Tag: Medicaid Managed Care

[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

[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 mramm@registermedia.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

[MM Curator Summary]: The PA MCO continues to have success; this time in a new region (for Medicaid anyway- they already had a strong duals presence there).

 
 

Enlarge

A billboard used to promote UPMC Health Plan’s Medicaid managed care product, UPMC for You, in the Philadelphia region.

UPMC Health Plan

Medicaid managed care companies serving the five-county Philadelphia region have new competition from western Pennsylvania.

During this year’s open enrollment period, Pittsburgh-based UPMC Health Plan signed up 11,142 Medicaid recipients in Southeastern Pennsylvania for its UPMC for You plan, which will operate statewide as of Sept. 1.

John Lovelace, president of UPMC Health Plan, said that enrollment number will likely rise in the days ahead because the state will be randomly assigning — in an equitable manner — any Medicaid beneficiaries who did not enroll in a Physical HealthChoices program plan to a program participant.

“We’re starting off our big push forward with about 130,000 new people across Pennsylvania on Thursday, and maybe more,” Lovelace said.

 
 

Enlarge

UPMC Health Plan President John Lovelace

UPMC Health Plan

The Pennsylvania Department of Health, after a process delayed by litigation for several years, this year changed its lineup of health insurers participating in the state’s Physical HealthChoices program. The program requires recipients of Medicaid, which covers health care costs for low-income families and individuals, to enroll in a choice of managed care plans.

The state has separate Medicaid manage cared programs for mental health services, for children and for people dually eligible for Medicaid and Medicare — the federal and state program that covers health care costs of the elderly.

UPMC was selected as a Physical HealthChoices program participant in all five geographic zones in the state including Southeastern Pennsylvania, where it will compete with Independence Health Group’s Keystone First and Health Partners Plans, both of which are based in Philadelphia, along with United Healthcare and Geisinger Health Plans.

The biggest change locally is Aetna will no longer be part of the program.

The five-county region has 1 million people who qualify for the Physical HealthChoices program. The two Philadelphia-based companies lead the market, with Keystone having about 524,000 Medicaid members and Health Partners Plans having about 273,000.

New enrollment numbers for all the plans, following open enrollment, are not yet available.

UPMC Health Plan already has a presence in the Philadelphia region, Lovelace said, covering about 32,000 people who are either dually Medicare and Medicaid eligible or Medicare special needs patients.

Lovelace said the plan is in the process of expanded its Children’s Health Insurance Program (CHIP) coverage in the Philadelphia region.

Prior to expanding into Southeastern Pennsylvania as well as Northeastern Pennsylvania, where it has picked up about 20,715 Medicaid members, UPMC had about 560,000 Medicaid plan members throughout the rest of the state.

Clipped from: https://www.bizjournals.com/philadelphia/news/2022/08/30/upmc-health-plan-medicaid-philadelphia-pittsburgh.html

[MM Curator Summary]: Planet Centene will pay out another 0.00019% of its revenue to WA state over PBM spread pricing allegations.

 
 

 

Attorney General Bob Ferguson and the Washington State Health Care Authority announced Centene, a publicly traded managed-care company, will pay $19 million to Washington state to resolve allegations of overcharging the state Medicaid program for pharmacy benefit management services.

The resolution is the second-largest Medicaid fraud recovery for Washington state in history. The amount goes back to the state through the state Medicaid Fraud Penalty Account.

As part of the resolution, an additional $13 million from Centene will be paid to the federal government for the administration of Medicaid in Washington state.

“Medicaid dollars are a precious resource meant to fund care for the most vulnerable among us,” Ferguson said. “My office works to ensure that these dollars go where they are intended — not toward fraud.”

Centene ranked No. 24 on 2021’s Fortune 500 list with its recorded revenue north of $100 billion, according to the Centene Corporation 2020 Annual Report.

Washington attorney general joins coalition challenging Idaho’s near-total abortion ban

The Attorney General’s Office and Health Care Authority’s Program Integrity Team began investigating pharmacy benefit managers in 2019 after a whistleblower provided information that they were failing to disclose true pharmacy benefits and services costs.

