Posted on

FWA (NJ)- Opioid Abuse Treatment Facility to Pay $3.15 Million for Kickback Violations, Obstructing Federal Audit, and False Claims Submitted to Government Insurance Programs

MM Curator summary

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

 
 

[MM Curator Summary]: 2 companies worked together to maximize reimbursement for methadone mixing services.

 
 

Clipped from: https://www.justice.gov/usao-nj/pr/opioid-abuse-treatment-facility-pay-315-million-kickback-violations-obstructing-federal

CAMDEN, N.J. – An opioid abuse treatment facility in Camden will pay a total of $3.15 million to resolve criminal and civil claims that it caused kickbacks, obstructed a federal audit, and fraudulently billed Medicaid, Attorney for the United States Vikas Khanna announced today. 

Camden Treatment Associates LLC (CTA) agreed to pay $1.5 million in criminal penalties to resolve allegations that it violated the federal Anti-Kickback Statute and obstructed a Medicaid audit. As part of the resolution, a criminal information was filed on December 2, 2022 in Camden federal court charging CTA with this conduct. CTA entered into a three-year deferred prosecution agreement (DPA) that requires it to abide by certain measures to avoid conviction.  CTA also entered into a civil settlement agreement to pay $1.65 million to the United States to resolve claims that it violated the federal False Claims Act by submitting fraudulent claims to Medicaid. 

Criminal Resolution

According to CTA’s admissions in the DPA:

Between 2009 and 2015, CTA and a second company were owned and managed by related parties. CTA had a kickback relationship with the second company in which CTA ordered all of its methadone mixing services from the second company and paid it more than $125,300 for those services. This arrangement resulted in kickbacks being paid because the second company paid the profits it made on CTA’s orders of methadone mixing to the related parties who owned and managed both companies. As a result, CTA was induced to order services from the second company and to have CTA patients receive treatment using methadone mixed only by that company. CTA received more than $2.78 million from Medicaid for methadone administration services. 

In a separate criminal scheme, CTA obstructed a Medicaid contractor’s 2016 audit of CTA’s claims for payment. CTA submitted falsified materials to the auditor purporting to justify its claims to Medicaid. Specifically, CTA added patient and counselor signatures to patient files, altered names of counselors listed as providing services, added credentials for staff listed as performing services, added sign-off dates for services and, in some instances, submitted entire patient notes to files to justify services rendered. Metadata from CTA’s electronic patient software program revealed that CTA employed these fraudulent means. 

Civil Resolution

The settlement resolves the civil allegations that CTA submitted false claims to Medicaid stemming from the kickback relationship with the methadone mixing company described above. The settlement further resolves allegations that between 2013 and 2016, CTA failed to comply with certain federal and state regulations governing substance abuse treatment facilities.  Specifically, CTA allegedly failed to maintain proper supervision and staffing at its facility. Instead, CTA typically used non-credentialed “counselor interns” to perform services at the facility and did not have sufficient licensed staff to properly supervise the interns. Consequently, CTA’s claims submitted to Medicaid for payment, which were contingent on CTA’s certified compliance with these regulations, were false.

The claims settled by this agreement are allegations only, and there has been no determination of liability.

Compliance Obligations

As part of the DPA, CTA is required to adopt several compliance measures, including:

  • have an effective compliance program, including enhanced compliance policies and annual compliance training regarding federal health care laws;

 
 

  • retain an independent health care compliance consulting firm specializing in substance abuse disorder facilities to conduct a comprehensive review of its compliance program and to make improvement recommendations;

 
 

  • create an independent board of advisors to oversee company compliance relating to federal health care laws;

 
 

  • have a chief compliance officer to oversee compliance-related functions at the company;

 
 

  • annually certify that its compliance program is effective; and

 
 

  • provide written reports to the United States every six months over a three-year period detailing its progress in developing and enhancing its compliance program.

 
 

Attorney for the United States Khanna credited agents of the U.S. Department of Health and Human Services Office of Inspector General, under the direction of Acting Special Agent in Charge Susan Frisco, with the investigation and prosecution of the case. He also thanked the FBI Health Care Fraud Unit Data Analysis Response Team at FBI Headquarters in Washington, D.C., under the direction of Special Agent Greg Heeb; IRS-Criminal Investigation, under the direction of Special Agent in Charge Tammy Tomlins in Newark; and the FBI’s South Jersey Resident Agency, under the direction of Special Agent in Charge Jacqueline Maguire in Philadelphia, for their assistance with the case. 

