Tag: State News

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IL- St. Anthony Hospital can sue Illinois over Medicaid payments

 
 

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[MM Curator Summary]: A hospital can now sue the state for stiffing it on millions of dollars in Medicaid bills- well technically for not making sure MCOs paid the bills.

 
 

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.

 
 

 
 

St. Anthony Hospital alleges that the state agency overseeing Medicaid has failed to make private insurers deliver payments on time.

 
 

St. Anthony Hospital

St. Anthony Hospital, a nonprofit safety-net hospital on Chicago’s Southwest Side, can sue Illinois’ Medicaid department for allegedly failing to ensure that private insurers pay the hospital on time, a federal appeals court ruled this week.

 
 

From previous story on this

 
 

St. Anthony Hospital is suing the state, alleging that problems with Illinois’ Medicaid program threaten the hospital’s ability to care for patients in the midst of the COVID-19 pandemic.

In a lawsuit filed yesterday in the U.S. District Court for the Northern District of Illinois, the Little Village hospital alleges that the state’s $12.5 billion Medicaid managed-care program doesn’t comply with federal law and subsequently hurts safety nets that treat large numbers of low-income patients.

 
 

From <https://www.chicagobusiness.com/health-care/little-village-hospital-sues-state-over-medicaid-program>

 
 

Under the program, the state pays six private insurers—known as managed-care organizations—to administer Medicaid benefits to beneficiaries in Illinois. The goal is to improve people’s health and control costs by ensuring all care is appropriate and high-quality. But health care providers, safety nets in particular, say claim denials and late payments from insurers jeopardize their operations.

“The state’s failure to provide the required oversight of (managed-care organizations) has placed unsustainable financial pressure on St. Anthony,” the lawsuit says. “Now, in the face of the COVID-19 pandemic, St. Anthony’s finances are approaching a crisis point.”

 
 

St. Anthony said in the complaint that as of mid-February it was owed more than $22 million for medical services provided to Medicaid patients. Meanwhile, it estimates that costs and lost revenue due to COVID-19 preparedness between March and May could be more than $10 million.

 
 

“Gov. J.B. Pritzker did not create this broken system, but hopefully he can fix it,” St. Anthony CEO Guy Medaglia said in a statement. “St. Anthony Hospital had no choice other than to sue the state in federal court to protect the vulnerable, largely Hispanic and African-American patients for whom we provide essential care to on the West and Southwest sides of Chicago.”

 
 

Defendant Theresa Eagleson is the director of the Illinois Department of Healthcare & Family Services, or HFS, which oversees Medicaid.

In an emailed statement, the HFS said it has been working with St. Anthony to “address the hospital’s claim that it has not received all of the payments it is due. To date, the hospital has not yet provided to the state any information demonstrating that it is due any payment. It is unfortunate that the hospital has chosen the path of litigation instead of continuing to discuss its concerns with us.”

In addition to payments for Medicaid claims older than 30 days, the hospital is seeking program changes that would result in more transparency and require HFS to have more oversight of the private insurers administering benefits.

“Given the lack of oversight from HFS, the actions by (managed care organizations) are not surprising,” the complaint says. The insurers “receive the funds HFS provides, but do not promptly and fully pay those funds to the providers. The difference presumably increases their bottom line.”

 
 

From <https://www.chicagobusiness.com/health-care/little-village-hospital-sues-state-over-medicaid-program>

 
 

 
 

Clipped from: https://www.chicagobusiness.com/health-care/st-anthony-hospital-can-sue-illinois-over-medicaid-payments

 
 

 
 

 
 

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SD- Concerns arise as dueling ballot measures both seek to expand Medicaid coverage in South Dakota

 
 

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[MM Curator Summary]: One measure is trying to amend the state constitution; the other is a simple ballot initiative.

 
 

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.

 
 

 
 

“It’s unfortunate that this life-saving issue has turned into a political bogeyman that people can use as a scare tool.”

 
 

SIOUX FALLS — Some advocates for Medicaid expansion in South Dakota are concerned that two ballot measures with different language and separate backers but the same goals may confuse or diffuse voters, reducing the chances of success in the November election.

The goal of each campaign is to provide health care coverage to more than 40,000 additional low-income South Dakota residents by broadening Medicaid insurance criteria as established by the Affordable Care Act, with the federal government covering 90 percent of the cost. Unlike Medicare, which provides coverage for the elderly, Medicaid focuses on low-income individuals and covers services such as hospital visits, preventative care, X-rays and family planning.

The ACA in 2010 expanded Medicaid to include nearly all adults with incomes up to 138% of the federal poverty level, which currently translates to an annual salary of about $18,000 for an individual (or $36,500 for a family of four). But the Supreme Court ruled in 2012 that states could reject the expansion and still get federal funding for traditional Medicaid costs, which all states currently receive.

South Dakota is one of just 12 states that hasn’t expanded Medicaid, making it an outlier even among neighboring Republican-led states such as North Dakota, Iowa and Nebraska. But expansion proponents are optimistic after seeing voters reject Amendment C – which would have made ballot measures involving state spending more difficult to pass – in the primary election June 7 with 67 percent of the vote.

Constitutional Amendment D, which is sponsored by South Dakotans Decide Healthcare and will appear on the November ballot, seeks to expand Medicaid by changing the state constitution, viewed traditionally as a more iron-clad method of initiating new policies. Amendment D is supported by the state’s major healthcare systems and the Fairness Project, a national advocacy group that assists in ballot measure campaigns.

The second Medicaid ballot measure, Initiated Measure 28, is spearheaded by former Democratic U.S. Senate candidate Rick Weiland, a frequent supporter of ballot measures who successfully campaigned to increase South Dakota’s minimum wage in 2014. Weiland’s group, Dakotans for Health, initially presented its measure as a way to give voters another option in case the 60-percent voting threshold was passed into law by the June primary vote.

“Historically, initiated measures have fared better than conditional amendments,” said Weiland. “There are groups of voters who just don’t like to mess with the constitution and could see Medicaid expansion as more appropriately accomplished by statutory measure.”

Since Amendment D had a later filing deadline to the Secretary of State’s office, the fiscal note from the Legislative Research Council includes additional offsets extended by the Biden Administration as part of the American Rescue Plan, showing the state’s share over the first five years of Medicaid expansion to be a total of $3.8 million. That information is not reflected in IM 28’s fiscal note, nor does that measure specify an implementation date.

These differences – plus the significant financial backing of South Dakota’s “big three” health systems: Sanford, Avera and Monument – lead state Sen. Reynold Nesiba, a Sioux Falls Democrat who supports Amendment D, to call for Weiland to pull Initiated Measure 28 off the Nov. 8 ballot to create a unified statewide effort.

“Rick Weiland and the people bringing the initiated measure need to withdraw it,” Nesiba told News Watch. “It’s got an inferior fiscal note attached to it, it doesn’t have an implementation date, and the constitutional amendment will have a more definitive impact.”

