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States should protect caregivers’ Medicaid funds from union skims

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[MM Curator Summary]: Biden recently re-instated the union graft practiced that Trump reversed that Obama strengthened.

 
 

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.

 
 

 
 

Associated Press/Elise Amendola

In this March 5, 2018 photo, Wil Darcangelo helps his 22-year-old adopted daughter, Lavender, who is blind and autistic, leave their home in Fitchburg, Mass. He is among Americans who care for family members in their homes full time.

Robert and Patricia Haynes live in Mich. and provide full-time care for their adult children, Kevin and Melissa, who suffer from severe cases of cerebral palsy. Until 2014, they were forced to give a portion of their Medicaid reimbursements to the Service Employees International Union (SEIU), a scheme propagated by unions such as SEIU and the American Federation of State, County and Municipal Employees (AFSCME) that is commonly known as to as “dues skimming.” 

Yet, while a number of states including Michigan have taken action to prohibit the dues skim, a May rule by the federal Department of Health and Human Services (HHS) reversed a Trump administration effort to stop the skim nationally. A separate 9th Circuit decision last week also continues to allow unions to trap home care providers into paying them.

The Hayneses, like other caregivers across the country, are eligible for Medicaid reimbursement from the state for the care they provide to their disabled children. However, over a decade ago, unions worked with state policymakers in about a dozen states to permit the siphoning of union dues from Medicaid money the Hayneses received. Without their permission or intent, the state reclassified the Hayneses as “public employees” at the behest of SEIU — and they had to pay their dues.

Many members of the “home care workforce” are relatives or friends providing care to sick family members or loved ones in need.

It took years to end the dues skim in Michigan, including administrative action by former Gov. Rick Snyder, legislative reform, lawsuits and the defeat of a ballot measure backed by the unions in a last-ditch effort to keep the dues skim alive. After the SEIU took $34 million from providers like the Hayneses, this unfair policy finally ended.

But caregivers in states such as Illinois, Oregon and Washington had to wait until 2014 before unions could stop forcing them to pay fees to take care of their loved ones. In a landmark case, Harris v. Quinn, the U.S. Supreme Court said unions could not force Pamela Harris — an Illinois mom caring for her son Joshua, who needed constant care for developmental disabilities — to pay union fees.

But that same year, HHS under President Obama adopted a federal rule to explicitly allow Medicaid funds to be diverted to unions. While providers did not need to pay, unions could still trap them into paying. By 2017, the Freedom Foundation estimated that unions were skimming an estimated $150 million each year, affecting 358,000 caregivers’ Medicaid funds.

The reason was that, after Harris v. Quinn, at least 11 states allowed dues skimming and unions were able to make providers pay dues by establishing arbitrary opt-out windows that limited when caregivers could leave and stop paying union fees. Cindy Ochoa, who was taking care of her disabled son, Adam, even experienced the union’s forgery of dues authorization signatures to keep the payments flowing.

Then, in 2019, the Trump administration reversed the rule, prohibiting unions from taking Medicaid payments from providers. Now, President Biden’s commitment to being the “most pro-union president ever” is coming to fruition: the new rule from HHS once again gives federal blessing to dues skimming.  

A debate exists over whether states or the federal government have the authority to issue policies pertaining to these Medicaid reimbursements. While Medicaid dollars are funded in part by the federal government, state governments allocate the money. Some states, such as Michigan, have banned dues skimming, but Biden’s decision means that caregivers in many states without such statutory protections may be forced to pay union fees.  

The nature of home care means that unions don’t represent these caregivers in the traditional workplace or in negotiations with an “employer.” A parent is not going to file a complaint against his or her sick child. Neither is a union going to negotiate benefits when the supposed “employer” is a sick or disabled relative.

Yet, the Biden administration’s HHS rule and the 9th Circuit decision are prioritizing the dues skim over the best interests and financial needs of caregivers and our nation’s most vulnerable patients.

As Michigan has done, states must act now and not wait for the federal government or the courts to rule justly. State policymakers owe it to caregivers like Robert and Patricia Haynes, Pamela Harris, and Cindy Ochoa to pass laws prohibiting the dues skim from Medicaid payments, ensuring that these caregivers have maximum support and flexibility to provide for those they love.

Lindsay B. Killen is vice president for strategy and communications at the Mackinac Center for Public Policy, a research and educational institute in Midland, Mich. Follow her on Twitter @LindsayBKillen.

F. Vincent Vernuccio is a senior fellow with Mackinac Center’s Workers for Opportunity project and president of the Institute for the American Worker. Follow him on Twitter @vinnievernuccio.

