Tag: Medicaid Managed Care

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OH- Rollout of Medicaid reforms delayed

[MM Curator Summary]: All of the OH Medicaid reforms except OH Rise are on hold while the state deals with the PHE wind-down efforts.

 
 

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 projected launch date of Ohio’s revamped and reformed Medicaid managed care system will still be July – except this month, given a potential crisis where many may be kicked off Medicaid, the state pushed back most of the reforms to the end of this year.

“It seems like this new phased approach still allows them to move forward with everything, but in a way that is manageable…to maybe take smaller bites of the apple,” said Loren Anthes, who chairs Community Solutions’ Center for Medicaid Policy.

Medicaid, government-paid health insurance for more than 3 million low-income or disabled Ohioans, is typically the state’s largest expenditure totaling billions of dollars. The “next generation” system is the result of an extensive process that started in 2019, looking at ways to overhaul the system after years of issues and lack of reform.

According to the Ohio Department of Medicaid, one of those reforms will still be up and running in July. OhioRISE is a new coverage system to treat children with severe behavioral and mental problems so parents don’t have to give up custody.

But all the other more complicated changes, such as a single pharmacy benefit manager to prevent prescription drug “middlemen” from overcharging taxpayers, won’t happen until October at the earliest. The same applies to the two to three new health plan options entering the system: AmeriHealth Caritas, Humana, and Anthem Blue Cross and Blue Shield.

 
 

Why the delay?

The planned July launch date could coincide with the end of the federal government’s COVID-19 emergency declaration, which prevented states from kicking ineligible people off Medicaid. When that ends, almost everybody will have to go through eligibility checks – a daunting task for an understaffed system that could also leave Ohioans confused over if they still have health insurance.

Spreading the Medicaid reforms out to later in the year would prevent a disaster scenario where both the eligibility checks and the new reforms go awry at the same time, said Anthes, the Medicaid policy expert.

“It is important that the reforms and improvements embodied in the Next Generation program are not compromised with a hurried launch, or potentially confusing communications,” the Medicaid department said in a document sent to lawmakers.

Despite the later timeline, Medicaid participants still can choose to enroll into one of the new plan options now, said department spokesperson Lisa Lawless. They’ll just remain on their current health plan until the end of the year when the switch occurs.

Starting dates for the new system were pushed back before, and some lawmakers have been concerned with how long implementation has taken. But the department insists they are not rushed.

“Doing this correctly is more important than meeting an administratively imposed timeline,” it told lawmakers.

 
 

Clipped from: https://insurancenewsnet.com/oarticle/rollout-of-medicaid-reforms-delayed

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Anthem Announces Finalization of Integra Managed Care Acquisition

[MM Curator Summary]: Anthem completed the acquisition of another LTSS plan as part of its strategy to extend services further into the home of Medicaid members.

 
 

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 payer shared that it aims to enhance its government business with its acquisition of Integra as it pursues whole-person care.

 
 

Source: Getty Images

 
 

By Kelsey Waddill

May 06, 2022 – Anthem has finalized its acquisition of Integra Managed Care, the payer announced.

Integra is a managed care company that offers managed long-term care plans. The organization serves four areas in the state of New York: New York City, Nassau, Suffolk, and Westchester. It will provide services to Anthem members who have disabilities or who require long-term care.

Integra will join the major payer’s government business division. The acquisition is strategically focused on the public payer space: the addition of Integra will expand Anthem’s ability to serve Medicaid beneficiaries in New York.

“We’re pleased to complete this acquisition and work alongside our new colleagues as we continue to grow our Medicaid business and enhance the healthcare experience for all of our members,” said Felicia Norwood, executive vice president of Anthem’s government business division. 

“Anthem and Integra’s shared commitment to deliver high quality, comprehensive whole-health care across communities throughout New York ensures that our members will continue to receive the care and support services that they have come to expect.”

Integra serves 40,000 Medicaid members. Members receive support from a care management team that includes a social worker. Additionally, a care coordinator helps with arranging to meet the member’s long-term care needs.

Anthem did not release any financial information about the deal.

The payer announced its plans to acquire Integra in November 2021. Prior to Anthem’s acquisition, Integra was a wholly-owned indirect subsidiary of Personal Touch Holding Corporation.

“This acquisition aligns with our goal of growing Anthem’s Medicaid business, while serving our members with a comprehensive and coordinated approach to care,” Norwood said at the time of the original announcement.

In addition to expanding its government business division, Anthem has used acquisitions to enhance its home healthcare services capabilities. The payer announced plans to acquire myNEXUS in March 2021 and only a month later the deal was completed, as projected.

In both the acquisition of myNEXUS and the acquisition of Integra, executives at Anthem cited whole-person care as a key motivator.

For those with long-term care needs, whole-person care is critical, specifically for those living with a serious illness or in need of palliative care, a study from AHIP found. The aging population also brings this conversation to the forefront.

