This week, our In Focus section reviews the Pennsylvania HealthChoices Physical Health Medicaid managed care request for applications (RFA), issued by the Pennsylvania Department of Human Services on October 15, 2019. Medicaid managed care organizations (MCOs) will serve the five HealthChoices zones covering all 67 counties: Southeast, Southwest, Lehigh-Capital, Northwest, and Northeast. Contracts are worth nearly $13 billion.
Pennsylvania failed to implement new contracts and negated awards from 2016 as well as the awards from the 2017 rebid. As result, the HealthChoices program is currently operating under extensions of contracts originally awarded in 2012. The most recent awards in early 2017, which would have been for a three-year, $12 billion contract, were for the following plans:
- Southeast Region: Gateway Health, Health Partners Plans, PA Health and Wellness (Centene), UPMC for You, Vista–Keystone First Health Plan
- Southwest Region: Gateway Health, PA Health and Wellness (Centene), UPMC for You, VistaAmeriHealth Caritas Health Plan
- Lehigh/Capital Region: Gateway Health, Geisinger Health Plan, Health Partners Plans, PA Health and Wellness (Centene)
- Northeast Region: Gateway Health, Geisinger Health Plan, UPMC for You
- Northwest Region: Gateway Health, UPMC for You, Vista-AmeriHealth Caritas Health Plan
However, after protests from Aetna, UnitedHealthcare, and AmeriHealth Caritas, the state elected to cancel the RFP and reissue the procurement. These three plans are incumbent plans serving about one half of all HealthChoices enrollees as of July 2019. Aetna and UnitedHealthcare were not awarded contracts for any regions and AmeriHealth Caritas, which serves more than thirty percent of all HealthChoices enrollees, was a successful bidder for two of the five regions.
Multiple MCOs will be selected for each of the five regions.
- Southeast Zone: 4-5 MCOs
- Bucks, Chester, Delaware, Montgomery, and Philadelphia counties
- Southwest Zone: 3-5 MCOs
- Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Somerset, Washington, and Westmoreland counties
- Lehigh-Capital Zone: 3-5 MCOs
- Adams, Berks, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Lancaster, Lebanon, Lehigh, Northampton, Perry, and York counties
- Northwest Zone: 3-4 MCOs
- Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, potter, Venango, and Warren counties
- Northeast Zone: 3-4 MCOs
- Bradford, Carbon, Centre, Clinton, Columbia, Juniata, Lackawanna, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Pike, Schuylkill, Snyder, Susquehanna, Tioga, Union, Wayne, and Wyoming counties
Technical applications will be scored based on:
- Soundness of Approach (85 percent)
- Accounting for the unique healthcare resources available to and healthcare challenges faced by members in the particular zone.
- Addressing all work statement requirements.
- Approach has been crafted to address the particular demographic, cultural, economic, geographic, or other relevant characteristics of the counties of the zone.
- Addressing how past performance has improved quality, access, and value for the HealthChoices program or a similar program.
- Personnel Qualifications and Staffing (5 percent)
- Overall organizational structure and proposed functions, staff, and subcontractors.
- Education, experience, qualifications, and other information for executive management, key administrative, and subcontracted staff.
- Prior Experience and Performance (10 percent)
- Corporate background and history
- Corporate qualifications and experience in Medicaid managed care systems
MCOs can score an additional 3 percent of the total score for domestic workforce utilization.
The total raw score for the technical submittal for each zone must be 75 percent or greater.
Applications are due December 17, 2019, and contracts are expected to begin January 2021, running for five years, with an option to extend for an additional period of three years. An award date was not announced.
Current Medicaid incumbents are Aetna, AmeriHealth Caritas, Gateway, Geisinger, Health Partners Plans, UnitedHealthcare, UPMC, serving approximately 2.26 million members.