Weiland, whose efforts to coordinate a petition-led campaign to pass Medicaid expansion date back to 2019, chuckled when informed of Nesiba’s remarks.

“Give me a break,” said Weiland, who served as an advisor to former U.S. Senator Tom Daschle. “The language in both these initiatives accomplish the same thing, and the implementation date is written into state law. As for voters being confused, there are only three measures on the ballot (the two Medicaid proposals and IM 27, which would legalize recreational marijuana). I don’t think that’s going to be too overwhelming for people.”

If both ballot measures pass and have the same intent, state law dictates that “the initiated measure or amendment receiving the greatest number of affirmative votes at the election shall be given effect.”

That provision could be construed as the measures competing against each other, though their aim is the same. The deadline to voluntarily remove a ballot measure is 120 days before the election (July 12 in this case), but so far both groups are holding firm.

“We are fully focused on campaigning for and passing a constitutional amendment that will expand Medicaid in South Dakota,” said Zach Marcus, a spokesperson for South Dakotans Decide Healthcare.

Erin Hislaw walks her son, Jairus, into the Indian Health Service clinic in Fort Thompson for a checkup in this 2017 file photo. This IHS branch was visited Monday by an investigator from the IHS regional office in Aberdeen.

Mitchell Republic file photo

General agreement on intent

One thing the factions agree on is that chronically underfunded Indian Health Service facilities and rural health clinics and nursing homes will receive a boost from federal Medicaid reimbursements if more low-income patients are covered. In addition to the 90% federal matching rate, states that implement expansion also see an increase in funding for traditional Medicaid populations under COVID-related American Rescue Plan provisions.

In South Dakota, the total cost of expansion over the first five years would amount to about $1.5 billion, of which the state’s share would be $166.2 million, according to the Legislative Research Council. Since total savings to the general fund – from federal matching and incentive funds and fewer reimbursement payments to hospitals for treating uninsured patients – is estimated at $162.4 million over that five-year period, the state’s net financial obligation would be $3.8 million.

“It will cost us less to expand Medicaid than it cost to buy the governor a new airplane,” said Nesiba, referring to the state’s $4.5 million purchase of a 2015 Beechcraft King Air 350 last year. “The failure of South Dakota to take this step is one of the most short-sighted economic decisions we have ever made.”

Under South Dakota’s current (non-expanded) Medicaid system, two-thirds of the roughly 130,000 enrollees are children who meet poverty level guidelines, while eligible adults include pregnant women, elderly or disabled individuals and parents of minor children up to 52 percent of the poverty level (for a household with three people, that means an annual salary of about $11,300).

Childless adults without a disability are ineligible for Medicaid coverage in South Dakota regardless of income level, and many don’t qualify for ACA subsidies to help obtain private coverage unless their income is at least 100 percent of the poverty level.

The number of these residents who “fall through the cracks” of health insurance coverage is estimated at 42,500 in South Dakota, just under 5 percent of the total population. Nearly 40 percent of them are estimated to be Native American, according to Georgetown University’s Health Policy Institute, compared with about 9 percent of the general population that is Native American.

The federal government pays 58% of the cost of standard Medicaid coverage, with slight increases made during the COVID-19 pandemic. Under Medicaid expansion, the federal government share increases sharply, especially with incentives added as part of the American Rescue Plan.

A study of state budgets from 2014-2017 by the Commonwealth Fund, a nonprofit that supports research on health policy reform, found that Medicaid expansion was associated with a 4.4% to 4.7% reduction in state spending on traditional Medicaid while also reducing the cost of uncompensated care, such as when the state reimburses hospitals for services provided to uninsured individuals.

Deb Fischer-Clemens, Avera Health senior vice president for public policy and a supporter of Amendment D, said that expanding coverage to uninsured residents helps not just those individuals or families but also entities that might incur those costs down the line, including state or county government, non-profit health systems or taxpayers.

“There’s a lack of preventative care when you don’t have insurance,” said Fischer-Clemens, a former state legislator who also serves as president of the South Dakota Nurses Association. “When you don’t have a lot of money, you’re using it all to pay for rent or groceries or gas, meaning you’re not getting that preventative colonoscopy. And when you find out there’s something wrong with you, instead of a couple thousand dollars, it’s tens of thousands of dollars, and a lot of time away from work and a lot of debt. The big picture of this is taking care of individuals who don’t have the resources to access care at the appropriate time.”

Medicaid expansion opponents, including GOP Gov. Kristi Noem and Republican Senate President Pro Tempore Lee Schoenbeck, counter that able-bodied individuals, such as currently uncovered childless adults, should be able to work and are not entitled to free health care. They also point to uncertainty about the state’s share of expenses once COVID-related incentives from the Biden administration phase out and the nation’s public health emergency expires, which is expected later this year.

Schoenbeck, who declined an interview request, made his position clear when asked about Medicaid expansion during a Senate primary event in May.

“I don’t happen to support more welfare,” he said.

Gov. Dennis Daugaard delivers a budget address before lawmakers at the South Dakota State Capitol in this file photo.

Mitchell Republic file photo

Expansion talks fizzle in state government

In 2016, two years after being re-elected as South Dakota governor with more than 70% of the vote, Dennis Daugaard undertook an effort to expand Medicaid despite lingering rancor toward “Obamacare” among most of his fellow Republicans.

The fiscally conservative Daugaard saw it as a good deal for South Dakota, since the state was already paying in part for Native American residents who couldn’t receive care at reservation IHS facilities because of lack of services or availability. The U.S. Health and Human Services Department agreed to an arrangement where those treated outside IHS facilities would be covered by federal Medicaid matching funds.

The problems Daugaard faced were not procedural but political, as state Republicans balked at expanding the ACA, the outgoing Obama’s signature achievement, and voiced their concerns about government handouts for adults who were able to work and fend for themselves.

The governor convened a Health Care Solutions Coalition, which produced a 2016 report that found the state spent $182 million on health care for Native Americans in fiscal year 2015, about $97 million of which was federal funds and $85 million was state funds. The report noted that “$85 million is more than enough to cover state costs for expansion.”

With legislative action stalled, Daugaard tried unsuccessfully to negotiate a work requirement provision with the federal government. Donald Trump’s victory in 2016 – along with Trump’s proclaimed goal to repeal the ACA – ended what little momentum had occurred, especially after Daugaard met with then-Vice President MIke Pence and discussed the new administration’s repeal strategy, which ultimately failed in Congress.

Fischer-Clemens, who served on Daugaard’s coalition, joined with other hospital officials and health associations to consider a new course, especially after Noem took office following the 2018 election and declared her opposition to Medicaid expansion. Advocacy groups in states such as Nebraska, Oklahoma, Missouri, Utah and Idaho had found success by taking the issue straight to voters with petition-fueled ballot measures, and that became the strategy.

“After seeing so many bills fail in committee over the years, we knew we couldn’t do it with legislative movement,” said Fischer-Clemens. “The philosophy in the Legislature is basically, ‘We’ve done enough with Medicaid, and if the federal government takes dollars away, then it’s going to lead to higher taxes.’ There was nowhere else to go.”

