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House Democrats unveil proposals on drug prices, Medicaid expansion

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The health spending legislation is shaping up differently in the two chambers, notably with a reduced planned HCBS Medicaid funding amount than previously expected.


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.



House Democrats on Thursday unveiled a range of health care measures to be included in their coming $3.5 trillion package, including provisions to lower prescription drug prices and expand Medicaid in the 12 GOP-led states that have refused to do so. 

The measure unveiled by the House Energy and Commerce Committee ahead of consideration next week includes House Democrats’ signature legislation to allow the Secretary of Health and Human Services to negotiate lower drug prices, known as H.R. 3. 

That is a contrast with Senate Democrats, who are working on their own proposal to lower drug prices, which is expected to be less far-reaching than the House bill, given the need to win the votes of some more moderate Senate Democrats. The final bill is expected to be closer to the Senate version, but for now House Democrats are sticking with their measure. There also is no text available yet for the Senate proposal, which Democrats say they are still working on. 

The House measure unveiled Thursday would also create a new federal health insurance program to provide Medicaid coverage in the 12 states that have refused to expand Medicaid under the Affordable Care Act, providing insurance to more than 2 million people. 

The new federal program would begin in 2025, with a transition period before then of subsidized private coverage in the ACA marketplaces. Creating a new federal health insurance program has drawn some pushback from the health care industry, which worries it could be a step toward a larger-scale public option for health insurance. 

The proposal includes $190 billion to provide care at home for seniors and people with disabilities, a cut from the White House’s initial proposal of $400 billion, as Democrats look to fit a range of priorities into the package. 

The measure would put $15 billion towards preparing for future pandemics, with steps including shoring up the Strategic National Stockpile and investing in vaccine manufacturing. That is in line with the latest White House request, a down payment on a $65 billion total pandemic preparedness plan. But it is below the $30 billion that had been sought by advocates and was initially proposed by the White House. 

On drug prices, House and Senate negotiations lie ahead on bridging the gap between the proposals, though the final version is expected to hew closer to the Senate version. One major difference is that the House bill sets a cap on drug prices using the prices paid in other wealthy countries. 

Some more moderate Senate Democrats have objected to that idea, and the Senate is instead looking at using a “domestic reference price,” which sources say could include using a version of lower prices paid by the Department of Veterans Affairs, which was first reported by Stat on Thursday. But that measure is still not finalized. 


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Governor Lamont Announces Public-Private Initiative to Address Homelessness and Chronic Health Problems

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CT has gotten federal approval to use Medicaid dollars to coordinate services for 150 homeless members, including housing services.


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.




Connecticut Among First States to Connect Medicaid and Housing Services

(HARTFORD, CT) – Governor Ned Lamont today announced that his administration has received federal approval to combine Medicaid health coverage with a range of housing services for Connecticut residents struggling with homelessness and chronic health issues.

The ‘CHESS’ initiative – short for Connecticut Housing Engagement and Support Services – will pool the efforts of state agencies and nonprofit partners to bring coordinated healthcare and housing support to individuals with mental health, substance use, and other serious health conditions.

“For the first time, the resources of Connecticut’s nationally-recognized Medicaid program will reinforce our ongoing initiatives in the areas of housing and homelessness prevention,” said Governor Lamont. “Also known as the HUSKY Health program, Medicaid will add a crucial dimension to our ability to not only stabilize a person’s housing situation, but to really improve the quality of his or her health and life. The CHESS initiative also reflects my direction to find ways to best coordinate expertise and services across our health and human services agencies.”

Connecticut Medicaid’s CHESS benefit is one of the first of its kind to receive federal approval, joining Arkansas, California, Minnesota, and North Dakota. It will combine the Coordinated Access Network and housing subsidy programs administered by the Connecticut Department of Housing; supportive housing programs administered by the Connecticut Department of Mental Health and Addition Services; and the Money Follows the Person program administered by the Connecticut Department of Social Services (the state agency administering Medicaid).

CHESS is aimed at managing the difficulties that are often part of homelessness, including access to health care and handling chronic health issues, with the overall goal of promoting health and well-being by coordinating targeted healthcare with housing.

“Simply put, we know that housing instability and serious health issues are often related,” said Department of Social Services Commissioner Deidre Gifford, who also serves as senior advisor to the governor for health and human services. “The new Medicaid benefit offers a flexible package of services to help people find and maintain housing, and to coordinate medical and behavioral health services, chronic disease management and wellness education. With CHESS, our public-private partnership aims to reduce homelessness and unnecessary hospitalizations, while making lasting improvements in the lives of some of our most vulnerable residents. The COVID-19 pandemic has also taught us more about the close relationship between safe, stable housing and health.”

Housing subsidies for CHESS enrollees, administered by the Department of Housing, will be prioritized for applicants who meet the Medicaid program requirements and are subject to separate eligibility requirements.

“We are proud to participate in this collaborative effort,” said Department of Housing Commissioner Seila Mosquera-Bruno. “Our goal is to reduce and end homelessness in Connecticut. The CHESS program contributes additional resources to our homeless service system, allowing it to provide the necessary supportive services to vulnerable residents and to maintain stable housing in our communities.”

“Nonprofit supportive housing providers across Connecticut have a tremendous amount of knowledge and years of experience serving people with complex needs and long histories of housing instability,” said Department of Mental Health and Addiction Services Acting Commissioner Nancy Navarretta. “I’m confident that the evidence-based supportive housing model that will be available to CHESS participants will contribute to our collaborative efforts to make homelessness rare, brief, and one time.”

