The School-Based Health Alliance is announcing a new learning collaborative focused on school-based health center (SBHC) start-up. This initiative aims to support partnerships between healthcare organizations and schools to provide or expand access to primary care and behavioral health services in schools. Throughout the learning collaborative, participating teams will: learn about the core competencies for SBHCs and practices to support SBHC sustainability, identify areas of strength and areas for growth, and identify action steps for strengthening partnerships, improving sustainability, and maintaining high-quality care. The learning collaborative will meet on select Tuesdays between Jan. and March 2024. Continuing education credits will be offered. For more information, see the program description. To apply, please complete the application form online. Applications are due Nov. 16, 2023. For any questions, contact Emily Baldi and Shameka Davis.

The Health Resources and Services Administration (HRSA) will host a Virtual Job Fair for rural health centers and clinics on November 16, 2023, from 6:00 – 9:00 p.m. Sign up here to receive notifications from the HRSA Virtual Job Fairs Team. Registering for this event does not guarantee a spot in the event. Selection is based on several criteria including: rural site designation; number of vacancies (note vacancies cannot expire prior to the event); HPSA score; and region across the country.

A new Spotlight PA analysis of opioid settlement payments shows which Pennsylvania counties are receiving the most money per resident to help them respond to an epidemic that continues to kill thousands of people each year in the state.

Key representatives from the Pennsylvania Department of Human Services (DHS) joined Pennsylvania’s community of Community Health Centers during last week’s 2023 PACHC Annual Conference and Clinical Summit. Here are some of the key takeaways from the session:

•  MATERNAL HEALTH.
  • This is a key priority of DHS Secretary Arkoosh and the Shapiro Administration. Some of the ways the administration is supporting improvements in outcomes include: Maternal Medicaid coverage extends to 12 months postpartum; HealthChoices managed care organizations (MCOs) will reimburse for home visits for the first 18 months of a baby’s life; DHS is requiring MCOs to have value-based care maternity teams and is providing incentives for closing equity gaps in prenatal and postpartum care; and DHS is working with the Pennsylvania Doula Commission toward statewide certification and doula enrollment in Medical Assistance; DHS is working to find solutions for the commonwealth’s “maternal deserts.” DHS noted that they are unable to enroll doulas as a Medicaid provider until there are enough certified doulas to ensure statewide network adequacy.
• MANAGED CARE ORGANIZATION (MCO) CREDENTIALING.
  • The 2024 HealthChoices MCO agreements will include a requirement that MCOs pay retroactive to the date of submission of a complete credentialing application.* DHS is also working with the MCOs on options to streamline credentialing processes while maintaining compliance with NCQA standards. *NOTE: Although the DHS Office of Medical Assistance Programs (OMAP) has shared this policy change with the DHS Office of Mental Health & Substance Abuse Services (OMHSAS), OMAP does not know at this time whether OMHSAS will align their policy for behavioral health MCOs with OMAP policy for physical HealthChoices MCOs.

• DENTAL PRODUCTIVITY.
  • DHS has been working with the Budget Office to discuss funding needed to implement one of the two previously submitted PACHC recommendations. Those recommendations included the elimination of dental hygienist productivity in the calculation of PPS rates OR the elimination of separate productivity thresholds for hygienists and dentists in favor of a combined productivity standard. Both recommendations have a significant financial impact that are not currently included in the approved 2023-2024 state budget. PACHC will share more information when DHS announces a decision.
• QUARTERLY MCO WRAPAROUND REPORTS.
  • It is in the best interest of all health centers to submit quarterly MCO wraparound reports whether or not there is a balance due. The reports help DHS confirm whether MCO are paying correctly, give health centers the opportunity for an advance on MCO reimbursement due to maintaining cash flow until MCO payment is made, and help DHS monitor MCO payment trends. Assessing MCO trends is important for both payments and denials, which you are encouraged to include on your wrap reports. Health centers that prefer not to receive the advance from DHS can simply check a box indicating so when submitting the report. It is possible to bill four T1015 codes per patient per day, but you can only bill and be paid one of each of the following types: medical, dental, BH, and vision per day. Denials should be reported, but only for informational purposes and not as part of the wrap calculation. The wrap reports have moved from Excel templates to an online portal. If you need access to the portal, please contact RA-PWOMAPFQHC-RHC@pa.gov. IMPORTANT: Only claims submitted to MCOs with a T1015 code should be included on MCO wraparound reports.
• HEALTH CENTER AUDITS.
  • The two most frequent issues discovered on audit by DHS’ Bureau of Financial Integrity (BFI) are: 1) including MCO-denied encounters in the encounter count on wraparound reports; and 2) submitting claims not submitted to the payor to DHS for payment.
• BEHAVIORAL HEALTH.
  • It is important to note that FQHC licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs) may ONLY bill for behavioral health (BH) encounters and then only when BH is in scope for the health center.
• GROUP BH THERAPY.
  • Since 2020, DHS has permitted billing at PPS for group therapy. See the bulletin for more information.

