Tag: Medicaid Managed Care

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Centene CEO: Missouri Medicaid decision an ’embarrassment’

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Centene CEO takes the gloves off and adds to rumors of the MCO giant moving HQ out of the state.

 
 

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.

 
 

JEFFERSON CITY, Mo. (AP) — The CEO of Centene Corp. has called Missouri an “embarrassment” after Republican Gov. Mike Parson and the GOP-controlled Legislature failed to approve funding for voter-approved Medicaid expansion.

The St. Louis Post-Dispatch reported Wednesday that Centene chief Michael Neidorff made the comments to Health Payer Specialist, a health industry trade publication.

“As the largest provider of Medicaid in the United States and a Fortune 42 company I have to ask myself, ‘Why am I in this state?'” Neidorff said. “This is a state that frowns on this business — what am I doing here?”

“It’s an embarrassment,” he added.

The comment raised further concern about Centene’s future in the St. Louis area, where it is among the region’s largest employers. Centene announced it June it would add thousands of jobs in North Carolina, rather than St. Louis County, with Neidorff citing worries about crime in St. Louis.

Medicaid expansion, approved by voters in August, would bring health coverage to 275,000 low-income adults starting in July. But without funding, it is expected to end up in court.

In an emailed statement, Parson said Medicaid expansion can’t proceed without a revenue source or funding from the Legislature. He said he is “grateful for Centene’s investments in Missouri.”

 
 

Clipped from: https://apnews.com/article/michael-brown-business-medicaid-5f25a838b47176263c377522a6c6d0d5

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Potential seen for big financial paybacks from insurers to Medicaid

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Georgia is getting ready for its next round of MCO procurements.

 
 

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 state’s Medicaid agency is setting up plans for a health insurer bidding competition that will award a new multibillion-dollar medical contract.

“We’ll be looking for the best bang for the buck,” Frank Berry, commissioner of the Georgia Department of Community Health (DCH), said last week at an agency board meeting.

 
 

Berry

The current Medicaid insurers are being paid a total of about $4 billion a year for delivering medical services to more than 1 million members.

Long before a new contract is reached, there could be a substantial payback of money by the insurers, called care management organizations (CMOs), to the government program.

According to industry rumors, the “clawbacks” of money from these insurers in Georgia could exceed $200 million.

Medicaid is jointly financed by the state and federal governments, covering low-income and disabled residents. The CMO insurers – Peach State, Amerigroup and CareSource – are paid a per-member, per-month rate to care for Medicaid members.

DCH officials told GHN that they are “reviewing for any clawbacks that may currently be unresolved.”

Clawbacks come when an organization believes it has overpaid for services, and “claws back that money,” said Bill Custer, a health insurance expert at Georgia State University. “It happens quite a bit in Medicare and Medicaid. Depending on the amount, it may be a big deal or not.”

State officials did not disclose the amount under review.

An insurance industry official who represents the CMOs, Jesse Weathington, also did not specify the amount of money being scrutinized.

“We appreciate Commissioner Berry’s willingness to have further discussion about the true effects of the COVID-19 pandemic on Medicaid,” said Weathington, executive director of the Georgia Quality Healthcare Association, in a statement Wednesday. “Like other health plans, we saw [medical care] utilization bounce back to normal levels very quickly following the statewide shutdown last year.  We look forward to working with DCH to ensure their estimates are based upon factual data.

“Our mission to improve health care outcomes in the most cost-efficient manner for over 1.5 million Georgians remains the same,” he said, “and not even a 100-year pandemic will deter us from that objective.”

Expanding managed care?

The current CMO contract is set to expire June 30, 2022. But DCH says it’s looking to extend the contract for another two years ”to allow for additional time to complete the new procurement.” That would mean an expiration date of June 30, 2024.

DCH officials said the state aims to focus primarily “on quality, performance and [medical] outcomes” with the new contract.

An open question is whether the state will eventually launch managed care for members who are eligible for Medicaid because they are “aged, blind or disabled.”

DCH said it “will first seek to explore what is best for this population in terms of quality, performance and outcomes prior to making this determination.

Many states have moved their aged and disabled Medicaid beneficiaries into managed care.

