| The Columbus Dispatch
Gov. Mike DeWine’s administration has unveiled plans for a long-awaited overhaul of the $28 billion Medicaid health-care program covering more than 3 million poor and disabled Ohioans.
The Ohio Department of Medicaid seeks to update its managed-care setup with a focus on wellness and improving the health of beneficiaries, meeting the needs of children with complex needs, and reducing administrative hurdles for patients and health-care providers.
The stakes are huge: The five current managed-care organizations received a combined total of more than $15 billion from the state.
It was the managed-care organizations that hired pharmacy benefit managers, which have grown controversial in Ohio during recent years for charging excessive rates and under-reimbursing pharmacies. But the Medicaid department, under a measure state lawmakers passed in July 2019, is moving to a single PBM next year hired by the state agency to keep closer watch over prescription drug benefits.
Frustrated by what he saw as a “ripoff” of Ohio taxpayers, DeWine order the new setup less than a month after taking office in January 2019.
“It’s time to re-look at these contracts, re-evaluate exactly what we want in the contract. We want to make sure there’s a very strong wellness component, (but) the PBM is one of the significant reasons to do this,” DeWine said then.
“We certainly can get a better deal for taxpayers than we have now, particularly in regard to the PBMs … there’s no doubt about it … the more I found out as attorney general the clearer it was that the status quo is not acceptable.”
The state invited privately operated managed-care organizations to submit applications for new managed care contracts by Nov. 20. Contracts will be awarded early next year with a new system in place in 2022. About 90% of Medicaid beneficiaries are enrolled in managed care.
Medicaid Director Maureen Corcoran said the plan is largely based on input solicited by the department from beneficiaries, physicians, hospitals and other health care providers, along with managed-care plans over the last 18 months.
“My greatest hope out of this is individuals served in the program would feel like this is focused on them, and about them and their care, and that these very complex children and their families who sometimes have to relinquish them would be given hope and services to enable them to stay together as a family,” Corcoran told the Dispatch.
The director referred to concerns with the current system which has forced some families with children in need of intensive and costly services, either in their home or residential settings, to relinquish custody so they qualify for Medicaid because they can’t afford the cost on their own.
Under the plan, Ohio Rise, so-called multi-system youth would qualify for modified eligibility requirements, allowing them to receive assistance while remaining in their family’s custody.
Angela Sausser, executive director of the Public Children Services Association of Ohio, said the children typically have behavioral health needs, sometimes along with developmental delays or substance abuse.
“Parents may have private insurance but is not approving the level of care or type of treatment services their child actually needs and that is when parents are often forced to consider relinquishing custody of their child to their county public children’s services agencies for the only reason to be able to have that child enrolled in Medicaid so they can access the services their child needs,” Sausser said.
“This will completely change how Ohio has always addressed multi-system youth issues and will have a significant impact on serving families and allowing children to stay with their families and being able to meet the complex needs of children.”
Deputy Medicaid Director Jim Tassie said another big focus will be on improving communication and coordination between the managed care plans and patients, and moving to a single system to credential or approve health care providers and pay claims. Currently, each managed care plans has its own system.
“We really wanted to design the program and have our program work for the individuals it serves instead of the other way around,” Tassie said, adding that the department received more than 1,000 responses to its initial request for input.
To respond concerns from beneficiaries difficulties getting information about different services, Tassie said, there will be “a much heavier focus on ensuring the individuals served by the program are getting the information they need, not only about coverage decisions, but what other sources of benefits and supports are available” like smoking cessation, transportation to appointments and translation services.”
Medicaid now employs five managed care plans. Tassie said he’s not sure how many will be selected under the new contract but likely no more than five.
Advocates for the poor applauded the plan.
“Expanding access to quality care and improving wellness through enhanced coordination and supports is exactly the right move,” said Julie DeRossi-King, chief operating officer of the Ohio Association of Community Health Centers, which serve nearly 900,000 Medicaid beneficiaries.
“We are excited to see many of the provisions in place in the (request for applications) like centralized credentialing – enacting a singular timely process so providers can get to work providing care to our communities and patients in greatest need.”