The study emphasized that case managers are key to providing holistic care for palliative care needs or for those who have serious illnesses. Such a role can help take on the burden of care planning, navigating benefits, and overall case management as well as communicating with caregivers. Additionally, case managers can provide support for social determinants of health needs.

All of these elements factor into a whole-person care approach for a person in long-term care.

In a study that Anthem commissioned, experts revealed that integrated health care benefits can be crucial for whole-person care as well. Such benefits bring together pharmacy needs with supplemental healthcare and additional benefits data in order to improve care coordination.

The acquisition of Integra intends to bolster the payer’s government business in Medicaid but also aims to enable better whole-person care options for members as they seek long-term care.

 
 

Clipped from: https://healthpayerintelligence.com/news/anthem-announces-finalization-of-integra-managed-care-acquisition

 
 

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OK- Proposed Medicaid solution in legislation aims to improve efficiency and outcomes

[MM Curator Summary]: The state is now going with a provider-led entity model to bring managed care back (maybe).

 
 

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.

 
 

 
 

Measures to create a system for managing Oklahoma’s Medicaid program in-state authored by Rep. Marcus McEntire, R-Duncan, and Sen. Greg McCortney, R-Ada, are headed for discussion in conference committee. (Photo by Alexandr Podvalny via Unsplash)

OKLAHOMA CITY – After the courts put an end to Gov. Kevin Stitt’s plan to privatize much of the state’s Medicaid program last year, it was left to lawmakers to come up with an alternative solution – one that would improve efficiencies and outcomes while keeping administrative dollars in-state.

Rep. Marcus McEntire, R-Duncan, and Sen. Greg McCortney, R-Ada, are authors on legislation intended to do that. The measures have some additional hurdles to clear before they can be implemented, however, and are sure to be intensely “cussed and discussed,” as McEntire put it, during the last few weeks of the legislative session.

McEntire recently told lawmakers on the floor of the House of Representatives claimed the plan lawmakers are working on could reverse the trend of the last few years and help rural hospitals reopen, or resume providing obstetrics care.

“Every hospital, rural or urban, will be profitable again on their Medicaid clientele since the first time since the ACA (Affordable Care Act) was passed,” McEntire told lawmakers when the bills came before the full House of Representatives on April 28. “And we’re talking real money here, that they’re going to be able to reinvest in their communities.”

The plan gives lawmakers more control to continually tweak the program to address constituent needs, and to ensure that the healthcare companies involved are focused on efficiently spending Medicaid dollars to get the best health outcomes for patients.

After voters approved State Question 802 in 2020, expanding Medicaid, lawmakers set about figuring out a way to pay for it and make sure the program was administered efficiently. Stitt pushed for managed care, having the Oklahoma Health Care Authority award roughly $6 billion in contracts to a handful of national insurance companies.

The Oklahoma Supreme Court struck down that deal, finding OHCA did not have the legislative approval to move forward with the managed care plan, and the expansion approved by voters did not authorize such a program.

Oklahoma last attempted managed care in the 1990s, but amended the plan after seeing a precipitous decline in participating physicians, resulting in scarcity of care.

Oklahoma-based companies would better implement the state’s Medicaid program, and lawmakers should monitor progress to ensure that the funding they receive is concentrated in providing healthcare services rather than boosting profits, McEntire said. The proposed plan would encourage provider-led entities such as Integris to expand their accountable care organizations statewide, and those Oklahoma-based organizations would likely partner with larger, national companies to provide financial backing, he said.

“This plan puts an Oklahoma provider-led entity in the middle of that,” McEntire said. “The money will stop there in state. There is no doubt these provider led entities do not have the financial reserves to take on this much risk; they will need somebody financially backing them…

“If they overshoot those capitated amounts they’re going to need an insurance company behind them with the financial reserves to come in and bail them out because the state is not going to,” McEntire said.

The plan shifts the Medicaid program from a fee-for-service model to a value-based system, providing bonuses for improved outcomes and encouraging providers to take a more holistic approach to care.

Plus, the state would be able to leverage federal dollars to make sweeping change while keeping the cost of the program “net revenue neutral” for the state, McEntire said.

The measures were introduced as amendments on the House floor, introducing a lot of new language late in the legislative process. Though the measures were approved with overwhelming support in the House, the amendments were rejected by the Senate on May 5, sending the bills into discussions in conference committees over the next few weeks.

 
 

Clipped from: https://journalrecord.com/2022/05/09/proposed-medicaid-solution-in-legislation-aims-to-improve-efficiency-and-outcomes/

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Contracted Medicaid Managed Care Providers Treated Few Beneficiaries

[MM Curator Summary]: The PAR rate is even worse than we thought.

 
 

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.

 
 

Treatment from contracted Medicaid managed care providers was highly concentrated, with a quarter of physicians and specialists accounting for the majority of claims.

