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U.S. Supreme Court To Hear Florida Medicaid Dispute

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SCOTUS will weigh in on legality of Medicaid agencies receiving shares in legal settlements to cover member care.


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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The Supreme Court will take up a legal battle about how much money Florida’s Medicaid program should be able to recoup from a legal settlement stemming from an accident left a girl in a vegetative state.

After getting off a Lee County school bus in November 2008, Gianinna Gallardo was struck by a truck and suffered catastrophic injuries.

Now, more than a decade later, her case could lead to a U.S. Supreme Court decision that will affect Medicaid programs across the country.

The Supreme Court on Friday said it will take up a legal battle about how much money Florida’s Medicaid program should be able to recoup from a legal settlement that Gallardo’s parents reached after the accident left her in a vegetative state.

Attorneys for Gallardo’s parents and the state Agency for Health Care Administration asked the Supreme Court to resolve the issue because of conflicting court decisions about a reimbursement issue involving Florida’s Medicaid program — and programs in other states.

“The uncertainty on the issue affects millions of Americans who rely on Medicaid for health care coverage,” attorney’s for the parents, Walter Gallardo and Pilar Vassallo, wrote in a March petition. “A beneficiary’s federal Medicaid rights should not depend on whether she lives in Idaho, West Virginia or Massachusetts. But until this (Supreme) Court resolves the question presented, identically situated Medicaid beneficiaries will receive different treatment under federal law.”

Medicaid, which is jointly funded by the federal and state governments, is operated through a maze of laws. But states are required to seek reimbursements of Medicaid payments for medical care if, in situations such as the Gallardo case, lawsuits result in settlements.

Documents filed by both sides show that the Agency for Health Care Administration, which runs Florida’s Medicaid program, paid $862,688 for Gallardo’s care after she was injured. Gallardo’s parents filed a lawsuit against the truck’s owner and driver and the Lee County School Board and ultimately reached an $800,000 settlement.

The petition filed in March at the Supreme Court said the settlement applied to claims for past medical expenses, future medical expenses, lost earnings and other damages. Under a formula used by the state Medicaid program, the Agency for Health Care Administration said it was entitled to $300,000 of the settlement — including a portion of the settlement that was for Gallardo’s future medical expenses.

The legal battle centers on whether the agency is only entitled to recover money in the settlement representing past medical expenses — or whether it can also tap into money in the settlement for future medical expenses.

U.S. District Judge Mark Walker in 2017 ruled in favor of the parents’ position that the agency should only be able to recover settlement money representing past medical expenses. But a panel of the 11th U.S. Circuit Court of Appeals overturned Walker’s decision and sided with the Agency for Health Care Administration.

Meanwhile, in a separate case, the Florida Supreme Court ruled that the Agency for Health Care Administration was only entitled to recover money in a settlement for past medical expenses — creating a conflict between the state Supreme Court and the federal appeals court.

Describing the legal conundrum, attorneys for the Agency for Health Care Administration wrote in a June 1 document that under the appeals court decision, the state “has a duty to recover payments for future care. But if it fulfills that duty, it defies the Florida Supreme Court’s ruling.”

In arguing that the Supreme Court should come to the same conclusion as the appeals court, the agency’s attorneys pointed to potential major financial ramifications.

“First, states, the federal government, and Medicaid recipients have a substantial interest in state Medicaid agencies obtaining full reimbursement from liable third parties,” the June 1 document said. “Ensuring that Medicaid is a payer of last resort is critical not only to state and federal budgets but also to Medicaid’s longevity.”

But in his 2017 ruling, Walker wrote that Gallardo was 13 years old at the time of the accident and that her parents were living a “nightmare” as they continued battling with the agency.

Attorneys for Gallardo’s parents wrote in the March petition that the Supreme Court should overturn the appeals court decision. But the attorneys also pointed to a need for a final resolution of the issues in the case.

“Every state has passed some type of third-party recovery statute to comply with the mandates of the (federal) Medicaid Act,” the petition said. “Unless and until this (Supreme) Court resolves the conflict, the states and their legislatures cannot know what federal law requires of them. There is an urgent need for this court’s guidance on the question presented.”


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Costs Watched as Medicaid Managed Care Begins in N. Carolina

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After 6 years, the North Carolina managed care implementation has finally arrived.


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.



After six years of preparations and delays, most of North Carolina’s Medicaid recipients switched over to managed care Thursday with its developers hopeful the changes will mean improved health outcomes and controlled costs.

“It’s been a long time coming,” said Rep. Donny Lambeth, a Forsyth County Republican who helped pass the managed care law in 2015 and other legislative adjustments, some finalized just this week.

