Tag: State News

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REFORM (OR)- Historic Move: Oregon’s medically necessary Medicaid benefit

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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 new OR waiver will get members AC unit, food and help with rent. It puts $1B towards health-related social needs (HRSN- that’s the new SDH password ICYMI).

 
 

 
 

Clipped from: https://www.cannonbeachgazette.com/news/historic-move-oregons-medically-necessary-medicaid-benefit/article_45f64ecb-852a-5a17-974b-c22730188e27.html

 
 

Oregon is moving to leverage Medicaid benefits to prevent homelessness, support behavioral health services, mitigate the impacts of climate change, pending federal approval.

Metro Creative Connection

The Oregon Health Authority (OHA is moving to leverage Medicaid benefits to prevent homelessness, support behavioral health services, mitigate the impacts of climate change, pending federal approval.

The OHA, in collaboration with Oregon Housing and Community Services (OHCS), has announced proposed timelines to begin offering new Medicaid benefits that eligible Oregon Health Plan (OHP/Medicaid) members would receive under Oregon’s ground-breaking 1115 Medicaid waiver agreement with the federal government.

If the federal government agrees to the proposal, eligible OHP members would start receiving benefits for climate-related supports in January 2024, housing insecurity in November 2024, and food insecurity in January 2025.

Oregon would be the first state in the nation to gain federal approval to offer six months of temporary rent assistance as a medically necessary Medicaid benefit. These benefits would first roll-out to people who are at risk of losing their current housing, beginning on Nov. 1, 2024, if the federal government approves the plan.

In lockstep with Governor Tina Kotek’s priority to reduce homelessness, state health officials have determined that the most immediate and effective way to implement Oregon’s new short-term Medicaid housing benefit is to help people who are medically and economically vulnerable avoid becoming homeless in the first place, according to a release from the OHA.

The rate of Oregonians losing housing is increasing faster than state and local programs can rehouse them, due to a critical statewide shortage in affordable housing, state housing experts said.

The short-term Medicaid rent assistance benefit will help prevent people from losing housing due to a health issue that disrupts their ability to stay current on their housing payments, or because they need to be connected to mental health or substance use services to maintain stable housing. The OHA said this preventive approach should help slow the rate of growth in the homeless population.

State officials estimate approximately 125,000 OHP members currently meet the federal housing definition of “at risk for homelessness” and could be eligible for the short-term housing benefit if they have health and housing needs that would require up to six months of rent assistance or other housing supports.

While assuring that these benefits help keep people housed, OHA will continue to have a strong focus on assisting OHP members that have a significant mental health or substance use disorder that exacerbates their housing insecurity.

“As a first step, we want to use these new and innovative Medicaid housing benefits to make sure that someone with a health problem stays in stable housing,” OHA’s interim Director Dave Baden said. “We can’t let more people wind up on the streets, where their health issues will worsen and get harder to treat, making sustainable, long-term housing harder to find, especially given the lack of affordable housing across the state.”

Medically necessary temporary rent assistance and other housing supports would become available to other OHP members, including people who are already homeless, later in the state’s five-year waiver implementation. That date has not been specified as state health and housing officials continue to work with federal partners to address barriers to housing access and other questions.

Input from housing providers, coordinated care organizations (CCOs) and other community voices informed the state’s strategy to focus on preventing homelessness in this first phase.

“Today’s actions build upon a longstanding commitment to addressing the social determinants of health in action,” OHCS Director Andrea said. “This historic rent assistance provision is a tangible pathway to deliver rent assistance as a health intervention. Housing and health barriers are connected. The solutions should be reflective of that reality.”

State officials also announced that climate-related supports for some OHP members will become available starting Jan. 1, 2024, if federal officials approve the proposed timelines. Under this benefit, eligible OHP members could qualify to receive air conditioners to help reduce health risks during extreme heat emergencies (if medically necessary) or air filters to protect from the respiratory effects of wildfire smoke.

Nutrition benefits, such as medically tailored meals, would become available starting Jan. 1, 2025.

Oregon’s five-year 1115 Medicaid waiver provides OHP coverage and more than $1 billion in federal funding to address the health-related social needs (HRSN) of people whose health is affected by the most pressing problems affecting Oregon communities, including homelessness, climate change and poverty. Under the state’s agreement with CMS, Oregon is required to begin making health-related social needs benefits available no later than Jan. 1, 2025.

1115 Medicaid waivers allow states flexibility to test new ways to deliver and pay for Medicaid benefits. A state must receive CMS approval to implement a waiver.

Medicaid provides health coverage to income-eligible people. Currently, more than 1.4 million Oregonians – or 1 in 3 state residents – are covered by OHP. Most people who qualify for Medicaid in Oregon are covered by OHP. Approximately nine in 10 OHP members have their care coordinated through one of 16 CCOs which operate in defined regions across the state.

Follow this developing story at curry.com and in the Wednesday print editions of The Pilot.

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REFORM (MO) Report: Nearly 85% maternal deaths in Missouri were preventable

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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]: Reminder- the maternal mortality crisis in Medicaid is NOT during labor and delivery. We need to be more accurate and address it as a broader MH/SUD problem if we want to start impacting this tragedy.

