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  • 22 Feb 2024 12:55 PM | Addie Thompson (Administrator)

    New guardrails for Medicare Advantage plans' use of AI may not be clear enough, experts told members of the Senate Finance Committee. 

    CMS sent a message to Medicare Advantage plans Feb. 6, clarifying how new prior authorization rules set forth by the agency apply to AI. The agency wrote that AI programs can be used to assist in coverage determinations, but it is the plans' responsibility to "ensure that the algorithm or artificial intelligence complies with all applicable rules for how coverage determinations by MA organizations are made." 

    The agency will also up its auditing of denials in Medicare Advantage plans, according to the message. 

    Lawmakers have urged CMS to do more to regulate the use of AI by Medicare Advantage plans. The Senate Finance Committee held a hearing probing the use of AI in healthcare Feb. 8. 

    At the hearing, Michelle Mello, PhD, professor of health policy at Stanford University, told the committee CMS should implement more specific guidelines on requirements for meaningful human review of claims denied by algorithms. 

    "Audits by CMS need to look very closely, as I believe they intend to, at denials where algorithms were involved," Dr. Mello said. 

    UnitedHealthcare and Humana, the largest Medicare Advantage insurers, are facing lawsuits alleging they wrongfully denied members care using an AI-powered algorithm. A spokesperson for Optum, the UnitedHealth Group subsidiary that operates the algorithm, told Becker's the tool is not used to make coverage determinations. 

    A spokesperson for Humana told Becker's its augmented intelligence maintains a "human in the loop" whenever AI is used, and "adverse coverage decisions are only made by physician medical directors."

    Ziad Obermeyer, MD, Blue Cross of California Distinguished Associate Professor of Health Policy and Management at the University of California Berkeley, told the committee AI learns from historical data and can reinforce existing trends rather than improve them. 

    "[AI] trolls through millions of records, and sees there are some privileged people with great insurance who stay in nursing homes longer than they should, and there are also vulnerable, underinsured people who are often kicked out too early," Dr. Obermeyer said. "Rather than undoing that problem, the AI reinforces it and encodes it as policy." 

    Well-designed AI programs could make these decisions better than humans, Dr. Obermeyer said. 

    "It could look at the patient's X-ray, it could look at the public transportation in their neighborhood, it could look at the layout of their house, and integrate all those things into a far better judgment than a doctor is able to make on who needs to be in that nursing home and who doesn't," he said. 

    Sen. Elizabeth Warren, a frequent critic of Medicare Advantage, said CMS should prevent MA plans from using AI in prior authorization until it can confirm algorithms do not result in wrongful denials of care. 

    "It takes the bad information and accelerates it, or [accelerates] the information that is bad practice," Ms. Warren said.


  • 22 Feb 2024 12:55 PM | Addie Thompson (Administrator)

    Algorithms and artificial intelligence-powered software tools can be used to support Medicare Advantage plans in making coverage decisions for members, but payers are still bound by CMS' internal benefits requirements and nondiscrimination rules under the ACA, the agency said in guidance to insurers regarding its final 2024 MA rule.

    "We are concerned that algorithms and many new artificial intelligence technologies can exacerbate discrimination and bias," the agency wrote Feb. 6. "MA organizations should, prior to implementing an algorithm or software tool, ensure that the tool is not perpetuating or exacerbating existing bias, or introducing new biases."  

    The guidance comes as scrutiny of payers' use of AI increased in 2023. UnitedHealthcareHumana and Cigna are facing lawsuits alleging they used AI tools or algorithms to wrongfully deny care to Medicare Advantage members.

    Four key takeaways:

    1. Because of how rapidly software technologies are evolving and overlapping definitions, CMS clarified its perspective on the difference between algorithms and artificial intelligence. Algorithms "can imply a decisional flow chart of a series of if-then statements," while AI is a "machine-based system that can — for a given set of human-defined objectives — make predictions, recommendations or decisions influencing real or virtual environments.

    2. Payers can use algorithms to support coverage decisions, but it is their responsibility to ensure that an algorithm or an AI-based tool is compliant with the agency's coverage decision requirements. For example, MA carriers must base coverage decisions on an individual member's medical history, physician recommendations or clinical notes, not on a larger data set.

    3. Algorithms can be used only to help predict length of stay for post-acute services and not as the basis for terminating coverage. Terminating coverage can be determined only by first reexamining a member prior to the termination notice. For inpatient admissions, algorithms and artificial intelligence alone cannot be used as the reason to deny admission or downgrade to an observation stay.

    4. MA organizations may deny coverage for basic benefits only for reasons such as network limitations or noncompliance with prior authorization rules. Algorithms should be used only to ensure compliance with internal coverage criteria. AI cannot be used to shift coverage criteria over time, and predictive algorithms cannot apply internal coverage criteria that are not public.


