Florida Medicaid and Managed Care
Justin M. Senior Deputy Secretary for Medicaid
Agency for Health Care Administration May 7, 2013
Florida Medicaid – A Snapshot
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Expenditures
• $20.7 billion estimated spending in Fiscal Year 2012-13 • Federal-state matching program – 57.73% federal, 42.27% state. • Florida will spend approximately $6,208 per eligible in Fiscal Year
2012-2013. • 42% of all Medicaid expenditures cover hospitals, nursing homes,
Intermediate Care Facilities for the Developmentally Disabled (ICF/DD’s); Low Income Pool and Disproportionate Share Payments.
• 10% of all Medicaid expenditures cover drugs. • Fifth largest nationwide in Medicaid expenditures.
• New York, California, Texas and Pennsylvania spend more.
Eligibles
• 3.35 million eligibles. • Elders, disabled, families, pregnant women, children in families below
poverty. • Fourth largest Medicaid population in the nation.
• California, New York and Texas have higher enrollment.
Providers/Plans • Approximately 76,000 Fee-For-Service providers; 29 Medicaid Managed Care plans (20 HMOs and 9 PSNs).
Florida Medicaid and Managed Care • Managed Care has existed as a delivery system in Florida since the
mid-1980s. • 47% of recipients currently receive their care through a managed
care plan. (Includes those enrolled in HMOs, PSNs and Nursing Home Diversion)
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Medicaid Enrollment As of April 2013
% of Total Enrollment
HMO 1,226,484 37.5%
PSN 283,594 8.7%
Nursing Home Diversion (NHD)
18,425 .56%
MediPass (PCCM) 588,548 18.1%
Fee-‐for-‐Service 1,195,587 36.58%
Current Acute Care Managed Care
• Managed Care in Florida is operated under two waivers • 1915(b) Managed Care waiver
• 1,194,606 enrollees • 1115 Medicaid Reform Demonstration waiver
• 317,335 enrollees
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Current Long-term Care Managed Care: Nursing Home Diversion (NHD) Program
• Operates under 1915(c) waiver authority. • Services are provided by managed care plans. • Eligibility - Medicaid Institutional Care Program,
Medicare parts A & B, and meet additional clinical impairment criteria
• Services - Case management, and 20 other home and community-based services, 11 acute care services, Medicare co-payments and co-insurance, and unlimited nursing facility care
• 20 NHD plans offering services in 66 of Florida’s 67 counties.
Statewide Medicaid Managed Care Program
• In 2011, the Florida Legislature created a new program: Statewide Medicaid Managed Care (SMMC) • Chapter 409, Part IV, Florida Statutes
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Statewide Medicaid Managed Care Program
Key Components: Managed Medical Assistance Program
(2014)
Long-‐term Care (LTC) Program
(Implemented First) (2013)
SMMC: Selecting Managed Care Plans
• Statutorily required to select Managed care plans through a competitive bid process (Invitation to Negotiate)
• Plans must bid separately for Long-term Care and Managed Medical Assistance programs
• State is divided into 11 regions
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Walton
Holmes
Wakulla
MadisonLeon
Gadsden
Jackson
Bay
Liberty
Gulf Franklin
Taylor
Lafayette
Hamilton
Baker
Nassau
Duv al
Flagler
Putnam
Clay
Dixie Alachua
Lev yMarion
Volusia
Citrus Lake
Orange
Seminole
OsceolaPolk
Pasco
Manatee Hardee
HighlandsSt. Lucie
SarasotaDe Soto
Charlotte Glades
Martin
LeeHendry Palm Beach
CollierBroward
Dade
Hernando
Region 4
Region 2
Region 1
Region 5
Region 3Region 7
Region 11
Region 9
Region 10
Region 6
Region 8
Region 1: Escambia, Okaloosa, Santa Rosa, and Walton Region 2: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington Region 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suw annee, and Union Region 4: Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia Region 5: Pasco and Pinellas Region 6: Hardee, Highlands, Hillsborough, Manatee, and Polk Region 7: Brevard, Orange, Osceola, and Seminole Region 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota Region 9: Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie Region 10: Brow ard Region 11: Miami-Dade and Monroe
Statewide Medicaid Managed Care Region Map
Federal Authorities and ITN for LTC Program
• Obtained a 1915(b) and 1915(c) combination waiver. • To identify and allow qualified individuals to receive
home and community based care services in lieu of nursing home care services.
• To enroll individuals in managed care plans statewide, and to allow for selective contracting of those plans.
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Seven Plans Selected for Participation in LTC Managed Care Program
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Region
Healthcare Plans American Eldercare, Inc.
Amerigroup Florida, Inc.
Coventry Health Plan
Humana Medical Plan, Inc.
Molina Healthcare of Florida, Inc.
Sunshine State Health Plan
United Healthcare of Florida, Inc.
