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MCO – Elevance Health Reports $1.3 Billion Profit And Insurer Ups Forecast Once Again

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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]: Elevance profits are down YOY, but revenues from non-Medicaid lines of business are increasing.

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Elevance Health reported a third quarter profit of $1.29 billion as the health insurer added health … [+] plan members despite a big dip in Medicaid enrollment due to the end of a pandemic-era coverage provision.

Elevance Health

Elevance Health reported a third quarter profit of $1.29 billion as the health insurer added new customers despite a big dip in Medicaid enrollment due to the end of a pandemic-era coverage provision.

Elevance, which sells government and commercial health insurance including Blue Cross and Blue Shield plans in 14 states, Wednesday reported third quarter profits decreased nearly 20% to $1.29 billion compared to $1.6 billion in the year-ago quarter. The dip in net income was due largely to an “operating loss of $741 million in the company’s “corporate & other segment” executives said was driven by “business optimization charges.”

“In the third quarter, we completed a strategic review of our operations, assets, and investments to enhance operating efficiency, refine the focus of our investments in innovation and optimize our physical footprint,” the company said in its earnings report. “This resulted in a net charge of $697 million, comprised of the write-off of certain information technology assets and contract exit costs, a reduction in staff including the relocation of certain job functions, and the impairment of assets associated with the closure or partial closure of data centers and offices.”

Still, revenue jumped 7% to $42.8 billion as overall health plan enrollment grew and the company’s Carelon health services business performed well.

Elevance’s membership grew by 42,000, or 0.1%, to 47.3 million as of September 30, 2023 compared to a year ago.

The growth was driven primarily by “growth in BlueCard, Affordable Care Act health plans, and Medicare Advantage membership, partially offset by attrition in Medicaid due to the resumption of eligibility redeterminations and a new entrant into one of our state Medicaid programs in the third quarter, as well as declines in our Employer Group risk-based business,” Elevance said in its third quarter earnings report.

The end of the U.S. Public Health Emergency in May after three years of the Covid-19 pandemic is impacting health insurers that have a significant business administering Medicaid coverage for states, which are conducting so-called “Medicaid redeterminations.” Medicaid redetermination, also described as Medicaid renewal or Medicaid recertification, is essentially when people are asked to show they are qualified for such coverage.

During the third quarter of 2023, medical membership decreased by 664 thousand driven by attrition in Medicaid due to the aforementioned dynamics,” Elevance said in its report.

Still, Elevance’s profits and continued growth are figured in the company’s forecast for increased profits with adjusted net income now expected to be “greater than $33.00 per share.” That is more than an earlier forecast for adjusted net income of company “greater than $32.85” per share.

“Elevance Health delivered another quarter of solid performance reflecting the strength and balance of our diversified portfolio of businesses, our continued investments in innovation and growth, and our relentless focus on affordability, simplicity, and customer experience,” said Elevance Health president and chief executive Gail K. Boudreaux. “With affordability a paramount concern for all payors and a more uncertain forward-looking operating environment, we took action during the third quarter that will enhance our ability to act nimbly and operate efficiently.”

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Molina loses anticipated Indiana Medicaid contract Dive

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[MM Curator Summary]: Molina has a surprise Medicaid RFP loss due to challenges meeting DSNP requirements.



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The health insurer expected to be offered a contract to manage the care of Medicaid seniors in a new long-term services and supports program, but wasn’t able to stand up products in time.


Molina’s contract loss in Indiana is not expected to change the payer’s financial outlook. Gerenme via Getty Images

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Dive Brief:

  • Molina will not be offered a Medicaid contract from Indiana that the payer expected to receive, after it was tied up in regulatory red tape, Molina disclosed on Monday in a filing with the Securities and Exchange Commission.
  • Indiana’s long-term services and supports contract required the health insurer to have a dual-eligible special needs plan available for 2024, but Molina wasn’t able to stand the product up in time because of CMS administrative requirements, according to the filing.
  • The regulatory requirements shouldn’t affect any of Molina’s other current or pending Medicaid contracts, the payer said. Molina still expects to bring in 2024 premium revenue around $38 billion.

Indiana’s Pathways for Aging is a new program meant to help seniors on Medicaid receive long-term care in a home and community-based setting. Long-term services and supports programs offer a variety of medical and social services to people who need help with daily activities because of age, disability or chronic illness.

The state is awarding contracts to managed care organizations before Pathways launches in 2024. Molina, along with Elevance, Humana and UnitedHealthcare, was supposed to receive a contract to manage beneficiaries’ care in the new program.

