Tag: Managed Care

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3 tips for Medicaid Health Plans on Inviting Solution Vendors to Your Next RFP

Many of our clients are health plan professionals working in the health and human services space (including Medicaid plans and Medicare Advantage plans). The article below is based on our experience working with health plan staff who have succeeded in improving vendor management and procurement activities.

Reading Time: 3 minutes

Intended Readers: Medicaid Health Plan vendor management teams and executives

Tip 1: Invite more than you need

Its always good to have options. You should try to have at least two very strong candidates make it past the initial evaluation period. And in order to do that, you probably need at least 4 bidders to submit a proposal. And in order to have that many proposals, you probably need to invite 5 or 6 bid. Invite specific vendors you have initially vetted (versus a broad open call) when possible. This will mean more work on the front end of your procurement effort, but will lead to stronger proposals and more interested vendors.

Tip 2: Rely on references from your health plan peers

Your number one asset in this process is other health plans who have done business with the bidders. In the Medicaid space, most plan staff are less concerned about competition (except during MCO contract award cycles) and are more concerned about improving the delivery of services in the Medicaid program. Don’t be shy about asking your contacts in other plans for their opinion on vendors.

  Tip 3: Hold a 1 on 1 pre-invitation discussion with each vendor

Remember your goal is high quality proposals. In order to provide those, vendors need to understand as much as they can about your goals for the project. In addition to the normal group Q&A call offered to vendors, consider offering 1 on 1 discussions to make sure vendors are aligned with your vision for the project. The number of vendors interested will dictate how much time you invest in this step. Its also recommended to conduct this part of the process with another trusted external consultant if possible. This step will minimize confusion over goals and scope before proposals are submitted, without adding even more workload to your operational staff.

How to get started implementing these tips

We assist clients with each of these strategies, and are happy to have a conversation anytime. If our services and expertise are a fit for your needs as you develop or execute your strategy, engaging with us is a simple process. If we are not the right fit, we are happy to make a referral to another firm who may be.

Knowing what to do is only the first step. Knowing how to implement these tips with your current team amid many other priorities is more complex.  Here are a few other pointers on improving your options for your next vendor procurement:

  1. Create a short list of invitees and gauge interest with them before executing your full procurement effort– List the three vendors that immediately come to mind, and have a half hour exploratory discussion with a small group from their team. This can help you rapidly identify any key changes or clarification needed to your requested project scope without the extensive resource cost of an RFI.  
  2. Assign an existing team member to own the procurement effort from a project management perspective OR hire an external consultant to focus on the effort- If your project is not too large, or not too complex, you can assign a team member to drive key work items that are often overlooked like scheduling and action item management.  

MostlyMedicaid: We can help.

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Centene’s Nevada Health Plan Awarded Medicaid Managed Care Contract

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The renewal keeps 77,000 Medicaid members on the Centene rolls.

 
 

 
 

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.

 
 

ST. LOUIS, Aug. 18, 2021 /PRNewswire/ — Centene Corporation (NYSE: CNC) announced today that its Nevada subsidiary, SilverSummit Healthplan, Inc., has been awarded a contract from the Nevada Department of Health and Human Services – Health Care Financing and Policy to continue providing managed care services for its Medicaid Managed Care program in both Clark and Washoe Counties.

“Centene is pleased to continue our important work with the state of Nevada to expand on innovation and value-based care for Nevada residents,” said Brent Layton, President of US Markets, Products and International, and Executive Vice President, for Centene. “Centene’s local approach to care leverages our strong provider partnerships to ensure we are delivering better health outcomes for our members at a lower cost to the state.”

SilverSummit Healthplan has served Nevada Medicaid members since 2017 and currently serves more than 77,000 members. The Nevada Medicaid program provides physical and behavioral healthcare as well as pharmacy benefits to over 760,000 TANF, SCHIP and Medicaid Expansion beneficiaries. Nevada’s Medicaid managed care program will advance the State’s goals through increased focus on Care Management, Member engagement, access and continued progress towards integration of services and efficiency.

