Tag: State News

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RX- Medicaid commission calls for flexibility in drug coverage

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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]: MEDPAC thinks Medicaid programs should be able to have their own rx coverage process other than “well I guess if it made it through the p*ss poor FDA process, we have to pay for it.”

 
 

Clipped from: https://www.axios.com/pro/health-care-policy/2023/01/27/medicaid-commission-drug-coverage-flexibility

Illustration: Megan Robinson/Axios

The Medicaid and CHIP Payment and Access Commission voted Friday to ask Congress to let states restrict Medicaid coverage of a drug when Medicare only covers it in clinical trials and while other data is collected on effectiveness.

Why it matters: Unlike Medicare, Medicaid has to fully cover FDA approved drugs regardless of their cost or how much real-world evidence exists on the drug’s effectiveness — which has the potential to wreak havoc on state budgets.

  • The commission wants Congress to level the playing field between Medicaid and other insurers and give states the option for more flexibility.

Reality check: Lawmakers on both sides of the aisle support making it harder for Medicare to limit coverage of FDA-approved drugs — so it would be an uphill battle to get Congress to expand the coverage pathway to Medicaid.

  • Regardless, the vote indicates this is a difficult issue that Medicaid stakeholders aren’t likely to drop anytime soon.

Driving the news: Last year, regulators decided Medicare will cover the controversial Alzheimer’s drug Aduhelm only for patients enrolled in randomized clinical trials.

  • The National Association of Medicaid Directors said in a February letter that limiting Medicare coverage would shift costs onto state Medicaid programs, since Medicaid programs don’t have the same option to restrict coverage.

Giving Medicaid the ability to cover drugs only in clinical trial settings could take some financial pressure off of states to cover expensive but questionably effective drugs, according to MACPAC.

  • The policy could also encourage drug manufacturers to move through traditional FDA approval and show adequate clinical benefit, the commission said.

 
 

  • But MACPAC noted during Thursday’s meeting that limiting Medicaid coverage of drugs can reduce beneficiaries’ access to therapeutics and create more administrative work for prescribing providers.

What they’re saying: “To me, the key issue here is that we’re talking about medications that have potential benefit, but we don’t actually know if it’s an actual benefit yet,” MACPAC Commissioner Angelo Giardino said during the commission’s Thursday meeting.

  • Commissioner Heidi Allen was the lone member to vote against the recommendation.
  • “I think [this flexibility] has equity and access implications, and it’s hard for us to look into the future to say what those would be,” Allen, a social work professor at Columbia University, said during the Thursday meeting.
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TECH- CMS Improves Medicaid Reimbursement for Digital Health Consults

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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]: Now specialists can bill for telehealth so we can stop gaming what the PCPs are getting paid to cover the specialists costs.

 
 

Clipped from: https://www.healthleadersmedia.com/technology/cms-improves-medicaid-reimbursement-digital-health-consults

The Centers for Medicare & Medicaid Services has issued guidance changing Medicaid and CHIP coverage for eConsults, or provider-to-provider specialty consults conducted via digital health or telehealth. The  ruling could expand the service, which helps primary care providers keep more of their patients and boosts access to care for underserved patients.

KEY TAKEAWAYS

The Centers for Medicare & Medicaid Services has issued new guidance on Medicaid and CHIP coverage for eConsults, or interprofessional consultations between a primary care provider and a specialist on treatment for a specific patient.

Under the new guidance, specialists are able to bill Medicaid for eConsults rather than primary care providers, who would often have to bill higher rates so that they could reimburse specialists for their services.

The platform is popular with primary care providers who want to keep more of their patients and specialists who want to expand their reach, while it improves access to care for underserved populations who can’t afford or won;t travel to see a specialist.

Federal officials have expanded coverage for specialty consults between care providers via digital health for Medicaid and Children’s Health Insurance Program (CHIP) members.

In guidance issued earlier this month, the Centers for Medicare & Medicaid Services (CMS) announced that interprofessional consultations, or instances when a care provider seeks the advice of a specialist for a patient’s treatment, via eConsults can be covered by state Medicaid or CHIP programs even when the patient is not present, as long as the consult is focused on that patient.

eConsults are clinical consults usually conducted via telemedicine (including the telephone) or digital health. They enable primary care providers to expand care management options for their own patients without having to send those patients off to a specialist. And they improve access to care for patients who might not want to travel to see a specialist due to a variety of reasons, including distance and cost.

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Alongside helping primary care providers retain more of their patients, the platform is popular with federally qualified health centers (FQHCs) and community health centers who treat underserved populations and in rural areas where access to specialists is scarce. It also helps specialists expand their reach and treat more patients in need of their services.

