Employers Pay 224% Of Medicare Prices For Hospital Services

Employers pay 224% of Medicare prices for hospital services | BenefitsPRO

Source: BenefitsPRO, by Scott Wooldridge

Employer-sponsored health plans paid on average 224% of what Medicare paid to hospitals for the same services at the same facilities, according to a new study from RAND Corporation. The report covers billing for hospital inpatient and outpatient services in 2020.

The study said that there were significant variances in prices across states or geographic areas and added that the difference in cost seemed to be linked to hospital market share rather than hospitals’ share of Medicare and Medicaid patients.

The researchers found that in Hawaii, Arkansas, and Washington, relative prices were under 175% of Medicare, while other in states, such as Florida, West Virginia, and South Carolina, relative prices were at or above 310% of Medicare.

In addition, the study found that prices for COVID-19 hospitalization were similar to prices for overall inpatient admissions and averaged 241% of what was paid for Medicare patients.

“Employers can use this report to become better-informed purchasers of health benefits,” said Christopher Whaley, the study’s lead author and a policy researcher at RAND, a nonprofit research organization. “This work also highlights the levels and variation in hospital prices paid by employers and private insurers, and thus may help policymakers who may be looking for strategies to curb health care spending.”

Cost variation: a “defining characteristic” of US health care

The researchers described the wide variation in prices paid for medical services as “a defining characteristic of the U.S. health care system.”

In 2019, the study said, spending on hospital services accounted for 37% of total health care spending for privately insured Americans and came to approximately $434 billion. “Hospital price increases are key drivers of growth in per capita spending among the privately insured,” the study added.

RAND researchers found the difference between employer prices and Medicare prices was actually a bit lower since a previous study in 2018, when employers paid 247% of Medicare costs. The researchers said the change was because of an increase in claims among states that generally pay lower rates for hospital costs.

Transparency in pricing has been a challenge for the health care industry. Despite efforts by both providers and government regulators to create more transparency, both employers and consumers lack useful information on pricing. And the public data that does exist has gaps, due in part to the fact that many hospitals have not yet complied with recent regulatory requirements.

An Indiana case study: employer pressure lowered prices

The study concludes by looking at efforts in some states to address relatively high hospital prices. In Indiana, employers in the Fort Wayne area were able to prompt price changes at the Parkview Health System in that community, which the RAND study had identified as having some of the highest prices in the country.

“Equipped with information on negotiated prices, employers were able to place pressure on a large hospital system and TPAs to achieve lower prices for their workforce,” the study said. “Other employer and policymaker pressures in Indiana led the Indiana University Health system to announce plans to reduce prices to the national average rate.”

Hospital association response: “Unfounded conclusions”

The American Hospital Association (AHA), however, quickly released a statement saying the RAND conclusions were an over-reach and unfounded.

“The report looks at claims for just 2.2% of overall hospital spending, which, no matter how you slice it, represents a small share of what actually happens in hospitals and health systems in the real world,” said AHA President and CEO Rick Pollack. “Researchers should expect variation in the cost of delivering services across the wide range of U.S. hospitals – from rural critical access hospitals to large academic medical centers. Tellingly, when RAND added more claims as compared to previous versions of this report, the average price for hospital services declined.”

Lowering Medicare Age Comes With Big Price Tag

Democrats push bill to lower Medicare eligibility age to 60 - CNNPoliticsSource: Axios, by Adriel Bettelheim

Giving Americans over 60 access to Medicare would add about 7.3 million people to the program’s rolls and swell the budget deficit by $155 billion over a five-year period, the Congressional Budget Office and Joint Committee on Taxation project said in a new analysis.

Why it matters: While it’s a popular idea with voters, the big price tag illustrates why Medicare expansion isn’t gaining centrist support and remains a legislative long shot.

What they’re saying: Lowering the eligibility age would result in about 3.2 million fewer people having employer-sponsored health coverage, with most transferring to Medicare.

  • * That would put the federal government on the hook for a larger share of medical spending while lowering per-person spending for work-based health plans.
  • * The policy would halve the uninsured rate for the newly eligible group, from 8% to 4%.

Flashback: While President Biden didn’t initially run on expanding access to Medicare, he agreed to support lowering the age from 65 to 60 in April 2020, when his campaign worked on a unity platform with Sen. Bernie Sanders (I-Vt.).

  • * The idea lost traction as centrists led by Sen. Joe Manchin (D-W.Va.) scaled back Biden’s social spending ambitions and the Build Back Better agenda.

Leapfrog Group: Patients report worse hospital experiences during COVID-19 pandemic, raising safety concerns

Leapfrog sees 'significant' infection increases across its largest-to-date  release of hospital safety grades | Fierce HealthcareSource: Fierce Healthcare, by Dave Muoio

The latest batch of hospital patient safety ratings from the Leapfrog Group shows a general decline among “several” hospital safety measures concurrent with the onset of the COVID-19 pandemic, according to the healthcare safety watchdog.


Released Tuesday, the scores are accompanied by a report from Leapfrog that highlights a “significant” decline in the experiences of adult inpatients at acute care hospitals during the pandemic, with many areas “already in dire need” prior to the pandemic deteriorating even further.

