Tag: Medicaid Managed Care

 
 

MM Curator summary

[MM Curator Summary]: A hospital can now sue the state for stiffing it on millions of dollars in Medicaid bills- well technically for not making sure MCOs paid the bills.

 
 

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.

 
 

 
 

St. Anthony Hospital alleges that the state agency overseeing Medicaid has failed to make private insurers deliver payments on time.

 
 

St. Anthony Hospital

St. Anthony Hospital, a nonprofit safety-net hospital on Chicago’s Southwest Side, can sue Illinois’ Medicaid department for allegedly failing to ensure that private insurers pay the hospital on time, a federal appeals court ruled this week.

 
 

From previous story on this

 
 

St. Anthony Hospital is suing the state, alleging that problems with Illinois’ Medicaid program threaten the hospital’s ability to care for patients in the midst of the COVID-19 pandemic.

In a lawsuit filed yesterday in the U.S. District Court for the Northern District of Illinois, the Little Village hospital alleges that the state’s $12.5 billion Medicaid managed-care program doesn’t comply with federal law and subsequently hurts safety nets that treat large numbers of low-income patients.

 
 

From <https://www.chicagobusiness.com/health-care/little-village-hospital-sues-state-over-medicaid-program>

 
 

Under the program, the state pays six private insurers—known as managed-care organizations—to administer Medicaid benefits to beneficiaries in Illinois. The goal is to improve people’s health and control costs by ensuring all care is appropriate and high-quality. But health care providers, safety nets in particular, say claim denials and late payments from insurers jeopardize their operations.

“The state’s failure to provide the required oversight of (managed-care organizations) has placed unsustainable financial pressure on St. Anthony,” the lawsuit says. “Now, in the face of the COVID-19 pandemic, St. Anthony’s finances are approaching a crisis point.”

 
 

St. Anthony said in the complaint that as of mid-February it was owed more than $22 million for medical services provided to Medicaid patients. Meanwhile, it estimates that costs and lost revenue due to COVID-19 preparedness between March and May could be more than $10 million.

 
 

“Gov. J.B. Pritzker did not create this broken system, but hopefully he can fix it,” St. Anthony CEO Guy Medaglia said in a statement. “St. Anthony Hospital had no choice other than to sue the state in federal court to protect the vulnerable, largely Hispanic and African-American patients for whom we provide essential care to on the West and Southwest sides of Chicago.”

 
 

Defendant Theresa Eagleson is the director of the Illinois Department of Healthcare & Family Services, or HFS, which oversees Medicaid.

In an emailed statement, the HFS said it has been working with St. Anthony to “address the hospital’s claim that it has not received all of the payments it is due. To date, the hospital has not yet provided to the state any information demonstrating that it is due any payment. It is unfortunate that the hospital has chosen the path of litigation instead of continuing to discuss its concerns with us.”

In addition to payments for Medicaid claims older than 30 days, the hospital is seeking program changes that would result in more transparency and require HFS to have more oversight of the private insurers administering benefits.

“Given the lack of oversight from HFS, the actions by (managed care organizations) are not surprising,” the complaint says. The insurers “receive the funds HFS provides, but do not promptly and fully pay those funds to the providers. The difference presumably increases their bottom line.”

 
 

From <https://www.chicagobusiness.com/health-care/little-village-hospital-sues-state-over-medicaid-program>

 
 

 
 

Clipped from: https://www.chicagobusiness.com/health-care/st-anthony-hospital-can-sue-illinois-over-medicaid-payments

 
 

 
 

 
 

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[MM Curator Summary]: Montana’s new Medicaid Director gets grilled on managed care out of the gate.

 
 

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.

 
 

The newly hired official tasked with running Montana’s Medicaid program got a grilling on Wednesday in his first public appearance before lawmakers, some of whom expressed concerns about the state potentially privatizing the system that handles health coverage for hundreds of thousands of low-income Montanans.