“We are honored to continue serving Nevada Medicaid beneficiaries with quality healthcare services and programs,” said Eric Schmacker, Plan President and CEO for SilverSummit Healthplan. “We look forward to our continued partnership with the state of Nevada, local providers and community partners to provide services that address health equity and social determinants of health and remove barriers to ensure our members receive the high-quality care they deserve.”

Pending regulatory approval, SilverSummit’s contract will commence on January 1, 2022.Clipped from: https://www.prnewswire.com/news-releases/centenes-nevada-health-plan-awarded-medicaid-managed-care-contract-301357405.html

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Molina Healthcare Awarded Nevada Medicaid Contract

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The award will allow Molina to add 630,000 members to its Medicaid footprint.

 
 

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.

 
 

 
 

LAS VEGAS, August 17, 2021–(BUSINESS WIRE)–Molina Healthcare, Inc. (NYSE: MOH) (“Molina”) today announced its Nevada health plan subsidiary was awarded a Medicaid managed care contract from the Nevada Department of Health and Human Services – Division of Health Care Financing and Policy (“DHCFP”).

The new four-year Medicaid contract, with a potential two-year extension, will commence on January 1, 2022. Molina’s Nevada health plan is one of four Managed Care Organizations offering health care coverage to approximately 630,000 Medicaid beneficiaries in Clark County (Las Vegas area) and Washoe County (Reno area) through the TANF, CHIP, and Medicaid Expansion programs. Molina will also participate in the state-based Affordable Care Act Exchange.

“We are honored that Nevada has awarded Molina the opportunity to serve the state’s most vulnerable citizens,” said Joe Zubretsky, president and chief executive officer of Molina Healthcare. “Molina looks forward to advancing the state’s goals of improving care management, member access, and overall health equity for its Medicaid members.”

Clipped from: https://finance.yahoo.com/news/molina-healthcare-awarded-nevada-medicaid-110000061.html

 
 

 
 

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Maryland Physicians Care Enlists Barbershops and Salons to Help Promote Medicaid Benefits

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MCOs are paying Baltimore barbershops to put up posters advertising Medicaid benefits.

 
 

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.

 
 

 
 

LINTHICUM, Md., Aug. 16, 2021 /PRNewswire/ — Maryland Physicians Care (MPC) – a statewide Medicaid managed care organization owned by Ascension Saint Agnes, Holy Cross Health, Meritus Health, and UPMC Western Maryland – is engaging Maryland barbershop and salon owners to help create awareness of Medicaid benefits.

MPC produced and distributed posters asking, “Do You Need Help Getting Free Medical Coverage?” The posters include a QR code that links to the MPC website, mpcMedicaid.com. There, people can check their Medicaid eligibility using a link to Maryland’s HealthChoice Program: MarylandHealthConnection.gov.

The posters, printed in English and Spanish, are currently placed in 75 barbershops and beauty salons throughout Prince George’s and Baltimore counties and Baltimore City.

Shop owners are compensated for displaying the posters and have expressed appreciation for the extra income as they work to recover from the financial hardships of COVID-19.

MPC’s outreach efforts in Maryland barbershops and salons were implemented June 1, 2021, the same week President Biden announced his “Shots at the Shop” initiative. Aiming for at least 70% of Americans to receive their first vaccination by July, Biden called on Black-owned barbershops to support COVID-19 vaccination practices.

Maryland Physicians Care provides free, quality health care services to Maryland’s HealthChoice enrollees by extending the full benefits of Medicaid through a comprehensive network of medical providers. Founded in 1996, MPC believes in helping its members make good decisions about their health through free, quality health care services.

Those interested in enrolling with MPC must first qualify for Medicaid at MarylandHealthConnection.gov.

