MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: The protests are in process in the press for the recent mega-procurement in California. Losing community plans are sounding the alarm about the impact of them going away.

 
 

In summary

The state’s new Medi-Cal contracts are part of an overhaul to improve patient care. But some say the new providers aren’t fully prepared to handle more Medi-Cal patients.

More than 1.7 million Medi-Cal patients may get a new insurance provider in the coming months as a result of the state’s first-ever competitive bidding process, but critics and some providers fear the change will cause major disruptions to care.

California’s Department of Health Care Services last month announced its intent to award $14 billion-worth of Medi-Cal contracts to three companies — Health Net, Molina and Anthem Blue Cross — down from nine. The deal is part of the department’s multifaceted effort to overhaul the behemoth program that provides health insurance for a third of all state residents. Medi-Cal is the state’s version of federal Medicaid, which serves low-income residents. 

“We are raising the bar for all of our managed care partners,” state Medicaid Director Jacey Cooper said. “We will be very focused on quality and access to care.”

The new contract includes strict new quality standards for patient outcomes and financial penalties for providers that do not meet the goals. The new benchmarks are “significantly better” than previous standards and competitive bidding is long-overdue, said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network.

“This is a really big deal. It’s something that we have consistently advocated for the state to do more often and on a specific schedule in order to maintain accountability,” Savage-Sangwan said.

Many patients will keep the same insurance provider, but in four counties — Los Angeles, San Diego, Sacramento and Kern — the largest incumbent plans were ousted, precipitating a significant transition for nearly half of commercial Medi-Cal patients.

“We are raising the bar for all of our managed care partners. We will be very focused on quality and access to care.”

state Medicaid Director Jacey Cooper

An ‘immeasurable’ disruption

In Los Angeles, Health Net, the largest Medi-Cal managed care plan in the state, lost its coveted contract to Molina. More than 1 million patients, roughly one-third of all Medi-Cal enrollees in the county, have Health Net. The other two-thirds have coverage through the county-operated L.A. Care Health Plan.

Medical providers in L.A. that serve primarily Medi-Cal patients say the decision to offer Molina the county contract could cause “immeasurable” disruption.

“It would be profound,” said Jim Mangia, president and CEO of St. John’s Community Health in south L.A. “You’re talking about completely changing providers and provider networks. It would completely interrupt their systems of care.”

Nearly 25,000 patients at St. John’s — a quarter of the facility’s patient population — have Health Net and would need to switch to Molina, which has far fewer patients and providers. Expecting the company to contract with an equivalent number of doctors and specialists as Health Net in the next year is unreasonable, Mangia said. 

The state expects new contracts to be fully implemented by January 2024 with the transition period starting as soon as Oct. 10. 

“They’re a minor player in the Medi-Cal market. “Can they get 10 times bigger in that many months? I doubt it,” Mangia said. “You’re going to see a tremendous lack of access to specialty care, to hospital care and to primary care.”

“Can they get 10 times bigger in that many months? I doubt it.”

Jim Mangia, president and CEO of St. John’s Community Health

Molina did not respond to multiple requests for comment. Health Net Vice President of Communications and Marketing Darrel Ng said in a statement that the company would defer to providers’ assessment of the ramifications of the contract change.

Health Net appealed the state’s decision in Los Angeles and eight other counties where it lost bids. In the L.A. appeal documents, Health Net alleges that the state’s decision to move to Molina will “jeopardize the stability of Medi-Cal and its provision of services to California’s most vulnerable.”

Some providers, however, were less concerned about the change, predicting that there would not be much of an impact on patients. 

“In theory nothing should change. Technically, Health Net and Molina switching places should have no impact on the consumer,” said David Ryu, chief strategy and advancement officer at Kedren Community Health Center, a primary care and acute psychiatric hospital system in South L.A.

That assessment, however, assumes Health Net will subcontract with Molina, giving them access to their network of providers. Neither Health Net nor Molina have stated whether they will pursue that option.

If Molina retains the contract offer after the appeal process, Medicaid Director Cooper said there will be a 15-month transition period to ensure enrollees are aware of the change and do not experience any interruptions in coverage. 

“We’ve been planning for this transition for months, probably even close to a year at this point,” Cooper said. 