Georgia State’s Custer said such a shift would require the formation of provider networks to serve that population, such as nursing homes.. An estimated 75 percent of nursing home residents in Georgia are covered by Medicaid.

Managed care for the aged, blind and disabled “would look very different” from the current format, Custer said. “The idea is to develop a medical home for that person.” A “medical home” is a model of care in which a patient’s total medical needs are coordinated by a specific provider.

The state would have to focus on monitoring quality of care for such an arrangement to succeed, he added.

 
 

Clipped from: http://www.georgiahealthnews.com/2021/05/potential-big-financial-paybacks-georgia-insurers-medicaid/

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Oklahoma lawmakers seek to put ‘guardrails’ on privatized Medicaid expansion

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OK anti-managed care sentiment pivots into increasing the oversight function of MCOs once implemented.

 
 

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.

 
 

OKLAHOMA CITY (KFOR) – Gov. Kevin Stitt has been pushing for privatized Medicaid expansion for months and it looks like he will get his wish.

It looks like legislators have given up their fight to keep the expansion, voted for by Oklahomans last year, in the hands of the state, but that doesn’t mean they are done with the issue.

House of Representatives votes on legislation to challenge Gov. Stitt’s plan to privatize Medicaid

They are now focusing on making sure Oklahoma doesnt repeat the mistakes made by the 42 other states that have some sort of managed care.

“There are some things that we have seen in other states that managed care companies have done that make it really hard for providers to be successful,” said Sen. Greg McCortney.

The Republican from Ada is talking about the rewriting of Senate Bill 131. Instead of pushing for state-run Medicaid expansion. The authors say it puts guardrails on the Governor’s privatized plan to make sure Managed Care Organizations keep up their end of the deal.

Gov. Stitt criticizes House Public Health Committee’s challenge to his Medicaid privatization effort

“Making sure our providers get paid in time, making sure that the Medicaid patients themselves don’t have to wait long for prior authorizations,” said Rep. Marcus McEntire, the bill’s co-author.

“In rural Oklahoma, we want to make sure that we protect those providers so our hospitals stay open, our doctors can stay in small town Oklahoma. So we put some guardrails in to make sure that the way they work with these managed care organizations can make everybody successful,” said McCortney.

The bill also makes sure that if MCO’s don’t follow rules they would be breaking state law

“Unfortunately, a lot of these policies have been around for a long time, since it took Oklahoma so long to accept Medicaid expansion. There are a lot of lessons to be learned from other states mistakes,” said Senator Mary Boren.

Oklahoma’s top physician & health groups file motion for injunction against Gov. Stitt’s Medicaid managed care plan

Lawmakers are calling this a compromise bill, but some still think state-run expansion was the way to go. They say only two of the four MCO’s involved are Oklahoma based.

“I just personally don’t want to see Oklahoma’s tax dollars going to enrich huge companies. I’d rather use that money to invest back into our healthcare system within the state,” said McEntire.

“It’s absolutely not my dream come true bill. I’ve come to believe that good policy is policy where everyone is angry and right now we have very good policy, I believe,” said McCortney.

Governor Stitt and Oklahoma Health Care Authority announce managed care organizations to assist with Oklahoma Medicaid, despite pushback from lawmakers

If the bill passes through the House and Senate as expected it would likely face a veto from the Governor.

“If the Governor vetos the bill, I very much expect the legislature to take up an override on the veto,” said McCortney.

We reached out to the Governor’s office. They say they don’t have any comment on the bill at this time. The guardrail bill did pass through the Senate today; it now moves to the House.

 
 

Clipped from: https://kfor.com/news/oklahoma-legislature/oklahoma-lawmakers-seek-to-put-guardrails-on-privatized-medicaid-expansion/

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Medicaid agency poised to extend contract with Centene, embattled insurer and big campaign donor

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Mississippi will use the optional renewals in the current contract to extend its agreement with Centene next year.

 
 

 
 

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 has been filling the campaign coffers of Mississippi officials for years and is one of Gov. Tate Reeves’ largest donors.

Mississippi’s contract with Centene, an insurance company state officials are currently investigating over suspicions it overcharges taxpayers to boost its profits, is set to expire at the end of June, providing an opportunity for the state to end business with the company.

