Category: Medicaid Managed Care

Alternative Headline: Spencer Hospital nears Medicaid deals

[MM Curator Summary]: Spencer Hospital plans to sign contracts with all three private insurers managing Iowa’s Medicaid program, despite concerns about the rushed privatization process.

====================================

Spencer Hospital anticipates it will reach contract agreements with all three of the private insurance companies selected by the state of Iowa to manage its Medicaid program.

During 2015 the state of Iowa initiated a process to transition from a state-run Medicaid program to a privately managed program. The program transition was initially scheduled for Jan. 1, but implementation has been tentatively delayed until March 1. Following a review process in December, federal officials announced the state was not sufficiently prepared for its planned January start date resulting in the implementation delay.

Spencer Hospital expects to sign contracts with Amerigroup Iowa Inc., AmeriHealth Caritas Iowa Inc. and UnitedHealthcare Plan of River Valley Inc. if negotiations continue to progress. Medicaid beneficiaries have until Feb. 17 to enroll with one of the private companies. If beneficiaries do not choose one of these managed care companies, they will be assigned to one by the state.

Spencer Hospital President Bill Bumgarner said the contracting process has been challenging due to the aggressive program transition schedule adopted by the state.

“The concerns of Medicaid beneficiaries, their families and healthcare providers regarding the state’s rush to implement the privatization plan have been widely reported,” Bumgarner said. “It’s unfortunate that the state chose not to approach such a major change with measured steps as other states have done. It’s resulted in a significant level of confusion for those involved with and impacted by the Medicaid program.”

Bumgarner said the hospital has expedited its contract review process as much as it reasonably could in an effort to provide Medicaid beneficiaries with the opportunity to make an informed decision about which managed care program to enroll with.

“We want to advise the public of our contracting status because we know people cannot make good decisions without information,” he explained. “These can be complicated decisions for the beneficiaries and their families, some of whom depend on a wide range of health care providers for their care. By pursuing contracts with all three companies approved by the state, we seek to offer our patients all options.”

Bumgarner said Spencer Hospital will join healthcare providers throughout the state to support patients during the transition process despite deep concerns about the long-term implications of privatizing the Medicaid program.

“Spencer Hospital’s mission is about putting patients first,” he said. “The state has a right to manage the Medicaid program in the way it chooses as long as it complies with federal and state regulations. However, the healthcare community believes the evidence is clear that outsourcing the Medicaid program is not in the best interest of patients nor is it sound health policy.”

He continued, “There are better and more progressive alternatives to enhance care outcomes for Medicaid patients while also seeking cost efficiency. That would require significant collaboration between the State of Iowa and its healthcare providers. It’s a process we have and continue to be willing to pursue. For whatever reason, the state chose to go a different way.”

Bumgarner said the hospital would make a public announcement when Medicaid contracting decisions were final.

https://www.spencerdailyreporter.com/articles/archive/spencer-hospital-seeking-agreements-with-private-medicaid-insurers/

COLOR CODE: 

General item, but important. Gets at main point of article= YELLOW

Has a dollar amount or number = GREEN

A specific topic that seems to be different than other topics = BLUE

Alternative Headline: Colorado Medicaid covers mental health

[MM Curator Summary]: Colorado Medicaid now reimburses clinics for mental health care under the Collaborative Care Model, aiming to expand access and early treatment despite staffing and implementation challenges.

====================================

Starting this past July 1, Colorado’s Medicaid program, Health First Colorado, began reimbursing primary care clinics for mental health services provided through the Collaborative Care Model, or CoCM. This change puts Colorado alongside 35 other states that now cover CoCM under Medicaid.

CoCM brings mental health care into primary care by creating a team made up of the patient’s primary care doctor, a behavioral health coordinator, and a psychiatrist who consults as needed. These team members regularly discuss patients’ progress and work together to update care plans, helping identify and treat mental health concerns earlier rather than later.

For patients, this means they can access support for conditions like depression, anxiety, or ADHD during regular doctor visits, without needing a referral to a specialist or facing long wait times. For clinics, especially those in rural areas, this new reimbursement may be key to maintaining behavioral health services that otherwise might not be sustainable.

According to the Colorado Department of Health Care Policy and Financing (HCPF), clinics must meet certain requirements to bill Medicaid: they need to have a contract with a Regional Accountable Entity (RAE) or Managed Care Organization (MCO), employ or contract behavioral health care managers and psychiatric consultants, and conduct regular case review meetings between care managers and psychiatric consultants.

“ This behavioral health coordinator who’s been added to the care team … helps the patient overcome known barriers like scheduling, stigma, transportation, social determinants of health, and medication adherence,” said Anna Bobb, executive director of Path Forward, a nonprofit advocating for the CoCM. “This person puts the patient directly at the center of care.” She added that psychiatrist time is “leveraged eight times over by using this model.”

HCPF estimates the program will cost the state’s general fund about $368,000 in its first year, unlocking roughly $1.1 million in federal matching funds.

“The fact that Health First Colorado is now going to be reimbursing for Medicaid is a huge step forward for the state,” Bobb said. “We have to think about the children of Colorado and what a huge impact this can have for them.”

Early intervention, Bobb emphasized, is one of the model’s greatest strengths, especially for young people.

“We know there’s often a 10-year delay between the start of symptoms and a diagnosis,” she said. “During that time, mental health conditions can worsen significantly. Collaborative care brings treatment into primary care, helping to intervene much earlier.