That planning includes hiring staff dedicated to the transition and contracting process and ensuring provider networks overlap significantly enough to prevent patients from losing access to doctors. 

“We will make sure through our readiness process of all managed care plans…that they are ready and able to handle those continuity-of-care requests,” Cooper said.

Mangia predicted, however, that community health centers will be left to handle the most vulnerable and difficult-to-manage patients. A third of St. John’s patients do not have valid phone numbers or addresses, largely due to housing instability. Those patients frequently have complex health needs and providers are only able to find them when they show up at emergency rooms.

“Where are they going to send the letter? The state is going to send them a letter that says ‘You no longer have Health Net. You need to choose a new plan.’ Then people come in, they don’t understand it, they need help filling out the application. That’s a huge responsibility to dump on community health centers,” Mangia said. 

“Every time there’s a change in health care in California, the cost and work of doing it gets pushed on the (health centers).”

Holding plans to higher standards

The state intends to award 28 new contracts across 21 counties to Health Net, Molina and Anthem Blue Cross, but the selections have raised questions about whether the plans can actually meet the new quality standards. Over the past decade, health outcomes and quality metrics have stagnated or gotten worse for Medi-Cal enrollees, and the three winners, which have current contracts across two-thirds of the state, maintain spotty track records. 

Some of the new requirements include:

• Meeting updated quality benchmarks; 
  
• Publishing reports on patient outcomes, appointment access and wait times, and patient satisfaction;
  
• Investing up to 7.5% of annual profits into community-based organizations with additional investments required if quality benchmarks are missed;
  
• Hiring a chief equity officer and developing a plan to reduce health disparities;
  
• Monitoring primary care utilization and identifying patients that may be missing preventive care opportunities.
  

In 2019, the department updated its quality benchmarks, requiring California Medi-Cal plans to perform better than 50% of all Medicaid plans nationwide. The previous requirement was to do better than 25% of plans nationwide. Enforcement of the benchmarks was suspended due to COVID-19.

“Before we were letting all of our plans fail. Now we’re holding them to the average,” Savage-Sangwan said.

Anthem Blue Cross, which was offered the greatest number of contracts, historically has achieved poor to mediocre outcomes. For example, between June 2020 and July 2021, Anthem failed to meet 59% of its quality benchmarks across the 12 regions where it serves Medi-Cal members. Those metrics include breast cancer screenings, diabetes management and completion of childhood immunizations. 

Health Net had a similar failure rate across seven counties. while Molina failed to meet quality benchmarks 38% of the time across four counties. Ng, of Health Net, said COVID-19 made 2020 “a difficult year for all of us” when it came to meeting quality standards, but the company recognizes the need for improvement and has made a “multi-million-dollar investment in quality over the past several years.”

Anthem and Molina did not respond to requests for comment. The state Department of Health Care Services said three years of quality metrics were analyzed during the bidding process.

Losing bidders have submitted appeals in more than half the counties where bidding took place, claiming competitors overpromised their Medi-Cal services and that the Department of Health Care Services implemented an unfair scoring system. 

One such appeal came from Community Health Group, the largest Medi-Cal provider in San Diego County and one of the highest-performing insurance plans in the state. It lost the initial bid to Health Net and Molina.

“(The decision) was quite shocking,” said chief operating officer Joseph Garcia. “In every measurable metric, we are way ahead.”

In 2019, Community Health Group was the fourth-highest-ranked Medi-Cal insurer in the state, according to state data, beaten only by San Francisco Health Plan and two Kaiser plans, which tend to serve healthier patients. In contrast, Molina’s San Diego plan ranked 16th and Health Net’s ranked 29th.

Garcia said he has “a lot of questions and a lot of concerns” about how the Department of Health Care Services awarded points to bidders. Health Net and Molina were awarded points for proposing community engagement strategies that Community Health Group already implements, he said.

“We’re going to give you more points because you’re going to do something? We should get more points because we’re already doing it and members don’t have to wait,” Garcia said. 

Like in L.A. County, San Diego providers say this decision will cause a major disruption to patient care. Community Health Group serves the largest proportion of Medi-Cal patients — approximately 326,000 — out of the seven Medi-Cal insurers in the county. 

