Tag: State News

Posted on by

Texas Medicaid coverage for moms under review

MM Curator summary

[MM Curator Summary]: CMS is poised to use maternity coverage as the site of its next ideological battle with The Lonestar State.

 
 

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.

 
 

HHSC said it was initially told the plan was “not approvable.” Federal Centers for Medicare and Medicaid Services issued a statement Friday saying Texas’ plan to extend coverage to six months was not rejected but still under review.

 
 

Sign up for The Brief, our daily newsletter that keeps readers up to speed on the most essential Texas news.

Texas’ application to extend Medicaid coverage for new mothers from two months to six months is not going to be approved by the federal government in its current form, according to the Texas Health and Human Services Commission. The federal Centers for Medicare and Medicaid Services said in a statement Friday that the application is still under review.

Legislators who pushed for the extension say they believe the application was not approved because of language that could be construed to exclude pregnant women who have abortions, including medically necessary abortions. The language in the bill that passed during the 2021 legislative session extended coverage to pregnant women who deliver a baby or have an “involuntary miscarriage.”

“That’s not a medical term, involuntary miscarriage,” said Rep. Donna Howard, D-Austin, a nurse and former health educator. “What I’m concerned about, and I think what maybe was the concern here, is those people who wanted their pregnancies to come to full term but have complications and a termination later in pregnancy and should be allowed to remain on Medicaid.”

Kelli Weldon, a spokesperson for the Texas Health and Human Services Commission, said CMS has verbally confirmed that Texas’ application is not approvable; HHSC officials have requested written confirmation. A spokesperson for CMS said the agency does not discuss ongoing conversations between the agency and states.

The stalled-out application process is a “self-inflicted wound,” Howard said. As part of the 2021 American Rescue Plan Act, the federal government eased the application requirements for states that expanded Medicaid for a full year postpartum.

The Texas House of Representatives overwhelmingly approved a bill that offered 12 months of coverage, but the Senate amended the legislation to six months instead. Because of that change, the state was required to go through the more onerous application process.

In a statement, Gov. Greg Abbott said the decision “risks the lives and health of Texas women and their babies all for the sake of a political agenda.” Abbott said President Joe Biden should “get ready for a fight with Texas” if his administration does not accept the state’s waiver.

House Speaker Dade Phelan, R-Beaumont, echoed this criticism.

“This is the latest hypocritical, disappointing move by the Biden administration that puts the care and needs of Texas mothers and babies at jeopardy — all in the name of partisan politics,” he said in a statement on Twitter.

Phelan indicated that he plans to once again push for a full year of postpartum Medicaid. State Rep. Toni Rose, D-Dallas, who filed the original bill last session, said she is optimistic about it passing both chambers next year.

“It was already my plan to work on adding the additional six months that we did not receive during the last legislative session,” Rose said. “But especially in light of today’s news and the Supreme Court decision to overturn Roe v. Wade, it’s never been more critical that our moms have access to comprehensive health care.”

Rose said she will also push to remove any language that may have resulted in issues with the application.

Texas is one of just 12 states that has not expanded Medicaid; as a result, Medicaid in Texas mostly serves low-income children. Pregnant Texans are more likely to be uninsured and less likely to seek early prenatal care than the rest of the country, and the state has staggering rates of maternal mortality and morbidity, especially among Black women.

Expanding postpartum Medicaid to one year was one of the top recommendations of the state’s Maternal Mortality and Morbidity Review Committee. Howard said this is going to become only more pressing now that Texas has banned all abortions, except to save the life of a pregnant patient.

“Over half of births in Texas are Medicaid births already,” she said. “Women who have means will be able to access abortion by traveling, and those with more limited means will have more barriers, so logically, that means an increase in Medicaid births.”

Right now, due to the ongoing federally declared Public Health Emergency, no one is being moved off of the Medicaid rolls, even after their eligibility expires. That state of emergency is set to expire this fall, though the federal government has extended it many times already.

“We are hopeful CMS will work with us toward approval before the end of the Public Health Emergency to ensure women in Texas Medicaid continue to receive postpartum care,” Weldon said in an emailed statement.

When you join us at The Texas Tribune Festival Sept. 22-24 in downtown Austin, you’ll hear from changemakers who are driving innovation, lawmakers who are taking charge with new policies, industry leaders who are pushing Texas forward and so many others. See the growing speaker list and buy tickets.