But the Mississippi Division of Medicaid, an agency under the governor’s office, expects to extend the contract for another year without issuing a new bid, agency spokesperson Matt Westerfield told Mississippi Today last Wednesday.

Centene, parent company to Magnolia Health, is one of three insurance companies the state pays to provide health coverage to the state’s most vulnerable residents, mostly children of poor families. Meanwhile, the insurer has been filling the campaign coffers of Mississippi officials for years and is one of Gov. Tate Reeves’ largest donors, contributing as large as $50,000 at a time to his campaign for a total of more than $200,000.

In the managed care program, called MississippiCAN, the state pays the insurers an up-front, per-member rate every month to cover about 485,000 recipients, as opposed to the state paying health care providers and pharmacies their fees and prices directly. About 64% of Medicaid recipients are in managed care and the rest — typically the more medically fragile patients — have fee-for-service Medicaid.

Centene pulls millions in taxpayer dollars for its role as middleman, and the state auditor and state attorney general are now investigating whether it used deceptive practices within its pharmacy benefits, the Northeast Mississippi Daily Journal first reported in March. Officials say the investigation resembles a lawsuit in Ohio, in which state officials allege Centene inflated drug dispensing fees, hid the true cost of pharmacy services and double-dipped its reimbursement.

A Magnolia Health spokesperson told Mississippi Today that the claims are unfounded and that the company has actually saved taxpayers millions of dollars. A written statement said Magnolia expects to return about $75 million to Mississippi “as a result of lower utilization brought on by COVID-19.”

“Recent criticisms and inaccuracies have been largely driven by parties with a longstanding agenda against Medicaid Managed Care,” the Magnolia statement reads.

Often when a state contract ends, the corresponding agency issues a Request for Proposals, or RFP. Vendors respond and the state awards a new contract based on how they score the proposals.

The Division of Medicaid typically takes its direction from the governor, but Westerfield said the agency believes it can extend its contract with Magnolia for another year “on its own” as long as it has approval from the Public Procurement Review Board.

Reeves’ office did not respond to Mississippi Today’s questions regarding the governor’s support for a contract extension.

The original three-year contract, which began in 2017 and was extended last year, is set to expire at the end of June, but contains an optional renewal through 2022. The Medicaid tech bill lawmakers passed this year also allows for an one-year emergency extension on the contract. Either would allow Magnolia to continue receiving millions from the state, even as the investigation continues.

“We as taxpayers deserve better than we’re getting,” said state Rep. Becky Currie, R-Brookhaven. “We need to let the RFP run its course in September (sic) just like it always does. I just believe that putting it off a year is just going to give Centene time to sweep things under the rug.”

Officials expect the investigation to conclude as early as this summer.

Investigators are focusing on the actions of Centene’s pharmacy benefit managers, third-party companies that manage pharmacy benefits for insurers. Magnolia paid its PBMs, extra middlemen that pharmacists have long bemoaned, more than $1.1 billion from 2016 to 2020, according to data the Medicaid division provided Mississippi Today.

The Mississippi Legislature addressed PBMs in 2018 when it prohibited the companies from including “gag clauses” in their contracts with pharmacies. These provisions had prevented pharmacists from telling patients cheaper ways to pay for their medication, such as if their copay is higher than the cash price of the drug.

When State Auditor Shad White took office later that year, his first announcement was that his office had found $600,000 worth of improper Medicaid payments to managed care companies. The office’s ongoing investigation into Centene began not long after; it sought help from a local firm in April of 2019, Daily Journal reported.

The lawsuit in Ohio is ongoing; Centene argues it adhered to its contract and followed state law. The Ohio attorney general Dave Yost alleged Centene’s “corporate greed” led its Ohio subsidiary to inflate costs through its pharmacy benefit managers.

“So why would we extend their contract?” Currie said. “Do we want to have a company with such corporate greed taking care of the most vulnerable people in our state? The sickest, fragile people in our state. I mean, it’s a no-brainer for me. We don’t want that.”

— Article credit to Anna Wolfe of Mississippi Today —

 
 

Clipped from: https://www.hubcityspokes.com/politics-state/medicaid-agency-poised-extend-contract-centene-embattled-insurer-and-big-campaign-60916a95579dd

 
 

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NJ Targeting Medicaid Members in Vaccine Push

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The state is relying on MCOs to increase vaccination rates.