• VALUE-BASED PAYMENT.
  • The MCO HealthChoices agreements require the MCOs to discuss conceptual VBP models with any interested FQHCs but do not require FQHCs to enter into these alternative payment methodology discussions. The 2024 HealthChoices agreement will require model implementation if an FQHC so chooses and the Centers for Medicare and Medicaid Services approves. For any VBP model, the PPS rate should remain on the payment floor unless a different agreement is reached between the MCO and the FQHC and approved by CMS.
• 340B.
  • The Centers for Medicare and Medicaid Services (CMS) is working on a process to identify 340B claims under Medicare Part D. In response, DHS has decided to pause its work on this issue for Medicaid managed care until CMS releases its recommendations in the hope that the CMS strategy will align with state strategy.
• STREET MEDICINE.
  • DHS has released a second MA Bulletin adding street medicine as a place of service for certain providers. FQHCs were inadvertently missed from the initial bulletin issued July 2023 but are and have been eligible to offer services outside of the health center to unhomed individuals.
• COVID-19 VACCINE REIMBURSEMENT.
  • DHS is federally required to cover COVID-19 vaccination through Sept. 2024. A vaccine-only visit is reimbursable at $40 per MA Bulletin 01-23-08. DHS is to get back to PACHC on whether the cost of the vaccine is reimbursable above and apart from PPS since the cost of the vaccine ($130-150/dose) is not included in FQHC PPS rate calculations and health centers are struggling with this increased cost of care.
• UPDATED PROMISE HANDBOOK.
  • DHS has a new goal of publishing the updated FQHC/RHC Provider Handbook (Appendix E) by the end of 2023.
• LONG-ACTING REVERSIBLE CONTRACEPTION (LARCs).
  • It has taken longer than DHS anticipated to submit for and get approval from CMS to pay for LARCs outside of the PPS rate. DHS hopes for approval of the state plan amendment (SPA) by early 2024.
• PHARMACISTS.
  • Beginning Jan. 1, 2024, DHS will permit the enrollment of pharmacists in Medical Assistance. PACHC is seeking confirmation that this means they will then be added to the list of providers eligible to generate an FQHC encounter.
• DIETICIANS.
  • DHS also intends to add dieticians to the list of providers eligible to enroll in Medical Assistance. More information will be shared when it is available.

From USA Today

One large health system with hospitals in Virginia and Ohio this year cut off in-network access to consumers enrolled in some Anthem Blue Cross Blue Shield Medicare and Medicaid health insurance plans.

Two doctors groups with Scripps Health in San Diego are terminating contracts with private Medicare plans over concerns about payments and routine denials.

For years, hospitals, doctors and health insurance companies have squared off over how much to pay for medical services. Insurers negotiate contracts with hospitals and doctors so their customers can get lower, in-network rates at those facilities. These negotiations, usually hammered out behind the scenes, are becoming increasingly tense and public as hospitals seek adequate payments and health insurance companies attempt to check spiraling medical bills.

