Posted on

Mostly Medicaid Announces Medicaid Solution Provider Innovations Awards Submissions

MM Curator summary

[MM Curator Summary]: We are highlighting innovative solution providers in the Medicaid space- nominate someone today!


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.




BIRMINGHAM, ALABAMA, UNITED STATES, June 1, 2022 / — MostlyMedicaid, the leading provider of Medicaid solution provider news, trends, insights and best practices announced the 2022 Medicaid Solution Provider Innovations project today.

Medicaid solution providers are a key part of the innovative programs delivered by states and managed care plans. These vendor partner companies provide solutions for things like data analysis, care management, transportation, and a whole range of other critical Medicaid business operations.

While some solution providers are well-known in our space, there are many that are not – and they are doing great work that can be leveraged in more Medicaid programs.

If you want to highlight the great work of a solution provider in the Medicaid space please fill out our simple survey here-

The survey is open for submissions as of June 1st, 2022. You can nominate a Medicaid vendor partner through October 20th, 2022. Early submissions are encouraged.

About Mostly Medicaid

Mostly Medicaid reaches thousands of Medicaid industry professionals, decision makers and influencers with its thought leadership publications and information sharing products. We also provide marketing and strategy consulting services for companies in the Medicaid industry, as well as premium educational content to enhance expertise for industry professionals. Mostly Medicaid offers a unique value in the Medicaid industry by focusing on data-driven business perspectives rather than policy-only or advocacy-only positions.

We began with one simple concept in mind – think of Medicaid as a massive industry. Besides the healthcare services provided to Medicaid enrollees, there are hundreds of thousands of people that process claims, build software, consult with hospitals – just to name a few segments. Those people need services and products to help them do their jobs, increase their revenues and improve their skills.

And that’s where Mostly Medicaid comes in. We are uniquely positioned to reach influencers across all segments and provide them with actionable information and recommendations. We have built a brand with 10,000 Medicaid industry professionals who trust us to bring non-biased information to them.

For inquiries about this announcement:
For Mostly Medicaid
Clay Farris
Mostly Medicaid
+1 919-727-9231
email us here

Clay Farris
Mostly Medicaid
+ +1 9197279231

email us here


Clipped from:

Posted on

California Healthcare Foundation highlights important work done by MostlyMedicaid to integrate care for a Medicaid managed care plan

A new report showcases a project where we led efforts to integrate key workstreams shared by a Medicaid managed care plan and their county partners. Special thanks and recognition also goes to our friends at Sellers Dorsey and Cruz partners.

Read the report to learn more. Reach out to kris@ to learn how we can help your Medicaid health plan do great things.

Loader Loading…
EAD Logo Taking too long?

Reload Reload document
| Open Open in new tab
Posted on

Vaccine mandate to kick in for first wave of health workers

MM Curator summary

[MM Curator Summary]: The CMS vaccine requirements for healthcare workers began on Thursday.


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 requirement to get vaccinated against COVID-19 kicks in Thursday for millions of health care workers in about half the states

Health care workers in about half the states face a Thursday deadline to get their first dose of the COVID-19 vaccine under a Biden administration mandate that will be rolled out across the rest of the country in the coming weeks.

While the requirement is welcomed by some, others fear it will worsen already serious staff shortages if employees quit rather than comply.

And in some Republican-led states that have taken a stand against vaccine mandates, hospitals and nursing homes could find themselves caught between conflicting state and federal demands.

“We would like to see staff vaccinated. We think that it’s the safest option for residents, which is our biggest concern,” said Marjorie Moore, executive director of VOYCE, a St. Louis County, Missouri, nonprofit that works on behalf of nursing home residents. “But not having staff is also a really big concern, because the neglect that happens as a result of that is severe and very scary.”

The mandate affects a wide swath of the health care industry, covering doctors, nurses, technicians, aides and even volunteers at hospitals, nursing homes, home-health agencies and other providers that participate in the federal Medicare or Medicaid programs.

It comes as many places are stretched thin by the omicron surge, which is putting record numbers of people in the hospital with COVID-19 while sickening many health workers.