Four statewide health plans and one multi-regional plan will now handle care for roughly 1.6 million of the nearly 2.5 million consumers covered by Medicaid — mostly poor children and older adults — as well as from another program for children in low- and middle-income families. Another smaller plan for Eastern Band of Cherokee Indians members also has started.

More Medicaid consumers, particularly those with substance abuse issues, developmental disabilities and severe mental health troubles, shift to similar managed care coverage in July 2022.

“It’s the biggest change to our program in its history,” said Health and Human Services Secretary Mandy Cohen, whose agency awarded the five-year plan contracts — expected to cost $6 billion annually — and carries out the law.

The Medicaid overhaul initially was supposed to start in 2018 or 2019. But it got delayed as Republican legislators and Democratic Gov. Roy Cooper were knotted in a budget impasse centered on whether to expand Medicaid to cover hundreds of thousands of adults through the federal Affordable Care Act. Expansion still has not happened.

As the largest state by population yet to switch to managed care, North Carolina’s foray into privatized Medicaid will be watched closely by other states and Medicaid experts. In mid-2018, almost 70% of the nation’s Medicaid enrollees were participating in managed care plans in nearly 40 states, or about 54 million people, according to Kaiser Family Foundation data. Enrollment

For decades, Medicaid has used a traditional fee-for-service process, whereby providers bill the state for each test or procedure. Now health plans will receive monthly payments for each patient enrolled. For example, health plans initially will receive on average $170 monthly for each covered child and $420 for each adult, according to Department of Health and Human Services data.

The plans’ financial gains or losses will depend on what’s left over after medical expenses and other costs. Healthier patients could mean monetary bonuses, with financial penalties possible for poorer outcomes.

Patients have signed up for a health plan — some operated by Blue Cross and Blue Shield and United Healthcare and others with less familiar names like WellCare and AmeriHealth Caritas — or have been enrolled automatically in one. Medical providers have entered into contracts with plans and consumers are being told what to expect.

“We feel very good at this point,” state Medicaid director Dave Richard said. “There will be things that don’t work anytime you have something this big, but I think we’re as prepared as possible come July 1.”

Managed care was embraced by former Republican Gov. Pat McCrory after Medicaid cost overruns in the late 2000s and early 2010s.

Initially, Medicaid spending under managed care will increase, with new administrative and underwriting expenses and more consumers still covered in the COVID-19 pandemic. Medicaid spending this coming year is projected at $18.3 billion, with 70% paid through federal funds and the rest from the state and other sources. Medical service spending is projected to decline as managed care matures.

Lambeth, a former hospital executive, is hopeful eliminating medical redundancies will curb overall costs. Keeping costs under control will require significant DHHS and legislative oversight of the health plans, said Hemi Tewarson, executive director of the National Academy for State Health Policy.

State officials must “really push them to do all the things that they should be doing or could be doing,” Tewarson said in an interview.

Tewarson said she’s anxious to see how North Carolina conducts pilot projects that will target further ways to address the non-medical needs of Medicaid patients such as homelessness, transportation and access to healthy foods.

Lambeth said he’s concerned some providers are not ready to handle the paperwork that managed care requires. Other small-town doctors or personal care agencies may not have entered contracts with multiple health plans, meaning some patients may learn they can’t use those providers.

Michelle White, a director of Cone Health’s HomeCare Providers, covering four central counties, said consumers who have been struggling during the pandemic may not realize how managed care could affect them.

“What’s going to happen July 1 and the days and the weeks to follow will be somewhat of an awakening as people start to understand that there have been changes with their Medicaid,” said White, whose agency will serve about 100 Medicaid managed care patients daily. “We’re going to have work to do as an industry to really help them get settled into the right plan, the plan that’s going to meet their needs.”


Photo via Robert Willett/The News & Observer and the Associated Press.

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Oregon Will Start Purging 200,000 From Medicaid Rolls Next Summer

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Oregon HHS has begun planning efforts to disenroll members no longer eligible once the COVID PHE ends.


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.


A temporary federal law that is allowing people to stay on Medicaid even if their income exceeds traditional limits will expire.

Oregon expects to boot roughly 200,000 people from its Medicaid rolls next year, once the pandemic is officially deemed over and people who are ineligible for the insurance under traditional – but temporarily waived — restrictions are re-evaluated and dropped, the latest state estimates show.


Under a March 2020 federal emergency law, Medicaid members in most states, including Oregon, were allowed to stay on the taxpayer-funded health care insurance even if their incomes rose above federal limits or they otherwise became ineligible. That pandemic-driven protection is expected to stay in place until January 2022.


