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More states rescinding Medicaid ‘retroactive eligibility’


For Kaiser Health News

If you’re poor, uninsured and fall seriously ill, in most states if you qualify for Medicaid — but weren’t enrolled at the time — the program will pay your medical bills going back three months. It protects hospitals, too, from having to absorb the costs of caring for these patients.

But a growing number of states are rescinding this benefit known as “retroactive eligibility.” On Nov. 1, Iowa joined three states that have eliminated retroactive coverage for some groups of Medicaid patients since the Affordable Care Act passed. Each state had to secure approval by the federal government.

Retroactive eligibility has been a feature of Medicaid for decades, reflecting the program’s emphasis on providing a safety net for poor, disabled and other vulnerable people. In contrast to private insurance, determining Medicaid eligibility can be complex and the application process daunting, advocates say. A patient’s medical condition also may keep families from applying promptly for coverage.

All four states — Arkansas, Indiana and New Hampshire, in addition to Iowa — have expanded Medicaid under the health law, which allowed states to include adults with incomes up to 138 percent of the federal poverty level, or about $16,000 for one person. So, in theory, most adults are required to have insurance under the ACA. In practice, each state still has a significant number of uninsured, ranging from 5 to 8 percent of the population.

The retroactive coverage “can compensate for the sorts of errors and lapses that can so easily occur on the part of both the applicant and the government bureaucracy” that delay applications, said Gordon Bonnyman, staff attorney at the Tennessee Justice Center, a public interest law firm that represents low-income and uninsured residents.

State and federal officials say eliminating the retroactive coverage helps encourage people to sign up for and maintain coverage when they’re healthy rather than waiting until they’re sick to enroll. It also fits into federal officials’ efforts to make Medicaid, the federal-state program that provides health care for low-income adults and children, more like private insurance.

But consumer advocates and health care providers say the shift will saddle patients with hefty medical bills and leave hospitals to absorb more uncompensated care when patients can’t pay. Some worry this could be the start of a trend.

In Iowa, the change applies to just about anyone coming into Medicaid — except for pregnant women and children under age 1. The change will affect up to 40,000 residents annually and save the program more than $36 million a year.

“We’re making it a lot more likely that Medicaid-eligible members are going to incur significant medical debt,” said Mary Nelle Trefz, health policy associate at the Child & Family Policy Center, in Des Moines, whose organization opposed the change.

When someone has a traumatic health event, the initial focus is to get them stabilized, not figure out how to pay for it, said MaryBeth Musumeci, associate director of the Program on Medicaid and the Uninsured at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Patients may neglect to apply immediately for Medicaid, leaving them financially responsible for days or months of care they received before they got in their application, even though they may have been eligible for Medicaid all along.

That’s not the only issue, advocates say. Unlike the commercial insurance market where re-enrollment through someone’s employer is routine, Medicaid requires that beneficiaries’ eligibility be reassesed every year.

“People fall through the cracks,” said Andrea Callow, associate director of Medicaid initiatives at Families USA, a consumer advocacy group.

In addition, complications can arise for people who might need Medicaid coverage for long-term care services. “The criteria are complicated. For a layperson to find those criteria and figure out if they’re eligible” is challenging and they may need extra time, said Musumeci. Once patients have secured coverage, they may already have accrued hefty expenses.

Maybe so, but some people argue that a 90-day retroactive eligibility guarantee is counterproductive.

“We’re trying to get people to behave more responsibly, not less responsibly,” said Gail Wilensky, an economist who oversaw the Medicaid and Medicare programs in the early 1990s under President George H.W. Bush. “That is not the signal you’re sending” with three months of retroactive eligibility. A 30-day time frame is more reasonable, Wilensky said.

In contrast to Iowa, the waivers in Arkansas, Indiana and New Hamsphire generally apply only to adults who gained coverage under the law’s Medicaid expansion. (Indiana’s waiver also applies to other groups.)

Kentucky has a request pending that, like Iowa, would eliminate retroactive Medicaid eligibility except for pregnant women and children under 1, according to KFF.

