Ohio is on the hunt for health insurers interested in serving the state's 2.6 million Medicaid members.
The state released a request for applications on Wednesday to procure managed care organizations for the safety-net program, which is undergoing a massive overhaul for the first time since 2005, when CMS approved Ohio's Medicaid program.
The contracts, which are for an initial two-year term and renewable on a one-year basis after that, will be awarded in January 2021 and go live in January 2022. The insurers will be paid more than $20 billion to provide services.
Later in the fall, the Ohio Department of Medicaid will ask for separate applications from organizations that want to serve members of a new children-focused behavioral health plan.
Ohio's Medicaid is transforming the safety-net program in several ways to give beneficiaries a more individualized healthcare experience and create greater transparency and accountability in the program. The request for applications comes after the department spent 18 months gathering feedback from providers, members and other stakeholders.
"From a structural perspective, the biggest difference is we are unbundling how we do managed care in Ohio," said Jim Tassie, the department's deputy director who oversees procurement.
"Today and pretty much for the last 15 years, the managed care program has been a mirror image of a traditional Medicaid program. All the services—dental, vision, behavioral health, transportation—everything gets paid for monolithically through the managed care plans. The model we created now basically unbundles some of that so we can get specialized expertise in areas where we need it," he said.
In one example of that "unbundling," Ohio is moving to a model in which it contracts with a single pharmacy benefit manager to handle Medicaid drug benefits. Previously, the insurers contracted with their own PBMs, so there were five or six companies handling drug benefits in the state. Under the new model, the Medicaid department and a vendor will determine the pharmacy network and rates; the PBM will focus on coordinating care and paying claims.
"We will have firsthand vision into what's happening with our pharmacy dollar, but also by separating out the responsibilities there's less of a chance of unforeseen influences, negotiations over rates, depending on who the PBM is or the pharmacy is," Tassie explained. "It really is a much more transparent and accountable system."
A few years ago, a state-sponsored study revealed that PBMs bilked $224 million from the Ohio Medicaid program. The Ohio Legislature later required the Medicaid department to move to a single PBM, and the department released a request for applications in July to find one. It received six bids.
Soon, Ohio pharmacists will be able to bill the Medicaid department directly as healthcare providers for certain clinical services that go beyond dispensing medications.
Ohio aims to shift the focus of the Medicaid program onto the individual with the new managed care contracts. The contracts will require health plans to work together to improve population health by reducing obesity, preventing or ending smoking, and improving maternal health, Tassie said.
The department is also strengthening the requirement that the plans take a strategic approach to care coordination, Tassie said. Managed care organizations will be required to partner with community organizations, such as a local health center, and contribute a part of their annual profits back in the communities.
Other requirements for the plans include clearer communication and cultural sensitivity and awareness training, so they can better support beneficiaries.
Providers in the state will also see changes. The Medicaid department will handle provider credentialing, so providers don't have to undergo the burdensome process with each managed care organization. Under the new Medicaid program, providers will also submit their claims and prior authorization requests to a single point of contact, rather than submitting them in multiple ways to each insurer.
Acting as a fiscal intermediary will allow the Medicaid department more visibility into claims data, prior authorization decisions, and how quickly insurers are making those decisions, Tassie said.
For the purposes of the Medicaid managed care, Ohio is divided into three regions. Five managed care plans currently serve each of those regions. They include Buckeye Health Plan, CareSource, Molina Healthcare, Paramount Advantage and UnitedHealthcare.