Montana is one of 11 states with an entirely government-run Medicaid system, which helps administer a range of healthcare benefits to more than 280,000 Montana adults and children. After a brief, tumultuous experience in the 1990s with what a 2008 legislative report called a “problem-plagued managed care contract,” the state has operated under a fee-for-service model in which providers are reimbursed for services they administer to patients who are covered by Medicaid.

Mike Randol, who previously oversaw Medicaid programs in Iowa and Kansas and started with the Montana Department of Public Health and Human Service in late May, told lawmakers on an interim health budget committee that his background in managed care is not necessarily a forecast for Montana’s Medicaid future.

“I have not had conversations with anyone relative to transitioning Montana to managed care,” Randol said in response to a question from Rep. Mary Caferro, D-Helena. “The only conversations I’ve had relative to managed care is sharing with [DPHHS] Director [Adam] Meier during my interview process my experience with managed care, as well as my experience with the fee-for-service.”

Republican and Democratic lawmakers returned to the topic of managed care several times over the course of Randol’s introduction to the committee, which lasted roughly twenty minutes. 

“I’ve gotten so many calls on this because people are very worried about Montana moving to privatization of our Medicaid program,” Caferro told Randol. Whether his plan includes managed care or not, she said, “what are your first steps and priorities for Montana’s Medicaid program?”

“My first priority for the program is to ensure we continue providing the services,” Randol replied, referencing provider shortages and geographic challenges that often make it hard for Montanans to access health care. “I’ve never been to Montana before, but it’s an extremely frontier, rural state, I can see.”

Senator Bob Keenan, R-Bigfork, also posed questions about Randol’s philosophy on managed care and what “opportunities” the new director might see “for managed care versus fee for service.” 

“It really is unique for each state,” Randol said. “If you’ve seen one Medicaid program, you’ve seen one Medicaid program … And it really is incumbent upon the state to determine what works best for that population. How can you provide those services to those vulnerable members in your Medicaid program? And that’s ultimately what we need to do.”

“My first priority for the program is to ensure we continue providing the services,”

newly hired Montana Medicaid Director Mike Randol

Since the state expanded adult Medicaid in 2015 under the Affordable Care Act, the number of uninsured people in Montana has dropped by more than 35%. Advocates often cite that statistic as an indication of the program’s importance for Montana residents under the current model. In contrast, many advocates still have a bad taste in their mouth left over from the state’s experience with managed care in the 1990s.

“On the managed care discussion, I would just say, as everyone across the state knows, it doesn’t give us a warm, fuzzy feeling,” said Mary Windecker, executive director of the Behavioral Health Alliance of Montana, during Wednesday’s meeting with lawmakers. “I’m not a fan of managed care and privatization at all.”

But Windecker and other providers also say the state’s current fee-for-service model, specifically reimbursement rates that fail to cover the cost of providing services, hinder the development of a robust network of health care professionals who opt to serve Medicaid patients. Meier, the state health department’s director, underscored that point on Wednesday to emphasize the fallibility of both funding models. 

“We’re in fee-for-service right now and I have providers banging down my door who are unhappy with rates,” Meier said. The success of a managed care program, he added, comes down to the fine-print details in contracts with the outside companies.

At other points in Wednesday’s meeting, Meier acknowledged that Montana’s current reimbursement rates are inadequate for retaining health care providers who serve Medicaid patients. Citing takeaways from an ongoing study of provider rates, Meier said it would cost Montana roughly $31.5 million to bring rates up to benchmark standards seen in other states, nearly a quarter more than what the state is currently spending on reimbursement. 

Randol told lawmakers that continuing to focus on the provider rate study is among his top priorities in the coming months. He also pointed to the anticipated end to the federal government’s COVID-19 pandemic public health emergency, which will allow states to remove ineligible people from their Medicaid programs for the first time since early 2020.

“We want to make sure that those that are eligible remain eligible and on the program, but those that are not, that we go through the redetermination process and ensure that we only keep those that are eligible,” Randol said.

