Quarterly Statewide Medicaid - FL Agency for Health Care ... · Quarterly Statewide Medicaid...

Quarterly Statewide Medicaid Managed Care Report

Business Intelligence Unit

Medicaid Data Analytics

Autumn 2015

Rick Scott, Governor Elizabeth Dudek, Secretary

Agency for Health Care Administration

i

Table of Contents List of Figures ............................................................................................................................................. ii

Executive Summary .................................................................................................................................. vii

Introduction ............................................................................................................................................... 1

Data Sources .......................................................................................................................................... 1

LTC Managed Care Program ...................................................................................................................... 3

Residential Setting ..................................................................................................................................... 3

LTC Enrollees in the MMA Program ........................................................................................................... 8

Comprehensive Plans ................................................................................................................................. 9

Transfers Into Nursing Facilities ............................................................................................................... 12

Transfers Out of Nursing Facilities ........................................................................................................... 14

LTC Services .............................................................................................................................................. 17

Enrollees Receiving Community and Institutional Services ................................................................. 19

Months in the LTC Program and Months Receiving Services .............................................................. 20

Institutional Care Services ................................................................................................................... 21

Community Care Services .................................................................................................................... 22

The Most Widely Used Community Services ................................................................................... 22

Other Widely Used Community Services ......................................................................................... 24

Less Widely Used Community Services ............................................................................................ 26

Least Widely Used Community Services .......................................................................................... 28

General Services ................................................................................................................................... 30

Therapy Services .............................................................................................................................. 30

Other General Services .................................................................................................................... 32

Participant Directed Option ..................................................................................................................... 33

Services Received by PDO Participants ................................................................................................ 36

Conclusion ................................................................................................................................................ 38

ii

List of Figures

Figure 1: Number and Percentage of LTC Enrollee Months by Residential Setting, March

2013 - July 2015 ....................................................................................................................... 3

Figure 2: Number and Percentage of LTC Enrollees by Month and Residential Setting, March

2013 - July 2015 ....................................................................................................................... 4

Figure 3: Percentage of LTC Enrollees by Residential Setting, March 2013 - July 2015 ............................ 4

Figure 4: Number and Percentage of Enrollee Months by Plan, March 2014 to July 2015 ....................... 5

Figure 5: Percentage of LTC Enrollee Months by Residential Setting and Plan, March 2013 -

July 2015 .................................................................................................................................. 5

Figure 6: Number of LTC Enrollee Months in the Community by Location Type and Plan,

March 2013 - July 2015 ............................................................................................................ 6

Figure 7: Number of LTC Enrollees by County, July 2015 .......................................................................... 6

Figure 8: Percentage of LTC Enrollees Residing in the Community, July 2015 .......................................... 7

Figure 9: Percentage of LTC Enrollees Residing in Nursing Facilities, July 2015 ........................................ 7

Figure 10: Number and Percentage of LTC Enrollees by MMA Plan Status, July 2015 .............................. 8

Figure 11: Percentage of LTC Enrollments by Month and MMA Plan Status, March 2014 - July

2015 ......................................................................................................................................... 8

Figure 12: Percentage of LTC Enrollees by Residential Setting and MMA Plan Status, July

2015 ......................................................................................................................................... 8

Figure 13: Percentage of LTC Enrollees by Month and Comprehensive Plan Status, March

2014 - July 2015 ....................................................................................................................... 9

Figure 14: Percentage of LTC Enrollees by Plan and Comprehensive Plan Status, July 2015 .................... 9

Figure 15: Percentage of Community and Institutional LTC Enrollees Who Were Enrolled in a

Comprehensive Plan by Month, June 2014 - July 2015 ......................................................... 10

Figure 16: Percentage of LTC Enrollees by Residential Setting and Comprehensive Plan

Status, July 2015 .................................................................................................................... 10

Figure 17: Number and Percentage of LTC Enrollees by MMA Plan and Comprehensive Plan

Status, July 2015 .................................................................................................................... 11

Figure 18: Number and Percentage of LTC Enrollees by Month and MMA Plan and

Comprehensive Plan Status, March 2014 - July 2015 ............................................................ 11

Figure 19: Number of LTC Enrollees Who Transfer to Nursing Facilities per 1,000 LTC

Enrollees in the Community, by Month, March 2014 - July 2015 ......................................... 12

Figure 20: Number of LTC Enrollees Who Transfer to Nursing Facilities per 1,000 LTC

Enrollees in the Community, by Month, and by Comprehensive Plan Status,

March 2014 - July 2015 .......................................................................................................... 12

Figure 21: Percentage of Community Enrollees Who Transferred to Nursing Facilities, Fiscal

Year 2014 - 2015 .................................................................................................................... 13

iii

Figure 22: Percentage of Community Enrollees Who Transferred to Nursing Facilities, by

County, March 2014 - July 2015 ............................................................................................ 13

Figure 23: Number of LTC Enrollees Who Return to the Community per 1,000 LTC Enrollees

in Nursing Facilities, by Month, March 2014 - July 2015 ....................................................... 14

Figure 24: Number of LTC Enrollees Who Return to the Community per 1,000 LTC Enrollees

in Nursing Facilities, by Month, and by Comprehensive Plan Status, March 2014 -

July 2015 ................................................................................................................................ 14

Figure 25: Percentage of Nursing Facility Enrollees Who Transferred to the Community, by

Plan, Fiscal Year 2014 - 2015 .................................................................................................. 15

Figure 26: Percentage of LTC Enrollees Who Transferred into and out of a Nursing Facility,

July 2014 - June 2015 ............................................................................................................. 15

Figure 27: Percentage of LTC Enrollees in Nursing Facilities Who Returned to the

Community, March 2014 - July 2015 ..................................................................................... 16

Figure 28: LTC Enrollees and Enrollee Months by Service Utilization, March 2014 - February

2015 ....................................................................................................................................... 18

Figure 29: LTC Enrollees with at Least One Service by Plan, March 2014 to February 2015 .................. 18

Figure 30: LTC Enrollee Months with at Least One Service by Plan, March 2014 to February

2015 ....................................................................................................................................... 18

Figure 31: Percentage of LTC Enrollees Receiving at Least One Institutional, Community, and

General Service, March 2014 - February 2015 ...................................................................... 19

Figure 32: Percentage of LTC Enrollees Receiving at Least One Institutional Service or

Community Service by Plan, March 2014 - February 2015 .................................................... 19

Figure 33: Percentage of LTC Enrollees by the Number of Months in the LTC Program, March

2014 - February 2015 ............................................................................................................. 20

Figure 34: Percentage of LTC Enrollees by the Number of Months Receiving Community or

Institutional Services, March 2014 - February 2015 .............................................................. 20

Figure 35: Percentage of LTC Enrollees Receiving at Least One Institutional Service by

Service, March 2014 - February 2015 .................................................................................... 21

Figure 36: Percentage of LTC Enrollees Receiving a Nursing Facility Service by Plan, March

2014 - February 2015 ............................................................................................................. 21

Figure 37: Percentage of LTC Enrollees Receiving Institutional Hospice Services by Plan,

March 2014 - February 2015.................................................................................................. 21

Figure 38: Percentage of LTC Enrollees Receiving at Least One Institutional Service by Service

and Comprehensive Status, March 2014 - February 2015 .................................................... 21

Figure 39: Percentage of LTC Enrollees Receiving at Least One of the Most Widely Used

Community Services by Service, March 2014 - February 2015 ............................................. 22

Figure 40: Percentage of LTC Enrollees Receiving Homemaker Services by Plan, March 2014 -

February 2015 ........................................................................................................................ 22

Figure 41: Percentage of LTC Enrollees Receiving Personal Care by Plan, March 2014 -

February 2015 ........................................................................................................................ 22

iv

Figure 42: Percentage of LTC Enrollees Receiving at Least One of the Most Widely Used

Community Services by Service and Comprehensive Status, March 2014 -

February 2015 ........................................................................................................................ 23

Figure 43: Percentage of LTC Enrollees Receiving Assisted Living Services by Plan, March

2014 - February 2015 ............................................................................................................. 23

Figure 44: Percentage of LTC Enrollees Receiving Home Delivered Meals by Plan, March

2014 - February 2015 ............................................................................................................. 23

Figure 45: Percentage of LTC Enrollees Receiving at Least One of the Other Widely Used