 
 

 
 

Clipped from: https://fox2now.com/news/missouri/report-nearly-85-maternal-deaths-in-missouri-were-preventable/

JEFFERSON CITY, Mo. – The state is making a historic investment in a maternal mortality prevention plan after learning Missouri has one of the highest rates of pregnancy-related deaths in the country.

In a new report, an average of 70 Missouri women died while pregnant or within one year after giving birth between 2018 and 2020. The Missouri Hospital Association (MHA) said Tuesday the most sobering piece of the report is nearly 85% of those deaths were preventable.

“Maternal mortality rates in Missouri are not great,” MHA spokesperson Renee Wilde said. “We are well below the national average, and we know that’s something we need to improve on.”

Missouri is looking at new ways to help save new moms. According to a recent report from the state’s Pregnancy-Associated Mortality Review (PAMR) Board, the number one cause of pregnancy-related deaths was mental health conditions, including substance use disorders.

“One thing that this report shows is that the highest occurrence of these deaths happen between 43 days and 365 days postpartum,” Wilde said. “So, it’s not that we’re even seeing these deaths during pregnancy, during childbirth, or even immediately after childbirth.”

The second leading cause is cardiovascular disease, like high blood pressure, followed by homicides. The number of suicide deaths doubled when compared to 2017-2019 with 2018-2020.

The PAMR Board found that the pregnancy-related mortality ratio was 32 deaths per 100,000 live births, which is up from 25.2 deaths in the 2017-2019 time frame. The report found the highest number of pregnancy-related deaths happened in 2020, at 85 deaths.

“The report also showed Black women have a three-times higher instance of maternal mortality than white women,” Wilde said.

Last week, a new law went into effect, extending Medicaid coverage for new moms four up to one year after the baby is born. By extending the coverage for up to one year after giving birth, the legislation is estimated to help more than 4,200 new moms a year.

“We know that health care access is critical and if you don’t have insurance, you probably are a lot less likely to receive prenatal care to continue seeking care postpartum and really getting those conditions treated,” Wilde said.

More than half of the country has already extended Medicaid coverage for new moms and the bipartisan legislation approved by the General Assembly this year is not only expected to save lives but cover thousands of women who would otherwise go uninsured two months after giving birth. Due to a provision in the federal American Rescue Plan Act of 2021, each state is allowed to expand Medicaid coverage to women up to 12 months. The state recently started Medicaid eligibility renewals again after the federal government prohibited states from removing people from Medicaid for three years.

Since the governor has signed the bill, the Department of Social Services (DSS) is reviewing to see which Medicaid patients recently gave birth or if currently pregnant, are eligible for the postpartum program. DSS said you’re a new mom on Medicaid who gave birth back in May, you will still receive extended postpartum care for up to 12 months.

“I thought if there was ever a time to spend money, what better way to spend it than on mothers and children,” Governor Mike Parson said. “We know we need to do a better job for it.”

The state is also spending more than $4.35 million to create a maternal mortality prevention plan. In addition, the General Assembly also funded four recommendations centered around improving the state’s maternal mortality.

  • Provide funding for a statewide Perinatal Quality Collaborative by 2023
  • Establish and fund a statewide Perinatal Health Access Project to aid healthcare providers in providing evidence-based mental health care, including substance use disorder treatment
  • Extend Medicaid coverage to one year postpartum for all conditions, even if the woman did not start treatment prior to delivery
  • Fund Medicaid expansion in 2023

“I think that’s why we did the appropriations this year. It’s one of the largest investments in really trying to change the need in that,” Parson said. “Now just to go out there and kind of talk about it but how do we really help those moms and those babies out there to make sure we save lives.”

The report shows that before extending coverage, women on Medicaid were 10 times more likely to die within one year of pregnancy than new moms on private insurance.

Back in January during his annual State of the State Address, Parson called the state’s high maternal mortality rate “embarrassing.”

Wilde says it will take years for Missouri to improve from having the 12th highest maternal mortality rate in the nation.

“I would say it’s shocking that we’re not seeing some sort of improvement,” Wilde said. “You would think with modern medicine and better access to care that we would be seeing slight improvements. We really are optimistic that with all of these programs that are being put in place, the funding and the legislation that we will start to see that needle move in a positive direction.

The report also found that women living in metropolitan counties were almost twice as likely to die of a pregnancy-related death than women in rural counties.

Click here to see the full 2018-2020 PAMR Board report.

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STATE NEWS (ID)- Idaho disability advocates stress need for more Medicaid staff, direct care workers

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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]: Advocates don’t see how managed care is gonna help the real problem- a shortage of direct care workers.

 
 

 
 

Clipped from: https://www.eastidahonews.com/2023/09/idaho-disability-advocates-stress-need-for-more-medicaid-staff-direct-care-workers/

 
 

Ruth Brown, Idaho Capital Sun

 
 

EastIdahoNews.com file photo

BOISE (Idaho Capital Sun) — Idaho lawmakers on the Medicaid Managed Care Task Force spent Thursday morning listening to representatives from disabilities communities in Idaho regarding their concerns about potential changes to the Medicaid system.