The state is already working on a process, to be implemented next spring, for re-assessing members of the Oregon Health Plan – the state’s version of Medicaid — and bumping those who exceed the income limits.


After the anticipated January 2022 expiration of the emergency law, the Oregon Health Authority will take about four months to reformat its Medicaid eligibility system back to the pre-pandemic rules, and need a further two-three months to determine which members no longer qualify for the insurance, according to the latest forecast. By July 31, 2022, the agency expects to begin dropping people who are no longer eligible.


The vast majority of those to be dropped will likely be adults, but thousands of children whose family incomes make them no longer eligible for Medicaid will also be dropped, according to the forecast.


The process, required by federal law, will be a massive and rapid shake-up for a system that has proven to be a vital safety net during the pandemic. It picked up tens of thousands of Oregonians who abruptly lost their jobs and their accompanying health insurance. Now at 1.31 million, enrollment is up 22% since the start of the pandemic.


The forecast shows Oregon’s Medicaid rolls growing to 1.4 million by next summer, then dropping by about 200,000 as the evaluation process removes people.


“After the (public health emergency) is over, it will take some time to finish processing the (Medicaid) applications from during the (public health emergency), make changes to the eligibility system, and then start processing applications and redeterminations under the (old) rules. As cases are reviewed, we expect a sharp initial drop,” said Lori Coyner, who was Oregon’s Medicaid director until the end of last month, when she switched to a new state Medicaid role.


But even after ineligible people are removed from Oregon’s Medicaid rolls, the plan will cover 1.2 million people, which is over 100,000 more than before the pandemic, according to the forecast. That’s due to a number of factors. For example, many Oregonians still have not regained their jobs and commercial health insurance, and unemployment remains high compared to before the pandemic. Plus, people who for the first time signed up for Medicaid during the pandemic now realize what a good financial deal it is and may try to get back on it. The insurance is essentially free to the member, with no premiums, deductibles or copays.


“Once people are familiar with Medicaid, even if they leave, they are more likely to return at a later date if they find themselves eligible once more,” Coyner said.


Federal Law Promises Extra Money

In Oregon, as in many states, Medicaid enrollment ballooned during the pandemic. The main reason is a federal law – passed by Congress in March 2020 and signed into law by then-President Donald Trump — that gives states extra Medicaid money for the duration of the pandemic on the condition that they let members stay on the insurance even if their income tops traditional federally-imposed limits.


Huge amounts of money are at issue. It costs the state, in combined federal and state money, about $6,400 to cover a Medicaid member for a year. Typically the federal government pays about 75%, and the state the rest. That’s about $7 billion a year in federal money, plus, under the March 2020 law, an estimated $307 million extra in 2020 and $580 million extra this calendar year. State officials have said the extra federal money has been enough so far to cover the extra enrollment, but that’s less certain for the coming 12 months.Under the temporary law, Oregonians can join Medicaid based on “self-attestation” of income, and the state does not check whether the figures are accurate. Also, even if members are found ineligible, for example because income exceeded the limits, they are kept in the program.


Nationally, Medicaid rolls swelled to 80.5 million earlier this year, up from 71.3 million in February 2020, as the pandemic was beginning, according to Kaiser Health News.


The Families First Coronavirus Response Act gives an extra 6.2% in Medicaid money to states in return for them not purging people from the rolls, unless members move out of state, choose to drop the coverage, die or are incarcerated.

Before the pandemic, annual Medicaid enrollment in Oregon fluctuated between 1.07 million and 1.1 million, rising and falling as newly eligible people joined, and people were dropped because higher income or other changed circumstances made them ineligible.


But now, the departures from Medicaid have dwindled to a trickle, while the number of new entries each month has held steady.

“In a nutshell, the growth in the (Oregon) Medicaid caseload is coming from a 75% decrease in exits every month, not from large numbers of new people entering Medicaid,” Coyner said. “With exits down substantially, and new enters essentially flat or down slightly, the caseload grows every month.”


Enrollment Growth Will Continue Into 2022

The growth has taken place in all types of Medicaid: Adult membership under the Affordable Care Act has grown from 350,000 pre-pandemic to over 500,000 now, and is forecast to reach about 600,000 by July 2022. At that point, about 150,000 people will be purged from the rolls, dropping the tally to 450,000 by late 2022, the forecast says.


Children’s Medicaid enrollment has grown steadily from a pre-pandemic level of 300,000, and is projected to hit 340,000 by July 2022. Then, as the rolls are purged, it is forecast to drop back to pre-pandemic levels. Separately, enrollment in the Medicaid CHIP – Children’s Health Insurance Program – will reach 110,000 by next July, up from 90,000 pre-pandemic, then drop back to pre-pandemic levels with the purging.


