Tag: Medicaid Managed Care

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D.C. plans to rebid its troubled Medicaid contracts, as risk of patients losing access to MedStar doctors looms

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One hospital-based health plan lost its DC contract and has threatened to not see Medicaid patients- and that has triggered a new MCO procurement.

 
 

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.

 
 

As a crisis roils D.C.’s Medicaid system, city leaders said on Friday that they will issue an entirely new procurement for insurance companies to manage poor patients’ care — an attempt that may or may not prevent MedStar from revoking access to its doctors for hundreds of thousands of poor patients.

The city’s Medicaid troubles reached a boiling point last week when Deputy Mayor Wayne Turnage said that MedStar, the hospital system that most often cares for D.C.’s beneficiaries, had announced its intention to stop providing routine care for most Medicaid patients in the coming months.

The new plan to rebid the contracts might represent one step toward resolving the impasse with MedStar, though a new procurement does not necessarily mean that low-income patients won’t face the loss of their current insurance plan or their access to some doctors this fall.

 
 

D.C. Medicaid patients could lose access to MedStar, the health system that most often treats the city’s poor and sick

 
 

The situation developed after a judge last year ruled that the city had improperly awarded the contracts, collectively worth about $1.5 billion, to three insurance companies to manage the care of 250,000 Medicaid beneficiaries and participants in the Alliance program for other low-income patients. The judge said MedStar, which operates both a hospital system and an insurance plan, had not followed procurement rules and shouldn’t have been awarded one of the contracts.

Under the ruling, MedStar is set to lose its contract at the end of September. With that date approaching, according to Turnage, MedStar told the other two insurers — who under the ruling were set to keep their contracts — that starting later this fall, it will no longer treat their Medicaid patients at its hospitals and doctors offices, except for emergency room visits, unless the insurers start paying much higher rates.

 
 

That set off a scramble last week by D.C. officials to prevent hundreds of thousands of patients from losing access to MedStar doctors. Friday’s announcement was the first step.

 
 

D.C. Council won’t take action that could allow MedStar to keep its Medicaid contract

 
 

Turnage said that the Department of Health Care Finance, which he heads, decided to now require Medicaid managed care plans to cover intensive inpatient mental health and substance abuse treatment programs that are currently paid for directly by the District, not by the insurance plans. This change in the managed care program will require the city to rebid the contracts, Turnage contends. That would have the secondary effect of eventually allowing MedStar another chance to win the contract, after the department issues its new request for proposals in November.

 
 

All three insurers who currently hold the contracts have either declined to comment or not responded to inquiries from The Washington Post. They would all need to bid again to stay in the program.

Turnage’s action Friday could give the appearance that the city found an excuse to redo the procurement just so that it could give MedStar a contract again — and thus satisfy the company so that it won’t revoke access to its doctors in the meantime. As the mayor and council have fought over the Medicaid situation for months, accusations of “contract steering” have flown back and forth. Council members have voted down Mayor Muriel E. Bowser and Turnage’s proposals that they viewed as unfairly crafted to make room for MedStar in the program, and Turnage said council members who tried to require the city to abide by the judge’s order were assisting Amerigroup, which could have replaced MedStar as the third insurer.

 
 

Turnage said he was not promising any business to MedStar, but acknowledged the timing of the decision could potentially help the District out of its current quandary. “Obviously if we have a chance to both modify the program to bring in new benefits and also take some actions to ensure there’s no disruptions, we take advantage of that propitious timing,” he said. “This is going to be a competitive procurement. There will be many comers, and nobody’s going to be guaranteed a spot.”

 
 

In the meantime, two major disruptions loom: First, when MedStar’s contract as an insurer ends in a month, the nearly 60,000 patients covered by the plan would be reassigned to either CareFirst or AmeriHealth. The three insurers all have contracts with the city’s major hospitals and clinics, but the change could still be a headache for some patients.

 
 

Turnage said that Bowser is studying that issue. Unless Bowser takes action to stop MedStar’s contract from ending — a power she may have under her coronavirus pandemic emergency authority — notifications are scheduled to go out to those patients about their new insurance coverage starting Wednesday.

 
 

And second, long before the new procurement is complete, CareFirst and AmeriHealth patients will lose access to MedStar doctors unless the insurers can broker some sort of agreement.

 
 

That’s what scares one Ward 7 resident, who spoke on the condition of anonymity to keep her health conditions private. The resident, a 50-year-old woman, is a longtime Medicaid patient who has lost access to her primary care provider in the past due to the fluctuating agreements between hospital systems and Medicaid managed care providers.

 
 

That time, it took her two years to find another primary care doctor, she said. The asthma that her old doctor had helped her control worsened, and she became prediabetic before she found a nonprofit clinic where she could get medical care.

 
 

Now, she is enrolled in AmeriHealth’s managed care plan and is seeing a cardiologist and a pulmonologist at MedStar. She fears she’ll lose access to her doctors once again.

 
 

“We don’t get to say anything. Because we’re poor, we don’t get no say, and it’s not fair,” she said. “They’re always talking about health disparities. How can we address them if we aren’t going to the doctor?”

 
 

Clipped from: https://www.washingtonpost.com/dc-md-va/2021/08/27/dc-to-rebid-medicaid-contracts/

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Ambulance carveout is latest Illinois Medicaid managed care battleground

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Ambulance providers are lobbying to go back to fee for service payment, but advocates oppose the move saying it will be more difficult to ensure quality member outcomes.

