Category: Managed Care

The 2025 Healthcare Perfect Storm: How Rising Costs and Increased Scrutiny Impact Insurers

The blog post examines the health insurance industry’s challenges in 2025, highlighting rising healthcare costs, increased patient demand, and heightened government scrutiny. Insurers, particularly those focused on Medicare Advantage, must reevaluate strategies to maintain profitability. Despite these hurdles, opportunities for innovation and growth exist through personalized care and strategic partnerships.

This blog post delves into the complex challenges facing the health insurance industry in 2025, a year poised to be a pivotal moment for insurers, particularly those heavily invested in Medicare Advantage plans. Rising healthcare costs, increased patient demand, and heightened government scrutiny are converging to create what we’re calling a “perfect storm.” This confluence of factors threatens profitability and necessitates a critical reevaluation of existing operational strategies. This post expands on the themes discussed in our latest podcast episode, exploring these challenges in greater depth and offering insights into potential solutions for both insurers and healthcare providers.

Rising Healthcare Costs: A Looming Crisis

The escalating cost of healthcare is arguably the most significant challenge facing insurers. Inflation, technological advancements, and the increasing complexity of medical treatments all contribute to this unsustainable upward trend. The post-COVID surge in patient utilization, with many seeking deferred procedures, has exacerbated the problem, placing immense pressure on insurers’ financial reserves. This increased demand is straining existing resources and impacting profitability, pushing medical loss ratios (MLRs) higher than ever before. The implications are profound, forcing insurers to re-evaluate pricing strategies, negotiate more effectively with providers, and explore innovative cost-containment measures.

The Impact on Medicare Advantage

Medicare Advantage (MA) plans, once considered a goldmine for insurers, are particularly vulnerable in this environment. The increased demand for MA plans, coupled with rising healthcare costs, is squeezing profit margins. Major players like Humana and UnitedHealth Group, heavily reliant on MA for revenue, are grappling with these challenges head-on. Their financial performance is becoming increasingly dependent on their ability to manage costs efficiently while maintaining patient satisfaction and adherence to regulatory requirements.

Increased Patient Demand: A Double-Edged Sword

While increased patient demand initially appears beneficial, in the context of rising costs, it becomes a major challenge. Insurers are faced with a difficult balancing act: fulfilling the needs of a growing patient population while simultaneously controlling costs and maintaining profitability. This necessitates a shift towards more proactive and personalized care models that prioritize preventative measures and disease management. Strategic partnerships with providers are crucial for achieving these goals.

The Need for Personalized Care

The sheer volume of patients requires a move beyond traditional, reactive models of care. Personalized care, driven by data analysis and predictive modeling, is becoming essential for identifying high-risk individuals and implementing targeted interventions. This approach not only improves patient outcomes but also helps to manage healthcare costs more effectively, ultimately impacting the MLR and safeguarding insurer profitability.

Increased Government Scrutiny: Navigating Regulatory Hurdles

The health insurance industry is facing unprecedented levels of government scrutiny. Lawmakers are increasingly focused on issues of transparency, affordability, and access to care. This heightened scrutiny translates into stricter regulations, increased audits, and potential penalties for non-compliance. Insurers must navigate this complex regulatory landscape while ensuring they maintain ethical and transparent practices.

Adapting to Regulatory Changes

The regulatory environment is constantly evolving, requiring insurers to be adaptable and proactive. Staying informed about new regulations, investing in compliance programs, and engaging with policymakers are crucial for navigating this challenging landscape. Failure to adapt could lead to significant financial penalties and reputational damage.

Opportunities Amidst the Storm

While the challenges are significant, the current climate also presents opportunities for innovation and growth. Entrepreneurs and healthcare providers can leverage this disruption by focusing on high-cost patient areas and developing innovative solutions that improve efficiency and reduce waste within the healthcare system. New models of care, such as value-based care, offer potential avenues for both improved patient outcomes and reduced costs.

Innovation in Healthcare Delivery

The need for cost-effective and efficient healthcare delivery models has never been greater. Entrepreneurs are stepping up to the plate, developing innovative technologies and solutions to address these challenges. These range from telehealth platforms and remote monitoring devices to AI-powered diagnostic tools and personalized treatment plans. Insurers that embrace these innovations and forge strategic partnerships with these innovators will be better positioned to thrive in the evolving healthcare landscape.

Conclusion

The healthcare industry in 2025 faces a perfect storm of rising costs, increasing patient demand, and intensified regulatory scrutiny. Insurers, especially those heavily reliant on Medicare Advantage, are experiencing significant financial pressure. This necessitates a complete re-evaluation of operational strategies, focusing on cost containment, personalized care, and proactive compliance. However, amidst these challenges lie significant opportunities for innovation and growth. By embracing new technologies, fostering strategic partnerships, and prioritizing patient-centric care models, both insurers and healthcare providers can navigate this turbulent environment and emerge stronger. To delve deeper into this topic and explore potential opportunities, please listen to our podcast episode, “2025 Opportunities in Healthcare: Navigating the Perfect Storm.” This episode provides further insights into the challenges and opportunities discussed in this blog post and offers actionable strategies for navigating the complexities of the 2025 healthcare landscape.