 
 

Source: Getty Images

 
 

By Victoria Bailey

May 04, 2022 – Around one-third of primary care and specialty physicians that contracted with Medicaid managed care plans saw fewer than ten Medicaid beneficiaries over a year, suggesting that network adequacy standards may not accurately reflect beneficiary access to physicians, a Health Affairs study found.

Over 70 percent of Medicaid beneficiaries are enrolled in managed care plans, which are responsible for constructing physician networks from which beneficiaries can seek care. Physician networks in Medicaid managed care plans are typically similar to those in private plans offered through the state health insurance market.

However, network directories may be out of date or list physicians that are not willing to treat Medicaid beneficiaries, indicating that the networks may not reflect the actual availability of physicians. In addition, beneficiaries may prefer providers not included in the network.

To understand how accurate Medicaid managed care plan networks are in determining the availability of physicians for Medicaid beneficiaries, researchers gathered administrative medical claims, Medicaid eligibility and enrollment files, and provider network directories for managed care plans in Kansas, Louisiana, Michigan, and Tennessee between 2015 and 2017.

There were around 22,000 physicians in adult primary care, pediatric primary care, cardiology, and psychiatry in Medicaid managed care networks across the four states, the study found.

About 16 percent of the physicians saw zero Medicaid beneficiaries over one year—defined as ghost physicians. Psychiatrists were the most likely to be ghost physicians, with 35.5 percent treating no Medicaid beneficiaries. Pediatric primary care physicians were least likely to be ghost physicians (11 percent).

Similarly, 17 percent of physicians treated between one and ten Medicaid beneficiaries and were classified as peripheral physicians. Nearly 43 percent of providers saw between 11 and 150 beneficiaries (standard physicians), while 23.7 percent of providers treated more than 150 beneficiaries within a year (core physicians).

The majority of physicians (87.8 percent) who provided care to Medicaid beneficiaries were contracted with Medicaid managed care plans, but 2,500 out-of-network physicians treated at least one Medicaid beneficiary. This suggests that there is a small level of care available to beneficiaries outside the physicians listed in network directories.

Treatment from physicians included in Medicaid managed care plan networks was highly concentrated among small percentages of physicians.

For example, among pediatric and adult primary care physicians that treated at least one Medicaid beneficiary, 25 percent of physicians were responsible for 86.2 percent of claims. Additionally, a quarter of cardiologists accounted for 69.2 percent of claims and 25 percent of psychiatrists were responsible for 86.5 percent of claims.

Among physicians who treated more than 150 Medicaid beneficiaries, 29 percent of primary care physicians accounted for 88 percent of care, 22 percent of cardiologists provided 632 percent of the care, and 15 percent of psychiatrists were responsible for 70.6 percent of care.

Care concentration was slightly higher in urban areas compared to rural areas, the study noted.

Network adequacy requirements vary across the 20 states that have them. Some require plans to contract with at least one primary care provider for every 100 beneficiaries, while others require one provider for every 2,500 beneficiaries.

Based on these network adequacy standards, 94.2 percent of the counties in the four states included in the study had sufficient access to primary care physicians, with an average of one primary care physician for every 440 beneficiaries.

Across the four states, 12.4 percent of counties met the standard for cardiologists, while 10.4 percent met the standard for psychiatrists. After excluding ghost and peripheral physicians, these figures decreased for each provider group.

“Our findings suggest that provider network directories may overstate the availability of physicians in the Medicaid program; many states’ reliance on directories to ensure network adequacy may be insufficient to ensure satisfactory access to physicians who are both valued by Medicaid managed care beneficiaries and willing to treat them,” the researchers wrote.

Medicaid managed care plans are required to demonstrate the adequacy of their networks, but federal leaders have not provided much oversight on how to do this, the study noted. In addition, state network adequacy standards and enforcement vary widely.

Researchers suggested two policy solutions to improve the oversight of Medicaid provider networks. First, states should direct resources to regularly evaluate managed care networks through a combination of audit studies and administrative claims data.

Additionally, states should enact strict penalties for managed care plans that do not comply with network adequacy standards.

 
 

Clipped from: https://healthpayerintelligence.com/news/contracted-medicaid-managed-care-providers-treated-few-beneficiaries
 

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Legislature delays negotiations of $4 billion Kansas Medicaid contracts until 2023

[MM Curator Summary]: The bill to handle MCO contract schedules directly by legislative power has moved forward in Kansas, but will be 1 vote shy of being veto proof from the Governor it is seeking to control.

 
 

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.

 
 

Bill also restricts governor’s authority to close churches during emergency

 
 

Rep. Brenda Landwehr, second from the left, and Rep. Kathy Wolfe Moore, center, sparred over whether delaying the negotiation process over the state’s Medicaid contracts would open the door to possible corruption. Opponents, like Wolf Moore, argue the passing the bill is the equivalent to a one year, no-bid contract extension for the three organizations overseeing KanCare. (Sherman Smith/Kansas Reflector)

TOPEKA — Kansas Republican legislators moved Tuesday to delay negotiations of the nearly $4 billion contracts for insurance companies managing the state’s Medicaid system until 2023.