Voters cast their ballots inside the Mitchell Career and Technical Education Academy in this Republic file photo.

Mitchell Republic file photo

Taking issues straight to ballot

There were some early discussions with Weiland, who was well-versed in the ballot measure process and knew of its pitfalls. After his successful effort to raise the state’s minimum wage in 2014, state legislators voted to exempt workers under age 18 from the required wage, so Weiland and other Democrats referred the law back to voters and won with 71 percent of the vote.

Two years later, Weiland spearheaded an electoral victory for IM 22, which revised lobbying and campaign finance laws while establishing a state ethics commission. But Republican legislators sought a preliminary injunction and later repealed the measure with an emergency clause that ensured it could not be sent back to voters.

Those South Dakota efforts against initiated measures, and delays in Nebraska as Gov. Pete Ricketts sought to restrict the implementation of voter-approved Medicaid expansion for several years, convinced South Dakotans Decide Healthcare and the Fairness Project that a constitutional amendment was the most logical course.

They used paid petition circulators to speed the process and submitted 47,000 signatures last November with the Secretary of State’s office, announcing in January that the proposal had qualified for the November 2022 ballot officially as Amendment D.

“We had seen some of the things that the legislature does with initiated measures,” said Fischer-Clemens. “Then some of us watched what was happening in Nebraska and basically said, ‘We don’t want to go through that – we’re not going to live that long.’ In the end we were more confident that we could reach our goal with a constitutional amendment.”

Weiland, however, points to Amendment A, the South Dakota recreational marijuana effort that passed with 54% of the vote in 2020. Noem’s administration challenged the measure, saying it violated the state’s requirement that constitutional amendments deal with just one subject, and won a 4-1 decision at the South Dakota Supreme Court that prevented legalization from taking place.

That single-subject clause had been a response to IM 22, meant to discourage sweeping voter-based changes to state law. When it became clear that Medicaid expansion would be on the ballot in 2022, Sen. Schoenbeck tried to orchestrate a preemptive strike with Amendment C, which was backed by the Koch Brothers-funded Americans for Prosperity and would have required a 60% vote for ballot measures that raise taxes or spend $10 million in general funds in their first five years.

The resounding failure of Amendment C was viewed by some as a message from voters to lay off the petition process, which Weiland interpreted as a potential buffer for initiated measures as well. He noted that state Sen. Wayne Steinhauer, R-Hartford, who chairs the Senate Health and Human Services Committee, led an effort during the 2022 legislative session to endorse or prepare for Medicaid expansion, a proposal that fell short but indicated a desire to get out in front of voter-backed measures. Steinhauer did not respond to an interview request.

“I think state legislators realize that they’re on thin ice when it comes to messing around with the will of voters,” said Weiland, whose group’s measure was certified June 9 by the Secretary of State’s office with 17,249 valid signatures (the threshold is 16,961). “We have a chance to hold their feet to the fire, because they mis-stepped on minimum wage, they mis-stepped on corruption, they mis-stepped on cannabis and they’re getting tired of mis-stepping. This whole notion that the only way to get things done is through constitutional amendment is not really the case anymore. I hope they both pass. We’re encouraging people to vote for both.”

The South Dakota Department of Tribal Relations says this map is meant as a general guide to where tribal lands are located but does not wholly represent tribal lands or reservations as they are today.

Map courtesy of the South Dakota Department of Tribal Relations

Finding support for Native populations

One of the most persuasive arguments for expanding Medicaid is its ability to address long-standing health care concerns that plague tribal communities in South Dakota, which has the fourth-highest percentage of Native American residents in the country.

A 2021 study by the Health Policy Institute at Georgetown found several predominantly Native counties (Buffalo, Oglala Lakota, Todd) with at least four times the national average of uninsured non-elderly adults.

Remi Bald Eagle, a member of the Cheyenne River Sioux Tribe who is part of the Dakotans for Health group, pointed to the limitations of IHS services on reservations and noted how Medicaid expansion could improve the level of care.

Some Native residents don’t live close to an IHS facility, or they require services that aren’t provided. Expanding Medicaid would allow those patients to be referred to other hospitals or clinics, which would then be reimbursed. Currently, referrals are determined by a “triage” system, meaning cases are prioritized by level of medical severity.

“IHS facilities have a capped budget they operate under,” said Bald Eagle, a former Democratic candidate for public utilities commissioner. “If a person’s condition is not seen as high priority, that person might not get referred.” He added that third-party billing through Medicaid expansion could potentially help IHS facilities expand services or upgrade medical personnel.

Among Native Americans with IHS access, Medicaid enrollment increased by 45% in expansion states and 25% in non-expansion states from 2010 to 2018, according to the IHS Tribal Self-Governance Advisory Committee.

Montana, which approved Medicaid expansion in 2016, saw more than 15,000 tribal members newly enrolled in Medicaid in the first two years, according to the state Department of Public Health and Human Services. The tribal and IHS facilities on the Blackfeet Reservation in northern Montana saw an additional $13.6 million for services reimbursed by the federal government during that time.

Bald Eagle supports the initiated measure but said both proposals are encouraging to many in South Dakota – not as government handouts, but as ways to address problems that low-income residents and health providers have faced for a long time.

“It’s unfortunate that this life-saving issue has turned into a political bogeyman that people can use as a scare tool,” he said. “The more people you have using these services, the more it helps everyone, not just Indian Country, but South Dakota as a whole.”

— This article was produced by South Dakota News Watch, a non-profit news organization online at sdnewswatch.org.

 
 

Clipped from: https://www.mitchellrepublic.com/news/south-dakota/concerns-arise-as-dueling-ballot-measures-both-seek-to-expand-medicaid-coverage-in-south-dakota

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‘Phantom’ provider lists limit Medicaid mental healthcare access, study finds

 
 

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[MM Curator Summary]: Nearly 60% of all providers listed in directories were not actually providing services to Medicaid members.

 
 

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.

 
 

 
 

 
 

Dive Brief:

  • Researchers found significant discrepancies between provider directories and the actual availability of providers in a large study examining access to mental health services among Medicaid recipients in Oregon. Directories full of “phantom” providers may prevent patients from obtaining necessary mental health care in a timely manner, the study authors said.
  • The inaccurate listings may be especially harmful for Medicaid enrollees, who already face high rates of serious mental illness, according to the researchers at Oregon Health and Science University and Johns Hopkins University.
  • “Constraining or disguising supply is an insidious barrier to realizing access to mental health treatment,” Howard Goldman, of the University of Maryland in Baltimore, wrote in an opinion piece accompanying the research findings in the July issue of Health Affairs.

Dive Insight:

Medicaid patients are disproportionately likely to have severe, persistent mental health disorders, in addition to complex social and medical needs, according to the non-partisan Medicaid and CHIP Payment and Access Commission.