“Timely access to specialty providers can improve the quality of care and treatment outcomes for both physical and behavioral health,” CMS wrote in its guidance. “While access to specialty care has been a challenge across a range of specialties, access to specialty care for mental health and substance use disorders has been a particular challenge.”

The ruling changes the payment model so that the consulting provider, or the specialist, can bill for the treatment. Previously, CMS allowed the treating provider to bill Medicaid, which in many case forced the program to pay higher rates to the treating provider so that he/she could reimburse the specialist for consulting services.

To qualify eConsult coverage, both care providers must be enrolled in the Medicaid program in the state where the patient is located, though the consultant can be located in another state.

“Given the potential for improving access to specialty care, a number of states have obtained authority through state legislation for or expressed interest in covering eConsults,” the Los Angeles-based Manatt, Phelps & Phelps law firm wrote in a recent blog. “States that choose to cover eConsult codes must submit a state plan amendment to CMS to add a payment methodology for the qualifying service, and should consider broadly communicating any related policy changes to their enrolled provider community.”

 
 

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MCOS- Human Services Department to cancel procurement process for the selection of managed care organizations to deliver Medicaid services

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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]: Maybe next year.

 
 

Clipped from: https://www.hsd.state.nm.us/2023/01/30/human-services-department-to-cancel-procurement-process-for-the-selection-of-managed-care-organizations-to-deliver-medicaid-services/

Current contracts to remain in place, no disruption in services  

SANTA FE – The New Mexico Human Services Department (HSD) announced today it will cancel the procurement process for the selection of managed care organizations to deliver services to the state’s 800,465 Medicaid Centennial Care members. 

The current contracts in place will continue until a new, expedited request for proposals (RFP) is issued, so there will be no disruption in services being provided. The contracts for those companies are set to expire at the end of 2023.  

The original RFP is being terminated so that the agency’s new leadership, given the planned departures of both Secretary David Scrase and the Medicaid Director Nicole Comeaux, can assess the design of the procurement.  

Since 2019, the Medicaid program has worked to improve program benefits, provider payments, and access to care. HSD has invested over $800 million in increased provider rates, extended postpartum coverage to 12 months, worked to eliminate the developmentally disabled waitlist for services, removed asset tests that create barriers for older adults, implemented home visiting programs for pregnant women, processed 6,534 Medicaid Provider enrollment applications, and added reimbursement of Adult Accredited Residential Treatment Center services. 

The Department is dedicated to continuing to provide robust and comprehensive services to Medicaid customers.      

###

We talk, interpret and smile in all languages.  We provide written information to our customers in both English and Spanish and interpretation services are available in 58 languages through our provider, CTS Language Link. For our hearing, and speech impaired customers, we utilize Relay New Mexico, a free 24-hour service that ensures equal communication access via the telephone to individuals who are deaf, hard of hearing, deaf-blind or speech disabled. 

The Human Services Department provides services and benefits to 1,076,746 New Mexicans through several programs including: the Medicaid Program, Temporary Assistance for Needy Families (TANF) Program, Supplemental Nutrition Assistance Program (SNAP), Child Support Program, and several Behavioral Health Services.

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Town Hall Ventures’ Andy Slavitt on how to invest in Medicaid

 
 

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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]: Andy’s got some ideas on how to make money in Medicaid.

 
 

Clipped from: https://www.statnews.com/2023/01/31/town-hall-ventures-medicaid-slavitt-health-tech/

 
 

SAN FRANCISCO — Part of Andy Slavitt’s core mission at Town Hall Ventures is proving that health tech companies can make a viable business out of reaching low-income people who also face social challenges, like a lack of housing or nutritious food options. It’s a bold assertion that hasn’t been proven out yet, though a handful of Town Hall Ventures’ portfolio companies — including Unite Us and Alphabet spinout Cityblock  — have already achieved valuations over $1 billion.

The stakes are growing steadily higher, especially for the millions who signed up for Medicaid coverage during the public health emergency and who risk losing it as temporary expansions end. And by investing in teams they trust to embed in vulnerable communities, build culturally sensitive products, and develop sophisticated analytics to assess social needs, Slavitt and his team are hoping to set an example for other venture funds who have historically avoided Medicaid.

“The clinical answers are not so hard. I can’t emphasize that enough,” Slavitt said. Though the diagnoses affecting low-income patients are largely the same as the ones affecting those with commercial insurance, the health care system isn’t set up to accommodate homeless people, or medically complex pediatric patients in health care deserts, he said. 

