Tag: State News

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PROVIDERS- Dental care rose among low-income pregnant women after 2015 Medicaid change

MM Curator summary

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.

 
 

[MM Curator Summary]: VA opened up dental services (beyond emergency extractions) for pregnant moms and has seen a 14% increase in utilization for dental services since 2015.

 
 

 
 

Clipped from: https://www.virginiamercury.com/2023/02/13/study-dental-care-rose-among-low-income-pregnant-women-after-2015-medicaid-change/

 
 

(Katie O’Connor / Virginia Mercury)

More pregnant women enrolled in Medicaid are getting dental care after a 2015 change in state regulations that expanded Virginia Medicaid coverage.

A new study from Virginia Commonwealth University’s School of Dentistry and Business found Medicaid-enrolled pregnant women who self-reported having dental insurance jumped from 44.4% to 71.6% between 2013-14 and 2016-19, the three-year period following the change, while those receiving dental services grew from 30.3% to 44.3%.

Prior to the 2015 change, emergency extractions were the only dental service coverage available for pregnant enrollees. 

Medicaid is “definitely a huge sigh of relief for people who need care,” said Shillpa Naavaal, lead author of the VCU study, especially for operations like root canals and crowns that can cost upward of $2,000 out of pocket.

However, researchers say many pregnant people enrolled in Medicaid still don’t know they have dental coverage and more work needs to be done to increase awareness.

A 2015 regulation issued by former Gov. Terry McAuliffe’s administration expanded Medicaid benefits to include comprehensive dental coverage for pregnant women aged 21 years and older through 60 days postpartum as part of the A Healthy Virginia Plan. 

Oral health problems during pregnancy are associated with serious health consequences for both mother and baby, the VCU study reports, including high blood pressure, premature birth and low birth weight. 

The purpose of the study, Naavaal said, was to understand when or how the change would impact pregnant Medicaid enrollees.

“The policy was put in place and things kind of moved on,” Naavaal said. “We really didn’t know what happened after.”

Nearly 35,000 pregnant Virginians are enrolled in Medicaid as of this month, according to the Virginia Department of Medical Assistance Services.

Researchers analyzed data from the Virginia Pregnancy Risk Assessment Monitoring System, a survey designed to capture women’s experiences during pregnancy in the years before and after Virginia’s policy change. 

While the increase in dental care is an encouraging sign, Naavaal said, the data indicate some pregnant women don’t realize they have dental benefits through Medicaid. 

There are many ways to increase awareness of the benefit, Naavaal said, such as media coverage and Medicaid itself directly informing enrollees and medical and dental providers.

Medicaid-enrolled pregnant women may not think about dental care during their pregnancy if they don’t know about the benefits, Naavaal said, but maternal care providers could inform them of the coverage and importance of using it. 

Additional barriers may also be preventing low-income women from getting dental services while pregnant. For example, it’s possible that some women in the study weren’t able to schedule time for an appointment within their window of eligibility or were unable to find a provider nearby who accepted Medicaid patients. 

Virginia lawmakers voted to expand Medicaid eligibility again in 2019 after years of Republican opposition by increasing the income threshold for eligibility to 138% of the federal poverty level, which is currently $18,754 for a single individual. 

In 2021, the state’s budget included dental care coverage for all new and current Medicaid enrollees ages 19 to 64, as well as coverage for pregnant women regardless of their immigration status. 

“Hopefully after five years we do the study again, we see that there are only a few that don’t know or that everybody now knows that they do have coverage,” said Naavaal.

Dental services for pregnant Medicaid enrollees are offered through the Smiles for Children program. Details can be found through the Virginia Department of Medical Assistance Services website. 

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MH/BH- Hundreds of thousands of Medicaid patients seek mental health care in emergency rooms

MM Curator summary

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.

 
 

[MM Curator Summary]: A new study begins to quantify how much ED is used for mental health in multiple states.

 
 

 
 

Clipped from: https://oregoncapitalchronicle.com/2023/02/13/hundreds-of-thousands-of-medicaid-patients-seek-treatment-in-emergency-rooms/

A study by Oregon Health & Science University found that patients in Iowa, Nevada and Ohio had the highest rates of use, while Oregon was in the middle

 
 

Emergency rooms, like the one at Oregon Health & Science University, end up boarding mental health patients who have no where else to go. (Christine Torres Hicks/OHSU)

A new study shows that hundreds of thousands of low-income patients seek mental health care every year in emergency departments across the country rather than in clinics designed to treat them.

