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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.

 
 

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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.

IN-DEPTH:In Tennessee, the death toll of the delta surge is higher than you think

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/

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Attempt to block $22 billion Medicaid contracts dismissed – Ohio Capital Journal

 
 

 
 

MM Curator summary

 
 

Paramount has lost in court (again).

 
 

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.

 
 

Appeal likely in dispute over managed care business

 
 

A judge on Tuesday dismissed an attempt to overturn more than $22 billion worth of managed-care business as the Ohio Department of Medicaid tries to reshape the way it works with 3 million low-income and disabled Ohioans.

However, questions remain about potential conflicts of interest on the part of some involved in awarding the business.

Franklin County Common Pleas Judge Julie M. Lynch dismissed an attempt by Paramount Advantage to stop the process by which the Medicaid department hopes to revamp the way it handles prescription drugs, coordinates care for kids with complex behavioral needs and delivers care to traditional Medicaid recipients. The new system is scheduled to go live next July.

Toledo-based Paramount claimed the procurement process was biased against it — and in favor of some of the country’s biggest corporations. Loss of the business will mean the loss of 600 jobs, the company’s lawyers said.

Judge Lynch said the company’s case didn’t pass legal muster.

“Paramount needed to show that the department of Medicaid abused its discretion” with clear and convincing evidence, Lynch said, later adding that Paramount “failed in every respect to meet that burden.”

In a little more than three days of testimony in late October and this week, Paramount’s attorneys entered evidence that they said showed the Medicaid department was biased against the managed-care company, which has worked with the department for more than 20 years.

For example, the Medicaid evaluators in some instances dinged relatively small Paramount for not working out of state, in contrast to huge bidders such as UnitedHealth, which works in many states.

Paramount also pointed out that while two of the successful bidders have been recently sued by the state on claims of fraud, they weren’t penalized, while Paramount got no credit for not being accused of such conduct.

And on Tuesday, the company called a statistician who testified that when they met, Medicaid evaluators lowered Paramount’s scores much more than any of the other applicants’ and in a way that was unlikely to be random.

But Lynch found the testimony and the other evidence unpersuasive, ruling that Paramount failed to show that the Medicaid department acted against it in a “conscious, intentional” way.

“While Paramount is disappointed with the court’s decision, we will continue to explore our strategic and legal options,” said a statement issued by Paramount after the ruling. “We remain committed to helping to ensure the best outcomes for our quarter of a million Medicaid members and our employees who have consistently provided them with the highest quality of service.”

An appeal of the ruling is likely, Paramount’s attorneys said.

Just before Judge Lynch read her ruling, attorney Kirstin R. Fraser complained of how slowly the Medicaid department turned over documents and other materials Paramount requested.

“We only became aware after the fact of the many conflicts of interest involved in this case,” she said.

Among possible conflicts is if Mercer, the consultant that facilitated the procurement, had clients among the companies that were selected for Medicaid contracts. The Medicaid department eventually turned over a memo addressing the matter, but the names of client companies were redacted.

Lynch on Tuesday declined to admit an unredacted version of the memo into evidence.

Another possible conflict is that Medicaid Director Maureen Corcoran seems to own stock in two of the parent companies that won business as part of the massive procurement. 

Corcoran reported owning at least $1,000 worth of each company’s stock last year as part of her regular ethics disclosure. But Medicaid lawyers conceded that Corcoran hadn’t filed an affidavit disclosing exactly how much stock she owned as she contracted with the companies.

Such a disclosure appears to be required by law. But in a court filing, Medicaid attorneys claimed that Corcoran didn’t have a conflict of interest because her investments were with parent corporations UnitedHealth Group and CVS Health, not their Ohio subsidiaries with which the Medicaid department is doing billions worth of business.

Corcoran was expected to testify about such matters, but Judge Lynch so sharply limited what Paramount’s lawyers could ask the Medicaid director that Corcoran ultimately never took the stand.

Foreshadowing issues that could be raised on appeal, Paramount attorney Shawn J. Organ listed some of the things he’d have asked Corcoran had he been allowed. Among them were questions about Corcoran’s stock holdings in managed-care companies, whether she communicated with any bidders during the procurement process and why she decided to restart contract negotiations with Buckeye Health Plan, which had just paid Ohio $88 million to settle claims of fraud.