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“What’s different largely speaking is that being poor really sucks and being miles away from anyone who can really care for you really sucks and needing to fill out 10 forms to get housing or child care or any of these other things is a big deterrent to getting care,” he said. “A system that doesn’t welcome you, doesn’t recognize where you live, really doesn’t work.” 

From an investment perspective, he said, there’s potential for a “decent margin — not a huge margin” in helping the country’s roughly 90 million Medicaid patients get better preventive health care, avoiding more expensive treatment in the future. “There’s no bigger market than Medicaid,” he said. 

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STAT spoke with Slavitt in San Francisco, where he and other investors and health care executives descended earlier this month for the J.P. Morgan Health Care Conference. This conversation has been edited for length and clarity. 

What types of companies do you think are best equipped to solve these problems?

The good news is there’s an awakening that the most needed area of investment is also investable space. Not everyone has figured it out.

There’s two types of ways of thinking about investing. One starts with how do I find a market opportunity and make a lot of money? And the other starts with is there a really big problem that I can figure out how to solve? Not every problem in health care will be solved with innovation. But some can, and the ones that can are the ones where you’ve got a clinical, social, behavioral model that addresses the need of a specific population where there’s also some payment model that allows you to meet those needs.

If you look across Medicaid, you can follow the journey from moms to babies, pregnant moms to pediatrics, complex pediatrics, then school-based programs, justice and teen mental health programs, disability, all the way up to [dual Medicare and Medicaid eligibles and eldercare]. We have activities in all those buckets. We have investments in most of those buckets. 

Finding people who really understand these problems at a really operational finite level [is important]. Take a company like Cityblock Health. There are several thousand available housing units in New York that don’t get used for homeless people because they’re only available for people with a psych diagnosis. And in order to get a psych diagnosis, you’ve got to go find a psychiatrist in New York, then make it to the appointment, then it gets rejected. … They’ve got a team of psychiatrists that do that, nothing but that, and they get people into housing. 

How will you know you’ve been successful?

If we’re massively successful, [Town Hall] will invest a few billion dollars over our life into these communities. We need hundreds of billions of dollars invested, and there’s all this capital that sits there trapped [in the health care industry] … or is repatriated to shareholders because these are incredibly profitable companies. And they come into these communities and they take the profits out. Money needs to be reinvested back into these communities. 

Do the communities you’re focused on use technology any differently than wealthier ones?

SMS is less expensive to use than a browser. There are subtleties. I went out to the field with a Cityblock community health partner and I said, “What’s your favorite part of your job?” And she said, “My iPad.” I don’t hear that a lot in health care, but she said, “I bring this into someone’s apartment and I can build access to the whole world for them. I can connect them to the thing they need, I can order something for them on the spot and they can see action. I can communicate with their daughter who is a big user of technology.” 

Amazon has a lot to teach us in coming into health care because they know how to deploy technology in ways that don’t feel like technology. 

How are the metrics you use to evaluate companies different from other markets?

It’s imperfect and it’s a little bit of a moving target. We started in earnest on it probably a year ago. We got more resources on our team to be able to collect the information from our companies. It was always part of the process but if you’d asked me the question for each one how are they doing, I wouldn’t have been able to give you a great answer. 

One easy tell, when I talk to a company, is, “Tell me what it is.” Plume, which is a trans health company, they’re like, “we have to reduce anxiety and depression scores very fast.” So they measure that like crazy. If I look at Eleanor Health, which is focused on addiction and recovery treatment, what they basically want to get to is lower craving levels. They don’t measure urine tests [as much] … they’ve learned that the frequency of touch points with people at various stages of their addiction recovery is really important, so they’ll measure that.

There’s a set of consistent metrics, but you’ve got to respect them to tell their own story. At some level they’re going to know their business better. 

If I don’t hear that they’re measuring Net Promoter Score rabidly in the right way, it tells me, OK there’s some other way you’re getting paid than doing your job. 

There’s questions we ask every company like diversity on your management team, diversity on your board, diversity at each level, diversity of promotions. There’s usually other investors at the table, and I’m pretty sure they’re going to ask the question about “how’s your sales acquisition doing?” But my first questions will always be what I think is important. You have to hire diversity, particularly in the early stages, and then their networks will come in. But you have to force it. 

This story, part of a series on health tech for underserved populations, was supported by USC Annenberg Center for Health Journalism’s national fellowship.

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DENTAL- Utah bill proposes expanding dental care coverage to adults under Medicaid

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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]: A local university is willing to foot the state’s share of the bill.