 
 

Clipped from: https://www.texastribune.org/2022/08/04/texas-medicaid-postpartum-application/

Posted on by

Massachusetts Suit Over Circumcision Medicaid Payments Fails

MM Curator summary

[MM Curator Summary]: Low income families will still have access to circumcision services, much to the chagrin of far left wing anti-circumcision extremists.

 
 

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.

 
 

Several Massachusetts taxpayers lost a lawsuit to prohibit the state’s Medicaid agency from paying for neonatal male circumcisions, because they have no actionable claim under either federal or state law, a state appeals court said.

Private citizens don’t have a right to enforce a state regulation precluding MassHealth from paying for services that aren’t medically necessary, because the decision of what constitutes a medically necessary service is committed to the agency’s discretion, the Massachusetts Court of Appeals said.

The plaintiffs alleged that most circumcisions aren’t medically necessary and usually are done at the request of the parents for cultural or …

 
 

Clipped from: https://news.bloomberglaw.com/health-law-and-business/massachusetts-suit-over-circumcision-medicaid-payments-fails

Posted on by

Nebraska Medicaid Announces Requests for Proposal For New Health Insurance Contracts

MM Curator summary

[MM Curator Summary]: Awards are currently expected late August.

 
 

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.

 
 

LINCOLN — The Nebraska Department of Health and Human Services (DHHS) has received bids from five health plans to provide healthcare services for its Medicaid managed care program. A request for proposals (RFP) was initially posted in April 2022, and bids were due July 1.

The five bidding companies are:

• Community Care Plan of Nebraska, Inc. d/b/a Healthy Blue

• Medica Community Health Plan

• Molina Healthcare of Nebraska, Inc.

• Nebraska Total Care, Inc.

 
 

• UnitedHealth Care of the Midlands, Inc.

Of the named bidders, Nebraska Medicaid will select two to three to provide physical health, behavioral health, pharmacy, and dental services. The chosen bidders will be contracted with DHHS for at least five years to provide most healthcare services to the members in managed care.

Nebraska Medicaid plans to announce the winning bidders in late August. From now until then, the bids will be scored based on specific and general expertise by Medicaid leaders. The State answered two rounds of bidders’ questions prior to the due date.

The bidders will be evaluated based on criteria through their proposals, which may include oral interviews, as part of the multi-stage process. The companies bring forward action plans and discuss their past learning experiences. From there, Medicaid will determine which are best suited to provide the best service to our members and providers over the next several years.

“Our goal throughout this RFP has been to improve our members’ and providers’ experience by building on previous successes and making thoughtful changes in response to stakeholder feedback,” Medicaid Director Kevin Bagley said. “That goal will be top of mind for our team as we rigorously evaluate these five proposals over the coming weeks.”

The new RFP includes several changes, integrating dental services with physical health, behavioral health, and pharmacy services; simplifying credentialing for providers; and improving electronic visit verification. After the winning bidders are chosen, Medicaid will work on implementing these changes as smoothly as possible for our members.

 
 

Clipped from: https://www.yankton.net/community/article_d1b96960-0c91-11ed-8f54-6bdccbfaa152.html

Posted on by

INDIANA- Local businessman accused of medicaid fraud, counterfeiting

MM Curator summary

[MM Curator Summary]: Timothy Adkins may or may not have forged doctor’s signatures thousands of times, depending on whether or not you believe the docs whose signature are in question. He’s facing about $950,000 of fraud allegations.

 
 

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.

 
 

 
 

Timothy Dwain Adkins

HANCOCK COUNTY — A six-year investigation by officials with the Family and Social Services Administration (FSSA) concluded a local man committed medicaid fraud and counterfeiting, resulting in the misuse of thousands of state dollars.

The case is being prosecuted by officials from the Attorney General’s office. It was officially opened in Hancock County Circuit Court last week under the supervision of Judge Scott Sirk.

Timothy Dwain Adkins, 66, 300 block of Shadow Creek Pass, Greenfield, has been charged with three Level 5 felony medicaid fraud charges and one Level 6 felony charge of counterfeiting from incidents in 2017 and 2018. The most serious charge carries up to six years in prison.