  • 22 Feb 2024 12:54 PM | Addie Thompson (Administrator)

    A Texas federal judge on Monday dismissed a lawsuit challenging the Biden administration’s Medicare drug price negotiations filed by the pharmaceutical industry lobbying group Pharmaceutical Research and Manufacturers of America (PhRMA). 

    The decision marks a small victory for the Biden administration, as it’s the first time a court has outright dismissed a challenge to Medicare’s new price negotiation powers.  

    There are eight other lawsuits filed by drug companies and other plaintiffs, and the legal fight could stretch for years. The federal government sent out its initial offer to drug companies earlier this month, and while the negotiations will end in August, the prices won’t take effect until 2026.

    Judge David Alan Ezra in the Western District of Texas granted the Biden administration’s request to dismiss the lawsuit, ruling that the plaintiffs lacked standing. 

    PhRMA was joined in the lawsuit by the National Infusion Center Association (NICA) and the Global Colon Cancer Association, but Ezra dismissed the NICA from the case because he said the court lacked jurisdiction.  

    As the NICA was the only plaintiff that resided in Texas, the entire case was dismissed. However, it was dismissed without prejudice and could be brought up again.  

    “We are disappointed with the court’s decision, which does not address the merits of our lawsuit, and we are weighing our next legal steps,” PhRMA spokesperson Nicole Longo said in a statement to The Hill.

    PhRMA represents some of the largest drug companies in the world. The group sued the administration in June, arguing Medicare negotiation is unconstitutional and violated drug companies’ due process.


  • 22 Feb 2024 12:53 PM | Addie Thompson (Administrator)

    Harrisburg, PA - The Pennsylvania Department of Human Services (DHS) today released recommendations from its Blueprint Workgroup, an interdisciplinary group comprised of representation from state and local governments, health care, education, service providers, managed care, and family advocates. The workgroup sought to evaluate challenges children and youth with complex, co-occurring physical and behavioral health care needs and their families experience like accessing care and services that adapt to a youth’s changing circumstances and needs, lessening the likelihood of child welfare system involvement, reducing trauma experienced by instability, prioritizing emotional wellbeing, and supporting family- and youth-driven care and choice.

    “The detailed recommendations outlined by the Blueprint Workgroup set a course that now allows DHS and partners at the local level and systems of care to begin the work necessary to see how we make change happen so children with complex needs get the care that improves their quality of life, and the family is supported as they navigate these systems,” said Dr. Val Arkoosh, Secretary of DHS. “Systems of care should uplift those we seek to help, not create confusion and consequences from lack of coordination. The Blueprint Workgroup recommendation align our focus around the children and families we must always prioritize, and I am grateful for the work to this point and moving forward that will build a better future for children and families in Pennsylvania.” 

    One in six children have a diagnosed behavioral or developmental disorder, and rates of depression and anxiety are growing among children and young adults. Youth with co-occurring physical health, behavioral health, and/or intellectual disability or autism-related needs are considered complex cases because they require close coordination between multiple care and service providers in order to ensure the child and their family are receiving comprehensive supports and services that meet their unique and evolving needs.  

    Care coordination for these cases involve multiple county and state-level entities that coordinate health care, education, and disability services, and, at times, the child and their family may be involved with child welfare, foster care, and justice systems. Children and youth with complex needs are also more likely to have experienced abuse, neglect, and trauma, disruptions to their education, communications challenges, and a complex diagnostic history causing delayed or incorrect services. These circumstances create opportunities for confusion and lack of communication that can affect care. 

    Children and youth with complex needs deserve access to the care and supports they need without barriers, delays, or risks of new or additional trauma, and their families and guardians deserve support as they navigate systems of care for their child. The Blueprint Workgroup was established to help guide systems of care towards a renewed focus on youth and family engagement, respect for individual choice, support for the caring workforce, better collaboration and integrated planning between systems that serve youth with complex needs, and timely, accessible, and coordinated service delivery for youth that is responsive to their evolving needs. 

    Recommendations from the workgroup include: 

    • Prioritizing prevention through early identification of needs, accurate and timely diagnosis, and prompt service intervention; 

    • Improving information sharing and resource navigation among child-serving systems of care; 

    • Developing clear and strong guidance to inform multi-system case planning and management that prioritizes family engagement, evidence-based practices, peer supports between families, streamlining processes for families, and avoids trauma or re-traumatization that can occur when a case information has to be presented by the youth or their family repeatedly;  

    • Supporting a qualified, dedicated workforce, assessing payment models, and increasing efficiencies for people working in this system where appropriate; 

    • Conducting a system needs and gaps analysis across child-serving systems to determine opportunities for improvement and establishing multidisciplinary care coordination teams where needed; and,  

    • Building further understanding of trauma and embed trauma-informed care and principles across systems that serve and interact with children and youth with complex needs and their families.  

