Tag: State News

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GA- Georgia Senate approves Medicaid expansion for new mothers

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[MM Curator Summary]: GA joins the list of states seeking maternity funding from ARPA.

 
 

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.

 
 

ATLANTA – New mothers in Georgia could receive health coverage through Medicaid for up to a year after giving birth, up from the current six months, under legislation that cleared the state Senate unanimously.

Gov. Brian Kemp backs the measure and included $28.2 million in his fiscal 2023 budget proposal to pay for it.

Expanding Medicaid coverage for new mothers was the top recommendation of a task force formed to examine the issue, Sen. Dean Burke, R-Bainbridge, the bill’s chief sponsor, told senators before Monday’s vote.

As the opioid crisis continues to ravage the U.S. in greater numbers, drug treatment facilities are having to keep up with the demand. Based on data from the Click for more.

State Sen. Nan Orrock noted that Georgia consistently has been among the states with the highest rate of maternal mortality. Low-income mothers used to receive Medicaid coverage for only two months postpartum in Georgia, which was increased to six months two years ago.

“This is a great leap forward,” Orrock said.

Senate Minority Leader Gloria Butler urged her colleagues to move beyond expanding coverage for new mothers to a full-blown expansion of Medicaid.

“We need to stop nibbling around the corners of this problem,” said Butler, D-Stone Mountain. “Senate Bill 338 will save lives. We can do more and save thousands more lives.”

Kemp and legislative Republican leaders oppose a full expansion of Medicaid as too expensive.

The bill now heads to the Georgia House of Representatives.

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

 
 

 
 

Clipped from: https://www.news-daily.com/local/health/georgia-senate-approves-medicaid-expansion-for-new-mothers/article_e7dc65eb-7532-5884-a1f4-59c39e94923f.html

 
 

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MO- Missouri looks at changing Medicaid funding

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[MM Curator Summary]: Legislators concerned over the budget impact of Medicaid expansion move to create the ability to fund the expansion year by year.

 
 

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.

 
 

Missouri looks at changing Medicaid funding

JEFFERSON CITY, Mo. – A House committee on Monday approved a proposed constitutional amendment that would change how Medicaid is funded in Missouri.

The Republican-backed proposed amendment comes after 53% of Missouri voters approved a constitutional amendment in 2020 to expand Medicaid funding, after the GOP-led Legislature for years refused to do so.

And a Missouri Supreme Court ruling last July forced the Legislature to fund the expansion, making thousands more state residents eligible.

On Monday, a House budget panel advanced the proposed amendment to the full house, the St. Louis Post-Dispatch reported.

If approved, the proposed constitutional change would give the Legislature the power to make annual appropriations for Medicaid, meaning lawmakers could choose not to fund the expansion.

House Budget Committee Chairman Rep. Cody Smith, R-Carthage, said the amendment would not necessarily mean all expansion costs would be cut. He argued it would allow lawmakers more flexibility to manage Medicaid spending.

Democrats said the proposal is another effort by Republicans to hurt poor people who need health coverage.

The proposal also includes a requirement for Medicaid recipients to work or perform community engagement.

 
 

Clipped from: https://journalrecord.com/2022/02/08/missouri-looks-at-changing-medicaid-funding/

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AR- State regulators give OK to Medicaid managed care company once dogged by investigations

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[MM Curator Summary]: Empower is back in the good graces of the state and now has new private equity backing to help keep solvent.

 
 

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

 
 

Two months ago, things were looking dire for Empower Healthcare Solutions, a managed care organization that serves roughly 20,000 Arkansas Medicaid beneficiaries with developmental disabilities, severe behavioral health disorders and other complex needs.

The attorney general’s office was investigating the company for suspected Medicaid fraud. The state Department of Human Services, which oversees Medicaid in Arkansas, suspended new enrollments to Empower in November due to alleged “misrepresentations” to DHS. And Empower was undergoing an acrimonious corporate divorce with one of its co-owners, Beacon Health Options, which Empower’s lawyers said was trying to “sabotage” Empower on its way out the door.

Now, Empower looks to be in the clear with state regulators – and has found a new financial backer in the form of a Dallas private equity firm.

On Monday, DHS notified Empower CEO Mitch Morris that the company had officially passed a months-long “readiness review” process. DHS officials initiated the review last year out of concern that Empower might not have been prepared to continue serving its members in the wake of its separation from Beacon, one of the nation’s largest behavioral health companies.

In addition to owning a 16.67 percent share of Empower, Beacon played a critical role in its day-to-day operations and provided key administrative services.

An independent consultant who reviewed Empower’s operational capacity in November on behalf of DHS found “significant concerns” about Empower’s transition away from Beacon. “The number and seriousness [of] issues identified without doubt draw into question Empower’s current readiness to carry out required … functions,” he wrote in a Nov. 30 letter to DHS.

However, that consultant ultimately recommended DHS allow Empower to keep operating in 2022, on a conditional basis, while it continued to monitor the company. With the readiness review now complete, Empower is able to resume enrolling Medicaid beneficiaries – and thus bring in more revenue.