Learn more about MPC by visiting mpcMedicaid.com

MEDIA CONTACT:

Marissa Bailey, BlaineTurner Advertising 

marissa@blaineturner.com

 
 

Clipped from: https://www.kpvi.com/news/national_news/maryland-physicians-care-enlists-barbershops-and-salons-to-help-promote-medicaid-benefits/article_c1d44b64-22c3-5ed7-b201-e88852c728a2.html

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Centene awarded Ohio Medicaid contract following $88M settlement

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The Ohio managed care contract valued at an estimated $1.5B was on hold while the AG negotiated the $88M settlement over PBM issues; once Centene agreed to pay the $88M, the managed care contract was awarded.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Dive Brief:

  • On Tuesday, Centene — the largest Medicaid managed care organization in the country — announced its Ohio subsidiary, Buckeye Health Plan, was awarded a new Medicaid contract by the state’s health department, to begin early 2022.
  • Ohio Medicaid originally held off deciding on Buckeye’s proposal after the state’s attorney general sued Centene, alleging it breached its Medicaid contracts and used its pharmacy benefit managers to jack up prices for care, resulting in millions of dollars of overpayments by Ohio’s health department.
  • Also Tuesday, Molina reported its subsidiary had nabbed a new Medicaid contract win in Nevada, its first in the state. The new four-year contract, with a potential two-year extension, will begin Jan. 1.

Dive Insight:

Insurers have been ramping up their presence in government programs as the economic volatility created by COVID-19 has caused some millions to lose job-based insurance, swelling Medicaid rolls and membership in the exchanges set up by the Affordable Care Act.

And more states are contracting with payers to manage their Medicaid programs. Currently, seven out of every 10 Medicaid enrollees are in plans run by an insurer, according to the Kaiser Family Foundation.

That growth has especially benefited payers with large government books of business, like Centene and Molina.

Centene on Friday was added to six managed care organizations already awarded shares of the $20 billion contract in Ohio, despite its history in the state.

In June, Centene agreed to pay the state $88 million to settle the dispute, and set aside more than $1.1 billion to to resolve similar claims in other states. Centene didn’t admit fault in any of the deals.

As a result of the settlement, Ohio Attorney General Dave Yost dropped his lawsuit against the St. Louis-based payer. Yost’s suit, originally filed in March, comes as legislators and regulators increasingly target pharmacy benefit managers to drive down pharmaceutical costs, especially as said PBMs merge with major health plans, complicating market incentives.

Centene said at the time of the settlement that it had restructured its PBM operations and aligned its Medicaid, Medicare and exchange products on more transparent pharmacy networks to eliminate “spread pricing,” a practice where PBMs eke out more money from taxpayer-funded health plans by charging the health plans one price for drugs but reimbursing the pharmacies differently.

Under the new contract, Buckeye will launch new technologies and local programs in partnership with providers and community groups to meet members health needs, Centene said. The subsidiary has been active in Ohio since 2004, and in 2020 was the state’s fastest-growing Medicaid plan according to market share, with more than 420,000 members, according to a release.

As for Molina, the Long Beach, California-based payer is now one of four managed care organizations offering coverage to roughly 630,000 Medicaid beneficiaries in Clark County and Washoe County. The addition of Nevada brings Molina’s Medicaid footprint to 19 states.

Nevada’s Medicaid and Children’s Health Insurance programs released a request for proposals for 2022 contract bids for the service area covering two urban counties of the state, Clark and Washoe, in March.

Contracts are worth about over $2 billion annually, according to consultancy Health Management Associates.

As part of the contacts, Molina will also participate in Nevada’s state-based ACA exchange. The state stipulates the payer must provide at least one silver and one gold qualified health plan by 2024 to ensure continuity of care for individuals and families that might experience a change in Medicaid or CHIP eligibility status.

Previously, Nevada only had three MCOs: Anthem, UnitedHealthcare’s Health Plan of Nevada and Centene’s SilverSummit Health Plan, according to the state health department.

