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EXPANSION- A gradual rise, not a flood, from Medicaid expansion

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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.

 
 

[MM Curator Summary]: SD Medicaid expansion uptake is going slowly, but officials don’t want to reduce the budget just yet.

 
 

 
 

Clipped from: https://www.keloland.com/news/capitol-news-bureau/a-gradual-rise-not-a-flood-from-medicaid-expansion/

 
 

PIERRE, S.D. (KELO) — People didn’t immediately rush to apply for services when eligibility for South Dakota’s Medicaid program expanded July 1, but the numbers of adults enrolling in the months since then have gradually gone up, according to the leader of the state Department of Social Services that oversees it.

Are SD children well? Report reveals status

Cabinet Secretary Matt Althoff told the state Board of Social Services on Tuesday that the program was funded for this first year to handle up to as many as 57,000 new adult enrollees, as eligibility expanded from 100% to 138% of the federal poverty level. For a one-person household, the maximum income to qualify is currently $1,677 a month.

So far, applications have flowed steadily into DSS offices but there’s been no flood. Data for June showed 43,953 adults and 79,590 children eligible, as COVID-19 eligibility wrapped up. Come July and voter-approved expanded eligibility, the numbers rose for adults to 44,965, while the children fell back to 75,760. The pattern continued in August, with 46,187 adults and 74,546 children; and again for September, with 47,445 and 73,436.

“I’m really grateful they didn’t all show up on July first,” Althoff said, referring to the 57,000. “We’re far short of that.” He estimated the expanded-eligibility group would reach 11,000 to 12,000 for the first year at the current pace. “But,” he added, “steadily increasing every week.”

Althoff said he spoke about the situation Tuesday morning with the state Bureau of Finance and Management and said other states that went through eligibility expansion have suggested South Dakota wait on downsizing any projections, because they eventually reached the estimates in their states.

“It is way, way, way too early to abandon ship on our 57,000,” he said.

The department eased its way in, delaying acceptance of claims for professional medical services by a month and claims for hospital services by about two months. The department’s deputy secretary, Brenda Tidball-Zeltinger, said the most immediate claims were for pharmacy services. She noted that pharmacy and dental services were the first to receive reimbursements.

“Now we’re starting to see some of those clinical visits,” she said, and hospital services will start to show up soon.

One thing Althoff described as “uncanny” was how many of South Dakota’s expansion enrollees filed an immediate claim.

They appear to be enrolling when they need medical care,” he said.

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FRAUD, EXPANSION (NC)- Scams reported ahead of N.C. Medicaid expansion

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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.

 
 

[MM Curator Summary]: Fraudsters are already exploiting the upcoming expansion of Medicaid in N.C. by communicating to existing and potential members they need to pay money to maintain Medicaid eligibility.

 
 

Clipped from: https://spectrumlocalnews.com/nc/charlotte/news/2023/10/15/medicare–medicaid–scams–healthcare–north-carolina-medicaid-expansion

North Carolina’s new state budget will expand Medicaid, making 600,000 additional people eligible for coverage.

What You Need To Know

  • The Better Business Bureau says it has received reports of scammers soliciting people who may qualify for Medicaid under North Carolina’s expansion

 
 

  • The BBB says it’s an attempt to steal identities and money

 
 

  • Scammers are also scaring people into believing they’ll lose Medicare benefits

The Better Business Bureau says it has gotten reports about scammers posing as government officials going after residents’ personal information ahead of Medicaid officially expanding on Dec. 1.

BBB president and CEO Tom Bartholomy says people who think they may be eligible for the federal program can be targets for scammers. They’re using emails, texts and social media to get through to potential victims.

“Anybody who’s not been in Medicaid before is going to go, ‘OK, maybe this is how I get going on this,'” he said. “But it’s really not the case. This is just a scammer that’s posing as state-sanctioned Medicaid expansion and they’re really just there to steal your money and steal your identity.”

Even if Medicaid isn’t on your radar, Bartholomy says con artists have other ways to get to you.