Nationwide, about 81% of nursing home staff members already were fully vaccinated as of earlier this month, ranging from a high of 98% in Rhode Island to a low of 67% in Missouri, according to the federal Centers for Medicare & Medicaid Services. The data is unclear about the vaccination levels in hospitals and other health care sites.

The mandate ultimately will cover 10.4 million health care workers at 76,000 facilities.

It is taking effect first in jurisdictions that didn’t challenge the requirement in court. Those include some of the biggest states, with some of the largest populations of senior citizens, among them: California, Florida, New York and Pennsylvania.

“There absolutely have been employee resignations because of vaccination requirements,” said Catherine Barbieri, a Philadelphia attorney at Fox Rothschild who represents health care providers. But “I think it’s relatively small.”

At Wilson Medical Center in rural Neodesha, Kansas, three of the roughly 180 employees are quitting, and several others have sought exemptions from the vaccine mandate, said hospital spokeswoman Janice Reese.

“We are very fortunate that that is all we are losing,” she said, noting that the hospital was not in favor of the mandate. “We didn’t feel like it was our place to actually try to tell a person what they had to do.”

Reese said the vaccine requirement could also make it more difficult for the hospital to fill vacancies.

In Florida, medical centers find themselves caught between dueling federal and state vaccination policies. They could lose federal funding for not adhering to the Biden administration mandate, but could get hit with fines for running afoul of state law.

Gov. Ron DeSantis, a Republican who has waged a legal campaign against coronavirus mandates, last year signed legislation that forces businesses with vaccine requirements to let workers opt out for medical reasons, religious beliefs, immunity from a previous infection, regular testing or an agreement to wear protective gear. Businesses that fail to comply can be fined $10,000 to $50,000 per violation.

Asked if the state would pursue fines against hospitals that enforce the federal mandate, a spokeswoman for the Florida attorney general said all employee complaints “will be thoroughly reviewed by our office.”

Some states already have their own vaccine requirements for health care workers. In California, for example, they have been required to be fully vaccinated since Sept. 30 and must get a booster b y Feb. 1.

The federal mandate is “better late than never,” said Sal Rosselli, president of the National Union of Healthcare Workers, which represents about 15,000 people in California. “But if it happened sooner, we wouldn’t have gone through the surge, and a lot more people would be alive today.”

The government said it will begin enforcing the first-dose vaccine requirement Feb. 14 in two dozen other states where injunctions were lifted when the U.S. Supreme Court upheld the mandate two weeks ago. The requirement will kick in on Feb. 22 in Texas, which had filed suit separately.

In Missouri, one nursing home served notice this week that it intends to take advantage of a state rule that allows facilities to close for up to two years if they are short-staffed because of the vaccine requirement.

“Obviously we are proponents of vaccines,” said Lisa Cox, a spokeswoman for the Missouri Department of Health and Senior Services. But “throughout all of this, we knew that mandating it would be a negative impact really on our health care system … just because of crippling staffing levels.”

Cox identified the facility that was closing as Cedarcrest Manor, in the eastern Missouri city of Washington. She said there are just 42 patients in the 177-bed facility amid the staffing shortages. A woman who answered the phone at the facility took a message but couldn’t immediately comment.

The Centers for Medicare & Medicaid Services ultimately could cut off funding to places that fail to comply with the mandate. But it plans to begin enforcement with encouragement rather than a heavy hand.

CMS guidance documents indicate it will grant leniency to places that have at least 80% compliance and an improvement plan in place, and it will seek to prod others.

“The overarching goal is to get providers over that finish line and not be cutting off federal dollars,” said MaryBeth Musumeci, a Medicaid expert with the nonpartisan Kaiser Family Foundation.

The states affected on Thursday are: California, Colorado, Connecticut, Delaware, Florida, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Tennessee, Vermont, Virginia, Washington and Wisconsin, along with the District of Columbia and U.S. territories.


Associated Press writers Ricardo Alonso-Zaldivar and Anthony Izaguirre contributed to this report.