However, the Indiana Family and Social Services Administration notified Molina in late September that it wouldn’t receive the contract to participate in Pathways. Molina said it would have had a DSNP product available by 2025, but Indiana already determined that Molina hadn’t met readiness review requirements.

The contract was expected to run for four years, with the potential for two one-year renewal terms. Pathways, when launched, will cover roughly 100,000 qualifying Hoosiers.

“Indiana is the only state in its portfolio in which a Medicaid contract, whether actual or expected, has been affected by the CMS administrative proceeding,” Molina said in the filing, adding that the contract loss would not be material to the payer’s financials.

Molina did not respond to a request for comment on what CMS requirements held up its DSNP launch.

The contract loss comes after recent Medicaid wins for Molina in California, Iowa and Nebraska, which should collectively add more than $4 billion in annual premium revenue for Molina and offset the worst of member losses from Medicaid redeterminations, according to management.

“While the Indiana development is slightly disappointing, we remain bullish on [Molina] given the substantial amount of new business won over the last year,” JP Morgan analyst Calvin Sternick wrote in a note Monday.

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New Hampshire seeking Medicaid contract bids

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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]: The Granite State fires up the MCO RFP machine, with contracts going live in September 2024.



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New Hampshire is looking for payers to administer its Medicaid managed care program starting next year.

The state said in early September it expects to select three insurers to administer benefits starting Sept. 1, 2024 through Aug. 31, 2029.

Those selected will administer Medicaid benefits to up to 190,000 enrollees under the age of 65, including acute care, behavioral health and pharmacy services.

“Respondents are expected to identify ways in which they will meet or exceed MCM Program

requirements and goals by offering innovative strategies for building on authentic patient/provider relationships with an emphasis on primary care prevention and provider-delivered care coordination to effectively reduce future illness burden and improve population health in every county of the state,” the state wrote.

The state expects discussions with selected bidders to begin in late November, with final approval expected in January.


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Centene lays off 3% of workforce

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[MM Curator Summary]: This story pins the layoffs on the wind-down. But the really question is: Did plans really staff up to handle the enrollment surge during the PHE? Was it hard to manage all those soft-ball rate cells?



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The layoffs at Centene follow similar workforce reductions at CVS Health earlier this summer.


Samantha Liss for Healthcare Dive

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Dive Brief:

  • Centene is laying off 2,000 employees — a little over 3% of its workforce — as the health insurer struggles with headwinds from Medicaid redeterminations and Medicare Advantage star ratings.
  • The layoffs were confirmed to Healthcare Dive by a company spokesperson. Centene has recently sold off assets, including AI platform Apixio and UK unit Circle Health Group, to refocus on its core business.
  • Centene is the latest payer to undergo layoffs this year. In August, CVS announced it would lay off 5,000 employees, or 2% of its workforce, amid cost pressures integrating recent multi-billion-dollar acquisitions.

Dive Insight:

Health insurers brought in record profits during the pandemic as individuals delayed non-essential medical services, but some have stumbled this year amid pressures like normalizing utilization, regulatory changes in MA and states resuming Medicaid eligibility checks.

Payers with a heavy government presence like Centene and Molina are particularly exposed to headwinds in Medicare and Medicaid.

Centene, which contracts with 31 states to offer Medicaid coverage, is the largest Medicaid managed care organization in the U.S. Earlier this year, the payer lowered its 2024 earnings guidance due to expectations that Medicaid redeterminations will increase spending and lower premium revenue next year.

States could begin removing Medicaid beneficiaries from their rolls as early as April after resuming eligibility checks for the safety-net health insurance program.

Centene lost 262,700 Medicaid members from redeterminations in the second quarter, dropping its total Medicaid lives to just over 16 million.

Research firm Wolfe Research downgraded Centene in July, citing the impact of redeterminations along with concerns about the payer’s ability to improve its Medicare Advantage star ratings. Morgan Stanley also downgraded Centene in August, expressing similar concerns.

Centene is one of several payers that saw their star ratings, a measure of plan quality and member satisfaction that results in bonuses, fall for 2023, pressuring earnings targets. The St. Louis-based payer has taken a number of steps to improve its stars, including investing in provider enablement and focusing more on medically complex members, which management has said should help.

The CMS will release 2024 star ratings in October.

Health insurers aren’t the only healthcare companies that have turned to layoffs to cut costs in a difficult operating environment. Nonprofit hospital giant CommonSpirit laid off an undisclosed number of employees during its third quarter and 2,000 additional positions in its fourthWalgreens laid off 10% of its corporate workforce in May.

