A delay to Feb. 1 in rolling out North Carolina’s Medicaid managed-care initiative has opened the door for three medical groups to renew their legal efforts to participate in the latest Medicaid managed-care initiative.
The N.C. Department of Health and Human Services announced Feb. 5 that it had selected AmeriHealth Caritas N.C., Blue Cross and Blue Shield of North Carolina, UnitedHealthcare of North Carolina, and WellCare of North Carolinas as the statewide prepaid health plans.
Those groups were chosen over Aetna Better Health of North Carolina, MyHealth by Health Providers and Optima Family Care of North Carolina Inc.
MyHealth was formed by 12 North Carolina health-care systems, including Novant Health Inc., Wake Forest Baptist Medical Center and Cone Health.
The groups filed their amended petition Thursday. Aetna said the petition “describes a range of concerns about the state’s procurement process.”
“We believe this petition demonstrates we earned the opportunity to serve the state’s beneficiaries,” Aetna said.
The DHHS said in a statement Thursday that “we are confident in the integrity and fairness of our procurement process.”
Set amount each monthMedicaid recipients in a 13-county section of the Triad and Northwest North Carolina, along with 14 counties in central North Carolina, including Alamance County, were scheduled to start service through prepaid health plans, or PHPs, on Nov. 1. Medicaid recipients in the rest of the state were set for a Feb. 1 start.
Medicaid serves 2.1 million North Carolinians. Of that total, 1.6 million will be enrolled in managed care under a federal waiver approved in October 2018.
PHPs represent a major change in how the state pays for Medicaid patients’ care. Currently, health providers are paid under a fee-for-service system. PHPs will pay providers a set amount each month for each patient’s costs. The state DHHS will reimburse the plans.
On June 26, a state administrative law court judge, Tenisha Jacobs, denied the three excluded health groups’ request for a stay of the rollout. In July, Jacobs turned down their appeals.
However, about $218 million in critical startup funding for the rollout has been held up in the dispute over the new state budget. The stalemate led DHHS officials on Sept. 3 to plan a statewide Feb. 1 rollout.
Democratic Gov. Roy Cooper vetoed both House Bill 966, the budget appropriations bill, and HB 555, which was amended to included much of the budget’s Medicaid managed-care funding language.
On Sept. 11, after 37 consecutive floor sessions without taking action on the budget veto, N.C. House Republican leadership held a surprise vote to override both vetoes. The session was held while 40 of the 55 House Democrats were not on the floor or were in a caucus meeting about redistricting maps.
The N.C. Senate has yet to place either veto override vote on its floor calendar.
“The delay had no bearing on our decision, nor do we consider the issue to be settled,” Aetna said.
The DHHS also chose just one of three potential provider-led entities, or PLEs, even though the General Assembly approved having up to 12 such groups last year.
Each of the six state regions could have had up to five PLEs providing services.
MyHealth has described the DHHS format as a “deeply flawed design and evaluation process.”
MyHealth said it “is requesting that Medicaid patients be given the choice of a provider-led entity operated by North Carolina’s most experienced health systems and its 15,000 physician partners, instead of out-of-state insurance companies with little or no Medicaid experience in North Carolina.”
“This is the choice the General Assembly intended,” My Health has argued.
Jacobs said in her ruling that the DHHS’ evaluation committee “determined that MyHealth was the sixth-ranked” applicant — behind Aetna — based on its evaluation format.
Jacobs said MyHealth “is not likely to succeed” in showing that state regulations require the DHHS to award six regional contracts even though legislators allowed for up to 12.
The judge said “it is not likely” MyHealth could prove the DHHS “erred in failing to consider it for regional contracts.”
Jacobs used similar language in her denials of the Aetna and Optima appeals.