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Three months in, Medicaid managed care deals crushing admin burden

By Clarissa Donnelly-DeRoven

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Speech therapists in NC continue to struggle to adapt to the new managed care model.

 
 

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.

 
 

Three months into North Carolina’s Medicaid transition, some small health providers say they’re struggling to navigate the new system. They describe spending hours more on new administrative tasks, trying to ensure their patients don’t experience lapses in care and that they get paid for the services they provide.

“I want to help everybody, and this is preventing me from doing that,” said Rebecca Rowe, a speech language pathologist who runs her own practice in Charlotte. Rowe and other small medical practice owners worry that the added administrative costs may make it untenable for them to serve as many Medicaid patients in the future. 

“When you’re talking about a small business, you have to maximize the time, right? Maximize the time spent one-on-one with clients,” Rowe said. “It’s hurting children first and foremost, but it’s also hurting small businesses and I don’t think that’s something that the North Carolina government understood.”

Dave Richard, the deputy secretary for North Carolina’s Medicaid system, said the agency is aware of these problems and working to address them through weekly conversations with the CEOs of each of the managed care organizations. Still, he said, some of the issues are just a function of the new system. 

“Managed care is managed care and there’ll be some of these changes that just are inevitable because of the way that managed care organizations have to work,” he said.

From public to private

On July 1, North Carolina’s Medicaid program transitioned from a system run and managed primarily by the state, to a system run and managed by five different private insurance companies, called managed care organizations or MCOs. About 1.6 million low-income North Carolinians had their coverage switched from state managed to MCO managed. Three quarters of those people — 1.2 million — are under 21 years old. 

Some 900,000 people who have more intense health care needs, ranging from developmental disabilities to chronic mental health issues, remain on state-run Medicaid and will see their plans turned over to the MCOs in 2022. 

Nationwide, about 70 percent of people on Medicaid receive coverage from a managed care entity, according to the Kaiser Family Foundation. Before the transition, North Carolina was the largest state in the country without a significant presence of corporate managed care organizations in its Medicaid system. 

The transition from state run to MCO run occurred by and large to save money and provide more budget predictability. 

When North Carolina ran its own Medicaid program, state employees were responsible for authorizing claims and allocating the funds to pay doctor bills. The cost of the program came in at $14.8 billion in 2019 and $16.8 billion in 2020. The federal government pays for the majority of Medicaid costs; over that two year period, North Carolina’s share came out to about $3.8 billion. 

The cost savings is expected to come from the shifting payment structure. The state-run Medicaid program operated using a fee-for-service model, where the state reimbursed health care providers for each visit, test and service. The model used by managed care organizations pays providers a set payment per patient. Under the new model, patient health outcomes will be one of the key benchmarks for measuring how well providers are doing.

The MCOs are for-profit entities. In the past, they made money by denying services and cutting reimbursement rates. Richard said there are accountability measures in place to prevent this kind of nefarious behavior, specifically through something called a Medical Loss Ratio.

The Affordable Care Act requires private health insurance companies to submit data on how they spend their money. The standard under the Medical Loss Ratio requires the companies to spend between 80 and 85 percent of the money they take in from premiums on actual health care services. If they don’t do that, and instead spend customer payments on things like executive compensation and advertising, they have to issue rebates. 

The rule extends to the MCOs working with North Carolina’s Medicaid program.

Division of Mental Health director Dave Richard speaks to reporters at the WakeBrook event Thursday. Photo credit: Rose Hoban

“They have to spend 88 percent of what we pay them on services,” Richard said. “It can’t be that they’re spending 80 percent, then they’re pocketing the rest. So there’s this real tight part in our managed care plan that I think holds them accountable at that level.”

With managed care, more logistics to deal with

Before the transition, service providers submitted requests for authorizations and claims directly to the state’s Medicaid program through the NCTracks online portal. Now they have to navigate the systems of multiple managed care companies. This, they say, is one of the most time consuming parts of the transition. 

Lakajai Harris, a speech language pathologist, runs her own practice and works with children in rural Beaufort County. About 95 percent of her patients are now on managed care plans. She is in-network with four of the five managed care plans and said navigating them has presented huge logistical burdens.

“It seems like all of these insurance companies, they have one site that you need to go on to submit claims and one site to submit payments,” she said. “That means that we’ve gone from NCTracks to eight different sites.”

Stacy Kozlowski, an occupational therapist who also runs her own practice, said the same. She operates primarily in Johnston County and is in-network with all of the managed care companies.

“Small businesses like myself that provide services in the more rural areas, rural areas that big hospital systems don’t go to.” she said. “We don’t have the overhead or the administrative ability to manage seven or eight different entities with different systems.”

Providers say the MCOs are allotting them shorter authorization periods for service than the state-run Medicaid program did, which adds to their administrative work. 

Rowe, the Charlotte speech therapist, said Carolina Complete Healthcare recently authorized her to see an existing patient for just one month. 

Rebecca Rowe is a speech language pathologist who runs her own therapy practice in Charlotte. She’s struggled to handle the added administrative burdens of the new Medicaid system. Photo courtesy of Rebecca Rowe.

