Business Beat: Neighborhood Health Plan and UnitedHealthcare to manage RI Medicaid

New contract includes quality, oversight, and financial management requirements that will lead to improved outcomes for Medicaid members and the state

The state has chosen two Medicaid Managed Care Organizations (MCOs) to serve Rhode Island Medicaid members beginning on July 1, 2025. Neighborhood Health Plan of Rhode Island (NHPRI) and UnitedHealthcare of New England (UHC) have been selected to provide managed care services for the next five years. 

The state says that Neighborhood Health Plan of Rhode Island scored 90.53 and UnitedHealth scored 88.71 on the application process, and other bidders did not meet the technical proposal score required for the solicitation.

“As part of my administration’s Rhode Island 2030 Plan, we are focused on ensuring a state Health care system that better supports affordable and accessible services to maximize Health outcomes for all Rhode Islanders,” said Governor Dan McKee. “The new managed care contract will provide better services for Rhode Islanders who rely on Medicaid for their Health care and stronger transparency and oversight of its vendors.” 

Rhode Island’s Medicaid Managed Care Organizations provide Healthcare delivery to nearly 320,000 – or 90% – of the state’s Medicaid members each year. 

“I would like to thank all of the bidders, and everyone involved in the development of the RFP and new contract over the last year,” said EOHHS Secretary Richard Charest. “Many of the improvements made to this contract will positively impact our members’ care, bring greater parity between medical and behavioral healthcare, incorporate Long-Term Services and Supports as an in-plan benefit, reduce unnecessary prior authorizations, and focus on health equity.” 

To prepare for this procurement, EOHHS conducted stakeholder outreach to gather feedback on the current managed care delivery 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 important feedback for the agency to consider while drafting the new RFP. Additionally, EOHHS staff consulted with other state Medicaid agencies and reviewed numerous managed care contracts from around the country to ensure national best practices for the administration and oversight of the program.

“We are committed to improving services for the Rhode Islanders who rely on Medicaid to manage their healthcare needs,” said Medicaid Director Kristin Sousa. “Medicaid members, providers, and community partners provided feedback on ways to improve Rhode Island’s managed care program before the request for proposals was written. That feedback was invaluable and is reflected in many of the key enhancements incorporated into this new contract. We look forward to our continued collaboration with the MCOs.” 

Some of the key improvements in the new contracts, to enhance quality, oversight and financial management, include: 

• Reducing unnecessary prior authorizations (PAs), particularly for behavioral health services through the elimination of the unnecessary administrative burden of PAs on providers and requiring an independent entity to review compliance with behavioral health parity requirements; 
• Requiring executive level compensation transparency, including job qualifications, organizational structure and ensuring ethical conduct of a MCO’s Board of Directors to ensure the appropriate use of Medicaid funds;
• 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 due to poor performance. Corrective action plans will be posted to the MCO’s website for further transparency with the ability to request a MCO to remove a subcontractor due to poor performance; 
• Increasing oversight and accountability for the use of Pharmacy Benefit Managers (PBM), including the prohibition of spread pricing – the practice of charging more for a product or service than the cost to obtain it, and keeps the difference as profit–and flexibility for EOHHS to move towards a single-state PBM under the review and direction of EOHHS;
• Increasing financial sanctions, performance metrics and publication of corrective actions against noncompliant MCOs; 
• 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;
• 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; 
• Robust program integrity safeguards and oversight requirements to mitigate and reduce fraud, waste and abuse;
• Incorporating Long-Term Services and Supports 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; and,
• 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. 

Current Rhode Island Medicaid members do not need to take any action. Members who are enrolled in Tufts Health Plan will be contacted about their options to select another MCO for their care. 

The new contract, which will begin on July 1, 2025, will run through June 30, 2030, with an option to extend for up to 5 additional years. 

For more information about Managed Care Organizations in Rhode Island, please visit EOHHS’ Managed Care website.