    Moving forward, DHS and Blueprint Workgroup members will begin work to determine work necessary to implement recommendations and identify barriers to implementation at the state and local level. The recommendations outlined in the workgroup’s report are a first step to strengthen supports for children and youth with complex needs and their families. Pennsylvania was also recently selected as one of eight states participating in a children’s behavioral health policy collaborative organized by Health Management Associates, the National Association of State Mental Health Program Directors, the National Association of Medicaid Directors, the Child Welfare League, and the American Public Human Services Association. The convening will build on this work by helping better align multi-system work to support youth with behavioral health needs. 

    To learn more about the Blueprint Workgroup and DHS’ work to support children and youth with complex needs, visit https://www.dhs.pa.gov/Services/Children/Pages/Complex-Case-Planning.aspx.

    MEDIA CONTACT: Brandon Cwalina - ra-pwdhspressoffice@pa.gov

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  • 20 Feb 2024 12:28 PM | Addie Thompson (Administrator)

    Opposition to expanding Medicaid programs to cover more low-income individuals is becoming increasingly difficult to maintain amid growing public support for adoption across states, policy analysts say.

    Ten years after the Affordable Care Act first allowed Medicaid programs to cover nearly all adults with incomes up to 138% of the federal poverty level—now roughly $15,000 for a single person in most states—all but 10 states have adopted the expansion. An estimated 1.9 million people in the states that haven’t expanded fall into what’s known as the Medicaid coverage gap, having incomes above their state’s eligibility for Medicaid but below the poverty level, according to KFF data.

    North Carolina became the latest state to expand in 2023 with the help of Republicans who came on board after multiple unsuccessful attempts to overturn the ACA in the courts and the American Rescue Plan Act’s temporary fiscal incentive to states that haven’t yet expanded their Medicaid programs. The American Rescue Plan Act, signed into law in 2021, included $1.9 trillion in federal funding to respond to the public health and economic impacts of the Covid-19 pandemic.

    Kansas Gov. Laura Kelly (D) introduced a proposal in January that would expand Medicaid to an additional 150,000 people in the state. But Republican leadership in the state legislature have vowed to block the legislation.

    A vocal segment of Republicans across the country has long opposed Medicaid expansion over concerns about strains to state budgets, with many calling for requirements that individuals have a job to qualify for coverage.

    While policy analysts predict a second Trump administration could lead to attempts to repeal or make cuts to Medicaid expansion, they say court wins supporting expansion, and voter demands for improved health access and affordability are likely to bring more bipartisan agreement on expanding Medicaid in the coming years.

    “As long as the national situation stays status quo with the Affordable Care Act not being repealed or extensively trimmed or modified or reduced, I think it is very likely we will eventually get all 50 states on board,” said Patrick O’Mahen, an assistant professor of medicine at the Baylor College of Medicine.

    Expansion Holdouts

    Without more states adopting expansion, “there’s just these massive gaps in what Medicaid does in terms of health-care coverage for people,” said Matt Salo, founder and CEO of Salo Health Strategies and former executive director of the National Association of Medicaid Directors.

    Coverage “can vary widely from state to state,” Salo said in an interview.

    Medicaid expansion has succeeded in getting support when brought to voters via ballot initiatives in six states—Idaho, Maine, Missouri, Nebraska, Oklahoma, and Utah. But out of the 10 states that have yet to adopt expansion, only Florida and Wyoming have pathways for expanding Medicaid through ballot measures.

    Elsewhere, “conservative Republican-controlled state legislatures seem to be the most common blocking mechanism,” said O’Mahen, whose research focuses on interactions between governments and health systems.

    Kansas, Texas

    Some Republicans have called for a hearing in Kansas on Kelly’s latest proposal. Last year, lawmakers left their legislative session without action on Kelly’s expansion proposal, despite the governor’s attempt to address Republican concerns by adding a work requirement, a tax on the Medicaid funding that hospitals receive to offset state costs, and allowing individuals to stay on private insurance while still receiving assistance from the state.

    Kansas House Speaker Dan Hawkins (R) said in an emailed statement, “right now, the votes aren’t there to pass Medicaid expansion.” He added, though, there will be an opportunity to discuss the issue more when the House Health Committee holds a hearing on the proposal this legislative session.

    “The facts remain though—Medicaid expansion siphons benefits away from the truly needy and disabled and gives them to a whole new population of able-bodied adults with other coverage options available … all on the backs of taxpayers,” Hawkins said.

    A 2023 poll by the Texas Politics Project at the University of Texas at Austin found 76% of survey participants supported Medicaid expansion, with just 17% opposed.

    But in the Lone Star State, where Republicans control both the governor’s office and legislature, the path toward expansion will likely be “longer given the depth of the ideological opposition,” said Jocelyn Guyer, senior managing director at Manatt Health.

    For Tanner Aliff, policy director of the Right on Healthcare Initiative at the conservative Texas Public Policy Foundation, health workforce shortages and rural populations’ difficulty accessing hospital care are more important issues for the state of Texas to address. More than 20 rural hospitals have closed in Texas over the past decade, according to the Texas Hospital Association.

