Author: MM_ADMIN

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Missouri’s thin dental safety net stretched amid Medicaid expansion

[ MM Curator Summary] Missouri expansion is expected to place more strain on the dental network.

 
 

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.

 
 

Only 27% of dentists in Missouri accept Medicaid, one of the lowest rates in the country

 
 

Dr. Elena Ignatova prepares to make an impression of a patient’s mouth to fit dentures at CareSTL Health in St. Louis. Only 27% of Missouri dentists accept Medicaid, and many of those who do work at safety-net clinics like CareSTL Health (photo: Bram Sable-Smith).

This story was originally published by Kaiser Health News and KSMU.

At the Access Family Care clinics in southwestern Missouri, the next available nonemergency dental appointment is next summer. Northwest Health Services, headquartered in St. Joseph, is booked through May. The wait is a little shorter at CareSTL Health in St. Louis — around six weeks.

Roughly 275,000 Missourians are newly eligible this year for Medicaid, the federal-state public health insurance program for people with low incomes, and they can be covered for dental care, too. Missouri voters approved expansion of the program in 2020, the latest of 39 states to do so as part of the Affordable Care Act, but politics delayed its implementation until Oct. 1. Adults earning up to 138% of the federal poverty level — about $17,774 per year for an individual or $24,040 for a family of two — can now get coverage.

But one big question remains: Who will treat these newly insured dental patients?

Only 27% of dentists in Missouri accept Medicaid, according to state data, one of the lowest rates in the country. Many of them work at what are known as safety-net clinics, such as Access Family Care, Northwest Health Services and CareSTL Health. Such clinics receive federal funds to serve uninsured patients on a sliding scale and was experiencing huge demand for dental services before expansion.

The reason so few Missouri dentists accept Medicaid is simple, according to Vicki Wilbers, executive director of the Missouri Dental Association: The state’s program pays dentists extremely poorly compared with private insurance or what a dentist could charge a patient paying cash. Adding to the strain, said Wilbers, dentists who do accept Medicaid often must deal with the state plus private insurers that administer Medicaid through a program known as managed care.

“You have more people on the rolls, you still don’t have reimbursement rates increase,” Wilbers said. “And it’s cumbersome.”

Still, for these new patients, the coverage can be life-changing.

Only 37% of adults in the state with incomes under $15,000 per year saw a dentist in 2018 compared with 76% of adults earning over $50,000, according to a state report. A survey by the American Dental Association found 53% of low-income Missourians have difficulty chewing, 43% avoid smiling because of the condition of their mouth and 40% experience pain.

“I just don’t think those stories are told enough,” said Steve Douglas, spokesperson for Access Family Care in Neosho.

Douglas described a patient of the clinic who believes his so-far-unsuccessful quest for higher-paying work has been hindered by the appearance of his teeth.

“We’re hoping that with the Medicaid expansion we can get him in for some care,” Douglas said. “He would like to save some of his teeth and not go to full dentures.”

About 62% of Missouri adults making under $15,000 per year have lost at least one tooth to decay or gum disease, and 42% of people 65 and older in that income range have lost all of them, according to the state report. For Missourians earning over $50,000, those rates are 34% and 8%, respectively.

Part of the dental care backlog at Access Family Care, which offers dental services at five locations around southwestern Missouri, is due to the pandemic. The clinic laid off all 95 of its dental staffers in March 2020 before gradually building back to full capacity. As with dental practices nationwide, many of their patients are now coming to get the dental work done that they delayed earlier over fears of exposure to the coronavirus.

But central to the huge demand is an overall need for more providers. Nearly 1.7 million Missourians live in a federally designated dental professional shortage area, one of the highest levels of unmet needs in the country. It’d take another 365 dentists to fill that void, at least one extra dentist for every 10 already practicing in the state.

“We could easily employ another four dentists and still have high demand,” Douglas said.

His clinic, Access Family Care, has indeed hired two new dentists to start in 2022. To manage the dental caseload until then, though, it had to temporarily stop seeing new patients.

In St. Louis, Dr. Elena Ignatova, director of dental services at CareSTL Health, had 18 patients scheduled on a recent Wednesday in November. About a quarter of them were insured through Medicaid.

By 10 a.m., she had cast a mold of one patient’s mouth to fit dentures, referred another to an oral surgeon for a root canal and prepped a fourth-year dental student for the extraction of a Medicaid patient’s remaining teeth. In Missouri, Medicaid covers simple tooth extractions for adults but not root canals or crowns.

“We remove teeth because the other treatment is too expensive and they cannot afford it,” Ignatova said. “Then it can take years for those patients to come up with the money for dentures.”

Ignatova is booked into February, but the clinic still takes walk-ins for dental emergencies. She’s also working her way through a waiting list of 39 patients who might be able to show up quickly if a cancellation or no-show opens a spot in her schedule.

