Govt. Affairs

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(From the Pennsylvania Attorney General’s office)

Attorney General Josh Shapiro Announces Grand Jury Recommendations for the Pennsylvania Medicaid Program

FOR IMMEDIATE RELEASE — April 15, 2019
CONTACT: Joe Grace, 717-574-9095, jgrace@attorneygeneral.gov

HARRISBURG — Attorney General Josh Shapiro today announced recommendations from a statewide Grand Jury investigation into the Pennsylvania Medical Assistance (MA) Program. The legislative actions recommended by the Grand Jury aim to assist the Pennsylvania Department of Human Services in identifying and preventing fraud from occurring in the program and provide law enforcement, particularly the Pennsylvania Office of Attorney General’s Medicaid Fraud Control Section, with the tools it needs to effectively investigate fraud within the program.

The Pennsylvania Medical Assistance—or Medicaid—program is implemented by the Department of Human Services and provides care to more than 2.7 million low-income Pennsylvanians. The Office of Attorney General’s Medicaid Fraud Control Section is dedicated to prosecuting anyone who defrauds the MA Program through unlawful billing or failing to provide services to those whom the program serves.

In the 2017 and 2018 calendar years, the Medicaid Fraud Control Section made a total of 292 arrests, achieved 173 convictions, and recovered more than $34 million for the commonwealth, making it the third highest ranking Medicaid fraud control unit in the country. Last month, the Section was nominated and selected for the U.S. Inspector General’s Award for Excellence in Fighting Fraud, Waste, and Abuse.

“Medicaid provides essential care to some of Pennsylvania’s most vulnerable citizens, including low-income individuals, children with serious health conditions, and individuals suffering from substance use disorder,” said Attorney General Josh Shapiro. “When bad actors take advantage of the system, they deny these people the care they deserve, take advantage of hard-working care providers, and scam Pennsylvanians out of their hard-earned tax dollars.”

This investigation stemmed from two independent Medicaid Fraud investigations that prompted the Grand Jury to conduct an investigation into how to identify and prevent fraud and ensure delivery of satisfactory care within the MA Program.

The Grand Jury heard testimony from state regulators, law enforcement officials, managed care organizations (MCOs), and health care providers about the MA program. They identified the following three systemic issues within the MA program that permit the exploitation of care-dependent Pennsylvanians for financial gain and impact the quality of care provided:

  1. The MA system does not currently require the individual providing services to be identified on the claim submitted for payment.
  2. MA claims submitted for payment do not require specific date and time information before payment is made.
  3. The individuals providing these services lack the knowledge and training to provide quality care and to properly bill for those services.

The Grand Jury heard evidence from six cases that illustrate these deficiencies in the system. In one case, an individual who was simultaneously working for three behavioral health agencies and as a substitute special education teacher would submit timesheets claiming she was providing services which overlapped with each other and/or her work as a teacher. The Grand Jury concluded that her fraud would have been caught sooner if there had been a mandate that the claims identify her as the individual providing the services and include specific dates and times of the services.
In a second case, a mother of a daughter with autism was directing her daughter’s caregivers to provide unauthorized services such as painting the house, feeding the dog, and running household errands. She was also instructing the workers to report their services incorrectly and falsely reporting that her husband and son provided services. The Grand Jury concluded that if the program had a standardized training module, the workers would have been able to identify that they were being required to document their services improperly and that the tasks assigned to them were not authorized. They would have also been more informed about how to report these violations.

The Grand Jury provided the three following recommendations to address these deficiencies. The Grand Jury asserted its belief that these recommendations will assist DHS in carrying out its mission and will provide the MFCS with the tools it needs to effectively combat fraud, resulting in increased criminal convictions and recoveries:

  1. State Provider Identifier (SPI): The legislature should enact a statute mandating that any individual seeking to provide services paid for, in whole or in part, with MA funds who does not have a National Provider Identifier (NPI) be required to register with the Commonwealth of Pennsylvania and obtain a SPI prior to the performance of said services. The legislation should mandate that every claim for MA services identify the actual individual providing the services by requiring that the providing individual’s NPI or SPI be placed on every claim.
  2. Date and Time Specificity: The legislature should enact a statute mandating that every claim for MA services document every date that a service was provided as well as the start and end times for each date of service.
  3. Standardized Training: The legislature should require that DHS establish and mandate standardized training for all persons providing services utilizing SPI. The standardized training should be specific to the type of services being provided and focus on the required level of care the recipient is to receive and what services are appropriately billable under that program. The training should also provide information on how to contact Protective Services and where to report fraud within the MA program.  The standardized training for each specific type of service must be completed prior to providing services.

