Posted on

MCOs-Ohio Medicaid rejects Mercy Health’s request to have members changed from Anthem plan

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]: In which a hospital recommends the state take away Medicaid enrollment from the plan it can’t come to payment terms with and give it to another plan. LOLZ.



Clipped from:


Credit: Bill Lackey


Mercy Health’s Springfield Regional Medical Center. BILL LACKEY/STAFF

Credit: Bill Lackey

Credit: Bill Lackey

The Ohio Department of Medicaid has rejected a request from Mercy Health to freeze enrollment in Anthem’s Medicaid managed care plans and transfer members to new Medicaid plans if they are an active Mercy Health patient.

Anthem Medicaid members became out-of-network at Mercy Health beginning July 1 after both sides could not agree to a new contract following negotiations. Mercy Health also plans to treat Anthem Medicare Advantage members as out-of-network beginning Oct. 1.

“It is indeed unfortunate that Ohio Medicaid members find themselves in the position of having to make potentially urgent or otherwise significant health care decisions because of a disagreement between two established and committed health care organizations that have told us that they have these members’ best interests at heart,” said Maureen Corcoran, director of Ohio Medicaid.

ExploreMercy Health prepares to go out-of-network for Anthem Medicaid members as negotiations stall

Mercy Health recommended Ohio Medicaid “freeze new enrollment in Anthem [Ohio Medicaid] for a period of ninety (90) days to ensure that new patients do not enroll without the understanding that they would not have long-term access to Mercy Health,” according to a letter from Corcoran sent to Don Kline, chief operating officer of Bon Secours Mercy Health.

That recommendation was unnecessary, Corcoran said, also finding another recommendation to transfer members to different Medicaid managed care plans unnecessary. Mercy Health recommended Ohio Medicaid “conduct a block transfer” of all Anthem Ohio Medicaid members “who have seen a Mercy Health provider in the last 12 months” to other Ohio Medicaid managed care organizations.

“Moreover, like MH’s proposed enrollment freeze, a block transfer would be disruptive to individuals, as well as unacceptably and impermissibly overbroad,” Corcoran’s letter said.

Corcoran said Ohio Medicaid will not override members’ choices of Medicaid managed care providers.

“ODM (Ohio Department of Medicaid) will not use its members as an incentive to force a resolution to that commercial, non-Medicaid disagreement,” Corcoran said. “I strongly encourage MH and Anthem to put their business dispute on another track and leave individuals served by Ohio Medicaid out of it going forward.”

Hospitals have faced increased costs, a Mercy Health spokesperson said, while Anthem says the requested cost increases for its employer-sponsored and Affordable Care Act plans is too high. Cost increases are not being requested for the Anthem Medicaid and Medicare supplement plans, but they are the ones feeling the pinch in these negotiations. The dispute involves rates for employer-sponsored and Affordable Care Act plans, Anthem said.

“We continue to stand ready and are in active conversations with Mercy,” said Greg LaManna, president of Anthem Ohio Medicaid. “We proposed creative solutions to them and put those on the table to try to resolve this without jeopardizing access to affordable care for any of our members.”

Mercy Health also referenced quarterly earnings for Anthem’s parent company, Elevance Health. Elevance Health’s operating gains increased to $2.6 billion, an increase of 12.0% year-over-year. Its operating revenue grew 12.7% year-over-year to $43.4 billion, according to Elevance Health.

“It is incomprehensible that Anthem refuses to reimburse the full cost of care to Mercy Health while simultaneously bringing in record profits, paid for by patients and employers,” said Adam Groshans, president of Mercy Health – Springfield. “We implore Anthem to return to the negotiation table to resolve this issue.”

ExploreMercy Health, Anthem agree to transition period for Anthem Medicaid members

References to Anthem’s parent company’s earnings are a distraction, LaManna said.

“Mercy is not honoring a contract that went into effect just a year ago that addresses the concerns that they’ve been highlighting publicly right around inflation and higher staffing costs,” LaManna said.

Anthem and Mercy Health have recently-signed contracts in place for all lines of business until Jan. 1, 2025. Medicaid, though, allows hospitals to terminate contracts with 60 days notice.

“The contract (that) went into effect last year has language in it that addresses those things,” LaManna said. “The fact of the matter is that Mercy is asking for three times inflation rate.”

In the meantime, Anthem is approving all continuity of care requests, LaManna said, which provide temporary coverage for care from an out-of-network provider.

Anthem Medicaid members who want to change plans should call the Ohio Office of Medicaid at 800-324-8680, a Mercy Health spokesperson said, where members can initiate a just cause transfer to an alternative managed care provider.

Posted on

MCO- Congressman Launches Investigation into Medicaid Prior Authorization Denials

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]: 1 in 8 (12.5%) Medicaid PA requests are denied by MCOs according to a new study. Compared to 5.7% in Medicare. So the Congressman from NJ has some questions.



Clipped from:

U.S. Representative Frank Pallone, Jr. (D-New Jersey) announced that he is looking into high prior authorization denial rates by Medicaid managed care health plans. It follows a report by the Office of Inspector General that found that Medicaid MCOs denied one out of every eight prior authorization requests in 2019.


U.S. Representative Frank Pallone, Jr. (D-New Jersey), Energy and Commerce Committee ranking member, announced Thursday that he is investigating the “high rates” of prior authorization denials by Medicaid managed care health plans. 

Prior authorization is an insurance practice that requires patients to receive approval for some healthcare services before they receive the care. The practice is often blamed for causing delays in patient care.



Driving for Results: 3 Key Benefits of Telehealth

Explore the myriad benefits telehealth offers to healthcare providers and patients alike. From enhanced convenience and improved privacy to streamlined workflows and elevated patient satisfaction, find out how telehealth is reshaping the future of healthcare delivery.

Michael Blackman, MD MBA – Greenway Health

The investigation is in response to a recent report by the Office of Inspector General that found Medicaid Managed Care Organizations (MCOs) denied 12.5% of prior authorization requests (or one out of eight) in 2019. Meanwhile, the Medicare Advantage prior authorization denial rate was 5.7% in 2019. The OIG report analyzed seven MCO parent companies that operated 115 MCOs across 37 states and covered nearly 30 million people in 2019.

“I’m deeply troubled by reports that Medicaid managed care plans denied an average of one out of every eight requests for treatment, more than double the rate of service denials in Medicare Advantage,” Pallone said in a statement.  

“Medicaid is a lifeline for over 80 million people, including children, people with disabilities, seniors, and hardworking families,” he continued. “This report strongly suggests that some private insurance plans, which states have contracted with to provide health care coverage to their residents, may be improperly denying access to critical services in order to maximize their profits.”