    “What’s the point of putting a Medicaid card in the hands of somebody that still has to travel 80 miles to the nearest critical access hospital just to wait in the ER,” Aliff said in an interview.

    ‘Here to Stay’

    Despite the opposition, policy analysts and proponents of Medicaid expansion say it’s possible these holdout states will eventually come on board.

    Roughly 76% of US adults included in a March 2023 KFF Health Tracking Poll said they had either a “very favorable” or “somewhat favorable” view of the Medicaid program, and two-thirds of respondents living in the states that haven’t expanded their programs said they want their state to do so.

    “The dominant sentiment, including among Republicans in places like North Carolina, is that the Affordable Care Act is here and it’s here to stay, and every single congressional effort to repeal, every single effort at litigation to get rid of it has failed,” Guyer said.

    In North Carolina, Republicans like Senate President Pro Tempore Phil Berger, who referred to himself as “one of the staunchest opponents to expanding Medicaid in North Carolina” for more than a decade, eventually changed his position. In a March 2023 op-ed, Berger argued the ACA and Medicaid expansion are “not going away, and refusing to accept that reality hurts North Carolinians and the state’s finances.”

    “Medicaid expansion if implemented in a reasonable, responsible manner is a positive for state fiscal and healthcare policy,” Berger wrote at the time, citing the fact that the federal government pays for 90% of Medicaid expansions in states.

    With former President Donald Trump currently the front-runner for the 2024 Republican presidential nomination, O’Mahen said a second Trump term likely means “legislation repealing the ACA’s Medicaid expansion and making deeper cuts to the program is very much on the table.”

    During the Trump administration, the Centers for Medicare & Medicaid Services broke from previous administrations by approving several Section 1115 waivers that conditioned Medicaid coverage on meeting work and reporting requirements—though courts later struck down many of these.

    Despite some roadblocks to future efforts, universal expansion across the country is not an unlikely scenario, O’Mahen said.

    “It becomes tougher and tougher for the holdouts to hang on because they can see that they’re leaving a lot of federal money on the table and everybody else is doing it,” he said.

    Continue Reading


  • 20 Feb 2024 12:25 PM | Addie Thompson (Administrator)

    South Carolina’s Senate passed a medical marijuana legalization bill on Wednesday, sending it to the House of Representatives for consideration.

    The vote on third reading passage was 24-19 and came one day after the body gave initial approval to the legislation from Sen. Tom Davis (R), which if enacted will allow medical cannabis access for patients with certain health conditions.

    In order to get to the desk of Gov. Henry McMaster (R), the bill still needs to clear the House—a prospect that’s far from certain. The Senate had passed an earlier version of the legislation in 2022 but it stalled in the opposite body over a procedural hiccup.

    Davis said during last week’s initial Senate debate on the current bill that his goal has always been to “come up with the most conservative medical cannabis bill in the country that empowered doctors to help patients—but at the same time tied itself to science, to addressing conditions for which there’s empirically based data saying that cannabis can be of medical benefit.”

    “I think when this bill passes—and I hope it does pass—it’s going to be the template for any state that truly simply wants to empower doctors and empower patients and doesn’t want to go down the slippery slope” to adult-use legalization, he said. “I think it can actually be used by several states that maybe regret their decision to allow recreational use, or they may be looking to tighten up their medical laws so that it becomes something more stringent.”

    Davis said during last week’s initial Senate debate on the current bill that his goal has always been to “come up with the most conservative medical cannabis bill in the country that empowered doctors to help patients—but at the same time tied itself to science, to addressing conditions for which there’s empirically based data saying that cannabis can be of medical benefit.”

    “I think when this bill passes—and I hope it does pass—it’s going to be the template for any state that truly simply wants to empower doctors and empower patients and doesn’t want to go down the slippery slope” to adult-use legalization, he said. “I think it can actually be used by several states that maybe regret their decision to allow recreational use, or they may be looking to tighten up their medical laws so that it becomes something more stringent.”

    Other changes that were adopted would prevent lawmakers and their immediate family members from owning or receiving compensation from medical marijuana businesses until 2029, ensure that vertically integrated businesses performing a certain function in the industry count against the total number of licenses allowed to be issued for that function, require dispensaries to have a pharmacist physically present on their premises during dispensing hours and further clarify that the definition of medical use does not include smoking.

    The body had previously approved two amendments during second reading consideration on Tuesday.

    One would make it so no more than three medical cannabis dispensaries could be located in any county. The other would clarify that regulators cannot prevent the “accurate listing of ingredients on a cannabis product that is a beverage,” with the sponsor of the amendment citing a recent letter from health officials that he said has “caused confusion” about the components of hemp-derived beverages.

    Other changes that were adopted would prevent lawmakers and their immediate family members from owning or receiving compensation from medical marijuana businesses until 2029, ensure that vertically integrated businesses performing a certain function in the industry count against the total number of licenses allowed to be issued for that function, require dispensaries to have a pharmacist physically present on their premises during dispensing hours and further clarify that the definition of medical use does not include smoking.