Medicaid is the single largest payer for mental health care in the U.S. Yet with high demand for those services, there is low provider participation and facility shortages in rural areas, the researchers at Oregon Health noted.

Research from Yale and Cornell universities, published earlier this year in Health Affairs, showed that managed care provider directories may overstate the availability of doctors to see Medicaid patients and suggested that private insurers may be padding networks with physicians unwilling to treat program beneficiaries.

U.S. lawmakers held a hearing earlier this year focused on a U.S. mental health crisis that was exacerbated by the COVID-19 pandemic, shining a spotlight on rising rates of depression, anxiety and suicidal ideation, as well as widespread inequities in insurance benefits.

The Oregon Health study, though limited to one state, shows federal and state efforts to enforce network adequacy standards may be falling short, the authors concluded.

The study compared listings of providers in network directories against provider networks constructed from administrative claims among members under the age of 64 who were enrolled in Oregon’s Medicaid managed care organizations in 2018. Provider directory files included 7,899 unique primary care providers, 722 mental health prescribers and 6,824 mental health non-prescribers in Medicaid managed care networks. 

Overall, 58% of network directory listings were “phantom” providers who did not see Medicaid patients, including 67% of mental health prescribers, 59% of mental health non-prescribers, and 54% of primary care providers.

The influence of provider networks is potentially greater in the Medicaid program than in commercial insurance, the study found, because out-of-pocket payment is often unaffordable, and enrollees are generally limited to contracted providers and do not have cost-sharing options for going out of network for non-emergency care.

 
 

Clipped from: https://www.healthcaredive.com/news/phantom-provider-networkst-medicaid-mental-health-care-access-Health-affairs/626617/

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States should protect caregivers’ Medicaid funds from union skims

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[MM Curator Summary]: Biden recently re-instated the union graft practiced that Trump reversed that Obama strengthened.

 
 

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.

 
 

 
 

Associated Press/Elise Amendola

In this March 5, 2018 photo, Wil Darcangelo helps his 22-year-old adopted daughter, Lavender, who is blind and autistic, leave their home in Fitchburg, Mass. He is among Americans who care for family members in their homes full time.

Robert and Patricia Haynes live in Mich. and provide full-time care for their adult children, Kevin and Melissa, who suffer from severe cases of cerebral palsy. Until 2014, they were forced to give a portion of their Medicaid reimbursements to the Service Employees International Union (SEIU), a scheme propagated by unions such as SEIU and the American Federation of State, County and Municipal Employees (AFSCME) that is commonly known as to as “dues skimming.” 

Yet, while a number of states including Michigan have taken action to prohibit the dues skim, a May rule by the federal Department of Health and Human Services (HHS) reversed a Trump administration effort to stop the skim nationally. A separate 9th Circuit decision last week also continues to allow unions to trap home care providers into paying them.

The Hayneses, like other caregivers across the country, are eligible for Medicaid reimbursement from the state for the care they provide to their disabled children. However, over a decade ago, unions worked with state policymakers in about a dozen states to permit the siphoning of union dues from Medicaid money the Hayneses received. Without their permission or intent, the state reclassified the Hayneses as “public employees” at the behest of SEIU — and they had to pay their dues.

Many members of the “home care workforce” are relatives or friends providing care to sick family members or loved ones in need.

It took years to end the dues skim in Michigan, including administrative action by former Gov. Rick Snyder, legislative reform, lawsuits and the defeat of a ballot measure backed by the unions in a last-ditch effort to keep the dues skim alive. After the SEIU took $34 million from providers like the Hayneses, this unfair policy finally ended.

But caregivers in states such as Illinois, Oregon and Washington had to wait until 2014 before unions could stop forcing them to pay fees to take care of their loved ones. In a landmark case, Harris v. Quinn, the U.S. Supreme Court said unions could not force Pamela Harris — an Illinois mom caring for her son Joshua, who needed constant care for developmental disabilities — to pay union fees.

But that same year, HHS under President Obama adopted a federal rule to explicitly allow Medicaid funds to be diverted to unions. While providers did not need to pay, unions could still trap them into paying. By 2017, the Freedom Foundation estimated that unions were skimming an estimated $150 million each year, affecting 358,000 caregivers’ Medicaid funds.

The reason was that, after Harris v. Quinn, at least 11 states allowed dues skimming and unions were able to make providers pay dues by establishing arbitrary opt-out windows that limited when caregivers could leave and stop paying union fees. Cindy Ochoa, who was taking care of her disabled son, Adam, even experienced the union’s forgery of dues authorization signatures to keep the payments flowing.

Then, in 2019, the Trump administration reversed the rule, prohibiting unions from taking Medicaid payments from providers. Now, President Biden’s commitment to being the “most pro-union president ever” is coming to fruition: the new rule from HHS once again gives federal blessing to dues skimming.  

A debate exists over whether states or the federal government have the authority to issue policies pertaining to these Medicaid reimbursements. While Medicaid dollars are funded in part by the federal government, state governments allocate the money. Some states, such as Michigan, have banned dues skimming, but Biden’s decision means that caregivers in many states without such statutory protections may be forced to pay union fees.  

The nature of home care means that unions don’t represent these caregivers in the traditional workplace or in negotiations with an “employer.” A parent is not going to file a complaint against his or her sick child. Neither is a union going to negotiate benefits when the supposed “employer” is a sick or disabled relative.

Yet, the Biden administration’s HHS rule and the 9th Circuit decision are prioritizing the dues skim over the best interests and financial needs of caregivers and our nation’s most vulnerable patients.

As Michigan has done, states must act now and not wait for the federal government or the courts to rule justly. State policymakers owe it to caregivers like Robert and Patricia Haynes, Pamela Harris, and Cindy Ochoa to pass laws prohibiting the dues skim from Medicaid payments, ensuring that these caregivers have maximum support and flexibility to provide for those they love.

Lindsay B. Killen is vice president for strategy and communications at the Mackinac Center for Public Policy, a research and educational institute in Midland, Mich. Follow her on Twitter @LindsayBKillen.

F. Vincent Vernuccio is a senior fellow with Mackinac Center’s Workers for Opportunity project and president of the Institute for the American Worker. Follow him on Twitter @vinnievernuccio.

 
 

Clipped from: https://thehill.com/opinion/finance/3535007-states-should-protect-caregivers-medicaid-funds-from-union-skims/

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NC- House passes Medicaid expansion study bill

MM Curator summary

[MM Curator Summary]: NC legislators commissioned the Medicaid agency to work with CMS to negotiate a Medicaid expansion with work requirements. Whelp.

 
 

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 N.C. House passed a bill Tuesday evening 101-6 that would direct the state’s health agency to come up with a Medicaid Modernization Plan. The bill lays out the fiscal requirements that members would require in order to vote to expand Medicaid to an estimated 600,000 new enrollees.

Those policies outlined in the Rural Healthcare Access and Savings Plan Act
(Senate Bill 408) include work requirements for enrollees, $1 billion earmarked for behavioral health and substance abuse, expansion of health care to rural areas, and a requirement that the state withdraw from Medicaid expansion if the federal government reverses its promise of covering 90% of the costs.