Physician enablement company Clover Health and doctor networking platform Doximity both laid off 10% of their employees earlier this year, while primary care chain Cano Health let 700 employees go over the summer.

Other companies that underwent layoffs this year include Oracle-owned EHR vendor Cerner, telehealth provider Teladoc, Google’s life sciences sister company Verily and testmaker Abbott.

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Casey Urges Medicaid Agency to Crack Down on Health Insurers Who Harm Patients by Denying Coverage of Medically Necessary Care

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[MM Curator Summary]: Focus on MCO prior auth behaviors intensifies.



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More than 67 million Americans receive Medicaid coverage from a managed care organization (MCO)

In letter, Casey raises concerns about health insurance companies routinely denying coverage of medically necessary care for people enrolled in Medicaid MCOs

Washington, D.C. Today, U.S. Senator Bob Casey (D-PA), Chairman of the U.S. Senate Special Committee on Aging, sent a letter to Center for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure seeking information about the oversight of Medicaid managed care organizations (MCOs). In the letter, Chairman Casey raises concerns about health insurance companies routinely denying coverage of medically necessary care for people enrolled in Medicaid MCOs—an issue examined in recent watchdog reports that Casey previously requested. The letter seeks information about the steps CMS and states are taking are being taken to protect Medicaid enrollees and prevent MCOs from putting their bottom line ahead of the interests of patients seeking care.

“It is abundantly clear that MCO denials of coverage can negatively affect patients,” wrote Chairman Casey. “The Office of the Inspector General’s findings—coupled with the everyday experiences of my constituents in Pennsylvania—demonstrate more must be done so that older adults, people with disabilities, and children, all receive the care they need and deserve.”

State Medicaid programs pay health insurance companies a fixed annual fee, known as capitated payments, to operate MCOs that provide health insurance to Medicaid enrollees. MCOs have grown to become the dominant delivery system for health care coverage within the Medicaid program. More than 67 million people received full or partial Medicaid coverage from MCOs in 2020, accounting for 84 percent of enrollees.

In 2019, Chairman Casey sent a letter to the Office the Inspector General (OIG) calling for an investigation of whether patients enrolled in MCOs can successfully access the services to which they are entitled. Subsequently, OIG released a series of oversight reports issuing recommendations to MCOs, states, and CMS to address issues including repeated instances of improper service denials and failures to provide enrollees with information needed to file appeals. Today’s letter from Chairman Casey seeks additional information and data from CMS and urges the agency to implement OIG’s recommendations to ensure patients are not being denied care.

Senator Casey has a long record of fighting to protect and expand Medicaid. Earlier this month, Senator Casey introduced the Medicaid for Every Child Act, which would automatically enroll every child in Medicaid from birth until age 18. The bill would guarantee coverage for over 2.6 million children in Pennsylvania, including over 645,000 children in rural counties where health care has historically been more difficult to access.

Read the full letter here or below:

Dear Administrator Brooks-LaSure:

I write concerning recent independent watchdog reports that show health insurance companies routinely deny coverage of medically necessary care for people enrolled in Medicaid managed care organizations (MCO). This month, the Office of Inspector General for the Department of Health and Human Services (OIG) released the last in a series of four reports examining improper MCO coverage denials. Conducted in response to my request, the OIG’s findings—coupled with the everyday experiences of my constituents in Pennsylvania—demonstrate more must be done so that older adults, people with disabilities, and children, all receive the care they need and deserve. Therefore, I am seeking information to ensure appropriate steps are taken to ensure MCOs are not putting their bottom line ahead of the interests of patients seeking care.

Operated by insurance companies, MCOs administer Medicaid benefits on behalf of states in exchange for fixed fees known as “capitated payments” that are based on the number of members enrolled in a given plan. Independent watchdogs have long expressed concern about the MCO model and the potential financial incentive for insurers to reduce costs by limiting payments and denying coverage.  In 2019, I asked OIG to examine whether patients enrolled in MCOs can successfully access the services to which they are entitled, and to review whether the Centers for Medicare & Medicaid Services (CMS) was providing sufficient oversight to ensure enrollees receive the care they deserve. MCOs’ footprint has grown tremendously to become what CMS recently described as the “dominant delivery system” for Medicaid, providing full or partial health coverage to more than 67 million Americans, which accounts for 84 percent of Medicaid enrollees.

