Category: GB-Managed Care Overview

Alternative Headline: New MA Market President

[MM Curator Summary]: John Koehn has been appointed Massachusetts market president for CareSource, a candidate who brings his significant experience in Long-Term Services and Supports, following its affiliation with Commonwealth Care Alliance.

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CareSource, a nationally recognized nonprofit managed care organization, announced the appointment of John Koehn as the Massachusetts market president, effective today. This announcement follows CareSource’s recent affiliation with Commonwealth Care Alliance (CCA), a nonprofit organization committed to providing innovative health plans and care delivery programs for individuals with significant health needs.

Koehn brings extensive and proven health care experience in integrated Long-Term Services and Supports (LTSS) to his role at CCA. His prior experience includes serving as market president for AmeriHealth Caritas’s LTSS program in Pennsylvania, where, under his leadership, the organization saw its first profitable year which enabled reinvestments in members and communities. Additionally, as health plan president at Amerigroup New Jersey, Koehn implemented strategies that helped the organization achieve the highest quality scores in the state. Most recently, he served as senior vice president of external affairs at InnovAge, where he led government relations efforts at both state and federal levels.

"John’s health care and leadership expertise are exactly what we need to ensure residents of Massachusetts with complex health needs continue to have access to person-centered, high-quality health care," said Erhardt Preitauer, CEO of CareSource. "His commitment to operational excellence and the member and caregiver experience will help to ensure CCA’s long-term sustainability and strong commitment to our members, patients and the Commonwealth.”

CareSource, through its affiliation with CCA, serves nearly 50,000 Massachusetts residents, many of whom face significant health challenges and social barriers. The organization also provides specialized primary care and innovative clinical programs, including a respite care unit for individuals experiencing acute behavioral health crises.

In his new role, Koehn will work closely with CareSource leadership and the executive team of CCA to ensure a seamless integration of services and operations to bolster the services and supports available to individuals with complex health needs in Massachusetts.

                                                                                                                                                                                             "Joining CareSource at this pivotal time is an honor," said Koehn. "I look forward to working alongside our talented CCA team to strengthen partnerships and ensure that everyone in Massachusetts has access to coordinated care that can genuinely enhance their quality of life.”

Koehn holds a Master of Arts degree in History from the University of Michigan and a Bachelor of Arts degree in History from the University of Connecticut. He will be based in Massachusetts as he steps into his new role.

About CareSource

CareSource is a nonprofit, nationally recognized managed care organization with over two million members. CareSource administers one of the largest Medicaid managed care plans in the U.S. The organization offers health insurance, including Medicaid, Health Insurance Marketplace and Medicare products. As a mission-driven organization, CareSource is transforming health care with innovative programs that address the social determinants of health, prevention and access to care. 

About Commonwealth Care Alliance 

Commonwealth Care Alliance® (CCA) is a mission-driven healthcare services organization that offers innovative health plans and care delivery programs designed for individuals with the most significant needs. Through our flagship Senior Care Options (SCO) and One Care plans in Massachusetts, CCA delivers comprehensive, integrated, and person-centered care by coordinating the services of local staff, provider partners, and community-based organizations to meet the unique needs of each individual we serve.

https://www.globenewswire.com/news-release/2025/06/09/3095962/0/en/CareSource-announces-John-Koehn-as-Massachusetts-market-president-following-its-recent-affiliation-with-Commonwealth-Care-Alliance.html

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Alternative Headline: Molina Cuts Outlook Again

[MM Curator Summary]: Molina slashed its 2025 earnings forecast again due to rising healthcare costs, particularly in the ACA market.

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Dive Brief:

• Molina lowered its 2025 earnings guidance for the second time in two weeks, after posting second-quarter results that were dinged by across-the-board medical cost pressures.
• Molina said the drop was primarily due to higher spending on members in its Affordable Care Act plans — the main culprit also identified by other insurers struggling with a dogged increase in costs, including Elevance and Centene.
• All told, Molina’s earnings outlook is now 22% lower than it was at the outset of the year.

