Care Coordinators: MCOs’ Best Kept Secret

For families who have children with complex health care needs, coordinating all the appointments, medications, and therapies can be difficult. When an individual has several doctors and specialists that they regularly see, the help of a care coordinator can be invaluable. A care coordinator, or patient care coordinator, is a health professional employed by an MCO, or managed care organization, to oversee complex care cases. They can help with getting needed appointments, acquiring resources outside of prescriptions, ensuring that medications are easily available and do not have any interactions, and help families have better peace of mind that all of their medical practitioners are on the same page.

Care coordinators are available to many patients, but they are rarely given as an option to overtaxed patients or patients’ parents. Primary care physicians sometimes recommend a care coordinator to help a patient or family, but as they are not familiar with every aspect of a patient’s life and health care, they will often assume that a family does not need a care coordinator when they would be greatly aided by having one. For those with a strong connection to a primary provider, asking them to request a care coordinator for their healthcare can be an efficient way to start the process. While a primary care physician is often the one to initiate the assistance of a care coordinator, is possible for a patient or their family to request care coordination on their own.

The process for requesting a care coordinator is different through different health care systems. The majority of individuals on Medicaid, also known as Apple Health, have their healthcare covered by an MCO. Calling the MCO’s customer service line is often the first step in getting a care coordinator.  The phone numbers of the five MCO’s that oversee apple health in Washington state are as follows: Amerigroup at 1-800-600-4441, Community Health Plan of Washington at 1-800-440-1561, Coordinated Care of Washington at 1-877-644-4613, Molina Healthcare of Washington at 1-800-869-7165, and UnitedHealthcare Community Plan at 1-877-542-8997.  If you are unsure which MCO is in charge of your healthcare, view our video on Who is in Charge of Your Apple Health Healthcare? If there are problems in getting through to your MCO, you can call the Health Care Authority, that oversees all Washington Medicaid MCOs, at 1-800-562-3022.

Patients Seek Mental Health Care From Their Doctor But Find Health Plans Standing in the Way

When a longtime patient visited Dr. William Sawyer’s office after recovering from covid, the conversation quickly turned from the coronavirus to anxiety and ADHD.

Sawyer — who has run a family medicine practice in the Cincinnati area for more than three decades — said he spent 30 minutes asking questions about the patient’s exercise and sleep habits, counseling him on breathing exercises, and writing a prescription for attention-deficit/hyperactivity disorder medication.

At the end of the visit, Sawyer submitted a claim to the patient’s insurance using one code for obesity, one for rosacea — a common skin condition — one for anxiety, and one for ADHD.

Several weeks later, the insurer sent him a letter saying it wouldn’t pay for the visit. “The services billed are for the treatment of a behavioral health condition,” the letter said, and under the patient’s health plan, those benefits are covered by a separate company. Sawyer would have to submit the claim to it.

But Sawyer was not in that company’s network. So even though he was in-network for the patient’s physical care, the claim for the recent visit wouldn’t be fully covered, Sawyer said. And it would get passed on to the patient.

Read the full article from KHN.

Why Millions on Medicaid Are at Risk of Losing Coverage in the Months Ahead

The Biden administration and state officials are bracing for a great unwinding: millions of people losing their Medicaid benefits when the pandemic health emergency ends. Some might sign up for different insurance. Many others are bound to get lost in the transition.

State Medicaid agencies for months have been preparing for the end of a federal mandate that anyone enrolled in Medicaid cannot lose coverage during the pandemic.

Before the public health crisis, states regularly reviewed whether people still qualified for the safety-net program, based on their income or perhaps their age or disability status. While those routines have been suspended for the past two years, enrollment climbed to record highs. As of July, 76.7 million people, or nearly 1 in 4 Americans, were enrolled, according to the Centers for Medicare & Medicaid Services.

When the public health emergency ends, state Medicaid officials face a huge job of reevaluating each person’s eligibility and connecting with people whose jobs, income, and housing might have been upended in the pandemic. People could lose their coverage if they earn too much or don’t provide the information their state needs to verify their income or residency.

Medicaid provides coverage to a vast population, including seniors, the disabled, pregnant women, children, and adults who are not disabled. However, income limits vary by state and eligibility group. For example, in 2021 a single adult without children in Virginia, a state that expanded Medicaid under the Affordable Care Act, had to earn less than $1,482 a month to qualify. In Texas, which has not expanded its program, adults without children don’t qualify for Medicaid.

State Medicaid agencies often send renewal documents by mail, and in the best of times letters go unreturned or end up at the wrong address. As this tsunami of work approaches, many state and local offices are short-staffed.

Read the full article from KHN.

The No Surprises Act Begins January 2022: This is What You Can Expect

The “No Surprises Act,” which establishes new federal protections against most surprise out-of-network medical bills when a patient receives out-of-network services during an emergency visit or from a provider at an in-network hospital without advance notice, will take effect next month. A new KFF brief outlines what to expect in 2022, summarizing key provisions that will be implemented.