Following my request, OIG conducted a national evaluation of Medicaid MCOs that it published in July. OIG’s review examined 115 plans, each with at least 10,000 enrollees, that were spread across 37 states and operated by seven companies. OIG found that the MCOs it evaluated denied 12.5 percent of requests for prior authorization during the report’s 12-month review period in 2019. Denial rates varied from state to state, company to company, and plan to plan. For example, OIG found that one insurer operating plans in 13 states had denial rates ranging from 5 percent to 29 percent, and that denial rates for various MCOs in California ranged from 7 percent to 29 percent. OIG also found that 2.7 million people were enrolled in MCOs that denied 25 percent or more of claims. One Illinois plan denied 41 percent of claims, while two other plans—in Georgia, and Texas—denied one-third of claims, according to the OIG report.

OIG wrote that it was “unclear why some MCOs had rates of prior authorization denials that were so much higher than their peers,” but it is abundantly clear that improper coverage denials can negatively affect patients. The denied care included drug therapy, health screening services for children, and inpatient hospital services, according to OIG’s report. In one instance, OIG detailed how an MCO denied in-home skilled nursing care requested for a pediatric patient diagnosed with cystic fibrosis, Down syndrome, and a series of other medical conditions that required gastrostomy tube feeding and enzyme therapy several times a day. In another instance, OIG found that an MCO denied covering the replacement of a broken stairlift for a partially paralyzed 77-year-old enrollee, before overturning its decision more than six weeks later when the denial was appealed. OIG identified several issues contributing to improper denials, including “MCOs allowing inappropriate staff or inadequately trained staff to make decisions about whether to approve prior authorization requests, using incorrect criteria to determine whether to approve requests, and failure to request additional information before issuing decisions.” OIG raised further concern that improper denials disproportionately affect communities of color and low-income communities.

While the OIG’s data suggest that Pennsylvania’s MCOs have comparatively low denial rates compared to other states, Pennsylvanians enrolled in MCOs nonetheless experience difficulties with improper denials. For example, one Philadelphia resident who relies on in-home care to bathe, use the toilet, and go to medical appointments, reported that the stress of fighting their MCO over cuts to covered care in-home care exacerbates their existing physical illnesses. Providers and patient advocates in Pennsylvania cited multiple examples of patients whose health was put at risk when time-sensitive care was delayed by denials that can take weeks, months, and even years, to appeal.

One attorney who frequently represents Medicaid enrollees on behalf of the Pennsylvania Health Law Project (PHLP), a legal aid organization that represents clients across the Commonwealth, observed that clients with declining health often experience “fear or reluctance … to ask for additional services,” due to concern that doing so will limit their existing access to services. In a recent letter to Pennsylvania’s Medicaid agency, PHLP shared data showing multiple examples of people receiving at-home medical care whose service hours were cut when they sought additional care coverage. PHLP’s data also showed MCOs cut in-home personal assistance services that had been previously approved, absent any demonstrable improvement in patients’ health status. PHLP cited 43 patients covered by a single MCO whose personal assistance hours were cut by 25 percent or more over a five-month period, more than half of whom had assistance hours cut by at least 50 percent. One northeastern Pennsylvania resident had their care hours cut from 70 to 35 hours a week despite having had three heart attacks, while still recovering from a car accident. The patient had several other serious health conditions including chronic pain, an unhealed ankle fracture, arthritis in his back, chronic obstructive pulmonary disease (COPD), a hematoma on the brain, nerve damage, dizziness, vision impairment, borderline diabetes, memory loss, and depression.

At Temple University Hospital, where Medicaid is the payer for nearly half of its patients, medical staff raised concern about delays and denials when patients are seeking cancer diagnoses and treatment. Temple reported that MCOs initially deny about 40 percent of imaging tests for cancer patients, even though such measures are the standard of care. Roughly 80 percent of the initial denials by MCOs for imaging are overturned following first-level appeals involving nurses or second-level appeals involving physicians, strongly suggesting the tests should not have been denied in the first place. Temple also reported that more than 10 percent of chemotherapy treatments are initially denied by MCOs. According to the hospital, 85 percent of these denials are overturned following physician-to-physician consultations.

When patients are denied coverage of medically necessary services, they often face tight timelines to file actionable appeals. Assuming such appeals are filed in a timely manner, the process can be complicated and time-consuming, creating barriers that can make it difficult for Medicaid enrollees to seek recourse. In its national evaluation, OIG found that just one in nine MCO denials were appealed, even though 36 percent of those appeals were successful in the first round—indicating that the requested services were medically necessary and should not have been initially denied. Only two percent of the denials that were upheld in the first round of appeals were elevated to a second level of appeal, OIG reported. Moreover, OIG cited multiple examples of MCOs missing required timelines to make coverage decisions, and raised concern about MCOs failing to provide enrollees with proper information about their right to appeal. Such issues have the potential to further impede access to care for those most in need.