“The healthcare workforce has faced unprecedented levels of pressure during the pandemic, and as a result, patients’ experience with their care appears to have suffered,” Leah Binder, president and CEO of the Leapfrog Group, said in a statement.


Leapfrog’s twice-annual reports assess more than 30 patient safety measures and component measures compiled from the Centers for Medicare & Medicaid Services (CMS) and Leapfrog’s hospital surveys between July 2018 and March 2021. The most recent release assigns letter grades to nearly 3,000 U.S. general hospitals and is the second collection of scores to incorporate safety and experience data from the COVID-19 pandemic.

This time around, Leapfrog assigned 33% of hospitals an “A,” 24% a “B,” 36% a “C,” 7% a “D” and less than 1% an “F”—a roughly equivalent distribution to those given in the fall.

Eight states had 50% or more of its hospitals receive an “A” grade, with North Carolina (59.8%) and Virginia (59.2%) leading the way.


On the other end of the spectrum, Wyoming, West Virginia, North Dakota and the District of Columbia had zero hospitals that received an “A” from the watchdog.

As before, Binder said that the “significant variation in safety performance” across different facilities underscores the need for public access to hospital assessment tools “so patients can make the best decision for themselves and their loved ones.”

Alongside the scores, Leapfrog placed a spotlight on patient experiences in a report comparing Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) scores across more than 3,500 U.S. hospitals before (2019) and during (mid-2020 to mid-2021) the COVID-19 pandemic.

The group found statistically significant declines between the survey periods in the average percentage of hospital patients who gave the most favorable responses for nine of the 10 HCAHPS measures.


The greatest decline was seen among patients’ experiences with hospital staff responsiveness (a 3.7 percentage point decrease), followed by communication about medicines (a 2.9 point decrease), and cleanliness of the hospital (a 2.9 point decrease).

Leapfrog noted that these patient experience areas and others—like understanding care transitions (which already claimed the least favorable responses)—are directly tied to patient safety events and likely took a hit due to pandemic strains on the healthcare workforce.

“We commend the workforce for their heroic efforts these past few years and now strongly urge hospital leadership to recommit to improved care—from communication to responsiveness—and get back on track with patient safety outcomes,” Binder said.

The inpatient experience report is the second in a series of three such analyses from Leapfrog focused on patient experience during the pandemic. The first report, released in early April, focused on a decline in favorable patient ratings for communications about procedures across ambulatory surgery centers and hospital outpatient departments alike.

Leapfrog’s broader Hospital Safety Grade rankings are available online as a free resource for patients and their families. The organization said its analyses are independently assessed and peer-reviewed, with the methodology of the scoring available online for review.

The prior round of ratings highlighted “significant” declines in hospitals’ performance on preventable hospital-acquired infections. Those findings echoed similar concerns from patient experience intelligence firm Press Ganey and the Centers for Disease Control and Prevention.

California Is Investigating The Corporation That Took Over Its Medicaid Drug Program

California handed its Medicaid drug program to one company. Then came a  corporate takeover. | Modern Healthcare

Source: Kaiser Health News, by Samantha Young

Prescription drug costs for California’s massive Medicaid program were draining the state budget, so in 2019 Gov. Gavin Newsom asked the private sector for help.

The new Medicaid drug program debuted this January, with a private company in charge. But it was woefully unprepared, and thousands of low-income Californians were left without critical medications for weeks, some waiting on hold for hours when they called to get help.

What happened in the two years between the contract award and the start of the program is a case study in what can go wrong when government outsources core functions to the private sector.

California awarded the Medi-Cal Rx program to a unit of Magellan Health, a company with expertise in pharmacy benefits and mental health. But Magellan was then gobbled up by industry giant Centene, worth roughly $50 billion, which was looking to expand its mental health portfolio.

Centene was already a big player in state Medicaid drug programs — but one with a questionable record. The company was accused by six states of overbilling their Medicaid programs for prescription drugs and pharmacy services and settled to the tune of $264.4 million. Three other states made similar allegations and have settled with the company, but the amounts have not been disclosed. Centene, in resolving the civil actions, denied any wrongdoing.

KHN has learned California health officials also are investigating Centene.

Handing Over Control

In his 2019 inauguration speech, Newsom vowed to use California’s “market power and our moral power to demand fairer prices” from the “drug companies that gouge Californians with sky-high prices.”

Drug spending by the state for its Medicaid, prison, state hospital, and other programs had been climbing 20% a year since 2012, so the first-term Democrat issued an executive order requiring California to make its own generic drugs and forge partnerships with counties and other states to buy drugs in bulk. He also directed the state to buy prescription drugs for Californians enrolled in Medi-Cal, the state’s Medicaid program, which covers roughly 14 million people.

Newsom no longer wanted to allow the state’s two dozen Medi-Cal managed-care health plans to provide prescription drug coverage to their enrollees, arguing the state would get a better deal from drug companies by harnessing its purchasing power.

That December, California awarded a competitive $302-million contract to Magellan Medicaid Administration, a subsidiary of Magellan Health, to make sure Medi-Cal enrollees get the medications that California would buy in bulk. Magellan provides pharmacy services to public health plans in 28 states and the District of Columbia.

Even though Magellan’s biggest money maker is mental health insurance, it met a key requirement of the state’s call for bids: It didn’t provide health insurance to any Medicaid enrollees in California.