“Good grief. Medi-Cal populations have a complexity of needs. It’s not like we can just transfer them and give them a new card. ” said Zara Marselian, CEO of La Maestra Community Health Centers in San Diego. “We’re going to have to hire more staff.”

“Medi-Cal populations have a complexity of needs. It’s not like we can just transfer them and give them a new card. ”

Zara Marselian, CEO of La Maestra Community Health Centers

Marselian said La Maestra has worked with Community Health Group for nearly three decades and its history as a health center that grew into a Medi-Cal insurance plan gives it insight into what the population needs. 

“They started managed care before the state did managed care,” she said. “They really understand the Medi-Cal population, the challenges, the disparities and the incredible amount of work it takes to help them navigate through all of the systems so they can attain health and well-being.”

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Clipped from: https://calmatters.org/health/2022/09/medi-cal-providers/

 
 

MM Curator summary

[MM Curator Summary]: A nice deep dive into the PHE impact on enrollment for one MCO in NY. Includes a detailed set of charts for all you chart people.

September 2022

PDF Version

Overview

MetroPlus Health Plan is a prepaid health services plan and a wholly owned subsidiary of NYC Health + Hospitals (H+H). MetroPlus contracts with H+H and other providers to offer managed care health care services such as Medicaid, Essential Plan, Child Health Plus (CHP) and Medicare Advantage plans, plans for eligible New York City employees and day care workers of City agencies, and private plans through NY State of Health (NYSOH, the State’s online marketplace) for over 670,000 members. Changes in MetroPlus enrollment have a direct impact on H+H’s financial stability. As more of its members choose H+H as a provider, the hospital system generates more revenue, an explicit goal of its strategic plan. This brief provides an update to MetroPlus enrollment trends as discussed in our report: NYC Health + Hospitals Check-Up: The Impact of COVID-19.

Pandemic Impact on MetroPlus Health Plan Enrollment

MetroPlus enrollment reached a record high of 670,915, an increase of 159,284 members (31 percent) between February 2020 and June 2022, the period impacted by the COVID-19 pandemic (see Figure 1).

FIGURE 1 – MetroPlus Enrollment

Sources: MetroPlus Health Plan; OSC analysis

Nearly 70 percent of MetroPlus membership is enrolled in the mainstream Medicaid managed care plan which experienced the largest actual membership growth of all plans offered. Enrollment in the Essential Plan, a subsidized basic health plan offered through NYSOH, experienced the largest growth rate of all plans at 44 percent (see Figure 2). In late January 2020, the Secretary of the U.S. Department of Health and Human Services (HHS) declared a public health emergency (PHE) for COVID-19 which permits the Centers for Medicare & Medicaid Services (a federal agency in the HHS) to grant states emergency flexibilities to respond to the crisis. The federal Families First Coronavirus Response Act, enacted in March 2020, authorized fiscal relief to states that created a requirement to keep most beneficiaries continuously enrolled in Medicaid during the PHE. The New York State Department of Health (DOH) is allowed to keep people enrolled in Medicaid, CHP and the Essential Plan without them going through their annual renewal while continuing to enroll newly eligible individuals. This provision means enrollment in these plans will likely continue to rise through the PHE which is currently authorized through mid-October 2022. 

FIGURE 2 – MetroPlus Enrollment By Plan Type

Notes: NY State of Health includes health plans for individuals and small businesses. Specialized Medicaid managed care plans include long-term care plans. MetroPlus Gold plans are available for all city employees and NYC day care workers of the Day Care Council of NY Local 205, DC 37 Welfare Fund. The Essential Plan is a subsidized basic health plan offered with the NY State of Health.

Sources: MetroPlus Health Plan; OSC analysis

Additionally, MetroPlus experienced an increased market share in mainstream Medicaid Managed Care and Essential Plan enrollment in the City. The MetroPlus share of citywide enrollment in mainstream Medicaid managed care plans, that covers the largest share of its members, increased from 14.8 percent in February 2020 to 15.8 percent in June 2022, the highest since 2014 (based on year over year February data) and the third largest plan in the City. Enrollment in these plans grew by 34 percent while enrollment in all other Medicaid Managed Care plans offered in the City grew by 24 percent. MetroPlus share of citywide enrollment in the Essential Plan increased from about 17 percent to 19 percent during the same time period. 