 
 

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.

 
 

 
 

State is spending $50 million to reach out, including calls to 260,000 people urging them to get vaccinated

 
 

State officials have taken proactive steps to support New Jersey’s nearly 1.9 million Medicaid members during the pandemic, including a recent push to expand COVID-19 immunization that involves phone calls to almost 260,000 individuals most at risk for infection.

Much of the work — which also involved mailings in English and Spanish, ongoing case management and partnerships with medical and social service providers to ensure members have proper care, plus food and other necessities — is being done by a handful of health insurance companies that provide Medicaid coverage under contracts with the state Department of Human Services.

While demand for COVID-19 vaccines outpaced supply for months — sparking widespread public frustration over a lack of access to shots — that has shifted recently and daily immunization numbers are now on the decline, raising concerns about the effect of vaccine hesitancy. State officials are actively working to overcome that trend in their campaign to vaccinate 4.7 million adult New Jerseyans by July.

“We have been working closely with the five managed-care organizations that administer our state Medicaid program on vaccine rollout, particularly on the best ways to deploy some of our state’s health-equity strategies,” DHS acting commissioner Sarah Adelman told members of the Senate Budget and Appropriations Committee on Tuesday in response to a question from Sen. Troy Singleton (D-Burlington).

The committee discussed the department’s $7.29 billion spending plan as part of its ongoing review of Gov. Phil Murphy’s budget proposal for the coming year. DHS has set aside more than $50 million over two years to help pay for COVID-19 vaccination administration among Medicaid patients, officials said. The federal government currently covers the cost of the shots themselves.

Adelman said DHS also worked with the insurance companies “on a more granular level” to review medical histories to identify those who were most at risk for COVID-19. The analysis revealed hundreds of thousands of Medicaid members with chronic illness or daily assistance needs that indicated they should be prioritized for immunization, she said. These groups were targeted for phone calls.

“When that outreach was made, in many cases it has included assistance in signing up for a vaccine, a warm handoff to the Department of Health (vaccine appointment-scheduling) hotline, and if the individual needed assistance with transportation to their vaccine appointment, the (insurance) plans can help with that as well,” Adelman said.

 

The five Medicaid plans — run by Horizon Blue Cross Blue Shield, UnitedHealthcare, Amerigroup, Aetna and WellCare — have also been asked to collect biweekly data to help the state track immunization progress and identify where additional investment is required. But the numbers are often delayed and incomplete, according to program leaders at DHS, who declined to share numbers Tuesday.

Push for vaccine equity

While the outcome of this investment may not yet be clear, the need for greater vaccine equity has been obvious for months. Murphy and Health Commissioner Judy Persichilli have regularly highlighted the need to improve interest in and access to COVID-19 shots among minority groups, low-income residents and others most at risk for infection.

The administration has partnered with churches and other community organizations, hosted virtual town halls, and expanded its advertising and other public outreach to boost vaccine equity. But Black and Hispanic individuals are still being inoculated at a slower pace than their white counterparts, state figures show.

Efforts to immunize frail, elderly individuals in nursing homes and other long-term care — a process overseen by the federal government, not the state — started slowly but has largely been successful, with at least 85% of nursing home residents now inoculated. Many of these residents are covered by Medicaid.

But DHS identified another 1.2 million Medicaid members who live in the community and were eligible for the vaccine early on based on their preexisting conditions. This group includes more than 583,000 members age 65 and up and who have multiple chronic medical conditions; nearly 260,000 of these individuals are considered the highest priority based on their past diagnoses or the fact that they live alone. This group is the focus of the “high touch” outreach conducted by the insurance plans, officials said.

Early in the pandemic the insurance plans sought to ensure that Medicaid members at risk had access to the health services and daily assistance as needed, program officials explained. As the outbreak ramped up, this evolved to helping individuals who were infected with COVID-19, tracking positive case numbers and coordinating hospital discharges.

Eventually the focus shifted to vaccines, with the bilingual mailings in late February to highlight the reasons to get immunized — like the protection it can offer to other family members — and information on how and where to sign up for a shot. Direct phone calls were added later for those in the highest-risk categories.

