Children’s Hospital of Alabama dropped Mississippi Medicaid, citing reimbursement issues.
The Mississippi Division of Medicaid (DOM) has implemented a managed care program called Mississippi Coordinated Access Network (MississippiCAN). MississippiCAN is designed to get a better return on Mississippi’s health care investment by improving the health and well-being of Medicaid beneficiaries.
United Healthcare currently pays half of the expenses for Mississippi Medicaid’s MississippiCAN managed health program. The other half is paid by Magnolia Healthcare.
This is determined by whether or not a patient falls under a “mandatory” or “optional” eligibility status with Medicaid. Those in mandatory population must be in MississippiCAN. They can choose between Magnolia Health or United Healthcare Community Plan. They do not get the option to keep regular Medicaid. There is also an “optional” population. They get to choose between regular Medicaid and MississippiCAN; if they choose MississippiCAN, they can pick between Magnolia Health or United Healthcare Community Plan. If a beneficiary does not choose a coordinated care organization within 30 days after receiving their initial letter, they will be assigned to one of the health plans. Then, they have 90 days to either change to the other health plan, opt-out (if eligible) or stay in the program that their currently in.
Once a plan is chosen, a nurse is assigned to act as a patient’s gatekeeper– to help them find great healthcare in a timely manner, but also assist the patient in maintaining their care.
With all of these connections in place, the current situation with Medicaid, United Healthcare and hospitals could have dire impacts on Mississippians.
“Their job is to manage those on Medicaid and help keep costs low,” said Chaney. “And that impacts income to the hospitals and clinics.”
The complexity of the reimbursements, the lawsuits, federal requirements and state burden have created quite the problem for health insurance in the state.
“United Healthcare, four years ago, began to run some of the managed care for Medicaid in the State of Mississippi, along with (Magnolia Healthcare),” said State Insurance Commissioner Mike Chaney. “Health and Human Services out of D.C. requires that you have at least two groups for managed care.”
“The way these insurance providers make their astronomical profit is by limited the reimbursement to the healthcare provider, such as the hospital,” said state Representative Steve Holland.
MississippiCAN has not always been the way Medicaid was structured in the state. Holland played a part initially in the set up of the program.
“I birthed this thing,” said Holland. “And honestly, I’m ready to bury it. It was a national trend sweeping around, a gate-keeping system, that was going to save taxpayer dollars.”
But with this set up, there are disagreements over the reimbursement time and process to the hospitals and clinics that provide healthcare to Medicaid patients.
Last year, North Mississippi Medical Center in Tupelo entered into a jumble of lawsuits and countered lawsuits with United Healthcare over slow and sometimes altogether lacking reimbursements from the insurance provider. The negotiation contract between the two entities ends on May 31–meaning the hospital could decide to cut ties with United Healthcare at that point.
NMMC claims United Healthcare shorted them $40-$50 million dollars.
“And if they truly owe that, they’ll have to pay damages,” said Chaney. “We at the Department of Insurance are mediating between those two parties.”
The Mississippi Department of Insurance does not handle cases with Medicaid directly, as that is in the hands of the Executive branch. For the Commissioner’s office to be involved in Medicaid investigations, it would have to come at the request of the Governor.
Since United Healthcare and Medicaid work hand-in-hand, a breakdown of the negotiations could have a large impact on healthcare in the state.
“It could have an impact on about ten to twelve thousand people in North Mississippi,” said Chaney. “We have asked United Healthcare to provide us what they would do to provide a network for those on Medicaid.”
The North Mississippi Medical Center is the largest rural hospital in the country, with six satellite locations.
“They have a very big footprint on healthcare in North Mississippi,” said the Commissioner. “And United Healthcare has to prove not only to our department, but the Division of Medicaid, the Governor, the federal government, and the North Mississippi Medical Center that they have adequate networks.”
In North Mississippi alone, the loss of United Healthcare could impact about 30,000 people.
The impact has already started. Chaney said large companies with a presence in the northern reaches of the state–such as Walmart, Cat, and Bancorp South– have already started moving from United Healthcare to offering other insurance plans to their employees because of the struggle with NMMC.
“It has been devastating to United Healthcare in that area,” said Chaney.
But if United Healthcare can’t provide proof of quality networks to the state and federal government, the impact could be vital statewide.
“About 100,000 people are on the CAN program in Mississippi,” said commissioner Chaney. “But I tell people to stay calm. Because we have currently five companies bidding for the MississippiCAN program, and I feel confident that the federal government will require Mississippi to accept at least three (bids).”
The competition created by more companies vying for the MississippiCAN program under Medicaid could positively impact state taxpayers and Medicaid patients. More companies mean more competition, and more competition means lower prices.
“We have had at least six companies that have come in and put in applications,” said Chaney. “That means good things for the consumer.”
The Commissioner said the Mississippi Hospital Association has created a group that has placed a bid on the MississippiCAN program. It has been certified through Medicaid’s regulatory board Centers for Medicaid Service (CMS).
News Mississippi has reached out to The Mississippi Hospital Association for more information and is awaiting a response.
However, the issues with Medicaid and United Healthcare won’t simply be fixed by bringing in more competition.
The agency is currently facing another budget cut.
“Medicaid is very complex,” said Representative Sam Mims. “We are currently going through the appropriations process for the Division of Medicaid.”
Mims stated that Medicaid is set to receive roughly $910 million dollars in appropriations for fiscal year 2018– that is $90 million short of what Medicaid requested.
This appropriation process is impacted by the collection of information received from legislative budget panels held in the fall of 2016.
During those panels, Division of Medicaid Executive Director Dr. David Dzielak told lawmakers that another cut “wasn’t an option” and that rising medical costs were part of the need for more money.
Senate Medicaid Chairman Brice Wiggins said that the Division of Medicaid’s requests for more appropriations have been confounding.
“What we have is enrollment going down and costs going up,” said Wiggins. “I’m in the process of trying to figure out why that is.”
Wiggins said inefficiencies in Medicaid, or the lack thereof, could be part of the reason why the agency keeps asking for more.
The senator added that there are a high number of people in Mississippi on Medicaid.
“We have a significant number of people on Medicaid,” said Wiggins. “80 percent of the costs of Medicaid are made up by 20 percent of the population (of Mississippi).”
Numerous hospitals have spoken out about the impact of Medicaid cuts on the services they are able to provide, but the Senator said that the message hasn’t made it to his desk.
“We are in a significant budget situation,” said Wiggins. “Nobody wants to see services cut and all that, but they have been aware of the budget situation. And personally, I’ve not had any of the hospitals come and talk to me about it.”
News Mississippi will continue to investigate the impact budget cuts and contract negotiations could have on taxpayers.
