Category Archives: North Dakota Medicaid
All Medicare/Caid Health Care Professionals: Start Contracting with Qualified Translators to Comply with Section 1557 of the ACA!!
Being a health care professional who accepts Medicare and/ or Medicaid can sometimes feel like you are Sisyphus pushing the massive boulder up a hill, only to watch it roll down, over and over, with the same sequence continuing for eternity. Similarly, sometimes it can feel as though the government is the princess sleeping on 20 mattresses and you are the pea that is so small and insignificant, yet so annoying and disruptive to her sleep.
Well, effective immediately – that boulder has enlarged. And the princess has become even more sensitive.
On May 18, 2016, the Department of Health and Human Services (HHS) published a Final Rule to implement Section 1557 of the Affordable Care Act (ACA). Section 1557 of the ACA has been on the books since the ACA’s inception in 2010. However, not until 6 years later, did HSD finally implement regulations regarding Section 1557. 81 Fed. Reg. 31376.
The Final Rule became effective July 18, 2016. You are expected to be compliant with the rule’s notice requirements, specifically the posting of a nondiscrimination notice and statement and taglines within 90 days of the Final Rule – October 16, 2016. So you better giddy-up!!
First, what is Section 1557?
Section 1557 of the ACA provides that an individual shall not, on the basis of race, color, national origin, sex, age, or disability, be
- excluded from participation in,
- denied the benefits of, or
- subjected to discrimination under
all health programs and activities that receive federal financial assistance through HHS, including Medicaid, most Medicare, student health plans, Basic Health Program, and CHIP funds; meaningful use payments (which sunset in 2018); the advance premium tax credits; and many other programs.
Section 1557 is extremely broad in scope. Because it is a federal regulation, it applies to all states and health care providers in all specialties, regardless the size of the practice and regardless the percentage of Medicare/caid the agency accepts.
HHS estimates that Section 1557 applies to approximately 900,000 physicians. HHS also estimates that the rule will cover 133,343 facilities, such as hospitals, home health agencies and nursing homes; 445,657 clinical laboratories; 1300 community health centers; 40 health professional training programs; Medicaid agencies in each state; and, at least, 180 insurers that offer qualified health plans.
So now that we understand Section 1557 is already effective and that it applies to almost all health care providers who accept Medicare/caid, what exactly is the burden placed on the providers? Not discriminating does not seem so hard a burden.
Section 1557 requires much more than simply not discriminating against your clients.
Section 1557 mandates that you will provide appropriate aids and services without charge and in a timely manner, including qualified interpreters, for people with disabilities and that you will provide language assistance including translated documents and oral interpretation free of charge and in a timely manner.
In other words, you have to provide written materials to your clients in their spoken language. To ease the burden of translating materials, you can find a sample notice and taglines for 64 languages on HHS’ website. See here. The other requirement is that you provide, for no cost to the client, a translator in a timely manner for your client’s spoken language.
In other words, you must have qualified translators “on call” for the most common 15, non-English languages in your state. You cannot rely on friends, family, or staff. You also cannot allow the child of your client to act as the interpreter. The clients in need of the interpreters are not expected to provide their own translators – the burden is on the provider. The language assistance must be provided in a “timely manner. “Further, these “on call” translators must be “qualified,” as defined by the ACA.
I remember an English teacher in high school telling the class that there were two languages in North Carolina: English and bad English. Even if that were true back in 19XX, it is not true now.
Here is a chart depicting the number of non-English speakers in North Carolina in 1980 versus 2009-2011:
As you can see, North Carolina has become infinitely more diverse in the last three decades.
And translators aren’t free. According to Costhelper Small Business,
It seems likely that telehealth may be the best option for health care providers considering the cost of in-person translations. Of course, you need to calculate the cost of the telehealth equipment and the savings you project over time to determine whether the investment in telehealth equipment is financially smart.
In addition to agencies having access to qualified translators, agencies with over 15 employees must designate a single employee who will be responsible for Section 1557 compliance and to adopt a grievance procedure for clients. Sometimes this may mean hiring a new employee to comply.