Most speakers pointed to the lack of staffing for direct care workers, as well as the lack of staff in the state’s Division of Medicaid. Multiple speakers referenced a report and recommendations from the Office of Performance Evaluations on the sustainability of the direct care workforce, released in February.

Christine Pisani, executive director of the Idaho Council on Developmental Disabilities, spoke on behalf of the Our Care Can’t Wait Coalition, which wrote to the task force in July about its concerns around changes to the Medicaid system.

She stressed the importance of adding staffing to the Division of Medicaid and increasing the number of home-based caregiver workers.

“Year after year, I observe the demoralizing effects on the staff at the Division of Medicaid who are repeatedly unable to meet the expectations of our state,” Pisani said. “I’ve watched countless quality staff leave the division because the workload is too tremendous due to too few staff.”

Recommendations are often proposed, but the division always says they don’t have the capacity to implement them, she said.

“If we are unable to maintain the home- and community-based service system, the cost to the state will be four to five times more through out of state placements and higher cost of institutional care,” Pisani said.

Staffing vacancies can lead to negative health outcomes, Idaho disability advocate says

David Lehman, representing the Idaho Association of Community Providers, told the committee that staffing vacancies for the association are at about 30% and that overtime makes up about 15-25% of payrolls. Asking employees to spend that much time working overtime while being paid about $15 an hour isn’t sustainable, he said. Even with the overtime, there is a significant waitlist of people that need to access services.

“We may see more institutionalization as a result of people not being able to access services in the community,” Lehman said. “Not only is it cheaper to provide services in community, but we don’t have to build facilities to do it.”

He hopes the Idaho Department of Health and Welfare would support training for direct care workers to help run those platforms. He also told committee members that he hopes to professionalize direct care and help people see it as a potential career with advancement options.

Legislators asked Lehman what he believes the result of switching to a managed care Medicaid system could mean for the association.

“There already is a management structure in place for individuals, whether they have a disability or not, [who] have the Healthy Connections provider and are referred out for services,” Lehman said. “So adding that next layer of complexity, I’m not sure it benefits at all individuals with disabilities. The system as it is now provides some of those protections for the taxpayer, making sure people are getting the right care at the right time.”

The goal of task force is to study cost-effective managed care after the 2023 budget request for Medicaid hit $4.7 billion. The Thursday meeting also included a review of other states’ Medicaid managed care plans.

After Idaho voters approved Medicaid expansion in 2018, eligible enrollees include people younger than 65 who are under 138% of the poverty level. Others who are eligible for Medicaid include pregnant women who are under 138 percent of the poverty level, people with disabilities, and people 65 years and older who meet certain income requirements.

The Medicaid Managed Care Task Force meets next on Sept. 11.

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RX (OR)- Audit finds lack of transparency in Medicaid prescription system

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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]: Oregon wants to get all up in the PBM’s bitness.

 
 

 
 

Clipped from: https://theworldlink.com/news/local/audit-finds-lack-of-transparency-in-medicaid-prescription-system/article_e2809128-6530-5223-8def-321767a90f55.html

 
 

Oregon needs to provide better oversight of pharmacy benefit managers so people on Medicaid can have equal access to medication, state auditors found.

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State regulators can do more to help Medicaid patients access medication by providing better oversight of an obscure but influential step of the prescription drug supply chain that starts with the manufacturer and ends with the pharmacist, auditors found.

An audit released Monday by the Secretary of State’s Office found the state’s regulation of pharmacy benefit managers is lax and limited, even though the organizations play a central role in the prescription medications of nearly 1.5 million low-income Oregonians enrolled in the Oregon Health Plan, the state’s Medicaid plan. That’s about one in three Oregonians.

Pharmacy benefit managers are middlemen in the prescription drug industry. They manage prescription drug plans for insurers, negotiating prices with manufacturers and pharmacies. They play a major role in the cost of drugs – Oregon Medicaid insurers spend hundreds of millions on medications a year – and patient access to crucial medications.

“Pharmacy benefit managers play an important role in delivering pharmacy benefits to millions of Oregonians, but as the audit shows, they operate in a complex structure that lacks transparency,” Oregon Secretary of State LaVonne Griffin-Valade said in a statement.

Their business practices can determine the financial health and viability of an independent pharmacy in rural Oregon – regardless of its distance from other pharmacies. Pharmacy benefit managers also influence whether a patient needs to travel to a specialty pharmacy to pick up a certain type of medication or what drugs an insurer will cover.

They can own pharmacies, too. That means that the pharmacies they own can get better reimbursements – and more money – than independent pharmacies, many in small rural towns with limited health care access.

“Pharmacists can help patients better manage their medications and their chronic diseases, which in turn can help them lead healthier lives, reduce hospital admissions and save money for the state, so that is a critical component,” Ian Green, the audits manager for the Oregon Secretary of State’s office, said in an interview with the Capital Chronicle. “We found that generally speaking, independent and community pharmacies have lower reimbursements than national pharmacy chains or specialty and mail order pharmacies.”