Just how the funding will pan out next year is unclear. State officials expect the extra federal money to run through the end of next March. At some point next year, the funding system will return to its pre-pandemic funding model. Whether or when Medicaid enrollment in Oregon will drop to its pre-pandemic level is anyone’s guess.


Oregon economists predict a robust recovery, which may be a harbinger of fewer people on Medicaid.

“Hopefully, a strong economy and maybe an increase in wages will decrease the number of Oregonians below or near the poverty line. If that happens, then, in the long run, the number of people on Medicaid will also decline, taking any potential population growth into account,” Coyner said.


But that may not happen for quite a while.

Pre-pandemic, in February 2020, Oregon’s economy was the strongest it had been in four decades, with a 3.3% jobless rate and 69,000 unemployed. In the throes of the pandemic, the jobless rate peaked at 13%, with 292,000 jobless. Now it is down to 5.9%, with 118,000 jobless, according to the Oregon Employment Department.”Total employment in Oregon will surpass pre-pandemic levels in late 2022 with the unemployment rate returning to 4 percent in 2023,” says the latest forecast from the Oregon Office of Economic Analysis.



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Medicaid in NJ to cover undocumented kids

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The bill that would cover kids who don’t have citizenship documentation was modified to not give politicians running for re-election issues.


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.


Gov. Phil Murphy announced his intention to expand New Jersey’s Medicaid program to cover the state’s nearly 90,000 uninsured childrenincluding those who are undocumented — as part of his budget address in February. He highlighted his “cover all kids” pledge again in late March at an event in Passaic with U.S. Rep. Bill Pascrell (D-9th) and a half-dozen state legislators and administration staff.

Last Tuesday, Murphy privately signed a revised “cover all kids” bill — which eliminates waiting periods and out-of-pocket costs for most families and provides $20 million to help cover the state’s additional costs — with no statement or fanfare. It was one of eight spending measures that officials said needed his OK before he approved the state’s $46.4 billion spending plan for the 2022 fiscal year, which began Thursday.

While the changes to Medicaid, also known as NJ FamilyCare, will benefit tens of thousands of low-income families, it is not clear how much — or how soon — it will truly help immigrant children. Advocates estimate there are at least 53,000 uninsured kids in New Jersey who qualify for the program economically but are not enrolled, and more than 18,000 of those children are undocumented. Advocates say the number of undocumented children could be much higher because no one is exactly sure how many are living in New Jersey.

No reference to undocumented kids

Unlike previous versions of the bill, the one passed almost unanimously by the Senate and Assembly and signed by Murphy does not mention undocumented or immigrant children. According to several people involved with the process, the language was changed so that lawmakers — who are all up for reelection this year, along with the governor — did not have to be on record voting for a measure that uses public dollars to fund health insurance for undocumented individuals.


Longtime legislative champions of expanding the Medicaid program to include undocumented youngsters said in a statement that the COVID-19 pandemic underscored the importance of insurance coverage and access to proper medical care. They also suggested their work was not done.

“We must keep working towards our goal of providing New Jersey families with quality, affordable health insurance if we want as many residents as possible to receive the care they both need and deserve,” read the statement from Sen. Joe Vitale (D-Middlesex) and Assembly Democrats Yvonne Lopez (Middlesex), Dan Benson (Mercer) and Gordon Johnson (Bergen). “Eliminating wait times and premiums while further promoting this important program will help us achieve this goal.”

Cumbersome process

Some stakeholders said that parents will now be able to enroll children who lack legal residency, but the new process is cumbersome for both the family and state regulators. Under the changes, parents of undocumented children would need to sign them up through a revised FamilyCare Advantage program, in which they are required to pay the full cost of the coverage, and then could apply for a “hardship waiver” to excuse these expenses after they were enrolled.

Administration officials said providing health insurance to undocumented children remains a priority for Murphy and noted the plan was proposed in two phases, with the second — focused on immigrant youngsters — still pending. Participation in Medicaid, which now covers nearly 2 million New Jerseyans, grew 17% between March 2020 and March 2021, according to state figures.

The state Department of Human Services (DHS), which oversees Medicaid, did not issue a formal statement on Murphy’s signing of the bill, but acting Commissioner Sarah Adelman added her support on Twitter. Adelman, who previously worked with the New Jersey Association of Health Plans, praised the 15-year effort of sponsors and advocates and noted “We will #CoverAllKids.”

‘This new expansion of NJ FamilyCare puts New Jersey one big step closer to universal coverage for all, starting with our kids.’