“The recent federal approval of Connecticut’s innovative CHESS Medicaid benefit will lay the groundwork for deeper engagement with our healthcare system partners in efforts to end homelessness in our state,” said Sonya Jelks, Connecticut Director for the Corporation for Supportive Housing. “This trailblazing approach, one of the first in the nation, will provide a new and sustainable source of funding for the critical support services that are key to successfully supporting persons who experience chronic homelessness. The Corporation for Supportive Housing is proud to have been a partner in developing and designing the CHESS approach and looks forward to continuing to collaborate to build on Connecticut’s success with supportive housing – linking services, including housing provisions and healthcare, to permanent housing solutions.”

With federal approval to use Medicaid funding for CHESS, the Department of Social Services has opened applications at Application information is also available by calling 1-888-992-8637 or 2-1-1.

As a new benefit to be evaluated by the UConn Center on Aging, CHESS is currently estimated to serve 150 participants through next fiscal year. The joint state/federal initiative was designed by a collaborative of the Department of Social Services, the Department of Housing, the Department of Mental Health and Addiction Services, the Department of Developmental Services, the Connecticut Housing Finance Authority, the Corporation for Supportive Housing, the Partnership for Strong Communities, and the Connecticut Coalition to End Homelessness.

CHESS provides supportive housing benefits under Medicaid, coordinated with Medicaid services and non-Medicaid housing subsidies. Medicaid-covered housing engagement and support services include chronic disease management and wellness education, in addition to pre-tenancy supports (help with locating and securing housing); tenancy sustaining supports (help with maintaining successful tenancy); and non-emergency medical transportation. The CHESS staff will help participants apply for housing subsidy vouchers.

“We are especially proud of the strong and enthusiastic partnership that is bringing the CHESS initiative forward,” Commissioner Gifford said. “It’s built on leading-edge work in both state government and the private, nonprofit community as we focus on the so-called social determinants of health. In this case, the focus is on the vital area of housing and how lack of stability there relates to chronic disease and, alternatively, well-being.”

The Connecticut Behavioral Health Partnership, through Beacon Health Options, will provide eligibility assessment and service authorization. Federal support is provided by the Center for Medicaid and CHIP Services, part of the Department of Health and Human Services’ Centers for Medicare and Medicaid Services.

Twitter: @GovNedLamont Facebook: Office of Governor Ned Lamont


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Ohio fighting Biden’s decision to eliminate work requirement for Medicaid

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Ohio has officially resisted the current CMS effort to break its contract with the state over work requirements.



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.



Credit: SEAN GLADWELL/Moment/Getty Images

COLUMBUS, Ohio)—Ohio Governor Mike DeWine is fighting the Biden Administration’s decision to eliminate a work requirement for Medicaid.

DeWine requested on Wednesday that Ohio Attorney General Dave Yost take necessary legal action to reverse the decision.

Yost’s Office filed a notice of appeal with the Centers for Medicare and Medicaid Services (CMS).

Biden requiring federal workers, contractors to get COVID shot with no testing opt-out

“Removing a provision that says a healthy, able-bodied individual should be working, looking for work, participating in job training, or participating in a recovery program in order to receive free taxpayer-funded healthcare is contrary to Ohioans’ values,” said Governor DeWine. “Eliminating reasonable requirements discourages people from becoming self-sufficient and only reinforces government dependency. Ohio’s program would offer assistance when Ohioans need it while providing opportunities for future success.”

The Biden Administration revoked Ohio’s work requirements last month following the 2019 approval by the Trump Administration.

Members of the Ohio legislature passed a bill in 2017 requiring the state to establish work requirements for the Medicaid expansion population.


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Medicare & Medicaid Facilities Are Put On Notice: Employees Must Be Vaccinated

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37% of all US healthcare spending will be contingent upon workforce vax policies under the new rules.


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.



Medicare and Medicaid certified facilities will be required to ensure that their employees are vaccinated for COVID-19, the Centers for Medicare & Medicaid Services (CMS) announced on September 9, 2021. Healthcare providers with 100 or more employees also may be subject to a forthcoming Emergency Temporary Standard (“ETS”) from the U.S. Department of Labor’s Occupational Safety and Health Administration (“OSHA”) that also will require that employees be vaccinated for COVID-19. These mandates are part of President Biden’s new six-prong COVID-19 Action Plan (the “Plan”) that he announced last week.

The CMS Vaccine Mandate

Importantly, the new requirements will be a condition of participating in the Medicare and Medicaid programs and will be issued through emergency regulations as an Interim Final Rule with Comment Period expected to be published in October 2021. CMS will accept public comments after the rule is published. The Interim Final Rule will apply to any healthcare facility receiving Medicare or Medicaid reimbursement. The Interim Final Rule builds on the Administration’s August 18, 2021 announcement of a vaccination requirement for nursing facilities. This new rule will apply not only to nursing home staff, but also to staff in hospitals, dialysis facilities, ambulatory surgical centers, and home health agencies. It also will extend to clinical staff and individuals providing services under arrangements, as well as volunteers and staff who are not involved in direct patient, resident, or client care. CMS expects that this new action will protect patients of the 50,000 providers and over 17 million healthcare workers in facilities that receive Medicare and Medicaid funding.

In the meantime, prior to the issuance of the Interim Final Rule, CMS expects certified Medicare and Medicaid facilities to “act in the best interest of patients and staff by complying with new COVID-19 vaccination requirements.” CMS urges facilities to use all available resources to support employee vaccinations, including employee education and clinics, so that facilities will be in compliance when the Interim Final Rule takes effect. CMS also strongly encourages unvaccinated healthcare workers to begin the vaccination process as soon as possible.


