Tag: State News

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IL- Rate Increases to the Medicaid Fee Schedule (Dental)

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[ MM Curator Summary]: IL dentists will get $10M in Medicaid payments next 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.

 
 

 
 

The Illinois State Dental Society (ISDS) advocated this past session to increase rates for dental care in the Illinois Medicaid program. ISDS was successful in the pursuit of the increased rates to the extent that $10 million was added to the budget for the rate increases.  

The Illinois Department of Healthcare and Family Services (DHFS) just announced these rate increases to the Medicaid Fee Schedule for select dental services that ISDS helped negotiate and are scheduled to begin January 1, 2022. The specific codes with rate increases can be found by clicking here. DHFS has highlighted the increased codes in yellow.

Highlighted in these new increases are restorative services, dentures, extractions, and anesthesia services.  To review the codes and see if participation in the Medicaid program would work in your practice, please click here to see the full Medicaid fee schedule.

To enroll and learn more about being a provider in the Medicaid program, please contact DHFS by calling 1-877-782-5565 (select option #1) or by going online to https://www2.illinois.gov/hfs/impact/Pages/ContactIMPACT.aspx.

We want to thank our members again for their persistent efforts in contacting and educating their legislators on the need for this additional funding. While we are very excited for this legislative win, our work is not done. We will continue, as always, to advocate for you, the members.

 
 

Clipped from: https://www.isds.org/news-details/2021/12/01/alert!-rate-increases-to-the-medicaid-fee-schedule

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Size of Medicaid Expansion Influenced Administrative Spending

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[ MM Curator Summary]: States that had more room to grow (ie had higher uninsurance rates) benefitted more when they expanded (in terms of administrative costs), likely due to economies of scale and handing over more scope to MCOs.

 
 

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.

 
 

 
 

 
 

States that enacted Medicaid expansion and had high uninsurance rates among low-income residents were considered large expansion states and subsequently saw a slight decrease in administrative spending.

 
 

Source: Getty Images

 
 

By Victoria Bailey

November 30, 2021 – Medicaid expansion did not impact overall administrative spending, but states with large expansions saw slight reductions in spending while smaller expansions led to minor increases, according to a Health Affairs report.

Administrative spending covers expenditures for eligibility and enrollment assessments and processes, interagency costs, claims processing, information technology systems, and more. States did not receive reimbursement for administrative costs following Medicaid expansion, and there is little research that speaks to whether expansion impacted this spending.

Researchers from Indiana University gathered data from all fifty states and focused on two outcomes in each state: the percentage of total spending that was administrative and per enrollee administrative spending.

State expansion, spending, and enrollment data from 2007 to 2017 were obtained through various CMS and Kaiser Family Foundation (KFF) reports.

The Health Affairs report looks at the differences in administrative spending between states that have expanded Medicaid and nonexpansion states. Additionally, the researchers compared large expansion states to small expansion states and states that expanded Medicaid traditionally through the Affordable Care Act to states that used Section 1115 to expand their program through waivers.

Researchers classified expansions as large or small by using the median uninsurance rate among nonelderly adults who had incomes below 100 percent of the federal poverty level in the year before the expansion. If the uninsurance rate was high, expansions were considered large.

Medicaid expansion became optional for states in 2014. Since then, 38 states and Washington DC have expanded their Medicaid programs.

Prior to 2014, expansion and nonexpansion states had similar levels of administrative spending, but most expansion states saw a larger unadjusted decline in per enrollee administrative spending after expanding their programs, researchers found.

The average annual per enrollee administrative spending in nonexpansion states before 2014 was slightly more than $444. Between 2014 and 2017, it fell to a little over $408, signifying a $35.60 decrease.

States that underwent large expansions saw a $106 annual decrease, going from an average of $507 per enrollee administrative spending pre-2014 to $401 between 2014 and 2017. States that had small expansions saw a slighter decrease of $20.99.

The adjusted analysis revealed very few differences in per enrollee administrative spending for nonexpansion and expansion states, including states that used ACA expansion methods and ones that expanded through waivers.

When categorizing Medicaid expansion states by expansion size, the differences were slightly more apparent. States that had large expansions saw a significant decrease in per enrollee administrative spending of $77 compared to nonexpansion states, while states with small expansions saw a nonsignificant increase compared to nonexpansion states.

In looking at the percentage of total spending that is administrative, researchers found similar results. Large expansion states had a nonsignificant reduction compared to nonexpansion states. Meanwhile, small expansion states had a significant increase in the percentage of spending that was administrative compared to nonexpansion states.

Overall, Medicaid expansion did not significantly escalate administrative spending for expansion states. But when considering expansion sizes, small expansions led to slight increases in administrative spending.

“States with larger expansions may experience economies of scale, where it becomes less expensive and they become more efficient as more people are enrolled in the program,” the report stated.

Additionally, states with larger expansions are known to have stricter eligibility criteria and may spend less on Medicaid overall, according to the researchers.

Small expansion states may have seen increases in administrative spending due to differences in reimbursement rates, application requirements, and eligibility and enrollment processes. States with smaller expansions also tend to have more generous Medicaid programs, which could exhibit higher spending, the report noted.

Twelve states have yet to expand Medicaid, barring access to healthcare coverage for many of their residents. Most of these states have high uninsurance rates and low eligibility thresholds which would lead to large expansions, researchers said. According to the study results, these expansions would increase coverage access while also reducing administrative spending.

The American Rescue Plan Act is encouraging states to expand Medicaid as well by offering an increase in federal medical assistance percentages (FMAP) for the first two years after expansion.

