Skip to main content
Sister Publication Links
  • ESG: THE NEW IMPERATIVE
Subscribe
  • Sign Up Free
  • Login
  • Subscribe
  • News
    • Current News
    • COVID-19
    • Providers
    • Insurance
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • Transformation
    • People
    • Regional News
    • Digital Edition (Web Version)
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • Midwest
    • Northeast
    • South
    • West
  • Digital Health
  • Insights
    • ACA 10 Years After
    • Best Practices
    • Special Reports
    • Innovations
  • Opinion
    • Bold Moves
    • Breaking Bias
    • Commentaries
    • Letters
    • Vital Signs Blog
    • From the Editor
  • Events & Awards
    • Awards
    • Conferences
    • Galas
    • Virtual Briefings
    • Webinars
    • Nominate/Eligibility
    • 100 Most Influential People
    • 50 Most Influential Clinical Executives
    • Best Places to Work in Healthcare
    • Excellence in Governance
    • Health Care Hall of Fame
    • Healthcare Marketing Impact Awards
    • Top 25 Emerging Leaders
    • Top 25 Innovators
    • Diversity in Healthcare
      • - Luminaries
      • - Top 25 Diversity Leaders
      • - Leaders to Watch
    • Women in Healthcare
      • - Luminaries
      • - Top 25 Women Leaders
      • - Women to Watch
    • Digital Health Transformation Summit
    • ESG: The Implementation Imperative Summit
    • Leadership Symposium
    • Social Determinants of Health Symposium
    • Women Leaders in Healthcare Conference
    • Best Places to Work Awards Gala
    • Health Care Hall of Fame Gala
    • Top 25 Diversity Leaders Gala
    • Top 25 Women Leaders Gala
    • - Hospital of the Future
    • - Value Based Care
    • - Supply Chain
    • - Hospital at Home
    • - Workplace of the Future
    • - Digital Health
    • - Future of Staffing
    • - Hospital of the Future (Fall)
  • Multimedia
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Video Series - The Check Up
    • Sponsored Video Series - One on One
  • Data Center
    • Data Center Home
    • Hospital Financials
    • Staffing & Compensation
    • Quality & Safety
    • Mergers & Acquisitions
    • Data Archive
    • Resource Guide: By the Numbers
    • Surveys
    • Data Points
  • MORE +
    • Contact Us
    • Advertise
    • Media Kit
    • Newsletters
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Providers
October 06, 2014 01:00 AM

Pa. Medicaid managed-care expansion plans struggle to sign providers

Virgil Dickson
  • Tweet
  • Share
  • Share
  • Email
  • More
    Reprints Print
    Corbett

    Medicaid managed-care plans providing coverage under Pennsylvania's Medicaid expansion are struggling to find enough hospitals and physicians for their networks.

    Insurers say the problem is false expectations created by the administration of Republican Gov. Tom Corbett and the state Department of Public Welfare that the plans would pay providers more than traditionally low Medicaid rates.

    “The problem is it's not funded as a commercial-type offering,” said Patricia Darnley, CEO of Gateway Health Plan, one of nine plans chosen for the so-called Healthy Pennsylvania demonstration program to expand Medicaid to as many as 500,000 adults with incomes between 100% and 138% of the federal poverty level. Providers “are looking for commercial funding and in our state commercial funding is nowhere near Medicaid funding.”

    Dennis Olmstead, chief strategy officer for the Pennsylvania Medical Society, said doctors also are balking based on the rate issue. “Absolutely, some may decline being part of the networks if they are given a choice, while others may feel it's their moral duty to serve these individuals,” he said. But he added that some doctors may not be able to decline because they have “all product” clauses in their contracts with insurers, requiring them to serve members of all plans offered by that insurer, including a Healthy Pennsylvania plan.

    The healthcare and political stakes are high. The Medicaid plans have until Oct. 17 to receive certification from the state that they have enough providers to offer adequate access to the expanded Medicaid-eligible population. Enrollment is scheduled to begin Dec. 1. The state needs the plans to be certified by Oct. 17 to begin outreach and enrollment.

