Radar on Medicare Advantage

As Centene Corp. defends allegations made by the Ohio Attorney General regarding its pharmacy benefit practices, recent court filings indicate the company’s strong desire to clear the air in a public way. At the same time, Centene and its affiliates allege that the plaintiffs lack a basic understanding of Medicaid billing and pharmacy benefits.

“There are no secrets here; there is nothing that needs to be hidden or, in fact, that even justifies the filing of this lawsuit,” argue Centene, Buckeye Community Health Plan and Envolve Pharmacy Solutions in a March 2 filing in the case, Ohio Dept. of Medicaid, et al. v. Centene Corporation, et al. (No. 21-cv-1502). Although the case was originally filed under seal in the Franklin County Court of Common Pleas, Centene requested that it be unsealed for the sake of transparency, and it has since moved to the U.S. District Court for the Southern District of Ohio. “The Complaint in this case reflects a misunderstanding of the admittedly complex world of Medicaid accounting and billing” in which MCOs and PBMs like Buckeye and Envolve operate, and the allegations can be “easily explained away once the facts about Buckeye’s reporting and billings” to the Ohio Dept. of Medicaid (ODM) are understood, contend the defendants.

As holdout states consider whether to accept the Biden administration’s offer of enhanced federal funding to expand Medicaid, a recent evaluation report on Indiana’s conservative Medicaid expansion demonstration may hold some lessons learned for states that look to managed care plans to do some of the heavy lifting for such programs.

The American Rescue Plan, signed into law by President Joe Biden in March, extends a five percentage-point bump in the Medicaid Federal Medical Assistance Percentage (FMAP) to states that newly expand Medicaid eligibility for all adults with income up to 138% of the federal poverty level (RMA 3/18/21, p. 8). Fourteen states have yet to expand Medicaid under the Affordable Care Act, although lawmakers in Tennessee have reportedly expressed an openness to exploring it while advocates in other red states like Georgia continue to push hard for expansion. Voters in Missouri and Oklahoma last year approved Medicaid expansion via a ballot measure (RMA 8/6/20, p. 1), but Republican lawmakers in Missouri are now trying to keep expansion out of the next budget. Funding-related uncertainties also face Oklahoma, which recently submitted a request to amend its SoonerCare demonstration to begin enrolling expansion adults in the next fiscal year.

As CMS kicks off the first performance year of a new care delivery model — in which provider groups and other entities will share risk and receive capitated payments for serving fee-for-service Medicare beneficiaries — the initial round of participants indicates solid interest from Medicare Advantage organizations. Meanwhile, CMS has paused applications for future years of the so-called direct contracting model and is reevaluating a component that would have included Medicaid managed care organizations, raising questions as to what other value-based care models the CMS Innovation Center might have in the works or what modifications it could potentially make to this one.

After an implementation period last fall in which participants weren’t accountable for costs or quality, the first performance year of the Global and Professional Direct Contracting (GPDC) Model began on April 1 and involves 53 Direct Contracting Entities (DCEs) that will serve FFS beneficiaries in 38 states as well as the District of Columbia and Puerto Rico, the Innovation Center announced on April 8.

More than three months after the intended award announcement date, the Ohio Dept. of Medicaid (ODM) on April 9 named six managed care organizations that will serve its newly redesigned Medicaid program starting in 2022. One notable exclusion from that group was Buckeye Community Health Plan, the Ohio subsidiary of Centene Corp. that received a designation of “Defer” as alleged violations of its current pact with ODM are the subject of ongoing litigation and, according to one industry expert, could have devastating effects for Centene.

In order from highest to lowest qualifying score, the six winners of the state’s request for applications (RFA) are: 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, and CareSource Ohio, Inc.

✦ Aiding in its efforts to deliver timely care and meet members in their “preferred environments,” Anthem, Inc. on March 24 said it will buy home-based nursing management company myNEXUS, Inc. According to a March 24 press release from the firms, myNEXUS provides integrated clinical support services for approximately 1.7 million Medicare Advantage members across 20 states. It utilizes a digital platform that combines an advanced analytic rules engine and a staff of more than 250 clinicians to “effectively plan for and to optimize home care.” It also has a nationwide network of high-performing home health providers and nurse agencies, including nine of the top 10 highest quality national and local providers. The transaction will allow myNEXUS to “broaden our capabilities as we strive to transform how quality healthcare is delivered to the people we serve,” said myNEXUS CEO Juan Vallarino. Upon close, myNEXUS will operate as a wholly owned subsidiary of Anthem and will join its Diversified Business Group. MyNEXUS currently manages approximately 830,000 Anthem MA members and group retirees in all states except Florida, Tennessee and New Jersey. The deal is expected to close in the second quarter of 2021 and is subject to customary closing conditions. Contact Leslie Porras at leslie.porras@anthem.com.

✦ Minneapolis-based not-for-profit insurer UCare has joined the industry-wide Community Connectors Program led by America’s Health Insurance Plans, which aims to vaccinate 2 million vulnerable Americans against COVID-19 over 100 days. UCare will utilize its community partners to help as many eligible members as possible receive their vaccines. Building on its current efforts to support vaccination, UCare will do the following: Host two large-scale COVID-19 vaccine events at the State Fairgrounds in spring and summer, offer UCare Healthmobile COVID-19 vaccine events in greater Minnesota and targeted neighborhoods in the Twin Cities metro starting this spring, conduct a multicultural educational campaign in UCare member languages and communities, make outreach calls to eligible members to help schedule COVID-19 appointments and/or register them with the Minnesota Dept. of Health COVID-19 Vaccine Connector, operate a vaccine hotline, and conduct community outreach and education to “ensure fair and just access to the vaccine for all populations UCare serves.” The insurer provides health benefits to 550,000 members, including those enrolled in Medicare and/or Medicaid, throughout Minnesota and parts of western Wisconsin. Contact Wendy Wicks at wwicks@ucare.org.