 
 

Clipped from: https://www.healthcaredive.com/news/centene-awarded-ohio-medicaid-contract-following-88m-settlement/605104/

 
 

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What are plans doing to integrate behavioral and physical health?

Many of our clients are part of efforts to further integration of behavioral health and physical health care in a variety of different structures across the country. Whether you are a plan that is part of a state transformation effort, examining the potential for integration as a driver for quality improvement or working with providers to develop value-based payment for integrated care, there is a tremendous amount activity in this area.

Reading Time: 7 minutes

Intended Readers: Plan Executive Level Staff and integration solution providers

Key Topics: Environments, Categories of integration efforts, Operational components

Environments

The landscape of integrated care in states is varied and dynamic. There are many states that have already moved to integrate responsibility for behavioral health and physical health at the plan or community care organization level. Some others are taking steps in this direction and still others have not started to move on this particular area yet, but could begin the process at any time.

The most direct route for states to incentivize integration in their Medicaid programs is to procure the services together from a single integrated health plan. However, it is not the only way states are trying to advance integrated efforts. Some are acknowledging that there are populations within the integration effort that may benefit from special focus in a carve-out or similar structure. There are also states that have not taken concrete steps to structurally incentivize integrated care but are using existing contracts to push inclusion of all member issues in developing care plans and treatment.

Plans have to operate within the environment of the state(s) where they work. Is this state integrating behavioral health and physical health in its procurement of services? Is this state still managing the behavioral health and physical health in different plans or structures, but expecting plans to work together to advance larger goals? Is there no expectation for integration at the plan level, but, instead, opportunity for plans to work to advance integration at the provider level?

Category 1 –   State Innovation Waivers (1915i)

States can bring integration efforts into the state through the use of Medicaid innovation waivers that allow them to leverage more creative payment structures to support the integration of behavioral health and physical health. Many states have done work in this area that has advanced the knowledge-base for integrated health services and identified potential avenues for further integration.

California is the most familiar example of a state pushing integration efforts through state transformation and Medicaid waivers. The CalAIM initiative is attempting to drive more integrated care, along with a combination of other initiatives. Currently, the state has a county-managed system with four different types of models. Those models do not easily facilitate integrated care, particularly when it comes to people with serious mental illness or substance use disorders.

Category 2 – State Procurement Driven Integration (1915c)

Several states have advanced integration through the procurement of health plans that are responsible for both the delivery of physical health and behavioral health services. These efforts give states direct levers to drive change and give plans flexibility in how they manage the various components of service delivery to ensure that costs remain manageable and outcomes are improved for their members.

Ohio and North Carolina have taken this procurement-driven approach in recent years, developing different delivery models, but both attempting to improve outcomes for members with behavioral health and physical health challenges and breaking down of silos between the service delivery systems. In Ohio, all behavioral helath services are now part of the responsibilities for the same plans that were previously managing physical health services. In their most recent procurement, Ohio also added a separate program to manage multi-needs children.

The State of North Carolina has gone through an extensive evolution of the management of behavioral health services – from a county-driven system, that is still in place in many states, to a regional “local managing entity” structure that brought together counties and leveraged the economies of scale, to those LME-MCOs merging and consolidating over the years, to a new model that will bring most behavioral health services under the same managed care plans who manage physical health, but individuals with more complicated behavioral health challenges being managed by “tailored” plans.

Plans that are operating under models where the state is attempting to integrate service management into its procurement of plan services have a clearer picture of what is expected and ability to deliver because of the dollars being included in the PMPM. These plans have to understand that the behavioral health provider networks are not on the same level as physical health provider networks in terms of sophistication of clinical service planning, electronic health records, documentation and claims processing. These integrated plans have the opportunity to help professionalize the behavioral health provider networks, but there is investment needed to support that work.

