Tag: State News

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Proposed Facelift For Arkansas’ Medicaid Expansion Sparks “Equal Access” Questions

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The proposed use of community engagement requirements to get Medicaid managed care (vs fee for service) is being targeted by opponents as a violation of the equal access clause of SSA.

 
 

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.

 
 

For the most part, Arkansas has been successful in navigating state politics and the federal waiver process to expand Medicaid coverage for its residents, albeit with that navigation resulting in some dubious policy choices. Arkansas intermittently added waiver features such as work and community engagement requirements, premium obligations for enrollees with household incomes above 100 percent of the federal poverty level, and health independence accounts (a swiftly discontinued feature that was operationally flawed) to achieve the required supermajority vote in both state legislative chambers to continue funding authorization for Medicaid expansion.

However, the major and most innovative feature of the state’s Medicaid expansion has been the use of “premium assistance”—a long-standing option for Medicaid but made feasible by standardization of the essential health benefit. Instead of enrolling eligible individuals in the Medicaid fee-for-service program or managed care organizations, Arkansas used Medicaid dollars to purchase individual market qualified health plans (QHPs) available on the Affordable Care Act’s newly established health insurance Marketplace. By doing so, the state unquestionably met the Medicaid “equal access” requirement—the requirement that payments are “sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area” for the expansion population.

Arkansas’ expansion program is currently undergoing another facelift with the passage of enabling legislation for Arkansas Health and Opportunity for Me, or ARHOME . This version of Medicaid expansion still sits on the chassis of premium assistance, but it incorporates incentives for “full-time work and attainment of economic independence” and “encourages personal responsibility for individuals to demonstrate that they value healthcare coverage and understand their roles and obligations in maintaining private insurance coverage.” Failure to participate in so-called “economic independence incentives,” including work and community engagement, does not result in loss of coverage as it did before. Courts and the Biden administration have closed that door. Instead, as initially proposed in the enabling legislation and as previously stated by supporters in remarks to the news media, an ARHOME enrollee in a QHP could be moved into Medicaid fee-for-service for failure to participate.

Evaluating The Premium Assistance Model

Being moved from a QHP to the Medicaid fee-for-service program could certainly be viewed as a penalty. After all, the stigma of Medicaid has been documented and is among the many reasons that Arkansas opted for a premium assistance model in the first place. The federally required evaluation of the Health Care Independence Program—the first iteration of expansion in Arkansas that was also known as the “Private Option”—showed that Medicaid enrollees in QHPs experienced better access—both perceived and actual—and higher-quality care than enrollees in fee-for-service. This is not at all surprising: It follows the mantra, “You get what you pay for.” The evaluation found that physician payment rates for outpatient services were about 95 percent higher in each of the three years under study for enrollees in a QHP compared to their Medicaid fee-for-service counterparts. For inpatient stays, there was a 53 percent difference in payment rates per discharge, inclusive of supplemental payments above the base rates.

These cost-related findings from the evaluation have been used by some Arkansas legislators to argue that the state should save its money by ending the premium assistance approach and moving all of the enrollees into Medicaid fee-for-service. In fact, a group of legislators filed a bill to do exactly that. Fortunately, the majority of the Arkansas General Assembly has not been tempted to move in that direction, confident that the premium assistance approach has not only improved quality and access for expansion enrollees but has also benefitted the individual insurance market by promoting enhanced competition and stabilizing premiums. Equally if not more attractive are the fiscal benefits to the state budget and providers from higher QHP reimbursement rates, which have shored up the state’s rural hospitals (only one has closed in Arkansas in recent years, compared to 57 in surrounding states that did not expand).

Medicaid Premium Assistance Versus Fee-For-Service

The ARHOME waiver application appears to have walked back on “reassignment” of QHP enrollees to Medicaid fee-for-service for failure to participate in economic independence incentives as originally proposed. The application indicates both a delay in implementation until 2023 and a regulatory process for defining what it means to be an “inactive” beneficiary for purposes of reassignment. Regardless, the waiver feature as originally proposed has sparked a debate about the Medicaid “equal access” requirement and whether compliance is in question.

Evaluation of the premium assistance model in Arkansas established that the QHPs provided beneficiaries with enhanced access and quality. Ideally, state officials would have used the evaluation findings to acknowledge and address what led to the disparities in access and quality—that is, the insufficiency of Medicaid fee-for-service payments. Instead, the ARHOME waiver application now proposes to evaluate “whether beneficiaries enrolled in a QHP recognize and value the health coverage as insurance above and beyond Medicaid medical assistance.” Federal officials should vigilantly examine compliance with Medicaid “equal access” requirements before considering waiver proposals from any state that would reassign a beneficiary to a care delivery strategy with lower provider payments.

To be fair, Arkansas Medicaid officials have launched a systematic review of reimbursement rates in response to a 2019 executive order issued by the governor, and the review must consider “the availability and access to care in each area of the state.” Prior to the executive order, there was no schedule or standardized process for rate review, despite the state’s being subject to a consent decree that requires court review of rate changes. In place since 1993, the consent decree is the result of a lawsuit brought by provider groups, and, while intended to ensure sufficient Medicaid payment rates, rates have actually stagnated under court oversight, with some providers not seeing rate increases in more than a decade.

Consent decrees resulting from “equal access” lawsuits have been at risk of being dissolved since the US Supreme Court held in 2015 that health care providers have no right to sue to enforce the terms of the federal Medicaid statute. To date, Arkansas Medicaid officials have not moved to dissolve the consent decree, but recent legislation passed by the Arkansas General Assembly requires the state to seek reconsideration of the consent decree in light of the 2015 Supreme Court decision.