Those patients include thousands of Oregonians, the study’s lead author told the Capital Chronicle.

John McConnell, a health economist at Oregon Health & Science University, led the study, which he said was one of the first of its kind to use newly available Medicaid data to chart emergency department visits for mental illness. 

“Mental health is very important to the Medicaid program,” McConnell said. “Medicaid covers a disproportionate number of people with mental health conditions. It’s hard to really measure access to mental health care, so you can consider this a proxy for access to care.”

Published in the journal Health Affairs, the study looked at 12 million adults in 2018 on Medicaid, which covers one in four in Oregon and nearly as many nationwide. The researchers found that these patients in some states – Iowa, Nevada and Ohio – had the highest number of per-capita emergency department visits for mental health care, while patients in other states – Colorado, West Virginia and Arizona – sought emergency care for a mental health issues at the lowest rates nationwide.

Oregon fell in the middle.

McConnell said that probably reflects an emphasis in Oregon on keeping people on Medicaid out of emergency departments. Regionally based insurers, called coordinated care organizations, manage care for Oregon’s Medicaid patients. The state has pressured them to reduce the rate of ER visits for mental health care, especially among patients with severe and persistent conditions.

McConnell estimated that Medicaid patients in Oregon sought emergency mental health care up to 12,000 times in 2018.

“In a perfect world, we don’t want a lot of people to go to the ER to get their mental health care,” McConnell said. “It’s a place that takes all comers. It’s really designed for acute care. A lot of mental health treatment requires something more than an hour-long visit.”

Mental health treatment can take time and sometimes requires medication. Residential facilities and clinics are designed to treat these patients – and can do so successfully, experts say.

Although Oregon falls in the middle in the study, nationwide surveys have shown a high prevalence of mental illness in Oregon and a low access to treatment. This session, the Legislature is looking again at boosting funding to expand residential treatment capacity and attract more workers to the field.

The study did not analyze why the patients sought help in emergency departments rather than clinics or other facilities. But researchers said this is something for states to look at. 

“Do high rates of utilization for both ambulatory and emergency mental health care suggest a region under duress, or are they an indicator of high capacity and low quality? Or do they reflect idiosyncratic patient preference and provider coding practice?” the study asked.

Researchers found little correlation between visits for anxiety and schizophrenia or between visits for depression and suicide.

“These findings suggest that a ‘one-size-fits-all’ solution to improving mental health may be less effective than programs likely tailored to the local population’s needs,” the study said.

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FWA- Tennessee Medicaid pursues felony charges against some members

MM Curator summary

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.

 
 

[MM Curator Summary]: Sometimes the effort to protect Medicaid resources from fraudsters gets the wrong people.

 
 

Clipped from: https://www.npr.org/sections/health-shots/2023/02/13/1156145443/tennessee-medicaid-mix-up-felony

 
 

Life was upended for LaShonia Ingram over the last year, and a shadow still follows her around.

Search her name online, and the first result includes the words “fraud” and “most wanted.”

“It was horrible. I couldn’t get a job,” says the 42-year-old mother from Memphis, Tennessee. “All doors were being closed in my face.”

Ingram resorted to selling purses out of her trunk to support her family. She says even DoorDash and Uber wouldn’t allow her to work with a felony charge.

Her alleged crime? Fraud.

The state of Tennessee accused her of living in nearby Horn Lake, Mississippi, while still being enrolled in the state’s Medicaid program, known as TennCare. It all turned out to be a mix-up, but the damage to her reputation and finances was done.

Tennessee is one of the most aggressive states in the nation when it comes to policing possible Medicaid fraud among beneficiaries like Ingram. The state posts the names and photos of people arrested for alleged fraud on a government website and social media. Some even wind up on a so-called “most wanted” list, as if they were dangerous and on the run.

The list is maintained by Tennessee’s Office of Inspector General. The office was launched in 2005 when most of the cases involved drug diversion: people were accused of using TennCare benefits to acquire massive quantities of narcotics to sell on the street. But as federal rules have slowed the illegal prescription drug market, arrests related to Medicaid are instead sweeping up people accused of moving out of state — often within the same community — without canceling their benefits.

