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Weekly Medicaid RoundUp: Week of November 6th, 2017

Soundtrack for today’s RoundUp pessimist readers- (for what ails ya!)

For optimist readers-  Do not forget Veteran’s Day!

LET’S TALK SHOP AT MEDICAID INNOVATIONS 2018 – I will be in Florida again (7th year for me, I think) for the Medicaid Innovations Conference. If you are going, let’s plan on meeting up. Jan 31-Feb 2, 2018. Check it out here-

PINE TREE STATE VOTES YES ON EXPANSION – Mainers voted yes on Question 2 on Thursday, making the preference of 59% of voters known. In an interesting move, the state elections officials set up a PayPal kiosk at polling places to collect the money needed to pay for the voters’ decision. While 59% voted yes on expansion, only $13.73 was collected on voting day. Seems voters want someone else to pay for it (they did their part by voting). If you are out of state and would like to contribute to the state share for the expansion, you may be able to make a donation via the Maine State Treasurer’s Office –  I have also agreed to be a donations bundler for the state expansion lobby, so if you send me your personal bank account information to I will be happy to make you’re your personal commitment to the cause is made known. #Resist!

CONSTITUTION STATE RETHINKS ITS EXPANSION MODEL- New Hampshire is looking to continue covering the expanded population now the waiver is up for renewal. But it wants to move expansion bennies from the exchanges (a premium subsidy program) to be covered under one of the actual Medicaid MCOs. Also wants to add work requirements for non disabled adults with no children. 

HAWKEYE STATE DEM CANDIDATES POOH POOH MCOS- All four of the brilliant Iowa Guvn’r candidates on the left side are promising to rollback managed care and return the state to its Halcyon days of fee for service, in all its unmanaged, abysmal quality and cost management glory. Idiots.

OLD DOMINION STATE GUBBNERS RACE RESULTS RESTARTS EXPANSION HOPES- Dems picked up 5 house seats in recent Virginia elections. Which will help to soften resistance to expansion in the legislature (its been shot down for several years). The Guvnr-Elect Northam also campaigned on expanding Medicaid.

WHAT THE LADY SAID – Flexibility. Work requirements. Faster approval for waivers and SPAs. The sleeper issue in Mrs. Verma’s speech to NAMD this week? State dashboards using new CMS data systems. Can you imagine the fallout if states were showing up on a regular report of poor quality metrics? Right now there might be a report of a few states on a few measures using data that lags 4 years. State dashboards would be the best thing to happen to Medicaid. Ever.

TREASURE STATE TO SPEND MORE TREASURE- A Montana legislative committee has put the kibosh on (did you know that word was originally kye-bosk, with the earliest citation in Dickens?) a proposed 2.9% provider rate cut. The state DHS officials are understandably frustrated because they feel avoiding the cut now will just make them have to make deeper cuts later. And, oh yeah – the same freaking legislature holding up the cuts ordered them to cut costs.

NEW HHS PICK MAY COME FROM PHARMA- Rumors have it that Alex Azar of Lilly USA fame may replace Price. As long as Azar can follow aviation policies, of course. (Ba-doom-boop-boom).

PRAIRIE STATE OBTAINS BOND TO PAY MEDICAID BACKLOGGED BILLS- MCO shareholders across the nation rejoiced on the news that Illinois sold $9B in bonds to help pay off debts to Medicaid providers. So we have finally done it – made Medicaid like the subprime mortgage fiasco by factoring the debt to outside investors. Holy cow. You can now basically buy stock in how poorly a Medicaid program is run via bond issues from states in fiscal default.

WELCOME TO THE SHOW MR BAKER, THE GENTLEMAN FROM THE PALMETTO STATE- Joshua Baker of SC Medicaid got promoted to the Director Chair this week. Glad to have you Mr. Baker!


GOOD GUVNR BROWN DECIDES TO GET THAT CASH BACK FROM MCOS AFTER ALL (THE BEAVER STATE)- A few weeks of bad press and the milk has soured. The gloves are off. Although early reports suggested Oregon would not attempt to recoup capitation payments made in error to MCOs, this week Dem Guvn’r Brown directed the agency to do just that. (After her GOP opponent in the 2018 race called her out on it). The errors are on the state enrollment side- people who should not have been enrolled, or duals for whom which Medicare should have paid first.  Current total of snafu is $74M. We covered this in last week’s news show by the way if you want to check out the recording-

SUNFLOWER STATE ASKS FOR $90M TO REDUCE WAIVER WAITING LIST- Kansas thinks it can open up a bunch of new waiver slots for HCBS waivers if the legislature will approve it.