It’s unclear whether any of these issues will matter legally, but they will likely come up before the Tenth District Court of Appeals.

Clipped from: https://ohiocapitaljournal.com/2021/11/10/attempt-to-block-huge-medicaid-contracts-dismissed/

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Closing Medicaid coverage gap could widen hospital margins, report says

 
 

 
 

MM Curator summary

 
 

Subsidizing exchange plans in non-expansion states could add $12B to hospital profits.

 
 

 
 

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.

 
 

 
 

If the Build Back Better Act goes into effect, hospital margins in the 12 states that have not expanded their Medicaid programs will increase by an estimated $11.9 billion, according to a Nov. 4 report by USC-Brookings Schaeffer Initiative for Health Policy.

Through the Affordable Care Act, states can extend their Medicaid programs to adults under age 65 with incomes below 138 percent of the federal poverty level, but 12 states have not done so.

In those 12 states, people with incomes below 138 percent of the federal poverty level are mostly ineligible for subsidized coverage. But the current draft of Democrats’ Build Back Better Act wants to fill the coverage gap.

Here are five things to know:

1. The current draft for the Build Back Better Act would fill the Medicaid coverage gap by making people below the poverty line in those 12 states eligible for ACA marketplace coverage. More than that, it would change marketplace coverage by eliminating all premiums and cost-sharing for people with incomes below 138 percent of the federal poverty line. This would add services that are covered by Medicaid but not the marketplace.

2. By making these changes, the report estimates that hospital margins in the 12 states would rise by $11.9 billion if the Build Back Better Act went into effect in 2023. The reason for this improvement is because hospitals would be paid for services they’re delivering anyway but aren’t currently being paid for. Additionally, more patients would be seeking care because of increased coverage, which would raise profits.

3. Hospitals in these states also would have smaller Medicare disproportionate share hospital payments. This is because the payments use a formula that looks at the national uninsured rate and the distribution of uncompensated care across hospitals. Both of these items would change.

4. If policymakers instead chose a federal Medicaid plan, these hospitals would receive smaller increases in margins at $3.6 billion. A federal Medicaid plan would most likely pay hospitals less than marketplace plans, according to the report, leading to hospitals receiving less revenue and less patient volume for uncompensated care.

5. The draft Build Back Better Act could help patients by allowing hospitals to provide care even if they have fewer resources. However, it could also allow hospitals to accept higher profits and increase costs, therefore not helping patients.

 
 

Clipped from: https://www.beckershospitalreview.com/finance/closing-medicaid-coverage-gap-could-widen-hospital-margins-report-says.html

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Medicaid managed care company sues outgoing corporate co-owner, alleging ‘sabotage’

 
 

 
 

MM Curator summary

 
 

An Arkansas provider-led BH organization is claiming Beacon Health has been working to destroy it from the inside.

 
 

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.

 
 

LITTLE ROCK — Empower Healthcare Solutions, a managed care organization that serves almost 20,000 Arkansas Medicaid beneficiaries with complex health needs, filed a lawsuit in federal court on Tuesday against a Boston-based company that owns a portion of Empower but is planning to leave by the end of the year.

The suit accuses Beacon Health Options of “seeking to destroy Empower … from within” to benefit one of Empower’s competitors.

Meanwhile, a letter obtained by the Arkansas Nonprofit News Network shows state Medicaid officials have concerns about Empower’s ability to operate after Beacon’s departure is finalized. The Arkansas Department of Human Services (DHS) said in its Nov. 2 letter to Empower that it has until Nov. 24 to complete a “readiness review” ordered by DHS, which oversees Arkansas’s Medicaid program.

 
 

Empower is one of four managed care organizations that contract with DHS to pay for and coordinate care for Medicaid beneficiaries with severe behavioral health disorders, intellectual or developmental disabilities, or both. Known as Provider-led Arkansas Shared Savings Entities, or PASSEs, they were created by a 2017 state law that promised to both control spending and provide better services to this high-need, high-cost group of patients. PASSEs basically play the role of insurance companies but must be partly owned by health care providers; it also provide “care coordinators” who act as case managers for beneficiaries.