Centene allegedly failed to pass on discounts it received to the state Medicaid program and inflated dispensing fees.

Earlier this week, Centene Corporation canceled its plans to build an east coast headquarters in Charlotte’s University City in what was originally considered the largest job announcement in Charlotte’s history. In July 2020, the company announced they were planning to create 6,000 new jobs once the headquarters were constructed, investing approximately $1 billion into the expansion.

Ferguson’s resolution with Wyeth is the only Medicaid fraud recovery larger than Centene. In 2016, Ferguson and the Attorney General’s Office recovered $46.7 million for the state Medicaid program, as the pharmaceutical company owed more than $780 million to states and the federal government for overcharging.

Centene has resolved cases with 10 other states over the same conduct.

Follow @http://twitter.com/Mynorthwest

 
 

Clipped from: https://mynorthwest.com/3607059/centene-guilty-of-overcharging-state-medicaid-program-owes-wa-19-million/

[MM Curator Summary]: The city council and mayor’s office are now communicating their disagreements about the MCO contracting process over twitter.

 
 

 
 

The awarding of the District’s nearly $3 billion Medicaid contract remains in limbo until D.C. Mayor Muriel Bowser formally submits her recommendations for D.C.’s selected managed care organizations to the D.C. Council for approval.

Managed care organizations (MCO) CareFirst BlueCross Blue Shield, Amerigroup DC, AmeriHealth Caritas and MedStar Family Choice District of Columbia each hope to be awarded the contract to serve the 230,000 residents who count as Medicaid patients. 

Medicaid, a federal government health insurance program, services poor and low-income Americans, with seniors and those with disabilities included in some cases. The council selects the managed care organizations that will service the recipients due to its responsibility to approve District government contracts over $1 million. Ultimately, three of the four MCOs will be chosen for the Medicaid contract. And while a final decision has not been made of who be chosen, observers note Amerigroup and AmeriHealth appear to be favored with Med Star and CareFirst vying for the third position.

The D.C. Medicaid process for this year’s contract which will remain in place for five years, has been mired in contention for nearly a year due to complaints lodged by MCOs about being treated unfairly during the process. Their complaints include technical errors faced when submitting their paperwork for approval. 

Three MCOs, CareFirst, MedStar and AmeriHealth, have taken the procurement process to the Contract Appeals Board for review. Meanwhile, Bowser missed a June 28 deadline to submit the new contract to the council. 

In a July 21 letter, D.C. Council Chairman Phil Mendelson (D), along with Council members Robert White (D-At Large), Brianne K. Nadeau (D-Ward 1), Janeese Lewis George (D-Ward 4) and Elissa Silverman (I-At Large) questioned why the contract hadn’t been submitted. In a response via Twitter, Deputy Mayor for Health and Human Services Wayne Turnage wrote, “to be clear, the results of the current procurement are under protest with the Contract Appeals Board (CAB), so without special permission from the CAB, the Department of Health Care Finance cannot move forward with the new contracts until the protests are resolved.” 

In his July 29 letter responding to the council members’ concerns, George Schutter, who leads the D.C. Office of Contracting and Procurement, backed Turnage, saying, “in partnership with the program agency and District leadership, [we] determined it was in the best interest of the District and the beneficiaries to await the results of these three CAB decisions to minimize disruption to the beneficiaries resulting from any possible change in provider plans.”

Bowser said she agrees with the agency leaders’ stance regarding the contract.

“The fact that there is this delay isn’t unusual,” Bowser said. “This is a difficult contract to execute. We support waiting until there is a ruling by the Contract Appeals Board before we send the contract to the council.”

Bowser said Medicaid recipients should have a clear sense of who will be serving them and that can be best facilitated after the appeals process. She said she doesn’t know which MCOs will get the contract or the council submission timeline.