Clipped from:

Posted on

Georgia bill aims to limit profits of Medicaid managed-care plans

MM Curator summary

[MM Curator Summary]: GA is one of only a few Medicaid managed care states that does not require a minimum Medical Loss Ratio (MLR).


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.


Georgia lawmakers will consider a bill that could force the state’s Medicaid managed-care insurers to repay millions of dollars if their spending on medical care doesn’t reach a certain threshold.

This story also appeared in Georgia Health News

The bipartisan bill, introduced Jan. 26 by the powerful Georgia House Speaker David Ralston, a Republican, is focused on improving the state’s mental health care system.

Tucked inside the legislation is a provision that would require the Medicaid managed-care companies to refund payments to the state if they don’t spend enough on medical care and quality improvements for patients.

Georgia Health News and KHN reported in September that Georgia was one of only a few states that doesn’t mandate a minimum level of medical spending for its Medicaid insurers.

Each year, Georgia pays three insurance companies — CareSource, Peach State Health Plan, and Amerigroup — a total of more than $4 billion to run the federal-state health insurance program for low-income residents and people with disabilities. For 2019 and 2020, the companies’ combined profits averaged $189 million per year, according to insurer filings reported by the National Association of Insurance Commissioners.

“Instead of ensuring adequate health care networks for Georgia’s children, Georgians with disabilities, and Georgians in nursing facilities, hundreds of millions of dollars go instead to the Georgia [insurers’] bottom lines,” said Roland Behm, a board member for the Georgia chapter of the American Foundation for Suicide Prevention.

Behm, who advised lawmakers on the bill, said the KHN and Georgia Health News article helped bring the issue to the attention of legislators crafting the bill.

Georgia is among more than 40 states that have turned to managed-care companies to run their Medicaid programs — and ostensibly control costs. According to an August report from the U.S. Department of Health and Human Services’ Office of Inspector General, 36 of those states and the District of Columbia set a benchmark “medical loss ratio” for the minimum spending by insurers on medical care. Besides Georgia, the report said, the five states not requiring a managed-care spending threshold were Kansas, Rhode Island, Tennessee, Texas, and Wisconsin.

Ralston (left), with Kevin Tanner, chairman of a mental health commission, and Insurance Commissioner John King (right), at the Capitol on Wednesday. Credit: Georgia Health News

Republican state Rep. Todd Jones, a co-sponsor of the new bill, told KHN that Georgia lawmakers should establish a strong benchmark for insurers to meet. “We should look at what other states are doing,” he said.

Most states with a spending requirement set that ratio at a minimum of 85% of premium dollars that insurers are paid. So when a Medicaid insurer spends less than that on medical care and quality improvements, it must return money to the government.

The Georgia bill also calls for setting the threshold at 85%. If the bill is approved, the Medicaid insurers would face the medical spending requirement in 2023.

If the benchmark had been in place in recent years, it could have forced a recoupment from the Peach State company, which has the largest Georgia Medicaid enrollment of the three insurers. State documents show it failed to reach the 85% mark from 2018 to 2020, KHN previously reported.

Andy Schneider, a research professor at Georgetown University’s Center for Children and Families, called the 85% mark “a win for taxpayers, for Medicaid providers, and for Medicaid beneficiaries.” He also said it would be more than fair to the Medicaid insurers, which could keep 15% of what the state pays them for administrative costs and profit.

Because Ralston is the lead sponsor of the bill in the House, it’s expected to pass that chamber.

But the insurance industry likely will work to remove the medical spending provision.

An industry official, Jesse Weathington, executive director of the Georgia Quality Healthcare Association trade group, declined to comment on the legislation.

Fiona Roberts, a spokesperson for the state Department of Community Health, which oversees the Medicaid program, said the agency needs time to review the measure before commenting on it.

The main provisions of the bill require insurers to provide coverage for mental health care or substance use treatment at the same level as other physical health needs.

The legislation would provide education loan support for people training in the fields of mental health and substance use disorders and seek to expand behavioral health services for children. It would also facilitate “assisted outpatient treatment” — when a judge could order a person with a serious mental illness to follow a court-ordered treatment plan in the community.

