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2018 Year in Review: You Can’t Put a Bow On It (Or Maybe You Can)

And now its that time of year we do the annual Mostly Medicaid (really Clay’s) Year in Review. For past reviews, visit here and here. If this is your first Year in Review with us, fair warning: it’s the one time I get all sappy. Provides a nice contrast to the cynicism and sarcasm you probably read the RoundUp for.[1]


You will need tissues.


Winter is a time for thinking.

A certain type of thinking, really. Reflection, introspection. All the eckshuns.

Spring is for hope and eagerness. Summer is for playing (and if you are a teenager in love it is a time of rhapsody and skirting curfews). Fall is for slowing down a bit, and breathing in the fresher, cooler air. Watching the oranges and reds and yellows on the trees.

But winter is a time for thinking.

And so I think, sitting in front of my fireplace. Warming my toes, my thoughts and-  I hope – my heart. For just as winter brings cold outside, it also brings cold to many hearts.

Hot soup can help. Or a game of cards with an old friend.




Sometimes we do things not knowing exactly why, but trusting they are important and will be valuable at some point in the future.

About 20 years ago, I started saving every single card people gave me and put them in a box. After a year or so, I outgrew that box. And now I am about to outgrow a large plastic tub.

Being a strict minimalist, cards are the one thing I let myself pack-rat.

I can remember the exact conversation that started this habit. A friend of mine and I both loved the same band (the Weakerthans). In their song Left and Leaving[2], are the lyrics:


Duct-tape and soldered wires
New words for old desires
And every birthday card I threw away

I wait in 4/4 time
Count yellow highway lines
That you’re relying on to lead you home


When discussing this song, my friend was struck by this particular line about throwing away birthday cards. They said something to this effect: “You know, every time someone sends you a card, they were thinking of you. Thinking of you enough to spend $2.99[3], write something about you specifically from their heart, and place it in the mail or hand it to you. We really shouldn’t throw those cards away.”

And from that moment on I didn’t.

I get rid of most things. I hate clutter. I don’t hold onto anything else for sentimental reasons. But – I have a box of birthday cards, get well cards, letters, graduation notes, thank you notes,[4] and myriad other similar items that has grown over the past 2 decades.

My thought is that one day when I am 80, I will sit and read these cards and be reminded of a time that I was loved and surrounded by those that I loved. That memories will flood in and drown out the sadness I see so often in the nursing homes I visit. That the effort to read someone’s poor handwriting inside a Snoopy-themed missive will pay off in smiles and remembered inside jokes.

Hold that thought. This will be the bow we put on the boxes that are sometimes painful to open.



But first, let’s talk about what happened in 2018 in Medicaid


Its been a wild, wild Medicaid ride hasn’t it dear reader? I looked back at the topics in our Monthly Medicaid News Roundtables, and made a short list of major happenings in our world this year:


Work requirements; Good vs Evil; Darth Vader; Orange Man Bad

It’s all a bit overblown, don’t you think? Reasonable people can disagree without casting each other as Nazi’s. At least they used to be able to. I yearn for a return of reasonable people discussing Medicaid. Hint – it does need fixing. Start there.

Another hint- a rebalancing of the state/federal “partnership” is long overdue.


Expansion on the ballot

This one took me by surprise. I wasn’t surprised that in state after state people voted for it (put any entitlement on the ballot and of course people will vote for it). I was surprised that it can even work this way. And I’m still not sure it can because it all has to go through the budget process. Stay tuned…


Social determinants

All 3 of these things are true:

  1. I believe food, clothing and shelter do impact healthcare outcomes
  2. I can’t sit through another academic presentation on this
  3. Its time to share info on specific, practical, starting point strategies. Go!


Managed care in the Tarheel State

North Carolina was added to the “managed care” column this year. Seems like 85% of the 2018 Medicaid conversations I had were around this. Now if we can get through the protests (I know we don’t have them yet, but I will bet you anything we will).




And now back to the things you think about sitting next to a fireplace (a wood fireplace, the only real kind)


Yes, it gets cold even in Birmingham, Alabama. Not as cold as some of the places you lunatic Yankees live (I’m looking at you my good friends in Michigan, Ohio, Maine- I mean, why not just live at the North Pole? That’s the one with penguins, right? Or is it the south pole? Or both?).

And I love fire.

I was the kid who other kids could not play with because I taught them how to play with fire. My first “date” was when I was seven and I went to see E.T. in theatres with a little girl my age. When her parents dropped her off, the first thing I did (to try and impress her?) was walk over to the nearest tree and show her how to strike a match and throw it at the tree.

I like fire. And fireplaces.

Many of you who have spoken to me the past few years know I have been slowly remodeling a 1974 elevated ranch. Well, I finally got around to fixing the fireplace. Which really was a chimney repair/ash dump investigation/damper replacement/flue cleaning/new cap install project. Just a small project. Only took me 2 months.

But now its done. And we sit by the fire whenever we can (I have come to think that first-thing-in-the-morning fires are the best. How nice it is to start your day with a fire and its heat and its light and the smoke wisping up into the flue as you drink a cup of coffee. Or see you children stumble out into the living room in their pajamas).

And these are the things I think about when I sit next to my newly working fireplace and stare into the flames.

I do not think about Medicaid.

I think about people.


My mom brought me a stack of old cards and I finally cried about Daddy dying for the first time almost a year after he died


As many of you know, Daddy died a year ago today (12/28/2018). My grieving has been different than most of my family members. For whatever reason, I did not really cry a lot when it happened. Or at the funeral. Or pretty much the entire year of 2018. I did cry here and there, but only a little.

I wasn’t holding it back (at least I don’t think I was). But it was noticeable to others, including my daughter who asked me – “Are you not sad? Now that Papa is gone?” I didn’t have a good answer. And I still don’t.

I am sad. But also not. Daddy left me with a clear view of death.

And its not that I don’t think about. I think about him most days. But in a good way. Memories of his little strange habits, or of conversations we had. Or ones I wish we would have had.

I try to spend my rememberings on things from when he was most alive. I do try to block out the gruesome final months of his life as he succumbed to brain cancer.

That was hard.

So hard that all I could do was work. Sitting in the room next to his, working away. Furiously trying to deny that he was 10 feet from me, his body and mind mangled more each day by this evil opponent.

I have many, many, many regrets in my life. But the one that has stuck with me most this past year is that instead of spending most of my time next to his bedside holding his hand in those last few weeks, I instead spent most of my time typing and analyzing and staring at a computer just a room away.

I’m sorry about that, Daddy.



I have learned in recent years, sometimes all our urges to find a silver lining, to make a happy ending, to put a bow on it (just look at all the idioms we have for this)- sometimes we can’t overcome the brutality of certain events. Sure, we can say “they’ll always live in our hearts” (never has made sense to me), or “make the most of life since its so short, and it will be ok as long as you live a full life” (always seemed like it missed the main point).