 
 

Clipped from: https://stateofreform.com/featured/2023/01/utah-bill-proposes-expanding-dental-care-coverage-to-adults-under-medicaid/

 
 

Senate Bill 19, a measure that would extend dental benefits under Medicaid to adults 21 years of age and older, advanced to the House after passage in the Senate by a vote of 19 to 0 with 10 abstentions Monday. 

 
 

 
 

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Sponsored by Sen. Evan Vickers (R – Cedar City), the measure passed with bi-partisan support and has the backing of the Utah Dental Association (UDA). 

Under current state law, only members who are pregnant, disabled, blind, age 65 or older, enrolled in Targeted Adult Medicaid (TAM) receiving treatment for substance use disorder, or children receiving Early Periodic Screening, Diagnostic and Treatment (EPSDT) have access to dental benefits through Medicaid. 

In partnership with the Utah Department of Health and Human Services (DHHS), the University of Utah School of Dentistry (UUSOD) administers dental care to these individuals through the school’s clinics and affiliated providers in over 150 locations throughout the state. 

“Back in 2008, the state eliminated all dental benefits for adults and the University of Utah School of Dentistry subsequently went to the legislature and said we’d like to partner and provide this care, and there are federal programs available that allow for that,” said James H. Bekker, Associate Dean for Professional and Community Partnerships at UUSOD. 

“The School of Dentistry participates in creating that pathway. And so we opened up gradually to first the TAM patients that have substance abuse disorder and then we added to that blind and disabled patients. And then we added to that elderly. So it’s just been something that’s happened gradually and we’ve been able to do well.”

SB 19 would allow the state to pursue federal Medicaid waivers that extend dental care to all adults 21 years of age and over who are eligible for Medicaid. The bill, like previous ones that expanded dental coverage eligibility, contains a zero fiscal note because UUSOD pays the state’s portion to receive federal matching funds to provide care. 

Should SB 19 pass, the number of Medicaid members eligible for dental coverage could grow from 70,000 to over 200,000, according to UUSOD estimates. 

“This program allows [dentists] to see the patients and be compensated at a much better rate,” Bekker said. “It’s clear that with [currently eligible] Medicaid patients, that’s about 70,000 patients throughout the state, the School of Dentistry can’t possibly see all those patients at our clinics.

And so we have created an associated provider opportunity so any dentist in the state of Utah can become associated with the School of Dentistry and thereby treat these populations in their own office. They bill directly to Medicaid, they’re reimbursed directly [by] Medicaid. It’s just that association that they need with a state entity in order to be able to qualify.”

As the legislative liaison to the UDA and its past president, Bekker says dentists in the state are supporting the proposal. 

General dentists had previously been reluctant to join the program and serve Medicaid patients because of low reimbursements rates, Becker noted. He has been working to change the perception that Medicaid does not pay adequately and recruit more dentists to participate and meet the potentially increased demand. 

“We’re doing what we can to educate dentists out there to understand that it’s different than it was,” Bekker said. “The compensation rates are better and this is a wonderful opportunity to enhance your practice and provide care to underserved populations.”

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PROV- Without 20 percent Medicaid boost, state’s providers say bed reductions will continue

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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]: More NY nursing homes are closing beds unless they get their 20% bump this year.

 
 

Clipped from: https://www.mcknights.com/news/without-20-percent-medicaid-boost-states-providers-say-bed-reductions-will-continue/

 
 

 
 

New York state nursing home advocates want a 20% Medicaid boost to pay rates, a demand struggling for traction while the governor’s budget framework puts money into home-based care instead. 

The demand was delivered officially to Gov. Kathy Hochul (D) Friday in a letter signed by the heads of five organizations representing nursing home providers and healthcare workers. Her budget proposal is scheduled to be released Wednesday. Without changes, more beds will be taken out of service and some facilities could close, providers warned.

“New York has underfunded nursing home care for the last 15 years,” said Stephen B. Hanse, president and CEO of New York State Health Facilities Association/New York State Center for Assisted Living, adding that New York was the only state to cut Medicaid to nursing homes during the pandemic.

Hanse’s organization represents 400 skilled nursing providers whose more than 60,000 employees care for more than 65,000 nursing home residents and assisted living clients. 

The statewide average Medicaid reimbursement is $211 per resident per day, Hanse said. Divide that by the 24-hour care that is required and it equates to the state paying providers $8.79 per hour to care for each resident, he noted in an email to McKnights Long-Term Care News.

“This is unacceptable … and is a driving factor why New York has a long-term care staffing crisis as nursing homes cannot compete in the labor market for desperately needed workers,” he explained. 