“Working with our partners in Governor Wolf’s Department of Human Services, we’re dedicated to doing everything in our power to ensure that the Medical Assistance Program runs as effectively as possible and minimize its vulnerability to fraud,” said Attorney General Shapiro. “I am grateful for the work of the Grand Jury to develop comprehensive, manageable recommendations for how to identify and prevent fraud in the program. These recommendations will make it easier for law enforcement to protect Pennsylvanians and for DHS to make sure people are getting the care they need.”

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The Pennsylvania Department of Labor & Industry’s (L&I) has reached out to RCPA in response to our letter last summer requesting an extension for the regulatory public comment period on the white collar overtime exemptions from Pennsylvania’s Minimum Wage Act. L&I has received numerous comments from stakeholders indicating that there is a lot of interest in the proposed rulemaking regarding the overtime exemptions.

As a result, L&I has contacted RCPA to determine if there is member interest in roundtable education and discussions on the white collar exemptions. L&I wants the opportunity to engage employers and affected organizations in a frank discussion on the application of these exemptions, and how the department can help employers and organizations comply with the exemptions’ requirements. Some of the public comments received indicated that there is some misinformation surrounding the required factors that would trigger any of the overtime exemptions. L&I stated that they would be open to any constructive suggestions that impacted individuals and groups may have in moving forward with modifications to the existing proposal.

L&I is in the process of setting up stakeholder outreach meetings in mid to late May and early June in five locations across the state:

  • Pittsburgh – Wednesday, May 15
  • Erie – Thursday, May 16
  • Harrisburg – Wednesday, May 22
  • Philadelphia region – Wednesday, May 29
  • Scranton region – Wednesday, June 5

While the above dates are tentative, they will be confirmed later this month. If your organization would like to attend one of these meetings, please send your request to Jack Phillips, RCPA’s Director of Government Affairs, by Thursday, April 25.

L&I has requested that participants come prepared with questions about the exemptions, as well as comments on how they believe exemptions may impact their operations. L&I has asked for no more than 15 participants at each session; this will allow them to hear from and engage with each individual and the organization they represent. Thank you in advance for your participation and cooperation. Please forward questions to RCPA Director of Government Affairs Jack Phillips.

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(Source: Buchanan, Ingersoll and Rooney, PC, Daily Health Care Daily Roundup, April 3, 2019)

Following House passage last week, the Senate passed, by voice vote, the Medicaid Services Investment and Accountability Act of 2019 (H.R. 1839), legislation that includes short-term extensions of several Medicaid programs such as the Money Follows the Person Program – which helps transition individuals with chronic conditions and disabilities from institutions back into their local communities to get care – and the Community Mental Health Services Demonstration Program, which allows community providers to expand access to treatment for mental and behavioral health. Specifically, the bill provides $20 million in additional grant funds for the Money Follows the Person Program and extend the Community Mental Health Services Demonstration Program through June 30, 2019, or for two years, whichever is longer. In addition, the bill:

  • Includes provisions of the Right Rebate Act, which allows the Secretary of Health and Human Services to require drug manufacturers to reclassify their drugs and impose civil monetary penalties when drugs are knowingly misclassified in the Medicaid Drug Rebate Program (MDRP);
  • Increases the number of days (from 90 to 100) that a state may delay payments in Medicaid to providers for medical services provided to a child with a medical support order; and
  • Extends states’ flexibility to disregard individuals’ spousal income and assets when determining eligibility for home and community-based services and supports through September 30, 2019.

Finally, the bill includes provisions of the Advancing Care for Exceptional (ACE) Kids Act that creates a state option to establish health homes for children with medically complex conditions, as well as provide two quarters of enhanced federal matching funds for states’ payments to health homes. The bill now heads to the President for his signature.

Questions, please contact Jack Phillips, Director of Government Affairs.