Under federal law, officials can waive some Medicaid coverage rules to give states flexibility to experiment with different approaches to providing services. And retroactive eligibility waivers in Medicaid are hardly new. A few states like Tennessee have had them in place for years. Tennessee officials eliminated retroactive eligibility for all Medicaid beneficiaries in 1994 when the state significantly expanded coverage under TennCare, as Medicaid is known there. At the time, the state even allowed uninsured people to buy into the program who wouldn’t otherwise qualify based on income, said Bonnyman.

“There was no reason for anybody to be uninsured except undocumented immigrants,” said Bonnyman. “It didn’t seem to have the potential for harm.”

But state officials revamped that program after serious financial problems. Eligibility for TennCare has become more restrictive again.

Other states that waived retroactive coverage for at least some Medicaid groups include Delaware, Maryland, Massachusetts and Utah, according to the Kaiser Family Foundation.

Bonnyman said his group frequently works with Medicaid beneficiaries who have medical bills they can’t afford that accumulated during the months before they applied for Medicaid.

“If you’re a moderate- to low-income working family, one or two days in the hospital is enough to ruin you financially,” he said.


21 Tenn. physicians sue over Medicaid payments


Twenty-one Tennessee physicians are suing CMS  in  a U.S. District Court Monday to stop the agency from recouping $2.3 million in Medicaid payments.

“The payments were made in 2013 and 2014 to physicians serving rural communities and disadvantaged populations to help them expand their practices and provide more services in areas with limited care,” Becker’s Hospital Review reported.

“However, CMS required TennCare, the state’s Medicaid program, to audit the physicians to ensure that they are either board-certified or bill 60 percent or more of their Medicaid codes within certain billing- code categories. More than 100 physicians across the state didn’t meet these requirements, and so TennCare is now seeking repayment.”

Becker’s reported that, according to a press release from Bass, Berry & Sims, the lawyers who filed the lawsuit, “one of the plaintiffs reportedly used the funds to open an outreach clinic for bilingual uninsured patients, expanded hours and upgraded other services, and another plaintiff hired a bilingual nurse and an internal medicine specialist.”

“Bass, Barry & Sims predicts physicians who received similar payments in other states may eventually face similar repayments,”  Becker’s reported.

To read more, please hit this link.

Getting big insurers to help the sick needy

By JAY HANCOCK, for Kaiser Health News


HARTSVILLE, Tenn. — Lynda Douglas thought she had a deal with Tennessee. She would adopt and love a tiny, unwanted, profoundly disabled girl named Charla. The private insurance companies that run Tennessee’s Medicaid program would cover Charla’s healthcare.

Douglas doesn’t think the state and its contractors have held up their end. In recent years she says she has fought battle after battle to secure essential care to control Charla’s seizures, protect her from choking and tube-feed and medicate her multiple times a day.

“If you have special-needs children you would not want to be taking care of these children and be harassed like this,” Lynda Douglas said. “This is not right. No way, shape or form is this right.”

State Medicaid programs across the country, which operate with large federal contributions, have outsourced most of their care management in recent years to insurance companies like the ones in Tennessee. The companies cover poor and disabled Medicaid members in return for a fixed payment from taxpayers.

That helps government budgets but sets up a fundamental conflict of interest: the less care these companies deliver, the more money they make. Nationwide, such firms made operating profits of $2.4 billion last year, according to regulatory data compiled by Mark Farrah Associates and analyzed by Kaiser Health News.

In an attempt to manage that tension, Washington regulators are about to initiate theb iggest overhaul of Medicaid managed-care rules in a decade. Prompted by growth of Medicaid outsourcing, concerns about access to care and stories like Charla Douglas’, the regulations are expected to limit profits and set stricter requirements for care quality and the size of doctor networks.

“We want the enrollees to have timely access to integrated, high-quality care,” James Golden, who oversees Medicaid managed care for the U.S. Department of Health and Human Services, told a group of insurance executives in February. “There’s been some question about some of these issues.”

Tennessee Medicaid plans — operated by BlueCross BlueShield of Tennessee, UnitedHealthcare and Anthem — are among the most profitable Medicaid insurers in the country, according to data from Milliman, a consulting firm. The state, which runs one of the most respected Medicaid managed-care programs in the country, adopted that design in the 1990s and named it TennCare.

State officials point to quality data and survey results as evidence that the companies are doing a good job while allowing the state to spend far less on Medicaid than predicted. More than 90 percent of TennCare customers surveyed last year said they were very satisfied or somewhat satisfied, officials note.