 
 

Clipped from: https://healthpayerintelligence.com/news/size-of-medicaid-expansion-influenced-administrative-spending
 

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State pushes back timeline for Medicaid bonuses; group home providers eye long-term solutions

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[ MM Curator Summary]: Florida is using an application process to distribute the recently approved federal funds for HCBS services, and providers want the money right now.

 
 

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.

 
 

Florida may be getting a boost in money intended to help people with intellectual and developmental disabilities, but it doesn’t look like those additional federal Medicaid funds are going to be handed out soon.

And that’s a conundrum for a system that already is under strain.

The hopes were this “bonus money” could be distributed by the end of the year, but the administration of Gov. Ron DeSantis has pushed back the timeline to distribute the funds with the goal of having the money distributed by “winter 2022.”

Given the federal government approved the state’s plan to bolster home- and community-based services in September, the timeline has some wondering why it could take five months to see the money.

“It can’t come fast enough,” Sen. Aaron Bean, chairman of the health care spending panel, told Florida Politics Monday.

 
 

Agency for Health Care Administration Chief of Staff Cody Farrill told members of the Senate Appropriations Subcommittee on Health and Human Services earlier this month that the agency’s goal is to post employer and employee bonus applications on its website in December.

Of the $1.2 billion in additional federal money coming Florida’s way, the state is setting aside $403 million in one-time stipends for employers to apply for and another $266.6 million for their employees, Farrill said.

He said the AHCA is developing potential distribution methodologies but won’t finalize any until it determines how many employers applied for the stipends. Provider caseload will also be taken into consideration in the distribution formulas, but Farrill in his testimony offered few other details.

“We understand we want to get this out the door as quickly as possible, but also want to balance the fact that we make sure these (payments) are going to the right providers that are eligible,” Farrill said.

Philadelphia transplant Tamika Walker moved to Florida in 2014 to help care for her husband’s 100-year-old grandmother. Walker initially was hired by United Community Options of South Florida seven years ago at $10 an hour. After getting promoted, she now earns $11.30 an hour, well below the $17 hourly wage she was paid in Philadelphia.

 
 

Though she hasn’t gotten a pay raise since her promotion in 2015, Walker heaps praise on her employer. She told Florida Politics that while she’s able to “make do” because of her husband’s salary, she works with others who are financially struggling. Some staff, she says, can’t afford their own cars. They rely on Uber and Lyft to get to work.

“If they want to do it, just do it. Don’t tell us about it. Just do it.” Walker said of the pay raises. “We are trying to come out of a pandemic. We had to go to work every day and put our lives on the line.”

The DeSantis administration moved over the summer to take advantage of a 10% bump in federal Medicaid dollars available under the American Rescue Plan Act of 2021. Every state moved to tap into the increased federal funds, Farrill said.

Most Florida Medicaid patients who receive home- and community-based services either are enrolled in the Medicaid managed long-term care program or the Medicaid iBudget program. The former is for frail and elderly individuals who qualify for nursing home placement but choose to receive assistance with daily living activities, such as eating and dressing, that enable them to continue to live in their homes or another non-institutional setting.

Similarly, the Medicaid iBudget program allows adults with intellectual and developmental disabilities to tap into the home- and community-based services they require to continue living outside of an institution and in their family home or a group home.

Lawmakers in recent years have committed additional funding to serve more clients and whittle down what has been a lengthy waitlist. For the iBudget program to work, however, there must be a provider network willing to serve the clients. And there are worries that Florida’s network is beginning to erode.

The Agency for Persons with Disabilities reports that between March 1 and Sept. 30, 99 group homes closed, requiring relocation of 271 clients. But during that same time span, the state reports, 108 new group homes were licensed. The APD data doesn’t indicate how many clients the newly licensed homes serve.

The Florida Association of Rehabilitation Facilities data on closures tracks APD’s but FARF did not have information on new facilities opening.

FARF President and CEO Tyler Sununu said many of the group homes that remain open have stopped accepting new clients or have limited the services they provide. Sununu surveyed his group home members this summer and found that on average there has been a 41% turnover rate at the facilities.

The survey also showed that 23% of the positions at group homes are vacant, Sununu said.

Sununu attributes the 100 closures group home closures to the trifecta of the COVID-19 pandemic, a tight labor force, and historically low Medicaid reimbursement rates

“We were really hoping the money would be available for the holidays and it looks like it’s not going to be. And that’s unfortunate,” he said. “But we are really happy the money will be coming.”

Sununu, though, has his eye on the bigger picture: getting lawmakers to increase by $147.5 million the amount Medicaid pays providers. Of that increase, about $93 million would be funded with state general revenue. The remainder comes from matching federal dollars. The increase, he maintains, would allow group homes to pay direct care workers an average $14 an hour, up from the current average wage of $11 an hour.

Bean has either helped craft or has taken the lead on developing the state’s Medicaid spending plans during most of his lengthy legislative career. He says he is awaiting the results of a state-contracted study on the state’s new minimum wage requirements and the impacts it will have on the rates providers need to be paid.

Bean said APD will get its attention during the 2022 session but made no promises about increasing provider rates.

“I fully acknowledge they are struggling. But everybody is struggling. Nursing homes are struggling, retailers are struggling, restaurants are struggling. It seems like everybody has a supply chain crunch and a working shortage. So this industry is not spared from all of the above,” he said.

Florida Developmental Disabilities Council
Executive Director Valerie Breen is less focused on the home- and community-based industry and more focused on the workforce needed to provide services now and in the future

“Definitely we need providers. But more importantly, there isn’t the workforce there to support them. That is the critical issue,” she said.

