Ohio is on the hunt for well being insurers fascinated by serving the state’s 2.6 million Medicaid members.
The state launched a request for purposes on Wednesday to acquire managed care organizations for the safety-net program, which is present process an enormous overhaul for the primary time since 2005, when CMS authorised Ohio’s Medicaid program.
The contracts, that are for an preliminary two-year time period and renewable on a one-year foundation after that, will likely be awarded in January 2021 and go reside in January 2022. The insurers will likely be paid greater than $20 billion to supply providers.
Later within the fall, the Ohio Division of Medicaid will ask for separate purposes from organizations that need to serve members of a brand new children-focused behavioral well being plan.
Ohio’s Medicaid is remodeling the safety-net program in a number of methods to offer beneficiaries a extra individualized healthcare expertise and create better transparency and accountability in this system. The request for purposes comes after the division spent 18 months gathering suggestions from suppliers, members and different stakeholders.
“From a structural perspective, the most important distinction is we’re unbundling how we do managed care in Ohio,” stated Jim Tassie, the division’s deputy director who oversees procurement.
“Right now and just about for the final 15 years, the managed care program has been a mirror picture of a standard Medicaid program. All of the providers—dental, imaginative and prescient, behavioral well being, transportation—every little thing will get paid for monolithically by means of the managed care plans. The mannequin we created now mainly unbundles a few of that so we will get specialised experience in areas the place we’d like it,” he stated.
In a single instance of that “unbundling,” Ohio is transferring to a mannequin by which it contracts with a single pharmacy profit supervisor to deal with Medicaid drug advantages. Beforehand, the insurers contracted with their very own PBMs, so there have been 5 – 6 corporations dealing with drug advantages within the state. Underneath the brand new mannequin, the Medicaid division and a vendor will decide the pharmacy community and charges; the PBM will concentrate on coordinating care and paying claims.
“We may have firsthand imaginative and prescient into what’s taking place with our pharmacy greenback, but additionally by separating out the duties there’s much less of an opportunity of unexpected influences, negotiations over charges, relying on who the PBM is or the pharmacy is,” Tassie defined. “It truly is a way more clear and accountable system.”
A couple of years in the past, a state-sponsored research revealed that PBMs bilked $224 million from the Ohio Medicaid program. The Ohio Legislature later required the Medicaid division to maneuver to a single PBM, and the division launched a request for purposes in July to search out one. It obtained six bids.
Quickly, Ohio pharmacists will be capable to invoice the Medicaid division instantly as healthcare suppliers for sure medical providers that transcend dishing out drugs.
Ohio goals to shift the main focus of the Medicaid program onto the person with the brand new managed care contracts. The contracts would require well being plans to work collectively to enhance inhabitants well being by lowering weight problems, stopping or ending smoking, and bettering maternal well being, Tassie stated.
The division can also be strengthening the requirement that the plans take a strategic method to care coordination, Tassie stated. Managed care organizations will likely be required to companion with group organizations, resembling a neighborhood well being heart, and contribute part of their annual income again within the communities.
Different necessities for the plans embody clearer communication and cultural sensitivity and consciousness coaching, to allow them to higher help beneficiaries.
Suppliers within the state will even see modifications. The Medicaid division will deal with supplier credentialing, so suppliers do not need to endure the burdensome course of with every managed care group. Underneath the brand new Medicaid program, suppliers will even submit their claims and prior authorization requests to a single level of contact, slightly than submitting them in a number of methods to every insurer.
Performing as a fiscal middleman will enable the Medicaid division extra visibility into claims information, prior authorization selections, and the way rapidly insurers are making these selections, Tassie stated.
For the needs of the Medicaid managed care, Ohio is split into three areas. 5 managed care plans presently serve every of these areas. They embody Buckeye Well being Plan, CareSource, Molina Healthcare, Paramount Benefit and UnitedHealthcare.