Category: MM Curator

Posted on by

CVS Health to Acquire Signify Health

MM Curator summary

[MM Curator Summary]: The CVS buy gets them much further into the member’s home and also gets a bigger stake in ACO models and Medicare Advantage opportunities.

 
 

 
 

 
 

 
 

WOONSOCKET, R.I., DALLAS and NEW YORK, Sept. 5, 2022 — CVS Health® (NYSE:CVS) and Signify Health (NYSE: SGFY) (“Signify”) have entered into a definitive agreement under which CVS Health will acquire Signify Health for $30.50 per share in cash, representing a total transaction value of approximately $8 billion.

Signify Health is a leader in Health Risk Assessments, value-based care and provider enablement. With a network of more than 10,000 clinicians across all 50 states and a nationwide value-based provider network, combined with its proprietary analytics and technology platforms, Signify Health is improving patient engagement, patient outcomes and care coordination for stakeholders across the health care system. Signify Health’s clinicians and providers can have an even greater impact by engaging with CVS Health’s unique collection of assets and connecting patients to care how and when they need it.

“Signify Health will play a critical role in advancing our health care services strategy and gives us a platform to accelerate our growth in value-based care,” said CVS Health President and CEO, Karen S. Lynch. “This acquisition will enhance our connection to consumers in the home and enables providers to better address patient needs as we execute our vision to redefine the health care experience. In addition, this combination will strengthen our ability to expand and develop new product offerings in a multi-payor approach.”

Signify Health’s network of clinicians – physicians, nurse practitioners and physician assistants – utilize home-based visits to identify a patient’s clinical and social needs, and then connect them to appropriate follow-up care and community-based resources in order for the patient to have a more connected, effective care experience. In 2022, Signify Health’s clinicians expect to connect with nearly 2.5 million unique members in the home, both in-person and virtually, and on average they spend 2.5 times longer with a patient in the home than providers spend in the average primary care office visit.  

Notably, since acquiring Caravan Health in March 2022, Signify Health has further expanded its focus on value-based care and population health. Today, Caravan is already a partner to over 170 providers participating in accountable care organizations (ACOs) serving Medicare beneficiaries with a focus on improving the health of underserved communities. Signify Health recently announced that its ACOs generated more than $138 million in gross savings in 2021, and in 2023 the Caravan business is expected to serve ACOs representing over 700,000 people – rivaling many standalone platforms. As part of CVS Health, Signify Health will continue to advance its extensive primary care enablement capabilities, including turnkey analytics, network, and practice improvement solutions, to help providers transition to value-based reimbursement and improve quality of care.

“Signify Health’s mission is to build trusted relationships to make people healthier by using actionable intelligence to understand what’s really impacting outcomes and cost today,” said Kyle Armbrester, CEO of Signify Health. “As we carefully considered our long-term strategic options, we determined that CVS Health is the ideal partner, given its focus on expanding access to health services and helping consumers navigate to the best sites of care. We are both building an integrated experience that supports a more proactive, preventive and holistic approach to patient care, and I look forward to executing on our shared vision for the future of care delivery.”

“We formed Signify Health and recruited Kyle and the team to build a strategic innovation platform focused on leveraging technology as a catalyst for connecting key health care stakeholders to drive better patient outcomes,” said Matt Holt, Chairman of the Board, Signify Health and President of Private Equity and Managing Director at New Mountain Capital, which owns a majority stake in Signify Health. “Together with CVS Health, Signify is uniquely positioned to continue to lead the transformation to value-based care. We look forward to the significant impact this transaction will make on health care for years to come.”

Following the close of the transaction, Kyle Armbrester will continue to lead Signify Health as part of CVS Health. Signify Health’s extensive network of over 50 health plan clients and their members will further augment CVS Health’s longstanding and leading offering of payor-agnostic solutions for a diverse set of health plan and employer clients.

Transaction details

CVS Health will acquire Signify Health’s stock for $30.50 per share. CVS Health expects to fund the transaction with existing cash from its balance sheet and available resources and is committed to maintaining its current credit ratings. The transaction was approved by the Board of Directors at each of the respective companies. It is subject to approval by a majority of Signify Health’s stockholders, receipt of regulatory approval and satisfaction of other customary closing conditions. Private equity funds affiliated with New Mountain Capital, which owns approximately 60% of the common stock of Signify Health, have agreed to vote the shares they own in favor of the transaction, subject to customary exceptions. CVS Health and Signify Health anticipate that the transaction will close in the first half of 2023.

“This is a major step as we continue to execute on our strategy,” said CVS Health Executive Vice President and Chief Financial Officer Shawn Guertin. “We expect the acquisition to be meaningfully accretive to earnings and, as a result, are increasingly confident we can achieve our long-term adjusted EPS goals as outlined at our Investor Day in December 2021.”

Joint Conference Call and Webcast

CVS Health and Signify Health will hold a joint conference call for analysts and investors on September 6, 2022 at 8:30 a.m. ET. An audio webcast of the conference call will be broadcast simultaneously on the Investor Relations portion of the CVS Health website at investors.cvshealth.com where it will be archived for a period of one year.

Advisors

BofA Securities is serving as financial advisor to CVS Health. CVS Health was advised on legal matters by Fried, Frank, Harris, Shriver & Jacobson LLP, Dechert LLP, and McDermott Will & Emery LLP. Goldman Sachs & Co. LLC and Deutsche Bank Securities Inc. are serving as financial advisors to Signify Health. Ropes & Gray LLP is acting as Signify Health’s legal advisor.

About CVS Health

CVS Health® is the leading health solutions company, delivering care like no one else can. We reach more people and improve the health of communities across America through our local presence, digital channels and over 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners. Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day. Follow @CVSHealth on social media.

About Signify Health

Signify Health is a leading health care platform that leverages advanced analytics, technology, and nationwide healthcare provider networks to create and power value-based payment programs. Our mission is to build trusted relationships to make people healthier. Our solutions support value-based payment programs by aligning financial incentives around outcomes, providing tools to health plans and healthcare organizations designed to assess and manage risk and identify actionable opportunities for improved patient outcomes, coordination, and cost-savings. Through our platform, we coordinate what we believe is a holistic suite of clinical, social, and behavioral services to address an individual’s healthcare needs and prevent adverse events that drive excess cost, all while shifting services towards the home.

 
 

Clipped from: https://www.signifyhealth.com/news/cvs-health-to-acquire-signify-health

Posted on by

Proposed CMS rule would streamline Medicaid, CHIP enrollment

MM Curator summary

[MM Curator Summary]: New rules could standardize Medicaid eligibility and enrollment processes nationwide, but it would come at the cost of making it more difficult for states to right-size the rolls more than 1x a year.

 
 

 
 

 
 

An article from

 
 

 
 

The exterior of the U.S. Department of Health and Human Service in Washington, DC. Alex Wong via Getty Images

This audio is auto-generated. Please let us know if you have feedback.

