Tag: Medicaid Managed Care

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[ MM Curator Summary]: A recent audit suggests the two programs do not duplicate services, but the Medicaid agency disagrees.

 
 

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

 
 

 
 

A look at the millions of dollars Florida is spending on health care and social services for pregnant women, infants and children shows little duplication and offers good news to those who support the programs.

A recently released report conducted by the Office of Program Policy and Government Accountability shows there’s not much overlap in care provided by state-contracted Medicaid managed care plans versus services offered by the Florida Healthy Start program.

“Overall, the report is extremely positive,” Catherine Timuta, chief executive officer of the Healthy Start MomCare Network, told Florida Politics Tuesday. “There weren’t any significant findings of duplication.”

OPPAGA began a review of the services the HealthyStart MomCare Network and statewide Medicaid managed care plans offer pregnant women to see if they were duplicating services and whether those services meet state and federal requirements.

To that end, OPPAGA researchers reviewed contracts between Medicaid-managed care plans and the Florida Association of Healthy Start Coalitions, which contracts with the plans on behalf of 33 local groups.

OPPAGA also reviewed Agency for Health Care Administration contracts, including one between AHCA and the Healthy Start MomCare Network, which holds contracts with the state on behalf of the 33 local Healthy Start Coalitions.

“These agreements show overlap between the entities in two areas: care coordination and data sharing,” the OPPAGA report notes.

Timuta noted, however, data sharing is mutually beneficial for the health plans and the coalitions, because it provides both entities with information on the enrollees and the services they receive.

To delve into the coordination of services, OPPAGA staff conducting the research also did follow up interviews with Healthy Start and representatives from Medicaid health plans to get additional details on the care coordination services provided. Eight of the nine health plans told OPPAGA there was no service duplication.

“While some services provided by health plans and Healthy Start may appear similar, Healthy Start and health plan staff reported that services provided via the two entities are largely distinct and complementary,” the report notes.

The Health plans and Healthy Start both provide home visits, but Healthy Start staff told OPPAGA researchers their program participants are visited at least once a month and are provided prenatal education, parenting education, interconception education, stress management education and screenings. The health plans told OPPAGA researchers home visits for health plans are short-term services and have a more medical focus.

AHCA, though, didn’t see things the same way.

According to the report, “AHCA staff reported that some services included in the AHCA-MomCare Network contract are also covered under the AHCA-health plan.”

However, the report notes that due to data limitations, the existence of duplication cannot be validated.

“OPPAGA staff requested AHCA claims data in an attempt to verify whether service duplication is occurring. However, while Healthy Start services are contained in AHCA’s claims data, health plans reported that the services that may be considered comparable to Healthy Start (e.g., home visits and community referrals) are provided as part of care coordination, which is not a billed service and thus does not appear in the claims data,” the report notes. “Because data for services provided by health plans are not available in AHCA’s encounter data, claims data analysis cannot be used to validate whether there is service duplication between Healthy Start and the health plans.”

According to the report, OPPAGA requested agency staff to provide them with the procedure codes used by health plans to ascertain if there was a difference between social and medical service provisions, but the agency did not provide OPPAGA the information.

OPPAGA is the research arm of the Florida Legislature. It provides lawmakers with data, evaluative research, and objective analyses meant to inform policy decisions.

The report shows that in state fiscal year 2020-21, Medicaid health plans submitted data on 104,935 enrollees to the Florida Healthy Start, of which 66,191 matched a case in the Florida Healthy Start system.

Of those 66,191 women, about 73% of them, or 48,267, received at least one service. When asked about the women who didn’t receive services, Timuta, chief executive officer of the Healthy Start MomCare Network, said the program is voluntary.

The report comes as Florida lawmakers prepare to meet for the 2022 Legislative Session where work on the upcoming fiscal year 2022-2023 budget begins.

The 2021 Legislature appropriated $63.1 million to AHCA for Healthy Start services provided under the contract between AHCA and MomCare, a $21.9 million increase from the prior fiscal year. The funds covered a near $11 million deficit, which AHCA said was caused by COVID-19, and provided services to a growing number of women, infants, and children.

A review of Gov. Ron DeSantis’ proposed budget for fiscal year 2022-2023, though, shows the Governor is not recommending that the $21.9 million bump in funding be continued in the 2022-2023 budget, which lawmakers will work to create when they meet in Session in January.

Christine Jordan Sexton is a Tallahassee-based health care reporter who focuses on health care policy and the politics behind it. Medicaid, health insurance, workers’ compensation, and business and professional regulation are just a few of the things that keep me busy.

Clipped from: https://www.claytodayonline.com/stories/report-medicaid-health-plans-florida-healthy-start-dont-provide-same-services,32402

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[ MM Curator Summary]: Molina completes another acquisition, this time adding 50,000 lives.

 
 

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

 
 

Dive Brief:

• Molina has completed its acquisition of rival health insurer Cigna’s Medicaid contracts in Texas, the California-based payer said Monday, as it continues to invest heavily in the safety-net insurance program.
  
• The purchase price for the transaction was approximately $60 million in cash, according to a recent filing with the SEC.
  
• Though Molina was already active in Texas, nabbing Cigna’s beneficiaries is a significant add: As of November, Cigna covered approximately 50,000 Medicaid beneficiaries in the state. Molina closed out 2020 with 357,000 members in Texas. 
  

Dive Insight:

Molina covers some 4.8 million people in the U.S., but Medicaid is the payer’s flagship business, representing more than three-fourths of its members (and premiums). The program has grown because of the pandemic, causing some players in Medicaid markets to ratchet up their investments and others to jump in for the first time.

Molina is known for being acquisitive, but has been on a tear as it looks to capitalize on this growth. Currently, the payer offers Medicaid plans in 18 states, with the greatest scale and revenues stemming from health plans in California, Ohio, Washington and Texas.

Moving to nab Cigna’s Medicaid contracts in Texas, first announced in April, is one such recent deal that should yield significant financial returns for Molina: Cigna’s some 50,000 Medicaid members in the state represent approximately $1 billion in annual premium revenue.

Along with recent contract wins in Nevada and Ohio, Molina also in October announced it had closed its acquisition of New York Medicaid health plan Affinity Health for approximately $380 million, and that it had entered into a definitive agreement to acquire AgeWell’s New York’s Medicaid managed long-term care business for approximately $110 million.

The AgeWell deal, which will add about 13,000 members to Molina’s rolls representing about $700 million in premium revenue, is expected to close by the third quarter this year.

Like most other major payers, COVID-19 ushered Molina to high profits in 2020, but more recently has negatively impacted the insurer’s finances. Molina’s net income in the third quarter of $143 million was down 23% year over year as the payer shelled out more for patient care than in the prior-year quarter.

Despite COVID-19’s volatility, Molina has been managing well in the markets, outperforming the S&P 500 last year. But the stability of the Medicaid rolls it’s so dependent on is a key area of interest for market watchers, as the longevity of the public health emergency will determine if and when a restart of Medicaid redeterminations will impact managed care organizations this year.

The Families First Coronavirus Act, passed in March 2020, gave states a temporary bump to their federal match funds in the Medicaid program as long as they ensured eligible beneficiaries stayed enrolled during the national emergency. That continuous coverage requirement contributed to Medicaid becoming the largest single source of insurance coverage in the U.S.

But when the emergency ends, states can resume redeterminations, potentially kicking millions off the safety-net insurance due to a change in income or other factors.

Molina said along with its third quarter financial release it expects the public health emergency to run at least through mid-January.

The payer’s Medicaid enrollment has ballooned to about 4 million members at the end of the third quarter, due primarily to the continuing suspension of redeterminations. Molina estimates that’s resulted in an increase of more than 700,000 Medicaid members since the beginning of the pandemic.

However, CEO Joe Zubretsky told investors in October the insurer expects to keep only half of those new Medicaid members gained during the pandemic after redeterminations are resumed nationwide.

Clipped from: https://www.healthcaredive.com/news/molina-closes-60m-acquisition-of-cignas-medicaid-contracts-in-texas/616674/

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[ MM Curator Summary]: A state legislator wants to pre-empt the MCO protest machine.

 
 

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.

 
 

 
 

Sen. Jason Brodeur filed SB 1950, a 36-page proposal to reduce Florida’s number of Medicaid managed care regions — from 11 to eight — and require managed care plans to contract with two of the state’s cancer hospitals.

Filed Monday, the bill, in an attempt to blunt potential legal challenges to the nine-figure Medicaid procurement, contains language that would preclude any managed care plan from providing care to any of its enrollees until all administrative challenges to the procurement are settled.

Brodeur’s proposal would reconfigure the current 11 Medicaid-managed care regions.

The bill consolidates Medicaid Regions 1 and 2 into a Medicaid Region A. Medicaid Regions 3 and 4 will roll into the new Medicaid Region B. And Medicaid Regions 5 and 6 are rolled together into Region C. The rest of the Medicaid regions remain the same, with letters replacing numbers.

Florida requires most Medicaid beneficiaries to enroll in a managed care plan to receive services from the cradle to the grave. Only Medicaid-managed care organizations that win competitively bid Medicaid contracts in a region can provide the care. The current Medicaid managed care contracts expire on Dec. 31, 2023. The agency is gearing up to begin the new procurement process and work on the new Medicaid managed care contracts to replace the current agreements.

 
 

The bill comes weeks after Agency for Health Care Administration Secretary Simone Marstiller signaled the agency would push for some legislative changes to the program.

Marstiller asked lawmakers in the fall to include an additional $2 million in her agency’s fiscal year 2022-2023 budget to hire outside counsel.

Marstiller said she wanted funding available to the agency “at the ready” to ensure her team can employ the best outside legal help available.

The Senate bill does not propose any changes to the Medicaid dental program, although Medicaid Director Tom Wallace hinted the agency might want to pursue changes.

The bill also requires Medicaid-managed care plans to contract with Sylvester Comprehensive Cancer Center and Moffitt Cancer Center.

The Brodeur bill eliminates the state’s requirement to allow the public to have feedback before submitting Medicaid amendments to the federal government for review. AHCA told Florida Politics Tuesday the public comment requirement being eliminated from the bill was specific to creating the Medicaid managed care program. Federal law still requires a public comment period.

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Clipped from: https://floridapolitics.com/archives/485399-medicaid-managed-care-bill-drops-on-eve-of-2022-legislative-session/

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[ MM Curator Summary]: Paramount throws in the towel now that Anthem will give its workers jobs.

 
 

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.

 
 

After claiming procurement bias, Paramount makes deal with Anthem

 
 

An Ohio-based Medicaid managed-care company is poised to end its legal action against the state.

Last year it accused the Ohio Department of Medicaid of bias and conflicts in a $22 billion bidding process. Toledo-based Paramount Advantage now says that if the department approves a deal for Anthem to take over Paramount’s patients, it will drop plans to appeal a lower-court ruling that dismissed its attempt to stop the huge procurement.

“Ensuring quality care for members and minimizing local job losses have been top priorities for Paramount since we learned that we had not been awarded a contract for the Ohio Department of Medicaid’s (ODM) new managed care program, which starts on July 1, 2022,” Paramount said in an emailed statement. “Entering into this agreement with Anthem will help address concerns related to these top priorities. And, if the transaction closes as planned, Paramount will not pursue further legal action against ODM.” 

The plans were first reported by Hannah News.

If the deal is approved, it will end a bitter challenge by Paramount to a procurement undertaken by Medicaid last year. 

Seeking to reshape the state’s Medicaid system, the department issued a request for applications by managed-care providers to show how they would prioritize the health of individual Medicaid recipients, who make up 25% of the Ohio population. At $22 billion, it was the biggest public procurement in Ohio history.

After years of claims that pharmacy middlemen working for managed-care providers were ripping off the state, the Medicaid department is taking that business away from those companies and is hiring a single drug middleman that will work directly with the Medicaid department.

Also as part of the overhaul, the department is hiring a single company that will create a continuum of services for 60,000 Ohio kids with complex behavioral health needs. The $1 billion program will work closely with the managed care providers under the revamped system, Medicaid officials have said.

Plans call for the new system to be implemented in July.

When the Medicaid department selected six companies to handle managed-care and another to run OhioRISE, the childrens’ program, it passed over Paramount, a longtime managed-care provider in the Ohio system. The department said the company’s application didn’t adequately explain how it would achieve the new goals the state was setting for its Medicaid program.

Paramount sued over the decision, and in court in October and November, it presented evidence that it was penalized for being relatively small and operating only in Ohio.

It also said the procurement didn’t consider that some of the huge companies that were selected had been accused of massive wrongdoing against Ohio taxpayers. 

For example, the Medicaid department restarted talks with Centene-owned Buckeye Health Plan in August —  just six months after the company announced it was paying $88 million to settle claims that it bilked tens of millions from the Ohio Medicaid program. The company also announced that it was setting aside $1 billion more to settle similar claims in other states.

Also, UnitedHealth Group’s United Healthcare Community Plan of Ohio was one of six companies selected for a multi-billion-dollar managed-care contract. It got the business even though the state is actively suing its pharmacy middleman, OptumRx, on claims that it ripped $16 million off of the Ohio Bureau of Workers Compensation.

In addition, Optum and CVS’s pharmacy middleman, CVS Caremark, were the companies accused of improperly inflating the prices of Medicaid drugs — charges they deny. Despite the claims, CVS’s Aetna got the billion-dollar OhioRISE contract.

In court, Paramount also pointed to potential conflicts of interest. 

Medicaid Director Maureen Corcoran has disclosed that in the past she owned at least $1,000 worth of stock in CVS and UnitedHealth Group, but she’s refused to say just how much she owned as she was negotiating and signing huge contracts with their subsidiaries.

And Mercer, the $9 million consultant that facilitated the procurement, refuses to say whether any of the selected clients also have consulting contracts with Mercer.

Franklin County Common Pleas Judge Julie M. Lynch on Nov. 10 dismissed Paramount’s case after disallowing evidence of the possible conflicts. Just after the dismissal, Paramount’s lawyers said they would appeal.

But Paramount and its parent, Toledo-based ProMedica, thought better of the strategy. It says it’s turning its business over to Anthem because it believes it’s the best of the six newly selected companies to provide care to Paramount’s Medicaid clients.

The two companies also are looking for landing spots for hundreds of Paramount employees.

“Anthem and ProMedica are working to identify open roles within both organizations that may interest affected Paramount employees,” Paramount said in a statement. “This would create opportunities for Paramount employees to join Anthem or continue with ProMedica in a different capacity.”

For its part, Anthem said it’s up to the task.

 “Anthem has served the whole-health needs of Ohioans for more than 81 years and we look forward to expanding access to comprehensive, high-quality healthcare services for more Medicaid-eligible individuals,” Greg LaManna, Anthem Blue Cross and Blue Shield’s Medicaid President in Ohio, said in an emailed statement. “This transaction expands our commitment to further the Next Generation of Ohio Medicaid Managed Care in advance of the new Medicaid contract.”

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Clipped from: https://ohiocapitaljournal.com/2022/01/05/medicaid-provider-to-drop-legal-action-against-state/

 
 

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[ MM Curator Summary]: The listening sessions for the next version of Nebraska Medicaid managed care have begun.

 
 

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.

 
 

LINCOLN, Neb. — Kevin Bagley, Director of the Division of Medicaid and Long-Term Care (MLTC) within the Department of Health and Human Services (DHHS) has announced a statewide listening tour for Medicaid’s managed care program. The tour will begin Jan. 11, 2022, and will stop at five locations throughout the state.

Nebraska Medicaid will be procuring new contracts for the capitated managed care program, Heritage Health, in 2022. As part of this process, the Medicaid team wants to gather input from community members who would like to share their experiences with Medicaid’s current health plans.

This feedback will help Medicaid develop its next managed care contracts. These listening sessions will take place at the following locations:

 
 

In the area, the tour will stop in Norfolk, Nebraska, on Thursday, Jan. 20, at the Norfolk Public Library — (Meeting Room A) from 1:30-2:30 p.m.

 
 

Clipped from: https://www.yankton.net/community/article_0ecda8a8-5d5a-11ec-9422-d77e485c926f.html

 
 

 
 

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[ MM Curator Summary]: The LA MCO awards are expected “next week.”

 
 

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.

 
 

Louisiana’s latest search for contractors to manage the health care services of nearly 1.6 million Medicaid patients is taking longer than expected, blowing past an early November timeline for announcing the contract awards.

The last bid process started by Gov. John Bel Edwards’ administration for the multibillion-dollar Medicaid managed care contracts was derailed two years ago in a legal dispute. The Louisiana Department of Health has been using emergency contracts to keep the current managed care companies in place while it evaluates new bids.

The health department released its request for proposals from contractors interested in handling the taxpayer-financed Medicaid work in June. The deadline for submissions was Sept. 10. At the time the bid solicitation was issued, the agency released a timeline that said it planned to announce the contract awards “on or about” Nov. 5.

That announcement hasn’t happened.

Health department spokesperson Kevin Litten said the agency hopes to have its recommendations to the Office of State Procurement, which oversees the bid solicitation process, by the end of this week.

“The expected dates first announced for awarding the Request for Proposals for Managed Care Organizations was an approximate timeframe, and LDH has continued working through this process over the past month,” Litten said in a statement. “The department is finalizing our internal evaluations.”

The managed care contracts account for roughly one-quarter of Louisiana’s annual operating budget and cover the health care for one-third of Louisiana’s residents. They allow private companies to oversee health services for about 90% of Louisiana’s Medicaid enrollees — mostly adults covered by the Medicaid expansion program, pregnant women and children.

The new contracts will be awarded for up to five years and are expected to start around the beginning of the new budget year in July, according to the bid solicitation.

Until new contractors are chosen, the health department has continued its existing emergency deals with the five companies currently managing Medicaid services: Aetna Better Health, AmeriHealth Caritas of Louisiana, Healthy Blue, Louisiana Healthcare Connections and United Healthcare of Louisiana.

Health Department Secretary Courtney Phillips announced in August that she would redo the Medicaid managed care contractor search, rather than continue a legal fight over the deals that her predecessor approved.

The prior bid process began in early 2019, under then-Secretary Rebekah Gee. Four companies were chosen for the Medicaid managed care work – three of the insurance companies that already hold contracts with health department and one new contractor. The contracts would have been worth an estimated $21 billion over three years.

But two losing bidders currently doing the managed care work that were slated to lose their lucrative contracts, Louisiana Healthcare Connections and Aetna Better Health, filed protests raising objections about the bid solicitation process and contract awards.

After reviewing the protests, Louisiana’s state procurement officer scrapped the contract awards, determining that the health department mishandled the bid process and failed to comply with state law or the agency’s own evaluation guidelines.

The health department and the four insurance companies chosen for the Medicaid deals initially challenged that decision. But Phillips decided it was best to start the process over when she became health secretary near the start of the coronavirus pandemic and as Louisiana’s Medicaid rolls ballooned larger.

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Follow Melinda Deslatte on Twitter at https://twitter.com/MelindaDeslatte

Clipped from: https://www.theintelligencer.com/news/article/Louisiana-Medicaid-contractor-search-slower-than-16683320.php

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[ MM Curator Summary]: Oregon’s next version of its big 1115 waiver will include actual performance dollar measures tied to health equity metrics yet to be defined.

 
 

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.

 
 

 
 

Emily Boerger | Dec 7, 2021 | Oregon

The Oregon Health Authority (OHA) opened the public comment period for the state’s draft 1115 waiver renewal application on Tuesday, signaling the latest step forward in the state’s effort to reform the Oregon Health Plan (OHP). OHA is preparing to submit the new five-year Medicaid program waiver to the Centers for Medicare & Medicaid Services (CMS) in February 2022. 

The new waiver, which would be in effect from 2022-2027, focuses on improving health equity within the Medicaid program. Concept papers released last month identified the five policy concepts that form the basis of the application. They include a focus on maximizing OHP coverage, stabilizing transitions to minimize disruptions in care, value-based global budgets, incentivizing equitable care, and focusing on equity investments. 

The public notice highlighting the public comment period lays out the state’s specific requests related to health equity. 

Through the waiver, the state is requesting authority to allow coordinated care organizations (CCOs) to spend 3% of their per-member per-month capitation rate on health equity investments, and for those to be counted as medical expenses when determining rates. The state is also requesting federal spending for infrastructure to support equity, and investments to support community-led equity interventions. 

The state is looking to change the process of selecting CCO incentive metrics to focus on equity and is requesting an expanded benefit for American Indian/Alaska Native OHP members so that Tribal-based practices are considered covered services. 

These are just a few of the many changes to the program that OHA is seeking public comment on. 

The public comment period will run from Dec. 7 through Jan. 7. The public can submit written comments through email at 1115Waiver.Renewal@dhsoha.state.or.us or through Oregon.gov/1115WaiverRenewal. 

The feedback will then be used to revise the draft and prepare it for final submission to CMS in February.  

 
 

Clipped from: https://stateofreform.com/featured/2021/12/public-comment-period-open-for-draft-medicaid-waiver-renewal-application/