An apparent clerical error leads to an arrest

Ingram was one of 28 Medicaid beneficiaries in Tennessee charged in 2022, according to the Tennessee OIG; more than a third of them were accused of not being a Tennessee resident, with many cases originating in the Memphis area where some of the suburbs are in Mississippi.

In Ingram’s case, Tennessee announced her arrest in a press release, saying she “eluded” authorities for nearly a year. Ingram says she didn’t have a clue about the charges until she got a ticket for not wearing her seatbelt.

“They pulled me over, and they said, ‘you have a felony warrant.’ And I said, ‘quit lying,'” she recalls. “I’ve never been in trouble a day in my life.”

It took $2,000 to bond out of jail and even more to hire an attorney. Not until more than six months later did prosecutors show her the evidence so she could refute the charges and clear her name.

The explanation ended up being pretty straightforward. During the time she was on Tennessee’s Medicaid program and living in Memphis, she filed for divorce from her husband who lived nearby in Mississippi. She says they had been separated for years, but her driver’s license still had the outdated Mississippi address.

After her arrest, Ingram showed her Tennessee lease and electric bills, and the Shelby County District Attorney dropped the felony charges.

Most states focus on health care provider fraud

Every state has an office to investigate Medicaid fraud committed by doctors and other health care providers, since that’s usually where the most money can be recovered. Not as many crack down on patients like Tennessee does.

“We try to apply the law compassionately,” Chad Holman, who leads the TennCare OIG, told NPR.

Some other states do have patient-focused units, but they don’t necessarily name the accused publicly. For example, South Carolina keeps them anonymous even after they’ve agreed to reimburse the state.

Holman defends Tennessee’s practice of posting a “most wanted” list for its Medicaid program. He says it’s supposed to be a deterrent: “It’s not to blast anyone or defame anyone. It’s to simply take care of the business that’s at hand, hold people accountable and do what we’re here to do,” he says.

As drug-related cases have diminished, enforcement has increasingly focused on ensuring that people enrolled in TennCare live in the state. In Memphis, 20 of the 27 Medicaid fraud cases since 2019 involved questions of state residency, according to the Shelby County District Attorney. And prosecutors have dropped at least a half dozen of those cases because the evidence was so weak.

Holman says his office won’t overlook low-level offenses.

“This is not murder,” he says. “But the legislature classified it as a felony, and that’s the law that I’m here to enforce.”

But enforcement is expensive. And Holman acknowledges it costs far more to run the TennCare fraud unit than the office will ever recoup from people on Medicaid, who are usually low-income to start with. Even if the state recovered every dollar from charges brought against beneficiaries in 2022, the total would amount to less than $900,000. The office has a budget of $6.4 million a year. Since its creation in 2005, the OIG has brought in less than $10 million and charged nearly 3,200 people with fraud, according to its own press releases.

And the rate of arrests has slowed dramatically. It now arrests fewer people in a year than it previously did in a single month.

A Medicaid ‘cliff’ is coming

At this point, about one in four Americans is on Medicaid or CHIP — the Children’s Health Insurance Program. The number of people enrolled increased by more than 20 million since early 2020. And for the first time since the start of the pandemic, states are going to be verifying income and addresses over the next year. Millions of Americans could lose their Medicaid coverage as a result. It’s up to each state to determine who is eligible and how to deal with potential fraud in the program.

Michele Johnson, executive director of the Tennessee Justice Center, says policing fraud among TennCare beneficiaries takes time and money that could be spent on something more helpful.

“It’d be great if our leaders would get out of the gotcha game and get into the getting people healthy game,” she says.

Especially now, as Medicaid programs are restarting checks on eligibility, Johnson says recipients shouldn’t have to worry that a mistake could eventually get them arrested.

Despite the ordeal she went through, Ingram is bouncing back. Still, she has legal bills to pay and has grown more frustrated at being ensnared by the state’s Medicaid dragnet.

“They made a big mistake,” she says.

This story was produced in partnership with Nashville Public Radio and Kaiser Health News.

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FWA- The Pill Club reaches $18.3M settlement for alleged Medicaid fraud in California

MM Curator summary

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.

 
 

[MM Curator Summary]: Was the name of the company really not a red flag?

 
 

 
 

Clipped from: https://www.mobihealthnews.com/news/pill-club-reaches-183m-settlement-alleged-medicaid-fraud-california

 
 

Photo: krisanapong detraphiphat/Getty Images

Online birth control pharmacy The Pill Club reached an $18.3 million settlement with California authorities for allegedly defrauding the state’s Medicaid program.