Sometimes we have to face the reality of loss. We have to accept for what it is. We can’t deny it. We can’t escape forever into our hobbies or pursuits or careers. Loss (primarily death) refuses to actually be transformed into something less than an awful, horrible, total thing.

We can’t put a bow on it.



I can still remember calling a friend and colleague who shares this Medicaid world of ours last February. I was at the Medicaid Innovations conference in Florida, and had stepped out to make a call to Dr. G.

The purpose of my call was to ask his opinion on a partner I was considering bringing on. Dr. G is someone whose opinion I trust (and his judgment even more). He started out as a client years and years ago.

And he is the reason I have a beard.

Dr. G was a key client stakeholder for a giant technology implementation contract my company at the time had (if I remember correctly, about $80M over a few years). In my first meeting with Dr. G, at the end of the meeting he had a new agenda item. It went something like this:

“You seem like a very impressive young man. And it seems like you have everything in order for the preparation for this project.”

He paused.

“But you look so young. I for one would appreciate a little more gray hair on a project of this size and complexity.”

I have always had a baby face.

I thought for a moment.

“Give me a month, Dr. G.”


I spent the next month growing a beard to try and look older (it used to work for my friends in high school when they tried to buy cigarettes, so why not for this?)

At our next meeting, I pointed to the beard.

“Do you feel better now, Dr. G?” I asked.


It was the start of a wonderful working relationship, and I have gotten to know one of the most committed, honorable men in this space. All because I threw away my razor.



Back to the call from sunny Florida this past February.

After giving me his insights into the question that occasioned the call, he also asked how I was doing.

And I told him it was hard to have not cried about Daddy yet now (at that time) that it had been more than a month.

And he told me of the story about how it took him a long time to cry about the loss of his parents. He shared a sacred part of his life with me that day.

And he let me know it was ok to not cry yet. But that it would come.

And to hope that God would bless me for it to come in a private moment. For when it comes, there will be no holding back the tears. It will overwhelm you and consume you and take control of not just tear ducts, but also breathing and your muscles and all your emotions and your mind. It will be an experience of recognizing the totality of the loss.

And then it will somehow be better.



My mom has been cleaning out things since Daddy died. I think people do this for various reasons. Some people do it to get rid of clutter. Some people do it to busy themselves and avoid thinking about the one who has died.

Some people do it as a way to remember the people who have died.

I think that’s what Momma has been doing with all her cleaning.

And in cleaning out things, she found a stack of letters and cards of mine. She brought them over one day in early November and left them on my kitchen counter.

At first all I noticed was the letter from my elementary school congratulating me on coming in 2nd place in the city-wide spelling bee. And I remembered how much I did not like the experience of 2nd place. And I remember vividly the face of the little girl who beat me (I do not remember the word I lost on).

And I told my children the story of this. And they laughed. And that was that.[5]

The next day, I saw the stack of cards on the counter again. If your house is like mine, there is a constant battle between you and one spot on your counter to keep it free from mail or books or keys or change or Home Depot receipts. The stack of cards was in that spot, staring back at me.

That’s when I noticed the other things under the spelling bee letter.

I opened the first one and began to sob. It was a highschool graduation card to me from Daddy’s very best friend. Emmet Ladner. Emmet and Daddy became fast friends on the Mississippi Gulf Coast due to their shared love of fishing. Emmet had died 10 years or more ago and I watched Daddy miss him.

And then I opened more cards. Many of them from Daddy. Or from aunts long dead. Or friends forgotten.

And I simply could not stop crying. But it was of joy. I was remembering the good things, all the many people God had placed in our lives and the times they thought enough of me to spend a few bucks and write down a few thoughts about me that they felt in their hearts.

It was not – as Dr. G had wished for me – a private moment.

My wife was there to hug me. My kids were there to see my cry. And I’m glad they did.




3 Kinds of People

I think this year I realized recently that there are mostly 3 kinds of people:

  1. Those you don’t want to be around. You choose to avoid these.
  2. Those you do want to be around, but can’t. They may be far away, they may dead, they may have an illness that prevents contact. They may be missionaries in a country where they have to be almost like secret spies for Jesus or else get killed, and that’s the reason you probably won’t ever get to see them again. There may be an un-crossable emotional rift between the two of you, spreading across and between your hearts like a chasm. With only darkness and echoes where what once was joy and laughter. And a bond you never doubted until one day it simply wasn’t there.

There are many reasons that created situation #2- the people you want to be around but cannot.

And that leaves us with the 3rd kind:

  1. People you do want to be around and still can.


I now think about the people in #2 a lot. And you should, too. You shouldn’t avoid it (if you do).

Its good to think about the people in #2. It is important to miss them. Important to grieve. To mourn. To ache. To cry.


But I need to start paying more attention to the people in group #3. (And so do you).


And this is where we put the bow on all this.




Card by card

I’m still saving this big ole’ box for when I am old and gray. I’m working on the old part. And the gray pokes through. But hopefully I still have decades longer to fill this box up and look at it when I am old.

But – I did sneak a peak at a few of them when Momma brought them over. A little stack. A small bundle of memories that jarred in me tears of joy.

And I would like to share just a few of those cards – or rather share a bit about who sent them- with you before we land this plane.

  • Emmet and Nell-  They are both dead and gone, but some of my earliest memories are of them.
  • Jo Elaine –Jo is my aunt and she’s a peach. On my Nanny’s side (who has been gone a long time). Jo is one of many aunts who always thinks of me on birthdays even though I rarely see her.
  • Bobby and Betty –Mr. B was also one of Daddy’s very best friends. I remember riding my bike next to he and Daddy as they ran at 4am each morning in Gulfport, MS. Mr. B was a Marine, rough around the edges but with a gooey center that loved people. He was a good man. He is also now gone.
  • Carrol and Nancy –Carrol was a true friend to Daddy in his toughest times, hiring him to work in his hardware store during one of Daddy’s hardest bouts of depression (it lasted 3 years that time). Nancy died in a car crash in the rain on an interstate exit ramp. But she was a dear friend to my mom before she left. Momma still misses her and I think of her every time I pass that exit ramp.
  • John and Louise – a sweet, sweet couple who managed a large farm operation in Kiln, MS (where I watched Brett Favre play highschool ball). They stopped smoking when 7 year old me told them I couldn’t be around it. They are both gone now but in no way forgotten.
  • Ganky and Pappy- Pappy was a retired railroad man and he sure did love Ganky. She was the first person I ever heard of with Lou Gehrig’s disease. Pappy once snuck into Daddy’s garden in the middle of the night to dig up and replace small tomato plants with very large ones to convince Daddy of the astounding overnight effectiveness of Miracle Grow. They have both been gone a long time.
  • Aunt Annette – one of my mom’s aunts who still sent me cards even though she had been estranged for decades. My mom misses her a lot.