 
 

Clipped from: https://thehill.com/opinion/finance/3535007-states-should-protect-caregivers-medicaid-funds-from-union-skims/

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NC- House passes Medicaid expansion study bill

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[MM Curator Summary]: NC legislators commissioned the Medicaid agency to work with CMS to negotiate a Medicaid expansion with work requirements. Whelp.

 
 

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

 
 

The N.C. House passed a bill Tuesday evening 101-6 that would direct the state’s health agency to come up with a Medicaid Modernization Plan. The bill lays out the fiscal requirements that members would require in order to vote to expand Medicaid to an estimated 600,000 new enrollees.

Those policies outlined in the Rural Healthcare Access and Savings Plan Act
(Senate Bill 408) include work requirements for enrollees, $1 billion earmarked for behavioral health and substance abuse, expansion of health care to rural areas, and a requirement that the state withdraw from Medicaid expansion if the federal government reverses its promise of covering 90% of the costs.

 “I feel confident that this plan has been set up in a way, with fiscal accountability and responsibility in place, if the secretary can meet that,” said Speaker Tim Moore, R-Cleveland, on the House floor Tuesday evening. “I’m certainly going to support it and encourage my colleagues to support it, because it’s the right path forward, with these guardrails in place.”

Six months to strike a deal

The bill authorizes Department of Health and Human Services Secretary Kody Kinsley to work with the federal Centers for Medicare and Medicaid Services (CMS) to come up with a plan specific to North Carolina and gives him until Dec. 15 to present it to lawmakers. A vote would then be held on that plan.

Democrats in the chamber Tuesday expressed concern that the bill’s plan requirements would be difficult to meet, asking the speaker if House leaders have designed to set it up for failure.

“Are these criteria such that they are almost impossible to meet?” asked Rep. William Richardson, D-Cumberland.

Moore assured him that Kinsley has agreed to the terms of the bill and believes they can be met.

“If I wanted this bill to fail, the easiest thing to do is to say we aren’t going to take it up, but that’s a lot of trouble to go through and a lot of hours spent for this to ultimately fail,” said Moore. “The beauty of this, though, is that instead of us giving that blank check out, we actually have the final say once the product comes back here. I believe these benchmarks will be met.”

 
 

House Minority Leader Robert Reives, D-Chatham (Image from YouTube)

House Minority Leader Rep Robert Reives, D-Chatham, encouraged Democrats to vote for the bill.

“I’m going to support this because I’d like to keep the conversation moving forward,” said Reives.

“The people who are being left out right now are people who are working. They are working, they are trying, and they are in a terrible gap,” he added. “If there is a human being out there who will say, ‘Hey, I got Medicaid insurance, now I’m going to quit my job,’ I’d like that person to come by my office because that would mean you would be homeless, you wouldn’t have any food. If you are homeless and you go without eating or drinking, the health insurance can’t save you.”

During the break between official legislative sessions, a study committee of members, chaired by Rep, Donny Lambeth, R-Forsyth, examined Medicaid expansion, talking to health care groups and officials from other states that have expanded the federal entitlement program. However, the committee’s report was never completed before the state Senate passed an outright Medicaid expansion bill in May.

Senate members have been pressing the House to take their bill up, but House leadership said they wanted a clearer view of the costs and to have their requirements met before they would agree. The House bill gives N.C. DHHS six months to hammer out the details to get a vote.

“If the secretary did bring back something that did not meet the criteria, there would probably be a lot of folks on this side who would vote no, and I don’t know if it would pass,” said Moore.

Some House Democrats wanted the body to take up the Senate’s bill, too, before adjourning. Gov. Roy Cooper has also called for Medicaid expansion since taking office in 2017.

“It’s no secret that the governor didn’t like the fact that there would be votes in December,” said Moore. “I made it very clear to the governor that if there was not a second vote in December on this bill, it would go nowhere in the House. So it was either this way or no way, just to be candid.”

In other states that have expanded Medicaid under the Affordable Care Act, experts generally underestimated the size of Medicaid expansion enrollments, underestimated its cost, and overestimated its health benefits.

What is in the bill

The bill lays out some additional requirements of NCDHHS’ proposed expansion plan including that, “Individuals who are not United States citizens shall not be covered except to the extent required by federal law.” DHHS is also required to establish a system of reporting back on enrollment numbers, whether enrollees are using preventive care, and how it is impacting health outcomes. 

Work requirement waivers to allow states to put work/volunteer requirements or a small co-pay into expansion plans were offered by the Obama administration to encourage states to expand the program back when the Affordable Care Act passed. Under the Trump administration, states that expanded Medicaid had their work waivers approved, but the Biden administration has put a stop to them. Kinsley will now be required to negotiate with CMS to pass them.