    The body had previously approved two amendments during second reading consideration on Tuesday.

    One would make it so no more than three medical cannabis dispensaries could be located in any county. The other would clarify that regulators cannot prevent the “accurate listing of ingredients on a cannabis product that is a beverage,” with the sponsor of the amendment citing a recent letter from health officials that he said has “caused confusion” about the components of hemp-derived beverages.

    Certain lawmakers have also raised concerns that medical cannabis legalization would lead to broader reform to allow adult-use marijuana, that it could put pharmacists with roles in dispensing cannabis in jeopardy and that federal law could preempt the state’s program, among other worries.

    Here are the main provisions of the bill

    • “Debilitating medical conditions” for which patients could receive a medical cannabis recommendation include cancer, multiple sclerosis, epilepsy, post-traumatic stress disorder (PTSD), Crohn’s disease, autism, a terminal illness where the patient is expected to live for less than one year and a chronic illness where opioids are the standard of care, among others.
    • The state Department of Health and Environmental Control (DHEC) and Board of Pharmacy would be responsible for promulgating rules and licensing cannabis businesses, including dispensaries that would need to have a pharmacist on-site at all times of operation.
    • In an effort to prevent excess market consolidation, the bill has been revised to include language requiring regulators to set limits on the number of businesses a person or entity could hold more than five percent interest in, at the state-level and regionally.
    • A “Medical Cannabis Advisory Board” would be established, tasked with adding or removing qualifying conditions for the program. The legislation was revised from its earlier form to make it so legislative leaders, in addition to the governor, would be making appointments for the board.
    • Importantly, the bill omits language prescribing a tax on medical cannabis sales, unlike the last version. The inclusion of tax provisions resulted in the House rejecting the earlier bill because of procedural rules in the South Carolina legislature that require legislation containing tax-related measures to originate in that body rather than the Senate.
    • Smoking marijuana and cultivating the plant for personal use would be prohibited.
    • The legislation would sunset five years after the first legal sale of medical cannabis by a licensed facility in order to allow lawmakers to revisit the efficacy of the regulations.
    • Doctors would be able to specify the amount of cannabis that a patient could purchase in a 14-day window, or they could recommend the default standard of 1,600 milligrams of THC for edibles, 8,200 milligrams for oils for vaporization and 4,000 milligrams for topics like lotions.
    • Edibles couldn’t contain more than 10 milligrams of THC per serving.
    • There would also be packaging and labeling requirements to provide consumers with warnings about possible health risks. Products couldn’t be packaged in a way that might appeal to children.
    • Patients could not use medical marijuana or receive a cannabis card if they work in public safety, commercial transportation or commercial machinery positions. That would include law enforcement, pilots and commercial drivers, for example.
    • Local governments would be able to ban marijuana businesses from operating in their area, or set rules on policies like the number of cannabis businesses that may be licensed and hours of operation. DHEC would need to take steps to prevent over-concentration of such businesses in a given area of the state.
    • Lawmakers and their immediate family members could not work for, or have a financial stake in, the marijuana industry until July 2029, unless they recuse themselves from voting on the reform legislation.
    • DHEC would be required to produce annual reports on the medical cannabis program, including information about the number of registered patients, types of conditions that qualified patients and the products they’re purchasing and an analysis of how independent businesses are serving patients compared to vertically integrated companies.

    After Davis’s Senate-passed medical cannabis bill was blocked in the House in 2022, he tried another avenue for the reform proposal, but that similarly failed on procedural grounds.

    The lawmaker has called the stance of his own party, particularly as it concerns medical marijuana, “an intellectually lazy position that doesn’t even try to present medical facts as they currently exist.”

    Meanwhile, a poll released last year found that a strong majority of South Carolina adults support legalizing marijuana for both medical (76 percent) and recreational (56 percent) use—a finding that U.S. Rep. Nancy Mace (R-SC) has promoted.


  • 20 Feb 2024 12:23 PM | Addie Thompson (Administrator)

    When North Carolina launched Medicaid expansion on Dec. 1, state officials said the measure would provide health insurance to an estimated 600,000 low-income adults over a span of two years.

    It took just two months to reach 58 percent of that goal. More than 346,400 newly eligible beneficiaries have been approved for coverage as of Feb. 1, according to data from the N.C. Department of Health and Human Services.

    The fast pace of enrollment was one of several expansion-related success stories that DHHS leaders shared with lawmakers during last week’s meeting of the monthly Joint Legislative Oversight Committee on Medicaid. It was the first formal report the department had presented to the 14-person committee since expansion took effect.  

    Expansion raised the state’s income limit for Medicaid, extending eligibility to people who make an annual income of up to 138 percent of the federal poverty level based on their household size ($25,820 for a family of three). The previous limit was 100 percent. 