Pallone added that the Medicaid MCOs need to be held accountable for these high prior authorization denial rates.



Payer’s Place: David Calabrese

OptumRx’s Chief Clinical Officer shares his insights on the latest developments and trends he’s seen in the healthcare industry.

HLTH and MedCity News

“I applaud the Office of the Inspector General for their important work on this report and for shining a light on these alarming practices,” he said. “I will be contacting each of these health insurance companies directly for additional information and questions regarding their prior authorization practices. It is essential that these state contracted plans are upholding their responsibility to patients and their families.” 

The OIG analysis found that of the 115 MCOs it looked into, 12 of them had prior authorization denial rates above 25%. In addition, most state Medicaid agencies didn’t regularly review the “appropriateness” of denials, nor did they collect data on the denials, the report discovered.

“The absence of robust oversight of MCO decisions on prior authorization requests presents a limitation that can allow inappropriate denials to go undetected in Medicaid managed care,” The OIG said.

The OIG also found that Medicare Advantage plans have better CMS oversight of prior authorization denials than Medicaid MCOs, including requiring Medicare Advantage plans to provide data on their denials.

The agency made several recommendations to CMS, including requiring states to review a sample of MCO prior authorization denials on a regular basis, as well as mandating states to collect data on MCO prior authorization denials.

Photo: Valerii Evlakhov, Getty Images

Posted on

MCOs- The Hidden Fee Costing Doctors Millions Every Year

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]: Doctors have to pay a fee to get paid.



Clipped from:


Credit: Alvaro Bernis for ProPublica

A powerful lobbyist convinced a federal agency that doctors can be forced to pay fees on money that health insurers owe them. Big companies rake in profits while doctors are saddled with yet another cost in a burdensome health care system.

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

It was a multibillion-dollar strike, so stealthy and precise that the only visible sign was a notice that suddenly vanished from a government website.

In August 2017, a federal agency with sweeping powers over the health care industry posted a notice informing insurance companies that they weren’t allowed to charge physicians a fee when the companies paid the doctors for their work. Six months later, that statement disappeared without explanation.

The vanishing notice was the result of a behind-the-scenes campaign by the insurance industry and its middlemen that has largely escaped public notice — but that has had massive financial consequences that have rippled through the health care universe. The insurers’ invisible victory has tightened the financial vise on doctors and hospitals, nurtured a thriving industry of middlemen and allowed health insurers to do something no other industry does: Take one last cut even as it pays its bills.

Insurers now routinely require doctors to kick back as much as 5% if they want to be paid electronically. Even when physicians ask to be paid by check, doctors say, insurers often resume the electronic payments — and the fees — against their wishes. Despite protests from doctors and hospitals, the insurers and their middlemen refuse to back down.

There are plenty of reasons doctors are furious with the insurance industry. Insurers have slashed their reimbursement rates, cost them patients by excluding them from their provider networks, and forced them to spend extra time seeking pre-authorizations for ever more procedures and battling denials of coverage.

Paying fees to get paid is the final blow for some. “All these additional fees are the reason why you see small practices folding up on a regular basis, or at least contributing to it,” said Dr. Terence Gray, an anesthesiologist in Scarborough, Maine. Some medical clinics told ProPublica they are seeking ways to raise their rates in response to the fees, which would pass the costs on to patients.

“It’s ridiculous,” said Karen Jackson, who until her retirement in March was a veteran senior official at the Centers for Medicare & Medicaid Services, the federal agency that posted, then unposted, the fee notice. Doctors, she said, shouldn’t have to pay fees to get paid.

But that’s precisely what’s happening. Almost 60% of medical practices said they were compelled to pay fees for electronic payment at least some of the time, according to a 2021 survey. And the frequency has increased since then, according to medical clinics. With more than $2 trillion in medical claims being paid electronically each year, these fees likely add up to billions of dollars annually.

Huge sums that could be spent on care are instead being siphoned off to insurers and middlemen. The fees can cost larger medical practices $1 million a year, according to an April poll by the Medical Group Management Association, which represents private medical practices. The figure sometimes runs even higher, according to a 2020 complaint to CMS from a senior executive of AdventHealth, which has 53 hospitals in nine states: “I have to pay $1.8M in expenses that I could use on PPE for our employees, or setting up testing sites, or providing charity care, or covering other community benefits.” Most clinics are smaller, and they estimated annual losses of $100,000 or less. Even that figure is more than enough to cover the salary of a registered nurse.

The shift from paper to electronic processing, which began in the early 2000s and accelerated after the Affordable Care Act went into effect, was intended to increase efficiency and save money. The story of how a cost-saving initiative ended up benefiting private insurers reveals a lot about what ails the U.S. medical system and why Americans pay more for health care than people in other developed countries. In this case, it took less than a decade for a new industry of middlemen, owned by private equity funds and giant conglomerates like UnitedHealth Group, to cash in.

How these players managed to create this lucrative niche has never previously been reported. And the story is coming to light in part because one doctor, initially incensed by the fees, and then baffled by CMS’ unexplained zigzags, decided to try to figure out what was going on. Dr. Alex Shteynshlyuger, a urologist who runs his own clinic in New York City, made it his mission to take on both the insurers and the federal bureaucracy. He began filing voluminous public records requests with CMS.


Dr. Alex Shteynshlyuger is on a crusade against payment processors’ fees, which he says threaten his practice. Credit: DeSean McClinton-Holland for ProPublica

What he discovered in internal emails and government documents, which he shared with ProPublica, was a picture sharply at odds with the image of CMS as a hugely powerful force in health care. The records showed, again and again, federal officials deferring not only to a single company, but to a single executive.

Over the past five years, CMS adopted that company’s positions on fees. Shteynshlyuger discovered that, when it comes to the issue he cares about, the most powerful decision-maker wasn’t a CMS official. It was the chief lobbyist for a middleman company called Zelis. And that man just happened to be a former CMS staffer who had authored a key federal rule on electronic payments.

For Shteynshlyuger, the intersection of medicine and money has a particular resonance. He was born in the Soviet Union, in what is now Ukraine, and his brother nearly died of pneumonia as an infant because doctors refused to administer an antibiotic. The doctors wanted his family to pay a “bribe,” according to Shteynshlyuger. His grandmother ended up finding a different doctor to pay off and his brother got the medicine. Shtenynshlyuger’s parents emigrated to the U.S. in 1991, when he was an adolescent, and they settled in Brooklyn’s Brighton Beach area.