“Half of all people with mental health conditions experience their first symptoms by age 14; three-quarters by 25,” she said.

Still, access remains limited. Although Collaborative Care is technically available in all 50 states, only about 100,000 people received these services through commercial insurance in 2023, less than 1% of the nearly 60 million Americans with mild to moderate mental illness who could benefit, according to a Milliman data analysis cited by Path Forward.

That said, some clinics in Colorado have been offering this kind of care for years. Sunrise Community Health is a federally qualified health center serving communities across northern Colorado, offering comprehensive medical, dental, and behavioral health services all in one place. Mark Wallace, Sunrise’s chief operating officer, said the Medicaid policy could help other clinics develop integrated behavioral health services like Sunrise’s, which includes behavioral health providers in all 15 of its primary care clinics.

He explained that these providers are fully involved in daily care.

“They’re on all the floors of our clinics,” Wallace said. “We do warm handoffs (with them) throughout the day … all day long there is this interchange between the behavioral health team and our clinical medical team.”

But implementing the model in smaller or rural clinics may come with challenges. Wallace noted that many practices may not have the staff or systems in place yet to take advantage of the new reimbursement structure.

“In some practices that are rural, they might not have a care coordinator or a care manager,” he said. “But if one of their medical assistants spends 25% of her time doing that kind of connection to behavioral health, now that practice has a source of funding to offset the cost.”

Setting up these systems, especially billing, will require time and training.

“Most clinics use electronic systems, so training will be really important,” Wallace said.

He warned that excessive auditing and paperwork can be frustrating if staff spend a lot of time on unreimbursed tasks: “If clinics don’t know how to document and bill properly, the system can fall apart quickly, and people get discouraged.”

Wallace also raised concerns about workforce shortages in behavioral health.

“It’s a tough world right now … employees often move between clinics and behavioral health companies,” he said. “There is a shortage (of trained staff) right now, and I do worry we’re not going to suddenly find a lot of new employees.”

He emphasized the need to support existing staff to prevent turnover, suggesting that Medicaid reimbursement could help clinics offer pay raises or other incentives to retain employees involved in care coordination.

However, despite challenges with implementation and workforce shortages, both Wallace and Bobb agree this policy marks important progress toward a more accessible mental health system.

“Having this best practice covered by your Medicaid program is going to be a game changer,” Bobb said.

She hopes the move toward broader integration, earlier care, and a system where mental health help is available in doctor’s offices will help close long-standing gaps in mental health access. This is especially important for communities that have been underserved for too long, she said.

https://gazette.com/news/mental-health/colorado-s-medicaid-policy-expands-mental-health-support-in-doctor-s-offices/article_4f5a64a5-3904-478b-ab82-8b983c6eaa26.html

COLOR CODE: 

General item, but important. Gets at main point of article= YELLOW

Has a dollar amount or number = GREEN

A specific topic that seems to be different than other topics = BLUE

Alternative Headline: Healthfirst Ranked Top Medicaid Managed Care Plan in New York

[MM Curator Summary]: Healthfirst earned the top spot among New York Medicaid Managed Care plans for 2023, recognized for high-quality care and member satisfaction.

========================================

NEW YORK–(BUSINESS WIRE)–

Healthfirst, a leading not-for-profit health plan serving more than two million New Yorkers, has been recognized as the top-performing Medicaid Managed Care plan in New York State’s Department of Health Medicaid Quality Incentive Program results for 2023, which were released in August 2025. Out of 12 participating plans statewide, Healthfirst achieved the highest rating for quality of care, underscoring its effectiveness in delivering access to coordinated, community-based care through its extensive provider network.

This press release features multimedia. View the full release here: https://www.businesswire.com/news/home/20250821564574/en/

“Healthfirst’s number one ranking reflects how we are delivering on our not-for-profit mission in partnership with our provider network of top-notch medical centers, doctors, and community physicians who are integral to our communities,” said Pat Wang, President and CEO of Healthfirst. “For more than 30 years, Healthfirst has earned the trust of members by putting their needs first and making health insurance easier to understand – grounded in our belief that all New Yorkers deserve the highest-quality care.”

For the past three years, Healthfirst has achieved tier one performance in the annual Medicaid Quality Incentive Program results and in 2023 received the highest ranking among all plans. Key drivers in the 2023 measurement year results include behavioral health programming designed to meet members’ needs, as well as ongoing efforts to enhance member experience. In addition, Healthfirst members rated our health plan above the statewide average in New York’s Medicaid Adult member satisfaction survey.

“Healthfirst’s number one ranking reflects how we are delivering on our not-for-profit mission in partnership with our provider network of top-notch medical centers, doctors, and community physicians who are integral to our communities,” said Pat Wang, President and CEO of Healthfirst. “For more than 30 years, Healthfirst has earned the trust of members by putting their needs first and making health insurance easier to understand – grounded in our belief that all New Yorkers deserve the highest-quality care.”

The New York State Medicaid Quality Incentive Program evaluates health plans based on nationally recognized quality measures and health outcomes. These measures include preventive care; management of chronic conditions such as diabetes, asthma, and cancer; maternity and postpartum care; behavioral health; and developmental screenings for children and adolescents. A plan’s performance in the program indicates the quality of care provided to its members relative to all plans in the Medicaid Managed Care market. The program uses multiple data sources to determine results, including:

• 2023 Healthcare Effectiveness Data and Information Set (HEDIS) and Quality Assurance Reporting Requirements (QARR) data (measurement year 2023);
• The most recent Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey for Medicaid (administered in fall 2023 with results released in May 2024); and
• Regulatory compliance information from 2022 and 2023.