Dive Insight:

Molina offers health insurance for 5.7 million people in Medicaid, Medicare and the Affordable Care Act exchanges — tricky businesses to be in right now, given pernicious cost pressures hitting government programs. The insurer grew its membership through acquisitions, contract wins and organic growth coming into 2025 despite early signs of higher spending, a decision that may be coming back to bite it.

On Wednesday, Molina reduced its 2025 adjusted earnings per share guidance to “no less than” $19 from the previous midpoint of $22, which was already down from Molina’s original $24.50 target.

Molina first slashed its guidance earlier this month following a similar move from rival Centene.

“We were skeptical that the [earnings per share] cut to $22 was enough; that view is validated,” Jefferies analyst David Windley wrote in a Wednesday note on Molina’s results.

Molina’s revenue guidance was unchanged. But the California-based insurer’s expectations for its full-year medical loss ratio — an important marker of how much it’s spending on patient care, versus retaining in profits — rose across all three lines of business.

The hike in predicted costs was highest in the ACA exchanges, a business line that’s stayed relatively steady coming out of the coronavirus pandemic despite flagging margins in other government programs. But the marketplaces are a rising concern, especially due to Molina’s recent growth in ACA members. Molina ended the second quarter with 690,000 marketplace enrollees, up 71% from the end of 2024. 

More members isn’t necessarily good if those members come with higher costs — and these have, executives said during a Thursday morning call with investors. The problem isn’t unique to Molina but seems to reflect a market-wide increase in enrollees’ health needs, a trend that’s outpacing checks and balances against spiking costs in the ACA risk pools.

“While risk adjustment might normally offset higher observed trend, our market indicators clearly detect that the overall market risk pool is also significantly elevated, reducing the value of the natural hedging effect of risk adjustment,” CFO Mark Keim said on the call. 

Data that Molina received from actuarial firm Wakely in late June confirms that “national market risk pools are trending higher,” Keim said.

“[Molina’s] outcome reinforces a deteriorating market morbidity,” Windley wrote. “No [exchange] plan is safe, basically.”

The safety-net Medicaid program is also an ongoing source of cost pressure, due to a mismatch between the health of its members and states updating their rates to keep up.

Medicaid beneficiaries are using more behavioral health services, primary and follow-up specialty care and high-cost drugs, executives said. More members are also being admitted to the hospital for complex health episodes, according to CEO Joe Zubretsky.

“This is the fourth consecutive quarter we have observed some combination of these trends. The magnitude and persistence of these medical cost increases are unprecedented,” Zubretsky said.

Molina is generally able to keep its Medicaid spending from spiking due to risk-sharing arrangements it has in place called risk corridors. But “risk corridor protection at this point is very limited and isolated,” the CEO said.

Overall in the second quarter, Molina reported revenue of $11.4 billion, up 16% year over year and above analyst expectations.

The payer’s net income of $255 million was down 15% compared to the prior-year quarter.

Molina plans to raise prices for its ACA plans next year to recapture margins. As for Medicaid, the payer is hopeful that states will continue raising their payment rates to account for elevated trend.

But Molina’s path forward is complicated by policy changes out of Washington that will cause significant volatility for Medicaid and ACA plans starting next year, leading Zubretsky to call the current moment a “season of great uncertainty.”

Millions of Americans are expected to lose coverage from Republicans’ recently passed tax and policy law overhauling federal healthcare programs. The so-called “Big Beautiful Bill” includes the largest cut to Medicaid in the program’s history and a significant rollback of the ACA that are expected to decimate U.S. insurance coverage gains and cut into payers’ earnings.

During the call, Zubretsky attempted to soothe investors that changes to Medicaid, including the imposition of work requirements, should be “modest and gradual,” allowing plans the opportunity to adjust.

Coverage losses from work requirements shouldn’t be dramatic, as two-thirds of Molina’s 1.3 million Medicaid expansion members already work in some capacity, while many others qualify for exclusions, the CEO said.

It’s trickier, however, to predict how states will respond to policies cutting federal Medicaid funding.

“States could limit eligibility, reduce benefits or keep their programs intact by funding it with additional state revenues. We anticipate that whatever a state elects to do will follow prevailing state-specific political tendencies,” Zubretsky said.