Auditors: Vague financial information

In Oregon, Medicaid insurers reported spending $767 million on prescription drug benefits in 2021. The state’s Medicaid insurers, also called coordinated care organizations, contract with the Oregon Health Authority to provide health benefits. They also subcontract with pharmacy benefit managers.

But auditors found that because pharmacy benefit managers are complex organizations with trade secrets it makes it close to impossible to gauge their profits and how much of the money comes from Oregon and U.S. taxpayers who pay for the Oregon Health Plan.

“This opaque system makes it impossible to understand the actual costs of prescription drugs and has garnered attention at multiple levels of government,” auditors wrote, noting that the Federal Trade Commission announced in 2022 it would launch an inquiry into pharmacy benefit managers.

Other findings of

the audit are:

• An Oregonian on Medicaid who qualifies and uses a prescription drug can lose access if they move from one part of the state to another. This means they may need to try an ineffective medication first and jump through red tape to get qualified for coverage again. This is because Medicaid insurers assigned to various parts of Oregon have different agreements with pharmacy benefit managers.

“They should have the same access to medications, no matter where they live in Oregon,” Green said.

• Low or unfair reimbursement rates have led to a decline in local independent pharmacies, reducing access in rural regions.

• Other states require pharmacy benefit managers to disclose more, including information about their payments and fees.

• The Oregon Health Authority, which oversees Medicaid, performs “minimal monitoring” of prescription benefit managers.

Audit recommendations

Auditors recommended the Oregon Health Authority require its Medicaid insurers to conduct annual independent audits of prescription benefit managers. Those audits are now optional, the report said.

Auditors also recommended the health authority assign employees to monitor compliance who don’t have a conflict of interest. Currently, the authority has limited staff for compliance because employees with the necessary expertise work with the authority’s Oregon Prescription Drug Program, which purchases prescription drugs for programs including Oregon Health and Science University and the Oregon State Hospital.

The Oregon Health Authority agreed with the recommendations. In a response letter, the authority said it should have more staff assigned by mid-2024 and enact requirements for independent outside audits of pharmacy benefit managers by January 2025.

Auditors also recommended lawmakers pass bills that would change the system, including a universal list of covered prescription drugs for all Medicaid insurers to ensure fairness and equal access, and requirements for pharmacy benefit managers to provide data annually, including information about its fees and profits.

Oregon Capital Chronicle is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. Oregon Capital Chronicle maintains editorial independence. Contact Editor Lynne Terry for questions: info@oregoncapitalchronicle.com.

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PHE- COVID-19 Provider Relief Fund: HRSA Continues to Recover Remaining Payments Due from Providers

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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]: HRSA is on the strugglebus trying to get some of the COVID Provider Relief Funds back. Roughly $2.6B of them to be exact-ish.

 
 

 
 

Clipped from: https://www.gao.gov/products/gao-23-106083

Fast Facts

The Provider Relief Fund spent $135 billion to help health care providers with COVID-related expenses and lost revenue during the pandemic. Most of the relief payments—about $85 billion—went to hospital-based health systems and hospital-affiliated providers.

To confirm that payments were accurate, the Health Resources and Services Administration took steps to review provider eligibility and if funds were used appropriately. In doing so, it found that $2.6 billion in payments should be recovered.

As of May 2023, the agency had recovered about half of the money and, as of August 2023, had set a schedule to get back the rest.

 
 

What GAO Found

The Health Resources and Services Administration (HRSA), an agency within the Department of Health and Human Services (HHS), administers and oversees the Provider Relief Fund (PRF). The PRF provided relief to health care providers for expenses or lost revenues attributable to the COVID-19 pandemic. As of May 2023, HRSA distributed $135 billion in payments kept by providers; hospital-based health systems and hospital-affiliated providers received the majority of payments—about $84 billion. HRSA made payments until June 2023, when the remaining unobligated funds for provider relief payments were rescinded

Among its efforts to ensure payment accuracy, HRSA conducted pre-payment reviews to verify provider eligibility and information on provider applications. HRSA also conducted post-payment reviews to check for potential payment errors and identify overpayments. HRSA plans to conduct these reviews on 59 types of potential payment errors, but the agency has been delayed in completing these reviews. As of May 2023, 21 of 59 remained open. In October 2021, GAO recommended that HRSA promptly complete the remaining reviews, but HRSA has not yet implemented the recommendation.

HRSA has taken steps to ensure that providers used PRF payments according to program requirements. HRSA required providers to report on their use of PRF payments, and it has been auditing a risk-based sample of providers to verify appropriate use of payments. HRSA also assessed fraud risks and implemented controls to ensure proper use of payments, though certain processes were only recently implemented. In particular, HRSA implemented recommendations from its 2021 fraud risk assessment. In March 2023, HRSA implemented a process to review irregular payments and, in June 2023, finalized procedures for responding to potential fraud.