The bill blocks all requests for proposals for managed care organizations administering KanCare until at least Jan. 1, 2023. The GOP-controlled Legislature was eager to push the process of awarding the new KanCare contracts until January, after the gubernatorial election. 

However, Democrats argued this move allowed no competition and no accountability over the three companies overseeing KanCare. They noted a previous version of the provision heard earlier this year lacked support beyond Republican legislators. 

Opponents also argued the delay would force the equivalent of a no-bid, one year extension of contracts with Sunflower Health Plan, United Healthcare and Aetna Better Health of Kansas, even if it is not delineated in the bill.

“What we are doing here is altering the procurement process for just the three MCOs. Why would we do that?” said Kathy Wolfe Moore, D-Kansas City. “That’s kind of a slippery slope. How many other times is the Legislature going to get involved in this? This is black and white. This is not right.”

Representatives approved the measure 84 to 38, following the lead of the 26 senators who cast affirmative votes before adjourning the regular session in early April. Gov. Laura Kelly has not yet expressed if she will act to veto the measure. The bill was a vote shy of a veto-proof majority in the Senate.

The bill also contains an unrelated section limiting Kelly’s power to close or restrict capacity at Kansas churches during a state of emergency. Legislators combined both measures into the new bill during a conference committee last month.

Rep. Brenda Landwehr, R-Wichita, insisted the new language would not require an extension of current contracts and argued the proposal would ease concerns from the state’s Medicaid director.

She also questioned Kelly’s desire to have the KanCare system managed by nonprofit entities. She argued the current for-profit organizations overseeing KanCare have done a good job providing services. 

“I don’t care if they are profit or nonprofit,” Landwehr said. “What I care about is the citizens that we serve get their services and they get them without interruption. That’s why I’m here.”

Rep. Sean Tarwater, R-Stilwell, called into question Kelly’s handling of previous RFPs and issues in other departments. He lambasted the governor for her handling of the strain placed on the state’s beleaguered unemployment system and said he could not be sure she would manage this better.

Tarwater also noted that Nebraska put out a similar request for proposal a few weeks ago with a deadline of the end of the year.

“It’s a simple process,” he said. “It can be done in a shorter time period, and it can be done properly.”

Kelly is running for reelection in 2022 and should she lose, control over these KanCare contracts would likely go to presumptive Republican opponent Derek Schmidt. Schmidt, the state’s attorney general, previously weighed in on the issue, saying the Legislature did have the authority to delay this process. 

Rep. John Carmichael, who previously ripped this tactic as a corrupt, “pay-to-play” scheme, asked lawmakers to remember the 2014 investigation into whether KanCare contributors paid off lawmakers.

“Where did this idea come from? Who is the proponent of this idea?” the Wichita Democrat asked. “No one can explain a good, legitimate reason to do this.”

House and Senate leadership have denied any misconduct in seeking to delay the contracts.

Carmichael also argued the Kansas constitution already enshrined the ultimate right to practice religion and passing the provision barring the governor from closing churches would simply be duplicative.

However, House majority leader Dan Hawkins, a Wichita Republican, said the governor “closed” churches early in the pandemic, thus requiring this measure. Kelly didn’t close churches, but did issue an executive order limiting mass gatherings in houses of worship.

“It’s important for us to do this because she did not listen to the constitution,” Hawkins said. “Maybe she’ll listen to the statue, maybe she won’t, but it will be in two places now.”

 
 

 
 

Clipped from: https://kansasreflector.com/2022/04/26/legislature-delays-negotiations-of-4-billion-kansas-medicaid-contracts-until-2023/

 
 

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Centene Profits Hit $849 Million On Medicaid, Medicare And Obamacare Growth

[MM Curator Summary]: If you’re the largest Medicaid plan on the planet, its been a good coupla years.

 
 

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.

 
 

 
 

Centene reported nearly $850 million in first quarter profit as membership grew by 1.9 million … [+] thanks to an increase in enrollment in Medicaid, Medicare and Obamacare plans, the company said April 26. 2022. This July 2, 2015, file photo shows the building housing Centene Corporation headquarters in Clayton, Mo. (AP Photo/Jeff Roberson, File)

ASSOCIATED PRESS

Centene reported nearly $850 million in first quarter profit as membership grew by 1.9 million thanks to an increase in enrollment in Medicaid, Medicare and Obamacare plans, the company said Tuesday.

Centene, which sells an array of government subsidized health insurance including Obamacare, said total managed care membership increased by 1.9 million members, or 8%, to 26.2 million, compared to the end of the first quarter of 2021.