The Office of Civil Rights (“OCR”) at HHS is the enforcer of Section 1557. OCR has been enforcing Section 1557 since its inception in 2010 – to an extent.
However, expect a whole new policing of Section 1557 now that we have the Final Rule from HHS.
Compelling Personal Care Workers to Pay Union Dues Violates Our Freedom of Speech: But I Still Have to Pay My HOA Dues!
I live in a community that requires homeowner association monthly dues. We have a homeowner association (HOA). More than once I have complained at the high cost of these monthly dues and the absurd endeavors on which our HOA spends my money. For example, we had a beautiful, clay tennis court. If you have ever played tennis on a clay court, you know how wonderful it is to play on clay. Clay tennis courts are also expensive to build. A few years ago, my HOA decided to turn the clay tennis courts into a gardening center. In place of the tennis nets, they built 10-12 raised beds to which the homeowners could purchase rights to use. Somehow, my HOA determined the clay tennis court would be better used as a place to hold raised beds instead of playing tennis.
Despite my intense disapproval of this decision, I was forced to continue to pay my HOA dues, and a part of my HOA dues was spent on the conversion from tennis court to garden center.
Not completely dissimilar, in many states, public sector workers are required to contribute to union dues, even if they disagree with the union’s actions. In-home care workers are considered public sector workers in Illinois because they care for the disabled and elderly and accept Medicaid money. Including Illinois, 19 states allow bargaining agreements for home care workers.
Last week the Supreme Court sent shockwaves to the 19 states that allow bargaining agreements with home care workers. The Supreme Court held that Illinois cannot compel personal care workers to pay union dues.
You may be asking yourself, why is Knicole blogging about an Illinois lawsuit and union dues. How in the world does this affect North Carolina health care providers who accept Medicare and Medicaid?
The narrow answer would be that the case has no effect whatsoever on NC health care providers. Unlike Illinois, North Carolina does not allow public sector bargaining. In fact, in NC, union contracts, or bargaining contracts for public sector employees are considered “illegal, unlawful, void and of no effect.” N.C. Gen. Stat. 95-98.
A broader view, on the other hand, is to understand that increases or decreases in personal care wages, better or worse benefits provided to personal care workers, and the overall profit or loss of personal care workers across the country, is relevant to NC personal care workers, and I prefer this broader view.
In the Supreme Court case, Harris, et al v. Quinn, Justice Alito wrote that compelling public sector workers to compensate a third party to “speak” for them, even if the worker disagrees with the third party’s speech violates the First Amendment.
In the Supreme Court opinion, Justice Alito writes:
“If we accepted Illinois’ argument, we would approve an unprecedented violation of the bedrock principle that, except perhaps in the rarest of circumstances, no person in this country may be compelled to subsidize speech by a third party that he or she does not wish to support.”
Individual states determine labor laws related to government employees. As previously stated, NC bans bargaining agreements. Virginia does as well.
In states that do allow bargaining agreements, if workers did not want to participate in the bargaining unit, the worker would opt out of full dues and pay only the cost of grievance administration and collective bargaining. Supposedly, this prevents the nonmembers, who benefit from the reward of collectively-bargained higher wages or better benefits, from reaping the benefits without paying for them. The whole “free-ride” idea…
In Illinois, Service Employees International Union (SEIU), a bargaining unit, argued that personal care workers should be compelled to contribute to it because personal care workers are public sector workers.
SEIU claims that it gets higher pay and better benefits for personal care workers. Approximately 1 million of the 3 million personal care workers nationwide are members of SEIU or other similar organizations.
However, the Supreme Court disagrees. According to the Harris decision, I shouldn’t have to pay for HOA dues if I disagree with the HOA’s actions (I’m kidding. Sadly, I have no case to cease paying my HOA dues).
Proponents of unions are not happy with the results, but let’s play out a hypothetical…what if the Supreme Court held that public sector workers were required to pay union dues, even against their will….
Because, think about it…the government cannot prevent us from contributing to political candidates nor can the candidate force you to contribute to a political campaign. Upholding the freedom of speech is not necessarily anti-union. The Supreme Court did not rule “against” unions per se. It ruled that a bargaining unit is “bargaining for” or “speaking for” its members. And you cannot be forced to pay for speech with which you disagree.