 
 

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.

 
 

 
 

Multiple ambulances are housed at the LeRoy Emergency Ambulance shed, pictured here Friday.

DAVID PROEBER, THE PANTAGRAPH

SPRINGFIELD — Stakeholders are calling on Gov. J.B. Pritzker to sign a bill that passed the General Assembly unanimously and would remove non-emergency ambulance services from the state’s Medicaid managed care program in favor of a fee-for-service model.

While an association group representing ambulance services says House Bill 684 is needed to counter arbitrary denials of claims by private insurers, the governor’s office and the state agency that oversees Medicaid expressed “serious concerns for patient safety and cost” as Pritzker continues to review the bill.

While the bill is a targeted carveout of ambulance services from the state’s Medicaid managed care program, or the privatization of Medicaid, it marks the latest catalyst for debate over the effectiveness of that program which was greatly expanded in 2017 under former Gov. Bruce Rauner.

 
 

Chris Vandenberg, president of the Illinois State Ambulance Association, said in a phone call Monday the bill was in response to the “arbitrary” denial of ambulance claims by Medicaid managed care organizations, or MCOs.

MCOs are private insurance companies that contract with the state to manage the care of individuals enrolled in Medicaid. Among other things, that involves working with patients to make sure they receive routine exams and preventive care, and coordinating services provided by their primary physicians and other specialists.

Vandenberg said that leads to MCOs padding profits through denial of claims.

“Since managed care began in Illinois, it’s been a struggle,” Vandenberg said. “So, we have EMTs and paramedics that are working, trying to transport patients, and really, we’re not able to get any of this reimbursement. …And so it’s really impacted the ability to attract and retain EMTs and paramedics, and really it’s causing a serious impact to Medicaid beneficiaries in that they’re not able to find transport as easily as they used to.”

Putting ambulances back in the fee-for-service system would allow providers to submit claims directly to the state Department of Healthcare and Family Services, which Vandenberg said would provide predictability and certainty to the billing process.

Jamie Munks, a spokesperson for HFS, said in a statement the department “remains strongly opposed” to the ambulance carveout, “because it has the potential to negatively affect the quality of service, create longer wait times for medical transports and payment delays for providers, and could create confusion for customers and providers.”

They protect and serve often at minimum wage or no pay at all.

DAVID PROEBER david.proeber@lee.net

Munks said about $3 million of potential lost revenue due to the state’s tax on MCOs which generates greater federal reimbursement resulting in hundreds of millions of dollars in revenue annually. She also noted unspecified “administrative costs” in switching ambulances back to fee-for-service.

If Pritzker doesn’t act on the bill by the end of the week, it would become law even without his signature. If he vetoes it, lawmakers would be able to override the action with a three-fifths majority when they meet for the veto session this fall.

Pritzker spokeswoman Jordan Abudayyeh said in a statement the governor “will take the appropriate action” before this weekend’s deadline, but “the administration is concerned that this legislation has the potential to disrupt care and reduce the quality of provided services to some of the most vulnerable Illinoisans.”

Specifically, the governor’s office said a Medicaid enrollee needing a non-emergency ambulance ride can currently contact their MCO and be connected with an ambulance transport that’s contractually obligated to respond “in a timely fashion.”

The administration fears if the governor signs the bill, “a consumer will be forced to use the vendor contracted with by the fee-for-services program — a vendor that is not contractually bound to provide timely services.”

“Consumers would be forced into the uncertain position of not knowing which of their health care services are covered by their MCO, and whether they will be able to secure transport in a timely fashion,” Abudayyeh said in the statement. “During the COVID-19 pandemic, the Department of Healthcare and Family Services received consumer complaints regarding the difficulty of securing transport from their fee-for-service vendors to get to non-emergency health care services like check-ups and dialysis.”

Advocates for the bill, including Rep. Will Davis, D-Homewood, who is one of its chief co-sponsors, argued the current MCO structure is what’s threatening response times.

Davis said private ambulance companies often handle the 911 calls for communities that are underserved medically. While companies contracting with those municipalities are already on the fee-for-service structure for emergency services due to changes made in April, payment uncertainty for other transportation services those providers render could affect staffing levels, Davis said.

“It’s not just, you know, the providers trying to get paid,” Davis said. “Their ability to receive resources helps their ability to keep their staffing levels up so they can bring down response times when people call 911. So there’s the staffing aspect of it, there’s the idea of making sure that they can provide services to underserved communities.”

Representatives of the Ambulance Association said an early amendment to HB 684 removed non-ambulance medical transports in an effort to address transportation concerns. The current bill is simply a way to “get paid for the services provided,” which they’ll still be obligated to provide under a fee-for-service system.

Samantha Olds Frey, CEO of the Illinois Association of Medicaid Health Plans, cited concerns similar to Pritzker’s about how the bill “impacts our most vulnerable members that need non-emergency ambulances for routine care such as dialysis treatments, doctor’s appointments, or scheduled hospital trips.”

She noted MCOs can offer higher reimbursement rates than HFS can for such a transportation service, so moving it back to a fee-for-service plan could further jeopardize those Medicaid enrollees. While MCOs have care coordinators that make follow-up calls to transporters to connect a customer to a service, HFS does not, she added.