In a written response to questions from nonpartisan legislative staff about spending on Medicaid, DHS officials said this spring that state officials will begin planning how to include undocumented children this year, but coverage for these families may not be available until the start of fiscal year 2023 next summer. The department also estimated the cost of this year’s changes could reach nearly $70 million, far more than the $20 million provided in the new budget.

No immediate access?

The DHS timeline squares with the expectations of Maura Collinsgru, the health care policy leader at New Jersey Citizen Action, one of several groups that have long fought to expand Medicaid access, especially for children. A plan unveiled in 2018 by New Jersey Policy Perspective (NJPP), another advocate for expansion, outlined mechanisms similar to those Murphy approved and predicted the changes would cost less than $70 million annually.


“This new expansion of NJ FamilyCare puts New Jersey one big step closer to universal coverage for all, starting with our kids,” something now in place in seven other states, Collinsgru said. “If the pandemic taught us anything, it is having access to health care is essential to our health and economic well-being. By increasing access to coverage, New Jersey can help close the health and wealth gaps that persist in communities of color.”

The new law (S-3798) eliminates a 90-day waiting period for some children to access Medicaid and ends the use of premiums or copays for families who earn less than 350% of the federal poverty level, or less than $6,400 a month for a family of three. It also calls for state officials to enhance and coordinate public outreach around Medicaid and the state’s health insurance exchange, which sells subsidized commercial plans to those who earn too much to qualify for Medicaid but aren’t covered through work.

How it would work

The changes also restart the FamilyCare Advantage program, which allows those who earn more than 350% of the poverty level to purchase this state coverage for their children at cost. This part of Medicaid, which had been unfunded for years, could be used to insure undocumented children, some stakeholders said, but the cost could also be prohibitive for some immigrant families. A “hardship waiver” process was also added to the law, but applying for this option requires additional time and paperwork.

While it does not mention undocumented children in the way previous versions of the legislation did, the law Murphy signed clearly notes: “No child who applies for enrollment in the program who otherwise meets the eligibility criteria for enrollment shall be denied immediate enrollment for any reason.”

That brings hope to many of those who have long advocated to provide undocumented children better insurance options. “All kids in New Jersey deserve access to affordable, high-quality health coverage,” said Brittany Holom-Trundy, an NJPP senior policy analyst. She praised the state for making “an important investment in the state’s future and the long-term health of New Jersey families,” and said she looks forward to working with the administration and health care leaders on “building the best health care system possible for all children in the Garden State.”

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IL- Pritzker signs bill making healthcare more affordable, accessible for Illinoisans on Medicaid

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IL will pay for members to stay on Medicaid even after the federal PHE ends, and will add new funding for multiple new initiatives.



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.



DOWNERS GROVE, Ill. (WSIL) — Governor JB Pritzker signed legislation Tuesday that aims to make healthcare more accessible and affordable for Illinois residents that rely on the state’s Medicaid system.

Senate Bill 2294 makes multiple changes to Illinois’ Medicaid system including expansion of the program to cover new services and the implementation of new Medicaid-adjacent services by the Illinois Department of Health and Family Services (HFS) and other agencies.

The legislation provides:

  • Continued Medicaid eligibility through the COVID-19 public health emergency and up to 12 months after it expires regardless of whether federally required or funded
  • Medicaid coverage for whole-health programs
  • Veteran support specialists so they receive care that recognizes their unique struggles
  • Individual and group programs for those seeking help ending their tobacco addiction
  • An expansion of mental health resources through the addition of clinical professional counselors and the creation of a comprehensive statewide behavioral health strategy
  • A requirement that in-patient status be given to anyone in need experiencing an opioid overdose, ensuring that lower-income residents aren’t turned away when they need it most
  • New coverage of kidney transplant medications regardless of residency
  • An expansion of HFS’s Medicaid enrollment assistance program through application agents, technical assistance, and outreach grants
  • An $80 million increase in the supportive living facility (SLF) rate — a 10% increase until March 31, 2022 — paid through federal ARPA funds

SB 2294 is effective immediately.


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Indiana Republicans oppose Biden administration’s block of Medicaid work rules

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Indiana lawmakers sent a letter to HHS Secretary Becerra requesting documentation and correspondence related to the decision to nullify the approved Indiana waiver.


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.




SOUTHERN INDIANA — All of Indiana’s Republican members of Congress signed off on a letter delivered Thursday opposing Democratic President Joe Biden’s administration’s block of the state’s work requirements for Medicaid recipients.

The U.S. Department of Health and Human Services informed state officials last week that the Indiana Gateway to Work Program, which includes an employment mandate, risks “significant coverage losses and harm to beneficiaries” and does “not promote the objectives of the Medicaid program,” according to the Associated Press.