According to the California Department of Justice, the company billed Medi-Cal for services it hadn’t provided, allegedly submitting claims for 30-minute face-to-face counseling sessions when its nurse practitioners didn’t have direct or real-time contact with patients. The California Department of Insurance said the birth control provider would bill for in-person visits when nurses were only reviewing patient questionnaires.

The state DOJ also claimed The Pill Club dispensed female condoms to beneficiaries who didn’t want or ask for the contraceptives, billing Medi-Cal significantly above the retail price.

The settlement calls for $15 million to be paid to the DOJ, while $3.3 million will go to the CDI. It comes days after a state court unsealed a whistleblower complaint against The Pill Club, where former nurse practitioners also alleged the company had defrauded private insurers in at least 38 states, including California.

According to a statement from their attorneys, the whistleblowers will receive nearly $5 million from the settlement. 

“The Pill Club unacceptably siphoned off Medi-Cal funding intended to help vulnerable communities access essential healthcare,” California Attorney General Rob Bonta said in a statement. “I am grateful to the whistleblowers and our investigators who were instrumental in holding The Pill Club accountable.

“At the California Department of Justice, we fight every day to protect and expand access to healthcare. We will not tolerate companies who attempt to unlawfully enrich themselves at Medi-Cal’s expense.”

A spokesperson for The Pill Club said it wasn’t required to be monitored or change any business practices as part of the settlement, and they noted it wasn’t settling in any other states. However, the company plans to improve its billing practices, update measures to ensure patients only receive medications and contraceptives they request, and implement new patient informed consent practices.

“When I joined The Pill Club just over two years ago, I was drawn to the challenge of strengthening our operations to live up to our mission. I’m glad to have the opportunity to resolve these issues and to bring our full focus back to expanding access to contraceptive care for all who need it,” Liz Meyerdirk, The Pill Club’s CEO, said in a statement.

THE LARGER TREND

The Pill Club, which launched in 2016, raised a $51 million Series B three years later and another $41.9 million in 2021.

The company briefly changed its name to Favor to highlight its non-contraceptive services, but it returned to its previous branding following a lawsuit from a restaurant and retail delivery company that also used the name.

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FWA- NY OMIG Finalizes Omnibus Regs Impacting Medicaid Providers’ and Plans’ Compliance Obligations

MM Curator summary

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.

 
 

[MM Curator Summary]: NY MCOs will have to ramp up their internal efforts to fight FWA.

 
 

 
 

Clipped from: https://www.jdsupra.com/legalnews/ny-omig-finalizes-omnibus-regs-2406437/

 
 

On December 28, 2022, the New York State Office of the Medicaid Inspector General (OMIG) finalized the proposed rule published on July 13, 2022, that significantly revises the provider and Medicaid managed care organization (MMCO) compliance obligations in New York with no substantive changes. The new regulations became effective immediately upon issuance; however, OMIG enforcement will be delayed until March 28, 2023 (90 days after the effective date of the regulations).

As we previously reported, the rules incorporate some of OMIG’s guidance issued to providers on compliance program best practices and expectations. Additionally, the rules expand the requirement for MMCOs to have a Special Investigations Unit (SIU); build upon existing requirements related to MMCOs’ requirements governing plans’ fraud, waste and abuse prevention programs; and codify OMIG’s self-disclosure protocols for providers and MMCOs, with limited changes. In conjunction with the promulgation of these new compliance regulations, OMIG will be providing ongoing guidance and training in the form of statewide presentations, webinars and compliance program reviews. OMIG has published new compliance guidance materials on its website under the Compliance Library tab, including a document that compares the requirements in effect prior to these final regulations to the current requirements.

We strongly recommend that providers and MMCOs perform a compliance program effectiveness review utilizing these new standards, as OMIG intends to commence compliance program audits of providers to assess their compliance with these new standards. OMIG indicated in a recent presentation that a score of less than 60% compliance may result in enforcement actions, and even a “passing” score likely will result in corrective actions.

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MEDICARE/FWA-Public Health & Policy Reading Room | CMS Rule Means Medicare Advantage Plans Will Pay Back Billions in Overpayments

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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.

 
 

[MM Curator Summary]: MA plans will have to pay back a lot of cash that they stole back when CMS let them get away with the rampant upcoding. The first year that CMS will enforce the paybacks will be 2018. Why that year? I wonder how much overpayments MA plans got the few years before that, and who was in charge at CMS those years, and did they have any specific connection to the overall RADV upcoding scandal? Probably just a bunch of dead end questions, I’m sure.