The House bill also requires that $1 billion be spent on opioid, substance abuse, and mental health crisis in North Carolina, “using savings from the additional federal Medicaid match available under the American Rescue Plan Act.” ARPA is the $1.9 trillion plan passed by Congress in 2021 that economists are blaming for the nation’s historic inflation rate.  

Under the House legislation, a DHHS-created task force of leaders in the faith community, law enforcement professionals, mental health experts, and addiction specialists would be required to guide the $1 billion in spending on drug and mental health issues.

The plan also has specific proposals to increase access to health care and preserve hospitals in rural areas of the state. Lambeth said North Carolina ranks 43rd out of 50 states for access to health care and that 11 rural hospitals have closed since 2005, with 19 currently at risk of shutting down.

“Members, we have universal care in this state and in this country. It’s called the emergency room,” said RIchardson Tuesday evening on the floor.

“The is a great step forward,” he added. “I urge you to vote for it, and in December I urge you to vote to put North Carolina as part of this plan so that our people can get adequate health care, so they can work and not live in the emergency room.”

What is NOT in the bill

The directives for DHHS in the House bill do not include some of the industry reform measures that the Senate offered in its bill, including the SAVE Act, which would address needs in rural areas and giving nurses more independence, and partial repeal of some certificate-of-need requirements.

Rep. Gale Adcock, D-Wake, a registered nurse, stood on the floor to object to the omission of the SAVE Act (House Bill 277) in the House Medicaid bill. It would allow nurses to work up to the level of their training, even if a doctor was not immediately available.  It is intended to address labor shortages in rural hospitals.

“I know that at least half the members of this chamber signed on as co-sponsors of the SAVE Act,” she said. “The SAVE Act does really important things for this state economically.”

Adcock announced on the House floor that she wanted to file a discharge petition to get the SAVE Act heard before lawmakers leave Raleigh.

Ultimately only six members of the House voted against the bill, with 101 voting in favor. It now goes to the Senate for approval.

“I believe that this will be successful, that we will have a product back that we can all be very proud of when we vote on this in December,” stressed Moore.

The legislature is driving to wrap up business and adjourn the short session by Saturday afternoon, July 2.

 
 

Clipped from: https://www.carolinajournal.com/house-passes-medicaid-expansion-study-bill/

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Tuscaloosa Mayor Walt Maddox: Expand Medicaid for Alabama in wake of Roe v. Wade decision

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[MM Curator Summary]: Maddox says Medicaid expansion is needed now more than ever in order to help pay for all the new births that will happen after the Dobbs v Jackson decision.

 
 

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.

 
 

 
 

Walt Maddox concedes defeat to Gov. Kay Ivey in the Alabama Governor’s race Tuesday, Nov. 6, 2018.

Tuscaloosa Mayor Walt Maddox took to Twitter this weekend in the wake of the U.S. Supreme Court’s overturning of abortion rights to say now is the time for Alabama to expand Medicaid coverage to address pre-natal care and the state’s poor infant mortality rates.

“With yesterday’s decision by #SCOTUS reversing #RoeVsWade, #Alabama‘s 3rd World ratings in pre-natal care and infant mortality MUST be addressed by #MedicaidExpanaion,” Maddox stated in a tweet on Saturday.

Medicaid expansion, he said in a follow-up tweet, “would make quantum leaps for Alabama’s ability to ensure healthy pregnancies and births. The time must be now.”

Medicaid is a joint federal and state program that, together with the Children’s Health Insurance Program (CHIP), provides health coverage to children, pregnant women, parents, seniors, and individuals with disabilities, according to the Medicaid.gov website. About 1 million people in Alabama are covered by one or more of Medicaid’s programs.

Expanding Medicaid was one of the priorities Maddox had during his 2018 run for governor in Alabama. He won the Democratic nomination but lost to Republican Gov. Kay Ivey in the General Election that year. Maddox is currently serving in his fifth term as Tuscaloosa’s mayor.

“Spent 18 months crisscrossing this state warning this day was coming and the consequences would be far reaching and more complicated than the talking points. Now, that states are in control, #Medicaid Expansion is the best chance in the next 24 to 48 months. #pragmatic,” Maddox stated in another tweet.

Ivey and other Republican leaders have repeatedly said that while ensuring every Alabamian has access to quality health care is important, the problem is how to pay for it. Alabama is one of about a dozen states that have declined to expand Medicaid with the federal government paying most of the cost as allowed under the Affordable Care Act.