Free speech allows all of us to individually decide which principles to support. Allowing personal care workers to choose not to support certain ideologies is not an attack on collective bargaining. Rather, it ensures that the free choices of personal care workers are represented by any union entity, rather than union leaders benefiting from coerced fees.
While the Harris decision does not apply to me and my HOA dues for many reasons, including the fact that I chose to live in the community knowing that the HOA existed, the Harris decision does have possible broad ramifications, especially as to in-home care workers and other public sector workers. It may mean that the 1 million in-home care workers now compelled to contribute to unions may have standing to stop if they so choose.
NC is #1 in USA!! (For Highest Percentage Increase in Total Medicaid Spending)…and What About the Rest of the USA?
On October 21, 2013, the magazine Modern Healthcare published an article, “Medicaid budgets By State,” which showed each state’s total Medicaid spent in 2012, total number of Medicaid enrollees in 2012, and average spending per enrollee in 2012.
Where does North Carolina rank in terms of our Medicaid budget versus other states? We hear constantly that we spend all this needless money on administrative costs of Medicaid. But, in terms of our Medicaid budget, where do we rank? And my next question…do we simply have more Medicaid recipients in NC in relation to other states? Is NC’s average spending per Medicaid enrollee grossly higher or lower than the national average?
Inquiring minds want to know!
Surprisingly, at least to me, Alaska has the highest average spending per Medicaid enrollee: $13,073, on average, per enrollee. But then I thought about, much of Alaska is rural…not only rural , but almost impossible to navigate due to the snow and ice. I don’t know for sure, but I would imagine that getting to and from Medicaid recipients or getting recipients to services (while not always reimbursed by Medicaid) must impact some of the costs.
[Important to note: The average spending per enrollee, to my knowledge, does not mean actual money spent per enrollee. I believe the authors took the total budget and divided it by the number of enrollees. So the average spent per enrollee includes built-in, administrative costs.]
Or…Maybe Alaska has a low number of Medicaid recipients and that is why Alaska spends the most per enrollee…maybe Alaska has a huge Medicaid budget without many recipients on which to spend it…few people, big pie…
Alaska had, in 2012, 109,000 Medicaid recipients.
The fewer people you have at Thanksgiving, the bigger the pie pieces. However, interestingly enough, Alaska spent $1.425 million total in Medicaid in 2012. Delaware spent $1.421 in Medicaid in 2012. (Close enough, right?). Yet, Delaware spent $6831, on average, per enrollee. Maybe the pie analogy doesn’t work. Maybe sometimes, even with a big pie and few people, too many rats and ants nibble at the pie.
Out of 50 states, where do you think NC falls? Top 10 highest spender? Bottom 10? Right in the middle?
The only 8 states that spend more than NC per Medicaid recipient are:
2. New Jersey (somehow that did not surprise me) ($11,433/recipient)
3. Rhode Island (that did surprise me…I mean, look how little RI is…how big a Medicaid budget can it have?) ($11,080/recipient)
4. North Dakota (a less populous state (less tax dollars), I believe) ($10,969/recipient)
5. Pennsylvania ($10,835/recipient)
6. Minnesota (there are big cities there (more tax dollars), no surprise) ($10,080/recipient)
7. Missouri (I went to law school in Missouri. This number surprised me a bit). ($10,022/recipient)
8. Connecticut ($9883/recipient)
9. NC ($9,430/recipient)
Crazy! What about Illinois? With the hugely populous, Windy City and it being Obama’s home state, surely, Medicaid spending per recipient is, at least, in the middle, right?
Wrong. Illinois is dead last with only $5229, on average, per recipient being spent.
Probably because too many people were invited to Thanksgiving…in 2012, Illinois had 2.626 million Medicaid recipients enrolled….or too many rats and ants.
Compare to NC in 2012 – 1.471 million Medicaid recipients.
What was Alaska’s Medicaid budget/spending in 2012 that the average spending per enrollee was $13,073?