There is easily enough demand for another dentist, but Ignatova said they’re still working on hiring the dental assistants and hygienists needed to reopen the school-based clinics for kids they operated before the pandemic. Those hirings are in the works, but it is slow going. As with many health care facilities, she and others said, President Joe Biden’s vaccine mandates have added an extra hurdle to recruiting and retaining staff.

One clinic that isn’t seeing a bottleneck of dental patients, though, is KC Care Health Center in Kansas City. Kristine Cody, the clinic’s vice president of oral health services, said a new patient could be seen there in about a week. The Kansas City region benefits from having the University of Missouri-Kansas City School of Dentistry, which offers reduced-cost care to patients at the clinic where its students are trained, plus several other safety-net clinics.

KC Care also added two dentists and extended its clinical hours in anticipation of Medicaid expansion.

“I just hope people look to use it,” Cody said.

 

 
 

 
 

Clipped from: https://missouriindependent.com/2021/11/16/missouris-thin-dental-safety-net-stretched-amid-medicaid-expansion/

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Florida- Medicaid modernization will take hundreds of millions and require more staff

[ MM Curator Summary] Florida is beginning the process to rebid its MMIS and downstream modules.

 
 

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.

 
 

 
 

Florida’s health care regulation agency is setting the stage for an expensive rebuild of the computer systems that bind the state’s multibillion dollar Medicaid program even though state legislators have not agreed to pay for it.

The Agency for Health Care Administration has dropped three different invitations to negotiate with vendors that can update the state’s antiquated Medicaid management information systems and is expecting responses on the three requests by early- to mid-December.

In hopes of having contracts inked between the summer and fall of 2022, the agency is assembling for each Invitation to Negotiate (ITN) two multiagency teams — one to evaluate the vendors’ responses and the other to negotiate with vendors that received top evaluation scores.

Now all the agency needs is the Florida Legislature to approve its legislative budget request for $117.8 million so it can pay the vendors for the needed work. It’s a number that one top House Republican already suggested may be “excessive.” 

Currently, the Medicaid management information system is a single integrated system for claims processing and information retrieval. But AHCA wants to transform that into a modern modular system that connects with other data sources and programs.

 
 

Florida Health Care Connections, or FX, is the moniker AHCA assigned to the transformation of the system and the subsequent modular procurements necessary to make it happen. Florida lawmakers have already appropriated more than $158 million over the past five budgets for the replacement of the system responsible for billing and payment to the managed care companies, doctors and pharmacies providing health care to millions of Floridians enrolled in Medicaid.

FX Program Director Mike Magnuson told members of the FX Executive Steering Committee on Wednesday the latest budget request for the upcoming fiscal year 2022-2023 budget, “includes the funding to start the contracts that we now put out on the street. So the majority of it will be the fixed price deliverables for those functions.”

In addition to requesting the $117.8 million to help initially pay the three ITNs, Magnuson told FX Steering Committee members the agency requested another $1.97 million to hire 12 full-time employees who can provide ongoing support to the office that will be created to help with the system.

Without the funding, Magnuson said, the agency would be reliant on paying contracted staff in order to operate the FX updates.

But Rep. Bryan Avila, the South Florida Republican charged with leading efforts to assemble a health care budget in the House of Representatives, recently questioned the size of the agency’s legislative budget request by asking if the project total was inflated.

 
 

Meanwhile, the three ITNs AHCA published have a combined value of nearly $350 million over a seven-year period.

The first ITN AHCA will award is for modular “unified operations centers” services. The contract would be in effect between Aug. 1, 2022, and July 31, 2029, and could be worth more than $161 million.

The second ITN AHCA will award is for modular provider management services.The system must allow for concurrent processing of enrollment and plan credentialing activities for both initial enrollment as well as renewals. According to the ITN, the contract would be in effect from Sept. 1, 2022, through Aug. 31, 2029, and would be worth more than $33 million.

The third ITN the agency will award is for so-called core systems and is expected to be worth $154.5 million. According to the ITN, the contract would be in effect between Nov, 1, 2022, and Sept. 30, 2029. 

“We are getting to the point where the rubber is starting to meet the road,” AHCA Secretary Simone Marstiller told members of the FX Executive Steering Committee. “It’s all starting to come together.”

Clipped from: https://floridapolitics.com/archives/472301-medicaid-modernization-will-take-hundreds-of-millions-and-require-more-staff/

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Long Predicted Medicaid Specialty Drug Trend Finally Surpasses 50% of Pharmacy Spend in the Latest Magellan Rx Management Medicaid Pharmacy Trend Report

[ MM Curator Summary] New analysis of Medicaid rx spending shows similar trends as previous years, with specialty drugs accounting for more than half of all drug spending.

 
 

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.