This spring the Alabama Legislature provided $4 million in the 2022-23 budget to extend Medicaid coverage for pregnant patients for a year after giving birth under the state’s new budget. The coverage had ended after 60 days. The extension, however, could be temporary because legislators gave the Medicaid Agency the task of reviewing costs, use of the services, and health outcomes to determine if it will continue.

With yesterday’s decision by #SCOTUS reversing #RoeVsWade, #Alabama‘s 3rd World ratings in pre-natal care and infant mortality MUST be addressed by #MedicaidExpanaion (1/2)

— Walt Maddox (@WaltMaddox) June 25, 2022

 
 

 
 

Clipped from: https://www.al.com/news/2022/06/tuscaloosa-mayor-walt-maddox-expand-medicaid-for-alabama-in-wake-of-roe-v-wade-decision.html

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How the Hyde Amendment Is Related to the Overturn of Roe V. Wade

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[MM Curator Summary]: The Hyde Amendment remains in place (preventing taxpayer spending via public programs on abortion)- but it was not included in Biden’s 2023 budget proposal and it is up for re-enactment each year.

 
 

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

 
 

 
 

 
 

People protest the Supreme Court decision to overturn Roe v Wade abortion decision in New York City, New York, U.S., June 24, 2022. REUTERS/Caitlin Ochs

  • The Hyde Amendment, which prevents the use of federal funds for abortions, took effect in 1976. 
  • Following the overturning of Roe vs. Wade, there have been renewed calls to abandon the Amendment. 
  • Biden excluded the amendment from a 2023 budget proposal, but it’s unclear if it will be added back. 

Following the Supreme Court’s Friday decision to overturn Roe v. Wade, there have been renewed calls from lawmakers and activists to abandon the Hyde Amendment, a legislative provision preventing federal funds from being used on abortion services. 

The Hyde Amendment, named for anti-abortion Congressman Henry Hyde who introduced the provision, was passed in 1976, just four years after the landmark Roe vs. Wade ruling that established the right to an abortion. The amendment, which prevents federal funds from services such as Medicaid to be used to provide abortions, was mired in legal challenges for its first years, leading to the Supreme Court case Harris v. McRae

In the 1980 Harris v. McRae decision, the Supreme Court held in a 5-4 vote that states participating in Medicaid programs were not obligated to fund medically necessary abortions under the Social Security Act. In the United States, adults with a low income, children, pregnant women, and people age 65 or over are covered by Medicaid services. In 2010, about 45 percent of births in the country were covered by Medicaid.

“The Hyde Amendment is designed to deprive poor and minority women of the constitutional right to choose abortion,” Supreme Court Justice Thurgood Marshall wrote in his dissenting opinion. “[F]or women eligible for Medicaid — poor women — denial of a Medicaid-funded abortion is equivalent to denial of legal abortion altogether.” 

With the Hyde Amendment in effect, abortions financed by federal Medicaid funds dropped from about 300,000 per year to a few thousand, according to the ACLU

The amendment has been reenacted every year since, with various changes. The 1978 version of the amendment offered new exceptions for rape survivors and incest cases, while later changes expanded the ban to prevent abortion funding from federal worker health plans, women in federal prisons, women in the military and peace corps volunteers.

Public support for federal abortion funding varies depending on the polling source and how the question is phrased — one 2014 CNN-ORC poll found just 39% of the public favors offering public funding for abortions for women who cannot afford them, while a 2021 Ipsos poll found 54% of people supported Medicaid-funded abortions. 

Over the last several years, Democratic lawmakers including Rep. Alexandria Ocasio-Cortez of New York and Rep. Ariana Pressley of Massachusetts have called for reversing Hyde Amendment funding restrictions on abortion, citing their disproportionate impact on marginalized women. 

“The Hyde Amendment is a back-end attempt to outlaw abortion that disproportionately denies the right of choice to low-income women and women of color,” Rep. Ocasio-Cortez said in a 2020 statement when she and other Congresswomen filed an amendment to repeal Hyde restrictions on funding. “It is critical that we put an end to this inhumane policy now.”

Though the amendment was not passed, Democrats in Congress attempted to remove Hyde Amendment restrictions in their government funding bills last year, the Wisconsin Examiner reported, but the terms were added back into the final spending package at the insistence of Republicans. 

Amid continued calls for the removal of the Hyde Amendment, President Biden similarly left such restrictions off his 2023 budget proposal, but it is unclear if they will be added back to the final bill text. 

We applaud the Biden administration for its recommitment to ending the Hyde Amendment by removing this decades-old policy, which disproportionately harms people of color working to make ends meet, from its budget,” Morgan Hopkins, the interim executive director of campaigns and strategies at All* Above All said in April when the budget was proposed, Prism reported. “It’s a significant step forward to ending a decades-old policy.”