“IAMHP met with the industry during the legislative session to try and find a solution that doesn’t jeopardize the care our members receive,” she said. “The ambulance industry refused to come to the table in good faith. However, we are still willing to understand what the systematic issue is and work toward a solution.”

Davis, meanwhile, said concerns over “arbitrary” claim denials from MCOs are nothing new or unique to the ambulance industry.

That’s why, as part of a health care reform backed by the Illinois Legislative Black Caucus earlier this year, lawmakers created a Managed Care Oversight Commission to, according to Davis, “really dive deep into if we’re going to continue to have an MCO structure – which, you know, some really don’t want – that we can have more oversight and input into how they operate versus kind of the autonomy that they enjoy right now.”

While Davis said HFS has “abdicated” its oversight role of MCOs, Munks said for over two years the agency has been “holding frequent meetings with providers and health plans, a forum to bring everyone together to resolve issues.”

She said HFS put in place a “claims clearinghouse” creating greater transparency into claim denials, “allowing the department to have better oversight of certain billing issues.”

She said claim denial rates for non-emergency ambulance services within the fee-for-service program are 40 percent, while MCO denial rates are between 10 and 15 percent, although the Ambulance Association disputed that claim, saying the denials it experiences are through MCOs.

As well, while HFS cited a billing complaint portal that has received only four claims in more than 17 months, the Ambulance Association dismissed that portal as “another way to give the providers the runaround.”

 
 

Clipped from: https://www.kpvi.com/news/national_news/ambulance-carveout-is-latest-illinois-medicaid-managed-care-battleground/article_cdd448f2-4b76-57b8-a6b0-7bd9ed444fb0.html

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Ohio Medicaid chief dodges when asked to explain business with company AG said “fleeced” taxpayers

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Ohio Medicaid officials are given hard questions about awarding a contract to Centene, who recently paid an $88M fine related to the PBM spread-pricing scandal.

 
 

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.

 
 

Massive contract restarted after settlement

 
 

The Centene Corporation headquarters. Photo from Google Maps.

Ohio Medicaid Director Maureen Corcoran didn’t give many straight answers Wednesday when she was pressed about why her agency restarted a massive contract with a company that earlier this year was accused of “fleecing” taxpayers out of tens of millions of dollars.

At one point, Corcoran even invoked lawyer-client privilege to avoid answering a question.

Appearing on WOSU’s “All Sides With Ann Fisher,” Corcoran was asked by Fisher why her agency would again trust Centene, the largest Medicaid managed-care contractor in the United States. The department earlier this month restarted negotiations for a 2022 contract with the company. 

That was just six months months after Ohio Attorney Dave Yost announced that Centene had agreed to pay $88.3 million to settle claims that the company had improperly inflated pharmacy claims by massive amounts. Centene also announced that it was setting aside more than $1 billion to settle similar claims in 21 other states. 

The company has emphasized that it didn’t admit to any wrongdoing in the settlement. But in March, Yost was unequivocal when he filed the suit.

“Corporate greed has led Centene and its wholly owned subsidiaries to fleece taxpayers out of millions,” he said.

The Medicaid department announced that it was restarting negotiations with Centene by posting a press release to its website saying the agency was giving Ohio Medicaid clients “more options.” It only alluded to the lawsuit by saying negotiations had been paused because of it and now that the suit had been settled, a contract would be awarded.

Asked at the time why the agency should now trust Centene with taxpayers’ billions, a Medicaid spokeswoman didn’t answer, other than to refer to the press release.

Fisher on Monday sought to press the question with Corcoran, asking why the agency would trust a company the state AG had just accused of fleecing taxpayers. Corcoran’s response was meandering.

“The action that was brought by the attorney general was really separate from the procurement process that we were engaged in which was of course very rigorous,” she said. “It is very common, normal practice in Medicaid that when there are any kinds of legal actions against any kind of managed care provider or a hospital or whomever, we have them identify that, we look into that. 

“So we are aware of and looking into legal actions whether here in Ohio or elsewhere is part of the normal Medicaid application process. So of course when we heard the attorney general was going to bring this action, we in similar fashion as I just mentioned took a step back and said we are going to make our own assessment. The attorney general then settled the case.

“There were still several weeks as you know that passed and we were making our own assessment at the same time and determined that we were going to proceed with them as part of our newly selected group of plans. They also, you may remember, scored the second-highest score (in a competitive procurement) from a quality point of view, so they provide good care, they’ve been a partner in Ohio.”

Transcripted excerpt of Corcoran’s interview on “All Sides with Ann Fisher.”

 
 

Ohio Medicaid Director Maureen Corcoran. Official photo.

Corcoran then pointed out that Centene’s alleged ripoff had to do with pharmacy benefits. She seemed to imply that since Centene wouldn’t have responsibility for the service under the new setup, there’s nothing to worry about.

“But I also think one thing that’s important to mention is that the issue that the attorney general brought has to do with pharmacy benefit managers and the role that they play with medications,” Corcoran said. “Two years ago, our General Assembly passed a law taking that responsibility away from the managed care plans and instructing the Department of Medicaid to set up a separate pharmacy benefit manager. 

“So, in essence, it was important for us to have good business partners, but in essence the underlying problem… and corporate oversight has changed and that set of responsibilities as part of our new design will not be with the individual plans, but will be managed directly by the state.”