And so many more even just in this little stack. From my siblings, from Momma and Daddy. Somewhere in the big box is a letter from my friend Cecille who died (along with her little brother) when she was hit by a train in her late teens. Way too many to write about.

What do I take away from all these cards? People come and go and everyone dies. But in the in-between parts, the times you spend with them, the times they still send you cards (and even after that when you read the cards years later)- something amazing happens. Somehow, despite all the insurmountable despair of loss we all must face, somehow we have the capacity to love one another.

Let’s do more of that in 2019.


One last detour

I almost didn’t write this part up. This thing has gotten way, way longer than I intended. And I hope for the 2019 Year in Review I can find a topic besides death and loss. 3 years in a row is surely enough.

But this part is fun.

When I was kid, we went to every Auburn game. Home and away.

This was before that jackass Alabama fan poisoned the big oaks on Toomer’s corner.

Back when you could still park all over campus on gameday, in crazy places. And camp out for 3 days before the game with 100,000 of your closest friends.

Like an idiot, I hated much of those times as a kid. Or at least I thought I did.

Now, I do things like return to Auburn and walk around with my kids. Just like Daddy did with me.

Not knowing why, we often return to the places our fathers took us.

What was really crazy, was that Daddy would just walk on the field after a game and walk into the locker rooms just to talk with players. And after that we would walk over to the players dorms and hang out with them. So as a 12 year old I’m chilling with the dude that just kicked the winning goal against LSU. Or the guy that missed the pass that could have beat Arkansas in the last 3 seconds. Those 2 guys have very different moods, by the way.

But the point is that Daddy had a way of getting into places (and people’s hearts) simply by acting like he was supposed to be there. Let them tell you no if they feel they must. But until then, sneak into the stadium.

And that’s what we did a few weeks ago. Passing through Auburn on our way back home from a trip with the kiddos.

There was one gate open at Jordan-Hare stadium that day (pronounced Jur-dan for those of you who don’t know). I snuck in first and waved to the kids to follow.

There was a worker there. He looked at me.

I froze.

“I gotta lock the gate, so please make it quick.”

I had the feeling he sees this a lot. And he was so kind and probably is to every Auburn fool wandering back in. Whoever he is, he was my hero that day. And I hope I get chances to be so kind to others in need of sneaking into stadiums, too.

We go back to the places our fathers took us.


Wrapping Up (Finally!)

So I know what I need to do now. How 2019 needs to go.

My box is overflowing.

I need to send more birthday cards so others can put them in a big box and pull them out one day and go through each one and defiantly shake their fist in the face of death and loss and separation and tell the Evil One he has not won because there was joy. There was love. There still is. But – most importantly- there still will be.

And it can be forever for those of us who choose it. Beyond time, forever joy. With our loved ones and with Christ. For all of you readers who are non-believers (so many of you are, and I hope you know by now I love you regardless of any differences of opinions or beliefs), suffer me one more time in 2018 to share the simple gospel:

You (and me and everyone ever born) are a sinner. You need a savior. His name is Jesus.


Merry Christmas and Happy New Year my dear readers! You are loved by me, each and every one of you. If you like you can print this out and put it in your box and count it as a card from me to you. Me thinking about you and writing it down.

Please don’t stop writing in ( and calling (919-727-9231). You have no idea how much it means to me when you write in and tell me your thoughts about what I write.

War Eagle!

Onward and Upward!

Trystero: The Father Sent the Son to Save the World (English)




[1] I have found my old love of footnotes again. It’s like a little side conversation beyond me and you. Titles that were also considered:

A Box of Letters

Looking At Life With Clear Eyes and A Full Heart

Memories as a Gift to Get Us Through Our Journey

Returning to the Places Our Fathers Took Us


[2] For those of you who have enjoyed my musical recommendations in the Roundup over the years, this song, album and band are in my opinion one of the most important things to happen to music in my lifetime. For people who have never heard The Weakerthans, I tell them their art is the closest thing to perfection in the combined genres of music and poetry that I have ever encountered. It may not be your style – but I drove from Baltimore to Toronto once just to see them play and its still one of the best life decisions I have made.

[3] For a fun look at the greeting card industry (including average prices, which have gone way up since the mid-1990s), see


[4] Oxford forever! Grammarians, unite and #Resist!

[5] 6 sentences in that segment started with “and.”

Posted on

Clay’s Weekly Medicaid RoundUp: Week of December 24th, 2018

Soundtrack for today’s RoundUp pessimist readers-


For optimist readers-

READY FOR MEDICAID INNOVATIONS 2019- I will be there again this year (my 9th time), chairing one of the very best Medicaid events you can go to. Also, its sunny Florida in February (I’m looking at you, Michigan). If you decide to go, let me know and we can meet up. Check it out here –

PELICAN STATE TO START USING IRS DATABASE TO CONFIRM MEDICAID ELIGIBILITY- After a few weeks of taking a beating in the news over blowing $80M on non-eligibles, Louisiana is rolling out several news stories about an enhanced system. To be fair, it looks like the enhancements were planned for some time (so I guess they have known their system is crappy for a while but still kept overpaying millions?). The new system will start using tax data for bennies in May of 2019 (one month after we all file our taxes).

AND ON THAT NOTE, A BRIEF MATH DETOUR- I’ve been working on a little math exercise where I try to figure out how much of my own personal taxes help pay for Medicaid. Its not easy (mostly because of the imaginary way we handle group expenses in our country under “budgets” and “debt”). But I am getting closer to a workable framework. Here’s my current, early, certainly wrong (but I invite you to provide alternative estimates) evaluation based on income groups. If you make $65k/year, then about $1,800 of what you pay in taxes goes to Medicaid spending (about 1/3rd the cost for one average bennie; about $185 from your taxes is lost to Medicaid fraud). If you make $120k/year, then about $3,400 of what you pay in taxes goes to Medicaid spending (about 2/3rds the cost for one average bennie; about $350 from your taxes is lost to Medicaid fraud). And so on… Once I am done, I will publish the broader analysis and will invite comments, corrections, etc…

BUCKEYE STATE JUST CAN’T GET RX RIGHT- The report of CVS spread-pricing shenanigans in Ohio will be conveniently delayed until after legislators consider a budget in 2 months. Note to CVS Grand Pooh-Bah: whatever you are paying your lobbyists in Ohio, they deserve a raise. In a related (?) note, reporters in the state are trying to get answers about why the state still has not implemented a unified drug list that was rolled out by Kasich as a key initiative 2 years ago (and in October of this year was still projected to go-live Jan 1, 2019). Medicaid officials announced this week that the effort would be “delayed indefinitely.” You know who opposed that initiative? PBMs. Why, you ask? Because they could no longer keep their rebate deals secret and states would know how much rebates they would have gotten vs what was passed on to them. Am I being too hard on you this week, PBMs? Open invite to come on the show and explain yourself anytime you like.