“That was down from six months that this child was receiving before, so that equates into extra manpower for our staff, for our front desk to continually do these authorizations,” she said. “Let’s say your practice sees 50 to 100 kids under these managed care companies. So you think about an hour every month getting a new authorization, right? That’s a lot of time and a lot of money.”

Harris said the time it takes the MCOs to authorize claims is slower than it was under the state-run system. In the past, she said it took about two weeks for her to receive a signature from their doctor and authorization from Medicaid before she could start services. Now, that timeline has doubled.

Since Harris knows when an existing client’s authorization will run out, she tries to submit the paperwork early enough that their new authorization for services will start immediately after their old one runs out, meaning the new waiting period primarily impacts new clients. 

Sometimes, though, existing patients get sucked in. She told the story of one boy whose authorization expired and his mother couldn’t make an appointment for a few days. By the time the boy’s doctor sent back the signed form to Harris and she submitted it to the child’s insurance, two weeks had passed. 

Harris said Blue Cross Blue and Shield of North Carolina, which runs HealthyBlue, requires 15 days to approve services. She said she called to see if they might be able to expedite the approval, but she had no luck. 

“This child has gone almost a month without services because I had to wait those 15 days to get approval,” Harris said. “I basically feel that I will have to start all over with him.”

Harris said BCBS of NC’s timeline for authorization feels especially arbitrary because some of the other entities, like AmeriHealth, approve authorizations in as little as two to three days.

More paperwork

Kozlowski said one MCO plan is asking her to send updated care plans every 30 days, which she said in her professional opinion is not necessary. 

“This is not like adult outpatient therapy where they’re progressing within six to eight weeks,” she said. “These are kids with chronic conditions that take greater periods of time to make progress.”

Sending an updated plan of care every 30 days means the therapist working with a child has to take daily notes, write up the new plan, and then Kozlowski’s office will fax it to the child’s pediatrician, wait for the pediatrician to sign and return it, and then submit it for authorization to the insurer. 

“We have to allow at least a month so that there’s no lapse in service,” she said. Kozlowski has hired additional staff to deal with the added administrative work that’s come from juggling five new insurance programs. 

Harris, who does her own billing, said she doesn’t know how sustainable a system like this is for a one-woman business. She only just received payment for services she provided in July, after a long hassle with one of the MCOs. The entity kept denying her claims, saying she wasn’t in-network, which she said wasn’t true. Eventually, she learned it was because the MCO entered her biographical information incorrectly into their system. But, it wasn’t easy to figure out.

“They kept just giving me the runaround, like, ‘Well, submit a claim, see what happens, and then we can go from there.’ And it would take a week or two before I get some type of response back,” she said. “I finally told the rep, if I wasn’t going to get paid soon — by the month of October — I would have to close down because I was not receiving payments. I’m still seeing these children, and I’m not getting paid for these children.”

Harris said her issue was only resolved after she submitted a complaint to the North Carolina Medical Society, an organization that serves as an intermediary between the MCOs and health care providers. 

“This managed care,” she said, “I don’t know how small businesses like me are going to survive.”

State expected some bumps

Richard, the head of North Carolina’s Medicaid program, said the agency was “preparing for the worst” during the first few days of the transition, such as a total crash of the program’s online systems. 

“But honestly, the big stuff went well. We’ve had what I call serious issues for people, but not the catastrophic problems that I think people were concerned would happen,” Richard told a virtual audience gathered during an October conference for the state chapter of the National Alliance on Mental Illness.

Some of the serious, but not catastrophic, issues included problems with non-emergency medical transport, a program that is supposed to help people get transportation to and from their medical appointments.

Kelly Zyablov, a mom with two children on the new managed care plans, told her children’s speech therapist — Rowe — that she couldn’t afford gas for the 45-minute trips back and forth between her house in Union County and the office in Charlotte. 

Rowe looked at a brochure, created by the N.C. Department of Health and Human Services, that describes the different services available to those on the new managed care plans. The services are designed to address social determinants of health. 

Under the “Other” section, Rowe noted the bullet point: “$20 in Uber or Lyft gift cards for college students for grocery stores, local events.” She told Zyablov to call the insurance company and see if they could give her that benefit, or something similar, so she could drive her son to therapy. 

That sounded like great news for Zyablov. She called the number and said: “My kids have therapy, we need to get back and forth. Do you offer gas cards? They said no, but if your children are obese, we can give you a food card.” No thanks, she said and hung up. 

Without the extra gas money, Zyablov can only take her son, who has a brain disorder called apraxia, to speech therapy once a week — and sometimes even that is a stretch. 

Richard said there must’ve been a miscommunication. Though non-emergency medical transport is not exactly the system designed to help someone in Zyablov’s situation, there are a handful of “value-added services” attached to each managed care plan that are designed to address social determinants of health, such as not being able to afford gas to and from appointments. 

What might managed care look like in years to come?

“We know that there’ll be some disruption right? Because as you make this change, managed care principles take place,” Richard said, “And we’ll see a few rocky moments.”