Companies mentioned in this episode:

Research Links:

The Definitive Playbook for Choosing Behavioral Health Markets – Value Based Care Advisory (VBCA) Podcast

Rate sheets don't tell the whole story.In this episode, Alex Yarijanian breaks down the 8-indicator playbook he uses to evaluate any tele-behavioral health market before committing capital — and names the specific states he'd enter today and why.Most operators default to the biggest states: California, Texas, Florida, New York. But population size alone is one of the weakest predictors of a winning market. The real levers live in parity law enforcement, workforce economics, MCO concentration, and infrastructure readiness.WHAT YOU'LL LEARNWhy the biggest states are rarely the best markets for tele-behavioral healthThe 8 indicators that separate win-win markets from cheap-rate miragesHow to build a weighted scoring model before entering a new marketWhat associate-level billing eligibility does to your workforce marginsHow MCO concentration affects contracting speed and rate-cut riskWhich states Alex rates as best all-around, high-risk, and growth-stage betsTHE 8 MARKET INDICATORSMedicaid market size: Total addressable population and realistic capture potentialPayment parity: State-level mental health parity laws and strength of enforcementCost of living index: The single best proxy for labor margin on clinical staffAssociate-level billing: Whether licensed associates can bill independentlyHRSA HPSA demand mapping: Documented unmet need in mental health shortage areasBroadband & 5G coverage: Infrastructure required for reliable telehealth deliveryMCO landscape: Plan count, behavioral carve-outs, any-willing-provider law exposureTax & corporate climate: State-level business environment and regulatory postureMARKET ARCHETYPESBest all-around: Arizona, Nebraska, Delaware, OregonVolume, thin margins: Arkansas, North DakotaHigh rate, high cost niche: AlaskaGrowth stage bets: New Mexico, Montana4 ACTION STEPSBuild a scroll scoring model — layer all 8 indicators into a weighted scorecardValidate demand on the ground — overlay HRSA HPSA maps + FCC broadband gap dataCheck your plan mix — count Medicaid MCOs and behavioral carve-outsRun a payroll stress test — model cost of living vs. your target clinician pay bandRESOURCES MENTIONED HRSA Mental Health HPSA maps: data.hrsa.govFCC broadband coverage maps: broadbandmap.fcc.govNCSL mental health parity law trackerLicensure compact maps: PSYPACT, ASWB Compact, Nurse Licensure Compact State Medicaid rate databases
  1. The Definitive Playbook for Choosing Behavioral Health Markets
  2. Medicare Negotiates Like an Owner. Commercial Doesn’t.
  3. The Rural Health Transformation Fund: What States Are Funding in 2026
  4. Medicare Advantage 2026: How Payers Are Choosing Partners
  5. Digital Health at a Crossroads: The Fallout from a $100M Adderall Fraud Scheme

New California PNA Requirements: A Shift in Healthcare Strategy

As of 2024, California healthcare plans must submit a Population Needs Assessment every three years to enhance community engagement and address diverse health needs. This shift aims to improve health outcomes through comprehensive analysis and collaboration with local partners, ensuring tailored programs that focus on preventive care and social determinants of health.

As of 2024, healthcare plans in California are now required to submit their Population Needs Assessment (PNA) to the Department of Health Care Services (DHCS) every three years, aligning with the goals of a broader Population Health Management (PHM) program. This new framework signals a shift in how health plans approach member care, focusing on deeper community engagement and a more comprehensive understanding of population needs.

What Does This Mean for Healthcare Plans?

Previously, annual assessments were a common method for health plans to gather insights into their members’ needs. However, these assessments often lacked the depth required to capture the evolving, multifaceted health challenges that different communities face. The new three-year PNA submission requirement allows health plans to conduct a more detailed and thorough analysis of their populations. This change is not simply about reducing the frequency of reporting—it’s about increasing the quality of the data collected and ensuring that the needs of diverse populations are addressed in a holistic way.

The Purpose Behind the New PNA

At the core of this updated requirement is the drive to improve health outcomes across California. As part of the PHM program, the PNA serves as a critical tool for identifying and addressing specific population health needs. Health plans are tasked with gathering data, analyzing trends, and collaborating with local health departments to build actionable strategies that improve overall health.

This isn’t just about treating illnesses—it’s about preventive care, social determinants of health, and the creation of sustainable, long-term strategies that improve quality of life for everyone. By conducting these assessments every three years, plans can track progress over time and make adjustments as needed to better serve their communities.

A Focus on Deeper Community Engagement

One of the most significant changes in the new PNA requirements is the emphasis on community engagement. Healthcare plans are encouraged to work closely with local health departments, nonprofits, and other stakeholders to get a clearer picture of what their members need. This goes beyond just collecting data—it involves truly engaging with communities to understand the barriers they face and the resources they require.

By fostering these relationships, healthcare plans can develop programs that are more aligned with the needs of their members, particularly in underserved or high-risk populations. Whether it’s addressing food insecurity, transportation, housing, or mental health services, this new approach aims to create a more holistic view of the factors influencing health outcomes.

DHCS Oversight: Ensuring Accountability

While healthcare plans have more flexibility to engage communities and tailor their services, there is still a strong element of oversight. The DHCS reviews all submitted PNAs to ensure they comply with state regulations and contribute to the overall goals of the PHM program. This process ensures that healthcare plans are not only identifying the needs of their populations but also taking concrete steps to address them.

The Bigger Picture: What This Means for Californians

For Californians, these changes represent a more thoughtful and inclusive approach to healthcare. With healthcare plans required to engage more deeply with their communities and submit comprehensive PNAs every three years, individuals can expect programs that are better tailored to their unique needs.

As healthcare plans collaborate with local partners and embrace more holistic strategies, we can expect to see improvements in preventive care, access to resources, and the overall health of populations across the state. The ultimate goal is to create healthier, more resilient communities where individuals receive not only the medical care they need but also the social and environmental support that impacts their well-being.

In Conclusion

The new PNA requirements are more than just a reporting change—they reflect a larger shift toward population health management that prioritizes deeper community engagement and a more comprehensive understanding of member needs. With the DHCS providing oversight and healthcare plans taking a more active role in working with local organizations, Californians can look forward to more responsive, equitable, and effective healthcare systems in the years to come.