One company’s approach

Horizon Blue Cross Blue Shield — the state’s largest insurance provider, with some 960,000 Medicaid members on its rolls, nearly 134,000 of whom are considered most high-risk — deployed their existing care managers to make calls and pulled from a pool of more than 500 nurses and social workers elsewhere in the company to pitch in, according to Wendy Morriarty, the company’s vice president and chief Medicaid officer.

“In a crisis we have these troops available,” she said. “But it was all hands on deck.”

Thanks to relationships Horizon has already established with its medical providers, including community clinics and other local organizations like churches, Morriarty said the company has also been able to do more direct in-person outreach in some neighborhoods. Through these partnerships, community health fairs become opportunities to connect people with a health-care plan, food assistance and vaccine access. “We’ve got that group mobilized literally on the street,” she said.

Like the other plans, Horizon has also tapped internal “data wizards” to help wrangle information from the state’s vaccine database, claims forms and federal sources, Morriarty said. But gaps in these systems leaves them with an incomplete picture of who is getting immunized. The company is also tracking vaccine uptake and refusals through its calls, she said, and all these figures are compiled in massive, complex spreadsheets that it shares with DHS.

What the data does show is “we’re not near done,” Morriarity said. “The next big hurdle for us, for this population, is folks who just don’t want to leave their house,” she added. They may not technically be homebound, but they might have limited mobility, or fear of getting sick.

“How do we make it easier to get the vaccine to them? That’s the next step,” Morriarty said.

READ:  Final, fast push on to get people vaccinated

To read this article in the original format, click: NJ targeting Medicaid members in vaccine push

 
 

Clipped from: https://www.tapinto.net/sections/health-and-wellness/articles/nj-targeting-medicaid-members-in-vaccine-push

 
 

 
 

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New partnership will connect Medicaid members with free cell phones

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Priority Health in Michigan is leveraging the new federal EBB program to provider members with cell phones and data plans.

 
 

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.

 
 

DETROIT — A new partnership will help connect Michigan Medicaid members with free cell phones and monthly service.

Priority Health announced Wednesday that its partnering with FeelSafe Wireless, a Michigan-based wireless company.

The initiative was created to help connect Medicaid members with underlying health conditions connect with their health care provider.

Priority Health says FeelSafe Wireless will offer free, name-brand smartphones and free monthly service to qualifying individuals. The service consists of 1,000 free minutes, 500 texts and 4.5 gigabytes of data per month.

FeelSafe Wireless will also be participating in the new Federal Communication Commission’s Emergency Benefit Broadband Program, which was designed to help households struggling to pay for internet service during the coronavirus pandemic.

For the temporary EBB program, FeelSafe Wireless will offer unlimited talk, text and 15 gigabytes of additional data monthly. Priority Health says lifeline benefits are available to those who use government programs like Medicaid or Supplemental Nutrition Assistance Programs (SNAP).

Medicaid members can learn more or enroll in the program online.
 

Clipped from: https://www.fox17online.com/news/local-news/new-partnership-will-connect-medicaid-members-with-free-cell-phones

 
 

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Kentucky must rebid Medicaid contracts again, judge rules

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The latest lawsuit will be the third round of procurements for these awards.

 
 

 
 

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.

 
 

This ruling puts six insurers at risk of losing their lucrative contracts with the state. It’s unclear when the state will rebid the work.

 
 

Fotolia

A Kentucky judge ruled Wednesday that the state must again rebid its lucrative Medicaid contracts previously awarded to some of the nation’s largest health insurers.

Franklin Circuit Court Judge Phillip Shepherd blamed “irregularities” in the state’s procurement process and said taken together they “severely undermine public confidence in the bidding process.”

This ruling puts six insurers at risk of losing their contracts with the state. However, to prevent any disruption for the more than 1 million patients covered by Kentucky Medicaid, the current awards will remain in place for now. It’s unclear when the state will begin the rebidding process.

“The judge’s orders are being reviewed and the impact is being assessed,” said Susan Dunlap, a spokesperson for Kentucky’s Cabinet for Health and Family Services, which oversees the state Medicaid program.

