Tag: Medicaid Managed Care

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[MM Curator Summary]: We have winners in the Sooner State (Aetna, Humana, Centene). Not sure we have one that is exactly “provider-led” as was intended by the do-over effort, but hey. Potato, Potato.

 
 

Clipped from: https://oklahoma.gov/ohca/about/newsroom/2023/june/ohca-selects-organizations-to-assist-in-serving-oklahoma-medicaid.html

Oklahoma City, OK – The Oklahoma Health Care Authority has selected three qualified and experienced contracted entities to assist in executing OHCA’s comprehensive health care model, SoonerSelect, for certain SoonerCare members.    

The selected contracted entities serving the medical plans are Aetna Better Health of Oklahoma, Humana Healthy Horizons of Oklahoma and Oklahoma Complete Health, a subsidiary of Centene Corporation. The selected contracted entity serving the children’s specialty program is Oklahoma Complete Health. Each of the contracted entities meets the statutory requirements of a provider-led entity and must also contract with local Oklahoma provider organizations. 

“By moving away from a fee-for-service model toward this new delivery system, we can increase the effectiveness of SoonerCare while achieving better health outcomes,” said Kevin Corbett, OHCA CEO. “SoonerSelect places a strong emphasis on quality of service and health outcomes while maintaining fiscal responsibility for Oklahoma taxpayers.”   

SoonerSelect will allow OHCA to incentivize health outcomes while maintaining oversight and authority over Oklahoma’s Medicaid program and the program funding. OHCA is committed to improving the health and lives of SoonerCare members and will hold its SoonerSelect partners to the highest standards through stringent accountability measures.   

By contracting with provider-led entities, OHCA will strengthen the voice of local providers and leverage their expertise and familiarity with Oklahoma communities in delivering health care services to SoonerCare members.  

This transition in health care delivery will allow OHCA to achieve the following payment and delivery system reform goals:   

• Improve health outcomes for Oklahomans   
  
• Move toward value-based payment   
  

 
 

• Improve SoonerCare member satisfaction   
  
• Contain costs by investing in preventive and primary care   
  
• Increase cost predictability to the State    
  

“The selected organizations are the best at what they do and their established partnerships with Oklahoma providers is vital to the success of the program,” said State Medicaid Director Traylor Rains. “I am confident in their ability to assist us in providing high-quality services to our SoonerCare members.”    

Oklahoma joins 40 other states in engaging third-party organizations to administer certain Medicaid benefits. States have reported positive outcomes by investing in primary care, preventive services and effective quality improvement strategies, such as addressing maternal health outcomes, obesity and smoking rates, and reduced emergency room utilization. 

It is common for these contracted organizations to be heavily invested in infrastructure, including technology, staffing, and research on best practices to coordinate care for members. The selected organizations must have an Oklahoma presence, including key staff and call center operations.   

The contracts were competitively bid and were selected after a technical evaluation and oral presentations. The contracts are for an initial term through June 30, 2025 with five renewal options. OHCA staff will spend the next several months working with the contracted entities to ensure a smooth transition for SoonerCare members and will continue to oversee the plans to ensure a high level of care for members.   

Subject to approval by the Centers for Medicare and Medicaid Services, OHCA expects to launch the medical and children’s specialty plans in April 2024. The SoonerSelect dental plans which were previously announced are expected to launch in February 2024.  

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[MM Curator Summary]: 2 brothers are working to help national MCOs crack open more of the LoneStar state. One of them is the chairman of the House Appropriations Committee. The other is the former Speaker of the House. Not making this up.

 
 

 
 

Clipped from: https://www.reformaustin.org/texas-legislature/bonnens-deal-to-prioritize-profit-in-medicaid-coverage/

 
 

As the budget fight in the Texas Legislature heats up over school vouchers, a quiet addition being pushed by the Bonnen Brothers could start funneling Medicaid dollars into more private, profit-driven companies’ pockets.

According to Quorum Report, former Texas Speaker of the House Dennis Bonnen has been pushing for a budget amendment on behalf of Amerigroup, a for-profit national medical coverage company that provides health insurance to low-income people. In practice, that means that Amerigroup stands to make billions of dollars when they win contracts to administer Medicaid coverage.

