Posted on

DC Council hits pause button on Medicaid contract

MM Curator summary


DC’s MedStar contract is now off again.


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.


Health care for Medicaid recipients in D.C. is in limbo yet again: The D.C. Council has effectively hit the pause button on a contract with the health care provider that was set to extend benefits to a quarter-million residents.

The complicated twists and turns of the contract process is entirely bureaucratic, and could result in the District’s most-vulnerable residents losing access to their doctors during a pandemic.

As the District’s Medicaid contract was less than a month from expiring, Mayor Muriel Bowser declared a state of emergency, allowing her administration to enter into a contract extension with MedStar Health.

The nine-month extension allowed for D.C. to restart the process of finding its next Medicaid provider. A previous selection process had awarded the contract to MedStar, but a judge last year nullified the award, citing a failure of the health care company to meet the requirements to win the $3 billion bid.

The contract extension would have passively passed the council had it not taken action in 10 days. But four council members co-signed a resolution of disapproval Friday, allowing it to “extend our review period from 10 to 45 days,” the resolution reads.

Four members of the council, Chair Phil Mendelson, Kenyan McDuffie, Elissa Silverman, and Robert White, co-signed the resolution, which questions the legality of the contracts.

“Extending our review period also gives time to the Mayor to re-evaluate the bid
proposals as ordered by the Contract Appeals Board last December 1st (the CAB expressly ordered the District to “re-evaluate the competitive range offerors’ proposals in accordance with District procurement law and regulation, the terms of the solicitation, and the instant decision,” Mendelson wrote in the resolution.

The council wants more time to review but has three options. First, to do nothing, which Mendelson contends given the controversy and legal advice, is “not a positive image for the Council.” The second option would be to disapprove the contracts, and the final option would be to act by emergency legislation and overrule the CAB’s decision and approve the contracts.

Deputy Mayor Wayne Turnage believes the mayor’s move to enter into extended contracts via emergency order was the only way forward.

“The mayor has responsibly submitted these contracts under emergency to avoid any disruption in the health care for over 250,000 people. That is the extent of what she can do at this point. So really, it’s up to the council,” said Turnage.

In response to the council’s resolution, the mayor outlined the potential outcomes of letting the contract expire. Among them, she said, the Department of Health Care Finance will have no legal authority to pay for health care services; District residents will have to navigate the health care system; and health care costs will likely increase.

“To avoid these substantial, unnecessary, and harmful disruptions, I urge Chairman Phil Mendelson to withdraw the disapproval resolution immediately as the Department of Health Care Finance resolicits the procurement over the next few months in order to add additional services for beneficiaries and to address the Council’s concerns,” Bowser said. 

The council is out on recess until Oct. 1, and sources within the council said its rules prohibit council members from voting until it reconvenes. Its next legislative meeting is set for Oct. 5.

“I think you could have made the argument early in his process that this was such a challenging issue, that people of goodwill were legitimately confused as to what should be done. I don’t think you can make that argument anymore. Everybody understands precisely what has happened. And precisely what will happen if the council disapprove these contracts. Or if they just take the entire 45 day review period,” Turnage told WTOP.

Clipped from:

Posted on

Georgia Eyes New Medicaid Contract. But How Is the State Managing Managed Care?

MM Curator summary


GA MCO contracts are expected to be rebid soon and journalists are reporting that current contracts lack financial controls that are standard in other states.


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.



(Hannah Norman / KHN photo illustration / Getty Images)

Just before Frank Berry left his job as head of Georgia’s Medicaid agency this summer, he said the state “will be looking for the best bang for the buck” in its upcoming contract with private insurers to cover the state’s most vulnerable.

But whether the state — and Medicaid patients — are getting an optimal deal on Medicaid is up for debate.

Georgia pays three insurance companies — CareSource, Peach State Health Plan and Amerigroup — over $4 billion in total each year to run the federal-state health insurance program for low-income residents and people with disabilities. As a group, the state’s insurers averaged $189 million per year in combined profits in 2019 and 2020, according to insurer filings recorded by the National Association of Insurance Commissioners. Yet Georgia lacks some of the financial guardrails used by other states.

“Relative to other states, Georgia’s Medicaid market is an attractive business proposition for managed-care companies,” said Andy Schneider, a professor at Georgetown University’s Center for Children and Families.

Georgia is among more than 40 states that have turned to managed-care companies to control Medicaid costs. These contracts are typically among the biggest in these states, with billions of government dollars going to insurance companies. Insurers assume the financial risk and administrative burden of providing services to members in exchange for a set monthly fee paid for each member.

The health plans, though, have at times drawn questions both on spending and quality of care delivered to Medicaid members.

“The transition to managed care was supposed to save states money, but it’s not clear that it did,” said Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation. (KHN receives funding support from the foundation.)

States can require Medicaid insurers to pay back money if they don’t hit a specified patient-spending threshold. That threshold is typically 85% of the amount paid to the insurance companies, with the rest going to administration and profit.

But Georgia does not require its Medicaid insurers to hit a specific target for spending on patient care, a federal inspector general report noted. Though Georgia is trying to “claw back” $500 million paid to its Medicaid insurers, it could have lost out on recoupment dollars, the report indicated.

And state documents show that the Peach State company, which now has the largest Medicaid enrollment of the three insurers, failed to reach the 85% mark from 2018 to 2020.

Overall, Georgia’s Medicaid “medical loss ratio,” which assesses how much was spent on patients’ claims and expenses, was fifth from the bottom nationwide last year, behind only Mississippi; Washington, D.C.; Wisconsin; and Arkansas, according to data from the insurance commissioners association. Spending rates on patient care in the state fell from 82.9% to 80.8% in 2020. (The NAIC uses a different method for calculating the ratio than the state and federal governments do.)