ALOHA STATE INCHES FORWARD MEDICAID PAYMENTS FOR HOUSING- Hawaii is leading the way towards getting Medicaid dollars approved for housing. An existing waiver that pays for house (or apartment) hunting help is being expanded. While the dollars can’t pay for rent, they can be used to help with all the effort to find a place. There are 8 other states with a request for similar funding for supportive housing from CMS.


SHOW ME STATE CONSIDERS THOSE EVIL WORK REQUIREMENTS- By now you can fill in the rest from here, right? Won’t be effective, just an evil ploy to kick people off rolls, Orange Man Bad.


SNEAKY STATE REPS IN THE GRANITE STATE TRYING TO UNDO CMS DEAL- This is pretty interesting. A week or so ago, CMS approved a New Hampshire request for work requirements (aka, “how the process works”). Without getting into the weeds (are there weeds in NH? In my mind its this idyllic place, with nothing out of place), duly elected reps in NH negotiated a deal in which the state’s expansion program can continue IF there are work requirements in place. So that got passed, then CMS approved what was agreed to by both parties. Now, Dems (Rosenwald and McWilliams) are introducing bills to make work requirements illegal in NH. When you’re opponents keep changing the rules, its hard to keep up. Will be fascinating to see how this one plays out. Some of the CMS comments were fairly clear on the tradeoff between expansion and work requirements as the heart of the bargain.


WAIT- YOU MEAN WE HAVE TO PAY FOR THIS EXPANSION THING BY PASSING A STATE BUDGET? Idaho activists were able to get expansion voted in back in November (seems ages ago, doesn’t it?). But now it seems the next steps are out of their hands. From what I understand in Idaho, each year this group of people called “legislators” get together in this place called the “Capital” and they manage something called an “appropriations process.” They have to make these things called “decisions.” And sometimes they have to choose between different priorities. And – here is the shocking part- some Idahoan reps think the function of Idaho state government is broader than Medicaid. Something about education, roads, state pensions – I mean does it matter?. Somebody connect these doofuses to Alexandria – she clearly has it all figured out.

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… Actually, in the spirit of Christmas, let’s just pretend there’s not bad guys stealing 10-20% of all the funds meant for the most vulnerable this week. We’ll pull our heads out of the sand again next week/year.


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 (burn all those amazon boxes) 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 .

Want the Curator News Pack for this week’s Roundup? Medicaid News Curator Volume 4


Trystero: Fadern skickade Sonen för att rädda världen.



Posted on

Clay’s Weekly Medicaid RoundUp: Week of December 3rd, 2018

Soundtrack for today’s RoundUp pessimist readers-


For optimist readers-


MAINERS GETTING MORE MEDICAID FEB 1- After a long battle against Medicaid expansion (which gave us a lot to cover for years), LePage may have finally lost. A judge ruled the voter-approved expansion must go forward. LePage will be gone (doing whatever Mainers do when they retire and its winter, I guess. Something in a cabin?), and the new Good Guvn’r Janet Mills will come in Jan. 2, with magic wands, puppy dogs, unicorns and Medicaid expansion promises.


NEW HAMPSHIRE WORK REQUIREMENTS STILL ON- Seems CMS still gets to decide which parts of requests it does / doesn’t approve. CMS approved NH’s work requirements waiver (basically as a trade-off to let them keep expansion). CMS did not approve a provision that would allow seasonal workers a different way to add up their hours to reflect the surges in employment they have during certain times of the year.


FLORIDIAN BENNIES NOW HAVE ONLY 30 DAYS TO FILE PAPERWORK- Several states have requested the option to reduce retro-active eligibility from 3 months down to 1. Florida got approval for this and the change will go into effect Feb 1. Officials estimate it will save the state $98M (women and children are exempt and still have 90 days). Other states with recent approvals for the same request include IA and KY.


PELICAN STATE PAYING MILLIONS FOR INELIGIBLES – Louisiana spent at least $60M and as much as $85M on bennies who were not eligible, according to an auditor’s new report. The system to confirm self-reported income was not effective at getting info about changes in income.


FORTUNE SEEKERS GO TO COURT- Did you know that’s one of the demonyms of Idahoans? A taxpayer-rights advocacy group is suing to stop the Medicaid expansion voted in by 60% of voters in November. According to the lawsuit, letting voters decide these types of things is “A sweeping and general delegation of legislative power with uncontrolled, unrestricted or unguided discretionary power [that] exceeds constitutional limits…”


MINIMUM WAGE HIKE IN JERSEY TRIGGERS $200M MORE IN MEDICAID SPEND- When you raise the wage for everyone, that includes Medicaid home health workers.


CALIFORNIA TO SPEND $3B ANNUALLY TO GIVE ILLEGAL IMMIGRANTS MEDICAID COVERAGE- A bill from last year is expected to get re-introduced in the next session. Would add about 1.2M people to the rolls.



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. Erik Dewayne Lean of Greensboro, NC was sentenced to 18 months for stealing $420k in a kickback scheme for his counseling business. Rajendra Bothra (of Detroit) and 4 of his buds were charged this week for stealing $500M from Medicare and Medicaid (so ineligible for this week’s award, but notable). How, you ask? By prescribing more than 13M doses of opioids. Based on initial reports, this could come close to some of the FL pill mill scandals from 10 years ago. Samuel Okere of Oklahoma City was sentenced to 1 year in federali lockup for stealing $141k in Medicaid counseling bucks (services not provided). John Ndunguru of Fairfax, VA has been charged with using his home health company to steal $4.5M from Medicaid. Mr. Ndunguru made submitted false Medicaid claims for patients not approved for long term care services. Still in VA (but now in Charlottesvile- about a 1hr 51 min drive south west from our last story), husband and wife team Dennis and Cheryl Gowin stole $210k from Medicaid by not disclosing that Dennis had a felony conviction (which would have made him not eligible as a Medicaid provider, or even become a licensed counselor in VA). Anil Desai of Hotlanta has agreed to pay back the $213k he stole from Care and Caid by getting paid for drugs they never provided to patients. Tara Rose of El Paso, TX plead guilty to stealing $1M from Medicaid using her speech therapy business (“Beyond Words”) to bill for imaginary patients and services that never happened. Faiz Ahmed of Houston, TX was sentenced to 5 years in prison for stealing $4.1M by ordering unnecessary tests. There’s actually more this week, dear readers. I am just tired of typing.. This week’s winner- Mr. Ndungura of Fairfax, VA! Taxpayers, you lost at least $510M in the last paragraph.



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 (finish up your Christmas shopping? We do all ours online) 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 .

Want the Curator News Pack for this week’s Roundup? Medicaid News Curator Volume 3

Here’s the one for the Fraud stff- Medicaid FWA Curator- Vol 4

Trystero: el Padre envió al Hijo para salvar el mundo.