Providers are worried about what those “managed care principles” might look like in practice. Many look to states that have recently switched over to managed care plans. Iowa, for example, moved from state-run Medicaid to a system operated by managed care organizations in April 2016. 

Over the last five years, providers have complained about declining reimbursements for care, while patients say they’ve been denied critical coverage. Two of the managed care companies, UnitedHealthcare and AmeriHealth Caritas, abruptly left the program just a few years in. UnitedHealthcare said it left because Iowa underfunded its Medicaid program, but Iowa officials said the insurance company left because it didn’t want to comply with oversight mechanisms. 

The possibility that the MCOs will cut reimbursement rates is what worries many providers the most, including Rowe. 

“These plans typically cut rates and cut services, right? That’s what they do to try to save money,” she said. “What will happen is, it’s all downstream. So these kids will go without services, they will get to their public school, they will be behind.”

Richard said that, hopefully, won’t be the case.

If the health plans do their job, and if our community based care management does its job, the way health plans are going to make money is by people being healthier,” he said. “And that’s really the goal that we have, is that healthier people will use less of the more intensive services, which then allows for those health plans to make their margins.”

 
 

Clipped from: https://www.northcarolinahealthnews.org/2021/10/19/three-months-into-medicaid-transformation-providers-say-the-new-administrative-burdens-are-crushing/

 
 

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Mass. Medicaid fraud case settled for record $25 million, AG’s office says

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The provider was using unlicensed workers at its mental health facilities.

 
 

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.

 
 

A private equity firm and two former top executives at a Massachusetts chain of mental health centers have agreed to pay $25 million in a whistle-blower lawsuit brought by the attorney general’s office, marking the largest MassHealth fraud settlement in state history, officials said Thursday.

South Bay Community Services (formerly known as South Bay Mental Health) has operated facilities in more than a dozen Massachusetts communities, including Boston, Brockton, Fall River, Lowell, Pittsfield, and Worcester, the office of Attorney General Maura Healey said in a statement.

South Bay has provided services to some 30,000 people receiving benefits through MassHealth, the state’s Medicaid program for low-income residents. But many of the staff at its mental health facilities were unqualified, unlicensed, and lacked proper supervision, violating MassHealth regulations, according to the AG’s office.

 
 

Clipped from: https://www.bostonglobe.com/2021/10/14/metro/mass-medicaid-fraud-case-settled-record-25-million-ags-office-says/

 
 

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Florida Medicaid, DOH, present FY 2022 budget requests

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FL Medicaid is asking to spend more on multiple program areas, including a planned upgrade to its MMIS.

 
 

 
 

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.

 
 

 
 

 
 

 
 

 
 

Nicole Pasia | Oct 14, 2021 | Florida

Three agencies — the Agency for Health Care Administration (AHCA), the Florida Department of Health, and the Department of Children and Families — presented their legislative budget requests (LBR) for fiscal year (FY) 2022 to the House Health Care Appropriations Subcommittee for consideration on Monday. 

Recurring requests among the agencies included health care workforce support to address high turnover rates, replacing outdated IT systems, and health quality assurance (MQA) measures. 

 
 

See a list of notable items from each agency below: 

Agency for Health Care Administration

Total legislative budget request (federal and state): $36.5 billion

  • Medicaid rate adjustments: $277.47 million in general revenue

Florida has seen 1.1 million more enrollments in Medicaid during the COVID-19 pandemic, leading to the state’s largest Medicaid population (4.9 million) in history. Rate increases to fit these new parameters were determined at the August 2021 Social Services Estimating Conference (SSEC). 

  • Florida KidCare adjustments: $53.9 million in general revenue

 
 

  • Institutional and Prescribed Drug Providers: $1.16 billion

This reflects cost adjustments for prescribed drug provider operations, such as over-the-counter prescriptions and drugs administered in outpatient settings.

  • Statewide Medicaid Managed Care Procurement Activities: $2.3 million in general revenue

This will support legal and actuary expenses to respond to protests of contract awards as during procurement negotiations. AHCA is required to reprocure contract awards every six years.

  • Medicaid Hospital Direct Provider Payment (DPP) Program: $154,000/2 FTE in general revenue

AHCA will create two positions to oversee this new program, which is expected to bring $1.8 billion in direct payments to hospitals and other providers in its first year. CMS approved this program earlier this year.

  • Florida Medicaid Management Information System: $117.8 million in general revenue

AHCA is set to replace its 20-year-old Florida Medicaid Management Information System.

  • Transfer of PACE from DOEA to AHCA: $37.7 million in general revenue/2 FTE

Revenue, administration, and authority over the Program for All-Inclusive Care for the Elderly, previously under the Department of Elder Affairs, will move to AHCA. AHCA Secretary Simone Marstiller said the move would streamline administrative processes and that AHCA was better suited to oversee PACE, as it is a health care program.

 
 

Department of Children and Families (DCF)

Total legislative budget request (federal and state): $3.8 billion

  • Replacing federal foster care funds: $32.5 million in general revenue

Due to changes in eligibility, Florida may not receive federal matching funds for Title IV-E foster care services and would need to use general revenue instead.