Magellan was supposed to take over the drug program in April 2021. But on Jan. 4 of that year, Centene — which was seeking a greater role in the lucrative behavioral health market — announced plans to buy Magellan.

St. Louis-based Centene, however, is one of the largest Medi-Cal insurers in the state, a factor that would have disqualified it from bidding for the original contract. Centene provides health coverage for about 1.7 million low-income Californians in 26 counties through its subsidiaries Health Net and California Health & Wellness. It earned 11% of its revenue from California businesses in 2019, according to its 2021 annual report to the U.S. Securities and Exchange Commission.

But the state bent over backward to make it work, delaying implementation of the program while Magellan set up firewalls, sectioned off its business operations from Centene, and paid for a third-party monitor.

State regulators reviewed the merger in a 30-minute public hearing in October 2021. They didn’t mention Centene’s legal settlements with other states.

The state Department of Managed Health Care approved the merger Dec. 30. Two days later, the state launched its new prescription drug program with Magellan at the controls.

Centene’s Legal Troubles

In the past 10 months, Centene has settled with nine states over accusations that it and its pharmacy business, Envolve, overbilled their Medicaid programs for prescription drugs and services: It settled with Arkansas, Illinois, Kansas, Mississippi, New Hampshire, and Ohio, according to news releases from attorneys general in those states. The three other states have not been identified by Centene or the states themselves.

The company has set aside $1.25 billion for those settlements and future lawsuits, according to its 2021 report to the SEC.

Centene, which has denied wrongdoing in public statements, did not respond to multiple requests by KHN for interviews, nor did it respond to emailed questions. Magellan also did not respond to interview requests.

From the start, other California health insurers opposed the state takeover of the Medi-Cal drug program, partly because it took away a line of business. They were even more furious when the state allowed one of their biggest competitors to seize the reins — especially given its legal entanglements.

The state Department of Health Care Services, which administers Medi-Cal, acknowledged to KHN in March that it’s investigating the company but declined to provide specifics. The state is investigating Centene’s role in providing pharmacy benefits before the state took the job from managed-care insurers.

“DHCS takes all allegations of fraud, waste, and abuse seriously and investigates allegations when warranted,” department spokesperson Anthony Cava said in a statement.

A Sale in the Offing?

When Medi-Cal Rx debuted Jan. 1, thousands of Californians couldn’t refill critical — sometimes lifesaving — medications for days or weeks. Doctors, pharmacists, and patients calling for help often languished on hold for as many as eight hours.

Magellan blamed the problems on staff shortages during the COVID-19 Omicron surge and missing patient data from insurance plans. State health officials went to great lengths to fix the problems and appeared before legislative committees to provide lawmakers with assurances that the contractor wouldn’t be paid in full.

But Medi-Cal patients still face uncertainty.

Not long after Magellan took over California’s Medi-Cal drug program, reports surfaced in Axios and other publications that Centene might sell Magellan’s pharmacy business.

Centene officials have not confirmed a sale. But it would align with the company’s recent moves to restructure its pharmacy operations in the face of state investigations — such as seeking an outside company to begin managing its drug spending.

“Once you tell a PBM they actually have to behave, that’s when there’s no more money in it. It’s time to go,” said Antonio Ciaccia, president of drug-pricing watchdog 3 Axis Advisors, referring to businesses known as pharmacy benefit managers.

Yet another ownership change in California’s drug program could bring more disruption to the state’s most vulnerable residents, some of whom are still having trouble getting their drugs and specialty medical supplies after Magellan’s rocky takeover.

“I don’t know what kind of instability that creates internally when there’s a change of this magnitude,” said Linnea Koopmans, chief executive of Local Health Plans of California, which represents the state’s publicly run Medicaid insurers that compete against Centene. “It’s just an open question.”

Koopmans and other Centene critics acknowledge that California has long relied on private insurance plans to offer medical and prescription drug coverage to Medi-Cal enrollees and that the state shouldn’t be surprised by ownership changes that come with consolidation in the healthcare industry. For example, Centene has a history of taking over California contracts after an acquisition — it did so when it purchased Health Net in 2016.

But consumer advocates say the Centene fiasco makes it clear that the state must improve oversight of corporate mergers if it chooses to hand over responsibility for public programs.

“In an ideal world, this is all backroom machinations that people don’t notice — until they do, until there is a problem,” said Anthony Wright, executive director of Health Access California, a consumer advocacy group. “It just increases the need to make sure that that oversight is there, that accountability is there.”

This story was produced by KHN (Kaiser Health News), one of the three major operating programs at KFF (Kaiser Family Foundation).

Record Fines Might Mean California Is Finally Serious About Improving Medi-Cal

Record Fines Might Mean California Is Finally Serious About Improving Medi- Cal | California HealthlineSource: Kaiser Health News, by Bernard J. Wolfson

Is California getting tougher on health plans that participate in Medi-Cal, the state’s insurance program for low-income residents?

A few weeks ago, state regulators imposed record $55 million in fines on L.A. Care, California’s largest Medi-Cal managed-care plan, for failing to ensure adequate care and allowing treatment delays that threatened enrollees’ health. Patient advocates hope the move signals stricter enforcement against other Medi-Cal insurers, which have many of the same shortcomings for which the regulators just fined L.A. Care.