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Clay’s Weekly Medicaid RoundUp: Week of November 12th, 2018

Soundtrack for today’s RoundUp pessimist readers-


For optimist readers-


MEGA RULE MUTATES- After a loooooong windup and much speculation, CMS finally showed its cards on possible changes to the Mega Rule. (Do you get the feeling they wait until early November for big stories just to make sure there are interesting convos in the NAMD hotel happy hours?) Highlights: Possible relief on cert for all those rate cells (may go back to ranges), 3 years to put on your big-boy pants related to pass-through payments, and more grace on using telehealth to meet network standards. And oh yeah – some stuff about making sure all you turkeys stop using different rate cells to game the federal match.


IL CRIES UNCLE- Following many other states (who are following judge’s orders in their own states), the Land of Lincoln (R-IL) has decided to open the floodgates on Hep-C coverage. Now no signs of disease or proof of sobriety are required to get the pills that cost about the same as a souped-up Civic. But hey- it used to be a new Vette.


MICHIGAN GETS TREATED LIKE AN ADULT- Add a W to the win column in the “restore a modicum of power back to the states game.” CMS approved Michigan’s request to negotiate their own deals for pricy drugs based on whether they actually work for the patient. This CMS approval comes 4 months after a similar gig for OK and a denial for MA. Right now the MI deal is focused on 4 drugs. I’m sure the list will expand, and if you say the magic words – “value-based-care,” “population health,” and“big data,” – four times fast, under a fool moon, wearing green slippers, the list of the next 4 drugs will magically appear in your left hand (if you’re left handed; else, your right hand).


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. Idris Talib of Columbia, SC got five years in the slammer for stealing $400k using false claims for counseling. Head on up 1 state to NC, where we meet Renee Borunda, who managed to steal $225K using another therapist’s billing ID for Medicaid claims that didn’t happen. Keep heading north until we get to Niagara Falls, NY (cool place if you haven’t ever visited), and we learn about Sadat Khan who used Wego Taxi Tours to steal $50k from Medicaid. How did he do it you ask? By falsifying pickup location addresses so the trips would appear longer and get more mileage reimbursement. Lets drop down to the paradise known as Detroit for our next shining light of Medicaid fraud- Jacklyn Price. Ms. Price and buddies stole $8.9M from Medicare (so can’t win today, sorry!) using a home health scheme. Over in Brooklyn, Yvette Juarez was picked up on a pretty decent-sized member fraud. She made too much money from her daycare business to be eligible for Medicaid, but falsified income statements in order to get about $72k in benefits. Now on to PA- 4 people operating “Moriarty Consultants” stole as much as $87M from Medicaid by fabricating personal care services claims. It gets good, in addition to boring stuff like faking timesheets, they made up employees and paid kickbacks to bennies to help pull it off (remember, fraud is most effective when you work as a team). Team Moriarty – you win! Your creativity and volume put you over the top; you do not live up to your namesake, however.

Taxpayer tab for this paragraph – about $96M. Work harder- and don’t complain or have bad thoughts about it, or else you’re a meanie!


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 (enjoy the early winter: apparently there are less sun spots right now?) 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 .


Want the Curator News Pack for this week’s Roundup? Medicaid News Curator Volume 2

Here’s the one for the fraud stuff


Trystero: Oče je poslal Sina, da reši svet.

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Clay’s Weekly Medicaid RoundUp: Week of November 5th, 2018

Soundtrack for today’s RoundUp pessimist readers-


For optimist readers-


VOTERS DECIDED TO GROW MEDICAID IN 3 STATES; SHOT IT DOWN IN 1- Idaho, Nebraska, and Utah all decided to “cover” more people with Medicaid (and to spend more money from the pockets of the people who voted against it (40% against in Idaho, 47% against in Nebraska, and 46% against in Utah). But hey – screw those guys! We voted yes, and now they have to pay for it. Losers buy!. 

IN RELATED NEWS, VA IS SHORT $460M IN ITS MEDICAID BUDGET- Sort of related, anyway. These are “unforeseen” costs that occurred before the expansion decision. I wonder if they would have disclosed these costs before the expansion decision, would that have impacted the expansion decision? Current theories as to the overage are higher costs under managed care than expected, and higher than expected CHIP enrollment. Most legislators in the state are already messaging that school spending in next year’s budget will have to go down to pay for this whoopsie.


MORE CONSOLIDATION IN THE IL MCO MARKET- Harmony and Meridian health plans are merging after the recent WellCare acquisition of Meridian for $2.5B. Harmony was struggling and was dinged back in May for having insufficient network.


CMS WORKING ON NEW RULE FOR STATE FLEXIBILITY ON NEMT- According to a notice of proposed rulemaking last week, CMS is cooking up a new reg that will give states some relief on how much they have to spend on non-medical transportation for Medicaid bennies (states have been asking for this for years, with AZ being the most current example I am aware of).


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. Get out your wallets taxpayers – we have some Medicaid fraud to pay for! ImmediaDent (a dental provider with a weird name) and Samson Dental Partners of KS have settled false claims allegations with three states (KY, IN and OH- I guess they didn’t want to fraudulate in their own state?) for $5M. What did they do? Billed simple extractions as surgical procedures, billed scale and root planings that never happened and put dental employees on volume-based commission plans. Sophia Eggleston of Detroit was convicted this week for her role in an $1M home health fraud scheme hitting the Medicare coffers. Travis Moriarity of Pittsurgh (and 3 of his buddies) were charged with defrauding PA Medicaid out of $87M this week. How did they rack up such a bigly fraud, you ask? With bogus claims for personal care services, care coordination and NEMT. If you want to hit the Medicaid fraud big leagues, you’ve got to diversify, people! Bernard Oppong of Blacklick, OH was charged with a pharmacy scheme. Oppong would partner with a pharmacy to send special medical crème to Medicaid members without ever examining them. So far all I have is that this is a “multi-million dollar” fraud… Pretty big whopper of a hospice fraud concluded this week when Patricia Armstrong of Coppell, TX plead guilty to her role in the $60M scam. Armstrong and others stole from Medicare and Medicaid by signing up bennies who didn’t need hospice and then billing for it. They forged terminal-illness certifications. Celestine “Tony” Okwilagwe, et al of Garland, TX were convicted for stealing $3.7M from Medicare and Medicaid using a home health scam. Bonus points- they were already barred from participating in any federal healthcare program. Jennifer Gardner of Summit Township, PA got $104k in member/provider fraud bucks illegally. Let me unpack this one: Ms. Gardner had one of these deals where Medicaid gives you cash to pay your own personal caretaker in your home. But her attendant moved away, she didn’t replace him and kept cashing the checks. Ms. Gardner, you win! You gave us a great illustration of the clear risks of this model! Thank you. Taxpayers, you lost about $159M in this last paragraph.


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 (do the first round of leaf-raking) 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 .

Want the Curator News Pack for this week’s Roundup? Here you go- Medicaid News Curator Volume 1

Here’s the one for the fraud stuff

Trystero: Otec poslal Syna, aby zachránil svet.