Back And Forth On “Equal Access” Monitoring

Following the 2015 decision, the Obama administration issued regulations requiring states to regularly submit reports documenting their monitoring of access for Medicaid enrollees and to prospectively submit for federal review any proposed rate reductions or changes that could result in diminished access. However, as documented in this Health Affairs blog post, in 2019 the Trump administration proposed regulations that would have abandoned efforts to ensure some level of state-based monitoring. What is more, the proposal fully retreated from prospective federal review of Medicaid provider payment reductions. Interestingly, the Trump administration’s proposed regulations were never finalized, which means that the Biden administration could rescind the proposed rule and reexamine whether the Obama-era regulations are effective at ensuring access.

Such an examination should consider the following questions at minimum:

Are State-Based Assessments Of Payment Rates And Monitoring Of Access Rigorous Enough To Determine Compliance With The Law?

As has been the case with demonstration waiver evaluations, the administration should be clear about the data collection, methodological, and measurement expectations for state reporting. It should also consider requiring an independent assessment.

How Do Medicaid Rates Compare To Both Medicare And Commercial Insurance Payment Rates?

Data to enable these types of comparisons are increasingly available. Both states and the federal government have invested in state-based all-payer claims databases, and they should use them as an available tool to enhance the assessment.

Should The Administration Establish A Standard Rate-Setting Methodology And Network Adequacy Requirements For Medicaid, Irrespective Of The Care Delivery Strategy?

Clearly Arkansas’ fee-for-service rates fall short of meeting the Medicaid “equal access” provision, and many other states report similar disparities, despite federally required access monitoring and reporting requirements. While offering the opportunity for more comprehensive measuring and stringent monitoring of access and quality contractually, managed care strategies similarly disappoint on the payment front. State requirements for managed care plans to offer minimum provider reimbursement—if there are requirements—are often tethered to Medicaid fee-for-service rates. The use of Medicaid premium assistance through QHPs by definition meets the “equal access” standard. Should we not expect more of other Medicaid delivery strategies?

The “equal access” quandary might not be at the top of the Biden administration’s policy priorities, but Arkansas’ waiver proposal is certain to provoke questions about how the administration can possibly square approval of a reassignment feature while advancing broadly applicable equal-access regulations. As the administration negotiates with states on one-off waiver features, it should be careful not to send mixed messages and erode long-established—albeit ill-defined and tepidly enforced—beneficiary protections engrained in Medicaid law.  

 
 

Clipped from: https://www.healthaffairs.org/do/10.1377/hblog20210624.640822/full/

 
 

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Many Louisiana residents may need to renew Medicaid benefits as COVID-19 emergency winds down

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Louisiana HHS officials have now sent the 2nd in a series of letters notifying members they need to submit documentation to maintain their Medicaid coverage.

 
 

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.

 
 

Louisiana residents who are enrolled in Medicaid may begin receiving letters from the Louisiana Department of Health informing them that their coverage will end when the federal public health emergency declaration for COVID-19 is lifted.

These “preclosure” letters are among the first public-facing steps Medicaid has taken towards a return to normal operations after a year and a half of emergency response.

The federal public health emergency, which underpins that emergency response, is expected to last until at least the end of 2021. But when it does end, the state’s Medicaid office will be faced with a backload of renewals and eligibility checks.

Over the course of the pandemic, the number of Louisiana Medicaid recipients has grown substantially. Emergency programs have supported much of that growth the past year, but the federal government has asked states to begin planning how to wind down emergency measures, which means, in large part, resuming eligibility checks and disenrolling recipients.

Most of Medicaid’s growth has come from the Affordable Care Act’s expansion program, which covers low-income adults.

In March 2020, 483,000 people received Medicaid under the Affordable Care Act’s expansion, and 1.6 million people were enrolled in total. By May 2021, those numbers were 639,000 and 1.9 million respectively — roughly 40 percent of the state’s residents.

That mirrors a national trend. According to a report released this week by the Centers for Medicare & Medicaid Services, fully a quarter of the U.S. population is now enrolled in Medicaid.

That rise comes partly because of job losses caused by the pandemic, and partly because over the course of the pandemic, Louisiana, like every other state, has virtually halted all Medicaid disenrollments.

That’s important because under normal circumstances, recipients would be subject to regular eligibility checks.

Those eligibility checks happen in several ways: On the most basic level, Medicaid recipients need to renew their coverage every year, either online or over the phone.

But Louisiana conducts the extra step of quarterly wage checks to determine whether someone has exceeded income limits over the course of the year. The checks are automated using a Louisiana Workforce Commission database, and when someone does not pass a check, they receive a letter asking them to provide more information or contest the decision.

The eligibility checks and renewals have been paused by a federal policy related to pandemic Medicaid funding. The cost of Medicaid is split between the state and the federal government, and during the pandemic, the federal government has paid for a larger share. The agreement required states to maintain their Medicaid rolls, with a few narrow exceptions for those who died or moved out of state. That will soon be coming to an end.

In December, the federal government asked states to begin planning for renewed eligibility checks. That guidance was released under the Trump administration, and according to a statement provided by Medicaid to the Lens, “we are prepared with an operational plan. Additional guidance from [the Centers for Medicare & Medicaid Services] is forthcoming.”