    Both Corbett, who is trailing in the polls in his November re-election contest, and the Obama administration have a lot invested in seeing Healthy Pennsylvania succeed. Corbett has been criticized by his Democratic opponent, Tom Wolf, for not promptly expanding Medicaid and costing the state hundreds of millions in federal Medicaid dollars. And the Obama administration badly wants more Republican-led states to follow Pennsylvania's example and expand Medicaid under the Patient Protection and Affordable Care Act, including through conservative-oriented models like Corbett's.

    The CMS approved Corbett's alternative Medicaid expansion model in August. As part of the initiative, the state is building a second Medicaid managed-care system, separate from the existing Medicaid system serving about 1.6 million residents who are not part of the expansion population. Those currently in the state Medicaid program will not have access to these new plans. Starting in 2016, enrollees in Healthy Pennsylvania with incomes above 100% of the poverty level must pay monthly premiums of up to 2% of their household income.

    There are nine designated regions of operation for the Healthy Pennsylvania plan across the state. The Corbett administration set a goal of having at least two plan options per region. As of Monday, there were some regions that had no plans certified as having adequate networks, said Michael Rosenstein, who coordinates the Pennsylvania Coalition of Medical Assistance Managed Care Organizations, an association of the state's Medicaid plans. He declined to identify those regions.

    Leesa Allen, the state Medicaid director, said so far three or four plans have been certified as having adequate provider networks, but that she is confident the other plans also will qualify for certification. “They still have nearly two weeks and they're making good progress,” Allen said. “We're feeling confident at this point.”

    Officials from other plans, including Geisinger Health Plan, confirmed they too were facing the problems in lining up an adequate provider network.

    The four-hospital Lehigh Valley Health Network, based in Allentown, said it has not yet contracted with any of the five Medicaid plans covering its region.

    It and other hospital systems say their rate expectations were based on procurement documents released by the state when it was looking for insurers to participate in the Healthy Pennsylvania program. In those documents, state officials said they were developing rates to allow plans to pay providers at “a midpoint between Medicaid and commercial pricing.” Pennsylvania officials said this was necessary because there would be limited buy-in from providers if plans offered the same rates as those paid by the state's current Medicaid managed-care insurers.

    “Because reimbursement rates in Medicaid have been historically lower than Medicare or commercial rates, many providers in Pennsylvania accept only limited numbers of Medicaid patients,” the state said in its original waiver proposal to the CMS. “Other providers cross-subsidize their Medicaid patients by charging more to their privately insured patients. As such, the 1115 Demonstration will seek to stabilize provider payments across payers, expand provider access, and reduce the need for providers to cross-subsidize.”

    Allen said that when the state initially developed rates for the Medicaid plans, it wanted enough so the plans could pay providers closer to what they were receiving from private health plans on the Obamacare insurance exchange. But she said that during the Corbett administration's negotiations with the CMS, the federal agency only agreed to allow plans to reimburse at levels slightly higher than what was currently being paid for Medicaid beneficiaries.

    Corbett administration spokeswoman Christine Cronkright said “the original proposal to the federal government did request that rates be as close to private rates as possible” but that request ultimately did not get approved.

    A CMS representative did not immediately respond to a request for comment.

    Under federal law, the CMS can only approve waivers for demonstrations that are not projected to cost the federal government more on a net basis than the existing program. And private Medicaid managed-care plans have the leeway to set their provider payment rates based on their own business calculations of what's needed to earn a profit. So it's not clear how the Corbett administration thought it could ensure that providers would receive closer-to-commercial rates.

    Officials from Corbett's office and the Department of Public Welfare did not respond to a request for comment on that issue.

    Last month, Department of Public Welfare officials held a conference call with more than 150 hospitals around the state to discuss the rate issue, said Paula Bussard, senior vice president for policy and regulatory services at the Hospital & Healthsystem Association of Pennsylvania. On the call, state officials blamed the CMS, saying federal officials insisted that the state pay lower rates to the plans than what the state was seeking, Bussard said.

    Nevertheless, Bussard said her organization's members and Medicaid plans are trying to work out deals allowing hospitals to participate in Healthy Pennsylvania.

    Rosenstein, with the state health plan coalition, said some hospitals say they still expect plans to pay closer to commercial rates. “We feel that a written document from the department would clear up any misgivings and we've asked for that, and we've yet to see it,” he said.