 
 

Clipped from: https://www.medpagetoday.com/reading-room/publichealthpolicy/medicare/102889

– Audits finding unsubstantiated claims will extrapolate overpayments to insurers’ other claims

With a more aggressive rule finalized Monday, the Centers for Medicare & Medicaid Services (CMS) said it expects to recover billions more in overpayments from Medicare Advantage plans that upcoded their enrolled beneficiaries as being sicker or requiring more intense levels of care than their medical records could support.

The agency’s revised risk adjustment data validation (RADV) tool will allow the agency to extrapolate the amounts of overpayments found in audited claims that must be repaid to much larger sets of claims submitted by the plan that year. It will “protect the fiscal sustainability” of Medicare, said Health and Human Services Secretary Xavier Becerra during a news conference.

The new extrapolation policy applies to plan years 2018 and later. CMS will not apply the policy to prior years, meaning Medicare Advantage plans will get to keep the money audits determined were wrongfully obtained.

Until now, the amount the plans were supposed to pay back was based just on those overpayments that audits found among the small sample of claims audited. But the new rule enables Medicare to extrapolate the amount owed from those audited claims to all claims submitted for patients in a diagnostic subgroup, thus putting companies on the hook to pay back a lot more money.

“Thanks to this final rule, CMS will now be able to provide appropriate oversight and ensure the integrity of the entire Medicare program by taking specific steps to collect payments made to Medicare Advantage plans to which they were never entitled under our laws and regulations,” Becerra said.

Dara Corrigan, director of the CMS Center for Program Integrity, estimated that in plan payment year 2018 alone, the agency expects to recover $479 million under the new rule. For the 10-year period of 2023 to 2032, it’s estimated the amount recovered will reach $4.7 billion.

The problem has evolved because Medicare Advantage organizations (MAOs) receive a lot more money from Medicare each month for patients with higher health risk scores, as sicker patients presumably will cost more money. But CMS audits have revealed enrollee health histories that do not substantiate their illness, along with patients never treated for their apparent conditions. “There is an incentive for MAOs to potentially over-code diagnoses to increase their payments, that is, to code diagnoses not properly substantiated by medical record documentation,” CMS said in its final rule.

Dozens of Office of Inspector General (OIG) investigations have found most of the largest Medicare Advantage plans have coded their enrollees with illnesses or conditions that the plan providers’ medical records could not support. In the last 2 years alone, OIG released results of investigations that found exaggerated upcoding worth $461 million, according to a MedPage Today search of the agency’s investigative findings.

The practice continues. In its final rule Monday, CMS said that in fiscal year 2021, based on 2019 payments, “we calculated that CMS made over $15 billion in Part C overpayments, a figure representing nearly 7 percent of total Part C payments.”

The agency had originally proposed beginning the extrapolation method for assessing overpayments that MAOs needed to pay back starting with the 2011 payment year.

Asked why the agency decided not to expand the new RADV rule to years before 2018, Corrigan said the agency had to consider all policy discussions and stakeholder input, and the integrity of the program.

The rule also explains that the 2018 year was selected as the starting point for the new policy because of the number of appeals expected from MAOs. “By not using an extrapolation methodology prior to [payment year] 2018, we expect to better control the total number of active appeals that are submitted in the first few years following finalization of this rule, which will alleviate burden on MAOs and CMS,” the rule explained.

Asked if MAOs will challenge the new rule with lawsuits, Becerra and Corrigan declined to comment. “We have a policy on not commenting on any future litigation,” said Corrigan.

In a press release accompanying the rollout of the final rule, CMS said that despite audit findings of overpayments to Medicare Advantage plans going back years, no risk adjustment overpayments have been collected since payment year 2007.

The rule explained that CMS will focus on overpayment subgroups identified by hierarchical condition categories (HCC), representing clinical diagnoses, that are at the highest risk for improper payments.

Better Medicare Alliance, a coalition of stakeholders including MAOs, said it is still reviewing the new rule. But the organization has concerns about “potential unintended consequence of creating an environment of higher premiums and fewer benefits for the more than 29 million seniors and people with disabilities who choose Medicare Advantage,” President and CEO Mary Beth Donahue, said in a statement. “We encourage CMS to work with stakeholders to put in place solutions that are transparent and fair to preserve stability for beneficiaries.”