Churn

Many of the people who are disenrolled may in fact no longer be eligible for Medicaid benefits. But the return to eligibility checks also creates the risk of disenrolling people who are eligible, a phenomenon known as “churn.”

Churn, in which eligible people repeatedly lose and reapply for coverage because of administrative procedures, predates the pandemic, said Stacey Roussell, the policy director of the Louisiana Budget Project, a left-leaning policy think tank.

“What you find in the income level of people who qualify for the Medicaid expansion is, it’s very common throughout the year to have fluctuations in income,” Roussell says. “There are parts of the year where maybe their household need is greater, and they’re going to pick up extra shifts.”

So even though a household may qualify for Medicaid on the basis of its annual income, a quarterly wage check may flag a seasonal fluctuation — like the spring tourist season — as a reason to end eligibility. When that happens, Medicaid sends the recipient a letter asking for more information.

But the recipient has only 10 days to respond, starting from the date the letter was mailed. That tight window, according to an April policy brief from the U.S. Department of Health and Human Services, “rais[es] concerns about the limited time allowed to gather appropriate documentation.”

LDH has published similar conclusions: a 2019 report to the state legislature found that 85 percent of Medicaid eligibility cases were closed because a recipient failed to respond to a request for information.

“These closures do not necessarily indicate ineligibility for Medicaid benefits, and individuals may return to eligibility if supporting information is provided,” the report reads.

The HHS policy brief also noted that churn may lead to higher per-patient Medicaid costs, both because recipients with sporadic coverage are less likely to seek preventative care, which is generally less expensive than emergency care, and because disenrolling and re-enrolling recipients creates high administrative costs for states.

Louisiana enrollees will have months before the end of the pandemic to respond to or contest Medicaid’s inquiries. Still, proving eligibility can present its own challenges, especially for people who may have lost shift work because of the pandemic.

160,000 facing end of benefits

In a December report produced by the legislature’s Joint Medicaid Oversight Committee, LDH estimated that 160,000 people would become ineligible as a result of reinstating eligibility checks. That’s more than the total growth during the pandemic to that point.

However, said Courtney Foster, the Louisiana Budget Project’s Medicaid policy advocate, “we have some issues with this number, because they estimate based on the number of people disenrolled at prior [quarterly wage checks]… [which] does not automatically mean they were ineligible. The number could set an expectation from the legislature or others that they should expect at least that number of people to be disenrolled immediately when the [Public Health Emergency] ends.”

“We want to make sure that, post COVID, as people have delayed care, that they’re as connected to the available health insurance as possible, or else I think we will see an increase in medical debt, or showing up in emergency rooms in need of care that they’ve forgone because they didn’t have health insurance,” said Roussell. “There’s a lot at stake going into 2022 and getting it right.”

A January report from the Commonwealth Fund warned that “erroneous disenrollment could affect tens of millions of Medicaid enrollees” across the country.

In the December report, LDH says that it expects an “overwhelming workload of over 500,000 tasks that are anticipated at the end of the [Public Health Emergency].” In that report, LDH expected to complete the transition process by six months after the end of the public health emergency.

That began with letters sent out in January to those who were up for renewal, “asking them to renew their coverage or to supply additional information,” according to a statement attributed to Medicaid provided by LDH spokesman Kevin Litten. 

The letters sent this month are a follow up to those initial communications.

“Starting this month, if members do not respond to these letters, they will lose their coverage when the public health emergency ends,” according to the Medicaid statement Litten provided. “At the end of the public health emergency, members will receive one final letter alerting them to their final date of health care coverage.”

There are steps that the state could take to soften the blow. One of them, expanding Medicaid coverage for people who have just given birth using funding from the American Rescue Plan, died in the 2021 legislative session. It’s also unclear how the legislature’s decision to set the Medicaid budget $24 million below Gov. John Bel Edwards’ original budget proposal will impact recipients. 

Roussell said that her organization’s goal is to see the process slow down and focus on people who still need coverage.

“If you’re entering into it just to say, ‘we must get everybody who is ineligible off the rolls as fast as possible,’ then you’re willing to sacrifice a huge number of people who may still be eligible,” she said. “We want to say, let’s first make sure that everybody has the best chance possible to show that they’re eligible.”

 
 

Clipped from: https://thelensnola.org/2021/06/29/many-louisiana-residents-may-need-to-renew-medicaid-benefits-as-covid-19-emergency-winds-down/

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Medicaid rebid stripped from Ohio budget. Other actions unclear

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The requirement to ensure a local plan wins contracts has been removed from the latest Ohio budget bill.

 
 

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 full implications of this week’s budget negotiations for a redesign of the Medicaid managed-care system seemed unclear Tuesday.

The Toledo Blade reported that language that would have required the Ohio Department of Medicaid to re-do a massive redesign and procurement in its managed-care system was stripped from the version of the state budget that was passed Monday. But the package was said to retain special considerations for Medicaid managed-care companies that are headquartered in Ohio.

Advocates following the issue closely said they were still studying the matter. The office of Gov. Mike DeWine declined to comment.

Two Northwest Ohio lawmakers, Senate President Matt Huffman, R-Lima, and Sen. Theresa Gavarone, R-Bowling Green, had inserted language requiring that the Medicaid system rebid the work after Paramount Advantage, a subsidiary of Toledo-based ProMedica, lost out badly in the original procurement earlier this year. Paramount said the process was biased against it.

The loss of the business, ProMedica has said, will cost the region 600 jobs. The company didn’t respond to a request for comment Tuesday.

Gavarone told The Blade that she was disappointed that language that would give Paramount another shot was stripped out during conference-committee negotiations. She was a member of the committee.