Dive Brief:

  • The CMS on Wednesday issued a proposed rule aimed at reducing coverage gaps by streamlining the application and renewal process for Medicaid enrollees and other programs like the Children’s Health Insurance Program.
  • Among other things, the proposed rule aims to make CHIP and Medicaid enrollment easier for children, older adults and those with lower incomes by limiting renewals to once a year, establishing standardized statewide renewal processes and giving applicants 30 days to respond to information requests.
  • The proposed rule comes as states begin to notify Medicaid beneficiaries about potential losses of coverage due to the impending end of the COVID-19 public health emergency.

Dive Insight:

The COVID-19 PHE created a continuous coverage requirement for Medicaid enrollees in states that accepted matching rates for Medicaid payments, allowing those with Medicaid coverage to forgo renewing for eligibility and retain their coverage.

Enrollment in CHIP and Medicaid programs jumped 24% during the PHE, making it the largest source of health coverage in the U.S. Estimates on how many could get kicked off coverage once the PHE ends range between 5 million and 14 million beneficiaries.

The proposed rule would make it easier to enroll and retain Medicaid coverage as some states begin notifying Medicaid beneficiaries that they may lose coverage when the COVID-19 public health emergency ends.

In addition to standardizing procedural enrollment and renewal processes for states, the proposed rule also attempts to lower coverage disruptions and churning, which can occur when people lose coverage and re-enroll quickly by simplifying the enrollment process and maintaining continuity of coverage for those eligible.

It initiates applications for Medicare Savings Programs, allowing those who use low-income subsidies to be eligible for MSP coverage “to the maximum extent possible.” Currently, there are no regulations that ensure efficient enrollment processes for MSPs, resulting in “millions” of eligible individuals to miss out on potential savings, according to the CMS.

“This proposed rule will ensure that these individuals and families, often from underserved communities, can access the health care and coverage to which they are entitled — a foundational principle of health equity,” CMS Administrator Chiquita Brooks-LaSure said in a news release.

People over 65 and with blindness or a disability, who are excluded from enrollment simplifications, would also have access to an easier enrollment process in the proposed rule. Renewals would occur no more than once a year, with the rule also proposing to eliminate in-person interviews and provide a minimum 90-day reconsideration period after termination for “failure to return information needed to redetermine eligibility.”

In the proposed rule, states would also see more federal oversight for their enrollment and renewal processes by establishing guidelines to check available data prior to determining eligibility if a beneficiary can’t be reached by mail and providing timelines for when renewals must be completed.

Other changes include:

  • Automatic enrolling, with some exceptions, for Supplemental Security Income recipients into Qualified Medicare Beneficiary groups.
  • Allowing projected and predictable medical expenses to be deducted from an applicant’s income when determining financial eligibility, including home care and prescription drugs.
  • Eliminating the requirement to apply for other benefits as a condition of Medicaid eligibility to reduce administrative hurdles.
  • Requiring states to keep Medicaid and CHIP records and case documentation from the time the case is active plus three years thereafter.
  • Establishing a clear process to prevent eligible termination for beneficiaries who should be transitioned between Medicaid and CHIP when their income changes or when the beneficiary appears to be eligible for the other program, even if the beneficiary fails to respond to requests for information.

 
 

Clipped from: https://www.healthcaredive.com/news/proposed-cms-rule-streamline-medicaid-chip-enrollment/631019/

Posted on by

FWA- U.S. Attorney Settles Fraud Lawsuit Against Non-Profit For Inflating Medicaid Reimbursements By Falsely Reporting Millions In Costs

MM Curator summary

[MM Curator Summary]: Henry Coley used his “non profit” for Medicaid I/DD members to funnel cash to family members and his other businesses.

 
 

 
 

 
 

Maranatha Human Services Agrees to Cease Operations and Will Pay $850,000

Damian Williams, the United States Attorney for the Southern District of New York, and Scott Lampert, the Special Agent in Charge of the New York Office of the U.S. Department of Health and Human Services, Office of Inspector General (“HHS-OIG”), announced that the United States has settled civil fraud claims against Maranatha Human Services, Inc. (“MARANATHA”) for falsely claiming that millions of dollars expended to benefit for-profit ventures owned and controlled by MARANATHA and its founder HENRY ALFONSO COLEY (“COLEY”), as well as payments to cover COLEY’s personal expenses and excessive payments to COLEY’s family members, were reasonable and necessary costs in connection with MARANATHA’s provision of Medicaid-funded services to individuals with developmental disabilities.  MARANATHA is a non-profit organization based in Poughkeepsie, New York; COLEY founded MARANATHA in 1988 and served as its chief executive officer until last year. 

Specifically, the Government’s complaint, which was filed in November 2021, alleges that MARANATHA, with its board’s approval, funded for-profit companies operated by COLEY; paid excessive salaries and consulting fees to COLEY’s family members, often in exchange for little to no work; and paid for tens of thousands of dollars of COLEY’s personal expenses.  The Government further alleges that, from 2010 to 2019, COLEY and MARANATHA submitted to the State of New York cost reports that falsely claimed millions of dollars of these expenses as “allowable” costs, which fraudulently inflated MARANATHA’s Medicaid reimbursement rates and resulted in MARANATHA receiving millions of dollars in Medicaid funds to which it was not entitled.

U.S. Attorney Damian Williams said:  “For a decade, Henry Alfonso Coley and Maranatha defrauded Medicaid by submitting reports that fraudulently claimed as allowable expenses millions of dollars spent on for-profit companies owned by them, excessive salaries and fees for Coley’s family members, and Coley’s personal expenses.  These expenses were not related to providing care or assistance to the individuals with developmental disabilities who Maranatha was meant to serve.  Now Coley and Maranatha have each agreed to pay damages, Coley has been barred from working for any entity that bills federal healthcare programs, and Maranatha will close its doors.”

HHS-OIG Special Agent in Charge Scott Lampert said:  “It is incumbent upon the recipient of Medicaid funds to ensure that costs reported for reimbursement are accurate and in accordance with the program’s regulations; this is a steadfast requirement of participating in the Medicaid program.  The use of federal dollars for unallowable expenses diverts much-needed resources meant to support health care services for vulnerable individuals.  Putting a stop to such activity, through collaboration with our law enforcement partners, is a prime objective of HHS-OIG.”

Under the settlement approved yesterday by U.S. District Judge Kenneth M. Karas, MARANATHA agrees to cease operations after transitioning the operation of its programs to other providers under the supervision of the governing state regulatory agency.  MARANATHA will also pay $340,000 to the United States and has admitted and accepted responsibility for conduct alleged by the Government in its complaint as further described below.  In addition, MARANATHA has agreed to pay $510,000 to the State of New York to resolve the State’s claims, for a total recovery of $850,000.  The settlement amount is based on the Office’s assessment of MARANATHA’s ability to pay based on the financial information it provided and its commitment to cease operations.  The United States previously resolved the claims against COLEY through a settlement approved by Judge Karas on November 17, 2021.  In addition to paying damages to the United States and the State of New York, COLEY was barred from working for any entity that bills federal healthcare programs; he also entered into a Voluntary Exclusion Agreement with HHS-OIG, which prohibits him from, among other things, billing Medicaid and other federal healthcare programs for 15 years.