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Clay’s Weekly Medicaid RoundUp: Week of October 29th 2018

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-

 WELCOME, MRS. MAYHEW- After bringing some predictability to the Maine Medicaid budget, Mary Mayhew was tapped to head Medicaid efforts at the federal level earlier this month. Her official title will be CMS Deputy Administrator. Congratulations, Mary!

BADGES? WE DON’T NEED NO STINKIN’ BADGES- If you thought CMS was holding the phone on work requirements while the KY lawsuit sorts out, you were wrong. CMS approved Wisconsin’s request to add a work requirement feature to its Medicaid benefits package. Also important- Wisconsin is a non-expansion state (many work requirements resisters have been holding out hope that CMS won’t approve work requirements in non-expansion states). CMS did not approve the state’s request to add drug testing requirements for members, but they did allow them to ask bennies about risky health behaviors as part of coverage determinations.


NEITHER DOES VIRGINIA- Sources say VA officials plan to submit a work requirements request to CMS by this Friday. Current proposal includes work/volunteer requirements (or job classes) and premiums up to $10/month. Many conservative lawmakers feel the new proposal is too watered down to matter, though.


 POSSIBLY ALSO NEITHER DOES MISSISSIPPI- MS Medicaid officials are chatting it up with CMS now that the public comment period on their work requirements request has ended.


NEBRASKA VOTERS TO DECIDE EXPANSION AS WELL AS WHICH MODIFIERS SHOULD PAY ON 99213 CODES IN THE NEXT VERSION OF THE POLICY MANUAL- Initiative 427 puts Medicaid expansion in the hands of Nebraskans next Tuesday. I’m not concerned they are low-informed voters on the details of Medicaid. Not at all. Nothing to see here. Move along.


 VERMA TROLLS MEDICARE-FOR-ALL MOB; THEY TAKE THE BAIT- Hey if Nebraskans who mostly probably don’t know the difference between Medicare and Medicaid can decide whether to double spending on it, why can’t the twitterverse tell CMS Administrator Verma (in the very polite ways we have come to expect from our leftist friends, of course) she was a terrible, doubleplus ungood person to tweet this in the spirit of Halloween. Remember, questions like “how would we pay for it?” and “does this even make basic logical sense?” don’t matter. All that matters is feelings and a deeply held conviction of a virtuous “resistance.”


OHIO MOVING UP HEP-C TREATMENT- Medicaid bennies in OH no longer have to wait until their Hep-C progresses to get specialty drugs. Starting Jan 1, OH will pay for treatment for any one diagnosed with Hep C. In tech speak, OH used to pay for patients with a Fibrosis Score (F score) of F2. Now the state will pay for all Fscores (starting at F0). Last year the state went from only paying for F4s to F2s.


CA PAID $4B OUT IN “QUESTIONABLE” PAYMENTS- Some pretty egregious examples in a recent state auditor’s report. Biggest findings – state kept paying MCOs and docs for services for 453,000 members who were ineligible for benefits. Worst example- an MCO got paid $383k for care for a member in LA County who had been dead for 4 years.


FINALLY, AFTER 300 YEARS, CMS APPROVES NC WAIVER- Congrats to the team that’s been working on bringing managed care to the state for the past few years!


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. Edwardo Yambo of Lake Grove, NY stole $939k for false lab claims. In addition to billing for claims his lab wasn’t even equipped to run, Mr. Yambo operated the lab without a director (a big no-no). Lanice Stamps and Tia Smiley of New Orleans were convicted this week for their $1.1M fraud in Louisiana using a bogus behavioral health company to steal from Medicaid. Bonus – both fraudsters were also Medicaid bennies. Not sure I have seen double-dipping on the provider and benny fraud side before. Nikkita Chesney of Bridgeport, CT plead guilty this week to using 150 stolen member IDs to file more than $1M in false claims. Celestine “Tony” Okwilagwe lead the way in convictions for a pretty large home health fraud in Dallas this week. Along with 3 of his buddies, Tony got popped for stealing $3.7M from Medicare and Medicaid. Special points on this one since 2 of these dudes had already been excluded from any federal health-care program for prior convictions. Matthew Neiswanger of Baltimore was in court last week and agreed to pay back $2.2M his nursing home stole from Medicaid. How did he do it? Evicting higher cost patients (sicker) and false claims. Joseph Dubin and David Dubin (father and son, a first for the follies) of Austin, TX were convicted of stealing $300k in a kickback scheme involving Medicaid psychology services. Fraudster and Sons paid another fraudster to refer Medicaid kids to their mental health services company. Lanice and Tia you win – I am just entranced by the double provider/member fraud angle! Plus, $1.1M is a pretty good take home. Taxpayers, you lose – about $8.2M in the stories covered in this paragraph. Work harder! Gotta pay for all that fraud somehow…

New content alert- The Medicaid Fraud, Waste and Abuse Curator Volume 1 is out. Includes links to the stories above and a lot more. Check it out here.

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 (clean your chimney, its that time already) 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: piyāṇan vahansē lōkayaṭa gaḷavannaṭa putrayā evū sēka.

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Clay’s Weekly Medicaid RoundUp: Week of October 8th 2018

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-


BUCKEYES TO GET MORE OPTIONS ON OPIOID RECOVERY MEDS- Based on what I am hearing, looks like Ohio may be removing prior auth for more drugs besides just suboxone and generics for buprenorphine and naloxone. If you know more, please dial into the show on Monday and weigh in.


NEW PROJECT TO UP CAID IMMUN RATES- If you’ve been around this Medicaid world a while, chances are you have bumped into the immunization “registries” (glorified excel files in a Medicaid official’s computer, usually). The CDC is funding a new consulting project (Nat’l Academy for State Health Policy got $800k) to figure out how to better integrate this data, encourage providers to submit more of it and close gaps for certain vaccines (i.e. Medicaid rotavirus rates for kids are 12 points lower than commercial).


MORE RUH-ROHS IN THE OH PBM SCANDAL- We will cover this in Monday’s show, so tune in. The gist: turns out one of the reasons Centene’s rx costs were more than other MCOs (all of them got caught up in the spread pricing scandal), is because they used their subsidiary (Envolve) as a sort of middle-middle man to the PBMs.


HOW MANY YEARS IS IT OK TO NOT HAVE A MEDICAID INSPECTOR GENERAL IN A STATE? 4 years is the answer if you’re Kansas. After the top Medicaid oversight spot (over the $3B program- but hey that’s chump change when its those taxpayer chumps funding it, right?) sat empty since 2014, the seat is now being manned (wo-manned, actually) by Sarah Fertig. Congratulations, Sarah!


CONGRATS TO OUR FRIENDS AT WELLCARE- It’s the time of year where we see which MCOs are doing better per NCQA quality ratings, and Wellcare just got high marks in NJ and NY. Congrats!