The interim budget committee is scheduled to meet again in September. Another interim committee that oversees policies relating to DPHHS, the Children, Families, Health and Human Services Interim Committee, is scheduled to meet on June 27. According to the preliminary agenda, Randol is not scheduled to reappear.

 
 

Clipped from: https://montanafreepress.org/2022/06/15/montana-lawmakers-probe-new-medicaid-director-on-privatization-future-priorities/

MM Curator summary

[MM Curator Summary]: And so it begins.

 
 

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.

 
 

Georgia is seeking input from individuals and organizations about what it should look for when it awards new multibillion-dollar contracts for the state’s Medicaid program.

The Georgia Department of Community Health’s request for information is the first step in the process of awarding the new health care contracts, which are expected to take effect by July 1, 2024.

Georgia’s Medicaid program contracts with private health insurers to provide health care services to around 1.7 million Georgians, most of them low-income children and pregnant women. The contracts are worth more than $4 billion annually.

Georgia is looking at five priority areas when deciding on the new contract holders: health-care quality, equity, access and outcomes, value, and coverage and services.

The request asks individuals, organizations, and companies to share feedback about the current program’s strengths and weaknesses and suggestions for improving outcomes, respecting linguistic and cultural needs, serving rural Georgia, and many other topics.

Responses are due by 2 p.m. June 24. Individuals and organizations should email responses to CMO.RFP@dch.ga.gov.

 
 

Clipped from: https://www.mainstreetnews.com/barrow/georgia-seeks-input-on-new-medicaid-contracts/article_af17ff93-d454-5034-a330-e335ef0f9e56.html

MM Curator summary

[MM Curator Summary]: Centene’s and Molina complaint trends are going down; Aetna and Humana’s are going up.

 
 

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.

 
 

 
 

The number of complaints concerning Florida’s Medicaid managed long-term care program have risen in recent months, members of a statewide medical care advisory panel were told Tuesday.

Paula James, the administrator for the Agency for Health Care Administration (AHCA) Bureau of Plan Management Operations, presented data showing there were 312 calls in May complaining about the contracted managed care plans that provide long-term care services in the state.

“The complaints, unfortunately, have been going up in the last three months. in some areas it’s gone down a little, but we do have a trending rate that has gone up in some of the complaints,” she said.

About a third of the calls were made about Sunshine Health Plan, the largest managed care provider in the state.

James attributed the 111 call complaints regarding Sunshine Health Plan to the company’s acquisition of StayWell and subsequent merger. The state hit Sunshine Health Plan with a record-breaking $9 million sanction in March for not making payments or delaying payment on 121,277 claims.

 
 

While Sunshine Health Plan had more complaints than any other provider, there is a downward trend in the number of complaints being made to the state about the health plan, according to James’ presentation to the Medicaid Managed Medical Care Long Term Care Advisory Subcommittee.

Sunshine and Molina Healthcare were the only two plans providing long-term care services to see a downward trend in complaints over the three-month period between March and May.

Humana Medical Plan, second only to Sunshine in the number of long-term care enrollees, with 28,739 members, had 59 complaints in May. That’s a continued upward increase in complaints over the three-month period.

Aetna Better Health
was the subject of 59 calls into the agency in May, which exceeds the number of complaints made against the insurer in March or April. Additionally, the number of complaints against Simply Healthcare Plan (43) also was up from the previous two months.

The calls came from providers and from Medicaid beneficiaries, but the state didn’t provide a further breakdown of the numbers.

 
 

James’ presentation did, though, provide details about what drives complaints about both groups.

Half of the complaints the state received in May from enrollees stemmed from an inability to access medical or dental benefits.

“In many instances, it’s a case of the recipient not knowing how to access the information or the fact that they have not gone back to the plan and requested assistance with this,” she said. “Or it could be a situation where they have asked for a particular provider and that provider is not in their network. So, a lot of it is education for the recipients.”

However, transportation, which is also classified as an access-to-care issue, continues to be an area where the state sees complaints from beneficiaries and providers, she said.

