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FL Medicaid- MEDICAL/HEALTH CARE PROGRAM ANALYST

The State Personnel System is an E-Verify employer. For more information click on our E-Verify Website.

Requisition No: 705889 

Agency: Agency for Health Care Administration

Working Title: 68064934 – MEDICAL/HEALTH CARE PROGRAM ANALYST

Position Number: 68064934 

Salary:  $1,659.66 – $2,157.56 Bi-Weekly 

Posting Closing Date: 09/06/2022 

Agency Overview:

 
 

The Agency for Health Care Administration (AHCA) is Florida’s chief health policy and planning entity. The Agency is responsible for the oversight and administration of the Florida Medicaid program, the licensure and regulation of nearly 50,000 health care facilities, and empowering consumers through health care transparency initiatives.

 
 

Under the direction of Agency Secretary Simone Marstiller, the Agency is focused on advancing Governor DeSantis’ vision for Florida’s health care system to be the most cost-effective, transparent, and high-quality health care system in the nation.

 
 

The Medicaid program provides low-income families and individuals with access to health care.  If you have a desire to use your talent and skills at an organization that provides critical services to millions of individuals and families across the state, AHCA invites you to apply to become an essential member of our team. As one of Florida’s leading state agencies, AHCA’s diverse workforce community of more than 1,400 employees is proud of its efforts to serve the people of Florida.

 
 

Agency Objectives:

 
 

COST-EFFECTIVE

Leveraging Florida’s buying power in delivering high quality care at the lowest cost to taxpayers.

 
 

TRANSPARENT

Supporting initiatives that promote transparency and empower consumers in making well informed healthcare decisions.

 
 

HIGH QUALITY

Emphasizing quality in all that we do to improve health outcomes, always putting the individual first.

 
 

Position Overview:

 
 

This is an exciting opportunity to help shape the quality of health care in Florida. We are seeking to hire a Medical/Health Care Program Analyst who desires to work to enhance the delivery of health care services through the Florida Medicaid Program.  This position requires a candidate who is creative, flexible, innovative, and who will thrive in a fast-paced, team-based work environment.

 
 

This position is located in the Bureau of Medicaid Policy. Medicaid Policy is responsible for the development, coordination, and implementation of Florida Medicaid program policies, including: all Medicaid federal authorities (e.g., the Florida State Plan, 1115 waivers and home and community-based waivers), administrative rules, coverage policies, managed care plan contracts, bill analyses, drug utilization review boards, preferred drug lists, supplemental rebate contracts, and KidCare/Title 21. 

 
 

This position is responsible for organizing, supporting project activities and facilitating project teams; organizing and supporting rulemaking processes, preparing reports and presentations; analyzing service utilization data and population health data; analyzing and developing fiscal impact statements on proposed program revisions; preparing legislative budget requests and proposals; preparing bill analysis; researching state and federal laws that govern the Medicaid program; and representing the Agency in local, state, and national meetings.

 
 

Research

The incumbent shall:

Maintain up-to-date knowledge concerning all aspects of the Florida Medicaid program, including federal regulations, state statutes, administrative rules, and the Florida Medicaid State Plan.

Maintain up-to-date knowledge of health care and relevant industry trends that may have an impact on Florida Medicaid or may inform policy development activities.

Remain informed about the operations of the Medicaid fiscal agent, including Medicaid claims process, billing procedures, reimbursement methodologies, encounter submissions, and provider enrollment.

Remain informed about Medicare policies, national Medicaid-related research and demonstration projects, Medicaid medical assistance program innovations for general and special populations, and alternative financing and service delivery systems models.

Conduct research on assigned topics, including, but not limited to performing a review of peer-reviewed research articles, federal and state laws, other reliable sources of evidence, the Medicaid State Plan, Agency communications, State Medicaid Director Letters, and vendor contracts.

 
 

Program Planning and Analysis

The incumbent shall:

Analyze health care/program related information (including alternative financing and reimbursement strategies) in order to determine the effect on the Florida Medicaid program and compliance with federal and state laws.

Assist in the analysis and development of programmatic and fiscal impact statements based on proposed federal/state program or policy changes.

Prepare reports of research findings, including synthesizing complex and/or large amounts of information into a useful format and presentation.

Assist in the development of legislative budget requests and program proposals.

Assist in the development of grant proposals.

Assist in the completion of legislative reports, including collection of necessary data elements.

Assist in the development and implementation of program designs, projects, and/or plans in order to meet bureau goals/priorities.

 
 

Policy Development

The incumbent shall:

Develop and maintain program policies and procedures under the Florida Medicaid program to ensure that programs operate in accordance with the goals and objectives of the Agency, state and federal laws, rules, regulations, and guidelines.

Assist in the development of policy language for: the Medicaid managed care report guide, Medicaid contracts and amendments; Dear Managed Care Plan letters, contract interpretations, policy transmittals, and provider alerts.

Track and monitor the routing and approval of all policy documents to ensure timely completion and adherence to Agency established deadlines.

 
 

Communication

The incumbent shall:

Assist in the development of training and providing technical assistance to ensure consistency in service/program operation and conformity with goals and objectives of the Agency, state and federal laws, rules, regulations, and guidelines.

Develop, coordinate, and implement statewide program training plans.

Identify and document training needs.

Design and evaluate training programs and materials.

Conduct statewide and local trainings, as required.

Provide technical assistance regarding service/program policies and procedures.

Provide consultation through the accurate presentation of data and other service/program information.

Participate on behalf of the Agency in local, state, or national meetings, conferences, workshops, and seminars related to the Florida Medicaid program.