This change marks an important step in making healthcare more proactive and patient-centered, ensuring that all individuals, regardless of their background, have access to the care and resources they need to live healthier, more fulfilling lives.

Unlock Financial Success with CalAIM: Budget Estimator Tool for CBOs

The CalAIM Budget Estimator Tool helps CBOs navigate the financial complexities of contracting under CalAIM. It offers an Excel-based template with built-in assumptions, cost input fields, revenue customization, and a summary tab. The tool supports informed decision-making, negotiation power, and sustainability, empowering organizations to enhance care and expand services.

Introduction

Navigating the financial complexities of contracting under the California Advancing and Innovating Medi-Cal (CalAIM) initiative can be challenging for community-based organizations (CBOs). With new Medi-Cal benefits such as Enhanced Care Management and Community Supports, understanding potential revenue and expenses is crucial. This is where the CalAIM Budget Estimator Tool comes in, offering a robust template to help CBOs project financial viability and ensure their mission’s sustainability.

Understanding the CalAIM Budget Estimator Tool

CalAIM Budget Estimator Tool: The CalAIM Budget Estimator Tool is an Excel-based template designed to help organizations estimate costs and potential revenue from providing Medi-Cal Enhanced Care Management and selected Community Support Services. These services include housing-related services and medically tailored meals.

Key Features

  • Built-in Assumptions: The tool incorporates assumptions about payment structures for these services, as outlined in the California Department of Health Care Services CALAIM Enhanced Care Management Policy Guide and Community Supports Policy Guide.
  • Cost Input: Users can enter organization-specific expenses such as staffing costs and other direct and indirect costs.
  • Revenue Customization: It includes generic rate ranges and areas for customizing expected revenue sources to calculate the program margin (ratio of revenue to expenses).
  • Summary Tab: A summary tab displays the projected margin by program year, helping users understand if their assumptions lead to a fiscally viable program.

The Importance of Financial Viability for CBOs

For CBOs, financial viability is paramount. The adage “No margin, no mission” rings true as these organizations aim to enhance services for individuals with complex health and social needs. The CalAIM Budget Estimator Tool enables organizations to model various scenarios for their programs, supporting meaningful feasibility discussions with financial officers and other decision-makers.

How the CalAIM Budget Estimator Tool Supports CBOs

The CalAIM Budget Estimator Tool is designed to facilitate informed discussions about future programming and the financial feasibility of providing new Medi-Cal services. Here’s how it supports CBOs:

  • Modeling Various Scenarios: The tool allows organizations to create multiple financial scenarios, enabling a comprehensive understanding of different potential outcomes.
  • Justifying Rate Requests: By organizing and highlighting critical financial information, the tool helps CBOs justify rate requests to MCOs during contract negotiations.
  • Enhancing Financial Confidence: With detailed projections, CBOs can confidently navigate the financial aspects of contracting with MCOs.

Step-by-Step Guide to Using the CalAIM Budget Estimator Tool

Step 1: Download the Tool

Step 2: Enter Costs

  • Input your organization-specific expenses, including staffing costs and other direct and indirect costs.

Step 3: Customize Revenue Sources

  • Use the tool to enter expected revenue sources. Customize the rates to reflect realistic projections for your organization.

Step 4: Review Summary Tab

  • Examine the summary tab to view the projected margin by program year. This will help you understand the financial viability of your program.

Benefits of Using the CalAIM Budget Estimator Tool

Informed Decision-Making: The tool provides comprehensive data to support strategic financial decisions. Enhanced Negotiation Power: With detailed financial projections, CBOs can negotiate better rates with MCOs. Sustainability: Ensuring financial viability helps CBOs sustain their mission and expand services under CalAIM.

Frequently Asked Questions

What is the CalAIM Budget Estimator Tool? The CalAIM Budget Estimator Tool is an Excel-based template designed to help organizations estimate costs and potential revenue from providing Medi-Cal Enhanced Care Management and selected Community Support Services.

How does the tool support CBOs in contracting with MCOs? The tool enables CBOs to model various financial scenarios, justify rate requests during negotiations, and make informed decisions about program viability.

What are the key features of the CalAIM Budget Estimator Tool? Key features include built-in assumptions, cost input fields, revenue customization, and a summary tab displaying projected margins.

Can the tool be customized for specific organizational needs? Yes, users can customize expense inputs and revenue projections to reflect their specific organizational needs.

How do I get started with the CalAIM Budget Estimator Tool? Download the tool, enter your organization-specific costs, customize revenue sources, and review the summary tab to understand financial projections.

Why is financial viability important for CBOs? Financial viability ensures that CBOs can sustain their mission and expand services, ultimately enhancing care for individuals with complex health and social needs.

Conclusion

The CalAIM Budget Estimator Tool is an invaluable resource for CBOs looking to contract with managed care organizations under CalAIM. By providing detailed financial projections, the tool empowers organizations to make informed decisions, justify rate requests, and ensure the sustainability of their mission. Download the tool today and take the first step towards financial success and enhanced service offerings.

Understanding State-Level Variation in Medicaid Managed Care Maternity Kick Payments

Understanding State-Level Variation in Supplemental Maternity Kick Payments in Medicaid Managed Care

Introduction

Today, we’re exploring an intriguing study on the state-level variation in supplemental maternity kick payments in Medicaid managed care. This study, conducted by Samantha G. Auty, Jamie R. Daw, and Jacob Wallace, provides valuable insights into how these payments impact delivery costs and care quality.

Post Introduction

In this post, we’ll break down the key findings of the study, understand the implications of kick payments on Medicaid managed care, and discuss how these variations can affect maternal health outcomes across different states. Let’s get started by understanding the basics of Medicaid managed care and why kick payments are essential.