Category 3 – Plan Driven Integration Efforts

Plans have incentives beyond state priorities and contracts to drive integration efforts. Barriers to access, network management, utilization management and quality can also drive a need for better integrated care. These plan driven efforts can be identified through quality improvement efforts, contract compliance efforts or work in data analytics that identifies populations who are experiencing challenges that could be prevented with a more integrated service delivery system.

Category  4 – Facilitating and Supporting Provider Level Integration Efforts

At the level closest to members, plans are piloting a variety of initiatives to better coordinate and integrate care for behavioral health and physical health with hospitals, health systems, Federally Qualified Health Centers and Certified Community Behavioral Health providers. These pilot projects demonstrate a return on investment and show the value of integration in a concrete, tangible manner.

 Operational Components

All of the operational areas within a plan can and should be involved in integration efforts, from the call center, to the care coordination team, utilization management, quality improvement, provider network management, data and information technology. All areas of plan operations have something to contribute to integration efforts.

How A Plan Can Enhance Its Efforts Toward Integration of Behavioral Health and Physical Health Services

Besides your own research into this topic, there are a few key tactics that can help you overcome the most common challenges related to integration of physical and behavioral health services.  If our services and expertise are a fit for your needs as you develop or execute your strategy, engaging with us is a simple process. If we are not the right fit, we are happy to make a referral to another firm who may be:

  1. Better understand the state environment for your plan – What waivers has the state requested? What waivers have been approved? What is the procurement cycle? What are the governor and legislature discussing when it comes to Medicaid? Are there other drivers for integration?  
  2. Surface concerns your team has around integration and barriers that have been experienced in trying to advance integration efforts –   An integrated care project will impact current workflows and business organization approaches. An initial listening-session series can save you a lot of time and mistakes.
  3. Identify projects that could advance integration in your health plan that also solve other challenges within the plan – pilots with providers, data analytics efforts and analysis of member journeys and experience – When you get into a full-scale integration project, small-wins will be important to establish momentum. And alignment with multiple objectives will be key to sustain success.  

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3 tips for Medicaid Health Plans on inviting solution vendors to your next RFP

3-minute read

Many of our clients are health plan professionals working in the health and human services space (including Medicaid plans and Medicare Advantage plans). The article below is based on our experience working with health plan staff who have succeeded in improving vendor management and procurement activities.

Tip 1: Invite more than you need

Its always good to have options. You should try to have at least two very strong candidates make it past the initial evaluation period. And in order to do that, you probably need at least 4 bidders to submit a proposal. And in order to have that many proposals, you probably need to invite 5 or 6 bid. But do invite specific vendors you have initially vetted (versus a broad open call) when possible. This will mean more work on the front end of your procurement effort, but will lead to stronger proposals and more interested vendors.

Tip 2: Rely on references from your health plan peers

Your number one asset in this process are other health plans who have done business with the bidders. In the Medicaid space, most plan staff are less concerned about competition (except during MCO contract award cycles) and are more concerned about improving the delivery of services in the Medicaid program. Don’t be shy about asking your contacts in other plans their opinion on vendors. You may need to do so informally to reduce any concerns over sharing confidential information.

Tip 3: Hold a 1 on 1 pre-invitation discussion with each vendor

Remember your goal is high quality proposals. In order to provide those, vendors need to understand as much as they can about your goals for the project. In addition to the normal group Q&A call offered to vendors, consider offering 1 on 1 discussions to make sure vendors are aligned with your vision for the project. The number of vendors interested will dictate how much time you can invest in this step. Its also recommended to conduct this part of the process with another trusted external consultant if possible. This step will minimize confusion over goals and scope before proposals are submitted.