 “I feel confident that this plan has been set up in a way, with fiscal accountability and responsibility in place, if the secretary can meet that,” said Speaker Tim Moore, R-Cleveland, on the House floor Tuesday evening. “I’m certainly going to support it and encourage my colleagues to support it, because it’s the right path forward, with these guardrails in place.”

Six months to strike a deal

The bill authorizes Department of Health and Human Services Secretary Kody Kinsley to work with the federal Centers for Medicare and Medicaid Services (CMS) to come up with a plan specific to North Carolina and gives him until Dec. 15 to present it to lawmakers. A vote would then be held on that plan.

Democrats in the chamber Tuesday expressed concern that the bill’s plan requirements would be difficult to meet, asking the speaker if House leaders have designed to set it up for failure.

“Are these criteria such that they are almost impossible to meet?” asked Rep. William Richardson, D-Cumberland.

Moore assured him that Kinsley has agreed to the terms of the bill and believes they can be met.

“If I wanted this bill to fail, the easiest thing to do is to say we aren’t going to take it up, but that’s a lot of trouble to go through and a lot of hours spent for this to ultimately fail,” said Moore. “The beauty of this, though, is that instead of us giving that blank check out, we actually have the final say once the product comes back here. I believe these benchmarks will be met.”

 
 

House Minority Leader Robert Reives, D-Chatham (Image from YouTube)

House Minority Leader Rep Robert Reives, D-Chatham, encouraged Democrats to vote for the bill.

“I’m going to support this because I’d like to keep the conversation moving forward,” said Reives.

“The people who are being left out right now are people who are working. They are working, they are trying, and they are in a terrible gap,” he added. “If there is a human being out there who will say, ‘Hey, I got Medicaid insurance, now I’m going to quit my job,’ I’d like that person to come by my office because that would mean you would be homeless, you wouldn’t have any food. If you are homeless and you go without eating or drinking, the health insurance can’t save you.”

During the break between official legislative sessions, a study committee of members, chaired by Rep, Donny Lambeth, R-Forsyth, examined Medicaid expansion, talking to health care groups and officials from other states that have expanded the federal entitlement program. However, the committee’s report was never completed before the state Senate passed an outright Medicaid expansion bill in May.

Senate members have been pressing the House to take their bill up, but House leadership said they wanted a clearer view of the costs and to have their requirements met before they would agree. The House bill gives N.C. DHHS six months to hammer out the details to get a vote.

“If the secretary did bring back something that did not meet the criteria, there would probably be a lot of folks on this side who would vote no, and I don’t know if it would pass,” said Moore.

Some House Democrats wanted the body to take up the Senate’s bill, too, before adjourning. Gov. Roy Cooper has also called for Medicaid expansion since taking office in 2017.

“It’s no secret that the governor didn’t like the fact that there would be votes in December,” said Moore. “I made it very clear to the governor that if there was not a second vote in December on this bill, it would go nowhere in the House. So it was either this way or no way, just to be candid.”

In other states that have expanded Medicaid under the Affordable Care Act, experts generally underestimated the size of Medicaid expansion enrollments, underestimated its cost, and overestimated its health benefits.

What is in the bill

The bill lays out some additional requirements of NCDHHS’ proposed expansion plan including that, “Individuals who are not United States citizens shall not be covered except to the extent required by federal law.” DHHS is also required to establish a system of reporting back on enrollment numbers, whether enrollees are using preventive care, and how it is impacting health outcomes. 

Work requirement waivers to allow states to put work/volunteer requirements or a small co-pay into expansion plans were offered by the Obama administration to encourage states to expand the program back when the Affordable Care Act passed. Under the Trump administration, states that expanded Medicaid had their work waivers approved, but the Biden administration has put a stop to them. Kinsley will now be required to negotiate with CMS to pass them.

The House bill also requires that $1 billion be spent on opioid, substance abuse, and mental health crisis in North Carolina, “using savings from the additional federal Medicaid match available under the American Rescue Plan Act.” ARPA is the $1.9 trillion plan passed by Congress in 2021 that economists are blaming for the nation’s historic inflation rate.  

Under the House legislation, a DHHS-created task force of leaders in the faith community, law enforcement professionals, mental health experts, and addiction specialists would be required to guide the $1 billion in spending on drug and mental health issues.

The plan also has specific proposals to increase access to health care and preserve hospitals in rural areas of the state. Lambeth said North Carolina ranks 43rd out of 50 states for access to health care and that 11 rural hospitals have closed since 2005, with 19 currently at risk of shutting down.

“Members, we have universal care in this state and in this country. It’s called the emergency room,” said RIchardson Tuesday evening on the floor.

“The is a great step forward,” he added. “I urge you to vote for it, and in December I urge you to vote to put North Carolina as part of this plan so that our people can get adequate health care, so they can work and not live in the emergency room.”

What is NOT in the bill

The directives for DHHS in the House bill do not include some of the industry reform measures that the Senate offered in its bill, including the SAVE Act, which would address needs in rural areas and giving nurses more independence, and partial repeal of some certificate-of-need requirements.

Rep. Gale Adcock, D-Wake, a registered nurse, stood on the floor to object to the omission of the SAVE Act (House Bill 277) in the House Medicaid bill. It would allow nurses to work up to the level of their training, even if a doctor was not immediately available.  It is intended to address labor shortages in rural hospitals.

“I know that at least half the members of this chamber signed on as co-sponsors of the SAVE Act,” she said. “The SAVE Act does really important things for this state economically.”

Adcock announced on the House floor that she wanted to file a discharge petition to get the SAVE Act heard before lawmakers leave Raleigh.

Ultimately only six members of the House voted against the bill, with 101 voting in favor. It now goes to the Senate for approval.

“I believe that this will be successful, that we will have a product back that we can all be very proud of when we vote on this in December,” stressed Moore.

The legislature is driving to wrap up business and adjourn the short session by Saturday afternoon, July 2.

 
 

Clipped from: https://www.carolinajournal.com/house-passes-medicaid-expansion-study-bill/

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Tuscaloosa Mayor Walt Maddox: Expand Medicaid for Alabama in wake of Roe v. Wade decision

MM Curator summary

[MM Curator Summary]: Maddox says Medicaid expansion is needed now more than ever in order to help pay for all the new births that will happen after the Dobbs v Jackson decision.

 
 

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.

 
 

 
 

Walt Maddox concedes defeat to Gov. Kay Ivey in the Alabama Governor’s race Tuesday, Nov. 6, 2018.

Tuscaloosa Mayor Walt Maddox took to Twitter this weekend in the wake of the U.S. Supreme Court’s overturning of abortion rights to say now is the time for Alabama to expand Medicaid coverage to address pre-natal care and the state’s poor infant mortality rates.