Experts say these disputes could be an early warning sign of more contract terminations ahead as hospitals and large doctor groups seek lucrative payments to offset inflation, healthcare workers’ double-digit raises and escalating prices for medical supplies.

But for patients caught in the middle of these disputes, the results can be devastating. Some need to switch doctors or insurance plans or potentially pay higher, out-of-network rates at a time when half of Americans are struggling to afford the rising cost of medical care.

Scripps Health ended the 2024 Medicare Advantage plan contracts with two medical units, called Scripps Clinic and Scripps Coastal. The decision will affect about 32,000 patients who will either need to switch Medicare plans or find new doctors.

“We’re unfortunately on the vanguard of what I think is going to be a very ugly few years between hospitals and commercial insurance companies,” said Chris Van Gorder, President and CEO, Scripps Health.

Hospitals target private Medicare plans

Many contract terminations involve hospitals rejecting terms for private Medicare insurance plans, known as Medicare Advantage plans. While traditional, government-run Medicare allows enrollees to choose from a wide variety of doctors and hospitals, private Medicare plans restrict access through networks and impose some cost-sharing requirements such as copayments or deductibles.

Hospitals that are rejecting private Medicare plans say they don’t reimburse at the same levels as traditional Medicare, delay or deny care through prior authorizations or impose other limitations.

Van Gorder said Scripps’ Medicare Advantage exit was a “very difficult decision” but one he had to make due to more than $75 million in annual losses. He tried to negotiate more lucrative reimbursement rates, but those talks fizzled.

While private Medicare plans are funded by government-run Medicare, they’re also profitable because insurers keep a portion of those payments before paying for care, he said.

Van Gorder described private Medicare offerings as “delay, deny or don’t pay” plans. “They’re in the business of making money,” he said.

Hospitals cut off insurers that ‘don’t reimburse us adequately’

Doctors groups and hospitals are more willing to air frustrations over private Medicare plans after think tanks and government watchdog agencies have issued critical reports about these insurers’ profits and practices, said David Lipschutz, associate director and senior policy attorney for the Center for Medicare Advocacy.

In 2022, a government watchdog report said private Medicare plans routinely rejected claims that should have been paid and denied services found to be medically necessary. These private plans rejected nearly one in five claims allowed under Medicare coverage rules and denied 13% of authorizations for medical services that government-run Medicare would have allowed, the U.S. Department of Health and Human Services inspector general investigators found.

Doctors and hospitals “are more willing to publicly express their frustration,” Lipschutz said, because these private Medicare plans get what “many people would characterize as overpayments.”

More than a half dozen other hospital systems from Bend, Oregon to Nashville, Tennessee have announced private Medicare contract terminations or lapses.

St. Charles Health System in Bend said it will end Medicare contracts next year with Humana, HealthNet and WellCare.

Mark Hallett, St. Charles’ chief clinical officer, said sticking with those private Medicare plans would “result in restrictions to patient care, longer hospital stays and administrative burdens” for doctors.

As of mid-April, Vanderbilt’s hospitals, clinics and doctors exited the networks of Humana’s HMO Medicare plan and Kentucky Medicaid plan. The hospital advised patients to either shop for a new insurance plan or contact Humana to find an in-network provider.

A Vanderbilt spokesman declined to answer questions about the lapsed contract, referring USA TODAY to the health provider’s website on the dispute. On the website, Vanderbilt cited the need for “fair partnerships” to cover higher costs for workers, supplies, equipment and medications.

“We can’t continue to partner with insurance plans that don’t reimburse us adequately,” Vanderbilt said.

Earlier this year, Bon Secours’ contract dispute with Anthem Blue Cross Blue Shield put tens of thousands of Medicare beneficiaries in Virginia and Medicaid recipients in Ohio out of network. In a lawsuit filed in August, Bon Secours alleged Anthem owed the health provider $93 million in unpaid claims. Last month, Bon Secours dropped the lawsuit as the two sides settled the payment dispute and reinstated in-network access for enrollees.

Despite these recent contract disputes, industry officials representing private Medicare plans say they remain wildly popular with seniors.