A snapshot of the providers’ complaints for May shows that 72% of the calls involve claims. While claims processing accounts for the overwhelming majority of the providers’ calls, the AHCA presentation showed that 15% of the calls from providers in May involve disputes between the plans and the providers over the accuracy of the information given to them by health plans.

The agency report also relayed that as of June 12 there were 372 unresolved complaints against Medicaid managed care plans. More than half of the pending claims involved allegations against Sunshine Health Plan.

James acknowledged to panel members that the number of unresolved claims “may” seem high. But she said that allegations involving claim payments are reviewed by a research team before health plans are notified. Moreover, she said the report includes information on complaints that her office received Monday and that some of the complaints “may” involve allegations about unpaid claims.

Medicaid is a safety net program for the poor, elderly and disabled that is funded and administered jointly between states and the federal government. There are more than 5 million people in the program as of the end of May.

Federal regulations require states to have a Medical Care Advisory panel that meets quarterly. The managed long-term care panel that met Tuesday is one of a handful of subcommittees that were created to examine issues.

There is a subcommittee for dental care as well as subcommittees that examine services for people with HIV/AIDS and children.

James said the other subcommittees will be meeting in the coming weeks.

The meetings come as Florida Medicaid officials begin work on a new procurement for the mandatory Medicaid managed care program.

The current Medicaid contracts the state has with selected managed care plans are set to expire on Dec. 31, 2023.

To have new contracts in effect by Jan. 1, 2024, the state wants to advertise the Medicaid bid by the end of the year.

While the number of complaints regarding the managed long-term care program are on the rise, not all the news James delivered Tuesday was bad.

She noted that in March 2018, 54% of the 100,209 people enrolled in the Medicaid managed long-term care program were receiving care in nursing homes.

Today, 62% of the 123,052 Medicaid managed long-term care enrollees are receiving services they need to keep living in a community setting and outside an institution. These services include adult companion care, attendant care, homemaker services, intermittent and skilled nursing, or personal care services.

“So, we are right where the agency has wanted to be all along. We are increasing the population that is able to receive services in their home or in a less restrictive environment like an assisted living facility rather than in a skilled nursing facility,” James said of the roughly 76,000 people on the waiver receiving home- and community-based services.

In addition to seeing a shift from non-institutional care to home and community-based services, James said there also has been an uptick in the number of people who are participating in what’s known as the Participant Directed Option (PDO).

PDO allows Medicaid beneficiaries who require assistance such as assistance with eating, bathing, grooming and homemaker services to hire workers providing certain long-term care services. The PDO is available to all long-term care enrollees who live in their own home or family home who hire friends, family members and even neighbors to provide the care.

The Medicaid managed care plan remains responsible for paying the providers the beneficiary chooses. Only services that are medically necessary can be covered through the PDO plan

Of the 67,875 people who qualified for PDO participation in March, about 16% were enrolled in the program.

Sunshine Health Plan Vice President of Long-Term Care and panel member Brad Shapiro asked James whether that was an increase from past years.

“My hope is it’s on the rise,” he said.

James didn’t have the comparison data but said participation had increased.

Sunshine Health Plan and Simply Health Care Plan have PDO participating rates of 19.1% and 18.7%, respectively.

Conversely, Molina, which has contracts in two of the 11 regions, had the lowest participation rates with just 9% of its eligible enrollees participating in the program.

But James said that plan size should not impact participation rates.

Simply has contracts in six regions and is second to Sunshine, which has contracts statewide, in the number of enrollees in the PDO program.

Humana has long-term care contracts in 11 regions but only 14% of its eligible enrollees participate in the program. That’s on par with Aetna Better Health which operates in three Medicaid regions and has an average PDO participation rate of 14%.

Clipped from: https://floridapolitics.com/archives/532538-medicaid-managed-long-term-care-complaints-are-increasing/

MM Curator summary

[MM Curator Summary]: Add $236M to the tab that Centene is paying to unwind its PBM chapter.