According to the Government’s complaint, from 2010 through 2019:

MARANATHA was required to submit cost reports, called Consolidated Financial Reports (“CFRs”), to the State of New York each year, specifying the reasonable and necessary costs MARANATHA incurred in providing services for its Medicaid-funded programs.  These costs were to be reported as “allowable” costs.  MARANATHA was required separately to report its other, “non-allowable” costs; “non-allowable” costs include costs unrelated to its Medicaid-funded programs, as well as any unreasonable or unnecessary costs. 

With its board’s approval, MARANATHA funded for-profit companies operated by COLEY and owned by COLEY or MARANATHA, as well as various unincorporated pet projects started by COLEY.  One of the chief purposes of these ventures was to serve as vehicles to funnel money to COLEY’s daughter, as well as others associated with COLEY, whom MARANATHA paid for work they purportedly did to support these ventures and projects.  Over the course of a decade, not one of these ventures ever launched a product or service or earned a single dollar in revenue.  COLEY and MARANATHA hired COLEY’s family members as employees and consultants, some in connection with these for-profit ventures, and others in connection with MARANATHA’s Medicaid-funded services.  COLEY and MARANATHA paid excessive salaries and consulting fees to COLEY’s family members, often in return for little to no work.  MARANATHA also paid for tens of thousands of dollars of COLEY’s personal expenses, including more than $34,000 for personal training sessions at a gym.

COLEY and MARANATHA knowingly submitted CFRs annually to the State of New York fraudulently reporting these expenses—totaling millions of dollars—as “allowable” costs.  On each CFR, COLEY falsely certified to the completeness and accuracy of the report.  COLEY and MARANATHA knew that the State of New York relied on providers’ CFRs when setting provider-specific reimbursement rates for certain Medicaid-funded programs, including MARANATHA’s largest Medicaid-funded program.  As a result of COLEY’s and MARANATHA’s falsely inflated cost reports, the State of New York awarded MARANATHA a higher reimbursement rate and MARANATHA received millions of dollars in Medicaid funds to which it was not entitled.

As part of the settlement, MARANATHA admits, acknowledges, and accepts responsibility for the following conduct:

  • COLEY made a presentation to MARANATHA’s board of directors acknowledging that “[i]t was always the plan for Maranatha to use government funds as a launching pad to create private enterprise that would enable it to not be dependent on [the] government while at the same time fulfilling its function” consistent with its mission.
  • MARANATHA knew of the requirement to distinguish “allowable costs” from “non-allowable costs” in its CFRs.
  • MARANATHA knew that the allowable costs reported in its CFRs are used by the New York State Department of Health, in part, to determine MARANTHA’s reimbursement rates for the provision of Medicaid services.
  • In each CFR that MARANATHA submitted from 2010 to 2019 (the “Covered Period”), MARANATHA’s CEO, COLEY, certified that (i) the “information furnished in this report . . . is in accordance with the instructions and is true and correct to the best of my knowledge”; and (ii) the statement attached to the CFR “fully and accurately represents all reportable income and expenditures made for services performed in accordance with the provision of the Mental Hygiene Law and approved budgets.”
  • Throughout the Covered Period, MARANATHA submitted CFRs every year that reported as “allowable costs” amounts expended not for MARANTHA’s provision of Medicaid-funded services but instead to pursue certain for-profit business ventures.
  • In particular, MARANATHA submitted CFRs reporting as “allowable costs” costs expended to benefit certain entities owned and/or operated by COLEY or MARANATHA that did not provide Medicaid-funded services (the “Non-Medicaid Ventures”).  
  • MARANATHA’s board, which approved MARANATHA funding these Non-Medicaid Ventures, was briefed on them by COLEY.
  • MARANATHA paid COLEY’s family members to perform work related to the Non-Medicaid Ventures.  For example, since 2010, MARANATHA paid COLEY’s daughter more than $300,000.  Though much of her time was spent on work related to the Non-Medicaid Ventures, MARANATHA reported her full compensation as an “allowable cost” in the CFRs.
  • Since 2010, MARANATHA paid COLEY more than $2 million in salary and benefits, and MARANTHA claimed the full amount of that compensation as “allowable costs” on its CFRs. However, COLEY devoted much of his time to working on the Non-Medicaid Ventures.
  • MARANATHA also paid for certain of COLEY’s personal expenses, including more than $34,000 spent on personal training sessions, as well as holiday gifts and jewelry.  MARANATHA reported these expenses as “allowable costs” in its CFRs.

This lawsuit originated as a whistleblower lawsuit filed under seal pursuant to the False Claims Act.

Mr. Williams praised the outstanding investigative work of HHS-OIG, and he thanked the Medicaid Fraud Control Unit at the New York State Attorney General’s Office for its extensive collaboration in the investigation.

The case is being handled by the Office’s Civil Frauds Unit.  Assistant U.S. Attorney Jacob Lillywhite is in charge of the case.

 
 

Clipped from: https://www.justice.gov/usao-sdny/pr/us-attorney-settles-fraud-lawsuit-against-non-profit-inflating-medicaid-reimbursements

Posted on by

MCOs- MetroPlus Health Plan: COVID-19 Enrollment Trends | Office of the New York State Comptroller

 
 

MM Curator summary

[MM Curator Summary]: A nice deep dive into the PHE impact on enrollment for one MCO in NY. Includes a detailed set of charts for all you chart people.

September 2022

PDF Version

Overview

MetroPlus Health Plan is a prepaid health services plan and a wholly owned subsidiary of NYC Health + Hospitals (H+H). MetroPlus contracts with H+H and other providers to offer managed care health care services such as Medicaid, Essential Plan, Child Health Plus (CHP) and Medicare Advantage plans, plans for eligible New York City employees and day care workers of City agencies, and private plans through NY State of Health (NYSOH, the State’s online marketplace) for over 670,000 members. Changes in MetroPlus enrollment have a direct impact on H+H’s financial stability. As more of its members choose H+H as a provider, the hospital system generates more revenue, an explicit goal of its strategic plan. This brief provides an update to MetroPlus enrollment trends as discussed in our report: NYC Health + Hospitals Check-Up: The Impact of COVID-19.

Pandemic Impact on MetroPlus Health Plan Enrollment

MetroPlus enrollment reached a record high of 670,915, an increase of 159,284 members (31 percent) between February 2020 and June 2022, the period impacted by the COVID-19 pandemic (see Figure 1).

FIGURE 1 – MetroPlus Enrollment

Sources: MetroPlus Health Plan; OSC analysis

Nearly 70 percent of MetroPlus membership is enrolled in the mainstream Medicaid managed care plan which experienced the largest actual membership growth of all plans offered. Enrollment in the Essential Plan, a subsidized basic health plan offered through NYSOH, experienced the largest growth rate of all plans at 44 percent (see Figure 2). In late January 2020, the Secretary of the U.S. Department of Health and Human Services (HHS) declared a public health emergency (PHE) for COVID-19 which permits the Centers for Medicare & Medicaid Services (a federal agency in the HHS) to grant states emergency flexibilities to respond to the crisis. The federal Families First Coronavirus Response Act, enacted in March 2020, authorized fiscal relief to states that created a requirement to keep most beneficiaries continuously enrolled in Medicaid during the PHE. The New York State Department of Health (DOH) is allowed to keep people enrolled in Medicaid, CHP and the Essential Plan without them going through their annual renewal while continuing to enroll newly eligible individuals. This provision means enrollment in these plans will likely continue to rise through the PHE which is currently authorized through mid-October 2022. 