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. Vicki Chisam of Batesville, AR was charged with her role in a $2M Medicaid fraud (part of the Preferred Family Healthcare mental health scheme we have covered). Chisam was apparently the EHR data manipulation specialist in the crimes. She herself is tied to $589k in pilfery. Lyubov Beylina of Brooklyn (along with 7 other upstanding citizens) was charged with stealing $600k for billing for therapy while on vacation in the Dominican Republic. She also forged signatures of parents of children she was therapy-ing. Joanna Michelle Phillips of Cheyenne, WY was sentenced to 18 months for stealing $58k via false claims. Mercy Ainabe of Houston, TX was sentenced this week for her role in a patient recruitment Medicaid fraud scheme. She and her fellow fraudsters used a home health care front to bill for medically un-necessary services, pay bennies to sign-up and send kickbacks to docs. Total tab – $3.6M (but to Medicare, so she can’t win this week). Epo Onega of Staten Island was popped for using her teaching job to steal $59k with bogus speech therapy claims. Vicki- you win! Hopefully you can re-connect with some of your old workmates once you all get sentenced. Taxpayers – you lost about $7M in this paragraph! Work hard! Somebodies gotta pay for all this fraud (hint- you do, chumps). Are you a Medicaid bennie on a waiting list for a waiver program? Keep waiting! Sorry, we have to make sure we keep paying fraudsters before we open up your slot.

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 (plant mums – they can actually do really well in the ground) 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: Otac je poslao Sina da spasi svet. Also – chuir an t-Athair am Mac gus an saoghal a shàbhaladh.

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Clay’s Weekly Medicaid RoundUp: Week of September 24th 2018

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-

LET’S SHAKE IT UP A BIT- And do the fraud follies first this week..

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. Husband and wife duo John and Diane Sink of Cheyenne, Wyoming plead out this week to $6.2M in Medicaid fraud. Their charge? Bogus group counseling bills for sessions that included coloring, karaoke, eating at restaurants and shopping. Nagy Mohamed Abdelhamed of York, PA got popped this week for member fraud (we are seeing more of these- is it more frequent, or just less taboo to talk about?). Mr. Abdelhamed’s case appears egregious – he received $1,124 a month in social security disability bucks and collected $30k worth of Medicaid and SNAP benefits in 2018. Problem is, when he applied for Medicaid (in 2014) he only listed $1k in cash assets, no monthly income and no property. Well- he owned a gas station, a Mercedes Benz E350 and has loads of dough in the bank ($58k at time of writing). Timing? He sold the gas station for $172k in the same month he applied for Medicaid. Richard Quitoni of Middletown, NY was charged with a $200k Medicaid fraud. Mr. Q submitted false claims for cab rides for Medicaid bennies, including some doozies for $50 tolls (they’re not that high anywhere in the Big Apple). Mi Ran Yu of Anchorage, AK was sentenced to 8 months in the slammer this week. Her crime? Stealing $90k using false personal care assistant claims. Aleah Mohammed of Queens used her multi-location pharmacy biz to steal $7.9M by submitting false claims to Medicaid (and Medicare). The bogus scripts were either not dispensed to patients, prescribed as claimed or medically necessary. Sonjay Fonn and fiancée (they’re practicing for husband-wife fraud capers) Deborah Seeger of Cape Girardeau, MO stole $1.6M from Medicaid (and Medicare). This one’s fun- Sonjay did spinal fusion surgeries and ordered all his spinal implants from lovey’s DME company. Problem is, lovey got 50% commission on all sales. Lovey then took the Medicaid bucks and bought her handsome prince a yacht and construction projects. John Bradley of Oklahoma City got 8 weeks in jail for stealing $180k in Medicaid bucks. He submitted a slew of false claims for counseling his niece and nephews. Health Management Associates (the hospital chain, not the consulting firm) will pay $260M to resolve claims it paid kickbacks to docs so they could rip off Medicare and Medicaid by ordering unnecessary tests and increasing admits from the ED.

Mr. and Mrs. Sink, you win this week’s award with a respectable $6.2M Medicaid fraud! Taxpayers, you lose…Total tab in this paragraph is around $278M by my count. Work harder, taxpayers – someone has to pay for all this fraud!


OK, NOW SOME QUICK NEWS HITS- For all you fraud junkies, was that like eating dessert first?

MRS VERMA DEFENDS WORK REQUIREMENTS – Seema spoke at a conference in D.C. yesterday and let folks know CMS is maintaining its ground on this, despite all the pearl-clutching.

SHE ALSO LET MCOS KNOW A BIG OLE’ MICROSCOPE IS COMIN’- Clients (and anyone who has been around me the past few years) know I have been saying this is coming since the Mega Reg dropped. An MLR-audit is a natural conclusion of the MLR floor, and it will give CMS a simple way to take back cash.

OREGON CONSIDERING NON-COVERAGE OF NEXT-GEN SEQUENCING TESTS– These are tests used in cancer treatment. Medicare just covered it, but OR Medicaid is studying whether the tests are ready for prime-time just yet. The latest report from the OR Medicaid committee studying effectiveness has a clear non-coverage recommendation. Analysts are watching this one because it could be a model for other state Medicaid programs concerned about the costs of these tests.

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 (marvel at the changing of the seasons) 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: Na auina mai e le Tama le Alo e laveai le lalolagi.

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Clay’s Weekly Medicaid RoundUp: Week of September 17th 2018

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-


IOWA PER-MEMBER MEDICAID COSTS TRIPLED IN SIX YEARS- Luddite MCO-bashers think it’s the MCOs’ fault. You guys may want to look at the impact of a little thing called taking the “expansion” money as well. The costs of the newly-eligibles surprised the heck out of all of us in every expansion state.

ONE REASON MAINE EXPANSION COULD GO THRU DESPITE LEPAGE’S PROTESTATIONS- It’s a state plan amendment, not a waiver. So the state is basically saying “can we please follow existing law” vs “can you give us permission to get an exception to the law.” Good catch by Michael Shepherd @ Bangor Daily. Roundup readers know all about Mr. LePage. After years of successfully blocking expansion, his agency finally submitted a request to CMS for it- with a catch. LePage sent it along with a memo that said – hey please don’t approve this thing.

SUPER SECRET OHIO PBM REPORT A DUD- Well it ended up being “heavily” redacted, anyway. A judge had considered releasing the report, rich with inside scoop on CVS drug pricing, in all its unredacted glory.

CMS APPROVES 6 NEW FINANCIAL EXPERIMENTS FOR 2019- The Big House approved a new set of APMs (Alternative Payment Models) for next year. MA ACOs, OH episode-based payments, TN retro-episodes, and 2 Washington MCO-based projects.