Detailed Story

What is Medicaid Managed Care?

Medicaid managed care (MMC) involves states contracting with private health insurers to provide Medicaid coverage. This model covers about 70% of pregnant Medicaid enrollees and finances approximately 41% of all births in the United States. Under MMC, insurers receive per-member-per-month capitated payments to cover a defined set of benefits. However, covering pregnant individuals poses a higher financial risk due to their increased healthcare needs, which often leads to states implementing one-time “kick payments” to MMC plans triggered by delivery events.

The Role and Variation of Kick Payments

Kick payments are designed to offset the higher costs associated with childbirth. The rates and use of these payments can significantly influence whether MMC plans are incentivized to attract or avoid pregnant enrollees. This study aimed to assess the prevalence and magnitude of these kick payments across different states and how they align with actual delivery costs.

Research Methodology

The researchers conducted a cross-sectional study, abstracting data from state documents and MMC contracts published between 2018 and 2020. They gathered information on whether states used kick payments, the services covered by these payments, and the specific rates.

Additionally, they compared these rates with average state Medicaid fee-for-service (FFS) payments for delivery hospitalizations in 2020 and the Medicaid-Medicare fee index.

Key Findings

The study revealed that out of the 38 states and the District of Columbia using comprehensive MMC, 33 states used maternity kick payments. These payments varied significantly, ranging from $2,838 in New Hampshire to $14,493 in Maryland. Interestingly, the variation in kick payment rates did not correlate with the Medicaid payments to physicians or the actual delivery costs, indicating that in some states, kick payments might exceed delivery costs, while in others, they fall short.

These payments varied significantly, ranging from $2,838 in New Hampshire to $14,493 in Maryland.

Expert Insights

To further explore the implications of these findings, let’s delve into some expert insights.

Potential Implications of Low Kick Payment Rates

When kick payment rates are set too low, MMC plans might attempt to limit services for pregnant enrollees or restrict access to maternity care providers. This can lead to disparities in care quality and access, particularly affecting Black and Indigenous women, who are disproportionately enrolled in Medicaid and face higher risks of maternal mortality and morbidity.

The Need for Aligned Incentives

Aligning kick payment rates with actual delivery costs and care quality is crucial. States need to design Medicaid payment policies that support maternal health and promote health equity. This requires continuous research to understand the effects of these payments on care access, quality, and outcomes.

In-Depth Analysis

The Study’s Limitations

While the study provides valuable insights, it has some limitations. It could not directly associate kick payment rates with MMC plan behavior or maternal health outcomes. Additionally, the comparison was made with Medicaid FFS payments rather than the prices MMC plans paid for delivery services, which were unavailable.

The Path Forward

Further research is essential to evaluate the impact of kick payments on maternal care access and outcomes. Policymakers need comprehensive data to design effective Medicaid payment strategies that ensure equitable and high-quality maternal care.

Practical Tips

For state policymakers and healthcare administrators:

  1. Regular Review of Kick Payment Rates: Ensure that kick payment rates are regularly reviewed and adjusted to reflect actual delivery costs and care quality needs.
  2. Focus on Health Equity: Design payment policies that address disparities in maternal health outcomes, particularly for vulnerable populations.
  3. Data-Driven Decision Making: Use comprehensive data to evaluate the impact of payment policies on maternal care access and outcomes.

FAQ Section

Q1: What are Medicaid managed care kick payments? A: Kick payments are one-time payments made to Medicaid managed care plans to offset the higher costs associated with childbirth.

Q2: Why do kick payment rates vary between states? A: The variation can be due to different state policies, healthcare costs, and the structure of Medicaid managed care contracts.

Q3: How can low kick payment rates affect maternity care? A: Low rates can lead to MMC plans limiting services for pregnant enrollees or restricting access to maternity care providers, affecting care quality and access.

Q4: What can states do to improve kick payment policies? A: States should regularly review and adjust kick payment rates, focus on health equity, and use data-driven approaches to design effective payment policies.

Source

State-Level Variation in Supplemental Maternity Kick Payments in Medicaid Managed Care

Introducing the Care MAP Tool: A Comprehensive Guide

Introducing the Care MAP Tool, designed to support healthcare providers in managing complex care needs. This user-friendly, Excel-based tool offers a structured framework for effective care coordination, resource allocation, and patient management. With modules for an overview and practical scenarios, plus a comprehensive resource library and FAQ section, the Care MAP Tool enhances care strategies and improves patient outcomes. Download it today and elevate your care management practices.

Effective care management is crucial in today’s complex healthcare landscape. To support healthcare professionals and organizations, we are excited to introduce the Care MAP Tool, a valuable resource designed to aid in complex care management. This blog will provide an overview of the Care MAP Tool, walk you through an example scenario, and offer access to a resource library and frequently asked questions (FAQ) section.

Module 1: Care MAP Overview

The Care MAP (Management and Planning) Tool is designed to support healthcare providers in managing and planning care for patients with complex health needs. This tool provides a structured framework to help clinics navigate the intricacies of care coordination, resource allocation, and patient management. Here’s what you can expect from the Care MAP Tool:

  • Framework for Complex Care Management: The tool offers a comprehensive structure to address the multifaceted needs of patients requiring intensive care management.
  • User-Friendly Interface: The Excel-based tool is intuitive and easy to navigate, ensuring that healthcare providers can quickly integrate it into their workflows.
  • Scalable and Adaptable: Whether you’re a small clinic or a large healthcare organization, the Care MAP Tool can be scaled and adapted to fit your unique needs.