Beacon, one of the nation’s largest behavioral health companies, has owned a 16.66 percent stake in Empower since the PASSE was formed in 2017. (The rest of Empower is owned by several health care entities based in Arkansas.) Beacon also contracts with Empower to provide administrative services and has played a critical role in Empower’s day-to-day operations.

 
 

But in 2020, Beacon was acquired by insurance giant Anthem. Anthem also owns a stake in another Arkansas PASSE, Summit Community Care, a rival of Empower. A state law passed earlier this year prohibited ownership in more than one PASSE, and Beacon began separating itself from Empower.

Now, Empower’s lawsuit says Beacon has been “intentionally attempting to sabotage Empower” on its way out the door.

“Since the merger, Beacon has engaged in conduct that suggests that it is functioning as a Trojan-horse for Anthem,” Empower’s complaint says. Empower claims Beacon has refused to turn over phone numbers, email accounts and critical databases and documents as the two companies finalize their divorce.

A representative for Beacon did not respond to a request for comment on the lawsuit. But a letter Beacon sent to DHS Aug. 26 show Beacon has had its own complaints about the separation.

The Aug. 26 letter, obtained from DHS with a public records request, described a dispute over Empower’s adoption of new policies for credentialing health care providers in its network after Beacon leaves. Beacon has been responsible for provider credentialing as part of its management services to Empower. The letter indicated Beacon considers the fruits of that work to belong to it alone – not Empower – and suggested Empower’s board was attempting to “negate Beacon’s credentialing of its own network.”

“The proposed Credentialing policy could have the effect of invalidating the credentialing decisions of our existing network,” wrote Melissa Ortega, a vice president of Beacon based in Little Rock. “Beacon obviously cannot agree to any policy that will have this result. Empower has been combative and non-cooperative in addressing these concerns.”

In its lawsuit, Empower cites this episode as further evidence of Beacon’s alleged attempts to sabotage Empower. “Beacon made false representations about Empower to DHS, which representations (if believed by DHS) could jeopardize Empower’s future participation in the PASSE program,” the complaint says.

The Department of Human Services pays each PASSE a fixed monthly amount per beneficiary enrolled. PASSEs must then cover the cost of care for those members, which can include costly services such as inpatient treatment or at-home help for disabled people. In 2020, the cost to Medicaid for the roughly 50,000 PASSE beneficiaries in Arkansas was almost $1.3 billion, according to documents provided to a legislative committee in June. (Empower’s revenues for 2020 were over $460 million, according to the lawsuit.)

Empower’s complaint says that Beacon was “essentially the operations manager” for the PASSE. Under the terms of a service agreement between the two companies, Beacon provided all “services required for [Empower’s] performance of the PASSE Contract [including] all staffing and administrative services.” Beacon was “compensated handsomely” for these services, the complaint says, receiving “more than $52 million in 2020 alone.”

But because Beacon has played such a large role in Empower’s day-to-day operations, the impending breakup raises questions about what comes next for the PASSE and the beneficiaries who rely on it.

The same day Empower filed its lawsuit, Nov. 2, DHS sent it a letter warning the PASSE that it had yet to complete a mandatory “readiness review” in advance of Beacon’s exit on Dec. 31. DHS gave Empower until Nov. 24 to address a list of outstanding requirements. If the PASSE misses that deadline, the letter suggested, it could be in danger of losing its contract with the state – its sole source of business.

DHS is obligated “to ensure a smooth transition and continuation of services for any Medicaid enrollee of a managed care entity whose contract is terminated or dissolved for any reason,” wrote DHS Division of Medical Services Director Elizabeth Pitman in the letter. The agency “must be able to make a final decision” by Dec. 1, she added, so that beneficiaries “and their receiving PASSEs have adequate notice to ensure continued services and as smooth a transition as possible.”

A DHS spokeswoman did not respond to questions about steps DHS might take if the Nov. 24 deadline is not met or whether Empower’s members would be assigned to one of the other PASSEs.

Empower CEO Mitch Morris said in an email that the company was “prepared to demonstrate compliance to DHS and remain[ed] very confident that it will provide formal approval for Empower to continue operating as an Arkansas PASSE for calendar year 2022 and beyond.” Morris declined to comment on the lawsuit.