His brother, Greg Bonnen, is currently the chairman of the House Appropriations Committee. He is supporting a new rule that would judge potential Medicaid vendors based not on quality of care, but by how profitable they are.

This comes during a time when a significant fight is happening over how Medicaid will be run in the state. Currently, for-profit entities like Amerigroup are trying to circumvent county programs that also offer Medicaid through their hospital systems. These non-profit organizations control 11 percent of the state’s Medicaid managed care networks and re-invest back into their local communities.

Because of this, they legally receive preferential treatment over for-profit organizations who instead put any excess money in investor pockets. Two bills this session have tried to eliminate the preferential treatment, making it easier for for-profit companies to swoop in and take over the contracts.

The budget addition would allow the voting process to be circumvented, and possibly not even be debated on the chamber floor.

In other jurisdictions where Amerigroup has taken over Medicaid, they have reported enormous profits up to 30 percent. They have also had to settle fraud lawsuits over denying care to patients that totaled in the hundreds of millions. In Texas, Amerigroup has been fined for denying care to disabled residents.

By allowing profit margins to determine a Medicaid managed care provider’s worthiness, it prioritizes companies that deny the most coverage as that increases their profitability. Poor Texans, especially in rural areas, will end up with fewer options for care and will be forced to go without.

Currently, insiders who spoke to Quorum Report say that Greg Bonnen is making the budget rider a top priority in the House, and has spoken to his counterpart Joan Huffman (R-Houston) in the Senate abut keeping the rider in the final budget bill. With all the fighting over school vouchers and property tax relief dominating the media coverage, a simple change to Medicaid managed care might very well fly under the radar.

Medicaid currently serves 5.4 million Texans, by far the largest medical insurance used in the state. It is also one of the stingiest programs in the nation, being completely unavailable to most non-disabled Texans regardless of income. Texas continues to refuse the Medicaid expansion offered by the Affordable Care Act, the largest state to still do so. Texas Republicans have allowed a small increase in availability for post-natal Texans that was aimed at curbing the state’s abysmal maternal mortality rate.

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[MM Curator Summary]: The new dental RFI is out in the Sunshine State.

 
 

 
 

Clipped from: https://floridapolitics.com/archives/612211-state-prepares-for-medicaid-dental-procurement/

 
 

Florida Medicaid officials released a request for information (RFI) seeking input from potential vendors as it prepares to put its Medicaid Prepaid Dental Program out to bid.

Responses to the four-page RFI are due by 5 p.m. May 30.

The agency must start the procurement process this year for the six-year dental contracts, which will take effect sometime in 2024.

The document solicits information on innovative ideas and best practices to improve Florida’s dental care services for Medicaid beneficiaries.

There appears to be an emphasis on ways to improve dental care services to people with intellectual and developmental disabilities enrolled in the Medicaid waiver program called iBudget.

 
 

For instance, the RFI seeks ways to: improve the integration of dental and primary care services for iBudget enrollees; and to identify different options for integrating sedation dentistry into dental services for iBudget enrollees.

The RFI also requested information on identifying certification(s) and accreditation(s) that allow for the safe and high-quality provision of dental care for individuals with intellectual and developmental disabilities; and educating future dentists about providing dental services for individuals with intellectual and developmental disabilities.

The RFI also asks for ways to:

—Utilize value-based payment (VBP) designs to simultaneously increase quality and reduce costs;

—Improve integration of dental and primary care services for children, adolescents, pregnant women, and the elderly;

 
 

—Provide enhanced orthodontia services;

—Innovate delivery methods for the dental care model, including care bundling, that empower recipients in making more informed health care decisions.

—Improve providers’ and recipients’ experiences with the prepaid dental program; and

—Achieve cost savings throughout the prepaid dental program.

Three prepaid dental plans currently have contracts with the state to provide dental care to Medicaid beneficiaries.

There was a legislative dogfight during the 2022 Session over Medicaid dental services and whether they should continue to be administered through a separate managed care program or be combined with the statewide Medicaid Managed Care Program, which also encompasses managed medical assistance, long term care, and specialty care.

The fight pitted the insurance industry, which wanted the program rolled into the larger managed care program, against dentists, who wanted the program to remain bifurcated. Ultimately, the Legislature agreed to keep them separate.