Those requirements are included in Gov. Eric Holcomb’s 2019 Healthy Indiana Plan program, which was approved by former President Donald Trump’s administration.

But the program was halted during the pandemic after a challenge through a federal lawsuit.

According to the AP, the agency’s response referenced the time and paperwork required for Medicaid recipients to receive coverage. The agency stated the Gateway to Work program would “influence the behavior of a very small number of individuals, while risking coverage loss for many.”

The letter sent Thursday by the Republican lawmakers and dispersed via a news release was addressed to Xavier Becerra, secretary for the agency.

“We write today to express our dismay that, under your watch, the Centers for Medicare & Medicaid Services (CMS) withdrew authorities enjoyed by the State of Indiana through its Healthy Indiana Plan (HIP) that permit our state to determine appropriate work and community engagement requirements for its Medicaid recipients,” Indiana’s Republican Congressional members wrote in the letter.

Those who signed the letter include Sen. Todd Young and Sen. Mike Braun, as well as Rep.Trey Hollingsworth.

“Indiana’s Gateway to Work program aims to require Healthy Indiana Plan members to report 20 hours of work, volunteer, school and other activities every month,” the members of Congress wrote in the letter. “CMS has not allowed the state of Indiana to fully implement the program, even while our state’s Governor has noted that the Gateway to Work program has the potential to ‘help many Hoosiers.'”

The Republicans go on to infer that it’s “curious” that the Biden administration is resorting to fear tactics by “prematurely” rescinding the program before the U.S. Supreme Court issues a decision.

They focus on a part of the agency’s response stating that the pandemic and its aftermath would make the work or volunteer requirements “infeasible.”

“As of May, Indiana’s unemployment rate stands at 4 percent – well below the national average – despite the challenges associated with the pandemic’s recovery,” they state in the letter. “Our state has low unemployment, employers looking to hire, educational and training opportunities abound, and yet your agency is making decisions to curtail our state’s ability to connect our Medicaid recipients to a network of community engagement that makes sense to Hoosiers.”

The letter concludes with a request for a response by July 12 to include documentation and communications regarding the decision.

Indiana’s plan included exemptions for people 60 or older, those with medical problems and people who are primary caretakers of young or disabled children.

According to the AP, more than 130,000 Hoosiers were predicted to be affected by the requirements as of 2019. Other states have attempted to implement similar restrictions, which were blocked by federal court orders.


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Anthem completes acquisition of Puerto Rico-based MA, Medicaid plans


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Anthem completed the purchase this week, adding 3% to its overall Medicaid enrollment numbers.


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.



Dive Brief:

  • Anthem on Wednesday announced it had completed its acquisition of Puerto Rico-based MMM Holdings, a vertically integrated health plan, in a move that will expand the payer’s presence in Medicare and Medicaid.
  • Anthem nabbed MMM from value-based payer InnovaCare Health in a deal first announced in February that represents the payer’s first foray into Puerto Rico. Financial terms of the acquisition were not disclosed.
  • MMM is the ninth-largest MA plan in the U.S. and the biggest in Puerto Rico, with more than 275,000 members, and Puerto Rico’s second-largest Medicaid plan, with 314,000 beneficiaries.

Dive Insight:

With the acquisition, Anthem is doubling down on its government business, which fueled the majority of its enrollment growth last year amid COVID-19 as commercial rolls stayed largely stagnant.

The Indianapolis-based payer’s commercial business makes up about three-fourths of its membership, but its government products have been growing rapidly, according to recent financial filings. At the end of the first quarter, Anthem covered 9.2 million people in Medicaid and 1.5 million people in MA.

With the addition of MMM’s beneficiaries, the payer is swelling its Medicaid rolls by 3% and its Medicare Advantage rolls by 18%.

In statements announcing the news, Anthem executives said MMM’s vertically integrated organization fit well with Anthem’s whole-person approach. MMM operates a series of physician groups and specialized clinics, which all together gives it a network of more than 10,000 providers across Puerto Rico.

Anthem, which covers 43 million Americans, said when announcing the acquisition earlier this year it wouldn’t have a material effect on 2021 earnings. The payer did originally cut its 2021 outlook after experiencing a rebound in care in the fourth quarter, depressing net income, but its finances had largely bounced back by the first quarter of this year.

In the quarter, Anthem reported year-over-year profit growth of over 9% — helped significantly by a major increase in Medicaid membership.

Now, Anthem expects 2021 net income to be greater than $24.05 a share. Part of its strategy to drive income growth coming out of the tumultuous economic and coverage environment created by the pandemic is building up its end-to-end care offerings and diversifying into health services, a step most major insurers are also taking as the line between traditional payers and providers increasingly blurs.