Most adults (2 in 3) say they worry about unexpected medical bills and among privately insured patients, about 1 in 5 emergency claims and 1 in 6 in-network hospitalizations include at least one out-of-network bill. The new federal protections will apply to most surprise bills for emergency care, as well as for non-emergency services provided at in-network facilities, potentially helping alleviate this worry.

The No Surprises Act prohibits providers from billing patients more than the applicable in-network cost sharing amount in these situations. Starting in 2022, providers will need to find out patient’s insurance status before submitting the surprise out-of-network bill directly to the health plan. However, patients can give written consent to waive their rights under the No Surprise Act and be billed more by out-of-network providers. It is expected this should only happen in limited circumstances.

The brief also describes procedures to arrive at payment amounts for surprise bills, including use of an independent dispute resolution (IDR) system. Under this system, it is likely that out-of-network payments will be close to the median rate that health plans pay for in-network services, and this would moderate health plan premiums overall. However, suits filed by provider organizations are pending and could result in further regulatory changes or delay implementation of the law.

If a patient receives what they believe is a surprise bill, the new brief highlights protections, and ways to seek help. This is a complex law, with enforcement being conducted in a variety of ways, both by federal and state agencies.

The No Surprises Act allows consumers to appeal disputes over coverage of surprise medical bills to an external reviewer. Another new KFF brief looks at the process for consumer appeal rights under the Affordable Care Act (ACA), which would also be used for surprise bills. Federal law gives consumers the right to appeal health plan claims denials and other adverse decisions, including the incorrect application of cost sharing, although limits apply. This brief describes consumer access to appeals and limits on appeal rights that have been adopted through federal regulations.

Washington Healthplanfinder Announces Statewide Adventure Tour

Visit one of the base camps at the cities below and speak to someone who can guide you through the sign-up process.

Keep an eye out for the Washington Healthplanfinder adventure van at these times and places:

Nov. 27 | Bellingham, WA
First Friday Shop Local | 4 pm – 9 pm | 1336 Cornwall Ave.

Dec. 3 | Moses Lake, WA
Moses Lake Street Party | 5 pm – 8 pm | Sinkiuse Square on Third Avenue

Dec. 4 | Walla Walla, WA
Farmer’s Market and Holiday Parade | 9 am – 7 pm | 106 W Main St.

Dec. 9 | Tri-Cities, WA
After School Pop-Up with Tri-City Health | Time to be determined

Dec. 10 | Vancouver, WA
Vancouver Mall (outdoor courtyard) | 11 am – 5 pm | 8700 NE Vancouver Mall Dr.

Dec. 11 | Wenatchee, WA
Pybus Public Market | 10 am – 6 pm | 7 N Worthen St.

Dec. 17 | Olympia, WA
Oly on Ice | 3:30 pm – 9 pm | 529 4th Ave. W

Dec. 18 | Seattle, WA
Children’s Home Society in Kent (King County Public Health) | 10 am – 4 pm | 215 5th Ave. S, Kent, WA

Dec. 19 | Yakima, WA
Los Hernandez Tamales | 2 pm – 6 pm | 3706 Main St., Union Gap, WA

Jan. 7 | Spokane, WA
Spokane First Friday | 1 pm – 8 pm | 1318 W 1st Ave.

A Record 3,834 Medicare Advantage Plans Will be Available in 2022

A record 3,834 Medicare Advantage plans will be available across the country as alternatives to traditional Medicare for 2022, a new KFF analysis finds. That’s an increase of 8 percent from 2021, and the largest number of plans available in more than a decade.

At the same time, the number of Medicare Part D stand-alone prescription drug plans that will be offered in 2022 is decreasing by 23 percent to 766 plans, primarily the result of firm consolidations leading to fewer plan offerings sponsored by Cigna and Centene, according to another new KFF analysis.

These findings are featured in two briefs released by KFF today that provide an overview of the Medicare Advantage and Medicare Part D marketplace for 2022, including the latest data and key trends over time. Medicare’s open enrollment period began Oct. 15 and runs through Dec. 7.

Medicare Advantage

More than 26 million Medicare beneficiaries – 42 percent of all beneficiaries – are currently in Medicare Advantage plans, which are mostly HMOs and PPOs offered by private insurers that are paid to provide Medicare benefits to enrollees.

In 2022, a typical beneficiary will have 39 plans to choose from in their local market. But the number of Medicare Advantage plans available varies greatly across the country, with an average of 42 plans in metropolitan areas and 25 plans in non-metropolitan areas. In 2022, 25 percent of beneficiaries live in a county where they can choose among 50 Medicare Advantage plans.

Most Medicare Advantage plans (89%) include prescription drug coverage. Fifty-nine percent of these plans do not charge any additional premium beyond Medicare’s standard Part B premium. More than 90 percent of non-group Medicare Advantage plans offer some vision, telehealth, hearing, or dental benefits.

Despite the average beneficiary having access to plans offered by nine different firms, Medicare Advantage enrollment is concentrated in plans operated by UnitedHealthcare, Humana, and Blue Cross Blue Shield affiliates. Together, UnitedHealth and Humana account for 45 percent of Medicare Advantage enrollment in 2021.