1 X X 2 X X 3 X X X 4 X X X X 5 X X X X 6 X X X X X 7 X X X X 8 X X X 9 X X X X 10 X X X X 11 X X X X X X X
LTC Timelines: Recipient Enrollment Schedule
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Region Plan Readiness
Deadline Enrollment EffecDve
Date Total Eligible PopulaDon
7 May 1, 2013 August 1, 2013 Region 7: 9,338
8 & 9 June 1, 2013 September 1, 2013 Region 8: 5,596; Region 9: 7,854 Total = 13,450
2 & 10 August 1, 2013 November 1, 2013 Region 2, 4058; Region 10, 7,877 Total = 14,853
11 September 1, 2013 December 1, 2013 Region 11: 17,257
5 & 6 November 1, 2013 February 1, 2014 Region 5: 9,963; Region 6, 9,575 Total = 19,538
1, 3 , 4 December 1, 2013 March 1, 2014 Region 1: 2,973; Region 3: 6,911; Region 4: 9,087 Total = 18,971
Program Enrollment: • Individuals must enroll in LTC managed care if they are 18
and older and enrolled in: • Nursing Facility
• Aged and Disabled Adult Waiver
• Consumer-Directed Care Plus for individuals in the A/DA waiver
• Assisted Living Waiver
• Channeling Services for Frail Elders Waiver
• Nursing Home Diversion Waiver
• Frail Elder Option
• Waivers listed above will end with implementation of the SMMC program
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Covered Services
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Adult companion care Hospice
Adult day health care Intermi\ent and skilled nursing
Assisted living Medical equipment and supplies
Assis_ve care services Medica_on administra_on
A\endant care Medica_on management
Behavioral management Nursing facility
Care coordina_on/Case management Nutri_onal assessment/Risk reduc_on
Caregiver training Personal care
Home accessibility adapta_on Personal emergency response system (PERS)
Home-‐delivered meals Respite care
Homemaker Therapies, occupa_onal, physical, respiratory, and speech
Transporta_on, non-‐emergency
SMMC Impact on Assisted Living Facilities (ALF) and & Adult Family Care Homes (ADCH) • ALFs are eligible to provide Assisted Living Service. • AFCHs are eligible to provide Assistive Care
Services. • ALFs & AFCHs will bill managed care plans for
service payments based upon terms of subcontract with the plan.
• Managed care plans must offer a contract to any ALF that was billing for Medicaid waiver services as of July 2012.
• After the first year of contract, plans can exclude ALFs for not meeting quality or performance standards.
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Program Enhancements: Increased Recipient and Provider Predictability
• Five year contracting period - less confusion for providers and recipients.
• Penalties for plan withdrawals. • Maintenance of role of critical community-based
providers (ADRCs and Aging Network providers). • Parameters for payments to certain providers
(nursing facilities, hospice). Parameters for participation of certain providers (nursing facilities, hospice)
Program Enhancements: Case Management, PDO, and Expanded Benefits
• New services and options such as: • Case Management for nursing facility residents • Participant Directed Option
• Plans are offering expanded benefits. • Some expanded benefits include adult dental
services, over the counter medication, additional nursing home transition services, and non-medical transportation.
Program Enhancements: Incentives for Home and Community Based Care
• The law requires that managed care plan rates be adjusted annually to provide an incentive to shift services from nursing facilities to community based care.
• Payment incentives are in place until no more than 35% of the plan’s enrollees are in institutional settings.
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Provider Participation Requirements
• Although health plans may limit the providers in their networks based on credentials, quality indicators, and price, plans are required to offer initial contracts to certain providers within their region.
• During the first year of the program, each selected plan must offer a network contract to all nursing facilities, hospices and aging network services providers in their region. Examples of aging network service providers include, but are not limited to, home health, durable medical equipment, therapy, and homemaker providers.
• After 12 months of active participation in a health plan’s network, the plan may exclude any of the providers listed above from the network for failure to meet quality or performance criteria.
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Participation of Nursing Facilities and Hospices
Nursing facilities and hospices that are enrolled Medicaid providers must participate in all eligible plans selected by the Agency in the region in which the provider is located [Section 409.982(2), F.S.].
Plans are required to pay nursing homes an amount equal to the nursing facility-specific payment rates set by the Agency; however, higher rates mutually acceptable to the plan and the provider may be negotiated for medically complex care.
Plans shall pay hospice providers through a prospective system for each enrollee an amount equal to the per diem rate set by the Agency.
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Program Challenges • Home-Like Environment requirements
• Requires providers that serve Medicaid recipients in the community maintain home and community-based characteristics, which includes person-centered services and a home-like environment
• Community Integration • Access to the greater community is facilitated by the ALF or
AFCH based on the resident’s abilities, needs and preferences • The ALF or AFCH setting must offer meaningful community
participation opportunities for their residents at times, frequencies and with persons of their choosing
• Timing of Transition • Plan terminations and transitions
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Resources
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Questions can be emailed to: [email protected]!orida.com
Information about the Long-term Care procurement is available via the Florida Vendor Bid System: http://my!orida.com/apps/vbs/vbs_www.main_menu
Updates about the Statewide Medicaid Managed Care program are posted at: http://ahca.my!orida.com/SMMC
Upcoming events and news can be found on the “News and Events” tab on the SMMC website.
a. Keep up to date on information by signing up to receive program updates by clicking the red “Sign Up for Program Updates” box on the right hand side of the page.
For information about the enrollment process and enhanced bene"ts of each plan, recipients and enrollees may visit http://wwwFLMedicaidManagedCare.com.
You can find more information on the SMMC program at:
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Youtube.com/AHCAFlorida
Facebook.com/AHCAFlorida
Twi\er.com/AHCA_FL