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By Amy Goldstein, MSN News

A federal judge in Washington threw a significant roadblock into the Trump administration’s efforts to require poor people on Medicaid to be compelled to work in exchange for health benefits, rejecting a Kentucky program for a second time while saying that rules in effect in Arkansas “cannot stand.”

The twinned opinions, in a pair of states that have been national leaders in the move towards Medicaid work requirements, cast doubt on the Trump administration’s approvals of efforts to re-envision the public insurance program. The opinions undo the permission the U.S. Health and Human Services Department had given those two states, telling the agency it must reconsider their applications with an eye towards the effect on poor people who depend on the coverage… Read full article here.

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This alert contains information from both the National Council for Behavioral Health and the American Medical Rehabilitation Providers Association (AMRPA).

On Monday, President Trump unveiled his Fiscal Year (FY) 2020 budget request — calling for a $4.7 trillion decrease in federal spending and detailing his Administration’s priorities for next year. The document revives efforts to block grant Medicaid and restrict eligibility, maintains spending to combat opioid addiction, and outlines other major health care priorities. As with most presidential budgets, this proposal stands little chance of being enacted into law as written. Instead, the President’s budget proposal will act more as a messaging tool to Congress, which is currently working to develop and pass a budget for FY 2020 over the next few months.

It is important to note that it is the role of Congress, not the President, to design and pass the federal budget. As with the President’s previous two budgets, this year’s ambitious spending cuts are unlikely to gain traction in Congress. Regardless, they present a starting point for the budget and appropriations processes and outline President Trump’s priorities as he navigates a divided Congress. It remains to be seen if any of the President’s recommendations (detailed below) will be taken up by Congressional appropriators as they move through the budget process.

Among the highlights of the President’s budget request for the Health and Human Services Department (HHS) for FY 2020:

Medicaid – Particularly notable among Medicaid proposals in the President’s budget are a requirement for all states to institute work requirements as a condition of enrollment and to eliminate the Medicaid expansion contained in the ACA. Earlier Kaiser Family Foundation estimates have found that a nationwide rollout of Medicaid work requirements could cost between 1.4 and 4 million individuals their health care coverage. Furthermore, the budget calls for Medicaid spending to be redirected into block grants or for per-capita caps to be imposed.

Although Congressional Republicans and the Administration have previously proposed to convert the Medicaid program to block grants through Graham-Cassidy and similar legislation, the Administration has recently given indications that it could attempt to implement block grants for some states through 1115 waiver authority. The budget also calls once again for passing legislation similar to the Graham-Cassidy bill, however, the chances for legislation that would make major changes to Medicaid and/or the Affordable Care Act passing the Democratic-controlled House are nonexistent.

Opioid Crisis — The budget would keep funding for a response to the opioid epidemic relatively flat. The Administration calls for the continuation of the $1.5 billion in State Opioid Response (SOR) grants, the same amount as FY 2019. The budget also asks for $1 billion for the NIH’s opioid and pain research programs, to set minimum standards for drug utilization review (DUR) programs, and $221 million to support and grow the behavioral health workforce. Of the funding to support the behavioral health workforce, $4 million would be set aside to train providers to prescribe medication-assisted treatment (MAT) for opioid use disorders. Additionally, the Administration proposes to continue funding Substance Abuse Prevention and Treatment block grants at $1.85 billion.

ONDCP – Trump’s fiscal 2020 budget blueprint for the third year in a row proposes slashing the White House’s Office of National Drug Control Policy’s (ONDCP) budget by more than 95 percent by moving the office’s two major grant programs into other federal agencies. The $100 million Drug Free Communities program would be folded into the Substance Abuse and Mental Health Services Administration (SAMHSA) while the $254 million High Intensity Drug Trafficking Areas grant would be transferred to the Department of Justice.

Mental Health — The President’s budget calls for $723 million (a $13 million increase) for the Community Mental Health Services Block Grant and $150 million for Children’s Mental Health Services, all level funding from FY 2019. Importantly, the President once again endorsed Certified Community Behavioral Health Clinics (CCBHC) model to care for people with serious mental illness and addiction, calling for level funding for CCBHC expansion grants at $125 million. In response to the Parkland school shooting, the budget also includes $133 million for school violence prevention efforts, which include school safety programs as well as trainings within schools for school personnel to better recognize the signs and symptoms of mental illness in students, such as Mental Health First Aid.

