models, share model test data with external researchers, and leverage existing and new mechanisms to enhance engagement with patients, providers and payers and improve transparency in model design and implementation.

As CMS continues to develop its strategy and application to the Innovation Center’s models, we will continue to share the latest information.  In addition, the latest information about the Innovation Center and details about Innovation Center models can be found on the innovation.cms.gov.

FOOTNOTES

[1] National Academy of Medicine, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care (2021).

[2] U.S. Department of Health and Human Services. (2021). Healthy People 2030 Questions & Answers.

 
 

Clipped from: https://www.natlawreview.com/article/centers-medicare-and-medicaid-innovation-center-equity-and-vision

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Wyoming Senate squash look at Medicaid expansion during special session

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Lawmakers voted 21 to 8 to not introduce an expansion bill in the Senate.

 
 

 
 

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.

 
 

 
 

A Healthy Wyoming rally for Medicaid expansion at the Nicolaysen Art Museum in September. (Gregory Hirst)

CASPER, Wyo. — The Wyoming Senate voted against introducing a bill to expand Medicaid in Wyoming during the legislature’s special session on Monday, October 27.

Sen. Cale Case (Fremont County), asked that the Senate approve Senate File 1011, which is known as the Medical Treatment Opportunity Act.

Case said that expanding Medicaid could benefit 25,000 people in Wyoming. He said the would be “mostly females that are working in this state.”

Article continues below…

“They are people that serve you breakfast, clean your hotel rooms. They have children and this would be a great thing for them,” Case said.

He added that the bill was sponsored by the Joint Revenue Interim Committee, noting that this made it different from most of the legislation proposed for consideration during the special session.

The Senate defeated the bill on a vote of 8-21 during its floor session on Monday afternoon. That vote was as follows:

  • Ayes: BALDWIN, CASE, FURPHY, GIERAU, KOST, ROTHFUSS, SCHULER, WASSERBURGER
  • Nays: ANDERSON, BITEMAN, BONER, BOUCHARD, COOPER, DOCKSTADER, DRISKILL, ELLIS, FRENCH, HICKS, HUTCHINGS, JAMES, KINSKEY, KOLB, LANDEN, MCKEOWN, NETHERCOTT, PERKINS, SALAZAR, SCOTT, STEINMETZ
  • Excused: PAPPAS

A recent poll conducted by New Bridge Strategy found that 66% of Wyoming registered voters support expanding Medicaid. That includes 98% of Democrats in the state, 64% of Independents and 58% of Republicans.

The Medical Treatment Opportunity Act would direct the Wyoming Department of Health, the state’s insurance commissioner and the governor to negotiated with the Centers for Medicare and Medicaid Services (CMS) to amend the state’s Medicaid plan and expand eligibility.

Under the 2010 Affordable Care Act, 90% of the cost of expansion would be paid by the federal government and Wyoming would pay 10%. The Wyoming Department of Health estimates expanding coverage would cover an estimated 24,000 (between 13,000 and 38,000) residents, and net the state $34 million in General Fund savings over the next biennium. The WDH estimates that 60% who would benefit from expansion are currently employed.

Proponents of Medicaid expansion have been working to push the legislature to again consider expanding Medicaid after a similar effort failed during the 2021 General Session. During that session, the House of Representatives passed a measure to expand Medicaid on a vote of 32-28 but the bill stalled out on a 2-3 vote in the Senate Labor, Health and Social Services Committee.

The group Healthy Wyoming held vigils across the state in September to raise awareness about projected savings for the state under expansion and to share stories of people who have suffered and died without health care.

The Casper contingent met at the Nicolaysen Art Museum on September 17 to hear from health care providers, legislators, and people directly affected by the issue. 

“This issue is a matter of life or death,” said Healthy Wyoming advocate Andrew Schneider in his remarks. He said people who can’t afford to go to the doctor allow chronic conditions, including mental illness, to “linger and worsen.” They also skip cancer screenings and other preventative measures and can’t budget for both prescriptions and food.

Linda Jones spoke about her friend and neighbor Earl, who died three years ago. She said Earl worked a steady job at Walmart until he slipped on the ice and injured his knee, and lost his job while recovering.

Without insurance, he was unable to achieve a full recovery, became afflicted with gout, and sold a cherished Camero to pay bills. His health declined rapidly and he was eventually found dead in his home.

“It was a difficult thing to watch another person be in so much pain and not know how to help,” Jones said. “At the time, we didn’t think there was anything that could be done about Earl not being able to see a doctor. … Now I know if that if our state had expanded Medicaid, Earl could have gotten the health care he needed.”