“Our patient satisfaction scores are at the highest over the last five years they’ve been in 20 years of the program,” said TennCare director Darin Gordon, who worries new HHS rules could hinder states from improving Medicaid quality while controlling costs. “Don’t hamstring us from doing other innovative activities that are going to be able to help try to improve the health and wellbeing of our population.”

But doctors and patient advocates say state savings and insurer profits come at the price of inadequate physician networks, long waits for care and denial of treatments like the ones for Charla Douglas. Answering another question in the survey, 30 percent of adults said the quality of their TennCare care last year was only fair or poor.

“BlueCross is more organized and more strategic in its denials, and the other plans might be more careless, but the way it plays out for folks on the ground level is the same,” said Michele Johnson, executive director of the Tennessee Justice Center, a nonprofit law firm that helps TennCare members navigate the system. “What we find is that all three plans will deny care.”

Medicaid’s expansion in most states under the Affordable Care Act has obscured another big but more gradual change: More than half of Medicaid beneficiaries now receive coverage from private insurers, known as managed care companies, with incentives to limit care. The surge helped prompt inquiries by HHS’s inspector general last year that found widely varying state standards for access to doctors and poor information for members on where to find them.

In one nationwide study, half the doctors listed in official directories weren’t taking Medicaid patients. Among doctors who were, a quarter couldn’t see patients for a month.

In Tennessee views diverge sharply on whether the proposed federal rules, expected soon, are necessary. Many say the system is far from adequate.

Dena Deweese, who runs a primary-care practice in Knoxville, has problems finding specialists for her patients who are covered through Amerigroup, a TennCare contractor and Anthem affiliate that recently began operating in the area.

“I kept running into no, no, no,” she said. “I’ve still got lots of folks that are simply not taking it.”

Amerigroup says it only recently started covering TennCare members in the area and is still expanding its network. Since January “we have added more than 3,600 specialty physicians,” said company spokeswoman Cindy Wakefield.

TennCare’s member-per-doctor standard for primary care is among the worst in states that have such rules — one provider per 2,500 members. Even for urgent care, TennCare rules allow waiting times of up to two days for an appointment.

The state allows one neurologist per 35,000 TennCare members, although most states have no network standards at all for such specialists.

Even when children are having seizures, Crossville pediatrician Dr. Suzanne Berman often can’t get a TennCare neurology referral for weeks.

“I have a kid who urgently needs to see a specialist,” she said. “We call and we beg. ‘We can see you in three months,’ the neurologist’s nurse will say. ‘OK we can see you in two weeks.’ No, we can’t wait that long.”

Often she must send the child to a hospital emergency room to get the proper care — it’s “the only way I have found to jump the queue,” she said.

Dr. Douglas Springer, a gastroenterologist and, until recently, president of the Tennessee Medical Association, recognizes states’ need to control Medicaid expense.

“The cost in that population keeps going up and up and up,” he said.

But he favors new rules to ensure adequate doctor networks and limit insurer profits.

“If they can make it hard on [a patient], and make it so the networks are poorly funded or poorly populated, then nobody can go see anybody,” he said. “They don’t have to spend any money.”

Evelyn Manley said she had to fight to get TennCare’s insurers to cover even a portion of the behavioral therapy that doctors recommend for Christian, her five-year-old son with diagnoses of autism and Down syndrome.

“I’m grateful” for TennCare, she said. “But it could definitely improve.”

Lynda Douglas, 69, knew she wanted to adopt Charla a decade ago as soon as she took her for foster care from the state. Charla’s problems include cerebral palsy, a badly curved spine, frequent seizures and osteoporosis. She cannot speak and takes most food by tube. She is 16, weighs less than 80 pounds and loves Barney the dinosaur.

Douglas, who lives about an hour east of Nashville, says she has often struggled to get adequate treatment for Charla. But she was grateful that TennCare’s contractors sent daytime nurses to monitor her seizures, keep her from choking, activate an implanted device to control seizures, administer medicine and maintain a tube that delivers medicine or nourishment eight times a day.