Such growth helped Centene’s revenues jump 24% to $37.2 billion. Net income was $849 million in the first quarter compared to a $699 million in the first quarter of 2021.

“Our strong first quarter performance demonstrates Centene’s ability to deliver on our financial goals while continuing to make progress against our value creation initiatives,” said Sarah London, Centene’s chief executive officer, who earlier this year succeeded the late Michael Neidorff. The longtime Centene CEO, Neidorff had announced his retirement before he passed away earlier this month.

Under the early days of London’s leadership, Centene’s growth story continues with the company’s strong first quarter performance contributing to management’s decision to raise its financial outlook for the rest of 2021. The health insurance giant now expects adjusted earnings per share in the rage of $5.40 and $5.55 compared to an earlier projection of between $5.30 and $5.50 per share.

Medicaid membership ended the first quarter at nearly 15.3 million compared to nearly 13.8 million in the year ago period while Medicare enrollment jumped to 1.45 million compared to 1.13 million in the year ago period.

Centene also saw an increase of more than 100,000 new health plan members who enrolled in “commercial marketplace” coverage under the Affordable Care Act known as Obamacare. Centene is the largest provider of Obamacare in the U.S. with more than 2 million enrollees as of the end of the first quarter compared to 1.9 million in the year-ago period.

 
 

 
 

Clipped from: https://www.forbes.com/sites/brucejapsen/2022/04/26/centene-profits-hit-849-million-on-medicaid-medicare-and-obamacare-growth/?sh=503b38c34d40

 
 

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TennCare legislation requires renewal with providers that didn’t win contracts

[MM Curator Summary]: Legislators in TN are looking for a way to guarantee incumbents keep their dual eligibles contracts even after losing the larger Medicaid contracts.

 
 

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.

 
 

 
 

Speaker of the House Cameron Sexton backed addition of Centene Corp. to TennCare through a no-bid contract. (Photo: John Partipilo)

Insurance conglomerate Centene, which has spent more than $1 billion to settle Medicaid lawsuits across the nation, could still get a shot at a TennCare contract it failed to win.

The bill’s sponsor wants to make sure TennCare recipients enrolled in a Medicare-Medicaid program are able to stay with their insurance carriers, including Centene and two others that didn’t receive a new contract, Cigna and Humana.

House Bill 2625 by Rep. Charlie Baum, R-Murfreesboro, would require TennCare to study the impact of not contracting with Centene and two other insurance companies and report back to the General Assembly. In the meantime, TennCare would take no action to remove the enrollees from their plans for a Medicaid-Medicare coverage program, which includes Centene, Humana and Cigna.

 
 

The legislation is to head to the House floor for a vote after receiving approval Tuesday from the House finance committee. 

It is unclear, though, whether the measure will make it through the full General Assembly. The Senate version sponsored by Sen. Todd Gardenhire, R-Chattanooga, hasn’t been amended and isn’t expected to reach the floor for consideration with the Legislature set to adjourn later this week.

The amendment Baum presented Tuesday in the finance subcommittee didn’t address insurance giant Centene as a managed care organization. Baum said he would not make an effort on the House floor, either, to re-insert Centene into the bill. 

But he said the legislation, as amended, should cover TennCare recipients who have selected Humana, Cigna and Centene. 

Those three companies have been providing coverage for TennCare recipients on the Medicaid-Medicare program, according to Baum, but did not win bids to continue serving.

The three contracts went instead to Americare, BlueCross BlueShield and Universal. 

According to TennCare spokeswoman Amy Lawrence, the portion of the bill dealing with dual enrollees in Medicaid-Medicare is “completely separate” from the managed care organization part previously included. The newest amendment does requires a study but also forces TennCare to renew expiring contracts with all contract contracted dual-coverage providers until the General Assembly adopts a resolution permitting non-renewal, according to Lawrence.

Regardless of what they do, what they tried to do and what they are currently trying to do to cover their tracks, at the instruction of the Speaker, is clear. The message they are sending is: If you don’t like a result, donate.

– Rep. Jason Hodges, D-Clarksville

Baum, who asserted he has not received any campaign contributions from Centene, said his intention was to enable enrollees to maintain their coverage with Centene, Cigna and Humana. He acknowledged the legislation went through several changes, including the effort to give Centene a contract, since it applied for the contract as a managed care organization.

House Speaker Cameron Sexton got behind the legislation and signed on as a co-sponsor, saying he felt the division of TennCare needed more “transparency.” He also objected to the potential removal of enrollees from their “dual-coverage” plans.

State Rep. Jason Hodges, a Clarksville Democrat, challenged the legislation when it surfaced a month ago, calling it a form of “bid-rigging.” The initial amendment also would have cost the state an estimated $2.8 million next fiscal year and $30 million in a third year, in addition to $60 million in federal funds, according to a fiscal impact document.

