Tag: Medicaid Managed Care

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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.

[MM Curator Summary]: Sometimes seeing the sausage made can be [insert your punchline here].

(SOPA Images / Getty Images)

[UPDATED at 9:35 a.m. ET on Oct. 18]

A health insurance giant that has paid out more than $485 million in legal settlements with states over pharmacy billing allegations has also been a major donor to Georgia’s Republican Gov. Brian Kemp and Attorney General Chris Carr, according to campaign finance records.

St. Louis-based Centene Corp. said Monday in a statement that it’s working to settle Medicaid billing issues with Georgia and eight other states, beyond the 13 states it has already agreed to pay. In the public agreements so far, state attorney general offices have been involved in setting the agreements’ terms and have announced the settlement amounts.

According to Carr’s campaign filings, Centene-related donations included spending around an event for him in late August.

The attorney general “appreciates those who support his campaign, but all should understand the attorney general will vigorously defend his client — the people of Georgia — and handle every case before him legally, ethically and honestly,” Carr campaign manager Neil Bitting said in a statement. Kemp’s campaign declined to comment.

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Centene is the parent company of Peach State Health Plan, which delivers managed-care services to about 1 million low-income Georgians enrolled in Medicaid and PeachCare for Kids. It is one of three companies that typically receive more than $4 billion, combined, from the state annually to run the public health insurance programs.

Centene has settled with 13 states over allegations the conglomerate overbilled state Medicaid programs for prescription drug services. It has paid a total of at least $489 million to 10 states, with the other three not yet publicly announced, KHN has reported.

A spokesperson for Carr’s office said Friday that it was waiting for direction from the state Department of Community Health, or DCH, Georgia’s Medicaid agency, before the state pursues a settlement with Centene. “The state is aware of other settlements in other states involving Centene, and the Law Department understands that DCH is conducting a review of its relevant information,” Kara Richardson said. “Once DCH comes to a decision, the Law Department stands ready to provide legal representation in any potential settlement negotiation or litigation.”

A spokesperson for the Community Health Department, David Graves, told The Atlanta Journal-Constitution on Monday that the agency “can confirm that we will be thoughtful and intentional with our approach in a way that ensures the taxpayers of Georgia are best protected.” The governor’s office did not respond directly to questions about possible settlement negotiations.

Centene is the national leader in Medicaid managed care, with more than 15 million members. The company earns about two-thirds of its revenue from Medicaid, which is jointly funded by state and federal taxpayers.

In many states, insurance companies such as Centene also administer Medicaid enrollees’ prescription medications through what is called a pharmacy benefit manager. These benefit managers act as middlemen between drugmakers and health insurers and as intermediaries between health plans and pharmacies. In some cases, Centene acted as both the Medicaid managed-care provider and the pharmacy benefit manager for those plans.

The company, in a statement on Monday, said that it donates to candidates of both parties and is generally supportive of incumbents: “As a member of the healthcare community, we work with elected representatives to help improve quality of care and access to services for the communities we serve.”

Kemp’s reelection campaign has received more than $100,000 in contributions from Centene, its subsidiaries, and its employees since 2018, according to state campaign records, with heavy giving after the first publicly announced settlements, with Ohio and Mississippi in 2021.

Most of the more than $70,000 in Centene-related giving to Carr’s campaign this year came from company executives, including $10,000 from CEO Sarah London. Carr’s campaign also got $6,000 from Centene general counsel Chris Koster, a former Missouri attorney general who has signed pharmacy billing settlements on behalf of the company.

Much of the Centene-related donations to Carr’s campaign occurred in late August, according to the campaign records. They include $3,097 for a venue rental Aug. 26 and catering costs of $3,000 on Aug. 24. The latter was paid by Kelly Layton, wife of Centene President Brent Layton, a former staffer at the Georgia insurance department. Five out-of-state Centene employees donated a total of $13,000 during that three-day period.