Empower is the largest of four so-called Provider-led Arkansas Shared Savings Entities (PASSEs), organizations that contract with DHS to pay for and coordinate care for high-need, high-cost Medicaid beneficiaries. PASSEs must be majority owned by health care providers, but their role is similar to that of insurance companies. Each PASSE receives a fixed monthly sum from DHS for each of its members – the equivalent of a premium. The PASSE is then responsible for paying for care for all its members, which can include costly services like inpatient psychiatric treatment or around-the-clock help for people with disabilities. In 2020, Medicaid paid out almost $1.3 billion to PASSEs for the roughly 50,000 beneficiaries in the system, according to documents provided to a legislative committee in June. About 20,000 of those are Empower members.

“We are happy to achieve full and final approval and look forward to continued collaboration with DHS,” Morris said in an emailed response to questions. He said Empower was “fully staffed and strongly positioned for continued operations.”

The letter DHS sent to Morris says the agency “will continue to monitor Empower and will hold regular meetings with Empower for enhanced monitoring.”

Empower is also free of the Medicaid fraud investigation. On Jan. 4, the attorney general’s office announced it had reached an almost $8 million civil settlement with Empower, which denies wrongdoing.

Morris said the company’s issues with the attorney general’s office “have been fully resolved.”

On Friday, Empower also completed a deal with a new co-owner: Trive Capital, a Dallas-based private equity firm. After gaining approval from the Arkansas Insurance Department – which regulates PASSEs to ensure they are financially solvent – Trive acquired the 16.67 percent share of Empower left behind by Beacon. The separation of Beacon and Empower was completed on Dec. 31, Morris said.

At an Insurance Department hearing Friday afternoon, Tanner Cope, a managing director at Trive, said the two sides had expected to close the deal by the end of the year but were delayed by the attorney general investigation and the DHS readiness review.

Morris said Trive and Empower began discussing the acquisition last summer. He declined to answer a question about the terms of the deal or the amount Trive was initially investing in the Arkansas company.

Asked whether Empower families should be concerned that a private equity firm had acquired a portion of their PASSE, Morris said no. “Empower’s #1 priority is always to provide industry-leading services and support to our members and their families. With these changes, Empower is better positioned to do so,” he wrote.

Trive did not respond to calls or emails on Friday seeking comment.

Trive will join the five Arkansas-based health care organizations that now co-own Empower: Arkansas Community Health Network, a consortium of hospital systems; Statera, a long-term care company; Independent Case Management, a provider of home and community-based services for people with developmental disabilities; The Arkansas Healthcare Alliance, a group of providers for behavioral health and developmental disability services; and, ARcare, a network of clinics and other providers.

 
 

Clipped from: https://www.thecabin.net/news/state-regulators-give-ok-to-medicaid-managed-care-company-once-dogged-by-investigations/article_94481979-1031-5d61-b2d6-e2cf5f6afec9.html

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FL- Five Medicaid changes Florida lawmakers are considering in 2022 – State of Reform

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[MM Curator Summary]: The new FL MCO procurement is set to bring major changes to the current incumbent landscape.

 
 

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.

 
 

Nicole Pasia | Feb 9, 2022 | Florida

A bill currently moving through the Florida House of Representatives will make changes to five major components of the state’s Medicaid program, which covers nearly five million Floridians. House Bill 7047‘s revisions would impact the Statewide Medicaid Managed Care (SMMC) program as the Agency for Health Care Administration (AHCA) conducts its next procurement in 2022-2023.

  
 

Representative Sam Garrison (R – Clay) introduced his bill to the House Health Care Appropriations Subcommittee this week and outlined five key changes it would bring:

1. Reprocurment Process

H.B. 7047 would authorize a statewide SMMC reprocurement, rather than by region. It would also consolidate the number of managed care regions from 11 to eight. The bill would also encourage healthy competition among Medicaid health plans, according to Garrison, by capping plan enrollment to 45% of the total enrollees in a region. According to a staff analysis, six regions had a health plan with more than 45% of the enrollees as of Nov. 30, 2021.

2. Dental Benefits

One of the more disputed parts of the bill was the restoration of dental services under SMMC. From 2014-2018, dental benefits were integrated into the health plans, during which the state saw higher dental service utilization. 

However, in 2016 the legislature directed AHCA to separate dental benefits into a stand-alone managed care program, which occurred from 2018-2019, which led to a halt or regression in dental service utilization, according to the staff analysis. As of October 2021, three dental plans are currently contracted to provide Medicaid dental services. 

3. Network Adequacy

Another section that drew opposition from House Democrats concerns network contracts between regional plans and statewide essential providers, such as hospitals. 

Currently, essential providers must offer to contract with all applicable Medicaid plans, but are not required to enter into the contract in order to receive supplemental payments. AHCA currently acts as the determining body on whether these contracts are made fairly. The bill would require network contracts and remove AHCA’s mediator role.

“[AHCA is] not equipped to do that and it’s not fair to ask them to do that,” he said. “What we’re trying to do with this process is create objective standards for AHCA to look at … You either have the contract or you don’t.”

Representative Nicholas Duran (D – Miami-Dade), put forth the bill’s sole amendment, which would remove the network contract requirement for providers to receive supplemental payments. Duran argued the amendment would “foster true competition” among plans and providers, but the amendment ultimately failed to pass.

4. Healthy Behaviors Program

One provision of the bill expands the Healthy Behaviors program, which supports enrollees’ overall health. Current conditions addressed under this program include tobacco smoking, weight loss, and substance use. The bill would expand tobacco cessation to include non-smokable tobacco products, and would have a focus on opioid abuse recovery.