Module 2: Example Scenario

To illustrate the practical application of the Care MAP Tool, let’s walk through an example scenario:

Scenario: Managing a Patient with Multiple Chronic Conditions

  1. Patient Overview:
    • Name: Jane Doe
    • Age: 65
    • Conditions: Diabetes, Hypertension, Chronic Obstructive Pulmonary Disease (COPD)
  2. Initial Assessment:
    • Medical History Review: Gather comprehensive information about Jane’s medical history, including past treatments, hospitalizations, and medications.
    • Social Determinants of Health: Assess factors such as living conditions, access to transportation, and social support.
  3. Care Coordination:
    • Interdisciplinary Team: Form a care team that includes primary care physicians, specialists, nurses, social workers, and community health workers.
    • Care Plan Development: Create a personalized care plan that addresses Jane’s medical and social needs, with clear goals and timelines.
  4. Monitoring and Evaluation:
    • Regular Check-ins: Schedule regular appointments and follow-ups to monitor Jane’s progress.
    • Adjustments: Modify the care plan as needed based on Jane’s response to treatment and changes in her condition.

Resource Library

The Resource Library is a curated collection of materials to further support your use of the Care MAP Tool. Here, you’ll find:

  • Guides and Manuals: Detailed instructions on how to use the Care MAP Tool effectively.
  • Case Studies: Real-world examples of the tool in action, showcasing its impact on patient outcomes.
  • Training Videos: Step-by-step video tutorials to help you and your team get up to speed quickly.

FAQ

To ensure you have all the information you need, we’ve compiled a list of frequently asked questions:

Q1: Who can use the Care MAP Tool?
A1: The tool is designed for healthcare providers, including clinicians, care coordinators, and administrative staff.

Q2: Is there a cost associated with the Care MAP Tool?
A2: No, the Care MAP Tool is available for free download.

Q3: How do I get support if I encounter issues with the tool?
A3: Support is available through our online helpdesk. You can also refer to the Resource Library for troubleshooting guides.

Care MAP Tool Download

By using the Care MAP Tool, you acknowledge that you have read and agree to the disclaimer below. If you share the tool, ensure that all individuals given access to it have reviewed and agreed to the disclaimer language before using it for any purpose.

Disclaimer: The Care MAP Tool is intended as a general framework to support considerations around complex care management in a clinic setting. It is not meant for final staffing, clinical, administrative, operational, and/or financial decision-making. Information obtained from this tool is not and should not be taken as legal or financial advice and is not a substitute for consulting a qualified professional. Community Initiatives does not accept responsibility for any loss that may arise from reliance on this tool.

Source Link:

Download Materials:

Care-MAP-Tool-Example-Scenario-3Download
Care-MAP-Tool-Blank-1Download

Feel free to reach out with any questions or feedback about the Care MAP Tool. Happy planning!

Managed Care Business Models 101 – Digital Therapeutics & Health Technology

The video titled “Managed Care Business Models 101 – Digital Therapeutics & Health Technology” on the channel Carenodes provides an in-depth discussion on healthcare business models, focusing on managed care, and is aimed at healthcare entrepreneurs, especially those new to the sector. Here’s a summary of key points covered in the transcribed part of the video:

The video titled “Managed Care Business Models 101 – Digital Therapeutics & Health Technology” on the channel Carenodes provides an in-depth discussion on healthcare business models, focusing on managed care, and is aimed at healthcare entrepreneurs, especially those new to the sector. Here’s a summary of key points covered in the transcribed part of the video:

  • Introduction to Healthcare Business:
    • The video begins with an overview of healthcare business, emphasizing the importance of understanding where healthcare money comes from and one’s role within the healthcare ecosystem.
    • It’s specifically designed for healthcare entrepreneurs, including those with varied backgrounds, highlighting the steep learning curve and business side of healthcare that is often overlooked by clinicians.
  • Speaker’s Background:
    • The speaker shares their extensive background in healthcare administration, including managing clinics, overseeing hospital networks, and working with health plans. This diverse experience underpins the insights shared in the presentation.
  • Key Concepts Discussed:
    • Healthcare as a Personal and Nuanced Field: The importance of hands-on, job-based learning over theoretical knowledge.
    • Navigating the Healthcare Ecosystem: For newcomers, understanding the ecosystem’s complexity and finding one’s place within it is crucial.
    • Importance of Demystifying Healthcare: Emphasizes the need for transparency and understanding in healthcare, drawing an analogy with a cave that becomes illuminated the moment a match is struck.
  • Ethical Considerations:
    • A significant portion of the video is dedicated to ethical considerations, urging participants to take healthcare seriously, understand their roles, and always prioritize patient well-being.
  • Managed Care and Its Components:
    • Managed care is defined, and its components are outlined, including payer-provider contracting, credentialing, and network development.
    • The video explains the managed care department’s role in ensuring that healthcare providers are credentialed and contracted with health plans.
  • The Business Side of Healthcare:
    • The speaker dives into the financial aspects of healthcare, explaining managed care’s focus on cost control and the shift towards value-based care.
    • Various healthcare financing mechanisms are discussed, with an emphasis on understanding the flow of funds within the healthcare system.

This summary covers the first part of the video. There are more pages available, indicating additional content not included here. If you’re interested in more detailed information or specific parts of the video, please let me know!

Watch the video here.

35 States with Any Willing Provider laws

As a provider, if your request to join a payer network in the following markets has been denied, you might have some recourse for appeals.

As a provider, if your request to join a payer network in the following markets has been denied, you might have some recourse for appeals.

Any Willing Provider and Freedom of Choice laws restrict the ability of managed care
entities, including pharmacy benefit managers, to selectively contract with providers. The
managed care entities argue this limits their ability to generate cost savings, while proponents of
the laws suggest that such selective contracts limit competition, leading to an increase in
aggregate costs.

