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ASES says $18M in supplemental drug claims recognized; reconciliation ongoing amid insurer concerns
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Summary
Agency staff told a public hearing that at least $18 million in supplemental medication payments (including HIV therapies) are confirmed and budgeted, while insurers have reported larger unpaid claims totals (figures up to ~$50M) that ASES says require system certification and reconciliation before recognition.
Lawmakers and municipal representatives pressed ASES on data gaps, unpaid supplemental payments and PBM coordination after Plan Vital—s MMIS/MMAS deployment.
Unidentified Speaker 1 said two insurers reported unpaid supplemental drug claims "que ronda los cincuenta millones" and asked whether ASES had documentation. Samuel (Medicaid operations staff, Unidentified Speaker 4) and agency staff described implementation-related denials, reconciliation work with the PBM, and the activation of supplemental-payment rules in production on the 18th of the prior month.
Agency representative (Unidentified Speaker 2) told the hearing: "por lo menos dieciocho millones de dólares de esas ... ya se reconocieron, pero ... cualquier cantidad adicional puede salir si procede." The agency said the $18 million is already contemplated in the current budget and that other insurer-asserted balances are under verification and require certified system outputs to be recognized.
On data synchronization, Samuel said daily eligibility transactions now run and reported roughly 95% synchronization overall, with several insurers showing zero discrepancy. The agency acknowledged pockets of mismatch tied to prior eligibility extensions and data maintenance gaps created during pandemic-era and emergency policy changes.
Why it matters: unresolved unpaid claims can shift liabilities to the government, create cashflow stress for providers and insurers, and affect beneficiary access to specialty medications (the hearing specifically referenced HIV therapies). Agency officials asked for further technical sessions and proposed a brief executive session to allow technicians to provide a consolidated number for the record.
Next steps: ASES said it would continue reconciliations with insurers and the PBM, provide more detailed documentation when available, and work with the incoming government to settle any validated balances. The agency declined to recognize unverified insurer totals publicly until certification and agreed to provide numbers in follow-up meetings.