 
 

PHOENIX–(BUSINESS WIRE)–Nov 15, 2021–

Magellan Rx Management, the full-service pharmacy benefits management division of Magellan Health, Inc. (NASDAQ: MGLN), released its sixth annual Medicaid Pharmacy Trend Report TM, the industry’s leading report exclusively detailing trends in the Medicaid pharmacy fee-for-service (FFS) space.

The Medicaid Pharmacy Trend Report highlights the evolving landscape of Medicaid, made even more dynamic from the events of the last two years. The report includes an in-depth analysis of class and drug trends, forecasting of Medicaid key conditions, drugs in the pipeline, and Medicaid pharmacy economics. This is also the only detailed industry source for the analysis of Medicaid pharmacy fee-for-service (FFS) gross, net, and forecasted drug cost trends.

“As our nation continues to navigate the lasting impacts of the COVID-19 pandemic, there is no doubt that states are facing unprecedented challenges across all areas of government, especially related to ensuring the mental and physical well-being of their citizens,” said Meredith Delk, PhD, MSW, general manager and senior vice president, government markets, Magellan Rx Management. “The Medicaid Trend Report illustrates critical data-driven observations and solutions. The valuable insights in this report can assist states on their mission to ensure a high quality and cost-effective prescription drug program for their most vulnerable populations.”

Key findings in this year’s report include:

  • In 2020, specialty drugs accounted for 51.4% of the net cost in Medicaid, a trend predicted for the last five years. A constant imbalance in spend, specialty drugs only accounted for 1.3% of utilization.
  • 2020 traditional net cost trend for Medicaid FFS was positive for the first time in five years with the introduction of new-to-market drugs.
  • Medicaid FFS top drug classes remained almost identical to previous years – with HIV/AIDS and antipsychotics accounting for more than 19.8% of the total net drug spend.
  • With a steady increase in pipeline drugs, most key conditions will experience increased trend over the next three years. Comparatively, conditions with generic drug introductions or specialized management strategies will see a decrease.

Many of the Medicaid FFS drug trends remained steady, but the drug pipeline, a concern for all lines of business and operating in a year unlike any other, forced states to consider alternative pathways to continuity of care for patients, largely focused on technology-based solutions.

“Our ability to offer comprehensive and configurable solutions that fundamentally connect the dots for our customers and their members around the efficacy of drugs, quality care and payments is key,” said Delk.

The Magellan Rx Management Medicaid Pharmacy Trend Report includes data from Magellan Rx’s Medicaid FFS pharmacy programs in 25 states and the District of Columbia. The material is reviewed and supported by a team of Magellan Rx experts with broad national expertise, including 369 years of combined pharmacy benefit administration (PBA) experience.

About Magellan Rx Management: Magellan Rx Management, a division of Magellan Health, Inc., is shaping the future of pharmacy. As a next-generation pharmacy organization, we deliver meaningful solutions to the people we serve. As pioneers in specialty drug management, industry leaders in Medicaid pharmacy programs and disruptors in pharmacy benefit management, we partner with our customers and members to deliver a best-in-class healthcare experience.

About Magellan Health:Magellan Health, Inc., is a leader in managing the fastest growing, most complex areas of health, including special populations, complete pharmacy benefits and other specialty areas of healthcare. Magellan supports innovative ways of accessing better health through technology, while remaining focused on the critical personal relationships that are necessary to achieve a healthy, vibrant life. Magellan’s customers include health plans and other managed care organizations, employers, labor unions, various military and governmental agencies and third-party administrators. For more information, visit MagellanHealth.com.

(MGLN-GEN)

View source version on businesswire.com:https://www.businesswire.com/news/home/20211115005141/en/

CONTACT: Media:Lilly Ackley,ackleyl@magellanhealth.com, (860) 507-1923

Investor: Darren Lehrich,lehrichd@magellanhealth.com, (860) 507-1814

KEYWORD: ARIZONA UNITED STATES NORTH AMERICA

INDUSTRY KEYWORD: PROFESSIONAL SERVICES HEALTH INSURANCE MANAGED CARE GENERAL HEALTH PHARMACEUTICAL

SOURCE: Magellan Health, Inc.

Copyright Business Wire 2021.

PUB: 11/15/2021 06:30 AM/DISC: 11/15/2021 06:30 AM

http://www.businesswire.com/news/home/20211115005141/en

 
 

Clipped from: https://tylerpaper.com/ap/business/long-predicted-medicaid-specialty-drug-trend-finally-surpasses-50-of-pharmacy-spend-in-the-latest/article_360c6494-eea7-5141-90c0-d131b94b6236.html

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NY- Former Employees At State Administrator Of Medicaid Transportation And Business Owner Charged With Submitting Fraudulent Claims

[ MM Curator Summary] 2 NY NET dispatchers routed trips to a company owned by a person they colluded with to commit fraud.

 
 

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.