Prepare presentations materials, as assigned.

 
 

Contract Management

The incumbent shall:

Perform contract management activities in accordance with goals and objectives of the agency and state and federal laws, rules, regulations, and guidelines.

Develop and execute provider contracts addressing standard contract documents, services to be provided, manner of service provision, method of payment, and special provisions.

Process, inspect, review, and approve deliverables, and invoices for payment.

Track and monitor provider expenditures.

Maintain appropriate contract files and records.

Carry out other necessary contract management activities.

 
 

All applicants must ensure that all employment and detailed information about work experience is listed on your applicant profile and/or resume (including dates of service, reason for leaving, military service, self-employment, job-related volunteer work, internships, etc.) and that gaps in employment are explained.  Applicants who do not provide all information necessary to meet the minimum requirements, will not be considered for this position.

 
 

Benefits of Working for the State of Florida:
Working for the State of Florida is more than a paycheck. The State’s total compensation package for employees features a highly competitive set of employee benefits including:


     •         State Group Insurance Coverage Options, including health, life, dental, vision, and other  supplemental insurance options;
     •         Flexible Spending Accounts;
     •         State of Florida retirement options, including employer contributions;
     •         Generous annual and sick leave benefits;
     •         9 paid holidays a year and 1 Personal Holiday each year;
     •         Career advancement opportunities;
     •         Tuition waiver for courses offered by Florida’s nationally ranked State University System ;
     •         Training and professional development opportunities;
     •         And more!
 

For more information about the Bureau of Medicaid Policy, please visit our website at http://ahca.myflorida.com/Medicaid/index.shtml.

 
 

Join us at the Agency for Health Care Administration in fulfilling our mission to provide “Better Health Care for all Floridians.”

 
 

KNOWLEDGE, SKILLS, AND ABILITIES

Ability to direct and coordinate the planning and implementation of operational and program reviews and program monitoring activities.

Ability to utilize problem-solving techniques.

Ability to understand and apply applicable rules, regulations, policies, and procedures pertaining to a health services program.

Ability to prioritize workload.

Ability to develop various reports.

Ability to design, develop and implement research models.

Ability to manage a health services program.

Ability to assess budgetary needs.

Ability to collect and analyze financial data.

Ability to formulate policies and procedures.

Ability to plan, organize and coordinate work activities.

Ability to communicate effectively.

Ability to establish and maintain effective working relationships with others.

Ability to travel with or without accommodations.

 
 

MINIMUM QUALIFICATIONS REQUIREMENTS

One year of experience developing health care related policies

One year of technical writing experience

One year of experience managing complex assignments

 
 

A bachelor’s degree from a college or university is preferred and can substitute for the required experience.

Two years of professional experience in program planning, program research, or program evaluation is preferred.

 
 

Please note a skills test will be required.

 
 

LICENSURE, CERTIFICATION, OR REGISTRATION REQUIREMENTS

N/A

CONTACT:  LEKIEVA CAMPBELL (850) 412-4210

The State of Florida is an Equal Opportunity Employer/Affirmative Action Employer, and does not tolerate discrimination or violence in the workplace.

Candidates requiring a reasonable accommodation, as defined by the Americans with Disabilities Act, must notify the agency hiring authority and/or People First Service Center (1-866-663-4735). Notification to the hiring authority must be made in advance to allow sufficient time to provide the accommodation.

The State of Florida supports a Drug-Free workplace. All employees are subject to reasonable suspicion drug testing in accordance with Section 112.0455, F.S., Drug-Free Workplace Act.

VETERANS’ PREFERENCE.  Pursuant to Chapter 295, Florida Statutes, candidates eligible for Veterans’ Preference will receive preference in employment for Career Service vacancies and are encouraged to apply.  Certain service members may be eligible to receive waivers for postsecondary educational requirements.  Candidates claiming Veterans’ Preference must attach supporting documentation with each submission that includes character of service (for example, DD Form 214 Member Copy #4) along with any other documentation as required by Rule 55A-7, Florida Administrative Code.  Veterans’ Preference documentation requirements are available by clicking here.  All documentation is due by the close of the vacancy announcement. 

 
 

 
 

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Director, Product Development & Management (Medicaid) Job in Long Island City, NY at Centene Corporation

 
 

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Centene CorporationLong Island City, NY

  • You could be the one who changes everything for our 26 million members.
  • Centene is transforming the health of our communities, one person at a time.
  • As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
  • Position Purpose: Oversee the product development and management of health and wellness products for the Medicaid (and other government programs) market.
  • Design, develop, implement, and manage new and existing products from initial conception through service delivery
  • Lead new product development efforts and cross-functional teams to develop and execute detailed project plans, outline workflows, sales and marketing collateral content, staffing models and product pricing, and client reporting specifications
  • Monitor market trends to identify new product opportunities or enhancements to existing products
  • Review product performance and outcomes and make recommendations for program improvements
  • Respond to product inquires and assess new product requests
  • Participate in the development of business strategy for the Medicaid market
  • Ensures legal and regulatory compliance of new products and product enhancements
  • Conduct training sessions for various internal teams on products
  • Education/Experience: Bachelor’s degree in Communications, Business Administration, or related field.
  • 5+ years experience with health care or Medicaid product development/management, marketing, or project management in a managed care or insurance environment.
  • Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
  • The above responsibilities will apply to the oversight of the Marketplace and Essential Health plan products for Fidelis Care.
  • Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.
  • Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different.
  • All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
  • Director, Product Development & Management (Medicaid)
  • Long Island City, New York