“With yesterday’s decision by #SCOTUS reversing #RoeVsWade, #Alabama‘s 3rd World ratings in pre-natal care and infant mortality MUST be addressed by #MedicaidExpanaion,” Maddox stated in a tweet on Saturday.

Medicaid expansion, he said in a follow-up tweet, “would make quantum leaps for Alabama’s ability to ensure healthy pregnancies and births. The time must be now.”

Medicaid is a joint federal and state program that, together with the Children’s Health Insurance Program (CHIP), provides health coverage to children, pregnant women, parents, seniors, and individuals with disabilities, according to the Medicaid.gov website. About 1 million people in Alabama are covered by one or more of Medicaid’s programs.

Expanding Medicaid was one of the priorities Maddox had during his 2018 run for governor in Alabama. He won the Democratic nomination but lost to Republican Gov. Kay Ivey in the General Election that year. Maddox is currently serving in his fifth term as Tuscaloosa’s mayor.

“Spent 18 months crisscrossing this state warning this day was coming and the consequences would be far reaching and more complicated than the talking points. Now, that states are in control, #Medicaid Expansion is the best chance in the next 24 to 48 months. #pragmatic,” Maddox stated in another tweet.

Ivey and other Republican leaders have repeatedly said that while ensuring every Alabamian has access to quality health care is important, the problem is how to pay for it. Alabama is one of about a dozen states that have declined to expand Medicaid with the federal government paying most of the cost as allowed under the Affordable Care Act.

This spring the Alabama Legislature provided $4 million in the 2022-23 budget to extend Medicaid coverage for pregnant patients for a year after giving birth under the state’s new budget. The coverage had ended after 60 days. The extension, however, could be temporary because legislators gave the Medicaid Agency the task of reviewing costs, use of the services, and health outcomes to determine if it will continue.

With yesterday’s decision by #SCOTUS reversing #RoeVsWade, #Alabama‘s 3rd World ratings in pre-natal care and infant mortality MUST be addressed by #MedicaidExpanaion (1/2)

— Walt Maddox (@WaltMaddox) June 25, 2022

 
 

 
 

Clipped from: https://www.al.com/news/2022/06/tuscaloosa-mayor-walt-maddox-expand-medicaid-for-alabama-in-wake-of-roe-v-wade-decision.html

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PA- Wolf pushes $91 million for nursing homes to offset costs of proposed new staffing regulations, but industry says it’s not enough

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[MM Curator Summary]: Long term care providers are sounding the alarm about funding needed to meet new requirements- They say they need $434M more each year; the Good Guvn’r has offered $91M.

 
 

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.

 
 

 
 

Spotlight PA is an independent, nonpartisan newsroom powered by The Philadelphia Inquirer in partnership with PennLive/The Patriot-News, TribLIVE/Pittsburgh Tribune-Review, and WITF Public Media. Sign up for our free newsletters.

HARRISBURG — Gov. Tom Wolf is asking the Pennsylvania legislature to spend millions to raise a key reimbursement rate for skilled nursing homes in the state to help offset costs from proposed new regulations that would increase daily required care.

With the state’s June 30 budget deadline quickly approaching, the Democrat wants to appropriate $91.25 million to increase the amount of money skilled nursing homes receive for residents on Medicaid.

Roughly 11,000 long-term care residents in Pennsylvania have died since the start of the COVID-19 pandemic, a toll that brought renewed attention to longstanding issues such as dangerously low staffing requirements and outdated regulations.

Groups including the Pennsylvania Health Care Association, which lobbies on behalf of long-term care providers in the state, say the state’s low Medicaid reimbursement rate is a major roadblock to providing higher levels of care. The current rate, they say, can leave nursing home facilities without funding to raise employee wages or buy supplies for patient care.

The association estimates that Wolf’s investment would raise the daily Medicaid reimbursement rate to about $210 per resident on average from the current $199.96 average rate. Neighboring states such as Ohio, Maryland, and New Jersey, have higher rates.

But while PHCA sees Wolf’s proposal as a welcome first step, the organization argues it’s not nearly enough. The trade group estimates the regulatory changes would require hiring 10,000 additional workers and spending $434 million more annually. That has led some to reject the plan as an unfunded mandate.

According to the Pennsylvania Department of Health, there are 683 nursing homes in the state serving about 80,000 total residents. That number is expected to rise in the coming years as the state’s population over the age of 65 grows. According to PHCA, about 66% of residents living in nursing homes across the state have their stay paid for by Medicaid. Medicare accounts for an additional 13%.

There does appear to be agreement among legislators that more investment is needed, but how to do so is still being debated. If funding for nursing homes remains as is, advocacy networks, experts, and nurses on the ground fear facilities may be ill-equipped to support the aging population.

“We’ve come to a place where we either need to make an investment in long-term care in this year’s state budget, or the entire system could collapse,” said Zach Shamberg, president and CEO of Pennsylvania Health Care Association. “That would be disastrous for our older population.”

Why do reimbursements matter?

With the way that Medicaid and Medicare funds are distributed, many nursing home facilities seek to take in Medicare-funded patients rather than Medicaid-funded ones.

“We’ve decided in this country not to cover long-stay nursing home care under Medicare,” said David Grabowski, a professor of health care policy at Harvard Medical School. “So it’s really the one major piece of services that are pushed today over to Medicaid.”

Medicare is a federal insurance program that typically covers short-stay patients, such as patients in physical therapy or post-surgery care.

Medicaid is a state-run assistance program that — following guidelines from the federal government — supports low-income people and typically covers long-stay patients. The reimbursement rate is what each nursing home is paid on behalf of the qualified patient by the state government.

According to Grabowski, the low Medicaid reimbursement in Pennsylvania encourages nursing homes to seek out Medicare patients planning on short stays rather than accepting Medicaid patients who will require long stays.

This dynamic, he continued, makes the federal government “a very generous payer,” and that windfall allows care facilities to typically hit double-digit margins on short-stay patients. Meanwhile, Medicaid patients usually result in negative margins for facilities, he said, causing a gap between the cost of care for residents and the amount of state funding.

According to a February study conducted for LeadingAge PA, a trade association that represents about 380 providers in the state who serve older adults, the daily gap between what nursing homes received for Medicaid residents versus what they spent was $86.26 per resident on average.

Grabowski said increasing the Medicaid reimbursement rate could relieve some of the problems. Lobbyists and advocates for the industry in Pennsylvania are asking for a $294 million investment, rather than Wolf’s proposed $91.25 million.

Grabowski argues any investment in the industry should also involve some form of accountability to make sure the funds improve the quality and are not misused.

“I do think we’re going to have to rethink what it means to both live and work at a nursing home,” Grabowski said. “Because the current economic model is definitely broken.”

More money, more oversight

Wolf’s $91.25 million pitch comes with proposed regulations that would require nursing homes to provide more hours of direct care to residents.

Spokespersons for state House and Senate Republicans confirmed the caucuses will consider the proposal and continue to make investments in nursing homes, but did not provide details.

