DC- CareFirst Questions D.C. Medicaid Contract Process

MM Curator summary

[MM Curator Summary]: D.C. MCO procurements are weird.


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


A component of one of the largest health care providers in the D.C. region wants to continue providing Medicaid services to District residents but its leaders complain the company has been caught up in an administrative and bureaucratic process that threatens its ability to deliver for its patients.

Ieisha Gray serves as the chief operating officer for the CareFirst BlueCross BlueShield Community Health Plan District of Columbia, herein known as CareFirst. Gray said her company has performed well in serving District residents on Medicaid and wants that to continue.

“We have a demonstrated record serving Medicaid patients in D.C.,” Gray said. “We have the perspective that Medicaid patients should have the same level of health care quality that District government officials have access to.”

Medicaid serves as the federally-funded, locally-managed health care plan for those who count as low-income, disabled, under the age of 19, pregnant, some senior citizens and needy single parents. 

In the District, managed care organizations (MCOs) like CareFirst serve Medicaid patients who do not pay for their medical care. Those who qualify for the program range from an individual who earns up to $19,000 annually to a family of four with a combined income of no more than $37,000 a year.

Statistics reveal over 230,000 residents – 33% of the city’s population, utilize Medicaid. The multi-year contract MCOs operate under amounts to $3 billion collectively.

CareFirst’s Complaints about the Procurement Process

CareFirst leaders said the recent MCO procurement process “was deeply flawed and highly unusual” in documents obtained by the Informer.

“It was marred by the disqualification of three-out-of-four plans for unimportant minutia – whether the listed certified business enterprise (CBE) numbers were the new ones or old ones and for simple typos in the numbers of bona-fide CBEs,” the documents said. “The District’s choice of Medicaid MCO plans has serious implications for its ability to address chronic diseases that disproportionately afflict low-income District residents.”

According to CareFirst documents, the first Request for Proposals took place in November. In January, the District’s Office of Contract and Procurement (OCP) disqualified three of the MCOs, including CareFirst for what it termed “non-substantive” errors in their subcontracting plans. Two competing plans – MedStar Family Choice and Amerigroup – used old CBE numbers given to them by subcontractors which terminated them from consideration while CareFirst received disqualification from the process due to small typos in its subcontracting plan.

In the District by law, there must be three MCOs to move forward with granting Medicaid contracts. As a result, the process moved into February in which OCP opened up a second round for consideration because only one MCO, AmeriHealth, had been selected.

 Meanwhile, the three MCOs that received denial appealed the decision to the District’s Contract Appeals Board (CAB). In consideration, CAB upheld MedStar’s disqualification but overturned Amerigroup’s. CareFirst’s disqualification remained with CAB ruling that the contracting officer had the right not to give it a contract based on the typos of which the company labeled “minor” and “non-substantive.”

In its documents, CareFirst officials said, ‘what happened next defies logic.” It said Amerigroup “was put back in the original procurement, the one that began in November 2021.” The two remaining plans in the original procurement – AmeriHealth and Amerigroup – received contracts by the OCP by default. As a result, CareFirst and MedStar had to compete for the third MCO spot in February. 

CareFirst officials complained that the plans didn’t receive assessment based on “substantive items that matter.”

“For instance, the quality of each plan’s provider network, care coordination and case management tools, etc.,” the documents said. “In other words, the items that have real consequences for the overall quality of healthcare received by low-income District residents were seemingly less important than whether the CBE number listed for a subcontractor was up-to-date.”

Gray said in 2021, CareFirst achieved the first perfect score on all six National Committee on Quality Accreditation criteria in the history of the city’s Medicaid program. She said CareFirst lead other MCOs in 10-out-of-14 quality categories measured by the District. Additionally, in regards to children’s access to routine care, CareFirst received a 95% compared to 83% and 77% by the other two plans.

“We have the largest network of health care providers,” Gray said. “We can give Medicaid patients the care they need.”

Ambrose Lane, Jr., the chairman of the Health Alliance Network, has watched the District’s Medicaid process over the years. He spoke about the contract procurement system’s shortcomings.

“There are flaws in the procurement process and they need to be addressed in order for things to go forward,” Lane said. “Last year, Amerigroup was the odd man out and this year, it is CareFirst.” 

Lane said D.C. Mayor Muriel Bowser should submit the contracts to the D.C. Council for approval adding that contracts over a $1 million must be approved by the council. 

“The executive doesn’t have to wait for the ruling from the CAB,” he said. “I was told by a councilmember that she doesn’t have to wait on them. But by the way things look now, it looks like she will have to request an extension until 2023.”

Regarding CareFirst’s complaints about the contracting process, OCP’s communication team sent the Informer a statement noting the November and February solicitations. 

“Both solicitations have since closed,” the statement said. “In accordance with District requirements and to ensure the sustainability of the District’s managed care program, the District will contract with up to three MCOs so that Medicaid beneficiaries will have a choice of providers. There are three pending protests at the [CAB]. OCP will complete the award process once these protests are resolved.”

Clipped from: https://www.washingtoninformer.com/carefirst-questions-d-c-medicaid-contract-process/