Stand out and contact Centene Corporation directly

Updated 2 days ago

 
 

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Cambia Health Solutions, Inc. Director, Medicaid Job in Portland, OR

 
 

Director of Medicaid

Oregon, Washington, Utah and Idaho (remote work available in these states)

Primary Job Purpose

The Director of Medicaid is the voice of Medicaid internally and externally reporting to the SVP, Government Programs. The Director of Medicaid is accountable for the Profit and Loss of the line of business. This leader is responsible for the strategy, business cases development and implementation of Medicaid in one or all of our four states. This includes overall performance of the market Medicaid line of business program, a focus on financial performance and membership growth. Oversees all aspects of market Medicaid programs, state contracting arrangements, product development, compliance with State and Federal Policies and requirements and partnerships with other divisions. Strategically builds, manages and sustains external business relationships, particularly with state and local regulators. Accountable for product development, administrative processes, interdepartmental communication and regulatory requirements. Develops an annual strategic plan and updates executive leadership on strategic issues/development, business performance and progress against objectives. Demonstrated passion and creativity in developing models of care serving low-income vulnerable populations.

General Functions and Outcomes

The position is responsible for the customer experience, achieving membership growth targets, overseeing & developing the Medicaid product portfolio and developing/executing market Medicaid strategy based on state and CMS requirements, national standards and alignment with overall national and market strategy. This position incorporates care delivery requirements into strategy and develops a strong partnership with the medical group and health plan delivery system.

Normally to be proficient in the competencies listed above:

Minimum 10 years of relevant experience in a Medicaid managed care organization. Minimum 7 years of management experience. Minimum 5 years in product line management to special populations. Bachelor’s degree or 4 years relevant experience.

Minimum Requirements

The Director, Medicaid must have a strong background working with Medicaid and/or Special Populations and unique health care needs. Must be a decisive, results-oriented leader of people, be able to work in a highly matrixed environment and have strong collaborative skills. Additional competencies include:

  • Understanding of state and federal Medicaid framework and regulatory requirements
  • Excellent negotiation skills, verbal/written communication skills
  • Strong analytical and strategic planning skills
  • Excellent public presentation skills
  • Strong persuasive and interpersonal skills
  • Product and Program development skills
  • Knowledgeable of Medicaid health care delivery systems
  • Knowledgeable of current trends in care management and industry related to care delivery to Medicaid population
  • Demonstrated ability to build effective partnerships and influence others who may have different perspectives

FTE’s Supervised

1-5 direct reports

15-20 total

Work Environment

Work is primarily performed remotely

Travel may be required, locally or out of state

May be required to work outside normal hours

Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We’ve been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.


If you’re seeking a career focused on making the health care experience simpler, better, and more affordable for people and their families, consider joining our team at Cambia Health Solutions. Cambia is a total health solutions company that is deeply rooted in a 100-year legacy of transforming the industry and the way people experience health care. We had our beginnings in the logging communities of the Pacific Northwest as innovators in helping workers afford health care. That pioneering spirit has kept us at the forefront as we build new avenues to improve access to and quality of health care for the future. Cambia is committed to delivering a seamless, personalized health care experience for the next 100 years.

This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit

www.cambiahealth.com/careers/total-rewards

.

We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.

If you need accommodation for any part of the application process because of a medical condition or disability, please email

Ca***********@**********th.com

. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our

Privacy Policy

. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our

Careers

site.

 
 

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Supervisor, Operations (Medicare and Medicaid Programs) in Owings Mills, MD – CareFirst

 
 

Resp & Qualifications

PURPOSE:
Supervise and provides daily direction to multi-functional team members regarding training and development, policies, procedures, and work production quantity and quality. Functional areas may include but not limited to: installation, implementation, client support, client services, client administration, customer service, enrollment and eligibility, claims processing, and call center operations. Reviews and resolves complex service issues not resolvable by subordinates.

ESSENTIAL FUNCTIONS:

  • Supervise employee outcomes by training, assigning, scheduling, coaching, and counseling employees; communicating job expectations; planning, monitoring, and appraising job contributions; adhering to policies and procedures.
  • Meets operational standards by contributing information to strategic plans and reviews; implementing production, productivity, quality, and customer-service; resolving problems; identifying system improvements.
  • Maintains customer service objectives by monitoring daily operations; resolving claims that require manual review or technical support, enrollment or billing related customer issues. Consistently reviews systems and makes necessary adjustments where needed, including resources/staffing. Researches and resolves escalated calls, review and resolve complex claims that have not been resolved by Claims staff.
  • Maintains and improves departmental operations by monitoring system performance; identifying and resolving operations problems; supervising process improvement and quality assurance programs; installing upgrades.
  • Prepares call center, claims and or enrollment and billing performance reports by collecting, analyzing, and summarizing data and trends.
  • Improves call center, claims and or enrollment and billing job knowledge by attending educational workshops.

SUPERVISORY RESPONSIBILITY:
This position manages 2-10 people.

QUALIFICATIONS:


Education Level:
High School Diploma or GED.

Experience: 3 years related professional experience with demonstrated leadership skills. Must have proficiency in the service, claims or enrollment & billing area.

Preferred Qualifications: Bachelor’s Degree. 

  • Familiar with the Market Prominence system
  • Three – Five years of supervision experience
  • Knowledge of Dual Eligible Special Needs Plans (DSNP)
  • Ideal candidate will have experience with Membership Enrollment and/or Managed Health Care Experience 

Knowledge, Skills and Abilities (KSAs)

  • Knowledge of call center operations, claims and/or enrollment and billing and work flows.
  • Strong presentation skills.
  • Highly proficient in Microsoft Office programs.
  • Excellent communication skills both written and verbal.
  • Ability to plan, review, supervise, and inspect the work of others.