“He wanted to get better; he wanted to work to provide for himself.”

Critics have cited concerns that expansion has led to significant cost overruns and decreased profit margins for hospitals in other states. They also worry that the federal government could change its match rates, leaving Wyoming “on the hook” for a greater percentage of costs.

 
 

Clipped from: https://oilcity.news/wyoming/legislature/2021/10/27/wyoming-senate-squash-look-at-medicaid-expansion-during-special-session/

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Democrats Mull Dropping Expanded Medicare, Medicaid in Unity Bid

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Dems need to cut the $3T price tag of the wishlist in half.

 
 

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.

 
 

Two significant elements of Democrats’ ambitious health agenda, expanding Medicare and Medicaid, face an uphill battle after a key party moderate signaled his opposition Monday.

Sen. Joe Manchin (D-W.Va.) said Monday he doesn’t want to expand Medicare benefits without first protecting the rest of the program from insolvency later this decade.

He also rebuffed legislation to extend coverage to millions of Americans in states that have refused to expand their Medicaid programs.

Extending federally funded coverage to people in the 12 non-expansion states effectively amounts to a penalty for states such as his that have paid a portion of growing their own safety nets, Manchin told reporters.

“For states that held out to get rewarded with 100% that’s not fair,” he said.

 
 

Anna Moneymaker/Getty Images

Sen. Joe Manchin (D-W.Va.) leaves a meeting at the office of Sen. Kyrsten Sinema (D-Ariz.) on Oct. 21, 2021, as Democrats sought consensus on trimming President Joe Biden’s spending legislation.

Expanding the two public health insurance programs were significant, and pricey, elements of the once-$3.5 trillion spending package Democrats (H.R. 5376) are hoping to rally around as soon as this week. Manchin said he wants to cut the total spending down to $1.5 trillion.

Supporters of expanding Medicare’s benefits to include dental, hearing, and vision coverage have been trying to save the provision from cuts or elimination.

The White House has suggested the spending package include $800 vouchers seniors could use to pay for dental services, Rep. Pramila Jayapal (D-Wash.) told reporters last week. Jayapal and other progressives have pushed to add the three new coverage areas to Medicare’s list of defined benefits.

Vouchers would leave many seniors without sufficient coverage and could disappear in coming years, supporters of expanding Medicare say.

“This cannot be a half-hearted attempt to throw a token at the problem,” said Frederick Isasi, executive director of Families USA, a health advocacy organization that’s been aligned with Democrats on defending the Affordable Care Act.

Manchin, who has been negotiating the terms of the spending package directly with President Joe Biden at times over the past few weeks, said he wants to first shore up Medicare’s finances.

“You’ve got to stabilize that first before you do an expansion,” he said Monday.

Drug Pricing Plan Also Trimmed

Democrats may have to pare back their health agenda to accommodate a narrower attempt to lower the cost of medicines in the U.S.

Party leaders are debating limiting their legislation to empower the government to negotiate for better prices to just drugs that lack exclusivity, meaning only those medicines that could already face competition from a generic or biosimilar version.

Such a change would limit how much a drug price negotiation proposal would reduce government spending on medicines. The drug pricing provisions of the spending package have long been meant to offset the cost of the health agenda.

Rep. Scott Peters(D-Calif.), who has opposed broad negotiating power, wrote legislation that also didn’t apply to many new drugs that have patent protections. He said recently his bill would reduce government spending by at least $200 billion, compared with the $458 billion in reduced spending expected from Democrats’ signature negotiation legislation (H.R. 3)

Leslie Dach, chairman of the Democratic-aligned Protect Our Care, told reporters Monday that exempting medicines that don’t have competitors would “basically gut the negotiation promise” Democrats had made.

“That is the key that unlocks lower prices,” Dach said.

Read more: Democrats Set to Scale Back Drug-Price Ambitions in Biden’s Bill

To contact the reporters on this story: Alex Ruoff in Washington at aruoff@bgov.com; Erik Wasson (Bloomgerg News) in Washington at ewasson@bloomberg.net

To contact the editor responsible for this story: Robin Meszoly at rmeszoly@bgov.com

 
 

Clipped from: https://about.bgov.com/news/democrats-mull-dropping-expanded-medicare-medicaid-in-unity-bid/

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Portman, Finance Committee Republicans raise concerns with improper Medicaid payments

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14 US Senators are asking CMS head Lasure to explain the plan to get a handle on the surging improper payment rate.