This will be the third time the contracts are rebid, Molina’s CEO Joe Zubretsky said on a call Thursday with investors. The contracts were re-bid last year after a new governor, Democrat Andy Beshear, was installed and wiped out the previous contracts that were awarded at the tail end of his predecessor’s term. Beshear was keen on beginning a new request for proposal process because he wanted to modify the state program, mainly to end the controversial Medicaid work requirements.

The same seven companies bid on the new proposal under the Beshear administration. The same five were awarded the work: Aetna, Humana, Molina, UnitedHealthcare and WellCare.

Anthem and Kentucky-based insurer Passport Health, both previous incumbents, were not selected again.

Anthem protested the contract loss and brought a lawsuit against the state. As part of the suit, Anthem wanted Molina removed as a contractor for hiring a former member of Beshear’s transition within one year after leaving the government post. The court did not remove Molina from the program, but it did allow Anthem to become the sixth Medicaid managed care organization for the state.

To expand its footprint in Kentucky, Molina acquired the second-largest Medicaid plan, boosting membership there to 315,000 members, which analysts said at the time would mean an additional $1.1 billion in premium revenue for the insurer.

“We’ll be bidding on the contract, but we’ll be bidding as a strong incumbent, we’ve already won the contract twice; we’ll win it a third time,” Zubretsky said Thursday.

Contracting with states to provide Medicaid coverage to low-income residents has become a lucrative service for insurers.

Many have noted that enrollment in this area has ticked up over the course of the pandemic. The public health emergency has played a part in that as it bars states from running re-determinations to kick people off who are no longer eligible. As states are blocked from terminating coverage, membership has increased for insurers like Anthem and Molina.

Plus, the strategy is similar for many insurers that offer Medicaid coverage; they also sell Affordable Care Act marketplace plans to those eligible for subsidies. They are poised to see growth in this area as President Joe Biden’s administration opened a special enrollment period due to the pandemic so no one goes without coverage at this time. The special enrollment period ends Aug. 15.

 
 

Clipped from: https://www.healthcaredive.com/news/kentucky-must-rebid-medicaid-contracts-again-judge-rules/599334/

 
 

 
 

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Centene earnings buoyed by Medicare/Medicaid

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Medicaid revenues were up 16% YOY for the latest reported period.

 
 

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 Corp. Tuesday posted better-than-expected profit and revenue growth for the first quarter, as stronger results from its Medicaid and Medicare businesses offset declining revenue from commercial programs.

The St. Louis-based healthcare company logged net earnings attributable to the company of $1.19 a share, up from 8 cents a share a year earlier. The total net earnings attributable to the company were $699 million, compared with $46 million in 2020’s first quarter.

Accounting for one-time items, Centene’s adjusted earnings were $1.63 a share. Analysts surveyed by FactSet had forecast an adjusted profit of $1.50 a share.

 

Centene’s revenue climbed to $29.98 billion from $26.03 billion in the year-ago period. Analysts were expecting revenue of $29.5 billion. Revenue from premiums rose to $26.93 billion from $23.21 billion.

Revenue from Medicaid programs rose 16% to $20.19 billion, while Medicare revenue grew 41% to $3.76 billion. Commercial revenue fell 5% to $3.9 billion.

Total membership grew 5% to 25.1 million.

Chief Executive Michael Neidorff said the company’s previously announced agreement to acquire Magellan Health in a $2.2 billion deal is on track to close in the second half of 2021.

Write to Matt Grossman at matt.grossman@wsj.com

 
 

Clipped from: https://www.marketwatch.com/story/centene-earnings-buoyed-by-medicaremedicaid-2021-04-27

 
 

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Paramount to appeal state’s denial of Medicaid business

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Paramount (ProMedica) is protesting the loss of its Medicaid contract in Ohio.

 
 

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.

 
 

ProMedica’s insurance subsidiary, Paramount, said Friday it will appeal a decision by the Ohio Department of Medicaid that it says could cost the Toledo area hundreds of professional jobs and disrupt services for a quarter of a million Medicaid recipients.

For reasons that ProMedica says are “baffling,” the state has rejected Paramount’s application to be one the state’s six Medicaid providers.

“We were shocked and baffled by the announcement because it did not reflect what our performance had been,” Paramount President Lori A. Johnston said in an interview with The Blade.

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“This decision will really not only have a devastating impact on our company, but more importantly it will disrupt the care coordination and support for nearly quarter million adults and kids who are enrolled in our network,” she said.