According to a probable cause affidavit, there is sufficient reason to believe Adkins committed medicaid fraud when he submitted claims to Indiana Medicaid stating doctors were the rendering Health Service Provider in Psychology (HSPPs) when they were not. Additionally, officials believe Adkins committed forgery in 67 instances where the signature of a doctor was signed on patient treatment plans.

The report states FSSA contacted the Medicaid Fraud Control Units (MFCU) and reported suspected fraudulent billing of in-home psychotherapy services, Behavior Source, LLC. Behavior Source is a provider of mental health services, owned by Adkins, who holds no psychology licenses or credentials.

According to the Better Business Bureau, the business was opened in Indianapolis 2012 with Adkins named as the business manager and director of operations. Behavior Source employs HSPPs and provides billing and HSPP oversight services to businesses who provide outpatient psychotherapy, the report states.

A doctor told officials he worked for Behavior Source as an HSPP until July 23, 2017. The doctor stated he did not see any patients of Behavior Source after July of 2017, contrary to billing data showing the rendering HSPP through May 2019.

A subsequent pull of billing data indicated billing was submitted by Behavior Source with the doctor listed as the rendering HSPP through March 8, 2021. In total, 12,472 claims were submitted to Indiana Medicaid totaling $475,116 where the doctor was listed as the rendering provider despite his statement he no longer worked for Behavior Source, the report states.

In March 2020, an investigator interviewed another doctor who said she was an HSPP for Behavior Source during two different time periods: first in 2016 or 2017 for approximately three or four months, and then starting again on August 12, 2019. Officials noted there were treatment plans which had her signature on them in 2018, but the doctor could not explain how her signature could be on the documents.

In September 2021, the MFCU sent a subpoena to Behavior Source for patient records to conduct a random sample audit of 23,812 claims submitted to Indiana Medicaid by Behavior Source from Jan. 1, 2017 to Aug. 20, 2021.

The report states a review showed a 60.30% error rate — meaning the percentage of the reviewed claims and patient records did not meet the program requirements necessary for reimbursement from Indiana Medicaid — because patient treatment plans were not signed by a physician or HSPP noting the HSPP signatures were forged, or the dates of review exceeded the regulatory requirements.

The fraudulent billing for non-compliant services equates to an actual over-payment of $12,936.63 and an extrapolated value to the total claims of $947,837.03, the report states.

Adkins was interviewed by investigators in February. Adkins told officials he was not surprised by the error rate and said he shared the concern of treatment plans not having HSPP signatures, the report states.

Adkins said, depending on the date, faxes from one doctor did not always come in on a regular basis. Adkins said the ability of therapists to get documentation back to him with HSPP signatures was “spotty,” the report states.

Adkins told officials one of the doctors would not sign the vast majority of the treatment plans submitted to him by therapists because the doctor wanted more definition in specific areas of the treatment plan. Adkins said this put him into a considerable “panic” because Behavior Source had just signed contracts with additional school districts and had therapists depending on HSPP approval from Behavior Source, the report states.

Adkins said he knew it was “messed up,” the report said, but he didn’t want to stop services to over 500 kids, 40 therapists and schools who would have no services. Adkins said he set aside money to pay back Indiana Medicaid and said, “I’ll fall on the sword if need be,” the report states.

According to the report, Adkins agreed that he was not providing services at the level they were required to be provided by Medicaid, as he was not having proper HSPP oversight of mid-level providers.

When asked about one doctor’s signatures on 67 documents, from January 2017 through August 2019, Adkins told officials in the report there was never a time the doctor’s signature was on paperwork for Behavior Source when she did not work for Behavior Source.

Adkins admitted his normal procedure during the doctor’s employment was to electronically cut out a signature, paste it on the document and send the pre-signed document to the doctor.

Adkins stated he did this so he wouldn’t need to meet with doctor in person, the report states. When officials interviewed the doctor, the doctor said her process was to always sign documents in pen. When asked if the doctor had ever received pre-signed documents from Adkins for review, she emphatically denied that ever happened, the report said.

When analyzing the billing data submitted to Indiana Medicaid by Behavior Source from January 2018, to August 2019 officials say where some 4,679 claims, totaling $92,650, were submitted to Indiana Medicaid where the doctor was listed as the rendering provider despite her statement she did not work for Behavior Source during this period and did not sign or authorize any documents.