Critics of the attempted do-over said it threatened the launch of OhioRISE, a program that would create wraparound services to up to 60,000 kids with complex behavioral needs. Such children are currently in the care of multiple agencies and in some cases, parents have to surrender custody to county health officials so that they can get the services they need. The program is a major priority of DeWine’s.

Also, rebidding the work threatened to at least delay restructuring the way the $29 billion-a-year Medicaid system purchases most of its prescription drugs. Managed-care providers currently hire pharmacy middlemen who work behind a veil of secrecy and have been shown to mark up generic drugs by hundreds of millions of dollars on Ohio.

The Medicaid redesign takes that work away from managed-care companies and gives it instead to a separate pharmacy middleman, or benefit manager, who would work directly for the state. The idea is to give state officials a window onto pricing and reimbursement data, as well as decisions regarding which drugs get preferred treatment.

Perhaps most significantly, when the budget conferees apparently eliminated language requiring that Medicaid managed-care business be re-bid, they upheld the philosophy of competitive procurement. Some critics expressed fears that if the re-bidding requirement stayed in the budget, it would have sent the wrong message to future disappointed bidders: If you lose out initially, all you have to do is lobby and litigate your way back into the game.

 
 

Clipped from: https://ohiocapitaljournal.com/2021/06/30/medicaid-rebid-stripped-from-ohio-budget-other-actions-unclear/

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Georgia officials seek to postpone limited Medicaid expansion

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Georgia HHS officials have asked for a minimum of a 1 month delay to implement their limited Medicaid expansion while they negotiate with a Biden administration hostile to its design.

 
 

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 — State health officials are asking the federal government’s permission to delay the implementation date of a limited, Georgia-specific expansion of Medicaid for at least a month.

In a letter dated June 24, state Community Health Commissioner Frank Berry cited a decision during the early weeks of the Biden administration to withhold approval of a Georgia Medicaid waver application then-President Trump’s administration signed off on last year.

Biden’s Center for Medicare & Medicaid Services objected to provisions in the proposed Georgia Pathways program requiring Medicaid recipients to work, attend school or volunteer at least 80 hours a month. CMS officials argued recipients would have a particularly hard time complying with a work requirement during the pandemic.

Berry disagreed with the federal agency position’s in a letter he sent to CMS in March.

“Georgia Pathways provides a wide range of qualifying activities in which individuals can engage,” the commissioner wrote. “Moreover, there is also a temporary ‘good cause’ exception if, after enrolling in Medicaid through Georgia Pathways, an individual or immediate family member experiences a hospitalization or serious illness or needs to quarantine due to COVID exposure.

“If anything, the COVID-19 crisis makes the qualifying hours and activities — which include work, job training, education, or volunteering — more important, not less. CMS must allow this program to begin as planned and authorized.”

With the program set to take effect July 1, Berry’s letter asks for more time while discussions between the state and CMS continue.

Gov. Brian Kemp rolled out the limited Medicaid expansion plan early in 2019 as an alternative to the Affordable Care Act then-President Obama steered through a Democratic Congress in 2010. The General Assembly passed legislation later in 2019 authorizing the governor to submit two waiver applications to the feds.

Besides the Medicaid waiver, a second waiver would substitute a private-sector alternative to the federal government’s healthcare.gov insurance exchange.

CMS is also revisiting that second waiver, which the Trump administration approved last fall. Earlier this month, the agency ordered the state to revisit the data used to justify the new approach, taking into account changes in federal law and policy that have occurred since Biden took office.

 
 

 
 

Clipped from: https://www.news-daily.com/news/state/georgia-officials-seek-to-postpone-limited-medicaid-expansion/article_7d3b2daa-d5dc-515d-85e1-9ef86466ee24.html

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OHIO- Proposed budget changes said to threaten Medicaid reforms

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New information suggests that the former Medicaid director helped the losing plan lobby lawmakers to require the bids be thrown out.

 
 

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.

 
 

Disappointed bidder seeking a do-over

The Republican leadership of the Ohio Senate is attempting to give an Ohio-based Medicaid managed-care company a do-over after it failed badly in a competitive process to keep its business with the state.

Critics say the do-over — which was apparently lobbied for by the previous Medicaid director — would at least delay a series of reforms to a Medicaid system that has been vulnerable to huge rip-offs related to prescription drug purchases. It also threatens a new program that would coordinate care for up to 60,000 kids with complex behavioral needs, critics add.

Perhaps worst of all, said one opponent, using legislation to possibly restore a contract to a business that lost it through competitive bidding sets a terrible example for all future failed bidders.

“Regardless of the rationale, I have tremendous concern that unravelling the Medicaid managed-care procurement after-the-fact undermines the whole intent of the competitive bidding process, which is a necessary accountability mechanism in the system,” said Antonio Ciaccia, who helped lead the drive to reform the way Ohio spends billions annually on prescription drugs. “It would send a signal to the entire insurer marketplace that if you underperform and lose out, all you have to do is lobby and litigate your way back into the winner’s circle.”

Whether the do-over will happen will partly be decided in the coming days as conferees from the Ohio House and Senate hash out a compromise budget that would go to Gov. Mike DeWine for his signature, or veto. If DeWine is forced to make such a decision, it promises to be politically dicey for him.

Claims of bias

The care company that would benefit from the do-over, Paramount Advantage, says it’s the victim of a flawed process that stands to cost Northwest Ohio 600 jobs.