    Jay Ludlam, the state’s deputy secretary for Medicaid, told the committee that DHHS launched expansion “in a way that was member-focused.” About 273,000 adults who had been enrolled in Family Planning Medicaid, a limited-coverage program for reproductive health services, were automatically upgraded to full Medicaid coverage when expansion went live in December

    “We ran the algorithm on the information that we had for that population,” Ludlam said. “We determined those individuals who would qualify for Medicaid expansion and those who wouldn’t, and we moved those individuals who [did] qualify onto expansion.”

    That strategy, he said, allowed the department to hit the ground running. Most of the new beneficiaries gained Medicaid with little or no action needed on their end.

    “Those individuals didn’t have to go into an office,” Ludlam said. “They didn’t have to call a DSS worker. They didn’t have to fill out a form. Effectively, they woke up on December 1st with a card in hand, and they were able to access the full Medicaid benefit on Day One.”

    People who were not part of the initial wave of automatic enrollments have been signing up for Medicaid at a steady clip since expansion launched. Ludlam said DHHS is adding an average of 1,000 beneficiaries to the rolls each day — a number he believes will taper off in the coming weeks.

    A disproportionate share of the state’s new enrollees are residents of rural, economically distressed counties. That isn’t entirely surprising, according to Ludlam. He said expansion was expected to have an outsize impact in rural areas. 

    “Broadly, in some of these communities, we would have anticipated high enrollment,” he said. “These are areas where individuals are working potentially more than one job to make ends meet.”

    ‘Knocking on death’s door’

    For people like DeAnna Brandon, the value of Medicaid can be measured in days rather than dollars.

    Diagnosed with a rare blood cancer in 2022, the Rowan County resident was told she had less than three years to live unless she received a stem cell transplant. Brandon, whose story was first reported by NC Health News, couldn’t afford the expensive procedure without health insurance — and her biological window of opportunity was growing smaller.

    The chemotherapy that helped Brandon manage the symptoms of her cancer threatened to cause irreversible damage to her cells, undermining the effectiveness of the transplant. The physical toll of the treatment also left her unable to work.


  • 20 Feb 2024 12:22 PM | Addie Thompson (Administrator)

    Danay Burke, 43, was released from prison on Nov. 1. Among the many tasks on her to-do list for reestablishing her life was to figure out how to manage her health care needs. But she left prison without health insurance, making that a difficult and costly prospect.

    “It’s slowing down the process of me helping myself,” Burke said.

    She said she needs a drug assessment, medications for her anxiety and depression, birth control, a mammogram and a sleep study. However, Burke said she’s delayed all this care because she lacked medical coverage. 

    Burke, like many others released from incarceration, fell into a health insurance coverage gap. Historically, most people reentering society after incarceration were either uninsured or uninsurable. 

    But that’s poised to change in North Carolina with Medicaid expansion that took effect on Dec. 1. 

    The expanded eligibility rules allow people ages 19 to 64 whose incomes are up to 138 percent of the federal poverty level for their household size to gain coverage, allowing about 600,000 more low-income residents to join the state’s Medicaid rolls. Now, a single adult living in a one-person household is eligible if their annual income is $20,120 or less before taxes. 

    This criteria allows substantially more justice-involved individuals — people who often work in low-paying jobs or struggle to find work because of their criminal history — to enroll in Medicaid. The program can cover a variety of services, including doctor visits, behavioral health treatments and prescription drugs.

    It’s a welcome change for Burke and others, who now have a path to getting health insurance that can pay for needed medical care — particularly as they shift out of a prison that was mandated to provide health care, to finding care in the community on their own.

    Burke heard she newly qualified for Medicaid coverage from a staff member at Benevolence Farm — a reentry program in Alamance County offering housing and employment to women recently released from North Carolina prisons where she is staying — who helped her apply in December. Burke said she was approved for coverage, and she is eager to take advantage of the benefits to start taking care of her backlog of medical needs when she receives her Medicaid card in the mail.

    However, Burke can’t help but think how much easier the path could have been without that disruption in care.

    “A lot of people don’t have access,” Burke said. “They aren’t able to take care of themselves properly. Your mental health is a big thing because if you can’t take care of your mental health, a lot of people end up turning back to drugs and back to prison because we’re not able to take care of ourselves mentally and emotionally. 

    “It’s a big, big issue.”

    The state prison system releases more than 15,000 people into the community each year, and prison officials estimate that 80 percent of them are now eligible for Medicaid. 

    They also recognize that inadequate access to health care can create a barrier to successful reentry into society. That’s why the N.C. Department of Adult Correction is working to ensure that fewer people are released into health care coverage gaps by helping people apply for Medicaid before they’re scheduled to leave prison.

    “One of the key things with reentry is that break in service can really be detrimental,” said George Pettigrew, deputy secretary for rehabilitation and reentry at the N.C. Department of Adult Correction. “Somebody can decompensate real quick with mental health issues, substance use issues. If they don’t have that insurance ready to go where they can go and have these [health] services, that can be a problem.”