Figure 46: Percentage of LTC Enrollees Receiving Personal Emergency Response Systems

services by Plan, March 2014 - February 2015 ...................................................................... 24

Figure 47: Percentage of LTC Enrollees Receiving Hospice Services in the Community by Plan,

March 2014 - February 2015.................................................................................................. 24

Figure 48: Percentage of LTC Enrollees Receiving Respite Care by Plan, March 2014 -

February 2015 ........................................................................................................................ 24

Figure 49: Percentage of LTC Enrollees Receiving at Least One of the Other Widely Used


February 2015 ........................................................................................................................ 25

Figure 50: Percentage of LTC Enrollees Receiving Home Health Services by Plan, March 2014

- February 2015 ...................................................................................................................... 25

Figure 51: Percentage of LTC Enrollees Receiving Adult Companion Care by Plan, March 2014

- February 2015 ...................................................................................................................... 25

Figure 52: Percentage of LTC Enrollees Receiving at Least One of the Less Widely Used


Figure 53: Percentage of LTC Enrollees Receiving Medication Management by Plan, March

2014 - February 2015 ............................................................................................................. 26

Figure 54: Percentage of LTC Enrollees Receiving Adult Day Health Care by Plan, March 2014

- February 2015 ...................................................................................................................... 26

Figure 55: Percentage of LTC Enrollees Receiving at Least One of the Less Widely Used


February 2015 ........................................................................................................................ 27

Figure 56: Percentage of LTC Enrollees Receiving Assistive Care Services by Plan, March 2014

- February 2015 ...................................................................................................................... 27

Figure 57: Percentage of LTC Enrollees Receiving Attendant Care by Plan, March 2014 -

February 2015 ........................................................................................................................ 27

Figure 58: Percentage of LTC Enrollees Receiving Home Accessibility Adaptation by Plan,

March 2014 - February 2015.................................................................................................. 27

Figure 59: Percentage of LTC Enrollees Receiving at Least One of the Least Widely Used


Figure 60: Percentage of LTC Enrollees Receiving Nutritional Assessment by Plan, March

2014 - February 2015 ............................................................................................................. 28

v

Figure 61: Percentage of LTC Enrollees Receiving Skilled Nursing Services by Plan, March

2014 - February 2015 ............................................................................................................. 28

Figure 62: Percentage of LTC Enrollees Receiving at Least One of the Least Widely Used


February 2015 ........................................................................................................................ 29

Figure 63: Percentage of LTC Enrollees Receiving Medication Administration by Plan, March

2014 - February 2015 ............................................................................................................. 29

Figure 64: Percentage of LTC Enrollees Receiving Caregiver Training by Plan, March 2014 -

February 2015 ........................................................................................................................ 29

Figure 65: Percentage of LTC Enrollees Receiving at Least One Therapy Service by Service,

March 2014 - February 2015.................................................................................................. 30

Figure 66: Percentage of LTC Enrollees Receiving Physical Therapy by Plan, March 2014 -

February 2015 ........................................................................................................................ 30

Figure 67: Percentage of LTC Enrollees Receiving Occupational Therapy by Plan, March 2014

- February 2015 ...................................................................................................................... 30

Figure 68: Percentage of LTC Enrollees Receiving at Least One Therapy Service by Service


Figure 69: Percentage of LTC Enrollees Receiving Speech Therapy by Plan, March 2014 -

February 2015 ........................................................................................................................ 31

Figure 70: Percentage of LTC Enrollees Receiving Respiratory Therapy by Plan, March 2014 -

February 2015 ........................................................................................................................ 31

Figure 71: Percentage of LTC Enrollees Receiving at Least One Other General Service by


Figure 72: Percentage of LTC Enrollees Receiving Medical Equipment and Supplies by Plan,

March 2014 - February 2015.................................................................................................. 32

Figure 73: Percentage of LTC Enrollees Receiving Transportation by Plan, March 2014 -

February 2015 ........................................................................................................................ 32

Figure 74: Percentage of LTC Enrollees Receiving Behavioral Management Services by Plan,

March 2014 - February 2015.................................................................................................. 32

Figure 75: Percentage of LTC Enrollees Receiving at Least One Therapy Service by Service


Figure 76: Number and Percentage of LTC Enrollees by PDO Status, July 2015...................................... 33

Figure 77: Number of LTC Enrollees in the Community by PDO Status, July 2015 .................................. 33

Figure 78: Number of LTC Enrollees in PDO by Month, March 2014 July 2015 ...................................... 34

Figure 79: Number of LTC Enrollees in PDO by Month and Plan, March 2014 - July 2015 ..................... 34

Figure 80: Number of Disenrollments from PDO by Reason for Disenrollment, March 2014 -

July 2015 ................................................................................................................................ 34

Figure 81: Percentage of PDO Enrollees Who Elected Specific Services by Service Category,

July 2015 ................................................................................................................................ 35

Figure 82: Percentage of LTC Enrollees in the Community Who Are in PDO by County, July

2015 ....................................................................................................................................... 35

vi

Figure 83: Percentage of LTC Enrollees Receiving at Least One PDO Service by Service and

Type, March 2014 February 2015 .......................................................................................... 36

Figure 84: Percentage of LTC PDO Enrollees Receiving at Least One non-PDO Community

Service by Service, March 2014 - February 2015 ................................................................... 36

Figure 85: Percentage of LTC PDO Enrollees Receiving at Least One General Service by


Figure 86: Percentage of PDO Participants Receiving PDO Homemaker Services by Plan,

March 2014 - February 2015.................................................................................................. 37

Figure 87: Percentage of PDO Participants Receiving PDO Adult Companion Care by Plan,

March 2014 - February 2015.................................................................................................. 37

Figure 88: Percentage of PDO Participants Receiving PDO Personal Care by Plan, March 2014

- February 2015 ...................................................................................................................... 37

Figure 89: Percentage of PDO Participants Receiving PDO Intermittent and Skilled Nursing by

Plan, March 2014 - February 2015 ......................................................................................... 37

Figure 90: Percentage of PDO Participants Receiving PDO Attendant Care by Plan, March

2014 - February 2015 ............................................................................................................. 37

vii

Executive Summary

Medicaid enrollees in the state of Florida have been receiving Long-term Care (LTC) services as a part of

the Statewide Medicaid Managed Care (SMMC) program since August 2013. The LTC program provides

nursing facility care and home and community-based services for aged or disabled individuals aged 18

and over who are determined by the Comprehensive Assessment and Review for Long-term Care

Services (CARES) to meet nursing facility level of care. This report updates topics covered in the First

Quarterly Statewide Medicaid Managed Care Report including residential setting of LTC enrollees,

transfers into and out of nursing facilities, and enrollment in comprehensive plans, but also covers new

topics including participation in the Participant Directed Option (PDO) program, and LTC services

received by enrollees. Residential setting, comprehensive plan status, PDO participation, and nursing

facility transfers are examined from March 2014 through July 2015. LTC services are reviewed from

March 2014 through February 2015. Some results are reported by enrollee months, which is the total

number of months a Medicaid recipient was enrolled in an LTC plan.

Residential Setting

Half of LTC enrollee

months for the review

period were in an

institutional setting.

The other half of LTC

enrollee months were in a

community setting.

Sixty-five percent of

enrollee months in the

community were living at

home.

Thirty percent of enrollee

months in the community

were in an assisted living

facility.

A shift of LTC enrollees from

institutional to community

settings occurred over the

review period.

In July 2014, 53 percent of all

LTC enrollees resided in an

institutional setting. By July

2015, just over half of LTC

enrollees lived in a community

setting.

Home456,67465.3%

ALF209,70130.0%

Adult Family Care Home256

Less Than 0.1%

Other32,7214.7%

CommunitySetting

699,35249.2%

InstitutionalSetting

722,53750.8%

Total LTC1,421,910100.0%

0%

25%

50%

75%

100%

47

.2%

47

.6%

47

.2%

47

.7%

48

.4%

49

.2%

55

.6%

50

.6%

50

.1%

50

.1%

49

.9%

50

.7%

50

.3%

52

.8%

52

.4%

52

.8%

52

.3%

51

.6%

50

.8%

44

.4%

49

.4%

49

.9%

49

.9%

50

.1%

49

.3%

49

.7%

Community Setting Institutional Setting

Source: Plan Submitted Enrollee Residence Report, March 2014 – July

2015, and Florida Medicaid Managed Information System (FLMMIS)

Eligibility Information, March 2014 – July 2015.