The criminal case was prosecuted by Acting Chief of the Health Care Fraud Unit Christina O. Hud, Chief of the Opioid Abuse Prevention and Enforcement Unit R. David Walk, Jr., and Assistant U.S. Attorney Diana V. Carrig of the Criminal Division in Camden. The civil case was prosecuted by Assistant U.S. Attorney Kruti Dharia of the Opioid Abuse Prevention and Enforcement Unit and Assistant U.S. Attorney Andrew A. Caffrey III of the District of Massachusetts and formerly of the District of New Jersey.

Posted on

FWA (NC)- Charlotte woman facing federal charges for Medicaid kickback scheme involving at-risk youth

MM Curator summary

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

 
 

[MM Curator Summary]: Bree’Anna Harris et al used foster kids for the billing IDs to steal $4M from NC Medicaid in a drug testing scam.

 
 

Clipped from: https://www.wbtv.com/2022/12/02/charlotte-woman-facing-federal-charges-medicaid-kickback-scheme-involving-at-risk-youth/

Bree’Anna Harris has agreed to plead guilty.

CHARLOTTE, N.C. (WBTV) – A Charlotte woman is facing federal charges for operating what’s described as a Medicaid fraud and kickback scheme in Mecklenburg County.

Newly unsealed court documents show Bree’Anna Harris is accused of stealing personal information from at-risk youth to get illegal kickbacks.

Federal prosecutors say she worked with drug testing labs that submitted more than $16 million in fraudulent claims to NC Medicaid, for which they received more than $4 million in reimbursements. They also say those labs paid more than $1.5 million in illegal kickbacks to Harris and her co-conspirators.

Two of those co-conspirators, Markeutric Stringfellow and Glenn Pair, were each sentenced to roughly six years in prison in 2021.

Court documents show the scheme started in 2016, when Bree’Anna Harris and others started paying college students to go to high schools and community centers to recruit at-risk youth for after-school and youth mentoring programs.

The programs were called Do It 4 The Hood, or D4H and Motivation Enterprises.

According to records, they sought out children who were Medicaid eligible and required them to submit urine for drug testing.

They then worked with laboratories that would pay kickbacks based on the number of drug tests submitted.

In a plea agreement, Harris’ attorney entered what’s called a Factual Basis, where Harris agreed to verify the information behind these charges as facts.

Harris is charged with conspiracy and money laundering conspiracy.

In one example listed, Harris and her co-conspirators sent representatives to Harding University High School in Charlotte to sign up a 16-year-old for Do It 4 The Hood.

Court documents show the child never participated in any programs, but submitted one urine sample after she signed up.

Harris and the others went on to submit samples under that child’s name using that child’s Medicaid information multiple times.

According to the filing, each time it was submitted, tens of thousands of dollars would go back to Harris’ bank account or an account set up under a company she created called BPolloni.

Another example details similar recruiting at West Mecklenburg High School.

WBTV reached out to CMS for a statement, but a spokesperson declined.

“To say that this situation is unfortunate, is an understatement,” Sabrina Gilchrist, the executive director of Right Moves for Youth, told WBTV.

Right Moves for Youth provides small group mentoring to students in classrooms across CMS and beyond.

“It’s essential that we maintain integrity and that they trust us,” Gilchrist said.

She was not familiar with Do It 4 The Hood, but says a scheme like this highlights the vulnerability of our youth and the importance of connecting students with fully vetted programs.

“Don’t lose hope,” she said. “Yes, be cautious about what you’re involving your children in, but know that for every one organization that is not doing what needs to be done, there are hundreds more that are doing great work in this community.”

WBTV reached out to Harris’ attorney for comment, but did not receive a response as of news time.

Posted on

FWA (NY)- Two Individuals Arrested for Pharmacy Health Care Fraud Kickback Schemes

MM Curator summary

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

 
 

[MM Curator Summary]: Huang and Wu paid bribes and kickbacks so they could bill Medicare and Medicaid for unnecessary prescriptions from their NY pharmacies.

 
 

Clipped from: https://www.justice.gov/opa/pr/two-individuals-arrested-pharmacy-health-care-fraud-kickback-schemes

Two New York women were arrested today on criminal charges related to their alleged participation in schemes to pay illegal kickbacks and bribes to Medicare beneficiaries and Medicaid recipients for medically unnecessary prescriptions filled by various pharmacies in New York that resulted in more than $10.5 million in total losses to Medicare and Medicaid. 