Adkins made his initial appearance in Circuit Court late Friday when he was officially arrested. No bond amount was listed, however he is not an inmate in the county jail. Adkins is slated to be back in court in late September for a pretrial conference.

 
 

Clipped from: https://www.greenfieldreporter.com/2022/07/26/local-businessman-accused-of-medicaid-fraud-counterfeiting/

Posted on by

New York Office of Medicaid Inspector General Proposes Regulations on Medicaid Provider Compliance Programs

MM Curator summary

[MM Curator Summary]: If the OIG has its way, MCOs will be added to the list of groups who have to prove they are dealing with fraud, waste and abuse.

 
 

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

 
 

The New York State Office of Medicaid Inspector General (OMIG) published proposed regulations in the July 13, 2022 issue of the New York State Register.  The proposed regulations would repeal the current Part 521 – Provider Compliance Programs of Title 18 of the New York Codes, Rules and Regulations (NYCRR) in its entirety and establish new requirements for providers to detect and prevent fraud, waste and abuse in the Medicaid Program under a new Part 521: Fraud, Waste, and Abuse Prevention (Part 521). Part 521 would implement provisions of the New York State Fiscal Year 2020-2021 Enacted Budget and recommendations from the Department of Health’s Medicaid Redesign Team II. 

If enacted, the proposed rules would implement changes related to Medicaid provider compliance programs, Medicaid managed care organization (MCO) fraud, waste, and abuse prevention, and Medicaid providers’ “obligation to report, return, and explain Medicaid overpayments through OMIG’s Self-Disclosure Program.”  We have highlighted below certain provisions from the first of Part 521’s three subparts, Subpart 521-1, that are relevant to New York Medicaid providers as they structure and update their compliance programs.

Scope and Applicability of Program – Section 521-1.1

These proposed regulations require certain “Required Providers” (defined below) participating in the Medical Assistance program (Medicaid) to adopt a compliance plan to detect and prevent fraud, waste, and abuse in the Medicaid program. The following are deemed Required Providers and are obligated to comply with this proposed regulation:

  • hospitals, nursing homes, residential care facilities, and home care service agencies;
  • family care homes and residential treatment facilities for children and youth;
  • any managed care provider or managed long term care plan; and
  • any other person for whom the Medicaid program is or is reasonably expected to be a “substantial portion of their business operations.”  “Substantial portion of their business operations” includes persons who have claimed or received at least $1,000,000 a year from the Medicaid program. The current statutory definition sets $500,000 as the threshold.

In the current regulations, managed care providers and managed long term plans are not included in the scope of the Required Provider definition. 

Duties of Required Providers – Section 521-1.3(a)

To receive payment through the Medicaid program, Required Providers must maintain a compliance program. The regulations define an “effective compliance program” as a program that is:

  • well-integrated into the company’s operations and supported by the highest levels of the organization;
  • promotes adherence to the Required Provider’s legal and ethical obligations;
  • and is designed and implemented to prevent, detect, and correct non-compliance with Medicaid program requirements, such as fraud, waste, and abuse.

The provider must ensure that contracts with contractors, agents, subcontractors, and independent contractors are subject to their compliance program, and if such individuals meet the definition of an Affected Individual, the contracts must include termination provisions for failure to adhere to the Required Provider’s compliance program requirements. The proposed regulations define Affected Individuals as “persons who are affected by the Required Provider’s risk areas including the Required Provider’s employees, the chief executive and other senior administrators, managers, contractors, agents, subcontractors, independent contractors, and governing body and corporate officers.”

Risk Areas for Providers and Medicaid MCOs – Section 521-1.3(d)

The proposed regulations indicate there are ten risk areas, defined as areas of operation affected by the compliance program, that the compliance program must apply to:

  • billings;
  • payments;
  • ordered services;
  • medical necessity;
  • quality of care;
  • governance;
  • mandatory reporting;
  • credentialing;
  • contractor, subcontractor, agent, or independent contract oversight; and
  • other risk areas that are or should reasonably be identified by the provider through “organizational experience.” 

The regulations define “organizational experience” to include four components, which include the Required Provider’s knowledge, skill, practice, and understanding in operating a compliance program; identification of issues or risk areas; experience, knowledge, skill, practice and understanding of its participation in the Medicaid program; and awareness of issues it should reasonably become aware of for its services.