 
 

Damian Williams, United States Attorney for the Southern District of New York, Scott J. Lampert, Special Agent in Charge of the New York Regional Office of the U.S. Department of Health and Human Services, Office of the Inspector General (“HHS-OIG”), and Ricky J. Patel, Acting Special Agent in Charge of the New York Field Office of the Homeland Security Investigations (“HSI”), announced the unsealing of an Indictment charging PATRICK NDUKWE, DAVID TRAVERS, and MICHELLE MARTIN with participating in a fraudulent scheme in which TRAVERS and MARTIN improperly routed trips for Medicaid-funded transportation to NDUKWE’s company, Quality Service Medical Transportation (“Quality”) and facilitated fraudulent Medicaid claims by Quality.  The case is assigned to U.S. District Judge Denise L. Cote.

U.S. Attorney Damian Williams said: “Every day, thousands of government employees and private contractors around New York are entrusted with handling, disbursing, and guarding public funds.  As alleged, David Travers and Michelle Martin, who were employees at the state manager for Medicaid-funded transportation, abused their roles and the public’s trust when they took payments to steer business to a private company and helped that company submit fraudulent Medicaid claims.  This Office and our law enforcement partners will always investigate and prosecute the illegal abuse of public programs for unjust enrichment.”

HHS-OIG Special Agent in Charge Scott J. Lampert said: “The defendants in this case allegedly engaged in a greed-fueled fraud scheme that undermined the Medicaid program and diverted taxpayer funds from their intended purpose of providing health care benefits to low-income individuals and families.  Together with our law enforcement partners, HHS-OIG will continue to vigorously pursue those who steal from government health programs for personal gain.”

HSI Acting Special Agent in Charge Ricky J. Patel said: “As alleged, these defendants lined their pockets by abusing a program created to provide assistance to the sick and injured in our communities.  Working with our partners, HSI will seek out and bring to justice those that attempt to undermine any federal or state program, explicitly those designed to help millions of our most vulnerable in New York.”

As alleged in the Indictment, which was unsealed today, public filings, and statements in court:[1] 

In New York, individuals who are enrolled in the state’s Medicaid program are eligible to have Medicaid pay for their transportation to and from medical appointments if they are not able to safely take public transportation.  To obtain Medicaid-funded transportation, the enrollee or their health care professional must schedule transportation by contacting the private company that is contracted to manage Medicaid-funded transportation in the New York City area (the “Transportation Manager”).

NDUKWE, 56, was the owner and operator of Quality.  From in or about May 2017 to March 2020, Quality was paid more than $7.3 million for more than 120,000 trips the company purportedly provided for Medicaid-enrolled customers in the New York City area.  However, many of these trip claims were fraudulent and never actually performed.  In some instances, the Medicaid-enrollee who purportedly used Quality to travel to a medical appointment had, in fact, never heard of or used the company for any transportation services.  In other instances, the driver who Quality said performed the trip had never actually worked for the company.  In yet other instances, Quality paid a periodic “kickback” to a Medicaid enrollee to use that enrollee’s personal identifying information to submit a trip claim.

TRAVERS and MARTIN were customer service representatives at the Transportation Manager.  Both were responsible for, among other things, receiving calls from Medicaid enrollees who needed transportation and then randomly assigning those trips among the dozens of eligible transportation companies in the New York City area.  However, both TRAVERS and MARTIN steered a disproportionately high volume of their trips to Quality.  In addition, when certain enrollees requested to be moved from Quality to another transportation company, TRAVERS and MARTIN ensured that the customers were eventually reassigned back to Quality.  TRAVERS and MARTIN also scheduled trips for Quality that they knew would not be performed and would allow Quality to submit fraudulent claims for payment.  For their fraud, both TRAVERS and MARTIN received payments from NDUKWE.

*                      *                      *

NDUKWE was arrested this morning in the Bronx and will be presented later today before U.S. Magistrate Judge Ona T. Wang in Manhattan federal court.  TRAVERS was arrested this morning in Syracuse, New York, and Martin was arrested this morning in East Syracuse, New York.  Both TRAVERS and MARTIN will be presented later today before U.S. Magistrate Judge Therese Wiley Dancks.

NDUKWE, TRAVERS, and MARTIN are each charged with one count of theft of government funds, in violation of 18 U.S.C. § 641; one count of health care fraud, in violation of 18 U.S.C. § 1347; one count of conspiracy to commit health care fraud, in violation of 18 U.S.C. § 1349; and one count of violating the Anti-Kickback statute, in violation of 42 U.S.C. § 1320a-7b. In addition, NDUKWE is charged with one count of aggravated identity theft, in violation 18 U.S.C. § 1028A. In February 2020, as part of the same investigation, the Government charged 13 defendants involved in a different transportation company.

The crimes of theft of government funds, health care fraud, conspiracy to commit health care fraud, and violating the Anti-Kickback Statute each carry a maximum sentence of 10 years in prison.  The crime of aggravated identity theft carries a mandatory two years in prison.  The maximum potential sentences in this case are prescribed by Congress and are provided here for informational purposes only, as any sentencings of the defendants will be determined by a judge.