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

“Profits for Georgia Medicaid HMOs are very healthy,” said Allan Baumgarten, an independent analyst and consultant.

When asked whether Georgia planned a spending requirement in the new contract, Fiona Roberts, spokesperson for the Department of Community Health, which runs Medicaid, said “a number of considerations are being discussed.” She noted that the state having a low medical loss ratio does not necessarily translate to “unreasonable profit” for the insurers.

The insurers also make money off their management services firms. In 2020, the insurer Peach State paid a subsidiary of its parent company, Centene Management Company, $114.7 million for administrative services. The nonprofit CareSource paid its management services firm $86.5 million in 2020.

“Fees paid to subsidiary companies represent another source of revenues for the parent companies,” said Baumgarten. “And it’s done in a way that does not allow the state to hold the HMOs accountable.”

The state’s latest performance data, which covers 2019, shows the plans did as well or better than the national median on many measures, including on access to a primary care provider.

But low birthweight rates appear to be on the rise despite the state’s goal of bringing them down to 8.6% or less. The companies hovered at an average of about 9.8% in 2019, the latest available data.

“We continue to hear stories from families and health care providers about children in Medicaid managed care who have considerable trouble getting the services they need — whether it’s medication to control their asthma, getting connected to behavioral health care after a mental health crisis lands them in the emergency room, or any number of health challenges,” said Melissa Haberlen DeWolf, who directs research and policy at the Voices for Georgia’s Children advocacy group.

Compared with other states, Georgia has a stunningly low rate of referring poor children to specialty services under Medicaid, according to a recently released National Health Law Program report. DCH said recently it’s investigating why the rate is so low.

And, currently, the state is reporting low covid vaccination rates for those 12 and older covered by the Medicaid managed-care companies. A state posting shows the rates for the three companies are each below 10%, far lower than Georgia’s overall rate.

The companies, when asked about profitability, quality of care and administrative costs, directed a reporter to Jesse Weathington, executive director of the Georgia Quality Healthcare Association trade group. He said he could not comment on individual companies’ financial performance.

“Our goal is to continue to drive quality improvement, and successful patient outcomes, in the most cost-efficient manner for taxpayers who fund Georgia Medicaid,” Weathington said.

Georgia is expected to open the high-stakes bidding process on a new Medicaid contract next year. The bid process typically is fierce and the results often contested.

It’s not clear, though, when Georgia’s new contract process will be completed as the timelines have hit snags in several other states. North Carolina rolled out its managed-care system July 1 after two years of delays. It will spend $6 billion annually, the largest contract in the state health agency’s history.

Last year, Louisiana’s contract process fell apart after insurers that lost out disputed the results. And Centene and other companies are protesting Pennsylvania’s decision not to award them contracts, delaying implementation.

St. Louis-based Centene has more Medicaid managed-care business nationally than any other company. Centene last year acquired WellCare, a Medicaid insurer in Georgia, then closed down that operation in May.

Centene has also faced questions about overbilling. Ohio settled an $88 million pharmacy fraud lawsuit it filed against Centene months before awarding it a contract, while Mississippi settled with it for nearly $56 million. Now Georgia is expected to get money back under the $1 billion that Centene set aside to settle with other states affected by the pharmacy overbilling.

Consumer groups want the state to take stronger steps to advance the health of those who rely on Medicaid and to make the deals with the insurers more transparent.

“Medicaid members are best served when they have ready access to providers, insurers are eager to resolve their health care needs, and policymakers exercise strong oversight to ensure members’ health and well-being are prioritized over profits,” said Laura Colbert, executive director of Georgians for a Healthy Future, a consumer advocacy group.

A bill that aimed to bring more transparency and accountability to the state’s health care plans was vetoed last year by Republican Gov. Brian Kemp. The legislation would have allowed a committee to examine records of health care contractors and compel the state to respond to questions about them. Kemp said the bill would have violated the separation of powers doctrine between the executive and legislative branches of government.


Clipped from:


Posted on

Physicians booted from board after blocking Stitt Medicaid plan

MM Curator summary


Doctors appointed by the Governor who thwarted his major health initiative have been removed from their appointments.



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.



OKLAHOMA CITY — Gov. Kevin Stitt fired the only two physicians who serve on the state’s Health Care Authority governing board after they opposed his plan to outsource Medicaid.

Dr. Jean Hausheer said when a Stitt staffer called Saturday to give her and Dr. Laura Shamblin the news, he was unable to provide a reason why the governor was kicking two of his own appointees off the nine-member board. The governor appoints five of the board members, to the panel, who serve as volunteers and which oversees more than $2 billion in taxpayer funds for state healthcare programs, including Medicaid.

The Legislature appoints the remaining four members.

Hausheer said the axe fell after the two doctors stymied Stitt’s latest effort to outsource the state’s Medicaid program using a backdoor administrative rules process instead of working with the Legislature and health care community.

Stitt has argued that outsourcing Medicaid could save money and improve health outcomes.

“He didn’t get his way, so he’s just getting rid of those of us that don’t see eye-to-eye with him,” Hausheer said.

She said as of Tuesday, Stitt had filled the posts with non-physicians.

Hausheer, an ophthalmologist with the Dean McGee Eye Institute, which is based in Lawton, said Stitt had previously tried a similar unsuccessful strategy to outsource the program to managed care providers. Earlier this year, the state’s highest court rejected that plan, ruling that it was pushed forward without proper legislative approval.

Hausheer said Stitt’s administration now is attempting to create administrative rules under Senate Bill 131, which put guardrails on the governor’s plan. She said lawmakers, though, told her the Senate bill never took effect because of the Oklahoma Supreme Court ruling.

