Contract Awards

News Briefs: Almost 5.5M Sign Up for Marketplace Plans

Nearly 5.5 million people have selected health plans since the Affordable Care Act open enrollment period began on Nov. 1, CMS said in its latest marketplace enrollment update. That total captures signups on HealthCare.gov through Dec. 3 and through Nov. 26 for the state-based marketplaces, and it represents an 18% increase compared to the same time period last year. So far 22% of total plan selections have been from individuals who are new to the marketplaces, while 78% are returning customers, CMS said. The open enrollment period lasts through Jan. 15 for HealthCare.gov states and most state-based marketplaces.

Blue Shield of California — which lost its bid to continue to serve California’s Medicaid managed care program — plans to lay off 373 employees by Jan. 25, Modern Healthcare reported. The decision from California’s Dept. of Health Care Services came in August after the state held its first competitive bidding process for Medi-Cal contracts. Blue Shield was not chosen — prompting the insurer to later sue the state — while Elevance Health’s Anthem Blue Cross Partnership Plan, Centene Corp.’s Health Net and Molina Health Care were selected to participate in varying service areas across 21 counties. The layoffs represent a small portion of Blue Shield’s total workforce of 7,800, Modern Healthcare noted, and the cuts are mostly concentrated at the insurer’s Sacramento-area offices.

0 Comments
© 2024 MMIT

States Seek Integrated Services and Health Equity in Pending Medicaid RFPs

The latest round of current and upcoming state requests for proposals (RFPs) is continuing a sea change toward integrated care and greater health equity in managed Medicaid programs. Several states are redesigning their programs altogether, with a focus on integrating physical and behavioral health, as well as addressing social determinants of health. New Mexico’s new Turquoise Care program will combine physical health, behavioral health and long-term care services, while Oklahoma will incorporate managed care into its Medicaid program for the first time in 2023. Notably, the state is soliciting bids from both MCOs and provider-led entities to integrate physical health, behavioral health and prescription drug services. Moreover, Georgia and Virginia both hinted at upcoming program changes as they prepare to release RFPs within the next year, with Georgia recently asking stakeholders how it could improve health care in underserved communities. Texas, meanwhile, in the second quarter of 2023 will unveil what’s sure to be a hotly contested RFP — its managed care plans currently serve more than 5 million people. See an overview of key RFPs that are expected to be issued or awarded in the coming months in the table below.

0 Comments
© 2024 MMIT

IngenioRx, Centene Contract Switch Take Spotlight in PBMs’ 3Q Earnings Calls

Although Centene Corp.’s decision to contract with Cigna Corp. rather than CVS Health Corp. for PBM services loomed large during major health insurers’ third-quarter earnings conference calls, it wasn’t the only PBM-related discussion worth noting.

For example, during Elevance Health, Inc.’s earnings call on Oct. 19, executives offered some insights about how the firm’s in-house PBM IngenioRx is carving out a niche in the marketplace.

“We are, as you know, trying to be a different PBM,” Peter Haytaian, Elevance’s president of Diversified Business and IngenioRx, said in response to an analyst’s question about the PBM’s progress selling its services to self-insured employers that already contract with Elevance.

0 Comments
© 2024 MMIT

Cigna’s New PBM Contract With Centene Brings Up-Front Capital Costs

Centene Corp. recently announced that it will shift the bulk of its pharmacy benefits business to Cigna Corp.’s Express Scripts PBM; while discussing Cigna’s latest quarterly results, the carrier’s executives told Wall Street analysts that the deal will likely be a drag on profitability in 2023. Health care insiders tell AIS Health, a division of MMIT, that regulatory compliance, temporarily elevated staffing needs, tech-related capital costs and manufacturer contracting transitions are the likeliest sources of overhead that the deal will generate.

Cigna executives told investors during a Nov. 3 conference call that the Centene deal, which analysts generally praised, would have some start-up costs. Centene Chief Financial Officer Drew Asher said during an Oct. 25 conference call with investors that “we have about $40 billion plus or minus of gross [drug] spend, and almost all of that is [currently] with Caremark,” CVS Health Corp.’s PBM. Cigna CEO David Cordani said that the deal will cover “approximately 20 million Centene members.”

0 Comments
© 2024 MMIT

Centene Posts Solid 3Q Results Despite Wall Street Concerns

Centene Corp. managed to beat Wall Street’s earnings expectations in the third quarter of 2022 while also reporting lower-than-expected Medicare Advantage Star Ratings and MCO contract struggles in California and Florida, two of the Medicaid-focused carrier’s largest states by enrollment. Reviews from Wall Street analysts were mixed, with financiers praising Centene’s continued efforts to spin off its PBM business but raising concerns over the contract disputes and the looming resumption of Medicaid eligibility redeterminations.

The insurer reported $1.30 in adjusted earnings per share (EPS), beating the Wall Street consensus projection of $1.24. Membership grew by 322,400 to over 26.7 million total members during the quarter, raising the year’s cumulative enrollment growth to nearly 950,000 members. Executives project an end-of-year EPS of $5.65 to $5.75, slightly up from a previous projection of $5.60 to $5.75. Centene’s medical loss ratio was 88.3%, and its total revenues reached $35.9 billion in the quarter, up 11% compared with the third quarter of 2021.