Twenty-five managed-care plans across the state provide care for nearly 12 million of the more than 14 million Californians enrolled in Medi-Cal, and the state is often accused of failing to hold the plans accountable for subpar care. Medi-Cal members are among the state’s most vulnerable people: They can face language and cultural barriers and have disproportionately high rates of chronic illness.

The state Department of Health Care Services, which runs Medi-Cal, is drafting a new managed-care contract, scheduled to take effect in 2024, that officials say will improve care by holding participating health plans to higher standards. The state hopes to reduce health disparities and improve health outcomes by tightening surveillance and enforcement.

“They are trying to do more, and that’s really positive,” says Abbi Coursolle, senior attorney at the National Health Law Program in Los Angeles. “Obviously, they have a lot more to do.”

DHCS and the state Department of Managed Health Care, which also regulates Medi-Cal managed-care plans, launched coordinated investigations of L.A. Care, based in part on a 2020 Los Angeles Times report that highlighted long, sometimes deadly, delays in care at facilities run by the Los Angeles County Department of Health Services. That agency operates the county’s public safety-net system and contracts with L.A. Care to provide care for hundreds of thousands of the health plan’s members. In their investigations, state regulators also relied on information that L.A. Care reported to them.

That they relied on these sources, Coursolle says, raises questions about the effectiveness of their own surveillance and auditing.

On March 4, the Department of Managed Health Care hit L.A. Care with a $35 million penalty — more than triple its highest previous fine. The Department of Health Care Services levied $20 million, nearly eight times its earlier record.

The state cited L.A. Care for more than 100,000 violations, including late responses to patient complaints and appeals, delayed or denied authorizations for necessary medical care, and failure to ensure the county health services agency complied with patient care regulations. The California Department of Public Health, which regulates hospitals and other health care institutions, didn’t respond to a question about whether it’s investigating any of the county’s medical facilities.

In announcing the fines, state agency directors said: “The magnitude of L.A. Care’s violations, which has resulted in harm to its members, requires immediate action.” The health plan has 2.4 million Medi-Cal enrollees.

“The recent enforcement action against L.A. Care signals that DHCS intends to exercise our authorities to protect our Medi-Cal enrollees,” department spokesperson Anthony Cava told me in an email.

L.A. Care’s CEO, John Baackes, says the plan is not contesting the findings. “What we are contesting is the amount of the fines, which we believe are unreasonable,” Baackes said. The dispute could take months, or even years, to settle.

In a statement released after the fines were announced, L.A. Care noted Medi-Cal’s notoriously low payments to providers and said the penalties create “yet another financial hurdle for a public health plan that is a crucial part of the health care safety net.”

Although L.A. Care has generated millions of dollars in profits in recent years, it reported a loss of $132 million in fiscal year 2020. But the plan can weather the fines. At the end of last year, its tangible net equity — a key measure of solvency — was seven times as high as the minimum required by law.

The violations described by regulators are painfully familiar to Theresa Grant, a Culver City resident I wrote about late last year who has struggled to find relief from a debilitating pain in her rib cage. The violations are “horrific,” she says, “and I think it’s very true.”

But she believes the specialist physicians who have been unable or unwilling to help her deserve a big share of the blame. “You know how long I’ve been dealing with my problem,” she told me. “It’s been over a year now, and not a damn thing is being done.”

Despite the significant penalties levied on L.A. Care, consumer advocates and some state lawmakers think California needs the authority to levy even larger ones.

A bill sponsored by the consumer advocacy group Health Access would increase many of the fines that state health plan regulators can impose at least tenfold. Supporters say the legislation, SB 858, is needed because the amount the department can legally levy on health plans hasn’t been raised in some cases since 1975.

“We want to make sure that insurance companies do not view these fines as just the cost of doing business,” says the bill’s author, state Sen. Scott Wiener (D-San Francisco). “By raising them, they become less a cost of business and more an actual incentive to follow the law.”

The fines imposed on L.A. Care are outliers because of their size, which was determined in part by the sheer number of violations. “For every fine like that, there are many that are dramatically lower,” Wiener says. “I wouldn’t want to rely on one case and say, ‘Oh, no problem, because they got a big fine.’”

Another important factor in holding health plans’ feet to the fire, Wiener says, is consumer complaints, which can help bring problems to the attention of regulators — and to the plans themselves.

But a report last year by KFF showed that consumer appeals of denied care are exceedingly rare.

If you have a problem with your health plan or want to appeal a delay or denial of coverage, a good place to start is the Department of Managed Health Care (888-466-2219 or HealthHelp.ca.gov).

The state also has an ombudsman for Medi-Cal managed care (888-452-8609 or MMCDOmbudsmanOffice@dhcs.ca.gov).

You can also try the Health Consumer Alliance (888-804-3536 or www.healthconsumer.org), which assists people in public and private health plans. It offers free advice, provides legal services, and can help you get your documents in order for an appeal.

Regulators and health plans alike frequently say they are working on behalf of the patient. So if you’re not getting the care you need, stand up and be part of the solution.

Biden’s Post-Pandemic Health Plans

Biden's post-pandemic health plans

Source: Axios, by Caitlin Owens

President Biden used the State of the Union not only to project optimism about the direction of the pandemic, but also to launch new efforts focused on mental health care and nursing home quality — two areas that have been shown to be deeply in need of reform over the last two years.