 
 

Clipped from: https://www.businessinsider.com/what-is-hyde-amendment-how-related-to-roe-v-wade-2022-6

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PA- Wolf pushes $91 million for nursing homes to offset costs of proposed new staffing regulations, but industry says it’s not enough

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[MM Curator Summary]: Long term care providers are sounding the alarm about funding needed to meet new requirements- They say they need $434M more each year; the Good Guvn’r has offered $91M.

 
 

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.

 
 

 
 

Spotlight PA is an independent, nonpartisan newsroom powered by The Philadelphia Inquirer in partnership with PennLive/The Patriot-News, TribLIVE/Pittsburgh Tribune-Review, and WITF Public Media. Sign up for our free newsletters.

HARRISBURG — Gov. Tom Wolf is asking the Pennsylvania legislature to spend millions to raise a key reimbursement rate for skilled nursing homes in the state to help offset costs from proposed new regulations that would increase daily required care.

With the state’s June 30 budget deadline quickly approaching, the Democrat wants to appropriate $91.25 million to increase the amount of money skilled nursing homes receive for residents on Medicaid.

Roughly 11,000 long-term care residents in Pennsylvania have died since the start of the COVID-19 pandemic, a toll that brought renewed attention to longstanding issues such as dangerously low staffing requirements and outdated regulations.

Groups including the Pennsylvania Health Care Association, which lobbies on behalf of long-term care providers in the state, say the state’s low Medicaid reimbursement rate is a major roadblock to providing higher levels of care. The current rate, they say, can leave nursing home facilities without funding to raise employee wages or buy supplies for patient care.

The association estimates that Wolf’s investment would raise the daily Medicaid reimbursement rate to about $210 per resident on average from the current $199.96 average rate. Neighboring states such as Ohio, Maryland, and New Jersey, have higher rates.

But while PHCA sees Wolf’s proposal as a welcome first step, the organization argues it’s not nearly enough. The trade group estimates the regulatory changes would require hiring 10,000 additional workers and spending $434 million more annually. That has led some to reject the plan as an unfunded mandate.

According to the Pennsylvania Department of Health, there are 683 nursing homes in the state serving about 80,000 total residents. That number is expected to rise in the coming years as the state’s population over the age of 65 grows. According to PHCA, about 66% of residents living in nursing homes across the state have their stay paid for by Medicaid. Medicare accounts for an additional 13%.

There does appear to be agreement among legislators that more investment is needed, but how to do so is still being debated. If funding for nursing homes remains as is, advocacy networks, experts, and nurses on the ground fear facilities may be ill-equipped to support the aging population.

“We’ve come to a place where we either need to make an investment in long-term care in this year’s state budget, or the entire system could collapse,” said Zach Shamberg, president and CEO of Pennsylvania Health Care Association. “That would be disastrous for our older population.”

Why do reimbursements matter?

With the way that Medicaid and Medicare funds are distributed, many nursing home facilities seek to take in Medicare-funded patients rather than Medicaid-funded ones.

“We’ve decided in this country not to cover long-stay nursing home care under Medicare,” said David Grabowski, a professor of health care policy at Harvard Medical School. “So it’s really the one major piece of services that are pushed today over to Medicaid.”

Medicare is a federal insurance program that typically covers short-stay patients, such as patients in physical therapy or post-surgery care.

Medicaid is a state-run assistance program that — following guidelines from the federal government — supports low-income people and typically covers long-stay patients. The reimbursement rate is what each nursing home is paid on behalf of the qualified patient by the state government.

According to Grabowski, the low Medicaid reimbursement in Pennsylvania encourages nursing homes to seek out Medicare patients planning on short stays rather than accepting Medicaid patients who will require long stays.

This dynamic, he continued, makes the federal government “a very generous payer,” and that windfall allows care facilities to typically hit double-digit margins on short-stay patients. Meanwhile, Medicaid patients usually result in negative margins for facilities, he said, causing a gap between the cost of care for residents and the amount of state funding.

According to a February study conducted for LeadingAge PA, a trade association that represents about 380 providers in the state who serve older adults, the daily gap between what nursing homes received for Medicaid residents versus what they spent was $86.26 per resident on average.

Grabowski said increasing the Medicaid reimbursement rate could relieve some of the problems. Lobbyists and advocates for the industry in Pennsylvania are asking for a $294 million investment, rather than Wolf’s proposed $91.25 million.

Grabowski argues any investment in the industry should also involve some form of accountability to make sure the funds improve the quality and are not misused.

“I do think we’re going to have to rethink what it means to both live and work at a nursing home,” Grabowski said. “Because the current economic model is definitely broken.”