Department

Department:MD Medicaid-Enrollment

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship.

#LI-LY1 

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Finance Professional – Medicaid Jobs in Louisville, KY – Humana

 
 

Finance Professional – Medicaid Job at Humana – 3.6 in Louisville, KY

Description

The Finance Professional analyzes and forecasts financial, economic, and other data to provide accurate and timely information for strategic and operational decisions. The Finance Professional work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

The Finance Professional collects, compiles, verifies, and analyzes financial information and economic indicators so that senior management has accurate and timely information for making strategic and operational decisions on, for example, acquisitions, investments, capital expenditure, divestitures, mergers, or the sale of assets. Analyzes the financial implications of proposed investments or other transactions so that senior managers can evaluate alternatives against the organization’s business objectives. Evaluates industry, economic, financial, and market trends to forecast the organization’s short, medium, and long-term financial and competitive position. Analyzes revenues, expenses, costs, prices, investments, cash flow, profits, labor market trends, inflation, interest rates, and exchange rates. May involve financial modeling, reporting and budgeting as well. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Required Qualifications

Bachelor’s degree ideally in finance, accounting or similar field


Demonstrated experience in a finance or accounting role


Proficient in manipulating financial data for analysis and reporting


Demonstrated proficiency with SQL


Proficient with Microsoft Excel

Preferred Qualifications

Previous health insurance industry experience working in a Finance/Accounting department

Additional Information

Location: Waterside bldg, Louisville, KY or IN, OH ((hybrid home/office/remote)

#LI-JW3

Vaccine Policy:
Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field. Every associate and contractor who work inside a Humana facility or in the field, regardless of vaccination status, must complete a daily health screening questionnaire.

Please note: Some areas of our business, such as the Primary Care Organization including CenterWell, Conviva, Kindred at Home, onehome, SeniorBridge, Neighborhood Centers, Pharmacy Distribution Centers and others, may be required to adhere to federal, state or local or additional workplace guidelines.

Work-At-Home Requirements:
WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.


A minimum standard speed for optimal performance of 25×10 (25mpbs download x 10mpbs upload) is required.


Satellite and Wireless Internet service is NOT allowed for this role.


A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Why Humana?

At Humana, we know your well-being is important to you, and it’s important to us too. That’s why we’re committed to making resources available to you that will enable you to become happier, healthier, and more productive in all areas of your life. Just to name a few:

Work-Life Balance


Generous PTO package


Health benefits effective day 1


Annual Incentive Plan


401K – Immediate company match (Change Jan 1 2023 remove Immediate Match)


Well-being program


Paid Volunteer Time Off


Student Loan Refinancing

If you share our passion for helping people, we likely have the right place for you at Humana.

Social Security Task:
Alert: Humana values personal identity protection. Please be aware that applicants being considered for an interview will be asked to provide a social security number, if it is not already on file. When required, an email will be sent from Hu****@*******ay.com with instructions to add the information into the application at Humana’s secure website.

Scheduled Weekly Hours

40

 
 

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MCOs- Molina, Elevance, Centene win big with Medicaid contracts in California

[MM Curator Summary]: This is the big show, and we now have winners (and losers) after years of anticipation.

 
 

The California state flag waves in the wind. The California Department of Public Health recently released guidance for school leaders about how to best mitigate the spread of COVID-19 as students and staff enter their fourth pandemic academic year. Stock Photo via Getty Images

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Dive Brief:

  • Elevance, Molina and Centene have won lucrative contacts to deliver Medicaid managed care in California beginning in 2024, the state’s Department of Health Care Services said Thursday.
  • The five-year contracts in California’s Medicaid program, called Medi-Cal, are the result of the state’s first-ever competitive procurement for commercial managed care plans, according to a DHCS release.
  • The state plans to award 28 contracts to Molina Health Care, Elevance-owned Anthem Blue Cross Partnership Plan and Centene-owned Health Net to deliver Medi-Cal services in 21 counties.

Dive Insight:

Medi-Cal is the largest Medicaid program in the U.S., covering more than 14.6 million low-income Americans as of this year.

Holding a competitive procurement for commercial managed care plans reflects California’s objective to hold managed care companies and their subcontractors more accountable for high-quality care, DHCS said. With the new contracts, DHCS wants to reshape how care is delivered to Medi-Cal beneficiaries, 99% of whom will be enrolled in managed care by 2024.

At that time, managed care plans will provide not only medically necessary healthcare services, but also additional services to treat the whole person. Plans can accomplish this through partnerships with local groups like health departments and social services, DHCS said.

Plans and their subcontractors with a positive net income will also be required to reinvest 5% to 7.5% of profits in local community infrastructure.

DHCS is also strengthening its oversight of Medi-Cal providers. Payments to plans will be linked more closely to member access and outcomes, and plans will be required to report on primary care utilization and spending, the state said.

Plans must also meet requirements for reducing health disparities and improving outcomes, including addressing unmet social needs like food insecurity.

DHCS is also allowing 17 counties to change the type of managed care model they participate in, and approved a proposed direct contract with Kaiser Permanente in 32 counties, subject to federal approval. That will allow Kaiser to continue selecting its customers, a controversial allowance that rivals argue allows the payer to select healthier and therefore less expensive members.

Molina, Centene and Elevance already held Medicaid contracts with California, but the overhaul in counties served is already causing one payer to consider appealing the proposed contracts.