These laws generally require health insurance companies to allow any qualified healthcare provider who is willing to meet the terms and conditions of the insurer’s contract to participate in their networks.

States listed below have some form of Any Willing Provider laws:

Alabama:

Section 27-1-19: The agreement providing coverage to an insured may not exclude assignment of benefits to any provider at the same benefit paid to a contract provider.

Section 27-45-3: Plan Beneficiaries may choose the licensed pharmacist or pharmacy of their choice. Health insurance policies and employee benefit plans may not deny licensed pharmacies or pharmacists the right to participate.

Arkansas:

Sections 23-201, 23-202, 23-203, 23-204, 23-205, 23-206, 23-207, 23-208, 23-209 : Benefit differentials are prohibited. Insurers must give qualified health care providers the opportunity to participate if providers are willing to accept the plan’s terms and conditions.

Colorado:

Section 10-16-122: Any PBM/intermediary whose contract with a carrier includes an open network must allow all area pharmacy providers to participate if they agree to the terms and conditions of the contract. PBms/Intermediaries may contract with exclusive pharmacy networks if a 60-day notice is given before the termination or the effective date of such contract by publication in a newspaper of general circulation.

Connecticut:

Section 38a-471: A prescription program administrator shall allow a pharmacy to enroll in a program absent cause for excluding it.

Delaware:

Sections 18-7301, 18-7302, 18-7303: Beneficiaries may choose any pharmacy that has agreed to participate according to the terms.  Benefit differentials are prohibited.

Florida:

Section 110.12315: The state employees’ prescription drug program requires the Department of Management services to allow prescriptions to be filled by any licensed pharmacy pursuant to contractual claims processing provisions.

Section 440.13(3) (j): The worker’s compensation statute allows for a sick or injured employee to have free, full and absolute choice in the selection of the pharmacy.

Georgia:

Section 26-2-144(a)(9): That at least 30 days prior to the date a program becomes effective, the program contract therefor shall be offered to all pharmacies located within those counties wherein reside enrollees in that program, which pharmacies shall have at least 30 days from the time they receive the offer to accept that offer and become participating pharmacies.

Section 33-30-25: Insurers may impose “reasonable limits” on the number/classes of preferred providers that meet the insurers’ standards. Insurers must give all licensed and qualified providers within a defined service are the opportunity to become a preferred provider.

Section 33-30-4.3: Beneficiaries who do not use mail-order shall not be penalized if the provider used by the insured has agreed to the same terms and conditions applicable to mail-order and has agreed to accept payment or reimbursement at no more than the same amount that would be paid for the same mail-order services.

Hawai’i:

Section 451 R-1: It shall be a violation of this section for a prescription drug benefit plan, health benefits plan under chapter 87A, or pharmacy benefit manager to refuse to accept an otherwise qualified retail community pharmacy as part of a pharmacy benefit manager’s retail pharmacy network.

Idaho:

Sections 41-2872 & 41-3927: Any insurance company or health maintenance organization issuing benefits must be willing to contract with qualified providers who meet the terms of the organization. Organizations issuing benefits must be willing to contract with qualified providers who meet the terms of the organization

Illinois:

Section 215-5/370h: Insurers/administrators must be willing to enter into agreements with any non- institutional providers who meet the established terms and conditions. The terms and conditions may not discriminate unreasonably against or among non-institutional providers.

Section 215-134/72(a) : A plan may not refuse to contract with a pharmacy provider that meets the terms and conditions established by the plan.

Indiana:

Section 27-8-11-3 : Pharmacists who agree to comply with established terms and conditions

are entitled to enter into contracts with insurers. Terms and conditions established by insurers may not discriminate unreasonably against or among providers.

Iowa:

Section 514C.5: Policies or contracts providing for third-party payment may not require a beneficiary to order prescriptions by mail if the pharmacy chosen by the beneficiary agrees to comply with the same terms and conditions as the mail-order pharmacy.

Kentucky:

Section 304.17A-270: A health insurer shall not discriminate against any provider who is located within the geographic coverage area of the plan and who is willing to meet the terms and conditions for participation established by the plan, including the Kentucky State Medicaid program and Medicaid partnerships.

Section 304.17A-505: …if the provider meets the insurer’s enrollment criteria and is willing to meet the terms and conditions for

participation, the provider has the right to become a provider for the insurer.

Louisiana:

Section: 22:1964: Policies/plans must allow beneficiaries to select the pharmacy/pharmacist of their choice as long as the chosen pharmacy agrees to meet the terms and conditions of the plan.

Pharmacies that agree to meet the established terms and conditions have the right to participate as contract providers. Renamed from Section 22:1214(15).

Section 22:2181: The Louisiana State University Health Sciences Center Health Maintenance Organization shall enter into a contract with any willing provider licensed by the Louisiana State Board of Medical Examiners or the Louisiana State Board of Dental Examiners to provide primary care services delivered in an outpatient setting including medical and surgical services.

Maine:

24-A M.R.S.A. § 4317: insurance carriers offering health plans subject to the Maine Health Plan Improvement Act that provide prescription drug benefits through a network of participating pharmacies may not refuse to contract with a pharmacy that is willing to meet the terms and conditions for participation in the health plan’s pharmacy network. If the network is a tiered network, Maine pharmacies must be offered the opportunity to participate in each tier. A pharmacy benefits manager may not require a pharmacist or pharmacy to participate in one network in order to participate in another network. The pharmacy benefits manager may not exclude an otherwise qualified pharmacist or pharmacy from participation in one network solely because the pharmacist or pharmacy declined to participate in another network managed by the pharmacy benefits manager.