Mr. Williams praised the outstanding work of DHHS-OIG and HSI.  He also thanked the Office of the New York State Medicaid Inspector General, New York Attorney General’s Medicaid Fraud Control Unit, United States Customs and Border Protection, the Syracuse Police Department, the Onondaga County Sheriff’s Office, the Internal Revenue Service, the New York City Police Department, and the U.S. Probation Office for the Northern District of New York for their assistance in the case.

This case is being handled by the Office’s General Crimes Unit.  Assistant United States Attorneys Brandon D. Harper and Kedar S. Bhatia are in charge of the prosecution.

 
 

[1] As the introductory phrase signifies, the entirety of the text of the Indictment are herein are only allegations, and every fact described herein should be treated as an allegation.

 
 

Clipped from: https://www.justice.gov/usao-sdny/pr/former-employees-state-administrator-medicaid-transportation-and-business-owner-charged

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Anthem, Inc. to acquire Integra Managed Care

 
 

[ MM Curator Summary] Anthem will complete its purchase of an I/DD plan in NY by mid-next 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.

 
 

 
 

INDIANAPOLIS, November 10, 2021–(BUSINESS WIRE)–Anthem, Inc. (NYSE: ANTM) today announced that the company has entered into an agreement to acquire Integra Managed Care, a Managed Long-Term Care Plan in New York that helps adults with long term care needs and disabilities live safely and independently in their own home.

Integra currently serves 40,000 Medicaid members who benefit from a dedicated care management team that includes a Registered Nurse, Social Worker, and Coordinator who work in partnership with members, their families, and health care providers to ensure their long-term care needs are met.

“This acquisition aligns with our goal of growing Anthem’s Medicaid business, while serving our members with a comprehensive and coordinated approach to care,” said Felicia Norwood, Executive Vice President of Anthem’s Government Business Division. “Like Anthem, Integra has established connections with community groups to gain a deeper understanding of how to best support the whole-health needs of the people we are privileged to serve.”

Anthem is acquiring Integra from a wholly-owned indirect subsidiary of Personal Touch Holding Corporation. Integra has been serving communities by providing government sponsored coverage for a full range of long-term care services including services in the home, such as nursing, licensed physical, occupational and speech therapy services, and home health aide services. The acquisition is expected to close by the end of the second quarter of 2022 and is subject to customary closing conditions. Upon closing, Integra will join Anthem’s Government Business Division. Financial terms of the transaction were not disclosed. Anthem’s legal advisors are White & Case, Hinman Straub, and Lewis Rice. Ruskin Moscou Faltischek, Greenberg Taurig, and ESOP Law Group are acting as legal advisors for Integra. Stifel acted as the exclusive financial advisor to Integra in this transaction.

About Anthem, Inc.

Anthem is a leading health benefits company dedicated to improving lives and communities, and making healthcare simpler. Through its affiliated companies, Anthem serves more than 117 million people, including more than 45 million within its family of health plans. We aim to be the most innovative, valuable and inclusive partner. For more information, please visit www.antheminc.com or follow @AnthemInc on Twitter.

About Integra Managed Care

Integra Managed Care is a New York State Managed Long Term Care Plan designed for adults living with long-term disabilities. Integra’s goal is to help members live safely and independently in the comfort of their own home with a dedicated team of nurses and social workers who will ensure the care and services that will help individuals live as independently as possible.

 
 

Clipped from: https://finance.yahoo.com/news/anthem-inc-acquire-integra-managed-130000105.html

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Centene Will Address Serious Mental Healthcare in AZ Medicaid

[ MM Curator Summary] Centene has won a new BH contract in AZ.

 
 

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 payer’s contract to address serious mental healthcare needs in Arizona will last three years, with the opportunity to extend the contract.

By Kelsey Waddill

November 16, 2021 – Centene Corporation (Centene) will be expanding its Medicaid coverage in Arizona to provide serious mental healthcare services in a competitive contract expansion, the payer announced.

“We are honored to continue our long-standing partnership with the state of Arizona to provide access to comprehensive, quality healthcare to members living with serious mental illness and other complex situations and crisis,” said Brent Layton, president and chief operating officer of Centene. 

“Centene has a long history of coordinating integrated physical and behavioral healthcare in Arizona, and we look forward to continuing to work with local providers and community partners to help Arizonans live better, healthier lives.”

The plan’s subsidiaries, Arizona Complete Health-Complete Care Plan and Care1st Health Plan Arizona, will offer physical and behavioral healthcare services to individuals with serious mental health conditions. 

Specifically, the payer will provide services for individuals eligible for Title XIX and Title XXI services. These groups of beneficiaries may all under Medicaid or Children’s Health Insurance Program (CHIP) coverage. Centene’s plans will also address crisis system functions and court-ordered evaluations in addition to services that run on grant funding.

