McKee, EOHHS announce procurement for Medicaid Managed Care Organizations

PROVIDENCE – Gov. Daniel J. McKee and the R.I. Executive Office of Health and Human Services announced the Request For Proposals for Managed Care Organizations Friday.

Rhode Island’s Medicaid Managed Care Organizations provide health care delivery to more than 320,000, or 90%, of the state’s Medicaid members each year, according to a news release. The RFP is available on the State’s purchasing website at https://www.ridop.ri.gov.

“As part of my administration’s Rhode Island 2030 Plan, we are building a state health system that better supports affordable and accessible services to maximize health outcomes for all Rhode Islanders,” McKee said. “The new Managed Care RFP will strengthen the services that our state’s Medicaid members receive and ensure increased oversight and transparency of awarded vendors to deliver value for Rhode Island taxpayers through a performance-based contract.”

According to the news release, the new RFP and contract requirements are meant to enhance quality, oversight and financial management through the following steps:

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  • Reducing unnecessary prior authorizations (PAs), particularly for behavioral health services through the elimination or unnecessary administrative burden of PAs on providers and requiring an independent entity to review compliance with behavioral health parity requirements
  • Ensuring appropriate use of Medicaid funds by requiring executive level compensation transparency, including job qualifications, organizational structure and ensuring ethical conduct of a MCO’s Board of Directors.
  • Increased market competition among MCOs to ensure fair and competitive market practices, ensure fair competition to reduce program costs and increase access to care for beneficiaries
  • Requiring EOHHS to approve contracts for MCO major subcontractors. MCOs will be required to inform EOHHS when they place a subcontractor on a corrective action plan because of poor performance. Corrective action plans will be posted to the MCO’s website for further transparency and ability to request a MCO to remove a subcontractor due to poor performance
  • More oversight and accountability for the use of Pharmacy Benefit Managers (PBM), including the prohibition of spread pricing and flexibility for EOHHS to move towards a single-state PBM under the review and direction of EOHHS
  • Increased information systems and testing review of protected health data to ensure privacy and protection for member health data and data system performance
  • Improving budget predictability and creating incentives for person-centered, efficient care with payments linked to member outcomes and flexibility to move towards full risk in SFY26
  • Increasing financial sanctions, performance metrics and publication of corrective actions against noncompliant MCOs
  • Revised amendment process to ensure federal and state law changes are implemented in a timely way to support provider rate stability
  • The designation of a children’s health coordinator to ensure all children enrolled in an MCO receive appropriate care, required vaccinations and lead testing through performance withholds
  • The flexibility to increase value-based payments through case management delegation to certified accountable entities and flexibility to implement primary care capitation models
  • Expanding Managed Care to Rhode Islanders who are dually enrolled in Medicare and Medicaid, so these members can choose to receive all care from the same health plan
  • Program integrity safeguards and oversight requirements to reduce fraud, waste and abuse
  • Incorporating Long-Term Services and Supports (LTSS) as an in-plan benefit for all populations, creating a more comprehensive benefit approach under Managed Care and support members to remain in community settings
  • Improving care coordination across the continuum, reducing duplication and fragmentation, with fewer transitions
  • Increasing investments in population health and health equity, focusing on the identification of health disparities, engagement of communities, and investment in addressing health-related social needs under new authorities granted by the federal government to address social determinants of health.

“We are committed to improving services for the Rhode Islanders who rely on Medicaid to manage their healthcare needs,” said Medicaid Director Kristin Sousa. “Many of the improvements made to this contract will positively impact our members’ care, bring greater parity between medical and behavioral healthcare, reduce unnecessary prior authorizations, and focus on health equity.”

To ensure a smooth transition all current Managed Care Organizations – Neighborhood Health Plan of Rhode Island, Tufts Public Health Plans and UnitedHealthcare – have signed contract extensions through June, 30 2025. This ensures that all current MCOs are focused on providing care through the end of the contract and no vendor will leave the marketplace early if they decide not to bid or do not win the bid, according to a news release.

The new contract will begin on July 1, 2025 and run through June 30, 2030 with an option to extend for up to an additional five years.

“The money invested in Rhode Island’s Managed Care Organizations is significant, and we regularly hear from stakeholders about the need for more transparency about how this funding supports Rhode Island Medicaid members,” said EOHHS Secretary Richard Charest. “Our team spent several months building a new Managed Care contract that reduces duplication and fragmentation and increases accountability and transparency of contracted MCOs.”

To prepare for this procurement, EOHHS conducted stakeholder outreach to gather feedback on the Managed Care system from Medicaid members, providers, health plans, other state agencies, member advocates and community partners. The agency also issued a Request for Information in May 2023, which led to 23 responses and over 600 pages of feedback for the agency to consider while drafting the new RFP, according to a news release. Also, EOHHS staff consulted with other state Medicaid agencies and reviewed several Managed Care contracts from around the county to ensure they followed national best practices for administration and oversight of the program.

Katie Castellani is a PBN staff writer. You may contact her at Castellani@PBN.com.