“Paramount maintains that the Ohio Department of Medicaid’s managed care organization… procurement process was systemically flawed and unfair,” Tausha Moore, its director of public relations, said in an email Wednesday. “Out-of-state, for-profit, multi-billion-dollar Fortune 500 companies appear to have been favored over mission-driven, not-for-profit managed care organizations headquartered in Ohio, including those that have received some of the highest quality scores as Medicaid managed care providers.”

Paramount Advantage is a subsidiary of Toledo-based ProMedica, a health care system operating in Northwest Ohio and Southeast Michigan. And while it and many other health care systems are 501(c)(3) nonprofit organizations, they’re quite profitable for their top employees.

ProMedica’s 2018 tax filings show that it had six employees making more than $1 million that year and 18 others earning more than $500,000.

Paramount is a longtime Ohio Medicaid managed-care organization, meaning that it creates networks of providers such as doctors for its Medicaid clients, handles reimbursements and works to create savings because it receives a fixed amount each year for each client it serves. But during its tenure, the Medicaid managed-care system has faced problems.

In 2016, Paramount and the other four managed-care companies serving Ohio Medicaid came under scrutiny over the conduct of companies they hired to handle pharmacy benefits. Pharmacists around the state complained that those companies, known as pharmacy benefit managers, used a non-transparent system to often reimburse them below their cost, billed companies such as Paramount top dollar and then pocketed the difference.

An analysis of 2017 transactions showed that for the cheapest class of drugs alone, pharmacy benefit managers CVS Caremark and OptumRx billed the state almost a quarter billion dollars more than they reimbursed pharmacists.

More recently, Centene, owner of another managed-care plan, this month agreed to pay $88 million after Ohio Attorney General Dave Yost accused it of a number of bad acts, including using a chain of pharmacy benefit managers in a scheme that amounted to double billing. The company has set aside more than $1 billion to settle claims of wrongdoing with other states’ departments of Medicaid.

Attempted reforms

DeWine’s Medicaid Director, Maureen Corcoran, and the legislature are implementing sweeping changes intended to address those and other problems.

One is intended to shed more light on drug transactions by hiring a single pharmacy benefit manager to work directly for the state, instead of behind the curtain of managed-care providers such as Paramount and Centene’s Buckeye Health.

The change seems to promise savings for taxpayers. Centene CFO Drew Asher last week described such carveouts as a “headwind” as he explained to analysts the company’s plans to grow profits.

Another reform is a broader redesign of the Medicaid managed-care system, with would-be contractors required to submit bids explaining how they would implement the new vision. And a big part of that vision is the implementation of the OhioRISE program.

A major DeWine initiative, the program is intended to coordinate services for kids with “significant mental/behavioral health and substance use disorders, in addition to medically complex illnesses,” the program’s description says. 

Currently, up to 60,000 such children are receiving care from various agencies. Advocates say a lack of coordination creates some excruciating gaps. 

“OhioRISE is the state’s answer to the ongoing, multi-decade issue of custody relinquishment,” said Loren Anthes, Treuhaft chair in health planning at the Cleveland-based Center for Community Solutions. “The idea is that adolescents that are involved in multiple systems — often who have developmental delays, and who are engaged with the foster-care system or Medicaid or the corrections system or all of the above — couldn’t get access to basic services and kept getting hospitalized over and over again. 

“In order for them to receive some essential services, many times parents would have to hand their children over to the county government in order to get those benefits and those parents were no longer the guardians,” he said.

Anthes explained that not nearly all of the children who would be helped by OhioRISE face being handed over by desperate parents to county health authorities. But the program is aimed at keeping all from that dire situation, he said.

“You don’t want to wait for them all to be hospitalized; you don’t want to wait until the moment of crisis,” he said. “But things aren’t very coordinated right now.”

Sen. Theresa Gavarone, R-Bowling Green. Official photo.

However, measures inserted into the budget at the behest of Senate President Matt Huffman, R-Lima, and Sen. Theresa Gavarone, R-Bowling Green, could keep OhioRISE from getting off the ground next year as planned. 

Anthes said the Medicaid redesign depends on multiple things occurring simultaneously. They include hiring managed-care providers — including the single pharmacy benefit manager, which would itself function as a managed-care provider. Those entities would then work together to help launch OhioRISE, he said.

“All of these things are premised on moving forward at the same time,” Anthes said, adding that if they don’t, everything will fall apart.

Paramount spokeswoman Moore said those concerns are unfounded.

“Whether stemming from misdirected concern or political motivation, that assumption is just not true,” she said. “An amendment (to the budget) specifically clarified that the changes in the MCO procurement process would not apply to OhioRISE.

Paramount lost by a lot in its unsuccessful bid to manage Medicaid care for two regions of Ohio. It received roughly half the score of the lowest of six companies that were selected to provide managed care starting next year.

The Toledo Blade last week reported that one knock against the Paramount proposal was that it didn’t adequately explain what Paramount would do to facilitate the launch of OhioRISE. For example, the Paramount bid only mentioned the program 17 times, while the highest-scored bid mentioned it 94 times.

Paramount President Lori Johnston seemed dismissive when asked about that critique.

“I guess in hindsight we should have thrown that buzzword out a few times,” she told The Blade. “I don’t think the number of times we used OhioRISE should be indicative of our approach and understanding of that plan. We support the program and are very committed to seeing the program is successful with that population.”