About Healthfirst

Healthfirst believes that every New Yorker deserves access to the best available healthcare. As one of New York’s highest-quality health insurers, we make this a reality for more than two million members. Founded more than 30 years ago by the leading hospital systems in downstate New York, Healthfirst established a partnership model that enables hospitals, health systems, and physicians in our network to prioritize health outcomes over profits, placing the needs of our members and community first. Healthfirst serves members in New York City, on Long Island, and in Westchester, Rockland, Sullivan, and Orange counties, offering market-leading products to suit every life stage. Our offerings include Medicaid plans, Medicare Advantage plans, Child Health Plus plans, Essential Plans, Long-Term Care plans, and Qualified Health plans. For more information on Healthfirst, please visit healthfirst.org.

View source version on businesswire.com: https://www.businesswire.com/news/home/20250821564574/en/

https://insurancenewsnet.com/oarticle/healthfirst-ranked-1-in-quality-among-new-york-state-medicaid-plans

COLOR CODE: 

General item, but important. Gets at main point of article= YELLOW

Has a dollar amount or number = GREEN

A specific topic that seems to be different than other topics = BLUE

Alternative Headline: Humana Slashes Prior Authorizations

[MM Curator Summary]: Humana will reduce and streamline prior authorizations by 2026, aiming to cut delays and ease burdens for patients and providers.

==============================

Most people know the frustration of needing prior authorization from a health plan, often before they’re even eligible for Medicare. Now, Humana, the second largest provider of Medicare Advantage plans, has announced it will reduce its use of prior authorizations and speed up the process for others.

Prior authorizations (PAs) are tools widely used by private insurance companies to contain costs. In addition to making sure your plan will cover the service, medication or equipment, PAs are also a way the health plan can decide if the care is medically necessary, safe, and cost effective. In 2023, Humana had an average of 3.1 prior authorization requests per MA enrollee and a denial rate of 3.5%, according to an analyzation of prior authorization data by KFF.

Humana joined other signatories in a pledge to streamline prior authorization processes for Medicare Advantage, Medicaid Managed Care, Health Insurance Marketplace®, and commercial plans, covering nearly 80% of Americans. This commitment was made at a Health and Human Services (HHS) roundtable attended by Secretary Kennedy and CMS Administrator Dr. Oz.

“Today’s healthcare system is too complex, frustrating, and difficult to navigate, and we must do better,” said Jim Rechtin, President and CEO of Humana in a press release.

“We are committed to reducing prior authorization requirements and making this process faster and more seamless to better support patients, caregivers, physicians, and healthcare organizations,” he added.

UnitedHealthcare, the largest provider of Medicare Advantage plans, continues to require prior authorization for certain services and procedures. However, it does not require it for emergency or urgent care.

How Humana will trim prior authorization wait times

Any way you slice it, prior authorizations are an inconvenience for both patients and doctors, that can slow you down from getting the care or assistance you need. If Humana sees through plans to streamline the process, it could lead to less waiting for patients and less paperwork for doctor’s offices.

Another win for consumers is Humana’s plan for increased transparency around the prior authorization process. Humana will begin publicly reporting its prior authorization metrics in 2026. This will include data on prior authorization requests approved, denied, and approved after appeal, as well as the average time between submission and decision.

Here is what Humana is planning to do to reduce wait times and the overall burden of prior authorizations:

• Eliminating one-third of prior authorizations for outpatient services: By January 1, 2026, Humana will remove prior authorization requirements for approximately one-third of outpatient services. This specifically includes diagnostic services such as colonoscopies, transthoracic echocardiograms, and select CT scans and MRIs.
• Focus on electronic submissions and interoperability: Humana is working to support greater adoption of electronic prior authorization requests (ePA) over methods like fax or phone. Their goal is to modernize and streamline the ePA process to expedite approvals and create a more seamless experience for patients and providers.
• Faster approval times for electronic requests: Humana commits to providing a decision within one business day for at least 95% of all complete electronic prior authorization requests by January 1, 2026. The company currently provides a decision within one business day for over 85% of outpatient procedures.
• National "Gold Card" program: In 2026, Humana will launch a new "gold card" program. This program will waive prior authorization requirements for certain items and services for providers who have a proven track record of submitting coverage requests that meet medical criteria and deliver high-quality care with consistent outcomes for Humana members.

How prior authorizations can impact physicians and patient care

Physicians offices are a nexus point for prior authorizations between patients and insurers and it takes a toll. A survey of physicians by the American Medical Association revealed how prior authorizations impact patient care.

On average, a physician’s office completes 39 prior authorizations per week that take at least 13 office hours to complete; 40% of the physicians surveyed have staff who work exclusively on PAs. Only 1 in 5 physicians appeal a denial, with over half saying the small number is because they lack the resources to file appeals (57%).

While eliminating prior authorization requirements by one-third is a significant reduction, the impact will depend on which services are no longer subject to prior authorization. Humana has specified certain diagnostic services like colonoscopies, echocardiograms, CT scans, and MRIs, which is a good start.

