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Everything you need to know about BMD and the industry.

Medicaid Announces Next Generation of Managed Care Organizations

Client Alert

For the first time since 2005, the Ohio Department of Medicaid (“ODM”) made significant changes to the structure of the Medicaid program by finalizing the Medicaid Managed Care Procurement process. The Procurement process began in 2019 at the behest of Governor Mike DeWine who had a goal to make Medicaid managed care more focused on the health and well-being of individuals.

According to ODM, the guiding principles for the next generation of managed care are a commitment to:

  • Improve wellness and health outcomes.
  • Emphasize a personalized care experience.
  • Improve care for children and adults with complex needs.
  • Reduce administrative burdens to give providers more time with patient care.
  • Increase program transparency and accountability.

On April 9, 2021, ODM announced the six MCOs selected for the next generation of the managed care program: 

  • UnitedHealthcare Community Plan of Ohio, Inc.
  • Humana Health Plan of Ohio, Inc.
  • Molina Healthcare of Ohio, Inc.
  • AmeriHealth Caritas Ohio, Inc.
  • Anthem Blue Cross and Blue Shield
  • CareSource Ohio, Inc.

Ohio Medicaid also announced that it is deferring for additional consideration its decision related to Buckeye Community Health Plan.

The selected MCOs will now be required to emphasize plan coordination with OhioRISE and the single pharmacy benefit manager (SPBM), also recently announced by ODM. The MCOs will also assist with initiatives such as centralized credentialing and work with a fiscal intermediary to streamline administrative functions and reduce duplicative processes for providers.

Current managed care plan members will continue to receive services with their existing plans until the transitions in early 2022. There should be no lapse in coverage. Members can also choose to select a new plan late this summer during an open enrollment period that has yet to be determined.

Additional Procurement Announcements

OhioRISE

ODM selected Aetna Better Health of Ohio to serve as the specialized managed care organization children with the most complex behavioral health needs under the new OhioRISE (Ohio Resilience through Integrated Systems and Excellence) program. Aetna will work with ODM and Governor DeWine’s Family and Children First Cabinet Council to implement a child and family-centric model featuring new targeted services and intensive care coordination delivered by community partners. Aetna also will coordinate with state and local organizers to expand access to in-home and community-based services for OhioRISE members and their families.   

Single Pharmacy Benefit Manager (SPBM)

ODM selected Gainwell Technologies to be the agency’s SPBM. ODM’s stated goal in contracting with one PBM is to realize greater transparency and accountability in Medicaid’s $3 billion pharmacy program. According to ODM, for Medicaid managed care members, the SPBM will mean less out-of-network restrictions and more choice in pharmacy. For providers, the goal is that the SPBM should also streamline clinical and prior authorization processes and provide a standard point of contact for administrative needs.

Fiscal Intermediary (FI)

ODM also awarded its FI service contract to Gainwell Technologies. The FI create a system to serve as a single clearinghouse for all provider claims and prior authorization requests, validating transactions and routing requests to the appropriate MCO for resolution and reimbursement. In addition, the FI will assist ODM in assessing compliance with Medicaid managed care regulations, review encounter data, and track performance measures. The separate FI system is new for Ohio, and providers and MCOs alike are anxiously waiting to see how the process works in reality.

For questions about the Procurement process or Medicaid generally, please reach out to the healthcare attorneys at Brennan, Manna & Diamond and check back on the Resources page for more information following the Procurement announcement.


Telehealth Flexibility Updates: HIPAA, DEA, and CMS

The Covid-19 Public Health Emergency (PHE) officially ended on May 11, 2023. But what does that mean for telehealth, a field that expanded exponentially during the PHE? Fortunately, many of the flexibilities will remain intact, at least temporarily. This client alert presents a brief overview of the timelines that providers need to follow, but for a more comprehensive review of telehealth flexibilities and when they will end

WEBINAR SERIES RECAP | Ending the Public Health Emergency + Post-Pandemic Check-Up

Some may take the position that the rest of the country already returned to a new “normal” following the COVID-19 pandemic.  But healthcare providers continue to implement COVID protocols and navigate the ever-changing healthcare regulations at both the federal and state levels.  It is important for healthcare providers to take time for a “Healthcare Check-Up” with the start of 2023 and the ending of the Public Health Emergency (“PHE”).

Sharp Rise in False Claims Act Cases - Navigating the FCA Waters

Recently, on April 18, 2023, the United States Supreme Court heard arguments regarding the FCA’s scienter, or mental state, requirement. To prove violation of the FCA, the statute requires that a defendant “knowingly” file false claims for payment. The term “knowingly” is defined within the statute to mean a person that acts with actual knowledge, deliberate ignorance, or reckless disregard. Circuit courts are split on how to interpret and apply the knowledge element of the FCA, and based on the Supreme Court’s decision, there will be a large impact on healthcare defendants and their businesses as well as anyone who contracts with, or receives money from, a federal program. A broader interpretation of the FCA would unnecessarily target and stifle healthcare, and other businesses, for simple errors in daily operations. This goes against the intended application of the FCA, which was to prevent fraudulent activity.

Areas of Opportunity in Columbus: Highlights from the Columbus Opportunity Summit

On April 27, 2023 Columbus Business First held its annual Columbus Opportunity Summit, bringing together business and economic development leaders to provide an update on how Central Ohio is preparing for expected growth in the coming years, an issue heightened by the arrival of Intel at its 1,000 acre site in Licking County, just outside of Columbus. The site will be home to two new chip factories with room to grow to a total of eight factories and is a $20 Billion investment.

BREAKING: Biden Administration Has Officially Ended the Two Remaining COVID Vaccine Mandates

As of May 1, 2023, the Biden Administration has officially ended the two remaining COVID vaccine mandates: (1) the Federal Contractor Mandate, and (2) the CMS Healthcare Provider Vaccine Mandate.