As of May 2023, HRSA had recovered about half of the $2.62 billion in payments identified for recovery. HRSA had established time frames to recover most of the $1.36 billion in payments not yet recovered, but had not established time frames to recover $250 million in remaining overpayments, unused payments, and some payments from non-compliant providers. However, in August 2023, HRSA established time frames for the recovery of these payments.

Provider Relief Fund (PRF) Payment Recoveries, as of May 2023


Why GAO Did This Study

The PRF was created in March 2020 to provide COVID-19 relief to health care providers and ensure access to essential health care services. Providers included those enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program.

The CARES Act includes a provision for GAO to monitor and report on the federal response to the COVID-19 pandemic. This report describes (1) PRF payment distributions; and examines (2) efforts to ensure the accuracy of PRF payments, (3) efforts to ensure that PRF payments were used according to program requirements, and (4) the status of efforts to recover PRF payments.

GAO analyzed data on PRF payments as of December 2022, by which time nearly all PRF payments had been distributed. GAO analyzed recoveries of PRF payments as of May 2023—the most recent data available at the time of the review. GAO also reviewed information and agency documentation on payment integrity activities, including program reports and risk assessments; interviewed agency officials; and compared payment integrity activities to agency requirements.

GAO’s draft report recommended that HRSA establish time frames to promptly recover remaining overpayments, unused payments and payments from all noncompliant providers. In response to the draft report, in August 2023, HRSA provided a time frame for the recovery of these payments. As a result, GAO removed the recommendation and modified the report accordingly.

For more information, contact Leslie V. Gordon at (202) 512-7114 or gordonlv@gao.gov.

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PHE- CMS requires 30 states to pause Medicaid disenrollments after systems error

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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]: States incorrectly processing child eligibility and the household level using automated systems are now being “required” by CMS to slow down.

 
 

 
 

Clipped from: https://www.healthcaredive.com/news/cms-pauses-medicaid-redeterminations-30-states/694485/

An article from

 
 

Nearly 500,000 people will regain Medicaid or Children’s Health Insurance Program coverage after being improperly removed from the rolls during redeterminations, according to the HHS.

 
 

Kameleon007 via Getty Images

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Dive Brief:

  • Federal regulators ordered 30 states to pause procedural disenrollments of Medicaid beneficiaries after warning about inappropriately removing children and other enrollees from coverage during the ongoing redeterminations process. 
  • Last month, the CMS sent a letter to all states, Washington, D.C., Puerto Rico and the U.S. Virgin Islands about a systems issue with automatic renewals. Some states were conducting eligibility checks at the family level, even though some members of the household — like children — face a lower bar to remain covered under the safety-program.
  • Nearly half a million people will regain Medicaid or Children’s Health Insurance Program coverage due to the fix, according to a release from HHS. 

Dive Insight: 

More than seven million Medicaid beneficiaries have been disenrolled from the program geared toward low-income people since the redeterminations process began this spring, according to health policy research firm KFF.

States are required to figure out which enrollees are still eligible for the safety-net program after a long period of continuous enrollment during the COVID-19 pandemic, where beneficiaries were kept enrolled in Medicaid to avoid coverage losses during a public health emergency. 

But patient advocates have raised concerns about the large number of procedural disenrollments, or cuts due to administrative reasons like not completing paperwork. 

Among states with available data, 73% were removed from coverage due to procedural reasons, according to KFF. 

In 16 states reporting age breakouts, children accounted for 42% of Medicaid disenrollments. 

The federal government has taken steps to cut down on the number of inappropriate disenrollments including offering states more flexibility and pausing coverage terminations in states that weren’t compliant with renewal requirements.

“I think unwinding has revealed that there have always been more procedural terminations than we realized. And that’s contributed to the historic patterns of churn on and off of Medicaid that have impacted people’s ability to keep their coverage,” said Allison Orris, senior fellow at the Center on Budget and Policy Priorities, during a meeting of the Medicaid and CHIP Payment and Access Commission Thursday. 

Automatic renewals, or ex parte renewals, use existing data to determine whether beneficiaries are still eligible for coverage, and are key tools to keep people enrolled with lower documentation burden, regulators said. 

But some states were enacting renewals of whole households at once, even though some members may have different eligibility requirements, the CMS said in a letter last month.

Alaska, Colorado, Connecticut, Delaware, Washington, D.C., Georgia, Hawaii, Idaho, Illinois, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Nebraska, Nevada, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Pennsylvania, Vermont, Virginia, West Virginia, Wisconsin and Wyoming were not auto-renewing at the individual level, according to preliminary data released Thursday.

ennsylvania and Nevada estimated the error affected more than 100,000 people in their states. Other states reported lower numbers or were still assessing the impact.

Dan Tsai, deputy administrator and director of the Center for Medicaid and CHIP Services, said Thursday there’s “no doubt” the Medicaid program will come out of the redeterminations process stronger due to the increased focus on eligibility and outreach.

“I hope this will lead to a renaissance over the next multi-year period of how we in the country collectively think about eligibility and the ease of maintaining and getting access to coverage through Medicaid and other programs,” he said during the MACPAC meeting. 