In a statement, Centene said it was pleased to have been awarded the contracts in nine counties, but was disappointed to lose contracts in Los Angeles, Sacramento and Kern.

“We strongly believe our exit in these counties will be a significant disruption in services to our members and providers. We are evaluating all options to appeal the decision,” the St. Louis-based payer said.

Centene, the largest Medicaid insurer in the U.S. (and in California), received the contract despite a recent California investigation into allegations that the insurer defrauded Medi-Cal by overbilling for prescription drugs.

CVS-owned Aetna and UnitedHealth are among the payers losing market share in the new contract selection. UnitedHealth told Healthcare Dive it decided not to submit a bid, and will work with DHCS on a transition plan.

At the end of last year, Aetna had contracts in two counties — Sacramento and San Diego — while UnitedHealth had a contract to serve San Diego.

Plans that lost bids have until Sept. 1 to appeal.

DHCS estimates that roughly 2.3 million managed care members, or 18%, will likely transition to a new plan as a result of the commercial procurement, with the majority of churn in the counties of Los Angeles, Kern, Sacramento and San Diego.

The contracts can be lucrative for managed care organizations. Centene’s Health Net, for example, reported net income of $127 million in the last quarter of 2021, while Molina brought in $59 million and Elevance’s Blue Cross of California Partnership Plan brought in $31 million, according to state data.

Clarification: This article has been updated to include that UnitedHealth did not submit a proposal for Medi-Cal.

Clipped from: https://www.healthcaredive.com/news/molina-elevance-centene-california-medicaid-medi-cal-contracts/630577/
 

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Homegrown Medi-Cal plan misses out in state’s new contracting program

[MM Curator Summary]: One of the losers in the recent Medi-Cal procurement was a community plan that has been operating for 40 years and serving 330,000 members.

 
 

More than half of San Diego County’s nearly 900,000 Medi-Cal recipients will have to switch health plans in 2024, according to a major consolidation effort announced by the state Department of Health Care Services Thursday.

The move pares the number of companies able to manage Medi-Cal plans for the state from seven to three in San Diego, awarding future contracts to giants HealthNet, Molina Healthcare and Kaiser Permanente. The move leaves Blue Shield of California, Aetna, United Health Care and Community Health Group on the outs.
 

For the record:

9:45 a.m. Aug. 29, 2022A previous version of this story indicated that Community Health Group was the sole non-profit Medi-Cal plan operating in San Diego County. Kaiser Permanente and Blue Shield of California are also non-profits. We apologize.

With about 330,000 members, Community Health Group is the largest Medi-Cal plan operating in the region and also has, by far, the deepest local roots. Created in San Ysidro 40 years ago, the organization is one of three only nonprofit health plans serving Medi-Cal members in San Diego County.

In a written statement, the organization decried the state’s announcement.

“We vigorously oppose this decision and will engage our community to join the cause,” said Norma Diaz, Community Health Group’s chief executive officer. “We have already begun the process of protesting this decision.”

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The organization employs more than 300 people in the county, with 95 percent of its staff living in the region.

No one currently covered by Medi-Cal, the state’s safety net health insurance system, will lose their coverage as a result of the announcement. Rather, there will be a smaller number of plans able to offer “managed care” services in the region. Managed care refers to the practice of having a health insurance company contract with a specific set of local medical providers to serve their members.

Starting in the 1970s, California has gradually migrated Medi-Cal beneficiaries into managed care plans and away from a “fee for service” model where those with coverage due to low wages or disability could seek care with any health care provider willing to accept the state program’s reimbursement schedule.

Today, about 12.3 million of California’s 14.6 million Medi-Cal enrollees are in managed care plans.

Most California counties have one or two different companies running Medi-Cal managed care plans, but that’s not the case in San Diego County, which has seven, and Sacramento County, which has five.

The reason why these two counties have followed a different path has to do with fundamental decisions made in the early 1990s. But the idea of having so many competing plans came under scrutiny in 2019 in a report from the California Healthcare Foundation. The nonprofit research organization commissioned an examination of Sacramento and San Diego Medi-Cal recipients as compared to urban counties with fewer plans.

Researchers found that the counties with more plans tended to do a few percentage points worse on everything from managing chronic disease to child and adolescent access to primary care. The differences weren’t always visible, with no differences observed, for example, in the percentage of patients who needed to be readmitted after receiving care.

Nonetheless, the state Department of Health Care Services, which runs the Medi-Cal program, decided to award no more than two managed contracts per county in a first-ever “procurement” program that was announced Thursday. The state will also maintain its existing contracts with Kaiser Permanente in many counties, including San Diego. As both provider and health insurance company, Kaiser is a little different than the others who competed for contracts.

The procurement is part of a larger “CalAIM” program designed to overhaul most aspects of Medi-Cal. The new system will requires plans to commit to more holistic operations and do more to pay for care that is more accessible, proactive, transparent and culturally competent.

San Diego County government has been behind the state’s move to narrow the playing field with Nathan Fletcher, chair of the county board of supervisors, and his colleague Nora Vargas, getting unanimous approval in a “letter of support” program on a county agenda in July of 2021.

Though Fletcher declined through a representative to comment on DHCS’s choice of plans in San Diego, he was clear during the board meeting last year that he thought shrinking the number of managed care plans operating in the San Diego region was a good idea. He said many local health care providers find it difficult to work with so many different players, each of which has its own unique operating procedures. Consolidating, he said, could make it easier to do broad-reaching work across the entire Medi-Cal population and it would have helped during the COVID-19 pandemic.