Healthcare providers, including those not subject to CMS requirement, may still need to consider the OSHA ETS which will require private employers with 100 or more employees to ensure their employees are either “fully vaccinated” or provide proof of a negative COVID-19 test at least once a week. OSHA will publish the ETS in coming weeks, and it will initially be effective for six months until a final rule is promulgated.

During a briefing on September 10, 2021, OSHA representatives stated that if an employer, including a healthcare provider, is subject to more than one requirement or standard under the Plan, employers will be expected to comply with all requirements and standards. However, OSHA said that its new ETS will be consistent with the other requirements and standards of the Plan. OSHA also stated during the briefing that guidance will be forthcoming for healthcare settings already subject to the current COVID-19 Healthcare ETS. Notably, that current Healthcare ETS permits weekly testing in lieu of vaccination, whereas the Plan does not appear to allow for that option. Therefore, as a result of the Plan, entities covered by the COVID-19 Healthcare ETS may need to revise their OSHA compliance plans.

With regard to compliance specifics and the timeline for complying, in a White House briefing on September 13, 2021, OSHA stated that the ETS will provide the answers. Further, OSHA expects to have a Q&A posted later this week addressing general questions such as coverage and information regarding state plans and covered public employees. Further, OSHA encourages employers who are not subject to the ETS to follow CDC guidance, including circumstances where employees are exposed to persons with unknown vaccination status.

While a publication date for the ETS is unknown, the White House announced it should be published in the coming weeks, with an effective date shortly thereafter. OSHA has the authority to issue citations for non-compliance with a penalty of up to $14,000 per violation. Note also that employers with Collective Bargaining Agreements will still have collective bargaining obligations, and OSHA has advised that the ETS will not change those obligations any more than any other OSHA standard would.

What’s Next

Pending publication of the CMS Interim Final Rule and the OSHA ETS, there are a number of unanswered questions for healthcare providers, including:

  • Whether the CMS Interim Final Rule will include a testing option for employees. As mentioned above, in stark contrast to the information provided about the anticipated OSHA ETS for private employers with more than 100 employees, the Plan does not state whether the CMS action will permit regular testing as an alternative to vaccination.
  • Who pays for the testing under the anticipated OSHA ETS for large private employers, and, if applicable, under the CMS Interim Final Rule. During the September 10 briefing, OSHA said it had not yet decided who will be required to pay for the weekly testing in lieu of vaccination under the forthcoming ETS.
  • The extent to which physician practices are covered by this requirement. The CMS press release has a hyperlink to the following site for Medicare facilities, which includes “all fee-for-service facilities.”
  • How healthcare providers are to verify vaccination status of employees. With respect to ETS compliance, OSHA said during its briefing that it has not yet decided on the process employers are to use to verify the vaccination of status of employees.
  • How this new requirement will affect those facilities and providers already struggling with a shortage of healthcare workers during the current surge in COVID-19 cases.

Because the CMS Interim Final Rule and the OSHA ETS will be issued without notice-and-comment periods beforehand, healthcare facilities participating in Medicare and Medicaid should re-double their efforts to get their workers vaccinated so they can comply. In the meantime, employers should monitor ongoing developments and new guidance and be prepared to pivot accordingly.


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CO: Centers for Medicare and Medicaid offer funding for Colorado’s Reinsurance Program

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CMS has approved 12 states 1332 waivers to use expanded subsidies to drive down premium costs.


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.



(AP Photo/Alex Brandon, File)

DENVER – On Tuesday, Sept. 7, the Centers for Medicare and Medicaid Services announced that it is now offering funding to Colorado and 12 other states to support the Affordable Care Act Section 1332 reinsurance waivers. This nearly $50 million for Colorado’s Reinsurance Program comes from expanded subsidies of individuals buying health insurance from the individual market, instead of an employer, as part of the American Rescue Plan.

$50 million of new federal funds will save Coloradans even more money on health care through the bipartisan Colorado Reinsurance Program,” said Governor Jared Polis. “By slashing health care premiums, Coloradans will have more money in their pockets for groceries or gas while also ensuring quality, affordable health care is available to every Coloradan. This $50 million in additional funds for Colorado’s Reinsurance Program will be used to further reduce insurance premiums.”

The Colorado Division of Insurance administers the Reinsurance Program, lowering premiums and offering affordable coverage by reducing the financial impact of high-cost health insurance claims. 

“The work of the Polis-Primavera administration and the work of the Division of Insurance continue to help Coloradans by making health insurance more affordable. This additional funding will not only help to decrease premiums and get more people covered, but it also helps to strengthen the reinsurance program,” said Colorado Insurance Commissioner Michael Conway.

The funding doled out by CMS ranges from $2.5 million to $139 million per state – varying on factors such as the size of a state’s reinsurance program. The exact amount Colorado will receive in additional pass-through funding will be $49,827,328. The 1332 waiver gives Colorado the ability to fund a substantial amount of the Reinsurance Program with federal funds—dollars that would not have otherwise come to the State. The additional pass-through dollars adds to that funding.

In 2020, the first year of reinsurance, the program saved people 20% on their health insurance. In 2021, it saved Coloradans nearly 21%.

Find more information about the Colorado Reinsurance Program at the DOI’s Reinsurance website.


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Ohio looking at appealing federal government decision on banning Medicaid work requirements

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Ohio is considering fighting the CMS reneging on its approved work-requirements waiver.


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



The State of Ohio is considering filing a lawsuit that will appeal the Biden administration ending proposed work requirements for some Medicaid recipients.