DEMS TRY TO SUBPOENA CMS DOCS ON WORK REQUIREMENTS– They say it hasn’t been thought-through enough, and inquiring minds in Congressional Lefty Land want to know (do you remember the old National Enquirer tag?). Two of our modern statesmen-luminaries, Elijah Cummings (D-MD) and Raja Krishnamoorthi (D-IL) are leading the subpoena charge. They claim the impact of work requirements on Americans is not being vetted, and they want to see projections, spreadsheets, etc. (keep in mind dear readers, they don’t really care- its all for the cameras. Cummings is set to easily be a part of the “Blue Wave” this November. And while Cummings will probably never lose in ultra-blue MD ((he took 75% of the vote last time)), Mr. K is not as safe and needs to appeal to his Big Healthcare industry buddies, who account for his largest campaign donors by far). Back to the story, though- if we can now subpoena CMS docs for policies impacting Americans that we don’t agree with (apply the “that” either to the policies or the Americans, reader choice), I would love to see the analysis done about 9 years ago on the impact of ACA on Americans. How many Americans with non-Medicaid coverage would lose their coverage? How many Americans would be priced out by absurd deductibles and premiums? How much will the taxes need to go up (i.e. the impact on taxpayers)?


CONGRATS AND WELCOME TO KEITH WISDOM- He’ll be the new CEO of Aetna Better Health in KS. Aetna was a recent winner in the MCO awards, and Keith will be the first Aetna KS CEO.


OREGON SOS ASKING FOR MONEY TO AUDIT MEDICAID – Sec. of State Richardson wants about $780k to staff up an audit team to figure out just what the heck is going on in the Medicaid program.


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- er, not so fast. Not enough time/ space this week, dear, dear fraudsters. Get your fix in the twitter feed. (There’s some big ones in there- I’d say at least $22M in total provider fraud, and a dee-lish $200k member! fraud).


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 (plant mums, soon) 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: Otets poslal Syna, chtoby spasti mir.

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Clay’s Weekly Medicaid RoundUp: Week of September 10th 2018

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-

4,353 ABLE-BODIED, WORKING AGE ARKANSANS DECIDE FREE HEALTCHARE IS NOT WORTH WORKING (OR VOLUNTEERING) 20 HOURS A WEEK- That’s how many AR Medicaid bennies got kicked off last week for failing to meet work requirements. Assuming pmpm of around $200 (typical for healthy, middle-aged Medicaid bennies), the state just saved $10,447,200 by giving the members a voice in whether the coverage was worth it to them. The flip side is 83-90% (depends on whether you count the denom of those subject in month 1 vs current) of AR bennies met the requirement or were grandfathered in. There are also 1,000 bennies who did not have a job before who chose to go out and get one to keep the coverage. Resistors- Commence name-calling, pearl-clutching, et cet era.

EXPANSION STILL NO DICE IN BAMA- The Good Guvn’r Kay Ivey re-iterated this week that Alabama will not be pursuing expansion any time soon. She seems stuck on this whole “you have to pay for it” silliness. Maybe she hasn’t heard the magical incantations about its free federal money? Or the wise counsel to ignore other tales of woe from expansion states that got shackled to crippling Medicaid debt? Quick, someone call Mrs. Ivey and tell her she simply must take the “free” money.

HEAD OVER 1 STATE EAST, THOUGH- And Stacey Abrams (Dem gubernatorial hopeful in Georgia) is promising Medicaid expansion “is the only answer to Georgia’s challenges.” I must say her background is interesting.. a career in finance and tax law. If anyone can figure out how to get more Medicaid moula, surely it would be a tax attorney. But wait a minute, there’s more- according to an op-ed she wrote for Forbes in the spring, she owes $50,000 in taxes and has outstanding credit card and student loan debt of $170,000. I must say- Mrs. Abrams is uniquely qualified to set Medicaid policy. All she has to do is take her current personal finance skills and scale it up to the level of a state agency. Onward and Upward!

OK, I KEEP READING ABOUT ABRAMS, AND IT JUST GETS BETTER- She is also a romance novelist. I kid you not. Titles include “Hidden Sins,” Secrets and Lies,” The Art of Desire,” and “Deception.” Here is a link to her Harper Collins author page if you don’t believe me. I am unable to resist the temptation to personify Medicaid (as the male interest, a public health Fabio, if you will) in one of her novels. “I looked across the meadow, and the Budget Deficit was staring at me. A look of voracious desire burned a hole into my bones. As he ran to meet me, all I could do was smile and think “Medicaid expansion.” The wind blew through his hair, and we embraced. Mr. Budget Deficit and I were a match made to be. Some might even say, a Federal Match.” FMAP- get it? Ba-dum-bum-bum. Please, please, please Georgia voters- elect this gem. She will give all us writers 4 years of complete silliness to write about.

WE WERE JUST KIDDING ABOUT MORE PRIOR AUTH RULES- Says the NV Medicaid agency. NV Medicaid spending doubled when in expanded, and regulators are desperately looking for any tools to help control costs. They wanted to put more prior auth around certain mental health services to slow down utilization – but providers were loud enough that the state decided not to. Also I think maybe there was a go fund me that raised $10M that said they would NOT call agency officials mean names if they reversed the decision. Or am I getting that confused with some other state?

THINGS IMPROVING IN CT NEMT- We reported previously on the challenged Veyo contract in CT. Looks like there have been significant turnaround efforts (re-training call center reps, improved provider outreach) and the call center wait times are down from 5.5 mins to 2.8. I’m loving the terms and conditions on this contract though- Veyo got $52M in year one of a three-year contract. Lots of terrible press in past few months about service quality, so they have been fined. Total fines Feb. to Sep- $13,500. You can’t make this stuff up.

REMEMBERING 9/11- That’s still ok to do, right? This week we hit the 17th anniversary of this evil attack on U.S. soil. I remember exactly where I was when it happened (living on a friend’s couch) and most of that day very clearly. Have a 9/11 story? Would love to hear it sometime. Send a note. Give a call. Too young to remember it? Here’s a recording of CNN coverage as it happened.

 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. Haydn Thomas and Catinia Farrington of Raleigh, NC plead guilty to stealing $4M Medicaid bucks using their mental health counseling business to submit false claims. Francis Steen and Alicia Sanders of Savannah, NY got caught in “Operation Find the Dough” (that’s the real name local investigators gave their op, and I love them for it). This dynamic duo provides for us one of our rare member fraud cases (rare in that they got caught and were above our $50k minimum for Roundup appearance, technically). It’s a pretty cool list of thieveries for these two- $23,957 in SNAP benefits, $676 in Low Income Home Energy Assistance Program (LiHeap- bonus points!), and $44,594 in Medicaid benefits. Centers Plan for Health Living in Staten Island agreed to pay $2M to double dog promise it did not steal Medicaid bucks by enrolling non-eligible members and then sending Medicaid the bill. Haydn and Catinia – You win! Taxpayers, you lose – about $6.1M based on the ones we showcased today. Work harder!

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 (get a surprise puppy and forever be a hero in the minds of your children) and keep running the race (you know who you are).

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