Why it matters: The pandemic exposed and exacerbated deep societal problems, including within the health care system, and the work of addressing them is likely just beginning.

Driving the news: The White House announced a new strategy to address the nation’s mental health crisis, including more funding to build up the mental health workforce and new ways of connecting people with the care they need.

  • * Biden also announced measures to improve nursing home quality, including minimum staffing levels.
  • * “As Wall Street firms take over more nursing homes, quality in those homes has gone down, and costs have gone up. That ends on my watch,” he said tonight. “Medicare is going to set higher standards for nursing homes and make sure your loved ones get the care they deserve.”

Between the lines: Neither are new issues. But the number of people — including children and adolescents — struggling with addiction, depression and other behavioral health problems has spiked over the last two years, and no institution has seen a higher death toll from the virus than nursing homes.

Yes, but: Money alone can’t solve either of these problems.

  • * A key problem plaguing both is a shortage of health care workers, and building up a well-trained workforce — particularly within mental health care — will take years.

What we’re watching: Biden also tried to jump start pieces of his domestic health agenda, which is stalled in the Senate, to move forward.

  • * Specifically, he mentioned capping out-of-pocket insulin costs, allowing Medicare to negotiate drug prices, closing the “coverage gap” — presumably in states that haven’t expanded Medicaid — and making enhanced Affordable Care Act subsidies permanent.

Millions In California Will Lose Health Care Coverage If Pandemic’s Stopgap Measures Expire

Covered California 2022 health insurance deadline is Monday | The  Sacramento Bee

Source: The Modesto Bee, Cathie Anderson

Millions of Californians face the prospect of losing health coverage this year as federal measures that vastly expanded the ranks of the insured amid the COVID-19 pandemic are set to expire this year.

Because of increased federal financial help from the American Rescue Plan, for instance, two out of every three state residents who enrolled through Covered California were able to get policies that cost $10 or less per month. The state-based insurance marketplace reported a record enrollment of 1.8 million after at the conclusion of this year’s open enrollment period, up from 1.6 million for the comparable period a year earlier.

“The law lowered premiums and boosted enrollment — with the biggest beneficiaries being communities of color, lower-income Americans and many in the middle class who got help paying for their coverage for the first time,” said Peter V. Lee, executive director of Covered California. “In the absence of federal action to extend these policies this year, people in California and across the country will have their access to health coverage and care dramatically reduced.”

Even middle-income Californians saw a significant benefit, with their policy costs dropping by hundreds of dollars because of the Biden Administration’s push to ensure that every American would have coverage if they were to contract COVID-19. The federal financial help will no longer be available when 2022 ends.

Californians who depend on Medi-Cal coverage also will be affected if another pandemic-related measure ends as expected in mid-April.

As part of the Families First Coronavirus Response Act, Congress required that states provide “continuous coverage” for beneficiaries of Medicaid coverage, known as Medi-Cal in California, during the public health emergency declared by President Biden.

The emergency order will expire on April 16, ending a two-year freeze on enrollment that ensured state residents with Medi-Cal coverage would not be dropped because of changes in income, access issues or failure to meet a number of other eligibility requirements.

Anthony Cava, a spokesman for the California Department of Health Care Services, said there’s always a chance that the public health emergency could be extended, but even if it isn’t, the federal agency that runs Medicaid has told state officials that it will give them up to 12 months, plus two additional months due to renewal processing policies, to return to normal eligibility and enrollment operations.

This means that counties will be able to redetermine Medi-Cal eligibility for their beneficiaries on a rolling basis, based on their next annual renewal date, rather than having to touch all the beneficiaries at once, Cava said.

“To minimize the risk of individuals losing coverage, the Department of Health Care Services…is currently engaged in various outreach efforts to keep beneficiaries informed about their Medi-Cal coverage and to encourage beneficiaries to provide their local county Medi-Cal offices with updated information, including reporting when they have a change in address,” Cava said. “As part of our outreach efforts, DHCS sent a notice to all Medi-Cal households in December 2021 to encourage beneficiaries to report updated contact information.”


DHCS reported in December that the Medi-Cal population was nearly 14.28 million In September 2021, up 13.7% from about 12.56 million in February 2020, the month before state shelter-in-place orders were instituted.

Among the 14.28 million beneficiaries in September, 49% identified as Hispanic, 17.5% as white, 9.5% as Asian/Pacific Islander and 7.1% as Black.

Experts have said that, because of longstanding, structural racism, people of color are more likely to experience the type of volatility and instability in their employment and housing that leads people to apply for Medi-Cal.

The end of the public health emergency means that a disproportionately high number of Latinos and African Americans will face losing health coverage when they need it most, wrote Manatt Health research consultants Patricia Boozang and Adam Striar in a report prepared for the Robert Wood Johnson Foundation.

They pointed out that individuals who are eligible for Medi-Cal often lose coverage when it’s time to re-certify their eligibility because of administrative barriers. For instance, Striar and Boozang wrote, they may not have online access needed to renew coverage, may not understand complicated paperwork or may not possess the necessary documents because their housing situation or health needs are precarious.

As a result, there could be an incredible amount of churn in the numbers of both Medi-Cal beneficiaries and Covered California beneficiaries amid a pandemic that has killed more than 85,000 state residents.