More than half of eligible Americans choose private Medicare plans over traditional Medicare because they deliver “better services, better access to care and better value,” said David Allen, a spokesman for America’s Health Insurance Plans, an industry group representing private health insurers.

Allen added private Medicare plans must maintain adequate networks of doctors and hospitals and notify customers when there are significant changes to these networks.

“Medicare Advantage includes robust protections for the people it serves,” Allen said.

Patients caught in the middle

As health providers such as Scripps Health sever ties with some insurers, consumers are confronted with difficult decisions on how and where to get medical care. Some face the prospect of seeking out-of-network care that might cost more.

Seniors in the San Diego area who will be cut off from the two Scripps Health doctors networks are scrambling to assess their options, said Craig Gussin, an insurance broker in Carlsbad.

“People are really upset with Scripps,” Gussin said.

Seniors on Medicare have the option to choose a new plan during Medicare’s annual open enrollment, which runs from mid-October through Dec. 7. Seniors can choose traditional government-run Medicare or switch to a private Medicare Advantage plan.

But some scenarios may catch enrollees off guard.

Traditional Medicare charges 20% coinsurance for medical care with no maximum limit. People on Medicare can purchase a supplemental insurance plan, called MediGap, which largely covers those extra medical bills. However, people can only enroll in MediGap at certain times such as when they turn 65 and initially sign up for Medicare coverage.

If people try to switch from a private Medicare plan to traditional Medicare, they may not be able to purchase this supplemental insurance. MediGap insurers can deny coverage for existing health conditions such as diabetes or heart disease or charge consumers more. Only states such as New York and Connecticut that have “guaranteed issue” laws that allow seniors to sign up for MediGap year-round.

“That trips so many people up,” Lipschutz said.

Gussin has been working long days answering calls from Scripps Health patients who want to know what their options might be. Some are willing to keep their existing private Medicare plan and change primary-care doctors. Others want to switch Medicare insurers.

Private Medicare plans must maintain an adequate network of providers. So if a hospital drops from an insurance plan’s network, that can raise questions about whether the insurance plan has enough in-network providers for enrollees, Lipschutz said.

If more hospitals and doctors drop private Medicare plans, ‘that further begs the question whether in fact that network is adequate,” Lipschutz said.

Medicare allows private insurers to set own rates

While the Centers for Medicare & Medicaid Services oversees private Medicare plans, the federal agency does not become involved in contract disputes.

The federal agency is prohibited from interfering in contract disputes or dictating reimbursement rates that private Medicare plans negotiate with health systems.

CMS evaluates whether contract disputes that terminate in-network coverage “have the potential to affect a large number of the (Medicare Advantage) enrollees,” a CMS spokesperson said.

If these contract terminations “result in significant network changes,” the federal agency can order a special enrollment period to allow beneficiaries to switch plans, the spokesperson said.

The agency said it did not have a number on how many such contract terminations or special enrollment periods are ordered each year.

Some private consultants who advise hospitals and health systems on how to get higher reimbursement from private insurers advise them to terminate contracts as part of a negotiating tactic, even if consumers face higher bills and collection threats.

Brad Gingerich is a vice president at Ensemble Health Partners, which describes itself as a tech-driven revenue cycle management company.

Gingerich said terminating a contract is “your last option” when negotiating with private insurers. Hospitals are adopting harder negotiating tactics with private Medicare plans because that’s where insurers are “making their money and refusing to really work in good faith” with hospitals and doctors.

“We don’t really put ourselves out as the bully on the block,” GIngerich said. “Sometimes you have to take more aggressive ways as a means to that end.

Bristol Myers Squibb has extended 340B contract pharmacy restrictions to all grantees, which affects health centers. They will recognize up to three contract pharmacies (one for Non-IMids, a second for IMiDs, and a third for Camzyos) for each covered entity. Furthermore, Merck, Teva, and Astellas have lifted 340B drug restrictions for all covered entities in Arkansas and Louisiana. Please note that these restrictions still apply to covered entities in other states. NACHC will continue to update their manufacturer restrictions chart as needed.