  • Stabilizing Children’s Legal Services Workforce: $4.8 million 

DCF would use funds to increase pay for 600 legal staff that manage court child welfare cases across the state. Staff turnover in this field has increased from 21% in 2017 to 49% this past year, according to Tony Lloyd, DCF assistant secretary for administration.

  • Comprehensive Behavioral Health Services: $109.7 million in trust fund authority

Federal funds from the American Rescue Plan, COVID-19 Relief, and the Substance Abuse and Mental Health Block Grant will expand behavioral health and substance use disorder services within the department, which have waiting lists of 2,000 and 1,000 people, respectively. 

  • State Opioid Response (SOR) Grant Budget Authority: $24.6 million in trust fund authority

Continued funding for this program has provided substance use disorder services for over 15,000 individuals in the last three years.

 
 

Department of Health (DOH)

State legislative budget request (general revenue and trust fund authority): $49.3 million

  • Infant Mortality and Prevention: $2.8 million in general revenue

Services would address the top two causes of infant mortality: sleep-related infant death and drowning. 

  • Office of General Counsel – Litigation: $2 million in general revenue

DOH will contract outside legal counsel due to “additional lawsuits arising from enactment of new laws and adoption of new rules governing the Department.” This request raised concern from Rep. Carlos Guillermo Smith (D – Orange), who filed a lawsuit in August over the department’s refusal to release daily COVID-19 data.

  • Group Care Program (GCP) Services: $3.8 million in general revenue

State funds would cover gaps between funding from county health departments and the GCP’s actual expenditures for group homes, schools, and other care services. 

  • Workload Medical Quality Assurance: $1.1 million in trust fund authority/19 FTE

DOH requests 19 positions due to an increase in applicants and high staff turnover rate for the Board of Nursing and the Board of Pharmacy.

  • Office of Medical Marijuana: $24.8 million in trust fund authority

This includes the creation of 85 positions within the department to serve additional patients and licensed Medical Marijuana Treatment Centers, accounting for nearly half of DOH’s budget request. 

Rep. Kelly Skidmore (D – Palm Beach), also expressed concern over DOH’s LBR, and asked why no COVID mitigation requests were included. DOH Deputy Secretary for Operations, Michele Tallent, responded that this was due to the department receiving over $3 billion in federal COVID support funds. 

 
 

Clipped from: https://stateofreform.com/news/florida/2021/10/florida-medicaid-doh-present-fy-2022-budget-requests/

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CMS is reviewing Missouri’s new Medicaid licensure policy

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CMS has decided to review Missouri’s efforts to increase oversight of safety regulations related to abortion providers.

 
 

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

 
 

 
 

The Centers for Medicare and Medicaid Services (CMS) is looking into Missouri’s new Medicaid rule, a spokesperson told The Missouri Times Thursday. 

“CMS evaluates all policies affecting the Medicaid program and is currently reviewing the new policy in Missouri,” the spokesperson said. 

New Medicaid regulations for abortion providers in Missouri took effect Wednesday, enacting requirements some said could potentially jeopardize funding for Planned Parenthood. 

Filed late last month, the emergency regulations tighten reporting requirements, allow state departments to work together to consider licensure, and enact new safety requirements. The rule expires on April 10, 2022. 

Under the new rules, the Department of Health and Senior Services (DHSS) can turn over its inspection records of abortion providers to the Department of Social Services (DSS). 

The Medicaid Audit and Compliance Unit then evaluates Medicaid eligibility for the provider, a change DHSS said would “increase further compliance with state and federal laws and regulations governing abortion facilities.”

“As a result, the Department of Health and Senior Services finds that there is a compelling governmental interest that requires an early effective date,” the notice read

The regulations also reinforce standards requiring providers to notify pathology labs of failed abortions within 24 hours, ensure all surgical tools are sterilized, perform pelvic exams on patients 72 hours before the procedure if medically necessary, and participate in yearly fire drills. 

Sen. Bill White, the Republican chair of the Senate Interim Committee on Medicaid Accountability and Taxpayer Protection, said the new regulations were based on recommendations from his committee that would allow DSS to deny or revoke licenses based on DHSS investigations rather than having to conduct their own reviews. 

The emergency rule was filed five days after the recommendation was unveiled.

“We say very general things, and the departments tighten them up and flush them out,” White told The Missouri Times. “The states are given the authority to establish standards for Medicaid providers and decide how to handle those that fail to keep them. These are very good rules.”

White, who also chairs the Joint Committee on Administrative Rules, said he did not believe the regulations put Missouri out of compliance with CMS or jeopardized any federal funding. 

However, representatives from Planned Parenthood of the St. Louis Region and Southwest Missouri (PPSLRSWMO) called on the Biden administration to intervene during a call with reporters Wednesday even though the new regulations will not impact Planned Parenthood’s services at this time. 

 
 

Clipped from: https://themissouritimes.com/cms-is-reviewing-missouris-new-medicaid-licensure-policy/

 
 

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Medicaid remains sticking point between GOP, Dems in NC’s budget

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The fight over Medicaid expansion may derail the NC state budget again this year.

 
 

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.