“We think that at the end of this we will arrive with a Medi-Cal system that has more consistency, that is easier for our providers to accommodate and will provide more services, particularly those services we think are most valuable and most important,” Fletcher said on July 13, 2021.

But Community Health Group is crying foul, indicating that health care quality reports have long shown that its members are doing well, in many cases better than those in other local managed care plans. The most-recent external quality review reports published by DHCS seem to bear that notion out.

For example, 63.2 percent of CHG members age 50 to 74 were said to have received cancer screening mammograms. That was one of the better scores among plan providers in San Diego County, slightly besting Molina’s score and significantly exceeding Health Net’s. Slightly lower percentages of Health Net and Molina patients needed to be readmitted after receiving care than was the case for CHG patients, though all three had numbers that beat expectations.

“We work hard to meet and exceed the Department of Health Care Services contract requirements and take pride in our audit results, high quality scores, proven access to care and exceptional customer service,” CHG’s statement said.

The new contracts start Jan. 1, 2024, meaning that local members have a year to wait before they have to make a decision.

 
 

Clipped from: https://www.sandiegouniontribune.com/news/health/story/2022-08-26/homegrown-medi-cal-plan-misses-out-in-states-new-contracting-program-contracting

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MCOs- Medicaid managed care plans send big checks to increase access to health care services

[MM Curator Summary]: The Florida RFP is expected to drop this fall.

 
 

Two Medicaid managed care plans this month have provided grant money in an effort to increase access to health care services.

Simply Healthcare Plans gave a $150,000 grant to the Florida Behavioral Health Association (FBHA) to support certified community behavioral health clinics (CCBHC).  

The CCBHC model is an innovative, integrated health care model developed to ensure access to a comprehensive array of behavioral health care services for mental health and substance abuse disorders for anyone who needs care, regardless of their ability to pay, where they live or their age. 

CCBHCs must provide care coordination to help people navigate behavioral health care, physical health care, social services and other systems they are involved in. 

The Substance Abuse and Mental Health Administration within the Department of Health and Human Services has offered grant opportunities for CCBHCs and is poised to announce the latest recipients soon.

 
 

There are 13 CCBHCs in Florida. Twelve of them, said FBHA President Melanie Brown-Woofter, are members of the association.

CCBHC patients in Florida have experienced a 69% decrease in hospitalizations for a mental health condition and a 92% decrease in incarcerations, Brown-Woofter said in a prepared statement.

“The CCBHC model is the future in quality, behavioral health care for all. The success these cutting-edge, patient-centered clinics have already had in Florida is incredible,” she said. “The FBHA is grateful to Simply for partnering with us to continue the work of the CCBHCs and ultimately improving the lives of Floridians.”

Simply Healthcare Plans presented the $150,000 check to the FBHA at its conference last week in Orlando. 

“As part of Simply Healthcare Plans’ ongoing commitment to address the physical, behavioral and social drivers that impact the health of the communities we serve, we are proud to support the Florida Behavioral Health Association in its mission to advance and advocate for better behavioral health for all Floridians,” Holly Prince, president of Simply Healthcare said.

 
 

Simply Healthcare Plans has contracts with Florida to provide Medicaid managed medical assistance and Medicaid managed long-term care plans as well as Florida Healthy Kids policies.

Meanwhile, Sunshine Health Plan announced Aug. 15 that it is committing $500,000 to Tallahassee Community College over the next five years to help abate the health care workforce shortage. The commitment was made after the success of a pilot program dubbed the “Gadsden Connect.” 

Sunshine agreed in 2020 to provide scholarships to Gadsden County residents who met the prerequisites for the nursing assistant and home health aide certification programs. The disruption caused by COVID-19 meant the pilot program was spread over a two-year period with a smaller group of students, a spokesperson for Sunshine said 60 residents had completed the TCC programs.

The commitment to TCC is just the beginning. Sunshine is finalizing similar type partnerships with Broward College and Hillsborough Community College.

Sunshine Health is a wholly owned subsidiary of Centene Corporation, a diversified, multinational health care enterprise. Sunshine Health has contracts with the Agency for Health Care Administration to provide Medicaid managed medical assistance, Medicaid managed long-term care and a Medicaid managed specialty plan for people with serious mental illness. It also has a contract with the Department of Health to provide health care to medically complex children.

The company also operates on the federal health insurance exchanges under the moniker Ambetter, and offers Medicare Advantage and Prescription Drug Plans under the Wellcare name.

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Clipped from: https://floridapolitics.com/archives/552678-medicaid-managed-care-plans-send-big-checks-to-increase-access-to-health-care-services/

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MCOs – Aetna Medicaid donates $450K to support Texas communities

[MM Curator Summary]: The Texas RFP drop has been imminent for, like, forever.

Sandra Levy

Senior Editor

 
 

Aetna Medicaid, a CVS Health company, donated a total of $450,000 to four community health partners across the state of Texas. The donations are supporting the important work of healthcare providers and amplifying the impact community organizations have on meeting needs, ranging from digital literacy to peer support for families of individuals with intellectual or developmental disabilities.

“Our commitment to communities and our partners in Texas is unwavering,” said Stephanie Rogers, CEO of Aetna Better Health of Texas. “These investments will enable access to much-needed resources and empower Medicaid members to take more control of their health.”