This move comes amid increasing scrutiny from Congress and the Centers for Medicare & Medicaid Services (CMS) and HHS, regarding prior authorization practices in Medicare Advantage. Humana’s proactive approach may be a response to this pressure and potential federal regulations

https://www.kiplinger.com/retirement/medicare/humana-to-reduce-prior-authorizations-for-medicare-advantage-plans-in-2026

COLOR CODE: 

General item, but important. Gets at main point of article= YELLOW

Has a dollar amount or number = GREEN

A specific topic that seems to be different than other topics = BLUE

Alternative Headline: UNH Faces Profit Collapse

[MM Curator Summary]: UnitedHealth’s Q2 2025 profits are projected to plunge nearly 29% as medical costs surge and regulatory scrutiny intensifies.​

==============================

UnitedHealth Group Incorporated UNH is set to release its second-quarter 2025 results on July 29, 2025, before market open. As a bellwether in the healthcare sector, UNH’s performance offers critical insight into the broader health insurance landscape, an industry currently grappling with surging medical costs and mounting regulatory scrutiny. Plunging profits from its UnitedHealthcare unit are expected to have affected UNH’s second-quarter results.

Recent challenges, including the withdrawal of the 2025 earnings outlook, a surprise CEO transition, and damaging headlines about federal investigations, have significantly eroded investor confidence. On Thursday, the company confirmed that the Department of Justice is probing aspects of its Medicare business. UNH stated it had “proactively reached out to the Department of Justice” after reviewing media reports and is now “complying with formal criminal and civil requests.”

Following UNH’s lead, peers like Centene and Humana Inc. HUM withdrew their 2025 profit outlook, while Molina Healthcare, Inc. MOH slashed its guidance. The stock performance across the managed care industry reflects these concerns: year to date, UNH shares have plunged 45%, matching Molina Healthcare’s decline, while Humana is down 9.7%. The broader industry has tumbled 34.3% over the same period, sharply underperforming the S&P 500’s 7.6% gain.

YTD Price Performance – UNH, HUM, MOH, Industry & S&P 500

Despite the sharp sell-off, UnitedHealth still trades at 11.98X forward 12-month earnings, slightly above the industry average of 11.58X. However, this is well below the company’s five-year median P/E of 19.20X, reflecting the market’s growing concerns around operational stability and regulatory risk.

In comparison, Humana and Molina Healthcare are currently trading at 15.76X and 6.48X, respectively.

Now let’s focus on the UnitedHealthcare, UNH’s biggest segment by revenue generation.

Spotlight on UnitedHealthcare Segment

Through this segment, UNH offers healthcare benefits worldwide. While it has significant exposure to the Medicare and Medicaid markets, it also serves individuals and employers. The defensive properties of the sector enabled UnitedHealth to maintain its momentum, which is now impacted by rising medical costs in Medicare Advantage and a surge in high-acuity patient volumes.

In the last reported quarter, the segment’s revenues jumped 12.3% year over year to $84.6 billion, whereas the operating income improved 18.9% to $5.2 billion. Considering the unit’s products, premiums increased 12.8% year over year to $81.5 billion in the first quarter, while service revenues grew 1.9% to $2.6 billion. Total revenues from the Employer & Individual Domestic, Medicare & Retirement and Community & State businesses increased 6.9%, 17.5% and 12.5% year over year, respectively. But, from global operations, UNH reported revenues of $782 million, down 49% year over year.

Q2 Segment Expectations: Revenues to Rise, Profits to Fall

The Zacks Consensus Estimate for UnitedHealthcare’s revenues indicates a 14.7% year-over-year increase from the year-ago level of $73.9 billion, whereas our model estimate suggests a 14.1% rise. The consensus mark for second-quarter operating income signals a more than 30% year-over-year decline from $4 billion a year ago.

With growing elective procedures, medical costs are expected to have remained elevated in the second quarter. This is expected to have resulted in UNH having a lower portion of premiums remaining after settling payments. As such, the consensus mark for the second-quarter 2025 medical care ratio is pegged at 88.6%, indicating an increase from the year-ago level of 85.1%, while our estimate of 87% suggests a lower jump.

The consensus estimate for Employer & Individual Domestic revenues indicates more than 6% year-over-year growth to nearly $19.8 billion. The consensus mark for UnitedHealthcare’s Community & State revenues suggests an 18.8% increase from the year-ago period’s $19.7 billion, whereas our model predicts a 19% gain. The consensus estimate for Medicare & Retirement business’ revenues suggests 18.2% year-over-year growth from $34.9 billion a year ago, while our estimate indicates a 16.3% improvement.

The Zacks Consensus Estimate for UnitedHealthcare’s total number of people served in the commercial domestic business indicates a 1.5% increase from the year-ago level of 29,570 thousand, while our estimate implies a 1.2% rise. The consensus mark for total UnitedHealthcare medical membership calls for 0.7% year-over-year growth in the second quarter.

Final Thoughts

Despite a projected 12.8% year-over-year increase in total revenues to $111.55 billion, the UnitedHealthcare unit is anticipated to have positioned the company for a significant year-over-year decline in profits. The Zacks Consensus Estimate for second-quarter earnings is pegged at $4.84 per share, representing a steep 28.8% drop from $6.80 a year ago.

UnitedHealth Group Incorporated Price, Consensus and EPS Surprise

UnitedHealth Group Incorporated price-consensus-eps-surprise-chart | UnitedHealth Group Incorporated Quote

Elevated costs and expenses are expected to have influenced UNH’s second-quarter profit margins, creating uncertainty about an earnings beat. Our estimate for total medical costs indicates a nearly 15% year-over-year increase, while we expect operating expenses to have increased by almost 14%. Further, we expect the cost of products sold to have jumped more than 10% year over year in the second quarter.

