Client Alerts, News Articles & Blog Posts

Everything you need to know about BMD and the industry.

Medicaid Announces Next Generation of Managed Care Organizations

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.

Changes to Physician Assistant Statutes in Florida

In the last year, there have been many changes to the scope of practice and collaboration/supervision requirements for advanced practice providers such as APRNs and physician assistants in the state of Florida. In a previous Client Alert we discussed House Bill 607, which expanded the autonomous practice of APRNs providing primary care services in Florida.

Ohio Senate Bill 49 – Ohio Expands Lien Rights for Design Professionals

Effective September 30, 2021, Ohio granted limited lien rights to design professionals, including architects, landscape architects, engineers, and surveyors. Ohio Governor Mike DeWine signed Senate Bill 49 into law on July 1, 2021. This new law established a statutory right to lien commercial real estate by Ohio design professionals who, until now, could not file a lien for non-payment of professional services. Senator Vernon Sykes, a primary sponsor of Senate Bill 49, stated that the “legislation ensures that architects, engineers and other designers will get paid for their work, regardless of the outcome of their projects . . . It will support hardworking Ohioans by protecting the value of their labor . . ..”

Primary Care Practice Officially Defined in Florida for APRNs Practicing Autonomously

As many providers in Florida are aware, House Bill 607 (the “Bill”), which was passed in February of last year, gives certain APRNs in Florida the ability to practice autonomously. The only catch is that they must work in primary practice. When the Bill was initially passed, there was question as to what was exactly considered primary care, absent a definition from the Florida Board of Nursing. However, as of February 25, 2021, “primary care practice” has officially been defined.

Part II of the No Surprises Act

The Department of Health and Human Services (“HHS”) published Part II of the No Surprises Act on September 30, 2021, which will take effect on January 1, 2022. The new guidance, in large part, focuses on the independent dispute resolution process that was briefly mentioned in Part I of the Act. In addition, there is now guidance on good faith estimate requirements, the patient-provider dispute resolution processes, and added external review provisions.

Safer Federal Workforce Task Force - Guidance for Federal Contractors and Subcontractors

The Safer Federal Workforce Task Force has issued its Guidance for Federal Contractors and Subcontractors (Guidance). Note that the Guidance applies only to “covered contracts,” which are contracts that include the clause (Clause) set forth in Sec. 2(a) of Executive Order 14042 (Ensuring Adequate COVID Safety Protocols for Federal Contractors). The Federal Acquisition Regulatory Council (FARC) is to conduct rulemaking and take related action to ensure that the Clause is incorporated into federal contracts. Until that happens, federal contractors likely will not see the Clause in its contracts. Following is a broad summary of the Guidance.