Medicaid is a federally funded, state-administered insurance program for people with poverty-level incomes.

Paramount administers Medicaid for about 240,000 clients in northern Ohio and Cincinnati. The premiums account for 75 percent of Paramount’s revenues and more than 20 percent of the total revenues of ProMedica Health System, according to Steve Cavanaugh, chief financial officer of ProMedica.

At stake are the jobs of more than 600 Paramount employees and hundreds more employed by vendors, many of which are in higher-paying positions like actuaries, nurses, and managers.

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“Those jobs are all at risk now. It easily could be approaching 1,000 lost jobs in this area and so that just is devastating to the economy, and those are good-paying jobs,” Mr. Cavanaugh said.

“They’ve gone through this selection process and clearly they have a strong bias to go with for these national, profit, out-of-state companies. You’re taking Ohio taxpayer dollars away from an Ohio-based, not-for-profit company and giving it to an out-of-state, for-profit company that are headquartered in other parts of the country,” Mr. Cavanaugh said.

“Some of these companies, we’ve been competing with them for years and doing better than them for years,” Mr. Cavanaugh said.

According to ProMedica, Paramount’s Medicaid program is a not-for-profit enterprise. Its non-Medicaid branch is a for-profit corporation.

The deadline to appeal the state’s April 9 decision was 3 p.m. Friday.

On April 9, the state Department of Medicaid announced the completion of a six-month competitive process to be one of six Medicaid providers in Ohio. The winners were UnitedHealthcare Community Plan of Ohio, Inc., Humana Health Plan of Ohio, Inc., Molina Healthcare of Ohio, Inc., AmeriHealth Caritas Ohio, Inc., Anthem Blue Cross and Blue Shield, and CareSource Ohio, Inc. The changeover to the new insurance administrators will take place in 2022.

“The Ohio Department of Medicaid is confident in its rigorous evaluation process that was designed to select the best managed-care organizations for the state’s dramatically redesigned Medicaid program,” the Ohio Department of Medicaid said in a statement Friday afternoon. “The procurement was highly competitive, broadly communicated, and structured to ensure partners were selected for their ability, expertise, and willingness to assist the state in meeting new, far-reaching goals for the redesigned Medicaid program.”

The applicants were ranked on a scale with a total possible score of 1100. In the two Ohio regions for which Paramount submitted proposals, it scored 358 in the West region — covering roughly the western third of Ohio including Toledo, Dayton, and Cincinnati — and 342 in the Northeast region. The six selected companies scored between 696 and 905. Paramount did not bid for the third region, named the Central region.

“The Ohio Department of Medicaid clearly outlined the goals of the redesigned program beginning in early 2020. Potential bidders had many opportunities to help shape the goals and requirements of the redesigned program, as well as the opportunity to object to any of the evaluation requirements and criteria. ProMedica did not object to any of the evaluation requirements or criteria,” the state agency’s statement added. 

Mr. Cavanaugh and Ms. Johnston said Paramount has consistently ranked first in the state for 28 years in the care of its clients who, they said, require a lot of hands-on assistance.

In its April 9 statement, the state Medicaid department said its bid awards will affect more than 3 million Medicaid members in Ohio and thousands of providers, at a cost of about $20 billion.

It said its process was based on “intensive stakeholder engagement” and that its guiding principles were to improve care, emphasize personalized care, improve care for children and adults with complex needs, reduce administrative burdens, and increase program transparency and accountability.

Paramount officials were critical of the process that they said was not transparent, and which gave them only 10 days to build a case for appeal. They said they requested public records necessary for the appeal, and were provided some of those.

In early 2020, Paramount withdrew from serving approximately 30,000 Medicaid customers in central and southeast Ohio after complaining that the state was basing the premium’s cost on the experience of average Medicaid clients whereas Paramount was handling Medicaid’s most challenging and costly patients. The company experienced a $103 million loss in 2019 because of the problem. The dispute with Paramount forced the state Department of Medicaid to correct its billing.

Mr. Cavanaugh did not rule out that Paramount may be experiencing payback because of its pushback on the issue in 2020.