Political implications

A spokesman for Senate Republicans didn’t respond to questions for this story. But they apparently inserted language mandating a new bid process partially at the urging of Barbara Sears, who was Medicaid director under DeWine’s predecessor, John Kasich. Corcoran, the current Medicaid director, early last year said she inherited a mess from Sears when she took the helm in early 2019.

Now a principal with the lobbying firm Strategic Health Care, Sears registered this year to lobby on behalf of Paramount owner ProMedica on the budget and on the Medicaid managed care procurement. 

Her participation is notable for a few reasons.

First, she’s in the pay a client that had a mammoth contract with Ohio Medicaid while she was running the agency. And if, as critics say, the Senate budget measure delays reforms it could mean Sears worked to delay fixes to problems that developed on her watch as Medicaid director.

She didn’t respond to questions sent to an email address listed on her lobbying-disclosure forms.

If House and Senate conferees keep the requirement to rebid Medicaid managed-care business in the budget, they’ll be placing DeWine in a politically painful position.

He’s already under attack from his right for taking measures against the coronavirus pandemic that some claim were dictatorial.

Now he might have to decide between two of his most important initiatives or issuing a veto that Paramount says would cost Northwest Ohio 600 jobs. And DeWine might have to make that decision with a contested primary less than a year away.

A DeWine spokesman didn’t respond to questions about the matter on Tuesday.

 
 

Clipped from: https://ohiocapitaljournal.com/2021/06/24/proposed-budget-changes-said-to-threaten-medicaid-reforms/

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NC Medicaid providers to be reimbursed for COVID-19 vaccine counseling

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Providers will now be paid to answer questions for patients about the vaccine.

 
 

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.

 
 

RALEIGH — To help Medicaid beneficiaries get the accurate information they need to make an informed decision about getting the COVID-19 vaccine, the North Carolina Department of Health and Human Services will reimburse Medicaid providers for providing counseling on the benefits of COVID-19 vaccination.

 NC Medicaid providers can now be reimbursed for up to 15 minutes for preventive medicine counseling and/or risk factor reduction intervention provided to an individual related to COVID-19 vaccination when provided to Medicaid beneficiaries. Many children do not yet qualify for the vaccine, but their family members do. Parents or guardians of children receiving Medicaid — even if they are uninsured — can also receive counseling from their child’s doctor. Medicaid providers will be reimbursed for this counseling as well. 

“It is our hope that other payers will adopt this additional reimbursement to acknowledge the time and effort front line practices are investing so that more COVID-19 vaccine makes it to North Carolinians before flu season arrives,” said Dr. Shannon Dowler, Chief Medical Officer of Medicaid at NCDHHS. 

Research done nationally and in North Carolina shows medical professionals are one of the top trusted sources for information about COVID-19 vaccines. With many North Carolinians still having questions about the vaccines, the additional payment for counseling will support health care providers in taking the time needed to understand a patient’s concerns and answer their questions.

NCDHHS has a toolkit to help health care providers promote vaccination within their practices. Healthcare providers are encouraged to use the materials to encourage patients to get vaccinated. 

There is increasing urgency for people to get vaccinated against COVID-19 as the more dangerous new Delta variant is rapidly spreading in the United States, including in North Carolina. The Centers for Disease Control and Prevention classified the Delta variant as a “variant of concern” because it spreads faster than current COVID-19 variants. Early data have also shown a possible increased risk of hospitalization in people infected with the Delta variant. The currently available COVID-19 vaccines are the best protection against the virus and its variants.

More information is available in the special bulletin about NC Medicaid’s new reimbursement code.

 
 

Clipped from: https://www.richmondobserver.com/national-news/item/12612-nc-medicaid-providers-to-be-reimbursed-for-covid-19-vaccine-counseling.html

 
 

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OHIO- Medicaid Contractor Data Breach Affected 334,000 Providers

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Maximus alerted Ohio, Maine and other states about the breach of its systems that occurred in mid-May.

 
 

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.

 
 

 
 

Maximus Corp. Says Personal Information Exposed in Unauthorized Access to App Doug Olenick (DougOlenick) • June 23, 2021    

 
 

Maximus Corp., a global provider of government health data services, says a data breach exposed the personal information of more than 334,000 Medicaid healthcare providers nationwide.

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The company says in a statement provided to Information Security Media Group that on May 19, it discovered an unauthorized party had accessed one of its applications related to Medicaid provider credentialing and licensing with the Ohio Department of Medicaid between May 17 and May 19.

“This incident did not affect patient or Medicaid beneficiary information. Some personal information about healthcare providers may have been impacted, including names, dates of birth and Social Security numbers,” the company states.

A breach notification provided to the Montana attorney general’s office says Medicaid providers’ Drug Enforcement Agency numbers also may have been exposed in the breach.

System Breached

In a filing with Maine’s attorney general, Maximus says 334,690 individuals were affected when one of the company’s external systems was breached. The notice states those affected will receive two years of free identity protection services through Experian.

In its statement provided to ISMG, Maximus did not supply a complete list of the states that were informed of the breach nor did the company offer details on the type of attack. The company says it began informing the individuals affected on June 18, along with filing formal data breach notifications with state officials where the victims are located.

As of Wednesday, the incident was not yet listed on the Department of Health and Human Services’ website that offers a tally of major health data breaches.

“Because the unauthorized activity was detected at a very early stage, Maximus believes our quick response limited potentially adverse impacts. This incident did not affect any other Maximus servers, applications or customers,” the company says in its statement. It says it has no evidence the attackers have misused any of the information.