In the current regulations, “ordered services” and “contractor, subcontractor, agent, or independent contractor oversight” are not risk areas that were are required to be addressed in a Required Provider’s compliance program. The proposed regulations also add ten additional risk areas for Medicaid MCOs, which must also be addressed in their compliance programs.  These additional areas of risk include:

  • Compliance with Medicaid MCO’s contract terms;
  • Cost reporting;
  • Submission of encounter data;
  • Network adequacy and contracting;
  • Provider and subcontractor oversight;
  • Underutilization;
  • Marketing;
  • Provision of medically necessary services;
  • Payments and claims processing; and
  • Statistically valid services verification.

Certification – Section 521-1.3(f)

Required Providers must submit an annual certification to the Department of Social Services that it maintains a compliance program.  The Required Provider must also submit a copy of such certification to each Medicaid MCO with which the Required Provider has a provider agreement.

Written Policies of Compliance Program – Section 521-1.4(a)

Required Providers are required to have written policies, procedures, and standards of conduct that govern the compliance program. These policies, procedures, and standards of conduct must cover several topics, including providing guidance on dealing with compliance issues, descriptions of how compliance issues are investigated and resolved, and include a policy of non-intimidation and non-retaliation for good faith participation in the compliance program. The policies and procedures must be reviewed at least annually.

Compliance Officer and Compliance Committee – Section 521-1.4(b)-(c)

In the current regulations, a Required Provider was responsible for designating one employee that is responsible for the compliance program’s operation.  Now, under the proposed regulations, Required Providers must designate a compliance officer who will oversee, monitor, and review the compliance program, implement compliance work plans, and investigate matters related to the compliance program. The compliance officer will also coordinate with a designated compliance committee. The compliance committee will be responsible for, among other things, collaborating with the compliance officer on written policies and procedures, ensuring that the compliance officer is allotted sufficient resources to perform their job, and enacting required modifications to the compliance program.

Compliance Training and Education – Section 521-1.4(d) 

Required Providers must maintain a compliance training and education program for the compliance officer and all Affected Individuals.  This training must be completed at least annually. The training and education must include, at a minimum, a discussion of the following:

  • risk areas and organizational experience of the Required Provider;
  • written policies, procedures, and standards of conduct related to compliance;
  • the role of the compliance officer and compliance committee;
  • the obligation of Affected Individuals to report compliance concerns, the procedures for reporting concerns, and the non-intimidation and retaliation policies of the Required Provider;
  • disciplinary standards related to the compliance program and fraud, waste, and abuse prevention;
  • corrective action plans and response to compliance issues;
  • Medicaid program requirements and the Required Provider’s category of services;
  • coding and billing requirements and best practices;
  • claim development and submission; and
  • for Medicaid MCOs only, the fraud, waste, and abuse prevention program requirements of Subpart 521-2 (which will be further discussed in a future Mintz blog post).

OMIG Compliance Program Reviews – Section 521-1.5 

OMIG may review a Required Provider’s compliance program to determine its compliance with the regulations. OMIG will notify a Required Provider of its intent to commence a review, and such notice will include the review period and procedures that will be undertaken to complete the review.  Once the review is complete, OMIG will advise the Required Provider if it satisfies the requirements of Part 521 and if any deficiencies need to be corrected.

Conclusion

If enacted, Part 521-1 will compel Medicaid providers and Medicaid MCOs to examine and, potentially, restructure their compliance programs. OMIG is accepting public comment on these proposed regulations through September 11, 2022.

Subscribe To Viewpoints

 
 

Clipped from: https://www.mintz.com/insights-center/viewpoints/2146/2022-07-26-new-york-office-medicaid-inspector-general-proposes

Posted on by

CareOregon helping Medicaid members stay cool in extreme heat

 
 

MM Curator summary

[MM Curator Summary]: The MCO is planning ahead this year to help members avoid heat stroke, using algorithms to identify those most at risk.

 
 

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.

 
 

Enlarge

CareOregon is targeting those who may be at risk for heat stroke.

skaman306

With temperatures forecast to sneak into the triple digits this week, CareOregon is reaching out to about 700 members in its Medicaid plan who are at risk of heat-related illness.