MetroPlus Financial and Operational Impact on NYC Health + Hospitals

The financial stability of H+H is impacted by MetroPlus’ ability to continue to attract new members and maintain its current membership, while focusing on better care management. To maximize revenues from MetroPlus, H+H is working with it to attract more of its members to utilize H+H’s health services and engage its members in routine chronic care management to avoid unnecessary high-cost utilization. Moreover, to address the needs of MetroPlus members with frequent hospital utilization at H+H, it has also taken steps to ensure that members have access to comprehensive care management including services that address medical, social and behavioral health needs. For example, in 2017, MetroPlus and H+H established a housing taskforce to connect H+H patients in need of affordable and supportive housing, including those that are MetroPlus members. As a result, over 300 MetroPlus members have been housed. Increasing use of primary care and specialty care services by insured patients at H+H healthcare facilities directly supports H+H’s strategic plan toward fiscal stability.

Despite MetroPlus’ and H+H’s efforts, the majority of MetroPlus members use health care providers other than H+H. The share of MetroPlus spending at H+H facilities declined from 40 percent in fiscal year (FY) 2019 to 39.1 percent in FY 2021 and rebounded in FY 2022 to 42.6 percent, but has yet to reach the H+H target of 45 percent (see Figure 3).

FIGURE 3 – Share of MetroPlus Medical Spending at H+H

Note: Third quarter data of each fiscal year.

Sources: MetroPlus Health Plan; OSC analysis

As part of its outreach efforts to obtain new members, MetroPlus directs individuals that are not eligible or cannot afford insurance to the NYC Care program, a financial assistance program which provides a broad range of health care services at H+H facilities on a sliding scale fee.

In line with the DOH’s efforts toward statewide Medicaid payment reform, H+H and MetroPlus have entered an agreement that incentivizes reimbursements based on quality and cost effectiveness of care, from a model that reimburses based on volume. This value-based payment (VBP) arrangement requires H+H to take on the medical risk of all covered services for all eligible patients within the VBP arrangement, even if that care is provided outside of the H+H system. MetroPlus makes a payment to H+H after settling the net amount remaining after paying for all medical expenses associated with the VBP arrangement. The risk sharing payables were $199 million and $428 million in FY 2021 and FY 2020, respectively.

In 2020, during the first wave of the COVID-19 pandemic, MetroPlus ranked the highest of 15 Medicaid Managed Care plans across the State in the DOH’s quality incentive program which assesses performance covering a wide range of quality measures.  

Wind Down of the Federal Public Health Emergency

When the PHE expires, the continuous enrollment provision will conclude as well as other enrollment flexibilities granted during the PHE. According to federal guidance, the DOH will need to return to regular eligibility and enrollment operations and complete all renewals within 14 months, a daunting process as Medicaid enrollment has reached record levels and renewals have not been processed in almost two and a half years. In preparation for the sunset of the PHE, the State has provided tools to assist stakeholders to inform enrollees about renewing their coverage. MetroPlus has developed strategies for education and outreach to its membership to maintain the enrollment growth achieved during the pandemic. It is likely that enrollment in these plans will decline when the process of member renewals returns to normal procedures and some members will not renew or become ineligible for coverage. However, the State fiscal year 2023 Enacted Budget includes provisions that expand eligibility in public health plans offered through MetroPlus. 

If MetroPlus is successful in adding newly eligible members to its plans it might offset any potential loss in enrollment. MetroPlus enrollment is at levels it has never reached before, but this will be challenging to maintain during the wind down of the PHE. MetroPlus in coordination with H+H is working to facilitate rapid reenrollment in Medicaid for those still eligible, and shift those who lose eligibility to Essential Plan coverage. MetroPlus is engaging City and State partners to continue to ease these transitions through effective use of public benefits data and eligibility flexibilities still available from the federal government to maintain members’ insurance coverage and prevent lapses in care. Continued collaboration with New York State remains critical to aid this effort. 

Additionally, H+H must continue to provide quality care and maintain efforts to improve patient satisfaction, such as keeping appointment wait times low, to continue to attract MetroPlus members. These efforts will enable H+H to work toward its goal of 45 percent of MetroPlus medical spending and therefore help to successfully execute on its strategic plan.