Then more than a year ago UnitedHealthcare reduced the nursing to one hour a day even though Charla’s condition hadn’t improved. Douglas protested with the help of the Tennessee Justice Center and a pro-bono lawyer and won, but TennCare appealed. It took two more rounds of adjudication before a judge ruled in Douglas’ favor late last year.

The managed-care companies “are making a mint down here,” Douglas said. “They’re getting rich at the expense of the kids. This is not right.”

UnitedHealthcare made operating profit of $236 million last year on revenue of $2.8 billion in its Tennessee Medicaid business, according to state filings. Anthem’s operating profit for TennCare came to $53 million on revenue of $946 million. BlueCross’s operating profit for TennCare was $121 million on revenue of $1.8 billion. Those results do not include expenses for taxes, depreciation and other items not directly related to health coverage.

“Our care teams worked with the family and with [Charla Douglas’] physicians and other providers to assure that her services were appropriate for her special healthcare needs,” UnitedHealthcare said in a prepared statement. The managed-care plan followed TennCare’s contract and care guidelines, it said. 

This year Charla switched to the BlueCross TennCare plan to better coordinate her care with two other disabled children in the Douglas household, one foster and one adopted. In March the plan denied coverage of the seizure-control pump that Charla’s doctors prescribed, saying it was medically unnecessary.

BlueCross now says it will pay for the procedure. A spokeswoman blamed the initial denial on a “physician’s failure to provide the needed medical information.”

Like TennCare officials, the managed-care industry is urging HHS not to publish overly rigid regulations that bog plans down in paperwork and hinder them from making investments to keep members healthy.

“You’re dealing with a huge variation in population” covered by Medicaid from state to state, said Jeff Myers, CEO of Medicaid Health Plans of America, an industry lobby. “Each state has an insurance commissioner. Presumably they’re very good about making decisions about insurance regulation” to suit local conditions, he said.

Myers and other officials expect HHS to issue rules for “medical loss ratios” that limit profits and force plans to spend a minimum portion of revenue on medical care. Such restrictions already apply to other insurance under the health law.

Imposing blanket profit standards on diverse Medicaid programs “would be terrible policy,” he said.

TennCare director Gordon, who frequently advises other states on Medicaid, rejects suggestions that managed-care networks are inadequate or that contractors deny needed care. Third-party surveys show that 90 percent of Tennessee doctors take TennCare and most of them take new TennCare patients, he said, although consumer advocates dispute this.

TennCare members sometimes have trouble seeing specialist doctors, but so do patients in commercial plans, he said. Like many state Medicaid directors, he wonders how HHS can publish network rules for 50 states with widely varying geographies and health systems.

“We actually have a pretty solid network,” he said, with systems to closely track how contracted insurers are performing. The HHS investigation into Medicaid doctor networks “looked at it very narrowly” and “gives you a less complete picture of what’s going on in the states,” he said.

Written the wrong way, Gordon said, HHS limits on managed-care profits could discourage spending on coordinators who improve care quality at decreased cost.

“Yeah, we’re a little concerned,” about the proposed rules to be published by the Centers for Medicare & Medicaid Services, or CMS, he added. “There are some things that we think may have adverse effects.”

Other Tennesseans tend to oppose Washington decrees no matter what they say.

“We need to keep CMS out of our business. They have done nothing but screw everybody up,” said Dr. Iris Snider, an Athens pediatrician who praises the job Gordon and other officials have done with TennCare. “It really worries me … when we finally get a system that’s working reasonably well for my patients.”

Tenn. weighs changing Medicaid mental-healthcare




Officials of TennCare, the Tennessee Medicaid program, seek to reform mental- and behavioral-health treatment under its 2016 budget.

The Nashville Tennessean reported that TennCare is proposing implementing ”an evaluation mechanism for people receiving mental health treatment under the bureau’s Level 2 case management classification. People under this categorization receive visits from case managers in addition to therapy or other treatments, such as medication.”

”The proposed changes would institute a review after three months to evaluate whether case manager visits are needed rather than everyone receiving visits, said Keith Gaither manager of managed-care organization (MCO) operations at TennCare.”

”Gaither said that the MCOs have been looking at this category of patients for more than two years to determine whether there was a way to tailor treatment on a case-by-case basis rather than extending the case management to everyone.”

It is unclear what impact all this might have on hospitals and Federally Qualified Health Centers.





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