In addition to Hanse’s group, the letter was signed by: LeadingAge New York; Greater New York Health Care Facilities Association; 1199 SEIU, United Healthcare Workers East; and Southern New York Association Inc., which represents more than 60 nursing homes encompassing 16,000 beds in southern New York, Westchester, and Long Island.

New York requires nursing homes to provide a minimum of 3.5 hours of care per resident per day. Facilities are also required to spend at least 70% of revenue on resident care with 40% of that amount patient facing. 

In 2021, New York gave a Medicaid boost of 1%, but operating costs have surged 42%, according to the Alliance for Senior Care. A letter to the editor in the Rochester Beacon from the seven members of that group said that more than 6,700 beds in the state are “off-line” and coalition members in western New York are limiting admissions due to staffing challenges. The head of Gurwin Healthcare System told Spectrum News that its two nursing homes, which operate a total of 580 beds on Long Island, are similarly limiting admissions and “temporarily closing beds.”

Hochul’s budget priorities released earlier this month did not include any mention of a Medicaid increase for long-term care, instead making investments into teams that would care for low-income adults in their homes, reported WSHU. A Hochul spokesman said the governor is “committed to ensuring that all New Yorkers can age with dignity and independence in the community of their choosing.” 

Hanse and other nursing home advocates will be ready to scour the budget to see what kind of legislative fight they will have on their hands.

“Home-based care is not an alternative to skilled nursing care, given the fact that residents of nursing homes are unable to be cared for in the community given their acuity levels and co-morbidities,” Hanse said.

 
 

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MEDICARE- CMS Issues Final Rule to Protect Medicare, Strengthen Medicare Advantage, and Hold Insurers Accountable

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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]: But will they recover the overpayments tho

 
 

Clipped from: https://www.cms.gov/newsroom/press-releases/cms-issues-final-rule-protect-medicare-strengthen-medicare-advantage-and-hold-insurers-accountable

Risk Adjustment Data Validation (RADV) final rule strengthens Medicare Advantage and restores payment oversight program

Today, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), finalized the policies for the Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program, which is CMS’s primary audit and oversight tool of MA program payments. Under this program, CMS identifies improper risk adjustment payments made to Medicare Advantage Organizations (MAOs) in instances where medical diagnoses submitted for payment were not supported in the beneficiary’s medical record. The commonsense policies finalized in the RADV final rule (CMS-4185-F) will help CMS ensure that people with Medicare are able to access the benefits and services they need, including in Medicare Advantage, while responsibly protecting the fiscal sustainability of Medicare and aligning CMS’s oversight of the Traditional Medicare and MA programs.

As required by law, CMS’ payments to MAOs are adjusted based on the health status of enrollees, as determined through medical diagnoses reported by MAOs. Studies and audits done separately by CMS and the HHS Office of Inspector General (OIG) have shown that Medicare Advantage enrollees’ medical records do not always support the diagnoses reported by MAOs, which leads to billions of dollars in overpayments to plans and increased costs to the Medicare program as well as taxpayers. Despite this, no risk adjustment overpayments have been collected from MAOs since Payment Year (PY) 2007. 

“Protecting Medicare is one of my highest responsibilities as Secretary, and this commonsense rule is a critical accountability measure that strengthens the Medicare Advantage program. CMS has a responsibility to recover overpayments across all of its programs, and improper payments made to Medicare Advantage plans are no exception,” said HHS Secretary Xavier Becerra. “For years, federal watchdogs and outside experts have identified the Medicare Advantage program as one of the top management and performance challenges facing HHS, and today we are taking long overdue steps to conduct audits and recoup funds. These steps will make Medicare and the Medicare Advantage program stronger.”

“CMS is committed to protecting people with Medicare and being a responsible steward of taxpayer dollars,” said CMS Administrator Chiquita Brooks-LaSure. “By establishing our approach to RADV audits through this regulation, we are protecting access to Medicare both now and for future generations. We have considered significant stakeholder feedback and developed a balanced approach to ensure appropriate oversight of the Medicare Advantage program that aligns with our oversight of Traditional Medicare.” 

The RADV final rule reflects CMS’s consideration of extensive public comments and robust stakeholder engagement after the release of the 2018 Notice of Proposed Rulemaking. The finalized policies will also allow CMS to continue to focus its audits on those MAOs identified as being at the highest risk for improper payments.  

The RADV final rule can be accessed at the Federal Register at  https://www.federalregister.gov/public-inspection/current.

View the fact sheet on the final rule here: https://www.cms.gov/newsroom/fact-sheets/medicare-advantage-risk-adjustment-data-validation-final-rule-cms-4185-f2-fact-sheet.