 
 

RALEIGH, N.C. (WNCN) – Republican House Speaker Tim Moore said this week that the possibility of expanding Medicaid coverage has come up in talks with Gov. Roy Cooper (D), but that there is still not enough support among his party’s members to include that in a final budget agreement.

The issue was one of the key reasons Cooper and the Republican-controlled legislature never agreed on a budget two years ago, as the governor has pushed for expanding the program to cover hundreds of thousands more lower-income people.

Republican legislative leaders have declined to do that, with Senate leader Phil Berger saying recently he still thinks it’s “bad policy.”

Still no end in sight for NC budget negotiations

Cooper, Berger and Moore are having private discussions about a potential budget compromise and have not made public what aspects of it they’re still trying to resolve with each other.

North Carolina is among 12 states that have not expanded Medicaid, according to the Kaiser Family Foundation.

Chrissy Burk is a working mom of two who lived in Fayetteville for 23 years until she moved to Ohio three weeks ago.

While living in North Carolina, she was uninsured and faced financial hardship.

“I had gotten so comfortable without having (health insurance), I learned how to move around not getting hurt or sick, or if I did using self-remedies, soothing myself,” she said.

She said she moved in with family in Toledo, taking just her clothes and her boys with her. Ohio is among the states that have expanded Medicaid.

“Since I’ve been here in three weeks, me and my kids were covered through Medicaid and I’ve already gotten a job, and I’ve only been here three weeks. And, the only thing I did different was leave the state of North Carolina,” she said.

Democrats in Congress recently tried to entice the remaining states that have not expanded Medicaid by offering to have the federal government pick up even more of the cost for two years. Under the Affordable Care Act, the federal government covers 90 percent of the cost, leaving states responsible for the rest. The American Rescue Plan included a provision to cover a 5 percentage point increase in the match rate for two years.

The Kaiser Family Foundation found that after accounting for the state’s cost for doing that, there would be a net increase of $1.2 billion in funding for North Carolina.

There’s also discussion of including a coverage option for people in states that have not expanded Medicaid in the $3.5 trillion so-called “human infrastructure” bill being debated in Congress.

North Carolina House Speaker Tim Moore said there are still outstanding questions about what that would mean for North Carolina if that passed.

“There’s questions about what impact does that have on the state. And, frankly, a lot of the time has been spent looking into… what would happen. What would it cost the state?” he asked. “A lot of real policy questions along there and we still can’t get them answered because we can’t get a clear answer from DC on them.”

Casey Cooper, CEO of the Cherokee Indian Hospital Authority, has been talking to leaders in Republican-leaning counties in the western part of the state, explaining to them the potential impacts of expanding Medicaid.

He pointed to working people who either don’t have insurance through their employers or can’t afford to purchase it themselves. He said that leads to some people forgoing treatment until they become so sick they have to go to the emergency room, which is much more expensive.

“Medicaid expansion is absolutely essential for small rural hospitals who are already operating on razor-thin margins,” he said.

Commissioners in Clay County adopted a resolution urging state lawmakers to expand Medicaid joining Graham, Jackson, Macon and Swain in the western part of the state, according to Care4Carolina.

“I think that perhaps maybe some of the resistance is just a lack of understanding and not understanding that Medicaid expansion is really the solution to this problem that our friends and families live with every single day,” he said.

Some conservative groups have been urging Republicans not to expand Medicaid.

Americans for Prosperity-North Carolina recently said it’s prepared to “launch a full-scale campaign to combat the effort.”

“As Senator Berger and most legislators who identify as ‘fiscally responsible’ have said for years: Medicaid expansion is— and always has been— bad policy. While some are letting the guise of unreliable federal funding dissuade their principles, our activists are gearing up to remind policymakers that Medicaid expansion will only exacerbate fiscal challenges for our state and North Carolina’s hardworking families,” said AFP-NC state director Chris McCoy in a statement.

It’s not clear how close Republicans and Gov. Cooper are to reaching a budget agreement. Republicans planned to send a counter-proposal to him this week. They haven’t said what the remaining issues are to resolve.

 
 

Clipped from: https://www.cbs17.com/news/capitol-report/medicaid-remains-sticking-point-between-gop-dems-in-ncs-budget/

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Six companies vying for latest $21B state Medicaid deal

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CMS is expected to release guidance on its new vaccine mandates for nursing homes and hospitals receiving federal funds.

 
 

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

 
 

The Centers for Medicare & Medicaid Services (CMS) revealed last week that it was in the rulemaking stage of a collaboration with the Occupational Safety and Health Administration (OSHA) on the establishment of a federal vaccine mandate.

Last Monday, Dr. Lee Fleisher, CMS’ chief medical officer and director of the Center for Clinical Standards and Quality (CCSQ), confirmed that the agency is slated to release its guidelines in late October. Fleisher did so while appearing at the National Association for the Support of Long-Term Care’s (NASL) annual meeting.

This means that Medicare-certified home health providers should expect CMS to release guidance any day now.