The payer will cover around 22,000 beneficiaries in 12 counties—seven counties in southern Arizona and five counties in the northern area of the state—as well as other regions that require crisis support.

The contract will last three years starting October 1, 2022. Arizona’s Medicaid program will have the option to renew the contract as a two-year contract twice.

“It is a privilege to have been selected to continue serving Arizonans living in crisis or with severe mental illness,” said Martha Smith, president and chief executive officer of Centene’s Arizona plan. 

“Our mission is to transform the health of our communities, one person at a time, which we believe requires a holistic approach to care that addresses mind, body, and social determinants of health, such as nutrition, housing, and employment. The result is improved health outcomes, lower costs, and a higher quality of life.”

The announcement comes shortly after Centene released a report on improving mental healthcare for children.

“Payers are uniquely positioned to play a critical role in advancing mental healthcare delivery through continued support of innovative technology, evidence-based clinical programs, educational programming, and community partnerships,” Centene’s report explained.

Centene is acquiring Magellan Health, a behavioral healthcare platform, in an effort to diversify and integrate its behavioral healthcare capabilities. The payer announced its plans to acquire Magellan Health in January 2021.

In Magellan Health’s 2021 second-quarter financial report, the behavioral healthcare company projected that the acquisition would finalize in the second half of 2021.

Integrating physical and mental or behavioral healthcare services is a key part of Centene’s behavioral healthcare strategy. 

Brett Hart, chief operating officer of medical strategy and former chief behavioral health officer at Centene, told
HealthPayerIntelligence that for the past three to four decades behavioral healthcare has been isolated from physical healthcare services. 

Thus, when instituting new efforts to bridge the gap between mental or behavioral healthcare and physical healthcare whether in the private payer setting or for a public payer such as Arizona’s Medicaid program, Hart noted that payers must address both historic barriers to integration as well as the new challenges that they face with new technologies and frameworks.

These efforts to integrate care are critical for Medicaid programs because Medicaid has proven instrumental in enabling access to substance abuse care and behavioral and mental healthcare treatment.

 
 

Clipped from: https://healthpayerintelligence.com/news/centene-will-address-serious-mental-healthcare-in-az-medicaid
 

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With big federal boost, Virginia shows Medicaid surplus this year, helping offset future costs

[ MM Curator Summary] Virginia predicts a Medicaid funding surplus next year, followed by a big jump to create nearly $1B more in Medicaid spending in the state within 2 years.

 
 

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.

 
 

Governor Northam talks about the state’s budget reserves

Virginia is showing a surplus of almost $654 million in its Medicaid program, boosted by federal spending that will help offset future cost increases in the next state budget for the $18 billion program for poor, elderly or disabled Virginians.

Medicaid costs will go up by a net $821 million in the two-year budget for July 1, 2022, to June 30, 2024, which Gov. Ralph Northam will introduce on Dec. 16, but state officials also foresee a $124 million windfall if the federal government raises its share of the program expenses by almost 1% next year as tentatively proposed.

Program costs are projected to grow 1% in the first year and 5% in the second, administration officials said Wednesday.

“The numbers have come in lower than they have historically,” Secretary of Finance Joe Flores said in a briefing with leadership of the Department of Medical Assistance Services, the state Medicaid agency.

At the same time, Virginia will begin sorting out the effects of the COVID-19 pandemic, which added 392,000 people to the Medicaid rolls, some temporarily, as well as refugees from the Taliban takeover of Afghanistan who have settled in the state and qualify for health care assistance. Medicaid now serves more than 1.9 million Virginians in a state of 8.6 million.

The federal government has boosted emergency support of the program during the pandemic, extending a temporary 6.2% increase in its share of funding through March 31. The enhanced aid will reduce Virginia’s share by almost $146 million in the fiscal year that began July 1 and save the state more than $1 billion since the public health emergency began in March 2020.

 
 

Clipped from: https://richmond.com/news/state-and-regional/govt-and-politics/with-big-federal-boost-virginia-shows-medicaid-surplus-this-year-helping-offset-future-costs/article_4f2d1ca3-2c17-5c67-a0a1-86223fbea569.html

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Louisiana Lawmakers Try to Tighten Medicaid Cost Estimates

 
 

[ MM Curator Summary] Louisiana is trying to figure out a way to more accurately predict Medicaid spending.

 
 

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.

 
 

Getty Images

BATON ROUGE (AP) — Louisiana lawmakers are trying a new approach to determine how much the state will spend on Medicaid services each year, as the program has ballooned to more than one-third of the state’s budget and added hundreds of thousands of people during the pandemic.

A Medicaid forecasting panel created by lawmakers last year held its first meeting Wednesday, to create a new process for estimating spending needs for a program that provides health care to 1.9 million people — about 41% of Louisiana’s population.