In previously announced settlements, Centene has not admitted any wrongdoing. Centene set aside $1.25 billion in 2021 to resolve the pharmacy benefit manager settlements in “affected states,” according to a July filing with the U.S. Securities and Exchange Commission that did not specify how many states were involved.

In January, Wade Rakes, president and CEO of Centene subsidiary Peach State Health Plan, alerted Community Health officials that the company, after an analysis of its pharmacy cost reporting, “may have a remittance obligation” to the state Medicaid program, according to an email obtained by KHN through a public records request.

William Perry, founder of Georgia Ethics Watchdogs, pointed out that nothing in state law bars Kemp or Carr from accepting donations from companies like Centene that do business with the state. “They’ll sit there and say they’ve done nothing unethical under the law, but if you come from an ethically moral position, it’s horrible,” he said. “It’s bad optics, and it just really makes me sick.”

The campaign of Carr’s Democratic opponent in the November election, Jen Jordan, criticized the attorney general for accepting the Centene contributions to his campaign. A Centene subsidiary donated $1,500 to Jordan in 2019, when she was running for reelection to the Georgia Senate, but the conglomerate doesn’t appear to have given to her campaign this cycle.

“This is yet another example of how Chris Carr prioritizes special interests over the people of Georgia, and the culture of corruption that characterizes the current office of the attorney general,” said Caroline Korba, a spokesperson for Jordan. “Our attorney general should not be bought and sold.”

A Centene subsidiary gave a total of $6,600 to Stacey Abrams, the Democrat running against Kemp, in three separate donations since 2015, the last coming in October 2018, during Abrams’ previous campaign for governor.

Maya T. Prabhu is a state government reporter for The Atlanta Journal-Constitution.

[Update: This article was updated at 9:35 a.m. ET with comments from the campaign of Attorney General Chris Carr.]

Clipped from: https://khn.org/news/article/centene-georgia-settlement/

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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.

[MM Curator Summary]: If you thought the losing plans were going to take this sitting down, you got another thing coming.

California’s first-ever Medicaid managed contract procurements are a major shakeup in the state’s Medi-Cal system, which has over 12 million enrollees, or a third of California’s population. 

Millions of residents will switch plans as a result of the changes, and a lengthy road of appeals and legal battles could lay ahead. 

California selected the intended recipients of the Medicaid managed contract procurement process Aug. 25. Here’s what you need to know about who won and lost in the bidding battle, and what comes next in the appeals process. 

1. California’s first-ever Medicaid managed contract procurement process was designed to promote health equity

The California Department of Health Care Services first issued a request for proposals from managed care organizations on Feb. 9, saying the process would “redefine” how care is delivered to Medi-Cal beneficiaries. 

The new contracts require plans to address social determinants of health, including food insecurity and housing. The contracts also include value-based payments, tying payments to quality metrics. 

The plans are also required to allocate between 5 and 7.5 percent of their profits to community investment. 

In an Aug. 25 news release, California Department of Health Care Services Director Michelle Baas called the contract awards a “defining moment for Medi-Cal and its millions of members.” 

2. The contracts are part of the state’s wider value-based Medicaid reforms 

California is implementing several efforts to improve Medi-Cal, including CalAIM, an initiative to improve outcomes and reduce health disparities, address social determinants of health and keep people continuously enrolled in Medicaid. 

“We know that 80 percent of a person’s ability to be healthy is predicated on social conditions or social determinants of health, and 20 percent is just the nuts and bolts of medical services,” Kelly Bruno-Nelson, executive director of Medi-Cal and CalAIM at CalOptima, told Becker’s in June.

“CalAIM recognizes that nuance and says, we shouldn’t be separating these two buckets, we should be bringing these two buckets together,” Ms. Bruno-Nelson said. 

The reforms have raised some concerns among providers, who say these reforms aren’t reaching the patients who need them most and don’t go far enough to reimburse providers. 

So far, 97,200 patients out of 14.7 million Medi-Cal recipients are enrolled in the CalAIM program, Kaiser Health News reported Oct. 10. 