As for the ACA, Molina continues to expect that Congress will allow more generous subsidies for marketplace plans to expire, which will cause enrollment to drop in 2026. New program integrity measures are also expected to cull membership.

But at the end of the day, Molina is less worried about membership than it is about margins, according to executives.

“We can prioritize margin and let membership fall where it may,” Keim said.

https://www.healthcaredive.com/news/molina-cuts-2025-earnings-outlook-aca-medicaid/753908/

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Alternative Headline: Outreach Boosts SUD Care

[MM Curator Summary]: A new outreach model successfully connects Medicaid SUD patients to care, reducing facility visits and improving outcomes.

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A new outreach model designed to engage Medicaid recipients with substance use disorders (SUDs) has yielded a 65% success rate in linking them to care. The program, led by Wayspring in partnership with Highmark Health Options, is engaging Delaware patients in a new “boots-on-the-ground” fashion and has reduced hospital and facility visits by as much as 30%.

Treatment initiation and adherence are notoriously low for patients with SUDs – even more so among Medicaid recipients who, on average, are diagnosed with SUDs at a higher rate. These factors compelled Nashville, Tennessee-based Wayspring, an addiction care provider that partners with health plans, to team up with Highmark Health Options, a prominent Medicaid managed care organization throughout Delaware.

Rather than expecting appointment reminders and phone calls to engage or re-engage an SUD patient in care, Wayspring outreach specialists met with individuals who were identified as having “the steepest barriers to care” at shelters and in neighborhoods. Amid these outreach efforts, the team identified 150 patients with 300 unique needs around clothing, housing and transportation access and helped meet those needs with wraparound services.

After these efforts, 200 Wayspring clinic appointments in the Delaware region were made and completed.

Although the current model is specific to Delaware, Wayspring has extended similar outreach services across its operations in Kentucky and Tennessee as well.

“Wayspring is evaluating how to do this in each one of our geographical footprints in our current states,” Ashley Potts, Wayspring’s vice president of operations in Delaware, told Behavioral Health Business. “Delaware was first, and then we quickly pivoted to be able to do this in our other states. ”

This type of “street medicine” model, as Potts calls it, differentiates itself from others because of the level of detail Wayspring outreach specialists get into within these communities. Their research extends beyond the neighborhoods and areas where they could have the most impact and takes into account the vehicles they drive into these communities, what they wear, the dialect they use and more.

“We don’t want to wear colors that mirror first responders, for example,” Potts said. “We want to remove any barrier that we can foresee and just try to be known to them as ‘Ashley from Wayspring is coming to help me.’ We really tried to look at it from every angle.”

Removing barriers down to a granular level like this removes resistance in these conversations, she explained.

To measure long-term success, Wayspring plans to continuously track how long a patient stays engaged after this outreach, if they are attending treatment, abstaining from use of substances and if emergency department visits for a specific patient go down from 20 visits one year to even 18 the next. These metrics may vary from patient to patient, she explained.

Even though this model focuses on engaging the Medicaid population and street medicine outreach, Potts said this type of work could and should be extended beyond these parameters.

“I think sometimes the historical way has been, if you’re using substances, you need to go to inpatient treatment, and that there is this exact linear progression that you’re supposed to follow,” she said. “But addiction is so complex… There’s just so much more to it than just ‘stop using drugs.’ If we could actually create a model that just reaches the whole person, wherever they may be, I think individuals would have a much greater chance of success.”

Companies featured in this article:

Highmark Health Options, Wayspring

https://bhbusiness.com/2025/07/18/how-wayspring-and-highmark-health-are-changing-the-sud-care-playbook/

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Alternative Headline: Medicaid Cuts, Texting Battle

[MM Curator Summary]: Trump’s Medicaid overhaul would cut millions from coverage and revives calls to lift outdated texting restrictions on managed care plans, restrictions which add to the difficulty of communication between providers and health-care users. 

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Stricter Medicaid eligibility checks look destined to be included in President Donald Trump-backed reconciliation legislation charging through Congress, dubbed the One Big Beautiful Bill.

New work requirements are likely to make it more difficult for current Medicaid enrollees to keep their insurance coverage, leading to a push aimed at exempting managed care plans from a 1991 law restricting their ability to text members.

