Ohio Takes Steps to Refocus Medicaid Managed Care Program
The Ohio Department of Medicaid (ODM) has announced several new steps in the evolution of its managed care program, including selecting six managed care organizations (MCOs) that will operate statewide. New features include a single pharmacy benefits manager, centralized credentialing, and a specialized managed care program for children with complex needs. The newly designed program is targeted for launch in January 2022.
The six MCOs are The six managed care organizations announced April 9 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. They will provide services for more than 3 million members and thousands of medical providers in Ohio’s $20 billion managed care program.
Ohio Medicaid is deferring for additional consideration its decision related to Buckeye Community Health Plan. As a story in the Columbus Dispatch notes, “Buckeye Community Health Plan was at least temporarily barred from getting a piece of the huge deal. That's because of a March 11 lawsuit filed by Attorney General Dave Yost on behalf of the Medicaid department alleging Buckeye and two associated firms improperly made off with tens of millions from the program. The legal action involving Buckeye — which scored the second-highest in the competition for the new contracts — was a factor in delaying the much-anticipated announcement, originally scheduled for Jan. 25.”
ODM’s next-generation program emphasizes plan coordination with OhioRISE (Ohio Resilience through Integrated Systems and Excellence), which addresses care for children with complex behavioral needs – and the single pharmacy benefit manager, which is designed to ensure more accountability and transparency in Medicaid’s pharmacy program. Initiatives such as centralized credentialing and fiscal intermediary are designed to streamline administrative functions and reduce duplicative processes for providers.
Ohio Medicaid’s procurement also required respondents provide more flexibility in establishing alternative payment models with providers who focus on patient care and improve outcomes.
ODM selected Aetna to serve as the specialized MCO for the OhioRISE program. Aetna will work with ODM and the 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 the state’s Medicaid MCOs and the new single pharmacy benefit manager to ensure medical and pharmaceutical services and supports are integrated in the child’s comprehensive health plan.
The OhioRISE program seeks to address gaps in Ohio’s healthcare system that currently result in 140 Ohio kids living out of state on any given day in order to access the behavioral health services they need. Other families voluntarily relinquish custody of their children to local child welfare agencies solely to access needed behavioral healthcare for their children. The OhioRISE managed care plan is designed to fill in these gaps by developing a network of care management entities and by working with Ohio’s behavioral health providers to offer new intensive, coordinated services for children and families statewide.
Ohio aims to enroll 55,000-60,000 Medicaid-eligible children, up to age 21, in the OhioRISE program. Though multiple state agencies serve a majority of these children, the current absence of accountable, focused coordination to integrate these programs leaves parents facing an overly complex system of care during times of family crisis.
ODM chose Gainwell Technologies to be the agency’s single pharmacy benefits manager (PBM). Gainwell provides services for 29 state Medicaid programs, processes more than 195 million pharmacy claims a year, and answers 6.6 million provider and recipient phone calls annually on behalf of state health care customers.
In 2019, the Ohio General Assembly instructed ODM to adopt a single PBM following release of a 2018 Health Data Solutions (HDS) report stating the PBMs were paid $224 million by Medicaid. At issue was the lack of transparency. Neither ODM nor the state auditor could verify or refute the appropriate use of funds. The auditor stated, “…we cannot be content to accept a ‘black box’ in the delivery of public services.” Ohio Medicaid and other state agencies had no means to audit potential steerage or conflicts of interest.
Once implemented, the idea is that the single PBM will eliminate costly duplicative administrative processes for ODM and providers alike. Currently, each of Ohio Medicaid’s six MCOs contracts with one or more PBM to manage prescription drug benefits. As a result, healthcare providers are subject to meeting unique, time-consuming processes required by each MCO to prescribe important, sometimes life-sustaining medications.
To bolster accountability in the pharmacy program, Ohio Medicaid soon will select a pharmacy operational support vendor (POSV) tasked with auditing the single PBM. The POSV will focus on ensuring that the incentives are properly and fairly aligned, self-dealing and steering are prevented, and monetary loopholes are closed. ODM expects to award the POSV vendor by summer 2021.