3. Molina Healthcare won big in the decisions, while Kaiser Permanente didn’t have to bid 

The state chose to award the contracts to three managed care providers: Molina Healthcare, Anthem Blue Cross Partnership Plan and Centene subsidiary Health Net. Molina won its largest ever Medicaid deal, scoring contracts in some of the state’s largest counties. It will add 1.4 million enrollees, the Los Angeles Business Journal reported, mostly at Health Net’s expense.  

These contracts cover 23 counties. The state also entered a controversial direct contract with Kaiser Permanente in 32 counties. The direct contract allowed the payer-provider to skip the bidding process. 

California Gov. Gavin Newsom approved the contract with Kaiser Permanente June 30. The contract was developed in secret with the governor’s office and allows Kaiser to pick its Medicaid enrollees. 

4. Up to 2 million people could switch plans

The state’s Department of Health Care Services estimates around 2.3 million Medi-Cal members will likely change managed care organizations.

The department said its priority is to ensure a smooth transition for members who will switch contracts. In an FAQ document, the department said members have continuity of care rights that will be “fully protected and enforced during the transition.”  

Additionally, the department says it does not expect any disruption of pharmacy benefits. 

In a Sept. 6 letter to the Department of Health Care Services, dozens of providers in San Diego county expressed concern about Community Health Group — the only locally-based Medi-Cal plan in the area — losing out on contracts in the county, urging the department to reinstate the plan.. 

“The lives of San Diego residents — especially its most vulnerable, marginalized, and high-need populations — are at stake,” the providers wrote. 

5. A legal battle is looming 

Payers that lost out on contracts — including Aetna, Blue Shield of California Promise Health Plan, Community Health Group Partnership and Health Net Community Solutions — are challenging the state’s decisions, according to documents from the Health Care Services department. 

Providers had until Oct. 7 to submit written responses and rebuttals to the appeal process. 

Payers slammed their rivals in appeal documents, Kaiser Health News reported Sept. 26. Health Net, which lost several contracts to Molina, said the payer’s application contained “false, inaccurate and misleading information” in its appeal. 

Blue Shield of California, which lost contracts in all 13 counties in which it bid, filed a lawsuit against the state Oct. 7, alleging it had violated public records laws by not turning over documents related to the contracts.

“We have waited in good faith and the Department of Health Care Services is refusing to provide the public information we are requesting or to provide a reasonable amount of time for the appeal process,” Kristen Cerf, president and CEO of Blue Shield of California Promise Health Plan, said in a news release.

A spokesperson for the Department of Health Care Services told Becker’s Oct. 7 that the department has no comment on pending or potential litigation. 

“DHCS remains committed to a robust procurement process to select awardees that demonstrate the capacity and capability to deliver on DHCS’ stated goals and priorities, including transparency, high-quality care, access, behavioral health services, children services, coordinated/integrated care, increased health equity, and accountability,” the spokesperson said. 

The Health Services Department intends for the contracts to take effect in January 2024. 

 

Clipped from: https://www.beckerspayer.com/payer/lawsuits-challenges-and-debates-where-californias-controversial-medicaid-contract-process-stands.html
 

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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.

[MM Curator Summary]: New MCOs, a new D-SNP, dental, rx and BH integration, and new EVV requirements- all going live in about 15 months.

HASTINGS, Neb. — The public health insurance program Medicaid is visiting communities across the state to share with healthcare providers and members their new changes. Medicaid is also listening to the biggest struggles the insurance users and healthcare providers are facing.

“One of the first things we want to do is try to understand what the root of the issue is,” said the Director of the Department of Health and Human Services (DHHS) Medicaid & Long-Term Care Division Kevin Bagley. ” What is causing access issues for our members? We heard a lot of that tonight.”

Bagley said that currently around 375,000 Nebraskans are insured with them.

Starting on Jan. 1, 2024, Medicaid will have new health plan contracts. The contracts will run until Dec. 31, 2028. Five companies put bids in to be Medicaid’s manage care plans, the three selected are: United Health Care, Nebraska Total Care and Molina Health Care.

