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Research: poor Medicaid managed care providers rarely punished

If you’re on SSI, there’s a good chance you get your healthcare through Medicaid. If you can’t work, you’re eligible for Medicaid once you’ve received Supplemental Security Income for a month. If you’re working while on SSI, you’re still eligible as long as you meet SSI’s income limit and eligibility rules, you need Medicaid to work, and your income is still insufficient to get healthcare through other programs.

If you are on Medicaid, you may have noticed the program is increasingly relying on managed care plans. The idea is that third-party plans can both save the state money and improve quality. As of 2011, nearly 64 percent of Wisconsin Medicaid recipients were enrolled in managed care programs, many of which operate in multiple states.

State health officials are required to monitor the plans’ quality and legal compliance but, unfortunately, there is evidence that some states are not doing a good job. Over the past few years, scandals have erupted in Illinois, Texas, Ohio and Florida over poor-quality care and Medicaid fraud by several plans. Yet only Texas has ever terminated a managed care plan’s contract, and only a handful of states have imposed significant fines.

“You have a situation where too many states take a hands-off approach. I think there’s a significant risk of substantial harm to consumers,” said a spokesperson for a health care consumer advocacy group. Disability Scoop relates:

  • In Florida, WellCare Health Plans remains the state’s largest managed care plan despite the fact that several of its former top executives have been convicted of scheming to defraud Florida’s Medicaid and Healthy Kids programs.
  • In Illinois, the Family Health Network, WellCare’s subsidiary Harmony Health Plan and Amerigroup Corp. (since bought by WellCare) are still under contract despite their care being described by the state’s Medicaid Deputy Administrator as “abysmal.”
  • In Ohio, CareSource remains the state’s largest managed care provider despite agreeing to pay a $26-million fine to settle allegations that it refused to provide covered services to people with special needs and submitted false data.
  • Texas canceled its contract with UnitedHealth Group subsidiary Evercare after it was fined more than $600,000 for problems including failure to provide proper access to people with disabilities and the elderly, but it continues to work with Evercare in the Dallas-Ft. Worth area.

Have you experienced a problem with a managed care Medicaid provider in Wisconsin?

Sources: 

  • Disability Scoop, "States Balk At Terminating Medicaid Contracts," Jenni Bergal, Kaiser Health News, Sept. 17, 2013
  • “Medicaid Managed Care Enrollment Report,” Department of Health and Human Services and Centers for Medicare and Medicaid Services, July 1, 2011

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