More money, more oversight

Wolf’s $91.25 million pitch comes with proposed regulations that would require nursing homes to provide more hours of direct care to residents.

Spokespersons for state House and Senate Republicans confirmed the caucuses will consider the proposal and continue to make investments in nursing homes, but did not provide details.

In 2020, Spotlight PA reported on long-criticized staffing and training regulations that were exposed by the pandemic. Shamberg said that PHCA has found that, on top of rising costs nationwide, nursing homes face these same issues today.

Since the start of the pandemic, the state has earmarked nearly $500 million to nursing homes through Acts 24 of 2020 and 2021. These funds were intended to help ease the burden of additional COVID-19-related costs. But as one-time infusions, PHCA said the money did not address the Medicaid reimbursement rate gap, and therefore did not increase staffing.

Karen Hipple, a licensed practical nurse at Oil City Healthcare and Rehabilitation Center in Venango County, said staffing ratios are too high — with one certified nursing assistant caring for 20 to 30 patients, in facilities she’s worked in and visited. She said that staffing increases need to be the top priority, which requires more funding.

Hipple blames the shortage on the low wages that many workers face in nursing homes. According to data from the U.S. Bureau of Labor Statistics, the average pay for a nurse assistant is $16.44 an hour.

WHILE YOU’RE HERE… If you learned something from this story, pay it forward and become a member of Spotlight PA so someone else can in the future at spotlightpa.org/donate. Spotlight PA is funded by foundations
and readers like you who are committed to accountability journalism that gets results.

 
 

 
 

Clipped from: https://www.spotlightpa.org/news/2022/06/pa-nursing-home-staffing-proposal-91-million-wolf/

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Vermont Medicaid Section 1115 Demonstration Extended Until 2027

MM Curator summary

[MM Curator Summary]: The renewal adds several new items, including a housing initiative, a data incentive program for BH and LTSS, focused substance-use disorder (SUD) treatment services for pregnant mothers, and an entirely new eligibility category based on SUD needs.

 
 

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

 
 

 
 

The Centers for Medicare and Medicaid Services (CMS) has approved an extension of Vermont’s Medicaid section 1115 demonstration, “Global Commitment to Health” through 2027. The extension will enable the state to continue to test, monitor, and evaluate a managed care-like delivery system, home and community-based services, and novel pilot programs, as well as pursue innovations to maintain high-quality services and programs that are cost-effective.

Overall, the demonstration extension will continue to promote health equity by expanding coverage and access to services.

Over the last 15 years, the Global Commitment to Health demonstration has been Vermont’s principal vehicle for major expansions of health coverage — building an extensive ecosystem for public health and health-related services, driving payer reform, and rebalancing long-term services and supports. As a result of these efforts, Vermont has nearly universal health coverage and one of the healthiest populations in the nation. Under the Global Commitment to Health demonstration, Vermont serves nearly 60 percent of enrollees eligible for nursing facility care in a home or community-based setting.

The extension approval allows Vermont to continue to fund a range of initiatives, from reducing the rate of uninsured and underinsured individuals to lowering healthcare costs, increasing access to quality health care, improving public health, investing in social determinants of health, and advancing home and community-based services and supports.

In this demonstration extension, Vermont is introducing new initiatives aimed at improving health coverage, access, and equity for people with Medicaid and other low-income individuals. Notable new initiatives include:

  • The Supportive Housing Assistance Pilot, which will provide individuals with support services in order to secure and maintain housing for their needs.
  • The Medicaid Data Aggregation and Access Program, a new incentive-based program to increase health information technology use and health information exchange connectivity by behavioral health and long-term services and supports providers.
  • The Maternal Health and Treatment Services initiative, which will provide a whole-person and family-centered care model for treating pregnant women and mothers with substance use disorder (SUD) and/or a mental health condition at the Lund Home facility. The Lund Home provides mental health and SUD treatment to pregnant women, postpartum women, and mothers with children up to age five in a setting that allows the family to stay and be treated together.
  • Establishing the SUD Community Intervention and Treatment eligibility group to increase access to SUD treatment services, such as counseling and residential treatment, for low- and moderate-income individuals with a SUD.

“I’m proud to approve this demonstration extension, which will expand access to behavioral health care, home and community-based services for seniors and people with disabilities, and whole-person care focused on treating substance use disorders and mental health needs during pregnancy,” said CMS Administrator Chiquita Brooks-LaSure, in a statement. “Vermont is also strengthening its data collection system, which will give us better information about the impact of the state’s demonstration and could inform future policymaking.”