While APD certifies direct support professionals who can work in Florida, Breen said there is no professional designation for the staff, whether they provide home- and community-based services at a family home or at a community group home. She said the workforce needs to be recognized and incentivized.

“It is a huge crisis nationally and we are definitely seeing it in Florida,” she said.

To that end, Breen said the Council will launch a message campaign dubbed “Pay Fair for Care.” She said hundreds of constituents will share their stories with lawmakers about the difficulty in getting direct support professionals.

“We are looking at an extreme caregiving situation. Where families are having to take it on,” she said. “They are absolutely having to take it on and they aren’t getting any support because the workforce that we depend on for direct support professionals is slowly and surely diminishing.”

Clipped from: https://floridapolitics.com/archives/476321-state-timeline-medicaid-bonuses/

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Some Colorado therapists will no longer take Medicaid patients

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[ MM Curator Summary]: CO Medicaid is trying to recoup payments from years ago, and providers say they billed properly but a tech vendor took off key information.

 
 

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

 
 

Several behavioral health providers say they will no longer treat Medicaid patients after 199 providers received letters ordering them to return payment for therapy already completed.

 
 

 
 

The logo for the Colorado Department of Health Care Policy and Financing, which administers Medicaid in the state, on a sign in the department’s offices on Feb. 26, 2019. (John Ingold, The Colorado Sun)

As a single parent going back to college, Carla D’Agostino-Vigil signed up for Medicaid and used the government-run health insurance to attend “life-saving” therapy. So when she graduated and started her own mental health counseling practice in Westminster, D’Agostino-Vigil was adamant that she would open her doors to Medicaid patients. 

“When it was my turn, I felt very strongly about being involved,” she said. “The way things have played out, my heart is broken.”

Two years after opening her practice, D’Agostino-Vigil is among the latest round of health care providers in Colorado who are quitting the Medicaid program. Nearly half of the 175 patients at Ignite Counseling Colorado are on Medicaid, and during a six-month transition phase, D’Agostino-Vigil will “try like heck” to find other counselors who will take them. If that doesn’t work, she intends to continue helping some pro bono. 

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Her list of reasons is long. There was the 20% rate cut in 2020, just ahead of an increase in need for mental health care because of the isolating days of the pandemic. There were the threatening letters warning her that she was “overusing” a billing code — the code for a full hour of therapy — and that she should instead see patients for 30- or 45-minute sessions. 

But what pushed D’Agostino-Vigil, one of the only specialists in obsessive compulsive disorder taking Medicaid in Colorado, over the edge was a “recoupment” notice received by her practice and nearly 200 others in Colorado this fall. The letter said that due to incorrectly filed claims, providers would have to pay hundreds or thousands of dollars to the agency – called Colorado Community Health Alliance — that dispenses their payments. In some cases, recoupment amounts have totaled $17,000 or $18,000 for a single mental health therapist in private practice. 

The letters, copies of which were reviewed by The Colorado Sun, warn that providers have 60 days to pay up or the management agency could withhold future payments. 

 
 

Nearly 200 behavioral health care offices received letters requesting recoupment for claims that were incorrectly filed. The letters said that if providers did not pay within 60 days, the contractor could recoup the funds by withholding future payments.

The debacle is the latest headache for Medicaid providers who for years have complained of redundant paperwork and clogged bureaucracy. And in this case, it’s not that therapists and counselors were overpaid — they are being asked to return money for services they provided during the prior two years, all because of a provider identification number that was not included in the claims. 

Multiple behavioral health clinicians told The Sun they included the provider identification number. It was the computer system used by their payer, Colorado Community Health Alliance, which is owned by private insurance giant Anthem, that scrubbed the identification numbers from its claims, thinking they were not needed. 

The health alliance, which is the middleman between providers and the state Medicaid program, realized its mistake two years ago and began warning therapy practices back in March 2020 that they would have to resubmit claims, said spokeswoman Colleen Daywalt. The provider number is required by state and federal law, so when the alliance discovered the problem in July 2019, the agency began working to correct its software system to include the number on its claim forms. The problem was fixed in October 2020, Daywalt said. 

Colorado Community Health Alliance, which is the payer for behavioral health providers in Boulder, Broomfield, Clear Creek, El Paso, Gilpin, Jefferson, Park and Teller counties, began notifying providers in March 2020 that claims filed during a two-year period were out of compliance. But many of the 1,175 providers under the alliance did not take action, overwhelmed by the task of resubmitting hundreds of claims. 

A therapist who saw a client weekly during those two years would have filled about 104 claims — and that’s just for one patient. 

Last month, the health alliance sent 199 letters asking for “recoupment” payments, setting off panic and a firestorm of complaints, including in a private Facebook group where therapists and counselors vent about Medicaid frustrations. 

 
 

Colorado Community Health Alliance sent letters to 199 mental health care providers asking for money to recoup payment for claims “paid in error.”

Daywalt said it’s not the health alliance’s intent to recoup any payments, only to comply with state and federal law. She would not say the total amount of money involved in the out-of-compliance claims or the range of recoupment amounts sent to providers. 

But several therapists contacted The Sun regarding the payment debacle and shared their recoupment amounts. 

Allison Harvey, who works at a small group practice in Arvada, said the health alliance is asking for $7,000 for 74 claims in 2020. “The problem is that we submitted all of these claims correctly with all of the information necessary for payment,” she said. “The data is getting removed sometime after the claims leave our hands. Our group, like all providers who choose to serve Medicaid clients, just want to simply be paid for the work we do with this important clientele.” 

