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Medicaid Acronym of the Day – PPACA

The Patient Protection and Affordable Care Act, often shortened to the Affordable Care Act (ACA) or nicknamed Obamacare, is a United States federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. The term “Obamacare” was first used by opponents, then reappropriated by supporters, and eventually used by President Obama himself. Together with the Health Care and Education Reconciliation Act of 2010 amendment, it represents the U.S. healthcare system’s most significant regulatory overhaul and expansion of coverage since the passage of Medicare and Medicaid in 1965.

The ACA’s major provisions came into force in 2014. By 2016, the uninsured share of the population had roughly halved, with estimates ranging from 20–24 million additional people covered during 2016. The increased coverage was due, roughly equally, to an expansion of Medicaid eligibility and to major changes to individual insurance markets. Both involved new spending, funded through a combination of new taxes and cuts to Medicare provider rates and Medicare Advantage. Several Congressional Budget Office reports said that overall these provisions reduced the budget deficit, and that repealing the ACA would increase the deficit. The law also enacted a host of delivery system reforms intended to constrain healthcare costs and improve quality. After the law went into effect, increases in overall healthcare spending slowed, including premiums for employer-based insurance plans.

The act largely retains the existing structure of Medicare, Medicaid, and the employer market, but individual markets were radically overhauled around a three-legged scheme. Insurers in these markets are made to accept all applicants and charge the same rates regardless of pre-existing conditions or sex. To combat resultant adverse selection, the act mandates that individuals buy insurance and insurers cover a list of “essential health benefits”. To help households between 100–400% of the Federal Poverty Line afford these compulsory policies, the law provides insurance premium subsidies. Other individual market changes include health marketplaces and risk adjustment programs.

The act has also faced challenges and opposition. In 2009, Senator Ted Kennedy died, and the resultant special election cost the Democrats their 60-seat filibuster-proof Senate majority before the ACA had been fully passed by Congress. The Supreme Court ruled 5 to 4 in 2012 that states could choose not to participate in the ACA’s Medicaid expansion, although it upheld the law as a whole. The federal health exchange, HealthCare.gov, initially faced major technical problems during its rollout in 2013. In 2017, a unified Republican government failed to pass several different partial repeals of the ACA. The law spent several years opposed by a slim plurality of Americans polled, although its provisions were generally more popular than the law as a whole, and the law gained majority support by 2017.

Further reading

https://www.healthcare.gov/glossary/patient-protection-and-affordable-care-act/

 

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Medicaid Acronym of the Day – CDC

Centers for Disease Control and Prevention – CDC works 24/7 to protect America from health, safety and security threats, both foreign and in the U.S. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same.

CDC increases the health security of our nation. As the nation’s health protection agency, CDC saves lives and protects people from health threats. To accomplish our mission, CDC conducts critical science and provides health information that protects our nation against expensive and dangerous health threats, and responds when these arise.

Further reading

https://www.cdc.gov/

 

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Medicaid Acronym of the Day – EHB

Essential Health Benefits – A set of 10 categories of services health insurance plans must cover under the Affordable Care Act. These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, and more. Some plans cover more services.

Plans must offer dental coverage for children. Dental benefits for adults are optional.

Specific services may vary based on state’s requirements.

Further reading

https://en.wikipedia.org/wiki/Essential_health_benefits

 

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Medicaid Industry Who’s Who Series: Steve Konsin, Sr.

Medicaid Who’s Who: Steve Konsin, Sr. – President, Syrtis Solutions

  1.  Which segment of the industry are you currently involved?

 A: Currently in Third Party Liability..but more specifically in “Medical and Pharmacy Claim “Cost Avoidance” vs. Pay and Chase which is     what we try to help our customers either minimize or move away from entirely. 

 2. What is your current position and with what organization?

 A: President, Syrtis Solutions.  My business partner and I started the company almost 10 years ago.

 3. How many years have you been in the Medicaid industry?

 A: 12 years directly involved in Medicaid programs

 4.  What is your focus/passion? (Industry related or not)

 A: Savings and Innovation which has been a constant throughout my career.

 5.  What is the top item on your “bucket list?”

 A: Go to an F1 race in Monaco.

 6.  What do you enjoy doing most with your personal time?

 A: Racing Vintage sports cars…a life-long hobby…

 7. Who is your favorite historical figure and why? 

 A: Benjamin Franklin because he was so diverse in his interests and accomplishments. He demonstrated that you can do just about anything if you put your mind to it…

8.  What is your favorite junk food?

A:  Pimento cheese (its a southern thing I picked up.)