 
 

 
 

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PHE- Alaska is scrambling to clear a monthslong food stamp backlog as major Medicaid change looms

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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]: The HHS agency is hiring 5 security guards to deal with threats from frustrated benefits applicants. I am not making that up.

 
 

Clipped from: https://www.adn.com/alaska-news/2023/01/28/alaska-is-scrambling-to-clear-a-monthslong-food-stamp-backlog-as-major-medicaid-change-looms/

 
 

Lutheran Social Services food pantry in Spenard as photographed on Thursday, Dec. 22, 2022. Food pantries are seeing increased pressure due to a food stamp processing backlog. (Bill Roth / ADN)

A month after a major backlog in Alaska’s food stamp application processing surfaced publicly, state officials are scrambling to hire emergency workers to address delays reaching crisis levels for Alaskans who depend on the federal program to feed their families.

Public frustrations have become so high that the state is hiring security guards to protect existing workers, officials with the state’s Department of Health said.

Meanwhile, another hurdle for the understaffed and overwhelmed Alaska Division of Public Assistance lurks around the corner: recertifying Medicaid applications for the first time since the COVID-19 pandemic began three years ago.

Officials say delays are currently extending to nearly all aid programs administered by the state’s public assistance division. Along with Medicaid and food stamps, those programs also include senior benefits, heating assistance, Temporary Assistance for Needy Families and basic emergency needs assistance for thousands of Alaska families annually.

To address the food stamp backlog and prepare for the Medicaid transition, the state is finalizing an emergency contracting process to hire workers who can sort out applications for benefits, Heidi Hedberg, the state health department’s commissioner-designee, said during a recent presentation to the Senate Health and Social Services Committee. The emergency contract, through the Alaska Department of Law, is expected to condense a two-year training for eligibility workers who process benefits across 18 programs down to two months, with new hires focusing solely on food stamps and Medicaid.

While Division of Public Assistance workers have made some progress working through the delays, Hedberg said, there’s still no firm timeline for clearing the food stamp application backlog.

The division has only finished processing applications through the month of September, she said. Nearly 900 applications for food stamps remain from October, plus an unknown number from November, December and January.

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The public’s frustration with the delays causing some to go hungry is spilling over to the people trying to process their applications.

The department is finalizing a contract to hire security guards for the state’s 11 Division of Public Assistance offices, Hedberg said, later adding she was aware of at least five threats to staff, though there may have been more.

“Alaskans are frustrated they don’t have their benefits,” she said. “When you’re hungry, you get really frustrated and you say things that you may not take action on — but we take everything seriously. We need to make sure that we protect our staff, so that they feel safe in their work environment.”

Short staffing and ‘antiquated’ IT

The extent of the food stamp application processing problem first surfaced in late December when multiple Alaska news outlets, including the Daily News, reported on major delays within the public assistance division, which processes the applications.

Thousands of Alaskans
in many cases had already been waiting months to receive their federally funded food stamp benefits, also referred to as the Supplemental Nutrition Assistance Program, or SNAP. They also reported spending hours on hold with the state’s virtual call center only to be told there was nothing they could do to speed up the process.

Many of the Alaskans calling about food stamps are also experiencing delays for other types of public assistance, including senior benefits, Medicaid and heating assistance, according to the state ombudsman’s office, an independent agency that investigates complaints against the government.

State officials attributed the food stamp application processing delays to a staff shortage, a cyberattack that disrupted online services for months, and an influx of recertification applications in early fall when an emergency pandemic-era program expired in September. The program made it easier for Alaskans to receive maximum benefits without annual recertifications. It ended with the state’s emergency declaration, which wound down in July.

Since December, the director of the Division of Public Assistance has been replaced, and 10 Alaskans have filed a lawsuit alleging that the delays were a violation of federal law.

 
 

Heidi Hedberg, interim commissioner of the Alaska Department of Health, speaks at a news conference on Thursday, Dec. 15, 2022, at the Alaska State Capitol in Juneau. (Photo by James Brooks / Alaska Beacon)

But Hedberg said that at this point, the state doesn’t know just how many food stamp applications still need to be processed: Getting a clear picture of the size of the backlog is complicated by the state’s “antiquated” IT system used to process benefits.

Right now, just one state IT employee, who happens to have experience with an outdated coding language, is able to maintain the food stamp system, she said.

The health department is looking to issue contracts to hire more programmers and eventually start processing benefits with a new IT system, she said.

Staffing recommendation ignored

The public continues to report major problems with the state’s public assistance program.