In 2020, Spotlight PA reported on long-criticized staffing and training regulations that were exposed by the pandemic. Shamberg said that PHCA has found that, on top of rising costs nationwide, nursing homes face these same issues today.

Since the start of the pandemic, the state has earmarked nearly $500 million to nursing homes through Acts 24 of 2020 and 2021. These funds were intended to help ease the burden of additional COVID-19-related costs. But as one-time infusions, PHCA said the money did not address the Medicaid reimbursement rate gap, and therefore did not increase staffing.

Karen Hipple, a licensed practical nurse at Oil City Healthcare and Rehabilitation Center in Venango County, said staffing ratios are too high — with one certified nursing assistant caring for 20 to 30 patients, in facilities she’s worked in and visited. She said that staffing increases need to be the top priority, which requires more funding.

Hipple blames the shortage on the low wages that many workers face in nursing homes. According to data from the U.S. Bureau of Labor Statistics, the average pay for a nurse assistant is $16.44 an hour.

WHILE YOU’RE HERE… If you learned something from this story, pay it forward and become a member of Spotlight PA so someone else can in the future at spotlightpa.org/donate. Spotlight PA is funded by foundations
and readers like you who are committed to accountability journalism that gets results.

 
 

 
 

Clipped from: https://www.spotlightpa.org/news/2022/06/pa-nursing-home-staffing-proposal-91-million-wolf/

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Vermont Medicaid Section 1115 Demonstration Extended Until 2027

MM Curator summary

[MM Curator Summary]: The renewal adds several new items, including a housing initiative, a data incentive program for BH and LTSS, focused substance-use disorder (SUD) treatment services for pregnant mothers, and an entirely new eligibility category based on SUD needs.

 
 

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

 
 

 
 

The Centers for Medicare and Medicaid Services (CMS) has approved an extension of Vermont’s Medicaid section 1115 demonstration, “Global Commitment to Health” through 2027. The extension will enable the state to continue to test, monitor, and evaluate a managed care-like delivery system, home and community-based services, and novel pilot programs, as well as pursue innovations to maintain high-quality services and programs that are cost-effective.

Overall, the demonstration extension will continue to promote health equity by expanding coverage and access to services.

Over the last 15 years, the Global Commitment to Health demonstration has been Vermont’s principal vehicle for major expansions of health coverage — building an extensive ecosystem for public health and health-related services, driving payer reform, and rebalancing long-term services and supports. As a result of these efforts, Vermont has nearly universal health coverage and one of the healthiest populations in the nation. Under the Global Commitment to Health demonstration, Vermont serves nearly 60 percent of enrollees eligible for nursing facility care in a home or community-based setting.

The extension approval allows Vermont to continue to fund a range of initiatives, from reducing the rate of uninsured and underinsured individuals to lowering healthcare costs, increasing access to quality health care, improving public health, investing in social determinants of health, and advancing home and community-based services and supports.

In this demonstration extension, Vermont is introducing new initiatives aimed at improving health coverage, access, and equity for people with Medicaid and other low-income individuals. Notable new initiatives include:

  • The Supportive Housing Assistance Pilot, which will provide individuals with support services in order to secure and maintain housing for their needs.
  • The Medicaid Data Aggregation and Access Program, a new incentive-based program to increase health information technology use and health information exchange connectivity by behavioral health and long-term services and supports providers.
  • The Maternal Health and Treatment Services initiative, which will provide a whole-person and family-centered care model for treating pregnant women and mothers with substance use disorder (SUD) and/or a mental health condition at the Lund Home facility. The Lund Home provides mental health and SUD treatment to pregnant women, postpartum women, and mothers with children up to age five in a setting that allows the family to stay and be treated together.
  • Establishing the SUD Community Intervention and Treatment eligibility group to increase access to SUD treatment services, such as counseling and residential treatment, for low- and moderate-income individuals with a SUD.

“I’m proud to approve this demonstration extension, which will expand access to behavioral health care, home and community-based services for seniors and people with disabilities, and whole-person care focused on treating substance use disorders and mental health needs during pregnancy,” said CMS Administrator Chiquita Brooks-LaSure, in a statement. “Vermont is also strengthening its data collection system, which will give us better information about the impact of the state’s demonstration and could inform future policymaking.”

 
 

Clipped from: https://www.hcinnovationgroup.com/policy-value-based-care/medicare-medicaid/news/21272596/vermont-medicaid-section-1115-demonstration-extended-until-2027
 

 
 

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Fraud- Three More Defendants Sentenced for Their Roles in Wide-Ranging Medicaid Fraud Conspiracy

MM Curator summary

[MM Curator Summary]: The $400k+ fraud involved multiple companies and members taking money for use of their IDs to steal from PA Medicaid.

 
 

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.

 
 

PITTSBURGH, Pa. – Two residents of Pittsburgh and a resident of Georgia were sentenced in federal court for conspiracy to defraud the Pennsylvania Medicaid program and related offenses, United States Attorney Cindy K. Chung announced today.

During sentencing hearings on June 28 and June 29, 2022, United States District Judge Cathy Bissoon sentenced Tiffhany Covington, 45, of Pittsburgh, to fifteen months’ imprisonment; Luis Columbie-Abrew, 36, of East Point, Georgia, to three years’ probation, including twelve months of home confinement; and Julie Wilson, 51, of Pittsburgh, to three years’ probation, including six months of home confinement. Covington, Columbie-Abrew, and Wilson were also ordered to pay restitution to the Pennsylvania Medicaid program totaling $245,376.26, $164,799.48, and $2,083.36, respectively. All three defendants previously pleaded guilty to conspiracy to commit health care fraud. Columbie-Abrew and Wilson also pleaded guilty to health care fraud, with Columbie-Abrew pleading guilty to an additional charge of aggravated identity theft.

During their plea hearings, each defendant admitted that they were employees of one or more of four related entities operating in the home health care industry—Moriarty Consultants, Inc. (MCI), Activity Daily Living Services, Inc. (ADL), Coordination Care, Inc. (CCI), and Everyday People Staffing, Inc. (EPS). MCI, ADL, and CCI were approved under the Pennsylvania Medicaid program to offer certain services to qualifying Medicaid recipients (“consumers”), including personal assistance services (PAS), service coordination, and non-medical transportation, among other services. Between 2011 and 2017, the defendants admitted that they participated in a wide-ranging conspiracy to defraud the Pennsylvania Medicaid program for the purpose of obtaining millions of dollars in illegal Medicaid payments through the submission of fraudulent claims for services that were never provided to the consumers identified on the claims or for which there was insufficient or fabricated documentation to support the claims. The Court was further advised that the defendants conspired with, among others, Arlinda Moriarty, the owner of MCI, ADL, and EPS; Daynelle Dickens, the owner of CCI and Arlinda Moriarty’s sister; various office workers at the companies, including Tamika Adams, Tony Brown, Terra Dean, Larita Walls, Keith Scoggins, and Tia Collins; and caregivers (“attendants”) at MCI, including Tionne Street and Autumn Brown. To date, each of these co-conspirators have also pleaded guilty for their roles in the conspiracy.