The Louisiana Department of Health currently does its own economic modeling and then seeks funding from state lawmakers to match the forecast, which often overestimates how much money will be needed to cover services. The Medicaid Estimating Conference will involve lawmakers, the Health Department, the governor’s chief budget adviser and an outside health care economist, along with financial advisers to the Legislature.

“This program is too big not to have adequate data,” said Sen. Sharon Hewitt, the Slidell Republican whose bill created the conference.

Louisiana’s Medicaid program is estimated to spend $16 billion in the current budget year on health care services, the large majority of it federally funded and much of it through managed care companies. Hewitt said the state’s putting up $1.8 billion of the cost from its general fund.

But estimating — and restraining — the program’s price tag can be difficult.

Many costs associated with Medicaid are out of the state’s control. To get federal Medicaid funding, states are required to provide certain services through the program, and they aren’t allowed to force people off the rolls if they took boosted Medicaid funds offered because of the coronavirus pandemic as Louisiana did.

Louisiana added more than 300,000 people to its Medicaid rolls since March 2020 when the coronavirus outbreak began.

Daniel Cocran, the state’s Medicaid deputy director, said about 70% of that growth was in the Medicaid expansion program. Democratic Gov. John Bel Edwards authorized the expansion when he took office in 2016, to cover working-age adults who don’t get health insurance through their employers. Nearly 700,000 people are currently enrolled in Medicaid through that expansion.

Many of those enrollees wouldn’t continue to qualify for Medicaid coverage because they now make too much money or stopped meeting other eligibility criteria. But Louisiana can’t kick them off the rolls because of the strings tied to the enhanced federal pandemic Medicaid financing.

Those people can be removed from Medicaid only when the federal public health emergency is lifted, Cocran said. It’s unclear when that will happen, and then federal regulations describe a lengthy process to bump someone from the program even after that, he said.

President Joe Biden’s social safety net expansion legislation pending in Congress also has further restrictions for removing people from Medicaid that would come into play if the measure passes, health officials said.

All of that will be considered as part of the new forecasting process, Hewitt said. She hopes to have the conference’s first forecast complete in December or January. The panel’s projections will be nonbinding but are expected to have a heavy influence on budgeting. The nonpartisan Legislative Fiscal Office hired a health care economist as part of the effort.

Sen. Gerald Boudreaux, a Lafayette Democrat on the conference, said he thinks the new approach can help lawmakers determine the true costs of the Medicaid program, but he also cautioned that he doesn’t want it to be used to try to limit access to health care services.

“It is very important to a lot of people, more people than some of us realize,” Boudreaux said.

 
 

Clipped from: https://www.bizneworleans.com/louisiana-lawmakers-try-to-tighten-medicaid-cost-estimates/

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Tennessee Republicans can’t stop Biden’s Medicaid expansion plan

[ MM Curator Summary] The journos are starting to gloat about being able to force expansion onto non-expansion 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.

 
 

Biden has a plan to expand Medicaid without actually expanding Medicaid. This is how it works.

 
 

A new White House proposal to offer nearly free health insurance to millions of low-income Americans would accomplish the same goal as previous efforts to expand Medicaid in Tennessee but would cut the need for state funding or approval from state lawmakers.

The plan – part of President Joe Biden’s sweeping “Build Back Better” agenda – would subsidize insurance purchased through the Affordable Care Act, commonly known as Obamacare, for impoverished Tennesseans who don’t qualify for TennCare, the state’s Medicaid program.

The proposal has the same aim and impact as Medicaid expansion but would not actually expand TennCare in any way. Instead, it would cover the same low-income population while sidestepping the primary obstacle preventing Medicaid expansion in Tennessee – state Republicans.

“It takes them completely out of the picture. It’s the federal government using federal funds to subsidize health insurance,” said John Graves, an expert on health care reform at Vanderbilt University Medical Center. “There is nothing the legislature can do about this.”

If the Biden proposal survives a divided Congress and is enacted into federal law, it could be transformative for Tennessee and other deep-red states where Medicaid expansion has long been a political non-starter.

But the transformation would be temporary. Biden’s proposal funds the new insurance subsidies for only four years. To extend the subsidies beyond 2025, Biden or his successor would need to secure more funding through a new law.

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What is the TennCare ‘coverage gap?’

TennCare, which is jointly funded by the federal and state government, provides health insurance to about one-fifth of Tennesseans, including many children, pregnant people, disabled adults and families who live at or below the poverty line.

But because Tennessee leaders repeatedly rejected Medicaid expansion, TennCare has a significant coverage gap: It does not cover childless adults — no matter how poor they may be — unless they fall into some other eligible category. 

This leaves no affordable insurance option for individuals who make less than $12,880 per year or couples who make less than $17,420, according to federal poverty guidelines. These people are poor enough to conceivably qualify TennCare but are not eligible since they don’t have children or a disability.

This is where the Biden plan kicks in.

The new federal subsidies would cover the entire Obamacare premiums for Tennesseans who live below the poverty line and aren’t eligible for TennCare or some other form of subsidized health insurance. It is estimated that about 120,000 Tennesseans fall into this gap, according to legislative analyses from the Kaiser Family Foundation and the Center for Budget and Policy Priorities.

For people impacted by this law, the subsidized Obamacare coverage would appear largely similar to the low-cost insurance they could have received through Medicaid expansion. Insurance would ultimately come from the same companies, like BlueCross BlueShield of Tennessee, and participants wouldn’t pay premiums but may face some small copays.

To a person on the receiving end of this coverage, the most significant difference would be how you sign up. Instead of joining TennCare under Medicaid expansion, enrollees will instead need to purchase a subsidized insurance plan through Healthcare.gov. 

Mandy Pellegrin, policy director at the Sycamore Institute, a nonpartisan think tank in Nashville, said this additional step may present an obstacle for some Tennesseans, causing a few eligible people to get lost in the process of choosing a coverage plan.

But beyond this small caveat, the proposal brings renewed optimism to efforts to insure the poor in Tennessee, Pellegrin said. Biden’s plan has “excited” advocates for Medicaid expansion who’ve grown exhausted of being stonewalled by lawmakers, she said.

“They are completely removed from this,” Pellegrin said. “It is 100% a workaround.”

Tennessee GOP stopped Medicaid expansion for years

Medicaid expansion, made possible under the Affordable Care Act in 2014, allowed states to grow their Medicaid programs to cover millions of low-income residents who were not previously eligible and unlikely to have insurance. Under the terms of the law, the federal government covered 90% of the cost of insuring these new enrollees.

Most states seized the opportunity to expand Medicaid while a minority rejected expansion, citing cost concerns or political objections to Obamacare in general. Additional states expanded years later due to political shifts or voter initiatives, and today there are just 12 non-expansion states – all of which are controlled by Republicans.

Tennessee is among the most steadfast of these holdouts.

Despite research showing expansion would benefit the poor and rural hospitals, and public polling that most Tennesseans support expansion, the state’s Republican supermajority have trounced every proposal to expand TennCare – even attempts from within their own party.

Former Gov. Bill Haslam presented an expansion-like plan in 2014 but it was promptly killed by lawmakers. Sen. Richard Briggs, R-Knoxville, a doctor, has repeatedly tried and failed to pass expansion bills. Democratic lawmakers fruitlessly push for expansion each year, but don’t wield enough power to advance a bill without Republican allies.

The debate was briefly revived after the election of Biden, who campaigned on a promise to improve Obamacare and woo non-expansion states to finally expand. Biden’s strategy was clear: offer a deal so sweet that no state could turn it down.

It didn’t work.

In a coronavirus relief law passed early this year, Biden offered to pay billions to hold-out states if they finally decided to expand. Tennessee could’ve gained as much as $900 million in two years on top of the federal government covering 90% of the expansion cost.

Tennessee’s Republican leadership said in March they would at least consider Biden’s new offer, but to date they have taken no action. In the eight months since Biden’s offer, lawmakers convened for legislative session three times and no serious discussion on expansion has occurred.

None of the other non-expansion states took Biden’s offer either.

Biden’s proposal must get through Congress and past Sen. Joe Manchin

While the Biden proposal completely sidesteps the state lawmakers in Nashville, it does require the approval of Congress in Washington D.C.

The expanded subsidies are part of a $1.85 trillion spending package that also includes universal preschool and large investments in efforts to combat climate change. Republicans balked at the price tag, and the legislation is likely to need votes from every Democrat to pass the Senate.

For now, fate of the proposal appears to hinge on a familiar thorn in Biden’s side – Sen. Joe Manchin.

Manchin, a centrist Democrat from West Virginia who wields significant political power because of his deciding vote, spoke in opposition to the proposal last month. He argued it was unfair for the federal government to pay for subsidies in the 12 non-expansion states when the rest of the country, including West Virginia, shouldered a portion of expansion costs for years.

“For states that held out to be rewarded 100% is not fair,” he said.

Other Democrats have tried to counter this argument. Georgia Sen. Raphael Warnock, who represents a holdout state, stress federal tax dollars collected in Georgia are funding Medicaid programs that low-income Georgians can’t join.

The status quo is not fair to them, Warnock argued. The same argument could be made for Tennesseans.

“People of Georgia are paying taxes for health care that they cannot access while subsidizing health care in West Virginia and in other states,” Warnock said.

The USA TODAY Network contributed to this story.

Brett Kelman is the health care reporter for The Tennessean. He can be reached at 615-259-8287 or at brett.kelman@tennessean.com. 

Clipped from: https://www.oakridger.com/story/news/health/2021/11/16/tennessee-republicans-cant-stop-bidens-medicaid-expansion-plan/6263982001/