This story is available through a news partnership with Georgia Health News.


Clipped from:

Posted on

Adolescents with SUDs in Medicaid Rarely Get Substance Abuse Care

MM Curator summary

[MM Curator Summary]: A large data study of teens covered by Medicaid shows that very few who need substance abuse treatment receive it.


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


Only half of adolescents enrolled in Medicaid received substance use screenings at their last medical visits and few adolescents with substance use disorders accessed substance abuse care.

By Victoria Bailey

January 31, 2022 – Adolescents enrolled in Medicaid who had substance abuse-related experiences, including opioid use disorder, had high rates of medical visits but were unlikely to receive substance abuse care, indicating a need for increased Medicaid services, an Urban Institute report found.

Substance use is common among adolescents and can lead to high rates of morbidity and mortality. Medicaid provides health insurance coverage for over half of Americans under the age of 19, putting the public payer in a key place to help address and prevent substance use disorders.

Medicaid offers coverage for screening and intervention services related to substance use through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, but low reimbursement rates and other Medicaid policies may lead to low utilization of these services.

Researchers analyzed data gathered from the National Survey on Drug Use and Health from 2015 through 2019, which consisted of survey responses from and demographics of 31,680 adolescents between the ages of 12 and 19 years who received coverage from Medicaid or the Children’s Health Insurance Program (CHIP).

The researchers categorized the adolescents into the following five substance use groups: those with no substance use, those with opioid use disorder, those with risky opioid use but not opioid use disorder, those with a non-opioid and non-tobacco substance use disorder, and those who used non-opioid substances but did not have a use disorder.

Health problems were more common among adolescents who used substances. For example, adolescents with opioid use disorder were twice as likely to have fair or poor health and ten times as likely to have a sexually transmitted disease than those who did not use substances. Substance users in general were more likely to have had a major depressive episode as well.

While most of the adolescents enrolled in Medicaid had a healthcare appointment in the last year, adolescents who used substances were more likely to have a medical visit, particularly an emergency department visit or an inpatient stay.

More than 60 percent of adolescents with opioid use disorder and 47 percent of those with risky opioid use or other substance use disorders had at least one emergency department visit in the last year, compared to 32 percent of non-users.

Despite the high rates of healthcare services, adolescents who used substances did not commonly receive treatment for their substance use. Only one in five adolescents was involved with a substance use prevention program outside of school.

Although substance use treatment was highest among adolescents with opioid use disorder, less than one in five received treatment, while 6.9 percent had received buprenorphine treatment and 8.6 percent had received alcohol-related treatment, the report stated. Just over 4 percent of adolescents with opioid use disorder sought treatment but never accessed it.

Only half of all adolescents who had a medical visit in the last year received substance use screenings during their appointments, the researchers found.

The study results indicate a need for better resources to address substance use in adolescents. Medicaid has the potential to help by enacting policy changes.

“The EPSDT Medicaid benefit could be expanded to explicitly include outreach and engagement with youth before a diagnosis, confidential screening and assessment, early intervention services, unlimited case management for comprehensive care coordination, and transportation to care,” researchers wrote.

However, providers may struggle with this increased care delivery without adequate reimbursement from Medicaid, thus the researchers recommended that policymakers should look to expand benefits through waivers. These waivers could cover therapeutic services such as mentoring, art therapy, and alternative recreational therapies.

The public payer should also take action to improve access to recovery services, including peer recovery coaching and recovery housing, the researchers urged.

Medicaid must also start reimbursing providers for harm reduction services for adolescents, the report concluded.

Clipped from:

Posted on

NJ Watchdog Says State Should Bar Poorly-Rated Nursing Homes From Medicaid

MM Curator summary

[MM Curator Summary]: A recent comptroller report recommends NJ stop payments to nursing homes with consistent poor performance.


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 new report by the New Jersey comptroller recommends tighter Medicaid restrictions on low-performing nursing homes

New Jersey Office of the State Comptroller

A new report by New Jersey’s state comptroller found 15 nursing homes consistently received low ratings by health inspectors, yet still take in about $100 million in Medicaid funding a year.