The president and CEO of America’s Health Insurance Plans (AHIP), Matt Eyles, also was not happy. He called the rule “unlawful and fatally flawed, and it should have been withdrawn instead of finalized. The rule will hurt seniors, reduce health equity, and discriminate against those who need care the most.”

The problem of Medicare Advantage upcoding has increased over the years as MAOs have engaged in aggressive — and sometimes deceptive — marketing and television advertising campaigns that have enrolled millions of seniors. CMS is now trying to curtail such campaigns by employing secret shoppers and requiring that all calls with plan representatives be recorded.

By the end of this year, more than half of all Medicare beneficiaries will be enrolled in a Medicare Advantage plan, attracted by zero or low monthly premiums and the promise of other benefits like dental care, some prescription drug coverage, or gym memberships. However, the downsides of such plans are often poorly explained, and some beneficiaries find that when they need services — a trip to the doctor or a certain prescription — they may have to make unexpected and sometimes pricey co-payments.

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REFORM- California prison inmates to get some Medicaid care

MM Curator summary

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.

 
 

[MM Curator Summary]: CVS is launching an ACO in Chicago and its convinced a Uni hospital system to go half-sies. Based on the CMMI REACH model (as seen in NY).

 
 

Clipped from: https://www.healthleadersmedia.com/innovation/rush-cvs-health-launch-aco-targeting-health-equity-medicaid-members

The Chicago health system and CVS Health are partnering on an ACO that will be part of CMS’ REACH direct contracting model, aimed at improving healthcare access for Chicago-area residents on Medicaid.

KEY TAKEAWAYS

Chicago’s RUSH University System for Health is partnering with CVS Health in an accountable care organization patterned after the Centers for Medicare and Medicaid Innovation’s redesigned Realizing Equity, Access, and Community Health (REACH) direct contracting model.

The model aims to improve health equity for underserved reisdents by addressing barriers to accessing care, including social determinants of health.

Residents in Chicago and Evanston who access care at CVS Health’s MinuteClinic locations will now have access to personalized care through RUSH, including virtual and home-based care, help with co-pays and transportation, and specialty and wellness services.

While some see retail healthcare services as competitors to traditional healthcare organizations, Chicago’s Rush University System for Health (RUSH) is launching a partnership with CVS Health aimed at improving health equity for Medicaid patients.

RUSH, which comprises RUSH University, three hospitals, and a network of outpatient care sites, is joining a newly created accountable care organization (ACO) developed by CVS Health. The collaboration is based on the redesigned  ACO Realizing Equity, Access, and Community Health (REACH) direct contracting model developed by the Centers for Medicare & Medicaid Innovation (CMMI).

Through the program, RUSH and CVS Health aim to create a care management network for Chicago-area residents on Medicaid. It will enable members seeking care at MinuteClinic locations in Chicago and Evanston to access additional services, including specialty care, through RUSH.

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“This provides another option for patients at a time when access to high-quality health care is more important than ever,” RUSH President and CEO Omar Lateef said in a press release. “It will help strengthen care coordination for patients, while enabling them to receive services convenient to where they live and work.”

“As part of CVS Health’s care delivery strategy, we are engaging our assets on behalf of this ACO REACH population to help drive high-quality outcomes, promote health equity, and bring healthcare costs down,” added Mohamed Diab, CEO of the CVS ACO. “Our strategic alignment with RUSH has the potential to help improve longitudinal care for their Medicare population of 35,000 beneficiaries.”

The partnership offers not only an interesting example of collaboration in the competitive primary care space, but highlights the efforts of the healthcare industry to tackle barriers to access for underserved populations, including social determinants of health. The program will include access to virtual and home-based care, transportation support for annual wellness visits, cost-sharing options on co-pays, and other incentives and services.

“RUSH has a long-held commitment to improving the health of the communities we serve,” Lateef said in the press release. “This agreement reflects that strong commitment and a terrific opportunity to build upon that foundation of strong community-based programs and partnerships and have impact for patients on day one.”

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REFORM- RUSH, CVS Health Launch ACO Targeting Health Equity for Medicaid Members

MM Curator summary

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.

 
 

[MM Curator Summary]: CMS is allowing CA to spend Medicaid dollars on inmates 90 days before release.