 
 

Christia Young, with Badass Therapy in Brighton, was asked to return $7,200. Now Young has stopped taking Medicaid patients through Colorado Community Health Alliance. Even before the latest claims issue, she was spending 80% of her time dealing with Medicaid claims because the health alliance was “repeatedly auditing” her filings, she said. 

And Sarah Carlson, a licensed marriage and family therapist who has accepted Medicaid for 13 years, is quitting her Medicaid contract with the health alliance effective next month. She founded The Parent-Child Interaction Center, one of the largest group practices that accepts Medicaid in Larimer, Weld and Boulder counties. 

Carlson said she’s been fighting about claims with the health alliance for years. The agency owes her thousands of dollars in past claims and now is asking for about $6,000 in recoupment on payments she received for 2020 and 2021, she said. 

“I love how they can find the claims suddenly when they want the money back, but somehow manage not to have the others on file?” Carlson said. “It’s a game, and it’s disgusting. Especially during the pandemic when the need has been soaring.”

 
 

Carlson said she would struggle to pay her office rent just serving Medicaid clients and has to subsidize Medicaid patients with those who have private insurance. “Sadly, it’s my underserved clients who will suffer, but I cannot continue this way any longer,” she said. 

The Colorado Department of Health Care Policy and Financing, which runs the Medicaid program and contracts with Colorado Community Health Alliance to disperse payments to the providers, said providers have been warned of the claims error via multiple newsletters and meetings in 2020 and 2021. 

“While we understand this is frustrating for providers, providers and payers are responsible for submitting and processing compliant claims,” said an emailed statement from department spokesman Marc Williams. “Our contractor identified a system issue preventing this and corrected the issue. They have given providers 21 months to submit corrected claims, which they are still able to do before the recoupments take effect.”

While some providers are ending their Medicaid contracts this fall, the number of behavioral health providers who take Medicaid has grown statewide in the last year, Williams said. Practitioners in the network reached 8,371 in June, compared with 6,029 in April 2020, he said.

But Stephanie Farrell, CEO of Left Hand Management, a consulting group that helps behavioral health care offices across the state with billing and training, said the health alliance caused the problem and should have to fix it — not put the burden on small counseling centers. Colorado Community Health Alliance should pay the consequences, Farrell said, including any potential federal fines for submitting incomplete paperwork. 

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“It’s just a clerical issue. A data issue,” she said. “Can’t they say, ‘Let’s call it a mulligan?'”

It’s the latest example in what Farrell says is a messed-up system in which the people providing the mental health care have no voice and are buried by mountains of paperwork. She blames the organizational structure and the contractors that dispense payment.

“It’s the wild, wild West,” she said. “They just do whatever they want and they are grinding up providers in the process.” 

Clipped from: https://coloradosun.com/2021/11/29/medicaid-mental-health-claims/

 
 

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Medicaid Change Sending up to 70 California Inmates in Nursing Home Care Back to Prison

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[ MM Curator Summary]: CA is unable to keep prisoners in nursing homes according to federal regulations that require no limitations on nursing home residents.

 
 

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 California policy and federal rules could limit medical parole to 70 inmates, sending dozens of quadriplegic, paraplegic or otherwise permanently incapacitated inmates from nursing homes back to state prisons.

California officials said they have no choice under a new approach to the enforcement of federal licensing requirements for nursing homes from the Centers for Medicare & Medicaid Services.

Prison officials said a change in federal rules led them to limit medical parole to only those inmates who are so ill they are hooked to ventilators to breathe, as their movement is so limited they are not a public danger.

The state policy previously allowed a much broader range of permanent incapacity, allowing inmates to be cared for in nursing homes outside of the prison walls. The policy change comes as the state of California has been reducing its prison population due to fear of spreading the coronavirus, as well as a push from voters and legislators to free infirm and after inmates who are less likely to commit more crimes.

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Nearly every state allows prisoners with serious medical conditions to be released on medical parole, according to the National Conference of State Legislatures, but the organization said in a 2018 review that such laws are rarely used.

Steve Fama, an attorney with the nonprofit Prison Law Office, said the court-appointed federal office that controls health care in California prisons told him the change could affect about 70 of the 210 inmates approved for medical parole under the current system.

“It’d be an awful shame if those people were returned to prison. Those patients have been proven not to need a prison setting given their medical conditions,” Fama said.

Federal officials have disagreed that revoking medical parole and putting the incapacitated inmates back into prison is the state’s only option, saying that California could leave the inmates in nursing homes with no prohibition on their leaving, or put them in different facilities that are not regulated by the federal government.

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For more reporting from the Associated Press, see below:

 
 

The federal agency has taken the position that parole officials can’t impose any conditions on inmates in community medical facilities, the state said. That includes a rule that inmates not leave except with permission from their parole agent—restriction state officials said is necessary to ensure public safety.

In response, only those on ventilators are being placed in the community, corrections department spokeswoman Dana Simas said.

Simas responded that sending offenders to such non-certified facilities “would require establishing an entirely new program to monitor and audit the care provided at these facilities.” Health care provided to offenders at the current facilities is checked by the federal receiver’s office and several outside agencies.

The policy change came after just one facility in Los Angeles County was informed following an inspection ending in early July that it was violating its licensing requirements, but state officials said the federal agency told them it will be enforced at all skilled nursing facilities.

The federal agency is citing a 2016 guidance memo that it said reiterated conditions under which parolees may remain in nursing facilities.

The state’s decision affects incapacitated inmates who are deemed to still need some sort of supervision, but it does not affect compassionate releases that are approved by a court and have no strings attached. Inmates can seek compassionate release if they are diagnosed with an illness that is deemed likely to cause their death in 12 months or less and is a medical condition they did not have when sentenced.