 
 

 
 

Clipped from: https://www.osc.state.ny.us/reports/osdc/metroplus-health-plan-covid-19-enrollment-trends

 
 

MM Curator summary

[MM Curator Summary]: Pretty sure this is data at the plan level (in TX) about MLR return payments.. But would love for someone to help me understand for sure. Excel file linked in story.

 
 

 
 

 
 

Per Federal requirement, (42 CFR §438.602(e) and (g); May 6, 2016, Federal Register (81 FR 27497); OMB No. 0938-0920), HHSC is posting the result of each agreed upon procedures review of all Managed Care Organizations’ and Dental Maintenance Organizations’ Financial Statistical Reports by year.

The files below are in Excel format. All totals stated are based on current figures and subject to change.

State Fiscal Year 2018: SFY18 FSR AUP Result Summary (Excel)

 
 

Clipped from: https://www.hhs.texas.gov/services/health/medicaid-chip/managed-care-contract-management/medicaid-chip-financial-statistical-report-agreed-upon-procedures-results

[MM Curator Summary]: The state needs a little more time on the clock to figure out who will be happy and who will be ticked.

 
 

 
 

Nebraska officials announced Tuesday that they are taking more time to review the five companies that bid to manage part of the state’s $1.8 billion Medicaid program.

State Medicaid Director Kevin Bagley said the winning bids will be announced Sept. 23, instead of Wednesday as previously planned. He said the delay will allow time to interview each of the companies and score the interviews.

“Our goal has been to do this right, even if it takes some time,” he said. “We know stakeholders are eager to learn who will be chosen for the next managed care contracts, and we appreciate their patience as we meet with the bidders to ensure the right plans are trusted with the care for our Medicaid beneficiaries.”

The winning bidders will manage physical and behavioral health care, pharmacy services and dental benefits for almost all Medicaid patients in a program called Heritage Health. Together, they will oversee the care of some 347,000 Nebraskans. 

The new contracts are slated to start July 1, 2023, and last through at least 2028.

The bidders include all three companies with current Heritage Health contracts. They are: Community Care Plan of Nebraska, doing business as Healthy Blue; Nebraska Total Care; and UnitedHealth Care of the Midlands, which operates as United HealthCare Community Plan of Nebraska. 

The two additional bidders include Medica Community Health Plan, which currently offers health coverage to Nebraskans through the Affordable Care Act Marketplace, and Molina Healthcare of Nebraska, which provides Medicaid, Medicare and ACA Marketplace plans in several other states. 

Bagley said that each of the bidders provided quality bids to the state. The interviews are an optional part of the procurement process. He said they will allow Medicaid program officials to ask additional questions of each of the bidders, which will assist in determining which companies are best suited for the job.

State lawmakers have criticized the state procurement process after at least three cases in which the process led to the selection of a low-cost bidder that ended up failing to do the job. The most recent example was the problematic 2019 contract with the Kansas-based Saint Francis Ministries.

Saint Francis got the job of managing metro-area child welfare cases by underbidding the contract, then negotiated a 55% boost in payments when financial shortfalls nearly forced its Omaha operations to shut down. Meanwhile, the private nonprofit never met contract terms or complied with state laws limiting caseload sizes.

The contract has since been terminated and oversight of child welfare cases transferred back to state workers. 

A law passed this year requires the state Department of Administrative Services, which handles procurement for the state, to hire a consultant to evaluate the procurement process. The consultant’s report is due by Nov. 15, giving lawmakers time to craft legislation for the 2023 session.

The current Heritage Health contracts date to 2017, when the state signed with three private companies to administer what was then $1.2 billion worth of Medicaid services. Since then, two of the original three companies merged, which led to the state signing a contract with Healthy Blue.

Heritage Health does not cover nursing home care and other long-term support and services for the elderly and people with disabilities.

 
 

Clipped from: https://journalstar.com/news/state-and-regional/govt-and-politics/nebraska-officials-delay-selection-of-contractors-managing-1-8-billion-program/article_eec0cc2d-f48f-5419-b032-360e087e9282.html

[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/
 

[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

[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/