Medicaid Fraud


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In Spring of 2010 I was on a Georgetown student consulting team that worked on figuring out if it was possible to detect Medicaid fraud from #opendata in small, medium, and large states.

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  • Net recoveries to the federal government $6.64 billion. the ratio of the federal government’s direct benefits from civil health care fraud enforcement to its costs is 15.0 to 1.
  • Institutional long-term care was the most expensive type of service among persons utilizing the service. Institutional care was used by only 5.8 percent of FFS enrollees but accounted for 31.4 percent of all FFS expenditures.
  • SPIA FY07
  • Maryland’s unique Health Services Cost Review Commission. Hospital rate regulation in Maryland was established by an act of the Maryland legislature in 1971. The law created the Health Services Cost Review Commission (HSCRC), an independent State agency with seven Commissioners appointed by the Governor. The law was strongly supported by the hospital industry. The HSCRC was given broad responsibility regarding the public disclosure of hospital data and operating performance and was authorized to establish hospital rates to promote cost containment, access to care, equity, financial stability and hospital accountability. The HSCRC has set rates for all payers, including Medicare and Medicaid, since 1977 and has largely achieved the key policy objectives established by the Maryland legislature. In recent years, the HSCRC has devoted considerable resources toward the development and implementation of payment-related initiatives designed to promote the overall quality of care in Maryland hospitals. Maryland remains the only state to retain such a system. The market for health care services in the United States has failed to produce results consistent with the Maryland legislature’s founding goals. The Maryland system shows that a “macro-oriented” approach to regulation, which seeks to correct only for the most obvious market failures, can assist policy-makers in controlling cost growth and, at the same time, enhancing access to care.
  • Maryland spending:3.1% ICF/MR; 9.6% MH; 49.6% NF; 37.7% HHNearly two-thirds of Medicaid recipients were enrolled in the HealthChoice Program. The remaining one-third tended to be either sicker (many institutionalized) or covered by Medicare. As a result, the distribution of MD's FFS claims may seem quite different from the distribution for other states.Maryland  MH Aged and IP Psych < 21: Prospective cost set by rate commission
  • Majority of Medicaid enrollees are in the MC program.
  • Source: Maryland Healthcare Commission: Long Term Care.  Long-Term Services and Supports in Maryland: Planning for 2010, 2020, 2030. December 1, 2007 (November 2007)
  • Maryland has 6000 aged, 1200 physical, and 1200 children waiting for waivers.Wisconsin has 13296 aged and disabled awaiting waivers.
  • HealthChoice is the name of the Maryland’s statewide mandatory managed care program which began in 1997. The HealthChoice Program provides health care to most Medicaid recipients. Eligible Medicaid recipients enroll in a Managed Care Organization (MCO) of their choice and select a Primary Care Provider (PCP) to oversee their medical care. The MCO enrollee selects a PCP who is part of their selected MCO’s provider panel either at the time of enrollment with the enrollment broker or once enrolled in their MCO.
  • §  NJ: IP Psych and ICF/MR both cost based instead of negotiated§  California high MH/Aged – no clue?! But CA isn’t in the top ten highest iltc pmts so ignore difference?
  • §  NJ: FFS Drugs high- again, only state without a copay
  • Medicaid Fraud

    1. 1. 1State Medicaid FraudGeorgetown Health Solutions
    2. 2. 2Purpose To provide an analysis of Medicaid programs, focusing on selected states, policies, and service cost areas in order to determine consulting opportunities for Alvarez & Marsal.