The outreach actually started several weeks ago, in an effort to get ahead of the summer heat, in light of last year’s Heat Dome. Nearly 100 people, 13 of whom were CareOregon members, died statewide due to the extreme heat in June 2021. Many were seniors, people with disabilities and people with underlying medical conditions.

“This year, we wanted to start earlier because didn’t want to end up in a super-reactive state,” said Jonathan Weedman, vice president of population health for CareOregon, the largest Medicaid subcontractor under Health Share of Oregon. “We did outreach in early June to start prepping for what we knew would be inevitable.”

CareOregon identified those at risk by evaluating if they had a past history of heat-related illness and if they have chronic conditions. They also used geomapping technology to determine if they live within “heat islands,” or neighborhoods where temperatures rise the most during extreme heat.

“We got more sophisticated and more targeted in terms of the algorithm,” Weedman said.

A rapid response team of nurses, navigators, care coordinators and social workers has been contacting members and asking if they have an air conditioning unit and all their medications. CareOregon is also providing nonemergency medical transportation to cooling centers.

CareOregon does sometimes provide window units, but Weedman said some members are not allowed to have them in their apartments. Since last year’s heat wave, CareOregon has distributed 240 air conditioners.

One person said they had a unit but didn’t want to use it for fear of running up their electricity bill. CareOregon got them some utility assistance, Weedman said.

“There’s the basics, but also problem solving for all these other things,” he said.

Beginning Monday, TriMet will not turn away anyone riding to a cool place who cannot afford to pay fare. Multnomah County provides an interactive map of pools, community centers and other cool community places.

CareOregon manages care for 511,000 members, mostly in the Portland metro but also in Columbia and Jackson counties.

 
 

Clipped from: https://www.bizjournals.com/portland/news/2022/07/25/oregon-heat-wave-medicaid.html

Posted on by

With Medicaid Waiver Plan, Washington State Envisions 10 Community Hubs

MM Curator summary

[MM Curator Summary]: WA’s renewal request goes deeper into the community-driven SDH-focused model and will add a tribal care component to the mix.

 
 

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.

 
 

In its request for an extension of its Section 1115 Medicaid demonstration waiver, Washington state said it plans to develop a”Taking Action for Healthier Communities (TAHC)” program that will create 10 “Community Hubs” to further invest in multi-sector, community-based partnerships and approaches to better support individuals and families.

The state’s initial waiver, called the Medicaid Transformation Project (MTP), was approved in January 2017. In 2018 and 2020, the Centers for Medicare & Medicaid Services (CMS) also approved Washington state’s amendments for substance use disorder and mental health treatment in certain types of inpatient facility setting.

Now Washington is seeking a five-year renewal for what will be known as “MTP 2.0.”

In a June 29, 2022, letter to CMS Administrator Chiquita Brooks-LaSure, Gov. Jay Inslee said that, “through MTP, our state is focusing on whole-person care through integrated care and coordination with community services, such as housing, employment, and more. Washington has also leveraged a broad, collaborative regional approach to building healthier communities through Accountable Communities of Health (ACH).”

In its waiver renewal application, the state says that by supporting meaningful connections among communities, service providers, and managed care plans, TAHC will ensure that: Medicaid enrollees are able to access the services they need; care across the healthcare and health-related services continuum is coordinated; and regional capacity to offer these services grows over time. “This vision is critical to Washington’s goals of addressing long-standing underinvestment in marginalized communities and populations, removing systemic barriers to health, and advancing health equity,” the state says.

Washington says its regional Accountable Communities for Health will play a critical implementation role within the TAHC program. ACHs are uniquely positioned in supporting strong community engagement and multi-sector collaboration. They provide a lens that recognizes the importance of health equity and social determinants of health.

Washington is requesting expenditure authority for the development and operation of nine Community Hubs and one Native Hub. These hubs are centers for community-based care coordination that focus on health-related social needs. They will provide screening for and referral to community-based services for enrollees in Apple Health, the name for the state’s Medicaid program. Hubs will collaborate with other existing care coordination entities.

Nine of the Community Hubs will be overseen by existing ACHs—and a Native Hub will be developed and overseen by a to-be-determined entity. The state Health Care Authority will partner with Tribes to identify and select the appropriate Native Hub oversight entity. Guidance and coordination for creation of the Native Hub will be provided through the Governor’s Indian Health Advisory Council to serve the state’s tribal community statewide, in recognition of the government-to-government relationship with Tribes and tribal sovereignty.