In total, SAMHSA sees its budget reduced by $62 million to $5.5 billion total. Some of that savings comes from regional substance abuse prevention and treatment programs and programs that provide advocacy for individuals with mental illnesses. Notably, the proposal eliminates the Primary and Behavioral Health Care Integration grants, a program that supports providers in implementing integrated care. The National Council will advocate for continued funding of this important program that improves care for individuals with co-occurring behavioral and physical health conditions.

NIH Funding — The budget rolls out the President’s initiative to end the HIV epidemic, a hallmark of his 2019 State of the Union address. HHS would receive $291 million for the initiative, including $140 million to the CDC for diagnosis and testing. The NIH would see an overall budget cut of approximately $5.5 billion.

Post-acute care providers – Unified PAC Payment System. The Budget proposes to “address excessive payment for post-acute care providers by establishing a unified payment system based on patients’ clinical needs rather than the site of care.” The Budget table shows savings from the reform beginning in FY 2020. The HHS Budget-in-Brief explains that the proposal will provide lower annual Medicare payment updates to SNFs, HHAs, and IRFs beginning in FY 2020 through FY 2024. In FY 2025, HHS would implement a unified post-acute care payment system for SNFs, HHAs, IRFs, and LTCHs. The payment rates would be budget neutral in FY 2025, risk adjusted, and established prospectively annually. According to HHS, the episode grouping and pricing would be based on the average cost for providing post-acute care services for a diagnosis, similar to the DRG methodology for inpatient hospitals. The proposal provides the Secretary with authority to adjust payments based on quality of care, geographic differences in labor and other costs, as well as other factors as determined appropriate.

Additional details on the President’s HHS budget request are outlined in the Department’s budget-in-brief document.

Questions, contact RCPA Director of Government Affairs Jack Phillips.

(From DHS Secretary Miller)

Effective March 25, Valerie Vicari is serving as Acting Deputy Secretary for the Office of Mental Health and Substance Abuse Services (OMHSAS). I would like to thank Lynn Kovich for her service to OMHSAS and Pennsylvania.

Valerie has been working in the ever-evolving human service field for over 25 years.  Her work has included experience in the children and youth service system and the behavioral health service system, both drug and alcohol services as well as mental health services.  Her various roles have included direct service, case management, county administration, and Commonwealth administration.  Valerie has been a leader within the behavioral health arena since the inception of the Medicaid Behavioral Health HealthChoices program in 2008.  She was part of the Office of Mental Health and Substance Abuse Services team that brought innovative behavioral health community programming to Pennsylvania.  Some examples of service development include telepsychiatry, Certified Peer Specialist (CPS) programs, Long Term Structured Rehabilitation programs (LTSR), and Assertive Community Treatment (ACT) teams.  As services evolved, telepsychiatry, CPS and ACT programming expanded to include individuals who have both behavioral health issues as well as forensic involvement.

Valerie’s most recent position has been the Chief Executive Officer at Torrance State Hospital since June 2016.  The oversight responsibilities include but are not limited to the civil psychiatric services, the Regional Forensic Psychiatric Center (RFPC) and the Sexual Responsibility Treatment Program (SRTP).  There are over 300 patients served at Torrance State Hospital on an ongoing basis.  In her leadership role at Torrance the hospital has become tobacco free, telepsychiatry has been developed within the forensic unit and numerous recovery focused initiatives have commenced.

People are complex, and their overall health is shaped by a variety of factors, many of which may not be visible or evident based on a conversation. We must equally focus on behavioral health and physical health and their interconnected nature in order to truly help the people we serve. Our mental and physical health do not exist in isolation, and both are influenced by the external circumstances in a person’s life.

You may know that we are working to improve care for Pennsylvanians by encouraging a whole-person focus that includes social determinants of health as well as physical and behavioral health needs. We want to encourage our physical and behavioral health providers and social service providers to work together to ensure that people do not slip through the cracks so we’re able to make a meaningful difference in their lives. Your work can help us move towards better long-term health outcomes for Pennsylvanians who use our services, and I am excited to partner with each of you to meet this goal.

On behalf of Governor Wolf, we are grateful to your commitment to the commonwealth and people affected by mental health and substance use disorders. Thank you for the work you do to elevate these issues and help people live better lives every day.