Hausheer, a practicing physician for more than 40 years, said Stitt appointed her to the board in 2019 with the understanding that she’d serve for four years. She and Shamblin were two of three women who served on the board and the only two licensed physicians. She said the timing was odd because the dismissal came during the month that honors women in medicine.

Hausheer said instead of attempting to outsource Medicaid through administrative rules, Stitt should put together a team that includes legislative leadership, Health Care Authority staffers and members of the state’s health care community.

“We would meet with him gladly and find a pathway forward,” Hausheer said. “(Managed care organizations) by themselves are not necessarily evil for all things. They’re not. It’s just that they would work better for some things and would work terrible for other things.”

She said that strategy would result in a more meaningful partnership as opposed to Stitt’s methods right now of getting rid of people who don’t agree with him.

In an email Tuesday, Carly Atchison, a Stitt spokeswoman, did not comment on why Stitt decided to boot Hausheer and Shamblin from the board.

“The governor is grateful for Dr. Hausheer and Dr. Shamblin’s service to the state of Oklahoma,” Atchison said.

She also said Stitt welcomes Susan Dell’Osso and Gino DeMarco to the board “to help make Oklahoma a Top 10 state for health outcomes.”

Atchison said Dell’Osso served as former chief innovation officer for Integris Health, has experience across the state’s different health systems, and a passion for serving Oklahoma communities.

“Gino DeMarco has voluntarily left retirement to once again serve the state, bringing a unique entrepreneurial talent for innovation, growth and development” including years as a senior executive at a Medicaid consulting and software company, she said. DeMarco previously served as the state’s “PPE czar” during the COVID-19 pandemic where he was tasked with obtaining personal protective equipment during a nationwide shortage. He also served as deputy director of the state’s Tourism and Recreation Department.

State Rep. Marcus McEntire, R-Duncan, said it’s disappointing that Stitt chose to dismiss the only two physicians who served on the board.

“Those people care deeply about our state and the direction it’s going with health care,” McEntire said. “I have an idea why he did it. But, I don’t think it bodes well for people who are willing to serve the state on these boards that if they make a decision that somebody higher above them doesn’t like, then they get axed. We’re all trying to pull the state in the right direction.”

McEntire, House author of Senate Bill 131, said the measure was intended to put limitations on the same policy that the Oklahoma Supreme Court voided. He said the measure didn’t take effect given the ruling.

He also said he’s disappointed Stitt is attempting to press forward with outsourcing managed care through administrative rules.

McEntire said the Health Care Authority governing board is comprised of medical experts, yet the majority continues to be against managed care.

Now the board is void of the expertise of practicing physicians, he said.

Support local journalism.

We are making critical coverage of the coronavirus available for free. Please consider subscribing so we can continue to bring you the latest news and information on this developing story.

Clipped from:

Posted on

After Weeks Of Uncertainty, D.C. Medicaid Recipients Avoid Losing Access To MedStar Doctors

MM Curator summary


After threatening to stop seeing Medicaid patients unless its competitor health plans paid them more, a hospital health plan got its contract extended for at least 9 months by the mayor of the U.S. capital.



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.



Thousands of Medicaid recipients were recently at risk of loosing access to their doctors.

Tyrone Turner / WAMU

Over the past several weeks, a chaotic situation unfolded in D.C.’s Medicaid system, potentially disrupting the care of thousands of the city’s poorest residents. 

MedStar, a health system in the city that also manages a health insurance company, announced that it was ending its contracts with two other companies that cover the city’s Medicaid recipients. Thousands of residents were at risk of losing access to a range of MedStar’s services – including primary care doctors, specialists, and pharmacies. 

According to the city, 80% of D.C.’s Medicaid recipients are people of color; 75% are Black residents living in wards 7 and 8. 

“You have to have a working Medicaid system in order to care for low income and poor communities,” says Ambrose Lane Jr., the founder of Health Alliance Network, a group that advocates for health equity in the city. “That’s what it was built for. Now, one could argue whether or not it was the best system that was built. Now, that’s an argument for a later date right now, we need health care coverage for poor and low income communities.” 

Mayor Muriel Bowser used an emergency order to extend the city’s contract with MedStar for at least nine months, but the debacle marked the latest development in a complicated relationship between MedStar and the D.C. government. 


Clipped from:


Posted on

Akron Children’s creates new company to care for 100,000 Medicaid patients

MM Curator summary


A children’s hospital is starting a Medicaid ACO for children.


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.


Akron Children’s Hospital is creating a new subsidiary to help coordinate and improve overall care of 100,000 Medicaid patients in a 13-county region. 

The new company called the Akron Children’s Health Collaborative will be what’s called an accountable care organization or ACO.

An ACO is a “partnership between doctors, hospital and other health care providers that work together to offer high quality care at a lower cost and directly with insurers,” said Kris Grayem, Akron Children’s vice president of population health. 


The first contract for the new company is with CareSource, the largest insurer of Medicaid-covered children in the state. The collaboration will begin Oct. 1. 

Akron Children’s is in negotiations with the other Medicaid managed-care insurers for children in its 35-county coverage area to create similar collaborations, hopefully within the next six months to a year, said Shawn Lyden, Akron Children’s chief strategy officer. 

This will be Children’s first foray into an ACO.

Instead of getting paid every time a child covered by CareSource is seen at the hospital or at Children’s physician offices,  Children’s will receive a set amount of money per CareSource enrollee per month, according to Grace Wakulchik, Children’s Hospital president and CEO. 