Massachusetts:

Section 176D(3B): Carriers who offer restricted pharmacy networks must follow certain requirements in contracting. Carriers must neither exclude nor favor individual pharmacies and must not impose greater restrictions on non-network pharmacies than those required on in-network pharmacies.

Mississippi:

Section 83-9-6: Beneficiaries may choose any pharmacy that has agreed to participate in the plan according to the insurer’s terms. Pharmacies that accept those terms are entitled to participate.

Benefit differentials are prohibited. Plans that restrict pharmacy participation shall give 60 days notice of offer to participate to all pharmacies in the geographic area.

Missouri:

Section 354.535: Every Health maintenance organization has to apply the same coinsurance, co- payment and deductible factors to all prescriptions filled by a pharmacy provider who participates in the network if the provider meets the contact’s product cost determination. Also HMOs may not set a limit on the quantity of drugs which an enrollee may obtain at any one time with a prescription unless such limit is applied uniformly to all pharmacy providers in the network.

Montana:

Section 33-22-1704: A preferred provider agreement must provide all providers with the opportunity to participate on the basis of a competitive bid.

Nebraska:

Section 44-513.02: Beneficiaries shall not be required to obtain pharmaceutical services from mail- order in order to obtain reimbursement.

Section 44-313(2) :…an insurer may contract with a licensed pharmacist for pharmacist professional

services. Nothing in this section shall prohibit an insurer from contracting with a licensed pharmacist who is not employed or associated with a pharmacy. Nothing in this section shall require a licensed pharmacist to contract with an insurer for pharmacist professional services.

New Hampshire:

Section 420-B:12(V): HMOs seeking bids from pharmacies for agreements to be preferred providers must admit and list all pharmacies that meet the bid.

New Jersey:

Sections 17:48-6j & 26:2J-4.7: An enrollee/subscriber shall be permitted to select a pharmacy/pharmacist provided the pharmacist or pharmacy is registered. Pharmacies/pharmacists shall have the right to participate as preferred providers if the agreement provides for coverage by preferred providers, so long as the pharmacy/pharmacist complies with the terms of the agreement. Benefit differentials shall not be imposed. Enrollees/subscribers shall not be required to use a mail- order pharmacy.

New Mexico:

Section16.19.6.7(f): “Point of care vendor” means an entity contracted with a prescriber to generate or transmit electronic prescriptions authorized by a practitioner directly to a pharmacy or to a “contracted” intermediary or “network vendor”, who will ultimately transmit the prescription order to a patient’s pharmacy of choice. Vendor must provide an unbiased listing of provider pharmacies and not use

pop-ups or other paid advertisements to influence the prescriber’s choice of therapy or to interfere with patient’s freedom of choice of pharmacy. Presentation of drug formulary information, including preferred and non-preferred drugs and co-pay information if available, is allowed.

North Carolina:

Section 58-51-37: Beneficiaries may choose any pharmacy that has agreed to participate according to the insurer’s terms. Pharmacies that accept such terms are entitled to participate and must participate if offered the opportunity. Benefit differentials are prohibited. Plans that limit pharmacy participation shall give 60 days notice of an offer to participate to all pharmacies in the geographic area.

North Dakota:

Section 26.1-36-12.2: Beneficiaries may choose any licensed pharmacy/pharmacist to provide services. Benefit differentials are prohibited. Licensed pharmacists who accept the terms may participate in the plan.

Oklahoma:

Section 36-3634.3 & 36-4511: Pharmacies must be provided the right to bid on a periodic basis on any pharmacy contract to provider pharmacy services. Employers may not require employees to obtain drugs from a mail-order pharmacy as a condition for reimbursement. Employers may not impose benefit differentials if they do not use mail-order.

Title 15 § 15-788(c): No third party prescription program administrator shall deny any pharmacy the opportunity to participate in any third party prescription program offered in this state in a manner which will restrain the right of a consumer to select a pharmacy.

Rhode Island:

Sections 27-18-33, 27-19-26, 27-20-23, 27-41-38: Insurers may not require covered persons to obtain prescriptions from a mail-order pharmacy as a condition of obtaining benefits.

RI Gen. Laws 27-29-1: Unfair competition and practices.

South Carolina:

Section 38-71-147: No individual or group accident and health or health insurance policy or HMO may prohibit a participant/beneficiary from selecting pharmacies/pharmacists that agreed to participate in the plan according to the terms of the insurer, or may deny pharmacies/pharmacists the right to participate as contract providers if they agree to insurer’s terms and conditions.

South Dakota:

Section 58-18-37: Group health insurance policies may not refuse to accept licensed pharmacies/pharmacists as participating providers if they agree to the same terms and conditions offered to other providers of pharmacy services under the policy.

Tennessee:

Section 56-7-117: Group medical benefit contracts covering prescriptions may not require a covered person to obtain prescriptions from mail-order, or to pay an additional fee, or be subjected to a penalty for declining to use a designated mail-order pharmacy.

Section 56-7-2359: Licensed pharmacies may not be denied right to participate on the same terms and conditions offered other participants; benefit differentials are prohibited.

Texas:

Section 21.52B 2(a) (2): A pharmacy/pharmacist may not be denied the right to participate as a contract provider under the plan if the pharmacy/pharmacist agrees to provide pharmaceutical services that meet all terms and requirements and to include the same administrative, financial, and professional conditions that apply to pharmacies/pharmacists that have been designated as providers under plan.

Utah:

Section 31A-22-617: Insurers must allow providers to apply for and be designated as preferred providers if they agree to meet established terms and conditions. “Reasonable limitations” may be placed on the number of designated preferred providers.

Virginia:

Section 38.2-3407: Insurers shall establish terms and conditions in order to receive payment as a preferred provider. The terms and conditions shall not discriminate unreasonably against or among such health care providers and cannot exclude any provider willing to meet the terms and conditions.