When provided with the Nov. 2 letter for review, Thomas Nichols, a lawyer with the advocacy organization Disability Rights Arkansas, said DHS was likely “covering their bases to make sure there’s not a gap in services” for beneficiaries.

PASSE members can’t afford any disruption in their coverage, Nichols said, because they are so deeply reliant on the services Medicaid pays for.

“Folks aren’t relying on this just for primary care appointments,” he said. “You have people who require 24/7 staff because they need that in order to live safely in a community setting. Folks rely on this sometimes for tube feedings … Some people rely on this for life-saving medication.”

“These are things that people have to have every single day. They have to be paid for every single day.”

Nichols said the uncertainty around Empower’s future illustrated the pitfalls of transferring responsibility for Medicaid to managed care companies.

“It is predictable that privatizing Medicaid services and feeding it to a for-profit world would result in the types of potential harms we now have,” he said. “It is inexcusable that individuals with significant developmental disabilities and mental illness are suddenly on the brink due to mergers and acquisitions.”

In addition to Beacon, Empower is co-owned by five other health care organizations. They are Arkansas Community Health Network, a consortium of four hospital systems; Statera, a long-term care company; Independent Case Management, a provider of home and community-based services for people with developmental disabilities; The Arkansas Healthcare Alliance, a group of providers for behavioral health and developmental disability services; and, ARcare, a network of clinics and other providers.

According to documents provided to a legislative committee in June, Empower has the largest share of beneficiaries among the four Arkansas PASSEs, with almost 20,000 members. Summit Community Care, the PASSE that is co-owned by Anthem, had more than 16,000 members. Arkansas Total Care, which is partially owned by health insurance company Centene, had over 13,000 members. The fourth PASSE is a newcomer to the state: CareSource PASSE, partially owned by an Ohio-based managed care company, was licensed earlier this year.

 
 

Clipped from: https://www.jonesborosun.com/news/medicaid-managed-care-company-sues-outgoing-corporate-co-owner-alleging-sabotage/article_bdf459e8-031e-5b4a-8360-72d21cfcbc52.html

 
 

 
 

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Fact Sheet: Biden Administration Announces Details of Two Major Vaccination Policies | The White House

 
 

 
 

MM Curator summary

 
 

Details of the new CMS and OSHA vaccine requirements have been released, with compliance required by January 4.

 
 

 
 

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.

 
 

New OSHA and CMS Rules Mean Two-Thirds of All Workers Now Covered by Vaccination Rules

Thanks to President Biden’s focus on getting Americans vaccinated, 70 percent of adult Americans are now fully vaccinated—up from less than one percent when the President took office. This is significant progress, made possible by a vaccinations program that made shots free and convenient for months. But more vaccinations are needed to save lives, protect the economy, and accelerate the path out of the pandemic. To that end, in July, President Biden began rolling out vaccination requirements for federal employees and contractors and calling on employers to do the same. Thousands of organizations across the country have answered the President’s call, and vaccination requirements have already helped reduce the number of unvaccinated Americans by approximately 40 percent since July.

Today, the Biden Administration is announcing the details of two policies to fight COVID-19 that will drive even more progress and result in millions of Americans getting vaccinated, protecting workers, preventing hospitalization, saving lives, and strengthening the economy.

First, the Department of Labor’s Occupational Safety and Health Administration (OSHA) is announcing the details of a requirement for employers with 100 or more employees to ensure each of their workers is fully vaccinated or tests for COVID-19 on at least a weekly basis. The OSHA rule will also require that these employers provide paid-time for employees to get vaccinated, and ensure all unvaccinated workers wear a face mask in the workplace. OSHA has a strong 50-year record of requiring employers to take common sense actions to prevent workers from getting sick or injured on the job. This rule will cover 84 million employees.

Second, the Centers for Medicare & Medicaid Services (CMS) at the Department of Health and Human Services is announcing the details of its requirement that health care workers at facilities participating in Medicare and Medicaid are fully vaccinated. The rule applies to more than 17 million workers at approximately 76,000 health care facilities, including hospitals and long-term care facilities.