    3. 3. 3Outline• Why Medicaid?• State Selection• Background• Small State Analysis• Medium State Analysis• Large State Analysis• Conclusion
    4. 4. 4
    5. 5. 5Spending• Health care costs have been rising for several years ▫ Expenditures on health care surpassed $2.3 trillion in 2008• Medicaid spending in the US (2007): $319,676,945,585• Starts are not well-positioned to withstand the loss of revenue and increased cost of healthcare associated with the economic downturn• 1% rise in unemployment adds 1 million enrollees in Medicaid and SCHIP Source: KFF: Medicaid, SCHIP, and Economic Downturn: Policy Challenges and Policy Responses
    6. 6. 6Fraud• Medicare fraud ranges from 3 to 10 percent of total expenditures ▫ Between $68 billion and $226 billion annually.• Takes critical resources out of the health care system• Causes health care costs to rise• Results in higher premiums for enrollees Source:
    7. 7. 7Recoveries• Recoveries to the federal government amounted to $7.269 billion over the 2000– 2004 period ▫ Whistleblowers were paid$627 million during this time period• Civil health care fraud recoveries in FY 2004 were $1.8 billion Source:
    8. 8. 8
    9. 9. 9State Selection Process & Criteria1. States were organized according to total population2. States were categorized by the number of laws/criteria that were met (FCA, qui tam, and DRA)3. 11 categorically unique states were selected ranging from large populations meeting all criteria to small populations meeting no criteria
    10. 10. 10 Selected States Number of Medicaid Total Medicaid Criteria Ordinal FMAP State Size Residents Enrollment Spending Met State Size (2007) (2007-2008) (2007) (2007)California Large 3 1 36,408,713 28.93% $35,967,973,808 50.0%New Jersey Large 2 11 8,528,286 10.72% $8,917,247,008 50.0%Ohio Large 0 7 11,328,525 17.97% $13,055,536,533 59.7%Texas Large 3 2 23,881,064 17.45% $20,590,458,601 60.78%Florida Large 2 4 18,016,995 16.75% $13,583,925,509 58.76%Wisconsin Medium 3 20 5,502,934 17.78% $4,937,145,634 57.5%Minnesota Medium 2 21 5,149,317 14.98% $6,191,584,929 50.0%Maryland Medium 0 19 5,534,528 13.73% $5,435,635,386 50.0%Nevada Small 3 35 2,571,148 11.00% $1,243,947,007 54.0%Delaware Small 2 45 859,761 21.54% $990,917,350 50.0%Vermont Small 0 49 611,672 25.60% $904,331,790 58.9% Sources: Kaiser Family Foundation
    11. 11. 11Federal Matching Assistance Percentage (FMAP) State Size 2007 2008 2009 2010 California Large 50.0% 50.0% 61.6% 61.6% New Jersey Large 50.0% 50.0% 58.8% 61.6% Ohio Large 59.7% 60.8% 70.3% 73.5% Texas Large 60.78% 60.53% 68.76% 70.94% Florida Large 58.76% 56.83% 67.64% 67.64% Wisconsin Medium 57.5% 57.6% 65.6% 70.6% Minnesota Medium 50.0% 50.0% 60.2% 61.6% Maryland Medium 50.0% 50.0% 58.8% 61.6% Nevada Small 54.0% 52.6% 63.9% 63.9% Delaware Small 50.0% 50.0% 60.2% 61.8% Vermont Small 58.9% 59.0% 67.7% 70.0% Sources: Kaiser Family Foundation
    12. 12. 12
    13. 13. 13State Policy and Fraud• False Claims Act (FCA) ▫ Empowers the United States, and private plaintiffs suing on its behalf, to bring lawsuits against individuals and companies suspected of defrauding the government• Qui Tam Action ▫ Cases brought about by a private plaintiff (whistleblower)• Deficit Reduction Act of 2005 ▫ Shift costs to beneficiaries and have the effect of limiting health care coverage and access to services for low- income beneficiaries; states meeting regulations increase federal funding for Medicaid by as much at 10%
    14. 14. 14Institutional Long-Term CareFour types of institutional and long-term inpatient care covered by Medicaid:1. Nursing facility services (NF) for Medicaid enrollees ages 55 and over2. Intermediate care facilities for mentally retarded and developmentally disabled individuals (ICF/MR)3. Mental hospital services for enrollees who are 65 or older (MH Aged)4. Inpatient psychiatric care for enrollees younger than 21 years of age (IP-Psych <21) Source: 2007 MAX Chartbook, CMS
    15. 15. 15Other Service Definitions• Durable medical equipment (DME) ▫ Includes the cost to rent, purchase, repair, or replace medical equipment, supplies, home improvement, and emergency response systems• Prescription drugs ▫ Outpatient prescription drug payments Source: 2007 MAX Chartbook, CMS