Maximus, which is based in Reston, Virginia, is an administrator of Medicaid enrollment broker services. The company says it answers more than 7 million Medicaid-related calls per month. It handles similar services in Australia, Canada, Italy, Saudi Arabia, Singapore, South Korea, Sweden and the U.K.

Other Recent Healthcare Incidents

Healthcare providers and their third-party suppliers have been targeted by cybercriminals in increasing numbers.

In a recent data breach notice, Attleboro, Massachusetts-based Sturdy Memorial Hospital said that on Feb. 9, it identified a security incident that disrupted the operations of some of its IT systems affecting about 57,400 people. The hospital reported paying a ransom in exchange for promises by the attackers to destroy stolen data.

On Monday, Reproductive Biology Associates , an Atlanta-based clinic operator, and its affiliate, MyEggBank North America, reported their systems were hit by a ransomware attack in April. The clinic operator says it regained control of its network and data after contacting the attackers.

 
 

Clipped from: https://www.govinfosecurity.com/medicaid-contractor-data-breach-affected-334000-providers-a-16929

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Judge rules Missouri doesn’t have to implement Medicaid expansion

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The judge said the state constitution requires specific funding for voter-approved initiatives.

 
 

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 Missouri judge on Wednesday ruled against a lawsuit seeking to force the state to implement Medicaid expansion under the Affordable Care Act, a setback for supporters of expansion.

 
 

© Istock Judge rules Missouri doesn’t have to implement Medicaid expansion

The ruling will be appealed, though, meaning it is not the final word.

 
 

Missouri voters passed a ballot measure last year to expand Medicaid, but GOP Gov. Mike Parson said in May he would drop plans to expand the program after the Republican-controlled legislature declined to provide funding for it.

Supporters of Medicaid expansion sued, seeking to force the state to expand the program starting July 1, which would provide health insurance to about 275,000 low-income people.

Judge Jon Beetem ruled against the lawsuit on Wednesday, writing that the voter-approved ballot measure was actually unconstitutional, since it sought to spend state funds without identifying a funding source, infringing on the legislature’s appropriations power.

“It is unfortunate that, yet again, hundreds of thousands of Missourians will have to wait even longer to access the health care they need,” Dwayne Proctor, CEO of the Missouri Foundation for Health, said in a statement.

Supporters of expansion said they would appeal.

The setback for expansion in Missouri comes as congressional Democrats are exploring ways to go around states and expand the program in the 12 states that have still not accepted expansion.

A federal program to provide coverage in those states could be included in an upcoming legislative package.

 
 

Clipped from: https://www.msn.com/en-us/news/politics/judge-rules-missouri-doesnt-have-to-implement-medicaid-expansion/ar-AALmCmp?ocid=BingNewsSearch

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Florida Eliminates COVID-19 Flexibilities For Medicaid

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Florida HHS released a series of notices letting people know pre-COVID limits are going back in place for various types of Medicaid services.

 
 

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

 
 

June 24, 2021

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Among the changes: “Wrap around” payments will go from a monthly back to a quarterly schedule and prior authorizations will resume for behavioral health services.

News Service of Florida | 6/21/2021

Gov. Ron DeSantis’ administration announced Friday that the state will next month step back from flexibilities that were offered to Medicaid providers and beneficiaries during the COVID-19 pandemic, including allowing people to receive behavioral health services without first obtaining prior authorization.

The Agency for Health Care Administration issued eight Medicaid notices announcing that the policies designed to make it easier for patients to access health care and for providers to bill for the care were being rescinded.

“The state of Florida led the national effort to distribute COVID-19 vaccines and now maintains a sufficient supply of COVID-19 vaccines for every eligible Floridian who desires to be vaccinated. The data demonstrates that Florida is positioned to transition to pre-pandemic activities,” the email alerts began.

Effective July 1, the state will once again limit the frequency and duration of Medicaid behavioral health services. And beginning July 15, the state will reinstate prior authorization requirements for behavioral health services.

Also, Medicaid “wrap around” payments made to federally qualified health centers will return to a quarterly payment schedule, effective July 1.

During the pandemic, the state was allowing the centers to request the money on a monthly basis to assist with cash flow.

Medicaid also is reinstating prior authorization requirements for hospital transfers prior to admission, including inter-facilitiy transfers, transfers to long-term care hospitals and transfers to nursing facilities.

Effective July 1, Medicaid also is reinstating preadmission screening and resident review requirements for nursing home placement.

The state also will require nursing homes to have a 95 percent occupancy limit to receive Medicaid reimbursement for what are known as “bed hold” days. While that change will take place July 1, Medicaid won’t begin evaluating the 95 percent occupancy rate until October.

Also effective July 1, prescribed pediatric extended care centers will no longer be authorized to deliver services in the home setting.

 
 

Clipped from: https://www.floridatrend.com/article/31551/florida-eliminates-covid-19-flexibilities-for-medicaid

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Texas Democrats propose bill to let local governments expand Medicaid without state consent

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A new plan from Dems would allow counties to operate Medicaid programs, get federal matching and force states to let them use state systems.

 
 

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.

 
 

 
 

AUSTIN — Local governments would be able to bypass conservative state leaders and implement their own Medicaid expansion programs for working poor Texans with federal funds, under federal legislation announced Monday by U.S. Rep. Lloyd Doggett, D-Austin.

Dubbed the “Cover Outstanding Vulnerable Expansion-Eligible Residents Now Act,” the legislation is a “homegrown solution” to a decade of resistance by a handful of red states to allowing more people who are struggling financially to access the federal health care program, said Doggett, chairman of the House Ways and Means Health Subcommittee and lead sponsor of the bill, which has more than 40 cosponsors.