 
 

Clipped from: https://www.nhregister.com/news/article/california-prison-inmates-to-get-some-medicaid-17744646.php

 
 

WASHINGTON (AP) — The federal government will allow Medicaid dollars to treat some people in prisons, jails or juvenile detention centers for the first time ever, the Centers for Medicare and Medicaid Services announced Thursday.

CMS will allow California inmates to access limited services, including substance use treatment and mental health diagnoses, 90 days before being released. Since Medicaid was established, federal law has prohibited Medicaid money from being used for people who are in custody, with inmates having access to their health care coverage suspended.

The move will provide more stability for inmates and juvenile detainees as they exit institutions and reenter the outside world, CMS administrator Chiquita Brooks-LaSure said Thursday.

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She said the change will allow the state to “make unprecedented advancements for incarcerated individuals who have long been underserved.”

At least 10 other states have asked CMS for exemptions to use Medicaid dollars to treat inmates before they are being released. California could be a model for those states, especially since the program is new territory for Medicaid and is expected to be a massive undertaking, said Vikki Wachino, who oversees the Health and Reentry Project.

California state officials said Thursday that they hope some inmates will begin accessing services through Medicaid starting in 2024. Incarcerated people will be screened and assessed for eligibility to access the state’s Medicaid program. If eligible, case workers will help them develop a care plan for reentry.

It will take at least two years to roll out the program in all the state’s prisons, said Jacey Cooper, the state’s Medicaid director.

Millions of people are expected to be affected, with California releasing nearly half a million inmates from state prisons or county jails every year and roughly 80% of those people qualifying for Medicaid.

People who are leaving prison, jail or juvenile detention often don’t know where to start with getting medical care, Wachino said.

“Right now, there is an enormous barrier to care when people leave prison and jail,” Wachino said. “As you know, many times when they’re released, they’ve been left to fend for themselves, with very, very few supports.”

___

This story was first published on Jan. 26, 2023. It was updated on Jan. 27, 2023, to delete an incorrect reference to the Health and Reentry Project being at the Commonwealth Fund. The project is not at the Commonwealth Fund.

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REFORM (SD)- Medicaid work requirement proposal passes South Dakota House committee

MM Curator summary

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.

 
 

[MM Curator Summary]: SD lawmakers are inspired by GA’s recent win.

 
 

Clipped from: https://www.dglobe.com/news/south-dakota/medicaid-work-requirement-proposal-passes-south-dakota-house-committee

A resolution looking to allow the legislature to consider work requirements on the newly expanded Medicaid program is one step closer to the 2024 ballot.

 
 

PIERRE, S.D. — An effort to allow South Dakota to consider work requirements on “able-bodied” members of the newly expanded Medicaid program in the state passed its first legislative hurdle by an 11-2 party-line vote at a House State Affairs hearing on Jan. 30.

While opponents relayed concerns about the implementation of work requirements and the supposed inefficacy of similar experiments in other states, Rep. Tony Venhuizen, a Republican from Sioux Falls, said he brought the amendment as a way to begin a work requirement conversation currently prohibited by the language of the Medicaid constitutional amendment passed by voters last year.

“The costs of administering it would likely be outweighed by the savings we would see by incentivizing work,” he told the committee. “But again, I don’t want to get too far into the detail of how this would be implemented because we are several steps away from that.”

As written, the proposed amendment would make an exception to the Medicaid constitutional language — which says the state “may not impose greater or additional burdens or restrictions” on those newly eligible for the Medicaid expansion program — allowing the legislature to consider imposing work requirements on “any person, under this section, who is able-bodied.”

The proposal to offer voters an opportunity to impose work requirements on able-bodied individuals carries the support of 30 lawmakers.

The legislature can refer ballot measures and amendments to voters with a majority vote in each chamber. Were Venhuizen’s proposal to succeed this session, it would go onto the ballot in the 2024 general election.

The Medicaid program, as it currently stands in the state, is a federal-state cost-share health care program available to children, low-income families and disabled adults.

However, upon the successful expansion of Medicaid last election, the eligible population grew, raising the eligible income levels for low-income families and allowing any adult under 138.5% of the federal poverty line to access the program.

Unlike the populations that Medicaid traditionally serves, Venhuizen argued, many in the expanded population are able to work.

Still, opponents to the proposal, many of them representing health care organizations in the state, expressed concern that the definition of “able-bodied” in the relatively general amendment offered by Venhuizen could have negative consequences.