How, Fisher asked, had Centene’s corporate oversight changed. Corcoran didn’t really answer, saying instead “we interact with them as a business partner” and that her team was making sure there will “be appropriate ethical training and that there be oversight and compliance monitoring.”

Then Corcoran was asked, since the Ohio attorney general acts as the Medicaid department’s lawyer, whether she had sought legal advice from Yost before deciding to continue the state’s business with Centene.

“As you know, attorneys and clients have a certain legal protection that, if I were aware of any of that, I wouldn’t be able to share it with you anyway,” Corcoran said in a reference to attorney-client privilege. That’s a doctrine that prevents an attorney from discussing privileged matters, but places no such restriction on the client.

Fisher again tried to get Corcoran to explain why she trusted Centene to be a good steward of Ohio’s money — this time in the toughest terms.

“Why would you continue to do business with a company that, as Attorney General Yost said, fleeced taxpayers out of millions?” Fisher asked. “It sounds like you’re doing business with a con man.”

Corcoran didn’t answer the question, instead launching into a 270-word talk about how rapidly the Medicaid program had grown and how the General Assembly has taken steps to reform how the agency handles drug transactions.

Corcoran did, however, answer one question directly.

It came to light this week that Michael Kiggin — a longtime friend of Gov. Mike DeWine — registered to lobby on Centene’s behalf just before Yost sued the company. Among the agencies Kiggin said he’d lobby were the governor’s office and the Medicaid department.

Asked if she knew Kiggin and whether Kiggin had communicated with her about the Centene contract, Corcoran said, “I don’t know Michael Kiggin. I’ve not talked with him, so I can’t really comment on that.”

Asked if Kiggin had communicated with Medicaid staff — including those involved in the Centene contract, Corcoran said, “Absolutely not.”

Clipped from: https://ohiocapitaljournal.com/2021/08/26/ohio-medicaid-chief-dodges-when-asked-to-explain-business-with-company-ag-said-fleeced-taxpayers/

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FL- Medicaid plans offer incentives to boost vaccinations

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FL MCOs are now offering gift cards to Walmart for $25 if members get the vaccine.

 
 

 
 

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.

 
 

 
 

TALLAHASSEE — As the delta variant of the coronavirus sweeps across the state and brings a record number of COVID-19 hospitalizations, managed-care plans that serve hundreds of thousands of Medicaid beneficiaries are offering incentives to get people vaccinated.

Gov. Ron DeSantis’ administration did not provide to The News Service of Florida the percentage of people in Medicaid managed-care plans who are 12 or older and are vaccinated against COVID-19.

But at least three Medicaid health maintenance organizations have started offering financial incentives to their members to get at least one vaccine dose.

The moves have come after a call by state Medicaid director Tom Wallace to increase COVID-19 vaccination rates, particularly for people age 50 or older.

Related: COVID is still a deadly threat to older Floridians

In a June 18 memo to health plans, Wallace called vaccines a “critical” prevention measure.

Simply Healthcare Plans sent a memo to its Medicaid network providers in July encouraging them to advertise the incentive program to patients who they thought could be good candidates for vaccination. The plan is offering $25 gift cards to Walmart.

Marc Kaprow, chief medical officer for Simply Healthcare, told the News Service that the initiative was partly in response to the state’s efforts to have at least 50 percent of Medicaid beneficiaries who are 50 or older vaccinated.

Simply has about a 10 percent market share in part of the Medicaid program that provides long-term care. It also has a presence in part of Medicaid that serves a broader population — known as Medicaid managed medical assistance — and in HIV/AIDS specialty markets where it operates under the Clear Health Alliance moniker.

“We do better when our patients stay healthy. The vaccines create a tremendous opportunity for that to happen,” Kaprow said, adding, “We want our folks to not be in the hospital, we want our folks to do well.”

Related: Biden to require COVID-19 vaccines for nursing home staff

Simply Healthcare did not provide to the News Service a breakdown of its vaccination rates among Medicaid beneficiaries.

Florida Department of Health data shows that 47 percent of the state’s overall population of people ages 12 to 19 had received at least one vaccine dose as of Thursday. Rates for people ages 50 to 59 and 60 to 64 were 72 percent and 80 percent, respectively, according to a department report published Friday.

Related: Florida adds 150,118 coronavirus cases, 1,486 deaths in past week

The state uses managed-care plans to oversee health services for about 3.8 million people in the Medicaid program.

The plans are paid monthly premiums by the state to oversee care, including preventive care, for low-income, elderly and disabled people. By focusing on prevention, the plans are supposed to avoid more costly hospital care.

Community Care Plan, a Broward County-based plan, is offering access to $20 gift cards to members who are willing to receive at least one vaccine dose. Suzanne Tamargo, a spokeswoman for the plan, owned by the North and South Broward hospital districts, said about 100 people have taken advantage of the offer.

While Tamargo did not disclose vaccination rates, she said the incentives helped the health plan exceed the state’s goal of vaccinating at least 50 percent of beneficiaries age 50 or older.

Vivida Health Plan, which operates in Lee, Collier, Charlotte, Sarasota, DeSoto, Glades, Hendry, Lee and Sarasota counties, also has been providing gift cards since Aug. 5 to people willing to get vaccinated, according to its website.