    Gaining coverage

    Mary Grillo, interim social work director and Medicaid expansion coordinator at the Department of Adult Correction, said the prison system has launched a department-wide effort to help people ages 19 to 64 who are within 90 days of their release date to apply for Medicaid coverage. 

    That effort is in line with one of the goals outlined in the state’s participation in Reentry2030, a national initiative that aims to dramatically improve reentry success. North Carolina joined the initiative through Gov. Roy Cooper’s January executive order seeking to boost reentry support.

    Reaching people about 90 days ahead of time is important, Grillo said, because it can take up to 45 days for a Medicaid application to be processed and eligibility determined. The goal is to have as many people as possible covered before their release, she said.

    “It’s one less thing that the individual has to do when they get out of prison,” Grillo said. “It’s one less thing to worry about.” 

    Grillo said prison staff, including three temporary workers hired in January to assist with the application process, are submitting about 100 Medicaid applications per week. 

    “The biggest challenge is getting the information out there and getting the education out there and letting people know that this is available,” Grillo said.

    To spread the word about the new opportunity for Medicaid coverage upon release, the prison system has distributed a flyer through electronic tablets that are available to all incarcerated people and hung paper flyers on bulletin boards across prisons.



  • 19 Feb 2024 4:19 PM | Addie Thompson (Administrator)

    A slew of states are pursuing Medicaid coverage for incarcerated populations ahead of their release from prison as a means to address substance use disorders. 

    In Jan. of 2023, California received federal approval to provide people in correctional facilities with Medicaid services before their release.

    One year later, a “groundswell” of other states seek to make similar strides in the hopes of reducing the rates of overdose-related death and other health care problems that are exacerbated in the weeks immediately after an incarcerated person’s release. 

    “There’s really a groundswell of state interest,” Vikki Wachino, founder and executive director of the Health and Reentry Project (HARP), told Addiction Treatment Business.

    HARP is an initiative that seeks to advance policy and practices that improve the lives, health and safety of incarcerated people as they return to their communities.

    “We see very poor health outcomes after people leave prison and jail,” she continued.
    “We see it across a range of conditions … but the real standout is with respect to opioid overdoses, where the rate of opioid overdose deaths for people right after they leave prison or jail is significantly higher than it is for the population as a whole.”

    More states are following the example set by California, which submitted an 1115 waiver petitioning the federal government to amend the federal law prohibiting Medicaid from covering most services when people are incarcerated.

    Other states have followed suit. Washington’s waiver was already approved, and other states are awaiting CMS approval.

    These waivers, or other legislature like them, will soon be all but universal, industry experts told Addiction Treatment Business.

    “It’s about health care, but it’s also about giving people second chances and the difference that health care can make between life and death,” Wachino said.

    The problem: heightened rates of overdose deaths

    Mental illness and substance use disorders are disproportionately prevalent among incarcerated people.

    Around 18% of the general population is estimated to have a mental illness, compared to 44% of people in jail and 37% of people in prison, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).

    Among the general population, approximately 11% of people aged 18 to 25 have an SUD, as well as approximately 6% of people over 25 years old. The rates skyrocket among incarcerated people, with approximately 63% of people in jail and 58% of people in prison having an SUD.

    “Because of the war on drugs, we’ve criminalized substance use,” Meghann Perry, a recovery coach professional educator and person with lived experience of substance addiction and incarceration, previously told Behavioral Health Business. “Therefore, the vast majority of people who are incarcerated, it’s related in some way to substance use.”

    Incarceration can exacerbate symptoms of SUD and make it more challenging to get appropriate treatment. These problems, in turn, can lead to people staying incarcerated for more extended periods.

    The transition from incarceration back into the general population can be perilous for those with SUD. People incarcerated in state prisons are 129 times more likely to die from an overdose compared to the general public, according to a study published in the New England Journal of Medicine

    The increased risk immediately post-release is due to the isolation of prison, according to Cooper Zelnick, chief revenue officer at Groups Recover Together.

    “What we have observed, and we have data on this because we’ve been doing transitional care and reentry planning work with departments of corrections for years, is that if you can get an individual plugged into treatment within the first 24 to 48 hours after release,” Zelnick said, “you can massively reduce fatal overdose, relapse and recidivism, which of course has a significant benefit from a societal cost perspective.”

    Woburn, Massachusetts-based Groups Recover Together provides SUD treatment using Suboxone, a brand name of buprenorphine, along with group therapy to promote members’ recovery through in-person or virtual care models.

    “We’d be able to provide them much better medical care and behavioral health care while incarcerated, which would really support them doing much better when they transition back into the community and not have that gap,” Perry said.

    “The primary barrier,” Zelnick added, “Is that most treatment providers won’t provide treatment unless they’re reimbursed for it.”