9.  Of what accomplishment are you most proud?

A:   Working thru and succeeding with some very difficult life challenges 

10. For what one thing do you wish you could get a mulligan?

A: When I missed a shift for the lead on the last lap going on to the front straight of Watkins Glen in the 50th running of the Collier cup race. The race I won 25 years earlier…man I wish I had won that trophy to put next to the earlier one…

11. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months? 

 A: 

  • The status of the economy as a whole.
  • The future or demise of the ACA.
  • The current administrations actions.

 

 

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Medicaid Acronym of the Day – ACIP

The Advisory Committee on Immunization Practices (ACIP) comprises medical and public health experts who develop recommendations on the use of vaccines in the civilian population of the United States. The recommendations stand as public health guidance for safe use of vaccines and related biological products.

ACIP was established under Section 222 of the Public Health Service Act (42 U.S.C. § 2l7a) and is governed by its charter .

Further reading

https://www.cdc.gov/vaccines/acip/about.html

 

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Weekly Medicaid RoundUp: Week of December 4th, 2017

Soundtrack for today’s RoundUp pessimist readers-

Soundtrack for optimist readers

 

LET’S TALK SHOP AT MEDICAID INNOVATIONS 2018 – I will be in Florida again (7th year for me, I think) for the Medicaid Innovations Conference. If you are going, let’s plan on meeting up. Jan 31-Feb 2, 2018. Check it out here- http://bit.ly/2mbKtl1

 

IN HONOR OF THE TAX BILL MAKING ITS WAY INTO LAW- Whether you believe the “its evil and terrible – the only thing more terrible are the last 5 Republican bills we promised were the most terrible ever” – nonsense about the developing tax plan, it’s a topic of discussion. Maybe not as big a topic as Stuart Smalley this week, but still- taxes are on most people’s mind (at least the 50% of us that pay taxes) this time of year anyway.  So, in honor of taxes (long live King George!): Let’s also look on the spending side. More specifically, the fraudulent spending side.

 

TO TEE IT UP- The latest GAO report on fraud in Medicare and Medicaid is out this week. You know, the one they put out every year that all of us in the space ignore because it ain’t our money (or whatever reason we use to justify not caring about 10% of the funds meant for these vulnerable members we claim to care so much about just vanishing. Most of my good friends opt for the “but fraud happens in other payer verticals, too” garbage.) This year’s report – out this week – shows $95B lost to improper payments in Medicare and Medicaid. Cue hair-splitting discussion re: fraud vs waste vs improper vs Oh, look a squirrel! GAO is giving CMS credit this year for new investments to fight fraud, notably red-flagging certain provider types, creating a Center for Program Integrity and requiring anti-fraud training. But that’s where the compliment sandwich ends (spoiler- its more of an open faced-sandwich this time). According to GAO, CMS has missed basics like conducting a fraud risk assessment for Care and Caid. And in GAO’s view, this is a big omission. The size and complexity of the 2 programs make this an “Of course there is a huge fraud risk here” issue. Check out the article on this in the twitter feed to make sure and see Kirk Nahra’s comments on anti-fraud data analytics being oversold in the last 20 years. Sobering.

 

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. Antoine E. Skaff of Charleston, WV stole $735k from Medicaid for dental services over 7,836 acts of fraud between 2011 and 2016. Salomon Melgen of West Palm Beach, FL is in court over $100M he stole from MediCARE using bogus eye visits and tests. Investigators nabbed him using data showing Melgen seeing 100 patients a day and performing procedures in seconds that should take 10 minutes. Kristina Mirbayeva of Brooklyn lead a huge fraud operation (34 defendants, spanning 14 companies and 100 bank accounts) that sent recruiters into soup kitchens and job centers to get Care and Caid members enticed with $40 kickbacks to go to one of their clinics and get a ton of tests done. In 2 short years this netted the bad guys about $146M. Joseph Korzelius of Tryon, NC was sentenced this week for using his counseling business to pilfer $436k from Medicaid. Mr. Tryon used his side job of elementary school guidance counselor to steal students’ Medicaid numbers and submit false bills. Maxim home health in Massachusetts settled with Medicaid this week over stealing $14M by billing for unnecessary services for elderly members (95,000 claims for services not covered). A new report out from the Louisiana DOH shows $717k in payments for dead members between 2013 and 2017. That’s better than the $1.85M paid for dead folks in 2012/2013. Cynthia Stiger and Jacques Roy of Dallas (along with 5 other defendants) just finished up their trial. These 2 stole $374M from MediCare using their bogus home health company. They made up fake plans of care and then the good doc (Roy) would sign off on them so they could bill. Hard to do a tally this week since there’s some big MediCare ones in there. But the clear winner is Kristina. She showed leadership by inspiring a huge team of defendants to navigate a complex web of deceit! But hey- evil Republicans reduce spending. Tax cuts for the 1% Eat the rich.. #Resist!!