SOONER STATE PULLS TRIGGER ON $34M IN PROVIDER CUTS- Oklahoma legislators said no-dice (short by 5 votes) on the new taxes (at least I think that’s how to translate “revenue-raising measures”) needed to fill the Medicaid budget hole this week. A total of $35M in cuts went into effect this week, with providers getting between 4 and 9% reductions.

BUCKEYE STATE OWES FEDERALIS TRUCKLOAD OF CASH. CMS ASKS FOR IT ALL IN SINGLES-  We have seen this issue in other states. Basically ACA handed out lots of rewards cash for increasing Medicaid enrollment, but it was only supposed to go for non-kids and non-ABD members (people who generally get pretty decent coverage; Mr. Obama was looking to add new types of people to the rolls, not those already eligible). Anywho- federal OIG says OH got $30M too much for improper classification of new enrollment, and they want CMS to get the money back.


BBBBUT MEDICAID IS UNDERFUNDED! GOLD RUSH IN THE GOLDEN STATE- A new report over at Kaiser Health News shows California MCOs making ridiculous (in the eyes of the beholder) amounts of profit on Medicaid operations. Would we ever see a story that shows the CA Medicaid budget “deficit” side by side with MCO “obscene” profits? Doubt it. That would not be helpful to the #Resistance.


FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph… Sorry friends, not this week. I have already been too verbose. Lots of fraud goodies for you in the twitter feed. Don’t worry, we lost millions again this week as well. Same as last week. And the week before…

That’s it for this week. As always, please send me a note with your thoughts to or give me a buzz at 919.727.9231. Get outside (send out your Christmas party invitations) and keep running the race (you know who you are).


FULL, FREE newsletter@ . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Bavê Kur şand ku cîhanê rizgar bike.

Weekly Medicaid RoundUp: Week of October 23rd, 2017

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-


A LITTLE LONGER THIS WEEK- Sit a spell. Let’s catch up.


STATES TO GET EASIER TIME ON WAIVER REVIEWS- CMS head Verma was at a conference this week in Ohio and let attendees know the agency is moving towards an
“unprecedented level of flexibility” for states to operate Medicaid the way they want to (v.s. being told what to do by the feds staring down the barrel of an FMAP). Sounds good to me, and should sound good to any freedom-loving person who thinks local autonomy is a good thing. Will of course ring alarm bells for lefties who want to continue using the feds to impose their views.

BADGER STATE STRUGGLES TO GET LEAD TESTS FOR KIDS- Guidelines require that kids get lead testing at 1 and 2 years of age. But it ain’t happening in Wisconsin. Less than 2/3rds of Medicaid kids there receive them according to a new report. Especially concerning since Medicaid kids have a 3X risk of lead poisoning.


… BUT APPROVES MORE SUBSTANCE ABUSE TREATMENT— The Good Guvnr Walker announced pay raises for mental health and substance abuse professionals treating Medicaid members this week. All in all, the state will spend about $17M on the rate increases, with the hopes it will entice more providers to offer more treatment.


SUNSHINE STATE TIGHTENS TIME AND DISTANCE STANDARDS TO INCREASE PHARMACY NETWORK- Florida changed requirements on MCOs to now have to have a pharmacy within a 10-mile drive of all patients this week. The move added thousands of pharmacies to the overall managed care network, with Staywell adding 1,400 alone (Molina added nearly 900). There were not a lot of rx access complaints before the change, so some analysts are left scratching their heads. Based on what I am reading it may be related to an ongoing independent pharmacy v.s. PBM lobbying scuffle, but not sure. Please write in or call with any intel if you are there on the ground.


… ALSO MOVES FORWARD WITH PLANS FOR NEW DENTAL PROGRAM – FL is rolling out a stand-alone dental program March of 2019. The RFP (technically and Invitation to Negotiate, or ITN) was released last week. Bids are due April next year. Considering bidding? Give me a ring. This is one of the ones we are tracking.