Thank you,

Secretary Teresa Miller

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(From DHS news room)

Wolf Administration: Trump-Proposed Cuts to Federal Health Programs Jeopardize Access to Life-Saving Health Care

Harrisburg, PA – The Wolf Administration today spoke out against potential cuts contained in President Trump’s proposed federal budget, which would significantly change Medicare, Medicaid, and the Affordable Care Act. In total, these programs help more than 5.5 million older, working, and low-income Pennsylvanians access routine and life-saving health care.

Under President Trump’s proposed budget, Medicaid expansion, which currently covers nearly 700,000 Pennsylvanians, would be eliminated. Medicaid would also be converted from an entitlement program that provides coverage to all who are eligible to block grant allocated to states based on a per-person funding cap.

“Medicaid allows more than 2.8 million Pennsylvanians to access health care coverage that would otherwise be unaffordable or inaccessible. Changing the program to a block grant system and eliminating the Medicaid expansion would result in significant losses of coverage and more people being unable to access the care they need to stay healthy,” said Human Services Secretary Teresa Miller.

The federal budget also proposes a nationwide work requirement for able-bodied, working-age Medicaid recipients, requiring them to find work, train for work, or volunteer in order to maintain coverage. This requirement would be similar to what is in place for Temporary Assistance for Needy Families (TANF) recipients, a program the Wolf Administration is currently redesigning to address barriers to employment and encourage better long-term employment outcomes for TANF recipients.

“A work requirement doesn’t get a person a job — let alone a family sustaining job. It jeopardizes their access to health care and other essential needs, and without the investment needed to assist them to address the factors that can hold them back, they continue to be stuck in a cycle of poverty and poor health,” said Secretary Miller. “Governor Wolf is redesigning Pennsylvania’s employment and training programs to better address the barriers that prevent people from obtaining family-sustaining jobs. The federal government should follow this work rather than creating another barrier to good health.”

The President’s proposed budget also encourages implementing the ACA replacement proposed by Senators Bill Cassidy and Lindsey Graham, which would end protections against inflated pricing for older consumers, tax credits for plans purchased through the health insurance exchange, and essential health benefits, among others. The plan was previously called a step backwards by the Wolf Administration in 2017.

“Pennsylvania’s uninsured rate is at an all-time low of just 5.5 percent, down from more than double digits before the Affordable Care Act took effect. Governor Wolf and I continue to strive to ensure all Pennsylvanians have access to coverage that is both affordable and comprehensive. Unfortunately, this budget would move in the opposite direction,” Insurance Commissioner Jessica Altman said. “We need to build upon the progress we have made, and not look to policies like those contained in President Trump’s budget proposal that could jeopardize the coverage gains we have made and the health care programs millions of Pennsylvanians rely on.”

Commissioner Altman noted for 2019, the aggregate statewide premium for individual ACA plans fell by 2.3 percent, a new insurer entered the state, and consumers in 30 counties had more options than in 2018, all indicating Pennsylvania’s individual health insurance market is moving toward stabilization.

“Under the Older Americans Act, the Department of Aging is responsible for serving as a visible and effective advocate on behalf of older Pennsylvanians,” said Acting Secretary of Aging Robert Torres. “President Trump’s proposed budget is the antithesis of what our seniors need and deserve.”

The budget proposes a 20% decrease in funding to the National Family Caregiver Support Program, a 26% percent decrease in funding to the State Health Insurance Assistance Program, and the elimination of funding for the Senior Community Services Employment Program and Elder Falls Prevention.

The administration called on President Trump and Congress to work together on federal health plans that break down barriers to work without jeopardizing vulnerable Pennsylvanians’ access to health care.

“Although this proposal is unlikely to pass Congress in this form, the spirit of this proposed budget still presents a cruel agenda that would jeopardize access to quality health care, making it more difficult for millions of Pennsylvanians,” said Secretary Miller. “Medicaid, Medicare, and the Affordable Care Act are lifelines, and the federal government must recognize the important role they play in many lives and strengthen these programs so they may continue to help people live healthy, productive lives for years to come.”

MEDIA CONTACT:   Ali Fogarty – 717.425.7606
Ron Ruman, PID – 717.787.3289
Drew Wilburne, Aging – 717.705.3702

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RCPA will be monitoring the federal budget in conjunction with our national associations and will inform members about any important updates. Further questions may be directed to Jack Phillips.