2 More Tips

Knowing what to do is only the first step. Knowing how to implement these tips with your current team and many other priorities is more complex.  Here are a few other pointers on improving your options for your next vendor procurement:

  1. Create a short list of invitees and gauge interest with them before executing your full procurement effort– List the three vendors that immediately come to mind, and have a half hour exploratory discussion with a small group from their team. This can help you rapidly identify any key changes or clarification needed to your requested project scope without the extensive resource cost of an RFI. We also help clients scan the competitive field for vendor shortlisting options, and are happy to discuss any time.
  2. Assign an existing team member to own the procurement effort from a project management perspective OR hire an external consultant to focus on the effort- If your project is not too large, or not too complex, you can assign a team member to drive key work items that are often overlooked like scheduling and action item management. We offer project management support in all our client engagements, and are happy to discuss any time.

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State files lawsuit, alleging company stole millions in Medicaid payments

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The OG AG continues their efforts to sue Centene, et al around spread pricing issues. Centene says the AG fails to understands complex and critical issues in the case.

 
 

 
 

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.

 
 

 
 

COLUMBUS, Ohio — The Ohio attorney general is accusing a trio of companies of stealing tens of millions of dollars in Medicaid payments.

Dave Yost teamed up with the Ohio Dept. of Medicaid to file the lawsuit in Franklin County Common Pleas Court back on March 11. At the time, it was filed under seal. Thursday night, it was unsealed.

The lawsuit names the Centene Corporation, Buckeye Health Plan and Envolve Pharmacy Solutions.

The complaint includes three counts and is 22 pages. Add in the exhibits, and the lawsuit exceeds 250 pages.

The state is alleging the companies broke Ohio’s Medicaid laws, breached their contract and conspired to steal money via their involvement in the Medicaid system. And the suit alleges those violations amount to tens of millions of dollars in unlawfully obtained Medicare payments.

Centene is accused of filing for reimbursement for payments that had already been made by third parties, failing to disclose the true cost of pharmacy services and inflating pharmacy dispensing fees.

The plaintiffs are asking for thousands of dollars in relief, including three times the payments wrongfully obtained. The suit also is seeking to terminate the companies’ contracts, which would amount to huge losses in revenue for them.

The defendants did make a filing in response, also asking for the case to be unsealed.

The filing said the complain reflects a “misunderstanding of the admittedly complex world of Medicaid accounting and billing” in which the companies operate. It also asserted that the plaintiffs ignored the contractual requirements to provide “timely written notification” of any alleged violation to make every reasonable effort to resolve the dispute. Instead, the defendants’ filing states the lawsuit was filed without consulting or notifying the company.

10TV reached out to attorneys for the state and the AG’s office. Yost was unavailable, so his office directed 10TV back to a previous press release issued on the date of the initial filing.

“Centene’s actions are deeply concerning and have a direct effect on the most vulnerable Ohioans,” Yost said in that release. “Centene has broken trust with the state of Ohio, and I intend to hold this company accountable for its deceptive practices.”

10TV also reached out to attorneys for the defendants and was directed back to Centene. 10TV made contact but has not yet heard back from the company.

 
 

Clipped from: https://www.10tv.com/article/news/local/ohio/state-files-lawsuit-alleging-company-stole-millions-in-medicaid-payments/530-893951af-0fdf-462e-8c3f-99463df43239

 
 

 
 

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CareSource wins procurement award to keep doing business with Ohio Medicaid

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OH has picked winners for the next round of MCO contracts: CareSource, UnitedHealthcare, Humana, Molina Healthcare, AmeriHealth Caritas, and Anthem Blue Cross and Blue Shield.

 
 

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.

 
 

Credit: DaytonDailyNews

Here are five facts about CareSource.

Credit: DaytonDailyNews

The state chose CareSource and five other insurance companies for a massive contract to manage benefits for the $20 billion Ohio Medicaid program.

These contracts announced Friday are the largest the state has ever issued, and the rules for how the money is spent is one of the most influential policy tools the state has. The contracts are the main business line for Dayton-based CareSource, one of the largest area employers.

The new system is intended to overhaul clunky bureaucracy and make the health insurance program more user friendly for the 1 in 4 Ohioans covered.

