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Humana and Molina Acquisition Proposals

In 2022, the Wisconsin Department of Health Services (DHS) was informed of a potential purchase of two managed care organizations that currently provide Medicaid long-term care services. That means the new companies will purchase their assets and begin managing their Medicaid programs.

Molina Health Care, Inc., plans to purchase My Choice Wisconsin.

After completing a series of reviews and certifications through DHS and the Office of the Commissioner of Insurance (OCI), Humana, Inc., finalized their plans to purchase Inclusa effective June 1, 2023. The program will continue routine operations under the name iCare. Members do not need to take action to continue with their current care plan.

DHS certifies all HMOs and MCOs that serve Wisconsin’s Medicaid members. If the purchases happen, Molina Health Care, Inc., and Humana, Inc., will need to prove they can meet all contract and program requirements, and provide quality services to members before DHS certifies them to serve Medicaid members.

Updates

Molina Health Care, Inc., has submitted certification documentation to DHS and will now need to work with the Office of the Commissioner of Insurance (OCI). After OCI has completed its review, DHS will decide whether requirements have been met to approve certification and, if so, reassign the contract.

DHS has determined that Humana has met the requirements for certification. As a result, the contract reassignment from Inclusa will take place.

Members and their families and guardians served by Inclusa should expect written notification about the acquisition. Normal operations will continue and members' care plans. care managers, and providers will not change because of the acquisition.

Review the DHS presentation (PDF) from the March 2, 2023 meeting of the Wisconsin Long Term Care Advisory Council (WLTCAC).

Provide your feedback

DHS held two online public forums in December 2022 and received feedback about these acquisition proposals.

Consolidated questions and answers from forums hosted in December 2022

Members would continue to get the same quality services that they have come to expect. All HMOs and MCOs must meet Wisconsin Medicaid’s quality standards and take part in quality improvement initiatives to be certified by DHS.

No. DHS does not anticipate any reductions in the available networks of providers.

All MCOs and HMOs must meet Wisconsin’s provider network standards. To successfully complete annual certification, MCOs and HMOs must show they can keep or develop a robust network of providers to meet member needs.

Members would still have a choice of HMOs or MCOs.

Every MCO in Wisconsin has a contract with DHS. Each contract has the same rules and requirements, regardless of whether the contract is with a for-profit or a nonprofit agency.

All MCOs must meet DHS’s quality expectations and contractual obligations.

Molina and Humana may eventually change the brand names of My Choice Wisconsin and Inclusa.

You will continue to be enrolled in your program. Your benefits and the providers you have access to will not change.

The care team will continue to manage your care; however, you may notice a change in the brand name and payor information for services.

DHS posts external quality reports and score cards for each MCO.

If you would like to discuss your enrollment options or change your MCO, please talk to your local tribal Aging and Disability Resource Specialist (ADRS) or visit your local Aging and Disability Resource Center (ADRC).

DHS has a dedicated team of quality and oversight specialists. MCOs must complete performance improvement projects annually and meet all DHS quality expectations.

Read more about projects DHS is working on to address the caregiver worker shortage.

DHS reviews all MCOs’ provider networks annually. Provider networks must be robust enough to meet all member care needs.

Any assets owned by Inclusa or My Choice Wisconsin will be sold to Humana and Molina, unless the assets are specifically excluded through legal paperwork written as part of the acquisition process.

The DHS-MCO contract, Article XVI, lists the steps an MCO must take to end a contract.

The MCO must work with DHS to develop an approved transition plan. MCOs must continue operations until all members have been transitioned to another MCO or program of their choice.

DHS pays MCOs a set fee each month for each member they serve. This is called capitation.

Rates are set annually based on claims, levels of care, target group, geographic adjustments, administrative costs, by contracted actuaries and approved by the Centers for Medicare & Medicaid Services (CMS).

Each MCO negotiates rates with providers in their network.

DHS is developing a minimum fee schedule for adult family homes, residential care apartment complexes, community based residential facilities, and supportive home care.

Please review your program handbook or contact the MCO’s member rights specialist for details on appeal rights and procedures.

You can also reach out to the Ombudsman at the Board on Aging & Long Term Care or Disability Rights Wisconsin for help with the appeal process.

Yes, an organization can operate both an MCO and an IRIS contractor.

DHS is revising contract language to create new protections for MCO members and IRIS participants.

You must visit your local tribal Aging and Disability Resource Specialist (ADRS) or local Aging and Disability Resource Center (ADRC) if you are considering changing your program enrollment.

Acquisitions are private business decisions. DHS does not have the legal power to stop an acquisition.

DHS does our due diligence to collect information that MCOs meet specific requirements to serve members in our programs. This process is called certification. Certification includes a review of policies and procedures, financial information, marketing, and more.

Certification information

HMOs and MCOs must be certified annually by DHS to serve Medicaid members. DHS works collaboratively with organizations during the certification process, which includes filing a three-year work plan and a certification checklist.

Specifically for the Molina and Humana acquisitions, DHS requires the organizations to submit information on various topics including, but not limited to, case management transition, provider contracts, governance and organizational structure, records, marketing and communications, and finances. Both organizations will also be required to submit a three-year work plan.

Service areas

If the asset purchases happen, Wisconsin Medicaid’s HMO Service Areas and Wisconsin Medicaid Long-Term Care’s Geographic Service Regions will remain the same. At least two HMOs and two MCOs would continue to serve each region to make sure all members can choose who they get care from.

HMO Service Areas
Family Care Geographic Service Regions (PDF)
Family Care Partnership/PACE Geographic Service Regions (PDF)
IRIS Contract Geographic Service Regions (PDF)

Last revised May 31, 2023