 
 

“CMS will soon issue the emergency regulation requiring staff vaccinations within the nation’s more than 15,000 Medicare and Medicaid-participating nursing homes and Medicare and Medicaid-certified health care providers that are regulated under CMS regulations, but we cannot comment on the specifics of the pending regulations as we are in the active rulemaking process,” a CMS spokesperson told Home Health Care News in an email. “There will be a 60-day comment period that will begin when the regulation is published in the Federal Register for the public to share their feedback with CMS.”

The journey to a federal vaccine mandate officially began last month after President Joe Biden announced a six-pronged approach to his administration’s COVID-19 strategy, with plans explicitly mentioning home health providers. The approach also pushed for American workers to get vaccinated and called for increased COVID-19 testing.

At the time, CMS confirmed that vaccinations would be a condition for participating in the Medicare and Medicaid programs.

 
 

“The staff vaccination requirement would only apply to Medicare and Medicaid-certified provider and supplier types that are regulated under the Conditions of Participation,” the agency said. “If an entity is not regulated under the CoPs, then this requirement would not apply.”

For now, providers can only speculate on the potential details of the mandate and if any exceptions will be taken into consideration. When one comes out, CMS will need to keep several considerations in mind, according to National Association for Home Care & Hospice (NAHC) President William A. Dombi.

“First, any mandate must provide sufficient time for reasonable compliance,” Dombi told HHCN in an email. “That matters primarily because there is a high risk of interruption of patient services resulting from lost clinical staff. The vaccine mandates in health care settings that already have occurred have demonstrated that some staff leave their jobs. In home care and hospice, there is a current staff shortage such that even the loss of one staff member can cause difficulties in continuing to serve existing patients as well as taking on new patients.”

Secondly, a CMS mandate must provide for exceptions with clear standards for applying those exceptions, he noted.

Additionally, “to the extent possible,” a CMS vaccine mandate should be evenly applied across the health care sector, NAHC’s leader advised. On top of that, CMS should also consider the costs of a vaccine mandate, especially on newer home health and home care agencies.

“A vaccine mandate presents a variety of new costs for home care companies,” Dombi said. “Appropriate compensation for such costs is a reasonable expectation as these costs are not built into today’s payment rates.”

On the state level, New York rolled out its own vaccine mandate back in August. The regulation mandates the vaccination of home health and personal care workers in the state, with the requirement that the first dose be administered by Oct. 7.

Since then, the rate for New York home-based care workers checked in at about 86% partially vaccinated and 71% fully vaccinated. About 34,000 caregivers have not begun the process at all, according to reports from The New York Times.

The state has received pushback from organizations such as the Home Care Association of New York State (HCA-NYS).

“We have been saying to our governor and our state health department, from the beginning, if you’re going to apply the mandate … you need to do it in a way that doesn’t cause a dislocation of care service for patients and a loss of workforce,” Al Cardillo, president of HCA-NYS, previously told HHCN.

Another East Coast state, Massachusetts, announced plans to require vaccinations for all staff at rest homes, assisted living residences, hospice programs, as well as home-based care workers.

Along these lines, individual home-based care providers have also taken a leap and implemented vaccine mandates within their organizations.

In August, Empath Health announced a policy that requires its staff, volunteers and vendors to be fully vaccinated against COVID-19 by Nov. 1.

“This was not a decision that was made lightly or quickly,” Dr. Neville Sarkari, chief medical officer at Tidewell Hospice, previously told HHCN. “We spent a great deal of time debating this internally. The vaccines are effective and safe, so we felt it was the right thing to do to protect our patients and our colleagues.”

Tidewell Hospice is one of Empath Health’s hospice subsidiaries.

CommonSpirit Health and its home-based care arm, CommonSpirit Health at Home, also announced that it would require its employees to be fully vaccinated by Nov. 1.

“As health care providers, we have a responsibility to help end this pandemic and protect our patients, our colleagues, and those in our communities – including the most vulnerable among us,” Lloyd H. Dean, CEO of CommonSpirit, said in a press statement. “An abundance of evidence shows that the vaccines are safe and highly effective. Throughout the pandemic, we have made data-driven decisions that will help us best fulfill our healing mission, and requiring vaccination is critical to maintaining a safe care environment.”

OSHA has already submitted its rulemaking on COVID-19 vaccination and testing requirements for private sector businesses of more than 100 employees.

“NAHC remains highly supportive of vaccinations,” Dombi continued. “We appreciate the efforts of the administration to get as many people vaccinated as possible and as quickly as possible. However, we must proceed with plans to address all the likely consequences of a mandate in order to ensure continuity in patient care and access to health care at home.”

Additional reporting by Jordyn Reiland

 
 

Clipped from: https://homehealthcarenews.com/2021/10/cms-getting-closer-to-vaccination-guidance-for-home-health-agencies-other-medicare-medicaid-providers/

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State official announce new initiative that will fund mental health and addiction care through Medicaid

 
 

MM Curator summary

 
 

Michigan lawmakers are planning on reimbursing CCBHCs at full cost.

 
 

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.