$1.425 million spent. Up 10.3% from 2011. And 109,000 Medicaid enrollees.
Here is NC:
Spending: $13.872 million. Up 22.8% from 2011. And 1.471 million recipients.
Here is a crazy one..Nevada:
In 2012, Nevada had 301,000 Medicaid enrollees. A little under 3x Alaska. Nevada spent $1.692 million on Medicaid (only 200,000-ish over Alaska), but Nevada’s average spending per enrollee was $5,621 (less than half of Alaska and the third lowest amount spent per enrollee). Where did all Nevada’s Medicaid money go?? Rats and ants eating away the pie?
North Dakota has the very least number of Medicaid enrollees in 2012…66,000. Wyoming is a close second with only 67,000 Medicaid enrollees in 2012.
North Dakota was the 4th highest state as to spending per enrollee with an average of $10,969/enrollee.
Wyoming was the 16th highest state as to spending per enrollee with an average of $8537/enrollee.
Guess which state had the highest total spending on Medicaid in 2012?
California. (Shocker!). California spent $47.726 million on Medicaid, up 4.2% from 2011. California also had the highest number of enrollees on 2012 with 2.624 million enrollees (over a million more than NC). California also spent the 5th lowest on average per enrollee, $6,065.
Having a high number of enrollees did not always have a direct correlation with spending the least, on average, per enrollee. Oregon only had 569,000 Medicaid enrollees in 2012 and spent the 4th lowest amount, on average, per enrollee, $6,007.
New York is the closest state to spending and number of recipients to California, but New York succeeded in a much higher average spending per enrollee than California.
New York spent $39.257 million total on Medicaid (less than $8 million difference from California) in 2012. New York had 5.004 million enrollees (2.8 million Medicaid enrollees less than California) and spent, on average, $7845/enrollee (absolute, dead-on-middle as compared to all states).
Georgia is, perhaps, the most comparable to North Carolina in terms of number of Medicaid enrollees in 2012. NC = 1.471 million enrollees in 2012. GA = 1.529 enrollees in 2012.
NC spent $13.872 million, while Georgia spent $8.497 million in 2012. So, Georgia had MORE Medicaid enrollees and spent over $5 million less……
Is that good or bad? Is Georgia more efficient? Did Georgia spend less in administration costs?
Actually (albeit there may be other factors), Georgia spent significantly less, on average, on each Medicaid enrollee.
Georgia spent 2nd lowest, on average, per Medicaid enrollee. Only Illinois surpassed Georgia in lowest spending, on average, per enrollee. Georgia spent, on average, $5,229 per enrollee.
NC spent $9430, on average, per enrollee. (Which, BTW, is more than enough for my “A Modest Proposal”).
That is a huge difference!
One other number jumped out at me when I reviewed Modern Healthcare‘s article, “Medicaid Budgets By State.” Remember I told you that NC spent $13.872 million on Medicaid in 2012…and that the amount spent was a 22.8% increase from 2011?
22.8% is a high percentage to increase in only one year!
I looked at the increases/decreases of the states. North Carolina gets the award for the highest percentage growth in spending on Medicaid in the entire nation. NC was the only state whose percentage “increase of Medicaid spending” percentage from 2011 to 2012 was in the 20s.
NC is #1 in the nation for percentage increase as to total Medicaid spending!!!! (Proud?)
The next state with the highest increase in spending on Medicaid is Mississippi with a 17.4% increase in spending from 2011. Next in line is Alabama with a 14.7% increase in Medicaid spending.
Guess which states decreased its Medicaid spending the most from 2011 to 2012?
Oregon (decrease of 23.2% spending) and Illinois (decrease of 15% spending). Is it coincidental that Illinois spent the absolute least, on average, per Medicaid recipient and that Oregon spent the 4th lowest, on average, per Medicaid recipient?
Regardless the size of the pie, the number of guests, and the number of rats and ants, we need to make sure that the guests (Medicaid recipients) are benefitting most from the pie.
Sometimes a decrease in spending equals a decrease in services to Medicaid recipients…sometimes not…I guess it depends on the number of rats and ants.