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Medicaid office director explains big changes her office is confronting

Sandra King-Young, director of the American Samoa Medicaid State Agency
Transition to individual enrollment and a chief medical officer are a must

Pago Pago, AMERICAN SAMOA — For American Samoa to qualify for the 17% local match instead of the current 30% local match for Medicaid funding, ASG Medicaid Office director Sandra King-Young told the Fono Joint Budget Committee last week that the local Medicaid program must transition into “individual enrollment”.

Furthermore, the US Centers for Medicaid and Medicare (CMS) has pushed for the Medicaid Office to recruit a chief medical officer and establish an integrity program division to monitor and prevent fraud and waste in Medicaid federal funds.

According to CMS, American Samoa and the Northern Mariana Islands are the only US jurisdictions, without a Medicaid Fraud Control Unit, which investigates Medicaid provider fraud and patient abuse or neglect in facility settings, and prosecutes those cases under State law or refers them to other prosecuting offices.

Responding to questions during her office’s FY 2022 budget hearing, King-Young explained that CMS has pushed for two years now for the need to recruit a chief medical officer for the ASG Medicaid Office to ensure a “check and balance” for the off island medical referral program — which is overseen by the LBJ Medical Center.

“This is a very important requirement, [that] we’re not complying with right now,” she said, noting that her office has only one staffer as an integrity program manager but federal law requires the set-up of a division in the local Medicaid Office to prevent fraud, waste and abuse in Medicaid funds. 

She was also asked by the committee about the current local match. She explained that because American Samoa does not use “individual enrollment” for Medicaid, the correct local match is 30% for every Medicaid dollar awarded to the territory, under the current “presumptive eligibility model” enrollment the territory.

For the “individual enrollment”, ASG’s matching funds is 17%, she said.

She informed lawmakers that CMS has stated that American Samoa’s “presumptive eligibility model” is no longer acceptable and must use “individual enrollment”. However, she said the reason for delaying the transition to “individual enrollment” is because it will have an impact on funding for LBJ Medical Center.

(It should be noted LBJ’s largest funding source for its annual budget is Medicaid with $41.53 million proposed in FY 2022 in which the hospital’s total budget is $65.5 million.)

“ If we transition to individual enrollment, which we must do as we have no choice — that means American Samoa also must secure an insurance service for people who are not Medicaid eligible,” she said.

She explained that, 40 years ago when the program was opened here, “the territory’s population was 87% U.S. national.”

This year, not only the local population decreased but only “about 42% to 45% of our population are now US nationals. Which means, that with the majority of non-US nationals population, CMS now sees that [under] our presumptive program... we are circumventing the Medicaid eligibility rule.”

It also means that American Samoa is using Medicaid money that should not be used for non-US nationals. “And that is a form of abuse and fraud. Our presumptive eligibility program circumvents CMS eligibility rules,” she further explained.

“So the understanding right now is, with increased federal funding, we must transition into individual-enrollment and we must find a way to cover those people who are not eligible for the Medicaid program,” she said. “Medicaid money can only be spent on US nationals, US citizens and allowable foreign children under the Medicaid law.”

“Foreign children, under the age of 21 and foreign pregnant women are also covered under Medicaid, as well as emergency services for non US nationals,” she said.

It remains to be seen whether American Samoa will transition into the individual enrollment requirement by CMS.