FIGURE 2 – MetroPlus Enrollment By Plan Type

Notes: NY State of Health includes health plans for individuals and small businesses. Specialized Medicaid managed care plans include long-term care plans. MetroPlus Gold plans are available for all city employees and NYC day care workers of the Day Care Council of NY Local 205, DC 37 Welfare Fund. The Essential Plan is a subsidized basic health plan offered with the NY State of Health.

Sources: MetroPlus Health Plan; OSC analysis

Additionally, MetroPlus experienced an increased market share in mainstream Medicaid Managed Care and Essential Plan enrollment in the City. The MetroPlus share of citywide enrollment in mainstream Medicaid managed care plans, that covers the largest share of its members, increased from 14.8 percent in February 2020 to 15.8 percent in June 2022, the highest since 2014 (based on year over year February data) and the third largest plan in the City. Enrollment in these plans grew by 34 percent while enrollment in all other Medicaid Managed Care plans offered in the City grew by 24 percent. MetroPlus share of citywide enrollment in the Essential Plan increased from about 17 percent to 19 percent during the same time period. 

MetroPlus Financial and Operational Impact on NYC Health + Hospitals

The financial stability of H+H is impacted by MetroPlus’ ability to continue to attract new members and maintain its current membership, while focusing on better care management. To maximize revenues from MetroPlus, H+H is working with it to attract more of its members to utilize H+H’s health services and engage its members in routine chronic care management to avoid unnecessary high-cost utilization. Moreover, to address the needs of MetroPlus members with frequent hospital utilization at H+H, it has also taken steps to ensure that members have access to comprehensive care management including services that address medical, social and behavioral health needs. For example, in 2017, MetroPlus and H+H established a housing taskforce to connect H+H patients in need of affordable and supportive housing, including those that are MetroPlus members. As a result, over 300 MetroPlus members have been housed. Increasing use of primary care and specialty care services by insured patients at H+H healthcare facilities directly supports H+H’s strategic plan toward fiscal stability.

Despite MetroPlus’ and H+H’s efforts, the majority of MetroPlus members use health care providers other than H+H. The share of MetroPlus spending at H+H facilities declined from 40 percent in fiscal year (FY) 2019 to 39.1 percent in FY 2021 and rebounded in FY 2022 to 42.6 percent, but has yet to reach the H+H target of 45 percent (see Figure 3).

FIGURE 3 – Share of MetroPlus Medical Spending at H+H

Note: Third quarter data of each fiscal year.

Sources: MetroPlus Health Plan; OSC analysis

As part of its outreach efforts to obtain new members, MetroPlus directs individuals that are not eligible or cannot afford insurance to the NYC Care program, a financial assistance program which provides a broad range of health care services at H+H facilities on a sliding scale fee.

In line with the DOH’s efforts toward statewide Medicaid payment reform, H+H and MetroPlus have entered an agreement that incentivizes reimbursements based on quality and cost effectiveness of care, from a model that reimburses based on volume. This value-based payment (VBP) arrangement requires H+H to take on the medical risk of all covered services for all eligible patients within the VBP arrangement, even if that care is provided outside of the H+H system. MetroPlus makes a payment to H+H after settling the net amount remaining after paying for all medical expenses associated with the VBP arrangement. The risk sharing payables were $199 million and $428 million in FY 2021 and FY 2020, respectively.

In 2020, during the first wave of the COVID-19 pandemic, MetroPlus ranked the highest of 15 Medicaid Managed Care plans across the State in the DOH’s quality incentive program which assesses performance covering a wide range of quality measures.  

Wind Down of the Federal Public Health Emergency

When the PHE expires, the continuous enrollment provision will conclude as well as other enrollment flexibilities granted during the PHE. According to federal guidance, the DOH will need to return to regular eligibility and enrollment operations and complete all renewals within 14 months, a daunting process as Medicaid enrollment has reached record levels and renewals have not been processed in almost two and a half years. In preparation for the sunset of the PHE, the State has provided tools to assist stakeholders to inform enrollees about renewing their coverage. MetroPlus has developed strategies for education and outreach to its membership to maintain the enrollment growth achieved during the pandemic. It is likely that enrollment in these plans will decline when the process of member renewals returns to normal procedures and some members will not renew or become ineligible for coverage. However, the State fiscal year 2023 Enacted Budget includes provisions that expand eligibility in public health plans offered through MetroPlus. 

If MetroPlus is successful in adding newly eligible members to its plans it might offset any potential loss in enrollment. MetroPlus enrollment is at levels it has never reached before, but this will be challenging to maintain during the wind down of the PHE. MetroPlus in coordination with H+H is working to facilitate rapid reenrollment in Medicaid for those still eligible, and shift those who lose eligibility to Essential Plan coverage. MetroPlus is engaging City and State partners to continue to ease these transitions through effective use of public benefits data and eligibility flexibilities still available from the federal government to maintain members’ insurance coverage and prevent lapses in care. Continued collaboration with New York State remains critical to aid this effort. 

Additionally, H+H must continue to provide quality care and maintain efforts to improve patient satisfaction, such as keeping appointment wait times low, to continue to attract MetroPlus members. These efforts will enable H+H to work toward its goal of 45 percent of MetroPlus medical spending and therefore help to successfully execute on its strategic plan.

 
 

 
 

Clipped from: https://www.osc.state.ny.us/reports/osdc/metroplus-health-plan-covid-19-enrollment-trends

 
 

Posted on by

MS- Letters create confusion about correct MS Medicaid coverag

MM Curator summary

[MM Curator Summary]: Oops.

 
 

 
 

 
 

Local


By Isabelle Taft

Thanks to misleading letters sent by the Mississippi Division of Medicaid in recent years, tens of thousands of new moms may have chosen to forgo health care after giving birth – even as the federal government was sending Mississippi extra money to help pay for their care during the pandemic.

Mississippians whose pregnancies were covered by Medicaid retained full benefits during the COVID-19 pandemic under federal law, instead of getting kicked off 60 days after giving birth as they ordinarily would under state policy. That should have allowed them to keep seeing their doctors and get treatment for conditions like postpartum depression, high blood pressure and anything else they needed to stay healthy after their baby’s birth.

But many women thought they didn’t have coverage because of letters sent to every recipient of pregnancy Medicaid telling them they were no longer eligible. While healthy adults under 65 generally don’t qualify for Medicaid, pregnant women are covered as long as they meet income requirements, and about 60% of births in Mississippi are covered by Medicaid. An untold number of pregnancy Medicaid recipients may have stopped going to the doctor after receiving the letters, believing they would be charged as if they had no health insurance.

Several recipients of the letters told Mississippi Today they only found out they had coverage after going to the doctor, in some cases so desperate for care that they were willing to pay whatever they had to out of pocket.

