With West Virginia Medicaid Plan, Highmark Hopes to Fight ‘Appalachian Fatalism’

In August, Highmark Inc. launched a new Medicaid managed care organization in West Virginia, becoming the Mountain State’s first Blue Cross Blue Shield-branded MCO. In doing so, the insurer will confront challenges that MCOs of all stripes are facing, such as building a comprehensive provider network and grappling with the financial pressures related to states resuming their routine eligibility checks after a multiyear pause.

The West Virginia Dept. of Human Services approved Highmark Health Options’ application to be the state’s newest MCO in January, giving the not-for-profit organization a statewide contract that runs for four years. Highmark Health Options will compete against a trio of MCOs in West Virginia that include Elevance Health, Inc.’s Unicare Health Plan of West Virginia, Aetna Better Health of West Virginia, and The Health Plan’s Mountain Health Trust. As of September, Highmark Health Options West Virginia had attained roughly 1,800 members, according to AIS’s Directory of Health Plans (DHP).

Although Highmark Health Options is new to West Virginia, Pittsburgh-based Highmark already serves approximately 285,000 members in individual and group plans in the state, according to DHP. Highmark has operated Medicaid plans for more than 30 years and says it “currently cares for more than 500,000 Medicaid beneficiaries across three regional states, including neighboring Pennsylvania and Delaware.”

Jason Landers, president of Highmark Health Options West Virginia, says the new health plan is prepared to take on the challenges currently facing Medicaid MCOs — as well as challenges that are more specific to West Virginia. Landers, who previously served in various executive roles at Highmark before leaving for a stint at West Virginia-based The Health Plan, returned to Highmark in 2022 to help the insurer launch its new West Virginia Medicaid plan. In an interview with AIS Health, a division of MMIT, Landers shared more about Highmark Health Options’ journey to becoming West Virginia’s newest MCO and what makes it stand out among its competitors.

Editor’s note: This interview has been edited for length and clarity.

AIS Health: Can you walk me through the process that led to Highmark Health Options becoming an MCO in West Virginia?

Landers: Initially the state planned to issue an RFP, and our legislators made a change almost in midstream. We spent a two-year period developing really a meaningful plan to operate the first Blue Cross and Blue Shield branded Medicaid plan in West Virginia history, and we were very excited about it. Maybe two months before the RFP was going to be issued, they changed it to an application. It kind of changed the rules; there are legal aspects that are different. We pivoted very quickly from our proposal to an application. The intent [with the RFP] was to open for bid one position amongst three MCOs providing Medicaid to the state. However, the application process was defined such that there’s not particularly a limit on the number of plans that can participate in the state. So, there were several plans that had expressed interest in entering West Virginia.

Under the new rules, the ramp-up is considerably different than if you are a new MCO replacing another one. So, we’re going to earn our members, and most of the other plans did not have that commitment to invest as much as $10 or $15 million in plan development for a three-year return, because it’ll take us several years to get the membership numbers that we expect we need to be break-even. But we are a mission-driven nonprofit…it was worth it for us, so we made that commitment to go ahead and apply.

AIS Health: It can be challenging for Medicaid managed care plans to construct robust provider networks, since Medicaid reimburses at lower rates than commercial plans. And rural areas, in particular, may struggle with provider shortages. How did Highmark Health Options overcome those challenges?

Landers: West Virginia is a really diverse state — the things that are important in our eastern panhandle, which is really a bedroom community of Washington, D.C., are very, very different than the things that are important in Clay County, which is one of the more rural counties in West Virginia. And those provider needs are very different as well. When I was approached to lead this effort, the one thing that I knew was that network development was going to be crucial, and it was going to be a lift. And so, we did a couple of things.

Highmark West Virginia has a great relationship with providers across the state. We are the largest commercial plan provider in the state of West Virginia, so we leveraged those existing relationships as a starting point. It was arduous — we probably started the contracting more than a year and a half ago, and we didn’t send out contracts and they all just came back magically. It required a lot of conversations and a lot of making sure people understand what our plan was, why it would be different and why it was important for them to participate with us.

We do have an adequate network — we are providing care all over the state, all levels of providers, from hospitals and hospital systems all the way down to midwives and nurse practitioners, and every level of therapist.