Today, Shteynshlyuger sees the fees for electronic payment through a similar lens. He’s a gadfly, but one with a wry, sometimes humorous disposition and an intellectual bent. He studied biology and economics in college and is capable of both rage at perceived unfairness and dispassionate observations about health policy. The unjust fees, as he sees them, threaten his medical practice, which he designed to serve middle-class patients. He prices his services at a discount. “Low cost is what keeps me in the business,” he said.

As a result, administrative combat has become a big part of his life. Unmarried, Shteynshlyuger, 45, stays up into the wee hours, writing lengthy memos to regulators. One recent missive spanned 155 pages, including appendices.

This New Year’s, he joined his family for a week off at his parents’ condo near Miami. Shteynshlyuger arrived with a desktop computer, which he set up in one of the bedrooms alongside two monitors that he keeps at the condo. While his nieces and brother enjoyed the beach, Shteynshlyuger sat indoors, drafting a 38-page memo to aid in one of two lawsuits he has filed in an effort to pry documents out of CMS.

Shteynshlyuger’s accent, with its distinctive Brooklyn-Russian mix, is unmistakable in calls with customer service representatives at insurance companies and payment processors. (He recorded many of the calls and shared them with ProPublica.) The calls follow a similar pattern: Posing questions in the manner of a genial but persistent litigator, Shteynshlyuger asks why he’s being charged a fee.

Ultimately, he’s informed that there’s no way to have an electronic funds transfer, or EFT, sent straight to his bank account without paying a fee. When the calls get escalated, representatives sometimes offer to shave a tiny amount off the fees — charging, say, 2.1% rather than 2.5%, a proposal made on one recent call with Zelis — but rarely is he offered a free transfer.


Shteynshlyuger spends hours on the phone with payment processors like Zelis, fighting their attempts to impose fees on electronic payments. Credit: DeSean McClinton-Holland for ProPublica

A spokesperson for Zelis, the payment-processing company that Shteynshlyuger has tangled with most often, said the company refers requests for free electronic payments to the insurers, but recordings and transcripts of recent calls show that did not happen when Shteynshlyuger called.

Shteynshlyuger and other doctors say payment processors routinely sign them up for high-fee payment methods without their consent. A brochure for one payment company, Change Healthcare, boasted of automatically enrolling 100,000 doctors and hospitals in a plan to receive virtual credit cards and sharing some $8 million a year in revenues with the large insurer it was working for. (Virtual credit cards are a form of electronic payment in which a payer sends a string of numbers that are typed into a credit card reader to generate a one-time payment. Fees for VCCs run as high as 5% versus a typical 2.5% for other kinds of electronic payments.)

Payment processors often boost insurers’ revenues by sharing the fees from virtual credit cards. One processor, VPay, says in its marketing materials that insurers can “make money on every virtual card transaction.” In response to questions from ProPublica, UnitedHealth, which owns Change and VPay, asserted that its services help medical clinics streamline recordkeeping, reduce administrative burdens and accelerate payments.

Zelis and other payment processors say they offer value in return for their fees: Doctors can sign up to receive reimbursements from hundreds of insurers through a single payment processor, and they can also get services that help match up electronic payments and receipts. Zelis asserted in a statement that its services remove “many of the obstacles that keep providers from efficiently initiating, receiving, and benefitting from electronic payments.” Zelis and other companies insist that it’s easy to opt out of their services, but Shteynshlyuger and other doctors say otherwise.


Virtual credit cards come with fees as high as 5%. Credit: Courtesy of Dr. Terence Gray. Redacted by ProPublica

When Shtyenshlyuger embarked on his mission of fighting the fees in 2017, his first step was research. He quickly came across an article from the American Medical Association that said the law was on his side.

Shteynshlyuger then approached the companies. He emailed senior executives of Zelis and VPay, asserting that the fees violated CMS rules. The companies denied breaking any rules and wouldn’t budge on the fees.

So Shteynshlyuger started filing complaints with CMS. The responses he received struck him as curious. CMS itself usually didn’t offer an opinion. Instead, it forwarded letters from a Zelis executive named Matthew Albright, who answered Shteynshlyuger’s complaints on at least five occasions. (The agency said this passive approach is part of its “informal” complaint resolution process.)

When Shteynshlyuger pressed a CMS official to articulate the agency’s position after it passed along Albright’s answer, the official wrote that the agency receives the “identical legal response” from Zelis to all such complaints. She added: “They believe that, according to their interpretation of the regulation, they are compliant.”

Shteynshlyuger was flummoxed. Who was Matthew Albright? A quick Google search revealed that Albright had once worked for CMS. That only piqued Shteynshlyuger’s interest. Had Albright been involved in the removal of the CMS notice prohibiting fees?

To Albright, the 2010 passage of the Affordable Care Act was a historic event of a magnitude akin to the moon landing. Then a policymaker with Washington state’s Health Care Authority, Albright was awed by the importance of the looming rewrite of U.S. health care rules. He felt he had to be part of it. “This is the Apollo 11 for regulators,” he recalled thinking, in an interview with ProPublica. “I’ve got to get to D.C. and write regulations.”


Matthew Albright, now chief legislative affairs officer at Zelis, made a series of explanatory videos in his days at the Centers for Medicare & Medicaid Services. Credit: Screenshot via YouTube

Now 55, Albright had unusual training for his new role. Instead of following the typical path through law school, he had studied sacred texts, first at the Pontifical University of St. Thomas Aquinas in Rome and later at Harvard University, where he earned a master’s degree in divinity. Those studies, Albright said, fostered what he called a “scholastic fascination with words and how they’re used to tell people what to do,” whether those words are in the Ten Commandments or the Code of Federal Regulations.

Articulate and cheerful, today Albright can still sound more like a divinity professor than a lobbyist when he describes his current job as studying laws and rules. “Hermeneutics,” he said, “it’s just like Bible study, right? Breaking it down into its understandable parts. And then, frankly, turning around and teaching it or turning around and explaining it in the vernacular, if you will. So I think that most of my job is looking at regulations and reading them and then explaining them to internal and external audiences.”

At CMS, Albright drafted a rule, published in 2012, that laid out standards for paying doctors via electronic funds transfers. The Affordable Care Act required all insurers to offer EFTs and encouraged doctors to accept them, and electronic payments quickly became the go-to method for handling medical claims. A CMS analysis predicted that eliminating the labor of manually processing paper checks and receipts would lead to savings of $3 billion to $4.5 billion over 10 years.

Albright became the agency’s point man on the issue. He looked every bit the government bureaucrat in a gray shirt and dark suit as he extolled the virtues of “administrative simplification” in earnest-but-stiff video segments that emulated a talk show. (Albright also created a personal YouTube channel when he taught a philosophy course. It had bite-sized explanations of, among other things, Kantian ethics — “do not use people” — and Ayn Rand’s philosophy — “selfishness is good.”)