Several other states have had to address the same issue, though federal officials couldn’t immediately say which, when or how they complied.

Researchers from the Vera Institute of Justice, a national nonprofit research and advocacy group, said barriers include limited eligibility criteria and the difficulty in applying for release. Their 2017 report found that Alabama had released 39 people on medical parole over eight years, while Texas approved 86 out of more than 2,000 requests in 2016. The legislative organization said those states had some of the highest rates of release.

California eclipsed those releases by approving 210 medical paroles and denying 110 requests since 2014, though that is a tiny fraction of the nearly 100,000 inmates currently imprisoned in the most populous state.

California Assemblyman Phil Ting, who heads the powerful Assembly Budget Committee, is carrying a bill to expand the criteria and create an easier process for placing incapacitated inmates in community health care facilities.

“Limiting it to only those on ventilators is arbitrary and not based on medical science,” he said. “Public safety is not improved by taking such an unnecessarily narrow view of this policy.”

Ting’s bill would include those who qualify for hospice care or have debilitating pain or a debilitating disease. Instead of leaving the decision to the state parole board, which is composed largely of law enforcement officials, it would create a new medical parole panel at each prison made up of health care providers. It also would keep patients in outside facilities even if they no longer meet the criteria for medical parole.

It was originally carried by former Assemblyman Rob Bonta, now the state’s attorney general, and cleared the Assembly before stalling in the Senate last summer. Ting plans to try again next year.

Those sentenced to death, life without parole or for murdering police officers are not eligible under California law, and that would not change under Ting’s proposal.

 
 

Clipped from: https://www.newsweek.com/medicaid-change-sending-70-california-inmates-nursing-home-care-back-prison-1654675

 
 

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Missouri’s thin dental safety net stretched amid Medicaid expansion

[ MM Curator Summary] Missouri expansion is expected to place more strain on the dental network.

 
 

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.

 
 

Only 27% of dentists in Missouri accept Medicaid, one of the lowest rates in the country

 
 

Dr. Elena Ignatova prepares to make an impression of a patient’s mouth to fit dentures at CareSTL Health in St. Louis. Only 27% of Missouri dentists accept Medicaid, and many of those who do work at safety-net clinics like CareSTL Health (photo: Bram Sable-Smith).

This story was originally published by Kaiser Health News and KSMU.

At the Access Family Care clinics in southwestern Missouri, the next available nonemergency dental appointment is next summer. Northwest Health Services, headquartered in St. Joseph, is booked through May. The wait is a little shorter at CareSTL Health in St. Louis — around six weeks.

Roughly 275,000 Missourians are newly eligible this year for Medicaid, the federal-state public health insurance program for people with low incomes, and they can be covered for dental care, too. Missouri voters approved expansion of the program in 2020, the latest of 39 states to do so as part of the Affordable Care Act, but politics delayed its implementation until Oct. 1. Adults earning up to 138% of the federal poverty level — about $17,774 per year for an individual or $24,040 for a family of two — can now get coverage.

But one big question remains: Who will treat these newly insured dental patients?

Only 27% of dentists in Missouri accept Medicaid, according to state data, one of the lowest rates in the country. Many of them work at what are known as safety-net clinics, such as Access Family Care, Northwest Health Services and CareSTL Health. Such clinics receive federal funds to serve uninsured patients on a sliding scale and was experiencing huge demand for dental services before expansion.

The reason so few Missouri dentists accept Medicaid is simple, according to Vicki Wilbers, executive director of the Missouri Dental Association: The state’s program pays dentists extremely poorly compared with private insurance or what a dentist could charge a patient paying cash. Adding to the strain, said Wilbers, dentists who do accept Medicaid often must deal with the state plus private insurers that administer Medicaid through a program known as managed care.

“You have more people on the rolls, you still don’t have reimbursement rates increase,” Wilbers said. “And it’s cumbersome.”

Still, for these new patients, the coverage can be life-changing.

Only 37% of adults in the state with incomes under $15,000 per year saw a dentist in 2018 compared with 76% of adults earning over $50,000, according to a state report. A survey by the American Dental Association found 53% of low-income Missourians have difficulty chewing, 43% avoid smiling because of the condition of their mouth and 40% experience pain.

“I just don’t think those stories are told enough,” said Steve Douglas, spokesperson for Access Family Care in Neosho.

Douglas described a patient of the clinic who believes his so-far-unsuccessful quest for higher-paying work has been hindered by the appearance of his teeth.

“We’re hoping that with the Medicaid expansion we can get him in for some care,” Douglas said. “He would like to save some of his teeth and not go to full dentures.”

About 62% of Missouri adults making under $15,000 per year have lost at least one tooth to decay or gum disease, and 42% of people 65 and older in that income range have lost all of them, according to the state report. For Missourians earning over $50,000, those rates are 34% and 8%, respectively.

Part of the dental care backlog at Access Family Care, which offers dental services at five locations around southwestern Missouri, is due to the pandemic. The clinic laid off all 95 of its dental staffers in March 2020 before gradually building back to full capacity. As with dental practices nationwide, many of their patients are now coming to get the dental work done that they delayed earlier over fears of exposure to the coronavirus.

But central to the huge demand is an overall need for more providers. Nearly 1.7 million Missourians live in a federally designated dental professional shortage area, one of the highest levels of unmet needs in the country. It’d take another 365 dentists to fill that void, at least one extra dentist for every 10 already practicing in the state.

“We could easily employ another four dentists and still have high demand,” Douglas said.

His clinic, Access Family Care, has indeed hired two new dentists to start in 2022. To manage the dental caseload until then, though, it had to temporarily stop seeing new patients.