Also, our proven model does not conclusively predict an earnings beat for UnitedHealth. The combination of a positive Earnings ESP and a Zacks Rank #1 (Strong Buy), 2 (Buy) or 3 (Hold) increases the chances of an earnings beat, which is not the case here. UnitedHealth has an Earnings ESP of -9.55% and currently carries a Zacks Rank #4 (Sell). You can uncover the best stocks to buy or sell before they’re reported with our Earnings ESP Filter.

You can see the complete list of today’s Zacks #1 Rank stocks here.

Ongoing operational and regulatory headwinds have eroded UnitedHealth’s investment appeal. With limited upside and heightened downside risk ahead of second-quarter 2025 results, the Sell rating reflects a cautious stance and urges investors to consider exiting their positions.

This article originally published on Zacks Investment Research (zacks.com).

Zacks Investment Research

https://www.tradingview.com/news/zacks:0ba880d7a094b:0-unitedhealthcare-pressure-builds-trouble-ahead-for-unh-s-q2-earnings/

COLOR CODE: 

General item, but important. Gets at main point of article= YELLOW

Has a dollar amount or number = GREEN

A specific topic that seems to be different than other topics = BLUE

Alternative Headline: Doula-Led Medicaid Care Launches

[MM Curator Summary]: Pacify and First Choice are teaming up to deliver tech-enabled doula and lactation support to improve maternal health for South Carolina Medicaid members.

==============================

, /PRNewswire/ — Pacify, a leading provider of maternity care solutions, is collaborating with First Choice by Select Health of South Carolina, the state’s oldest and largest Medicaid managed care health plan, to deliver tech-enabled, doula-led wraparound maternal health services to First Choice’s members who qualify for the program. Pregnant members will receive care that addresses barriers to a healthy pregnancy and start to their baby’s life. 

This alliance combines virtual and in-person pre- and post-delivery doula services with 24/7 lactation support designed to improve health outcomes. It is a comprehensive care model that offers professional guidance along the pregnancy journey to address challenges that expectant and new mothers face.

Studies have shown that doula-supported births and lactation support services can help expectant mothers and their newborns, with benefits including:

• 47% reduction in Cesarean rates,
• 29% decrease in the risk of preterm births,
• 46% higher likelihood of attending a postpartum checkup, and a
• 57.5% lower chance of developing postpartum depression or anxiety.

"We are thrilled to partner with First Choice to bring our innovative maternal health services to its members," said Jennifer Sargent, CEO of Pacify. "This collaboration represents a significant step forward in our mission to ensure that every expectant and new mother has access to the support they need to experience a healthy pregnancy and postpartum period."

"By collaborating with Pacify, First Choice by Select Health will advance its commitment towards addressing disparities in maternal care by providing equitable access to culturally responsive support services," said Select Health Market Chief Medical Officer Diego Martinez, MD, MBA, MPH. "We are able to offer our members access to evidence-based services that complement our existing programs, including Bright Start® and Keys to Your Care®, to help ensure healthier outcomes for mothers and infants across South Carolina."

Learn more about how Pacify is driving better health outcomes by downloading its original research, case studies, and reports.

About Pacify

Pacify is a leading provider of maternity care solutions, partnering with public health agencies, health plans, and Medicaid MCOs. With over 10 years of experience in delivering maternity management support, Pacify offers comprehensive, doula-led support and guidance to expectant and new mothers through our digital platform and team of experienced healthcare professionals. With a core focus on empowering parents and promoting healthier outcomes, Pacify is dedicated to setting a new standard for maternity care. For more information, visit www.pacify.com.

About First Choice by Select Health of South Carolina

Select Health of South Carolina, part of the AmeriHealth Caritas Family of Companies, contracts with the South Carolina Department of Health and Human Services (SCDHHS) to offer First Choice, the state’s oldest and largest Medicaid managed care health plan, in all 46 counties statewide. For more information about First Choice by Select Health, visit www.selecthealthofsc.com.

Select Health also offers the First Choice VIP Care Plus Medicare-Medicaid plan and First Choice VIP Care (DSNP) Medicare Advantage Special Needs Plan for dual eligibles in 42 counties, as well as the First Choice Next Health Insurance Marketplace® product in 17 counties. For more information about First Choice VIP Care Plus, visit www.firstchoicevipcareplus.com. For information about First Choice VIP Care, visit www.firstchoicevipcare.com. For more information about First Choice next, visit www.firstchoicenext.com.

Media Contacts:

Pacify

Kaitlyn Tuson

me***@********io.com703-914-3191

First Choice by Select Health of South Carolina

Scott D. Bluebond

sb*******@****************as.com

215-840-8605 

View original content to download multimedia:https://www.prnewswire.com/news-releases/pacify-announces-collaboration-with-first-choice-by-select-health-of-south-carolina-302509296.html

SOURCE Pacify

https://www.easternprogress.com/pacify-announces-collaboration-with-first-choice-by-select-health-of-south-carolina/article_60680817-a17e-512e-9af4-aff98249f8a2.html

COLOR CODE: 

General item, but important. Gets at main point of article= YELLOW

Has a dollar amount or number = GREEN

A specific topic that seems to be different than other topics = BLUE

Alternative Headline: Centene Beats Revenue, Misses EPS

[MM Curator Summary]: Centene topped revenue forecasts in Q2 2025 with a reported revenue of $48.7 billion, but reported a sharp EPS loss due to rising medical costs and revenue adjustments.