 
 

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.

 
 

WASHINGTON, D.C. – U.S. Senator Rob Portman (R-OH), along with the other 13 Senate Finance Committee Republicans, sent a letter to the Centers for Medicare & Medicaid Services (CMS) highlighting concerns with the rising rate of improper payments in Medicaid, in anticipation of the next Medicaid Payment Error Rate Measurement (PERM) audit.

The November 2020 report found improper payments totaled over $86.5 billion — over 21 percent — mostly driven by eligibility errors. The letter further calls for enhanced program integrity measures and state-by-state analysis to ensure beneficiaries receive the services they are entitled to without wasting taxpayer dollars.

“One of the most common eligibility errors often occurs when failing to verify information provided by the applicant, including income. Failure to properly verify that applicants are eligible for the program, especially to this extent, harms the nation’s taxpayers and takes resources away from those who are eligible and who truly need the program,” said the senators.

“There is concern that the November 2020 improper payment rate estimate of 21.4 percent was unrealistically low because the eligibility reviews excluded one-third of states.

“Congress needs complete and updated information about the improper payment rate in Medicaid as well as the corresponding drivers of this problem. We understand that the essential work on the 2021 CMS improper payment report has concluded, and drafts of the report have been completed. While state and Federal responses to COVID-19 halted some payment and eligibility reviews in 2020, this work is too vital to remain paused when the consequences are so dire,” continued the senators.

Full text of the letter can be found below.

Dear Administrator Brooks-LaSure:

As some in Congress consider proposals to expand the Medicaid program by potentially half a trillion dollars over the next decade, it is vital that both Senators and Members of the House of Representatives have accurate information about how the program is using taxpayer resources. Every November, the Centers for Medicare and Medicaid Services (CMS) releases estimates of improper payment rates for programs within its jurisdiction. The November 2020 report showed that the Medicaid improper payment rate reached 21.4 percent, with total federal improper payments in the program amounting to $86.5 billion annually. Medicaid’s improper payment rate has significantly increased since the passage of the Affordable Care Act, which dramatically expanded Medicaid. In 2013, the year before the ACA’s Medicaid expansion took effect, the improper payment rate was just 5.8 percent.

According to last year’s report, eligibility errors are the major drivers of the increased Medicaid improper payment rate. According to CMS, “Eligibility errors are mostly due to insufficient documentation to affirmatively verify eligibility determinations or non-compliance with eligibility redetermination requirements.” One of the most common eligibility errors often occurs when failing to verify information provided by the applicant, including income. Failure to properly verify that applicants are eligible for the program, especially to this extent, harms the nation’s taxpayers and takes resources away from those who are eligible and who truly need the program.

There is concern that the November 2020 improper payment rate estimate of 21.4 percent was unrealistically low because the eligibility reviews excluded one-third of states. Since the Obama Administration cancelled eligibility audits from 2014-2017, this year’s forthcoming report will be the first complete assessment of all states since the expansion took effect. Given its more complete nature, the upcoming assessment has the potential to show that the improper payment rate in the program exceeds 25 percent, totaling above $100 billion annually.

Such a high improper payment rate demonstrates that the program requires a stalwart defense to ensure those that are eligible receive the care they need. This rate also raises questions of whether Congressional and regulatory actions have made Medicaid too complicated for the Federal government to properly oversee it, especially given the differing improper payment rates among states. Congress needs complete and updated information about the improper payment rate in Medicaid as well as the corresponding drivers of this problem. We understand that the essential work on the 2021 CMS improper payment report has concluded, and drafts of the report have been completed. While state and Federal responses to COVID-19 halted some payment and eligibility reviews in 2020, this work is too vital to remain paused when the consequences are so dire.

Given the importance of accurate data to inform ongoing policy discussions, by Monday, November 8, we ask that you provide:

The updated improper payment rate in Medicaid;
A breakdown of improper payment rates by state; and
The corresponding estimated total of improper payments from insufficient verification or non-compliance with eligibility requirements.

When asked about this at a June hearing in front of the Senate Finance Committee, Secretary Becerra committed to making available such data. We also request a briefing with Committee Members’ staff, so that Congress can ask informed questions on this important matter.

 
 

Clipped from: https://highlandcountypress.com/Content/In-The-News/In-The-News/Article/Portman-Finance-Committee-Republicans-raise-concerns-with-improper-Medicaid-payments/2/20/73497