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PROVIDERS / FINANCE- As clock ticks toward massive Medicaid disproportionate share hospital cuts, proposed bill would bring relief

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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]: Our annual pretend-fest that our “representatives” will honor a key part of the ACA deal from 13 years ago.

 
 

Clipped from: https://www.hfma.org/payment-reimbursement-and-managed-care/medicaid-payment-and-reimbursement/clock-ticks-toward-massive-medicaid-disproportionate-share-hospital-cuts/

Big Medicaid DSH cuts have been pending for almost a decade but have yet to be implemented. That will change soon if Congress does not act.

A congressional bill that would impose additional transparency requirements on providers also would offer a respite from a sizable cut to a key supplemental payment.

A $32 billion reduction to Medicaid disproportionate share hospital (DSH) payments is scheduled to span four years, beginning when federal FY24 gets underway Oct. 1. The Lower Costs, More Transparency Act would push back the start of the cut to FY26.

A scheduled House vote on the bill was postponed Sept. 18, with no immediate announcement of when the vote would take place. The bill apparently did not have the two-thirds support required to meet the threshold for fast-tracked legislation in the House.

The bill can still be considered anytime under normal rules, which would require only a simple majority but also allow for floor debate and amendments that could delay proceedings. Potential obstacles also include the distraction of the looming standoff between the parties over legislation to keep the federal government funded past Sept. 30, plus the need for the bill to ultimately clear the Senate.

Other provisions in the bill extend the graduate medical education program for academic medical centers through FY30, beginning with a $175 million allocation in FY24. Also included are two-year funding extensions, through CY25, for community health centers ($4.4 billion per year) and the National Health Service Corps ($350 million per year).

Sounding the alarm

The Medicaid DSH cuts would amount to 54% of scheduled Medicaid DSH payments in the upcoming fiscal year, according to estimates in a 2023 report by the Medicaid and CHIP Payment and Access Commission (MACPAC).

Such a decrease could “disrupt the financial viability of some safety-net hospitals,” MACPAC said. If the cuts aren’t delayed, they should be phased in more gradually than the current schedule allows, the commission wrote.

The Medicaid DSH cut would coincide with a $943 million reduction in Medicare uncompensated care payments as finalized in the FY24 rule for hospital inpatient payments.

Seeking a delay in the Medicaid cuts, America’s Essential Hospitals wrote a Sept. 14 letter to congressional leaders, with signatures from more than 250 member hospitals.

“These cuts would undermine America’s healthcare safety net and significantly reduce our hospitals’ ability to provide lifesaving services to the communities you represent,” the letter states.

In its own letter, Premier Inc. noted a large DSH cut especially would hamper hospitals amid the ongoing wave of Medicaid eligibility redeterminations that have accompanied the end to continuous-enrollment provisions after the COVID-19 public health emergency.

Members of Congress seem to understand the scenario. In August, a bipartisan group of 51 senators wrote to the chamber’s leadership asking that the looming cut be addressed, stating, “Cuts of this magnitude could undermine the financial viability of hospitals, threatening access to care for the most vulnerable Americans.”

What’s behind the cut

Medicaid DSH reductions totaling $18 billion initially were supposed to start in 2014 as a mechanism to pay for the coverage expansion in the Affordable Care Act (ACA). Subsequent delays have offered relief in the short term but also resulted in increases to the funding reduction target.

“Unfortunately, the projected coverage levels have not been realized and hospitals continue to care for patients for whom they are not receiving payment,” the American Hospital Association (AHA) wrote in an April letter supporting an earlier bill to delay the cut.

The cut would vary drastically by state based on factors such as uninsured rates and the degree to which a state’s DSH funding is targeted to hospitals with high volumes of Medicaid patients and uncompensated care. The percentage decrease in funding would range from 6.1% in South Dakota to 90% in Rhode Island, according to MACPAC.

In theory, the cuts would be especially adverse for safety net hospitals in the 10 states that have not expanded Medicaid as authorized by the ACA, since those hospitals would lose funding without having benefited from the anticipated increase in insured patients. However, MACPAC projects that non-expansion states would face lower percentage reductions (47.3%) in DSH funding compared with expansion states (59.9%), in part based on how uninsured rates would factor into the decrease.

The Medicaid DSH formula has been affected by a change included in 2021 funding legislation. In calculating a hospital’s payment, the 2021 provision calls for excluding costs and payments that are related to services furnished to Medicaid beneficiaries who also have Medicare or commercial insurance.

As detailed in a 2023 proposed rule, the change does not apply to hospitals in the 97th percentile or higher of patients entitled to both Medicare Part A and Supplemental Security Income benefits.

Two sides of the same bill

While the Lower Costs, More Transparency legislation would maintain Medicaid DSH funding over the next two years, terms in the bill that expand site-neutral payments to cover all Medicare drug administration services are projected to create about $380 million per year in federal savings.

In reacting to the provisions as introduced several months ago in committee legislation, the AHA linked site-neutral payment policies with the proposed delay in the Medicaid DSH cuts. In other words, one was being used to help fund the other.

“Robbing Peter to pay Paul is not the way to achieve the objective and would add to the financial fragility of many hospitals,” the AHA said in a statement attributed to Stacey Hughes, executive vice president.