“Their other angle now is that with Medicare, open enrollment is starting on Oct. 15, and so they’re reaching out to people who are Medicare age,” he said.

He says the impostors are threatening to take away benefits unless you “take action” right away.

He recommends going directly to the government’s websites to learn more.

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FRAUD (AK)- Alaska Medicaid fraud investigation leads to indictment for Kenai doctor and staff

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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.

 
 

[MM Curator Summary]: 23 people in AK conspired to steal Medicaid dollars using fraudulent bills to the state and MCOs.

 
 

 
 

Clipped from: https://alaskapublic.org/2023/10/13/alaska-medicaid-fraud-investigation-leads-to-indictment-for-kenai-doctor-and-staff/

 
 

The exterior of the Nesbett Courthouse in downtown Anchorage on August 31, 2022. (Valerie Kern/ Alaska Public Media)

A Kenai doctor and his clinics’ managers face nearly two dozen felony charges in an alleged Medicaid fraud case after a grand jury indicted them Wednesday.

Prosecutors say Dr. Ray Lynn Carlson, owner of MediCenter clinics on the Kenai Peninsula, fraudulently billed Alaska Medicaid and two insurance companies – Aetna and Premera – from 2014 to 2019.

Also named in the indictment are Scott Carlson, Charise Carlson and Joseph Hurley, as well as a corporation in Ray Carlson’s name, under which he owned two MediCenter clinics, one in Kenai and one in Nikiski.

Each of the defendants faces 23 criminal counts, including fraud, theft and fraudulent insurance acts.

There is limited information about the alleged fraud in the grand jury’s indictment, but it indicates the defendants overbilled Medicaid and the insurance companies and, in at least some instances, submitted false medical billing codes.

Carlson’s MediCenter clinics appear to have closed sometime after the Alaska Medicaid Fraud Control Unit’s investigation began. According to a Peninsula Clarion newspaper story from 2019, investigators had searched MediCenter’s offices that July.

Phone numbers at both clinics are now disconnected. None of the defendants had attorneys listed in court records as of Friday.

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FWA (KY)- Oxygen Plus to pay $200,000 to resolve allegations of bilking Medicare, Medicaid

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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.

 
 

[MM Curator Summary]: 2 whistleblowers tipped off investigators about the company’s bogus billing for vent machines.

 
 

 
 

Clipped from: https://mountain-topmedia.com/oxygen-plus-to-pay-200000-to-resolve-allegations-of-bilking-medicare-medicaid/

 
 

STANVILLE, Ky. — A Floyd County company has agreed to pay $200,000 to resolve allegations that it defrauded the government by billing for unnecessary medical equipment.

The U.S. Attorney’s Office for the Eastern District of Kentucky announced the settlement on Tuesday.

Oxygen Plus, based in Stanville, rents non-invasive ventilators for patients with severe respiratory diseases to use at home. The company was accused of submitting more than 300 false claims to Medicare and Medicaid between 2017 and 2021, by continuing to bill for the rentals even after the patients were no longer using them.

The allegations were brought to light by two whistleblowers who worked at the company as a respiratory therapist and a bookkeeper. They accused the company of pressuring employees to solicit Medicare and Medicaid beneficiaries to rent the machines.

The lawsuit lists five patients who were given lifetime prescriptions for the ventilators, despite not showing symptoms to support a diagnosis of respiratory failure. One of those patients was never examined by a doctor.

For reporting the false claims to the government, the whistleblowers will split a $32,000 share of the settlement.

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FRAUD (FL)- 20 arrested, accused in $5 million Medicaid transportation scheme involving Jacksonville company

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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.

 
 

[MM Curator Summary]: The GPS systems in their vehicles helped get the conviction.

 
 

 
 

 
 

Clipped from: https://www.news4jax.com/news/local/2023/10/12/20-arrested-accused-in-5-million-medicaid-transportation-scheme-involving-jacksonville-company/

20 arrested, accused in $5 million Medicaid transportation scheme involving Jacksonville company

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20 arrested, accused in $5 million Medicaid transportation scheme involving Jacksonville company

JACKSONVILLE, Fla. – Florida Attorney General Ashley Moody said in a statement Thursday that 20 people have been arrested in a $5 million Medicaid scheme involving a Jacksonville transportation company.