“Your Medicaid eligibility has ended,” the sparse letter from the Division of Medicaid said. The heading read “TERMINATION NOTICE – Loss of Medicaid Eligibility.”

A second letter delivered later, titled “NOTICE OF MEDICAID REINSTATEMENT DURING COVID-19 PUBLIC HEALTH EMERGENCY,” explained that those covered as of March 18, 2020 would have their coverage reinstated. But it did not make reference to the first letter or explain what kind of coverage recipients now had.

Some women told Mississippi Today they never got the second letter.

Termination letter

Dr. Anita Henderson, a Hattiesburg pediatrician and president of the Mississippi Chapter of the American Academy of Pediatrics, said she screens moms for postpartum depression during their newborns’ early checkups. During the public health emergency, she and colleagues expected new moms to retain Medicaid coverage indefinitely.

“We found that some of those moms were coming back and saying, ‘We don’t have Medicaid, or we don’t know that we have Medicaid.’ Or they were saying, ‘No, I have gotten this termination letter,'” Henderson said. “Once we offered clarification and discovered they still qualified, they would go to that appointment, or we would help set up the appointment and they would go. But if they did not know they had coverage, they may not have utilized it.”

The new moms’ confusion and reluctance to seek care almost certainly saved the Division of Medicaid money – and one expert believes the confusing communication may have been intentional.

The first letter notified the recipients that they had been kicked off of the managed care plan, a program through which the state pays a set amount of money to a “coordinated care organization” each month, which then pays for recipients’ care.

The reinstatement described in the second letter shifted them to another type of Medicaid in which the state pays directly for each visit and treatment. The fewer services new moms sought, the less money the Division of Medicaid had to spend.

Joan Alker, executive director and co-founder of the Center for Children and Families (CCF) at Georgetown University and an expert on Medicaid, said she had not heard of other states moving people from managed care to fee-for-service coverage during the pandemic.

“I fear this is an intentional strategy to cut costs on the backs of these postpartum women,” Alker said.

Matt Westerfield, communications director for Medicaid, said the department could not provide a “validated analysis” of postpartum spending during the public health emergency by publication time.

“Generally, it appears that monthly medical costs have exceeded $200 per beneficiary per month in months 3 to 12 of the postpartum period,” he wrote.

The state pays managed care companies between $1,076 and $1,186 monthly per pregnant woman, depending on the beneficiary’s location.

In a statement to Mississippi Today last week, the Division of Medicaid acknowledged the letters were a mistake.

“An automated form letter related to disenrollment from a managed care plan should have been updated to mention the continuing availability of full Medicaid benefits,” said Westerfield. “We have directed that the form letter be updated, and staff is currently reviewing other beneficiary communications to make improvements where needed.”

Rationing visits

Trista Carlton gave birth to her daughter in June 2021. The 28-year-old Laurel resident had Medicaid as her secondary insurance, and about 60 days postpartum, she got the letter informing her that her coverage had been terminated.

Carlton started rationing her visits to the doctor because she was worried about the cost.

“Not only do you have your copay, you have what your insurance doesn’t cover afterwards, so it definitely makes you second-guess making a visit to go to the doctor and see what’s going on,” she said. “Having a new baby, that comes with added costs that you’re thinking about. You kind of put yourself on the back burner, not knowing what’s going on.”

She never got the second letter telling her the coverage had been reinstated, but she eventually decided she needed to see her doctor for anxiety and depression. Only then did she learn she still had coverage.

Carlton then called local Medicaid offices in Laurel and Brandon to ask what was going on. She said staff there told her she only had family planning Medicaid coverage, which pays for up to four annual visits related to birth control. Before the Public Health Emergency, women who gave birth on Medicaid were rolled onto family planning coverage for one year after they lost full coverage.

“I’ve never really been able to get a direct answer,” she said. “But all of my primary care visits have gone through. And as far as I know, I’m still covered under Medicaid.”

Several other women told Mississippi Today they had similar experiences after receiving the letters.

Chelsea Brooks, a new mom in Florence, canceled a doctor’s appointment because she got the letter telling her she had lost coverage. More than two months later, she got the reinstatement letter and contacted her doctor. The experience was “very confusing,” she said.

Kristen Elliott, a mom in Brandon, got the first letter a few months ago and thought she had lost coverage. But when she went to the doctor a few weeks ago, she found out she was still covered.

“I’m not even sure what was going on with it,” she said.

In March 2020, Congress passed a law requiring “continuous coverage” for Medicaid recipients to ensure no one lost access to health care during the COVID-19 pandemic. That forced states to do something they had never done before: change their systems to stop kicking people off of Medicaid even if they lost eligibility, said Jennifer H. Wagner, director of Medicaid Eligibility and Enrollment at the Center on Budget and Policy Priorities.

Nearly 150,000 more Mississippians are on Medicaid than before the pandemic, said Westerfield, the state Medicaid communications officer.

In Mississippi, the termination notice at 60 days postpartum was already programmed to be sent to recipients. Creating a totally new notice to explain instead that recipients still had coverage is “more complicated than it sounds,” Wagner said. Instead, the state just added a second letter telling recipients their coverage was reinstated.

Wagner said that though she understood why the state sent the letters, they were confusing.

“Coverage is only good if you know you have it,” she said.

The continuous coverage requirement also came with extra federal funding for states. That funding exceeded the extra costs of covering more people in every state. But no state got a better deal from the feds than Mississippi, where the extra federal funding was six times higher than the expanded coverage costs, according to an analysis by KFF, a nonprofit research organization. (The state already had the highest federal matching rate in the country before the pandemic.)

By moving women from managed care to fee for service, and then paying for fewer services, the state saved money.

Mississippi has the second-highest share of births covered by Medicaid in the country, at 60%.

More than 21,000 Mississippi women gave birth while covered by Medicaid in 2020. Nearly all of them should have been able to continue seeing their doctors until the public health emergency ended. The Biden Administration has not yet said when that will happen, but is expected to extend it until at least January 2023.

Mississippi has a high maternal mortality rate relative to the national average. Black women in Mississippi are three times likelier than white women to die of pregnancy-related complications.

Doctors and public health advocates argue that extending postpartum Medicaid would save lives and improve infant and maternal health by ensuring women have access to health care for the first year of their baby’s life. After passing the Senate with broad bipartisan support this year, a proposal to extend coverage to a year postpartum died in the House thanks to opposition from Speaker Philip Gunn, R-Clinton.

Sen. Kevin Blackwell, R-Southaven and chair of the Medicaid Committee, has vowed to reintroduce the legislation. With abortion now banned in Mississippi, lawmakers are under pressure to help families and babies who suffer the nation’s highest rate of infant mortality.

Drew Snyder, the director of the Division of Medicaid, has so far declined to take a stance on whether postpartum Medicaid coverage should be extended. But he recently told the talk radio host Paul Gallo that data from the pandemic, when pregnant women didn’t lose coverage after giving birth, could be used to inform the conversation.