    16. 16. 16Cost Measures• States can elect the levels at which they provide ILTC ▫ Complete, conditional, or none• As such, the variable nature of their programs is reflected within our statistics• To help mitigate this issue, average payments were utilized Source: 2007 MAX Chartbook, CMS
    17. 17. 17
    18. 18. 18Spending Federal and State Spending (in thousands) $1,400,000Total Spending (In Thousands) $1,200,000 $1,000,000 $800,000 $600,000 $400,000 $200,000 $0 Delaware Nevada Vermont Small FMAP (FY07) 50.00% 54.00% 58.93% State Spending (FY07) $495,458 $573,086 $371,409 Federal Spending (FY07) $495,458 $670,860 $532,922 Source: Kaiser Family Foundation
    19. 19. 19ILTC Service Costs Average Per ILTC User$160,000$140,000$120,000$100,000$80,000$60,000$40,000$20,000 $0 MH Aged IP Psych < 21 ICF/MR NF FFS Delaware $8,449 $58,382 $139,496 $44,155 Nevada $3,249 $26,538 $126,946 $32,020 Vermont $1,044 $0 $135,092 $29,405Differences in IP Psych<21, can be attributed to Nevada having a cost based negotiated rate. Delaware’s IP Psych is per diem based. Source: MAX 2005, Kaiser Medicaid Database
    20. 20. 20 Other Service Costs Average Payment Per User ILTC $2,500 $2,000 $1,500 $1,000 $500 $0 Drugs DME ILTC Drug FFS MC Nevada $2,292 $721 $8 $19 Delaware $2,285 $716 $23 $584 Vermont $1,491 $447 $0 $0 Further exploration of differences in FFS drug costs, as well as MC costs, may bebeneficial . Vermont’s managed care plans only include MCOs, thereby eliminating the need to pay for ILTC and drug costs individually. Source: MAX FY 2003-2005
    21. 21. 21 Fraud and Recoveries (2007) Legislative Criteria Total Total Total Total Recovered Expenditure for Overpayments Recoveries from ALL State Qui Medicaid Discovered as a from ROI FCA DRA Medicaid Tam Integrity Result of Provider Integrity Activities Provider Audits Audits ActivitiesDelaware Yes Yes No 1,054,000 5,168 N/A 5,302,402 503.1%Nevada Yes Yes Yes 2,311,606 121,720 1,802,838 1,802,838 78%Vermont No No No N/A 206,529 206,529 206,529 N/A The Return On Investment data suggests that the most risk averse Medicaid recovery opportunities exist in Delaware due to a lack of data in Vermont and a poor recovery rate in Nevada. Sources: SPIA 2007, Kaiser Family Foundation
    22. 22. 22Problem Statement• Cost of drugs per enrollee in DE differs significantly when compared to other comparable states ▫ Twice as much as VT in FFS program ▫ More than 30 times as much as NV in MC program• Nationwide, drug prices have been on the rise with brand-name drug prices averaging an increase of 9% while generic drug prices decreased 10.6% between 2008-2009 Source: MSIS FY 2005, AARP Bulletin Today, 2009
    23. 23. 23 Existing Solutions DE NV VTThink DRA will reduce Not likely, but Not likely, but N/Aoutpatient Medicaid costs determined determinedFlexibility given to Medicaid Data not available and state No MCO-model All drugs carved out ofManaged Care organizations has MCO-model Medicaid Medicaid managed managed careto Develop Pharmacy Policies managed care careRx Drug Purchasing Pool Top$ N/A SSDCComparative Effectiveness Yes N/A YesReviews UsefulCollection of rebates onPhysician-Administered Some N/A AllDrugsMedicaid Claims Processing Currently working onSystems that Allow for the N/A Yes, system in place upgradesBilling of NDCsMedicaid Medication Yes N/A NoManagement Programs Source: National 2006
    24. 24. 24Further Analysis• According to OIG in 2008, the Drug Rebate program had a difference between debits and credits of over $98 million ▫ Further investigation of this issue with reporting and record-keeping could reveal fraudulent practices• Based on the drastic differences in drug costs in similar states, it would be beneficial to investigate the potential for fraud within the state of Delaware Source: OIG 2008
    25. 25. 25A&M Opportunities• Assist in the restructuring of DE’s maximum allowable limits, particularly for generic drugs and reimbursement formulas• Provide an analysis on the benefits of enrolling in a different interstate bulk-purchasing program• Develop a process that will assist Delaware with collecting all rebates from physicians’ offices• Advise DE regarding the advantages and disadvantages of instituting co-payments for patients purchasing medications
    26. 26. 26