A Covered California analysis has found that, if the subsidies provided by the American Rescue Plan were allowed to expire, enrollees who currently earn less than 400% of the federal poverty level — $52,000 for a single person and $106,000 for a family of four — would face monthly premiums increases of 71% for 2023.


Researchers at the state-based insurance marketplace said that 1 million Californians — earning between $17,775 and $32,200 a year for an individual and from $36,570 to $66,250 for a family of four — would see their health insurance premiums more than double.

The American Rescue Plan made a number of changes that increased affordability for working-class and middle-class Californians. Among them:

▪ It increased the amount of financial help available for all consumers.

▪ It capped health insurance premiums at 8.5 percent of household income.

▪ It ensured that consumers who earned less than 150 percent of the federal poverty level ($19,230 for an individual and $39,750 for a family of four) paid no premiums on plans in the silver tier. Silver plans cover 70 percent of medical expenses.

▪ It also extended financial help to middle-income consumers, those who earn more than $51,250 as an individual or $106,000 for a family of four. They previously had been ineligible for assistance.

“While lower-income consumers would still be getting federal tax credits, many of those who would see their premiums double will be priced out of the coverage they want and need,” Lee said. “A total of 1 million Californians, those who can least afford it, will be hit the hardest if these critical subsidies are allowed to expire.”


Payers, Medicaid Officials Ask Congress For 120-Day Glide Path To End Of COVID-19 Emergency

Payers, Medicaid officials ask Congress for 120-day glide path to end of  COVID-19 emergency | Fierce Healthcare

Source: Fierce Healthcare, by Robert King

Several major payer groups and Medicaid advocates are pressing Congress for a 120-day heads up when the COVID-19 public health emergency ends, arguing they need as much time as possible to make Medicaid enrollees aware they could lose coverage.

A collection of payer and Medicaid state advocacy groups wrote to congressional leadership on Thursday asking for the greater lead time. The letter comes as providers and other stakeholders are preparing for an end to key flexibilities granted back in January 2020.

States and payers are facing the daunting task of redetermining the eligibility of Medicaid enrollees. The PHE prevented states from dropping any enrollees off Medicaid rolls for the duration of the emergency. States will have a year after the PHE ends to fully redetermine eligibility.

But states, plans and providers need sufficient lead time to process millions of eligibility redeterminations, the groups said.

If enough time isn’t provided, then “millions of individuals who otherwise remain eligible for Medicaid become uninsured,” according to the letter.

Insurance lobbying group AHIP signed on to the letter as well as Medicaid Health Plans of American and National Association of Medicaid Directors.

Other advocacy groups such as the National Association of Community Health Centers and Association for Community Affiliated Plans signed on.

State Medicaid officials and payers have been bracing for months on how to handle the coming wave of redeterminations. Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure said back in September 2021 that the center is working to help ensure that people who drop off Medicaid can get coverage on the Affordable Care Act’s insurance exchanges.

How the redeterminations are handled could also affect coverage for millions of people. A study from the Urban Institute last year estimated that 15 million people could lose Medicaid insurance coverage after the end of the PHE. The think tank said states should be working hard to reach out to affected beneficiaries about other coverage options.

The current PHE ends in April and can be extended for another 90 days.

Former acting Department of Health and Human Services Secretary Eric Hargan had promised stakeholders a 60-day notice of when the PHE would end.

Some hospital groups have wanted the PHE to be extended again as facilities are still struggling financially due to the latest surge of COVID-19. House Republicans, on the other hand, pressed HHS Secretary Xavier Becerra to end the period and to give a glide path for an easy transition.

Millions Of Children Could Lose Medicaid Coverage Once The Public Health Emergency Ends

Millions of children could lose Medicaid coverage once the public health  emergency ends - CNNPolitics

Source: CNN Politics, by Tami Luhby

The number of kids covered by Medicaid or the Children’s Health Insurance Program has soared to a record 40 million during the pandemic, aided by a congressional provision that bars states from disenrolling them during the public health emergency.

However, at least 6.7 million children are at risk of losing that coverage and going uninsured for a period once the emergency expires, according to a new analysis released Thursday by the Georgetown Center for Children and Families. That could happen in July  the Department of Health and Human Services has promised to provide states with 60-days notice.

States will then resume checking families’ eligibility for Medicaid, including making sure parents’ incomes have not risen above the program’s thresholds. That process has been on hold since March 2020, when lawmakers passed a coronavirus relief package that boosted states’ federal Medicaid match rates by 6.2 percentage points during the public health emergency. In exchange for that additional aid, states could not remove anyone involuntarily from coverage.

The situation presents a “unique and unprecedented set of public policy circumstances that create a grave risk to the stability of health coverage in the year ahead for millions of children and their families,” said Joan Alker, executive director of the Georgetown center and co-author of the report.

Total enrollment in Medicaid and CHIP hit a record 83.6 million in July 2021, the most recent data available, up 11.4% since February 2020. About half of the nation’s children are now covered by the two programs.

Some 4.4 million children were uninsured in 2019, according to the latest figures available from the US Census Bureau.

Children at risk

Since they will lose the boost in federal Medicaid matching funds, states will be under great pressure to conduct the eligibility reviews quickly and reduce their enrollment, Alker said.

