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TECH- Insurers, states can now text Medicaid beneficiaries

MM Curator summary

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]: The federalis are loosening anti-spam text laws to help states/MCOs deal with the Return to Normal Operations.

 
 

 
 

Clipped from: https://www.fiercehealthcare.com/payers/managed-care-plans-states-can-now-text-medicaid-beneficiaries-warn-enrollment-changes

 
 

 

From <https://chat.openai.com/chat>

 
 

 
 

 
 

 
 

Managed care plans and states can now deliver robocalls and texts Medicaid beneficiaries without fear of violating a federal law, a critical change as states face eligibility redeterminations in a few months. 

The Federal Communications Commission (FCC) released new guidance Tuesday on the change after getting a letter from the Department of Health and Human Services (HHS) back in April 2022. States and managed care plans face a looming April 1 deadline to start redetermining the eligibility of everyone on Medicaid.

FCC’s goal is to ensure that “millions of Americans can receive the information they need to maintain enrollment in Medicaid and other governmental healthcare programs to avoid losing healthcare coverage,” according to an agency release. 

The guidance said that states and partners that include local agencies and managed care plans can under certain circumstances use robocalls or automated texts to raise awareness of eligibility issues.

HHS wrote a letter to FCC in April 2022 asking for an exception to the federal anti-robocall law, noting that states and managed care plans have looked to automated robocalls and texts to remind beneficiaries to respond to requests from their local Medicaid agency. 

FCC’s guidance comes at a pivotal time for states and managed care plans. At the onset of the pandemic, the federal government agreed to boost the matching rate for Medicaid payments, but only if the state did not drop anyone off Medicaid’s rolls for the duration of the COVID-19 public health emergency.

The PHE remains in effect until later this year, but Congress included a provision in a spending bill late last year that allowed states to start eligibility redeterminations April 1. The provision also phased out the bump to the matching rate for the rest of the year.

States and managed care plans have been prepping for months for the redeterminations to start, and a key issue has been outreach to affected beneficiaries. 

It remains unclear whether future exceptions will be granted to the Telephone Consumer Protection Law, a 1991 statute that restricted the use of robocalls. 

Insurers have been pressing the FCC to expand a 2015 order that enabled healthcare auto-calls. 

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MCOs- Elevance Health Reports $949 Million Profit Thanks To Medicaid Enrollment Growth

 
 

MM Curator summary

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]: There is lots of profit in Medicaid; you just have to know how to extract it.

 
 

Clipped from: https://www.forbes.com/sites/brucejapsen/2023/01/25/elevance-health-reports-949-million-profit-as-medicaid-growth-bests-flat-commercial-enrollment/?sh=6aa888b62e2c

 
 

Elevance Health reported $949 million in fourth quarter profits as the health insurer formerly … [+] known as Anthem continued to grow its national portfolio of medical and prescription drug benefits.

Elevance Health

Elevance Health reported $949 million in fourth quarter profits as the health insurer benefitted from higher premiums and growth in Medicaid coverage for poor Americans and Medicare Advantage for seniors.

Elevance, which operates an array of government and commercial health insurance including Blue Cross and Blue Shield plans in 14 states, Wednesday reported fourth quarter profits dipped 16.5% to $949 million, or $3.93 per share, compared to $1.1 billion, or $4.63 per share, in the year ago quarter. Revenue jumped 9% to $39.9 billion compared to $36.6 billion a year ago.

“Last year marked the fifth consecutive year in which we met or exceeded our long-term adjusted earnings per share growth target, and we are well-positioned to do it again in 2023,” Elevance Health president and chief executive officer Gail K. Boudreaux said.

Elevance’s membership grew by 2.2 million, or 4.8%, to 47.5 million as of December 31, 2022 compared to a year ago driven by growth of government business, particularly Medicaid. “During the fourth quarter of 2022, medical membership increased by 248 thousand driven by organic growth in Medicaid, which we attribute primarily to the suspension of eligibility recertification, as well as the acquisition of Vivida Health, which added 29 thousand Medicaid members,” Elevance said in its earnings report.

Elevance’s profits and continued growth are figured in the company’s forecast for increased profits and revenues for the new year, 2023, with adjusted net income expected to be “greater than $32.60” per share.