    27. 27. 27Spending Federal and State Spending (in thousands) $7,000,000Total Spending (In Thousands) $6,000,000 $5,000,000 $4,000,000 $3,000,000 $2,000,000 $1,000,000 $0 Maryland Minnesota Wisconsin Medium FMAP (FY07) 50.00% 50.00% 57.47% State Spending (FY07) $2,717,817 $3,095,792 $2,099,768 Federal Spending (FY07) $2,717,817 $3,095,792 $2,837,377 Source: MAX FY 2003-2005
    28. 28. 28 ILTC Service Cost Average Paid Per ILTC User $180,000 $160,000 $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 MH Aged IP Psych < 21 ICF/MR NF FFS Maryland $114,425 $77,398 $169,694 $38,281 Minnesota $18,558 $25,214 $59,583 $20,561 Wisconsin $17,793 $14,148 $86,626 $24,558Maryland’s rates are far greater than similar states. Differences between ICF/MRand NF may be attributed to MD’s use of a cost-based reimbursement method for these services. Sources: MAX 2005, Kaiser Medicaid Database
    29. 29. 29 Other Service Cost Average Paid Per User $4,000 $3,500 $3,000 $2,500 $2,000 $1,500 $1,000 $500 $0 Drugs DME ILTC Drug FFS MC Maryland $3,539 $1,033 $82 $224 Minnesota $3,161 $1,841 $1,245 $65 Wisconsin $2,420 $468 $9 $38Differences in MC ILTC costs in Minnesota require further analysis. These differences may be attributed to an increased case mix in their MC population.Additionally, differences in average cost of DMEs would benefit from further analysis. Sources: MAX 2005, Kaiser Medicaid Database
    30. 30. 30 Fraud and Recoveries (2007) Legislative Criteria Total Total Total Total Overpayments Recovered Expenditure Recoveries Discovered as from ALL State for Medicaid from ROI FCA Qui Tam DRA a Result of Medicaid Integrity Provider Provider Integrity Activities Audits Audits ActivitiesWisconsin Yes Yes Yes N/A 6,248,872 N/A 10,353,053 N/AMinnesota Yes Yes No N/A 7,891,716 9,323,000 N/A N/AMaryland* No No No 3,989,120 21,228,872 21,228,872 22,936,011 575%*Maryland passed a FCA on April 9, 2010 allowing for penalties and damages for falseclaims, as well as up to 30% of the proceeds to go to the whistleblower. The Return On Investment data suggests that the most risk averse Medicaid recovery opportunities exist in Maryland due to a lack of data in Wisconsin and Minnesota. Sources: SPIA 2007, Kaiser Family Foundation, MD Chamber of Commerce
    31. 31. 31Problem Statement• MD spends 6x more for MH aged, 3x more for IP Psych<21, and 2x more for ICF/MR than next analyzed state• State spends 49.6% of its budget for ILTC costs on nursing facilities• Residents aged 85 and older are projected to nearly double by 2030• Patients prefer to receive LTC at home, but MD spends almost 90% of the state’s Medicaid funds on institutional care
    32. 32. 32Existing Solutions• Move institutionalized patients into the community• Home and Community Based Services (HCBS) Waivers (FFS based) ▫ Offered to older adults, persons with disabilities, and children with chronic illnesses ▫ MD spends 11% of its Medicaid LTC HCBS money for older people and adults with physical disabilities ranking it at 39th in spending on home care services for this population Sources: MD DHMH
    33. 33. 33Existing Solutions cont’d• Managed Care Programs ▫ Program for All-Inclusive Care for the Elderly (PACE)  Allows them to receive long-term care from home  Only for those in the Baltimore area ▫ HealthChoice  Coordinates care among a variety of services  Contractor is responsible for this coordination  Offer HCBS• New Directions ▫ Allows enrollees to manage their own care
    34. 34. 34Further Analysis• MD is issuing more waivers, but would be beneficial to determine if the number of available beds is decreasing in these institutions• Determine why cost setting commission does not lower reimbursement rates• Further investigation on the role fraud is playing on high costs may be warranted
    35. 35. 35A&M Opportunities• Further explore who exactly is being left in institutions and determine ways to assist them in a less expensive manner within those facilities• Develop solutions that will increase the number of waivers awarded• Assist in the expansion of managed care programs• Review rate setting commission practices
    36. 36. 36
    37. 37. 37Spending Federal and State Spending $40,000,000 $35,000,000Total Spending (In Thousands) $30,000,000 $25,000,000 $20,000,000 $15,000,000 $10,000,000 $5,000,000 $0 California New Jersey Ohio FMAP (FY07) 50.00% 50.00% 59.66% State Spending (FY07) $17,983,986 $4,458,623 $5,266,603 Federal Spending (FY07) $17,983,986 $4,458,623 $7,788,933 Source: Kaiser Family Foundation