==============================

Centene Corp Reports Q2 2025 Revenue of $48.7 Billion, Exceeding Estimates, Despite EPS Loss of $(0.51)

Financial Performance and Challenges in a Shifting Healthcare Landscape

Summary

• Revenue: Achieved $48.7 billion, surpassing the estimated $44.5 billion for the quarter.
• EPS: Reported a GAAP diluted loss per share of $(0.51), significantly below the estimated earnings per share of $1.14.
• Premium and Service Revenues: Increased by 18% year-over-year to $42.5 billion, driven by growth in the PDP and Marketplace businesses.
• Health Benefits Ratio: Rose to 93.0% from 87.6% in the previous year, influenced by increased medical costs and adjustments in Marketplace risk revenue.
• Cash Flow: Generated $1.8 billion in cash flow from operations, aided by improved pharmacy rebate remittance timing.
• SG&A Expense Ratio: Improved to 7.1% from 8.0% year-over-year, reflecting expense leveraging over higher revenues.

On July 25, 2025, Centene Corp (CNC, Financial) released its 8-K filing detailing its financial results for the second quarter of 2025. Centene, a managed care organization focusing on government-sponsored healthcare plans, reported a diluted loss per share of $(0.51) and an adjusted diluted loss per share of $(0.16), both falling short of the analyst estimate of $1.14 earnings per share. The company serves 22 million medical members, primarily in Medicaid, Medicare, and the individual exchanges.

Performance Overview and Challenges

Centene Corp (CNC, Financial) reported total revenues of $48.7 billion for the second quarter, surpassing the estimated revenue of $44,482.07 million. However, the company faced significant challenges, including a reduction in the Marketplace risk adjustment revenue transfer estimate and increased medical costs in both the Marketplace and Medicaid sectors. These factors contributed to the reported losses and highlight the volatility and complexity of managing healthcare costs in a dynamic regulatory environment.

Financial Achievements and Industry Context

Despite the challenges, Centene achieved an 18% increase in premium and service revenues, reaching $42.5 billion compared to $36.0 billion in the same period last year. This growth was driven by an increase in membership and premiums in the Medicare Prescription Drug Plan (PDP) business and the Marketplace. Such achievements are crucial for healthcare plan providers like Centene, as they reflect the company’s ability to expand its market presence and adapt to changing healthcare demands.

Key Financial Metrics and Statements

The health benefits ratio (HBR) increased to 93.0% from 87.6% in the previous year, indicating higher medical costs relative to premium revenues. The SG&A expense ratio improved to 7.1% from 8.0%, reflecting better expense management despite revenue growth. Cash flow from operations was robust at $1.8 billion, driven by improved pharmacy rebate remittance timing.

Analysis and Commentary

Centene’s performance in the second quarter underscores the challenges faced by healthcare providers in managing costs and regulatory changes. The company’s CEO, Sarah M. London, acknowledged the disappointing results but emphasized the strength of Medicaid, Medicare, and the Individual Marketplace. She stated,

We are disappointed by our second quarter results, but we have a clear understanding of the trends that have impacted our performance, and are working with urgency and focus to restore our earnings trajectory."

Centene’s strategic focus on adapting to market changes and delivering value to stakeholders remains critical as the company navigates the complexities of the healthcare industry. The company’s efforts in community engagement and recognition as a top workplace further highlight its commitment to social responsibility and employee satisfaction.

Explore the complete 8-K earnings release (here) from Centene Corp for further details.

https://www.gurufocus.com/news/3004893/centene-corp-reports-q2-2025-revenue-of-487-billion-exceeding-estimates-despite-eps-loss-of-051

COLOR CODE: 

General item, but important. Gets at main point of article= YELLOW

Has a dollar amount or number = GREEN

A specific topic that seems to be different than other topics = BLUE

Alternative Headline: Molina Faces Medicaid Uncertainty

[MM Curator Summary]: Molina Healthcare dipped 0.14% amid high trading volume as investors weigh Medicaid policy risks, compliance updates, and limited short-term momentum.

====================================

On August 20, 2025, (MOH) closed with a 0.14% decline, trading on $350 million in volume, ranking 303rd in market activity for the day. The stock’s muted performance reflected broader sector dynamics amid mixed earnings expectations and regulatory scrutiny in the healthcare insurance space.

Recent developments highlighted Molina’s exposure to evolving Medicaid policy shifts, with analysts noting potential volatility as states adjust enrollment practices post-pandemic. A regulatory filing earlier this month revealed updated compliance measures, though details remain limited. Market participants remain cautious, balancing optimism over renewed membership growth with concerns over premium rate constraints.

Historical trading patterns suggest limited short-term momentum for high-volume stocks, as evidenced by a backtest of a top-500 trading-volume strategy. The approach generated cumulative returns of $2,385.14 since 2022, marked by gradual gains interspersed with minor drawdowns, underscoring the challenges of volume-driven trading in a low-volatility environment.