RELATED | I-TEAM: Patients left stranded by non-emergency medical transportation provider

Many of the suspects are from Jacksonville, including Jose Hernandez Fernandez, who is the owner Sweet Transportation.

Investigators said the company, which provided non-emergency transportation for Medicaid recipients, billed Medicaid for thousands of patient trips that never happened. The trips were supposed to help patients receive medical care.

Hernandez Fernandez is accused of fraud, racketeering and money laundering.

The Medicaid transportation system has received plenty of complaints and was the subject of an I-TEAM investigation last year.

According to investigators, Jose Hernandez Fernandez started Sweet Transportation in 2019, and in 2020, when the company had just two drivers, it contracted with Modivcare, which is a vendor with the state to coordinate transportation for Medicaid patients. It was in 2022, investigators said, that Sweet Transportation reached its peak of 30 drivers.

The I-TEAM has previously reported on concerns about Modivcare and their various subcontractors arriving late for appointments or not at all.

On Thursday, News4JAX spoke again with Rene Reynolds, who said that her 84-year-old father struggled to get reliable transportation from Modivcare before his death earlier this year.

“It gives me a little bit more encouragement that there are good things that happen when somebody speaks up, me and other people speak up,” Reynolds said.

She said she’s not sure if Modivcare ever assigned Sweet Transportation to transport her father because she typically wasn’t made aware of which subcontractors were providing him rides.

According to investigators, Sweet Transportation drivers would bill for trips that never happened and inflate mileage for trips they did complete, but they were busted with help from the mandatory GPS technology installed in their vehicles.

In a separate civil lawsuit filed by the attorney general’s office, investigators said Hernandez Fernandez charged Florida Medicaid for nearly 3,000 trips as a driver in the Jacksonville area when he was actually in South Florida, Georgia, New York, Massachusetts, Colorado, Nebraska, Kansas and Puerto Rico.

“It’s refreshing to know that there is there is some justice out, there but I think it’s a drop in the bucket this fellow I think that there’s plenty more,” Reynolds said.

Hernandez Fernandez and 20 employees of Sweet Transportation are all accused of participating in the Medicaid scheme and are facing criminal charges and named in a civil racketeering lawsuit brought by the state.

According to police records, the investigation into Sweet Transportation began after United Health Care, which manages Medicaid services, complained about possible fraud.

A spokesperson for Modivcare sent the I-TEAM a statement Thursday, stating, “Modivcare has fully cooperated with the [Attorney General’s] Medicaid Fraud Control Unit (MFCU) through the entirety of this investigation.”

News4JAX tried to reach Hernandez Fernandez’s attorney but has not yet received a response.

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TECH- Waymark Secures Additional $42M to Scale Tech-Enabled, Community-Based Care for Primary Care Providers and People Enrolled in Medicaid

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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.

 
 

[MM Curator Summary]: CVS makes another huge investment into its tech portfolio.

 
 

 
 

 
 

Clipped from: https://www.newswire.com/news/waymark-secures-additional-42m-to-scale-tech-enabled-community-based-22151010

New Funding Will Support Waymark’s Market Expansion and Technology Investments to Continue Improving Access and Outcomes for Medicaid Recipients

 
 

SAN FRANCISCO, October 18, 2023 (Newswire.com) – Waymark, the Medicaid provider enablement company, today announced $42 million in new financing to scale technology-enabled, community-based care for primary care providers and their patients enrolled in Medicaid programs. Existing investor Lux Capital led the oversubscribed round, and CVS Health Ventures, the venture capital arm of CVS Health, joins the company as a new investor. Existing investors Andreessen Horowitz (a16z) and New Enterprise Associates (NEA) also participated in the round. The investment consists of $22 million in equity capital and a $20 million line of credit, bringing Waymark’s total capital raised to date to $87 million. 