In St. Louis, Dr. Elena Ignatova, director of dental services at CareSTL Health, had 18 patients scheduled on a recent Wednesday in November. About a quarter of them were insured through Medicaid.

By 10 a.m., she had cast a mold of one patient’s mouth to fit dentures, referred another to an oral surgeon for a root canal and prepped a fourth-year dental student for the extraction of a Medicaid patient’s remaining teeth. In Missouri, Medicaid covers simple tooth extractions for adults but not root canals or crowns.

“We remove teeth because the other treatment is too expensive and they cannot afford it,” Ignatova said. “Then it can take years for those patients to come up with the money for dentures.”

Ignatova is booked into February, but the clinic still takes walk-ins for dental emergencies. She’s also working her way through a waiting list of 39 patients who might be able to show up quickly if a cancellation or no-show opens a spot in her schedule.

There is easily enough demand for another dentist, but Ignatova said they’re still working on hiring the dental assistants and hygienists needed to reopen the school-based clinics for kids they operated before the pandemic. Those hirings are in the works, but it is slow going. As with many health care facilities, she and others said, President Joe Biden’s vaccine mandates have added an extra hurdle to recruiting and retaining staff.

One clinic that isn’t seeing a bottleneck of dental patients, though, is KC Care Health Center in Kansas City. Kristine Cody, the clinic’s vice president of oral health services, said a new patient could be seen there in about a week. The Kansas City region benefits from having the University of Missouri-Kansas City School of Dentistry, which offers reduced-cost care to patients at the clinic where its students are trained, plus several other safety-net clinics.

KC Care also added two dentists and extended its clinical hours in anticipation of Medicaid expansion.

“I just hope people look to use it,” Cody said.

 

 
 

 
 

Clipped from: https://missouriindependent.com/2021/11/16/missouris-thin-dental-safety-net-stretched-amid-medicaid-expansion/

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Florida- Medicaid modernization will take hundreds of millions and require more staff

[ MM Curator Summary] Florida is beginning the process to rebid its MMIS and downstream modules.

 
 

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.

 
 

 
 

Florida’s health care regulation agency is setting the stage for an expensive rebuild of the computer systems that bind the state’s multibillion dollar Medicaid program even though state legislators have not agreed to pay for it.

The Agency for Health Care Administration has dropped three different invitations to negotiate with vendors that can update the state’s antiquated Medicaid management information systems and is expecting responses on the three requests by early- to mid-December.

In hopes of having contracts inked between the summer and fall of 2022, the agency is assembling for each Invitation to Negotiate (ITN) two multiagency teams — one to evaluate the vendors’ responses and the other to negotiate with vendors that received top evaluation scores.

Now all the agency needs is the Florida Legislature to approve its legislative budget request for $117.8 million so it can pay the vendors for the needed work. It’s a number that one top House Republican already suggested may be “excessive.” 

Currently, the Medicaid management information system is a single integrated system for claims processing and information retrieval. But AHCA wants to transform that into a modern modular system that connects with other data sources and programs.

 
 

Florida Health Care Connections, or FX, is the moniker AHCA assigned to the transformation of the system and the subsequent modular procurements necessary to make it happen. Florida lawmakers have already appropriated more than $158 million over the past five budgets for the replacement of the system responsible for billing and payment to the managed care companies, doctors and pharmacies providing health care to millions of Floridians enrolled in Medicaid.

FX Program Director Mike Magnuson told members of the FX Executive Steering Committee on Wednesday the latest budget request for the upcoming fiscal year 2022-2023 budget, “includes the funding to start the contracts that we now put out on the street. So the majority of it will be the fixed price deliverables for those functions.”

In addition to requesting the $117.8 million to help initially pay the three ITNs, Magnuson told FX Steering Committee members the agency requested another $1.97 million to hire 12 full-time employees who can provide ongoing support to the office that will be created to help with the system.

Without the funding, Magnuson said, the agency would be reliant on paying contracted staff in order to operate the FX updates.

But Rep. Bryan Avila, the South Florida Republican charged with leading efforts to assemble a health care budget in the House of Representatives, recently questioned the size of the agency’s legislative budget request by asking if the project total was inflated.

 
 

Meanwhile, the three ITNs AHCA published have a combined value of nearly $350 million over a seven-year period.

The first ITN AHCA will award is for modular “unified operations centers” services. The contract would be in effect between Aug. 1, 2022, and July 31, 2029, and could be worth more than $161 million.

The second ITN AHCA will award is for modular provider management services.The system must allow for concurrent processing of enrollment and plan credentialing activities for both initial enrollment as well as renewals. According to the ITN, the contract would be in effect from Sept. 1, 2022, through Aug. 31, 2029, and would be worth more than $33 million.

The third ITN the agency will award is for so-called core systems and is expected to be worth $154.5 million. According to the ITN, the contract would be in effect between Nov, 1, 2022, and Sept. 30, 2029. 

“We are getting to the point where the rubber is starting to meet the road,” AHCA Secretary Simone Marstiller told members of the FX Executive Steering Committee. “It’s all starting to come together.”

Clipped from: https://floridapolitics.com/archives/472301-medicaid-modernization-will-take-hundreds-of-millions-and-require-more-staff/

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NY- Former Employees At State Administrator Of Medicaid Transportation And Business Owner Charged With Submitting Fraudulent Claims

[ MM Curator Summary] 2 NY NET dispatchers routed trips to a company owned by a person they colluded with to commit fraud.

 
 

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.