    Follow Virgil Dickson on Twitter: @MHvdickson

    Letter
    to the
    Editor

    Send us a letter

    Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.

    Recommended for You
    Screen Shot 2023-02-01 at 4.02.50 PM.png
    Cancer Treatment Centers of America completes City of Hope rebrand
    rural-health1.png
    Transgender patients in rural states struggle to find doctors
    Most Popular
    1
    More healthcare organizations at risk of credit default, Moody's says
    2
    Centene fills out senior executive team with new president, COO
    3
    SCAN, CareOregon plan to merge into the HealthRight Group
    4
    Blue Cross Blue Shield of Michigan unveils big push that lets physicians take on risk, reap rewards
    5
    Bright Health weighs reverse stock split as delisting looms
    Sponsored Content
    Modern Healthcare A.M. Newsletter: Sign up to receive a comprehensive weekday morning newsletter designed for busy healthcare executives who need the latest and most important healthcare news and analysis.
    Get Newsletters

    Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox.

    Subscribe Today
    MH Magazine Cover

    MH magazine offers content that sheds light on healthcare leaders’ complex choices and touch points—from strategy, governance, leadership development and finance to operations, clinical care, and marketing.

    Subscribe
    Connect with Us
    • LinkedIn
    • Twitter
    • Facebook
    • RSS

    Our Mission

    Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data.

    Contact Us

    (877) 812-1581

    Email us

     

    Resources
    • Contact Us
    • Advertise with Us
    • Ad Choices Ad Choices
    • Sitemap
    Editorial Dept
    • Submission Guidelines
    • Code of Ethics
    • Awards
    • About Us
    Legal
    • Terms and Conditions
    • Privacy Policy
    • Privacy Request
    Modern Healthcare
    Copyright © 1996-2023. Crain Communications, Inc. All Rights Reserved.
    • News
      • Current News
      • COVID-19
      • Providers
      • Insurance
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • Transformation
        • Patients
        • Operations
        • Care Delivery
        • Payment
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition (Web Version)
    • Digital Health
    • Insights
      • ACA 10 Years After
      • Best Practices
      • Special Reports
      • Innovations
    • Opinion
      • Bold Moves
      • Breaking Bias
      • Commentaries
      • Letters
      • Vital Signs Blog
      • From the Editor
    • Events & Awards
      • Awards
        • Nominate/Eligibility
        • 100 Most Influential People
        • 50 Most Influential Clinical Executives
        • Best Places to Work in Healthcare
        • Excellence in Governance
        • Health Care Hall of Fame
        • Healthcare Marketing Impact Awards
        • Top 25 Emerging Leaders
        • Top 25 Innovators
        • Diversity in Healthcare
          • - Luminaries
          • - Top 25 Diversity Leaders
          • - Leaders to Watch
        • Women in Healthcare
          • - Luminaries
          • - Top 25 Women Leaders
          • - Women to Watch
      • Conferences
        • Digital Health Transformation Summit
        • ESG: The Implementation Imperative Summit
        • Leadership Symposium
        • Social Determinants of Health Symposium
        • Women Leaders in Healthcare Conference
      • Galas
        • Best Places to Work Awards Gala
        • Health Care Hall of Fame Gala
        • Top 25 Diversity Leaders Gala
        • Top 25 Women Leaders Gala
      • Virtual Briefings
        • - Hospital of the Future
        • - Value Based Care
        • - Supply Chain
        • - Hospital at Home
        • - Workplace of the Future
        • - Digital Health
        • - Future of Staffing
        • - Hospital of the Future (Fall)
      • Webinars
    • Multimedia
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Video Series - The Check Up
      • Sponsored Video Series - One on One
    • Data Center
      • Data Center Home
      • Hospital Financials
      • Staffing & Compensation
      • Quality & Safety
      • Mergers & Acquisitions
      • Data Archive
      • Resource Guide: By the Numbers
      • Surveys
      • Data Points
    • MORE +
      • Contact Us
      • Advertise
      • Media Kit
      • Newsletters
      • Jobs
      • People on the Move
      • Reprints & Licensing