Part D

As a result of consolidations in the stand-alone drug plan market, the typical Medicare beneficiary will have a choice of 23 stand-alone drug plans next year, seven fewer than in 2021. Beneficiaries receiving low-income subsidies (LIS) will also have fewer premium-free plan choices in 2022, which could make it more difficult for some enrollees to find a premium-free plan that covers all their prescription medications. In the stand-alone drug plan market, 8 out of 10 enrollees next year are projected to be in stand-alone plans operated by just four firms: CVS Health, Centene, UnitedHealth, and Humana.

The estimated average monthly premium for Medicare Part D stand-alone drug plans is projected to be $43 in 2022, based on current enrollment, while average monthly premiums for the 16 national stand-alone drug plans available in 2022 are projected to range from $7 to $99.


Nearly three-fourths, or 10 million, of the 13.3 million stand-alone drug plan enrollees who don’t qualify for low-income subsidies will have to pay higher premiums next year if they stick with their current plan, and many will also face higher deductibles and cost sharing for covered drugs. While the average weighted monthly PDP premium is increasing by $5 between 2021 and 2022 (from $38 to $43), nearly 4 million non-LIS enrollees (28%) will see a premium increase of $10 or more per month. Substantially fewer non-LIS enrollees (0.2 million, or 2%) will see a premium reduction of the same magnitude.

In addition to these two new analyses, KFF has updated its collection of frequently asked questions about Medicare Open Enrollment to help beneficiaries understand their options during the annual open enrollment period. A recent KFF analysis found that 7 in 10 Medicare beneficiaries say they did not compare their options during a recent open enrollment period. Comparing and choosing among the wide array of Part D plans can be difficult, given that plans differ from each other in multiple ways, beyond premiums, including cost sharing, deductibles, covered drugs, and pharmacy networks. Comparing Medicare Advantage drug plans may be made more difficult by the fact that not only drug coverage varies but also other features, including cost sharing for medical benefits, provider networks, and coverage and costs for supplemental benefits.

Most Insurers Participating in the Marketplaces Don’t Expect COVID to Affect Their 2022 Costs

After a tumultuous year of unpredictable COVID-19 changes to utilization and spending, a review of early rate filings for individual market insurers participating in the Affordable Care Act Marketplace finds that most are expecting a return to normal in 2022 without the pandemic playing a large role.

The review of insurers’ preliminary rate filings in 13 states and the District of Columbia reveals that most expect health utilization patterns to return to their pre-pandemic levels and generally aren’t expecting any additional costs or savings related to COVID-19 in their 2022 rates. Of the 75 insurer filings submitted in these states, 16 predict that COVID-19 will have an impact in 2022, generally pushing rates up by less than a 1 percentage point.

The pandemic led to a sharp drop in health spending in April 2020, as many providers cancelled elective procedures and patients practiced social distancing and avoided health care facilities. Since then, spending has mostly rebounded, though utilization this year remains somewhat lower than normal.

Other factors that insurers cite as impacting their 2022 rates include continued use of telehealth services in place of in-person visits, and a somewhat healthier marketplace population due to increased tax credits included in the American Rescue Plan Act. Few mentioned any impact from the No Surprises Act, which prohibits most surprise out-of-network bills starting next year.

Although the ACA Marketplaces cover a relatively small share of the privately insured population, the rate filings for this market are quite detailed and publicly accessible, making them a useful source of information on how insurers are thinking about their likely health costs. Insurers largely made similar assumptions about how COVID-19 would affect their group market costs, the analysis finds.

The brief is available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

A Hospital Charged $722.50 to Push Medicine Through an IV. Twice.

Claire Lang-Ree was in a lab coat taking a college chemistry class remotely in the kitchen of her Colorado Springs, Colorado, home when a profound pain twisted into her lower abdomen. She called her mom, Jen Lang-Ree, a nurse practitioner who worried it was appendicitis and found a nearby hospital in the family’s health insurance network.

After a long wait in the emergency room of Penrose Hospital, Claire received morphine and an anti-nausea medication delivered through an IV. She also underwent a CT scan of the abdomen and a series of tests.

Hospital staffers ruled out appendicitis and surmised Claire was suffering from a ruptured ovarian cyst, which can be a harmless part of the menstrual cycle but can also be problematic and painful. After a few days — and a chemistry exam taken through gritted teeth — the pain went away.

Then the bill came.

Patient: Claire Lang-Ree, a 21-year-old Stanford University student who was living in Colorado for a few months while taking classes remotely. She’s insured by Anthem Blue Cross through her mom’s work as a pediatric nurse practitioner in Northern California.

Total Bill: $18,735.93, including two $722.50 fees for a nurse to “push” drugs into her IV, a process that takes seconds. Anthem’s negotiated charges were $6,999 for the total treatment. Anthem paid $5,578.30, and the Lang-Rees owed $1,270 to the hospital, plus additional bills for radiologists and other care. (Claire also anted up a $150 copay at the ER.)

Read the full article from Kaiser Health News.