“This is a bold, new vision for Ohio’s Medicaid program — one that focuses on people and not just the business of managed care,” Ohio Medicaid Director Maureen Corcoran said.

Ohio Medicaid aims to launch the new system in early 2022. Any company that wants to protest the decision will need to file a protest by April 23.

CareSource and the other insurance companies working with Ohio Medicaid were asked to refer requests for comment back to the state.

The contracts announced Friday are preliminary because they are not signed yet.

It’s not clear yet how the new system will impact CareSource’s core business — managing 1.3 million Ohioans’ Medicaid benefits — compared to the old system or whether CareSource will lose market share.

Ohio Medicaid covers 3.2 million people with low incomes or certain disabilities, including more than 412,000 people in the local nine-county region. About 90% of Ohioans who are covered by Medicaid don’t have their benefits managed directly by the state government. Instead, people get an insurance plan managed by insurance companies like CareSource.

Nearly half of Ohio children, half of Ohio births and the majority of nursing home care is covered by Medicaid. By rebidding the contracts and resetting the conditions for how the money gets spent, the DeWine administration is trying to engineer better outcomes for the different Ohioans with Medicaid.

Some examples of these changes include that providers will be able to work out one Medicaid contract, instead of having to broker deals with all the different Medicaid plans. Claims billing and prior authorizations will be processed through a single system instead of with each plan individually.

Loren Anthes, who researches Ohio Medicaid for Cleveland-based Center for Community Solutions, said providers can get bogged down in all the paperwork and redundancy that can come with Medicaid payments.

“By simplifying things, streamlining them administratively, means doctors and nurses and other folks who are serving the Medicaid population can focus more on delivering care, rather than appropriately managing the red tape,” Anthes said.

In addition, some of the changes include:

  • A new separate program will help kids with lots of behavioral health needs and help their families navigate the different systems their child gets services from. Aetna will manage this new separate program.
  • Insurance plans like CareSource must contribute 3% of annual profits to community reinvestment, and that number eventually increases to 5%.
  • Ohio’s Medicaid plans will work with a single company that will transparently manage pharmacy benefits.
  • There will also be provider advisory councils so that providers can be heard by the insurance companies.

Jim Tassie, Ohio Medicaid deputy director, said the department wants insurers in the new system to work together, “not competing against each other by offering certain bonuses or trinkets,” but instead working for a holistic, collective impact on the Medicaid population.

Along with working more with each other, Tassie said the insurance plans will work more with community organizations.

“One of the things that we learned from many of our members is they turn to their community organizations, whether it’s their community action agency or a federally qualified health center or even their primary care provider. Those are the folks to whom they look to get guidance on their health care,” Tassie said, adding that this is part of the reason why the insurers have to give some of their profits back to the community.

The new program will be carved up among six insurance companies with the possibility of a seventh.

Along with CareSource, others selected were UnitedHealthcare, Humana, Molina Healthcare, AmeriHealth Caritas, and Anthem Blue Cross and Blue Shield.

Centene’s subsidiary Buckeye Community Health Plan could potentially be added to the program as a seventh but the department wrote that it is “deferring for additional consideration” on that decision. Centene is currently contesting a lawsuit filed by Ohio Attorney General Dave Yost.

When the state was deciding who to award these contracts to, they gave each of the bidding insurance companies a score and CareSource scored the lowest. UnitedHealthcare scored the highest.

Some people in the Dayton-area with Medicaid are covered by one of the insurance plans that lost their bid.

Members will continue to receive services with their current managed care plans until the transition in early 2022 and will not lose coverage. Members will have the opportunity to select a new plan during the 2021 open enrollment period later this summer. If members do not select a plan, one will be automatically assigned to them.

 
 

Clipped from: https://www.daytondailynews.com/local/ohio-medicaid-announces-caresource-wins-bid-keep-managing-billions-in-state-benefits/FWVAFBQNAFBE5KRACHYYUISRJY/

 
 

 
 

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Open enrollment underway for NC’s new Medicaid system

 
 

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The long-awaited move to managed care in NC is now under way.