White serves as the chairman of the Committee on Government Operations and Facilities and will play a major role in the eventual awarding of the MCO contract. He said, “the executive can’t execute or implement the contract before the Contract Appeals Board ruling. But by law, the executive is able to send contracts to the council for review and doesn’t have to wait until the CAB issues a decision.”

“In fact, the executive used that process last year for existing MCO contracts, which [Schutter] recognized in the letter he sent to me and other council members on Aug. 11,” he added. 

White said he doesn’t have a favored MCO provider but has problems with the present procurement process. 

“My goal with procurement, as with all procurements, is to ensure that decisions are made through an independent, fair, transparent, legal and expeditious process,” he said. “Unfortunately, the MCO procurement has repeatedly failed to meet that standard over a period of years. Most recently, the administration agreed to send contracts to the council for review by June 2022 to avoid further extensions and that has not yet happened.”

White said the MCO procurement process needs reform or at least further investigation.

“The administration’s lack of transparency means that, at this point, the council doesn’t know what the issue is,” he said. “If the executive didn’t follow the legal procurement process, that would likely be a valid basis for a protest or appeal. But currently, we don’t have anything of substance that we can rely on to say they didn’t.”

White said alternatively, the process functions the way it should within the law and if a problem arises with the way it operates, reform might be needed. He said if the administration disagrees with the outcome, then “that is not a valid reason to hold up the legal procurement process.”

“Our residents see what happens when we disregard the legal process and it is those with the least resources who stand to lose the most in this situation with the MCOs,” he said.

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Clipped from: https://www.washingtoninformer.com/d-c-medicaid-contract-remains-in-limbo/

 
 

MM Curator summary

[MM Curator Summary]: The buy comes one month after a similar buy by Molina in the same market, and 1 day after the transaction to divest its majority stake in Kindred’s hospice assets completed.

 
 

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.

 

 
 

Dive Brief:

• Humana said Friday it will acquire most of the assets of Inclusa, a managed care organization in Wisconsin that provides long-term care and support services to seniors and adults with disabilities. Financial terms of the transaction were not disclosed.
  
• The deal will boost the number of Medicaid recipients enrolled in Humana plans. The Louisville, Kentucky-based health insurer said it currently covers about 1 million Medicaid beneficiaries across Florida, Illinois, Kentucky, South Carolina and Wisconsin and was recently awarded contracts in Ohio and Louisiana.
  
• The acquisition comes a day after Humana completed the $2.8 billion divestiture of its majority interest in Kindred at Home’s hospice, palliative, community and personal care divisions. Those businesses have been restructured into a standalone company.
  

Dive Insight:

The purchase of Inclusa broadens Humana’s offerings in the rapidly growing Medicaid managed care market.

Enrollment in Medicaid has surged during the COVID-19 pandemic, supported by state expansions and relief legislation that suspended coverage terminations for the duration of the public health emergency. A Kaiser Family Foundation analysis predicted Medicaid enrollment will grow by 25% from 2019 through the end of fiscal year 2022.

Growth in Medicaid managed care organization enrollment has tracked with the overall rise in Medicaid coverage during the pandemic, KFF has found. More than two-thirds of all Medicaid beneficiaries are insured through managed care organizations, according to the nonprofit, and more states are moving to include seniors and people with disabilities in MCOs.

Inclusa provides long-term care and support services to about 16,600 older people and adults with disabilities through Wisconsin’s Family Care Medicaid program. Services promote independent living for beneficiaries. The MCO is contracted with Family Care in 68 of the state’s 72 counties.

The CMS is encouraging managed care plans to help states prevent people from losing their insurance when the federal continuous coverage requirements eventually end. The agency has issued guidance to states for working through the renewal process, calling it the single largest health coverage transition event since the first marketplace open enrollment following enactment of the Affordable Care Act.

Policy experts fear millions of Americans could lose coverage after the pandemic protections expire, and the hope is that insurers will be able to shift Medicaid enrollees who have access to subsidized coverage through the ACA marketplace to those plans.

 
 

Clipped from: https://www.healthcaredive.com/news/humana-inclusa-medicaid-managed-care/629628/

MM Curator summary

[MM Curator Summary]: More info on the recent CareSource win in MS and the partnership with TrueCare.