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (pour some salt on your steps) and keep running the race (you know who you are).

 

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: phrabida daisong phra bud pheu banthuk olk.

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Medicaid Acronym of the Day – QHP

Qualified Health Plan – Under the ACA, the designation of qualified health plan (QHP) is given to health insurance plans that are sold in the marketplace (exchange).  The same basic rules apply to plans sold both in and out of the exchanges:  they must be guaranteed issue, follow the ACA’s cost-sharing guidelines, and cover “essential health benefits” with no lifetime or annual maximums.

But in order to be sold in the exchanges, a health plan must also be certified by the exchange as a qualified health plan.  In the spring of 2013, health insurance carriers in each state submitted plan designs and pricing to the exchanges – the ones that were approved are considered QHPs.  The QHP label is basically an extra layer of consumer protection, one that makes shopping in the exchanges a good idea even for people who don’t qualify for subsidies.

Further reading

https://obamacarefacts.com/insurance-exchange/qualified-health-plan/

 

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Medicaid Acronym of the Day – ACAP

The Association for Community Affiliated Plans (ACAP) is a national trade association representing 57 Medicaid-focused health plans in 26 states. Headquartered in Washington, D.C., ACAP advocates on behalf of its community-affiliated member health plans operating throughout the United States. ACAP’s advocacy work focuses on representing publicly sponsored programs and health care providers who serve vulnerable populations. ACAP also promotes universal access to quality and cost-efficient care.

ACAP members are nonprofit plans that serve public insurance programs and the safety net. Collectively, ACAP plans serve more than 17 million enrollees, which is over 50 percent of individuals enrolled in Medicaid-focused health plans.[1]

Further reading

https://www.communityplans.net/

 

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Medicaid Acronym of the Day – ABP

Alternative Benefit Plan – States have the option to provide alternative benefits specifically tailored to meet the needs of certain Medicaid population groups, target residents in certain areas of the state, or provide services through specific delivery systems instead of following the traditional Medicaid benefit plan. Key Requirements of the Rule Include:

The term 1937 Medicaid Benchmark or Benchmark Equivalent Plan has been retitled to Alternative Benefit Plans.
ABPs must cover the 10 Essential Health Benefits (EHB) as described in section 1302(b) of the Affordable Care Act whether the state uses an ABP for Medicaid expansion or coverage of any other groups of individuals.
Individuals in the new adult VIII eligibility group will receive benefits through an ABP.

Further reading

https://www.medicaid.gov/State-Resource-Center/Eligibility-Enrollment-Final-Rule/Alternative-Benefit-Plans-and-Essential-Health-Benefits.pdf

https://www.federalregister.gov/documents/2013/07/15/2013-16271/medicaid-and-childrens-health-insurance-programs-essential-health-benefits-in-alternative-benefit#h-14

 

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Medicaid Acronym of the Day – ABA

Applied Behavioral Analysis – ABA is an empirically validated approach to improve behavior and skills related to core impairments associated with autism and a number of other developmental disabilities. ABA involves the systematic application of scientifically validated principles of human behavior to change inappropriate behaviors. ABA uses scientific methods to reliably demonstrate that behavioral improvements are caused by the prescribed interventions. ABA is presently considered the gold standard of autism interventions.

ABA’s focus on social significance promotes a family-centered and whole-life approach to intervention. Common methods used include: assessment of behavior, caregiver interviews, direct observation, and collection of data on targeted behaviors.

A single-case design is used to demonstrate the relationship between the environment and behavior as a means to implement client-specific ABA therapy treatment plans with specific goals and promote lasting change. ABA also includes the implementation of a functional behavior assessment to identify environmental variables that maintain challenging behaviors and allow for more effective interventions to be developed that reduce challenging behaviors and teach appropriate replacement behaviors.

Further reading

https://www.hca.wa.gov/assets/billers-and-providers/ABA-services-20161001.pdf