Resources

Client Alerts, News Articles, Blog Posts, & Multimedia

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.


Community Banks: Collaboration, not isolation, is the key to protecting/ enhancing the cannabis business you pioneered

As we prepare for the plenary session of the informal institutional cannabis lenders community announced in my previous article, I am pleased to advise that participants now include 5 of the best-known dedicated loan funds; a select group of commercial banks ranging in size from single state community banks to mid-size regionals making cannabis loans into the mid-8 figures; and, a syndicator of credit union cannabis loans.

Inflation Reduction Act: Healthcare Provisions

On August 16, 2022, President Joe Biden signed into law the Inflation Reduction Act (the “Act”), a landmark climate, healthcare, and tax bill. Though the Act’s climate provisions have received most of the media attention, the healthcare aspects of the Act present some of the most significant changes to the American healthcare system since the passage of the Affordable Care Act.

The Current State of Assignment of Benefits Litigation in Florida

On May 25, 2022, Florida lawmakers approved property insurance reforms that remove attorney’s fees, with respect to assignment of benefits (“AOB”) property insurance litigation. One-way attorney’s fees are a longstanding problem in Florida and the reforms come at a time when AOB litigation increasingly affects homeowners in a negative way.

Proposed Community Revitalization Grants for Ohio Projects

Jason A. Butterworth client alert ohio tax credits historic preservation tax credits community revitalization grants

Ohio Senate Bill 225 Paves the Way for Greater Investment in Opportunity Zones and Historic Districts

Ohio Senate Bill 225 is poised to make dramatic enhancements to certain tax credit programs in Ohio, specifically those surrounding investments in “Opportunity Funds” and historic buildings. Signed into law by Governor Mike DeWine in June 2022, the Bill is positive news for real estate developers working to revitalize Ohio communities with investment and rehabilitation projects.