Earlier this week, Elevance Health said it will expand its portfolio of Anthem brand health plans by buying Blue Cross and Blue Shield of Louisiana for an undisclosed sum.

The deal announced Monday will bring 1.9 million health plan customers and another state market to Elevance Health’s family of affiliated Anthem Blue Cross Blue Shield branded health insurance plans. Louisiana will become the 15th state where the Anthem Blue Cross brand of health insurance will be sold once Elevance’s purchase closes later this year.

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MCOS; STATE NEWS- State dodges questions about Medicaid procurement during latest update

MM Curator summary

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]: A reporter doesn’t understand why an official wasn’t giving MCOs ammunition for protest later.

 
 

 
 

Clipped from: https://floridapolitics.com/archives/583312-state-gives-update-on-medicaid-procurement-dodges-answering-questions/

 
 

The Agency for Health Care Administration (AHCA) is getting poised to post an invitation to negotiate six-year Medicaid managed care contracts that are worth more than $100 billion in the aggregate and tens of billions of dollars for health plans that submit winning bids.

But Florida Medicaid Director Tom Wallace avoided answering some of the questions members of the Senate Health Policy Committee had for him Monday, saying that “we are in a blackout-type period.”

The agency, which houses the state’s Medicaid program, has been working on a new invitation to negotiate (ITN) the state’s Medicaid managed medical assistance and Medicaid long-term care programs. 

The ITN is at least 27 days away from being published. Once published, there is a statutory blackout period where respondents to the ITN or individuals acting on their behalf cannot contact the agency or any state official about the ITN.

Sen. Gayle Harrell pressed Wallace about the minimum number of Medicaid managed care plans the state is required to contract with in each region. 

 
 

The Legislature last year passed SB 1950which trimmed the number of regions from 11 to nine and increased the minimum number of plans in each region the state is required to contract with.

Then Harrell asked Wallace about minimum contract requirements for Medicaid specialty populations, such as children with complex medical issues and children in the child welfare program. 

How are you going to address that statewide?” Harrell asked. “Are you going to have one plan as we do with Sunshine or are you going to have a number of plans?”

“You are starting to ask a lot of detailed questions,” Wallace replied. “We are in a blackout-type period, almost, here. I know the ITN has not been released, but we are just trying to be cautious on exactly how I respond to some of these questions.”

That wasn’t the only question Wallace dodged.

 
 

Sen. Bryan Ávila asked Wallace about possible hurdles or challenges with the procurement and executing new six-year contracts.

“We are going through the process. I hate to come out there and say too much about what I am thinking right now related to the process,” Wallace told Avila.

Avila, who said he was “sensitive” to Wallace’s predicament, encouraged the Medicaid director to “brush around the details,” and let them know whether there will be vast differences when the state transitions from the current six-year contracts to new contracts.

We are looking for improvement. … We’ve seen gains in each of the procurement cycles we’ve gone through,” Wallace said. “We have (SB) 1950 out there. Respective entities can look at that and see what the statutory requirements are to meet. That’s pretty much all I feel comfortable responding to right now.”

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MCOS- Connecticut Bucks the Medicaid Managed Care Trend

MM Curator summary

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]: According to this piece, docs like the approach more, it keeps administrative costs lower than MCOs, and it keeps per member cost increases lower than national norms. AND it does the dishes, too.

 
 

Clipped from: https://www.managedhealthcareexecutive.com/view/connecticut-bucks-the-medicaid-managed-care-trend

Most states have contracted with insurers to manage their Medicaid programs. Connecticut uses administrative services only contracts and a variety of means to manage the care.

This is the second installment in our occasional series on Medicaid programs. We profiled North Carolina’s program in the September 2022 issue.

 
 

For more than four decades, state Medicaid directors have paid private health insurers to manage the care of their Medicaid beneficiaries under comprehensive risk-based contracts. Today, Medicaid managed care, as it is called, is the rule, not the exception — with 40 states and the District of Columbia running their Medicaid programs this way.