 
 

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.

 
 

 
 

 
 

JACKSON • The state Division of Medicaid will award a new contract for managing insurance benefits for Mississippi’s most vulnerable citizens to a not-for-profit backed by some in-state hospitals and two other private organizations.

The division said in a press release on Wednesday that it intends to award TrueCare, Magnolia Health and Molina Healthcare with the lucrative contracts for administering Medcaid’s managed care system, called MississippiCAN, and the Children’s Health Insurance Program.

Two state agencies investigated Magnolia Health, the Mississippi subsidiary of health giant Centene, over allegations tied to pharmacy benefit managers. 

TrueCare is a not-for-profit formed by some private hospitals and the Mississippi Hospital Association over their belief that in-state hospitals can provide better services to patients, which is different from a traditional managed care organization.

To manage the benefits, TrueCare partnered with CareSource Management Services, an Ohio-based managed care operation. CareSource will manage the day-to-day operations and TrueCare will provide “local expertise and oversight,” according to TrueCare’s proposal it submitted to the division.

“Our mission is to ensure Mississippians can easily access their benefits to live healthier lives, while prudently managing state resources,” the proposal reads.

The organizations who submitted applications to the Division of Medicaid are still technically under procurement rules that require them to be silent, meaning entities are limited in what they can publicly say.

Senate Public Health Chairman Hob Bryan told the Daily Journal he thinks that having a not-for-profit and traditional managed care organizations managing Medicaid benefits in the state at the same time will be a “great controlled experiment.”

“I think this is a great opportunity,” said Bryan, D-Amory. “The Hospital Association for years has said they can do a better job of providing these benefits. Well, here’s their chance to prove it.”

Mississippi’s Medicaid managed care system provides health insurance benefits for about 480,000 poor adults and children, disabled people, pregnant women, and others.

The Division of Medicaid pays managed care organizations a set rate per patient to administer those benefits.

The other two organizations who are set to receive contacts — Molina and Magnolia — are for-profit managed care entities who are also currently administering portions of the state’s Medicaid benefits.

Another surprising development from the division’s announcement was that United Healthcare, a managed care firm who was already administering part of the state’s Medicaid benefits, was not awarded any contract.

Groups have seven calendar days to protest the division’s decisions on who should receive contracts, but it’s unclear if any organizations who submitted proposals intend to file a protest petition.

After the protest period lapses, the contracts will go before the state’s procurement review board for approval.

The division’s decision comes at a time when traditional managed care organizations have come under scrutiny by some physicians, independent pharmacists and lawmakers.

Hospitals leaders and independent pharmacists have criticized managed care firms and PBMs for putting profits ahead of patient services. But managed care organizations largely contend that they’ve accomplished their goal of controlling the state’s fluctuating Medicaid costs.

State Auditor Shad White inked an agreement in April 2019 with Ridgeland-based law firm Liston and Deas to help investigate if Magnolia Health, the Mississippi subsidiary of health giant Centene, was over-inflating its bills to the state Medicaid division, as previously reported by the Daily Journal.

The investigation by the outside attorneys, White and Attorney General Lynn Fitch centered on one portion of the managed care system: pharmacy benefit managers.

These subcontractors, known as PBMs, serve as middlemen between insurance companies, drugmakers and pharmacies. They manage drug benefits, negotiate drug prices and reimburse pharmacists on behalf of companies.

Centene settled with the state in June 2021 for $55.5 million. The company did not admit any wrongdoing in the agreement, and the state said the company was providing quality health services.

The settlement, though, hasn’t stopped White’s office from continuing to examine the billing practices of PBMs. White’s office in March signed an agreement with data analytics firm Intelaform Services to collect and analyze a wide breadth of data involving PBMs that do business with the state.

The contract between White and Intelaform authorizes the private firm to investigate and analyze data generated by PBMs, pharmacy benefit administrators and managed care organizations that conduct business with state agencies — a wide scope of data.