EMBOLDENED DEMS GEAR UP FOR TROTTING OUT “PUBLIC OPTION” – After the multiple nothing-burger attempts at repeal died on the garbage piles of our Congress and Senate, “progressive” Dems (I love that adjective and how its used – what is the corollary- indeed is one allowed in modern discourse?- for Republicans whom journalists want to give them linguistic halos? I digress) are now trotting out the revolutionary (think Che) idea of selling Medicaid to the masses via the exchange. This is the “public option” that ACA footsoldiers dreamed of nearly 10 years ago. Senators from HI and NM are leading the charge. Let’s do a poll – would you buy Medicaid if you had a choice? Assume: no changes to benefits or network compared to Medicaid in your state today; you pay a similar percentage of the total costs as you do for your commercial coverage today; and there are no subsidies. Please do comment or write in on this one.


NM BUDGET GROANS, PARTLY DUE TO CHIP RE-AUTH UNCERTAINTY- $82M short for Medicaid this year. $31M is being pinned on CHIP, which is still currently in the air in The District. $15M is tied to the ACA expansion bill coming due (states like NM who expanded start paying more of the costs of that decision this year).


AZ GOP NOT GIVING UP ON FIGHTING EXPANSION, DESPITE D.C. GOP FAILURES TO REPEAL/REPLACE— If you’ve been following this, you know its been a long road. If you are pro-expansion, you view these guys as the zombies that just won’t die. If you are pro-taxpayer, you admire their stick-to-it-ness. After being denied at the state appeals court, the AZ lawmakers get their day in the AZ Supreme Court this week. Recap: Good Guvn’r Brewer expanded unilaterally. State GOP said it’s a tax passed without their consent, which is against AZ laws.


GOOD GUVN’R USES CHIP FUNDING CRISIS TO RENEW PUSH FOR EXPANSION- The state that brought us the Batman-Villain-Eyebrows VP Candidate, continues to grace us with current Good Governor McAuliffe (Virginia). The Good Guvn’r insists that the way to deal with CHIP uncertainty is to expand Medicaid. Can someone please let him that’s so 2015? The hip thing now, Terry, is to sell Medicaid on the exchanges, under the “public option.”


CONVERT YOUR NURSING HOME TO BE “COUNTY-OWNED” IN THE HOOSIER STATE, GET 30% HIGHER RATES FROM MEDICAID— All you have to do is lease your nursing home to a county health system and you get higher rates. Pretty much every facility in Indiana knows about the loophole now, so 90% of them lease themselves to county hospitals. No big deal though. Spending over past 5 years on IN nursing homes has only increased a paltry $1B. That’s less than 1% of a typical pay-off-Iran-in-the-middle-of-the-night-with-a-ship-load-of-cash scheme. Seems legit.


DIRECTORS SAY CAID SPENDING WILL INCREASE 5.2% IN FY 2018, V.S. 3.9% IN FY 2017— This is even with slower enrollment growth. Seems most states are resolved to pay most providers more (except hospitals). 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. Isaiah Bongham, owner of Dynamic Visions (a home health agency in D.C.) has been ordered to pay back $2M he stole from Medicaid. Actually he stole $480k, but the Fraudulent Claims Act triples it (that’s cool). Santila Terry of Morgan Park, IL stole $1M using her speech therapy operation. She kept billing for services provided by an employee long after the employee left her firm. Christina Benson of Orlando was sentenced to 4.5 years for her role in a scheme that enticed homeless Medicaid members to get services at her psych rehab center. Mrs. Benson’s kickback scheme cost FL about $200k. Charline Brandon of Little Rock is accused of billing Medicaid nearly $300k for hospice care for patients without a terminal diagnosis. Jerrold Rosenberg of Jamestown, RI plead guilty this week to accepting $180k in kickback payments in exchange for prescribing a version of Fentanyl called Subsys. He was conspiring with AZ-based Insys Therapies. Cesar Tavera of Cherry Hill, PA was sentenced this week for embezzling $1.5M from the community mental health center he ran. His wife plead guilty to Medicaid fraud earlier this year.  Mr. Tavera – you win on sheer volume alone! Congratulations! This weeks total taxpayer tab: $3.5M.


That’s it for this week. As always, please send me a note with your thoughts to or give me a buzz at 919.727.9231. Get outside (make a bonfire) and keep running the race (you know who you are).


FULL, FREE newsletter@ . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: abeojineun sesang-eul guhagi wihae adeul-eul bonae syeossda.


Weekly Medicaid RoundUp: Week of September 18th, 2017

Clay’s Weekly Medicaid RoundUp: Week of September 18th, 2017

Soundtrack for today’s RoundUp pessimist readers-


For optimist readers-


OCEANIA INSPECTOR #1731- As service to my country (Oceania) I have enlisted as a social media inspector. My current duties are limited to tagging suspect articles with “thoughtcrime” but may expand pending further instruction from BB. If you see me comment on social media with this label please do not be alarmed. This entry was written with special digital ink only visible to good citizens who comply with the Party, so if you can read this you are OK. </doublespeak>.


FLIGHT OF THE NAVIGATORS- As ACA money dries up, Ohio is nixing its navigator program (navigators are sort of like guides to help applicants understand options for exchanges and Medicaid). We will likely see similar stories in other states over the coming weeks. In Ohio, the Navigators contract went to the OH Association of Foodbanks, which just watched its annual budget go from $1.7M to $485k.


ADD COLORADO TO LIST OF DEADBEAT MEDICAID STATES- Its taking a little while to work out the kinks of the new claims payment systems. Hospitals are owed a little north of $200M for services dating back to March (when the new system launched). There are currently 98,000 pending claims.


BRIGHT SPOT FOR NC BABIES AND MOMS- New results from North Carolina’s Pregnancy Medical Home are uplifting. The program is credited with reducing maternal mortality by 40% in the last 15 years. NC pairs a pregnancy care manager with high risk moms to help ensure the right dots are connected. There are about 400 of these pregnancy care managers across the state, helping about 25,000 moms each year.


FHN SELLING ENROLLMENT TO COOK COUNTY HEALTH SYSTEM- If you have been watching the Illinois market you know there are myriad challenges. All the stress and strain was too much for Family Health Network (one of the largest existing MCOs), and they are starting the exit process. Cook County Health System (a big winner in the recent contract awards) will start transitioning 160k legacy FHN members November 1.


COPAYS AND PREMIUMS MOVE FORWARD IN NEW MEXICO- State officials are moving forward with the plan to charge $10-$50 premiums for some members (with exemptions for the most poor and for Native Americans). Copays would be $2 for scripts, $5 for pcp visits and $50 for hospital admissions. NM is also considering eliminating retro-active coverage (for a discussion on how this work, and other states considering this same change – check out the recording of last week’s news show).


CHICKEN LITTLE FATIGUE- Another bill to dramatically alter Obamacare has been introduced, and the Resistance has been re-activated by Generals Slavitt, Schumer and Moore. In an amazing coincidence, the Graham-Schumer bill has the same purported outcomes as all previous 4 attempts this year – it will kill all babies, all the elderly and make the solar system implode. We haven’t done a deep dive on this one yet, but who needs it really? We know the truth from the media talking heads so why bother questioning what they say will happen if the bill would pass. (thoughtcrime)


PELICAN STATE RE-UPS MMIS WITH MOLINA- Molina got another extension (the 4th 1-year extension), this time with a $46M price tag. MMIS-bid watchers collectively moved onto other states for another year…

I WILL BE AT MHPA 2017 IN OCT., WILL YOU? You can check it out here – Every 100th registrant will get a free Medicaid Foundations Course registration (our online training course).


FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph… Not so fast my little fraud junkies. Not enough room in this week’s roundup, but I put plenty of fraud stories in the twitter feed for you. Check out the “food stamp millionaire” story for sure.

That’s it for this week. As always, please send me a note with your thoughts to or give me a buzz at 919.727.9231. Get outside (even though the weather tricked us and its still not sweater weather) and keep running the race (you know who you are).

FULL, FREE newsletter@ . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: preahbeta ban chat preah botra aoy yeang mk sangkroh mnoussa lok


Medicaid 2.0

Here’s a great chart (below- click to enlarge) from our friends at MHPA to help you understand all the different pieces of legislation as well as the waiver apps in play.

Many thanks to Alex Shekhdar of Medicaid Health Plans of America for sharing.


Check out MHPA here –

And check out Alex on the News Roundtable show this Friday, along with Kris Vilamaa and Cathy Huff.

If you want to attended the 2017 MHPA conference (I’ll be there), here’s the link –

Monday Morning Medicaid Must Reads: September 4th, 2017

Helping you consider differing viewpoints. Before it’s illegal. 


Article 1:   Building the Infrastructure of the Affordable Care Act: Hillary Clinton, UnitedHealth Group/Optum, and the Center for American Progress, Katherine Tillman, Journal of American Physicians and Surgeons, Winter 2015 

Clay’s summary: Wow. This is like a laundry list of the rich and powerful and how they show up under the banner of “health reform” inside the walls of CMS.

Key Passage from the Article

 The ACA is also the legal catalyst for a massive information technology (IT) infrastructure connecting, tracking, and exploiting economic, social, and cultural components of American society. Government departments may now arbitrarily structure thousands of regulations and policies from this poorly written legislation, all of which have an impact on the personal lives of citizens from prenatal exams to hospice.  But who is in charge? 

We have yet to understand the full scope of the ACA. Its execution is in the hands of powerful, interlocking individuals and organizations, many having been involved in designing
“healthcare reform” since the Clinton Administration. A central part of the transformation is compiling and tracking our most sensitive data, from health records and tax returns,
which can now be used in making coercive decisions about our medical care, to help achieve the “progressive” social goals of this elite, powerful group.

Read it here 

Article 2:   The War on Medicaid Is Moving to the States, Greg Kaufmann, 8/31/2017, The Nation

Clay’s summary: #Resist!

Key Passage from the Article

 Waivers are intended for state pilot projects designed to improve health-care coverage for vulnerable populations. But that’s not what conservative governors are pursuing. In Maine, for example, as citizens prepare to vote on a referendum that would force the state to expand Medicaid to 70,000 people, Governor Paul LePage is moving in the opposite direction. His Department of Health and Human Services has requested permission to create a 20-hour-a-week work requirement, impose copays and premiums, and implement a $5,000 asset cap on Medicaid beneficiaries. The result, health-care experts warn, will be that low-income people in Maine will be kicked off the program.

Read it here



Weekly Medicaid RoundUp: Week of August 28th, 2017

Soundtrack for today’s RoundUp pessimist readers-


For optimist readers-


IT’S BEEN A LITTLE WHILE, PEEPS – Been running the conference marathon. Let’s do this…


IL COULD CUT RETRO-ELIGIBILITY- A proposal to CMS from IL HHS is asking to remove the need to pay for services up to 3 months before a member became eligible for Medicaid (for example if a health emergency hits and they can’t pay for it so they apply for retro-active eligibility). Estimates put this one at saving the state $37M. My question – does it matter if they’re not paying their bills for people who were eligible anyway? See also – IL has a multi-year, multi-Billion backlog to providers and MCOs.


AN ENTITLEMENT BY ANY OTHER NAME WOULD SMELL AS SWEET- The Good Guvnr LePage of the Pine Tree State (Maine) is ruffling the feathers of lefty-birds when he insists on calling Medicaid “welfare” in recent interviews. LePage continues to oppose expansion, much to the chagrin of our Progressive Overlords who know what’s best for state budgets (and of course are better, more moral people than those who care about other budget items). Here, Hear!


MS PROTESTS CONTINUE- The much-maligned managed care awards from the Magnolia state completed the administrative appeals process this week (with the agency affirming its decisions), but there remains a lawsuit to be dealt with. Amerigroup and True Health have raised red flags around lower scoring for some of their responses they think were very similar to winner’s responses.


ARMCHAIR MEDICAID PUNDITS IN D.C. SPECULATE TX MAY EXPAND CAID IN LIGHT OF HARVEY, CHANNELING RAHM’S “NEVER LET A GOOD CRISIS GO TO WASTE”- No one from TX has suggested such (yet anyway). From all the video I am seeing, Texans are pretty self-reliant. Maybe if CMS covers outboard motors under DME?


WELCOME BLAKE TO GA MEDICAID – GA DCH has a new director this week. Blake Fulenwider will start in his new role September 15th.


BE ON THE LOOKOUT FOR THE MONDAY MORNING MEDICAID MUST READS NEXT MONDAY- Absolutely incredible article about interconnected players and companies inside CMS/HHS over past 2 decades.


THE VOX POPULI GIVES THUMBS UP TO MEDICAID WORK REQUIREMENTS- Politico polled about 2,000 people and 51% support tie-ing Medicaid to employment and 37% opposed. Food for thought as CMS weighs a pile of waiver apps to require weekly work hours to get a Medicaid card.


I WILL BE AT MHPA 2017 IN OCT., WILL YOU? You can check it out here – Every 100th registrant will get a free Medicaid Foundations Course registration (our online training course).

