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“MEDICAID REQUIRES PROPOSED PROVIDER MUST PHYSICALLY EXIST AND BE OPERATING”

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Dear Editor,  

In response to Mrs. Saili Samoa’s Letter to the Editor (LTE) on Friday, March 10, 2023, I want respond in kind in this LTE, to correct important inaccuracies or misunderstanding about the requirements of the Medicaid program and how to become a Medicaid provider.

First and fundamental, to become a Medicaid provider, the Mission of Hope Clinic referenced by Mrs. Saili, must actually exist. That is, there must be an operating physical facility with working clinical and administration staff actually serving patients. Medicaid cannot enroll a provider based on proposed plans whatever they may be—there must be a physical facility in existence so that CMS and the American Samoa State Medicaid Agency can inspect, certify, enroll and approve a facility for Medicare and Medicaid reimbursement. As far as I know to date, the Mission of Hope Clinic has not been built and is currently not in operation.

Second, it is incorrect that only government sponsored “primary care clinics” can be reimbursed by Medicaid. The AS Medicaid State plan currently allows any private clinic whether for profit or not-for-profit to apply to enroll as a Medicaid provider, however, there must be a payment method in the state plan to define how Medicaid will reimburse that provider. There has been no urgency to amend the state plan to do a payment method for the Mission of Hope, because it isn't operating yet. Further, I don’t recommend setting the clinic’s payment methodology until we have documentation of its expenditures so we can negotiate an allowable Medicaid payment method for the Mission of Hope Clinic.

Currently, the DOH community health centers have a payment method in the state plan as they were the first community health clinics that Medicaid brought into the program after more than 35 years of LBJ being the only Medicaid provider on island. Other examples of private providers are--MyVision Eye Center, approved in 2022 and has a negotiated fee schedule and the provider has been in existence on-island for several years. Our medical equipment provider in Matu’u uses the Medicare Fee Schedule and is a Guam-owned business with a branch in AS and it has been in existence for several years. Hope House is an approved Medicaid provider and they have their own $100,000 local match appropriated by the Fono and they have been in existence for decades. All these services are new Medicaid services and have never been done before outside of LBJ—but these examples show that these providers have a history of health care delivery. Adding new payment methods is very hard work because it requires policy, regulatory, utilization data, financial analysis and data documentation often not in existence or difficult to obtain. If these are not available, it will prolong the process of provider enrollment.

Third, there must be a source of local match identified to meet the local match needs for the new Mission of Hope Clinic. The local match must come from government revenues, it cannot come from private donations or in-kind contributions. Currently, the administration provided a local match of $3 million in FY23 for the Medicaid off-island medical referral program. This is not enough to meet all the medical expenditures for services currently being supported by the Medicaid program. Medicaid needs approximately $17 million in local match for the funds not used by LBJ. Once we do individual enrollment, Medicaid will be able to use the 83% Federal Matching Assistance Percentage and will need approximately $9 million in local match funding. In other words, to add services, CMS requires that we also identify where the local match revenues will come from. If we want more Medicaid services, our people and our government need to understand that because the local match must come from government revenues, there must be a set-aside from taxes, new sales tax or other government revenue source for the Medicaid local match. With sufficient local match and more on-island private providers, Medicaid can be a strong economic driver for our economy and support a new health industry workforce. The more we can do on island, the better for our people.

Finally, I have met with Mrs. Saili Samoa and the Board of Mission of Hope several times over the past 5 years. Medicaid’s answer to their request to be a Medicaid provider remains the same and has never changed. I welcome and highly encourage anyone or any business interested in becoming a Medicaid provider to come see me and my staff to discuss provider eligibility. 

Thank you Mrs. Saili Samoa for raising this issue in the public forum. It is important to have this conversation in the public sphere about expanding our health care system and funding the local match for Medicaid. It is also important to impress on our elected leaders the importance of allocating local match for the Medicaid program. Amending the state plan is not an issue so long as all policy, regulatory and funding issues are adequately addressed—which in the case of Mission of Hope Clinic, have not been met.

Sandra King Young

Medicaid Director, American Samoa Medicaid State Agency