By Ilene MacDonald, Editorial Director
RISE summarizes recent regulatory-related headlines and reports.
KFF: 16M MEDICAID ENROLLEES HAVE LOST COVERAGE DURING UNWINDING PROCESS
Sixteen million people have been disenrolled from the Medicaid program since the unwinding of the continuous enrollment provision began 10 months ago, according to KFF’s latest analysis of state-level data.
However, KFF said there are reasons to expect disenrollment rates to moderate in the second half of the unwinding as states reduce procedural disenrollments and work through “likely ineligible” populations.
Since the start of the unwinding, Medicaid enrollment has declined by about 10 percent nationally based on the latest available data, with decreases in every state, ranging from 32 percent in Idaho to one percent in Maine. Two states—South Dakota and North Carolina—expanded Medicaid in 2023, which should limit enrollment declines in those states.
Implementation of 12-month continuous coverage for children and postpartum individuals, as well as extended multi-year continuous eligibility for children in some states, could help to stabilize coverage after the unwinding.
HOME HEALTH OWNER SENTENCED TO NINE YEARS IN PRISON FOR $2.8M MEDICARE FRAUD
An Indian national was sentenced to nine years in prison for orchestrating a nearly $2.8 million health care fraud and wire fraud conspiracy and engaging in money laundering, aggravated identity theft, and witness tampering, according to the Justice Department.
Yogesh K. Pancholi, 43, of Northville, Mich., owned and operated Shring Home Care Inc., a home health company based in Livonia, Mich. Despite being excluded from billing Medicare, Pancholi purchased Shring using the names, signatures, and personal identifying information of others to conceal his ownership of the company. In a two-month period, Pancholi and his co-conspirators billed and were paid nearly $2.8 million by Medicare for services that were never provided. Pancholi then transferred these funds through bank accounts belonging to shell corporations and eventually into his accounts in India. After being indicted, and on the eve of trial, Pancholi, using a pseudonym, wrote false and malicious emails to various federal government agencies alleging a government witness had committed various crimes and should not be allowed to remain in the United States to keep the witness from testifying.
In September 2023, a federal jury in the Eastern District of Michigan convicted Pancholi of conspiracy to commit health care and wire fraud, two substantive counts of health care fraud, two counts of money laundering, two counts of aggravated identity theft, and one count of witness tampering.
EBRI: MEDICARE BENEFICIARIES NEED MORE SAVINGS TO PAY FOR HEALTH EXPENSES DURING RETIREMENT
A new research report from the Employee Benefit Research Institute (EBRI) finds that savings Medicare beneficiaries could need for health expenses increased again in 2023. In fact, some couples could need as much as $413,000 in savings.
To project how much Medicare beneficiaries may need to save to have a reasonable chance of meeting their health care spending requirements in retirement, EBRI built a simulation model allowing for uncertainty due to mortality and rates of return on assets in retirement. This model incorporates recent changes to Medicare Part D enacted by the Inflation Reduction Act of 2022 and tests varying assumptions about Medicare Advantage and Medigap plans that Medicare beneficiaries may purchase, according to Jake Spiegel, research associate, Health and Wealth Benefits Research, EBRI. The output of this updated simulation model is the basis of this new report.
The report found:
- The predicted savings target for Medicare beneficiaries to cover premiums, deductibles, and prescription drugs in retirement rose in 2023, representing a slight increase from the $383,000 savings target last year.
- To have a 90 percent chance of meeting their health care spending needs in retirement, a man will need to have saved $184,000, and a woman will need to have saved $217,000. Couples enrolled in a Medigap plan with average premiums, meanwhile, will need to have saved $351,000 to have a 90 percent chance of covering their medical expenditures in retirement.
- Representing an extreme case, a couple with particularly high prescription drug expenditures will need to have saved $413,000 to have a 90 percent chance of having enough money to cover their health care costs in retirement.
- Although there is significant individual-level variation, enrollees in Medicare Advantage plans have lower savings targets. A man enrolled in Medicare Advantage who has median drug expenditures and is an average user of health care services will need to have saved $99,000 to have a 90 percent chance of meeting his health care spending requirements in retirement. Meanwhile, a woman will need to have saved $116,000 to have a 90 percent chance of having enough to cover her health care costs in retirement. Couples will need to have saved $189,000 to have a 90 percent chance of covering their health care expenditures in retirement. Of course, there are tradeoffs to consider; Medicare Advantage plans often have limited networks or may require approval before certain medications or services are covered.
“The results from EBRI’s projection model indicate that basic health care costs incurred by Medicare beneficiaries are high. While the savings targets tend to be lower for Medicare Advantage enrollees relative to Medigap enrollees, there are important limitations to take into account,” said Spiegel.