Ask Aime: What’s behind Molina Healthcare’s recent price dip?

volume weighted portfolio performance(6548)

View 6548 results

https://www.ainvest.com/news/molina-healthcare-falls-0-14-350m-volume-ranks-303rd-regulatory-scrutiny-medicaid-shifts-2508/

COLOR CODE: 

General item, but important. Gets at main point of article= YELLOW

Has a dollar amount or number = GREEN

A specific topic that seems to be different than other topics = BLUE

Alternative Headline: Medicaid Cuts Reshape Market

[MM Curator Summary]: The 2025 Budget Reconciliation Law slashes Medicaid funding by $990 billion, triggering enrollment declines, state financing struggles, and uncertainty for major Medicaid insurers.

========================================

Q2 2025, which ended on June 30, is not just another quarter.  That’s because on July 4 the Budget Reconciliation Law (P.L. 119-21) was signed into law.  That law makes major cuts to Medicaid, reducing federal payments to states by $990 billion over the next ten years and leaving 7.5 million Americans uninsured in 2034. The sheer scale of these Medicaid cuts, which have almost nothing to do with reducing fraud and abuse against the program, are likely to cause a major disruption in the Medicaid managed care market now dominated by Centene, CVSHealth/Aetna, Elevance, Molina, and UnitedHealth Group—the “Big Five”.  Exactly how this disruption plays out for each of these companies and their Medicaid enrollees is uncertain.  What is certain is that Q2 2025 will be one benchmark against which future results for the “Big Five” will be assessed.  So where do things stand?

Figure 1 maps the journey of total Medicaid enrollment in all the “Big Five” companies, from the beginning of COVID-19 public health emergency (30.1 million), through the beginning of the unwinding of the continuous eligibility policy in place during the PHE (44.2 million), to Q2 2025 (36.2 million).  The Q2 total is only slightly (1%) lower than the Q1 total of 36.6 million, suggesting a plateau of sorts at the end of the unwinding.  (In all cases these numbers are the net of disenrollments offset by new enrollments).   How long that enrollment plateau will hold in the face of the federal Medicaid funding cuts and related coverage losses is now the question.

The total enrollment numbers for the “Big Five” mask considerable variation from company to company. As shown in Table 1, since the beginning of the unwinding on April 1, 2023, total “Big Five” enrollment has dropped 18.1%, from 44.2 to 36.2 million.  This mirrors the overall decline in Medicaid enrollment during the unwinding in both managed care and fee-for-service states.  Among the “Big Five,” however, the declines varied from a low of 1.2 percent (Molina) to 26.6 percent (Elevance). 

There’s not as much transparency around Medicaid revenues as there is around Medicaid enrollment.  Table 2 presents the results for the three companies for which this information is available: Centene, Molina, and UnitedHealth.  From the beginning of the unwinding on April 1, 2023, through June 30, 2025, the latter two reported revenue increases of 26 percent in the Medicaid lines of business despite enrollment declines; only Centene reported a drop in revenues, and that was small (2.3 percent) in comparison to its enrollment decline over that same period (21.5 percent).

As our colleagues Edwin Park and Sabrina Corlette comprehensively explain, the Budget Reconciliation Law changes federal Medicaid policy by, among other things, targeting the 41 Medicaid expansion states (and their more than 20 million adults who are covered by Medicaid) with policies designed to reduce enrollment and restrict the ability of all states to finance their share of Medicaid costs using revenues from provider taxes.  The impact will vary from state to state, but in no state will these changes stabilize the Medicaid managed care market, much less strengthen it.  In the Medicaid expansion states, losses of eligibility by low-income adults due to new mandates for imposing work reporting requirements and for conducting eligibility redeterminations every six months will be large. (Parents and children are also at risk).  CBO estimates that these two changes alone will result in the loss of coverage by 6.0 million Americans in 2034. 

The CEO of the Medicaid Health Plans of America, of which the “Big Five” are members, reportedly believes that the CBO estimates are low.  He is not alone.  The demands on state Medicaid agencies in implementing the Budget Reconciliation Law are daunting.  Mitigating enrollment losses due to red tape and complexity will be particularly challenging.  In managed care states, it would be logical for Medicaid agencies to involve the MCOs with which they contract in addressing these issues.  However, the law expressly bars state Medicaid agencies from using MCOs (or their contractors) to “determine beneficiary compliance” with work reporting requirements.  Depending on CMS interpretation, this “conflict of interest” prohibition could seriously compromise MCO efforts to mitigate enrollment losses, leaving under-resourced state agencies to engage other eligibility and enrollment contractors or manage themselves.

During the portions of the Q2 earnings calls in which the company’s Medicaid line of business came up, the discussions tended to focus on what senior managements described as “elevated cost trends” in Medicaid and other lines of business as well as their ongoing work with state Medicaid programs to better align capitation rates with the increasing acuity of medical need among enrollees.  Notably, there was no mention of the new law’s prohibition on adoption of new provider taxes or increases in existing provider taxes, including taxes on MCOs (section 71115).  According to KFF, 21 states plus DC had MCO taxes in place as of FY 2025 (AR, CA, IL, IA, KS, LA, MD, MA, MI, MN, NH, NJ, NY, OH, OK, OR, PA, RI, TX, WA, WV). Those states are prohibited from increasing those taxes, and no additional states will be able to adopt such taxes.  In addition, the new law invalidates the existing MCO taxes in at least 7 of those states (CA, IL, MA, MI, NY, OH, and WV).  The Secretary of HHS may (but is not required to) allow each of these states a transition period of up to three years. (section 71117). This issue also did not come up.  

