Clay’s Weekly Medicaid RoundUp: Week of June 25th 2018

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-

SIMPLIFY THE MATH, UP THE SAVINGS- Pretty entertaining to watch the debate over “savings” of the new Medicaid managed care ramp up in Iowa (I say new, its been a year or 2 now, just seems new since the media keeps tarring and feathering it anew each day). The numbers have been a roller coaster, hitting a high of $232M last year, then dropping to $47M. Now the “savings” is back up to $141M. The New New Medicaid Math is simpler and better, mainly because it shows more savings. Here’s an idea – how about fee for service sucks in terms of quality of care and that’s a good enouch reason to have managed care in Medicaid? Is that good enough to let Iowa move into the 21st century healthcare system for Medicaid members? Let me know when we start scrutinizing savings estimates of more popular “innovations” like social determinants waivers or health lifestyle / member engagement programs. Ready to have your savings math beaten up every day for 2 years on those?


CMS SAYS NAH (READ THAT IN YOUR BEST APPROXIMATION OF BOSTON ACCENT) TO MA- Short backstory, Massachusetts wanted to opt out of the Medicaid Drug Rebate Program because it forces them to pay for whatever drugs are approved on the federal formulary (I’m simplifying). Early analysis suggests MA was hoping to have their cake and eat it, too. They wanted to exclude some drugs in their program, but also keep getting the rebate goodness on other drugs via MDRP. CMS said that is not workable. Sort of the basic way the MDRP functions, folks. Maybe MA will revise the request to opt out of MDRP altogether? Or follow OK, which recently got its plan approved to modify its Medicaid rx program (by adding more rebate deals tied to outcomes of the drugs)?


CMS READY TO START CHECKING RATE CELLS- CMS will be doing some verifying of who goes in what rate cell. For non-MCO readers, think of rate-cells as buckets that members get put into. The MCO gets paid different amounts based on the bucket. If Clay is in the 20-25 year old healthy male bucket, the MCO might get $200pmpm. If instead he is in the TANF-SNAP-SSI-DISABLED-ELDERLY bucket, the rate cell would pay out much higher (maybe around $1,200 pmpm depending on the market). From a state perspective, you want to get as many people as possible in the ObamaCare Magic Money bucket / rate cell – because that’s the one feds pay almost all the costs for (going rate of 90% as we come down from the high of ACA expansion coercive fmaps). CMS will now be doing more audits to confirm that enrollees are correctly placed in the pre- or post-expansion rate cells. The agency also announced audits of states like CA that OIG found to be incorrectly enrolling people in Medicaid.


HOLY SMOKES BATMAN! UPDATE THE WORK REQUIREMENTS MAP TO SHOW MICHIGAN- I think this is the state that the legislators passed a law that would stop salaries for the Governor’s HHS staff if he didn’t submit a waiver request to CMS for work requirements. Looks like the strong-arm tactics worked (I have never seen anything like this in all my 87 years of doing Medicaid). The bill passed includes terminating the expansion program (people who did not have Medicaid before 2014 or so) if CMS does not allow the state to charge a 5% premium to able-bodied, non-elderly bennies at 100-133% federal poverty level. The gloves are off.


CONGRATS TO THE KANSAS MCO CONTRACT WINNERS- Aetna, United and Centene (Sunflower State Health Plan) all won renewals in KS this week. Amerigroup got the boot. Winners – Congrats!


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.  Susan Britt of Norwich, CT was arrested this week on charges of getting paid $91k for services not provided (she’s a mental health counselor). Felicia Blount and Charlotte Hunter of Gary, IN were charged with stealing $100k using inflated mileage reports in their medical transportation business. Collins Anyanwu-Mueller of Westchester, NY was sentenced on Monday for stealing $392k from Medicaid using false claims for private-duty nursing care. He got caught when investigators found claims for the same time he was in Europe and for other times when the members were in a hospital or being cared for by another nurse. Frank Patino of Livonia, MI got nabbed for stealing 112M Medicaid bucks using an illegal opioid prescribing scheme. There is something in this story about Patino giving away free hams, but I can’t verify it. Please, please, please write in if you know anything about the hams. Patricia Lancaster of Wheeling, WV was convicted on false claims charges this week. She stole $181k from Medicaid by submitting false claims for “adult companion services” (seems like personal care services, based on what I am seeing). Problem is (in addition to the bogus claims) that she lived with the patient – which made her ineligible for the payments. She knew this, which is why she tried to hide it from the agency. Mr Patino – the $112M and intrigue of the hams put you over the top this week. You win! Taxpayer you lost (about $113M to be exact, just on the ones I found this week).


That’s it for this week. As always, please send me a note with your thoughts to or give me a buzz at 919.727.9231. Get outside (batten the hatches! Summer storms are here) and keep running the race (you know who you are).

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