Section 38.2-3407.7: Insurers shall not prohibit any person receiving pharmacy benefits from selecting, without limitation, the pharmacy of his choice.

Section 38.2-4209: Providers who are willing to accept established terms and conditions may qualify for payment under preferred provider contracts.

Section 38.2-4209.1: Corporations must allow beneficiaries to select the pharmacy of their choice if pharmacies that are non-preferred providers have previously notified the corporation of their agreement to accept reimbursement at rates applicable to preferred providers.

Section 38.2-4312.1: No Health maintenance organization shall prohibit any person receiving pharmaceutical benefits from selecting, without limitation, the pharmacy of his choice. No monetary penalty which would affect or influence any person’s choice of pharmacy shall be imposed.

Wisconsin:

Section 628.36 (2m): An annual 30-day open enrollment period during which any pharmacist may elect to participate is required.

Wyoming:

Section 26-22-503: Any provider willing to meet the established requirements has the right to enter into contracts relating to health care services.

Section 26-34-134: Providers willing to meet an HMO’s established terms shall not be denied the right to contract. An HMO may not discriminate against a provider on the basis of the provider’s academic degree.

Please note that laws can change over time, so it’s always a good idea to verify the current status of AWP laws in specific states if you need the most up-to-date information.

Maryland Physicians Care (MPC) Provider Relations Representatives Maryland Physicians Care

Maryland Physicians Care (MPC) Provider Relations Representatives Maryland Physicians Care

Maryland Physicians Care (MPC) Provider Relations Representatives Maryland Physicians Care

MPC providers have designated Provider Relations Representatives based on the practice/group location. This specialist will be your primary contact with MPC and will keep you updated on any policy changes. To find your Provider Relations Representative, select a territory for the list below.

Phone: 1-800-953-8854 (follow prompts to PR dept.)
Fax: 866-333-8024

Download the Territory List

MPC Provider Relations Representatives

Comprehensive Medicaid Actuarial Data (FL)

Advanced financial and statistical support relating to Capitation Rates, Risk Adjustment Models, and Payment Methodologies.

Agency: Florida Agency for Health Care Administration

Market: Florida

Line of Business: Medicaid

Market: Florida

Line of Business: Medicaid

Agency: Florida Agency for Health Care Administration

Source: Medicaid Actuarial Services

Advanced financial and statistical support relating to Capitation Rates, Risk Adjustment Models, and Payment Methodologies.

Medicaid Actuarial Services

This post is useful for those seeking information on Medicaid actuarial services and related rates in Florida.

  • Outlines Medicaid actuarial services provided by the Bureau, including advanced financial and statistical support for Capitation Rates, Risk Adjustment Models, and Payment Methodologies.
  • Provides information on Managed Medical Assistance (MMA), Long-Term Care (LTC), and Dental Capitation Rates for various years.
  • Includes a link to a Special Needs Plan Revenue and Expense Schedule Statement Template Tool.

Unit Responsibilities include:

  • Support of Capitation Rate Development and Adjustment
  • Management of External Actuarial Service Contracts
  • Monitoring Medicaid Program Changes
  • Trend Analysis
  • Rate Impact Analysis

Medicaid Actuarial Services

This post is useful for those seeking information on Medicaid actuarial services and related rates in Florida.

  • Outlines Medicaid actuarial services provided by the Bureau, including advanced financial and statistical support for Capitation Rates, Risk Adjustment Models, and Payment Methodologies.
  • Provides information on Managed Medical Assistance (MMA), Long-Term Care (LTC), and Dental Capitation Rates for various years.
  • Includes a link to a Special Needs Plan Revenue and Expense Schedule Statement Template Tool.

For Institutional Reimbursement rates, please click here.

SMMC Capitation Information

Managed Medical Assistance (MMA)

Long-Term Care (LTC)

Dental

Medicare Dual Eligible Special Needs Plans (D-SNPs) and Fully Liable Medicare Advantage Plans

Special Needs Plan Revenue and Expense Schedule Statement Template Tool [ excel 160.5 kB ] Effective July 1

Medi-Cal Managed Care Enrollment Report

This dataset contains the total number of Medi-Cal Managed Care enrollees based on the reported month, plan type, county, and health plan.

This dataset contains the total number of Medi-Cal Managed Care enrollees based on the reported month, plan type, county, and health plan.

Medi-Cal Managed Care Enrollment Report

The Medi-Cal Managed Care Enrollment Report is a dataset that contains information about the number of people enrolled in Medi-Cal Managed Care plans based on reported month, plan type, county, and health plan. This report is an important tool for policymakers and researchers who want to better understand the state of healthcare in California.

The dataset provides valuable insights into the number of people enrolled in Medi-Cal Managed Care plans, which are designed to provide affordable healthcare to low-income Californians. By analyzing the data in the report, policymakers and researchers can identify trends in enrollment, plan type, and county-level differences in enrollment rates.

One important trend that the report highlights is the increasing popularity of Medi-Cal Managed Care plans. As of the latest reported month, the total number of people enrolled in these plans was higher than ever before, indicating that more Californians are taking advantage of these affordable healthcare options.

Another important trend is the differences in enrollment rates across different counties in California. The report shows that some counties have higher enrollment rates than others, indicating that there may be disparities in access to healthcare across the state.

Overall, the Medi-Cal Managed Care Enrollment Report is an essential resource for anyone interested in understanding the state of healthcare in California. By providing detailed information about enrollment in Medi-Cal Managed Care plans, this report can help policymakers and researchers identify areas where improvements can be made, and ensure that all Californians have access to affordable, high-quality healthcare.

Medi-Cal Managed Care Enrollment Report