Audrey Brown, chief executive officer of the industry group Florida Association of Health Plans, said gift cards are unusual but that the plans are looking at “every possible action that we can think of in order to get the Medicaid recipients vaccinated.”

While she said she did not have updated data, Brown said she had seen numbers from several weeks back that indicated several health plans had met the 50 percent mark for people 50 or older.

“It’s been an uphill battle, but incredibly important,” Brown said.

While health plans are offering incentives to their members, the state also is offering incentives to the plans to increase vaccination rates.

In the June memo, Wallace said the state would be willing to lower what are known as “liquidated damages” assessed against health plans if every plan met the 50 percent vaccination rate in the 50-plus population by Aug 31. The state levies liquidated damages against health plans when they don’t meet terms of their Medicaid contracts.

Wallace revised the policy last week, eliminating the requirement that all managed care plans meet the 50 percent threshold before reductions in liquidated damages could be triggered. Under the revised policy, any health plan that hits the 50 percent vaccination rate for people age 50 or older could qualify for lower liquidated damages.

Longtime social services lobbyist Karen Woodall said the policy is a “little screwed up.”

“It’s screwed up because it’s their job. Their job is to ensure adequate health care to their members,” Woodall said. “So they should already be focused on encouraging vaccines for their members.”

Woodall said the policy suggests that the plans have subpar vaccination rates. If they don’t, she said, the state is providing incentives to the health plans for goals they already are reaching.

By Christine Sexton, News Service of Florida

Clipped from: https://www.tampabay.com/news/health/2021/08/23/medicaid-plans-offer-incentives-to-boost-vaccinations/

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Ohio delays rollout of revamped Medicaid system to July 2022

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Ohio managed care and PBM changes will begin 6 months later than originally planned.

 
 

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.

 
 

 
 

Ohio pushed back its projected launch date of its revamped and reformed Medicaid managed care system to July 1 of next year,  the Ohio Department of Medicaid announced Wednesday.

The initial timeline set the launch of the long-awaited system in January.

“Our priority since the beginning of this administration has been on doing this right for the people we serve,” said Ohio Medicaid Director Maureen Corcoran. “A July 2022 go-live gives us time to support and inform our members about the new program, to work with community leaders and respond to the feedback received from the plans and providers.”

The “next generation” managed care system is the result of an extensive process that started in 2019, looking at ways to improve and overhaul the system after years of issues and without any reform.

More:Six companies will split $20B in managed-care work under biggest contract in Ohio history

More:Ohio children on Medicaid now eligible for $100 COVID-19 vaccine incentive

Medicaid, the governmental health insurance for more than 3 million low-income or disabled Ohioans, is typically the state’s largest expenditure, with billions of dollars at stake.

The department already has many of the reforms planned and designed out; it’s just a matter of feedback and implementation. Of note are the additions of OhioRISE, which would treat children with severe behavioral and mental problems so parents don’t have to give up custody, and a single pharmacy benefit manager system, to fix the issue of such prescription drug “middlemen” overcharging taxpayers.     

The delay in rolling out these reforms is partly due to the unanticipated “persistence of COVID-19 and its impact on individuals served by the program and their providers,” said the Medicaid department.

There’s uncertainty on when the end of the federal public health emergency declaration for COVID-19 will be. The declaration’s end will impact the department’s plans in terms of whether there will be additional federal money, said Corcoran in a media briefing. Medicaid officials were also worried how the transition could cause instability for consumers amid a pandemic.  

Other factors will complicate the situation. As part of the overhaul, the department re-selected which health plans got its lucrative contracts to handle Medicaid managed care, and those who lost out have complained.

Buckeye Community Health Plan and its parent company Centene were initially deferred due to an ongoing lawsuit from the state alleging the company unlawfully took Medicaid money. But that has since been settled, and Centene was recently granted a contract.

Paramount Advantage, owned by Toledo-based ProMedica, is the only current Medicaid managed care organization that lost out on a contract. It tried to reverse that by appealing the decision and asking state lawmakers for help, but those efforts failed.

The Toledo company now has a lawsuit in the state seeking to halt the overhaul and invalidate the contracts. If successful, that could further derail the department’s timeline.

According to court records, a trial assignment was scheduled for July 25, 2022. A hearing for a preliminary injunction is set for earlier, on Oct. 12.    

Titus Wu is a reporter for the USA TODAY Network Ohio Bureau, which serves the Columbus Dispatch, Cincinnati Enquirer, Akron Beacon Journal and 18 other affiliated news organizations across Ohio.

 
 

Clipped from: https://www.coshoctontribune.com/story/news/healthcare/2021/08/25/ohio-delays-rollout-revamped-medicaid-system-july-2022-procurement-reform-pharmacy-managed-care/5589283001/

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Nevada awards Medicaid contracts to 4 insurers

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NV MCO winners announced.

 
 

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:

  • The state of Nevada intends to award four insurers separate $11 billion contracts to coordinate care for the state’s Medicaid beneficiaries.
  • The four-year contracts with UnitedHealthcare, Molina, Centene and Anthem are set to begin on Jan. 1 and run through the end of 2025, according to a notice of award. The insurers have an optional two-year extension in the contract if they can agree to terms with the state.
  • The awards must still gain final approval from the Governor’s Board of Examiners, Theresa Carsten with the state’s Department of Health and Human Services, said via email.