    38. 38. 38Spending Federal and State Spending $40,000,000 $35,000,000Total Spending (in Thousands) $30,000,000 $25,000,000 $20,000,000 $15,000,000 $10,000,000 $5,000,000 $- California Florida Texas FMAP (FY 2007) 50% 60.78% 58.76% State Spending (FY 2007) $17,983,986 $8,075,577 $5,596,577 Federal Spending (FY 2007) $17,983,986 $12,514,800 $7,987,348 Source: Kaiser Family Foundation
    39. 39. 39ILTC Service Cost Average Paid Per ILTC User $200,000 $180,000 $160,000 $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 MH Aged IP Psych < 21 ICF/MR NF FFS California $126,827 $20,719 $78,626 $29,328 New Jersey $57,971 $78,234 $181,632 $39,765 Ohio $7,299 $5,225 $89,042 $31,520 The high costs of ICF/MR in New Jersey requires further analysis. Source: MAX 2005
    40. 40. 40ILTC Service Cost Average Paid Per ILTC User $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 MH Aged IP Psych <21 ICF/MR NF California $126,827 $20,719 $78,626 $29,328 Florida $35,367 $- $94,972 $28,848 Texas $13,800 $8,730 $66,775 $18,755 The high costs of MH Aged in CA requires further analysis. Source: MAX 2005
    41. 41. 41Other Service Cost Average Paid Per User $3,000 $2,500 $2,000 $1,500 $1,000 $500 $0 Drug DME ILTC Drug FFS MC California $2,574 $264 $62 $74 Florida $2,166 $639 $32 $71 Texas $1,116 $519 $11 $351 While the number of enrollees in Florida and Texas are closer in number to California’s enrollees, their per user payments do not contribute an explanation to California’s cost discrepancies. In a FFS Drug cost comparison, California’s high rates in comparison to FL and TX can be explained by their 18% AWP rate and high dispensing fees. Source: MAX 2005, Kaiser Medicaid Databse
    42. 42. 42Other Service Cost Average Paid Per User $5,000 $4,500 $4,000 $3,500 $3,000 $2,500 $2,000 $1,500 $1,000 $500 $0 Drugs DME ILTC Drug FFS MC California $2,574 $264 $62 $74 New Jersey $4,561 $696 $56 $320 Ohio $2,114 $202 $4 $79In regards to the high FFS drug payments in NJ, the high payments may be related to the low percentage of Third Party Liability Payments and lack of required Copays. Since this time, New Jersey has begun to require copays for their prescription drug coverage, as such, this trend should decrease in coming years. Source: MAX 2005, Kaiser Medicaid Databse
    43. 43. 43 Fraud and Recoveries (2007) Legislative Criteria Total Total Total Total Recovered Expenditure for Overpayments Recoveries from ALL State Qui Medicaid Discovered as a ROI FCA DRA from Provider Medicaid Tam Integrity Result of Provider Audits Integrity Activities Audits ActivitiesCalifornia Yes Yes Yes 80,869,196 61,551,360 162,455,640 162,455,640 200% Florida Yes Yes No 7,650,000 17,176,208 35,731,280 84,000,000 1098%New Jersey Yes Yes No N/A 1,727,481 N/A 4,494,019 N/A Ohio No No No N/A 7,655,831 320,440 1,152,188 N/A Texas Yes Yes Yes 2,692,267 125,185,173 N/A 418,079,369 15530% The Return On Investment data suggests that the most risk averse Medicaid recovery opportunities exist in Texas and Florida. ROI data in New Jersey and Ohio were unavailable. Sources: SPIA 2007, Kaiser Family Foundation
    44. 44. 44Problem Statements• California MH Aged: ▫ Of the states considered, California has the lowest per claim payment for Medicaid. At the same time, their 2005 MH Aged payments are 55% higher than the other large states. ▫ The population of California residents aged 85 and older is projected to grow 98% over the next 20 years. Furthermore, they still spend 49% of their long term care dollars on institutional care.• New Jersey ICF/MR: ▫ New Jersey’s ICF/MR per user expenditures are almost twice that of any other large state. ▫ 40% of 2300 ICF/MR eligible individuals are in continuing placement status due to a lack of appropriate facilities ▫ Prior to 2003 data was skewed due to several ICF/MR facilities inaccurately reporting recipients Sources: MAX 2005, AARP 2009, Wenzlow 2002, Smith 2007
    45. 45. 45Existing Solutions: California ILTC ▫ Phase out ILTC and implement Community Based Care. ▫ Encouraging residents to purchase their own ILTC insurance which prevents dependence on Medi-Cal ▫ Created “Medi-Cal Asset Protection” which allows seniors to take out ILTC insurance policies to protect their assets for their heirs. These policies are vetted by the State for proffered benefits. Source: Doty 2000, AARP 2009, 2009