 
 

Damian Williams, United States Attorney for the Southern District of New York, Scott J. Lampert, Special Agent in Charge of the New York Regional Office of the U.S. Department of Health and Human Services, Office of the Inspector General (“HHS-OIG”), and Ricky J. Patel, Acting Special Agent in Charge of the New York Field Office of the Homeland Security Investigations (“HSI”), announced the unsealing of an Indictment charging PATRICK NDUKWE, DAVID TRAVERS, and MICHELLE MARTIN with participating in a fraudulent scheme in which TRAVERS and MARTIN improperly routed trips for Medicaid-funded transportation to NDUKWE’s company, Quality Service Medical Transportation (“Quality”) and facilitated fraudulent Medicaid claims by Quality.  The case is assigned to U.S. District Judge Denise L. Cote.

U.S. Attorney Damian Williams said: “Every day, thousands of government employees and private contractors around New York are entrusted with handling, disbursing, and guarding public funds.  As alleged, David Travers and Michelle Martin, who were employees at the state manager for Medicaid-funded transportation, abused their roles and the public’s trust when they took payments to steer business to a private company and helped that company submit fraudulent Medicaid claims.  This Office and our law enforcement partners will always investigate and prosecute the illegal abuse of public programs for unjust enrichment.”

HHS-OIG Special Agent in Charge Scott J. Lampert said: “The defendants in this case allegedly engaged in a greed-fueled fraud scheme that undermined the Medicaid program and diverted taxpayer funds from their intended purpose of providing health care benefits to low-income individuals and families.  Together with our law enforcement partners, HHS-OIG will continue to vigorously pursue those who steal from government health programs for personal gain.”

HSI Acting Special Agent in Charge Ricky J. Patel said: “As alleged, these defendants lined their pockets by abusing a program created to provide assistance to the sick and injured in our communities.  Working with our partners, HSI will seek out and bring to justice those that attempt to undermine any federal or state program, explicitly those designed to help millions of our most vulnerable in New York.”

As alleged in the Indictment, which was unsealed today, public filings, and statements in court:[1] 

In New York, individuals who are enrolled in the state’s Medicaid program are eligible to have Medicaid pay for their transportation to and from medical appointments if they are not able to safely take public transportation.  To obtain Medicaid-funded transportation, the enrollee or their health care professional must schedule transportation by contacting the private company that is contracted to manage Medicaid-funded transportation in the New York City area (the “Transportation Manager”).

NDUKWE, 56, was the owner and operator of Quality.  From in or about May 2017 to March 2020, Quality was paid more than $7.3 million for more than 120,000 trips the company purportedly provided for Medicaid-enrolled customers in the New York City area.  However, many of these trip claims were fraudulent and never actually performed.  In some instances, the Medicaid-enrollee who purportedly used Quality to travel to a medical appointment had, in fact, never heard of or used the company for any transportation services.  In other instances, the driver who Quality said performed the trip had never actually worked for the company.  In yet other instances, Quality paid a periodic “kickback” to a Medicaid enrollee to use that enrollee’s personal identifying information to submit a trip claim.

TRAVERS and MARTIN were customer service representatives at the Transportation Manager.  Both were responsible for, among other things, receiving calls from Medicaid enrollees who needed transportation and then randomly assigning those trips among the dozens of eligible transportation companies in the New York City area.  However, both TRAVERS and MARTIN steered a disproportionately high volume of their trips to Quality.  In addition, when certain enrollees requested to be moved from Quality to another transportation company, TRAVERS and MARTIN ensured that the customers were eventually reassigned back to Quality.  TRAVERS and MARTIN also scheduled trips for Quality that they knew would not be performed and would allow Quality to submit fraudulent claims for payment.  For their fraud, both TRAVERS and MARTIN received payments from NDUKWE.

*                      *                      *

NDUKWE was arrested this morning in the Bronx and will be presented later today before U.S. Magistrate Judge Ona T. Wang in Manhattan federal court.  TRAVERS was arrested this morning in Syracuse, New York, and Martin was arrested this morning in East Syracuse, New York.  Both TRAVERS and MARTIN will be presented later today before U.S. Magistrate Judge Therese Wiley Dancks.

NDUKWE, TRAVERS, and MARTIN are each charged with one count of theft of government funds, in violation of 18 U.S.C. § 641; one count of health care fraud, in violation of 18 U.S.C. § 1347; one count of conspiracy to commit health care fraud, in violation of 18 U.S.C. § 1349; and one count of violating the Anti-Kickback statute, in violation of 42 U.S.C. § 1320a-7b. In addition, NDUKWE is charged with one count of aggravated identity theft, in violation 18 U.S.C. § 1028A. In February 2020, as part of the same investigation, the Government charged 13 defendants involved in a different transportation company.

The crimes of theft of government funds, health care fraud, conspiracy to commit health care fraud, and violating the Anti-Kickback Statute each carry a maximum sentence of 10 years in prison.  The crime of aggravated identity theft carries a mandatory two years in prison.  The maximum potential sentences in this case are prescribed by Congress and are provided here for informational purposes only, as any sentencings of the defendants will be determined by a judge.

Mr. Williams praised the outstanding work of DHHS-OIG and HSI.  He also thanked the Office of the New York State Medicaid Inspector General, New York Attorney General’s Medicaid Fraud Control Unit, United States Customs and Border Protection, the Syracuse Police Department, the Onondaga County Sheriff’s Office, the Internal Revenue Service, the New York City Police Department, and the U.S. Probation Office for the Northern District of New York for their assistance in the case.

This case is being handled by the Office’s General Crimes Unit.  Assistant United States Attorneys Brandon D. Harper and Kedar S. Bhatia are in charge of the prosecution.

 
 

[1] As the introductory phrase signifies, the entirety of the text of the Indictment are herein are only allegations, and every fact described herein should be treated as an allegation.