Source: Plan Submitted Enrollee Residence Report, March 2014 – July 2015, and

Florida Medicaid Managed Information System (FLMMIS) Eligibility Information,

March 2014 – July 2015.

viii

Nursing Facility Transfers LTC enrollees who meet financial and clinical eligibility

requirements for nursing facility level of care choose

whether to receive services in a nursing facility or

community setting. LTC plans assess enrollees in

nursing facilities for appropriateness of transitioning to

a community setting. If an enrollee chooses to

transition to the community, the LTC plan is required to

provide the care coordination and supports necessary

to ensure a successful transition.

LTC plans receive an incentive adjustment in capitation rates to encourage increased utilization

of home and community-based services and reduced nursing facility placement.

During fiscal year 2014 – 2015, 3 percent of enrollees in nursing facilities transferred to

community settings.

During the same period, 1.6 percent of enrollees in community settings transferred to nursing

facilities.

Rates of transferring

LTC enrollees from

nursing facilities to

community settings

ranged from 2

percent for Sunshine

to 6 percent for

Amerigroup.

Four plans

transferred at least 2

percent of the

respective plan’s

enrollees from

community settings

to nursing facilities

during fiscal year

2014 – 2015.

0

2

4

6

8

Amerigroup AmericanEldercare

Coventry Humana Molina United Sunshine

6.2

4.9 4.4

3.7 3.3

2.6 2.0

Percent Enrollees in an Institutional Setting Who Returned to the Community in FY 2014-2015

0

2

4

6

8

AmericanEldercare

Molina Amerigroup Coventry Humana United Sunshine

5.0

2.4 2.4 1.9

1.2 1.1

0.1

Percent Enrollees in a Community Setting Who Transferred to Nursing Facility in FY 2014-2015

0%

2%

4%

Percentage ofCommunity

Enrollees whoTransferred to aNursing Facility

Percentage ofNursing FacilityEnrollees who

Transferred to theCommunity

1.6%

2.9%

Source for Figures on this page: Plan Submitted Enrollee Residence Report, June 2014 – July 2015, Plan Submitted Nursing

Home Transfer Report, March 2014 – May 2014, and Florida Medicaid Managed Information System (FLMMIS) Eligibility

Information, March 2014 – July 2015.

ix

Comprehensive Plans LTC enrollees began to enroll in the

Managed Medical Assistance (MMA)

program in May 2014, the month the

MMA program began implementing.

Sixty-one percent of LTC enrollee

months were also spent in the MMA

program.

The review period includes two

months (March 2014 and April 2014)

when the MMA program was not yet

operating, and four months when the

MMA program was implementing

(May 2014 through August 2014).

A comprehensive plan is a plan that provides both LTC and MMA services to enrollees. An

enrollee must be enrolled in the same plan for both LTC and MMA services to be in a

comprehensive plan.

Half of LTC enrollee months spent in the MMA program were in a comprehensive plan.

Participant Directed Option The Participant

Directed Option

program allows

enrollees to hire,

supervise, and

dismiss direct

service workers.

PDO is available

to LTC enrollees

who live at

home.

PDO is a small

but growing

program encompassing

1.5 percent of enrollee

months for the review

period.

As of July 2015, the PDO program had 1,956 participants.

617 701

799 884

950 992 1,117

1,223 1,331

1,410 1,472

1,552 1,629

1,689 1,791

1,897 1,956

0

500

1,000

1,500

2,000

PDO Enrollees

Not in MMA560,24539.4%

In MMA861,66560.6%

Non-Comprehensive

428,69049.8%

ComprehensivePlan

432,97550.2%

Total LTC1,421,910

100.0%

Source: Plan Submitted Enrollee Residence Report,

March 2014 – July 2015, and Florida Medicaid

Managed Information System (FLMMIS) Eligibility


Source: Plan Submitted PDO Report, March 2014 – July 2015, and Florida

Medicaid Managed Information System (FLMMIS) Eligibility Information, March

2014 – July 2015.

x

LTC Services Fifty-four percent of LTC

enrollees received an

institutional service during

the review period.

Forty-nine percent of LTC

enrollees received a

community service.

The percentage of

enrollees who received

institutional or community

services varied greatly by

plan.

Sunshine and United were

the only plans with a larger

percentage of enrollees

receiving institutional as

opposed to community

services.

Amerigroup had the

largest percentage of

enrollees receiving a

community service at 75

percent of enrollees.

The most widely used community

services among LTC enrollees were

homemaker, personal care, assisted

living, and home delivered meal

services.

8.3%

51.0%

0% 10% 20% 30% 40% 50% 60%

Hospice Institutional

Nursing Facility

12.8%

14.5%

15.8%

19.4%

0% 5% 10% 15% 20%

Home Delivered Meals

Assisted Living

Personal Care

Homemaker Services

56.8%

62.4%

54.4%

45.6%

44.2%

47.0%

45.4%

27.9%

39.9%

44.2%

48.7%

51.3%

52.5%

57.1%

58.4%

74.9%

-80% -60% -40% -20% 0% 20% 40% 60% 80%

United

Sunshine

Across All Plans

Coventry

Humana

American Eldercare

Molina

Amerigroup

% Enrollees Receiving Institutional Services

% Enrollees Receiving Community Services

Percentage of LTC Enrollees Receiving Institutional or Community Service by Plan*

*Some services can be received in either an institutional or community setting and

are not included in this graph. Therefore, institutional and community percentages

will not total to 100 percent of enrollees.

Fifty-one percent of LTC enrollees received

nursing facility services during the review period.

Eight percent of LTC enrollees received

institutional hospice services.

Source for Figures on this page: Florida Medicaid Managed Information System (FLMMIS) Encounter Claims Data, March 2014 –

February 2015, and Florida Medicaid Managed Information System (FLMMIS) FFS Claims Data for American ElderCare, March 2014 –

August 2014.

1

Introduction

For over two years, Medicaid enrollees in the state of Florida have been receiving Long-term Care (LTC)

services as a part of the Statewide Medicaid Managed Care (SMMC) program. The SMMC LTC program

began operating in August 2013, and was fully implemented by March 2014. The Department of Elder

Affairs worked with the Agency to implement the program and partners with the Agency to administer

the program. The LTC Program emphasizes care coordination in the delivery of LTC services. The

Participant Directed Option (PDO), a program within the LTC program, provides opportunities for LTC

plan enrollees living at home to direct their own service delivery for select LTC services.

Medicaid recipients 65 years of age and older, and recipients 18 through 64 years of age with

disabilities, may receive LTC services through the Long-term Care program. The LTC program provides

nursing facility care and home and community-based services for individuals who require nursing facility

level of care.

Seven Long-term Care plans were awarded contracts and are responsible for coordinating the care of

LTC enrollees. The seven LTC Plans have opportunities to improve the quality of enrollees’ healthcare

and enhance the alignment of resources and support services for enrollees.

This report, the Third Quarterly Statewide Medicaid Managed Care Report, covers the LTC program. This

report updates topics that were featured in the First Quarterly Statewide Medicaid Managed Care

Report by examining where enrollees receive LTC services, transfers into and out of nursing facilities,

and comprehensive plan status of enrollees. Additional topics are covered including LTC plan enrollees’

use of services and the Participant Directed Option (PDO) program.

Data Sources The results in this report are based on analyses of data from several different sources. Data sources are

detailed in the table below and cited with relevant tables and figures.

Implementation of the LTC program was completed in March 2014. Analyses of residential setting,

nursing facility transfers, comprehensive plan status, and the PDO program include data from March

2014 through July 2015. Analyses of enrollee services use data from March 2014 through February 2015

to allow time for encounters to be submitted and processed after the service is rendered.

Information about enrollment in LTC plans comes from the Enrollee Residence report submitted by each

LTC plan. Enrollee Residence report data is checked against eligibility information in the Florida

Medicaid Managed Information System (FLMMIS), and only enrollee months found to be eligible in

FLMMIS are included in analyses in this report.

Some measures are reported by enrollee months, which is the total number of months a Medicaid

recipient was enrolled in an LTC plan. Enrollees living in community settings are those for whom LTC

plans are responsible for coordinating and assuring access to services designed to support community

living in lieu of nursing facility placement.

2

Effective July 1, 2015, Humana and American ElderCare merged. Humana transferred its LTC enrollees

to American ElderCare and began operating its LTC plan as Humana American Eldercare. Results for July

2015 in this report include Humana’s LTC enrollees as a part of American ElderCare.