Under the Trump administration, Ohio was able to get a waiver that would require able-bodied people, who don’t have any children, to either work twenty hours a week or get job training for their Medicaid health benefits. The work requirements were supposed to start on January 1, 2021, but with the pandemic, the start date was delayed. In August, the federal government told Ohio they cannot go ahead with this plan because it goes outside the bounds of how Medicaid was set up. Lt. Gov. Jon Husted believes that having work requirements is beneficial to everyone involved.


“We believe it is ultimately valuable for them because an adult who is abled bodied and is not working is probably not doing a lot of constructive things in life,” says Husted. “We want them to do constructive things. We want to help them do constructive things and we want to help give them purpose and opportunity so they can live a better version of the American dream.”

Husted and Governor Mike DeWine have asked Ohio Attorney General David Yost to proceed with the lawsuit, but it hasn’t been filed yet.


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CMS, TX Dispute Over Medicaid Pay Programs Could Affect Provider Pay

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The CMS reneging on the approved TX DSRIP waiver will gut provider payment rates in a month.


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.


Texas providers worry they could face pay cuts if Texas Medicaid officials and CMS don’t promptly hash out an agreement on a state-directed payment proposal that CMS earlier said it wouldn’t approve.

CMS’ notice that it wouldn’t okay the plan as proposed came after a judge ordered the agency to tell Texas it either planned or did not plan to approve the payment programs. Though the payment programs require CMS approval separate from the state’s 1115 waiver, Texas said CMS was violating the terms and conditions of the waiver by dragging its feet on the payment programs.

The judge’s order is part of an ongoing lawsuit Texas filed over the Biden CMS’ decision to revoke a 10-year extension of the state’s 1115 uncompensated care waiver that was granted in January in the final days of the Trump administration. The judge has since placed a temporary injunction on CMS’ rescission of the waiver extension, though CMS previously maintained that it has been acting as though the January waiver was still in effect since May due to Texas also having filed an appeal with the HHS Departmental Appeals Board.

The 1115 waiver as extended in January includes a transition program for Texas’ Delivery System Reform Incentive Program (DSRIP), which rewards performance bonuses to safety net providers that improved health metrics and is set to expire Sept. 30. The transition program, known as the Public Health Providers Charity Care Pool, would still provide incentives but from a smaller pool of money than DSRIP. Texas designed state-directed payment programs to recoup about 80% of the remaining funds that will be lost when DSRIP expires.

John Hawkins, senior vice president of government relations at the Texas Hospital Association, said that not having the state-directed payment programs would hurt provider payments, since some of the payment programs were created as a substitute for a hospital rate increase program in the state. Authority to operate the rate increase program, made possible through the budget neutrality savings from the 1115 waiver, is set to run out at the end of the month, Hawkins said.

The situation also presents challenges for the state’s mental health safety net providers. DSRIP funding was instrumental in building out state mental health capacity. State-directed payment programs — and specifically the behavioral health directed payment program — need to be approved because Medicaid rates alone are not enough to support the level of service delivery Texas wants it providers to sustain, said Danette Castle, CEO of the Texas Council of UHC Community Centers, which represents behavioral health centers across the state.

CMS, in an Aug. 13 letter to Texas, listed areas where the payment programs needed to be altered and offered to extend for one year the DSRIP program. Texas has known since 2017 that funding for the DSRIP program would be phased out by this year. The program is would expire Sept. 30 if not extended for a year.

In an Aug. 16 response to CMS, Texas indicated it believed a one-year DSRIP extension was inconsistent with the Jan. 15 waiver extension.

The Texas Hospital Association hasn’t taken a formal position on whether it would support extending DSRIP for a year, but Hawkins said it is pushing for whichever solution keeps the most capacity in the system with the least amount of disruption. Given that goal, trying to get the state-directed payment programs approved is preferable to a DSRIP extension, he said.

Castle, whose organization petitioned prior to the January extension approval for a DSRIP extension, said if it were between no funding and a DSRIP extension, continuing DSRIP would be the right move. But she doesn’t think the state will have to make that choice.

“We remain confident that the Health and Human Services Commission or state leadership and CMS will be able to come to agreement, whether that is through direction of the court, whether that is through the extension that has been in essence resubmitted, whether it’s through the negotiations going on right now,” she said. “It’s too important not to and I think all parties understand how important it is to do that.”

Hawkins also said he thinks the state is still hopeful that the state-directed payment programs can be approved soon because extending DSRIP isn’t a long-term solution.

The Texas Health and Human Services Commission said it was unable to comment on whether discussion between the state and CMS have begun on the state-directed payment programs because of ongoing litigation. CMS also did not respond to an inquiry by publication. — Maya Goldman (

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Some Medical Clinics Are Hiring Lawyers To Improve Patients’ Health

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More states are providing lawyers to help members sue to get more benefits.


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.



In her 19 years of living with cerebral palsy, scoliosis and other ailments, Cynthia Enriquez De Santiago has endured about 60 surgeries and her heart has flatlined at least four times.

But the most unusual doctor’s referral of her life came last year: Go see an attorney.

Enriquez De Santiago sought help at a Commerce City, Colo., health clinic that takes a novel approach to improving the health of its patients: It incorporates legal assistance into its medical practice for patients facing eviction or deportation proceedings, among other legal woes. And the state’s Medicaid program helps fund the initiative.

Although Medicaid traditionally doesn’t fund clinics to supply legal assistance, Colorado is one of several states that have been given permission to use some of their Medicaid money to help pay for such programs. Every day in Commerce City, four lawyers join the physicians, psychiatrists and social workers at Salud Family Health Centers’ clinic in this suburb north of Denver, as part of Salud’s philosophy that mending legal ills is as important for health as diet and exercise.