The new contracts come at a time when the House and Senate Insurance Committees are set to convene a hearing on Aug. 29 to examine PMBs and the state’s insurance plan.

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Clipped from: https://www.djournal.com/news/state-news/division-of-medicaid-to-contract-with-nonprofit-backed-by-state-hospitals-to-administer-benefits/article_7c97c5a8-d1a0-5700-af98-5b9289428e0f.html

MM Curator summary

[MM Curator Summary]: D.C. MCO procurements are weird.

 
 

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.

 
 

A component of one of the largest health care providers in the D.C. region wants to continue providing Medicaid services to District residents but its leaders complain the company has been caught up in an administrative and bureaucratic process that threatens its ability to deliver for its patients.

Ieisha Gray serves as the chief operating officer for the CareFirst BlueCross BlueShield Community Health Plan District of Columbia, herein known as CareFirst. Gray said her company has performed well in serving District residents on Medicaid and wants that to continue.

“We have a demonstrated record serving Medicaid patients in D.C.,” Gray said. “We have the perspective that Medicaid patients should have the same level of health care quality that District government officials have access to.”

Medicaid serves as the federally-funded, locally-managed health care plan for those who count as low-income, disabled, under the age of 19, pregnant, some senior citizens and needy single parents. 

In the District, managed care organizations (MCOs) like CareFirst serve Medicaid patients who do not pay for their medical care. Those who qualify for the program range from an individual who earns up to $19,000 annually to a family of four with a combined income of no more than $37,000 a year.

Statistics reveal over 230,000 residents – 33% of the city’s population, utilize Medicaid. The multi-year contract MCOs operate under amounts to $3 billion collectively.

CareFirst’s Complaints about the Procurement Process

CareFirst leaders said the recent MCO procurement process “was deeply flawed and highly unusual” in documents obtained by the Informer.

“It was marred by the disqualification of three-out-of-four plans for unimportant minutia – whether the listed certified business enterprise (CBE) numbers were the new ones or old ones and for simple typos in the numbers of bona-fide CBEs,” the documents said. “The District’s choice of Medicaid MCO plans has serious implications for its ability to address chronic diseases that disproportionately afflict low-income District residents.”

According to CareFirst documents, the first Request for Proposals took place in November. In January, the District’s Office of Contract and Procurement (OCP) disqualified three of the MCOs, including CareFirst for what it termed “non-substantive” errors in their subcontracting plans. Two competing plans – MedStar Family Choice and Amerigroup – used old CBE numbers given to them by subcontractors which terminated them from consideration while CareFirst received disqualification from the process due to small typos in its subcontracting plan.

In the District by law, there must be three MCOs to move forward with granting Medicaid contracts. As a result, the process moved into February in which OCP opened up a second round for consideration because only one MCO, AmeriHealth, had been selected.

 Meanwhile, the three MCOs that received denial appealed the decision to the District’s Contract Appeals Board (CAB). In consideration, CAB upheld MedStar’s disqualification but overturned Amerigroup’s. CareFirst’s disqualification remained with CAB ruling that the contracting officer had the right not to give it a contract based on the typos of which the company labeled “minor” and “non-substantive.”

In its documents, CareFirst officials said, ‘what happened next defies logic.” It said Amerigroup “was put back in the original procurement, the one that began in November 2021.” The two remaining plans in the original procurement – AmeriHealth and Amerigroup – received contracts by the OCP by default. As a result, CareFirst and MedStar had to compete for the third MCO spot in February. 

CareFirst officials complained that the plans didn’t receive assessment based on “substantive items that matter.”

“For instance, the quality of each plan’s provider network, care coordination and case management tools, etc.,” the documents said. “In other words, the items that have real consequences for the overall quality of healthcare received by low-income District residents were seemingly less important than whether the CBE number listed for a subcontractor was up-to-date.”

Gray said in 2021, CareFirst achieved the first perfect score on all six National Committee on Quality Accreditation criteria in the history of the city’s Medicaid program. She said CareFirst lead other MCOs in 10-out-of-14 quality categories measured by the District. Additionally, in regards to children’s access to routine care, CareFirst received a 95% compared to 83% and 77% by the other two plans.