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SDH / TECH – Uber Eats to accept SNAP benefits for grocery deliveries in 2024

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]: Yep. Uber tapped in SNAP funding. That’s a 10-year total addressable market of $1.223Trillion per CBO. Somebody at that disruptive lil’ ole ride share got a promotion on this one.

 
 

 
 

Clipped from: https://thehill.com/changing-america/respect/poverty/4217069-uber-eats-to-accept-snap-benefits-for-grocery-deliveries-in-2024/

Story at a glance

  • Starting in 2024, SNAP recipients will be able to buy grocery deliveries through Uber Eats.

 
 

  • Uber also announced it is working to help support Managed Medicaid and Medicare Advantage plans by accepting FSA cards, Flex cards and waiver payments on Uber for its services.

 
 

  • Tapping into artificial intelligence, Uber is poised to launch later this year an AI-powered assistant to outline new available dishes and cuisines on the app, sort through deals at popular restaurants and reorder previous meals more quickly, per the release.

(KXAN) — Beginning in 2024, Supplemental Nutrition Assistance Program (SNAP) recipients will be able to purchase grocery deliveries through Uber Eats, the company announced Wednesday.

“We know that online food delivery can have a meaningful impact in reducing barriers to fresh groceries, especially for the most vulnerable–including people living in food deserts, seniors, and those facing disabilities or transportation barriers,” company officials wrote in the announcement. “Helping to improve access to quality food is incredibly important to our work at Uber and we’re proud to use Uber’s technology and extensive local delivery networks to offer SNAP recipients the ability to use their benefits to access fresh groceries conveniently from our app in 2024.”

DeSantis vows to revoke funding for COVID vaccines if elected in 2024

Uber also announced it is working to help support Managed Medicaid and Medicare Advantage plans by accepting FSA cards, Flex cards and waiver payments on Uber for its services. Some of those payment methods will be ready and accepted come 2024, per the announcement.

Tapping into artificial intelligence, Uber is poised to launch later this year an AI-powered assistant to outline new available dishes and cuisines on the app, sort through deals at popular restaurants and reorder previous meals more quickly, per the release.

The AI assistant can also be used to denote sales on grocery items or reorder ingredients from recipes previously used. Uber announced its Uber Eats Sales Aisle concept will highlight grocery store promotional deals and sales to help streamline shopping.

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PROVIDERS (LTC)- Biden’s nursing home staffing proposal is dangerously inadequate

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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]: This journo says that the rule all the LTC providers are freaking out about will go nowhere anyway.

 
 

 
 

Clipped from: https://thehill.com/opinion/healthcare/4214467-bidens-nursing-home-staffing-requirements-are-dangerously-inadequate/

 
 

Tina Sandri, CEO of Forest Hills of DC senior living facility, left, helps resident Courty Andrews back to her room, Dec. 8, 2022, in Washington. The federal government will, for the first time, dictate staffing levels at nursing homes, the Biden administration said Friday, Sept. 1, 2023, responding to systemic problems bared by mass COVID deaths. (AP Photo/Nathan Howard, File)

As nursing home residents and staff died by the thousands in the first months of the COVID-19 pandemic, one thing became clear: Understaffing in America’s nursing homes is lethal. Most facilities lacked the staff needed to prevent neglect and avoidable harm to residents. 

President Biden responded to the nation’s nursing home crisis by declaring that his administration would create a minimum staffing standard for nursing homes, to help ensure basic care and services for the nation’s more than 1 million nursing home residents.

This announcement was heralded by long-term care residents and their supporters. For years, nurses, physicians, researchers, consumer advocates and government reports had been sounding the alarm that understaffing in nursing homes jeopardized residents’ health and safety. 

Consider the result of understaffing in four New York nursing homes recently sued for abuse. 

One resident was so neglected his son couldn’t recognize him. Another resident was dying from an infected pressure sore that grew “cavernous” and ended up “eating away most of his buttocks.” Staff had so little time to provide basic care that they left windows open to reduce the stench of unclean residents, leaving residents “freezing” and swarmed by flies.

Unfortunately, the federal agency responsible for drafting Biden’s new staffing standard has just dropped a bombshell. On Sept. 6, it published a proposed staffing standard so minimal and with such huge exceptions that many nursing home residents will see no benefit at all.

To be sure, the proposal has some good news for residents. It requires a registered nurse to be present in a nursing home 24 hours a day, replacing the current federal requirement of only 8 hours. That’s a major step forward. RN levels predict nursing home quality, and RNs play a critical role in assessing, diagnosing, planning, and overseeing care. 

But when it comes to total staffing levels, the federal agency in charge, the Centers for Medicare and Medicaid Services (CMS), has proposed that nursing homes only be required to provide three hours of staff time per resident per day. That’s far less than what many states with state-specific minimum staffing standards require. It’s only 73 percent of the 4.1 hours per day that a rigorous CMS study found is necessary to avoid neglect. 

A lower standard might be understandable if the federal government planned to make all nursing homes comply with it. It doesn’t. 