“CVS Health Ventures’ investment portfolio is comprised of innovative companies that are at the forefront of transforming care delivery. Waymark’s use of proprietary data science technologies to improve access and quality of care is doing exactly that,” said Vijay Patel, Managing Partner and co-founder, CVS Health Ventures. “We expect this investment will provide Medicaid members expanded access to coordinated and holistic health care.”

Waymark will use its new investment to continue improving healthcare access and outcomes for people enrolled in Medicaid programs. Patients receiving Medicaid benefits often experience challenges accessing care, prescriptions, and social support like housing and food. Waymark hires, trains, and deploys local teams of community health workers, pharmacists, therapists and care coordinators to work directly with primary care practices — at no cost to the practice — and address gaps in care for their patients enrolled in Medicaid. The company’s local teams are supported by Waymark Signal™, a proprietary machine learning technology that has shown industry-leading performance in identifying “rising risk” populations, or patients at risk of avoidable emergency room (ER) and hospital utilization, and helps to direct Waymark teams to the best evidence-based intervention to meet patient goals. The technology is integrated into a care management software built by Waymark specifically for community-based teams, and incorporates data from multiple sources (e.g., local ERs, primary care practices, social services databases, and health plan data) to engage patients who are traditionally hard to reach. 

“Medicaid programs have historically been overlooked and under-innovated, but Waymark’s groundbreaking partnerships demonstrate the positive impact technology-enabled services can have for communities who need it most,” said Deena Shakir, General Partner at Lux Capital. “By aligning business incentives with patient outcomes, Waymark continues to build a uniquely effective approach to advance population health. There is no better team or technology out there to take this challenge on, and we are thrilled to deepen our partnership with the entire Waymark team.”

Waymark is currently supporting approximately 50,000 people enrolled in Medicaid across both Washington state and Virginia. Since launching in January 2023, the company has secured partnerships with several large health systems, a federally qualified health center (FQHC), and independent practices across both markets. Through its evidence-based care pathways, Waymark has shown promising early improvements in quality scores and clinical outcomes — including reduced non-emergent emergency department (ED) visits and hospitalizations.

Providence, one of the largest health systems in the country, is working with Waymark to improve access to care for patients receiving Medicaid. “At Providence, we’re committed to addressing inequities in the communities we care for,” said Dr. Scott Anders, CMO, Value Based Care, Providence Clinical Network, Providence Health & Services. “Waymark provides a disciplined Medicaid population health management approach that improves access to high-value care. Waymark’s use of data science combined with a local, person-centered process is compelling, and we are eager to see how they proactively help patients access the care they need.” 

At community clinics like Country Doctor Community Health Center (CDCHC), a Seattle-based federally qualified health center (FQHC) with roots in the civil rights movement, Waymark is helping to increase provider capacity and deliver whole-person care to patients. “We chose to partner with Waymark because their local, community-based, multidisciplinary care model aligns not only with the evidence of what works in Medicaid, but also our own mission and values,” said Matthew Logalbo, MD and Medical Director, CDCHC. “We have worked hard to develop services tailored to the needs of our patients (e.g., our low-barrier addiction treatment clinic, peer support specialists, re-entry CHWs, and healthcare for the homeless services), but we can’t meet the level of demand that exists alone. Waymark provides us with more capacity outside the clinic setting to engage and support patients, bring them into care, and connect them to our programs and other resources in the community that can address patients’ social determinants of health.”

Waymark enters into risk-based contracts with Medicaid MCOs to deliver community-based care for their rising risk populations and transition primary care practices to value-based arrangements. By building a new community health workforce to support primary care providers (PCPs) — paid for through value-based arrangements with MCOs — Waymark seeks to increase the capacity of its healthcare delivery system and align payment incentives to enable whole-person care.

“We created Waymark because the evidence of what works to improve Medicaid outcomes exists, but the operational capacity, technology and funding is insufficient to scale to the level of need that exists in communities across the country,” said Dr. Rajaie Batniji, co-founder and CEO of Waymark. “This new financing will allow us to continue hiring and training a new community health workforce, expand PCP capacity, and ultimately deliver on our charter to improve access and quality of care for people receiving Medicaid.” 

