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Gold Coast Health Plan Reaches Settlement with Federal Regulators

Thursday, August 18, 2022

Resolution brings an end to a 7-year dispute

CAMARILLO, Calif., August 18, 2022 – Gold Coast Health Plan (GCHP) has reached a mediated settlement with federal regulators on a 7-year-old dispute regarding disbursements of Medicaid funding to network providers for the benefit of the then-newly eligible adult expansion population resulting from the implementation of the Affordable Care Act. Under the mediated settlement agreement, GCHP agreed to pay $17.2 million – about 24% of the total settlement – and enter into a Corporate Integrity Agreement (CIA) with federal regulators.

The settlement reflects a compromise resolution of a multi-year disagreement between GCHP and the U.S. Department of Justice (DOJ) and the Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) over the appropriate amount of disbursements to its providers under the Adult Expansion Program.

“Although Gold Coast Health Plan believes that its disbursements to providers under this program were lawful and proper, we agreed to participate in a mediation with the regulators to reach a settlement to prevent an expensive and protracted process,” said Nick Liguori, GCHP’s chief executive officer. “The settlement reflects a compromise that will finally and fully resolve this dispute.”

Upon the substantial expansion of Medicaid eligibility in 2014, GCHP network providers faced a sizeable increase in previously uninsured residents who had enrolled in California’s Medicaid program, known as Medi-Cal. GCHP sought to support its providers by promptly developing the Adult Expansion Program, which offered funding to providers aimed at improving patient outcomes through enhanced service offerings that were not already required under existing contracts.

“The intent of Gold Coast Health Plan’s leadership at that time was to disburse the Adult Expansion Program funds in a lawful and equitable manner,” Liguori said. “Without established regulatory guidance, Gold Coast Health Plan designed its program through a transparent and deliberative public process.”

The program included specific criteria that had to be met by providers seeking funding to ensure that claims for funding were consistent with the mandate of covering the additional costs to providers resulting from the care of the new adult expansion population.

As part of the settlement, GCHP also has entered into an agreement with the OIG. The CIA is a five-year binding agreement that delineates best practices in the implementation of compliance programs to ensure plans are meeting the state and federal requirements of the Medicaid program.

“Regulatory compliance is a cornerstone of our participation in the Medi-Cal program,” said Robert Franco, GCHP’s compliance officer. “We have a robust compliance program and the additional layers of oversight required by the Corporate Integrity Agreement will further strengthen the health plan as we continue to adjust to the ever-evolving regulatory environment.”

The settlements come at a time of major transformation in the Medi-Cal program that will expand the benefits and services that are available to the most vulnerable members.

GCHP’s recently appointed CEO added, “with a new leadership team in place, we are reaffirming our commitment to our mission and to a high performing Medi-Cal program in Ventura County. We are poised to usher in a new era of improved health, greater access to quality health care, and a superior experience for the members and communities we serve.”

About Gold Coast Health Plan
Gold Coast Health Plan proudly serves nearly 240,000 Medi-Cal beneficiaries in Ventura County through its network of primary care physicians, specialists, behavioral health providers, hospitals, and pharmacies. Since it was founded in 2011, Gold Coast Health Plan has been committed to providing access to high-quality care and improving the health of its members, which include 1 in 5 county residents, 1 in 8 seniors, and 1 in 2 children up to the age of 5. To learn more, visit: www.goldcoasthealthplan.org.