The goal: Reduce dangerous levels of stress and keep families intact, on the premise that it will serve their health for years to come, says Marc Scanlon, the attorney who directs the program.

Mostly, that has meant helping people with unemployment benefit claims and Social Security Disability Insurance denials. But it also regularly entails helping patients — many of whom speak only Spanish after having arrived here from Mexico or Central America — with immigration hearings.

Based in health clinics, but only rarely using Medicaid dollars

The program is among at least 450 existing medical-legal partnerships across the nation that typically serve impoverished people and migrants. The vast majority don’t rely on Medicaid dollars, which are only used in fewer than 10 states, according to the National Center for Medical-Legal Partnership.

The role of these sorts of medical-legal partnerships has grown over the past year as millions of people in the U.S. have faced lost income and the threat of losing their homes during the COVID-19 pandemic. Some partnerships have helped patients secure unemployment checks, while others have fought some of the evictions that weren’t already barred by state or federal moratoriums.

“All the issues that people are struggling with in the pandemic are the same issues that medical-legal partnerships have been trying to work with forever,” says Vicki Girard, a law professor and co-director of the Georgetown University Health Justice Alliance in Washington, D.C.

In Montana, Kallie Dale-Ramos helped persuade a primary care association, the state’s legal aid organization and six community health centers operating in cities across Montana to pool $20,000 to help hire an attorney, who can split time among the clinics to help patients affected by the pandemic.

Since the start of 2020, that investment has helped more than 130 patients seek unemployment claims — and potentially stave off financial ruin.

One woman had been waiting for unemployment assistance since applying in March 2020, and only recently received her first check, says Dale-Ramos. Without legal help along the way, the woman “would have just been like, ‘I can’t do this anymore,’ ” Del-Ramos says.

This sort of legal-medical partnership is centered on the notion that doctors can do only so much to keep their patients healthy.

Advocates for such programs cite the example of a child suffering from asthma caused by mold in a dilapidated apartment. While a doctor couldn’t force a landlord to clean up the property or allow a tenant to break their lease, a letter from a lawyer might be persuasive, says Dr. Tillman Farley, Salud’s chief medical officer.

Proponents see lasting impact

“Some of these impacts carry out for decades,” Farley says. “And once you get into effects like that, then you’re really talking generational changes in health outcomes.”

Beyond common sense, evidence from emerging research suggests the approach can work. Patients at Veterans Affairs clinics in Connecticut and New York, for example, saw their mental health improve significantly within three months of consulting a clinic attorney, according to a 2017 study in Health Affairs.

And at Colorado’s partnership, a survey of patients from 2015 to 2020 found statistically significant drops in stress and poor physical health, as well as fewer missed medical appointments among its 69 respondents, says Dr. Angela Sauaia, a professor at the Colorado School of Public Health who led the research.

The possible reasons for missing fewer doctor appointments after getting the legal help, Sauaia says, included patients having more income, being less depressed and having an improved immigration status that made them less fearful to venture into public.

Medical-legal partnerships should be considered part of health care, Sauaia believes. “You should be referring to them the same way a provider would be referring a patient to a specialty, such as endocrinology or surgery.”

The biggest challenge for these programs is securing stable funding. Many are funded with a small amount of seed money, or by grants that run only a year or two.

Medicaid, established in 1965, is a nationwide health care program for people who have low incomes or are disabled. It’s jointly funded by the federal government and each state, and traditionally has covered medical costs such as physician visits and hospital stays.

In recent years, though, some states have increasingly sought to use Medicaid dollars to fund initiatives such as using social workers or offering legal assistance to address the social determinants of health. That includes North Carolina, which is using a federal waiver and hundreds of millions of dollars in a highly scrutinized effort to transform its Medicaid program. Among its strategies is more legal aid for patients.

Some critics see overreach by Medicaid plans

The nationwide shift has prompted some health policy experts to question whether Medicaid is beginning to run too far afield of its purpose.

“Everybody agrees that social factors play a very large role in health outcomes; the question is what to do about it,” says James Capretta, a resident fellow of the American Enterprise Institute who was an associate director of the Office of Management and Budget during the George W. Bush administration.

“Medicaid is already an immense program with lots of financial challenges,” Capretta notes. “The program was not built for Medicaid to pay for too many services beyond the more direct services that are related to a medical condition or a disability.”

The small-scale use of waivers and supplemental Medicaid dollars to fund programs aimed at the social factors of poor health — such as housing for people with severe mental illness — works in some places, says Matt Salo, executive director of the National Association of Medicaid Directors. But for Medicaid to provide widespread funding for such social service programs would be unsustainable, and shouldn’t happen, he says.

“It is not — and should not be — Medicaid’s responsibility to figure out how to pay for it,” he says.

Some advocates for legal assistance programs and health policy experts worry about a potential backlash based on misperceptions about how the little-known medical-legal partnerships use Medicaid. For one, the programs generally aren’t reimbursed for services in the same way traditional Medicaid programs are, notes Sara Rosenbaum, a health law and policy professor at George Washington University.

A 2019 Manatt Health Strategies report on funding for medical-legal partnerships said “the time is ripe” for these partnerships to explore the little-used avenues available in Medicaid.

The states that administer the Medicaid programs and the managed care organizations that contract with them have some discretion to fund non-clinical services that improve access or outcomes for social determinants of health, according to the report.

