Medicaid coverage deemed inadequate
Plans that were recently awarded local contracts unable to offer enough providers for low-income clients, state says
Thursday, May 24, 2012
The two health insurance plans awarded contracts to provide care for 65,000 Clark County managed Medicaid clients were unable to meet network adequacy requirements.
The state gave the plans until May 16 to establish a network of providers to provide care for the county's Healthy Options and Basic Health members, who are mostly low-income women and children.
The plans, Molina Healthcare of Washington and Coordinated Care Corp., assembled "relatively sufficient" networks but do not have enough providers to care for the entire county, as contract terms require, said Preston Cody, deputy director of the state Health Care Authority.
"As we looked at all the network adequacy, we've found that we have networks established in 38 of 39 counties, with Clark County as the potential exception," Cody said.
Despite the news, Cody said he believes the state will be able to implement new contracts in Clark County by July 1.
When it became apparent the plans couldn't meet the requirements, two plans that were not awarded new contracts in Clark County, but did get deals in other counties, applied to expand their services into Clark County.
Those plans are UnitedHealthcare Community Plan, a Fortune 500 company, and the nonprofit Community Health Plan of Washington, which currently provides Medicaid services for about 3,000 Clark County residents.
The state gave all four plans — the two awarded contracts and the two that want to expand — until 8 a.m. Thursday to submit materials proving they have the ability to provide for local clients. Now the state will review all of the information and decide how to move forward within the next couple weeks, Cody said.
According to Cody, the state is considering the following options:
• Revert to fee-for-service and give members the option to enroll with Molina or Coordinated Care. The two plans would only serve a portion of the county.
• Extend the current contracts with the Medicaid insurance plans while the state rebids Clark County, essentially starting the process over. If this happens, Cody said the state and insurers will have to discuss how to reduce provider reimbursement rates in Clark County.
• Allow UnitedHealthcare Community Plan and/or Community Health Plan to expand into Clark County.
Once a decision is made, the state will likely extend open enrollment in Clark County so Medicaid members have sufficient time to research their options, Cody said.
Columbia United Providers, a community-based health insurance plan owned by PeaceHealth Southwest Medical Center and local providers, currently provides Medicaid services for 47,000 Clark County residents but was not selected for a new contract.
CUP and Community Health Plan, which was also denied a new contract, joined forces to file a lawsuit against the Health Care Authority earlier this year. That suit has not yet gone to trial.
The recent news regarding network adequacy prompted the two plans to forge another partnership.
When Community Health Plan officials filed a request to expand services into Clark County, they asked CUP to become a partner in the effort. Officials from the two plans spent five days hammering out the details of an agreement that, if the state approves, would allow CUP to continue serving Clark County residents and allow patients to stay with their providers, said Dr. Lisa Morrison, CUP medical director.
If the deal goes through, CUP will continue to process all claims and referrals for local providers and patients will remain with their current physicians. Community Health Plan would have the contract with the state.
CUP worked with providers to negotiate lower reimbursement rates, with decreases ranging from 10 to 30 percent. CUP will also receive a lower premium, as it will be split with Community Health Plan, said Ann Wheelock, CUP chief executive officer.
"CUP providers have made tremendous financial sacrifices to make sure these members continue to receive care," said Wheelock, adding that many won't receive enough reimbursement to cover costs.
For CUP officials and Medicaid patients in Clark County, the next few weeks will be filled with uncertainty, just as they have been since the state announced the new insurance plans in January.
The decision, Wheelock said, lies in the hands of state officials.