 
 

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.

 
 

 
 

RALEIGH — A massive overhaul of North Carolina’s Medicaid system, passed in 2015, is finally going into effect, and open enrollment is currently underway. The sign-up process, which started March 15 and ends May 14, enrolls new beneficiaries to a managed care system, as the old “fee-for-service” system will be replaced this summer. 

“Medicaid Transformation, after several delays, appears to be on track for implementation on July 1,” N.C. Senate Health Appropriations Committee Co-Chair Joyce Krawiec (R-Forsyth) told NSJ in an email on April 5. “We expect results to be better health outcomes, greater access to care and lower costs.” 

In 2015, the North Carolina General Assembly passed H.B. 372, Medicaid Transformation and Reorganization, now known as Session Law 2015-245. The purpose of the bill, according to its “intent and goals” sections, is to “provide budget predictability for the taxpayers of this State while ensuring quality care to those in need.”

The changes were set to go into effect earlier, but a 2019 budget stalemate between the Republican legislature and Democratic Gov. Roy Cooper delayed the transition. 

State budget writers had been complaining for years about the unpredictability of N.C.’s fee-for-service model of Medicaid. There were frequent budget overruns by the program because the costs were not known until providers and Medicaid administrators negotiated the fees for each service provided to each beneficiary. 

Other states had success in moving to a “managed care” model in which Medicaid would pay a flat rate to companies, called Managed Care Organizations (MCOs), per beneficiary for managing the care of those patients. The companies are responsible for overruns past what they are paid to manage the care of that patient, incentivizing them to prevent waste and to focus on the overall health of the beneficiaries through preventative care. Due to the success of this approach, the majority of states now use managed care rather than the fee-for-service model. 

“Beneficiaries will also have a Care team. I believe this will result in much better health outcomes,” Krawiec said. “Beneficiaries will have choices in the providers they have access to. During the sign up period, they are able to choose the providers they wish to have. This has not been possible in the past.”

Six MCOs were selected by the N.C. Department of Health and Human Services (NCDHHS) in a competitive bidding process and together will receive $6 billion to manage the care of around 2 million North Carolina Medicaid beneficiaries. Four of the MCOs will offer plans statewide —  AmeriHealth Caritas of North Carolina, Blue Cross and Blue Shield of North Carolina, UnitedHealthcare of North Carolina and WellCare of North Carolina. Another, Carolina Complete Health, Inc., will offer care only in three designated regions. 

The final MCO is Cherokee Indian Hospital Authority, which will be offering the Eastern Band of Cherokee Indians (EBCI) Tribal Option for their recognized members only. Unlike the other five, who are offering prepaid health plans, the ECBI Tribal Option will be limited to case management. 

Because of the large amount of money on the line, the bidding process to be one of these MCOs became very competitive and controversial. Aetna narrowly lost in the scoring system to rival Blue Cross Blue Shield and filed a lawsuit to get the NCDHHS’s decision reversed. 

The lawsuit alleged there were conflicts of interest between NCDHHS and BCBS which led to the scores being adjusted in BCBS’s favor, costing Aetna the contract. 

“The Department unilaterally manipulated the scoring to ensure that its favored Offeror, [BCBS], would receive an award,” the suit stated. “Aetna was denied the award of a statewide contract by a mere razor-thin margin of 2.06 points, just 0.2 percent of the total possible points by a conflicted Evaluation Committee.”

Aetna’s case, in which two smaller bidders joined as well, was dismissed by state Superior Court.

The new system will officially launch July 1, 2021. Medicaid beneficiaries who do not select a plan by May 14 will have a plan selected for them on May 15.

 
 

Clipped from: https://nsjonline.com/article/2021/04/open-enrollment-underway-for-ncs-new-medicaid-system/