5. Workforce Development

This part of the bill would expand the type of health education funding that may be included in a plan’s medical loss ratio (MLR), or the amount of premium revenue spent on “clinical services and quality improvement,” according to CMS guidelines. In addition to current expenditures for medical residency positions, the bill would add funding for graduate and undergraduate student nursing education positions and “student positions in any degree or technical program deemed [in] critical shortage by AHCA.” This provision would incentivize plans to invest in workforce development initiatives, according to Garrison.

The bill passed favorably out of the Health Care Appropriations Subcommittee with a 10-5 vote along party lines and now sits in the full House Health and Human Services Committee.

 
 

Clipped from: https://stateofreform.com/news/florida/2022/02/five-medicaid-changes-florida-lawmakers-are-considering-in-2022/

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CA- ‘Somebody is gonna die’: Omicron hobbles California’s new Medicaid prescription system

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[MM Curator Summary]: Magellan is struggling to keep up with requests for prior authorization and call center calls during the pandemic.

 
 

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.

 
 

 
 

(Via Pixabay)

Problems with California’s new Medicaid prescription drug program are preventing thousands of patients from getting their medications, including some life-saving ones. State officials say they’re working on fixes.

A month into its debut, California’s new Medicaid prescription drug program is riddled with problems, leaving thousands of patients without medications — often after languishing on hold for up to eight hours on call center phone lines.

On Jan. 1, the state handed control of its Medicaid drug program, known as Medi-Cal Rx, to Magellan Health, which is administering prescription drug coverage for California’s 14 million Medicaid patients, most of whom previously got their medications from about two dozen managed-care plans.

But Magellan has tripped up implementation. It didn’t anticipate that calls to its help center would take so long, and a large number of its call center workers have been sickened during the Omicron surge — with 100 of 220 absent during the first two weeks of January, state officials said. Magellan also didn’t get some data it needed from managed-care plans.

This has left Californians from Redding to Oceanside without their medications for days, sometimes weeks.

“We’ve had many, many patients who are sort of in this limbo,” said Dr. James Schultz, chief medical officer of Neighborhood Healthcare, which operates 17 clinics in Riverside and San Diego counties.

“Somebody is gonna die if they haven’t already,” added Schultz, who said some of his clinics’ patients have experienced delays getting life-saving medications such as antibiotics or those used to prevent seizures and blood clots. “That’s why we’re fighting so hard.”

Officials from the California Department of Health Care Services, which administers Medi-Cal, California’s Medicaid program for low-income people, called the problems “unacceptable.” The department and Magellan Health are scrambling to find missing patient data, fix improper claim denials, add call center staffers, and provide pharmacists with codes to override prescription denials.

Handing over Medi-Cal’s drug program to a single pharmacy benefit manager is one of Gov. Gavin Newsom’s big health care initiatives. His administration estimates it will save the state $414 million in the 2022-23 budget year alone, in part by getting bigger discounts on drugs than the managed-care insurance plans did.

But the massive transfer has been rocky for many providers, pharmacists, and patients, especially patients who use medications their doctors consider medically necessary but require prior authorizations from Medi-Cal Rx and are generally not on the state’s approved drug list. Magellan has received more than 95,000 prior authorization requests since it took over, state officials said.

In the months leading up to the switch, patients and doctors were told all their medications would be grandfathered into the new system for 180 days, but that hasn’t always been the case.

Marilyn Bloomer of Oceanside had gone nearly a week without a specialty histamine prescription that she takes to regulate an overactive allergic response in her body, a condition known as mast cell activation syndrome, because her pharmacist and Magellan said it was no longer covered. When she finally reached someone at the Magellan call center last week — six hours after she placed the call — a supervisor gave her a code the pharmacist could use to override the denial.

But the pharmacy wouldn’t accept it.

On Monday, Bloomer’s health plan secured an emergency five-day supply for her, but she doesn’t know what will happen when it runs out. Without the medication, called ketotifen, Bloomer gets bright red, patchy hives all over her face.

“I’m getting the runaround, and I’m getting confused,” said Bloomer, 57, who said her face had been beginning to swell. “It’s beyond frustrating.”

State officials said Magellan representatives had answered more than 81,000 calls at the 24-hour, 7-day-a-week call center as of Feb. 1 and paid 11 million prescription claims totaling approximately $1.3 billion as of Feb. 4.

“As we sit here, clearly five weeks into operations, Magellan, our contractor, has really struggled with some service operations,” Jacey Cooper, the state’s Medicaid director, told lawmakers at an Assembly budget subcommittee hearing Monday.

She said that the Department of Health Care Services is holding daily meetings with Magellan to discuss its management of the program and that the state has provided staffers to help answer calls at the Medi-Cal Rx call center. The immediate goal, Cooper added, is to ensure medications that require prior authorization are approved within 24 hours. In the meantime, she said, the state has given pharmacies the go-ahead to fill emergency prescriptions for up to two weeks. It also has removed prior authorization requirements for some medications.

Magellan referred media questions to the Department of Health Care Services.

After the hearing, Assembly member Joaquin Arambula (D-Fresno), who chairs the Assembly budget subcommittee that oversees Medi-Cal, said he is satisfied with the administration’s plan. “I believe there’s a real path forward to implementing the system successfully,” he told KHN.