“We hope we’ll see better communication,” Bagley said. “They [Insurance users] will have those plans which will have a better focus on the ‘whole person care,’ and not just physical and behavioral health.”

To select the three companies, Medicaid performed interviews and asked specific questions that stakeholders wanted to know the answers to during Medicaid’s listening tour in January.

For members who are also eligible for Medicare, starting on Jan.1, 2024, Medicaid will offer to them a Medicare Advantage Plan called Dual Eligible Special Needs Plans (D-SNPs).

“That allows the same plan to manage their Medicaid and Medicare benefits, so those members won’t have two places to work through. They’ll have one for both insurances,” Bagley said.

With the new contracts, dental services will be covered and integrated with physical, behavioral health and pharmacy services. Bagley said that in their first listening tour, stakeholders brought up multiple times the huge need for dental care.

“As part of that, we sat down with a lot of our dental stakeholders to try and understand what some of the barriers are,” Bagley said. “One of the things that we determined was to shift away from having a single manage care plan for dental like we do today, to work with those plans that have a ‘whole person care’.”

“I’m optimistic about the new plan going forward,” said Pediatric Dentist Dr. Jessica Meeske. “We know there is a shortage of dentists right now that are accepting Medicaid, and there are a lot of Nebraskans that have this insurance plan and they would like a place to go and have their dental needs met.”

Bagley said that as part of the new contracts, starting a year after Jan. 1, 2024, the process of credentialing healthcare providers will be simplified.

“It shouldn’t be a six-month time frame to get people credentialed,” Bagley said. “So our providers today might have to do it [credentialing] three times in three different ways, starting on January of 2025 they’ll do it one time, one way.”

“We don’t want to spend a lot of time filling up paperwork, we need to spend our time taking care of our patients,” Dr. Meeske said.
 

Changes will also be made to electronic visits verification.

“For folks that are involved in either personal care services or home health services, they’ll be required to have some changes on that front,” Bagley said.

He added that care and case management will be more robust.

“We recognize that’s the only way we can ensure that we are actually helping people live better lives,” Bagley said. “By actually talking to them, working with them, understanding what their personal needs are, and how we address those needs.”

NE Medicaid will start coverage for continuous glucose monitoring (CGM) devises for eligible members with diabetes on Jan. 1, 2023. The devices measure intestinal glucose levels for those with type one and type two diabetes. Bagley said the eligibility is currently being developed.

The Medicaid insurance plans vary depending on the person. According to Bagley, NE Medicaid spends $3 billion a year on those 375,000 individuals insured with them.

Bagley said Medicaid is planning to soon release a strategic plan for key initiatives. They also plan to start a new phase of community outreach to continue the conversations with the public through meetings. He added that they are thinking of doing their statewide tour every six months, to keep hearing from stakeholders, providers and Medicaid members.

Bagley already visited Lincoln, Omaha, Scottsbluff, North Platte and Hastings. Before October ends, they hope to visit South Sioux City, and Fremont. Bagley is also holding virtual meetings with stakeholders, providers, and members.

For more information about the upcoming Medicaid updates visit this website.

Clipped from: https://nebraska.tv/news/local/starting-in-2024-nebraska-medicaid-will-have-multiple-changes

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[MM Curator Summary]: The dumpster fire that is D.C. Medicaid has moved to the one-throat-to-choke/find-a-vendor-to-scapegoat stage. But to be honest, that 30% profit is looking pretty bad.

Meet Amerigroup. It’s a Fortune 500 company that manages state-run health plans for low-income people. Its subsidiaries also have a history of fines and allegations over the handling of patients in multiple states. Amerigroup is now set to get back part of the District’s $1.5 billion Medicaid contract.

Welcome to D.C.’s Medicaid saga.