 
 

 
 

State official announce new initiative that will fund mental health and addiction care through Medicaid

https://www.abc12.com/2021/10/13/state-official-announce-new-initiative-that-will-fund-mental-health-addiction-care-through-medicaid/

Senator Debbie Stabenow announced on Wednesday an initiative that would fund the two as healthcare-reimbursed through Medicaid for the full cost…

 
 

By Dawn Jones

Published: Oct. 13, 2021 at 5:48 PM CDT|Updated: 17 hours ago

FLINT, Mich. (WJRT) – A major change is coming to how mental health and addiction treatment is funded in Michigan.

Senator Debbie Stabenow announced on Wednesday an initiative that would fund the two as healthcare-reimbursed through Medicaid for the full cost of services.

Starting this month, the nearly three dozen Certified Community Behavioral Health Clinics in Michigan will begin to be reimbursed through Medicaid for the cost of services. This is something that has never been done.

“I use the example all of the time you have a heart attack, you go into the emergency room, actually you need surgery. They would never say I’m so sorry that grant ran out six months, ago, but that’s what happens to somebody with a mental illness or with a substance abuse issue everyday that kind of thing is said to folks and that’s what we want to stop,” said Stabenow.

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According to the CDC, one in five Americans will experience Mental illness in their lifetime. The Agency also reporting that in 2020, during the pandemic, drug overdose deaths rose by 30%.

Wednesday’s announcement by Michigan Senator Debbie Stabenow would give people in these crisis access to help through Certified Community Behavioral Health Clinics.

Clinics that are held to the same standards as health centers and are funded to meet those standards. Stabenow explains why it’s a game changer for the mentally ill and drug addicted among us.

“It includes 24 hour psychiatric crisis services so people aren’t sitting in the emergency room, people aren’t sitting in jail just because there is no help available to them. And it places where this has been robustly funded now in other states we are seeing really meaningful changes in peoples lives and frankly with how we are using public services,” said Stabenow.

She said that this is one step to achieving the vision laid out by President John Kennedy in the 1963 Community Mental Health Act.


 

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DMAS prepares for post-public health emergency Medicaid disenrollment

MM Curator summary

 
 

Virginia is gearing up for the disenrollment effort.

 
 

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.

 
 

 
 

DMAS prepares for post-public health emergency Medicaid disenrollment – State of Reform | State of Reform

  

The Department of Medical Assistance Services (DMAS) is currently preparing for the impending end of the federal public health emergency (PHE) declaration, which will instigate a lengthy eligibility redetermination process for one in five Virginians who currently benefit from Medicaid. 

 
 

DMAS Director Karen Kimsey provided an update on the organization’s preparation for potential disenrollment, or “unwinding,” and its impact on the state budget to the Joint Subcommittee for Health and Human Resources Oversight earlier this month. 

Medicaid enrollment has increased significantly in the state, with 373,634 new members enrolling in Medicaid since the beginning of the State of Emergency on Mar. 12, 2020. Over 116,000 of these were children. DMAS also implemented several policy changes this year, such as extending postpartum coverage and adding dental services, that are associated with added costs to the state budget. 

Kimsey was unable to provide exact spending numbers for the next fiscal year as DMAS is still preparing to submit its 2022 Medicaid forecast on Nov. 1. However, she said increased federal funding has saved the state an average of $133 million per quarter. DMAS will also reinvest additional state general fund savings into home and community-based services (HCBS), which stem from federal American Rescue Plan (ARP) funding

However, Kimsey said the agency must pay attention to potential changes in the state’s Medicaid population.

 
 

“While the longer PHE will continue to bring [general fund] savings from enhanced FMAP, if that happens, there is a cost for us, as the Commonwealth, in terms of keeping our populations on Medicaid, as well as what time we are going to need once it ends, to actually redetermine all those individuals’ [eligibility].” 

 
 

Virginians under Medicaid are currently protected from being disenrolled due to the Families First Coronavirus Response Act. However, once the PHE ends, DMAS will need to redetermine each member’s eligibility, a lengthy process that Kimsey said can take anywhere from six to 12 months. This is in part because eligibility may be determined at a local-level, case-by-case basis. 

The Centers for Medicare and Medicaid Services (CMS) have released guidance for states as they begin the redetermination process, but did not specify exactly when the PHE will end. The most recent PHE renewal will expire on Oct. 18, and the Department of Health and Human Services (HHS) expects to renew it one more time through the end of 2021, according to Kimsey. However, that means the PHE could expire as soon as Jan. 2022. 

The disenrollment freeze prevented an exact estimate of people who would lose Medicaid eligibility, although Kimsey said over 337,000 cases (equating to over 644,000 members) in the state may need to be redetermined. This included individuals who turn 65 and may need to transfer to Medicare, pregnant people who reached the end of the postpartum coverage period, and individuals with changes in circumstances, such as increased income.

Kimsey said DMAS is currently working with several partners across the state to provide navigation resources to disenrolled members. CMS is also employing marketing campaigns to encourage people to sign up for insurance through the market exchange, as well as extending open enrollment until Jan. 15, 2022.

 
 

“That’s going to be the most important part, is the messaging that we share with individuals to help encourage them along [in applying].”