OIG warned that capitated payment models “can create an incentive for insurance companies to deny the authorization of services to increase profits,” and its work makes clear that the issues faced by Medicaid enrollees in Pennsylvania and across our Nation must be addressed. I appreciate CMS’s commitment to partner with states to strengthen the monitoring and oversight of MCOs. However, it is concerning that CMS did not provide concrete answers to OIG’s recommendations aimed at addressing issues identified in its report. As such, I request that you respond to the following questions no later than November 16, 2023:

  1. CMS uses robust oversight tools to evaluate Medicare Advantage coverage denials but does not require states to conduct similar oversight of MCOs, which have higher denial rates. Of the 37 states it reviewed, OIG found that 22 did not conduct regular appropriateness reviews of MCO denials, including 13 that did not conduct such reviews at all. An additional 15 states did not analyze MCO denial data. Based on these findings, OIG recommendations called on CMS to (a) require states to regularly review the appropriateness of a sample of MCO prior authorization denials; (b) require states to collect data on MCOs’ prior authorization decisions; and (c) require states to implement automatic external medical reviews of upheld MCO prior authorization denials. Please indicate whether CMS concurs with each of the recommendations, and the specific actions CMS plan to take to carry them out.


  1. In addition to lower rates of initial denials, OIG found that Medicare Advantage plans were more likely than MCOs to overturn denials at the first stage of the appeals process. OIG suggested that the difference may be due to Medicare Advantage plans having more robust appeals processes in place than MCOs, including the use of external medical reviews. What steps has CMS taken to ensure that MCOs provide more robust appeals processes to Medicaid enrollees, including, but not limited to, external medical reviews?


  1. An OIG audit released in December 2022 found that a Pennsylvania MCO sent denial letters that failed to inform recipients of their right to a state “fair hearing.” OIG determined the omission was due to the Pennsylvania Medicaid agency removing language that informed enrollees of this right from a notice template that MCOs are required to use. OIG also identified inaccurate appeals information in denial letters sent to enrollees by an MCO operating in Iowa. While the OIG’s audits indicated the issues in both states had been resolved in response to its recommendations, such omissions and misstatements mean that enrollees may not have information necessary to understand their rights and options within the appeals process. Has CMS taken steps to ensure that all Medicaid enrollees are receiving accurate and accessible information about their right to appeal denials?


  1. States have the authority to take corrective measures and levy fines when MCOs fail to follow requirements set out by the Social Security Act and associated regulations. CMS requires Medicaid programs to report plan-level, state-specific sanctions for MCOs in Managed Care Program Annual Reports (MCPAR), including all administrative penalties, and corrective action plans, it issued. Please provide data from July 1, 2021 onward that each state, territory, and the District of Columbia has reported to CMS in tab D3 of their respective MCPARs.

I appreciate your commitment to ensuring that the Medicaid program, a bedrock for tens of millions of American, remains strong and is subject to appropriate oversight. I look forward to working with you to further strengthen it to ensure patients receive the care they deserve. If you or your staff have questions, please contact Peter Gartrell, chief investigator, at 202-224-5364.


Robert P. Casey, Jr.


Special Committee on Aging

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MCO (FL) – CareSource and Spark Pediatrics Partner to Serve Florida Medicaid Enrollees

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[MM Curator Summary]: CareSource adds another partner to its dance card for the FL market. This time with a focus on children with a need for medical daycare.



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Partnership unites two innovative, mission-driven healthcare companies as ImagineCare

JACKSONVILLE, Fla.–(BUSINESS WIRE)-CareSource, a nationally recognized managed care organization, and Spark Pediatrics, the leading provider of prescribed pediatric extended centers (PPEC or Medical Daycare) in both Florida and nationally, announced today the launch of ImagineCare — a partnership to serve Florida Medicaid enrollees as a Provider Service Network (PSN). ImagineCare is an innovative managed care organization focused on deploying a provider-driven, community-centric, value-based care model for enrollees with medical complexities.

ImagineCare intends to participate in the procurement to serve Floridians who are part of the Statewide Medicaid Managed Care program administered by the Florida Agency for Health Care Administration. At the heart of the partnership is the mission to address social determinants of health that will directly improve the lives of vulnerable Floridians, including strong alignment with Hope Florida’s Pathways to Prosperity program that connects people to organizations empowered to help with all SDoH needs, leading them on an individualized path to prosperity, economic self-sufficiency and hope.