Source: Waymark

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TECH – Gainwell Enables Breakthrough Southern Methodist University Research on Hospital Readmissions for Medicaid Diabetes Patients

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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.

 
 

[MM Curator Summary]: Gainwell is re-selling state Medicaid data to researchers.

 
 

 
 

Clipped from: https://www.streetinsider.com/Globe+Newswire/Gainwell+Enables+Breakthrough+Southern+Methodist+University+Research+on+Hospital+Readmissions+for+Medicaid+Diabetes+Patients/22282075.html

New model holds key to accurately predicting 30-day patient readmission

IRVING, Texas, Oct. 17, 2023 (GLOBE NEWSWIRE) — Hospital readmission for diabetes patients is an enormous health risk and an expensive problem for the U.S. healthcare system. The question is how do we address it?

Gainwell Technologies (Gainwell), a leading innovator in healthcare technology solutions, partnered with its state Medicaid clients and SMU (Southern Methodist University) to develop an answer.

Diabetes affects roughly 13 percent of the U.S. population. These patients have elevated rates of hospital admission and all-cause mortality. They are also twice as likely to be readmitted within 30 days of discharge as similar patients without diabetes. The estimated cost of hospital readmissions is $20 billion to $25 billion annually.

While predictive hospital readmission models for diabetes exist for Medicare, they do not for Medicaid, which is the single largest source of health insurance in the U.S. This fact helped motivate this research.

SMU determined the first step was to develop a model to predict which Medicaid patients admitted to a hospital for any reason are most likely to be readmitted within 30 days. To develop a predictive model, Gainwell enabled SMU’s research by providing an advanced research platform and de-identified Medicaid claims from its clients in seven states.

SMU used 69,640 claims for the research that focused exclusively on patients who were diabetic, admitted to the hospital for any reason and discharged either to their homes or a non-hospice facility.

Using claims data only, SMU concluded Medicaid patients with diabetes were much more likely to be readmitted to hospitals within 30 days of their release than Medicaid patients without diabetes.

This important research was published in The
American Journal of Managed Care
(AJMC), a respected peer-reviewed medical journal.

Some of the most significant findings from the research were:

  • Researchers derived and validated a Medicaid claims-only statistical model to predict 30-day readmission for hospitalized Medicaid patients with diabetes.
  • The model’s accuracy is similar to that of other models that are based on more granular clinical and demographic data. It identifies populations by risk and suggests targets for interventions to improve outcomes.
  • The model will be of use to insurers, policymakers and health systems as they seek to categorize patients by risk to improve health outcomes and contain readmission costs in Medicaid programs.

The research will enable payers and health systems to use a patient’s age, gender and admissions history to predict the likelihood of a readmission.

“This research provides important guidance to clinicians,” said Daniel Heitjan, Ph.D., professor and chair of Statistics and Data Science at SMU. “Our new predictive model is accurate and much simpler to process. That’s a significant advantage when predicting the likelihood of readmission.”

A cost driver in healthcareThirty-day readmissions are widely recognized as a driver of increased healthcare costs. And it is to the benefit of hospitals and health plans to address it.

“These results are important to ensure patients get the care they need for this pervasive and deadly disease. This predictive model will help providers and payers identify Medicaid patients with a higher risk of readmissions. It also enables them to proactively focus on care transitions to improve outcomes and decrease costs,” said Gainwell Chief Medical Officer Dr. Gary Call.

“By identifying high-risk diabetics, clinicians will be better equipped to focus on patients during and after hospitalizations to improve treatment adherence and avoid readmissions. These models can also track high-risk population outcomes, develop care management programs and monitor the effectiveness of existing ones,” Dr. Call said.

He added the research would not have been possible without the foresight of Gainwell’s clients who enabled the company to share the de-identified Medicaid claims for this vital research.

Cooperative researchThis research is one in a series of studies Gainwell has enabled for top universities on issues ranging from hospital readmissions to opioid addiction to the impact of the social determinants of health.

Gainwell facilitated the research data environment for SMU under the umbrella of Australia’s Digital Health CRC (Cooperative Research Centre) to sponsor this study. The DHCRC connects government, academic and industry partners to harness digital technology to address many of the world’s most challenging healthcare issues.

About Gainwell TechnologiesGainwell Technologies is the leading provider of digital and cloud-enabled solutions vital to the administration and operations of health and human services programs. With more than 50 years of proven experience, Gainwell has a reputation for service excellence and unparalleled industry expertise. We offer clients scalable and flexible solutions for their most complex challenges. These capabilities make us a trusted partner for organizations seeking reliability, innovation, and transformational outcomes. Learn more at gainwelltechnologies.com.

About SMUSMU is the nationally ranked global research university in the dynamic city of Dallas. SMU’s alumni, faculty and over 12,000 students in eight degree-granting schools demonstrate an entrepreneurial spirit as they lead change in their professions, communities and the world.

CONTACT: Elizabeth Bonet, Gainwell Technologies972-556-5082 elizabeth.bonet@gainwelltechnologies.com

 
 

Source: Gainwell Technologies LLC

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STATE NEWS (AZ)- Arizona seeks to cover traditional Native healing practices under Medicaid

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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.

 
 

[MM Curator Summary]: AZ will try a third time to get CMS to allow federal dollars for Native American health services.

 
 

 
 

Clipped from: https://stateofreform.com/featured/2023/10/arizona-seeks-to-cover-traditional-native-healing-practices-under-medicaid/

 
 

Hannah Saunders | Oct 16, 2023 | Arizona

With traditional Native healing practices being the cornerstone of health and wellbeing of Native communities since time immemorial, the Arizona Health Care Cost Containment System (AHCCCS) is seeking federal approval to cover these services under Medicaid. Arizona would be the first state in the country to do so.

Title 19 Medicaid dollars cannot be used for traditional healing services as it currently stands, and that’s what we’re trying to change with our 1115 waiver request,” Alex Demyan, assistant director of the Division of Community Advocacy and Intergovernmental Relations at AHCCCS, told State of Reform. 

 
 

 
 

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AHCCCS initially submitted this request in their 1115 waiver in 2015, which the Centers for Medicare and Medicaid Services (CMS) rejected. The agency submitted the request again in 2020 during the current waiver period, but CMS was unable to approve native healing services at the same time they approved other 1115 waiver requests. Demyan said AHCCCS is actively negotiating the coverage of these services, but is uncertain of when it would be approved. 

Christine Holden, tribal liaison for AHCCCS, who is part of the White Mountain Apache Tribe, believes it is crucial to incorporate Native healing services into traditional Western medicine. Native healing services take on a holistic approach, where the medicine man or medicine woman does not separate the physical from the mind or spirit. 

Holden noted this effort represents a new beginning, and that by incorporating traditional Native health into state systems and non-Tribal healthcare systems, Arizona is conveying that it recognizes the importance of Indigenous traditions. 

“Bringing us back to our traditional ways that kept us alive for thousands and thousands of years. So, bringing that back into the western picture really will help from that Native perspective—Native identity and also respecting Tribal sovereignty and the right of Tribes to determine what their healthcare should look like without having to fit in any type of box.”

— Holden

Holden cited Canada and New Zealand, which have incorporated traditional healing practices into Western medicine, which she said has assisted with improving the mental and physical health of patients. Arizona currently has 22 federally recognized tribes. 

“The thing I appreciate about traditional healing is they never look at Western medicine as ‘it doesn’t have a place’ in helping our people heal,” Holden said. “They understand that it complements the traditional piece.” 

Traditional Native healing practices consist of using local roots, plants, and trees as medicine or ailments. Sweat lodges continue to be used as a way of easing an individual’s challenges with mental health. Holden explained how these sweat lodges were historically used during periods of war to treat trauma and post-traumatic stress order for survivors. 

“Native communities recognized this, and how powerful it is to separate the individual that goes to war, from the individual that is a family man, that is a grandfather, that is an uncle,” Holden said. 

Holden explained how prior to going off to fight in wars, Native and Indigenous individuals would visit the medicine man, who would provide the individuals with warrior names.

“The way they kept our warriors from experiencing PTSD or any mental health issues when they came back from those types of situations is they would have a sweat lodge. You pray and ask for forgiveness, and move from that warrior name back to whatever your traditional name was. That gave warriors the tools to be able to separate the things that they did that they weren’t proud of—but had to do to survive—from that person.”

— Holden

Burning of sage and cedar is a historic Native healing method that continues to be used today, including by Holden. She said Natives will light sage and pray, then put the sage on their feet, body, and mind, and waft in the smoke. When saying prayers, Natives believe the smoke will carry those prayers to the creator, and it’s helpful to physically see the prayers being carried. 

“I’ve seen that help, especially younger kids,” Holden said. “They like to see things physically happening, and so when they see that smoke rise for them, that symbolizes okay, my prayers and what I’m asking for is being carried to [the] creator, and that helps them to hold onto that hope.” 

Demyan said the waiver request seeks the maximum amount of discretion to be given to Native and Indigenous communities to establish relevant programs for each community, although CMS will enact minimal federal requirements upon approving the request. Federal requirements may include policy oversight, background checks and verification of training, among others. 

“We are asking the permission to reimburse for traditional healing services using Title 19 dollars—that’s the high level,” Demyan said. “We really want to give the maximum amount of discretion to the individual Tribal communities to define what those services look like, what the qualifications for the medicine man or the traditional healing practitioner are. As a state, we don’t view it as our place to define that for the communities.” 

Demyan said the proposal contemplates limiting services to individuals served in the Indian Health Services (IHS) 638 and Urban Indian facilities—for IHS 638 facilities, AHCCCS is contemplating paying the “all-inclusive rate,” that is annually established by the federal government, and is considerate of higher and lower cost services. 

“On the IHS 638 system side, that’s how we’ve backed into a rate that makes sense for the facilities, and our traditional healing workgroup is comfortable, and has been comfortable with that model,” Demyan said. “Urban Indian organizations—those facilities do not get paid the AIR [all-inclusive rate], so we’re still going through the rate setting process there.” 

While waiting for CMS approval, AHCCCS will continue to negotiate terms. If approved, AHCCCS will work with the traditional healing workgroup, and develop and implement policies prior to reimbursement for services. 

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STATE NEWS (CO) – Medicaid audit finds unclear messaging, inaccuracies

MM Curator summary

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.

 
 

[MM Curator Summary]: In one example, one family got 48 letters with 460 pages of information in 2 months from the Medicaid agency.

 
 

 
 

Clipped from: https://denvergazette.com/news/state-auditors-office-medicaid-audit-innacuracies-unclear-information/article_9e944fcc-6c59-11ee-a0f1-9f9d7a206300.html

 
 

A state audit released Monday showed that communications from Medicaid to its members is not always accurate, complete or understandable.

The report from the the Office of the State Auditor says that information needs to be more accurate, understandable, informative and clear.

The audit found that of 80 sampled letters sent to Medicaid members, 72 had one or more problems, including duplicated information, contradictory and confusing  messages, unclear guidance and complicated sentences and word choice, according to a news release from the auditor’s office. 

In January and February this year, one family got 48 Medicaid letters with 460 pages. In the same two-month time period, a second family got a 57-page Medicaid letter that repeated the same message 63 times, the audit said.

Letters also contained inaccuracies, such as deadline dates that didn’t comply with state Medicaid requirements, inconsistent response timeframes for the same type of information requests and Spanish-language translations that were unclear. 

“Unclear, inaccurate, and incomplete correspondence can create frustration and confusion for Medicaid members and ultimately lead to barriers with accessing health care, wasted resources, and potential legal issues for the Department,” Kate Shiroff, the audit manager, said in the news release.

As of July, the Department of Health Care Policy and Financing reported about 1.7 million Coloradoans enrolled in Medicaid, which is a federal-state program providing healthcare coverage and services to low-income families. 

Medicaid is administered federally be the Centers for Medicaid and Medicare Services under Title XIX of the Federal Social Security Act and, in Colorado, by the Department of Health Care Policy and Financing.