Why it matters: There has been a painfully long battle royale over management of the city’s Medicaid services. Since 2017, four companies, including Amerigroup, have engaged in finger-pointing and contract appeals as they compete for the three open contract slots.

• One in three D.C. residents, including the poorest and most vulnerable patients, receive health insurance through Medicaid. They are caught in the middle of being shuffled between different health care providers over recent years.
  

Driving the news: The District selects three contractors to run its Medicaid program through a competitive bidding process, and the D.C. Council is now set to act on the contract for Amerigroup and the other awardees, MedStar and AmeriHealth.

• Amerigroup is at the center of this conflict.
  
• Since losing out on the contract, CareFirst, which is one of the current Medicaid contractors, is publicly lobbying to push the D.C. Council to intervene.
  

State of play: Council member Vincent Gray, who chairs the Health Committee, and other critics are pointing out that Amerigroup and its subsidiaries have a history of paying out fines and facing allegations of bad patient care across the nation.

• Gray wrote to colleagues last Monday that he was considering disapproving the new contractors, known as managed care organizations (MCO).
  
• “We are poised to bring back an MCO with a checkered history in the District and a well-known reputation for denying care to vulnerable Medicaid members,” Gray wrote in the letter, acquired by Axios.
  

Zoom in: An Amerigroup subsidiary previously served the District over two separate periods, most recently from 2017 to 2020. In their final year, the deputy mayor for health, Wayne Turnage, told a D.C. Council committee that patients left Amerigroup in droves to seek coverage from other providers.

• At that July 2020 hearing, Turnage was flabbergasted by Amerigroup’s 30% profit margin, compared to 4% for its competitor.
  
• “I have never seen a public funded health plan have a margin of 30%,” Turnage testified. “In Virginia, when we had plans make more than 6%, they came back and voluntarily cut us checks.”
  

Turnage declined to comment to Axios last Friday on the contracts, citing the ongoing process. He referred to his public comments from 2020 about Amerigroup.

The other side: In response, Amerigroup says that patients left its services for other companies because MedStar, the D.C. region health giant, refused to offer its services for Amerigroup patients. (D.C. later began requiring that all Medicaid providers offer their services to each other.)

Amerigroup D.C. president Adrian Jordan wrote his own letter to lawmakers. He dismissed Gray’s criticisms as “the product of a broader campaign of disinformation that is being waged by an unsuccessful offeror,” referring to CareFirst’s lobbying efforts. He echoed similar sentiments in a statement to Axios, adding “Amerigroup D.C. is committed to providing no or low-cost access to healthcare for D.C. residents enrolled in Medicaid.”

One black eye for Amerigroup is a $225 million fine in 2008 to settle accusations of federal and state Medicaid fraud claims. A central allegation was that the company systematically denied pregnancy care in Illinois.

• More recently, in Texas, Amerigroup told state lawmakers in 2018 that it paid $20 million in fines after allegations of denying medical care to disabled patients. In Iowa, a 2021 audit faulted Amerigroup for denying some patients care.
  

What’s next: Several council members on Tuesday told me they were still waiting for the contracts to be formally transmitted by Mayor Muriel Bowser, who had promised they would be out last week.

• The waiting game is fueling last-minute jitters in a bureaucratic process that feels like a comedy of errors, with serious consequences.
  

Town Talker is a weekly column on local politics and power. Send me tips:
cuneyt@axios.com

Clipped from: https://www.axios.com/local/washington-dc/2022/10/12/amerigroup-dc-medicaid-saga

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[MM Curator Summary]: Congrats to BCBS, HealthPartners, Hennepin Health, Itasca Medical Care, Medica, PrimeWest Health, South Country Health Alliance, UCare and United Healthcare Community Plan of Minnesota. This round is the first time for-profits have been able to bid, so this was a greenfield opp for UHC (even though it’s the home turf for the MCO giant).

From <https://www.echopress.com/news/new-managed-care-contracts-will-serve-600-000>

UnitedHealthcare

UnitedHealthcare has its headquarters in Minnetonka.