CBO estimates that these two provisions will reduce federal payments to states by $191.1 billion and $34.6 billion, respectively, over the next ten years.  Without the ability to finance their share of Medicaid, states will have difficulty aligning rates with acuity, either now or in the future (if coverage losses produce further changes in the risk profiles of MCO enrollees). 

That said, one exchange put these changes in context.  In response to an analyst’s question, Centene’s CEO made the following observation: 

“When you think about One Big Beautiful Bill, there’s a lot of conversation about how those provisions have landed and what the negative impact may be. I think it’s really important to also remember that there were a number of far more disruptive provisions that were discussed and could have been introduced in that. So, things like per capita caps, FMAP reductions, block grants, all of which really got taken off the table very early in the conversation. And the reason I point that out is just because what that should tell you is that Medicaid has more bipartisan support than it has ever had as a program. So that’s really sort of the core of our view of the staying power in Medicaid.”

It’s indisputable that the Budget Reconciliation Law could have done much more structural damage to Medicaid.  But the harm that will be done by the law will hardly be marginal.  People covered by Medicaid, state Medicaid agencies, and MCOs face very strong headwinds for the foreseeable future.  Time will tell of course, but unless Congress reconsiders, going forward Q2 2025 may prove to be the highwater mark for Medicaid enrollment in many states.

https://ccf.georgetown.edu/2025/08/15/medicaid-managed-care-the-big-five-in-q2-2025/

COLOR CODE: 

General item, but important. Gets at main point of article= YELLOW

Has a dollar amount or number = GREEN

A specific topic that seems to be different than other topics = BLUE

Alternative Headline: Meridian, McLaren Form Partnership

[MM Curator Summary]: Meridian Health Plan partnered with McLaren Health Care to expand in-network access for over 500,000 members across Michigan.

==================================================

Members enrolled in our health plans will be able to receive their care close to home

, /PRNewswire/ — Meridian Health Plan of Michigan, Inc. (Meridian), a leading managed care organization in Michigan, is pleased to announce its new partnership with McLaren Health Care, one of the region’s most respected healthcare systems. This collaboration will expand access to high-quality medical services for over 500,000 Meridian members in our plans across the state.

Effective Aug. 15, Meridian members enrolled in our Medicaid, Medicare, Dual, and Marketplace plans will have full in-network access to McLaren facilities, which includes 12 hospitals in Michigan, ambulatory surgery centers, imaging centers, and an extensive network of primary and specialty care providers. This is the first time in Meridian’s history that we have partnered with McLaren to expand our network, and it’s a meaningful step forward in our mission to deliver accessible, high-quality medical care to our members.

“This partnership reflects our commitment to ensuring that our members receive the best care, close to home,” said Patty Graham, Plan President and CEO of Meridian. “By aligning with McLaren, we’re strengthening our network and bringing greater choice, convenience, and quality to the communities we serve.”

“One of our mandates as a health care provider is to develop access to our care and services for everyone in the communities we serve,” said Chad Grant, McLaren Health Care Chief Operating Officer. “Entering into this agreement advances our goal of ensuring more families and individuals are able to receive their care close to home, and we are grateful to welcome them to McLaren.”

Members will begin receiving detailed information about how to take advantage of the expanded provider network in the coming weeks.

Below is the full list of 35 counties where McLaren will be serving Meridian members:  

• Arenac
• Bay
• Clare
• Crawford
• Eaton
• Genesee
• Gladwin
• Gratiot
• Huron
• Ingham
• Ionia
• Iosco
• Isabella
• Jackson
• Kalkaska
• Lapeer
• Livingston
• Macomb
• Mecosta
• Midland
• Missaukee
• Montcalm
• Oakland
• Ogemaw
• Osceola
• Oscoda
• Otsego
• Roscommon
• Saginaw
• Sanilac
• Shiawassee
• St. Clair
• Tuscola
• Wayne
• Wexford

About Meridian Health Plan of Michigan, Inc. 
Meridian provides government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid (Meridian), Medicare Advantage and Medicare Prescription Drug Plans (WellCare), Medicare-Medicaid Plans (MeridianComplete) and the Health Insurance Marketplace (Ambetter from Meridian). Meridian is a Centene Corporation company. For more information, visit www.mimeridian.com.

About McLaren Health Care 
McLaren Health Care, headquartered in Grand Blanc, Michigan, is a $7.3 billion, fully integrated health care delivery system committed to quality, evidence-based patient care and cost efficiency. The McLaren system includes 12 hospitals in Michigan, ambulatory surgery centers, imaging centers, a 640-member employed primary and specialty care physician network, commercial and Medicaid HMOs covering more than 732,838 lives in Michigan and Indiana, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network and a wholly owned medical malpractice insurance company. McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, a National Cancer Institute-designated comprehensive cancer center. McLaren has 28,000 full-, part-time and contracted employees and more than 113,000 network providers throughout Michigan, Indiana, and Ohio. Learn more at mclaren.org.

View original content to download multimedia:https://www.prnewswire.com/news-releases/meridian-partners-with-mclaren-to-expand-its-network-in-35-counties-across-michigan-302524594.html

SOURCE Meridian of Michigan

https://themalaysianreserve.com/2025/08/08/meridian-partners-with-mclaren-to-expand-its-network-in-35-counties-across-michigan/

COLOR CODE: 

General item, but important. Gets at main point of article= YELLOW

Has a dollar amount or number = GREEN

A specific topic that seems to be different than other topics = BLUE