Each ACH will be responsible for developing and managing the functions of a Community Hub.

The Community Hub is an evolution of work that began in MTP—embedded within the ACH infrastructure—and will align with recent efforts by the Care Connect Washington program.

MTP and Care Connect funding established a solid foundation of community information exchange that TAHC will leverage and expand upon to ensure Community Hubs have effective data-sharing capabilities between CBOs and healthcare organizations. The state will explore managed care flexibilities and contracting levers to support increased payment for community-based workforce through the Community Hub model. This demonstration will provide an implementation path that will be reinforced through MCO contracts and other accountability mechanisms, including the development of definitions and standards to support training and payment of community-based workers. The state stresses that ACHs are not evolving into Community Hubs. Rather, the ACH organizational infrastructure will remain, and each ACH will oversee, manage, and coordinate Community Hub functions. These functions will be performed by an ACH or entity contracted by the ACH.

Community Hubs will use community information exchange and resource and referral processes to support the coordination of and connection to community resources and organizations for Apple Health enrollees. Community Hubs will be instrumental in identifying unmet needs within the community and at the individual level, the state said. 

Community Hubs will work with networks of community organizations to ensure individuals are connected to the needed community services and supports, including promoting and coordinating health-related services, as the state looks to expand services that address unmet social needs throughout Washington.

 
 

Clipped from: https://www.hcinnovationgroup.com/policy-value-based-care/medicare-medicaid/article/21274610/in-medicaid-waiver-washington-state-envisions-creating-10-community-hubs
 

Posted on by

Medicaid expansion faces hurdles in South Dakota

MM Curator summary

[MM Curator Summary]: The 2 ballot initiatives have been consolidated, but a pesky $456M annual state funds additional costs estimate still hangs out there.

 
 

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.

 
 

 
 

Facade of South Dakota Capitol building in Pierre.

Paul Brady Photography / Shutterstock

(The Center Square) – Zach Marcus of South Dakotans Decide Healthcare is confident South Dakota voters will approve Medicaid expansion in November. 

Ask him why and he will quote numbers he says were given to him by the state’s Legislative Research Council. 

“Forty-two thousand, five hundred South Dakotans are currently stuck in the coverage gap, right?” Marcus, the campaign manager for the organization, told The Center Square. “They’re working hard but still they’re stuck making too much money to qualify for Medicaid, not enough money to actually afford health care.”

And there’s another number. Medicaid expansion would bring back $1.3 billion in federal funding to the state, Marcus said. 

Until earlier this week. South Dakotans Decide Healthcare and Dakotans for Health both had Medicaid expansion measures on the ballot. The groups have joined forces in a grassroots effort to get the measure passed. 

“We are grateful to the 24,000 South Dakotans who signed our petition, and the hundreds of South Dakotans who worked tirelessly to get Initiated Measure 28 on the ballot,” Rick Weiland, co-founder of Dakotans for Health, said in a news release. “After conversations with South Dakotans Decide Healthcare members, we have agreed that the best path forward to accomplishing this goal is to join efforts behind one campaign.”

The groups have an adversary in Gov. Kristi Noem, who has staunchly opposed Medicaid expansion. Noem’s administration did not immediately return a message seeking comment. But when lawmakers discussed passing Medicaid in February, a member of Noem’s administration said it would be costly. 

The Department of Social Services would need an additional $456 million a year in ongoing taxpayer funding, said Laurie Gill, the department’s secretary. The department would need an additional 64 full-time employees, she said.

“This growth of the program is out of line with our charge to be fiscally responsible,” Gill told the South Dakota Senate Health and Human Services committee

The Medicaid expansion effort has broad support from South Dakota’s health care community. Among the groups backing the amendment are the American Cancer Society Cancer Action Network, AARP South Dakota, South Dakota State Medical Association, Avera Health, Monument Health, Sanford Heal and the American Heart Association

South Dakota is one of 12 states that has not expanded Medicare. 