Encounter data are used to examine services received by LTC enrollees. Because encounters may be

submitted and processed several months after the service was rendered, only encounters with dates of

service through February 2015 are examined for this report. The Agency has been working with health

plans to improve the quality of encounters. Encounters must include specific information and meet

certain standards in order to be accepted and processed by the Agency’s encounter data system.

Encounters that are missing required information or do not meet the standard for other reasons are

denied by the system. Particular attention has been given to improving the encounter submission

process. Because the Agency is still working with plans to improve the quality of encounter data, both

paid and denied encounters were used to analyze the number of enrollees who received a service. An

enrollee with any encounter, whether paid or denied, was designated as having received a service.

Data Period Source

LTC Plan Enrollment information

March 2014 – July 2015 as of September 1, 2015

Florida Medicaid Managed Information System (FLMMIS) Eligibility Information

LTC Residence Information


Plan Submitted Enrollee Residence Report

LTC Nursing Residential Transfers

June 2014 – July 2015 as of September 1, 2015

Plan Submitted Enrollee Residence Report

LTC Nursing Residential Transfers

March 2014 – May 2014 as of September 1, 2015

Plan Submitted Nursing Home Transfer Report

PDO Enrollment Information


Plan Submitted PDO Report

LTC Enrollee Services March 2014 – February 2015

as of August 26, 2015 Florida Medicaid Managed Information

System (FLMMIS) Encounter Data

LTC Enrollee Services March 2014 – August 2014 as

of September 17, 2015

Florida Medicaid Managed Information System (FLMMIS) FFS Claims Data for

American ElderCare

3

LTC Managed Care Program

The LTC program is designed to meet the needs of persons eligible for Medicaid who are aged or

disabled, who are 18 years of age or older, and who are assessed to require skilled nursing level of care

services. Nursing facility level of care services can be provided in a nursing facility or in the community.

LTC enrollees access home and community-based services (HCBS) or nursing facility services through

their Long-term Care plan. Plans provide access to a complete range of LTC supports and services and

have nursing facilities, assisted living facilities, hospice, and home and community-based service

providers in their networks.

The Agency has contracts with seven LTC plans for the provision of LTC services. These organizations

are: 1) American ElderCare, Inc., 2) Amerigroup, 3) Coventry, 4) Humana, 5) Molina, 6) Sunshine Health

Plan, and 7) United Healthcare.

Residential Setting

LTC enrollees receive services either in an institutional setting or a community setting. Home and

community-based services (HCBS) are designed to help enrollees remain in a community setting.

Enrollee months for the review period are close to evenly split between institutional and community

settings.

Figure 1: Number and Percentage of LTC Enrollee Months by Residential Setting, March 2013 - July 2015

In a Community Setting 699,352

49%

In an Insitutional

Setting 722,537

51%

Source: Plan Submitted Enrollee Residence Report, March 2014 – July 2015, and Florida Medicaid

Managed Information System (FLMMIS) Eligibility Information, March 2014 – July 2015.

4

About half of enrollees each month receive services in an institutional or community setting.

Figure 2: Number and Percentage of LTC Enrollees by Month and Residential Setting, March 2013 - July 2015

While about half of all enrollee months are split between institutional and community settings, some

enrollees move between the two and spend some time in each type of setting. Other enrollees reside

only in institutional settings or only in community settings.

Figure 3: Percentage of LTC Enrollees by Residential Setting, March 2013 - July 2015

40

,07

6

39

,63

5

39

,37

9

39

,19

9

39

,32

4

39

,68

2

39

,34

8

40

,02

4

40

,97

8

40

,85

1

46

,38

8

41

,95

1

41

,98

0

42

,04

4

42

,46

5

43

,16

5

42

,86

3

42

,25

7

43

,06

1

43

,87

0

43

,40

5

43

,94

8

43

,61

9

43

,98

0

43

,89

3

43

,65

0

42

,21

1

36

,96

9

40

,92

3

41

,78

9

41

,95

0

42

,68

9

41

,92

3

42

,40

0

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000


Institutional Setting Only

40.4%

Community Setting Only

41.9%

Both 17.8%

Source: Plan Submitted Enrollee Residence Report, March 2014 – July 2015, and Florida

Medicaid Managed Information System (FLMMIS) Eligibility Information, March 2014 –

July 2015.

Source: Plan Submitted Enrollee Residence Report, March 2014 – July 2015, and Florida Medicaid Managed

Information System (FLMMIS) Eligibility Information, March 2014 – July 2015.

5

AmericanEldercare231,39416.3%

Coventry77,7825.5%

Sunshine

536,595

37.7%

United337,114

23.7%

Ameri-group

77,8425.5%

Molina91,4706.4%

Humana69,6924.9%

Total LTC1,421,910100.0%

Over three-quarters (77.7%) of

enrollee months were spent in

the three largest plans –

Sunshine, United, and American

ElderCare. The four remaining

plans – Molina, Amerigroup,

Coventry, and Humana – each

had less than 7 percent of

enrollee months.

Plans vary in the relative

mix, or case mix, of

institutional and community

enrollees they serve.

Sunshine and United serve a

larger percentage of

enrollees in an institutional

than community setting

relative to other plans. Over

three quarters of

Amerigroup’s enrollees

receive services in a

community setting.

75.4% 58.5% 57.7% 57.6% 53.6% 49.2% 42.6% 42.5%

24.6% 41.5% 42.3% 42.4% 46.4% 50.8% 57.4% 57.5%

0%

25%

50%

75%

100%

Amerigroup Molina AmericanEldercare

Humana Coventry All Plans United Sunshine


Figure 5: Percentage of LTC Enrollee Months by Residential Setting and Plan, March 2013 - July 2015*

Figure 4: Number and Percentage of Enrollee Months by Plan, March 2014 to July 2015


Medicaid Managed Information System (FLMMIS) Eligibility Information, March 2014 – July

2015.


Florida Medicaid Managed Information System (FLMMIS) Eligibility Information, March

2014 – July 2015.

*Humana enrollees are included with American ElderCare from July 2015 forward. Beginning July 2015, Humana

began operating its LTC plan as Humana American Eldercare.

6

Most enrollees who

receive services in the

community live at

home as opposed to an

assisted living facility or

adult family care home.

There are enrollees in every county of

the state. However, the enrollee

population is more concentrated in five

urban counties: Pinellas (St. Petersburg),

Hillsborough (Tampa), Palm Beach (West

Palm Beach), Broward (Ft. Lauderdale),

and Miami-Dade (Miami).

Figure 6: Number of LTC Enrollee Months in the Community by Location Type and Plan, March 2013 - July 2015*

*Humana enrollees are included with American ElderCare from July 2015 forward.

Beginning July 2015, Humana began operating its LTC plan as Humana American

Eldercare.

0

50,000

100,000

150,000

200,000

250,000

Sunshine United AmericanEldercare

Molina Amerigroup Humana Coventry

Home ALF AFCH HCBS Not Specified

Esc

ambia

SantaRosa

Okalo

osa Walton

Holmes

Wash-ington

Bay

Jackson

Gadsden

Liberty

Franklin

Leon

Wakulla

Je

f fers

on

Taylor

MadisonCal-houn

Gulf

Hamilton

Colu

mbia

Union

Brad-ford

Suwannee

Lafayette

Gil-christ Alachua

Dixie

Levy

Putnam

Marion

Citrus

Hernando

Lake

Sum

ter

Pasco

Pi n

ell a

s

Hillsborough

Highlands

HardeeManatee

Polk

Orange

Osceola

Seminole

Bre

vard

SarasotaDesoto

Charlotte

Lee

Collier

Hendry

Glades

Indian River

Martin

St. Lucie

Palm Beach

Oke

echob

ee

Broward

Miami-Dade

Monroe

Baker

Nassau

Duval

Clay

St . Jo

hns

Flagler

Volusia

Less than 100

100 to 499

500 to 3,999

4,000 to 6,999

Number of LTC Enrolleesin July 2015

7,000 to 18,099

Figure 7: Number of LTC Enrollees by County, July 2015



July 2015.

Source: Plan Submitted Enrollee Residence

Report, March 2014 – July 2015, and Florida

Medicaid Managed Information System

(FLMMIS) Eligibility Information, March 2014

– July 2015.