Kate Burkhart, the Alaska ombudsman, says her office is still receiving between 70 and 100 calls a week about delays with public assistance
—
amounting to
nearly 300 since the beginning of this year, with as many in
the month of January as her office received in all of 2022.

The ombudsman’s office helps connect callers to the Division of Public Assistance if they have waited more than 30 days for assistance, Burkhart said. Staff also have been referring Alaskans to local food banks and pantries while they wait, she said. But not all communities have that resource.

“What we have learned is those programs are extremely packed right now,” Burkhart said. “If you live in a community where there’s no food bank, what do you do?”

[To help fight food insecurity, a community fridge opens in Anchorage’s Mountain View neighborhood]

Burkhart also cited the state agency’s failure to increase staffing — the public assistance program lost 100 positions in 2021 — even after a 2018 investigation by her office that followed very similar complaints about the Division of Public Assistance, including lengthy delays and spotty communication.

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“There’s a reason we recommended adequate staff and maintaining of staffing to address the backlog, and to make sure it didn’t happen again,” she said. “And here we are now.”

A ‘huge’ Medicaid challenge

Once the Department of Health clears the food stamp application backlog, it faces another hurdle: the looming change to Medicaid eligibility, which could soon pose challenges for recipients as well as program operators, Hedberg said. Medicaid, which helps low-income and disabled Americans with health care costs, is operated by states and the federal government.

That issue is expected to come to a head in the coming months.

In exchange for extra federal COVID-19 funding, states agreed in 2020 to keep Medicaid recipients enrolled in the program until the end of the public health emergency. A federal spending bill passed in December ended that moratorium, and normal Medicaid eligibility requirements will resume in April.

Those pandemic-era Medicaid requirements saw a jump in the number of enrollees nationwide. The Kaiser Family Foundation, a nonprofit that studies the health care sector, found that there was a 27.9% increase in enrollments between February 2020 and September 2022.

In Alaska, just over 213,000 people were enrolled in Medicaid as of April 2019. The latest Department of Health data from December showed that over 260,000 Alaskans — or over 35% of the total population — received Medicaid, an increase of 22%.

Starting April 1, the state will need to determine if all of the low-income Alaskans receiving Medicaid are still eligible to receive benefits, a process that will be phased out over a year with monthly reporting requirements as federal Medicaid contributions to the state are also scaled down.

“It’s huge,” said Hedberg.

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[Alaska’s Medicaid backlog violates federal and state law, attorneys say]

Alaskans who lose Medicaid coverage would be eligible to receive benefits through the federal health insurance marketplace, but gaps are possible.

In June 2022, the Department of Health sent a letter to all Medicaid recipients warning them of the upcoming changes. Beneficiaries were told to check that their current mailing address and other contact information was still current, and to check the mail for a letter to re-apply for Medicaid.

Hedberg said the department is looking to contract extra staff to help with the Medicaid recertification process starting in April, but the ongoing food stamps backlog is taking precedence and outreach efforts have been delayed.

As the flood of calls has continued, a virtual call center launched in 2021 has seen its role change as staff became overwhelmed. Previously used by technicians working remotely to process applications from beginning to end, the call center now handles only basic functions, such as callers checking on the status of their applications, Hedberg said.

For now, the plan is for that shift to be only temporary.

Annie Berman reported from Anchorage and Sean Maguire from Juneau.

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FWA- Father, daughter get near identical sentences in Medicaid fraud scheme

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]: Another personal care services fraud got about $30k from your W2s.

 
 

Clipped from: https://www.wibw.com/2023/01/31/father-daughter-get-near-identical-sentences-medicaid-fraud-scheme/

 
 

FILE(MGN)

WICHITA, Kan. (WIBW) – A father-daughter pair from Wichita have both been sentenced to repay more than $14,000 and $16,000 as well as to serve a year of probation following a Medicaid fraud scheme.

Kansas Attorney General Kris Kobach says that a man from Wichita has been sentenced to repay more than $14,000 to the Kansas Medicaid system following a conviction on two fraud-related charges.

AG Kobach indicated that Johnson Kongvongsay pleaded guilty in December to one felony count of making a false claim, statement or representation to the Medicaid program and one misdemeanor count of unlawful acts concerning computers.

Court records show that Sedgwick Co. District Judge Tylor Roush on Jan. 26 sentenced Kongvongsay to 18 months in jail, however, the jail sentence was suspended and he was ordered to repay the Kansas Medicaid program a total of $14,857.78 and serve a year of supervised probation.

Kobach noted that an investigation found Kongvongsay and his daughter, Kyla, at different points in time had worked as personal care assistants for a relative who was a Medicare beneficiary. Investigators found the pair had submitted false claims and purported to provide personal care services when they were actually working other jobs.