    The solution: passing 1115 waivers for incarcerated people

    One method of breaking down that barrier is through an 1115 waiver designed to provide incarcerated people with Medicaid access prior to their release.

    “The waivers basically build a bridge to help people access services right after release,” Wachino said.

    The “bridge” covers a targeted set of services while still incarcerated, creating connections to community services.

    “We’d be able to provide them much better medical care and behavioral health care while incarcerated, which would really support them doing much better when they transition back into the community and not have that gap,” Perry said.

    California was the first state to receive federal approval to provide people in prisons, jails and youth correctional facilities with some Medicaid and Children’s Health Insurance Program (CHIP) services through an 11115 waiver called the California Advancing and Innovating Medi-Cal (CalAIM).

    California’s waiver “blazed the path with CMS,” and now other states are following suit.

    Two states, California and Washington, have approved waivers, and 16 other states have currently pending proposals.

    “It’s really notable that a number of those states, like New Hampshire and West Virginia, have a specific focus on substance use or mental health services as part of their waiver,” Wachino said. “What we see here is governors and legislators of both parties looking to reentry waivers as a tool to address some of the national challenges that we face with respect to substance use overdoses and mental health.”

    According to industry experts, both sides of the political aisle are supportive of addressing substance use disorders and related issues. 

    New Hampshire’s waiver, called ​​”Substance Use Disorder Serious Mental Illness and Serious Emotional Disturbance Treatment Recovery and Access,” would provide a limited package of care coordination services to incarcerated people in state prisons who are receiving treatment for SUD, opioid use disorder (OUD), serious mental illness (SMI) or serious emotional disturbance (SED).

    West Virginia, Montana and Kentucky are also among the states with waivers that mention SUD.

    Even among states that have not yet proposed similar waivers, the impact of California’s progress has sparked change.

    “The state of Maine has, since 2018, received grants to serve the uninsured that are primarily designed to bridge that gap between incarceration and Medicaid coverage,” Zelnick said. “I imagine that this will be a thing that happens everywhere.”

    States are motivated to follow in California’s footsteps partly because of potential cost savings.

    “If you can give people access to benefits, they are much more likely to pursue care,” Zelnick said. “That care is likely to have a positive impact on recidivism, which massively reduces the cost center that is our criminal justice system, and on top [of that, you get positive] health outcomes, so it’s win-win.”

    The waivers attract little criticism but have garnered questions on how the policies will be implemented.

    “I think that’s a very valid question,” Wachino said.

    To properly implement 1115 waivers, states must “set a big table” for the conversations to come, Wachino said, with place settings for correctional officials, health care providers, law enforcement officials, managed care plans and people who have themselves been incarcerated.

    As California and Washington both work on implementing their approved waivers, more states will follow their examples.

    “I imagine that this will be a thing that happens everywhere,” Zelnick said. “It’s still really tricky for a whole bunch of reasons. But the trend is moving in the right direction here.”

    The waivers have the potential to be “groundbreaking,” Wachino said.

    “It is a real opportunity to connect people to services and strengthen their health and the health of the communities that they live in,” she said. “This is a very substantial step forward, both by state and federal leaders.”


  • 19 Feb 2024 4:19 PM | Addie Thompson (Administrator)

    A new report by the Elevance Health Public Policy Institute underlines the positive health impacts of doula access on pregnant patients. Elevance Health provides Medicaid managed care plans nationally, including in Texas through Wellpoint.

    The institute found that overall, patients had better birth and postpartum outcomes when accessing doula services. Researchers measured Medicaid patients across the health system’s locations and compared those who had a doula to those who did not.

    Patients who used doula care were often Black and lived in communities with a shortage of OBGYN and maternal care. Jennifer Kowalski, the vice president of the public policy institute, said the organization intentionally did outreach to patients who were at higher risk for pregnancy complications.

    She said even though these patients were at higher risk, the report still found “better outcomes among those [people]. That’s an important thing to underscore and perhaps somewhat surprising.”

    The report found that people who worked with a doula had lower rates of C-sections and lower postpartum anxiety and depression. Patients were also more likely to attend their postpartum visits.

    “I think doula services for folks who are pregnant is an important part of [a] whole health approach,” Kowalski said.

    The report recommends states lower barriers for doula services to be covered by Medicaid. Midwives and free-standing birth centers are covered under Medicaid in Texas, but doulas are not.

    Last year, Texas lawmakers introduced legislation to create a pilot program for doulas to be covered under Medicaid, but the bill stalled in committee.

    “Expanding access to doula services more broadly is really the hope,” Kowalski said. “Over time, knowing that we’re seeing such positive results from our study…that this encourages investment in doula workforce and that [patients] who need these services can access them more widespread than they do today.”

    Texas did pass and get federal approval for 12 months of postpartum coverage, which goes into effect March 1.

    Advocates, birth workers and researchers have said this extended coverage will lower the rates of maternal mortality and morbidity in the state.

    Got a tip? Email Elena Rivera at erivera@kera.org


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