7

Some Florida counties have a

larger ratio of LTC enrollees

receiving services in a community

setting as opposed to an

institutional setting. Ninety

percent or more of LTC enrollees

residing in Liberty, Glades, or

Union county reside in the

community. Miami-Dade and

Broward counties have sixty to

ninety percent of LTC enrollees

residing in the community.

Some counties have a larger

ratio of LTC enrollees receiving

services in an institutional as

opposed to community setting.

In six Florida counties, over three

quarters of LTC enrollees reside

in an institution. These counties

are Gilchrist, Calhoun, Baker,

Bradford, Henry, and Monroe

(Key West).

Figure 8: Percentage of LTC Enrollees Residing in the Community, July 2015

Figure 9: Percentage of LTC Enrollees Residing in Nursing Facilities, July 2015

Esc

ambia

SantaRosa

Okalo

osa Walton

Holmes

Wash-ington

Bay

Jackson

Gadsden

Liberty

Franklin

Leon

Wakulla

Je

f fers

on

Taylor

MadisonCal-houn

Gulf

Hamilton

Colu

mbia

Union

Brad-ford

Suwannee

Lafayette

Gil-christ Alachua

Dixie

Levy

Putnam

Marion

Citrus

Hernando

Lake

Sum

ter

Pasco

Pi n

ell a

s

Hillsborough

Highlands

HardeeManatee

Polk

Orange

Osceola

Seminole

Bre

vard

SarasotaDesoto

Charlotte

Lee

Collier

Hendry

Glades

Indian River

Martin

St. Lucie

Palm Beach

Oke

echob

ee

Broward

Miami-Dade

Monroe

Baker

Nassau

Duval

Clay

St . Jo

hns

Flagler

Volusia

Less than 25

25.00 to 39.99

40.00 to 59.99

60.00 to 89.99

Percentage of LTC Enrollees in the Community

90.00 to 100.00

Esc

ambia

SantaRosa

Okalo

osa Walton

Holmes

Wash-ington

Bay

Jackson

Gadsden

Liberty

Franklin

Leon

Wakulla

Je

f fers

on

Taylor

MadisonCal-houn

Gulf

Hamilton

Colu

mbia

Union

Brad-ford

Suwannee

Lafayette

Gil-christ Alachua

Dixie

Levy

Putnam

Marion

Citrus

Hernando

Lake

Sum

ter

Pasco

Pi n

ell a

s

Hillsborough

Highlands

HardeeManatee

Polk

Orange

Osceola

Seminole

Bre

vard

SarasotaDesoto

Charlotte

Lee

Collier

Hendry

Glades

Indian River

Martin

St. Lucie

Palm Beach

Oke

echob

ee

Broward

Miami-Dade

Monroe

Baker

Nassau

Duval

Clay

St . Jo

hns

Flagler

Volusia

None

Less than 40.00

40.00 to 59.99

60.00 to 74.99

75.00 to 84.99

Percentage of EnrolleesLiving in Nursing Facilities

85.00 to 88.99

Source: Plan Submitted Enrollee Residence Report,

March 2014 – July 2015, and Florida Medicaid

Managed Information System (FLMMIS) Eligibility


Source: Plan Submitted Enrollee Residence Report, March

2014 – July 2015, and Florida Medicaid Managed Information

System (FLMMIS) Eligibility Information, March 2014 – July

2015.

8

LTC Enrollees in the MMA Program

LTC enrollees may also be enrolled in the

SMMC Managed Medical Assistance (MMA)

program. The MMA program provides

medical, dental, and behavioral health services

to enrollees. Some LTC enrollees are not

enrolled in MMA plans because: 1) they have

other health insurance, such as Medicare

Advantage plans; 2) they are eligible for waiver

programs and have chosen not to enroll in

MMA; or 3) they have had recent changes in

Medicaid eligibility or residence that made

them ineligible to receive MMA services.

The MMA program

began enrollment in

May 2014 and finished

implementation in

August 2014. By

September 2014, 77

percent of LTC enrollees

were also enrolled in an

MMA plan. By July

2015, 79 percent of LTC

enrollees were also in an

MMA plan.

Among LTC enrollees who are

not enrolled in MMA, more

reside in community settings

than in institutional settings.

No MMA, Community

Setting 13.0%

MMA, Community

Setting 37.2%

MMA, Institutional

Setting 41.6%

No MMA, Institutional

Setting 8.1%

Figure 12: Percentage of LTC Enrollees by Residential Setting and MMA Plan Status, July 2015

In LTC but Not in MMA

Plan 18,047

21%

In LTC and MMA Plan

67,216 79%

0%

25%

50%

75%

100%

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

De

c-1

4

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

In LTC and MMA Plan In LTC but Not in MMA Plan

Figure 10: Number and Percentage of LTC Enrollees by MMA Plan Status, July 2015

Figure 11: Percentage of LTC Enrollments by Month and MMA Plan Status, March 2014 - July 2015

Source for Figures 10-12: Plan Submitted Enrollee Residence Report, March 2014 – July

2015, and Florida Medicaid Managed Information System (FLMMIS) Eligibility


9

Comprehensive Plans

A health plan that has a contract with the Agency and operates as a Long-term Care plan and as a

Managed Medical Assistance plan in a region has a Comprehensive Long-term Care Plan contract. An

enrollee is enrolled in a comprehensive plan only if the enrollee is enrolled in the same plan for LTC and

MMA services. If the enrollee is enrolled in different plans, one for MMA and another for LTC services,

the enrollee is not considered part of a comprehensive plan.

Enrollment in a comprehensive plan has the potential to enhance care coordination by bringing

monitoring of both LTC and MMA services within a single system of management. Enhanced care

coordination may improve the quality of healthcare and result in increased efficiencies in management.

After the

implementation of

the MMA Program

was complete,

around 39 percent

of LTC enrollees

were enrolled in

comprehensive

plans each month.

Sunshine is the only plan

with over half of its

enrollees in a

comprehensive plan.

0.0

%

0.0

%

8.1

%

14

.9%

30

.0%

34

.7%

39

.0%

39

.0%

38

.4%

38

.0%

38

.2%

38

.6%

38

.5%

38

.4%

38

.0%

37

.8%

39

.3%

0.0%

25.0%

50.0%

75.0%

100.0%

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

De

c-1

4

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Comprehensive Plan Non-Comprehensive Plan

Figure 13: Percentage of LTC Enrollees by Month and Comprehensive Plan Status, March 2014 - July 2015

61.9%

34.4% 25.9% 19.6% 19.3% 13.5% 0%

25%

50%

75%

100%

Sunshine United Amerigroup HumanaAmericanEldercare

Molina Coventry

Comprehensive Not Comprehensive

Figure 14: Percentage of LTC Enrollees by Plan and Comprehensive Plan Status, July 2015*

*Humana enrollees are included with American ElderCare from July 2015 forward. Beginning July

2015, Humana began operating its LTC plan as Humana American Eldercare.

Source for Figures 13 and 14: Plan Submitted Enrollee Residence Report, March 2014 – July 2015, and Florida Medicaid Managed

Information System (FLMMIS) Eligibility Information, March 2014 – July 2015.

10

A greater

percentage of

enrollees in

institutional

settings as

compared to

community

settings are

enrolled in

comprehensive

plans.

More enrollees in comprehensive

plans reside in an institutional

setting than community setting.

More enrollees in non-

comprehensive plans reside in a

community than institutional setting.

Non-Comprehensive,

Home and Community

33.4%

Comprehensive, Home and

Community 16.9%

Comprehensive, Institutional

22.4%

Non-Comprehensive,

Institutional 27.3%

Figure 16: Percentage of LTC Enrollees by Residential Setting and Comprehensive Plan Status, July 2015

0%

10%

20%

30%

40%

50%

Community Institutional

Figure 15: Percentage of Community and Institutional LTC Enrollees Who Were Enrolled in a Comprehensive Plan by Month, June 2014 - July 2015



July 2015.

Source: Plan Submitted Enrollee Residence Report, March 2014 – July 2015, and Florida Medicaid

Managed Information System (FLMMIS) Eligibility Information, March 2014 – July 2015.

11

More LTC enrollees are enrolled

in non-comprehensive than

comprehensive plans in part due

to enrollees who are not enrolled

in an MMA plan. Among

enrollees who are enrolled in an

MMA plan, half are enrolled in

comprehensive plans.

After implementation of the MMA program was complete, less than 25 percent of LTC enrollees were

not enrolled in the MMA program.