States also can write the medical-leaderships programs into a larger federal waiver application for experimental, pilot or demonstration projects that promote Medicaid’s objectives.

“The dollars are minimal,” says Ellen Lawton, former director of the National Center for Medical-Legal Partnership, and a senior fellow at HealthBegins, a consulting firm. “And I think what we’re seeing is that — appropriately — the Medicaid programs are pacing themselves. They’re looking to see what works — what works in our state, what works in our region, what works with the populations that we’re focused on.”

States have been creative in funding these sorts of legal assistance programs. Colorado officials say they amended their Medicaid spending plan to provide grants to two such partnerships. Other states have sought federal waivers allowing them to support those programs. The Department of Veterans Affairs also has funded medical-legal partnerships at clinics.

Scanlon, the attorney at the Salud clinic, is part of a nonprofit organization called Medical Legal Partnership Colorado that operates under a joint agreement with the clinic. Colorado’s Medicaid program approved a $300,000 grant to the partnership that was renewed this year to pay for three attorneys’ salaries.

Authorizing the funding took little convincing, says Michelle Miller, chief nursing officer for the state’s Medicaid program. “When we were asked to approve funding for this, I jumped at it,” Miller says.

One woman’s story

For Cynthia Enriquez De Santiago, the 19-year-old patient from Salud’s Commerce City clinic, legal advice made all the difference to her medical care.

In addition to her cerebral palsy, the teen is blind and has difficult speaking; she needs round-the-clock care, including help eating and using the bathroom. Her doctor at the clinic put Rafaela De Santiago, Cynthia’s mother, in touch with an attorney who could help her continue to be her daughter’s legal guardian after the teen turned 18 last year.

The timing of that legal help proved critical: Several months after seeing the attorney, Cynthia was rushed to a hospital. For no obvious reason, she’d became hypothermic; her blood pressure dropped and her blood-oxygen levels cratered.

“The doctors were telling me I had to be ready for the worst,” says the teen’s mother through an Spanish-to-English interpreter.

Because she was Cynthia’s legal guardian, her mother was able to sign off on follow-up tests after that emergency to quickly get to the root of the medical problem and help prevent it from happening again.

Without guardianship, “it would have been really, really hard, because I wouldn’t know where to begin the process,” Rafaela De Santiago says.


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Pa. DHS wants to move Medicaid assessments to Maximus, angering legislators

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PA wants to take away the assessments from AAAs, who have a conflict of interest because they also provide the services driven by the assessments.


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.


The change is part of a long-term effort to eliminate conflicts of interest in determining who is eligible for Medicaid benefits.


Meg Snead is the Acting Secretary of Human Services. The agency plans to change who does physical assessments for Medicaid eligibility in Pennsylvania. In West Philadelphia in June, she spoke on the safety and health precautions for families and their children this summer.Read moreTYGER WILLIAMS / Staff Photographer

Democrats and Republicans in Harrisburg don’t agree on much, but this week at a joint hearing held by four committees, they were united in their dismay over a Wolf administration effort to change who conducts physical assessments of elderly and disabled Pennsylvania residents when they apply for at-home services under Medicaid.

County agencies on aging such as the Philadelphia Corporation for Aging now provide those assessments by the thousands, while Maximus Inc., a publicly traded company based in Reston, Va., collects financial information from individuals and enrolls them in Medicaid if they qualify. The company is getting paid $36 million this year for those services.

Now, the Human Services department, which administers Medicaid, wants to take the contract for physical assessments for home and community-based services away from the local agencies and give it to Maximus, as well. Department officials declined to say how much additional money Maximus would receive under the proposed new contract.

The change, which also would take business away from agencies that serve disabled people, doesn’t sit well with consumer advocates and elected officials, who say they already hear regular complaints about Maximus in its current role. Kansas dropped Maximus from its Medicaid program at the end of the last year. The company has also come under fire in New York and other states.


We’ve spent millions of dollars on a company that has time and time again fallen short on meeting the individual needs of our loved ones,” State Sen. Michele Brooks, a Republican from Northwestern Pennsylvania who chairs the Health and Human Services Committee, said during opening remarks.

The three other panels were the Senate Aging & Youth Committee, the House Aging & Older Adult Services Committee, and the House Human Services Committee. Republicans control the state legislature.

“The fact that we have never had a joint hearing this large before and with so many members in agreement about the impact this decision could have for our communities underscores our collective resolve to see our commonwealth’s government do better by our constituents,” said State Sen. Maria Collett, a Democrat who represents parts of Montgomery and Bucks Counties and is minority chair of the Aging & Youth Committee.

Neither the human services department nor Maximus, which says on its website that it already conducts similar assessments in 14 other states, testified at the hearing Monday because the department’s award of the assessments contract is under protest by the Pennsylvania Association of Area Agencies on Aging.

After the hearing, officials at the department and at Maximus, which had $3.5 billion in revenue and $214 million in net income in the year ended Sept. 30, 2020, said they could not comment. The stock is up about 15% year-to-date and closed Thursday at $84.60.

Maximus’ performance improved last year, state records show. The company completed processing for 73,611 applications, and 94% of them were done within the expected 90-day window, up from 84% in 2019, according to the state data.

The Human Services department did not act in a vacuum when it hired Maximus five years ago as an independent Medicaid enrollment broker. Federal regulators had urged the agency to separate the enrollment function from the provision of services to Medicaid beneficiaries. The fear was that the local agencies had a conflict of interest because they were doing both at the time.