Not enough attention is being paid to the risks children are facing of becoming uninsured and to transitioning them to other forms of coverage, the analysis said.

“Even children who remain eligible for Medicaid could lose their coverage for procedural reasons, such as the verification request getting lost in the mail or being sent to an old address,” said Tricia Brooks, research professor at Georgetown’s McCourt School of Public Policy and a co-author of the report.

Even prior to the pandemic, many families were dropped from Medicaid for administrative hurdles or income fluctuations – though 44% of these children were reenrolled within a year.

Families have experienced a lot of changes since they last had to renew their eligibility two years ago, Alker said. She expects to see a record number of denials for procedural reasons due to the volume of verifications and the push to act on them quickly.

A majority of kids who lose Medicaid because their families’ income has increased modestly could probably shift to CHIP, which has higher earnings limits. But some states require additional enrollment steps, which parents may not complete, leaving children uninsured.

Another concern: Many states are understaffed, which could lead to mistakes and make it more difficult for families to get the assistance they need to complete their eligibility verifications or transition to other sources of coverage.

What happens to both children and adults in low-income families will greatly depend on states’ renewal procedures, which can vary. Children are more at risk of losing coverage in states that charge premiums in their CHIP programs, that don’t provide 12 months of continuous Medicaid coverage for children and that process fewer than half of their renewals using existing data sources.

States can take steps now to minimize problems during the eligibility determinations, including using quarterly wage data and other sources to check enrollees’ incomes now, working with insurers to update Medicaid beneficiaries’ addresses in state records, conducting outreach campaigns to low-income families and establishing multiple ways to reach out to enrollees when action must be taken to renew coverage.

Why Millions on Medicaid Are at Risk of Losing Coverage in the Months Ahead

Why millions on Medicaid are at risk of losing coverage in the months ahead

Source: Kaiser Health News, by Rachana Pradhan

The Biden administration and state officials are bracing for a great unwinding: millions of people losing their Medicaid benefits when the pandemic health emergency ends. Some might sign up for different insurance. Many others are bound to get lost in the transition.

State Medicaid agencies for months have been preparing for the end of a federal mandate that anyone enrolled in Medicaid cannot lose coverage during the pandemic.

Before the public health crisis, states regularly reviewed whether people still qualified for the safety-net program, based on their income or perhaps their age or disability status. While those routines have been suspended for the past two years, enrollment climbed to record highs. As of July, 76.7 million people, or nearly 1 in 4 Americans, were enrolled, according to the Centers for Medicare & Medicaid Services.

When the public health emergency ends, state Medicaid officials face a huge job of reevaluating each person’s eligibility and connecting with people whose jobs, income, and housing might have been upended in the pandemic. People could lose their coverage if they earn too much or don’t provide the information their state needs to verify their income or residency.

Medicaid provides coverage to a vast population, including seniors, the disabled, pregnant women, children, and adults who are not disabled. However, income limits vary by state and eligibility group. For example, in 2021 a single adult without children in Virginia, a state that expanded Medicaid under the Affordable Care Act, had to earn less than $1,482 a month to qualify. In Texas, which has not expanded its program, adults without children don’t qualify for Medicaid.

State Medicaid agencies often send renewal documents by mail, and in the best of times letters go unreturned or end up at the wrong address. As this tsunami of work approaches, many state and local offices are short-staffed.

The Biden administration is giving states a year to go through the process, but officials say financial pressures will push them to go faster. Congress gave states billions of dollars to support the coverage requirement. But the money will dry up soon after the end of the public emergency — and much faster than officials can review the eligibility of millions of people, state Medicaid officials say.

In Colorado, officials expect they’ll need to review the eligibility of more than 500,000 people, with 30% of them at risk of losing benefits because they haven’t responded to requests for information and 40% not qualifying based on income.

In Medicaid, “typically, there’s always been some amount of folks who lose coverage for administrative reasons for some period of time,” said Daniel Tsai, director of the CMS Center for Medicaid and CHIP Services. “We want to do everything possible to minimize that.”

In January the eligibility of roughly 120,000 people in Utah, including 60,000 children, was in question, according to Jeff Nelson, who oversees eligibility at the Utah Department of Health. He said that 80% to 90% of those people were at risk because of incomplete renewals. “More often than not, it’s those that just simply have not returned information to us,” he said. “Whether they didn’t receive a renewal or they’ve moved, we don’t know what those reasons are.”

Arizona Medicaid director Jami Snyder said 500,000 people are at risk of losing Medicaid for the same reasons. She said that processing all the eligibility redeterminations takes at least nine months and that the end of the federal funding bump will add pressure to move faster. However, she said, “we’re not going to compromise people’s access to care for that reason.”

Still, officials and groups who work with people living in poverty worry that many low-income adults and children — typically at higher risk for health problems — will fall through the cracks and become uninsured.

Most might qualify for insurance through government programs, the ACA insurance marketplaces, or their employers — but the transition into other coverage isn’t automatic.

“Even short-term disruptions can really upend a family,” said Jessie Mandle, deputy director of Voices for Utah Children, an advocacy group.

‘More Marginalized People’

Low-income people could still be in crisis when the public health emergency ends, said Stephanie Burdick, a Medicaid enrollee in Utah who advocates on behalf of patients with traumatic brain injuries.