The state watchdog’s report says poor performers shouldn’t be rewarded if they fail to improve and is recommending progressive measures to force fixes — including barring repeatedly low-ranking facilities from additional public dollars.

“Bottom line: New Jersey taxpayers should not be funding nursing homes that have failed to improve for years, appear unlikely to improve, and put residents in harm’s way,” Acting Comptroller Kevin Walsh said in a statement.

The comptroller’s office analyzed New Jersey’s 339 nursing homes and found 15 of them earned the lowest score on the national grading rubric for long-term care facilities for most quarters in 2020 and 2021. Nursing homes, which have been under close scrutiny amid the COVID pandemic, are evaluated based on federal guidelines set by the Centers for Medicare & Medicaid Services on a scale of one to five stars, with one being the lowest.

“These are facilities that year over year performed poorly in some very critical areas, specifically staffing shortages and the amount of nursing hours that are available,” said Laurie Facciarossa Brewer, the state’s long-term care ombudsperson, who consulted with the comptroller’s office on the report.

“It would appear that there doesn’t seem to be an effort by those facilities to improve. It almost seems as if a one-star rating is basically baked in as the cost of doing business,” she said.

State inspectors evaluate nursing homes during unannounced visits and, over several days, grade residents’ quality of care, medication management, nursing home administration and food services. The report found one in 14 nursing homes statewide received a one-star rating in the most recent quarter.

“It’s not the minor stuff that gets you a one-star rating. It’s having multiple deficiencies over time in a wide array of areas,” Brewer said.

They’re making a profit off of the one-star facilities all while taxpayers are paying for one-star care

Acting New Jersey Comptroller Kevin Walsh

The report also found that 14 of the 15 lowest performing nursing homes, or 93%, are run by for-profit companies — statewide, 77% of the facilities are run by for-profits.

“They’re making a profit off of the one-star facilities all while taxpayers are paying for one-star care,” Walsh said.

According to the report, the 15 low performers received more than $300 million in Medicaid funding between 2017-2019. And many have scored poorly since 2013, the data shows.

The comptroller’s office is recommending the state issue a series of restrictions to problem facilities that range from a warning, banning the nursing home from accepting new patients and ultimately, withholding Medicaid dollars. One of the problems the report identified is that the state agency overseeing residential care is different from the agency that distributes the money.

New Jersey’s Division of Medical Assistance and Health Services within the Department of Human Services oversees the state’s Medicaid program but it’s up to the Department of Health to conduct health inspections and evaluate the facilities.

“The agencies need to work together in order to ensure that the residents’ interests and the Medicaid dollars that the state spends are all protected,” Walsh said. He said New Jersey would be the first state to withhold Medicaid dollars from low-rated nursing homes if it decides to accept the recommendation.

Nursing homes have been under increased scrutiny in the last two years after the pandemic sickened and killed more than 8,000 residents and 148 staff, state data show. Brewer said the report’s suggested fixes will complement larger reforms already underway.

Last year, Gov. Phil Murphy signed into law measures to ensure minimum staffing levels, increase wages for direct care staff and mandate that 90% of Medicaid funds be used for direct patient care.

The comptroller’s office has also released a dashboard of the 15 lowest-performing facilities here. Four of the 15 are in Burlington County. If the state considers the report’s recommendations, which could ultimately limit the number of patients at these facilities, it could limit where residents can access long-term care.

“It underscores how very difficult it is when you’re talking about people’s health care,” Brewer said. “Everybody involved has to be really, really mindful of the fact that regardless of how bad the place is, it is where somebody lives.”



Clipped from:

Posted on

Ohio Medicaid director says program change won’t disrupt health care

MM Curator summary

[MM Curator Summary]: OH is requiring members to pick their plan for the first time.


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.



Karen Kasler


Statehouse News Bureau

Ohio Medicaid Director Maureen Corcoran testified before the House Finance Commission discussing the two-year state budget in February 2021.