Sharon Ng, pharmacy director at the Venice Family Clinic, isn’t as optimistic. Even though state officials say they have given pharmacies authorization to use override codes and fill temporary emergency prescriptions, prescriptions continue to be denied.

“It’s just chaos,” Ng said. “We just kept getting rejections. It’s been so frustrating because the rejection doesn’t tell you what’s wrong. And then if you finally go through their lines, they don’t help you either. They’re just guessing.”

What Magellan needs, she added, is a dedicated hotline for pharmacists — like the managed-care plans had — so they don’t have to compete with Medi-Cal patients.

Patients and legal advocates say they are confounded by the chaos because both the state and Magellan had plenty of time to prepare for the rollout, since the program was delayed by nearly a year after the health care company Centene announced plans to acquire Magellan.

Medi-Cal Rx finally launched Jan. 1 after state officials ruled in December that Magellan could independently administer the Medi-Cal drug benefit without any conflict of interest with its new owner.

“Magellan should have come into this understanding fully what the volume and the needs were going to be,” said Jack Dailey, an attorney with the Legal Aid Society of San Diego, which is representing some Medi-Cal enrollees unable to get their medication. “I did not think this is where we would be a month into this process.”

Shah’ada, a mother in Redding, has spent the past two weeks desperately trying to get her 16-year-old son’s birth control medication approved. He is transgender and hadn’t had a period in five years until last week, she said. Without the birth control, he bled for 11 days.

“Things in our household have started dissolving,” said Shah’ada, who asked that her last name not be published to protect her son’s privacy. “He’s been depressed, unable to go to school for several days, really high anxiety. It’s just very emotional and frustrating.”

When Shah’ada tried to fill the prescription, the pharmacist told her that it was denied because of her son’s gender.

She dialed the prescription call center every chance she got. Her managed-care plan suggested there was a glitch in the system but didn’t know how to help since it no longer controls prescription drugs for its members. Her son’s doctor tried to submit more paperwork to no avail, and she submitted a grievance to Medi-Cal Rx.

Over the weekend, she finally got approval for her son’s birth control, but she’s worried about refilling the prescription in three months.

Schultz, the San Diego County physician, said his staff is also directed to the call center to ask questions when patients are denied medications. But the appeal form they are asked to fill out is incomplete, he said, lacking a section for the previous medications a patient has tried, for instance, information Medi-Cal Rx requires for approval.

“We’ve got people out with COVID. We really don’t have time to sit on hold for eight hours. We have dozens of patients in the same boat,” Schultz said. “Theoretically, all of our staff could be tied up on hold with Magellan. We can’t do it.”

 
 

Clipped from: https://lookout.co/santacruz/health-wellness/story/2022-02-09/omicron-hobbles-california-new-medicaid-prescription-system

 
 

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CA- California inks sweetheart deal with Kaiser Permanente, jeopardizing Medicaid reforms

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[MM Curator Summary]: Kaiser Permanente got exempted out of the new CA MCO bidding process and other MCOs are calling foul.

 
 

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.

 
 


SACRAMENTO, California—Gov. Gavin Newsom’s administration has negotiated a secret deal to give Kaiser Permanente (KP) a special Medicaid contract that would allow the healthcare behemoth to expand its reach in California and largely continue selecting the enrollees it wants, which other health plans say leaves them with a disproportionate share of the program’s sickest and costliest patients. 

The deal, hammered out behind closed doors between KP and senior officials in Newsom’s office, could complicate a long-planned and expensive transformation of Medi-Cal, the state’s Medicaid program, which covers roughly 14 million low-income Californians. 

It has infuriated executives of other managed-care insurance plans in Medi-Cal, who say they stand to lose hundreds of thousands of patients and millions of dollars a year. The deal allows KP to limit enrollment primarily to its previous enrollees, except in the case of foster kids and people who are eligible for both Medicare and Medi-Cal.  

“It has caused a massive amount of frenzy,” said Jarrod McNaughton, CEO of the Inland Empire Health Plan, which covers about 1.5 million Medi-Cal enrollees in Riverside and San Bernardino counties. “All of us are doing our best to implement the most transformational Medi-Cal initiative in state history, and to put all this together without a public process is very disconcerting.”

Linnea Koopmans, CEO of the Local Health Plans of California, echoed McNaughton’s concerns.

Insurance plans got wind of the backroom talks when broad outlines of the deal were leaked days before the state briefed their executives Thursday.

Bechara Choucair, M.D., Kaiser Permanente’s chief health officer, argued in a prepared written response (PDF) on behalf of KP that because it operates both as a health insurer and a healthcare provider, KP should be treated differently than other commercial health plans that participate in Medi-Cal. Doing business directly with the state will eliminate complexity and improve the quality of care for the Medi-Cal patients it serves, he said. 

“We are not seeking to turn a profit off Medi-Cal enrollment,” Choucair said. “Kaiser Permanente participates in Medi-Cal because it is part of our mission to improve the health of the communities we serve. We participate in Medi-Cal despite incurring losses every year.” 

His statement cited nearly $1.8 billion in losses in the program in 2020 and said KP had donated $402 million to help care for uninsured people that year.

KP, the state’s largest managed-care organization, is one of Newsom’s most generous supporters and close political allies. 