Financially, the stakes are still significant for the aging agencies. Statewide, the 52 local agencies received nearly $34 million for assessment services. The Philadelphia Corporation for Aging alone was paid $11 million for assessment services in the year ending June 30. Najja Orr, the agency’s chief executive, testified that the nonprofit had $87 million in revenue last year.

JR Reed, executive director of the Lehigh County Office of Aging and Adult Services, testified that losing the revenue from the assessments would cost his agency six case workers — about a quarter of the total — and one supervisor.

The contract, technically a grant agreement, for physical assessments is currently held by the Pennsylvania Association of Area Agencies on Aging Inc., though the work is done by local agencies.

It is common for losing bidders to formally protest contract decisions by the Human Services and other state departments, as the Pennsylvania Association of Area Agencies on Aging did in this case. Since 2015, the Human Services department has been trying to award new contracts for insurers to manage Medicaid benefits that cover physical health, but has been stymied by protests and court losses.

Following protests, the state Department of Health at least temporarily abandoned its plan to award contracts to new local agencies to manage the Special Supplemental Nutrition Program for Women, Infants, and Children, commonly known as WIC, Spotlight Pa. reported Wednesday.

Elected officials at Monday’s hearing heard the excruciating account of Tammy Schwab’s 11-month — and counting — struggle with Maximus to secure home care for her 20-year-old daughter, Teneille, who has physical and intellectual disabilities. The Mercer County woman said the only person she could count on for help was a representative of the Mercer County Area Agency on Aging.

Directors of four area agencies on aging and one county commissioner testified about the problems — delays, lost paperwork, unreturned phone calls — seniors already have with Maximus, even before the company takes on the additional responsibility of physical assessments.

Diane Marseglia, a Bucks County commissioner and social worker by training, said that in addition to performing 3,300 assessments last year, her county’s Area Agency on Aging fielded 842 calls from people asking for help dealing with Maximus.

Reed, from Lehigh County, said at the hearing that a hospice case worker complained that it took six months for one client to get through Maximus and become eligible for hospice care at home.

“Their clients don’t have this amount of time to be without services,” he said.


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Montana’s plan to end continuous Medicaid coverage sparks objections

MM Curator summary


MT lawmakers want to increase the frequency of eligibility determinations to reduce spending on ineligible members, but some advocates say the disruption to care is not worth 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.


HELENA — Some Montana Medicaid recipients are pushing back against plans to end 12-month continuous coverage for certain people enrolled in public health insurance programs as the state’s public comment period on the new policy draws to a close. If successful, the change would likely alter two Medicaid programs in Montana in significant ways, both for enrollees who rely on the state for health care coverage and for officials tasked with operating the new system.

The state will stop accepting public comment on its proposals on Aug. 31.

While the state Department of Public Health and Human Services estimates that ending continuous eligibility, or a year of uninterrupted health care coverage, will save the federal and state governments roughly $22 million a year in the cost of benefits, critics say the change could result in temporary lapses in coverage for more than 20,000 people in a given year. 

Inherent to opponents’ concerns is the prospect of Montanans losing coverage because of paperwork, communication and bureaucratic errors rather than true income ineligibility, an outcome DPHHS has said it would make every effort to avoid. 

“I’m still unclear as to what the outcome is that the department hopes to seek. But I am pretty sure that, whether intended or not, the outcome will be a reduction in the rolls.”

Rep. Mary Caferro, D-Helena

The department contends that checking eligibility on a more frequent basis will help ensure that people who don’t qualify for the public program won’t remain on the rolls, saving the state money in the process.

But vagueness about what might replace the state’s current system has sparked anxiety among some residents insured by the impacted programs, including single adults with incomes below 138% of the federal poverty level and people diagnosed with a serious disabling mental illness (SDMI). 

“I depend on Medicaid for my mental health problems, and when I have my medicine I feel normal. Please don’t make me worry about going without my medicine,” said one man in a written comment submitted to the department through the nonprofit Montana Women Vote. “Do not end continuous eligibility.”

Montana Free Press is not publishing the names of quoted commenters, who did not respond to interview requests, in order to protect personal medical information. Montana Women Vote estimated it has helped submit roughly 175 comments from individuals in the past month.

Another woman wrote to the department out of concern for her goddaughter, saying it would be “unfair and cruel to end continuous eligibility,” and that the change would make it “difficult or impossible” for her goddaughter to maintain health care coverage.

One recipient told state health officials he depended on Medicaid for “life saving” medicine for diabetes, and urged them not to alter the program’s verification process.

“Please don’t do this to the people that depend on this,” he wrote.


Montana and New York are currently the only states that permit continuous eligibility through an agreement with the federal government agency that administers Medicaid and Medicare. Ending continuous eligibility would happen through a waiver submitted to those federal officials, who may accept or reject the proposal. 

The draft waiver changes developed by DPHHS contain no details about what would replace Montana’s current process of vetting eligibility and income once a year. Department staff said deliberations about program logistics will likely continue between federal and state officials after the waivers are submitted.

“We are implementing this waiver change under the direction of the Montana state Legislature. The funding to pay for continuous eligibility was removed from our budget and there was clear language in directing us to pursue this policy.”

Marie Matthews, DPHHS

The department’s move comes in the wake of a legislative session in which lawmakers failed to pass a complex bill, Senate Bill 100, that would have ended continuous eligibility and made several other changes to how Montana verifies Medicaid eligibility.

Late in the session, lawmakers then passed a budget amendment authorizing DPHHS to end continuous eligibility for adults who are covered through the 2015 Medicaid expansion program. That group includes single adults whose income is up to 138% of the federal poverty level. Nearly 10% of Montana’s total population, or 101,484 enrollees, were covered by Medicaid expansion as of this July.