Hodges, who is not seeking re-election, said Tuesday, “Regardless of what they do, what they tried to do and what they are currently trying to do to cover their tracks, at the instruction of the Speaker, is clear. The message they are sending is: If you don’t like a result, donate. The amendment doesn’t change anything for me.”

Sexton’s office did not respond to questions immediately Tuesday. 

A bill to give a no-bid contract to0 Centene has been withdrawn but bill sponsor Rep. Charlie Baum, R-Murfreesboro. wants to make sure TennCare recipients enrolled in a Medicare-Medicaid program are able to stay with their insurance carriers, including Centene

Centene Management has not contributed money to any lawmakers in the last two years but gave two donations of $4,200 each to Gov. Bill Lee in January 2021. 

The Division of TennCare has opposed the bill, saying it ran a “fair and open process” in its most recent procurement. It also contends no enrollees will lose coverage because they will have plenty of time to switch to a new provider. 

Centene has been pushing hard for the legislation and started pressing the matter this week. Recently, it asked Sen. Kerry Roberts, R-Springfield, to sign on as co-sponsor of the Senate bill, which remains stuck in the Calendar and Rules Committee.

Rhythm Health Tennessee, which is part of Centene Corp., previously filed a protest against the bidding process. It has agreements with several Tennessee health-care providers, including a preferred agreement with Vanderbilt Health Affiliated Network.

Hodges also raised questions about Centene because it was connected to a bid-rigging lawsuit filed against the state.

In May 2021, the Department of Correction opted to take new bids on a $123 million contract for inmate mental health services because of the lawsuit, which was dismissed with prejudice this January. 

Nationally, it has run into several problems as well.

In mid-2021, Centene announced it would spend $1.25 billion to settle disputes with 22 state Medicaid systems, though the company admitted no wrongdoing, according to an Ohio Capital Journal report.

That included $55 million in a settlement with Mississippi for failing to give contractually guaranteed discounts on Medicaid drugs. 

An $88.3 million settlement with the state of Ohio centered on accusations by the attorney general that Buckeye Health, a Centene subsidiary, set up a chain of businesses that double-charged the state for services.

The report also details comments by Centene chief Michael F. Neidorff in June 2021, in which he said the company’s goal is to increase its net income margin by 3.3%, to $120 billion.

 
 

 
 

Clipped from: https://tennesseelookout.com/2022/04/27/centene-guarantee-removed-from-tenncare-contract-legislation/

 
 

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California investigating Centene over alleged Medicaid fraud

[MM Curator Summary]: CA begins its efforts to access the $1.2B set aside by Centene to deal with PBM spread pricing allegations.

 
 

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.

 
 

California regulators are investigating Centene Corp. over allegations that the company overcharged the state’s Medicaid department for drugs, according to a state Department of Health Care Services spokesperson.

DHCS did not specify which branch of Centene it was investigating. Centene subsidiaries offer Medicaid managed-care plans in California and administer the state’s Medicaid prescription drug program.

Centene receives the majority of its revenue from Medicaid managed-care contracts, and California represents its largest market with 2.14 million enrollees. In 2021, the state paid Centene $6.8 billion to manage its Medicaid program, the DHCS spokesperson said.

Centene did not respond to an interview request about the investigation.

Centene reached agreements with nine state attorneys general and has reserved $1.25 billion to settle allegations that it overcharged state Medicaid departments for medications, the insurer wrote in its annual filing with the U.S. Securities and Exchange Commission.

It has so far publicly disclosed paying $246.4 million to Illinois, Arkansas, Mississippi, Ohio and Kansas as part of these deals. Georgia, South Carolina and Indiana are also reportedly investigating the insurer over its now-defunct Envolve pharmacy benefit manager. The attorney general in South Carolina declined to comment, while attorneys general in Indiana and Georgia did not respond to interview requests.

California accepted new bids to run its Medicaid managed-care program until April 11, and it will announce winners in August. Centene executives are likely doing everything they can to ensure regulators are satisfied with their response, said Ari Gottlieb, a principal at A2 Strategy Group.

“It’s a highly material part of their business,” Gottlieb said. “My guess is that they’re throwing a bunch of extra resources, apologizing, really going all-in on fixing the problem.”

Existing problems in California

California’s investigation comes as state regulators withheld $3.8 million from subsidiary Magellan Health’s January contract after worker shortages left patients and providers waiting for prior authorization approvals, some of whom were on hold with the company’s call centers for eight hours at a time.

Both state regulators and Magellan Health blamed delays on contract changes, noting that a new vendor was taking over the administration of the state’s Medicaid prescription drug program for the first time. Magellan Health’s $302 million annual contract went live at the start of the year.

Rival insurers criticized the deal, saying the move would give Centene insight into their member demographics and give them a leg up when it came to bidding to run the largest Medicaid program in the nation. Centene’s pharmacy services reputation did not help: Patients and providers noted the irony of hiring a vendor that recently settled drug overcharging allegations from other state Medicaid departments.

“There’s a specter surrounding Centene and its legal troubles with regards to pharmacy benefits,” Antonio Ciaccia, president of drug pricing watchdog 3 Axis Advisors and head of 46brooklyn Research. “While their PBM has taken the disproportionate share of public lashings today, they’re not different from anybody else in this market.”

It’s hard to fault Centene when it recently acquired Magellan Health, and it hasn’t been fully integrated the businesses, Gottlieb said. California regulators approved the $2.2 billion merger two days before Magellan Health took over the state’s Medicaid prescription drug program. Moreover, delays in processing claims and prior authorization requests are common when public health programs change, and formulary updates made at the start of the year could have complicated the process, he said.

“Part of it is on the regulators, honestly, they should be doing their due diligence and readiness assessments to ensure their vendors can perform,” Gottlieb said.

DHCS said it measured the agency’s and Magellan Health’s internal capacities to administer the program prior to launch. Delays processing prior authorization requests, adjudicating provider claims and answering provider and patient calls “have stabilized and all backlogs have been cleared” since the start of the year, the spokesperson said.

Magellan Health has processed all prior authorization requests within 24 hours since February 11, and paid all pharmacy providers on time since the start of the year, a Magellan spokesperson wrote in an email. The company’s call centers levels are currently meeting their contractual requirements, the spokesperson wrote.

Long wait times disproportionately impacted–and continue to impact–the state’s safety net facilities, where up to 60% of their patients are insured through Medicaid, said Isabel Becerra, CEO of the Coalition of Orange County Community Health Centers, a not-for-profit consortium safety net clinics in southern California. While the backlog from the start of the year has been resolved, Becerra said providers are still spending more time than they had before the merger to secure care for their patients.

“It’s still not fixed,” Becerra said. “There’s still a lot of time that’s being taken with these patients.”

Delays cloud Sunshine Health Plan

California is not the only market where providers are complaining of long wait times with Centene. Lags in the company’s payment, claims adjudication and prior authorization systems have also plagued Florida, Centene’s second-largest Medicaid market with 1.78 million enrollees. The deadline to bid on continuing to run Florida’s Medicaid program is also approaching, Gottlieb noted.

In March, Florida regulators fined Centene $9.1 million and suspended enrollment in its Sunshine Health Plan after technology glitches related to its integration of insurer Wellcare led it to mistakenly deny medical claims for more than 121,100 lower-income adults and children.

In response, Sunshine Health agreed to provide a corrective action plan to the state. Since its October merger with Wellcare of Florida, 99.1% of its claims were paid within 30 days, a Sunshine Health spokesperson wrote in an email.

But hospitals and independent providers are still reporting delays, said Mary Mayhew, president and CEO of the Florida Hospital Association.

“A lot of the fallout will continue,” Mayhew said.

One provider still navigating the change in payers is Children’s Orthopaedic and Scoliosis Surgery Associates, which claims to be the state’s largest private children’s orthopedic provider. Sunshine Health Plan owes the independent practice $200,000 over improperly denied claims and prior authorizations, repricing and categorizing consults as new patient visits, administrator Carol Ittig said.

In late March, Ittig said she had a virtual meeting with Centene executives about the payment problems, telling them she would have to delay paying the practice’s physicians because of the insurer’s lag in accurately processing claims. Three days later, Ittig woke up to a $70,000 no-strings-attached loan from Sunshine Health.

“They told me to hold on to it as long as I think that there’s still issues,” she said. “I’m very grateful. But that shows that they know that there are issues, that they want to rectify it but they know that it’s gonna take them a minute to fix.”

 
 

 
 

 
 

Clipped from: https://preparedpatriot.net/2022/04/25/california-investigating-centene-over-alleged-medicaid-fraud/

 
 

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UnitedHealth (UNH) Inflated Drug Costs, Louisiana AG Alleges in Suit

[MM Curator Summary]: UHC is now facing its own spread pricing allegations related to its subsidiary PBM OptumRx.

 
 

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.

 
 

UnitedHealth Group headquarters in Minnetonka, Minnesota.

Photographer: Mike Bradley/Bloomberg

By

John Tozzi

April 20, 2022, 11:09 AM CDTUpdated onApril 20, 2022, 2:04 PM CDT

UnitedHealth Group Inc. was accused by Louisiana’s attorney general of inflating prescription drug charges in the state’s Medicaid program by billions of dollars.

UnitedHealth’s pharmacy benefits manager, Optum Rx, used secret prices and the complexity of the supply chain to cause the safety-net health program “to needlessly pay billions of dollars more per year for prescription drug benefits,” according to a lawsuit from Attorney General Jeff Landry. The action was filed April 13 in state court.