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. Mark Johnson of Janesville, WI pled guilty this week to stealing $740k from Medicaid using fake scripts. Antoine Skaff of Charleston, WV pled guilty this week to stealing $700k from Medicaid and MCOs for dental procedures not actually provided and for inflating billings for procedures that did actually happen. This one also includes the crowd dental favorite – getting paid for removing the same tooth multiple times. Hin Wong of Manhattan was popped for stealing $15M from NY Medicaid, using an HIV-drug kickback scheme. Ms. Wong spent the ill-gotten gains on plastic surgery, travel and luxury goods. Godwin Oriakhi of TX will spend 40 years in prison for his role in a $17M scheme that bilked both Care and Caid using a home health kickback arrangement (kickbacks were to patient recruiters and physicians). Victor Aldeza, Regino Aldeza, Albert Aldeza, George Aldeza and Lovelyemy Libao (all 5 are siblings) of AK stole $365k from Medicaid by pretending Regino was disabled. Chandra Wrightsell of Lincoln, NE was sent up the river for using her counseling company to file 1,200 false claims. Her tab? $100k. Ms. Wong – you win this week’s award! Total taxpayer tab this week – $33.9M lost to fraud. And remember – say it with me- that’s just the ones that made the news (99% do not). This week.

That’s it for this week. As always, please send me a note with your thoughts to or give me a buzz at 919.727.9231. Get outside (feel fall coming) and keep running the race (you know who you are).


FULL, FREE newsletter@ . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Äkesi Ulın qutqarw üşin Ulın jiberdi

Weekly Medicaid RoundUp: Week of August 7th, 2017

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-

RED AND WHITE SMOKE SEEN ON DAY 62 FROM THE TOWERS OF THE MCO NEGOTIATION COUNCIL- After a few months of dancing around the issue of insufficient rates in the press, Iowa officials and MCO folks are in closed-door sessions to figure it out. New price negotiations were expected to conclude in July, but now its looking like mid to late August. In addition to price it looks like plans may be asking for more control over care management and utilization. You know, the things they are on the hook for. The number 1 complaint I hear from plan clients is they are held accountable for things they are not allowed the tools to impact. Hear, here.


PLANS BICKERING IN THE MAGNOLIA STATE- Amerigroup and Mississippi True are protesting the late-June MCO awards. United, Magnolia Health and Molina all won another round on the MS Medicaid ride. Mississippi True is a new provider-sponsored plan arguing that the RFP requirements around experience were designed to lock out any bidders besides the incumbents. Three state lawmakers are petitioning the Governor to instruct the Caid agency to take another look. Its nice to see lawmakers take such an interest in the Medicaid procurement process. I am sure they are Medicaid experts with a lot of insight into who the Medicaid agency should select and how they should evaluate proposals.


TARHEEL STATE SUBMITS REVISED MANAGED CARE PROPOSAL- This one is from the new Guv (Cooper), updating the one from 14 months ago by the old Guv (McCrory). Right now its shaping up to be focused on integrating physical and behavioral health (makes absolute since given the efforts in the NC market in recent years), telemedicine (a bit of a surprise), opioids and care management. No word yet on whether The Good Guvnr Cooper is looking to horsetrade with CMS to expand Caid enrollment. Let’s get managed care in there first, fellas.


IOWA DID NOT COLLECT $700K IN RX REBATES. SUBTRACTS AMOUNT FROM NEXT SFY BUDGET REQUEST- Just kidding on that last part. Silly kids! Medicaid spending NEVER, EVER goes down. If it did, the pink elephants at the center of the earth’s core would stop marching and our planet would fall from its orbit and go hurtling into space and we would all die because the Republicans hate everybody and only Democrats are GoodPeople. At least that’s what General Spend-It-All in charge of the Resistance tells me.


WONDERS NEVER CEASE. NEW CLAIMS PAYMENT SYSTEM IN THE CENTENNIAL STATE BEGINS LIFE ON STATUS: SNAFU- Colorado’s new claims payment system (interChange- note the lowercase first letter, but the Capital letter in the middle of the name. That means its sophisticated.) is not a hit with providers (at least the ones being interviewed). According to them, claims that previously sailed through are now being rejected. Many providers are out a good bit of cash and have decided to stop taking any new Medicaid patients until the problems are resolved. In defense of the new system all providers had to re-enroll during implementation, and many of the problems are being seen with ones who failed to do so. Other interesting parts of this story: The vendor is DXC Technology, which I guess is maybe a new MMIS-ish vendor? And the contract is for $187M over 8 years. That has to be the cheapest claims payment system I have ever heard of – even when the price does double like we all know it will. Hear that sound? That’s the sound of change orders piling up on some project manager’s excel spreadsheet somewhere.