In general, being uninsured can limit access to medical care. Covid vaccination rates among Medicaid enrollees are lower than those of the general population in multiple states. That puts them at higher risk for severe disease if they get infected and for exorbitant medical bills if they lose their insurance.

“They’re more marginalized people,” Burdick said. She said she worries “that they’re going to fall off and that they’re going to be more excluded from the health care system in general and just be less likely to get care.”

Burdick knows this firsthand as someone who experienced traumatic brain injury. Before covid-19, she would periodically lose her Medicaid benefits because of byzantine rules requiring her to requalify every month. The gaps in coverage kept her from seeing certain specialists and obtaining necessary medicines. “I really do remember being at the pharmacy not being able to afford my medication and just sobbing because I didn’t know what to do about it,” she said. “It was horrible.”

The covid Medicaid continuous coverage requirement was enacted under the Families First Coronavirus Response Act, which gave states an increase of 6.2 percentage points in federal funds if they agreed to maintain eligibility levels in place at the time.

The boost meant tens of billions of additional dollars would flow to states, estimates from KFF show. The U.S. Department of Health and Human Services can extend the public health emergency in 90-day increments; it is currently set to end April 16.

Groups that advocate for the needs of low-income Americans say the renewal tidal wave will require outreach rivaling that of almost a decade ago, when the ACA expanded Medicaid and created new private insurance options for millions of people.

Independent research published in September by the Urban Institute, a left-leaning think tank based in Washington, D.C., estimated that 15 million people younger than 65 could lose their Medicaid benefits once the public health emergency ends. Nearly all of them would be eligible for other insurance options, including heavily subsidized plans on the ACA marketplaces.

Tsai said the 15 million estimate provides a “helpful grounding point to motivate everybody” but declined to say whether the Biden administration has its own estimates of how many people could lose benefits. “I don’t think anyone knows exactly what will happen,” he said.

Tsai and state officials said they have worked hand in hand for months to prevent unnecessary coverage loss. They’ve tried to ensure enrollees’ contact information is up to date, monitored rates of unreturned mail, worked with insurers covering Medicaid enrollees, and conducted “shadow checks” to get a sense of who doesn’t qualify, even if they can’t disenroll people.

Some enrollees could be renewed automatically if states verify they qualify by using data from other sources, such as the Internal Revenue Service and the Supplemental Nutrition Assistance Program.

For others, though, the first step entails finding those at risk of losing their coverage so they can enroll in other health benefits.

“It’s a big question mark how many of those would actually be enrolled,” said Matthew Buettgens, a senior fellow in Urban’s Health Policy Center and author of the September report. One factor is cost; ACA or job-based insurance could bring higher out-of-pocket expenses for the former Medicaid enrollees.

“I am particularly worried about non-English speakers,” said Sara Cariano, a policy specialist with the Virginia Poverty Law Center. “Those vulnerable populations I think are at even higher risk of falling out improperly.” The law center is planning enrollment events once the unwinding begins, said Deepak Madala, its director of the Center for Healthy Communities and Enroll Virginia.

Missouri, already sluggish in enrolling eligible people into the state’s newly expanded Medicaid program, had 72,697 pending Medicaid applications as of Jan. 28. Enrollment groups worry the state won’t be able to efficiently handle renewals for nearly all its enrollees when the time comes.

By December, the Medicaid rolls in the state had swelled to almost 1.2 million people, the highest level since at least 2004. The state — one of several with histories of removing from the program people who were still eligible — did not say how many people could lose their benefits.

“I want to make sure that everybody that is entitled to and is eligible for MO HealthNet is getting the coverage that they need — all the way from babies to older individuals to individuals on disability,” said Iva Eggert-Shepherd of the Missouri Primary Care Association, which represents community health centers.

‘No End in Sight’

Some people argue the current protections have been in place long enough.

“There’s no end in sight. For two years, it’s still a quote-unquote ‘emergency,’” said Stewart Whitson, a senior fellow with the Foundation for Government Accountability. The conservative think tank has argued that states can legally begin trimming people from Medicaid rolls without jeopardizing their funding.

“This is the kind of problem that just grows worse every day,” he said of not removing ineligible people. “At the beginning of the pandemic, people were in a different position than they are now. And so responsible legislators and government officials in each state have to look at the facts as they are now.”

Tsai said “it’s quite clear to us” that for states to be eligible for the covid relief bill’s enhanced Medicaid funding, they must keep people enrolled through the emergency. “Those two things are interlinked,” he said.

Meanwhile, states still have no idea when the renewal process will begin. HHS has said that it would give states 60 days’ notice before ending the emergency period. The additional Medicaid funds would last until the end of the quarter when the emergency expires — if it ended in April, for example, the money would last until June 30.

“It’s hard to do a communication plan when you say, ‘You’ve got 60 days, here you go,’” Nelson of Utah’s Department of Health said.

Colorado officials had debated sending letters to enrollees when the public health emergency was nearing its scheduled end on Jan. 16 but held off, expecting that it would be extended. HHS announced a 90-day extension only two days before it was set to expire.

“Those kinds of things are really confusing to members,” Medicaid Director Tracy Johnson said. “OK, your coverage is going to end. Oh, just kidding. No, it’s not.”

Last Updated 06/29/2022

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