“As alleged, the defendants repeatedly paid illegal bribes and kickbacks to be able to fill medically unnecessary prescriptions at pharmacies in Brooklyn and Queens, costing Medicare and Medicaid millions of dollars,” said Assistant Attorney General Kenneth A. Polite, Jr. of the Justice Department’s Criminal Division. “Together with our partners, the department is committed to tackling these illicit relationships that defraud federal health care programs designed to assist some of our most vulnerable citizens.”

According to court documents and proceedings, Hua Huang, 47, of Fresh Meadows, and Huiling Wu, 40, of Brooklyn, were separately charged by complaint for their roles in schemes to defraud Medicare and Medicaid through the submission of claims for prescription drugs that were induced by illegal health care kickbacks and bribes at three pharmacies in Brooklyn and Queens. 

“The payment of kickbacks in Medicare serves only to enrich the complicit parties at the jeopardy of the program’s integrity and the expense of the taxpayers,” said Acting Special Agent in Charge Susan A. Frisco of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “Our agency and law enforcement partners remain strong in our resolution to investigate and pursue individuals who allegedly operate counter to laws protecting federal health care programs.”

Huang was an employee of NY Elm Pharmacy Inc. (NY Elm), located in Flushing. She allegedly referred an individual to a podiatrist who signed prescriptions – including for durable medical equipment and Diclofenac Epolamine – that NY Elm and other entities with common ownership then billed to Medicare and Medicaid. Huang provided the individual with supermarket gift certificates for each prescription brought to the pharmacy and also provided the individual with cash in exchange for the individual’s monthly insurance allowance for over-the-counter products. Federal law enforcement agents executed a search of NY Elm concurrent with Huang’s arrest. 

Wu was an owner and employee of 888 Pharmacy Inc. (888 Pharmacy), located in Brooklyn. She allegedly referred an individual to specific podiatrists who signed prescriptions that 888 Pharmacy then billed to Medicare and Medicaid. Wu provided the individual with store credit for each prescription brought to 888 Pharmacy. She also provided the individual with supermarket gift certificates in exchange for the individual’s monthly insurance allowance for over-the-counter products. Federal law enforcement agents executed a search of 888 Pharmacy concurrent with Wu’s arrest. Two additional pharmacies were searched, one in Brooklyn and one in Hawaii.

“The defendants allegedly participated in schemes designed to defraud Medicare and Medicaid through a coordinated system of kickbacks and bribes for unnecessary prescriptions,” said Assistant Director in Charge Michael J. Driscoll of the FBI York Field Office. “The FBI along with our law enforcement partners remain resolute in our efforts to protect government sponsored health care programs designed to aid members of our community in need. Individuals willing to scam these programs will be held accountable for their actions in the criminal justice system.”

If convicted, Huang and Wu each face a maximum penalty of 10 years in prison. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

The HHS-OIG and FBI New York Regional Offices are investigating the case.

Trial Attorney Patrick J. Campbell and Assistant Chief Miriam Glaser Dauermann of the Criminal Division’s Health Care Fraud Strike Force are prosecuting the case.

The Fraud Section leads the Criminal Division’s efforts to combat health care fraud through the Health Care Fraud Strike Force Program. Since March 2007, this program, comprised of 15 strike forces operating in 24 federal districts, has charged more than 4,200 defendants who collectively have billed the Medicare program for more than $19 billion. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at https://www.justice.gov/criminal-fraud/health-care-fraud-unit.

A criminal complaint is merely an allegation. All defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law.

Posted on

FWA (CA)- Three Health Care Providers Agree to Pay $22.5 Million for Alleged False Claims to California’s Medicaid Program

MM Curator summary

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

 
 

[MM Curator Summary]: Dignity and Tenet used false billings for “enhanced services” to make it look like they were meeting the required MLR floors.

 
 

Clipped from: https://www.justice.gov/opa/pr/three-health-care-providers-agree-pay-225-million-alleged-false-claims-california-s-medicaid

Dignity Health (Dignity), a not-for-profit health system that owns and operates three hospitals and one clinic in Santa Barbara County and San Luis Obispo County, California, and Twin Cities Community Hospital (Twin Cities) and Sierra Vista Regional Medical Center (Sierra Vista), two acute healthcare facility subsidiaries of Tenet Healthcare Corporation operating in San Luis Obispo County, California, have agreed to pay a total of $22.5 million pursuant to two separate settlements to resolve allegations that they violated the federal False Claims Act and the California False Claims Act by causing the submission of false claims to Medi-Cal related to Medicaid Adult Expansion under the Patient Protection and Affordable Care Act (ACA).

