Multi-billion-dollar Medicaid contract at stake in legal filing by Aetna Better Health. Insurer asks for review of DHHS selection process. | Local News


“The state also has failed to fulfill its own well-documented commitments to the federal government and the public.”

Moving ahead

The main launch challenge is getting the four statewide PHPs operational by the enrollment date.

Managed care is a system under which people agree to see only certain doctors or go to certain hospitals, as in a health maintenance organization, or HMO, or a preferred provider organization, or PPO, health-insurance plan.

Under the current Medicaid system, providers are paid on a fee-for-service model administered by DHHS.

By contrast, the PHPs will pay health-care providers a set amount per month for each patient’s costs. There will be a limited number of special-needs individuals who will remain with fee-for-service providers.

The next big rollout step for DHHS is formulating the per-patient rates for providers by November and submitting them to CMS.

DHHS will reimburse the PHPs, and people will be able to choose which PHP they want to sign up for, or a provider will be assigned to them by May 14.

Some of the initial Medicaid transformation funding would go toward patient enrollment-broker contracts, provider credentialing, data analytics and other program-design components.

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