Health Plan Weekly

Although spring is just around the corner, many families are still reeling from an autumn and winter season that served up a severe onslaught of respiratory syncytial virus (RSV) and influenza cases. But also starting last fall, select members of Highmark Inc. health plans have been given access to a tool that helps them mitigate their risk: a “local illness alert” program that offers regular, data-driven reports about what’s going around in their area. 

The insurer and the company Kinsa, which developed the tool, tell AIS Health, a division of MMIT, that there is already evidence that the pilot program is driving behavioral changes among members, such as avoiding crowded indoor spaces when illness levels are high. And if final results from the pilot also look promising, Highmark will expand the program to more members — possibly spurring other insurers to do the same.  

CareSource and Walmart Inc. have struck a new deal that will see Walmart aim to improve care for pregnant Medicaid enrollees and CareSource members who require treatment for cardiometabolic conditions in Ohio, building on a partnership announced earlier this year to deliver pregnancy care to CareSource members in Georgia. The deal could be a model for similar partnerships between Medicaid managed care organizations and retailers, experts say, and demonstrates Walmart’s interest in achieving national health care scale. 

CareSource, a nonprofit insurer covering 2.3 million lives (2 million of which are in Medicaid plans) in five states, will partner with Walmart to “address racial health inequities” by connecting eligible CareSource members with Walmart’s “in-store community health workers.” Eligible members “will receive monthly funds to spend on food, a Walmart+ membership for no cost, and access to tele-nutrition services to aid in improving their health outcomes,” according to a press release. The move comes just weeks after Walmart and CareSource agreed to a similar arrangement focused strictly on prenatal, early maternal and children’s health care in Georgia, a partnership that also includes Johnson & Johnson. Neither CareSource nor Walmart responded to requests for comment by press time. 

With the maternal mortality rate in the U.S. notoriously higher than many other developed countries and care access issues a perennial concern, payers can play an important role in efforts to improve perinatal care. During a recent session at AHIP’s Medicare, Medicaid, Duals & Commercial Markets Forum in Washington, D.C., panelists discussed how a deeper understanding of coverage data can fuel those efforts. 

Medicaid pays for more than four in 10 births nationally and more than half of births in some states, said Usha Ranji, associated director for women’s health policy at the Kaiser Family Foundation (KFF). Federal law requires all states to provide Medicaid coverage for pregnancy-related services to women with incomes up to 133% of the federal poverty level and cover them up to 60 days postpartum, but many states have extended the income threshold “well over 200%” of FPL, according to Ranji. 

Many Medicaid agencies’ “frontline eligibility” divisions and call centers are understaffed, according to the Kaiser Family Foundation’s (KFF) just-released annual survey of state Medicaid officials, which was fielded in January. That could complicate income checks and other parts of the eligibility redetermination process, which will resume on April 1 after a yearslong pause due to the COVID-19 pandemic.  

State Medicaid programs are ultimately responsible for determining whether a Medicaid enrollee is in fact eligible for enrollment in the program, but Medicaid managed care organizations (MCOs) also have a hand in managing disenrollments — and have strong incentives to keep as many members enrolled as possible. Indeed, the survey found that 41 states are relying on Medicaid MCOs to “conduct outreach and assist members” as they navigate the disenrollment process; 33 states provided MCOs with “advance lists of members up for renewal,” and 26 states have sent out “advance lists of members who may be disenrolled because they have not responded to requests for information.”