Pursuant to the ACA, beginning in January 2014, Medi-Cal was expanded to cover the previously uninsured “Adult Expansion” population – adults between the ages of 19 and 64 without dependent children with annual incomes up to 133% of the federal poverty level. The federal government fully funded the expansion coverage for the first three years of the program. Under contracts with California’s Department of Health Care Services (DHCS), if a California county organized health system (COHS) did not spend at least 85% of the funds it received for the Adult Expansion population on “allowed medical expenses,” the COHS was required to pay back to the state the difference between 85% and what it actually spent. California, in turn, was required to return that amount to the federal government.

The two settlements resolve allegations that Dignity, Twin Cities and Sierra Vista knowingly caused the submission of false claims to Medi-Cal for “Enhanced Services” that Dignity purportedly provided to the Adult Expansion patients of a COHS between Feb. 1, 2015, and June 30, 2016, and that Twin Cities and Sierra Vista purportedly provided to such patients between Jan. 1, 2014, and April 30, 2015. The United States and California alleged that the payments were not “allowed medical expenses” permissible under the contract between DHCS and the COHS; were pre-determined amounts that did not reflect the fair market value of any Enhanced Services provided; and/or the Enhanced Services were duplicative of services already required to be rendered. The United States and California further alleged that the payments were unlawful gifts of public funds in violation of the California Constitution.

As a result of the settlements, Dignity will pay $13.5 million to the United States and $1.5 million to the State of California, and Twin Cities and Sierra Vista will pay $6.75 million to the United States and $750,000 to the State of California.

“When health care providers misuse Medicaid funds, they undermine the integrity of the Medicaid program and waste taxpayer funds,” said Deputy Assistant Attorney General Michael D. Granston of the Justice Department’s Civil Division. “These settlements demonstrate the Department’s continued commitment to prevent providers from inappropriately using Medicaid or other federal health care programs for their own financial gain.”

“These health care providers siphoned critical Medicaid funding for their own gain instead of using it to provide health care services to patients most in need,” said U.S. Attorney Martin Estrada for the Central District of California. “These major settlements demonstrate our commitment to hold accountable health care providers that seek to exploit the Medicaid program and harm the American taxpayer.”

“Every day, Medi-Cal provides support for Californians in need of essential healthcare, and when companies take advantage of this system at the expense of patients, they must be held accountable,” said Attorney General Rob Bonta. “I want to express my gratitude to the U.S. Department of Justice and the U.S. Attorney’s Office in Los Angeles for their extensive efforts throughout the course of this investigation. The California Department of Justice will continue to prosecute corporations that seek to abuse the Medi-Cal system for their own benefit.”

“Bad actors who target and exploit Medicaid for unlawful profit drain the program of much-needed funds intended to support the health and safety of our nation’s individuals who need these resources the most,” stated Special Agent in Charge Timothy B. DeFrancesca of the Department of Health and Human Services. “HHS-OIG readily applies our investigative aptitude to, with our law enforcement partners, pursue providers suspected of defrauding this and other federal health care programs.”

The civil settlements include the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Julio Bordas, the former medical director of the COHS that contracted with Dignity, Twin Cities, and Sierra Vista for the provision of health care services under Medi-Cal. Under the act, a private party can file an action on behalf of the United States and receive a portion of any recovery. The qui tam case is captioned United States and State of California ex rel. Bordas v. Dignity Health and Tenet Healthcare Corporation, et al. (C.D. Cal.). Mr. Bordas will receive $3.9 million as his share of the federal recovery.

The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, the U.S. Attorney’s Office for the Central District of California and the California Department of Justice, with assistance from HHS-OIG and DHCS.

The investigation and resolution of this matter illustrates the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).

Trial Attorneys Mary Beth Hickcox-Howard and Tiffany Ho of the Civil Division’s Commercial Litigation Branch, Fraud Section and Assistant U.S. Attorney Jack D. Ross for the Central District of California handled this case.

The claims resolved by the settlements are allegations only and there has been no determination of liability.

Posted on

MCO – Oklahoma Reissues Medicaid Managed Care RFPs, Proposals Are Due February 8, 2023

MM Curator summary

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

 
 

[MM Curator Summary]: Let’s try this again.