AIS Health: Highmark Health Options says it built what it calls a “high-performing social care network,” composed of 10 nonprofit organizations that address key health-related social needs in members’ communities, like hunger and housing security. Could you explain what that means and how those partnerships work? 

Landers: When you think about a Medicaid plan, you think about people going to the doctor, you’re trying to drive people in for preventive care to really empower people to be healthy. But the reality is, I can give you immunizations if you’re my member, and I can make sure you’re on schedule for visits, but if you’re hungry, you’re not going to be healthy. And so, we took it upon ourselves to create what we call a high-performing social care network — it is a network of community-based organizations that we partner with. We incentivize them to not only assist us with providing those community-based services, like a food bank, but also when we make that referral of a member who needs food, we want them to come back to us and say, “We closed that loop — we made contact, we made sure that they came in, we actually gave them food.”

AIS Health: Is it just a referral-based system, or is there money changing hands in those relationships?

Landers: It’s a real network. We’ve formalized our relationships with these entities; we have agreements that say here’s what we’re going to do, here’s what we expect you to do. And there’s real money changing hands in the form of incentives. It’s one thing to give a food bank $25,000 or whatever and say, “Buy some food and help everyone.” We’re doing that, too, but what we’re talking about is maybe the next iteration of that, and that is, let’s make sure that when we find someone in need and make that referral, you actually reach out to them and then come back to us and let us know that, “Hey, we closed that loop, we’ve made that connection and we’ve solved that need.” Until you’re doing that, it’s almost “care by hope.”

AIS Health: Can you share what else differentiates your health plan from the other MCOs, in terms of what it offers to members?

Landers: When I was approached about leading this organization, I really wanted to make sure that it carried that Blue brand. The reason I wanted to know is there is a very real and perceived level of quality associated with being a Blue-branded organization. I grew up in rural West Virginia, and when I was a kid, if your dad was a miner and covered by Blue Cross, that really meant something — it gave the physicians the comfort of knowing that they were going to get paid. So that was important to me, and I don’t want to discount that, but there are a lot of reasons why we’re different.

First of all, we are owned by Highmark West Virginia; we are a very locally run organization. I’ve said this countless times — and this will sound fluffy, and I apologize — but our members are my family. These people are real to me, and I want to make a difference in their lives — not just their health, but their lives. We really are trying to go beyond that care, and we’re creating relationships with the community colleges in West Virginia, where we’re going to identify opportunities for our members to re-enter the workforce when they can.

There’s a thing called Appalachian fatalism, and it’s when “things have always been bad, so I’m never going to escape this.” We want to spend time not only making sure that we’re checking those boxes on, you’re getting your immunizations and you’re getting the doctor visits, but also, “Hey, did you know most education at the community college level is free? And we can help you navigate those waters.” I tell people all the time, give me anyone in West Virginia, and one year, no money, I can teach them to be a welder at a community college, and in 15 months, they’re going to be making more money than I am.

We really need people to understand that there are opportunities, and we’re going to spend time talking to people about what those opportunities look like and how they can access them.

AIS Health: Some of the major publicly traded health insurers that offer Medicaid managed care have disclosed financial pressures, as some states haven’t yet adjusted their capitation rates to reflect the costlier-to-insure risk pool that resulted from Medicaid redeterminations. Is Highmark Health Options facing similar challenges, and if so, how are you responding?

Landers: One of the reasons I’m here is I’ve been in this state and in Medicaid long enough that I know what those challenges look like. There’s always going to be these cyclical swings in funding in Medicaid, and while we’re the new plan and we’re the small plan, Highmark West Virginia is very committed to the people of West Virginia. That was another question that I had very early on: “Do we understand what this is going to look like, and what is our level of resolve for being the new entrant?” That level of commitment is there, I’ll assure you, or I wouldn’t be here. I think we are well-positioned because of our experience and because of that level of commitment — not just financially, but from top leadership at Highmark all the way through Highmark West Virginia. We know what it’s going to look like, we know what those challenges are, in terms of financial pressures, but we are very resolved to be in this market — and we’re in it for the haul.

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