But since 2012, Connecticut has gone against the grain of this trend. Late in 2011, the state ended the $800 million contracts it had with Aetna, UnitedHealthcare’s AmeriChoice division, and a nonprofit insurer, Community Health Network of Connecticut (CHNCT). It assumed the full financial risk of 529,000 people in the state’s Husky Health program, a group that
included adults and family members covered by Medicaid and children in the Children’s Health
Insurance Program (CHIP)
. Connecticut adopted a self-insured system similar to what large employers use and contracted with three companies to provide administrative services under administrative services only (ASO) contracts and approve payments for hospitals, physicians and other providers serving Medicaid and CHIP members. The three ASOs are Beacon Health Options Connecticut for behavioral health, Bene-Care for dental care and CHNCT for medical claims.

Related: North Carolina: Medicaid Leader, Medicaid Laggard

An ‘over-the-top yes’

The healthcare of people covered by Connecticut’s Medicaid program is still managed. But instead of depending on insurers with Medicaid managed care contracts, state officials introduced what they call a managed fee-for-service program in which physicians in primary care medical homes handle some management of patient care, explains Sheldon Toubman, an attorney with the New Haven Legal Assistance Association and patient advocate with Disability Rights Connecticut, a nonprofit agency for the disabled. Primary care medical home practices are tasked with — and paid for — this management, he says.

In addition to the medical homes, two of the ASOs, CHNCT and Beacon, took on intensive care management programs for patients with medical and behavioral health needs.

Are Connecticut and Husky members better off now? Ellen Andrews, Ph.D., executive director of the Connecticut Health Policy Project, answers, “Yes, and that’s an unqualified, over-the-top yes. We are better off, and I don’t think you’ll find too many people in Connecticut who disagree.” Andrews’ nonprofit organization is focused on the state’s health policies.

Soon after adopting the managed fee-for-service program, access to primary care, specialist physicians and other providers increased, Toubman says. Andrews agrees, saying, “In the first year after the state fired the MCOs (managed care organizations), the number of participating physicians went up 33%. That’s pretty clear evidence that it was managed care holding physicians back from participating in Medicaid.”

Another factor in the success of Connecticut’s move away from conventional Medicaid managed care contracts is that the Affordable Care Act required state Medicaid programs to match what Medicare was paying for primary care services in 2013 and 2014. The increased payment provided an incentive for more physicians to take care of people with Medicaid coverage, Toubman explains.

Under the new arrangement of ASO contracts and managed fee for service, the average per member, per month cost of Connecticut’s Medicaid dropped from $718 in 2012 to $646 in 2013 and then dropped again during the next two years to a low of $605 in 2015 before rising to $648 in 2020, according to a report issued last year by the state’s Department of Social Services. The administrative costs of running the state’s Medicaid program also declined so that by fiscal 2019 those costs totaled 2.8%, whereas the national average was 8.2%, the report showed.

The state report also noted that data from the federal Medicaid and CHIP Payment and Access Commission that used different criteria to measure costs showed the Husky program’s administrative costs for 2019 were 4.2%, which was lower than the national average of 4.7% and 17th lowest among the states.

In 2019, Connecticut’s annual spending per Medicaid and CHIP enrollee was $8,405, a sliver below the median annual Medicaid spending level of $8,436 for all states and territories, according to data from Medicaid.gov. That level of spending is impressive because Connecticut’s cost of living is among the highest in the U.S. States with a more expensive cost of living tend to have higher healthcare costs because labor and other expenses are greater.

However, the early declines in spending have reversed and Connecticut’s Medicaid costs have been rising since 2020. In 2019, state officials settled a lawsuit that the Connecticut Hospital Association and other hospitals filed in 2015, challenging the hospital fees that the state had established in 2012 to help pay for the Medicaid program, explains Andrews. As in most states, Connecticut’s Medicaid program spends more on hospital care than on home care, physician services and drugs; hospital costs in 2019 accounted for almost 30% of all Connecticut Medicaid spending.

Some of the hospitals had sought refunds from the state totaling more than $1.7 billion. Others appealed the Medicaid rates the state was paying, and some sought retroactive increases for multiple rate periods in effect since 2012. If the hospitals prevailed on all claims, state officials estimated the total liability would have been about $4 billion.

Under the settlement, the state agreed to reduce hospital user fees and increase payments to over seven years (2020 through 2026) totaling $871.5 million.