 
 

Clipped from: https://openminds.com/market-intelligence/news/oklahoma-rereleases-medicaid-managed-care-rfps-proposals-are-due-february-8-2023/

On December 1, 2022, the Oklahoma Health Care Authority (OHCA) reissued a request for proposals (RFP 8070000052) to implement Medicaid managed care for a program to be called SoonerSelect and the SoonerSelect Children’s Specialty Program for youth involved with the foster care and/or juvenile justice systems. The contractors will be responsible for medical, behavioral, and pharmacy coverage. All health plans will be required to provide SoonerSelect members with the same health care services currently offered by SoonerCare (the state’s Medicaid program) but may offer extra benefits to help improve the health of its members. The state intends . . .

Restricted Content

You must be an Elite member to view this resource.

Log in | Sign up or learn more about membership options

Tagged As:
Posted on

TX- Non-Medical Home Remediation Study Could Be Game-Changer For Texas Medicaid Patients

MM Curator summary

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

 
 

[MM Curator Summary]: A new report commissioned by the TX legislature supports funding for improving air quality inside asthmatic Medicaid members’ homes.

 
 

Clipped from: https://www.reformaustin.org/healthcare/non-medical-home-remediation-study-could-be-game-changer-for-texas-medicaid-patients/

 
 

Evidence from a recent national study of Medicaid benefits shows that newly implemented programs utilizing preventative products and services to address respiratory and other health issues resulted in improved outcomes for Medicaid enrollees. The result of using these non-medical programs was that patients had fewer emergency room visits, took fewer sick days, and ultimately saved on the cost of their medical care.  

A report prepared by researchers at Episcopal Health Foundation and the Center for Health Care Strategies illustrates how such programs could benefit Medicaid recipients in Texas. 

The report is part of 2022 legislative recommendations from the Texas Value-Based Payment and Quality Improvement Advisory Committee, which urges state lawmakers to expand preventative Medicaid programs that cover non-medical drivers of health. They provide a forum to promote public-private, multi-stakeholder collaboration in support of quality improvement and value-based payment initiatives for Medicaid.

The research that led to the report focused on indoor environmental conditions in which people live and work that influence their health and wellness in non-medical programs covered by Medicaid. 

They focused on these three areas:

  1. Air quality issues that trigger asthma attacks in homes and offices
  2. How the lack of access to affordable healthy food contributes to overall health issues
  3. And the maintaining of housing quality to aid in positive health outcomes

An example cited in the report describes how an asthma remediation program identified mold in a 12-year-old girl’s home as a primary trigger of her asthma attacks. So, the program paid to remove and replace moldy carpeting. 

The results were profound — she suffered fewer asthma attacks, and no absences from school — and a better ability to keep her asthma under control. 

According to the Mayo Clinic, many patients suffer from allergic asthma, which not only includes reactions to typical triggers like pollen, dust mites, and pet dander but also mold and mildew, which the non-medical remediation and other air filtration machines greatly reduce.

“This is a game changer that could improve the health and wellness of Texans most in need in an entirely new way,” Barnes said. “We have to change the way we think about health and how we pay for it. The report shows how things could change for the better in Texas,” said Dr. Ann Barnes, a physician, and CEO of Episcopal Health Foundation. 

“As a philanthropy, we’ve funded asthma remediation projects and food as medicine programs that have shown great health improvements, but they were limited to patients of a single clinic or area. This report describes a great opportunity for Medicaid in Texas to cover these non-medical programs on a much larger scale across the state with sustainable funding,” Barnes added.

“Medical care makes up about 20% of what determines a person’s health, yet right now we spend almost all health dollars – including Medicaid – treating conditions medically and not preventing disease outside the exam room,” she continued.

The Centers for Disease Control reviews of similar nationwide asthma remediation showed that for every $1 invested, projects returned anywhere from $5 to $14 in overall savings. 

The report also found that the Center for Medicaid and CHIP Services has approved similar non-medical programs in other states, and it provides new guidance that will outline how states like Texas can use “in lieu of services” authority to pay for programs that cover non-medical approaches to health instead of only covering traditional medical care.  

According to AsthmaMD.com, 11 Americans die from asthma every day in the U.S., resulting in more than 4,000 deaths due to asthma each year, many of which are avoidable with proper treatment and care. 

And the non-medical care advocated by the study could greatly impact this number if adopted more broadly.