[Read more: New Aetna plan leverages CVS Health’s enerprise strengths]

Aetna’s community donations totaling $450,000 were made to the following organizations:

  • The Texas Association of Area Agencies on Aging is a statewide network of local area agencies on aging that provides a forum for collaboration, training and outreach across the state, supporting people age 60 years old and older and their caregivers. COVID-19 has exposed and exacerbated gaps in digital literacy, particularly among older Americans. A 2020 survey found that nearly 50% of older adults in Central Texas are beginner users or have never used technology. This donation is ultimately helping T4A review, refine and promote evidence-based programs that enhance digital literacy so seniors can overcome barriers to participating in healthcare programs such as those related to disease management, improving balance and caregiver stress management;
  • Texas Parent to Parent works to improve the lives of children and adults with disabilities, chronic and mental health conditions and other healthcare needs. It fosters independence and empowers families to be stronger advocates through parent-led support, resource referral and education. The CDC reported that, in 2020, 3% of adult Texans had difficulty completing self-care tasks, like bathing and dressing, while 11% had mobility challenges. This donation is advancing efforts to improve health and well-being by helping families and people with disabilities effectively develop a personal support network that includes healthcare providers and peers;
  • National Alliance on Mental Illness Texas supports individuals living with mental illness, family members, friends and professionals. It works to improve the lives of people affected by mental illness through education, support and advocacy. The pandemic has had a significant impact on mental health particularly for frontline healthcare and public safety professionals. For example, during mid-2020, as the COVID-19 pandemic progressed, 93% of healthcare workers were experiencing stress, 86% reported experiencing anxiety, 77% reported frustration, 76% reported exhaustion and burnout and 75% said they were overwhelmed. This donation is expanding mental health and wellness programs for behavioral health providers and first responders, mitigating workforce shortages in the field and providing timely support and services to meet the mental health needs of Texans; and
  • Memorial Hermann Community Benefit Corporation supports the vision of Memorial Hermann, a not-for-profit health system, to create healthier communities, now and for generations to come. Census data shows that 13% of people in Texas are in poverty. The CBC’s Community Resource Centers offer efficient and early interventions for at-risk populations in the Houston area to bridge healthcare and social services. This donation is helping fund the Community Resource Center at Memorial Hermann Southwest Hospital to meet a range of social health needs.

[Read more: CVS Health investing $18.9M in affordable housing in Columbus]

“Area Agencies on Aging help local community members remain in their homes and offer classes on topics important to ensuring seniors stay healthy and lead independent lives,” said Ginny Lewis Ford, executive director of the Texas Association of Regional Councils. “As community support and health services providers shift their delivery models, access to these programs may only be online. Increasing and enhancing digital literacy is vital for seniors and their caregivers to maintain access to health services from their homes, especially when travel is challenging. Telehealth and telemedicine are transforming how and where programs and healthcare are administered, and this donation is helping us take a big step forward in identifying and implementing digital literacy programs that will educate and empower older adults and their families through the existing area agency on aging network in Texas.”

Since 2021, Aetna Medicaid has donated more than $600,000 to a range of community health partners throughout the state to positively impact population health and provide those in need with more options to access quality health care.

Aetna Better Health of Texas serves more than 140,000 enrollees across the state through the Texas Medicaid STAR, STAR Kids and Children’s Health Insurance Program programs.

 
 

Clipped from: https://drugstorenews.com/aetna-medicaid-donates-450k-support-texas-communities

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MCOs- Iowa’s $7 billion privatized Medicaid program will work with 3 health insurance companies

[MM Curator Summary]: The new contracts start next summer. Winners-Amerigroup (incumbent), Molina (highest score), and Total Care (Centene, incumbent).

 
 

Iowa will soon have three health insurance companies to help run its Medicaid program.

On Wednesday, the Iowa Department of Health and Human Services announced the intent to award managed care contracts to two winning bidders: Amerigroup Iowa and Molina Healthcare of Iowa. Iowa Total Care currently holds a managed care contract with Iowa that lasts through 2025.

Starting next year, these for-profit companies will help manage the joint federal and state program that finances roughly $7 billion in health care annually for nearly 790,000 Iowans who are lower income or have disabilities.

The state’s decision to privatize the Medicaid system in 2016 has been a controversial one. Over the years, Medicaid enrollees and health care providers have reported reduced services or challenges with receiving accurate reimbursement. The abrupt exit of two carriers within the first years of privatization also caused turmoil for its members.

But the head the state program says this round of contract negotiations includes steps to mitigate any future issues within the program.

“From when we first implemented managed care in 2016 to now, we’ve taken a lot of lessons learned,” Iowa Medicaid Director Elizabeth Matney said in an interview with the Des Moines Register.

What’s next for Iowa Medicaid?

There will be no immediate changes for Iowa Medicaid members with this week’s announcement. Four-year contracts with these managed care organizations begin July 1, 2023.

Medicaid members will be distributed among the three insurers as equitably as possible, Matney told reporters Wednesday. She did not say whether members could be assigned a new managed care organization, but noted member preference will play a role in the upcoming transition.

Matney said state officials are evaluating Medicaid provider networks to ensure members won’t have to seek a new provider if they transition to a new organization.

“We really want members to be able to make choices based on something other than which provider is in each one of the managed care organizations network,” she said.

Though there’s more optimism among critics in this latest round of contract negotiations, some said they had lingering concerns about the impact a transition will have on Medicaid members.

“I do believe the management team at Iowa HHS will do a better job of helping with this transition to adding a third (managed care organization) than we have seen in the past,” said state Sen. Pam Jochum, a Democrat from Dubuque. “But having said that, it will still be a tremendous upheaval for providers, for Medicaid members and for their families.”

A Medicaid member town hall meeting with state officials is scheduled for Thursday, Sept. 8. Details can be found on the Department of Human Service’s website.

