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 Medicare’s Physician Fee Schedule and Outpatient Prospective Payment System

Come the beginning of 2022, both the Medicare Physician Fee Schedule (“MPFS”) and Outpatient Prospective Payment System (“OPPS”) will look a little different. As a refresher, the MPFS lists the fees associated with reimbursement of services to providers at certain facilities, taking into account geography and costs. By contrast, OPPS sets reimbursement rates for hospitals and community mental health centers for outpatient services, which are determined in advance. A summary of some of the more pertinent changes to each rule will be outlined below.

CMS to Once Again Reprocess Outpatient Clinic Claims

The Hospital Outpatient Prospective Payment System (OPPS) Rule was passed in November 2018, which was intended to prevent the Centers for Medicare and Medicaid Services (CMS) from paying more for services rendered in outpatient settings than what they paid for the same services rendered in physician offices that are simply owned by hospitals or health systems.[1]

New Vaccine Requirement for Select CMS-Participating Facilities

On November 4, 2021, the Centers for Medicare and Medicaid (“CMS”) released a new rule requiring certain healthcare facilities to implement policies requiring employees to be vaccinated against COVID-19. It does not matter if a staff member does not perform patient treatment services, they must still be vaccinated if an employee of an applicable facility.

OSHA COVID-19 EMERGENCY TEMPORARY STANDARD (ETS) Vaccination, Testing, Recordkeeping, and Reporting

The Occupational Safety and Health Administration has issued its long-awaited COVID-19 Emergency Temporary Standard (ETS). Note that the ETS does not apply to employers covered under the Safer Federal Workforce Task Force COVID-19 Workplace Safety: Guidance for Federal Contractors or Subcontractors (see here), or to settings where employees provide healthcare services subject to OSHA’s ETS for the healthcare industry (see here).

Interesting Trends Revealed in 50-State Medicaid Budget Survey

Results of the KFF annual survey of state Medicaid directors reveal some fascinating trends in Medicaid service delivery and benefit coverage. Read on for a summary of the highlights we find most noteworthy. Background As a preliminary matter, many of the trends KFF identifies and that we highlight below are no doubt a result of the Covid-19 pandemic. The pandemic triggered a public health emergency and economic crisis that resulted in increased Medicaid enrollment, service offerings, and flexibility in service delivery, along with a heightened awareness of disparities in access to care and health outcomes.