“Maybe one of the benefits of deferring a decision on this is that Mississippi and every other state is going to have 2021 data to show … Did anything happen with maternal health outcomes?” Snyder said. “Particularly late maternal death … That may be a good argument for advocates of the 12-month [extension] to say, ‘Hey, we need to do this.'”

Ignoring COVID

Mississippi doctors and national experts say that idea ignores the effects of COVID-19 on pregnant women. The virus has been linked to higher rates of stillbirth and maternal death.

And now, it appears that many women may not have known they still had health insurance throughout the pandemic.

Henderson saw the coverage help moms – if they knew they had it.

“I have moms who are at two months, four months, six months, 12 months and are on antidepressants and now have those medications covered,” she said. “They are getting therapy. They are getting their asthma and hypertension treated. So, I do know from a parent (and) patient standpoint, that my patients have been positively impacted if their mothers have been able to continue with access and continue with coverage in those instances.”

 
 

Clipped from: https://www.sunherald.com/news/local/article265445286.html

Posted on by

FWA- Philipsburg Woman Sentenced for Social Security, Medicaid Fraud

MM Curator summary

[MM Curator Summary]: Mr. Pearson lied about hubbs moving out in order to keep receiving SSI and Medicaid benefits for over 10 years that she wasn’t supposed to.

 
 

 
 

 
 

 
 

56-year-old Virginia Pearson of Philipsburg will be spending a year and a day in prison after admitting in Missoula Federal Justice Court on Wednesday that she lied for over 10 years to receive Social Security and Medicaid benefits that she was not eligible to receive.

Federal court records indicate that Pearson knew that she was obligated to report her income and other resources, but instead lied for over 10 years to receive over $101,000 in Social Security benefits, over $23,000 from the Montana Department of Health and Human Services, and over $18,000 from Medicaid.

Pearson applied for Social Security benefits in 2006 and was approved to receive the benefits starting in 2008.

Pearson is married to Doyle Pearson, but falsely claimed that he had moved out of their home, thus increasing her benefits significantly. She received nine cost of living adjustments and two ‘change in payment’ letters which explicitly detailed her obligations to report all her income and resources.

Sign up for the Newstalk KGVO 1290 AM & 98.3 FM Newsletter

Get the best of Newstalk KGVO 1290 AM & 98.3 FM delivered to your inbox everyday

An investigation revealed that her statements were false and that she and her husband lived together and co-owned the house.

Montana’s U.S. Attorney Jesse Laslovich said Pearson was sentenced to one year and a day in prison and ordered to pay restitution of $142,542.

U.S. District Court Judge Donald Molloy presided over the case and remanded Pearson into custody.

Inspector General for the Social Security Administration, Gail S. Ennis, said:

“This sentence holds Ms. Pearson accountable for defrauding government programs. As part of her scheme, she abused the Supplemental Security Income program, the needs-based safety net for the most vulnerable among us by falsifying her true circumstances and causing SSA to improperly pay her over $101,000. My office will continue to pursue those who exploit SSA programs for personal gain. I thank our law enforcement partners for their support in this investigation and the U.S. Attorney’s Office for prosecuting this case.”

Assistant U.S. Attorney Karla Painter prosecuted the case.

 
 

Clipped from: https://newstalkkgvo.com/philipsburg-woman-sentenced-for-social-security-medicaid-fraud/

Posted on by

The Territories- Medicaid becomes clashing point in Northern Mariana Islands governor’s race

MM Curator summary

[MM Curator Summary]: Seems the tension between “spend all the money on Medicaid” and “leave a little for other things” exists outside just the 50 states.

 
 

 
 

 
 

The US House of Representatives passed the American Rescue Plan Act in 2021. The goal of the Act is to help states and territories recover from the COVID-19 pandemic. The bill seeks to increase access to vaccines and provide economic relief.  

The American Rescue Plan has become imperative for the Northern Mariana Islands. The pandemic has hit the territory particularly hard; deaths per 1000 are twice the average in the United States.  

The effects of COVID-19 have become a major discussion in the upcoming race for governor. Current governor Ralph Torres (R) is seeking reelection against Christina Sablan (D). 

The American Rescue Plan offers the territory $28 million for Medicaid. However, Torres and his government must match $5 million to receive the subsidy. House committees have prompted Torres to take the offer. With the healthcare crisis worsening in the islands, there is pressure on Torres to act.

If he does not contribute $5 million, the federal government will rescind the offer of $28 million. Without this financial support, Medicaid agencies will have to close critical healthcare providers. Such shutdowns will decrease the availability of doctors and increase wait times for treatments. 

Sablan has made her stance on the American Rescue Plan clear. She has criticized Torres for his lack of urgency in matching the $5 million. Torres responded that he believes the Northern Mariana Islands have enough Medicaid. He has also disapproved of Sablan’s use of the media as a mediator, imploring Sablan to address her concerns directly, rather than through the media. 

The elections will be held this November. 

 
 

Clipped from: https://pasquines.us/2022/09/06/medicaid-becomes-clashing-point-in-northern-mariana-islands-governors-race/

Posted on by

MT/BH providers- Study proposes increases to Montana’s Medicaid provider rates

MM Curator summary

[MM Curator Summary]: The consultants say the state is under paying MH providers by about $82M/ year.

 
 

 
 

 
 

For Dave Eaton, hiring enough staff to help developmentally disabled clients in Livingston with day-to-day tasks is a constant, brutal cycle. Out of every 10 people who come to work at Counterpoint Inc., the small nonprofit he leads, Eaton estimates three leave within a year.

Eaton, the organization’s longtime executive director, attributes the high turnover to one key factor: finding people who want to work a tough job for less than $16 an hour isn’t easy. 

“The work that we’re doing, it involves a lot,” he said. His employees help clients with essential parts of their lives, he explained, like shopping for groceries, applying for jobs and attending community events. Counterpoint’s starting wage is $15.72 an hour.

If he could, Eaton said, he would raise wages to stay competitive with other job options. But Counterpoint, like many other Montana health and social service providers, relies heavily on dollars from Medicaid, the state-administered, federally subsidized public health insurance program. While Montana is responsible for setting reimbursement levels for providers who accept Medicaid patients, money the state puts into its program is matched by federal dollars. 

Eaton estimates Medicaid payments make up about three-quarters of Counterpoint’s revenue, but says they ultimately don’t come close to covering the true cost of its services. The nonprofit routinely resorts to soliciting donations to make ends meet — otherwise, Eaton said, his wages would be even lower.

“We’re competing with organizations, fast food organizations or whomever, to try to pay a living wage,” Eaton said. “And it’s really been impossible for us to do that, given the Medicaid reimbursement.”

A new study, commissioned by the Legislature and supported by Gov. Greg Gianforte’s appointed leadership at the state health department, affirms what providers like Eaton have been saying for years: that Montana Medicaid has underpaid providers for the care they provide to seniors in assisted-living facilities, people with disabilities, and children and adults with mental illnesses and addiction.  

The 186-page report, authored by the international consulting firm Guidehouse Inc., found that Montana’s Medicaid rates for those types of providers are nearly 22% below what the consultants identify as “benchmark standards” for actual cost of care, based on provider records and comparable data from other states and health care organizations. For disability service providers like Counterpoint, Guidehouse calculated the state is underpaying by even more, nearly 26%.