Dive Insight:

It’s a big contract win for Molina, which currently does not provide services to Nevada, per its latest annual report.

The payer, which posted a profit in the second quarter despite increases in utilization and COVID-19 inpatient costs, had 3.9 million Medicaid members as of June 30, a year-over-year jump of nearly 25%.

Molina joins three incumbents, UnitedHealthcare (Health Plan of Nevada), Centene (SilverSummit Healthplan) and Anthem Blue Cross Blue Shield (Community Health Care Plan of Nevada).

A total of eight insurance companies bid on the work, including Aetna, according to state scoring documents related to the request for proposal.

The insurers will offer coverage to about 630,000 Medicaid beneficiaries in Clark and Washoe Counties, representing the Las Vegas and Reno areas respectively.

Nevada, like other states, has reported record Medicaid enrollment as a result of the pandemic, which spurred an economic downturn.

Officials in Nevada said enrollment peaked at 810,000 in February, a new record for the state following the previous high of 690,596 set in August 2018.

The Medicaid and Children’s Health Insurance Program overall now cover one in four people in the U.S., a record high. That was helped in part by the freeze on disenrollment for the COVID-19 pandemic, which will run until the end of the public health emergency that is expected to last at least through this year, as well as an increase to the federal matching rate.

 
 

Clipped from: https://www.healthcaredive.com/news/nevada-awards-medicaid-contracts-to-4-insurers/605514/

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Georgia in line to recover $500 million in Medicaid overpayments

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GA is completing its effort to recover managed care funds not spent during the pandemic.

 
 

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 in line to recover $500 million from state Medicaid insurers for overpayments in 2020 and 2021, according to an insurance industry official who represents the companies.

Special Photo: Georgia Health News

ATLANTA — Georgia is in line to recover $500 million from state Medicaid insurers for overpayments in 2020 and 2021, according to an insurance industry official who represents the companies.

The half-billion-dollar payout will come from two separate Medicaid recoveries, Jesse Weathington, the executive director of the Georgia Quality Healthcare Association, said. Due to the federal role in financing Medicaid, much of the returned money would likely go to the U.S. government.

The insurers were told the reduction was due to many Medicaid patients skipping medical care during the COVID-19 pandemic, along with other adjustments, Weathington said.

“It was surprising in terms of timing and the amount,” Weathington said. He added that the three Medicaid insurers were not given detailed breakdowns of how the state actuary arrived at the numbers.

The Georgia Medicaid insurers – Peach State, Amerigroup and CareSource – are paid a per-member, per-month rate to care for Medicaid members. These insurers continued to receive those payments from Medicaid while there was a drop-off in patient visits.

The repayments are known as clawbacks: When an organization believes it has overpaid for services, it takes steps to get the money back.

“Clawbacks mean people did not get health care,” Laura Colbert, executive director of Georgians for a Healthy Future, a consumer advocacy group, said. “Essentially, people may have missed services they needed last year. That’s no fault of the [Medicaid insurers] because we saw that happen across the board, regardless of the type of insurance. The state still has a right to address that based on their contract.”

The Department of Community Health, which runs Medicaid in the state, did not respond to GHN’s requests for comment.

The $202 million retrospective rate adjustment for 2020 is now awaiting approval from the federal Centers for Medicare & Medicaid Services, Weathington said. Another $300 million mid-year adjustment for 2021 is currently under negotiation, he added.

Medicaid, jointly financed by the federal government and individual state governments, covers low-income and disabled residents. Georgia pays the Medicaid insurers more than $4 billion each year to provide care to low-income children and other vulnerable populations. The state covers about one-third of those costs, with the feds funding the rest.

It’s unclear how much of the recovered funds will go to the feds and how much to Georgia’s coffers. But if it’s split by the normal funding formula, the state would gain more than $165 million.

The projected $500 million recovery comes after Medicaid insurers posted big profits during 2020, according to the Center for Children and Families at Georgetown University.

Before the pandemic, many states had measures in place to limit the profits that state Medicaid insurers could make on their contracts and ensure taxpayer dollars went to patient care. Georgia was not one of those states, according to the Center on Budget and Policy Priorities.

Other states have adopted or bolstered measures to recover taxpayer dollars that went to Medicaid programs while patients stayed home during the pandemic. There are different ways states can do this.

For example, Virginia directed state Medicaid insurers to increase payments to medical providers.

 
 

Two of the Georgia insurers – Peach State and Amerigroup – are owned by publicly traded, for-profit corporations, Centene and Anthem, respectively. Centene last year acquired WellCare, another Medicaid insurer, and closed down its WellCare Medicaid operations in May.

A third Medicaid insurer, CareSource, is a nonprofit company based in Ohio.

Clipped from: https://www.news-daily.com/news/georgia-in-line-to-recover-500-million-in-medicaid-overpayments/article_a660e200-f871-5353-8685-507aebfef43b.html

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NC calls Medicaid payment delays unacceptable

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Some speech therapists are reporting delayed payments, but the overall claims denial rate is lower than expected.

 
 

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.

 
 

 
 

CHARLOTTE, N.C. — Therapists who work with some of North Carolina’s most vulnerable children are growing increasingly frustrated with the state’s transition to Medicaid Managed Care.