LOOK UP DUMPSTER FIRE IN THE DICTIONARY AND YOU WILL FIND A PICTURE OF THE ILLINOIS STATE BUDGET- Its just terrible. Terrible. The stories won’t stop. This week: 10 IL SNFs were allowed to continue their lawsuit against the state for not getting paid the correct rate for 4 years. IL NPR also ran a story about various pediatricians out hundreds of thousands of dollars as they wait for the state to pay.


AND APPARENTLY JAMES COMEY IS IN CHARGE OF THE IL MEDICAID PRESS OFFICE?  I can honestly say I have never seen this: There was a news story this week letting the world know that CountyCare is a winner in the IL MCO bids. All the other winners (and losers) will have to wait until later to find out the rest of the results. Appears there’s a leaker in IL someplace.


I WILL BE AT MESC NEXT WEEK, WILL YOU? If so send me a note and let’s meet up.

I WILL BE AT MHPA 2017 IN OCT., WILL YOU? You can check it out here – Every 100th registrant will get a free Medicaid Foundations Course registration (our online training course).

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph … Not enough space this week. Lots of fraudster goodies for you in the twitter feed, though.

That’s it for this week. As always, please send me a note with your thoughts to or give me a buzz at 919.727.9231. Get outside (practice your eclipse poses) and keep running the race (you know who you are).


FULL, FREE newsletter@ . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Viśvada uḷisalu tande maganige kaḷuhisalāgide

Weekly Medicaid RoundUp: Week of July 31st, 2017

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-


MONDAY’S STATE MEDICAID SPOTLIGHT SHOW FEATURES PRESTON CODY, DIRECTOR OF WA MEDICAID PROGRAM INTEGRITY- After a long break, our State Spotlight show is back. Sign up free here if you are not already –

YOUR MEDICAID DRIVER IS 3 MINUTES AWAY- The Greater Buffalo ACO has inked a deal with Lfyt to carry bennies to their appointments. NET is a big, fat, tempting budget item that a small set of providers have had to themselves for years. I am amazed it took this long to “disrupt” this “market.”

PREZ USES BROAD DISCRETION BUILT INTO ACA AND HEALTHCARE POOH-BAHS CLUTCH PEARLS- Just kidding. Trump’s not doing crazy things allowed in ACA like suspending the individual or employer mandate during an election cycle (what kind of cynical, Machiavellian tyrant would do stuff like that?). In all fairness the whole CSR payments drama is a perfect analogue to the abuse of power that was set up nicely in ACA. He does really have them by the яйца (yaytsa if your pc doesn’t have the right font installed), doesn’t’ he? CMS is also encouraging states to submit waivers to alter the eligibility conditions (i.e. all the work requirements waivers you’ve been hearing about) and in some cases the benefit packages (ex: Iowa got approval to limit NET). #Resist!

UPDATE ON MA EMPLOYER FEE FOR MEDICAID- Covered this last week. Seems the outrage was less about forcing employers to cough up $750 per employee on Caid and more about daring to tie that to an expected effort to reduce spending. The Good Guvn’r has repented of this sin and now the deal simply taxes employers (a total $200M in new fees) and does not dare attempt the evil, hateful- dare I say it, Republican? – cuts (would have been $150M in Medicaid spending cuts tied to the tax). Forgot Draconian. APA style manual says you must use “draconian” when talking about Medicaid cuts.

THREE NEW STUDIES OUT ON MEDICAID AND KIDS- Good sum at the AAP blog – . One looks at Caid costs by level of illness and concludes that a full 1/3 of all costs are for kids with chronic disease. The other 2 look at child ER super users and Rx costs.


CLEVELAND CLINIC ON THE REBOUND AFTER GETTING DUMPED- Seems CareSource OH ditched Cleveland Clinic from the network recently and it stung. So now CC has started dating Molina- this is the first time CC has been in network for Molina. CareSource and CC have said they will cement the break up if no agreement can be reached until Sept 1.

IF YOU LIKE YOUR MEDICAID INSURANCE, YOU CAN KEEP YOUR MEDICAID INSURANCE- A recent national survey found that Medicaid members gave their plans 78 more points than commercial members (out of a total of 1,000 points- 0.078% diff). So, when its free, its less than 1% more popular than something that costs an average of $5k + OOP when you do pay for it for a family of 4. Sounds awesome. Break out the champagne. Ready the confetti. Or maybe do all that you can to eliminate meaningful commercial coverage so there will be nothing to compare to and the peasants will accept whatever you give them all for “free”?


FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. LaMar Taylor of Bowie MD was charged this week for scamming Medicaid out of $600k using his day-treatment services company to submit bogus claims. Bertha Blanco, an employee of the FL HHS agency was popped this week for her role in a $1B Medicaid fraud scheme. Her crime? In exchange for bribes, she helped a shady nursing home operator keep their license, which was easy since she was a state inspector. It was a slow week this week – only a few cases. But we did rack up $1.06B in tax payer loss. Quality, not quantity dear readers. Mrs. Blanco – you win this week’s award!

I WILL BE AT MESC IN 1 WEEK, WILL YOU? If so send me a note and let’s meet up.

I WILL BE AT MHPA 2017 IN OCT., WILL YOU? You can check it out here – Every 100th registrant will get a free Medicaid Foundations Course registration (our online training course).


That’s it for this week. As always, please send me a note with your thoughts to or give me a buzz at 919.727.9231. Get outside (tomatoes are finally red) and keep running the race (you know who you are).

FULL, FREE newsletter@ . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Sang Rama ngutus Sang Putra nylametaké jagat

Monday Morning Medicaid Must Reads: July 31st, 2017

Helping you consider differing viewpoints. Before it’s illegal. 


Article 1:  Ron Johnson: Medicaid expansion may be fueling opioid crisis. Todd Shepherd, July 27, 2017. Washington Examiner

Clay’s summary: That pesky Republican Senator from Wisconsin makes some good points.

Key Passage from the Article

 Johnson’s letter did not draw a perfect causal link between the two by suggesting Medicaid is the prime driver of the opioid crisis. But it offered up enough case studies to suggest that the expansion since 2014 has contributed.

Johnson told the HHS inspector general that internal data from the agency showed that overdose deaths, “largely from opioids, are surging much faster in Medicaid expansion states than in non-expansion states.”

“The number of convictions for improperly using Medicaid to obtain opioids, identified through such a cursory search, suggests a larger systemic problem,” Johnson concluded. “Because opioids are so available and inexpensive through Medicaid, it appears that the program has created a perverse incentive for people to use opioids, sell them for large profits, and stay hooked.”

Read it here 

Article 2:  Medicaid Reform. Heritage Foundation, July 27, 2017

Clay’s summary: Lots of pesky facts in this one. My favorite – when asked how the feds should focus Medicaid spending, 56% of poll respondents say the focus should be on the elderly and disabled. 46% say it should be for income-based groups instead.

Key Passage from the Article

By changing the formula reimbursement, Obamacare incentivized the addition of able bodied adults to the Medicare rolls. Eighty-three percent of the increase in Medicaid enrollment during 2014–2016 occurred in states that adopted the Obamacare expansion of able-bodied adults. Over the 3-year period (2014, 2015, and 2016), Medicaid grew 14 million; of that, 11.7 million (83 percent of total growth) occurred in states who expanded Medicaid to able-bodied adults. The increased funding to this group means there is less money available for the original beneficiaries of Medicaid—elderly disabled, pregnant women, and children in poverty.

Read it here


Article 3:  His Wife Runs Medicaid, but This Doctor’s Practice Won’t Accept It. Phil Galewitz, The Daily Beast, July 27, 2017

Clay’s summary: The headline is clickbait, but the rest of it is a good look at how Medicaid can not draw critical provider types like child psychiatrists into the network.

Key Passage from the Article

 Members of the Trump administration and Republicans on Capitol Hill repeatedly say the country’s Medicaid system is “broken” and enrollees struggle to get care because many doctors refuse that coverage.

The top U.S. official overseeing Medicaid—Seema Verma—doesn’t have to look far to find an example. Her husband, Dr. Sanjay Mishra, is one of them.
Mishra is a child psychiatrist in Carmel, Ind., and a partner and medical director of Indiana Health Group, a large medical practice specializing in mental health. That group doesn’t accept Medicaid.

“It’s sadly ironic, but given what I know… I am not one bit surprised,” said Dr. J. Wesley Boyd, associate professor of psychiatry at Harvard Medical School, who co-authored a study this year on the struggles children enrolled in Medicaid face looking for care.

Verma is administrator of the Centers for Medicare & Medicaid Services and a former consultant who helped design Indiana’s Medicaid program.

Jane Norris, a CMS spokesman, said Verma’s husband does not accept Medicaid because that “helps avoid any further conflict of interest or complication of her recusal obligations.”

Read it here



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