Minnesota has awarded contracts worth about $5 billion next year to health plans that will pay for and manage the medical needs of about 600,000 people.

The contract awards, which were announced this week by the state Department of Human Services, cover the primary health insurance programs for lower-income state residents outside the metro area.

Minnetonka-based UnitedHealthcare, which last year became the first for-profit HMO to win a contract in the public programs, was among the winners, picking up business in two counties.

Under the contracts, Eagan-based Blue Cross and Blue Shield of Minnesota and Minnetonka-based Medica will see even larger expansions. Bloomington-based HealthPartners, meanwhile, will no longer be an option in 22 counties across central and northern Minnesota.

For decades, Minnesota has hired HMOs and county-based purchasing organizations to manage care for enrollees in the public programs, which are jointly funded by the state and federal governments. While health plans can make money on the contracts, the funds mainly pay for health care services.

Before 2017, state law blocked for-profit HMOs from bidding on the contracts.

The latest procurement covered 80 counties in greater Minnesota for the families and children portion of MinnesotaCare as well as prepaid Medical Assistance (PMAP), which is Minnesota’s largest program for Medicaid beneficiaries. The insurance programs provide coverage for lower-income Minnesotans.

“These contracts are expanded to improve timely, equitable access to care,” Human Services Commissioner Jodi Harpstead said in a news release.

The state also awarded contracts to manage care across all counties for older adults and adults with disabilities who qualify for three smaller public programs.

Contracts are awarded on a county-by-county basis, which means residents choose from different sets of health plan options depending on what county they live in. With the new contracts, nearly 31,000 people in public programs will need to pick a new health plan or have one assigned to them.

Other contract winners include: Hennepin Health, Itasca Medical Care, PrimeWest Health, South Country Health Alliance and UCare. All health plans that currently have managed care contracts in the public programs will return for 2023 in at least one county.

HealthPartners remains an option in 12 counties, but decided to pull back its service area due to “the uncertainties the pandemic and federal public health emergency have created for the market,” the insurer said in a statement to the Star Tribune.

The Department of Human Services in conjunction with county officials scored bids, with priority placed on how the health plans will address “equity, eliminating disparities in health outcomes and responding to the needs of rural Minnesotans,” DHS said in a news release.

“For older Minnesotans and adults with disabilities, DHS prioritized stability and continuity of care by ensuring that these enrollees could keep their current health plans,” the department said.

Last year, UnitedHealthcare was among the winning bidders on contracts to manage care for about 700,000 people in the seven-county Twin Cities metro.

Altogether, managed care contracts in the state public programs account for about $8.7 billion in annual spending, with coverage provided for about 1.3 million residents.

Clipped from: https://www.startribune.com/minnesota-awarding-contracts-worth-5-billion-to-medicaid-health-plans/600213731/

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[MM Curator Summary]: The new MCO contract approach will bring lots of changes, including changing the name from Centennial Care to Turquoise Care. Current contracts end late 2023.

State to select managed care partners to deliver health care services to half of New Mexicans 
 

SANTA FE – The New Mexico Human Services Department (HSD) announced today they are soliciting competitive proposals from health insurance companies, known as Medicaid Managed Care Organizations (MCOs), to deliver services to the state’s 969,093 Medicaid members. Managed care organizations work in partnership with the state’s Medicaid program and clinicians to provide access to physical and behavioral health, and long-term care services.  

The announcement comes as contracts with HSD’s current MCOs, Blue Cross Blue Shield of New Mexico, Presbyterian Health Plan, and Western Sky Community Care are set to expire at the end of 2023. Beginning in 2024, the state’s Medicaid program, known as Centennial Care 2.0, will become Turquoise Care and will begin operation with the newly awarded MCOs.  

The department released the Request for Proposals (RFP) for the Turquoise Care Medicaid contracts on Friday, Sept. 30, 2022.  