With those funds, the company is “entrusted to use to care for these group of Medicaid children,” Wakulchik said. “The thought being with our excellent clinical coordination systems, we can coordinate that care better so that those kids get better front-end care. So we manage their health better so there aren’t those adverse expensive hospitalizations. 

“We want to intervene early. We want to coordinate your care. We want to have the best possible outcome and so that’s the risk we are taking by accepting this per member per month amount that we will be able to manage that care better for those families,” she said. 

Akron Children’s officials declined to share financial details of the contract. 

How does the Akron Children’s Health Collaborative work?

Currently, the hospital loses money on each Medicaid patient, Wakulchik said.  

“We’re hoping by managing kids getting preventive care, dental care and other care, we’ll be able to manage their care when it costs less not only to us but to keep the kids healthier,” she said. “In the long run, I don’t know this will be as profitable per se, but hopefully we won’t lose as much money.” 

About 42% of the 100,000 children who will be part of this new care model are currently Akron Children’s patients and already get some of the holistic care through the hospital’s population health efforts, which started in 2017, Lyden said.  

For instance, Children’s already has been helping with other social barriers to health care —such as transportation needs, food insecurity and housing needs — for its existing Medicaid patients, said Grayem. 

But 58% of children covered in the new collaborative have primary care physicians who are independent practitioners or aren’t affiliated with Children’s. The monthly money Children’s collaborative will get can be used for some of those same social barriers for all covered children in the plan, according to Lyden and Wakulchik. 

Part of the model will be partnering with those providers to engage them in the proactive care of the children. Those independent practitioners still have their contract with CareSource and also will receive an incentive from Children’s ACO company to work together. 

An example, Wakulchik said, is “say we have a pathway that helps asthmatics stay out of the hospital. We’re not just going to use that for patients we serve in Akron Children’s. We want to work with our community partners and they will use them in their practice to help keep them healthier.” 

Medicaid is Akron Children’s single largest payor, accounting for 53% of total charge, Lyden said. 

“This is a ripe area for us to get involved in this accountable care population health,” he said. 

Akron Children’s has been working with a network of independent physicians and federally qualified health centers to set up the collaborative and also will have five members on the collaborative board, Wakulchik said. 

In a statement, CareSource Ohio Market President Steve Ringel said “CareSource’s history is built on breaking down the barriers of health care to increase access to seamless high-quality cost-effective care. 

“Our partnership with Akron Children’s Hospital will continue to support our youngest members and their families in northeast Ohio.” 

13 counties covered

The collaborative’s CareSource contract will cover 13 counties: Summit, Stark, Portage, Wayne, Medina, Ashland, Carroll, Holmes, Tuscarawas, Trumbull, Mahoning, Columbiana and Huron. 

There are still another 120,000 Medicaid-covered children in the 13 counties with other insurers that are not yet covered under this new model, Lyden said.  

Akron Children’s currently has a 35-county service area and will consider opportunities to expand the collaborative in future years, he aid. 

The new model is not a “patient-steering mechanism” to try to get more patients to Akron Children’s facilities, Wakulchik said. While she would like it if working with more community partners would involve better access to Akron Children’s facilities, the collaborative would be responsible for children’s care in the program anywhere they go. 

“They can go anywhere they want,” Lyden added. “They could go to Columbus and it’s still on our nickel. It still comes out on our fixed payment.” 

Said Grayem: “The main thing is we want to improve the health of kids by focusing on quality and improving health equity for better outcomes.” 

 Beacon Journal staff reporter Betty Lin-Fisher can be reached at 330-996-3724 or Follow her @blinfisherABJ on Twitter or To see her most recent stories and columns, go to


Clipped from:

Posted on

D.C. plans to rebid its troubled Medicaid contracts, as risk of patients losing access to MedStar doctors looms

MM Curator summary


One hospital-based health plan lost its DC contract and has threatened to not see Medicaid patients- and that has triggered a new MCO procurement.


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.


As a crisis roils D.C.’s Medicaid system, city leaders said on Friday that they will issue an entirely new procurement for insurance companies to manage poor patients’ care — an attempt that may or may not prevent MedStar from revoking access to its doctors for hundreds of thousands of poor patients.

The city’s Medicaid troubles reached a boiling point last week when Deputy Mayor Wayne Turnage said that MedStar, the hospital system that most often cares for D.C.’s beneficiaries, had announced its intention to stop providing routine care for most Medicaid patients in the coming months.

The new plan to rebid the contracts might represent one step toward resolving the impasse with MedStar, though a new procurement does not necessarily mean that low-income patients won’t face the loss of their current insurance plan or their access to some doctors this fall.


D.C. Medicaid patients could lose access to MedStar, the health system that most often treats the city’s poor and sick


The situation developed after a judge last year ruled that the city had improperly awarded the contracts, collectively worth about $1.5 billion, to three insurance companies to manage the care of 250,000 Medicaid beneficiaries and participants in the Alliance program for other low-income patients. The judge said MedStar, which operates both a hospital system and an insurance plan, had not followed procurement rules and shouldn’t have been awarded one of the contracts.

Under the ruling, MedStar is set to lose its contract at the end of September. With that date approaching, according to Turnage, MedStar told the other two insurers — who under the ruling were set to keep their contracts — that starting later this fall, it will no longer treat their Medicaid patients at its hospitals and doctors offices, except for emergency room visits, unless the insurers start paying much higher rates.


That set off a scramble last week by D.C. officials to prevent hundreds of thousands of patients from losing access to MedStar doctors. Friday’s announcement was the first step.


D.C. Council won’t take action that could allow MedStar to keep its Medicaid contract


Turnage said that the Department of Health Care Finance, which he heads, decided to now require Medicaid managed care plans to cover intensive inpatient mental health and substance abuse treatment programs that are currently paid for directly by the District, not by the insurance plans. This change in the managed care program will require the city to rebid the contracts, Turnage contends. That would have the secondary effect of eventually allowing MedStar another chance to win the contract, after the department issues its new request for proposals in November.


All three insurers who currently hold the contracts have either declined to comment or not responded to inquiries from The Washington Post. They would all need to bid again to stay in the program.

Turnage’s action Friday could give the appearance that the city found an excuse to redo the procurement just so that it could give MedStar a contract again — and thus satisfy the company so that it won’t revoke access to its doctors in the meantime. As the mayor and council have fought over the Medicaid situation for months, accusations of “contract steering” have flown back and forth. Council members have voted down Mayor Muriel E. Bowser and Turnage’s proposals that they viewed as unfairly crafted to make room for MedStar in the program, and Turnage said council members who tried to require the city to abide by the judge’s order were assisting Amerigroup, which could have replaced MedStar as the third insurer.


Turnage said he was not promising any business to MedStar, but acknowledged the timing of the decision could potentially help the District out of its current quandary. “Obviously if we have a chance to both modify the program to bring in new benefits and also take some actions to ensure there’s no disruptions, we take advantage of that propitious timing,” he said. “This is going to be a competitive procurement. There will be many comers, and nobody’s going to be guaranteed a spot.”


In the meantime, two major disruptions loom: First, when MedStar’s contract as an insurer ends in a month, the nearly 60,000 patients covered by the plan would be reassigned to either CareFirst or AmeriHealth. The three insurers all have contracts with the city’s major hospitals and clinics, but the change could still be a headache for some patients.


Turnage said that Bowser is studying that issue. Unless Bowser takes action to stop MedStar’s contract from ending — a power she may have under her coronavirus pandemic emergency authority — notifications are scheduled to go out to those patients about their new insurance coverage starting Wednesday.


And second, long before the new procurement is complete, CareFirst and AmeriHealth patients will lose access to MedStar doctors unless the insurers can broker some sort of agreement.


That’s what scares one Ward 7 resident, who spoke on the condition of anonymity to keep her health conditions private. The resident, a 50-year-old woman, is a longtime Medicaid patient who has lost access to her primary care provider in the past due to the fluctuating agreements between hospital systems and Medicaid managed care providers.


That time, it took her two years to find another primary care doctor, she said. The asthma that her old doctor had helped her control worsened, and she became prediabetic before she found a nonprofit clinic where she could get medical care.


Now, she is enrolled in AmeriHealth’s managed care plan and is seeing a cardiologist and a pulmonologist at MedStar. She fears she’ll lose access to her doctors once again.


“We don’t get to say anything. Because we’re poor, we don’t get no say, and it’s not fair,” she said. “They’re always talking about health disparities. How can we address them if we aren’t going to the doctor?”


Clipped from:

Posted on

Ambulance carveout is latest Illinois Medicaid managed care battleground

MM Curator summary


Ambulance providers are lobbying to go back to fee for service payment, but advocates oppose the move saying it will be more difficult to ensure quality member outcomes.


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.



Multiple ambulances are housed at the LeRoy Emergency Ambulance shed, pictured here Friday.


SPRINGFIELD — Stakeholders are calling on Gov. J.B. Pritzker to sign a bill that passed the General Assembly unanimously and would remove non-emergency ambulance services from the state’s Medicaid managed care program in favor of a fee-for-service model.

While an association group representing ambulance services says House Bill 684 is needed to counter arbitrary denials of claims by private insurers, the governor’s office and the state agency that oversees Medicaid expressed “serious concerns for patient safety and cost” as Pritzker continues to review the bill.

While the bill is a targeted carveout of ambulance services from the state’s Medicaid managed care program, or the privatization of Medicaid, it marks the latest catalyst for debate over the effectiveness of that program which was greatly expanded in 2017 under former Gov. Bruce Rauner.


Chris Vandenberg, president of the Illinois State Ambulance Association, said in a phone call Monday the bill was in response to the “arbitrary” denial of ambulance claims by Medicaid managed care organizations, or MCOs.

MCOs are private insurance companies that contract with the state to manage the care of individuals enrolled in Medicaid. Among other things, that involves working with patients to make sure they receive routine exams and preventive care, and coordinating services provided by their primary physicians and other specialists.

Vandenberg said that leads to MCOs padding profits through denial of claims.

“Since managed care began in Illinois, it’s been a struggle,” Vandenberg said. “So, we have EMTs and paramedics that are working, trying to transport patients, and really, we’re not able to get any of this reimbursement. …And so it’s really impacted the ability to attract and retain EMTs and paramedics, and really it’s causing a serious impact to Medicaid beneficiaries in that they’re not able to find transport as easily as they used to.”

Putting ambulances back in the fee-for-service system would allow providers to submit claims directly to the state Department of Healthcare and Family Services, which Vandenberg said would provide predictability and certainty to the billing process.

Jamie Munks, a spokesperson for HFS, said in a statement the department “remains strongly opposed” to the ambulance carveout, “because it has the potential to negatively affect the quality of service, create longer wait times for medical transports and payment delays for providers, and could create confusion for customers and providers.”

They protect and serve often at minimum wage or no pay at all.


Munks said about $3 million of potential lost revenue due to the state’s tax on MCOs which generates greater federal reimbursement resulting in hundreds of millions of dollars in revenue annually. She also noted unspecified “administrative costs” in switching ambulances back to fee-for-service.

If Pritzker doesn’t act on the bill by the end of the week, it would become law even without his signature. If he vetoes it, lawmakers would be able to override the action with a three-fifths majority when they meet for the veto session this fall.

Pritzker spokeswoman Jordan Abudayyeh said in a statement the governor “will take the appropriate action” before this weekend’s deadline, but “the administration is concerned that this legislation has the potential to disrupt care and reduce the quality of provided services to some of the most vulnerable Illinoisans.”

Specifically, the governor’s office said a Medicaid enrollee needing a non-emergency ambulance ride can currently contact their MCO and be connected with an ambulance transport that’s contractually obligated to respond “in a timely fashion.”

The administration fears if the governor signs the bill, “a consumer will be forced to use the vendor contracted with by the fee-for-services program — a vendor that is not contractually bound to provide timely services.”

“Consumers would be forced into the uncertain position of not knowing which of their health care services are covered by their MCO, and whether they will be able to secure transport in a timely fashion,” Abudayyeh said in the statement. “During the COVID-19 pandemic, the Department of Healthcare and Family Services received consumer complaints regarding the difficulty of securing transport from their fee-for-service vendors to get to non-emergency health care services like check-ups and dialysis.”

Advocates for the bill, including Rep. Will Davis, D-Homewood, who is one of its chief co-sponsors, argued the current MCO structure is what’s threatening response times.

Davis said private ambulance companies often handle the 911 calls for communities that are underserved medically. While companies contracting with those municipalities are already on the fee-for-service structure for emergency services due to changes made in April, payment uncertainty for other transportation services those providers render could affect staffing levels, Davis said.

“It’s not just, you know, the providers trying to get paid,” Davis said. “Their ability to receive resources helps their ability to keep their staffing levels up so they can bring down response times when people call 911. So there’s the staffing aspect of it, there’s the idea of making sure that they can provide services to underserved communities.”

Representatives of the Ambulance Association said an early amendment to HB 684 removed non-ambulance medical transports in an effort to address transportation concerns. The current bill is simply a way to “get paid for the services provided,” which they’ll still be obligated to provide under a fee-for-service system.

Samantha Olds Frey, CEO of the Illinois Association of Medicaid Health Plans, cited concerns similar to Pritzker’s about how the bill “impacts our most vulnerable members that need non-emergency ambulances for routine care such as dialysis treatments, doctor’s appointments, or scheduled hospital trips.”

She noted MCOs can offer higher reimbursement rates than HFS can for such a transportation service, so moving it back to a fee-for-service plan could further jeopardize those Medicaid enrollees. While MCOs have care coordinators that make follow-up calls to transporters to connect a customer to a service, HFS does not, she added.

“IAMHP met with the industry during the legislative session to try and find a solution that doesn’t jeopardize the care our members receive,” she said. “The ambulance industry refused to come to the table in good faith. However, we are still willing to understand what the systematic issue is and work toward a solution.”

Davis, meanwhile, said concerns over “arbitrary” claim denials from MCOs are nothing new or unique to the ambulance industry.

That’s why, as part of a health care reform backed by the Illinois Legislative Black Caucus earlier this year, lawmakers created a Managed Care Oversight Commission to, according to Davis, “really dive deep into if we’re going to continue to have an MCO structure – which, you know, some really don’t want – that we can have more oversight and input into how they operate versus kind of the autonomy that they enjoy right now.”

While Davis said HFS has “abdicated” its oversight role of MCOs, Munks said for over two years the agency has been “holding frequent meetings with providers and health plans, a forum to bring everyone together to resolve issues.”

She said HFS put in place a “claims clearinghouse” creating greater transparency into claim denials, “allowing the department to have better oversight of certain billing issues.”

She said claim denial rates for non-emergency ambulance services within the fee-for-service program are 40 percent, while MCO denial rates are between 10 and 15 percent, although the Ambulance Association disputed that claim, saying the denials it experiences are through MCOs.

As well, while HFS cited a billing complaint portal that has received only four claims in more than 17 months, the Ambulance Association dismissed that portal as “another way to give the providers the runaround.”


Clipped from:

Posted on

Ohio Medicaid chief dodges when asked to explain business with company AG said “fleeced” taxpayers

MM Curator summary


Ohio Medicaid officials are given hard questions about awarding a contract to Centene, who recently paid an $88M fine related to the PBM spread-pricing scandal.


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.


Massive contract restarted after settlement


The Centene Corporation headquarters. Photo from Google Maps.

Ohio Medicaid Director Maureen Corcoran didn’t give many straight answers Wednesday when she was pressed about why her agency restarted a massive contract with a company that earlier this year was accused of “fleecing” taxpayers out of tens of millions of dollars.

At one point, Corcoran even invoked lawyer-client privilege to avoid answering a question.

Appearing on WOSU’s “All Sides With Ann Fisher,” Corcoran was asked by Fisher why her agency would again trust Centene, the largest Medicaid managed-care contractor in the United States. The department earlier this month restarted negotiations for a 2022 contract with the company. 

That was just six months months after Ohio Attorney Dave Yost announced that Centene had agreed to pay $88.3 million to settle claims that the company had improperly inflated pharmacy claims by massive amounts. Centene also announced that it was setting aside more than $1 billion to settle similar claims in 21 other states. 

The company has emphasized that it didn’t admit to any wrongdoing in the settlement. But in March, Yost was unequivocal when he filed the suit.

“Corporate greed has led Centene and its wholly owned subsidiaries to fleece taxpayers out of millions,” he said.

The Medicaid department announced that it was restarting negotiations with Centene by posting a press release to its website saying the agency was giving Ohio Medicaid clients “more options.” It only alluded to the lawsuit by saying negotiations had been paused because of it and now that the suit had been settled, a contract would be awarded.

Asked at the time why the agency should now trust Centene with taxpayers’ billions, a Medicaid spokeswoman didn’t answer, other than to refer to the press release.

Fisher on Monday sought to press the question with Corcoran, asking why the agency would trust a company the state AG had just accused of fleecing taxpayers. Corcoran’s response was meandering.

“The action that was brought by the attorney general was really separate from the procurement process that we were engaged in which was of course very rigorous,” she said. “It is very common, normal practice in Medicaid that when there are any kinds of legal actions against any kind of managed care provider or a hospital or whomever, we have them identify that, we look into that. 

“So we are aware of and looking into legal actions whether here in Ohio or elsewhere is part of the normal Medicaid application process. So of course when we heard the attorney general was going to bring this action, we in similar fashion as I just mentioned took a step back and said we are going to make our own assessment. The attorney general then settled the case.

“There were still several weeks as you know that passed and we were making our own assessment at the same time and determined that we were going to proceed with them as part of our newly selected group of plans. They also, you may remember, scored the second-highest score (in a competitive procurement) from a quality point of view, so they provide good care, they’ve been a partner in Ohio.”

Transcripted excerpt of Corcoran’s interview on “All Sides with Ann Fisher.”


Ohio Medicaid Director Maureen Corcoran. Official photo.

Corcoran then pointed out that Centene’s alleged ripoff had to do with pharmacy benefits. She seemed to imply that since Centene wouldn’t have responsibility for the service under the new setup, there’s nothing to worry about.

“But I also think one thing that’s important to mention is that the issue that the attorney general brought has to do with pharmacy benefit managers and the role that they play with medications,” Corcoran said. “Two years ago, our General Assembly passed a law taking that responsibility away from the managed care plans and instructing the Department of Medicaid to set up a separate pharmacy benefit manager. 

“So, in essence, it was important for us to have good business partners, but in essence the underlying problem… and corporate oversight has changed and that set of responsibilities as part of our new design will not be with the individual plans, but will be managed directly by the state.”

How, Fisher asked, had Centene’s corporate oversight changed. Corcoran didn’t really answer, saying instead “we interact with them as a business partner” and that her team was making sure there will “be appropriate ethical training and that there be oversight and compliance monitoring.”

Then Corcoran was asked, since the Ohio attorney general acts as the Medicaid department’s lawyer, whether she had sought legal advice from Yost before deciding to continue the state’s business with Centene.

“As you know, attorneys and clients have a certain legal protection that, if I were aware of any of that, I wouldn’t be able to share it with you anyway,” Corcoran said in a reference to attorney-client privilege. That’s a doctrine that prevents an attorney from discussing privileged matters, but places no such restriction on the client.

Fisher again tried to get Corcoran to explain why she trusted Centene to be a good steward of Ohio’s money — this time in the toughest terms.

“Why would you continue to do business with a company that, as Attorney General Yost said, fleeced taxpayers out of millions?” Fisher asked. “It sounds like you’re doing business with a con man.”

Corcoran didn’t answer the question, instead launching into a 270-word talk about how rapidly the Medicaid program had grown and how the General Assembly has taken steps to reform how the agency handles drug transactions.

Corcoran did, however, answer one question directly.

It came to light this week that Michael Kiggin — a longtime friend of Gov. Mike DeWine — registered to lobby on Centene’s behalf just before Yost sued the company. Among the agencies Kiggin said he’d lobby were the governor’s office and the Medicaid department.

Asked if she knew Kiggin and whether Kiggin had communicated with her about the Centene contract, Corcoran said, “I don’t know Michael Kiggin. I’ve not talked with him, so I can’t really comment on that.”

Asked if Kiggin had communicated with Medicaid staff — including those involved in the Centene contract, Corcoran said, “Absolutely not.”

Clipped from:

Posted on

FL- Medicaid plans offer incentives to boost vaccinations

MM Curator summary


FL MCOs are now offering gift cards to Walmart for $25 if members get the vaccine.



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.



TALLAHASSEE — As the delta variant of the coronavirus sweeps across the state and brings a record number of COVID-19 hospitalizations, managed-care plans that serve hundreds of thousands of Medicaid beneficiaries are offering incentives to get people vaccinated.

Gov. Ron DeSantis’ administration did not provide to The News Service of Florida the percentage of people in Medicaid managed-care plans who are 12 or older and are vaccinated against COVID-19.

But at least three Medicaid health maintenance organizations have started offering financial incentives to their members to get at least one vaccine dose.

The moves have come after a call by state Medicaid director Tom Wallace to increase COVID-19 vaccination rates, particularly for people age 50 or older.

Related: COVID is still a deadly threat to older Floridians

In a June 18 memo to health plans, Wallace called vaccines a “critical” prevention measure.

Simply Healthcare Plans sent a memo to its Medicaid network providers in July encouraging them to advertise the incentive program to patients who they thought could be good candidates for vaccination. The plan is offering $25 gift cards to Walmart.

Marc Kaprow, chief medical officer for Simply Healthcare, told the News Service that the initiative was partly in response to the state’s efforts to have at least 50 percent of Medicaid beneficiaries who are 50 or older vaccinated.

Simply has about a 10 percent market share in part of the Medicaid program that provides long-term care. It also has a presence in part of Medicaid that serves a broader population — known as Medicaid managed medical assistance — and in HIV/AIDS specialty markets where it operates under the Clear Health Alliance moniker.

“We do better when our patients stay healthy. The vaccines create a tremendous opportunity for that to happen,” Kaprow said, adding, “We want our folks to not be in the hospital, we want our folks to do well.”

Related: Biden to require COVID-19 vaccines for nursing home staff

Simply Healthcare did not provide to the News Service a breakdown of its vaccination rates among Medicaid beneficiaries.

Florida Department of Health data shows that 47 percent of the state’s overall population of people ages 12 to 19 had received at least one vaccine dose as of Thursday. Rates for people ages 50 to 59 and 60 to 64 were 72 percent and 80 percent, respectively, according to a department report published Friday.

Related: Florida adds 150,118 coronavirus cases, 1,486 deaths in past week

The state uses managed-care plans to oversee health services for about 3.8 million people in the Medicaid program.

The plans are paid monthly premiums by the state to oversee care, including preventive care, for low-income, elderly and disabled people. By focusing on prevention, the plans are supposed to avoid more costly hospital care.

Community Care Plan, a Broward County-based plan, is offering access to $20 gift cards to members who are willing to receive at least one vaccine dose. Suzanne Tamargo, a spokeswoman for the plan, owned by the North and South Broward hospital districts, said about 100 people have taken advantage of the offer.

While Tamargo did not disclose vaccination rates, she said the incentives helped the health plan exceed the state’s goal of vaccinating at least 50 percent of beneficiaries age 50 or older.

Vivida Health Plan, which operates in Lee, Collier, Charlotte, Sarasota, DeSoto, Glades, Hendry, Lee and Sarasota counties, also has been providing gift cards since Aug. 5 to people willing to get vaccinated, according to its website.

Audrey Brown, chief executive officer of the industry group Florida Association of Health Plans, said gift cards are unusual but that the plans are looking at “every possible action that we can think of in order to get the Medicaid recipients vaccinated.”

While she said she did not have updated data, Brown said she had seen numbers from several weeks back that indicated several health plans had met the 50 percent mark for people 50 or older.

“It’s been an uphill battle, but incredibly important,” Brown said.

While health plans are offering incentives to their members, the state also is offering incentives to the plans to increase vaccination rates.

In the June memo, Wallace said the state would be willing to lower what are known as “liquidated damages” assessed against health plans if every plan met the 50 percent vaccination rate in the 50-plus population by Aug 31. The state levies liquidated damages against health plans when they don’t meet terms of their Medicaid contracts.

Wallace revised the policy last week, eliminating the requirement that all managed care plans meet the 50 percent threshold before reductions in liquidated damages could be triggered. Under the revised policy, any health plan that hits the 50 percent vaccination rate for people age 50 or older could qualify for lower liquidated damages.

Longtime social services lobbyist Karen Woodall said the policy is a “little screwed up.”

“It’s screwed up because it’s their job. Their job is to ensure adequate health care to their members,” Woodall said. “So they should already be focused on encouraging vaccines for their members.”

Woodall said the policy suggests that the plans have subpar vaccination rates. If they don’t, she said, the state is providing incentives to the health plans for goals they already are reaching.

By Christine Sexton, News Service of Florida

Clipped from:

Posted on

Ohio delays rollout of revamped Medicaid system to July 2022

MM Curator summary


Ohio managed care and PBM changes will begin 6 months later than originally planned.


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.



Ohio pushed back its projected launch date of its revamped and reformed Medicaid managed care system to July 1 of next year,  the Ohio Department of Medicaid announced Wednesday.

The initial timeline set the launch of the long-awaited system in January.

“Our priority since the beginning of this administration has been on doing this right for the people we serve,” said Ohio Medicaid Director Maureen Corcoran. “A July 2022 go-live gives us time to support and inform our members about the new program, to work with community leaders and respond to the feedback received from the plans and providers.”

The “next generation” managed care system is the result of an extensive process that started in 2019, looking at ways to improve and overhaul the system after years of issues and without any reform.

More:Six companies will split $20B in managed-care work under biggest contract in Ohio history

More:Ohio children on Medicaid now eligible for $100 COVID-19 vaccine incentive

Medicaid, the governmental health insurance for more than 3 million low-income or disabled Ohioans, is typically the state’s largest expenditure, with billions of dollars at stake.

The department already has many of the reforms planned and designed out; it’s just a matter of feedback and implementation. Of note are the additions of OhioRISE, which would treat children with severe behavioral and mental problems so parents don’t have to give up custody, and a single pharmacy benefit manager system, to fix the issue of such prescription drug “middlemen” overcharging taxpayers.     

The delay in rolling out these reforms is partly due to the unanticipated “persistence of COVID-19 and its impact on individuals served by the program and their providers,” said the Medicaid department.

There’s uncertainty on when the end of the federal public health emergency declaration for COVID-19 will be. The declaration’s end will impact the department’s plans in terms of whether there will be additional federal money, said Corcoran in a media briefing. Medicaid officials were also worried how the transition could cause instability for consumers amid a pandemic.  

Other factors will complicate the situation. As part of the overhaul, the department re-selected which health plans got its lucrative contracts to handle Medicaid managed care, and those who lost out have complained.

Buckeye Community Health Plan and its parent company Centene were initially deferred due to an ongoing lawsuit from the state alleging the company unlawfully took Medicaid money. But that has since been settled, and Centene was recently granted a contract.

Paramount Advantage, owned by Toledo-based ProMedica, is the only current Medicaid managed care organization that lost out on a contract. It tried to reverse that by appealing the decision and asking state lawmakers for help, but those efforts failed.

The Toledo company now has a lawsuit in the state seeking to halt the overhaul and invalidate the contracts. If successful, that could further derail the department’s timeline.

According to court records, a trial assignment was scheduled for July 25, 2022. A hearing for a preliminary injunction is set for earlier, on Oct. 12.    

Titus Wu is a reporter for the USA TODAY Network Ohio Bureau, which serves the Columbus Dispatch, Cincinnati Enquirer, Akron Beacon Journal and 18 other affiliated news organizations across Ohio.


Clipped from: