DC leaders conflict over finest insurer to take care of low-income sufferers

As DC lawmakers put together to award among the metropolis’s most profitable contracts — paying three insurance coverage corporations greater than $2 billion to supply well being take care of a few third of all DC residents — council members are caught in a bitter battle over which insurers ought to win.

Town’s Medicaid program has been wracked by controversy for years. After a courtroom ruling towards the previous contracts with insurers, a menace by a significant hospital system to cease seeing Medicaid sufferers, and legislative infighting, Mayor Muriel E. Bowser (D) vowed final 12 months to start out over with a brand new procurement to re-select the three insurance coverage corporations that the District would pay to supply care to Medicaid recipients.

DC plans to rebid its troubled Medicaid contracts

Town’s Workplace of Contracting and Procurement accepted bids, scored the proposals and awarded the contract to 2 suppliers already within the system — MedStar and AmeriHealth — together with a 3rd firm, Amerigroup, rather than present supplier CareFirst.

Bowser has requested the DC Council to approve the contracts at its legislative assembly Tuesday. However some council members have raised issues about whether or not Amerigroup is match to insure low-income sufferers.

The corporate has a troubled observe report, as lobbyists for CareFirst, together with former DC Council member David Catania, have identified: Greater than a decade in the past, an audit discovered that Amerigroup overcharged the District. It has been criticized for its function in different states’ Medicaid packages as properly, together with in Florida, the place it paid a $2 million advantageous for denying youngsters speech remedy.

“We’re poised to deliver again an [insurance plan] with a checked historical past within the District and a widely known fame for denying care to weak Medicaid members,” Council member Vincent C. Grey (D-Ward 7) wrote in a letter to Metropolis Administrator Kevin Donahue and council members, saying he was “strongly contemplating” urging members to vote down all three contracts on the grounds that the method had gone poorly and in a nasty winner. “We can’t stick our low-income residents with underperforming well being plans for the following 5 years and faux that our fingers are tied and that we now have executed the very best for our residents.”

However CareFirst, too, has a historical past of overcharging the District, just lately agreeing to pay a $95 million settlement to finish an over 13-year authorized battle over long-ago Medicaid fees. And Adrian Jordan, president of Amerigroup’s DC plan, mentioned that lots of the issues Grey alluded to don’t have anything to do along with his plan. The Amerigroup model consists of insurance coverage that act utterly individually from state to state, he mentioned, and the corporate is underneath totally different possession than the plan that carried out poorly within the District within the 2000s.

“The well being plans are utterly separate and unbiased,” Jordan mentioned. “Amerigroup DC is a stand-alone well being plan answerable to me and me alone. I’ve no visibility into some other plans within the nation.”

Amerigroup proved unpopular in DC the final time it held a Medicaid contract. Twenty % of its members selected to change to a special Medicaid supplier, greater than those that switched from different plans.

Jordan — who’s himself near some council members as a former council staffer — mentioned that will not occur once more. MedStar runs each an insurance coverage program and a significant hospital system fashionable with low-income sufferers within the District, and prior to now, the corporate did not attain settlement on a contract with another insurers, together with Amerigroup. That meant numerous Amerigroup sufferers who wished to see a MedStar physician needed to swap plans.

MedStar’s twin function turned way more of an issue final 12 months, when the corporate, confronted with the prospect of shedding its insurance coverage contract, threatened to cease letting its medical doctors deal with sufferers on some other Medicaid plan, an ultimatum that threw the Medicaid system into chaos and led to the brand new procurement that the town is now conducting.

Since then, the DC Division of Well being Care Finance has labored on guidelines and agreements meant to finish all hospitals within the District to just accept all Medicaid sufferers. If these agreements work, Amerigroup sufferers will not have that very same cause to change insurers.

Nonetheless, in its try to not lose the high-paying contract, CareFirst employed lobbyists, together with Catania, to attempt to persuade council members that switching tens of 1000’s of Medicaid sufferers from its plan to different plans can be detrimental, notably if the swap is to Amerigroup.

“If the council approves the contracts, over 70,000 DC Medicaid enrollees can be moved from a confirmed, high-quality plan to a plan with a demonstrated historical past of overcharging and denying care to sufferers,” mentioned Ieisha Grey, COO of CareFirst’s DC plan. CareFirst has argued that it misplaced out to Amerigroup primarily based on small technicalities in the best way DC scores procurements, not on high quality or price. “Minor typos might price over 70,000 District residents their well being care, and I do not assume that time might be underscored sufficient.”

In 2017 and in 2020, judges on DC’s Contract Appeals Board dominated that the Workplace of Contracting and Procurement erred in awarding Medicaid contracts. However this time, the Contract Appeals Board heard CareFirst’s protest and dominated that the procurement course of had been carried out correctly.

Choose says DC erred in awarding profitable Medicaid contracts

Council member Robert C. White Jr. (D-At Massive) has urged members to vote sure on the three contracts, saying they ought to respect the procurement course of. “The scale of those contracts is so giant that there was extra scrutiny and extra money and lobbying poured into it. On the finish of the day, it is a procurement that the town has run, that has been appealed, that has been finalized, and that the council shouldn’t intervene in,” White mentioned in an interview. “It could be a disaster for the council to ship the message that we are going to get entangled in procurements. As a result of each time there is a main procurement, we will be swarmed with lobbyists.”

White additionally criticized the give attention to Amerigroup’s health to carry the contract, noting that its opponents have additionally triggered main issues within the District’s Medicaid program.

CareFirst can pay $95 million to DC, ending 13-year authorized battle over surplus funds

“We shouldn’t be in search of the great actor, as a result of we will be wanting for a very long time. Town simply finalized a $95 million lawsuit with CareFirst. MedStar single-handedly broke our Medicaid system,” he mentioned. “All people has points right here.”

Michael Brice-Saddler contributed to this report.