In Texas, that could be as many as 1 million newly eligible residents — most of them people of color — who currently fall into that gap because they can’t afford private health insurance and can’t qualify for subsidies, but make too much to qualify for Medicaid.

The bill sponsors include all of the Texas congressional Democrats and most Democrats from 12 other states that have refused to expand Medicaid through the Affordable Care Act. It is the first time local governments have been able to directly contract with the federal government for Medicaid funds.

“For many of our most disadvantaged citizens, this bill offers a pathway to access a family physician, necessary medicine, and other essential coverage that thirteen States continue to deny,” Doggett said in a statement. “The COVER Now Act empowers local leaders to assure that the obstructionists at the top can no longer harm the most at-risk living at the bottom.”

The bill allows counties, cities and other political subdivisions to apply directly to the U.S. Centers for Medicare and Medicaid Services for funds that were declined by their states, including Texas. States would be required to cooperate and authorize access to state Medicaid systems for those entities, with incentives for cooperation and potential penalties otherwise.

That amounts to 100% federal funding for three years and tapering to 90% federal funding by year seven and beyond, Doggett said.

The bill will be filed later Monday, he said. Other proposals being floated in D.C. include doing the same thing through a federal program or expanding access to the marketplace to lower income people, Doggett said.

“All of these have pros and cons,” he said.

An effort by a bipartisan coalition of state lawmakers to expand Medicaid during the most recent session of the Texas Legislature became mired in conservative opposition and never got a hearing.

Opponents of expanding Medicaid to an estimated 1 million Texans who would qualify under the Affordable Care Act of 2010 argue that the program is poorly managed and financially unsustainable, and that expansion encourages government dependence, delivers poor health outcomes, and crowds out children and people with disabilities who need it the most.

The new federal legislation would further burden a program that is already “a poorly performing program which leaves millions of low-income and disabled Americans without real access to quality care,” said David Balat, director of the Right on Healthcare initiative at the Texas Public Policy Foundation, a conservative think tank.

Balat pointed to several measures that were passed by the Texas Legislature this year, and championed by conservative leaders, that are “strong steps” toward helping the uninsured, would serve more people than would be covered by Medicaid expansion, and don’t threaten funding for other services like education and public safety, he said.

Some of those measures included programs that reduce the cost of some prescription drugs, ease continuity of Medicaid coverage for children, require transparency in medical billing, expand availability of telehealth and broadband services, expand Medicaid coverage for new mothers, and increase insurance plan options through small businesses, agricultural nonprofits and associations, among others.

“Putting millions more people into a struggling program will only further hurt current beneficiaries, mostly low-income women and children, the elderly and the disabled, and do nothing to address the existing issues of access to care,” he said. “The bottom line is that this is just an effort by some counties and cities to gain access to federal dollars without actually doing anything to help patients.”

A request for comment from Republican Gov. Greg Abbott, who has resisted calls to expand Medicaid, was not immediately answered on Monday morning.

The death of the state legislation left on the table billions of dollars in federal incentives that supporters said would not only have paid for the expansion but added money to state coffers and lowered costs for hospitals that care for large numbers of uninsured patients.

“The lack of access to health care during COVID killed people. It killed people. It decimated their finances, it drove people deeper into poverty. And we’re not talking about poverty that only impacts immediately family at that given time. I’m talking about generational poverty, and on the border, it is most chronic,” said U.S. Rep. Veronica Escobar, D-El Paso. “We’ve got to stop hoping they [state leaders] will open their hearts and get off the culture war train, and we’ve got to take care of our people.”

Under Doggett’s proposed COVER Now Act, that money would be directly available to local governments through pilot programs approved by CMS without the state’s involvement.

“Health care coverage is as vital to a community as education, roads, or reliable power,” said Tom Banning, CEO of Texas Academy of Family Physicians, which supports the proposed legislation. “Sadly Texas has stubbornly refused federal assistance to expand Medicaid, leaving millions of our fellow Texans to get their health care by waiting in a long line at a free clinic, ignoring a treatable problem, or using the ER when that treatable problem worsens. That isn’t just morally wrong, its economically dumb.”

With more than 5 million of its residents without coverage, Texas has the largest number of uninsured residents in the nation, many of them working adults who can’t afford private or subsidized insurance but don’t qualify for Medicaid because they earn too much.

Roughly 20% of the state’s population lacks health insurance — a number health officials say has grown since more than a million Texans lost jobs and, in many cases, health coverage because of the COVID-19 pandemic.

Some 4.2 million people are on Medicaid in Texas — including more than 3 million children. The rest of the recipients are people with disabilities, pregnant women and parents living below 14% of the federal poverty level, or about $300 per month for a family of four.

Adults with no disabilities or dependent children don’t qualify for Medicaid, and the vast majority of children on Medicaid have parents who do not qualify.

The ACA allows states to expand that threshold to 138% of the poverty level, or $3,000 per month for a family of four.

In a University of Texas/Texas Tribune Poll conducted in April, 55% of Texas voters said they support Medicaid expansion, while 26% opposed it and another 20% said they didn’t know or had no opinion. Two recent polls by other groups show that 70% of Texans support Medicaid expansion.

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Clipped from: https://www.itemonline.com/news/local_news/texas-democrats-propose-bill-to-let-local-governments-expand-medicaid-without-state-consent/article_5bf9fa85-45d7-55b7-ba14-e192ea075f55.html