The Administration has previously implemented policies requiring millions of federal employees and federal contractors to be fully vaccinated. To make it easy for businesses and workers to comply, the Administration is announcing today that the deadline for workers to receive their shots will be the same for the OSHA rule, the CMS rule, and the previously-announced federal contractor vaccination requirement. Employees falling under the ETS, CMS, or federal contractor rules will need to have their final vaccination dose – either their second dose of Pfizer or Moderna, or single dose of Johnson & Johnson – by January 4, 2022. OSHA is also clarifying that it will not apply its new rule to workplaces covered by either the CMS rule or the federal contractor vaccination requirement. And, both OSHA and CMS are making clear that their new rules preempt any inconsistent state or local laws, including laws that ban or limit an employer’s authority to require vaccination, masks, or testing.

The Administration is calling on all employers to ensure that as many of their workers are vaccinated as quickly as possible. As detailed in a recent White House report, vaccination requirements work and are good for the economy. Vaccination requirements have increased vaccination rates by more than 20 percentage points – to over 90 percent – across a wide range of businesses and organizations. According to Wall Street analysts, vaccination requirements could result in as many as 5 million American workers going back to work, and a survey of prominent, independent economists found unanimous agreement that vaccination requirements will “promote a faster and stronger economic recovery.”

Today’s announcements include:

New Vaccination Requirement for Employers With 100 or More Employees: OSHA is issuing a COVID-19 Vaccination and Testing Emergency Temporary Standard (ETS) to require employers with 100 or more employees (i.e., “covered employers”) to:

  • Get Their Employees Vaccinated by January 4th and Require Unvaccinated Employees to Produce a Negative Test on at Least a Weekly Basis: All covered employers must ensure that their employees have received the necessary shots to be fully vaccinated – either two doses of Pfizer or Moderna, or one dose of Johnson & Johnson – by January 4th. After that, all covered employers must ensure that any employees who have not received the necessary shots begin producing a verified negative test to their employer on at least a weekly basis, and they must remove from the workplace any employee who receives a positive COVID-19 test or is diagnosed with COVID-19 by a licensed health care provider. The ETS lays out the wide variety of tests that comply with the standard. Given that vaccines are safe, free, and the most effective way for workers to be protected from COVID-19 transmission at work, the ETS does not require employers to provide or pay for tests. Employers may be required to pay for testing because of other laws or collective bargaining agreements.
     
  • Pay Employees for the Time it Takes to Get Vaccinated: All covered employers are required to provide paid-time for their employees to get vaccinated and, if needed, sick leave to recover from side effects experienced that keep them from working.
     
  • Ensure All Unvaccinated Employees are Masked: All covered employers must ensure that unvaccinated employees wear a face mask while in the workplace.
     
  • Other Requirements and Compliance Date: Employers are subject to requirements for reporting and recordkeeping that are spelled out in the detailed OSHA materials available here. While the testing requirement for unvaccinated workers will begin after January 4th, employers must be in compliance with all other requirements – such as providing paid-time for employees to get vaccinated and masking for unvaccinated workers – on December 5th. The Administration is calling on all employers to step up and make these changes as quickly as possible.

New Vaccination Requirements for Health Care Workers: CMS is requiring workers at health care facilities participating in Medicare or Medicaid to have received the necessary shots to be fully vaccinated – either two doses of Pfizer or Moderna, or one dose of Johnson & Johnson – by January 4th. The rule covers approximately 76,000 health care facilities and more than 17 million health care workers – the majority of health care workers in America – and will enhance patient safety in health care settings. The rule applies to employees regardless of whether their positions are clinical or non-clinical and includes employees, students, trainees, and volunteers who work at a covered facility that receives federal funding from Medicare or Medicaid. It also includes individuals who provide treatment or other services for the facility under contract or other arrangements. Among the facility types covered by the rule are hospitals, ambulatory surgery centers, dialysis facilities, home health agencies, and long-term care facilities. Today’s action will help provide patients assurance about the vaccination status of those delivering care, create a level playing field across health care facilities, and help to address challenges facilities have faced with staff sickness and quarantines impacting delivery of care.