‘It’s not acceptable’

Small healthcare business owners from Charlotte, Concord and Salisbury told WCNC Charlotte the private companies that recently took over the state’s Medicaid program continue to overburden their practices with paperwork and delay critical payments.

In the face of their anger, a top state official promised action.

“If I was the organization that wasn’t getting paid, I would feel exactly the same way,” North Carolina Medicaid Deputy Secretary Dave Richard said.

While Richard said the transition to managed care has gone relatively smoothly overall, he told WCNC Charlotte technical issues with provider coding in the claims process led to higher than normal denials in the first weeks of the program.

“It’s not acceptable,” Richard said of the delays in some businesses getting reimbursed. “We’re fixing it.”

At the beginning of August, the state reported a 12% denial rate.

“The number that we received actually was less than we would have anticipated with this transition,” he said.

‘Our patients will definitely pay the price’

Speech-language pathologist Tara Puma said her Salisbury in-home therapy business has yet to receive more than $5,000 in payments for services already provided.

“I haven’t been paid at all from two of the managed care organizations,” Puma said. “There hasn’t been clear and consistent guidance. They definitely seem ill-prepared.”

Puma said she is waiting on more than 70 claims.

“With the managed care companies that are not paying, I am looking at putting those children on hold for services until we can get reimbursed for them,” Puma said. 

After years of preparation, North Carolina officially switched to Managed Care on July 1. In doing so, the state handed over control of its Medicaid program to five private companies.

Medicaid covers nearly 1.6 million low-income adults, children, pregnant women, seniors and people with disabilities throughout North Carolina.

“It is very frustrating and our patients will definitely pay the price because there are some practices that are going under or are putting some kids on hold for services,” Concord business owner and speech-language pathologist Stephanie McGowan Fish said. “Every day there’s something new that’s coming up.”

She said her practice is waiting on $35,000 in payments.

“Our patience is kind of wearing thin at this point,” she said. “We need some hardcore problem solving because we’re just not getting that. We’re just getting lip service at this point.”

‘I can’t think of another business where you don’t get paid for an entire month’ 

Richard said not only are the state and private companies committed to solving the problems, but they’re also both willing to cover critically hurting businesses’ costs, in the form of advances, while they wait.

“If we have providers in a place to where they can’t get paid, health plans can’t do it, we’re prepared to be that backstop,” he said, citing available emergency hardship advances. “If they’re at that place to where they believe that they can’t take patients because they’re not getting paid, we want to know, because that’s not something that’s acceptable to us.”

Richard said the state has received 17 requests for hardship payments.

He also said the state has taken “way too long” reprogramming its claims system related to last-minute legislation that requires providers to bill Medicaid directly for the Infant and Toddler Program rather than the new health plans. He said the needed changes will be in place by Aug. 16.

Charlotte speech-language pathologist Rebecca Rowe said she’s owed more than $9,000 in reimbursements.

“At this point, we do not feel taken care of,” Rowe said. “I can’t think of another business where you don’t get paid for an entire month, and that’s the problem.”

Richard said the state is committed to its transition promise that patients would continue to be seen and providers would be paid.

“I appreciate you raising these questions for us,” he told WCNC Charlotte. “These are really important things.”

The executive director of the North Carolina Association of Health Plans declined an on-camera interview, but in a statement, called any single incident or issue “unfortunate.”

“Since joining the Association of Health Plans as the Executive Director on July, I’ve been impressed by what I’ve witnessed,” Peter Daniel said. “While any single incident or issue is unfortunate, there’s an incredible amount of communication and coordination among regulators, health plans, providers and other stakeholders- all of whom share a commitment to make this transition work for the more than 1.6 million beneficiaries who deserve exceptional, integrated care. And while there is work still to do, we are already seeing measurable success in the transition.”

 
 

Clipped from: https://www.wcnc.com/article/money/nc-medicaid-payment-delays-unacceptable/275-b6963a76-c05f-4aa1-8465-c6ad0d5f9a39

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NCDHHS Announces Medicaid Managed Care Regional Behavioral Health I/DD Tailored Plans- Bladen County Included

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The winners were announced last week, and will be live Sept 1.

 
 

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 North Carolina Department of Health and Human Services announced the selection of seven organizations to serve as Behavioral Health and Intellectual/Developmental Disability Tailored Plans (Behavioral Health I/DD Tailored Plans). Individuals who need certain services to address a serious mental illness, serious emotional disturbance, severe substance use disorder, intellectual/developmental disability or traumatic brain injury may be eligible to enroll in a Behavioral Health I/DD Tailored Plan.

Following a competitive selection process, the following organizations were awarded a contract to serve as regional Behavioral Health I/DD Tailored Plans:

• Alliance Health

• Eastpointe

• Partners Health Management

• Sandhills Center

• Trillium Health Resources

• Vaya Health

• Cardinal Innovations Healthcare*

*While Cardinal Innovation Healthcare was awarded a contract, it is anticipated they will not operate a Behavioral Health I/DD Tailored Plan at launch due to the consolidation with Vaya Health. 

Behavioral Health I/DD Tailored Plans will provide integrated physical health, behavioral health, long-term care, pharmacy services and will address unmet health-related resource needs for qualifying North Carolinians under one plan. These plans will provide the same services as NC Medicaid Standard Plans with additional specialized services to serve individuals with significant behavioral health conditions, including those utilizing 1915(c) Home and Community-Based Services waivers and those utilizing State Funded Services. 