Albright’s work at CMS, by his description, became a “turning point” for health care payments. The shift to electronic funds transfers facilitated the growth of an industry of payment processors. It also made Albright’s skill set very valuable. In 2014, he was recruited to the industry he previously regulated. Two years later, he landed at Zelis. The company had just been created via a merger of four businesses owned by Parthenon Capital, a private equity firm. Zelis is now co-owned by private equity giant Bain Capital and headed by a former Bain partner. (Parthenon declined to comment; Bain referred a request for comment to Zelis.)

Zelis, which once described itself as having a “regulatory-based business model,” touted Albright’s government resume when it hired him as vice president of legislative affairs. Albright said at the time he would “advocate for rational regulatory approaches.”

Rational regulatory approaches, from Zelis’ perspective, included the right to charge doctors for electronic payments. That was a crucial revenue stream for the company, but it could dry up if CMS enforced a rule prohibiting such fees. Who better than Albright, the man who had drafted rules on electronic payments, to help the company navigate the situation?

When Shteynshlyuger began to receive documents from CMS in response to his Freedom of Information Act requests, he was first struck by how deferential CMS officials seemed to be to Albright. In July 2019, for example, as Shteynshlyuger continued to complain about Zelis, a CMS official named Gladys Wheeler contacted Albright. “You may be familiar with Dr. Alex Shteynshlyuger,” Wheeler wrote. “To assist with resolution of the complaints, I have a few questions. Can I send the questions to you, or can you redirect me?” She added, “Just let me know the best approach. Thanks, and take care, Gladys.” (Wheeler did not respond to requests for comment.)

The tone of the conversations between Albright and CMS could be downright chummy. “Should we respond to it as per usual?” Albright asked in another July 2019 email about a new complaint filed by a doctor in Washington state. “Send the Zelis response for documentation purposes,” Wheeler responded in between banter that she and Albright exchanged about Chicago’s winter weather (bad) and architecture (great).

Shteynshlyuger was growing more frustrated. He didn’t understand why CMS had yanked the notice about the prohibition on fees from its website. If his months of effort couldn’t extract clear answers, how could other doctors with less inclination for bureaucratic battle figure out what to do?

What Shteynshlyuger didn’t know was that, less than two years earlier, a lobbying campaign had begun behind the scenes at CMS. The documents that he eventually obtained would provide a rare, nearly day-by-day glimpse into how one lobbyist — Albright — managed to bend the agency to his will with an artful combination of cajoling, argument and legal threats.

On Aug. 11, 2017, CMS’ website had posted the notice that EFT fees were prohibited. Such notices, presented in the form of answers to frequently asked questions, are meant to explain the agency’s complex rules in plain language. CMS based the notice on a rule from 2000 that banned fees in excess of normal telecommunication costs (such as, say, the tiny fractions of a penny to cover the cost of an email) that a doctor would incur if they were receiving the bill “directly” from an insurer.

The notice triggered an immediate protest from Zelis, according to emails and an internal CMS memo. Albright had “multiple conversations” with CMS staff and demanded that the agency revise the notice.

The nub of Albright’s argument was that CMS’ 2000 rule prohibited insurers from charging excessive fees for “direct” transactions. But, he argued, the rule was meant to apply to insurers dealing with doctors. Albright represented payment processors who work for insurers; those weren’t direct transactions between insurers and doctors. Thus, he argued, the fee prohibition couldn’t apply to EFT payments.

CMS, which took months or longer to respond to Shteynshlyuger, quickly complied with Albright’s request and removed the fee notice on Aug. 14, 2017, only three days after it was posted.

CMS published an updated notice in late September 2017. But the agency stood firm on the key point: The new document stated that insurers and payment processors “should not charge providers communications fees” for EFTs.

Shortly after the revised notice went up, Albright emailed the director of the CMS division that issued it. “Hope the kids have settled into the school year okay,” he began. He then asked for “our day in court to educate” the agency. He suggested that Zelis was preparing to escalate its complaints but offered to “work through this without causing too much noise.”

Two days before Thanksgiving, Albright confronted Christine Gerhardt, then deputy director of the CMS division that issued the fee notice. In a phone call, Albright demanded that CMS revise the document again, according to Gerhardt’s summary of the call. Gerhardt refused. Albright began debating her on the legal differences between the explainer and the regulation that it summarized.

The following week, Albright pressed harder, asking Gerhardt whether the prohibition on fees was enforceable. He told Gerhardt that if she did not answer, that itself would be an answer. It would, Albright said, “give me a sense of what steps need to be taken next” to challenge the agency’s notice. Gerhardt, who is now retired, said she assured him that the agency wasn’t implementing a new rule; only clarifying existing rules. Albright was pushing hard, but at that point, Gerhardt hadn’t bent.

Then, in January 2018, Zelis brought in the lawyers. A firm called Nixon Peabody wrote to CMS, demanding that the agency “withdraw or correct the offending language” in its notice. Nixon Peabody argued that the fee prohibition wasn’t a restatement of existing rules but that it amounted to a new rule that should have been issued via the formal rulemaking process. Nixon Peabody threatened to sue if CMS didn’t comply with Zelis’ demand. (Nixon Peabody did not reply to a request for comment.)

The legal threat set off a scramble within CMS. “Let’s just take it down,” Gerhardt wrote in a Feb. 9, 2018, email to colleagues. Her division not only removed the notice saying that fees were prohibited but also went so far as to institute a moratorium on any new notices. CMS was essentially depriving all medical providers of guidance on these issues because one company had complained.

The response puzzled even some within CMS. “What was the basis for withdrawal if the request was from a single entity and potentially harms providers?” Jackson, then CMS deputy chief of operations, wrote in an email.

Albright, his goal accomplished, sought to soothe Gerhardt and two of her colleagues. “I know I butted heads with all three of you,” he wrote a few weeks later. Albright offered to meet to explain why Zelis is not “one of the bad guys in this area.” (Zelis did not address detailed questions about Albright’s interactions with CMS.)

In March 2018, after Zelis complained and CMS removed a notice saying that payments to doctors couldn’t carry fees, Albright emailed three key agency staffers to patch things up. Credit: Email exchange provided by Alex Shteynshlyuger

CMS told ProPublica in a statement that it reversed its position because it concluded that it had no legal authority to “flat-out prohibit fees.” The agency declined to comment on Shteynshlyuger’s complaints, but said it takes seriously any allegations of noncompliance with its rules. As for Zelis’ lobbying, CMS said it “receives feedback from a wide range of stakeholders on an ongoing basis. The information received helps the agency understand where guidance and clarification of existing policy may be needed.”

The American Medical Association and over 90 other physician groups have urged the Biden administration to reinstate guidance protecting doctors’ right to receive EFTs without fees. For its part, the massive Veterans Health Administration system has been refusing to pay the fees, which it has described as illegal in letters to Zelis and insurers.

So far the protests have had no visible effect. In fact, when CMS finally issued a new explainer that addressed fees in July 2022, more than four years after erasing the previous one, the agency made explicit what had previously been implicit: EFT fees are allowed.

Shteynshlyuger is continuing his lonely campaign. Two months after CMS stated that fees are OK, a Zelis customer service representative contacted him. Shteynshlyuger had just submitted his 80th complaint to CMS. Emails show the rep offered to help him get signed up for no-fee EFTs — but the offer only applied to payments from one of the more than 700 insurers and other payers that Zelis represents. Shteynshlyuger demurred, saying he did not want the issue resolved without CMS’ intervention because then other doctors could not get the same assistance. As often as not, Shteynshlyuger and other doctors are left with little recourse; many insist on being paid by paper check rather than allowing Zelis to take a cut.

In mid-December, Shteynshlyuger finally got the long-awaited replies to eight other complaints he had filed over the years. CMS dismissed all eight because Shteynshlyuger didn’t file them against insurers but instead against companies like Zelis, which CMS referred to as “business associates” of the insurers. CMS said it now believes its oversight extends only to insurers, not to their business associates. The phrasing may have been bureaucratic, but the news was dramatic: CMS had fully surrendered, giving up on regulating payment processors entirely.

Shteynshlyuger hasn’t filed a new document request yet to uncover whether Zelis or perhaps another company influenced that decision. He has his suspicions.

Do You Have Insights Into Health Insurance Denials? Help Us Report on the System.

Insurers deny tens of millions of claims every year. ProPublica is investigating why claims are denied, what the consequences are for patients and how the appeal process really works.


Posted on

Human Services Department Announces Intent to Award Medicaid Contracts

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]: Winners – BCBS, Presby, UHC and Molina.



Clipped from:

SANTA FE – Today, the New Mexico Human Services Department (HSD) announced its intention to award Medicaid managed care organization (MCO) contracts to four health plans for Turquoise Care, the state’s Medicaid managed care program. The state will negotiate contracts with BlueCross BlueShield, Presbyterian Health Plan, United Health Plan, and Molina Health Plan with a start date of July 1, 2024. The state announced that it does not intend to negotiate a Medicaid contract with current MCO Western Sky Community Care. 

The Human Services Department also announced a decision to rescind the cancellation of the Turquoise Care Request for Proposals (RFP), which was made on January 30, 2023, to allow agency leadership an opportunity to assess the design of the procurement.  

“HSD spent the past several months reviewing the MCO contracts in depth and making improvements that focus on advancing and incentivizing health plan performance and ensuring that Medicaid customers have access to this information when they pick their health plan,” said HSD Acting Secretary Kari Armijo. “We will be negotiating contracts that reflect these improvements with the expectation of achieving better health outcomes for Medicaid customers.”  

HSD has engaged with a consultant to make recommendations for improving MCO contract enforcement and compliance, and the agency is making several contract improvements with the existing health plans that will go into effect September 2023. 

The new go-live date for the MCO contracts is July 1, 2024, a change from the original planned go-live date of January 1, 2024. The extension will allow HSD to complete the Medicaid unwinding, which requires a full recertification of every Medicaid customer over a 12-month period that extends through March 2024. This process was suspended during the COVID-19 Public Health Emergency. Open enrollment for the new MCO contracts will begin in April 2024 after the unwinding is complete. 

“The new contract go-live date will minimize disruption for Medicaid customers by allowing HSD to focus on the important work of recertifying eligibility for the 934,305 customers who are enrolled in the program,” said Armijo. “We want all Medicaid customers to be watching for their turquoise envelopes and submitting the required paperwork to make sure they stay covered if eligible and to help them transition to other health insurance coverage if they no longer qualify for Medicaid.” 

Medicaid customers can learn more about how to renew their Medicaid coverage by visiting HSD’s Renew New Mexico! website at or by calling HSD at 1-800-283-4465. 


We talk, interpret and smile in all languages.  We provide written information to our customers in both English and Spanish and interpretation services are available in 58 languages through our provider, CTS Language Link. For our hearing, and speech impaired customers, we utilize Relay New Mexico, a free 24-hour service that ensures equal communication access via the telephone to individuals who are deaf, hard of hearing, deaf-blind or speech disabled. 

The Human Services Department provides services and benefits to 1,046,816 New Mexicans through several programs including: the Medicaid Program, Temporary Assistance for Needy Families (TANF) Program, Supplemental Nutrition Assistance Program (SNAP), Child Support Program, and several Behavioral Health Services.

Posted on

MCOs- Elevance Health reaches $1.9B in profits in strong Q2

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]: Medicaid helps the giant add $367M to Q2 operating gains.


Clipped from:

Revenues hit $43.7 billion, an increase from Q2 2022’s $38.6 billion.


Photo: d3sign/Getty Images

Elevance Health posted a strong second quarter, achieving about $1.9 billion in revenue, good for 13.2% growth over the previous year’s $1.6 billion haul, according to the company’s latest earnings report.

Revenues also grew 12.7%, hitting $43.7 billion, an increase from the $38.6 billion in revenue posted in Q2 2022.

Elevance also saw double-digit growth in operating earnings, and adjusted earnings per share, the company said.

President and CEO Gail Boudreaux attributed the strong showing to “focused efforts to optimize our mature businesses, invest in high-growth opportunities, and accelerate our growth through Carelon to meet the whole health needs of consumers.”

Given the strong performance, the company now expects GAAP net income to be greater than $29.09 per share in 2023, and adjusted net income to be greater than $32.85 per share.


Operating revenue was $43.4 billion in the second quarter of 2023, an increase of $4.9 billion, or 12.7% year-over-year. The increase was primarily driven by premium rate increases in the Health Benefits business and higher premium revenue due to membership growth in Medicaid and Medicare, said Elevance.

Medical membership totaled about 48 million as of June 30, an increase of 938,000, or 2% year-over-year, driven primarily by growth in Medicaid, BlueCard, ACA health plan, and Medicare Advantage members, and partially offset by attrition in the Employer Group risk-based business.

During the second quarter of 2023, medical membership decreased by 135,000, driven by attrition in Medicaid due to the resumption of eligibility redeterminations, Elevance said.

Operating cash flow was about $2 billion, or 1.1 times net income in the second quarter of 2023.

Operating gain in the Health Benefits segment totaled $2.1 billion in the second quarter of 2023, an increase of $367 million from $1.8 billion in the second quarter of 2022, representing growth of approximately 21%. The increase was primarily driven by premium rate adjustments to more accurately reflect cost of care and membership growth in Medicaid, said Elevance – partially offset by a charge associated with a court ruling impacting health plans in a certain state related to prior years’ COVID-19 costs.

Operating gain in the Carelon segment was $632 million in the second quarter of 2023, an increase of $40 million from $592 million in Q2 2022.

The company reported an operating loss of $152 million in the Corporate & Other segment for the second quarter of 2023, a decrease of $125 million from an operating loss of $27 million in the second quarter of 2022, driven by an increase in unallocated corporate expenses, Elevance said.


Elevance Health announced the launch of healthcare services brand Carelon in June 2022. Carelon services range from research to integrated whole-person care delivery, pharmacy, behavioral health and digitally enabled solutions.

Elevance acquired BioPlus, a comprehensive specialty pharmacy, in November. BioPlus provides a range of specialty pharmacy services for patients living with complex and chronic conditions such as cancer, multiple sclerosis, hepatitis C, autoimmune diseases and rheumatology.

Earlier this year, Elevance said it would be pursuing an acquisition of Blue Cross Blue Shield of Louisiana. The two organizations said they’re “aligned in a mission” to improve access, quality and affordability for Louisianans.

Twitter: @JELagasse
Email the writer:

Posted on

Elevance rebrands Amerigroup segment as Wellpoint

MM Curator summary

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


[MM Curator Summary]: The brand we haven’t seen since 2014 returns.


The return of the Wellpoint brand is the payer’s latest corporate reinvention.

Published Aug. 1, 2023

Rebecca Pifer Senior Reporter

Elevance headquarters in Indianapolis, Indiana. Permission granted by Elevance Health

Blues plan giant Elevance is rebranding its entire Amerigroup segment to Wellpoint, saying the move signifies the health insurer’s commitment to whole-person health.

Elevance’s relaunch of the Wellpoint brand — the payer’s original name from its founding — is meant to unify its Medicaid, Medicare and commercial health plans in select markets, states where Elevance doesn’t offer Blue Cross and Blue Shield branded products, the payer said.

The rebrand announced Monday will roll out in January 2024 in six states: Arizona, Iowa, New Jersey, Tennessee, Texas and Washington. Amerigroup plans in Maryland were rebranded as Wellpoint earlier this year.

The Amerigroup brand will remain in Washington, D.C. and Georgia, which are on a separate timeline for rebranding, according to an Elevance spokesperson.

The Indianapolis-based payer first announced the rebrand last summer along with the unveiling of its healthcare services business, Carelon, as payers continue to invest in nontraditional offerings to find new areas of growth. Carelon includes Elevance’s pharmacy benefit management company CarelonRx.

Elevance doesn’t break down members by state, but currently covers roughly 3 million Medicare members and 11.7 million Medicaid members.

The Medicaid program is facing significant turmoil as states resume eligibility checks for the safety-net coverage that were put on hold during the pandemic.

The majority of beneficiaries who have lost coverage have lost it due to procedural reasons, such as improper paperwork, rather than true ineligibility. Regulators have cited a number of hurdles to a smooth redeterminations process, including a lack of resources and state experience with redeterminations, the volume of people to process and difficulty communicating updates to enrollees.

Elevance did not respond to a question on whether it is concerned renaming its Medicaid plans during the redeterminations process might add another layer of confusion for enrollees.

The spokesperson did note that Wellpoint’s website is currently live, and Elevance has begun an advertising campaign on the rebranding that will run through the rest of the year. Elevance also plans to reach out to affected members directly regarding the business’ name change.

Elevance, which covers 48 million people nationwide, is no stranger to rebrands.

Keep up with the story. Subscribe to the Healthcare Dive free daily newsletter

A valid email address is required. Please select at least one newsletter.

Roughly three decades ago, Blue Cross of California created WellPoint Health Networks to operate its for-profit managed care business. The company was renamed as WellPoint in 2004, following a merger with insurer Anthem.

In 2014, WellPoint changed its name to Anthem — the brand of the majority of its healthcare insurance products. Anthem then rebranded as Elevance last year, saying the name change was necessary to highlight its offerings beyond traditional health insurance.

The latest rebranding of Amerigroup to Wellpoint won’t affect Wellpoint members’ benefits or coverage, according to the payer. The spokesperson did not respond to questions on how much Elevance is investing on the rebrand.

The payer reported second-quarter earnings earlier this month that beat analyst expectations, with revenue of $43.7 billion and profit of $1.9 billion.

Payers with significant exposure to redeterminations like Elevance — the second-largest Medicaid managed care organization in the U.S., after Centene — are trying to recapture lost Medicaid lives in other plans, including on the Affordable Care Act exchanges. Elevance lost 135,000 people from its Medicaid rolls due to redeterminations in the second quarter.

The payer said it expects roughly 45% of beneficiaries added to Medicaid during the public health emergency will stay on the safety-net coverage by the end of the redeterminations cycle, while 20% will end up on its ACA products.


From <>

Posted on

MCO- Centene aims to enroll back some lost Medicaid members

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]: Lose 260k in Medicaid lives, gain 3.7M in commercial lives.



July 28, 202310:31 AM CDTUpdated 5 days ago

A person walks by a Wellcare and Fidelis Care location, part of the Centene Corporation, in Queens, New York, U.S., November 16, 2021. REUTERS/Andrew Kelly

July 28 (Reuters) – Centene Corp (CNC.N) said on Friday it was working to enroll people back into government-backed Medicaid plans after the end of pandemic-relief measures left hundreds of thousands of members without coverage.

Medicaid memberships, the largest contributor to Centene’s revenue, were hit by the removal of pandemic-related relief measures on April 1 that rendered several members ineligible for insurance coverage.

Advertisement · Scroll to continue

The relief withdrawal allowed states to resume their routine check to determine if people qualified for the government-backed health insurance plan for low-income people or not.

Centene lost a little more than 260,000 Medicaid members in the second quarter due to redetermination, and had around 16 million members under Medicaid as of June 30. Shares of Centene declined nearly 5% to $66.50 in morning trade following its earnings, but the company said it has launched a major outreach effort to recapture some people who may still be eligible for Medicaid but were disenrolled.

Advertisement · Scroll to continue

“Year-to-date, we have made 9 million outreach attempts, with early indications of higher-than-normal member engagement,” said CEO Sarah London in the earnings conference call.

The company on Friday, however, beat Wall Street estimates for second-quarter profit, helped by strong membership growth in its commercial marketplace business even as a fall in Medicaid memberships hurt.

“Medicaid redeterminations have started cutting into its Medicaid population and look likely to constrain its results in the near-term, especially in 2024,” said Morningstar analyst Julie Utterback, but added that the commercial business growth appeared robust.

Advertisement · Scroll to continue

Centene’s commercial plans saw a 62% jump in memberships to 3.73 million, as of June 30. The insurer also raised its full-year earnings adjusted profit forecast by 5 cents to at least $6.45 per share on expectations that premium collections will be higher this year from the commercial health insurance business.

On an adjusted basis, the company earned $2.10 per share in the second quarter, above estimates of $2.03.

Reporting by Mariam Sunny and Leroy Leo in Bengaluru; Editing by Shinjini Ganguli and Shounak Dasgupta

Our Standards: The Thomson Reuters Trust Principles.


From <>



Posted on

MCOs- Elevance (Anthem) Earnings: 2023 Outlook Increased Despite Utilization and Medicaid Redetermination Trends

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]: Anthem tells shareholders they will get through the PHE wind-down just fine. Largely because those people kicked off of Medicaid are going to go back to getting commercial coverage from their employers (which Anthem will sell to them).



Clipped from:



Elevance Health’s ELV strong second-quarter results contributed to a mild 2023 outlook increase and caused the shares to rise closer to our $520 fair value estimate in early trading July 19. Our expectations for the year remain in line with the new target, and we’re keeping our fair value estimate intact. The firm’s narrow moat looks solid, built on local scale leadership that helps it offer lower prices than most competitors.

In the second quarter, Elevance turned in 13% revenue, 12% operating profit, and 13% adjusted EPS growth, including recent share repurchases. Despite increasing medical utilization trends and the resumption of Medicaid redetermination activities after the public health emergency, the medical insurance segment led the way, increasing revenue 11% and operating profits 21%. Medical membership grew 2% year over year, including strong growth in the individual business (18%) and decent growth in Medicare Advantage (6%) and Medicaid (5%). Sequentially, Medicaid membership started to decline a bit (down 1%) after the resumption of redetermination efforts in the quarter to ensure only qualified individuals are covered. Eventually, we suspect there will be a membership mix shift from Medicaid to higher-margin employer-sponsored or individual plans, but redeterminations create a near-term risk to profits, especially if there is a coverage gap during this transition.

Overall, though, Elevance turned in a solid quarter that appeared to relieve investors worried about medical utilization trends recently highlighted by key managed-care organization peers. Management said Elevance already tried to price for such trends in 2023 and even mildly raised its 2023 adjusted EPS outlook to at least $32.85 while largely maintaining its margin assumptions, including for its medical loss ratio. Our 2023 EPS forecast remains roughly in line with the firm’s new goal, and we do not anticipate making significant changes to our assumptions based on this announcement.

Posted on

MCOs (FL)- State modifies Medicaid procurement, answers 520 questions

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]: In addition to the 520 questions asked by MCO bidders and a few providers, the state also clarified unicorns will be invited to join the party (Medicaid “Accountable Care Organizations.” Silly rabbit, there is no accountability in Medicaid. Everyone knows that!)




Clipped from:


Health care providers have an extra week to make the state an offer to provide managed care plans, health care networks and accountable care organizations through the statewide Medicaid Managed Care Program that serves nearly 4.5 million Floridians.

The Agency for Health Care Administration (AHCA) released a lengthy addendum to its invitation to negotiate (ITN), bumping the deadline for vendors to reply to Sept. 22.  

While the vendors have an additional week to prepare their ITN responses, the anticipated date for the state to electronically post the names of the winning vendors remains the same: Dec. 11. Additionally, the state still intends to negotiate with as many as 10 health plans between October and November.

The addendum includes changes to the initial ITN posted in April and contains the answers to 520 questions 16 entities submitted to the state by the May 3 deadline.

One change to the underlying ITN included in the addendum is adding accountable care organizations (ACOs) to the list of health plans with whom the state plans to ink Medicaid contracts.


ACOs are groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high-quality care. To date, they have operated in the Medicare market.

The addendum also alters the ITN to prohibit managed care plans from using flat-rate payment arrangements in their agreements with subcontractors and providers. The addendum notes that the prohibition doesn’t preclude managed care plans from using value-based purchasing arrangements (VBPA).

The addendum adds language to the ITN requiring managed care plans to ensure contracted subcontractors “utilize value-based purchasing arrangements to the fullest extent.”

VBPAs link payments to performance in hopes of holding health care providers accountable for both the cost and quality of care they provide. 

AHCA disclosed in its answers that while there is no pre-determined budget for the Statewide Medicaid Managed Care Program, the state estimates the contracts to be worth between $120 billion and $150 billion over the six-year span.


For more than a decade, Florida has required most, but not all Medicaid managed care beneficiaries, from the cradle to the grave, to enroll in a managed care plan to deliver health care. The Legislature last year agreed to make changes to the law, primarily administrative, including merging the number of Medicaid regions from 11 to nine.

Florida’s existing managed care contracts expire Dec. 31, 2024, and the ITN sets an ambitious timeline to ensure new contracts are negotiated, signed and executed by then. This is the third time the state has put its Medicaid Managed Care program up for competitive bid.

Sunshine State Health Plan, AmeriHealth Caritas Florida, Humana Healthy Horizons of Florida, United Healthcare of Florida and Community Care Plan, a provider-sponsored network run by a Broward County hospital district, all submitted questions to the state to be answered.

Questions were also submitted by some less-recognized names.

For instance, the Alliance of Florida PPECs asked AHCA to clarify whether children enrolled in prescribed pediatric extended care centers (PPECs) will be placed in Medicaid managed care plans. 

Currently these children are not required by law to enroll in managed care plans, but the ITN said AHCA intended to enroll non-mandatory populations into the managed care plans.

“Yes,” AHCA replied to the question, adding the people will be given “the ability to opt out of managed care at any time.”

PPECs serve medically complex children eligible from birth through age 20 with continual medical care, but they do not provide residential care. 

Post Views: 0

Posted on

MCO News – A Closer Look at the Five Largest Publicly Traded Companies Operating Medicaid Managed Care Plans

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]: Its almost as if there are a few Billion rea$on$ the national MCOs are pushing all the chicken littles to squawk. I mean rea$on$ besides their altruistic, Fortune 100 little hearts.




Clipped from:

Total Medicaid and CHIP enrollment is now over 90 million. The latest national Medicaid managed care enrollment data (from 2020) show 72% of Medicaid beneficiaries were enrolled in comprehensive managed care organizations (MCOs). In FY 2021, payments to comprehensive Medicaid MCOs accounted for 52% of total Medicaid spending (or more than $376 billion). Medicaid is a major source of revenue and profits for multi-state insurance companies. KFF analysis of National Association of Insurance Commissioners (NAIC) data show gross margins per enrollee in the Medicaid managed care market were higher in 2021 than they were pre-pandemic. Medicaid MCOs have played a key role in responding to the COVID-19 pandemic and are expected to work with states in conducting outreach and providing support to enrollees during the “unwinding” of the continuous enrollment requirement. Beginning April 1, 2023, states were able to restart disenrollments (which had been paused since February 2020) after conducting a full review of eligibility. Many people will likely be found to be no longer eligible for Medicaid, while others could face administrative barriers and lose coverage despite remaining eligible. Medicaid MCOs have a financial interest in maintaining enrollment, which could also prevent disruptions in care for enrollees. This brief takes a closer look at the five largest publicly traded companies (also referred to as “parent” firms) operating Medicaid MCOs which account for half of Medicaid MCO enrollment nationally. Information and data reported in this brief come from quarterly company earnings reports, financial filings, and other company materials as well as from national administrative data.


Medicaid enrollment in the five largest publicly traded companies operating Medicaid MCOs

Five for-profit, publicly traded companies – Centene, Elevance (formerly Anthem), UnitedHealth Group, Molina, and CVS Health – account for 50% of Medicaid MCO enrollment nationally (Figure 1). All five are ranked in the Fortune 500, and four are ranked in the top 100, with total revenues that ranged from $32 billion (Molina) to $324 billion (UnitedHealth Group) for 2022. Each company operates Medicaid MCOs in 12 or more states (Figure 2). All five firms also operate in the commercial and Medicare markets (Figure 3); however, the distribution of membership across markets varies across firms. Two firms – Molina and Centene– have historically focused predominantly on the Medicaid market. Medicaid members accounted for over 90% of Molina’s overall medical membership and nearly 70% of Centene’s medical membership as of March 2023 (Figure 3).



Combined Medicaid enrollment across the five firms increased by 13.5 million or 44.1% from March 2020 to March 2023 (Figure 4). Medicaid enrollment overall grew by more than 20 million (or about 31%) during the continuous enrollment period (February 2020 to January 2023), resulting in growth in MCO enrollment as well. Enrollment growth has been primarily attributed to the Families First Coronavirus Response Act (FFCRA) provision that required states to ensure continuous enrollment for Medicaid enrollees in exchange for a temporary increase in the Medicaid match rate. Growth in parent firm Medicaid enrollment may also reflect other activity including firm acquisitions and/or new contracts. For the firms that report this information, Medicaid revenue growth 2022 over 2021 ranged from 11% (Centene) to 18% (UnitedHealth) to 21% (Molina). These same firms reported Medicaid revenue growth ranging from 13% (Centene) to 16% (UnitedHealth) to 43% (Molina) year-over-year 2021 over 2020. Molina reported the medical margin earned by the Medicaid segment was $3.0 billion in 2022 and $2.3 billion in 2021 (medical margin = premium revenue – medical costs).

Implications of “unwinding” for the five largest publicly traded companies operating Medicaid MCOs

All five firms expect Medicaid enrollment losses following the end of the continuous enrollment requirement (over 2023 and 2024); however, firms expect to retain some members who lose Medicaid coverage in their Marketplace and other products (Appendix Table). The Consolidated Appropriations Act, 2023 ended the continuous enrollment provision and allowed states to resume disenrollments starting April 1, 2023. While the number of Medicaid enrollees who may be disenrolled during the unwinding period is highly uncertain, it is estimated that millions will lose coverage. KFF estimates 17 million people could lose Medicaid coverage – including some who are no longer eligible and others who are still eligible but face administrative barriers to renewal. Rates of Medicaid coverage loss will vary across states depending on how states approach unwinding. CMS has issued specific guidance allowing states to permit MCOs to update enrollee contact information and conduct outreach about the eligibility renewal process to facilitate continued enrollment as well as Marketplace transitions, where appropriate. In June 2023, CMS released new guidance highlighting several new strategies available to states to prevent procedural terminations including permitting managed care plans to assist enrollees in completing certain parts of renewal forms.


In first quarter 2023 investor earnings calls, executives of the publicly traded companies operating Medicaid MCOs expressed the aim of maximizing continuity of coverage for members through supporting continued enrollment in Medicaid and transitions to the Marketplace (and other products), where appropriate. The firms report conducting direct and indirect outreach, including text messages, live calls, and community-based provider campaigns, to educate members about Medicaid redeterminations and the renewal process as well as about their Marketplace options if they are no longer eligible for Medicaid (Appendix Table).

All five firms offer a Qualified Health Plan (QHP) in the ACA marketplace in many states where they operate a Medicaid MCO, however there may not be plan alignment if plans operate regionally. Current enrollees who are determined to no longer be eligible for Medicaid may be eligible for ACA marketplace (which has higher income eligibility thresholds than Medicaid) or other coverage (e.g., CHIP coverage or employer sponsored insurance (ESI)). Individuals eligible for coverage in the Marketplace may qualify for plans with zero premiums; however, individuals transitioning to Marketplace coverage may face higher cost-sharing and different provider networks. Prior analyses suggest that individuals face barriers moving from Medicaid to other coverage programs and many may experience gaps in coverage. CMS guidance outlines states may encourage MCOs that also offer a QHP to share information with their own enrollees who have been determined ineligible for Medicaid to assist in the transfer of individuals to Marketplace coverage (as long as state-specific laws and/or contract requirements do not prohibit this activity). To avoid gaps in coverage, managed care plans may reach out to individuals before they lose coverage to allow them to apply for Marketplace coverage in advance.

Looking Ahead

Medicaid managed care plans have a financial interest in maintaining enrollment, which could also prevent disruptions in care for enrollees. The five publicly traded firms that are the subject of this analysis account for half of all Medicaid MCO enrollment nationally. As states unwind the continuous enrollment provision, many people will likely be found to be no longer eligible for Medicaid. Others could face administrative barriers and lose coverage despite remaining eligible. Medicaid managed care plans can assist state Medicaid agencies in communicating with enrollees, conducting outreach and assistance, and ultimately, in improving coverage retention – including facilitating transitions to the Marketplace.