Streamlining Implementation and Setting One Deadline Across Different Vaccination Requirements: The rules released today ensure employers know which requirements apply to which workplaces. Federal contractors may have some workplaces subject to requirements for federal contractors and other workplaces subject to the newly-released COVID-19 Vaccination and Testing ETS. To make it easy for all employers to comply with the requirements, the deadline for the federal contractor vaccination requirement will be aligned with those for the CMS rule and the ETS. Employees falling under the ETS, CMS, or federal contractor rules will need to have their final vaccination dose – either their second dose of Pfizer or Moderna, or single dose of Johnson & Johnson – by January 4, 2022. This will make it easier for employers to ensure their workforce is vaccinated, safe, and healthy, and ensure that federal contractors implement their requirements on the same timeline as other employers in their industries. And, the newly-released ETS will not be applied to workplaces subject to the federal contractor requirement or CMS rule, so employers will not have to track multiple vaccination requirements for the same employees.

 
 

Clipped from: https://www.whitehouse.gov/briefing-room/statements-releases/2021/11/04/fact-sheet-biden-administration-announces-details-of-two-major-vaccination-policies/

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South Dakotans will vote on Medicaid expansion in 2022, pending petition validation

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The state hospital association has gathered enough signatures for its version of the voter Medicaid expansion ballot initiative.

 
 

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.

 
 

PBS NewsHour

Voters will decide whether to expand Medicaid to more low-income South Dakotans as long as the secretary of state verifies enough petition signatures were turned in on Monday.

South Dakotans Decide Healthcare said it turned in 46,119 signatures from registered South Dakota voters. That’s more than the 33,921-signature threshold needed for initiated constitutional amendments to be placed on the November 2022 ballot.

The number “really shows the grassroots energy and excitement around this,” said spokesman Zach Marcus.

South Dakotans Decide Healthcare was the only group to turn in its proposed ballot question ahead of Monday’s deadline for initiated constitutional amendments. Initiated measures have a later deadline.

Medicaid is a federal-state health insurance program for low-income people. South Dakota is one of 12 states that has not accepted federal incentives to expand Medicaid eligibility, according to the Kaiser Family Foundation.

Medicaid expansion has only failed once when put before voters, according to Health Affairs. Voters in Maine, Idaho, Utah, Nebraska, Oklahoma and Missouri approved expansion. Montanans rejected expansion — which would have been covered through a tobacco tax increase — but lawmakers later approved it.

 
 

The South Dakota amendment would expand Medicaid to people between 18 and 65 who earn 133% or less of the federal poverty level.

Expansion would make Medicaid available to 42,500 additional South Dakotans in its first year, according to the non-partisan Legislative Research Council.

Studies show Medicaid expansion improves healthcare outcomes while producing economic benefits for recipients, healthcare systems and the overall economy.

Medicaid expansion faces a challenge after the Legislature voted in 2020 to refer a constitutional amendment to the voters during the June 2022 election — before the Medicaid vote in November 2022.

The proposed amendment says any ballot question that raises taxes or spends at least $10 million — such as the Medicaid expansion question — must be approved by 60%, not 50%, of the voters.

Sen. Lee Schoenbeck, R-Watertown, supports the amendment.

 
 

Schoenbeck “acknowledged that his expedited push was motivated by the Medicaid expansion campaign, but argued the vote threshold should apply to all ballot initiatives that levy taxes or spend significant state funds,” according to the Associated Press.

Expansion supporters are concerned about voter turnout in the June election since it’s a primary election without a presidential race. Just 26% of South Dakota voters participated in the June 2018 election compared to 65% in November.

“When we educate voters on why this is going to be helpful for South Dakota, when we educate voters on why this matters and will help them and their families, South Dakota voters respond to this,” Marcus said. “So if we need to get 60% of the vote for this to pass, that’s what we’ll do.”

South Dakotans Decide Healthcare is a statewide ballot question committee that raised $21,639 by the start of 2021, records show. Donors include the AARP, Farmers Union, healthcare organizations and the Fairness Project, a D.C.-based social and economic justice nonprofit.

Proposed initiated amendments that won’t be on the ballot addressed redistricting and elections. Those groups did not turn in petitions Monday, according to the secretary of state. A proposed initiated measure for recreational marijuana and an initiated measure that also addresses Medicaid expansion have a May 3 deadline.

 
 

Clipped from: https://listen.sdpb.org/healthcare/2021-11-08/sd-medicaid-expansion-to-appear-on-2022-election-ballot-pending-validation