Not in MMA 18,047

21%

In a Different MMA Plan

33,707 40%

In a Comprehensive

Plan 33,509

39%

Figure 17: Number and Percentage of LTC Enrollees by MMA Plan and Comprehensive Plan Status, July 2015

0%

25%

50%

75%

100%

Not in an MMA Plan

In A Different MMAPlan

In a ComprehensivePlan

Figure 18: Number and Percentage of LTC Enrollees by Month and MMA Plan and Comprehensive Plan Status, March 2014 - July 2015

Source: Plan Submitted Enrollee Residence Report, March 2014 – July

2015, and Florida Medicaid Managed Information System (FLMMIS)

Eligibility Information, March 2014 – July 2015.


Florida Medicaid Managed Information System (FLMMIS) Eligibility Information,

March 2014 – July 2015.

12

Transfers Into Nursing Facilities

The number of LTC enrollees who transferred from the community to nursing facilities each month

fluctuated over the review period. The number of enrollees who transferred to nursing facilities each

month varied from 1.4 to 2.6 per 1,000 LTC enrollees. On average, two enrollees for every 1,000

enrollees in the community transferred to nursing facilities each month.

Figure 19: Number of LTC Enrollees Who Transfer to Nursing Facilities per 1,000 LTC Enrollees in the Community, by Month, March 2014 - July 2015

On average, more enrollees in non-comprehensive than in comprehensive plans transfer to nursing

facilities each month. In fact, enrollees in the community are less than half as likely to transfer to

nursing facilities when in comprehensive versus non-comprehensive plans.

Figure 20: Number of LTC Enrollees Who Transfer to Nursing Facilities per 1,000 LTC Enrollees in the Community, by Month, and by Comprehensive Plan Status, March 2014 - July 2015

1.9

1.4

2.6

2.0 1.8

2.4

1.7

2.2

1.7 1.8 2.0 2.0

1.8

2.4 2.2 2.4 2.2

0

0.5

1

1.5

2

2.5

3

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

Non-Comprehensive Plan Per 1000 Comprehensive Plan Per 1000

Average Non Comp (2.45) Average Comp (0.84)

Source: Plan Submitted Enrollee Residence Report, June 2014 – July 2015, Plan Submitted Nursing Home Transfer Report, March

2014 – May 2014, and Florida Medicaid Managed Information System (FLMMIS) Eligibility Information, March 2014 – July 2015.

Source: Plan Submitted Enrollee Residence Report, June 2014 – July 2015, Plan Submitted Nursing Home Transfer Report,

March 2014 – May 2014, and Florida Medicaid Managed Information System (FLMMIS) Eligibility Information, March 2014 –

July 2015.

13

The rate of transfers from the community to nursing facilities for fiscal year 2014 – 2015, ranged from a

low of one-tenth of a percent of Sunshine’s enrollees to a high of 5 percent of American ElderCare’s

enrollees.

Figure 21: Percentage of Community Enrollees Who Transferred to Nursing Facilities, Fiscal Year 2014 - 2015

Transfer rates of community enrollees to nursing facilities are not uniform

across the state geographically. In 3 counties, Escambia (Pensacola), Santa

Rosa, and Franklin, between 4.5 and 6.0 percent of enrollees living in the

community transferred to nursing facilities between March 2014 and July

2015. During the same period, 7 counties - Liberty, Lafayette, Dixie, Gilchrest,

Levy, Hardee, and Glades - did not report any transfers to nursing facilities.

0

2

4

6

8

AmericanEldercare

Molina Amerigroup Coventry Humana United Sunshine

5.0

2.4 2.4 1.9

1.2 1.1 0.1

Figure 22: Percentage of Community Enrollees Who Transferred to Nursing Facilities, by County, March 2014 - July 2015

Esc

ambia

SantaRosa

Okalo

osa Walton

Holmes

Wash-ington

Bay

Jackson

Gadsden

Liberty

Franklin

Leon

Wakulla

Je

f fers

on

Taylor

MadisonCal-houn

Gulf

Hamilton

Colu

mbia

Union

Brad-ford

Suwannee

Lafayette

Gil-christ Alachua

Dixie

Levy

Putnam

Marion

Citrus

Hernando

Lake

Sum

ter

Pasco

Pi n

ell a

s

Hillsborough

Highlands

HardeeManatee

Polk

Orange

Osceola

Seminole

Bre

vard

SarasotaDesoto

Charlotte

Lee

Collier

Hendry

Glades

Indian River

Martin

St. Lucie

Palm Beach

Oke

echob

ee

Broward

Miami-Dade

Monroe

Baker

Nassau

Duval

Clay

St . Jo

hns

Flagler

Volusia

No Transfers to Insti tutions

Less than 0.50

0.50 to 1.49

1.50 to 3.99

3.00 to 4.49

Percentage of Community EnrolleesWho Transferred into Nursing Facilities

4.50 to 6.00

Source for Figures 21-22: Plan Submitted Enrollee Residence Report, June 2014 – July 2015, Plan Submitted

Nursing Home Transfer Report, March 2014 – May 2014, and Florida Medicaid Managed Information System

(FLMMIS) Eligibility Information, March 2014 – July 2015.

14

Transfers Out of Nursing Facilities

On average, 3.6 of every 1,000 enrollees in nursing facilities transfer to the community each month.

Figure 23: Number of LTC Enrollees Who Return to the Community per 1,000 LTC Enrollees in Nursing Facilities, by Month, March 2014 - July 2015

More enrollees in non-comprehensive than comprehensive plans transfer from a nursing facility to the

community each month. In fact, enrollees in a comprehensive plan were about 60 percent as likely as

enrollees in a non-comprehensive plan to return to the community between May 2014 and July 2015.

Figure 24: Number of LTC Enrollees Who Return to the Community per 1,000 LTC Enrollees in Nursing Facilities, by Month, and by Comprehensive Plan Status, March 2014 - July 2015

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Non-Comprehensive Plan Per 1000 Comprehensive Plan Per 1000

Average Non Comp (4.12) Average Comp (2.48)

3.6 3.6 4.1 3.9 3.9

3.7 3.9

4.2

3.1 3.3 3.3 3.3 3.7

4.3

3.1

2.4 2.8

0.00

1.00

2.00

3.00

4.00

5.00

Community Transfers per 1,000 in Institution

Average Community Transfers per 1,000 (3.56)

Source for Figures 23-24: Plan Submitted Enrollee Residence Report, June 2014 – July 2015, Plan Submitted Nursing Home

Transfer Report, March 2014 – May 2014, and Florida Medicaid Managed Information System (FLMMIS) Eligibility


15

The rate of transfers from nursing facilities to the community for fiscal year 2014 – 2015 ranged from a

low of 2 percent of Sunshine’s nursing facility enrollees to a high of 6 percent of Amerigroup’s nursing

facility enrollees.

Figure 25: Percentage of Nursing Facility Enrollees Who Transferred to the Community, by Plan, Fiscal Year 2014 - 2015

On average, plans transferred 2.9 percent of enrollees from nursing facilities to the community during

fiscal year 2014 – 2015. Only 1.6 percent of community enrollees transferred into nursing facilities

during the fiscal year.

0

2

4

6

8


Coventry Humana Molina United Sunshine

6.2

4.9 4.4

3.7 3.3

2.6 2.0

Figure 26: Percentage of LTC Enrollees Who Transferred into and out of a Nursing Facility, July 2014 - June 2015

0%

2%

4%

Percentage of CommunityEnrollees who Transferred

to a Nursing Facility

Percentage of NursingFacility Enrollees who

Transferred to theCommunity

1.6%

2.9%

Source for Figures 25 and 26: Plan Submitted Enrollee Residence Report, June 2014 – July 2015, Plan Submitted

Nursing Home Transfer Report, March 2014 – May 2014, and Florida Medicaid Managed Information System


16

Rates of enrollees in nursing facilities returning to the community are not uniform across the state

geographically. In three counties, Liberty, Brevard (Melbourne), and Broward (Ft. Lauderdale), over 6.5

percent of enrollees in nursing facilities returned to the community between March 2014 and July 2015.

At the same time, five counties - Wakulla, Dixie, Union, Hardee, and Glades - did not report any returns

to community.