Ohio’s Medicaid director is taking issue with a report from a progressive think tank that suggests millions of people in the program could have their health care interrupted because of a change that takes effect in July.

Medicaid participants will be notified soon they must confirm which of seven managed care plans they want – though people who’ve been in Medicaid haven’t had to do that if they wanted to stay with their plan. Ohio Medicaid Director Maureen Corcoran said part of the reason for that is to get people to be more engaged and informed about their health care.

“We know that when people have to kind of stop and think about it, they’re going to get more drawn into their health care,” Corcoran said. “We want to encourage people to be affirmative and learn and be active in their health care.”

Those who don’t respond could be assigned to different plans later this year, but Corcoran said they can always switch back.

“If a person doesn’t choose and we then make an assignment, they still can choose to go back to the plan they had had maybe a year ago or – they still have a choice, even if they hadn’t responded previously. So prioritizing choice is number one,” said Corcoran.

Eventually, as many as 80,000 Ohioans could be moved to the new plans that need participants, but Corcoran says they can change back till the end of November. But Corcoran notes that’s a very small percentage of the program’s participants.

The group Innovation Ohio suggested those reassignments could disrupt health care for millions. But Corcoran says careful matching – finding plans that keep people in their networks, for instance – should mean that won’t happen, or that it would be rare.

And Corcoran noted that for now, no one can be disenrolled from Medicaid because there’s a public health emergency declaration still in effect for the pandemic.


Clipped from:

Posted on

Next big health crisis: 15M people could lose Medicaid when pandemic ends

MM Curator summary

[MM Curator Summary]: The general press oversimplifies post-PHE enrollment 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.


State audits could lead to as many as 15 million people, including 6 million children, losing their health insurance, according to one analysis.


The Biden administration recently extended the public health emergency another three months, through April 15, but the White House is likely to allow it to expire once Covid-19 cases wane and vaccinations increase.

Congress could help, they say, if it decouples the requirement to keep people on state Medicaid rolls from the public health emergency and sets a date for when the pandemic-era policy will end. State officials are also asking federal lawmakers for more money and eyeing additional requirements for the unwinding effort, which some say could safeguard against pressures from state lawmakers to expedite the process in order to save money and remove people from welfare rolls as soon as possible.

People typically lose Medicaid coverage because their income increases above the eligibility threshold, or they fail to submit the proper paperwork to prove they qualify. But when the pandemic began, Congress, in exchange for additional federal funding, barred states from kicking people off Medicaid. Enrollment surged nearly 20 percent over the next 16 months to 76.7 million, according to the Centers for Medicare and Medicaid Services, an all-time high.

Now, states fear that unwinding the expanded social safety net could prove messy — as many of the millions removed from the rolls may not know they’ve lost their health insurance or which options are available for new coverage. It’s a problem not just for states but for the Biden administration, which might be forced to grapple with rising uninsured rates in an election year.

“Most of us go to sleep at night thinking about this and what we can do the next day around this,” said Daniel Tsai, director of the Center for Medicaid and CHIP Services, describing the level of engagement across HHS and CMS on this issue as “unprecedented.”

“We are pulling out all the stops,” Tsai said.

Utah, which undertook a similar effort last year for its Children’s Health Insurance Program, offers a preview of what the rest of the country could experience. More than 41 percent of the 15,000 kids enrolled in Utah’s program lost their health insurance during the redetermination process — despite the state’s efforts to reach out to people, update addresses and send out notifications in advance.

“So maybe, just maybe, we are a canary in the coal mine, or maybe, just maybe, we are a cautionary tale for some other states on what needs to happen,” Nelson told the Medicaid and CHIP Payment and Access Commission last week.

State health officials say a firm date would allow them to hire and train additional staff amid an ongoing workforce shortage, build out call center capacity to limit wait times and conduct outreach campaigns with local community organizations to ensure enrollees know they need to provide certain information to the state to keep their coverage.

“That’s really one of the big risks, that people will be eligible but become unenrolled just because they don’t get the message and don’t know how to continue their coverage and are just out of the habit, quite honestly, of doing renewals and redeterminations after almost two years,” said Suzanne Bierman, administrator of Nevada’s Medicaid program.