ImagineCare brings together two mission driven organizations that have a steeped history in delivering best-in-class care for the underserved populations. CareSource is a nationally recognized managed care organization with more than 30 years of Medicaid managed care experience, a nonprofit mission, and an established reputation as a leader in quality and operational excellence. In addition, CareSource is committed to enrollee-centric care and value-based provider partnerships, and — through its subsidiary, The Columbus Organization – has a steeped Florida history of similarly providing community-based services to Floridians.

Together through ImagineCare, CareSource and Spark intend to elevate Florida’s healthcare delivery model through operational ease for providers and a more person- and family-centered approach that empowers all enrollees to improve their everyday activities and lives.

“ImagineCare will clearly further our mission to transform care delivery for the most vulnerable populations in Florida,” said Jeff Soffen, Chief Executive Officer of Spark Pediatrics. “CareSource’s operational excellence and its leadership in focusing on social determinants of health will bring much needed care and innovation for this underserved population. We envision a world where all people, regardless of their medical condition, have access to the care and support they need to thrive, and are excited to bring this partnership to life in service of that mission.”

Further bolstering ImagineCare healthcare delivery is the leadership of The Columbus Organization, a subsidiary of CareSource. Columbus participates in a Florida Medicaid Waiver program, Consumer Directed Care Plus, which provides the opportunity for individuals to improve the quality of their lives by being empowered to make choices about the supports and services that will meet their needs and help them reach their goals.

ImagineCare will combine Spark and Columbus’ capabilities and understanding of the Florida healthcare delivery system with CareSource’s operational proficiency, its history as a recognized healthcare innovator and its industry leadership in expanding access to quality care beyond the four walls of the doctor’s office.

“As a nonprofit organization, we focus first on the people and the communities we serve, not shareholders,” said Erhardt Preitauer, President & CEO of CareSource. “With ImagineCare, we have an opportunity to be an innovative, sustainable partner to the state that will make a lasting difference in the health and well-being of Floridians while driving better quality and outcomes.”

ImagineCare is committed to improving the health of Floridians by leveraging local physician experience to inform decision-making, aligning incentives, using data more effectively and reducing friction between the delivery and the financing of healthcare.

“With ImagineCare, we are investing directly in Florida, in our communities, and in our enrollees,” said Larry Smart, Chief Financial Officer at CareSource. “As a full-time Florida resident for more than 30 years working in our state’s managed care industry, I am thrilled to be a part of this exciting announcement.”

If you are a provider interested in learning more about ImagineCare, please email

About ImagineCare

ImagineCare is a joint venture between CareSource and Spark Pediatrics combining both organization’s mission-driven approaches for a lasting difference in the health of enrollees and communities in Florida. Supported by CareSource’s 30+ years of managed health plan experience and Spark Pediatric’s 12 years of Florida experience providing in-home healthcare services and clinic-based therapies, ImagineCare intends to offer Florida Medicaid managed care recipients comprehensive health coverage and provide access to high-quality providers while delivering compassion and care.

About Spark Pediatrics

Spark Pediatrics is the best-in-class provider of care for children with medical complexities. Spark is the country’s largest provider of Prescribed Pediatric Extended Care (“PPEC”) centers, also known as Medical Daycare, an innovative community-based care center that provides a team-based, quality-driven, and empathetic environment for children with medical complexities to receive critical skilled nursing while promoting interpersonal socialization. Each clinic is staffed with pediatric-specialized nurses and complex care therapists supporting Physical, Speech and Occupational Therapy, as well as Applied Behavioral Analysis. Spark Pediatrics currently operates as the largest PPEC operator in Florida and Texas and serves as a strategic partner to hospital systems, health plans, pediatricians, specialists, and community organizations to deliver the best outcomes for children with medical complexities and their families. Spark is backed by Altitude Capital and Town Hall Ventures, both of whom specialize in funding the next generation of innovation for underserved populations.

About CareSource

CareSource is a nonprofit, nationally recognized managed care organization with over 2.3 million enrollees. Since its founding in 1989, CareSource administers one of the largest Medicaid managed care plans in the U.S. The organization offers health insurance, including Medicaid, Health Insurance Marketplace and Medicare products. As a mission-driven organization, CareSource is transforming health care with innovative programs that address the social determinants of health, health equity, prevention and access to care.

CareSource Florida Co. was formed to offer programs and products in the state of Florida.

About The Columbus Organization

A subsidiary of CareSource, The Columbus Organization empowers individuals to realize their meaningful-life goals through nationally recognized care/support coordination, professional clinical staffing, and quality improvement services for the intellectual/developmental disability (I/DD) or behavioral needs community. The Company delivers an unmatched depth of expertise, breadth of resources, diversity of thinking, and dedication to finding the most appropriate, personalized solutions for its customers.