“I think the lack of definition around the word able bodied [is a concern.] We saw this in North Dakota actually a lot when I was spending some time up there with the legislature, folks that deal with mental health issues,” said Tim Rave, the executive director of the South Dakota Association of Healthcare Organizations. “They’re probably physically able to work if that was the definition, but the challenges that they’re having with their mental health problems could be prohibiting them from being active in employment.“

Other opposing arguments cited research from Arkansas that work requirements created “substantial coverage loss” among expanded populations and the infeasibility of implementation due to federal opposition.

While the Biden administration has struck down work requirements in every case — as Medicaid is a program with federal oversight and states must seek approval to change certain rules — Venhuizen noted that 13 states imposed these requirements under the Trump administration, and nine more, including South Dakota, pending approval.

“I do think it’s fair to assume that, if there’s a change in administration, this could be back on the table,” he said.

Venhuizen and the members of the committee in favor of moving the proposal to the House floor argued that several of the points brought up by the opposition were well-founded; however, he argued that giving the legislature the option to discuss the proposal would be the better venue for discussing the specifics.

“I thought that line of argument raised an important concern,” Venhuizen said, specifically referencing a point raised about the seasonal nature of parts of the state economy. “I can see arguments on both sides, but that’s exactly the kind of thing we should be thinking about [as a legislature.] It’s a little concerning to me that the Medicaid amendment in its current form makes that decision for us.”

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REFORM (IA)- House panel advances bill to change who qualifies for SNAP, Medicaid

MM Curator summary

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.

 
 

[MM Curator Summary]: Indiana lawmakers are positioning to tighten up SNAP spending.

 
 

Clipped from: https://www.iowapublicradio.org/state-government-news/2023-01-26/iowa-house-panel-advances-snap-bill-medicaid

 
 

Republicans on a House panel advanced a bill Thursday that would change who can qualify for food and medical assistance in Iowa.

It would establish new limits on assets Iowans could hold while receiving food assistance, known as SNAP. Under the bill, the state would also ask the federal government for permission to enforce work requirements for some Medicaid recipients. And the bill would direct the state to do additional verification of Iowans’ eligibility for SNAP and Medicaid.

Republicans on the panel said the House Health and Human Services Committee would be working on changes to the bill in the coming weeks, which would include seeking federal permission to ban the use of SNAP benefits to buy candy and soda.

Supporters of the bill say it will ensure taxpayer dollars are only spent on people who truly need the help.

A wide range of groups that advocate for low-income Iowans, people with disabilities, children, and health care organizations oppose the bill. They say people who need help with food and medical care could lose their benefits if the bill becomes law.

Journey Berzett of Urbandale told lawmakers she has a disability and relies on SNAP to buy food. She asked them to consider people like her.

“To you, I’m a stranger. You think people like me are probably the one exception who is worthy of these entitlement programs,” Berzett said. “Or maybe you don’t. Maybe you think the right to life, liberty and the pursuit of happiness only applies to those who can afford it. What I do know is that community is about coming together and helping each other, and this bill does not do that.”

Tyler Raygor, a lobbyist for Americans for Prosperity, said he supports the bill because public assistance should be narrowly tailored.

“We think it’s important to remember we’re dealing with finite taxpayer dollars,” Raygor said. “When you have folks on these programs who don’t need them, that puts these programs in jeopardy for folks who truly do need them, like folks that we’ve heard from today.”

Only two other groups publicly support the bill. One is the Opportunity Solutions Project, a group associated with a conservative think tank based in Florida called the Foundation for Government Accountability. The organization has been pushing for public assistance asset tests and Medicaid work requirements in Iowa for years. The other is Iowans for Tax Relief.

Lina Tucker Reinders, the executive director of the Iowa Public Health Association, said she is very concerned about the proposed asset test. She said SNAP is a tool people can use to pull themselves out of poverty.

“When people are using the other tools available to them to do things like save for a down payment for a home to move to a neighborhood for their children, to save money in a 529 plan for their kids’ college—things that we know are effective in breaking generational poverty—it creates a cliff effect,” she said. “And so they’re punished for doing those things that they’re told are the right things to do to break the cycle of poverty.”

Other opponents of the bill say it could put SNAP benefits at risk for some Iowa families that have more than one car. They also raised concerns about how much it would cost the state to hire more people and get a new computer system to make more eligibility checks possible.