“With over eighty percent of New Mexico’s Medicaid population receiving care through the managed care delivery system it is essential to select managed care partners that provide access to quality, cost-effective health care — and that can help transform the health care system to deliver measurably improved outcomes to New Mexicans.” said David R. Scrase, M.D., cabinet secretary for the New Mexico Human Services Department. 

Since 2019, the Medicaid program has worked to improve program benefits, provider payments, and access to care. Under Gov. Michelle Lujan Grisham’s leadership, HSD has invested over $800 million in increased provider rates, extended postpartum coverage to 12 months, worked to eliminate the developmentally disabled waitlist for services, removed asset tests that create barriers for older adults, implemented home visiting programs for pregnant women, processed 6,534 Medicaid Provider enrollment applications, and added reimbursement of Adult Accredited Residential Treatment Center (AARTC) services.   

“This request for proposals increases accountability for our managed care partners. The new contract reflects our intent to require our managed care organizations and their subcontractors to work with providers and community partners to improve access, advance health equity, reduce disparities, and deliver comprehensive quality care that results in positive outcomes for New Mexicans.” said Nicole Comeaux, JD, MPH, Director of the New Mexico Medicaid Program. 

This RFP sets forth HSD’s process for soliciting, evaluating, and scoring proposals for and selecting contractors to provide the scope of work requirements identified in the RFP and those in the Model Contract. Going forward, notable improvements in this new contract include: 

• Creating a specialized plan for children in state custody under the Children, Youth and Families Department 
  
• Implementing a uniform prescription drug list and supplemental rebate program  
  
• Providing a minimum reimbursement rate for contract providers at or above the state plan approved fee schedule  
  
• Developing more stringent provider network requirements, including appointment availability standards, provider training, and greater accuracy of provider directory information  
  
• Expanding MCO reporting and monetary penalties for non-compliance  
  
• Requiring that 90 percent of capitation go to payment for delivery of services and efforts to improve quality of care  
  
• Creating direction to use a single centralized vendor to process applications for credentialing perform primary source verifications 
  
• Taking a population health approach to improve health outcomes and member satisfaction  
  
• Identifying and remediating cultural and linguistic health care disparities  
  
• Focusing on identifying and addressing social determinants of health  
  
• Putting an emphasis on care coordination delivered by community-based individuals and entities  
  
• Enhancing MCO staffing requirements, including qualifications, staffing levels, and training  
  

The Turquoise Care Medicaid Managed Care Organizations Request for Proposals and Procurement Library is available on the HSD website at https://www.hsd.state.nm.us/2022-turquoise-care-mco-rfp-procurement-library/ 

###  

The department wants to ensure our clients of uninterrupted access to the benefits available to them. The easiest way to do this is to make sure contact information is up-to-date on the YESNM website: www.yes.state.nm.us. Users can simply and easily update their address using the chat functionality there. Step-by-step directions on how to update your address are available here. Individuals seeking to apply for or check their SNAP benefits may apply online through www.yes.state.nm.us or by phone at 1-800-283-4465 

 We talk, interpret, and smile in all languages. We provide written information to our customers in both English and Spanish, and interpretation services are available in 58 languages through our provider, CTS Language Link. For our hearing, and speech impaired customers, we utilize Relay New Mexico, a free 24-hour service that ensures equal communication access via the telephone to individuals who are deaf, hard of hearing, deaf-blind or speech disabled. 

The Human Services Department provides services and benefits to 1,070,231 New Mexicans through several programs including: the Medicaid Program, Temporary Assistance for Needy Families (TANF) Program, Supplemental Nutrition Assistance Program (SNAP), Child Support Program, and several Behavioral Health Services. 

Clipped from: https://www.hsd.state.nm.us/2022/10/03/new-mexico-medicaid-releases-request-for-proposals-for-new-turquoise-care-contracts/

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[MM Curator Summary]: Winners: Molina, Centene, UHC. Losers: Community care of NE (HealthyBlue) and Medica Community Health Plan.

