Tag: Medicaid Reform

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[MM Curator Summary]: The state is looking to ensure its existing rules around payment for abortion are actually followed.

 
 

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

 
 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MM Curator summary

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

 
 

[MM Curator Summary]: Georgia even had to fight to do its healthcare marketplace website the way it wants to- and now their new one won’t really point people to “free” (subsidized) plan options.

 
 

 
 

Clipped from: https://www.gpb.org/news/2022/12/30/georgia-establishes-its-own-health-insurance-portal-georgia-access

Caption

The homepage for the new Georgia Access website, set to go live in January, was built by the state government in fall 2022.

Credit: Screenshot

ATLANTA — After failing to win federal approval to exit the federal insurance marketplace earlier this year, Georgia has established its own health insurance portal directing people to private insurers and brokers to buy health insurance. 

The new website, called Georgia Access, includes links to 10 health insurance companies — including big players such as United, Kaiser Permanente, and Aetna — as well as seven online brokers, organizations that help people shop for and enroll in health insurance.  

The dueling state and federal websites each offer a different route to the same destination: signing up for health insurance.  

Georgians can use the links on GeorgiaAccess.gov to explore the insurance companies’ and brokers’ offerings, which include but are not limited to the same marketplace plans offered on the federal website.  

The new Georgia Access site also includes links to companies and brokers that offer dental and vision plans, basic information about Medicaid and PeachCare for Kids, and links to state health care agencies that assist with mental health.  

But notably absent from the state’s new portal is a link to the federal HealthCare.gov, a one-stop shop for buying health insurance coverage through the Affordable Care Act. The HealthCare.gov website provides comparisons of the different companies’ health plans.

The state decided to set up the GeorgiaAccess.gov portal with the resources it had initially devoted to its plan to exit the federal marketplace, said Gregg Conley, executive counsel for the Georgia Department of Insurance.  

Republican Gov. Brian Kemp first sought permission to exit the federal health insurance marketplace back in 2020. But the Biden administration rejected the Georgia plan earlier this year after analyses showed it would cover fewer, not more, Georgians than the federal marketplace.  

According to Georgia Access, 1.3 million Georgians lack health insurance.

“I would encourage people to sign up for health [insurance],” Conley said. “What we don’t want is people not to have health care.”

But many advocates argue that online brokers and private insurers are not the best custodians of consumers’ interests.  

Insurance companies and brokers, most of which are for-profit entities, may push people to enroll in “substandard” plans that don’t cover all services, Joan Alker, a research professor at Georgetown University, wrote earlier this year.  

Brokers may fail to help people enroll in Medicaid or other state health insurance plans for people with low incomes and they may not adequately cater to the needs of racial and ethnic minorities and people who are not proficient in English, Alker wrote. 

In Georgia, legislative Democrats have called for expanding Medicaid to address the state’s large population of uninsured people.  

“Georgia should expand Medicaid,” House Minority Leader James Beverly, D-Macon, said Wednesday. “I am calling on the governor and the Georgia legislature to make it priority No. 1 to ensure every Georgian has access to quality health care benefits.”

Open enrollment for marketplace plans ends on Jan. 15, 2023. That gives Georgians just two more weeks to select their plans for next year, whether through the links provided on GeorgiaAccess.gov or the federal HealthCare.gov. 

This story is available through a news partnership with Capitol Beat News Service, a project of the Georgia Press Educational Foundation.

MM Curator summary

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

 
 

[MM Curator Summary]: Reminder- there’s more than 50 Medicaid programs.

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

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

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

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

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

 
 

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

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

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

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

Territory Funding Caps

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

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

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

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

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

More Money for Cancer Treatment

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

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

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

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

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

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

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

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

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

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

 
 

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MM Curator summary

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

 
 

[MM Curator Summary]: David beat Goliath; Goliath whines after the loss.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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MM Curator summary

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

 
 

[MM Curator Summary]: The state thinks fathers that can pay should pay.

 
 

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

 
 

(Kelly Sikkema | Unsplash)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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