Figure 27: Percentage of LTC Enrollees in Nursing Facilities Who Returned to the Community, March 2014 - July 2015

Esc

ambia

SantaRosa

Okalo

osa Walton

Holmes

Wash-ington

Bay

Jackson

Gadsden

Liberty

Franklin

Leon

WakullaJe

f fers

on

Taylor

MadisonCal-houn

Gulf

HamiltonC

olu

mbia

Union

Brad-ford

Suwannee

Lafayette

Gil-christ Alachua

Dixie

Levy

Putnam

Marion

Citrus

Hernando

Lake

Sum

ter

Pasco

Pi n

ell a

s

Hillsborough

Highlands

HardeeManatee

Polk

Orange

Osceola

Seminole

Bre

vard

SarasotaDesoto

Charlotte

Lee

Collier

Hendry

Glades

Indian River

Martin

St. Lucie

Palm Beach

Oke

echob

ee

Broward

Miami-Dade

Monroe

Baker

Nassau

Duval

Clay

St. Jo

hns

Flagler

Volusia

No Transfers to Community

Less than 1.00

1.00 to 2.49

2.50 to 4.99

5.00 to 6.49

Percentage of Enrollees Living in Nursing FacilitiesWho Transferred back into the Community

6.50 to 100.00

Source: Plan Submitted Enrollee Residence Report, June 2014 – July 2015, Plan Submitted Nursing Home Transfer Report, March

2014 – May 2014, and Florida Medicaid Managed Information System (FLMMIS) Eligibility Information, March 2014 – July 2015.

17

LTC Services

Long-term Care services are services provided to enrollees who require skilled nursing level of care.

They may be provided in an institutional or community setting.

Long-term Care plans are required to ensure the provision of the covered services listed below to the

plan’s enrollees:

Adult Companion Care

Adult Day Health Care

Assistive Care Services

Assisted Living

Attendant Care

Behavioral Management

Caregiver Training

Care Coordination/Case Management

Home Accessibility Adaptation Services


Homemaker Services

Hospice

Intermittent and Skilled Nursing

Medical Equipment and Supplies

Medication Administration

Medication Management

Nutritional Assessment/Risk Reduction Services

Nursing Facility Services

Personal Care

Personal Emergency Response Systems (PERS)

Respite Care

Occupational Therapy

Physical Therapy

Respiratory Therapy

Transportation Services

Additionally, the LTC plans all offer Expanded Benefits (Extra Benefits). Listed below are Approved LTC Expanded Benefits:

ALF/AFCH Bed Hold Box Fan Caregiver Information/Support Cellular Phone Services Dental Services Document Keeper Emergency Financial Assistance Hearing Evaluation Household Set-Up Kit Mobile Personal Emergency Response

System

Non-Medical Transportation Nurse Helpline Services Over-The-Counter (OTC)

Medication/Supplies Pill Organizer Support to Transition Out of a Nursing

Facility Vision Services Welcome Home Basket Wellness Grocery Discount

Source: Statewide Medicaid Managed Care (SMMC) Contract, Attachment l, Scope of Services

18

Ninety-six percent of LTC enrollees received one or

more services during the review period. In 88

percent of enrollee months, enrollees received one

or more services.

Over 90 percent of the

enrollees in each LTC plan

received at least one service

between March 2014 and

February 2015. However,

this percentage varied by

plan. Amerigroup had the

highest percentage at 98.8

percent, and United had the

lowest at 90.8 percent.

The percentage of enrollee

months in which enrollees

received a service ranged

from 98 percent of

Amerigroup’s enrollee

months to 70 percent of

United’s enrollee months.

98.8% 98.6% 97.8% 96.4% 93.3% 92.6% 90.8%

0%

25%

50%

75%

100%


Molina Sunshine Coventry Humana United

Figure 29: LTC Enrollees with at Least One Service by Plan, March 2014 to February 2015

98% 96% 94% 91% 91% 90%

70%

0%

25%

50%

75%

100%


Sunshine Molina Humana Coventry United

Figure 30: LTC Enrollee Months with at Least One Service by Plan, March 2014 to February 2015

Any Service 88.2%

No Service 11.8%

Enrollee Months With a Service

Any Service 95.5%

No Service

4.5%

Enrollees With a Service

Figure 28: LTC Enrollees and Enrollee Months by Service Utilization, March 2014 - February 2015

Source for Figures 28-30: Florida Medicaid Managed Information System (FLMMIS) Encounter Data, March 2014 – February

2015, and FLMMIS FFS Claims Data for American ElderCare, March 2014 – August 2014.

19

Enrollees Receiving General Services 58.1%

Enrollees Not Receiving General Services 41.9%

Enrollees Receiving Community and Institutional Services Enrollees may reside in institutional or community settings. Institutional services are used by enrollees

in institutional settings. Community services are used by enrollees in community settings, and are

designed to help enrollees remain in the community. Enrollees may move between the two settings and

receive each type of service at different points in time. General services, such as transportation and

medical services and equipment, may be received by enrollees residing in either setting.

Fifty-four percent of LTC enrollees

received institutional services

over the review period. Forty-

nine percent of LTC enrollees also

received one or more community

service. Fifty-eight percent of LTC

enrollees received general

services.

The percentage of LTC enrollees receiving institutional and community services differs by plan. Only

Sunshine and United had larger percentages of enrollees receiving institutional services than community

services. Close to 60 percent of Sunshine’s and United’s enrollees live in an institutional setting.

Three-quarters of Amerigroup’s

enrollees received community

services. Over three-quarters of

Amerigroup’s enrollees live in a

community setting.

Figure 32: Percentage of LTC Enrollees Receiving at Least One Institutional Service or Community Service by Plan, March 2014 - February 2015*

Figure 31: Percentage of LTC Enrollees Receiving at Least One Institutional, Community, and General Service, March 2014 - February 2015

Enrollees Receiving

Institutional Services 54.4%

Enrollees Not Receiving

Institutional Services 45.6%

Enrollees Receiving

Community Services 48.7%

Enrollees Not Receiving

Community Services 51.3%

56.8%

62.4%

54.4%

45.6%

44.2%

47.0%

45.4%

27.9%

39.9%

44.2%

48.7%

51.3%

52.5%

57.1%

58.4%

74.9%

-80% -60% -40% -20% 0% 20% 40% 60% 80%

United

Sunshine

Across All Plans

Coventry

Humana

American Eldercare

Molina

Amerigroup

% Enrollees Receiving Institutional Services

% Enrollees Receiving Community Services

Source: For Figures 31 and 32, Florida Medicaid Managed

Information System (FLMMIS) Encounter Data, March 2014 –

February 2015, and FLMMIS FFS Claims Data for American

ElderCare, March 2014 – August 2014.

*Some services such as medical

equipment and supplies can be received

in either an institutional or community

setting. Therefore, institutional and

community percentages will not total to

100 percent of enrollees.

20

Months in the LTC Program and Months Receiving Services

Over half (54.9%) of LTC

enrollees were enrolled in the

LTC program all twelve months

of the review period. A

quarter (25.5%) of enrollees

were enrolled for six months

of the review period or less.

Among LTC enrollees who

received community

services, a third (33%)

received community

services in all twelve

months of the period. A

little more than a quarter

(26.3%) of enrollees who

received community

services during the period

received these services for

three months or less.

Similarly, a third (34%) of enrollees who received an institutional service during the period received

institutional services for all twelve months, and about a quarter (23.2%) of enrollees who received an

institutional service during the period received these services for three months or less.

4.5% 4.5% 5.3% 3.3% 4.0% 3.9% 3.3% 3.8% 3.5% 4.7% 4.4%

54.9%

0%

10%

20%

30%

40%

50%

60%

1 2 3 4 5 6 7 8 9 10 11 12

Number of Months in SMMC-LTC

12

.9%

7.7

%

5.7

%

8.2

%

4.5

%

4.0

%

3.3

%

3.8

%

4.0

%

5.4

%

7.5

%

33

.0%

8.0

%

8.6

%

6.6

%

5.1

%

5.7

%

5.0

%

4.0

%

4.7

%

4.9

%

6.5

%

7.0

%

34

.0%

0%

5%

10%

15%

20%

25%

30%

35%

40%

1 2 3 4 5 6 7 8 9 10 11 12

Number of Months Receiving Services

Community Services Intsitutional Services

Figure 33: Percentage of LTC Enrollees by the Number of Months in the LTC Program, March 2014 - February 2015

Figure 34: Percentage of LTC Enrollees by the Number of Months Receiving Community or Institutional Services, March 2014 - February 2015

Source: Florida Medicaid Managed Information System (FLMMIS) Encounter Data, March

2014 – February 2015, and FLMMIS FFS Claims Data for American ElderCare, March 2014 –

August 2014.