 
 

One of DMAS’s partners is the Virginia Poverty and Law Center (VPLC). In a previous conversation with State of Reform, Deepak Madala, Esq., VPLC director of the Center for Health Communities and ENROLL Virginia!, mentioned the importance of making resources more accessible for underserved communities, such as providing limited-English proficiency (LEP) individuals with resources in their native languages. 

Aside from the redetermination process, Kimsey shared other updates with subcommittee members. During the August special session, the General Assembly approved a 12.5% increase in reimbursement rates for Medicaid providers. The funding has been available since July 31, although it has yet to be transferred to providers. Kimsey said DMAS would “ideally” have funds transferred by the end of this month.

Kimsey also briefly spoke on DMAS’s Cardinal Care program, which will consolidate the agency’s managed care organizations with its fee-for-service programs in a single contract by July 1, 2022. DMAS plans to share a draft of the contract with relevant stakeholders in Spring 2022. 

A full recording of DMAS’s legislative update can be found here.

 
 

https://stateofreform.com/news/virginia/2021/10/dmas-prepares-for-post-public-health-emergency-medicaid-disenrollment/

 
 

 
 

  

 

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Missouri has enrolled 4,300 people in expanded Medicaid program

MM Curator summary

 
 

The uptake and processing of applications is going very slow so far.

 
 

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.

  

Roughly 4,300 Missourians eligible for health care under Medicaid expansion have been enrolled, a top Missouri Medicaid official said Thursday….

 
 

Roughly 4,300 Missourians eligible for health care under Medicaid expansion have been enrolled, a top Missouri Medicaid official said Thursday.

That figure represents a little over a quarter of the more than 17,000 applications the state has received since it began accepting applications for Medicaid expansion coverage in August, the Centers for Medicare & Medicaid Services said in a news release Monday.

Kirk Mathews, the chief transformation officer within MO HealthNet, Missouri’s Medicaid program, told lawmakers during a Senate Interim Committee on Medicaid Accountability and Taxpayer Protection hearing Thursday that the 4,300 figure was as of two days before that, with pending applications still being evaluated.

Matthews said he did not know how quickly applications would be processed, noting the state has up to 45 days to determine eligibility on applications.

Advocates and attorneys for plaintiffs who sued the state to force it to implement Medicaid expansion have been keeping a close eye on whether applications would begin to be processed starting Oct. 1 as the state said it would.

Despite a Cole County judge’s August ruling that eligible residents must be permitted to enroll, the Department of Social Services said it would need two months to make necessary system updates and train staff.

Applications for coverage under Medicaid expansion that were submitted after July 1 — the date Medicaid expansion was initially slated to go into effect — were denied, kept in a queue and are “being reevaluated for their eligibility determination now,” Matthews said.

A Centers for Medicare & Medicaid Services spokeswoman confirmed Thursday that Missouri began processing applications Oct. 1 and is making eligibility determinations for Medicaid expansion applicants.

A DSS spokeswoman said Thursday that enrollment figures will start to be published in a monthly report that is expected to be released in November.

The state will also be eligible to draw down an estimated $968 million in federal funds for its Medicaid program over the next two years through the American Rescue Plan, according to the news release.

Approximately 275,000 Missourians are eligible for health care under Medicaid expansion. In the weeks leading up to Oct. 1, advocates have been working to help eligible residents sign up.

Under Medicaid expansion, adults aged 19 to 64 are eligible if their household incomes are 138% of the federal poverty guideline or less. That translates to $17,774 a year for a single person or $36,570 for a family of four.

When asked what comes next with Medicaid expansion enrollment, Matthews said the next few months will bring the unknown.

“We don’t know how rapid the take-up will be, where those numbers will settle in,” Matthews said. “But that’s where we are to date.”

 
 

https://www.joplinglobe.com/news/local_news/missouri-has-enrolled-4-300-people-in-expanded-medicaid-program/article_5017acb2-2841-11ec-9e49-3b2e1bd7e64f.html

 
 

 
 

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Appeals court upholds Tennessee’s Medicaid reimbursement cap

MM Curator summary

 
 

The TN rule designed to reduce spending on inappropriate ED spending has been upheld.

 
 

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

 
 

 
 

 
 

The Court of Appeals in Nashville, Tenn., ruled that TennCare, the state’s Medicaid program, did not violate a state law when it imposed a $50 reimbursement limitation for nonemergent medical services provided by emergency department physicians, according to court documents filed Oct. 7.

Emergency Medical Care Facilities, a company that provides services in Tennessee emergency departments, said TennCare did not follow the correct procedure for making the $50 cap rule under the Uniform Administrative Procedures Act. The case required the appeals court to determine whether the rule falls under the UAPA.

The trial court had determined that the $50 cap rule is defined as a “rule” by the UAPA, is subject to the law’s requirements, and that TennCare did not comply with the law’s requirements for rule-making.

TennCare appealed the decision. The appeals court determined that the $50 cap rule is not subject to the UAPA because it falls under the internal management exception in the 2009 version of the law, reversing the trial court decision.

 
 

https://www.beckershospitalreview.com/legal-regulatory-issues/appeals-court-upholds-tennessee-s-medicaid-reimbursement-cap.html