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Two Medicaid managed care insurers become one The state’s overhauled Medicaid managed care program is back to six insurers with the consolidation of two health plans. Meanwhile, sanctions against the largest insurer in the state have been amended.

Crain's Chicago Business

Thursday, November 8, 2018  |  Column  |  Stephanie Goldberg

Medicaid, Managed Care

And then there were six … again.

 

The state’s overhauled Medicaid managed care program is back down to six insurers following the consolidation of two health plans.

 

Harmony Health Plan is becoming part of Meridian Health Plan following WellCare’s $2.5 billion acquisition of Meridian. Harmony members will automatically be enrolled with Meridian on Jan. 1, unless they request otherwise.

 

The consolidation came at a good time for Harmony. In a May letter to the health plan, the state said it would no longer automatically enroll members in the plan since Harmony didn’t have enough doctors and hospitals in its network to ensure adequate access.

 

“During this time, we are committed to providing a seamless transition for our members, providers and state partners, WellCare said in a statement. “As a result of these changes, our provider partners will be able to operate with one combined plan, which will grant broader network access to our members in Illinois.”

 

WellCare spokeswoman Patti Flesher said in an email that Meridian will not inherit Harmony’s sanctions.

 

The Illinois Department of Healthcare & Family Services oversees HealthChoice Illinois, the state’s nearly one-year-old Medicaid managed care program, in which private insurers administer Medicaid benefits.

 

Meanwhile, the state has eased sanctions against another participating insurer, Blue Cross & Blue Shield of Illinois. As of last month, Medicaid enrollees can once again select plans from the largest insurer in the state.

 

Blue Cross was placed on an enrollment hold in April for not having enough doctors and hospitals in its network to ensure adequate access for members in certain areas, and failing to address a backlog of grievances and appeals from members.

 

Despite demonstrating “changes the health plan has made to come into compliance,” Blue Cross remains on a corrective action plan and members will not be automatically enrolled, according to a letter Healthcare & Family Services sent the insurer on Oct. 19.

 

A follow-up audit and file review is scheduled to take place next month. If Blue Cross does not show “necessary improvement,” the department can reinstate the full enrollment hold and impose a performance penalty starting at $50,000, the letter states.

 

“We demonstrated our commitment to make things right for our members and we continue to make improvements in our technology, process, staffing and training,” Blue Cross spokeswoman Colleen Miller said in an email.

 

As of Sept. 1, Blue Cross had enrolled about 416,000 people, which is 19 percent of total HealthChoice Illinois enrollment, state data shows. Meridian leads the board with about 609,000 people or 27 percent of total enrollment—not including Harmony’s nearly 247,000 enrollees.

 

It hasn’t been unusual to see fines since the program launched. Blue Cross, Molina Healthcare of Illinois and NextLevel Health have all been fined at least $100,000 for failing to submit complete and comprehensive encounter data, or records of covered health care services.

 

As Healthcare & Family Services employees have today off work for Election Day, the department did not immediately respond to a request for comment.