The new, five-year contract, confirmed to KHN by administration officials and expected to be announced publicly Friday, will take effect in 2024 pending approval from the legislature—and will make KP the only insurer with a statewide Medi-Cal contract. It allows KP to solidify its position before California’s other commercial Medi-Cal plans participate in a statewide bidding process—and after those plans have spent many months and considerable resources developing their bidding strategies.

Other health plans fear the contract could also muddle a massive and expensive initiative called CalAIM that aims to provide social services to the state’s most vulnerable patients, including home-delivered meals, housing aid for homeless people and mold removal from homes. Under its new contract, KP must provide some of those services. But some executives at other health plans say KP will not have to enroll a large number of sick patients who need such services because of how it limits enrollment.

Critics of the deal noted Newsom’s close relationship with KP, which has given nearly $100 million in charitable funding and grant money to boost Newsom’s efforts against homelessness, COVID response and wildfire relief since 2019, according to state records and KP news releases. The healthcare giant was also one of two hospital systems awarded a no-bid contract from the state to run a field hospital in Los Angeles during the early days of the COVID pandemic, and it got a special agreement from the Newsom administration to help vaccinate Californians last year.

Jim DeBoo, Newsom’s executive secretary, used to lobby for KP before joining the administration. Toby Douglas, a former director of the state Department of Health Care Services, which runs Medi-Cal, is now Kaiser Permanente’s vice president for national Medicaid.

Partnering with CA Governor Gavin Newsom, Kaiser Permanente increases its commitment to addressing homelessness https://t.co/ncYzG8nWdt

— Paul Erskine (@Paul_Erskine) January 17, 2020

Still, many critics agree that Kaiser Permanente is a linchpin of the state’s healthcare system, with its strong focus on preventive care and high marks for quality of care. Many of the public insurance plans upset by the deal subcontract with KP for patient care and acknowledge that their overall quality scores will likely decline when KP goes its own way.

Michelle Baass, director of the state Department of Health Care Services, said Medi-Cal had risked losing KP’s “high quality” and “clinical expertise” altogether had it been required to accept all enrollees, as the other health plans must. But she said KP will have to comply with all other conditions that other plans must meet, including tightened requirements on access, quality, consumer satisfaction and health equity. 

The state will also have greater oversight over patient care, she said.

“This proposal is a way to help ensure Kaiser treats more low-income patients, and that more low-income patients have access to Kaiser’s high-quality services,” Baass said. 

Though Kaiser Permanente has 9 million enrollees, close to a quarter of all Californians, only about 900,000 of them are Medi-Cal members. 

Under the current system, 12 of the 24 other managed care insurance plans that participate in Medi-Cal subcontract with KP to care for a subset of their patients, keeping a small slice of the Medi-Cal dollars earmarked for those patients. Under the new contract, KP can take those patients away and keep all of the money.

In its subcontracts, and in counties where it enrolls patients directly, KP accepts only people who are recent Kaiser Permanente members and, in some cases, their family members. It is the only health plan that can limit its Medi-Cal enrollment in this way. 

The new contract allows KP to continue this practice, but it also requires Kaiser Permanente to take on more foster children and complex, expensive patients who are eligible for both Medi-Cal and Medicare. It allows KP to expand its geographic reach in Medi-Cal to do so. 

Baass said the state expects KP’s Medi-Cal enrollment to increase 25% over the life of the contract. 

KP defended the practice of limiting enrollment primarily to its previous members, arguing that it provides “continuity of care when members transition into and out of Medi-Cal.” 

The state has long pushed for a larger KP footprint in Medi-Cal, citing its high quality ratings, its strong integrated network and its huge role on the broader healthcare landscape.

“Kaiser Permanente historically has not played a very big role in Medi-Cal, and the state has long recognized that we would benefit from having them more engaged because they get better health outcomes and focus on prevention,” said Daniel Zingale, a former Newsom administration official and health insurance regulator who now advises a lobbying firm that has Kaiser Permanente as a client. 

But by accepting primarily people who have been KP members in the recent past, the health system has been able to limit its share of high-need, expensive patients, say rival health plan executives and former state health officials.

The executives fear the deal could saddle them with even more of these patients in the future, including homeless people and those with mental illnesses—and make it harder to provide adequate care for them. Many of those patients will join Medi-Cal for the first time under the CalAIM initiative, and KP will not be required to accept many of them.

“Awarding a no-bid Medi-Cal contract to a statewide commercial plan with a track record of ‘cherry picking’ members and offering only limited behavioral health and community support benefits not only conflicts with the intent and goals of CalAIM but undermines publicly organized health care,” according to an internal document prepared by the Inland Empire Health Plan. 

The plan said it stands to lose the roughly 144,000 Medi-Cal members it delegates to KP and about $10 million in annual revenue. L.A. Care, the nation’s largest Medicaid health plan, with 2.4 million enrollees in Los Angeles County, will lose its 244,000 KP members, based on data shared by the plan. 

The state had been scheduled on Wednesday to release final details and instructions for the commercial plans that are submitting bids for new contracts starting in 2024. But it delayed the release a week to make the KP deal public beforehand.

Baass said the state agreed to exempt KP from the bidding process because the standardized contract expected to result from it would have required the insurer to accept all enrollees, which Kaiser Permanente does not have the capacity to do. 

“It’s not surprising to me that the state will go to extraordinary means to make sure that Kaiser is in the mix, given it has been in the vanguard of our health care delivery system,” Zingale said.