Start the process too early, and states worry they’ll be paying for resources they don’t yet need and wasting what might be the one shot they have to communicate with a vulnerable population. Start too late, and states might not have the infrastructure in place to help hundreds of thousands of residents re-enroll in Medicaid or transition to coverage on state health insurance exchanges.

While states are accustomed to some level of uncertainty from the federal government, Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation, said this is a unique situation.

“Just not knowing how much longer this will be in place is creating significant challenges,” Tolbert said. “The pressures are heightened and the uncertainty is even greater.”

Without a firm date, state health officials say they are doing what they can, including asking enrollees to update their contact information — like addresses, phone numbers and emails — so the state will be able to find them once the actual redetermination process starts.

In Pennsylvania, state Medicaid and exchange officials are shoring up the data transfer process to make it easier for people to sign up for an Obamacare plan if they lose their Medicaid coverage.

In Massachusetts, the state invested $5 million in a community-based Medicaid redetermination and vaccination outreach campaign to communities hit hardest by the pandemic.

And in New York, Gov. Kathy Hochul’s budget included an additional $69 million to the state health department’s budget, some of which the agency says will be used to facilitate the unwinding of the public health emergency.

“We have a big job ahead of us. We know that already,” New York Health Commissioner Mary Bassett told reporters last week. “Our goal is to make it orderly and keep people insured.”

State health officials credited the Biden administration with offering some help, pointing to assurances early last year that the public health emergency would run at least through the end of 2021, and that states would have 60 days’ notice before it ended. CMS also released guidance last summer that answered some of states’ most pressing questions and a best practices list in November as states prepare for the end of the continuous enrollment requirement. There are also calls at least twice a month between state and federal officials.

“We are highly cognizant that states kind of need to know an end date to get things moving,” Tsai said. “Our message has been, ‘We should just plan for that coming as soon as possible.’ Not to say it will be … but the answer is, ‘Do not sit and wait.'”

Jennifer Wagner, director of Medicaid eligibility and enrollment for the Center on Budget and Policy Priorities, a left-leaning think tank, worries that some states may welcome the chance to purge their welfare rolls and do little to help people prove their eligibility or find new coverage.

“What we have seen historically is that so many eligible people get caught up in the chaos of this, of states not doing good ex parte [renewals], of not updating addresses, not leveraging SNAP information for addresses or income or other things, relying on paper-based mail instead of any effort to phone calls or text messages or other things,” she said.

Medicaid experts point to Ohio — where the state has contracted with an outside vendor that will automate eligibility redeterminations in exchange for a cut of state Medicaid savings and plans to process redeterminations in 90 days — as a particularly concerning case. The Ohio Department of Medicaid declined to comment.

Medicaid advocates are also concerned that states may have a financial incentive to clear their rolls as quickly as possible. The additional federal matching funds that Congress provided to help pay for the swelling Medicaid rolls will be cut at the end of the quarter in which the public health emergency ends, giving states a reason to rush through the process instead of taking the full 12 months the Biden administration has said it will allow.

Democrats proposed extending those additional federal payments as part of their social spending package, but the effort is stalled in Congress.

Medicaid advocates caution that the faster states rush through the process, the greater the chance eligible individuals could lose coverage for not filling out the right paperwork. Kicking people off state Medicaid rolls who are eligible stands to not only disrupt patient care — meaning less management of underlying conditions at doctor’s offices and more utilization of higher-cost care in hospitals — but also could cost states down the road in staff time to reprocess those individuals if and when they reapply for Medicaid.

It’s also likely to have a disproportionate impact on low-income communities of color, given that more than half of Medicaid recipients identify as Black, Hispanic, Asian American, or another non-white race or ethnicity, according to MACPAC.

Tricia Brooks, a research professor at the Georgetown University McCourt School of Public Policy, warned that states trying to complete redeterminations over a short time period could see call centers quickly overwhelmed — reminiscent of the strain state unemployment systems came under at the beginning of the pandemic.