Colorado’s Medicaid program is called Health First Colorado.

In January and February, the Department of Health Care Policy and Financing sent more than 400,000 letters to members each month out of the Colorado Benefits Management System related to eligibility for Medicaid programs. The department’s vendors also sent over 24,000 prior authorization approval and denial letters to members each month. 

Many of the same issues found in the 2023 audit were also found in work conducted in 2016 by a communications contractor with the Department of Health Care Policy and Financing. Many of them were found again by an audit contractor in 2020.  

“These problems persist because the department has not fully implemented previous recommendations to change its monitoring functions, work processes, guidance to workers, and system design,” the news release says. 

The full audit is available on the OSA website at www.colorado.gov/auditor.

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MCO – Elevance Health Reports $1.3 Billion Profit And Insurer Ups Forecast Once Again

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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.

[MM Curator Summary]: Elevance profits are down YOY, but revenues from non-Medicaid lines of business are increasing.

Clipped from: https://www.forbes.com/sites/brucejapsen/2023/10/18/elevance-health-reports-13-billion-profit-as-insurer-ups-forecast-once-again/?sh=655338e76c53

Elevance Health reported a third quarter profit of $1.29 billion as the health insurer added health … [+] plan members despite a big dip in Medicaid enrollment due to the end of a pandemic-era coverage provision.

Elevance Health

Elevance Health reported a third quarter profit of $1.29 billion as the health insurer added new customers despite a big dip in Medicaid enrollment due to the end of a pandemic-era coverage provision.

Elevance, which sells government and commercial health insurance including Blue Cross and Blue Shield plans in 14 states, Wednesday reported third quarter profits decreased nearly 20% to $1.29 billion compared to $1.6 billion in the year-ago quarter. The dip in net income was due largely to an “operating loss of $741 million in the company’s “corporate & other segment” executives said was driven by “business optimization charges.”

“In the third quarter, we completed a strategic review of our operations, assets, and investments to enhance operating efficiency, refine the focus of our investments in innovation and optimize our physical footprint,” the company said in its earnings report. “This resulted in a net charge of $697 million, comprised of the write-off of certain information technology assets and contract exit costs, a reduction in staff including the relocation of certain job functions, and the impairment of assets associated with the closure or partial closure of data centers and offices.”

Still, revenue jumped 7% to $42.8 billion as overall health plan enrollment grew and the company’s Carelon health services business performed well.

Elevance’s membership grew by 42,000, or 0.1%, to 47.3 million as of September 30, 2023 compared to a year ago.

The growth was driven primarily by “growth in BlueCard, Affordable Care Act health plans, and Medicare Advantage membership, partially offset by attrition in Medicaid due to the resumption of eligibility redeterminations and a new entrant into one of our state Medicaid programs in the third quarter, as well as declines in our Employer Group risk-based business,” Elevance said in its third quarter earnings report.

The end of the U.S. Public Health Emergency in May after three years of the Covid-19 pandemic is impacting health insurers that have a significant business administering Medicaid coverage for states, which are conducting so-called “Medicaid redeterminations.” Medicaid redetermination, also described as Medicaid renewal or Medicaid recertification, is essentially when people are asked to show they are qualified for such coverage.

During the third quarter of 2023, medical membership decreased by 664 thousand driven by attrition in Medicaid due to the aforementioned dynamics,” Elevance said in its report.

Still, Elevance’s profits and continued growth are figured in the company’s forecast for increased profits with adjusted net income now expected to be “greater than $33.00 per share.” That is more than an earlier forecast for adjusted net income of company “greater than $32.85” per share.

“Elevance Health delivered another quarter of solid performance reflecting the strength and balance of our diversified portfolio of businesses, our continued investments in innovation and growth, and our relentless focus on affordability, simplicity, and customer experience,” said Elevance Health president and chief executive Gail K. Boudreaux. “With affordability a paramount concern for all payors and a more uncertain forward-looking operating environment, we took action during the third quarter that will enhance our ability to act nimbly and operate efficiently.”