More: Iowa introduces new Health and Human Services agency, but merger is still far from over

About the three companies working with Iowa Medicaid

Amerigroup, which currently holds a managed care contract with the state, is the only insurer that has been with the Medicaid program since the beginning. The company is a subsidiary of Indiana-based Elevance Health (formerly known as Anthem), which provides Medicaid coverage for 11 million members in 25 states.

Iowa Total Care is also already working within the program. Its contract ends in 2025. The Missouri-based subsidiary of Centene joined the program in mid-2019.

On Wednesday, officials at Iowa Total Care said it will continue to be part of the Iowa Medicaid program, regardless of the state’s intent to award new contracts.

“We look forward to continuing our partnership with the state, health care providers and community partners in delivering quality, effective care to our members,” officials said in a statement.

Molina Healthcare, headquartered in California, provides managed care services to roughly 5.2 million Medicaid and Medicare members through state insurance marketplaces.

In a statement Wednesday, Iowa HHS officials said they will be working with Molina on their readiness to join the program, and will continue to work with Amerigroup and Iowa Total Care to continue to provide services to members.

More: Iowa’s latest round of monkeypox vaccines in smaller, equally effective doses

How were winning bids selected?

Five potential vendors submitted bids after the state posted the request for proposals in February.

State officials said in Wednesday’s announcement that the process to evaluate these proposals included “a multi-disciplinary team across the HHS agency” who work in a number of initiatives relevant to the managed care program.

According to a summary review of the bidders’ proposals provided to the Register, Molina received the highest score among the five vendors, followed second by Amerigroup.

The state noted that Molina’s proposal showed advanced preparation, including documented engagement with providers and stakeholders as well as proposed staff positions that went beyond the state’s initial bid requirements.

Last year, the company had announced the hiring of Jennifer Vermeer as chief executive officer of Molina Healthcare of Iowa. Vermeer was the Iowa Medicaid director from 2008 to 2014, and most recently served as an executive at the University of Iowa Health Care.

In July, Molina Healthcare faced $1 million in penalties from California for failure to resolve provider disputes in a timely manner. To offset potential claims issues, Matney said Iowa is establishing strong oversight within the program to ensure insurers are meeting timeliness standards on reimbursements.

State officials said in a statement Molina was selected for the company’s “deep understanding” of managed care, especially its understanding of individuals who rely on long-term services and supports, a Medicaid waiver that covers individuals with the most complex health conditions.

“Having Molina working alongside Amerigroup and Iowa Total Care will position the state well to deliver on critical program improvements,” state officials said in a statement.

Officials did not specify why the other bidders — Aetna Health of Iowa, CareSource Iowa and UCare Iowa — were not selected.

However, in the review of the bidders’ proposals, officials highlighted weakness within individual applications to join the program. Reasons companies were docked points included limited managed care experience or lack of details in how initiatives would be deployed in Iowa.

State officials say the Medicaid program has improved

It’s been a little more than a year since Matney took the helm as director of the Iowa Medicaid program. In that time, Matney said program administrators are listening to members’ and providers’ feedback “like we never have before,” and taking those experiences to build a strategy to improve Iowa Medicaid.

“Since Day One, Director Matney has focused on tangible improvements for the Medicaid program,” said Kelly Garcia, director of the Iowa Department of Health and Human Services. “She has charted out a vision to identify and address gaps, to focus on outcomes, to improve infrastructure and operations and to promote transparency.”

Garcia continued, “Under Director Matney’s leadership the Iowa Medicaid program is really addressing the needs heard from the Iowans who rely on us. Making sure those we serve and those who advocate on their behalf are embedded in the conversation is the right thing to do and the work we’re doing reflects that.”

After a troubled history, state officials say they’ve included more checks on the program

Then-Gov. Terry Branstad announced his decision to switch to private management of the Medicaid program in early 2015, and despite intense pushback from Democrats and other critics, moved forward with the plan the following year.

Less than two years after rollout, AmeriHealth Caritas, one of the three national companies picked to manage Iowans health care, withdrew from the giant program.

Then in 2019, another managed care organization — UnitedHealthcare — quit after company officials disputed its contract with state leadership. Iowa Total Care took the helm shortly after the exit.

The “lessons learned” from these departures included creating a bid process and onboarding process for new managed care organizations that is robust to mitigate future issues with members getting services and providers being paid, Matney said.

That includes rigorous testing of claims submissions for services provided to members. Matney said prior to the 2016 implementation of managed care, program administrators learned they needed more provider input. This time around, Matney said the state is “going to be pushing hard and knocking on a lot of doors to get that participation.”

“From the initial rollout of managed care, we really did learn a lot about oversight and a lot about relationship development,” Matney said. “But we also learned a lot about what the program needs from the perspective of really solid rate development — not just for the managed care organizations, but for providers as well.”

Both AmeriHealth and UnitedHealthcare complained about the loss of hundreds of millions of dollars managing health care for thousands of fragile Iowans. While it’s not the state’s goal to help make companies rich off the Medicaid program, Matney said state leaders “do need to have everything in place so that they are financially stable.”

Matney said she’s also working to build transparent relationships with these insurers, so the state can be supportive as these companies manage often complex health benefits for Iowans.

“Ultimately, their success is our success,” Matney said.

Michaela Ramm covers health care for the Des Moines Register. She can be reached at mr***@***********ia.com, at (319) 339-7354 or on Twitter at @Michaela_Ramm.

This article originally appeared on Des Moines Register: Iowa’s Medicaid program will soon have 3 insurance companies

 
 

Clipped from: https://www.yahoo.com/video/iowas-7-billion-privatized-medicaid-171117909.html