CMS proposes granting waivers to both rural facilities and facilities in communities with below-average numbers of health care providers. Facilities must make a “good faith effort” to recruit and retain staff to get a waiver, but this effort doesn’t have to include offering the higher wages or benefits needed to attract workers. 

So long as a facility offers the “prevailing wage”— which is notoriously low — it can avoid the minimum staffing requirement. The Economic Policy Institute found that long-term care workers (over 80 percent of whom are women and who are disproportionately Black and immigrant women) are substantially underpaid and most lack any employer-provided retirement or health benefits.  

The nursing home industry argues that it can’t afford higher staffing requirements. Yet even nursing homes that are dependent on Medicaid (which the industry claims doesn’t pay enough) are being bought up by private equity firms because of their profit potential. And stories abound of nursing homes claiming poverty while their owners pocket millions.  

It’s time for the federal government to stop allowing nursing homes to operate with unsafe staffing levels. After all, the federal government foots the bill for three-quarters of nursing home residents. And the federal government shouldn’t continue to expect taxpayers to pay for nursing homes that lack the minimum staff needed to provide adequate care.

Nursing home residents, their families and their supporters need to demand minimum staffing standards that are higher and that apply to all nursing homes (rural residents deserve good care too). They may not have the resources of the nursing home industry, which routinely spends over $100 million a year on lobbyists. But they can make themselves heard. One way to do so: commenting directly on CMS’s proposed standard on the federal government’s dedicated website. CMS is legally required to read these comments and consider them in developing the final rule.

Inadequate nursing home staffing is not just an issue for today’s residents. Each of us may be one accident away from a nursing home. Whether we are 80 years old with a broken hip or 30 years old with a head injury, we shouldn’t have to worry that we’ll end up neglected in a nursing home too understaffed to keep us safe. 

As one longtime nursing home resident explained, understaffing means “you don’t get cleaned or changed which leaves you susceptible to all kinds of sicknesses” and that’s “counterintuitive to how you’re supposed to live in a nursing home. You’re not supposed to get sicker here because of low staffing.” He’s right. 

Nina A. Kohn is a visiting professor at Cornell Law School, a distinguished scholar in Elder Law at the Solomon Center for Health Law and Policy at Yale Law School and the David M. Levy Professor at Syracuse University College of Law. Charlene Harrington is professor emeritus at the University of California San Francisco’s School of Nursing.
Lori Smetanka is executive director of the National Consumer Voice for Quality Long-Term Care.

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FRAUD (TX)- Texas couple allegedly scammed Medicaid out of $14 million by fixing the same wheelchairs hundreds of times

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]: The Yzaguirres stole $14M of your tax dollars thru a DME scam.

 
 

 
 

Clipped from: https://www.morningstar.com/news/marketwatch/20230902324/texas-couple-allegedly-scammed-medicaid-out-of-14-million-by-fixing-the-same-wheelchairs-hundreds-of-times

 
 

By Lukas I. Alpert

Jeremiah and Maria Yzaguirre are accused of using the money to buy luxury cars, real estate and pricey movie memorabilia

A Texas couple has been charged with ripping off Medicaid to the tune of $14 million by claiming to have repaired the same handful of motorized wheelchairs hundreds of times.

Many of the claims were made for patients who were bedridden and unable to use the wheelchairs at all, according to fraud, money-laundering and identity-theft charges filed in federal court in Brownsville, Texas.

Federal prosecutors accuse Jeremiah Yzaguirre, 44, and his wife, Maria Luisa Yzaguirre, 43, of Harlingen, Texas, of making the claims on behalf of 37 people who had been customers of their medical device company, Southwest Medical Homepatient.

The pair are accused of then using the proceeds of the alleged scam to buy a luxury $150,000 Acura NSX sports car, high-priced real estate and hundreds of thousands of dollars worth of cryptocurrency. They also allegedly amassed a collection of expensive movie memorabilia including a Johnny 5 robot prop from the 1986 film “Short Circuit,” worth over $100,000.

An attorney for Jermiah Yzaguirre, who was arrested on Aug. 22 on a sealed indictment, didn’t immediately respond to a message seeking comment. Maria Yzaguirre was arrested Wednesday morning and it wasn’t immediately clear if she had retained an attorney. She is expected to make her first appearance in court on Thursday afternoon, prosecutors said

According to court filings, between 2019 and 2023 the couple submitted claims on several occasions for hundreds of the same repairs to the same wheelchairs.

In one case, the Yzaguirres are accused of submitting over 300 repair claims for the same wheelchair, including 132 to fix its expandable controller, 107 to fix its motor gearbox and 84 to replace its battery.

According to court documents, prosecutors have asked the judge to allow them to seize hundreds of thousands of dollars in cryptocurrency wallets and regular cash accounts, the Acura sports car, drone equipment and a long list of valuable anime figurines and movie-themed Lego sets the couple owned.

If convicted, the Yzaguirres each face up to 10 years in prison for fraud and money laundering and two years for each count of aggravated identity theft.

-Lukas I. Alpert

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(END) Dow Jones Newswires

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