“You would hope folks wouldn’t let that get in the way of trying to make very important public policy decisions for millions of Ohioans. But people are people sometimes, and consciously or unconsciously they may carry their biases from past interaction with folks into a process,” Mr. Cavanaugh said. “I have to sit here and wonder if that’s come into play. The folks that we had some very challenging interactions with are probably the same ones doing the scoring of our bid.”

According to Ohio Medicaid’s report card for 2020, Paramount performed as well or better than three other companies that won the state’s Medicaid bid. Paramount received 16 stars overall, while Molina Healthcare received 15 and United Healthcare Community Plan received 14 stars. CareSource received 16 stars.

Robin Reese, the head of Lucas County Children Services attacked the state’s decision in a letter Friday to Maureen Corcoran, director of the state Medicaid department.

“The Ohio Department of Medicaid’s decision to exclude Paramount will disempower parents,” Ms. Reese wrote on the Children Services Board’s behalf. “This move will interrupt the continuity of care, and is indifferent to the needs of our community.”

She said nearly two-thirds of children in LCCS custody are enrolled in Paramount’s managed-care plan — more than twice as many as Paramount’s closest competitor, Buckeye Health Plan.

“Several of the selected HMOs have no footprint at all in northwest Ohio,” she said.

She credited Paramount with having championed the “social determinants of health” since 2009, before it was “fashionable.”

First Published April 23, 2021, 9:59am

 
 

Clipped from: https://www.toledoblade.com/news/medical/2021/04/23/paramount-to-appeal-state-s-denial-of-medicaid-business/stories/20210423093

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Molina buys up Cigna’s Medicaid business in Texas for $60M

MM Curator summary

 
 

Molina will gain 48,000 members from the deal.

 
 

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.

 
 

With this deal, Molina will expand upon its existing services in Texas as a part of its growth strategy.

 
 

Photo by Martin Barraud/Getty Images

Molina Healthcare has entered into a definitive agreement to purchase Cigna’s Texas Medicaid business for approximately $60 million in cash.

Also included in the transaction are Cigna’s Medicare-Medicaid Plan contracts in the state, as well as certain operating assets, the companies said in the announcement.

The deal is expected to close in the second half of 2021, subject to federal and state regulatory approvals.

WHY THIS MATTERS

With this deal, Molina will expand upon its existing services in Texas as a part of its growth strategy. It will gain about 48,000 Medicaid members and roughly 2,000 dual enrollment members across the state.

Additionally, Molina expects to capture about $1 billion in new annual revenue through the purchase.

“Acquiring Cigna’s Texas Medicaid business provides us with a stable base of membership and revenue that will deepen Molina’s service offerings in Texas, allowing us to meet the needs of thousands of additional Medicaid and MMP members,” Molina said by statement. “The transaction demonstrates continued execution and is nicely representative of our growth strategy.”

Amid the ongoing economic fallout of the COVID-19 pandemic, more people are becoming eligible and enrolling in Medicaid and CHIP, according to the Kaiser Family Foundation. By its estimates, total enrollment grew to 78.9 million last November – an increase of 10.8%, or 7.7 million, from February 2020.

THE LARGER TREND

Molina experienced company growth throughout 2020, despite the pandemic, according to its fourth-quarter and full-year financial report. It ended the year with $19.4 billion in revenue, up 15% from 2019, and more than 4 million members across its health plans.

Its growth was driven, in part, by a number of acquisitions it completed over the course of last year. In January, it announced plans to acquire all of the capital stock of NextLevel Health Partners.

Then last summer it entered into a definitive agreement to acquire certain assets related to the Medicaid and DSNP lines of business of Passport Health Plan. Rounding out the year, it shared plans to buy up Affinity Health Plan for $380 million.

ON THE RECORD

“We are proud of the positive impact we have made on customer lives through our Texas Medicaid business, and are confident that Molina will build on our work to improve their health, well-being, and peace of mind,” Cigna said by statement.

“We remain fully committed to the state of Texas, and look forward to continuing to bring affordable, predictable, and simple health care solutions to the millions of Texans we serve through our Medicare, Commercial, and Health Services businesses.”

Twitter: @HackettMallory
Email the writer: mhackett@himss.org

 
 

Clipped from: https://www.healthcarefinancenews.com/news/molina-buys-cignas-medicaid-business-texas-60m