 
 

Clipped from: https://www.justice.gov/usao-sdny/pr/former-employees-state-administrator-medicaid-transportation-and-business-owner-charged

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Centene Will Address Serious Mental Healthcare in AZ Medicaid

[ MM Curator Summary] Centene has won a new BH contract in AZ.

 
 

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 payer’s contract to address serious mental healthcare needs in Arizona will last three years, with the opportunity to extend the contract.

By Kelsey Waddill

November 16, 2021 – Centene Corporation (Centene) will be expanding its Medicaid coverage in Arizona to provide serious mental healthcare services in a competitive contract expansion, the payer announced.

“We are honored to continue our long-standing partnership with the state of Arizona to provide access to comprehensive, quality healthcare to members living with serious mental illness and other complex situations and crisis,” said Brent Layton, president and chief operating officer of Centene. 

“Centene has a long history of coordinating integrated physical and behavioral healthcare in Arizona, and we look forward to continuing to work with local providers and community partners to help Arizonans live better, healthier lives.”

The plan’s subsidiaries, Arizona Complete Health-Complete Care Plan and Care1st Health Plan Arizona, will offer physical and behavioral healthcare services to individuals with serious mental health conditions. 

Specifically, the payer will provide services for individuals eligible for Title XIX and Title XXI services. These groups of beneficiaries may all under Medicaid or Children’s Health Insurance Program (CHIP) coverage. Centene’s plans will also address crisis system functions and court-ordered evaluations in addition to services that run on grant funding.

The payer will cover around 22,000 beneficiaries in 12 counties—seven counties in southern Arizona and five counties in the northern area of the state—as well as other regions that require crisis support.

The contract will last three years starting October 1, 2022. Arizona’s Medicaid program will have the option to renew the contract as a two-year contract twice.

“It is a privilege to have been selected to continue serving Arizonans living in crisis or with severe mental illness,” said Martha Smith, president and chief executive officer of Centene’s Arizona plan. 

“Our mission is to transform the health of our communities, one person at a time, which we believe requires a holistic approach to care that addresses mind, body, and social determinants of health, such as nutrition, housing, and employment. The result is improved health outcomes, lower costs, and a higher quality of life.”

The announcement comes shortly after Centene released a report on improving mental healthcare for children.

“Payers are uniquely positioned to play a critical role in advancing mental healthcare delivery through continued support of innovative technology, evidence-based clinical programs, educational programming, and community partnerships,” Centene’s report explained.

Centene is acquiring Magellan Health, a behavioral healthcare platform, in an effort to diversify and integrate its behavioral healthcare capabilities. The payer announced its plans to acquire Magellan Health in January 2021.

In Magellan Health’s 2021 second-quarter financial report, the behavioral healthcare company projected that the acquisition would finalize in the second half of 2021.

Integrating physical and mental or behavioral healthcare services is a key part of Centene’s behavioral healthcare strategy. 

Brett Hart, chief operating officer of medical strategy and former chief behavioral health officer at Centene, told
HealthPayerIntelligence that for the past three to four decades behavioral healthcare has been isolated from physical healthcare services. 

Thus, when instituting new efforts to bridge the gap between mental or behavioral healthcare and physical healthcare whether in the private payer setting or for a public payer such as Arizona’s Medicaid program, Hart noted that payers must address both historic barriers to integration as well as the new challenges that they face with new technologies and frameworks.

These efforts to integrate care are critical for Medicaid programs because Medicaid has proven instrumental in enabling access to substance abuse care and behavioral and mental healthcare treatment.

 
 

Clipped from: https://healthpayerintelligence.com/news/centene-will-address-serious-mental-healthcare-in-az-medicaid
 

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With big federal boost, Virginia shows Medicaid surplus this year, helping offset future costs

[ MM Curator Summary] Virginia predicts a Medicaid funding surplus next year, followed by a big jump to create nearly $1B more in Medicaid spending in the state within 2 years.

 
 

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 Northam talks about the state’s budget reserves

Virginia is showing a surplus of almost $654 million in its Medicaid program, boosted by federal spending that will help offset future cost increases in the next state budget for the $18 billion program for poor, elderly or disabled Virginians.

Medicaid costs will go up by a net $821 million in the two-year budget for July 1, 2022, to June 30, 2024, which Gov. Ralph Northam will introduce on Dec. 16, but state officials also foresee a $124 million windfall if the federal government raises its share of the program expenses by almost 1% next year as tentatively proposed.

Program costs are projected to grow 1% in the first year and 5% in the second, administration officials said Wednesday.

“The numbers have come in lower than they have historically,” Secretary of Finance Joe Flores said in a briefing with leadership of the Department of Medical Assistance Services, the state Medicaid agency.

At the same time, Virginia will begin sorting out the effects of the COVID-19 pandemic, which added 392,000 people to the Medicaid rolls, some temporarily, as well as refugees from the Taliban takeover of Afghanistan who have settled in the state and qualify for health care assistance. Medicaid now serves more than 1.9 million Virginians in a state of 8.6 million.

The federal government has boosted emergency support of the program during the pandemic, extending a temporary 6.2% increase in its share of funding through March 31. The enhanced aid will reduce Virginia’s share by almost $146 million in the fiscal year that began July 1 and save the state more than $1 billion since the public health emergency began in March 2020.

 
 

Clipped from: https://richmond.com/news/state-and-regional/govt-and-politics/with-big-federal-boost-virginia-shows-medicaid-surplus-this-year-helping-offset-future-costs/article_4f2d1ca3-2c17-5c67-a0a1-86223fbea569.html