“We have the largest network of health care providers,” Gray said. “We can give Medicaid patients the care they need.”

Ambrose Lane, Jr., the chairman of the Health Alliance Network, has watched the District’s Medicaid process over the years. He spoke about the contract procurement system’s shortcomings.

“There are flaws in the procurement process and they need to be addressed in order for things to go forward,” Lane said. “Last year, Amerigroup was the odd man out and this year, it is CareFirst.” 

Lane said D.C. Mayor Muriel Bowser should submit the contracts to the D.C. Council for approval adding that contracts over a $1 million must be approved by the council. 

“The executive doesn’t have to wait for the ruling from the CAB,” he said. “I was told by a councilmember that she doesn’t have to wait on them. But by the way things look now, it looks like she will have to request an extension until 2023.”

Regarding CareFirst’s complaints about the contracting process, OCP’s communication team sent the Informer a statement noting the November and February solicitations. 

“Both solicitations have since closed,” the statement said. “In accordance with District requirements and to ensure the sustainability of the District’s managed care program, the District will contract with up to three MCOs so that Medicaid beneficiaries will have a choice of providers. There are three pending protests at the [CAB]. OCP will complete the award process once these protests are resolved.”

Clipped from: https://www.washingtoninformer.com/carefirst-questions-d-c-medicaid-contract-process/

MM Curator summary

[MM Curator Summary]: Average claims processing time is 12.8 days, but some providers still wait much longer.

 
 

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.

 
 

 
 

By Travis Fain, WRAL state government reporter

One year into a multibillion-dollar overhaul of North Carolina’s Medicaid program, providers complain that billing delays from insurance companies that manage claims are leaving patients without full treatment and the providers with financial problems.

Providers who’ve reached out to the state’s help line to complain describe the transition as a debacle. Some fear losing their businesses as late payments stretch into six figures.

“I’m losing sleep wondering if I am going to be able to make payroll,” Sharon Jordan, the chief executive of a Charlotte speech therapy company, said in an email to the state ombudsman charged with troubleshooting problems.

“I’m so tired,” Jordan wrote in a June email released through the state open records act. “I’m so depleted. I am tired of fighting. If this is what the state of North Carolina intends to happen with this change, then you’ve won.”

The state’s top Medicaid official and a spokesman for the five insurance companies that manage the plans acknowledge problems, and companies that pay late must pay penalties and interest. The department last week said it couldn’t immediately tally those amounts, which go to the providers.

But DHHS and the companies themselves say they’re generally pleased with how the program’s going, considering they’ve shifted more than 1.7 million people from a single, state-run Medicaid program to five new ones overseen by private insurers. This new managed Medicaid system has handled 17.2 million medical claims in a year, with 14 million paid and 3.2 million denied, according to DHHS. The average processing time is 12.8 days, the department said.

“Overall it’s going relatively well,” said Dave Richard, DHHS’ deputy secretary for Medicaid.

“I know that a couple of those providers that have gone through that process have really been hurt financially,” Richard said. “That’s unacceptable. We need to work through these quicker. We need to make sure that people are getting paid.”

‘Kids need these’

When the state laid out its Medicaid transformation plan, it created a help desk to help walk providers through a newly complex billing system. It also created an ombudsman to handle the most persistent problems.

That ombudsman received 439 calls or emails in June—the second highest monthly total since the program went online in June of 2021, according to DHHS numbers.

Transformation is meant to check escalating costs for the state’s Medicaid program, which provides health insurance to more than 2.8 million people, mostly children, senior citizens and people with disabilities. The program’s annual budget is slightly more than $18 billion, most of which is federal money.

In past years Medicaid spending ballooned unexpectedly, blowing holes in the annual state budget. That led the Republican-led General Assembly to pass transformation, which Gov. Roy Cooper’s administration implemented, picking five insurance companies to manage most claims.

