Health plan shake-up could disrupt coverage for low-income Californians

Nearly 2 million of California’s poorest and most medically fragile citizens may possibly have to swap health and fitness insurers as a final result of a new technique by the condition to make improvements to care in its Medicaid plan.

A very first-at any time statewide contracting competition to take part in the software, identified as Medi-Cal, necessary industrial managed-care designs to rebid for their contracts and contend versus some others hoping to just take those contracts away. The contracts will be revamped to involve insurers to offer you new gains and meet stiffer benchmarks for treatment.

The long-planned reshuffle of insurers is very likely to appear with brief-term pain. 4 of the managed-treatment insurers, which include Health and fitness Web and Blue Shield of California, stand to shed Medi-Cal contracts in a tiny in excess of a 12 months, in accordance to the preliminary results of the bidding, announced in late August. If the outcomes stand, some enrollees in rural Alpine and El Dorado counties, as perfectly as in populous Los Angeles, San Diego, Sacramento, and Kern counties, will have to improve overall health strategies — and maybe medical professionals.

“I’m even now stunned and I’m however reeling from it,” explained John Sturm, just one of about 325,000 users of Community Wellness Team, the greatest Medi-Cal system in San Diego County, which could eliminate its agreement. “Which health professionals can I hold? How very long is it heading to take me to switch plans? Are there contingency strategies when, inevitably, folks slip by the cracks?”

Sturm, 54, who has three mental wellbeing problems, mainly simply because of childhood sexual abuse, said obtaining a psychologist and psychiatrist he could rely on took a great deal of time and effort and hard work. He pointed to the disruption brought on by the rollout of Medi-Cal’s new prescription drug plan this yr, in spite of assurances it would go smoothly.

“I have concerns, and I know other persons in the local community have considerations about what we’re staying informed versus what the fact is heading to be,” Sturm mentioned.

Arguably, the most significant loser in the bidding is Health and fitness Web, the greatest professional insurance company in Medi-Cal, which stands to drop 50 percent its enrollees — including more than 1 million in Los Angeles County on your own. St. Louis-primarily based Centene Corp., which California is investigating more than allegations it overcharged the point out for prescription medications, purchased Well being Net in 2016, in portion for its Medicaid organization, of which L.A. is the crown jewel.

But the state’s health approach options are not established in stone. The losing insurers are fiercely contesting the final results in formal appeals that study like declarations of war on their opponents and on the state. Some of the losers are primarily contacting their successful rivals liars.

The stakes are significant, with contracts in perform worthy of billions of dollars each year. Insurers that lose their appeals with the point out Office of Health Treatment Expert services, which operates Medi-Cal, are probable to acquire their grievances to court. That could delay closing decisions by months or yrs, producing a headache for the section, which would like coverage under the new contracts to start off Jan. 1, 2024.

State officials hope to devote the relaxation of this 12 months and all of 2023 making sure that the decided on wellness strategies are up to the endeavor, which includes having adequate taking part suppliers to minimize disruptions in care.

“Member entry and continuity are definitely our major priorities as component of this transition, and we have committed groups that will be performing with the health and fitness plans on the transition setting up and the continuity setting up,” Michelle Baass, director of the division, explained to Kaiser Well being News.

Baass also famous that enrollees have continuity of treatment rights. “For example, if a member is currently less than the care of a health practitioner all through the prior 12 months, the member has the proper to keep on seeing that medical professional for up to 12 months, if selected situations are satisfied,” she said.

The competitive bidding course of action is an exertion by the department to tackle persistent problems that it has not efficiently monitored subpar overall health options.

Eight professional insurers bid for Medi-Cal business in 21 counties. They ended up essential to submit voluminous documents detailing each individual factor of their functions, which includes previous overall performance, the scope of their company networks, and their capacity to fulfill the terms of the new, stricter contracts.

The new contracts consist of quite a few provisions supposed to bolster high-quality, health care fairness, and transparency — and to boost accountability of the subcontractors to whom well being strategies often outsource affected person care. For case in point, the plans and their subcontractors will be necessary to attain or exceed the 50th percentile among Medicaid plans nationally on a host of pediatric and maternal care measures — or facial area economical penalties.

They will also be on the hook for providing nonmedical social services that address socioeconomic variables, this sort of as homelessness and foodstuff insecurity, in an bold $8.7-billion, 5-calendar year Medi-Cal initiative identified as CalAIM, which is underway.