As part of that strategy, Anthem in February completed its acquisition of Beacon Health Options, previously the biggest independent behavioral health organization in the U.S., serving more than 34 million people. Two months later, Anthem finalized a second acquisition, this time of post-acute benefits management company myNexus.

The insurer has also been upping its tech investments in a bid to streamline back-end functions and create more cohesive consumer platforms. In February, Anthem pledged to invest at least $25 million in Sharecare, a digital health company that aims to help consumers manage different elements of their health in one platform. Then, in April, Anthem launched a joint venture in partnership with investment giant Blackstone and digital health startup K Health focused on leveraging technology to better triage patient care and cut costs.

Anthem is now grabbing MMM from White Plains, New York-based InnovaCare, which manages more than 500,000 lives. InnovaCare is a portfolio company of global growth equity investor Summit Partners, which has invested in a number of healthcare companies, including dialysis operator U.S. Renal Care and MD VIP, a concierge physician practice.

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New York Ends Telehealth Waivers; Issues New Medicaid Guidance


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NY Medicaid has made permanent telehealth services that were temporarily expanded during COVID.


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 York’s telehealth emergency waivers have expired, according to a June 25, 2021 announcement issued by Governor Andrew Cuomo’s Office declaring the waivers (contained in Executive Orders 202 through 202.11 and 205 through 205.3) are no longer necessary. Concurrent with the Governor’s announcement, the New York State Department of Health issued a guidance document on the New York Medicaid program’s continued coverage of telehealth services for the duration of the federal Public Health Emergency (PHE). The guidance is designed to maintain the ability of Medicaid providers to use telemedicine and digital health to deliver health services for the remainder of the federal PHE. The guidance will remain in effect until the federal PHE expires or the Department of Health issues permanent Medicaid telehealth rules, whichever comes first. The guidance also may be a preview of additional guidance to be issued in the near future regarding telehealth in New York State beyond the Medicaid Program.

This article discusses the top five highlights in the New York Medicaid telehealth guidance.

1. Scope of Telehealth Services

  • Telehealth Definition: The term telehealth is broadly defined as “the use of electronic information and communication technologies to deliver health care to patients at a distance.” Medicaid-covered telehealth services include assessment, diagnosis, consultation, treatment, education, care management and/or self-management of a Medicaid patient. During the PHE, “telehealth” includes telephonic, telemedicine, store and forward, and remote patient monitoring. The guidance uses the term “telemedicine” to denote two-way audiovisual communication.
  • Originating Site Restrictions: An originating site is where the Medicaid patient is located at the time health care services are delivered to him/her by means of telehealth. Originating sites during the PHE can be anywhere the member is located including the member’s home.
  • Distant Site Restrictions: A distant site is the site where the telehealth provider is located while delivering health care services by means of telehealth. During the PHE, any site within the fifty United States or United States’ territories, is eligible to be a distant site for delivery and payment purposes. This includes Federally Qualified Health Centers and providers’ homes.

2. Expansion of Eligible Providers

During the PHE, any provider authorized to deliver Medicaid billable services is eligible to provide services via telehealth, so long as the services are appropriate for telehealth and within the provider’s scope of practice. Providers must still comply with HIPAA and all other relevant privacy and security laws when delivering care remotely.

3. Consent and Recording

Providers must confirm the patient’s identity and provide the patient with basic information about the services the patient will receive via telehealth. The patient need not give written consent to telehealth services, but if verbal consent is given the provider should document this in the medical record. Providers cannot record telehealth sessions without the patient’s consent.

4. Billing Rules for Telephonic (Audio-Only), Asynchronous, and Remote Patient Monitoring Services

The Medicaid program will cover telephonic services during the federal PHE. Telephonic service is “two-way electronic audio-only communications to deliver services to a patient at an originating site by a telehealth provider located at a distant site.” The guidance provides detailed billing instructions and a 2-page table setting forth in detail the billing and coding rules, along with modifiers, for telephonic services. The guidance also expands and elaborates previous rules for billing and coverage of two-way audiovisual communication, store and forward, and remote patient monitoring.

5. Specialty Program Requirements Still Apply

The Medicaid guidance document applies to all Medicaid providers under the Medicaid FFS program and Medicaid managed care plan contracts. However, other State agencies have also issued their own separate guidance on telehealth standards and practice. If a provider’s specialty area renders them subject to licensure or registration with one of these agencies, those rules will apply in addition to the Medicaid reimbursement rules. The Office of Mental Health, the Office for People with Developmental Disabilities, the Office of Addiction Services and Supports, and the Office of Children and Family Services have issued their own guidance materials and regulations. Providers should review these carefully.