In April, the Agency for Health Care Administration published an ITN for the statewide Medicaid Managed Care Program.

Interested parties have until May 30 to submit written questions to the state about the ITN.

AHCA has not replied to Florida Politics’ requests for the questions or the names of the companies that submitted the questions.

The statewide Medicaid Managed Care Program contracts are worth tens of billions of dollars to the companies that submit winnings bids. Companies that don’t secure contracts with the state are essentially locked out of Florida’s Medicaid market.

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[MM Curator Summary]: Sentara is moving around some of its covered lives. Not sure why yet, but will try to find out.

 
 

Clipped from: https://www.beckerspayer.com/payer/virginia-premier-medicaid-members-shifting-to-optima-health.html

Virginia Premier will move its 300,000 Medicaid members to Optima Health on July 1.

Both are owned by Sentara Health and collectively support nearly 750,000 Virginia Medicaid members, according to a May 10 news release from the Norfolk, Va.-based health system. 

“Bringing the Virginia Premier Medicaid membership over to Optima Health will enable us to continue to provide a superior customer experience for our Medicaid membership — while also creating efficiencies that support lower costs for the state and reduced administrative burden on healthcare providers,” Sentara Health Plans President Colin Drozdowski said in the release. 

Virginia Premier Medicaid members enrolled as of June 30 will keep their same coverage and benefits but will become Optima Health members. Virginia Premier D-SNP will continue to operate under the Virginia Premier name, and there will be no changes in benefits and services, the release said.

Subscribe to the following topics: virginia premiermedicaidoptima healthsentara healthvirginia

 
 

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[MM Curator Summary]: Lets see which is better- FFS or MCOs.

 
 

 
 

 
 

Clipped from: https://whatsupnewp.com/2023/04/sen-ujifusa-introduces-bill-to-audit-medicaid-middlemen/

 
 

Taxpayers pay almost $2 billion each year to three private health insurance companies, also known as Managed Care Organizations (MCOs), to administer benefits for about 90% of Rhode Island Medicaid enrollees. Sen. Linda Ujifusa, a member of the Senate Health and Human Services Committee, has proposed legislation to audit these companies to ensure those taxpayer dollars are being properly spent.

“With skyrocketing health care costs, hospitals closing or being sold to out-of-state, for-profit entities, primary care providers leaving in droves and virtually no replacements even applying to fill empty jobs, we all see our health care system is in crisis,” said Senator Ujifusa. “Past efforts to ‘reinvent Medicaid’ by putting private middlemen MCOs in charge have clearly failed.”

Three MCOs, Neighborhood Health Plan of Rhode Island, Tufts Health Plan and United Healthcare Community Plan, currently administer health benefits for about 316,000 Rhode Islanders. For many years, the Rhode Island Auditor General has noted the state lacks effective auditing and monitoring of MCO activity, likely leading to inaccurate reimbursements.

Senator Ujifusa’s bill (2023-S 0109) would instruct the Auditor General to hire an independent consultant to compare costs and patient outcomes of the MCO program to those that could be achieved under a fee-for-service, state-managed program. If the audit determines the state could save money by switching, the legislation instructs the state to come up with a plan to transition away from MCOs. Rep. Joseph  J. Solomon Jr. (D-Dist. 22, Warwick) has introduced companion legislation (2023-H 5474) in the House.

In 2009, Connecticut conducted a similar MCO audit which found the state was overpaying its three MCOs (United Healthcare, Aetna, and Community Health Network of Connecticut) nearly $50 million per year. In 2012, Connecticut implemented a state-run, fee-for-service Medicaid program and saved hundreds of millions of dollars and achieved the lowest Medicaid cost increases in the country, while improving access to care.

“We should follow Connecticut’s lead,” said Senator Ujifusa. “Everyone recognizes that Medicaid reimbursements to providers have been too low, but what we’ve missed is that the best way to increase Medicaid reimbursements without increasing taxes is to focus on middlemen MCOs and their pharmacy benefit managers (PBMs),” Senator Ujifusa said.

The multi-year contracts with all three MCOs are set to be renewed this fall.