The charge is led by Abner Mason, chief strategy and transformation officer at GroundGame.Health, who has worked with plans to change the law for the last decade but is viewing the situation with renewed vigor. He is beginning to speak with a coalition of stakeholders including America’s Health Insurance Plans and the Medicaid Health Plans of America, hoping to leverage their expertise and lobby senators for the policy’s inclusion in the bill.

His plan could have motion among lawmakers hoping to reduce spending but minimize the disruptions brought about by work requirements.

“The need to modernize communication has increased tenfold,” he told Fierce Healthcare in an interview.

President H. W. Bush signed the Telephone Consumer Protection Act into law to stop intrusive robocalls and telemarketing practices. Part of that law says a person can’t be texted unless they give permission. Because Medicaid enrollees are assigned a health plan by a state or county, legal teams at health plans say implied consent is not present like it would be through another line of business, such as Medicare Advantage or the individual market.

Some insurers have sent members a text asking for permission to continue texting, but other health plans have refused since even an initial text could be considered a violation. Each infraction, or text, could result in a $500 to $1,500 fine. Multiplied over hundreds of thousands of members, those costs add up quick.

In Virginia, only about 3% of Medicaid enrollees agreed to opt into receiving messages from the state’s program, reported KFF.

An inability to text enrollees in 2025 is staggeringly inconvenient and unrealistic for health plans, said Mason. It’s important plans are able to text updates about an upcoming diabetes screening appointment, for example. If Republicans’ bill passes—requiring states to conduct eligibility checks every six months among the latest provisions—members should not face any additional complications in remaining enrolled.

The Medicaid and CHIP Payment and Access Commission expressed similar concerns in 2022 for members that do not receive mailed notices and are then subject to coverage loss.

Managed care plans have been able to text enrollees in two instances. During the COVID-19 public health emergency, plans were allowed to communicate strictly about the pandemic. That flexibility disappeared when the emergency ended.

The Centers for Medicare & Medicaid Services and the Federal Communications Commission, under the Biden administration, also issued guidance allowing plans to text about Medicaid redeterminations once the public health emergency was lifted, though that guidance could be easily revoked.

If texting is not an option, members are forced to communicate with their insurers through traditional mail or even fax. Some low-income members on Medicaid may have a phone but not have easy access to a computer.

Ideally, said Mason, texting a member would incentivize them to follow a care navigation plan, remember critical preventive screenings and get better educated on how to live a healthy life. He sees a path, if a narrow one, to convince Republicans the importance of exempting managed care plans of requirements he deems outdated.

Trump has repeatedly said he does not want Medicaid cut other than by rooting out waste, fraud and abuse. Some senators on the right are wary of touching the program, concerned at how constituents back home would react. Hardliners justify the changes, saying the program needs to be reined in to support Medicaid’s original intent. Meanwhile, leadership across the Department of Health and Human Services has shown a desire to modernize the department in the name of efficiency and effectiveness.

“We’ve got to thread that needle,” Mason said of the push to update the texting restrictions. “Why would you force people to use a horse and buggy when you know there are more modern ways of getting people from point A to point B?”

Republicans have steadily pushed the reconciliation bill out of the House, despite blowback from health systems, patient advocates and insurers over how reduced Medicaid spending could affect the healthcare ecosystem.

Today, the Congressional Budget Office projected the proposal’s work requirements would slash spending by $344 billion. Medicaid changes alone would result in 7.8 million fewer insured individuals—10.9 million people when factoring in other changes.

Overall, the reconciliation bill would reduce spending in healthcare by more than $1 trillion. The Trump administration hopes to sign the bill into law in July.

https://www.fiercehealthcare.com/payers/medicaid-work-requirements-trump-bill-revives-calls-update-managed-care-texting-ban

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Alternative Headline: HOP Boosts Health, Economy

[MM Curator Summary]:  Access East’s HOP program improves Medicaid patient health and local economies through non-medical services in eastern North Carolina.

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Since its inception in March 2022, the Healthy Opportunities Pilot (HOP) initiative has worked to mitigate the effects of food insecurity, housing instability, interpersonal violence/toxic stress and lack of access to transportation.