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Missouri Supreme Court to hear Medicaid expansion lawsuit

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The plaintiffs who lost their bid to force the state to expand despite no funding for it will get their chance before the Missouri Supreme Court.


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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D.C. – Gray Accuses Colleagues of Medicaid Contract Steering

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Councilmembers in the district are accusing each other of corrupt handling of MCO contract awards.


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.


Ward 7 Councilmember Vince Gray accused fellow lawmakers of attempted contract steering in the latest chapter of the Medicaid managed care contract debacle. Councilmembers framed the debate during the June 29 legislative meeting as a struggle between disruption in medical coverage for Medicaid enrollees versus fidelity to contracting law.

In a letter sent to all D.C. councilmembers Monday, Gray wrote that a bill from Chairman Phil Mendelson and Councilmembers Robert White (At-Large) and Kenyan McDuffie (Ward 5) “is a thinly veiled attempt to steer a contract to Amerigroup,which last year lost its bid to manage healthcare for some of the District’s Medicaid beneficiaries. In June of 2020, the Office of Contracting and Procurement awarded the $1.5 billion Medicaid contract to MedStar, CareFirst, and AmeriHealth.

The bill in question would require OCP to re-evaluate bids from all four companies as ordered by the Contract Appeals Board. Last December, the CAB, a quasi-judicial body that adjudicates government contract disputes, upheld a protest from Amerigroup and ordered OCP to re-evaluate, but the agency has been dragging its feet for the past six months.

In its re-evaluation, OCP must take into consideration the CAB’s ruling in another case. In August 2020, the CAB ruled that bidders’ proposals must include a plan for how they will subcontract with small local businesses. D.C. law says the subcontracting plan must be included in the initial proposal. OCP has previously admitted that it has violated the law for years and allowed subcontracting plans to come in later in the process. Medstar did not submit a complete subcontracting plan in its initial proposal, so a re-evaluation could replace Medstar with Amerigroup.

“Ethically, this is a path Council should never contemplate, let alone take,” Gray wrote in the letter. He argued that with MedStar removed from consideration in the Medicaid contract, the bill would disrupt medical coverage for about 65,000 people.

White, responding to Gray’s letter during the legislative meeting, called the allegation of contract steering a red herring. The issue, as White sees it, is about holding local agencies accountable when they violate the law.

“That is offensive and unnecessary,” White said to Gray’s accusation of contract steering. “I have such great respect for my colleague, and I hope he will contradict what he put in his letter because it was inappropriate.”

McDuffie was more pointed.

“It is disgusting to me that there would be allegations of contract steering by the Council, when in fact what [Deputy Mayor Wayne Turnage] and mayor are asking us to do is steer a contract,” McDuffie said Tuesday. “To retroactively fix a mess they created.”

Since the CAB ruling, the Bowser administration has repeatedly tried to avoid it. Like Gray, executive branch officials have said the re-evaluation will be disruptive to tens of thousands of Medicaid enrollees.

During Tuesday’s debate, At-Large Councilmember Christina Henderson questioned why the bill was still necessary. She pointed to a letter Turnage sent to members of the Committee on Health last week. The letter, according to Henderson, said the re-evaluation has already begun.

McDuffie was still was not convinced.

“Who is it coming from?” McDuffie asked. “Because if it’s coming from the same deputy mayor, then when I ask questions about procurement, he doesn’t seem to know the answers to those, but he conveniently has answers about procurement when it benefits what he wants to see happen in terms of who gets this contract.”

McDuffie pointed out that instead of hearing from OCP Director George Schutter, Mayor Muriel Bowser, and Gray, who chairs the health committee and has oversight in this area, the Council is largely hearing from Turnage.

“He’s saying they’re doing this. There’s no real indication to me that they are,” McDuffie said of Turnage. “Do you have any evidence they’ve started re-evaluation? Because in terms of credibility, I’m not willing to just stand on what he’s saying these days.”

In an email to Loose Lips following the Council debate, Turnage emphasized his commitment to truthfulness in his dealings with the mayor and the Council since he became director of the Department of Healthcare Finance in 2011.

“I have always been completely transparent and honest in my communications with the Mayor’s office and the Council,” Turnage wrote in the email. “That Councilmember McDuffie would, without the slightest justification, impugn my character in a public meeting, says a lot more about him than it does me.”

The bill passed 9-4. Gray, along with Councilmembers Brooke Pinto (Ward 2), Brianne Nadeau (Ward 1), and Mary Cheh (Ward 3), voted no.


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