“It is imperative we finally do an in-depth audit of MCOs now, before those contracts are renewed,” said Senator Ujifusa. “State efforts to study skyrocketing health care costs have focused almost exclusively on patients and providers as cost-drivers. But patients and providers are struggling. The only ones doing well financially are the middlemen MCOs and PBMs, so it’s time we stop ignoring the elephants in the room.”

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[MM Curator Summary]: The FL bid has dropped. Ready, set, Go!

 
 

 
 

Clipped from: https://stateofreform.com/uncategorized/2023/04/ahca-releases-invitation-to-negotiate-for-statewide-medicaid-managed-care-program/

 
 

Shane Ersland | Apr 12, 2023 | Florida

The Florida Agency for Health Care Administration (AHCA) released an invitation to negotiate for the upcoming new Statewide Medicaid Managed Care Program (SMMC) contract on Tuesday.

Most Medicaid recipients in Florida are enrolled in the SMMC, which covers 4.4 million individuals, and consists of:

• Managed Medical Assistance (MMA), which provides Medicaid-covered medical services like doctor visits, hospital care, prescription drugs, mental healthcare, and transportation for these services. Most Medicaid recipients receive their care from a plan that covers MMA services.
  
• Long-Term Care (LTC), which provides Medicaid LTC services like nursing home, assisted living, or home care. LTC recipients must be at least 18 years old, and meet nursing home level of care requirements (or meet hospital level of care requirements if they have cystic fibrosis).
  
• Dental, which provides all Medicaid dental services for children and adults. All people on Medicaid must enroll in a dental plan.
  

This will be the second SMMC re-procurement since the program began in 2013. Current contract holders include Centene, Community Care Plan, CVS/Aetna, Elevance Health, Florida Community Care, Humana, Molina, and UnitedHealthcare.

Current contracts began in December 2018 and were slated to run through 2024. The  new contracts will run from Oct. 1st, 2024, through Dec. 31st, 2030.

The upcoming procurement will award contracts for MMA and LTC. Proposals are due on Aug. 15th, and the anticipated award date is Dec. 11th.

Important deadlines for the process include:

• May 3rd: deadline for the receipt of written questions
  
• June 27th: anticipated date for agency responses to written questions
  
• Aug. 15th: deadline for receipt of responses; public opening of responses
  
• Aug. 17th: anticipated posting of respondent names for provider comment
  
• Sept. 5th: deadline for receipt of provider comments
  
• Oct. 2nd through Nov. 17th: anticipated dates for negotiations
  
• Dec. 11th: anticipated posting of notice of intent to award
  

The agency intends to award contracts to nationally accredited managed care plans that: 

• Incentivize value and quality
  
• Offer an enhanced service delivery system and integration of behavioral and physical health services
  
• Ensure the availability of comprehensive, quality-driven provider networks
  
• Streamline processes that enhance the enrollee and provider experience 
  
• Provide expanded benefits targeted to improve outcomes for enrollees
  
• Have top quality scores and high rates of enrollee satisfaction
  
• Are able to deliver an efficient, high-quality, innovative, cost-effective, integrated healthcare delivery model
  
• Provide pathways towards self-sufficiency, purpose, and independence   
  

The anticipated term of the contract will begin from the date of the contract’s execution through Dec. 31st, 2030. The contract cannot be renewed, however, the agency may extend the resulting contract’s term to cover any delays during the transition to a new plan.

 
 

 
 

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[MM Curator Summary]: Families are saying Anthem is denying or delaying critical services. DCH and Anthem say that’s not the case.

 
 

 
 

 
 

Clipped from: https://journalrecord.com/2023/04/11/georgia-medicaid-insurer-denied-psychotherapy-for-thousands/

 
 

Georgia Human Services Commissioner Candice Broce, right, testifies at the Georgia state Capitol in Atlanta. Broce said that the insurer managing care for Georgia’s foster children is denying too many requests for mental health care. (AP file photo/Jeff Amy)

ATLANTA (AP) – A newspaper finds that the insurance company that manages medical care for many Georgia children has denied or partially denied more than 6,500 requests for psychotherapy between 2019 and mid-2022.

The Atlanta Journal-Constitution reports that many of the requests denied by Amerigroup, a unit of insurance giant Elevance Health, were for children in state-run foster care.