“Under the lawsuit settlement, the hospitals got a lot more money than they were getting and that means Medicaid costs have started going back up almost to where we were in 2012,” Andrews explains. “But Medicaid costs have gone up in every other state over the past 10 years.” The net result is that Connecticut’s Medicaid spending is lower than what it might have been without the changes made in 2012, she says.

Keys to success

In Toubman’s view, Connecticut’s switch from conventional Medicaid managed care to Husky Health’s unique combination of ASO contracts and other ways of managing care has meant improved care coordination and additional transparency. The Husky program improved care coordination by expanding a small pilot program that the state had used before 2012 to deliver primary care case management, he says. Patient advocates were successful in persuading state officials to add primary care medical homes to the Husky program from the start, according to Toubman. The medical homes attracted physicians, increasing access to care and improving care coordination.

Toubman says the Husky program also has meant that advocates and others have a clearer picture of state Medicaid spending and patient care. State officials disclose the program’s results in monthly and annual reports. Andrews says that insurers with Medicaid managed care contracts were slow to publish reports and when they did, each would report results in a different format: “It was like going into an orchard of fruit trees every time, because we knew we’d be getting apples and oranges.”

Toubman says increasing Medicaid payment to physicians has also been instrumental in the Husky program’s success. Higher payment for primary care has reduced the number of adults and children seeking expensive emergency department care, he says.

Joseph Burns
is an independent journalist in Brewster, Massachusetts, who writes about health policy and health insurance.

 
 

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MCOs- Highmark Wholecare boosts Medicaid membership by over 70,000

MM Curator summary

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]: Highmark ate Gateway (nee Wholecare) and added 25% to its waistline.

 
 

Clipped from: https://www.beckerspayer.com/payer/highmark-wholecare-boosts-medicaid-membership-by-over-70-000.html

Highmark Wholecare has increased its Medicaid membership by nearly 25 percent since August, growing to more than 375,000 members. 

The company said Jan. 11 the increase came after a managed care contract procurement process with Pennsylvania. Total membership at Wholecare, which includes Medicaid and D-SNP plans, now exceeds 410,000. The company’s network includes 29,000 providers.

Highmark Health purchased Wholecare, formerly Gateway Health, in 2021. It officially rebranded as a BCBS licensee Jan. 1, 2022.

 

 
 

 
 

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MCOS; FWA; MEDICARE- Insurers Are Fighting To Protect Their Medicare Fraud

MM Curator summary

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]: The big players in the Medicare Advantage upcoding / HCC scams are not really wanting there to be a true-up for the estimated $650M they got in overpayments about 10 years ago.

 
 

Clipped from: https://www.levernews.com/insurers-are-fighting-to-protect-their-medicare-fraud/

 
 

This year, for the first time, a majority of seniors eligible for Medicare will be on privatized Medicare Advantage plans. Now, the insurance companies raking in giant profits from these for-profit plans are mounting a pressure campaign and planning to sue the government to protect years of overpayments they’ve extracted from Medicare.

A cash cow for big insurers, the for-profit version of Medicare has not been a great deal for the American public. Medicare Advantage plans cost the government more per beneficiary than traditional Medicare, and often wrongfully
deny care.

What’s more, federal audits have found Medicare Advantage plans systematically overbilling
the public — mostly by billing as if patients are sicker than they really are, a scheme known as “upcoding.” Officials estimate the private plans collected $650 million in overpayments from 2011 to 2013.

 
 

Listen to reporter Andrew Perez discuss this article.

The Biden administration is expected to finalize a rule next month to try to recoup some of these overpayments — but Medicare Advantage insurers are threatening to sue if the rule moves forward as written, according to Stat News. If insurers sue, it could further delay the government’s efforts to claw back excess payments stretching back more than a decade, as well as future overpayments.

The health insurance industry argues that regulators should allow for some level of payment errors — and should only apply new rules to audits moving forward, instead of retroactively punishing past misconduct.

“It’s crazy,” said Diane Archer, founder of Just Care USA, an organization that opposes Medicare privatization. “They overcharged. Who’s ever heard of a situation where you’re overcharged and you don’t get your money back? It’s beyond comprehension. The Medicare trust fund should not be paying out funds inappropriately, and it’s driving up Medicare [insurance] premiums.”

Tip Jar

“Hundreds Of Millions Of Dollars, If Not More, At Stake”

President Joe Biden is doing nothing to slow the Medicare privatization push. Indeed, his administration has hiked payments to Medicare Advantage insurers while expanding a program called ACO REACH that allows companies to enroll seniors on traditional Medicare into private health care plans without their informed consent.

But in a significant shift, last month the Biden administration proposed new regulations to prevent Medicare Advantage insurers from wrongfully denying claims or refusing to approve services that would be paid under the traditional public Medicare program.

Consumer advocates like David Lipschutz, associate director of the Center for Medicare Advocacy, were pleasantly surprised by the proposal — even if it came a decade late.

Lipschutz noted that the industry response to the proposed claim denial regulations has been “been pretty muted so far.”

He said insurers are far more concerned about two planned announcements from the Centers for Medicare and Medicaid Services next month that could have much greater impact on their bottom line.

“There are potentially hundreds of millions of dollars, if not more, at stake,” said Lipschutz.

Regulators could decide whether to factor insurers’ upcoding tactics into how much they pay Medicare Advantage plans. They are also expected to announce a final audit rule to prevent future overpayments and recoup some of the cost of excessive disbursements that have gone to Medicare Advantage insurers in the past.

Speaking at the annual J.P. Morgan Healthcare Conference this week, Humana’s chief financial officer, Susan Diamond, said “the industry likely will go to litigation” if the final audit rule does not include a so-called fee-for-service adjuster. Such a provision would allow insurers to get away with some level of diagnosis coding and billing errors — and it would likely substantially reduce the sums that insurers would have to pay back to the government.

The dollars at stake are significant. In September, the office of the inspector general at the Health and Human Services Department (HHS) released audit
reports finding that even just the Medicare Advantage plans affiliated with Humana owed the government nearly $44 million worth of overpayments from 2016 and 2017.

A separate HHS inspector general audit
found a Florida Humana plan overcharged Medicare by nearly $200 million in 2015.

“Prospectively, Not Retroactively”

Medicare Advantage has become a major profit-driver for the insurance industry, with government funds now accounting for a majority of most big insurers’ health plan revenues.

That’s especially true for Humana, which received more than 90 percent of its health plan revenue from taxpayers in 2021. UnitedHealth Group and CVS Health, which owns Aetna, both brought in more than 70 percent of their health plan revenue from the government.

Those insurers are part of the Better Medicare Alliance, a health insurance industry front group that spent nearly $3 million on TV ads promoting Medicare Advantage between Election Day and the end of the year, according to data from AdImpact.

 
 

The Better Medicare Alliance has called on the government to audit every Medicare Advantage plan annually “to increase program oversight and ensure that arbitrary decisions about which contracts are audited do not disproportionately impact some organizations more than others.”

The group has additionally argued that “changes to audit methodologies should be applied prospectively, not retroactively,” because doing the former “would invalidate actuarial assumptions made by health plans over more than a decade and threaten the care that seniors rely on today.”

Having the audit rule changes apply prospectively would allow insurers to retain years of overpayments.

Lipschutz said that the Better Medicare Alliance “and the folks that fund them don’t want to pay out what could be owed to the program looking backwards, so they want to try to focus on moving forward.”

While the Better Medicare Alliance does not disclose its donors, CVS Health reported donating $3 million to the group in 2021. Humana gave $2
million that year and $1 million in the first half of 2022.

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Executives from CVS Health, Humana, and UnitedHealth Group serve on the alliance’s board of directors. (UnitedHealth Group does not voluntarily disclose its donations to dark money front groups like the Better Medicare Alliance.)

Humana and CVS Health also belong to America’s Health Insurance Plans (AHIP), the powerful D.C. health insurance industry lobby.

Last summer, AHIP submitted a comment letter opposing the Medicare Advantage audit rule, arguing it “fails to account for errors in [fee-for-service] Medicare data” and complaining that it would apply retroactively.

Retroactive rulemaking is unfair, inappropriate, and legally impermissible,” wrote AHIP.

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MEDICARE- CMS data: Medicare Advantage tops 30M

MM Curator summary

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]: Up 2M from last year’s number.

 
 

Clipped from: https://www.fiercehealthcare.com/payers/cms-data-medicare-advantage-tops-30m

 
 

Enrollment in Medicare Advantage (MA) has topped 30 million, according to new data from the Centers for Medicare & Medicaid Services.

This represents coverage across 776 contracts, according to the data, as of Jan. 1 payments, which reflect enrollments accepted through Dec. 2. Enrollment in standalone prescription drug plans was also about 22.7 million, bringing total enrollment across all types of private Medicare plans to nearly 50.3 million.

This represents growth of about 2 million from 2022. An analysis from the Kaiser Family Foundation found that enrollment in MA plans was about 28 million last year

Enrollment in the program has surged over the past decade and now encompasses nearly half of all Medicare beneficiaries.

In a statement, America’s Health Insurance Plans President Matt Eyles lauded the landmark.

“This milestone shows that people are choosing MA for better affordability and health outcomes. The continued growth of the program is a testament to the tremendous value MA offers to all enrollees, and especially those with chronic illnesses who require care coordination and management, as well as those with low incomes who rely on MA’s access to additional benefits at little or no cost,” Eyles said.

MA enrollment numbers were a key topic at the J.P. Morgan Healthcare Conference last week, with some insurers, like Humana, posting significant increases, while others, like CVS Health, called their performance during the annual enrollment period “disappointing.”

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MCOs, CA- Medi-Cal adds more insurance plans after pushback

MM Curator summary

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]: Move the L for CA community plans to the W column.

 
 

 
 

Clipped from: https://calmatters.org/health/2023/01/medi-cal-insurance-plans/

In summary

State health officials last year launched a first-ever competitive bidding process for its Medi-Cal insurance contracts, aiming to implement higher standards. But when the winners were announced, several insurers complained about the process and potential impact on patient care.

Lea este artículo en español.

In a significant course change, the California Department of Health Care Services announced that it has negotiated with five commercial health plans to provide Medi-Cal services in 2024, scratching a two-year-long bidding process for the coveted state contracts.  

This upends the state’s previous plans of awarding contracts to only three health plans. It  means more Medi-Cal enrollees will likely get to keep their current insurer and doctors, averting a confusing re-enrollment process for most members and preventing disruption to patient care. It also means that the state will avoid a protracted legal battle amid lawsuit threats from insurers who had previously been left out. 

The big winners: Blue Shield and Community Health Group will get a contract after initially having lost bids, and Health Net will get to keep at least some of its Los Angeles enrollees. 

“To bring certainty for members, providers and plans, the State used its authority to work directly with the plans to re-chart our partnership and move with confidence and speed toward the implementation of the changes we want to see,” the department wrote in a statement released Friday afternoon. The department did not provide answers to follow-up questions before publication. 

“At some level it makes the transition easier, but we want to do better than the status quo,” said Anthony Wright, executive director of Health Access, a consumer advocacy group. “Less disruption is good, but we don’t want to lose the reason for the change, which is to have more accountability on these plans going forward.”

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Medi-Cal provides health coverage to more than 14 million low-income Californians, more than a third of the state’s population. In 2021, the Department of Health Care Services, which oversees the Medi-Cal program, embarked on a bidding process that would allow it to rework contracts with commercial Medi-Cal health plans.  The state’s goal was to reduce the number of participating health plans from the current nine and move forward with only the most qualified plans, which would be held to higher standards related to patient outcomes, wait times and satisfaction, as well as improving health disparities. 

In August of last year, the state announced that it would tentatively award $14 billion worth of Medi-Cal contracts to three companies — Health Net, Molina and Anthem Blue Cross. This proposed decision would force close to 2 million Medi-Cal enrollees to switch insurance and likely find new providers. Some health providers decried the department’s original contract decision, claiming it would have caused “immeasurable” disruption to care.

 “Less disruption is good, but we don’t want to lose the reason for the change, which is to have more accountability.”

Anthony Wright, executive director of Health Access

Kaiser Permanente negotiated a special contract with the state early last year, bypassing the bidding process. And most nonprofit community-based health plans did not have to compete for a contract.

The state’s summer announcement quickly became controversial as health plans that were left out questioned the state’s process for choosing the three insurers, appealed the decision and sued the state. 

This change of course calls into question the power that insurance companies can have in pressuring state action with legal threats. Health advocates say they hope it does not set a precedent. Wright at Health Access said he’d like for the department to make clear that the state is not backing away from the competitive contract process in the future, as he considers it is a key tool for accountability. 

Blue Shield, one of the insurance companies initially left out, filed a complaint against the Department of Health Care Services, requesting that the department release all documents used in the selection process. 

The insurance giant even launched a campaign in the fall asking Californians to speak out against the state’s decision. The company argued that the state failed to sufficiently engage Medi-Cal enrollees and doctors in the process. “The message of this campaign is that it’s not too late for the state to change course and make choices that will advance innovation and health equity for everyone,” Kristen Cerf, president and CEO of Blue Shield’s Medi-Cal plan, said in a statement in October. 

Under the revised agreement, Blue Shield will get to keep serving the San Diego area. Blue Shield declined a request for an interview, instead referring reporters to a statement released Tuesday. 

Meanwhile, Health Net, which in the summer was tentatively awarded contracts in nine counties but lost its previous and largest contract in Los Angeles, also sued the state. Under the new agreement, Health Net will get to stay in Los Angeles and will divide its share of Medi-Cal enrollees evenly with its commercial counterpart, Molina Healthcare. Health Net will also keep its Sacramento membership but lose the San Diego market.

Centene, the parent company of Health Net, said in a Tuesday statement that it would end its legal actions against the state’s health services department.

The splitting of members evenly between Molina and Health Net through a subcontracting agreement is a “step in the right direction,” said Jim Mangia, president and CEO of St. John’s Community Health, which serves low-income patients in south LA, but much remains uncertain.

“Who’s the 50 percent that are going to be able to stay with Health Net and who are the 50 percent that are going to have to move?” Mangia said. “We don’t have answers to that, so I think it’s problematic in that it still displaces a significant number of patients.”

Currently, Health Net manages more than 1 million Medi-Cal patients in Los Angeles County. Nearly a quarter of St. John’s Community Health patients have Health Net, with the publicly run L.A. Care Health Plan accounting for the rest. (Most Angelenos with Medi-Cal are enrolled in and will be able to continue with L.A. Care, a publicly operated plan.)

Mangia said the latest decision will still disrupt services for the 12,500 patients at St. John’s alone who will be forced to switch to Molina. He anticipates the clinic needing to hire more staff to help with patient navigation, but there’s no money for that.

“It was obviously an attempt to rectify the initial decision, but I’m not sure the impact on patients is going to be all that different. That’s my concern,” Mangia said. “It’s essentially an unfunded mandate.”

“Who’s the 50 percent that are going to be able to stay with Health Net and who are the 50 percent that are going to have to move?”

Jim Mangia, president and CEO of St. John’s Community Health

Health Net and Molina Healthcare did not reply to requests for comment, but in an early Tuesday morning call with investors, Molina CEO Joseph Zubretsky characterized the state’s final decision as “taking three steps forward, taking one step back” for the company, which had originally hoped to triple its Medi-Cal membership under the tentative award announced in August. 

In discussing the decision, Zubretsky and CFO Mark Keim alluded to closed-door negotiations between Molina, the state health care services department and the appealing insurers. When asked whether the state ever considered restarting the bidding process, Zubretsky said California regulators had “broad discretionary authority” to award contracts and new bids could have taken a significant amount of time. 

“With that as the understanding, we thought it best for the company, for membership and for investors to participate in the negotiation,” Zubretsky said.

Molina has agreed not to protest the final contract award and will subcontract with Health Net in Los Angeles County in the “negotiated settlement,” Zubretsky said. Molina will double its Medi-Cal membership — from 600,000 to 1.2 million — by 2024 as a result of this latest contract.

“We’ve agreed to the membership allocations that the state has now articulated in addition to waiving other types of legal rights that one would normally have,” Zubretsky told investors.

Community Health Group, the largest Medi-Cal provider in San Diego County, will also get a new contract in 2024. The insurer was excluded in the original summer announcement, but appealed the state’s decision. 

Community Health Group declined an interview request, but over the summer, the company’s chief operating officer, Joseph Garcia, told CalMatters that the state’s decision had been shocking because his company routinely outperformed other insurers. 

Zara Marselian, CEO of La Maestra Community Health Centers in San Diego, said the state’s new decision was a welcome surprise. La Maestra’s clinics serve low-income patients throughout the county and have worked with Community Health Group for nearly three decades. About 26% of its patients rely on Community Health Group for Medi-Cal, the most of any single patient group. Previously, Marselian had also predicted having to hire more staff to help patients navigate the transition.

“It’s really better for the Medi-Cal recipients that will not now have to transfer to another health plan and have their whole continuity of care disrupted,” Marselian said. “I’m really grateful however this happened. I’m really grateful on behalf of our patients.”

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MCOs; PayVider- JPM23: CVS weighs next steps in its primary care ambitions

MM Curator summary

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]: CVS may or may not buy up Oak Street Health to continue its march deeper down the PayVider path.

 
 

Clipped from: https://www.fiercehealthcare.com/payers/jpm23-cvs-health-still-weighing-next-steps-its-plans-foray-primary-care

 
 

SAN FRANCISCO—The top brass at CVS Health reiterated Tuesday that the healthcare giant is still plotting its move into primary care but emphasized that they want to ensure the next steps are the right ones.

CVS presented early on the second day of the J.P. Morgan Healthcare Conference as media reports circled that its primary care target could be Oak Street Health. Bloomberg reported that a $10 billion deal could be reached in weeks, citing people familiar with the negotiations.

However, Bloomberg’s sources did note that the ongoing talks between the companies could end without a deal in place.

For her part, CVS CEO Karen Lynch did not address the reported conversations with Oak Street Health. She said that while the company is still planning its push into primary care, it doesn’t want to act hastily.

“What we’ve been very clear about is we want to make sure it’s the right asset at the right time,” she said. “This isn’t a one-and-done.”

Lynch said during the company’s second-quarter earnings call in August that CVS was planning to get some kind of primary care deal on the books by the end of 2022. It reportedly courted and was rejected by concierge care provider One Medical, which is in the process of being bought out by Amazon.

Instead, it announced plans to acquire Signify Health, a move that instead enhances CVS’ capabilities in home health and value-based care.

The $8 billion deal is currently under regulatory review, and Lynch said the company expects it to close in the first half of 2023.

Signify’s strengths also align with key priorities at CVS, she said, as home health is the “future of healthcare,” and the company is aiming to make a greater push into enabling value-based care. A tightrope the company had to walk, though, is working with its competitors such as Humana that are also existing Signify clients.

Lynch said that as major insurers become increasingly diverse and vertically integrated, they’ve had to navigate the combination of direct competitors who are also clientele.

“As we think about the industry, we’re all kind of working with each other, and we’re all kind of customers of each other,” she said. “We’ve committed to them to be payer agnostic, and we think that’s how the industry will evolve over time.”

The Signify deal also brings with it Caravan Health, which is built to assist in establishing accountable care programs and was scooped up by Signify in early 2022. Lynch said Caravan’s capabilities will be critical to CVS’ ambitions in the provider space moving forward.

Chief Financial Officer Shawn Guertin added that the company’s plans around primary care also feed back into its focus on value-based care, as effective, accessible primary care is central to the care continuum.

“This is the first leg of the stool in our longer strategy,” Lynch said.

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MCOs; IN- New contract for Medicaid operator

MM Curator summary

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]: MDWise gets another 4 (or 6 with options) to keep running managed care in the state (its been doing it for almost 30 years).

 
 

 
 

Clipped from: https://www.wowo.com/new-contract-for-medicaid-operator/

INDIANAPOLIS (Inside Indiana Business) – The operator of Indiana’s Medicaid program will continue to run the healthcare insurance system for the state. The Family and Social Services Administration has awarded MDwise a four-year contract to provide risk-based managed care services statewide.

MDWise has managed healthcare benefits to low-income residents through Hoosier Healthwise and the Healthy Indiana plan since 1994.

The new contract includes the possibility of two one-year extensions.

Meanwhile, the nonprofit health maintenance organization has hired its first health equity officer. MDwise says Anye Carson will oversee an action plan to reduce health disparities in its coverage.

The organization says Carson will incorporate culturally and linguistically appropriate services for MDwise members.

Carson most recently worked North Carolina-based clinical research organization Parexel. She also previously worked for the IUPUI Extension for Community Health Outcomes Center.