READ THE STUDYDownload

The study says it would cost the state and federal governments an additional $82 million a year to bring Medicaid reimbursement rates up to par for child and adult mental health providers, addiction treatments, disability services and senior and long-term care facilities. The state’s share of that cost would be roughly $28 million annually. In comparison, lawmakers allocated about $856 million in state funds to the state health agency for the current fiscal year.

Department of Public Health and Human Services Director Charlie Brereton acknowledged the importance of the study’s findings in an emailed statement and said the health agency is considering the recommendations. 

“As expected, the preliminary results of our provider rate study demonstrate significant disparities in Montana’s Medicaid reimbursement rates,” Brereton said. “DPHHS is eager to use these evidence-based findings to inform its budget request for the next biennium and support potential rate adjustments that will further develop Montana’s continuum of care.”

The final Guidehouse report is based on a detailed survey of provider expenses, input from months of work group meetings with different provider categories, feedback from union leaders, and public comment. The study’s $2.75 million price tag will be covered by federal pandemic relief funds.

Providers say the problems identified in the study predate the pandemic by several years. When the study was authorized by the Legislature last year, some stakeholders were pessimistic about launching into an expensive and drawn-out process that might only confirm what providers already knew, said Patrick Maddison, CEO of Flathead Industries and board president of the Montana Association of Community Disability Services (MACDS), in an interview this month. But with the results now in hand, Maddison said the study could provide the Gianforte administration and Legislature the hard data they need to prioritize fixing the issue. 

“What the rate study really shows is how underfunded our system has been for over a decade,” Maddison said. “I’m very hopeful that the intent was really how to fix the problem and how to not kick the can down the road. Because I think this administration has inherited the can that’s been kicked down the road for a very long time.”

One of the earliest indications of the study’s impact will be whether Gianforte includes a proposal to increase Medicaid rates in his November budget draft before the 2023 Legislature begins in January. In an emailed comment, Gianforte press secretary Brooke Stroyke said the governor supports the state health department’s efforts “to modernize Montana’s provider rates, and looks forward to receiving the agency’s recommendations.” 

Maddison, Eaton, and other providers said implementing the changes proposed by Guidehouse would help their struggling institutions stay afloat and continue providing critical services. In a MACDS poll of 35 disability service providers last summer, Maddison said, the average staff vacancy rate was 25%. Finding workarounds to adequately staff group homes and outpatient services is complicated, he said, and the wait-list of people seeking services just keeps growing. 

“We are still expected to care for the same amount of people with a quarter less manpower that we need to do the job,” Maddison said. 

At Counterpoint, Eaton said, those staffing struggles are familiar. But increasing rates in line with the study’s recommendations, he said, would be “a game changer for our field.”

“It would be a chance for Montana to really do what needs to be done,” Eaton said. “These are really, really necessary and vital services to the people we work for.”

Providers in other parts of the health care industry, including the Behavioral Health Alliance of Montana, shared similar sentiments. Matt Bugni, CEO of the statewide mental health and disability service provider AWARE, said the Guidehouse rate recommendations “will be a great start to shoring up this system of care that is teetering on collapse,” if adopted in the governor’s budget and the Legislature.

The study’s final recommendations have yet to be dissected in public hearings before interim legislative committees. Rep. Matt Regier, R-Kalispell, who chairs the bipartisan budget committee with oversight of the state health department, said he plans to set aside “a couple hours” to discuss the report during the committee’s upcoming Sept. 14 meeting.

latest stories

Courtroom comment triggers back-and-forth with tribe


Last week, the Fort Belknap Tribe rebuked Secretary of State Christi Jacobsen’s top attorney for a “deeply offensive” comment in a recent election laws trial. The attorney, Austin James, has responded that it was a “misunderstanding.”

by Alex Sakariassen 09.07.202209.07.2022

Can better data help UM retain Indigenous students?


Backed by funding from the Gates Foundation, the University of Montana is trying to use data to improve the campus experience for Indigenous students — starting with smoother service in financial aid.

by Alex Sakariassen 09.06.202209.07.2022

 ‘A great piece of history’


The once and future home to US Bank is currently covered in scaffolding as a cadre of carpenters, masons and other tradespeople work to eliminate any evidence of a 1972 renovation that obscured brick and limestone walls, arch windows and a cornice around the top of the five-story structure.

by Frank Eltman 09.05.202209.06.2022

 
 

Clipped from: https://montanafreepress.org/2022/09/07/study-proposes-increases-to-montanas-medicaid-provider-rates/

Posted on by

NC/SDH- New housing program faces hurdles

MM Curator summary

[MM Curator Summary]: The money is there, the referral system is in place- there’s just not enough actual houses.

 
 

 
 

 
 

By Clarissa Donnelly-DeRoven

North Carolina’s state Medicaid office is sending millions of dollars to organizations that help people with housing, domestic violence, and other chronically stressful situations. 

By paying these agencies to help people on Medicaid with extreme life stressors, the state hopes it can help those same people avoid illness and in the process save money that would otherwise be spent on health care.

The project, called the Healthy Opportunities Pilot, or HOP, began its three-phase roll out in March after years of planning. It started with services to reduce hunger, which many say are going pretty well. In May, the pilot began funding housing and transportation services. In June, the state planned to begin reimbursing organizations that deal with domestic violence. 

 
 

Some portions of the project have been stalled, though.

Researchers have long documented the ways that extremely stressful situations, such as homelessness and domestic violence, impact mental and physical health. The last two decades have also brought research showing how these events can wreak havoc on the mind and body. 

Experiencing and coping with stress is a critical part of human development. Stress – in moderate amounts – is designed to keep us safe. The so-called “fight or flight” response causes the heart to start beating faster, blood vessels to restrict to more quickly push blood, oxygen, and other nutrients throughout the body. We make hormones – like adrenaline – that can give the energy needed to fight, flight, or flee. Our immune system turns up its inflammatory response.

As the body tunnels all its energy into overcoming a stressful situation, it diverts resources from other energy-intensive bodily processes, such as reproduction and the part of the brain that deals with decision-making and controlling emotions.

Over short periods of time, the response works. But if it never turns off — which is what happens when you’re constantly worried about where you’ll sleep, or if your partner will put you in the hospital again — that’s where problems start. 

A heart pumping too hard for too long can cause vascular disease, high blood pressure, and increase the likelihood of a heart attack. Too many stress hormones can exacerbate conditions like diabetes, while reproductive hormones needed to sustain a healthy pregnancy can struggle to turn back on after being suppressed for too long. 

An overactive inflammatory response can lead to the suppression of the immune system — so rather than stress causing sickness, it stops a body from being able to fight off diseases as effectively. Brains can even begin to “rewire,” building up the parts that deal with the threat response, while ignoring the parts that deal with complex problem solving.

Paying someone’s rent is no good if there’s no houses

No other state has ever attempted a project like Healthy Opportunities before, and so there’s been a fair amount of growing pains, from issues with the referral process, to a lack of information about the pilot for Medicaid recipients.

Some of the issues the pilot is facing are more issue specific — the state-wide housing shortage, for one.


Amy Upham is the executive director of the Buncombe County’s Eleanor Health Foundation, an organization helping people with substance use disorder and other mental illnesses connect with transportation, housing, affordable medications, employment, and more.

“We’re ready. We’ve got staff. We’ve got reserves where we can front the cost until we get reimbursed by Medicaid,” Upham said. “We’ve got all the resource lists for housing. We are able to house someone.”

But, she added, “Is there a place to put them? No.”

“We’re finding that there’s not a lot of housing available in Murphy,” said Charam Miller, the director of Macon Program for Promise. “I feel like it’s just a struggle for all of Western North Carolina right now to find safe, affordable housing.”

Those experiences are echoed by research done by the National Association of Realtors, which found that post-pandemic, housing prices across the U.S. rose by about 30 percent, even as the inventory of homes for sale dropped to record lows in 2021. 

At a roundtable discussion hosted by the Duke Margolis Center in July, officials from different agencies involved in the project acknowledged the scope of this issue. 

“When we think about housing, we have a strain in our housing system,” said LaQuana Palmer, who works with the platform NCCARE 360 through which all the program referrals happen.

Even with their expertise and funding, some HOP providers have been struggling to find places for Medicaid recipients in need to live. Other organizations have successfully helped only a handful of Medicaid patients, either through getting them on a housing waitlist or helping them with their utility bills. 

Then there’s the paperwork: housing sustainability plans, inspections and other federal requirements. 

“We can’t even find them a place to live, let alone that they’re gonna want to jump through all these hoops or that the landlord’s gonna want to jump through all these hoops to house this person,” Upham said.

 
 

“Housing services, in particular, have been one of the more challenging types of services for us to implement,” said Amanda Van Vleet, the associate director of innovation at NC Medicaid who oversees the pilot. “The really challenging part there, the core of it, really gets to integrating non-medical services into the Medicaid program.” 

Getting paid by reimbursements, rather than grants, is new for many of the participating organizations. And the process is more cumbersome because the federal Centers for Medicare and Medicaid Services has strict documentation rules for providers that haven’t participated in Medicaid before — which, for the Healthy Opportunities Pilot, is all of the organizations. 

“We are proposing modifications to that right now to try to eliminate what we can while still having enough program integrity in place, but making it a little bit more doable and manageable for the [organizations],” Van Vleet said.

Privacy concerns complicate help for domestic violence survivors

Despite the challenges, housing services are actually starting to get up and running. 

Domestic violence services are a different story. This part of the pilot was supposed to begin its roll out in June, but it didn’t, and the state doesn’t have a timeline for when it will begin. 

The first challenge comes from strict federal privacy laws around handling information and data about domestic violence survivors. These laws are often major funding sources for domestic violence agencies, and they impose limitations on how client information can be shared, and with whom. 

For the purposes of the HOP project, the state is treating domestic violence survivors as Medicaid patients, but that’s tricky.

“A health plan, for example, will need to know who received the service and if they’re a covered member of theirs so that they can pay for their services,” Van Vleet said. “They also need to know exactly what service that person received in order to reimburse for it.”

The state and domestic violence agencies realized that these needs conflict with each other, but it seems they underestimated how complicated they would be to disentangle. 

“That’s the fundamental tension that we’ve been dealing with, is kind of how we’re able to make both of those things work,” Van Vleet said. 

There are technical changes that need to be made to the NC CARE 360 referral platform in order to comply with federal privacy regulations. Those have to be made by the company Unite Us, which contracts with the state to run the platform. 

In a statement, Unite Us said they’re working with state officials and advocates to protect survivors while allowing service providers to get paid.

Contracts between the state and every organization participating in the pilot also need to be updated to include stipulations about data gathering and sharing. And anyone in the program who deals with participants’ data will need to undergo training about domestic violence, privacy, and data security. 

“Because receiving domestic violence services is such a delicate topic, survivors need to be aware of who will know that they have qualified for these services,” said Kathleen Lockwood, the policy director at the North Carolina Coalition Against Domestic Violence, an organization that’s pushed the state around best practices for years.

Each agency in an individual case needs to be mindful of survivor safety. The clearest way this comes up, Lockwood explained, is in contact preferences. For example, if somebody says not to call them or leave a message, that request must be respected — for many, it could be a matter of life or death. 

“We anticipate a survivor accessing services through the Healthy Opportunities Program versus through interacting with their domestic service provider in the community to be receiving a very similar if not the same experience,” Lockwood said.

A stop-gap solution

Organizations have been creating privacy workarounds, explained Jennifer Turner-Lynn, the assistant director at REACH of Macon County, an organization that supports survivors of domestic violence and plans to participate in the pilot.

“When a client comes to us, and we believe they qualify for services, we discuss those service options with them,” she said. “If they are interested… we have them sign a release of information. We assist them in contacting Medicaid.” 

Once they reach their Medicaid case manager, they’ll be referred to another organization in the pilot. Then the client tells that organization they want to receive services through REACH. 

“Our staff completes the service, provides the assistance, and places notes in the system, but never at any point stipulates this person is a ‘victim’; because it’s in [the other organization’s] system,” Turner-Lynn said. “It will look just like any client they serve as it’s under their umbrella, not ours.”

The other human service organization bills Medicaid and then pays REACH after receiving payment. 

“There is only one person, outside of REACH, who ever knows that this person qualifies as a victim, and that’s the key point person at the contracted [human service organization] with whom they talk with immediately,” she said.

It’s definitely roundabout, she said, but so far it’s worked. Those in the field hope the problems will be resolved soon, so they can start providing services and have the effectiveness of their services be evaluated.

“From our perspective any data — however long the span or however short the span — that can show the linkages between health and safety in the domestic violence realm will be valuable data,” Lockwood said. 

“The correlation or causation between receiving services and later health outcomes are really going to make the case for communities to continue to invest in domestic violence services.”

 
 

Clipped from: https://www.northcarolinahealthnews.org/2022/09/08/new-housing-program-faces-hurdles/

Posted on by

MCOS- Medicaid and CHIP Financial Statistical Report Agreed Upon Procedures Results

MM Curator summary

[MM Curator Summary]: Pretty sure this is data at the plan level (in TX) about MLR return payments.. But would love for someone to help me understand for sure. Excel file linked in story.

 
 

 
 

 
 

Per Federal requirement, (42 CFR §438.602(e) and (g); May 6, 2016, Federal Register (81 FR 27497); OMB No. 0938-0920), HHSC is posting the result of each agreed upon procedures review of all Managed Care Organizations’ and Dental Maintenance Organizations’ Financial Statistical Reports by year.

The files below are in Excel format. All totals stated are based on current figures and subject to change.

State Fiscal Year 2018: SFY18 FSR AUP Result Summary (Excel)

 
 

Clipped from: https://www.hhs.texas.gov/services/health/medicaid-chip/managed-care-contract-management/medicaid-chip-financial-statistical-report-agreed-upon-procedures-results