 
 

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:

• Centene has agreed to pay New Mexico $13.7 million to settle allegations it overcharged the state’s Medicaid drug program.
• Centene was accused of allegedly “layering fees” and not passing on retail discounts to the state Medicaid program.
• As part of the settlement, Centene will provide pricing transparency on all pharmaceutical benefits and services provided to the state’s Medicaid program, New Mexico Attorney General Hector Balderas said Monday in a statement. 

Dive Insight:

Centene, the nation’s largest Medicaid managed care organization, has settled a number of similar suits with a handful of states across the country.

The St. Louis-based insurer has agreed to pay more than $236 million to five other states, including Arkansas, Illinois, Mississippi, New Hampshire and Ohio, according to Healthcare Dive reports. 

The settlement with New Mexico now brings the settlement total to nearly $250 million.

“This no-fault agreement reflects the significance we place on addressing their concerns and our ongoing commitment to making the delivery of healthcare local, simple and transparent,” Centene said in a statement.

Centene previously disclosed it had set aside $1.1 billion, what it called a “reserve estimate,” to resolve future potential settlements, according to a filing with the Securities and Exchange Commission last June.

The insurer plans to no longer operate a pharmacy benefit management firm in-house. It’s in the process of bidding out the $30 billion in annual pharmacy spend to a third party, and expects to award a contract by the year’s end, according to comments newly appointed CEO Sarah London made during the first quarter earnings call. It will also sell two separate pharmacy units in a $2.8 billion deal as it continues to review the potential sale of non-core assets.

In New Mexico, Centene provides care to 1 million residents and is known in the state as Centennial Care.

The attorney general’s office will continue its investigation of pharmacy benefit managers contracted with the state’s Medicaid program, the attorney general said, pointing to other agencies like the Federal Trade Commission, which has recently launched a separate investigation into the conduct of PBMs.

 
 

Clipped from: https://www.healthcaredive.com/news/centene-settles-new-mexico-pbm-overcharging-allegations/625492/

MM Curator summary

[MM Curator Summary]: Humana is making donations to 8 different groups in the Columbus area, including food banks, BH providers, housing non-profits, and others.

 
 

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.

 
 

Community investments benefit eight organizations throughout Ohio

COLUMBUS, Ohio–(BUSINESS WIRE)–Humana Healthy Horizons, the Medicaid business of leading health and well-being company Humana Inc. (NYSE: HUM), announced today that it has invested $4.6 million to support community organizations in Ohio that share the company’s passion for overcoming public health challenges and improving the health and well-being of Ohioans.

“The Foodbank is thrilled to work on health equity with Humana. The funds from Humana will be spent providing services to food-insecure residents across the Miami Valley”

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“We are committed to supporting the important work being done by these community organizations across Ohio to improve the lives of people in the communities we serve,” said Jeff Corzine, Regional President-Ohio Medicaid at Humana. “We’re investing in community programs that will have a lasting impact on improving the holistic health and well-being of all Ohioans.”

The investments are going to community partners helping parents, families and individuals in need, including new mothers and children, and assisting with housing security, health and wellness, education, work force development, food security and more.

“The Foodbank is thrilled to work on health equity with Humana. The funds from Humana will be spent providing services to food-insecure residents across the Miami Valley,” said Michelle L. Riley, CEO of The Foodbank, a Dayton-area organization serving the Miami Valley through food distribution. “Ensuring our most vulnerable populations have the resources needed for a healthy and happy life is critical for our community to thrive. We thank Humana for its insight and leadership as we work to eliminate hunger in our communities.”