 
 

Clipped from: https://www.thecentersquare.com/south_dakota/medicaid-expansion-faces-hurdles-in-south-dakota/article_4f1772ea-03a4-11ed-b7fc-27de89e00e7c.html

Posted on by

Silver Spring woman sentenced to 10 months in prison for defrauding D.C. Medicaid program of over $100K

MM Curator summary

[MM Curator Summary]: Susan Tingwei claimed she was providing Medicaid services while she was actually attending law school classes.

 
 

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.

 
 

She admitted to filling out false timesheets, according to authorities

 
 

A Silver Spring woman was sentenced to 10 months in prison last week after federal authorities say she defrauded Washington, D.C.’s Medicaid program out of more than $100,000.

Susan Engonwei Tingwei, 44, worked at two home health agencies in the district between 2016 and 2018, according to the U.S. Attorney’s Office for the District of Columbia. Tingwei’s job was to help Medicaid beneficiaries with daily tasks such as getting in and out of bed, bathing, dressing and eating.

According to authorities, Tingwei earned a law degree from the University of Maryland in May 2017. She was admitted to the New York state bar in 2018 and the Maryland bar in 2020.

According to Tingwei’s guilty plea, she was supposed to fill out timesheets and then submit them to home health agencies, which would then bill Medicaid for her services. Tingwei told authorities that she submitted false timesheets claiming to provide services that she did not provide, according to the U.S. Attorney’s Office.

Want more Montgomery County news?
 

Subscribe to the daily Bethesda Beat newsletter to get the latest updates straight to your inbox. 

According to authorities, Tingwei submitted time sheets 118 times between August 2016 and May 2017 claiming that she worked as a personal care aide. However, the times listed on the timesheets were during the hours when Tingwei was scheduled to attend law school classes in Baltimore or would have been traveling to or from them.

Tingwei admitted to defrauding the D.C. Medicaid program out of $131,656, according to the U.S. Attorney’s Office. She pleaded guilty in November 2021 to health care fraud. On July 14, she was sentenced to 10 months in federal prison, followed by two years of supervised release. She must also pay restitution equal to the amount of money she defrauded the Medicaid program.

Tingwei’s attorney, Jonathan Zucker, could not immediately be reached for comment Monday afternoon.

Dan Schere can be reached at daniel.schere@bethesdamagazine.com

Before you go…

We believe all Montgomery County residents deserve in-depth reporting, perspectives and resources to help us better enjoy, understand and impact our community. 

If you can, we hope you’ll help keep our journalism free for all readers by becoming a Bethesda Beat member.

 
 

Clipped from: https://bethesdamagazine.com/bethesda-beat/courts/silver-spring-woman-sentenced-to-10-months-in-prison-for-defrauding-d-c-medicaid-program-of-over-100k/

Posted on by

Twin Falls provider sentenced for fraud and obstruction of medicaid fraud investigation

MM Curator summary

[MM Curator Summary]: Pat Anderson stole Idaho Medicaid bucks by filing false claims for personal care services.

 
 

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.

 
 

 
 

Public Domain Pictures

BOISE, Idaho (KIFI) – Attorney General Lawrence Wasden announced a Twin Falls woman was sentenced on Monday for provider fraud and obstruction of a Medicaid fraud investigation.

52-year-old Patricia Anderson pleaded guilty in April.

Fifth District Judge John Butler sentenced Anderson to a suspended sentence of three years with one year fixed. Anderson was then placed on supervised probation for three years, ordered to pay $2,000 in fines and serve 300 hours of community service. She has paid $1,782 in restitution.

An investigation revealed that in 2017, Anderson billed Medicaid for services she didn’t provide. Investigators determined the fraudulent billing by establishing that Anderson traveled out of state on several occasions, yet billed Medicaid for services she purported to provide a family member in Idaho during the same periods. Payments for these services were reimbursed by the Idaho Medicaid Program. Investigators also determined that during questioning, Anderson did not accurately represent the extent of her travels during the periods in question.

The case was investigated by the Medicaid Program Integrity Unit of the Idaho Department of Health and Welfare and the Attorney General’s Medicaid Fraud Control Unit. Deputy Attorney General Kenneth M. Robins prosecuted the case.

 
 

Clipped from: https://localnews8.com/news/crime-tracker/2022/07/15/twin-falls-provider-sentenced-for-fraud-and-obstruction-of-medicaid-fraud-investigation/