Having a direct statewide Medi-Cal contract will greatly reduce the administrative workload for KP, which will now deal with only one agency on reporting and oversight, rather than the 12 public plans it currently subcontracts with. 

And the new contract will give it an even closer relationship with Newsom and state health officials.

In 2020, KP gave $25 million to one of Newsom’s key initiatives, a state homelessness fund to move people off the streets and into hotel rooms, according to a KHN analysis of charitable payments filed with the California Fair Political Practices Commission. The same year, it donated $9.75 million to a state COVID relief fund.

In summer 2020, when local and state public health departments struggled to contain COVID spread, the healthcare giant pledged $63 million in grant funding to help contract-tracing efforts.

KP’s influence extends beyond its massive charitable giving. Its CEO, Greg Adams, landed an appointment on the governor’s economic recovery task force early in the pandemic, and Newsom has showcased KP hospitals at vaccine media events throughout the state. 

Thank you @GavinNewsom @CHHSAgency @MayorOfLA
@LAPublicHealth
@HildaSolis for joining KP CEO Greg Adams, @NancyGinMD and @KP_LAMC physicians & staff during this historic moment. We appreciate your leadership as we work together to end this devastating #pandemic. #COVID19
pic.twitter.com/E9nHdrPpTd

— Kaiser Permanente Southern California (@KPSCALnews) December 14, 2020

“In California and across the U.S., the campaign contributions and the organizing, the lobbying, all of that stuff is important,” said Andrew Kelly, Ph.D., an assistant professor of health policy at California State University-East Bay. “But there’s a different type of power that comes from your ability to have this privileged position within public programs.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Clipped from: https://www.fiercehealthcare.com/payers/california-inks-sweetheart-deal-kaiser-permanente-jeopardizing-medicaid-reforms

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Georgia bill aims to limit profits of Medicaid managed-care plans

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[MM Curator Summary]: GA is one of only a few Medicaid managed care states that does not require a minimum Medical Loss Ratio (MLR).

 
 

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.

 
 

Georgia lawmakers will consider a bill that could force the state’s Medicaid managed-care insurers to repay millions of dollars if their spending on medical care doesn’t reach a certain threshold.

This story also appeared in Georgia Health News

The bipartisan bill, introduced Jan. 26 by the powerful Georgia House Speaker David Ralston, a Republican, is focused on improving the state’s mental health care system.

Tucked inside the legislation is a provision that would require the Medicaid managed-care companies to refund payments to the state if they don’t spend enough on medical care and quality improvements for patients.

Georgia Health News and KHN reported in September that Georgia was one of only a few states that doesn’t mandate a minimum level of medical spending for its Medicaid insurers.

Each year, Georgia pays three insurance companies — CareSource, Peach State Health Plan, and Amerigroup — a total of more than $4 billion to run the federal-state health insurance program for low-income residents and people with disabilities. For 2019 and 2020, the companies’ combined profits averaged $189 million per year, according to insurer filings reported by the National Association of Insurance Commissioners.

“Instead of ensuring adequate health care networks for Georgia’s children, Georgians with disabilities, and Georgians in nursing facilities, hundreds of millions of dollars go instead to the Georgia [insurers’] bottom lines,” said Roland Behm, a board member for the Georgia chapter of the American Foundation for Suicide Prevention.

Behm, who advised lawmakers on the bill, said the KHN and Georgia Health News article helped bring the issue to the attention of legislators crafting the bill.

Georgia is among more than 40 states that have turned to managed-care companies to run their Medicaid programs — and ostensibly control costs. According to an August report from the U.S. Department of Health and Human Services’ Office of Inspector General, 36 of those states and the District of Columbia set a benchmark “medical loss ratio” for the minimum spending by insurers on medical care. Besides Georgia, the report said, the five states not requiring a managed-care spending threshold were Kansas, Rhode Island, Tennessee, Texas, and Wisconsin.

Ralston (left), with Kevin Tanner, chairman of a mental health commission, and Insurance Commissioner John King (right), at the Capitol on Wednesday. Credit: Georgia Health News

Republican state Rep. Todd Jones, a co-sponsor of the new bill, told KHN that Georgia lawmakers should establish a strong benchmark for insurers to meet. “We should look at what other states are doing,” he said.

Most states with a spending requirement set that ratio at a minimum of 85% of premium dollars that insurers are paid. So when a Medicaid insurer spends less than that on medical care and quality improvements, it must return money to the government.

The Georgia bill also calls for setting the threshold at 85%. If the bill is approved, the Medicaid insurers would face the medical spending requirement in 2023.

If the benchmark had been in place in recent years, it could have forced a recoupment from the Peach State company, which has the largest Georgia Medicaid enrollment of the three insurers. State documents show it failed to reach the 85% mark from 2018 to 2020, KHN previously reported.

Andy Schneider, a research professor at Georgetown University’s Center for Children and Families, called the 85% mark “a win for taxpayers, for Medicaid providers, and for Medicaid beneficiaries.” He also said it would be more than fair to the Medicaid insurers, which could keep 15% of what the state pays them for administrative costs and profit.

Because Ralston is the lead sponsor of the bill in the House, it’s expected to pass that chamber.

But the insurance industry likely will work to remove the medical spending provision.

An industry official, Jesse Weathington, executive director of the Georgia Quality Healthcare Association trade group, declined to comment on the legislation.

