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.

El Contrato Escrito: La Herramienta Predilecta

No existe mejor herramienta a una disputa contractual que un documento firmado por las partes en el cual se expongan las obligaciones y acuerdos entre éstas.

New State Budget Institutes Licensure Requirement for Ohio’s Hospitals

On July 1, 2021, Governor Mike DeWine signed Ohio’s final budget codified at Ohio Revised Code 3722.01 et seq., which includes a new licensing requirement for Ohio’s hospitals. For years, Ohio was the only state in the country that did not license its hospitals. This approach will now be replaced with new, detailed requirements that will require careful review and compliance. Here are some of the highlights concerning these new changes:

Healthcare Provisions in the Ohio FY 22-23 Budget

Governor Mike DeWine signed Ohio’s Fiscal Year 2022-2023 budget bill (HB 110) into law on July 1, 2021. At almost 1,000 pages and 74.1 billion dollars, the budget lays out the State’s spending for the next two years. Below are a few highlighted provisions from the budget that will be important for the healthcare industry in Ohio

Interim Final Rule for Surprise Billing

In an effort to implement the new bipartisan No Surprises Act, on July 1, 2021, the Department of Health and Human Services (HHS), along with the Departments of Labor and Treasury, issued an interim final rule to safeguard patients against unforeseen medical bills arising from out-of-network care.

President Biden Seeks to Limit Non-Compete Agreements

Today, President Biden announced he would issue an Executive Order that calls on the Federal Trade Commission (FTC) to adopt rules to curtail worker non-compete agreements. Interestingly, a week ago, the FTC approved changes to its Rules of Practice to modernize and expedite the way it issues Trade Regulation Rules. If you have followed our alerts, we predicted the elimination of non-competes would probably happen. In 2016, then-Vice President Biden was a vocal opponent against non-compete agreements. He led the Obama administration’s initiative seeking to limit or eliminate non-compete agreements. In his presidential campaign, Biden promised to “work with Congress to eliminate all non-compete agreements, except the very few that are absolutely necessary to protect a narrowly defined category of trade secrets . . ..”