 
 

Clipped from: https://www.hcinnovationgroup.com/policy-value-based-care/medicare-medicaid/news/21272596/vermont-medicaid-section-1115-demonstration-extended-until-2027
 

 
 

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Fraud- Three More Defendants Sentenced for Their Roles in Wide-Ranging Medicaid Fraud Conspiracy

MM Curator summary

[MM Curator Summary]: The $400k+ fraud involved multiple companies and members taking money for use of their IDs to steal from PA Medicaid.

 
 

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.

 
 

PITTSBURGH, Pa. – Two residents of Pittsburgh and a resident of Georgia were sentenced in federal court for conspiracy to defraud the Pennsylvania Medicaid program and related offenses, United States Attorney Cindy K. Chung announced today.

During sentencing hearings on June 28 and June 29, 2022, United States District Judge Cathy Bissoon sentenced Tiffhany Covington, 45, of Pittsburgh, to fifteen months’ imprisonment; Luis Columbie-Abrew, 36, of East Point, Georgia, to three years’ probation, including twelve months of home confinement; and Julie Wilson, 51, of Pittsburgh, to three years’ probation, including six months of home confinement. Covington, Columbie-Abrew, and Wilson were also ordered to pay restitution to the Pennsylvania Medicaid program totaling $245,376.26, $164,799.48, and $2,083.36, respectively. All three defendants previously pleaded guilty to conspiracy to commit health care fraud. Columbie-Abrew and Wilson also pleaded guilty to health care fraud, with Columbie-Abrew pleading guilty to an additional charge of aggravated identity theft.

During their plea hearings, each defendant admitted that they were employees of one or more of four related entities operating in the home health care industry—Moriarty Consultants, Inc. (MCI), Activity Daily Living Services, Inc. (ADL), Coordination Care, Inc. (CCI), and Everyday People Staffing, Inc. (EPS). MCI, ADL, and CCI were approved under the Pennsylvania Medicaid program to offer certain services to qualifying Medicaid recipients (“consumers”), including personal assistance services (PAS), service coordination, and non-medical transportation, among other services. Between 2011 and 2017, the defendants admitted that they participated in a wide-ranging conspiracy to defraud the Pennsylvania Medicaid program for the purpose of obtaining millions of dollars in illegal Medicaid payments through the submission of fraudulent claims for services that were never provided to the consumers identified on the claims or for which there was insufficient or fabricated documentation to support the claims. The Court was further advised that the defendants conspired with, among others, Arlinda Moriarty, the owner of MCI, ADL, and EPS; Daynelle Dickens, the owner of CCI and Arlinda Moriarty’s sister; various office workers at the companies, including Tamika Adams, Tony Brown, Terra Dean, Larita Walls, Keith Scoggins, and Tia Collins; and caregivers (“attendants”) at MCI, including Tionne Street and Autumn Brown. To date, each of these co-conspirators have also pleaded guilty for their roles in the conspiracy.

As part of the conspiracy, the defendants each admitted that co-conspirators fabricated timesheets to reflect the provision of in-home PAS care they provided to consumers but that, in fact, never occurred. In addition, certain co-conspirators, including Covington and Columbie-Abrew, stopped using their own names as the attendant on timesheets and instead used the names of “ghost” attendants, some of whom permitted their names to be used in exchange for a kickback of resulting fraudulent salary payments. The defendants also admitted that certain co-conspirators submitted false timesheets for PAS care they never provided during times when they were actually working at other jobs or living out of the area. In some cases, as the defendants acknowledged, Medicaid claims were submitted for PAS care that purportedly occurred while consumers were hospitalized, incarcerated, or deceased, and in other instances, co-conspirators paid kickbacks to consumers in exchange for the consumers’ agreement to participate in the submission of fraudulent timesheets in support of Medicaid claims. Indeed, Columbie-Abrew specifically admitted causing the submission of hundreds of thousands of dollars of Medicaid claims for purported care of consumers who lived in the Pittsburgh area, despite the fact that he—as the purported attendant—lived several states away in Georgia.

The defendants also admitted that Arlinda Moriarty directed co-conspirators, including Covington, to bill the maximum allowable PAS and service coordination hours for consumers to maximize profits and to ensure that the state did not require MCI, ADL, and CCI to forfeit underutilized consumer hours. To that end, Wilson acknowledged that, at Moriarty’s behest, she collected information about consumers who had “unused” PAS care hours—that is, hours of authorized PAS care that had not been performed and, as a result, had not been billed to Pennsylvania Medicaid. In response, Wilson would provide lists of such consumers and their “unused” hours to Moriarty and Dickens. Moriarty, in turn, would direct Wilson to submit false claims, in bulk, for some or all of the “unused” hours—without the relevant consumers’ knowledge or consent. Wilson further admitted that she would then send Moriarty a list of the “unused” hours Wilson had billed and that required the creation of back-dated timesheets to document the purported care. Rampant document fabrication also occurred during the course of state audits of the Moriarty-related entities.

Assistant United States Attorney Eric G. Olshan and Special Assistant United States Attorney Edward Song are prosecuting this case on behalf of the government. The Federal Bureau of
Investigation, Pennsylvania Office of the Attorney General – Medicaid Fraud Control Unit, Internal Revenue Service – Criminal Investigation, U.S. Department of Health and Human Services – Office of Inspector General, and United States Postal Inspection Service conducted the investigation of the defendants.

 
 

Clipped from: https://www.justice.gov/usao-wdpa/pr/three-more-defendants-sentenced-their-roles-wide-ranging-medicaid-fraud-conspiracy

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MCOs- Medicaid: State Directed Payments in Managed Care | U.S. GAO

MM Curator summary

[MM Curator Summary]: GAO found that CMS does not know how much was actually paid through the $20B provider-incentive model- they just have estimates from states.

 
 

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

States and federal Medicaid funds pay managed care plans based on the number of beneficiaries.

The managed care plans then pay health care providers for services. But starting in 2016, states could propose ways to steer payments to providers that met certain goals, such as improved timeliness.

As of February 2022, Medicaid approved 79 proposals just for payments starting on or after July 1, 2021—totaling $20 billion in estimated payments.

Medicaid is trying to improve oversight, but there are still unknowns. For example, states only have to report estimated payments, so Medicaid won’t know how much of that $20 billion is paid out.

State Directed Payments Approved in 2021

What GAO Found

The federal government and states share responsibility for financing Medicaid payments for care provided to Medicaid beneficiaries. One way states may provide Medicaid services is under a managed care model. Generally, managed care plans determine how they pay providers. In 2016, the Centers for Medicare & Medicaid Services (CMS), which oversees Medicaid, began allowing states to direct payments to providers in Medicaid managed care under certain circumstances and generally contingent upon CMS approval. Within those parameters, states determine the criteria for provider receipt of a payment. For example, a state may establish a directed payment for providers that meet a performance target for improving timely access to care. State use of directed payments has become widespread.

Widespread Use of State Directed Payments

Notes: CMS approval is generally required before a state can implement a directed payment, which the agency began permitting for managed care contract rating periods on or after July 1, 2017. States’ contract rating periods differ and may not correspond with the year CMS approved the state directed payment proposal. Dollar amounts for approved payments beginning on or after July 1, 2021, are state estimates from 79 proposals in 2021 and 2022.

CMS has taken recent actions and has planned others to enhance oversight of state directed payments, though the effectiveness of these efforts is unknown. In 2021, CMS clarified guidance and began requiring states to submit additional information, such as estimated payment amounts, prior to approval of directed payments, in part, to strengthen program integrity. Other efforts are underway. For example, CMS officials said the agency is considering ways to make approved proposals public, which would increase transparency.

Although CMS has recently made efforts to enhance oversight and has others planned, information gaps remain; for example, CMS requires states to estimate the amount of directed payments prior to approval, but CMS does not have information on the actual amounts paid. In December 2020, GAO made a recommendation that if implemented would address some of the information gaps CMS faces. Specifically, GAO recommended CMS should collect and document complete and consistent provider-specific information about Medicaid payments to providers, including state directed payments. Doing so would likely improve CMS’s ability to identify potentially impermissible financing and payments for additional review. GAO plans to continue examining CMS’s oversight of these payments.

Why GAO Did This Study

Medicaid—a joint, federal-state health care financing program—covered an estimated 78 million individuals at an estimated cost of $709 billion in fiscal year 2021. CMS is responsible for ensuring that Medicaid payments and the way that states’ finance the nonfederal share of these payments is consistent with federal requirements. In general, states may not make additional payments for services covered under the contracts nor direct managed care plans’ payments to providers. In 2016, CMS issued regulations establishing the circumstances under which states can direct payments under managed care. In 2021, CMS updated its state directed payment guidance and review process.

GAO conducted this work under the Comptroller General’s authority to conduct evaluations to assist Congress with its oversight responsibilities. In this report, GAO describes (1) the use of state directed payments in Medicaid, and (2) CMS’s changes to guidance and oversight of these payments. To do so, GAO analyzed agency data and documents on approved payments; reviewed CMS guidance and forms; and interviewed CMS officials.

For more information, contact Carolyn L. Yocom at (202) 512-7114 or YocomC@gao.gov.

 
 

Clipped from: https://www.gao.gov/products/gao-22-105731

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