Child advocates tell the newspaper that the Department of Community Health, which is supposed to oversee the contract, isn’t holding Amerigroup accountable.

“The state is not doing its duty,” said Joe Sarra of the Georgia Advocacy Office, a federally mandated organization that works for people with disabilities.

In a January report to state lawmakers, the department said fewer than 100 psychotherapy requests were denied in calendar year 2019 and the 2021 and 2022 budget years by the state’s Medicaid managed care contractors, including Amerigroup.

But the newspaper found through documents obtained in open records requests that Amerigroup denied hundreds of authorization requests for psychiatric residential treatment, something the Department of Community Health didn’t include in its report to lawmakers. Amerigroup also denied thousands of requests for evaluations related to mental or behavioral health issues and hundreds of requests for autism-related services.

Melvin Lindsey, who leads Amerigroup in Georgia, has denied wrongdoing, telling lawmakers in a January hearing that children’s needs come before profits.

“I’ve never made a decision about how to treat anyone, particularly a foster care kid, that was related to cost and I never will,” Lindsey said. “We will get people the right services at the right time, all the time.”

But Human Services Commissioner Candice Broce, who also leads her department’s Division of Family & Children Services – the state’s foster care agency – has been sharply critical. She urged changes as the Department of Community Health seeks new bids on the Medicaid managed care contract that covers foster children. Broce wrote in a 2022 letter that children must wait weeks or months for an appointment, are rejected for services based on a narrow definition of “medical necessity” and are deprived of care coordination for their complex needs.

Among children denied entrance to residential treatment: an 11-year-old girl who smeared feces in the bathroom of a foster care home and attempted to jump out of a window hours after being released from a psychiatric unit. Amerigroup approved a residential stay months later after the girl tried to both drown and electrocute herself, according to the state’s foster care agency. At that point, no facility would accept her.

Amerigroup also denied a medical provider’s request for a residential treatment of a 13-year-old foster child who was trying to hurt herself and was aggressive toward others. While the state appealed the company’s decision, she tried to overdose on lithium pills and cut herself with glass.

“This is a problem that far exceeds foster care,” said Melissa Carter, executive director of the Barton Child Law and Policy Center at Emory University. “The fact of the matter is, many of those children who are currently in foster care may not need to be if parents were able to access services to meet their children’s needs in the community.”

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[MM Curator Summary]: Some highlights of what UPMC is doing in its whole-person model. TL/DR: increased SA treatment, increase primary care and increase screenings for SDH needs.

 
 

 
 

 
 

Clipped from: https://www.miragenews.com/upmc-review-confirms-pa-medicaid-as-national-971974/

PITTSBURGH, PA (March 22, 2023)—Experts from UPMC Health Plan and Community Care Behavioral Health Organization recently published a state mental health policy description that shows how Pennsylvania’s county-based model of Medicaid behavioral health managed care exemplifies the integration of services to support “whole-person” care. The piece appears in the journal Psychiatric Services.

In Pennsylvania, Medicaid behavioral health is funded through and managed by counties that contract with behavioral health managed care organizations. The counties also manage human services, such as those related to aging, children and youth, and housing. Having all these services coordinated under one umbrella allows for the use of a “human services integration” model for delivering Medicaid-funded behavioral health and other supportive services. This model supports engagement with physical health managed care organizations and multidisciplinary care teams for individuals with co-occurring medical health conditions.

“The strategies, lessons learned, and metrics we have outlined demonstrate that a whole-person approach to behavioral health care facilitates positive outcomes, coordinates community and physical health supports and resources, and aligns providers to focus on the best interest of the individuals we serve,” said Matthew Hurford, MD, President of Community Care Behavioral Health Organization and Vice President of Behavioral Health for UPMC Insurance Services. “Coordinating and managing care with county partners ensures a personalized approach to care that more smoothly and comprehensively integrates behavioral, physical and other needs.”

This whole-person care model has resulted in the following noteworthy outcomes:

• The number of Community Care members receiving medication-assisted treatment—a highly effective form of substance use treatment that involves prescription medication and therapeutic support—increased 43 percent from January 2018 to June 2022.
  