In addition, asthma is indicated as a contributing factor for nearly 7,000 other medical emergency deaths each year. 

And the cost of treating asthma is a staggering $18 billion per year, while direct costs account for nearly $10 billion, with hospitalizations being the single largest portion, and indirect costs are $8 billion in lost earnings due to illness or death.

For adults, asthma is the fourth leading cause of work absenteeism resulting in nearly 15 million missed or lost or non-productive work days each year. 

And, and chronic disease is the top reason for school absences among children ages 5 to 17, which costs the nation’s students an annual loss of more than 14 million school days per year, roughly eight days per year. It results in more hospitalizations than any other childhood disease

And these figures do not include the impact on the parents of children with asthma, who also suffer lost work days when their children are forced to stay home due to attacks and other respiratory symptoms. 

Other successful non-medical programs cited in the report include medically-tailored meals for those with diabetes and other chronic illnesses, fresh produce prescriptions for low-income families, and health-supporting grocery projects for seniors and pregnant women. 

These programs show health improvements such as fewer hospital visits and sick days, and also reduced Medicaid spending on medical care by an average of $220 a month per person

The report found similar evidence of health and financial benefits in housing-related programs that assist people in getting apartments after leaving mental health facilities. Programs that provide financial assistance for making homes accessible for disabilities, helping people learn how to maintain their housing, and negotiations with landlords also greatly benefit recipients.

Along with showing the benefits of these non-medical programs, the report outlines specific ways that Medicaid, Texas Health and Human Services, and Medicaid-managed care organizations could implement the interventions.  

Posted on

DeSantis urged to release plan for Florida’s looming Medicaid crisis

MM Curator summary

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

 
 

[MM Curator Summary]: Ronnie is being asked what his plan is.

 
 

Clipped from: https://www.tampabay.com/news/health/2022/12/08/desantis-medicaid-looming-crisis-florida-children-uninsured-covid-19-pandemic/

 
 

Hundreds of thousands of Florida’s poorest children could lose health insurance next year when the federal government is expected to end expanded Medicaid coverage put in place during the COVID-19 pandemic.

The looming crisis has prompted a coalition of 40 Florida nonprofits, health organizations and child advocacy groups to sign a letter sent Wednesday to Gov. Ron DeSantis, urging the state to release its plans for managing the transition.

The number of Floridians relying on the federal program that provides medical coverage for individuals with disabilities and very low-income families and children rose by 1.7 million during the public health emergency to 5.5 million, roughly one quarter of the state’s population.

Related: Medicaid expansion in Florida? South Dakota vote may show the way.

That was largely the result of the federal government paying states additional money to keep people covered through the federal program during the pandemic even though they were no longer eligible, according to a study by the Georgetown University Center for Children and Families.

But that money will dry up when the federal government ends the public health emergency declaration, possibly as soon as April.

Florida has yet to publish a plan on how it will deal with Medicaid recipients who are no longer eligible and at risk of losing health coverage. The state also faces the burden of having to recertify the eligibility of its 5.5 million recipients, a potential logjam that could force it to hire hundreds of additional workers.

“The public health emergency unwind will mean a tsunami of coverage loss,” said Alison Yeager, executive director of the Florida Health Justice Project. “We know who’s going to be hit the hardest by this loss — parents, children and young adults, postpartum women and the elderly and disabled.”

Florida Department of Children and Families officials said in a statement released Wednesday that they are working with the Agency for Health Care Administration, community partners and other state agencies to begin an effort to reach out to current Medicaid enrollees, emphasizing the importance of providing current contact information so they can be reached.

“To those groups creating unnecessary panic by insinuating that Florida is not prepared, we can assure you that the department is prepared,” the statement says. “There is a plan in place.”

But Florida has not published its plan as states like North Carolina, Utah and Oklahoma have already done.

The coalition’s letter calls for the state to ensure that qualified Floridians maintain their Medicaid coverage and those who are no longer eligible receive help finding other health insurance such as the marketplace options offered under the Affordable Care Act or KidCare, a subsidized insurance program for children.

It also states Florida should follow the recommendation from the Centers for Medicare & Medicaid Services that states stagger a return to pre-pandemic Medicaid operation over a 12-month period.

 
 

Related: Why millions on Medicaid are at risk of losing coverage

Nationwide, the Georgetown study warns that 6.7 million children are at risk of losing coverage, potentially more than doubling the nation’s uninsured rate for children if states do not take steps to keep eligible ones enrolled during the transition.