Fiona Roberts, a spokesperson for the state Department of Community Health, which oversees the Medicaid program, said the agency needs time to review the measure before commenting on it.

The main provisions of the bill require insurers to provide coverage for mental health care or substance use treatment at the same level as other physical health needs.

The legislation would provide education loan support for people training in the fields of mental health and substance use disorders and seek to expand behavioral health services for children. It would also facilitate “assisted outpatient treatment” — when a judge could order a person with a serious mental illness to follow a court-ordered treatment plan in the community.

This story is available through a news partnership with Georgia Health News.

 
 

Clipped from: https://thecurrentga.org/2022/01/28/georgia-bill-aims-to-limit-profits-of-medicaid-managed-care-plans/

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NJ Watchdog Says State Should Bar Poorly-Rated Nursing Homes From Medicaid

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[MM Curator Summary]: A recent comptroller report recommends NJ stop payments to nursing homes with consistent poor performance.

 
 

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

 
 

 
 

A new report by the New Jersey comptroller recommends tighter Medicaid restrictions on low-performing nursing homes

New Jersey Office of the State Comptroller

A new report by New Jersey’s state comptroller found 15 nursing homes consistently received low ratings by health inspectors, yet still take in about $100 million in Medicaid funding a year.

The state watchdog’s report says poor performers shouldn’t be rewarded if they fail to improve and is recommending progressive measures to force fixes — including barring repeatedly low-ranking facilities from additional public dollars.

“Bottom line: New Jersey taxpayers should not be funding nursing homes that have failed to improve for years, appear unlikely to improve, and put residents in harm’s way,” Acting Comptroller Kevin Walsh said in a statement.

The comptroller’s office analyzed New Jersey’s 339 nursing homes and found 15 of them earned the lowest score on the national grading rubric for long-term care facilities for most quarters in 2020 and 2021. Nursing homes, which have been under close scrutiny amid the COVID pandemic, are evaluated based on federal guidelines set by the Centers for Medicare & Medicaid Services on a scale of one to five stars, with one being the lowest.

“These are facilities that year over year performed poorly in some very critical areas, specifically staffing shortages and the amount of nursing hours that are available,” said Laurie Facciarossa Brewer, the state’s long-term care ombudsperson, who consulted with the comptroller’s office on the report.

“It would appear that there doesn’t seem to be an effort by those facilities to improve. It almost seems as if a one-star rating is basically baked in as the cost of doing business,” she said.

State inspectors evaluate nursing homes during unannounced visits and, over several days, grade residents’ quality of care, medication management, nursing home administration and food services. The report found one in 14 nursing homes statewide received a one-star rating in the most recent quarter.

“It’s not the minor stuff that gets you a one-star rating. It’s having multiple deficiencies over time in a wide array of areas,” Brewer said.

They’re making a profit off of the one-star facilities all while taxpayers are paying for one-star care

Acting New Jersey Comptroller Kevin Walsh

The report also found that 14 of the 15 lowest performing nursing homes, or 93%, are run by for-profit companies — statewide, 77% of the facilities are run by for-profits.

“They’re making a profit off of the one-star facilities all while taxpayers are paying for one-star care,” Walsh said.

According to the report, the 15 low performers received more than $300 million in Medicaid funding between 2017-2019. And many have scored poorly since 2013, the data shows.

The comptroller’s office is recommending the state issue a series of restrictions to problem facilities that range from a warning, banning the nursing home from accepting new patients and ultimately, withholding Medicaid dollars. One of the problems the report identified is that the state agency overseeing residential care is different from the agency that distributes the money.

New Jersey’s Division of Medical Assistance and Health Services within the Department of Human Services oversees the state’s Medicaid program but it’s up to the Department of Health to conduct health inspections and evaluate the facilities.

“The agencies need to work together in order to ensure that the residents’ interests and the Medicaid dollars that the state spends are all protected,” Walsh said. He said New Jersey would be the first state to withhold Medicaid dollars from low-rated nursing homes if it decides to accept the recommendation.

Nursing homes have been under increased scrutiny in the last two years after the pandemic sickened and killed more than 8,000 residents and 148 staff, state data show. Brewer said the report’s suggested fixes will complement larger reforms already underway.

Last year, Gov. Phil Murphy signed into law measures to ensure minimum staffing levels, increase wages for direct care staff and mandate that 90% of Medicaid funds be used for direct patient care.

The comptroller’s office has also released a dashboard of the 15 lowest-performing facilities here. Four of the 15 are in Burlington County. If the state considers the report’s recommendations, which could ultimately limit the number of patients at these facilities, it could limit where residents can access long-term care.

“It underscores how very difficult it is when you’re talking about people’s health care,” Brewer said. “Everybody involved has to be really, really mindful of the fact that regardless of how bad the place is, it is where somebody lives.”


 
 

 
 

Clipped from: https://gothamist.com/news/nj-watchdog-says-state-should-bar-poorly-rated-nursing-homes-medicaid

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Ohio Medicaid director says program change won’t disrupt health care

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[MM Curator Summary]: OH is requiring members to pick their plan for the first time.

 
 

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.

 
 

 
 

Karen Kasler

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Statehouse News Bureau

Ohio Medicaid Director Maureen Corcoran testified before the House Finance Commission discussing the two-year state budget in February 2021.