• Primary and specialty care use in a widespread health integration model increased over a two-year period by more than 30 percent, while overall medical costs decreased by 15 percent due to a reduction in hospital-based services.
  

 
 

• Increased routine screening of social needs built into several managed care and provider-based care strategies resulted in connecting individuals with resources to address health disparity-related needs, including housing, food security, employment, and job training to better support long-term recovery.
  

“We believe this integrated approach leaves no stone unturned in addressing the clinical and other needs of individuals seeking behavioral health services,” said James Schuster, MD, Chief Medical Officer for the UPMC Insurance Services Division. “This kind of coordination and cooperation may, in part, be why Mental Health America once again rated Pennsylvania among the top three states in the country for addressing mental health challenges.”

/Public Release. This material from the originating organization/author(s) might be of the point-in-time nature, and edited for clarity, style and length. Mirage.News does not take institutional positions or sides, and all views, positions, and conclusions expressed herein are solely those of the author(s).View in full here.

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[MM Curator Summary]: They even had the winner’s awards letters ready to go. Oh yeah, also the “sorry you lost” letter was ready to go, too.

 
 

Clipped from: https://www.abqjournal.com/2581850/new-mexico-medicaid-providers-canceled-procurement.html

SANTA FE – In mid-January, state Human Services Department officials had letters ready to go notifying four of the five bidders for massive contracts to run New Mexico’s Medicaid program that they had been selected.

But those letters were never sent and, just over a week later, the agency announced it was taking the unusual step of canceling the procurement process and starting over, according to records obtained by the Journal.

The abrupt decision, which was made after Gov. Michelle Lujan Grisham expressed concern about a possible disruption of services if a current Medicaid managed care organization was not issued a new contract, has rattled the Roundhouse and prompted some lawmakers to demand more information.

Legislators earlier this month asked for the full scores of the initial Medicaid contract bidders, after a Journal report on the evaluations, while also questioning top Human Services Department officials about the decision to cancel the process.

“Knowing what those scoring sheets look like, I think that would be useful to us while we’re still here at the Legislature,” said Sen. William Sharer, R-Farmington, during a Senate Finance Committee meeting earlier this month.

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In response, Human Services acting Secretary Kari Armijo said the agency was in the process of hiring an outside Medicaid expert and should have recommendations about the new contract structure within the next 45 days.

In the time since Armijo addressed legislators, the state has contracted with an outside expert who will make recommendations regarding the procurement process and timeline, HSD spokeswoman Marina Piña said this week.

In her discussion with lawmakers, Armijo also said she could not discuss specific evaluations, but vowed to provide senators with the score sheets in question.

“There were concerns expressed about low scores in certain critical areas almost across the board on all bidders in certain key areas that are very important to the Medicaid program,” Armijo said.

She also said health insurers need to bring their “A game” in their follow-up bids.

However, she did not tell lawmakers just how close the department was to readying the announcement of the new contract recipients under the state’s Medicaid program, which were set to take effect next year as part of a rebranded program known as Turquoise Care.

The new documents obtained by the Journal show the state readied intent letters announcing the awarding of contracts for the health care insurers vying for Turquoise Care contracts less than two weeks before canceling the procurement.

The documents, which include email communications involving Armijo, former HSD Secretary David Scrase and former Medicaid Director Nicole Comeaux, also show the direct involvement of the Governor’s Office in the abrupt decision to not forge ahead with the prepared letters.

Specifically, Armijo sent a Jan. 29 email to Teresa Casados, the chief operating officer in the Governor’s Office, that references a letter that would notify managed care organizations of the state’s intent to cancel the contract process and was drafted at the “direction” of Casados two days earlier.

The email also suggested Charles Canada, HSD’s procurement manager, had not yet been notified of the decision.

Procurement scrapped

The state decided to cancel the procurement process the same day Scrase publicly announced his retirement, but did not announce the decision until three days later — on Jan. 30.

The decision, according to Piña, in part came from the low scores the five bidders received.

Blue Cross and Blue Shield of New Mexico, one of four providers on the state’s current Medicaid contract, scored the highest with 1,083.5 points out of a maximum of 1,815 points.

Western Sky Community Care, a subsidiary of St. Louis-based Centene Corp. and also a current managed care organization, was the lone provider not recommended for a new contract under the previous procurement, scoring a total of 1,022 points.