Community, publicly ruled Medi-Cal options, which deal with about 70{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of the 12.4 million Medi-Cal members who are in managed treatment, did not participate in the bidding, however their general performance has not usually been prime-notch. Kaiser Permanente, which this yr negotiated a controversial offer with the state for an exclusive Medi-Cal contract in 32 counties, was also exempt from the bidding. (KHN is not affiliated with Kaiser Permanente.)

But all Medi-Cal overall health insurers, like KP and the area strategies, will have to commit to the same goals and demands.

In addition to Health and fitness Web, Blue Protect of California and Community Health Group — which have contracts with Medi-Cal only in San Diego County — are also big losers, as is Aetna, which misplaced bids in 10 counties.

Blue Protect, which shed in all 13 counties where by it submitted bids, submitted an attractiveness that accuses its rivals Anthem Blue Cross, Molina, and Health and fitness Internet of failing to disclose hundreds of thousands and thousands of dollars in penalties in opposition to them. It accused individuals three strategies of very poor general performance “and even mendacity” and explained they loaded their bids with “puffery,” which the state “bought, hook, line and sinker,” with no “an iota of unbiased evaluation.”

Wellness Net’s attraction slammed Molina, which defeat it out in L.A., Sacramento, Riverside, and San Bernardino counties. Molina’s bid, Wellbeing Net explained, “contains wrong, inaccurate and deceptive details.” The complete bidding course of action, it reported, was “highly flawed,” ensuing in “erroneous agreement awards that jeopardize the balance of Medi-Cal.”

In certain, Well being Web explained, the Section of Health and fitness Treatment Providers “improperly reopened the procurement” following the deadline, which allowed Molina to make “comprehensive changes” that raised its score.

The protesting health and fitness plans are requesting that they be awarded contracts or that the bidding process start off above from scratch.

Joseph Garcia, chief functioning officer for Neighborhood Overall health Team, stated, “It would be easiest for all worried if they just extra us. They never have to take away anybody.”

Group Well being Team has garnered an outpouring of guidance from healthcare facility executives, medical doctor teams, local community clinics, and the heads of numerous publicly ruled Medi-Cal options who sent a letter to Baass declaring they were “shocked, involved, and pretty disappointed” by the state’s choice. They known as Local community Health and fitness Team “our strongest partner of 40 decades,” for whom “equity is not a buzzword or a new priority,” noting that a lot more than 85{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of its team is bilingual and multicultural.

Local community Well being Team mentioned in its attraction that it had missing by much less than a issue to Well being Net, which gained a San Diego agreement — “a miniscule variation that in alone resulted from deeply flawed scoring.”

Garcia said that if Community Overall health Group loses its attractiveness, it will “absolutely” sue in condition court. A hearing officer appointed by Baass to take into account the appeals has set deadlines to obtain published responses and rebuttals by Oct. 7.
There is ample precedent for protracted legal battles in bidding for Medicaid contracts. In Louisiana, Centene and Aetna protested the results of a 2019 rebidding process, which led the point out to nullify its awards and restart the bidding. The new outcomes ended up announced this 12 months, with Centene and Aetna between the winners. In Kentucky, the state court docket of appeals issued a ruling this thirty day period in a contested Medicaid procurement that experienced been held two several years previously.

A further issue could delay the new deal: California is juggling various large Medi-Cal modifications at the identical time. Between them are the implementation of CalAIM and the predicted enrollment of practically 700,000 unauthorized immigrants ages 26 to 49 by January 2024, on top rated of practically a quarter-million unauthorized immigrants 50 and more mature who became eligible this yr. And then there’s the recalculation of enrollees’ eligibility, which will consider put every time the federal COVID-19-relevant community wellness crisis ends. That could thrust 2 million to 3 million Californians out of Medi-Cal.

“Just listening to you list all these things gave me a slight stress assault,” mentioned Abigail Coursolle, a senior legal professional at the Countrywide Overall health Law Plan. “They are making a good deal of operate for them selves in a shorter volume of time.”

But, Coursolle extra, the condition has “a very positive vision for increasing entry and bettering the high quality of products and services that individuals in Medi-Cal acquire, and that is extremely essential.”

This tale was produced by KHN (Kaiser Well being News), just one of the a few important functioning courses at KFF (Kaiser Household Foundation).