Florida residents currently covered by Medicaid may be more at risk from the end of the public health emergency than most.

Florida is among just 11 states to not take advantage of an Affordable Care Act provision that provides additional money to expand Medicaid eligibility. Doing so would would make an estimated 900,000 Floridians eligible, or more than 4% of the state’s population. That includes more than 400,000 who earn below the federal poverty level, according to the Florida Policy Institute, a Tallahassee nonprofit.

Staff writer Romy Ellenbogen contributed to this report.

Posted on

Up to 18 million people could lose Medicaid coverage after COVID-19 PHE

MM Curator summary

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

 
 

[MM Curator Summary]: A new sky is falling number hides the punchline that 10M will go back to getting insurance from their employer, and more than 1M will get heavily-subsidized marketplace coverage. And that all of this is due to the fact that Medicaid will be returning to normal eligibility rules.

 
 

Clipped from: https://www.healthcarefinancenews.com/news/18-million-people-could-lose-medicaid-coverage-after-covid-19-phe

Findings suggest the result could see the largest changes in coverage since the ACA came into force more than a decade ago.

 
 

Photo: Image Source/Getty Images

Upwards of 18 million people could lose Medicaid coverage, and four million people could become uninsured entirely when the COVID-19 public health emergency expires next year, according to a recently published analysis from the Urban Institute.

This could result in the biggest changes in coverage since the Affordable Care Act was implemented more than a decade ago, findings suggested.

The most recent data shows that enrollment jumped by more than 18 million people from February 2020 to June 2022. This increased enrollment largely owes to the continuous coverage requirement of the Families First Coronavirus Response Act, which has prevented state Medicaid agencies from disenrolling people during the PHE unless they specifically request it.

Using the latest available administrative data on Medicaid enrollment, recent household survey data on health coverage, and the Urban Institute’s Health Insurance Policy Simulation Model, analysts estimated that about 3.2 million children are estimated to transition from Medicaid to separate Children’s Health Insurance Programs, so total Medicaid and CHIP enrollment will decline by 14.8 million people.

About 3.8 million people will become uninsured, data showed, while about 9.5 million people will either newly enroll in employer-sponsored insurance after losing Medicaid, or transition to employer-sponsored insurance as their only source of coverage after being enrolled in both employer-sponsored insurance and Medicaid sometime during the PHE.

On top of that, more than one million people will enroll in the nongroup market, most of whom will be eligible for premium tax credits in the marketplace.

Further extensions of the PHE are possible, according to the Urban Institute. If it’s extended for an additional 90 days, the number of people losing Medicaid will likely rise to nearly 19 million.

WHAT’S THE IMPACT?

The largest share of people losing Medicaid, 9.5 million, will end up with employer-sponsored insurance (ESI), the report found. Nationally, unemployment has nearly returned to pre-pandemic levels, and many people will lose Medicaid eligibility precisely because they gained new employment during the PHE. An unknown number of those transitioning from Medicaid to ESI only was enrolled in both types of coverage during the PHE; the number of people newly enrolling in ESI after the PHE will likely be considerably lower than 9.5 million.

The end of the PHE is still uncertain. If it is extended for 90 more days, about one million more people will lose Medicaid after its expiration. The Biden administration has promised to give 60 days’ notice before the end of the PHE but has resisted requests by many states for more notice.

While nearly four million people are likely to become uninsured, people transitioning from Medicaid to private coverage will pay more in premiums and out-of-pocket health costs. It is possible that more people losing Medicaid, particularly those without access to ESI, may experience a temporary interruption in health coverage before enrolling in alternative coverage.

State policy decisions during the transition following the PHE expiration will affect how many people lose coverage, how rapidly they lose coverage, and how many people will enroll in other coverage, according to the Urban Institute.

Medicaid enrollment during the PHE may have other lasting effects, such as raising awareness of churning in health insurance coverage, and possibly changing perceptions of Medicaid, authors said. The experience may also inform the debate around other issues related to churn and continuity of coverage, such as 12-month continuous eligibility in Medicaid and better coordination between Medicaid and the marketplaces.

THE LARGER TREND

The public health emergency will be extended past its current deadline of January 11. The new deadline will be in April if it’s extended for another 90 days.

The PHE keeps waivers and policies in place for Medicaid coverage, telehealth coverage, and add-on payments to hospitals and physicians. Telehealth waivers will expire 151 days after the end of PHE.
 

Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com

Posted on

19 States Must Align Medicaid Vaccine Coverage Policies with IRA

MM Curator summary

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

 
 

[MM Curator Summary]: Most of the states that will need to cough up more for vaxxes are non-expansion states.

 
 

Clipped from: https://healthpayerintelligence.com/news/19-states-must-change-medicaid-vaccine-coverage-policies-to-comply-with-ira

Both fee-for-service programs and Medicaid managed care plans will have to review their Medicaid vaccine coverage policies.

 
 

Source: Getty Images

 
 

By Kelsey Waddill

December 06, 2022 – Almost two-fifths of US states—particularly those that have avoided Medicaid expansion—will need to change their Medicaid vaccine coverage policies in order to align with the Inflation Reduction Act, an Avalere white paper found.

The Inflation Reduction Act passed through Congress and received the presidential signature on August 16, 2022.

The law requires states to cover all recommended vaccines for adult Medicaid enrollees with zero cost-sharing by the beginning of October 2023. Coverage will be similar to commercial market requirements.

Avalere examined the difference between vaccine coverage pre-implementation of the Inflation Reduction Act and post-implementation. The white paper received funding but no editorial input from Pfizer.

The researchers used publicly available data to observe changes for five recommended vaccines: influenza, tetanus/diptheria/acellular pertussis (Tdap), human papillomavirus (HPV), pneumococcal polysaccharide vaccine (PPSV23), and pneumococcal conjugate vaccine (PCV13). Avalere conducted this research from April through December 2021.

There were 11 fee-for-service programs and 6 Medicaid managed care plans that did not cover at least one of the recommended vaccines. The researchers noted that states that did not adopt Medicaid expansion were more likely not to cover one or more of the recommended vaccines.

States were most likely not to cover vaccines that involved risk-based or shared clinical decision-making. Across the states that had coverage gaps, eight fee-for-service and Medicaid managed care plans did not cover the HPV vaccine. Six plans—five fee-for-service programs and one Medicaid managed care plan—did not cover the PCV13 vaccine. Every plan covered the influenza vaccine.

Additionally, five fee-for-service programs and one Medicaid managed care plan covered a vaccine but required cost-sharing, which could range from $0.65 to $4.00.

These findings are critical for the 19 states that need to adjust their Medicaid coverage policies or review Medicaid managed care plans’ coverage to align with the Inflation Reduction Act.

“Although IRA requirements will not take effect until October 1, 2023, states that do not already cover all ACIP-recommended vaccines without cost sharing for their full adult Medicaid populations will need to act quickly and modify coverage policies in the coming months to meet the IRA timeline,” Avalere researchers noted.

Avalere anticipated that CMS would offer guidance to help Medicaid programs and stakeholders understand their obligations.

The researchers warned that the law could be pursued in a way that increases care disparities. The Inflation Reduction Act did not fix low provider reimbursement rates for vaccinations that disincentivize this form of preventive care, and the law may not reimburse pharmacists and set up billing barriers.

“These barriers may also extend to safety net providers which disproportionally serve vulnerable individuals and families, like Federally Qualified Health Centers. These barriers could lead to increased health disparities for patients. Some Medicaid-related vaccine topics are likely to be addressed in forthcoming implementation guidance; interested stakeholders should consider whether and how to engage CMS to shape that guidance,” Avalere recommended.

During the coronavirus pandemic, health equity in coronavirus vaccine distribution was a critical issue, but the challenges proved to have a presence beyond the coronavirus vaccine as well.

 
 

Posted on

MCOS- Centene to pay Oregon $17M in latest Medicaid overbilling settlement

MM Curator summary

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

 
 

[MM Curator Summary]: Rinse, repeat.

 
 

Clipped from: https://www.beckerspayer.com/payer/centene-to-pay-oregon-17m-in-latest-medicaid-overbilling-settlement.html

Centene will pay Oregon $17 million to settle allegations the payer overcharged the state’s Medicaid program for pharmaceutical services, the Oregon Justice Department said Dec. 6. 

The payer has settled with several other states over similar allegations, including Arkansas, Illinois, Kansas, Massachusetts, Mississippi, New Hampshire, New Mexico, Ohio, Texas and Washington. 

According to Kaiser Health News, Centene has paid settlements to other states not disclosed. 

According to a 2021 Securities and Exchange Commission report, Centene created a $1.25 billion reserve to pay for these settlements.