The community partners receiving funds are:

• The Foodbank
• Greater Cleveland Food Bank, the largest hunger relief organization in Northeast Ohio
• Mid-Ohio Food Collective, which provides food to people across 20 central and eastern Ohio counties
• Volunteers of America Ohio & Indiana, which provides behavioral health services, support for veterans, reentry from the criminal justice system and housing
• CHN Housing Partners, an affordable housing developer, housing services provider and residential lender
• March of Dimes, which works to improve the health of mothers and babies
• Ohio Academy of Family Physicians, a statewide professional association
• Ohio University, based in Athens

“Connecting families to healthy and nutritious food is an important part of Mid-Ohio Food Collective’s mission,” said Matt Habash, president and CEO of Mid-Ohio Food Collective. “We are thankful to have support from Humana as we continue to work together to find innovative solutions to hunger.”

“With Humana’s support, we are able to reach more people with our signature programs as we work toward our goals of improving maternal health and pregnancy outcomes so more babies will be born full-term and healthy,” said Lisa Amlung Holloway, director of maternal infant health for the March of Dimes in Ohio.

In April 2021, Humana was selected by the Ohio Department of Medicaid (ODM) to deliver health care coverage to Medicaid beneficiaries who live throughout Ohio. When Humana’s program entry is implemented, Humana will serve adults and children across Ohio with the goal of helping them improve their health and well-being through a whole-person, value-based approach that goes beyond traditional clinical care.

Humana has a strong and steadfast commitment to Ohio. As of March 31, 2022, approximately 563,700 Ohioans have health coverage through Humana Medicare Advantage plans, Medicare prescription drug plans, commercial group health plans, and the TRICARE military health care program as administered by Humana.

Humana is proud to be a community partner in Ohio by addressing community and social determinants of health through its Bold Goal program. The Bold Goal is Humana’s population health strategy to improve the health of people it serves, and Cincinnati is one of Humana’s official Bold Goal communities.

In addition, throughout the pandemic, the company has stepped up to support people and programs working to keeping our communities safe and functioning, and to support vaccination efforts.

About Humana Healthy Horizons

Humana manages Medicaid benefits for more than 950,000 members nationally under the Humana Healthy Horizons™ brand, which reflects our expertise in managing complex populations, our commitment to creating solutions that lead to a better quality of life for our members, and our efforts to deliver human care that makes the healthcare experience easier, more personalized and more caring.

During more than two decades of serving people with Medicaid, Humana Healthy Horizons has developed a wide range of capabilities to serve children, parents, childless adults, and beneficiaries that are aged, blind or disabled. We integrate physical health, behavioral health, pharmacy, long-term care, and social services for a whole-person approach to improve the health and well-being of our members and the communities we serve.

Humana Healthy Horizons serves Medicaid enrollees through the following programs:

• Medicaid Managed Care (MMC)
• Managed Long Term Services and Supports (MLTSS)
• Centers for Medicare and Medicaid Services (CMS) Financial Alignment Initiative Dual Demonstrations
• Medicare Advantage Dual-eligible Special Needs Plans (D-SNPs) and Medicare Prescription Drug Plans (PDPs)

Humana Healthy Horizons is a Medicaid Product offered by affiliates of Humana Inc.

About Humana

Humana Inc. is committed to helping our millions of medical and specialty members achieve their best health. Our successful history in care delivery and health plan administration is helping us create a new kind of integrated care with the power to improve health and well-being and lower costs. Our efforts are leading to a better quality of life for people with Medicare, families, individuals, military service personnel, and communities at large.

To accomplish that, we support physicians and other health care professionals as they work to deliver the right care in the right place for their patients, our members. Our range of clinical capabilities, resources and tools – such as in-home care, behavioral health, pharmacy services, data analytics and wellness solutions – combine to produce a simplified experience that makes health care easier to navigate and more effective.

More information regarding Humana is available to investors via the Investor Relations page of the company’s web site at www.humana.com, including copies of:

• Annual reports to stockholders
• Securities and Exchange Commission filings
• Most recent investor conference presentations
• Quarterly earnings news releases and conference calls
• Calendar of events
• Corporate Governance information

 
 

Clipped from: https://www.businesswire.com/news/home/20220615005259/en/Humana-Healthy-Horizons-Commits-4.6-Million-to-Improve-Health-of-Ohioans