0 Comments
© 2024 MMIT

News Briefs: Reporting 3Q Earnings, UnitedHealth Group Saw Revenues Climb 12% From a Year Ago

As the Medicare Annual Election Period gets underway, CMS is warning Medicare Advantage organizations and Prescription Drug Plan sponsors that it will be closely monitoring marketing activities during and beyond the AEP, including through “secret shopping” activities. Given increasing concerns about the marketing practices of all entities, including third-party marketing organizations, CMS has engaged in secret shopping by calling numbers associated with television advertisements, mailings, newspaper ads and internet searches and discovered that some agents are not complying with current rules and are “unduly pressuring beneficiaries, as well as failing to provide accurate or enough information to assist a beneficiary in making an informed enrollment decision,” according to an Oct. 19 memo. However, starting Jan. 1, 2023, television advertisements will no longer qualify for CMS’s “File and Use” framework that allows materials submitted to be distributed five days after submission. Moreover, the agency will review all previously submitted television ads to confirm that materials meet CMS requirements and may take compliance action against plans that use “CMS-disapproved advertisements.” In addition, the agency during the AEP and into the new plan year will enhance its oversight of plan marketing in numerous ways, such as through enhanced review of select marketing materials submitted under File and Use criteria, targeted oversight of MAOs and Part D sponsors with higher or increasing rates of complaints during the AEP, and review of recordings of agent and broker calls with potential enrollees, CMS said.

0 Comments
© 2024 MMIT

Medicaid MCOs Will Aid Ambitious New Waiver Demos in Massachusetts, Oregon

Recently, the Biden administration approved a pair of wide-ranging Medicaid waiver demonstration programs in Massachusetts and Oregon, granting those states authority to test unique policies such as keeping certain populations enrolled in Medicaid for more than a year and covering clinically tailored housing and nutritional supports. Medicaid managed care plans that serve Massachusetts and Oregon tell AIS Health that they’re planning to play a major role in helping to implement the new waiver programs, which will allow them to expand some of the social-needs-based interventions that they’re already providing and reduce the enrollee churn that can stymie care-management efforts.

0 Comments
© 2024 MMIT

Delaware Is Latest State to Face Retiree Pushback on MA Transition

A newly formed retiree advocacy group called RISE Delaware has filed a lawsuit to stop the “unilateral implementation” of a private Medicare Advantage plan that will replace state retirees’ current health care coverage in Delaware. Highmark Blue Cross Blue Shield of Delaware in February was awarded a three-year contract to serve some 30,000 retired state employees and has reportedly made accommodations to address retirees’ concerns, but the plan’s opponents maintain that it was established by the State Employee Benefits Committee (SEBC) in a clandestine manner without proper input from stakeholders and without consideration for a suitable alternative proposed by a separate committee. And, like a lawsuit in New York City, the group is concerned about the extent to which beneficiary care will be subject to prior authorization under MA.

0 Comments
© 2024 MMIT

News Briefs: Anthem Must Face Lawsuit Involving Alleged Failure to Delete Inaccurate MA Diagnosis Codes

A New York District Court judge denied Anthem, Inc.’s request to transfer a False Claims Act lawsuit to another district and to strike allegations contained in an amended complaint. The suit in question was filed by the U.S. Attorney for the Southern District of New York in 2020 and alleges that while conducting chart reviews aimed at identifying additional diagnosis codes for obtaining risk adjusted payment through the Medicare Advantage program from 2014 to 2018, Anthem neglected “its duty to delete thousands of inaccurate diagnoses” and “often generated $100 million or more a year in additional revenue” as a result. According to an opinion filed by U.S. District Judge Andrew Carter on Sept. 30, the company now known as Elevance Health filed a motion to transfer this action to the Southern District of Ohio (or dismiss the suit altogether) and to strike portions of the complaint referencing the government’s settlements with other MA organizations or health care providers.

0 Comments
© 2024 MMIT

TennCare Acquiesces to CMS’s Demands for Demo Revisions

Bowing to CMS’s request after another public comment period, Tennessee is reluctantly pursuing a series of changes to the pending TennCare III demonstration that had been approved by the Trump administration for a start date of Jan. 8, 2021. In what one source says is an unusual back-and-forth on public display, the state will abandon its notorious plans to implement a closed Medicaid formulary and adopt a fixed funding mechanism.

Shortly before President Joe Biden took office, the Trump administration in January 2021 approved Tennessee’s request to use an “aggregate cap” for Medicaid funding that many industry observers had likened to a block grant. Through that approach, Tennessee would have received federal Medicaid funds based on a fixed budget target that is determined by CMS and the state using historical enrollment and costs data. If spending fell below that target cap but certain quality goals were met, the state would earn up to 55% of annual savings to reinvest back into other state health programs.

0 Comments
© 2024 MMIT