“We are implementing this waiver change under the direction of the Montana state Legislature,” DPHHS Medicaid and Health Services branch manager Marie Matthews said in an August hearing before lawmakers. “The funding to pay for continuous eligibility was removed from our budget and there was clear language in directing us to pursue this policy.”

Though not instructed to do so by the state Legislature, DPHHS has said it will also submit a waiver amendment to the federal government to end continuous eligibility for roughly 20,000 Montanans covered by the WASP (Waiver for Additional Services and Populations) program, which insures low-income families and caretakers as well as people 18 and older who are diagnosed with a serious disabling mental illness (SDMI). The department has said its reason for doing so is to avoid “significant additional administrative burden” if the state continues 12-month continuous eligibility in one program and not the other.

During the August meeting, department officials stressed that a person would be removed from the program only after verification that their permanent monthly income level has exceeded the eligible amount.

“If somebody makes enough income that they’re no longer eligible for Medicaid coverage, then the next tier is the subsidized [Affordable Care Act] plans on the exchange,” said DPHHS Director Adam Meier, who added that he would expect some residents’ health outcomes to eventually improve after leaving Medicaid, based on a presumption that they will have a larger income.  

“I would think that as people improve their economic situations, as they’re making more income, that would then be their impetus for no longer qualifying [for Medicaid], then we may see a corresponding increase or improvement in health outcomes,” Meier said.


None of the members of the public who testified before lawmakers in August voiced support for the proposed DPHHS waivers. 

Asked how many public comments the department had received so far, and whether those comments supported or opposed the proposals, a DPHHS spokesperson told MTFP that information will be available after public comment closes on Aug. 31 and the department has submitted its proposals to the federal government. 

Democratic lawmakers on the Children, Families, Health, and Human Services Interim Committee in August repeatedly asked members of the department to explain what they consider the benefits of discontinuing continuous eligibility, and how many people would likely be impacted by the change. 

“There’s lots of research that basically shows that by providing people more stable coverage, they end up being healthier. They are able to get primary and preventive care so that they don’t have a diabetic coma, so that if they have asthma, they don’t end up in the emergency room.”

Dr. Leighton Ku, Director of the Center for Health Policy Research at George Washington University

“I’m still unclear as to what the outcome is that the department hopes to seek,” said Rep. Mary Caferro, D-Helena. “But I am pretty sure that, whether intended or not, the outcome will be a reduction in the rolls.”

The department, citing a 2013 study conducted by researchers from George Washington University, estimated that ending continuous eligibility would reduce months of coverage by 2.6%. Caferro said that calculation seems to use “sterile language” to avoid accounting for the impact on real Montanans.

“You know, when you say 2.6% of whatever, we’re talking about people,” she said. “WASP, for example, covers people who are seriously mentally ill and also the families who live in extreme poverty … we are talking about people’s health care and people’s lives.”

Pinpointing the number of people affected by the waiver change is difficult, said Dr. Leighton Ku of George Washington University, one of the researchers whose work DPHHS cited in its estimate of reduced coverage. 

In a written comment submitted to the department and in a later phone interview, Ku said a reduction of 2.6% covered months would likely be distributed across enrollees who would temporarily lose coverage for a short amount of time within a year. If enrollees had their coverage discontinued for roughly two months before they could re-enter the program, Ku said, the number of affected residents could reach as high as 15.6%, or roughly 21,500 people.

Ku said that “churn,” the process of people exiting public programs only to re-apply a short time later, can also create administrative strain on public health departments, on top of the increased vetting and communication demands on state employees. In its proposed waiver changes, DPHHS does not estimate the anticipated costs of running the program with more frequent eligibility checks.

If people fall through the cracks because of miscommunication with DPHHS about their income and eligibility, Ku said, their health care may also be more expensive when they come back to a public health insurance program. More importantly, he said, interrupted health care could have serious repercussions for some individuals.

“If you have diabetes, for example, that means that actually you want your insulin and your medications all year round,” Ku said. “You don’t want to say, OK, insulin for 10 months, two months I’ll go without. That’s how you end up having problems. Like you go into diabetic coma.”

Nationally, health care researchers have encouraged states to enact continuous eligibility policies for particularly vulnerable people with public insurance, such as children, because of improved long-term health outcomes. Ku said he and others are suggesting that states apply that perspective to their Medicaid policies for adults as well. 

“There’s lots of research that basically shows that by providing people more stable coverage, they end up being healthier. They are able to get primary and preventive care so that they don’t have a diabetic coma, so that if they have asthma, they don’t end up in the emergency room,” Ku said. “If there is someone who has, you know, a mental health problem, that they don’t go off their medications, they can still get counseling, so they don’t have a psychotic attack.”

After the close of public comment next Tuesday, DPHHS has until Sept. 3 to apply changes to the proposed waivers and submit them to the federal government. Before any waivers are approved, federal officials will open another 30-day public comment period and could enter negotiations with state officials on the details of proposed plans.

One other logistical reality hangs over Montana and other states looking to change their enrollment and eligibility processes for Medicaid. Given the federally declared public health emergency in place because of the COVID-19 pandemic, states must keep continuous eligibility in place or risk losing an enhanced federal match rate for Medicaid. 

In its presentations on the topic, DPHHS has said it will continue to follow the federal pandemic guideline so as not to sacrifice that boosted rate. The department has said the federal emergency declaration is expected to continue until Dec. 31, and could possibly be extended further, likely pushing the implementation of any changes to Montana’s Medicaid programs into 2022.

by Eric Dietrich 08.23.202108.23.2021


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