Dive Brief:

• Nebraska has selected three insurers to provide healthcare coverage to the roughly 360,000 beneficiaries in the state’s Medicaid managed care program, called Heritage Health. The three health plans are Molina Healthcare of Nebraska, Centene subsidiary Nebraska Total Care, and UnitedHealthcare of the Midlands, the state announced.
  
• The new contracts are for five years, with the option to renew for two additional years, Nebraska’s Department of Health and Human Services said. The state’s Medicaid managed care program offers access to physical health, behavioral health, pharmacy, hospital, dental and other services.
  
• The state received five bids for the contracts from health plans in July, following a request for proposals in April. Not selected were Community Care Plan of Nebraska, known as Healthy Blue, and Medica Community Health Plan.
  

Dive Insight:

Enrollment in Medicaid swelled during the COVID-19 pandemic, supported by state program expansions and federal relief legislation that suspended enrollee coverage terminations during the public health emergency. Managed care organizations cover more than two-thirds of all Medicaid beneficiaries.

Nebraska voters approved Medicaid expansion in a 2018 ballot initiative, and the state implemented the program on Oct. 1, 2020. The CMS agreed to the state’s two-tiered plan that offers “basic” coverage for qualified recipients and a “prime” package with enhanced benefits for enrollees who complete a work requirement. Prime benefits include vision, dental and over-the-counter drug coverage.

Nebraska said it incorporated input from stakeholder listening sessions held earlier this year into the selection process, and considered factors such as whether the plans use case management, standardize provider credentialing to ease administrative burdens, and improve access to providers across the state.

Of the three payers chosen for the state’s new Medicaid managed care contracts, Nebraska Total Care and UnitedHealthcare already have contracts with the state, and Molina Healthcare is new. The new contracts begin on Jan. 1, 2024.

Millions of Americans stand to lose Medicaid coverage once eligibility redeterminations resume after the public health emergency ends. The CMS is encouraging managed care organizations to help states prevent people from losing their coverage and has issued guidance for working through the renewal process, in hopes that insurers will be able to shift people to subsidized plans through the Affordable Care Act exchanges.

Clipped from: https://www.healthcaredive.com/news/Nebraska-Medicaid-managed-care/632712/

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[MM Curator Summary]: The TX price extracted for Centene PBM ruh-rohs has been set at $165M

Centene made no admission of liability and maintained its business practices are lawful. 

Photo: Jose Luis Pelaez/Getty Images

Centene has settled with Texas for $165 million to resolve claims of Medicaid fraud by the Texas attorney general.

Centene made no admission of liability, and maintained that its business practices were lawful. 

Under the terms of the settlement, Centene will pay more than $165.6 million to resolve Attorney General Ken Paxton’s investigation into whether certain of Centene’s business practices violated the Texas Medicaid Fraud Prevention Act. The AG alleged that Centene overcharged Medicaid in the prescription drug program.

Paxton announced the finalization of the settlement with Centene and its subsidiaries that provide services to the Texas Medicaid program. Centene, based in St. Louis, Missouri, serves as an intermediary for government-sponsored and privately insured healthcare programs.

WHY THIS MATTERS

This is the latest in a string of settlements for Centene.

In August, the company agreed to pay more than $33 million to resolve claims that it overcharged Apple Health in Washington, the state’s Medicaid program, according to Reuters.

In June, Centene agreed to pay $13.7 million to New Mexico to settle an investigation of inflationary pricing and reporting of pharmacy benefits in the state’s Medicaid program.

THE LARGER TREND

Centene has settled similar claims with 10 other states, including New Hampshire, Ohio and Mississippi, for a total of more than $260 million, according to the Reuters report.

ON THE RECORD 

“Protecting taxpayer funds and the financial integrity of the Texas Medicaid Program is a top priority for my office,” said Attorney General Paxton. “The results we achieved in this case send a clear message to providers that Texas expects transparency from its Medicaid partners as required by Texas law.”   

Clipped from: https://www.healthcarefinancenews.com/news/centene-settles-medicaid-fraud-claims-texas-165-million