As part of the conspiracy, the defendants each admitted that co-conspirators fabricated timesheets to reflect the provision of in-home PAS care they provided to consumers but that, in fact, never occurred. In addition, certain co-conspirators, including Covington and Columbie-Abrew, stopped using their own names as the attendant on timesheets and instead used the names of “ghost” attendants, some of whom permitted their names to be used in exchange for a kickback of resulting fraudulent salary payments. The defendants also admitted that certain co-conspirators submitted false timesheets for PAS care they never provided during times when they were actually working at other jobs or living out of the area. In some cases, as the defendants acknowledged, Medicaid claims were submitted for PAS care that purportedly occurred while consumers were hospitalized, incarcerated, or deceased, and in other instances, co-conspirators paid kickbacks to consumers in exchange for the consumers’ agreement to participate in the submission of fraudulent timesheets in support of Medicaid claims. Indeed, Columbie-Abrew specifically admitted causing the submission of hundreds of thousands of dollars of Medicaid claims for purported care of consumers who lived in the Pittsburgh area, despite the fact that he—as the purported attendant—lived several states away in Georgia.

The defendants also admitted that Arlinda Moriarty directed co-conspirators, including Covington, to bill the maximum allowable PAS and service coordination hours for consumers to maximize profits and to ensure that the state did not require MCI, ADL, and CCI to forfeit underutilized consumer hours. To that end, Wilson acknowledged that, at Moriarty’s behest, she collected information about consumers who had “unused” PAS care hours—that is, hours of authorized PAS care that had not been performed and, as a result, had not been billed to Pennsylvania Medicaid. In response, Wilson would provide lists of such consumers and their “unused” hours to Moriarty and Dickens. Moriarty, in turn, would direct Wilson to submit false claims, in bulk, for some or all of the “unused” hours—without the relevant consumers’ knowledge or consent. Wilson further admitted that she would then send Moriarty a list of the “unused” hours Wilson had billed and that required the creation of back-dated timesheets to document the purported care. Rampant document fabrication also occurred during the course of state audits of the Moriarty-related entities.

Assistant United States Attorney Eric G. Olshan and Special Assistant United States Attorney Edward Song are prosecuting this case on behalf of the government. The Federal Bureau of
Investigation, Pennsylvania Office of the Attorney General – Medicaid Fraud Control Unit, Internal Revenue Service – Criminal Investigation, U.S. Department of Health and Human Services – Office of Inspector General, and United States Postal Inspection Service conducted the investigation of the defendants.

 
 

Clipped from: https://www.justice.gov/usao-wdpa/pr/three-more-defendants-sentenced-their-roles-wide-ranging-medicaid-fraud-conspiracy

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Arizona Medicaid Director Points to Success of Supportive Housing

MM Curator summary

[MM Curator Summary]: The state has leveraged supportive housing to reduce ED usage by 31% and hospital admits by 44%.

 
 

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.

 
 

 
 

Jami Snyder, who oversees Arizona’s Medicaid and CHIP program, says the state has seen improved health outcomes among patients who have received supportive housing funding from the state. In its 1115 Medicaid waiver renewal request to CMS, Arizona is asking for federal matching funds to extend that type of housing support.

On June 28 Snyder sat down with the National Committee for Quality Insurance President Margaret (Peggy) O’Kane to discuss Arizona’s recent strategic direction and quality improvement initiatives. She oversees an agency that provides acute, behavioral health, and long-term care services and supports to more than 2.3 million Arizona residents at an annual cost of $18 billion.

Snyder said the data on the impact of supportive housing is impressive. Over the last 11 years, the state Medicaid program in Arizona has received about $27 million in funding annually to provide rental subsidies to members. They are able to serve approximately 2,500 individuals each year with those rental subsidies.

“What we know from our data is that it’s really two things: It’s housing paired with Medicaid compensable wraparound supports — that’s what will ensure that an individual is able to stabilize,” she said. “We have some really good data on hand to demonstrate how we can move the needle on health outcomes when we stabilize someone in housing for six months or more. Our 2020 data demonstrated that for those that we house for six months or more with permanent supportive housing — rental subsidies paired with wraparound supports — we saw a 31 percent reduction in ED utilization, a 44 percent reduction in inpatient admits and a savings of over $5,500 per member per month.”

She said they talked with CMS about funding transitional housing through the 1115 waiver. “The data shows us that we can be more impactful when we house someone long term than we can with perhaps any other clinical intervention,” she adds, “so there’s a very compelling case to be made from my perspective. We are asking them essentially to match that state contribution of $27 million, with a standard federal match rate each year to extend certain supports that we’ve traditionally only offered to our long-term care population, like home modifications. We know that there are a lot of individuals outside of our long-term care population who need basic home modifications, in order to be successful in an independent living setting. We also want to be able to reimburse for services when an individual is preparing to leave a correctional setting. We want to be able to reimburse for those care coordination and case management services, so we can get individuals connected to care quickly when they leave that correctional environment through a variety of providers, including our justice clinic sites.”

Snyder said Arizona also wants to be able to reimburse for outreach and engagement services that it can’t currently in order to engage with homeless populations or individuals who are at risk of homelessness — just letting them know what benefits are available to them through the Medicaid program. “Finally, our big ask in the housing arena with our CMS waiver renewal is to be able to fund up to 18 months of transitional housing for individuals who are homeless or at risk of homelessness, and leaving some sort of institutional placement, whether that’s a correctional setting, a nursing facility, and extended inpatient stay,” she said. “We have a number of providers in the State of Arizona who have successfully implemented transitional housing models with blended funding from municipalities, from counties, from philanthropic sources, but we’d like to be able to provide more stable funding Medicaid funding to those entities that are committed to this work, because we know that individuals are much more likely to be successful long term, if we can stabilize them clinically in a transitional setting, before we transition on to permanent supportive housing.”

In another new development, Snyder said the state will begin providing incentives for community-based organizations to participate in its Community Cares closed-loop referral system operated by the state health information exchange. “The community-based organizations in Arizona don’t really want to become Medicaid providers,” she said. “They’re not interested in billing, like traditional providers do, but they do want to partner with us in ensuring the individuals that we serve are connected to community-based supports. So the incentives that the Department of Health Services is able to offer to CBOs —  I think those are going to be really critical to ensuring that we have that partnership among those community-based organizations, in addition to the Medicaid-enrolled providers that we support in our delivery system.”

Another request in the 1115 waiver renewal that’s in front of CMS now is to reimburse for traditional healing. “We’ve been working on this for years, as have California and Nevada,” Snyder said. “We know that traditional healing is present within our Tribal Nations now, but we want the ability to be able to reimburse for those services with Medicaid dollars.”

Clipped from: https://www.hcinnovationgroup.com/policy-value-based-care/medicare-medicaid/article/21272735/arizona-medicaid-director-points-to-success-of-supportive-housing