Ohio’s Medicaid director is taking issue with a report from a progressive think tank that suggests millions of people in the program could have their health care interrupted because of a change that takes effect in July.

Medicaid participants will be notified soon they must confirm which of seven managed care plans they want – though people who’ve been in Medicaid haven’t had to do that if they wanted to stay with their plan. Ohio Medicaid Director Maureen Corcoran said part of the reason for that is to get people to be more engaged and informed about their health care.

“We know that when people have to kind of stop and think about it, they’re going to get more drawn into their health care,” Corcoran said. “We want to encourage people to be affirmative and learn and be active in their health care.”

Those who don’t respond could be assigned to different plans later this year, but Corcoran said they can always switch back.

“If a person doesn’t choose and we then make an assignment, they still can choose to go back to the plan they had had maybe a year ago or – they still have a choice, even if they hadn’t responded previously. So prioritizing choice is number one,” said Corcoran.

Eventually, as many as 80,000 Ohioans could be moved to the new plans that need participants, but Corcoran says they can change back till the end of November. But Corcoran notes that’s a very small percentage of the program’s participants.

The group Innovation Ohio suggested those reassignments could disrupt health care for millions. But Corcoran says careful matching – finding plans that keep people in their networks, for instance – should mean that won’t happen, or that it would be rare.

And Corcoran noted that for now, no one can be disenrolled from Medicaid because there’s a public health emergency declaration still in effect for the pandemic.

 
 

Clipped from: https://www.wksu.org/government-politics/2022-02-02/ohio-medicaid-director-says-program-change-wont-disrupt-health-care

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CNMI- Governor vetoes Medicaid personnel bill

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[MM Curator Summary]: The Governor of CNMI has shot down a bill that would codify various authorities for the Medicaid agency.

 
 

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.

 
 

 
 

GOVERNOR Ralph DLG Torres on Friday vetoed House Bill 22-53, which proposes to “further enable recruitment, retention and appropriate classification and compensation” in the Commonwealth Medicaid Agency.

Introduced by Rep. Leila Fleming Staffler, the bill aims to:

1) Codify the authority of the Medicaid director to reprogram funding appropriated for Medicaid program among the established business units in a fiscal year budget;

2) Direct the Office of Personnel Management to undertake a repricing study for eligibility, enrollment, claims processing, and health information technology personnel and retention based on the classification and compensation of Commonwealth Healthcare Corp.; and

3) Authorize OPM to hire Medicaid Enterprise System, data analysis, program integrity, and auditing personnel under excepted service employment contracts until the market-based repricing classification and compensation study is completed.

According to the bill, the CNMI government’s fiscal year 2021 budget established a Compliance and Medicaid Enterprise System as a new business unit “to balance the program needs for administration and medical reimbursement with the legal requirements of Title XIX of the Social Security Act.”

In addition, the Legislature also provided the Medicaid director the authority to reallocate the funds appropriated in the budget law.

H.B. 22-53 clarifies the authority of the Medicaid director to reprogram funds among the Medicaid business units categories or any other business units the Legislature may establish in the appropriation measure.

The bill also stated that positions for Medicaid Enterprise System personnel approved and funded, at a minimum, with 50% to 90% federal funds, as approved by the Centers for Medicare and Medicaid Services, “have yet to be recruited, resulting in delays to important project activities and time lines.”

The measure states that “specialized health information technology and Medicaid data analytics personnel required by Medicaid are in short supply until OPM is able to undertake a market-based classification and compensation pricing study for health information technology and data analytics personnel that, in minimum, reflects the comparable classification compensation of like positions at CHCC.”

Ambiguous

In his veto message, the governor said due to ambiguities in the language of the bill as noted by the attorney general, and similar concerns of OPM, “I must respectfully exercise my constitutional authority to veto this bill.”

He said if approved, the measure would create a narrow exception to the reprogramming restrictions in the Planning and Budgeting Act, with regard to the Medicaid Agency.

He said funds appropriated to the Medicaid Agency may be reprogrammed by the director regardless of whether the funds are for personnel or non-personnel expenditures.

Right now, the governor said, the Planning and Budgeting Act permits the reprogramming of funds from personnel to non-personnel or operations, but not vice versa.

The governor also noticed that the bill would require OPM to establish personnel positions for the Medicaid Agency that fall under Medicaid Enterprise System. The MES positions, he added, are approved by the Centers for Medicare & Medicaid Services.

OPM is further tasked with performing a review and study of the classification of personnel required by the Medicaid program with classification and compensation rates comparable to CHCC and private insurers and providers.

In recruiting prospective employees, the governor said OPM would be directed to interview and employ individuals who have demonstrable and specific knowledge, skills, experience, training and abilities applicable in Medicaid administration and similar healthcare management and analytics program.

But the governor said H.B. 22-53 would exempt MES employees from the civil service system. Upon completion of OPM’s classification and compensation study to be approved by the Medicaid director, the MES employees may opt to convert to the civil service system and become civil service employees.

According to the governor, the attorney general makes it clear that Legislature’s lawmaking authority over the civil service system “is not plenary.” Only the Civil  Service Commission has the authority over civil service system and is the sole authority to exempt positions from civil service classification, the governor said.

 
 

Clipped from: https://mvariety.com/news/governor-vetoes-medicaid-personnel-bill/article_d9534576-8288-11ec-87c3-e3fe2accaba7.html