    46. 46. 46Existing Solutions: New Jersey ILTC ▫ Current Legislation: New Jersey Protection & Advocacy v. Davy  NJP&A asserts Department of Human Services Commissioner has used Conditional Extension Pending Placement (CEPP) status and confine persons to state psychiatric hospitals without creating further plans for placement ▫ May 2007 “Path to Progress” plan to transition 1,850 transitional developmental center residents to community over next 8 years Source: Smith 2007
    47. 47. 47Further Analysis• Any major discrepancy in average payments may indicate fraud. One way to detect these discrepancies is to look for states who have failed to report data.• Look at the sample size of populations to ensure that these trends are accurate. Due to the phasing out of ILTC, only 10 people are enrolled in MH Aged ILTC in California. Source: MAX 2005, Wenzlow 2002
    48. 48. 48A&M Opportunities• Look at states who have committed to shifting from ILTC to Community Based care. Evaluate how effective these plans have been in transforming ILTC populations.• Create evidence based strategies to assist states with ILTC to Community Based care transitions based on a comparative state by state analysis.• Research Medicaid suits in Texas and Florida to investigate possible patterns that lead to large ROI
    49. 49. 49
    50. 50. 50ConclusionFindings• ILTC ▫ Average payments were higher for service types which were cost based rather than prospective or negotiated• Drugs ▫ Several states with higher than average managed care drug costs do not require enrollees to pay copayments• DME ▫ Due to the state-by-state differences in coverage, assertions are difficult to make regarding DME trends▫ Large cost variations between states more closely represent differences between reimbursement regulations and mechanisms rather than the false claims legal climate
    51. 51. 51ConclusionAlvarez & Marsal Opportunities• Assist in the restructuring of prescription drug maximum allowable limits• Conduct performance assessments of ILTC to HCBS programs• Develop strategies that will allow states to expand HCBS programs• Determine solutions to de-institutionalize long-term care• Assist in the expansion of managed care programs
    52. 52. 52
    53. 53. 53Sources: All States• 2003-2007 MAX Data The Medicaid Analytic eXtract (MAX) data system produced by Centers for Medicare & Medicaid Services enables much more detailed analyses of long-term care utilization and expenditures at the person level.• 2007 SPIA Data The State Program Integrity Data. (SPIA) represents the first CMS approach to annually collect standardized, national data on State Medicaid program integrity activities for the purposes of program evaluation and technical assistance support.• Kaiser Family Foundation: State Facts Database• Kaiser Family Foundation: Medicaid Database• KFF: Medicaid, SCHIP, and Economic Downturn: Policy Challenges and Policy Responses
    54. 54. 54Sources: Small States• Arbamson, Richard G., et al. Generic drug cost containment in Medicaid: lessons from five State MAC programs• Basler, Barbara. “Drug prices soar.” AARP Bulletin Today. 16 Apr 2009.• Medicaid prescription reimbursement rates by state. Retrieved from: /142005/154195/article.pdf.• National Association of State Medicaid Directors. State Perspectives on Emerging Medicaid Pharmacy Policies and Practices, November 2006• Office of the Inspector General. Follow-up Audit of the Medicaid Drug Rebate Program in Delaware. Jul 2008.• Qualters, Sheri. Pharmacy groups sue Delaware over Medicaid drug reimbursement rate cuts. National Law Journal: 13 Jul 2009.
    55. 55. 55Sources: Medium States• let.pdf•• AARP Long-Term Care in MD (2009)
    56. 56. 56Sources: Large States• AARP. “Long Term Care in California” 2009.• . California Partnership for Long Term Care. 2009.• Doty, P. “Cost-Effectiveness of Home and Community-Based Long-Term Care Services” HHS. 2000.• Smith, G. “Home and Community Services Litigation Report.” 2007. Human Services Research Institute.• Wenzlow, A. “A Profile of Medicaid Institutional and Community-Based Long-Term Care Service Use and Expenditures Among the Aged and Disabled Using MAX 2002: Final Report.” HHS, 2008.