“When you have an hour wait time at a call center, you can’t expect the consumers are getting the information that they need and you need to be able to hit the pause button,” Brooks said. “I worry that we’re not going to be able to hit the pause button before too much damage is done.”

Clipped from:

Posted on

CNMI- Governor vetoes Medicaid personnel bill

MM Curator summary

[MM Curator Summary]: The Governor of CNMI has shot down a bill that would codify various authorities for the Medicaid agency.


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



GOVERNOR Ralph DLG Torres on Friday vetoed House Bill 22-53, which proposes to “further enable recruitment, retention and appropriate classification and compensation” in the Commonwealth Medicaid Agency.

Introduced by Rep. Leila Fleming Staffler, the bill aims to:

1) Codify the authority of the Medicaid director to reprogram funding appropriated for Medicaid program among the established business units in a fiscal year budget;

2) Direct the Office of Personnel Management to undertake a repricing study for eligibility, enrollment, claims processing, and health information technology personnel and retention based on the classification and compensation of Commonwealth Healthcare Corp.; and

3) Authorize OPM to hire Medicaid Enterprise System, data analysis, program integrity, and auditing personnel under excepted service employment contracts until the market-based repricing classification and compensation study is completed.

According to the bill, the CNMI government’s fiscal year 2021 budget established a Compliance and Medicaid Enterprise System as a new business unit “to balance the program needs for administration and medical reimbursement with the legal requirements of Title XIX of the Social Security Act.”

In addition, the Legislature also provided the Medicaid director the authority to reallocate the funds appropriated in the budget law.

H.B. 22-53 clarifies the authority of the Medicaid director to reprogram funds among the Medicaid business units categories or any other business units the Legislature may establish in the appropriation measure.

The bill also stated that positions for Medicaid Enterprise System personnel approved and funded, at a minimum, with 50% to 90% federal funds, as approved by the Centers for Medicare and Medicaid Services, “have yet to be recruited, resulting in delays to important project activities and time lines.”

The measure states that “specialized health information technology and Medicaid data analytics personnel required by Medicaid are in short supply until OPM is able to undertake a market-based classification and compensation pricing study for health information technology and data analytics personnel that, in minimum, reflects the comparable classification compensation of like positions at CHCC.”


In his veto message, the governor said due to ambiguities in the language of the bill as noted by the attorney general, and similar concerns of OPM, “I must respectfully exercise my constitutional authority to veto this bill.”

He said if approved, the measure would create a narrow exception to the reprogramming restrictions in the Planning and Budgeting Act, with regard to the Medicaid Agency.

He said funds appropriated to the Medicaid Agency may be reprogrammed by the director regardless of whether the funds are for personnel or non-personnel expenditures.

Right now, the governor said, the Planning and Budgeting Act permits the reprogramming of funds from personnel to non-personnel or operations, but not vice versa.

The governor also noticed that the bill would require OPM to establish personnel positions for the Medicaid Agency that fall under Medicaid Enterprise System. The MES positions, he added, are approved by the Centers for Medicare & Medicaid Services.

OPM is further tasked with performing a review and study of the classification of personnel required by the Medicaid program with classification and compensation rates comparable to CHCC and private insurers and providers.

In recruiting prospective employees, the governor said OPM would be directed to interview and employ individuals who have demonstrable and specific knowledge, skills, experience, training and abilities applicable in Medicaid administration and similar healthcare management and analytics program.

But the governor said H.B. 22-53 would exempt MES employees from the civil service system. Upon completion of OPM’s classification and compensation study to be approved by the Medicaid director, the MES employees may opt to convert to the civil service system and become civil service employees.

According to the governor, the attorney general makes it clear that Legislature’s lawmaking authority over the civil service system “is not plenary.” Only the Civil  Service Commission has the authority over civil service system and is the sole authority to exempt positions from civil service classification, the governor said.


Clipped from:

Posted on

U.S. Supreme Court To Hear Florida Medicaid Dispute

MM Curator summary


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.



Wiki Commons


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.”


Clipped from: