Health plan shake-up could disrupt coverage for low-income Californians

Almost 2 million of California’s poorest and most medically fragile residents might have to change well being insurers on account of a brand new technique by the state to enhance care in its Medicaid program.A primary-ever statewide contracting competitors to take part in this system, referred to as Medi-Cal, required business managed-care plans to rebid for their contracts and compete in opposition to others hoping to take these contracts away. The contracts will probably be revamped to require insurers to supply new advantages and meet stiffer benchmarks for care.The long-planned reshuffle of insurers is prone to include short-term ache. Four of the managed-care insurers, together with Health Net and Blue Shield of California, stand to lose Medi-Cal contracts in a little bit over a 12 months, based on the preliminary outcomes of the bidding, introduced in late August. If the outcomes stand, some enrollees in rural Alpine and El Dorado counties, in addition to in populous Los Angeles, San Diego, Sacramento, and Kern counties, should change well being plans — and probably medical doctors.“I’m nonetheless shocked and I’m nonetheless reeling from it,” mentioned John Sturm, considered one of about 325,000 members of Community Health Group, the most important Medi-Cal plan in San Diego County, which could lose its contract. “Which medical doctors can I hold? How lengthy is it going to take me to change plans? Are there contingency plans when, inevitably, people slip by the cracks?”Sturm, 54, who has three psychological well being circumstances, largely due to childhood sexual abuse, mentioned discovering a psychologist and psychiatrist he could belief took loads of effort and time. He pointed to the disruption brought on by the rollout of Medi-Cal’s new prescription drug program this 12 months, regardless of assurances it will go easily.“I’ve considerations, and I do know different folks locally have considerations about what we’re being advised versus what the truth goes to be,” Sturm mentioned.Arguably, the most important loser within the bidding is Health Net, the most important business insurer in Medi-Cal, which stands to lose half its enrollees — together with greater than 1 million in Los Angeles County alone. St. Louis-based Centene Corp., which California is investigating over allegations it overcharged the state for prescribed drugs, purchased Health Net in 2016, partly for its Medicaid enterprise, of which L.A. is the crown jewel.But the state’s well being plan alternatives usually are not set in stone. The shedding insurers are fiercely contesting the leads to formal appeals that learn like declarations of battle on their opponents and on the state. Some of the losers are primarily calling their profitable rivals liars.The stakes are excessive, with contracts in play value billions of {dollars} yearly. Insurers that lose their appeals with the state Department of Health Care Services, which runs Medi-Cal, are prone to take their complaints to court docket. That could delay last selections by months or years, inflicting a headache for the division, which needs coverage beneath the brand new contracts to start out Jan. 1, 2024.State officers hope to spend the remainder of this 12 months and all of 2023 guaranteeing that the chosen well being plans are as much as the duty, which incorporates having sufficient collaborating suppliers to reduce disruptions in care.“Member entry and continuity are actually our prime priorities as a part of this transition, and we’ve devoted groups that will probably be working with the well being plans on the transition planning and the continuity planning,” Michelle Baass, director of the division, advised Kaiser Health News.Baass additionally famous that enrollees have continuity of care rights. “For instance, if a member is at present beneath the care of a health care provider through the prior 12 months, the member has the fitting to proceed seeing that physician for as much as 12 months, if sure circumstances are met,” she mentioned.The aggressive bidding course of is an effort by the division to handle persistent complaints that it has not successfully monitored subpar well being plans.Eight business insurers bid for Medi-Cal enterprise in 21 counties. They have been required to submit voluminous paperwork detailing each side of their operations, together with previous efficiency, the scope of their supplier networks, and their capability to satisfy the phrases of the brand new, stricter contracts.The new contracts comprise quite a few provisions meant to bolster high quality, healthcare fairness, and transparency — and to spice up accountability of the subcontractors to whom well being plans typically outsource affected person care. For instance, the plans and their subcontractors will probably be required to achieve or exceed the fiftieth percentile amongst Medicaid plans nationally on a number of pediatric and maternal care measures — or face monetary penalties.They will even be on the hook for offering nonmedical social companies that tackle socioeconomic elements, similar to homelessness and meals insecurity, in an bold $8.7-billion, five-year Medi-Cal initiative referred to as CalAIM, which is underway.Local, publicly ruled Medi-Cal plans, which cowl about 70% of the 12.4 million Medi-Cal members who’re in managed care, didn’t take part within the bidding, although their efficiency has not all the time been top-notch. Kaiser Permanente, which this 12 months negotiated a controversial cope with the state for an unique Medi-Cal contract in 32 counties, was additionally exempt from the bidding. (KHN isn’t affiliated with Kaiser Permanente.)But all Medi-Cal well being insurers, together with KP and the native plans, should decide to the identical objectives and necessities.In addition to Health Net, Blue Shield of California and Community Health Group — which have contracts with Medi-Cal solely in San Diego County — are additionally huge losers, as is Aetna, which misplaced bids in 10 counties.Blue Shield, which misplaced in all 13 counties the place it submitted bids, filed an enchantment that accuses its rivals Anthem Blue Cross, Molina, and Health Net of failing to reveal a whole bunch of hundreds of thousands of {dollars} in penalties in opposition to them. It accused these three plans of poor efficiency “and even lying” and mentioned they crammed their bids with “puffery,” which the state “purchased, hook, line and sinker,” with out “an iota of impartial evaluation.”Health Net’s enchantment slammed Molina, which beat it out in L.A., Sacramento, Riverside, and San Bernardino counties. Molina’s bid, Health Net mentioned, “accommodates false, inaccurate and deceptive info.” The entire bidding course of, it mentioned, was “extremely flawed,” leading to “inaccurate contract awards that jeopardize the steadiness of Medi-Cal.”In specific, Health Net mentioned, the Department of Health Care Services “improperly reopened the procurement” after the deadline, which allowed Molina to make “complete adjustments” that raised its rating.The protesting well being plans are requesting that they be awarded contracts or that the bidding course of begin over from scratch.Joseph Garcia, chief working officer for Community Health Group, mentioned, “It can be best for all involved if they simply added us. They don’t need to take away anyone.”Community Health Group has garnered an outpouring of help from hospital executives, doctor teams, group clinics, and the heads of a number of publicly ruled Medi-Cal plans who despatched a letter to Baass saying they have been “shocked, involved, and really dissatisfied” by the state’s choice. They referred to as Community Health Group “our strongest accomplice of 40 years,” for whom “fairness isn’t a buzzword or a brand new precedence,” noting that greater than 85% of its workers is bilingual and multicultural.Community Health Group famous in its enchantment that it had misplaced by lower than a degree to Health Net, which gained a San Diego contract — “a miniscule distinction that in itself resulted from deeply flawed scoring.”For the file:2:42 p.m. Sept. 26, 2022An earlier model of this text incorrectly named Health Net as an insurer that protested a Medicaid contracting choice in Louisiana. Centene — the mum or dad firm of Health Net — was the insurer making the protest. It makes use of a special identify in Louisiana.Garcia mentioned that if Community Health Group loses its enchantment, it can “completely” sue in state court docket. A listening to officer appointed by Baass to think about the appeals has set deadlines to obtain written responses and rebuttals by Oct. 7. There is ample precedent for protracted authorized battles in bidding for Medicaid contracts. In Louisiana, Centene and Aetna protested the outcomes of a 2019 rebidding course of, which led the state to nullify its awards and restart the bidding. The new outcomes have been introduced this 12 months, with Centene and Aetna among the many winners. In Kentucky, the state court docket of appeals issued a ruling this month in a contested Medicaid procurement that had been held two years earlier.Another issue could delay the brand new contract: California is juggling a number of huge Medi-Cal adjustments on the similar time. Among them are the implementation of CalAIM and the anticipated enrollment of almost 700,000 unauthorized immigrants ages 26 to 49 by January 2024, on prime of almost a quarter-million unauthorized immigrants 50 and older who grew to become eligible this 12 months. And then there’s the recalculation of enrollees’ eligibility, which is able to happen every time the federal COVID-19-related public well being emergency ends. That could push 2 million to three million Californians out of Medi-Cal.“Just listening to you checklist all these issues gave me a minor panic assault,” mentioned Abigail Coursolle, a senior legal professional on the National Health Law Program. “They are making loads of work for themselves in a brief period of time.”But, Coursolle added, the state has “a really constructive imaginative and prescient for bettering entry and bettering the standard of companies that folks in Medi-Cal obtain, and that’s crucial.”This story was produced by KHN (Kaiser Health News), one of many three main working packages at KFF (Kaiser Family Foundation).

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