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MCOS (NY)- New York managed Medicaid plan shutting down, prompting layoffs

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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]: Its not every day you see a MLTC plan close shop. This one could not deal with the “must also have a D-SNP” requirement happening in the NY market in 2024.



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Amherst, N.Y.-based Fallon Health Weinberg is closing a long-term Medicaid managed care plan and laying off 31 employees between Dec. 15 and Jan. 12, 2024, according to a WARN notice filed with the state.

Fallon Health Weinberg was founded in 2014 as a joint partnership between Worcester, Mass.-based Fallon Health and Weinberg Campus, a retirement community in suburban Buffalo, N.Y.

Fallon Health Weinberg offers an all-inclusive managed care plan for the elderly (PACE) and a managed long-term care (MLTC) plan for Medicaid eligible residents.

The MLTC plan is set to close following new state requirements mandating all health plans to offer a D-SNP plan by 2024. Fallon Health Weinberg was unable to meet the Jan. 1 deadline and chose to end the program, Buffalo Business First reported Aug. 15.

A spokesperson for Fallon Health told Becker’s it is one of several plans closing a long-term managed care program because of the new state requirements.

“We are disappointed that we will no longer be able to support these individuals and are focused on helping them transition to other programs, as appropriate,” the spokesperson said. “We anticipate they will receive information from the state in the coming weeks regarding their options. We will support all MLTC employees affected by this decision in the months ahead with severance and with job search and outplacement services.”

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MCOs (MI)- Michigan to rebid contracts for health plans under Medicaid and MIHealthyLife

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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]: The new RFP will require a pretty decent network. One with actual contracted providers, not just LOIs.



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LANSING — The Michigan Department of Health and Human Services has provided new information related to the rebidding of contracts for health plans that provide services to 2.2 million Michiganders receiving coverage through Medicaid and Michigan’s Healthy Michigan Plan.

MDHHS is announcing network requirements and minimum qualifications for bidders in its upcoming request for proposals for the Comprehensive Health Care Program contract for Michigan’s Medicaid health plans.

“We want to provide Michiganders served by Medicaid health plans with a more equitable, coordinated and person-centered system of care,” said Elizabeth Hertel, MDHHS director. “Through this rebid process, MDHHS seeks to provide improved affordable health care coverage for Michiganders served by Medicaid health plans.”

The contract is being rebid during fiscal year 2024, which begins Oct. 1, with new contracts beginning in fiscal year 2025. The rebid is part of MIHealthyLife, an initiative to strengthen Medicaid services informed by input from nearly 10,000 enrollees and family members, health care providers, health plans and other community partners.

Consistent with federal standards and input from MIHealthyLife stakeholders, the rebid will include updates to Michigan’s Medicaid Health Plan network adequacy and timely access standards, which can be found at

When determining whether these standards are met, MDHHS will only consider providers with whom bidders have executed contracts at the time of bid submission. MDHHS is releasing its updates to the Comprehensive Health Care Program network adequacy and timely access standards in advance of the rebid to provide time for potential bidders to review their provider networks and execute provider contracts necessary to meet the new standards.

MDHHS’s new Medicaid Health plan network adequacy and timely access standards can be found at, along with mandatory minimum requirements Medicaid Health Plans must meet in order to qualify for review under the rebid.

In addition, the request for proposals will incorporate several Comprehensive Health Care Program changes intended to advance the MIHealthyLife pillars. These include:

— A commitment to health equity demonstrated by plans achieving the NCQAs Health Equity Accreditation, beginning the process no later than Oct. 1, 2024.

— A strong emphasis on addressing social determinants of health demonstrated by investment and engagement with community-based organizations.

— Efforts to increase childhood vaccination rates, including increasing provider participation in the Vaccines for Children Program.

— Adoption over time of a more person-centered approach to mental health care coverage.

The Medicaid Health Plan request for proposals will be posted to the SIGMA system in fall 2023, with responses due in January 2024. New contracts resulting from this rebid are scheduled to begin on Oct. 1, 2024. MDHHS reserves the right to change mandatory minimum requirements, dates or any other information deemed necessary.

Go online to for more information.

Questions about MIHealthyLife can also be sent directly to

Procurement-related questions can be sent to


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Posted on

MCOs (LA)- State officials scrutinize BCBS Louisiana sale to Elevance

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]: State senators and the AG want to know more about how the proceeds of the sale will work.



Clipped from:

Three Louisiana state senators and the attorney general are calling for a delay of Blue Cross Blue Shield of Louisiana’s sale to Elevance Health, reported Aug. 16. 

The senators’ call for a delay stemmed from reports commissioned by the state’s insurance commission that was released shortly before a six-hour legislative hearing on the deal, according to the report. 

The independent reports from actuarial firms hired by the commission questioned how BCBS plans to structure the deal, according to the report. 

BCBS has proposed giving a fraction of the sale proceeds to policyholders, according to the report. That group includes employers and some beneficiaries who have purchased plans individually, but not every person in the state covered by the payer. Policyholders would receive about $307 million, which amounts to about $3,000 per policyholder. The rest would go to a nonprofit foundation called Accelerate Louisiana that would be created as a result from the sale.  

Louisiana Attorney General Jeff Landry said he does not have a position on the deal but has concerns about how it could affect premiums, how proceeds will be split between policyholders and a foundation that will be formed from the sale and whether the foundation is in the best interest of state residents, according to He also said he opened an investigation into the deal for potential antitrust violations. 

BCBS Louisiana CEO Steve Udvarhelyi, MD, defended the deal before lawmakers, saying it is the best way to bring technology, better pharmacy benefits and new programs to Blue Cross beneficiaries. He said there will be no changes or layoffs, “but if we do not do something now to secure our future, the forces at play in the marketplace, the inevitable forces of consolidation, will happen and we will have to consolidate from a position of weakness.”

Elevance announced plans to acquire BCBS Louisiana in January. The company will become a for-profit subsidiary of Elevance if the deal is approved.  

The deal needs approval from the state insurance commissioner along with two-thirds of BCBS policyholders, according to the report. 

Subscribe to the following topics: blue cross blue shield of louisianaelevance healthaccelerate louisianasteve udvarhely

Posted on

MCOs (GA)- CareSource Georgia rolls out mobile clinics to help Medicaid recipients maintain health coverage

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]: CareSource is sending in Wellness on Wheels to places where the data shows members are missing wellness visits.



Clipped from:


Jason Bearden, president of CareSource Georgia, talks about how the care management organization is using a mobile clinic to reach people at risk of losing their Medicaid coverage during the unwinding. Jill Nolin/Georgia Recorder

The state has leaned on its three care management organizations as part of its strategy to alert all 2.8 million Medicaid enrollees of the return of the renewal process, which the federal government had paused during the pandemic.

And on Wednesday, one of them – CareSource Georgia – publicly launched part of its plan to reach its members: Go to them.

CareSource Georgia says it is partnering with providers across the state to use mobile clinics, dubbed Wellness on Wheels, to help spread the word about what people need to do to keep their Medicaid coverage.

Laptops are on board to help people update their information in the state system and go ahead and renew their coverage if it’s their turn to go through the process. The state is handling the renewals in groups one month at a time.

An alarming number of people have been losing their Medicaid coverage during the unwinding for procedural reasons – like not responding to renewal notices in time – and not because they are no longer eligible.

“You can communicate, advertise all day, but to have tools and the resources right there at their fingertips to get it done – there’s nothing like it,” said Jason Bearden, president of CareSource Georgia.

So far, CareSource Georgia and its partners have five such rolling mobile clinics throughout the state. Wednesday’s press conference outside the state Capitol featured Atlanta-based Eastchester Family Services.

Dr. Seema Csukas, chief medical officer at CareSource Georgia, said the program targets “medical deserts” and brings medical and behavioral health providers to those areas. Data showing where members have missed routine wellness checks helps determine destinations.

“We’re looking for areas where there are a lot of gaps, and that’s where we want to set up shop,” Csukas said.

If someone is no longer eligible for Medicaid, Bearden said CareSource staffers are trying to help educate members on their other options, including a new Medicaid program launched in July.

Georgia Pathways to Coverage is an option for low-income Georgians who complete 80 hours of work or qualifying activity each month to gain and keep coverage. The state has planned for as many as 100,000 people to enroll in the program, but the new initiative is off to a slow start. Just 265 people signed up in the first month.

Bearden said about 50 CareSource members signed up for Pathways, which he called “critical.”

“If it is determined that they’re above – unfortunately – the Medicaid eligibility lines, the first stop is ‘Hey, let’s look at Pathways. Are you eligible for Pathways? Are you in school? Are you doing volunteer work? Are you working? Part time or full time, that might qualify you for Pathways,'” Bearden said.

“So, that is a big part of the continuum,” he said. 


Ariel Esteves (left), vice president of clinical operations with CareSource, gives a tour of the exam room on board a mobile clinic. CareSource Georgia and its partner Eastchester Family Services are using the clinic to help people keep their Medicaid coverage. Jill Nolin/Georgia Recorder