After the scores were shared, the governor and top staffers in her office “shared concerns” with top HSD officials about a possible disruption of services, a Lujan Grisham spokeswoman told the Journal last month.

But the Human Services Department previously said the reason for halting the procurement process was due to the high-level departures of Scrase and Comeaux, and in order to give their successors the ability to help guide the contract process.

Comeaux has declined to comment on the issue, while Scrase said last month he did not have much insight into the decision.

Scores were low

New Mexico currently pays about $935 million in state funds to run its Medicaid program, and roughly $8 billion total when federal matching funds are included.

While the Human Services Department has withheld the submitted bids, describing them as “confidential,” the agency has disclosed the final scores of the five health insurers seeking to land Medicaid contracts.

Those scores show the four highest-ranked bidders were Presbyterian Health Plan, UnitedHealthcare of New Mexico, Blue Cross and Blue Shield of New Mexico and Molina Healthcare of New Mexico.

Drafted intent letters were written for all four of those insurers, according to records obtained by the Journal.

The records also show a letter had been drafted notifying Western Sky Community Care that it had not been selected for a contract for the new Medicaid program.

While Human Services Department officials have insisted the agency still intends to pick new providers before the end of this year, some lawmakers have floated the possibility of more legislative involvement in future instances when a procurement is canceled.

“I think the Legislature may have the authority to look at the RFPs and say, ‘Here are the top five providers,'” said Sen. George Muñoz, D-Gallup, the Senate Finance Committee’s chairman.

MM Curator summary

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[MM Curator Summary]: The loss stings, but new(ish) CEO London assures shareholders that there is robust lesson-learning happening.

 
 

Clipped from: https://www.bizjournals.com/stlouis/news/2023/03/14/centene-comes-up-short-on-new-indiana-medicaid.html

 
 

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Centene’s headquarters in Clayton.

Dilip Vishwanat | SLBJ

Clayton-based Centene Corp. (NYSE: CNC) has lost out on a lucrative contract for a new managed care program in Indiana.

The Indiana Department of Administration recommended on March 1 that negotiations begin with four bidders to provide services so Medicaid recipients over the age of 60 can continue to live in their homes.

Those companies are Anthem Blue Cross and Blue Shield, Humana Healthy Horizons in Indiana, Molina Healthcare of Indiana and UnitedHealthcare Community Plan. A wholly-owned subsidiary of Clayton-based Centene, Managed Health Services, was not chosen, along with CareSource Indiana and MDWise Inc.

The estimated value for the four-year contracts is $3.8 billion for each of the companies chosen through a request for proposal, which the state of Indiana issued in February 2022. Managed Health Services ranked fifth in the final RFP score to provide long-term services and supports, referred to as LTSS.

The outcome is the latest in a series of ups and downs in the post-CEO Michael Neidorff era. In late December, Centene won back two big-ticket Medicaid contracts in California after filing appeals. A California state agency scrapped an RFP and issued direct contacts with Centene’s subsidiary to serve Medicaid enrollees in Los Angeles County – with a 50% subcontract to Molina Healthcare of California – as well as in Sacramento and eight other counties.

A few weeks earlier, the U.S. Department of Defense on Thursday bypassed Centene in awarding $136 billion in contracts for the health insurance provided to active-duty military members, a blow to Centene, which long held some of the work.

Centene’s current CEO, Sarah London, was asked Tuesday at the Barclays Global Healthcare Conference about the RFP pipeline this year.

“The recent Indiana LTSS result was certainly not what we were looking for,” said London. “But I will say that the organization across all lines of business has an increased discipline around looking at where things don’t always go the way we want them to and pulling out valuable lessons learned.”

Enlarge

Centene CEO Sarah London

Centene Corp.

The new program, Indiana Pathways for Aging, is scheduled to launch in the summer of 2024, according to a spokesperson for the Indiana Family and Social Services Administration.

Managed Health Services is a managed care entity that has operated in Indiana for about 25 years through the Hoosier Healthwise and Hoosier Care Connect Medicaid programs and the Healthy Indiana Medicaid alternative program. MHS also offers a Medicare Advantage plan and health plans through the Affordable Care Act marketplace in Indiana.