Those insurers—United Healthcare, WellCare, Carolina Complete Health, AmeriHealth Caritas and Healthy Blue, which is part of Blue Cross and Blue Shield—get paid a per-person fee, and it’s up to them to keep health care costs beneath what they’re paid.

With that change came five new ways to bill insurance plans, plus a sixth one for Medicaid patients still in the state’s old program. Providers now dealing with multiple companies describe varying degrees of rigamarole, shifting rules and massive amounts of wasted time as they deal with some combination of the insurers.

Each company is doing different things, according to Jordan, the speech therapy CEO. One week they pay, the next week the same procedure is denied and, “it’s not as easy as picking up the phone,” she said.

“It’s just ridiculous,” said Emma Bentham, a Fayetteville audiologist who said she never had a problem getting hearing aids cleared for children until transformation.

“Kids need these,” Bentham said. “There have literally been children that have gone a whole year now without hearing aids.”

Some providers believe insurers are purposefully denying or delaying claims to save money. That was always a concern for critics of Medicaid transformation: That there’s a profit motive to deny coverage for some of the state’s most vulnerable people.

Peter Daniel, executive director of the North Carolina Association of Health Plans, said that’s not what’s happening. The industry group represents the insurance plans running Medicaid managed care in North Carolina.

Daniel said communication problems, exacerbated by having to hire and train call center workers during the pandemic, are to blame.

“This is a glitch in the system of escalating issues,” he said. “It is not the companies trying to slow-walk providers at all.”

The five insurers have contracts with the state totaling about $6 billion a year, and Richard said the state requires each insurer to spend at least 88% of that money on care. Asked whether the companies have a profit motive to deny claims, Richard said the state “will aggressively review … to make sure that’s not happening.”

Daniel acknowledged that some providers – many of them small businesses – have not been paid. He said the plans “are taking these situations very seriously,” and he predicted rapid improvement.

“You’ll see over the next few weeks a clearing of these flagged claims,” Daniel said in late July. “They’re genuinely trying to get down to what the communications issues are.”

Hospitals have had problems as well. Cynthia Charles, spokeswoman for the North Carolina Healthcare Association, called the bill process “complicated and cumbersome” with “a tremendous amount of administrative burdens put on hospitals.”

‘Very apologetic’

Several providers told WRAL News that they saw improvement when the state’s ombudsmen got involved in their case.

“It seemed to push things much faster,” said Jonathan Wilkins, a therapist in Troy.

But Wilkins said his dealings with two of the companies he’s billed was “a nightmare for me as a sole proprietor.”

“Doing my own billing and having to bill these insurance companies that have these clearing houses,” Wilkins said. “And I was getting no communication about whether or not I needed to do something different.”

Corey Peña, who owns Royal Orthotics in Concord, has been fighting insurers for a year. Things improved recently, Peña said, once he went to the media, reached out to state lawmakers and had conversations with Richard, the state’s head of Medicaid.

After that, Peña said United Healthcare and AmeriHealth Caritas both reached out to schedule meetings about his problems. Carolina Complete Health CEO Chris Paterson met with him at the end of July.

“He was very apologetic,” Peña said. “He said, ‘We’re going to make this right.'”

Peña’s company makes leg braces for children, and he said the companies that he bills for Medicaid want “a stack of paperwork” – far more than the state required. Payment delays got so bad that Peña said he was considering selling his house or declaring bankruptcy. In a July email to Sen.

Ralph Hise

, a leading proponent of transformation when the General Assembly passed it, Peña called the state’s insurance companies “criminal.”

Peña was more upbeat last week. He expected a $69,000 payment soon from Carolina Complete and he had meetings set with other companies. But he remained skeptical. “You hear promises for over a year, you don’t know what to believe,” Peña said.

“I’m still in war mode where I’ve won one battle,” he said. “And now I’ve got to go on to my next battle in this war until I’m done.”

 
 

Clipped from: https://www.wral.com/nc-medicaid-providers-say-they-re-owed-big-bucks-while-children-go-without-care/20403738/