UnitedHealth said in a statement that its services are performed in accordance with state regulations and the Medicaid program’s requirements outlined in its contract. “We believe this lawsuit is without merit and will defend ourselves against these unsupported allegations,” the statement said. 

Pharmacy benefits managers have come under growing scrutiny from employers and governments over how they calculate drug costs. The case is the latest attempt by state authorities to curb what they call fraudulent pricing practices by pharmacy benefits managers hired to run Medicaid drug plans. UnitedHealth rival Centene Corp. took a $1.1 billion charge last year to resolve similar claims from several states.

UnitedHealth is one of several companies Louisiana hired to administer Medicaid, the state-based insurance plan for low-income residents. Contracts require the companies to spend a minimum share of their premiums on medical care, a threshold known as the medical-loss ratio, or MLR.

UnitedHealth also owns pharmacy benefit manager Optum Rx, which contracts with its health insurance plans. The AG alleged that Optum had an incentive to pump up its drug costs to help parent UnitedHealth meet its required spending on health care.

“Since only United is required to abide by the MLR requirement, inflating the drug costs paid to Optum actually helps United meet its MLR but does not create an actual loss to their parent company,” the AG’s filing said. “Inflated payments to Optum are additional profits for United, yet are counted as costs for the purposes of meeting the MLR.”

The petition alleges that Optum overcharges the state for generic drugs; engages in spread pricing by charging the state more than it pays pharmacies to fill prescriptions; and claws back money from pharmacies without passing it back the state.

“Unregulated middlemen, cloaked in secrecy, drive up their own profits at the expense of Louisiana citizens,” Landry said in an emailed statement. He alleged that PBMs take advantage of “an unclear web of contracts” with drugmakers, health plans and pharmacies, “taking a share of profits from each entity.”

The action cites a breach of contract, violations of the Louisiana Unfair Trade Practices Act and other violations. In addition to damages, restitution, and penalties, the AG asked the court to force United to turn over documents that the state requested during its probe but was unable to obtain.

The case is State of Louisiana vs. OptumRx and United Healthcare of Louisiana Inc., C-717848, East Baton Rouge Parish.

(Updates with attorney general’s statement in ninth paragraph)

 
 

 
 

 
 

Clipped from: https://www.bloomberg.com/news/articles/2022-04-20/unitedhealth-inflated-drug-costs-louisiana-ag-alleges-in-suit

 
 

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Despite opposition, Pennsylvania Medicaid contracts keep unionization language

[MM Curator Summary]: The corrupt inclusion of union-boss graft in Medicaid contracts remains in the latest version of Medicaid health plan contracts.

 
 

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 Center Square) – As Medicaid contracts are worked out to take effect in the summer, draft language remains unchanged that could compel unionization in some Pennsylvania health systems.

As The Center Square previously reported, the HealthChoices Medicaid Managed Care agreements cover the physical health portion of Pennsylvania’s Medicaid contracts, which cover almost 3 million Pennsylvanians and were worth $65 billion over the past five years.

Despite questioning from state senators and representatives who urged the draft language in the contracts to be amended, the Department of Human Services has not modified them. 

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Originally expected to go into effect in July, DHS has delayed them until Aug. 1. “The Department became aware of an issue involving difficulties experienced by at least one managed care organization in its efforts to develop and negotiate inclusion of certain UPMC facilities in its network, which potentially impacts the review of network adequacy requirements,” said Ali Fogarty, communications director of DHS.

However, the language has yet to be finalized, though the original plan was to have contract language finalized by April 1. “The agreements are still in draft form at this time,” Fogarty said.

The contract draft language reads, in part: “The PH-MCO may not include in its network any Provider with a history of one or more work stoppages during the five years immediately preceding the Effective Date of this Agreement, unless the Provider is or becomes a signatory to a valid collective bargaining agreement or is or becomes a signatory to a labor peace agreement with any labor organization that informs the Provider that it is seeking to represent the Provider’s employees at any site in the PH-MCO’s network that delivers services to HealthChoices enrollees.”

The agreement “is intended to prevent service disruptions to the PH-MCO’s members caused by employee unrest or dissatisfaction,” it reads. 

That has not sat well with the Hospital and Healthsystem Association of Pennsylvania, which has sent multiple letters to DHS opposing the language.

“Pennsylvania’s hospital community is very concerned about proposed language in upcoming Medicaid managed care contracts that, based on recently updated estimates, could jeopardize access to health care for hundreds of thousands of Pennsylvanians,” said Liam Migdail, director of media relations for HAP. “If enacted, this proposal would preclude a dozen or more hospitals from caring for patients, including some that are the only hospitals in their rural communities and others that offer specialized care for women, children, and people with cancer.”

 
 

Clipped from: https://www.wfmz.com/news/state/despite-opposition-pennsylvania-medicaid-contracts-keep-unionization-language/article_a7d36912-5a01-572c-8519-2a8d0e51566a.html