Investigators also found that the pair had committed $30,947.45 worth of fraud.

Kobach indicated that Kyla, 22, also pleaded guilty in December to one felony count of making a false claim, statement or representation to the Medicaid program and one misdemeanor count of unlawful acts concerning computers. She was sentenced to repay $16,089.67 and 12 months of supervised probation.

 
 

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FWA- Eastern District of North Carolina | Illinois Medical Device Manufacturer Agrees to Pay $500,000 to Resolve Allegedly Fraudulent Medicaid Claims

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 device maker did a backdoor billing / kickback scheme with the help of some local DME providers.

 
 

Clipped from: https://www.justice.gov/usao-ednc/pr/illinois-medical-device-manufacturer-agrees-pay-500000-resolve-allegedly-fraudulent

RALEIGH, N.C. – United States Attorney Michael Easley announced today that Joint Active Systems, Inc. (JAS), a manufacturer of range-of-motion devices located in Effingham, Illinois, has agreed to pay $500,000 to settle civil claims under the Federal and North Carolina False Claims Acts concerning allegations that JAS caused submission of false claims to the North Carolina Medicaid program for certain durable medical equipment.

Specifically, the United States and the State of North Carolina alleged that from January 6, 2012 through January 29, 2021, JAS was unable to directly bill North Carolina Medicaid for its “EZ” range-of-motion devices because JAS did not meet North Carolina Medicaid requirements and/or lacked credentials necessary to do so.  JAS allegedly bypassed those requirements—and its concomitant inability to bill North Carolina Medicaid directly—by entering into arrangements with local North Carolina orthotics and prosthetics providers to bill EZ devices on its behalf.  JAS allegedly directed the local North Carolina orthotics and prosthetics providers to improperly submit claims for JAS EZ devices as orthotics using “L-Codes” under the Healthcare Common Procedure Coding System (“HCPCS”), thereby bypassing the medical necessity reviews and/or authorization processes that may have otherwise taken place.  The Governments alleged that the JAS EZ devices did not qualify for reimbursement as “L-Code” orthotics under North Carolina Medicaid, and that the JAS EZ devices were not listed as reimbursable devices on the North Carolina Medicaid fee schedule.  Indeed, JAS received an official coding verification from the Centers for Medicare and Medicaid Services that designated one of JAS’s EZ devices as an “E-Code” (durable medical equipment) device, not as an “L-Code” (orthotic) device.  The Governments alleged that JAS nevertheless continued to use local North Carolina providers to bill its EZ devices as “L-Code” devices.  In turn, JAS allegedly would pay the local orthotics and prosthetics providers by allowing them to retain a certain amount of the reimbursement.

“The Department of Justice is actively pursuing health care companies and medical device manufacturers who overcharge government healthcare programs,” said United States Attorney Michael Easley.  “We cannot allow companies to bypass rules and regulations to enrich themselves, while depleting taxpayer funds set aside for legitimate patient care.”

“My office’s Medicaid Investigations Division will hold accountable Medical device manufacturers who drain resources from our government healthcare programs, no matter how elaborate and layered the scheme may be,” said North Carolina Attorney General Josh Stein.

The Federal and North Carolina False Claims Acts authorize the Governments to recover triple the money falsely obtained, plus substantial civil penalties for each false claim submitted.  

It should be noted that the civil claims resolved by settlement here are allegations only, that there has been no judicial determination or admission of liability, and that JAS denies the allegations. 

This matter was investigated by the United States Attorney’s Office for the Eastern District of North Carolina and the Medicaid Investigations Division of the North Carolina Attorney General’s Office (“MID”).  Special Deputy Attorney General Matthew R. Petracca, who also serves as a Special Assistant United States Attorney, represented the United States and the State of North Carolina.

The United States Attorney’s Office for the Eastern District of North Carolina, in partnership with law enforcement agencies and state entities, investigates and prosecutes healthcare providers that defraud government programs, including Medicare and Medicaid, and abuse their patients.  The Medicaid Investigations Division investigates and prosecutes healthcare providers that defraud the Medicaid program, patient abuse of Medicaid recipients, patient abuse of any patient in facilities that receive Medicaid funding, and misappropriation of any patients’ private funds in nursing homes that receive Medicaid funding.  To report Medicare fraud or patient abuse in North Carolina, please visit the United States Department of Health and Human Services’ website at https://oig.hhs.gov/fraud/.  To report Medicaid fraud or patient abuse in North Carolina, please call the MID at 919-881-2320.