Spanning multiple counties, including Pitt, Beaufort, Chowan, Edgecombe, Hertford, Martin, Halifax, Northampton and Bertie, the Access East HOP consists of a network of community-based organizations, called Human Service Organizations (HSOs), which provide essential services. By leveraging resources and expanding local economies, HOP ensures that critical support reaches those in need.

HSOs play a vital role in bridging the health care gap. By working alongside Medicaid, they offer non-medical services that directly impact health outcomes.

Programs target individuals with chronic conditions, addressing socioeconomic needs for all age groups. Access East acts as the HOP lead for eastern North Carolina, building the HSO network and coordinating insurance claims.

“Eligible Medicaid Managed Care enrollees receive these services to help manage non-medical factors that improve health outcomes,” said Tina Dixon, vice president of Healthy Opportunities at Access East. “For example, if someone does not have food security, they aren’t able to consistently eat healthy meals with fresh fruits and vegetables that play a large role in preventing conditions like diabetes and hypertension.”

One HSO, Good Shepherd Food Pantry of Bertie County serves about 1,200 families per month in Bertie County, ensuring anyone in need has access to food. Good Shepherd Food Pantry of Bertie County provides large-scale food distributions to residents in Bertie County, including delivering about 150 food boxes per week through the HOP program. Deborah Freeman, executive director of Good Shepherd Food Pantry of Bertie County, uses fresh produce from local farms, which not only generates steady revenue for local businesses like the farm but also provides employment opportunities, contributing to economic stability.

In 2022, Good Shepherd was among the first agencies to join the Access East HOP Program, a decision that has allowed them to hire eight new employees, many of whom are seniors, to help with food delivery, with additional staff packing food boxes and supporting operations through a senior employment program. These positions provide not only financial stability for older adults but also an opportunity for them to give back to their communities. Ninety percent of their drivers are over 70 years old, with additional staff packing food boxes and supporting operations through a senior employment program.

HOP has also helped fund their backpack program, an initiative that provides children with two breakfasts, two lunches, milk, juice, and fresh fruit to ensure children have access to nutritious food. They delivered 9,600 backpack meals to elementary and middle school students in Bertie County during the past school year. Reimbursements from HOP food boxes deliveries provided over $70,000 to fund the backpack program.

“There are so many babies who go to school hungry,” said Freeman. “Teachers know which children are struggling when they come back on Monday. We allow schools to identify those in need, provide a count, and we ensure that backpacks are delivered every Thursday.”

Freeman says her team has witnessed firsthand how HOP has transformed the lives of many people in her county.

“There are just so many stories that come back from my drivers,” said Freeman. “When they go to certain homes, they really get to know the families over months, even a year sometimes, because they keep getting recertified. At first, you have to face the reality of the conditions people are living in, but then you witness the transformation. We provide food, but then other HSOs step in to repair homes and offer more support. One of my drivers shared that, at the beginning, you could see the ground through one person’s house, but by the end of six months, the house had been repaired, food boxes were coming in, and HOP was really helping improve lives.”

While Good Shepherd Food Pantry’s work has helped address food insecurity at the local level, the broader impact of HOP extends beyond individual communities. By supporting local businesses, creating jobs, and providing essential services, HOP helps improve the health and well-being of recipients while adding to local economies.

“HOP not only offers these services to improve the lives of Medicaid patients, HOP also greatly benefits local economies,” said Dixon. “Local businesses are growing and flourishing because of the funds from HOP. It provides a steady income for these businesses, and they’re able to provide services for those in need and even expand their services outside of HOP recipients.”

Since its inception, Access East’s HOP has enrolled 12,190 clients and served 10,396 individuals, ensuring access to essential services. With a total of more than 220,000 contracted services provided, the initiative has had a significant impact on the community. The value of services delivered amounts to $44,454,724, with 223,283 invoices submitted for payment. Access East HOP’s invoicing specialists carefully review each invoice, ensuring accurate payments are made to the HSOs. These funds have been instrumental in supporting both local residents and the HSOs dedicated to serving them, improving access to critical resources.

https://www.ecuhealth.org/three-years-of-healthy-opportunities-pilot-at-access-east-changing-lives-across-eastern-north-carolina/

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