“NCDHHS looks forward to working with the awardees to make this innovative design a reality for the thousands of North Carolinians who will benefit from a whole person centered, well-coordinated system of care,” said NCDHHS Secretary Mandy K. Cohen, M.D. “Today moves us closer to that goal as we begin to implement this important program design.” 

At launch, Behavioral Health I/DD Tailored Plans will operate regionally, offering robust care management to approximately 200,000 individuals estimated to enroll. An additional unique feature of Behavioral Health I/DD Tailored Plans is the combination of Medicaid and state funding to support enrolled populations. 

The contract award covers counties in each catchment area as of July 26, 2021, as well as realignments approved by Secretary Cohen effective Sept. 1, 2021. Given additional county requests for disengagement, NCDHHS anticipates county alignments for Behavioral Health I/DD Tailored Plans will be significantly different at launch. County realignment and disengagement requests must go through the process identified in law and rule which ultimately require DHHS Secretary’s approval. The list below indicates the anticipated county alignments at go-live. 

“We will work closely with LME/MCO’s to assure a smooth transition to Behavioral Health I/DD Tailored Plans while they continue to oversee the crucial services currently provided through the LME/MCO’s” said Deputy Secretary of NC Medicaid, Dave Richard. 

Only entities operating as LME/MCOs were eligible to apply to become Behavioral Health I/DD Tailored Plans. The first Behavioral Health I/DD Tailored Plans contract term will last four years. The Department has the authority to award no more than seven and no fewer than five regional Behavioral Health I/DD Tailored Plan contracts and may not award any statewide contracts.

Under Medicaid Managed Care, Standard Plans and the Eastern Band of Cherokee Indians (EBCI) Tribal Option launched on July 1, 2021, followed by Tailored Plans on July 1, 2022. 

For information specific to Behavioral Health and I/DD Tailored Plans, please visit the Behavioral Health I/DD Tailored Plans page. 

More information about the transition to NC Medicaid Managed Care can be found on the Medicaid website at medicaid.ncdhhs.gov/transformation.

 
 

Projected County Alignments at Tailored Plan Launch for July 1, 2022

This list reflects projected county assignments based on disengagements requested or approved. County realignment and disengagement requests must go through the process identified in law and rule which ultimately require approval by the NCDHHS Secretary.

Alliance Health: Cumberland, Durham, Johnston, Orange, Mecklenburg and Wake. 

Eastpointe: Duplin, Edgecombe, Greene, Lenoir, Robeson, Sampson, Scotland, Wayne and Wilson.

Partners Health Management: Burke, Cabarrus, Catawba, Cleveland, Davie, Forsyth, Gaston, Iredell, Lincoln, Rutherford, Stanly, Surry, Union and Yadkin.

Sandhills Center: Anson, Davidson, Guilford, Harnett, Hoke, Lee, Montgomery, Moore, Randolph, Richmond and Rockingham. 

Trillium Health Resources: Bladen, Brunswick, Carteret, Columbus, Nash, New Hanover, Onslow, Pender, Beaufort, Bertie, Camden, Chowan, Craven, Currituck, Dare, Gates, Hertford, Hyde, Jones, Martin, Northampton, Pamlico, Pasquotank, Perquimans, Pitt, Tyrrell and Washington.

Vaya Health: Alamance, Alexander, Alleghany, Ashe, Avery, Buncombe, Caldwell, Caswell, Cherokee, Clay, Franklin, Graham, Granville, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Person, Polk, Rowan, Swain, Transylvania, Vance, Watauga, Wilkes and Yancey.

Pending: Chatham, Halifax, Stokes and Warren. 

 
 

Clipped from: https://bladenonline.com/ncdhhs-announces-medicaid-managed-care-regional-behavioral-health-i-dd-tailored-plans-bladen-county-included/

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Kentucky Medicaid recipients get a $100 gift card with in-home vaccinations

 
 

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KY MCOs are increasing efforts to increase the low vax rate among 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.

 
 

 
 

A Kentucky managed care program is using $100 gift cards to entice Medicaid recipients into getting the COVID-19 vaccine. WellCare Kentucky is providing the in-home shots in an effort to stem the spread of the coronavirus.

“We’re here to help those who want to be protected from COVID-19. We’ve gone community-by-community, neighborhood-by-neighborhood, and now we’re going door-to-door,”  WellCare Kentucky Chief Medical Officer Sandra Guerra, M.D., said. “Meeting our members where they are to ensure they have the care and services they need to get and stay healthy is critical to our mission and an integral part of our efforts to make vaccines available to anyone who wants one.”

Roughly 44% of Kentucky residents have been fully vaccinated so far — well below the national rate of 49%. In some rural parts of Kentucky the vaccination rate is below 25%. COVID-19 cases have been spiking in Kentucky over the past month. At the end of June, the state had a seven-day moving average of 162 cases. Last Friday, that number shot up to more than 600 cases.

Only WellCare members who opt in and agree to participate will be able to schedule an in-home appointment and receive a gift card. The program is available July through August.

 
 

Clipped from: https://www.mcknightsseniorliving.com/home/news/home-care-daily-news/kentucky-medicaid-recipients-get-a-100-gift-card-with-in-home-vaccinations/