July 2015.

21

Institutional Care Services Institutional services consist of nursing facility services and hospice services delivered in an institutional setting. Fifty-one percent of LTC enrollees received nursing facility services during the review period.

Nursing Facility services are services provided by a licensed skilled nursing facility as part of the standard per diem charges. These services include room and board, nursing care, and other standard services. Hospice services are designed to meet the physical, social, psychological, emotional and spiritual needs of terminally ill enrollees and their families. Hospice care focuses on palliative care rather than curative care, and can be provided in an institution or community setting. Institutional Hospice services are hospice services provided in an institutional setting.

Half of all enrollees in non-comprehensive plans received nursing facility services while 46 percent of

enrollees in comprehensive plans received nursing facility services.

Coventry

HumanaAmerigroup

American ElderCare Molina

Sunshine

United

All Plans

Figure 35: Percentage of LTC Enrollees Receiving at Least One Institutional Service by Service, March 2014 - February 2015

Figure 36: Percentage of LTC Enrollees Receiving a Nursing Facility Service by Plan, March 2014 - February 2015

Figure 37: Percentage of LTC Enrollees Receiving Institutional Hospice Services by Plan, March 2014 - February 2015

0%

20%

40%

60%

Nursing Facility

(50.99%)

8.3%

51.0%

0% 10% 20% 30% 40% 50% 60%


Nursing Facility

0%

20%

40%

60%


(8.25%)

Sunshine, which has the

largest percentage of LTC

enrollees in an

institutional setting, had

the largest percentage of

LTC enrollees who

received Nursing facility

services at 59 percent.

Figure 38: Percentage of LTC Enrollees Receiving at Least One Institutional Service by Service and Comprehensive Status, March 2014 - February 2015

7.4%

49.9%

6.1%

45.8%

60% 40% 20% 0% 20% 40% 60%


Nursing Facility

Non-Comprehensive Comprehensive



Source: Descriptions of specific services on pages 21-32 are taken from the Statewide Medicaid Managed Care Contract,

Attachment II, Exhibit II-B, Long-term Care (LTC) Managed Care Program.

22

Community Care Services Community services consist of 18 different services that are provided in the community or the enrollee’s

home. Five of these services may be received as PDO services for participants in the Participant Directed

Option (PDO). These services are covered in the PDO section of this report.

The Most Widely Used Community Services

Four community services

were used by more than ten

percent of all LTC enrollees.

These services include

homemaker services,

personal care, assisted living

services, and home delivered

meals.

Homemaker services are general household

activities such as meal preparation and routine

household care provided by a trained homemaker

when the individual regularly responsible for

these activities is temporarily absent or unable to

manage these activities. Chore services, including

heavy chore services and pest control may be

included in this service.

Personal Care services provide assistance with eating, bathing, dressing, personal hygiene, and other activities of daily living. It includes assistance with preparation of meals, and may include housekeeping chores such as bed making, dusting and vacuuming.

Figure 39: Percentage of LTC Enrollees Receiving at Least One of the Most Widely Used Community Services by Service, March 2014 - February 2015

Homemaker Services

(19.38%)

0%

10%

20%

30%

40%

Figure 40: Percentage of LTC Enrollees Receiving Homemaker Services by Plan, March 2014 - February 2015

Personal Care

(15.75%)

0%

10%

20%

30%

40%

Figure 41: Percentage of LTC Enrollees Receiving Personal Care by Plan, March 2014 - February 2015

12.8%

14.5%

15.8%

19.4%

0% 5% 10% 15% 20%


Assisted Living

Personal Care

Homemaker Services

A larger percentage of

Amerigroup’s than

other plans’ enrollees

used homemaker

services.

Amerigroup also had the

largest percentage of LTC

Enrollees receiving

personal care services at

36.9 percent.

Coventry

HumanaAmerigroup


Sunshine

United

All Plans

Source for Figures 39-41: Florida Medicaid Managed Information System (FLMMIS) Encounter Data, March 2014 – February 2015,

and FLMMIS FFS Claims Data for American ElderCare, March 2014 – August 2014.

23


non-comprehensive

enrollees used these four

services than

comprehensive enrollees.

Assisted living services

were the most widely

used community service

among comprehensive

plan enrollees.

Homemaker services were the most widely used community service among non-comprehensive plan

enrollees.

Assisted Living services provide personal care,

homemaker, chore, attendant care,

companion care, medication oversight, and

therapeutic social and recreational

programming in an assisted living facility that

provides a home-like environment. This

service includes twenty-four hour onsite staff

to meet scheduled or unpredictable needs and

ensure the safety and security of enrollees.

Home Delivered Meal services deliver

nutritionally sound meals to the residence of

an enrollee who has difficulty shopping for or

preparing food without assistance.

Coventry

HumanaAmerigroup


Sunshine

United

All Plans

0%

10%

20%

30%

40%

Assisted Living

(14.46%)

Figure 43: Percentage of LTC Enrollees Receiving Assisted Living Services by Plan, March 2014 - February 2015

Figure 44: Percentage of LTC Enrollees Receiving Home Delivered Meals by Plan, March 2014 - February 2015

Assisted Living Services

were used by 24.5 to 27.3

percent of enrollees in

Amerigroup, American

ElderCare, and Coventry.

On average, 13 percent of LTC enrollees

received at least one home delivered meal.

Over 21 percent of Amerigroup’s LTC enrollees

had at least one home delivered meal.

Figure 42: Percentage of LTC Enrollees Receiving at Least One of the Most Widely Used Community Services by Service and Comprehensive Status, March 2014 - February 2015


0%

10%

20%

30%

40%

(12.80%)

16.3%

12.9%

19.7%

14.4%

5.1%

6.6%

9.7%

12.6%

25% 15% 5% 5% 15% 25%

Personal Care


Homemaker Services

Assisted Living


Source for Figures 42-44: Florida Medicaid Managed Information System (FLMMIS) Encounter Data, March 2014 – February 2015, and

FLMMIS FFS Claims Data for American ElderCare, March 2014 – August 2014.

24

Other Widely Used Community Services

Five community services were

used by 5 to 10 percent of all

LTC enrollees. These services

include personal emergency

response systems, hospice in

the community, respite care,

home health care services, and

adult companion care.

Personal Emergency Response Systems

services provide for the installation and service

of an electronic device that enables enrollees at

high risk of institutionalization to secure help in

an emergency. The system is connected to the

person's phone and programmed to signal a

response center once a "help" button is

activated. The enrollee may also wear a

portable "help" button to allow for mobility.

These services are generally limited to those

enrollees who live alone or who are alone for

significant parts of the day and who would

otherwise require extensive supervision.

Hospice services are designed to meet the physical, social, psychological, emotional and spiritual needs of terminally ill enrollees and their families. Hospice care focuses on palliative care rather than curative care, and can be provided in an institution or community setting. Community Hospice services are hospice services provided in the community setting. Respite Care services provide short-term relief

for enrollees’ caretakers when enrollees are

unable to care for

themselves.

0%

5%

10%

15%

Personal EmergencyResponse System

(9.13%)

0%

5%

10%

15%

Respite Care

(5.99%)

0%

5%

10%

15%

Hospice Community

(6.37%)

Figure 46: Percentage of LTC Enrollees Receiving Personal Emergency Response Systems services by Plan, March 2014 - February 2015

Figure 47: Percentage of LTC Enrollees Receiving Hospice Services in the Community by Plan, March 2014 - February 2015

Figure 48: Percentage of LTC Enrollees Receiving Respite Care by Plan, March 2014 - February 2015

5.5%

5.9%

6.0%

6.4%

9.1%

0.0% 2.5% 5.0% 7.5% 10.0%


Home Health Care Services

Respite Care

Hospice Community

Personal Emergency Response System

Figure 45: Percentage of LTC Enrollees Receiving at Least One of the Other Widely Used Community Services by Service, March 2014 - February 2015

The percentage of LTC

enrollees who used a

personal emergency

response system ranged

from 12 percent for

Amerigroup and American

ElderCare to 7 percent for

Coventry.

Sunshine had the largest

percentage of LTC

enrollees receiving

hospice services in the

community at 8 percent.

Amerigroup had the largest percentage of LTC enrollees receiving respite

services during the review period at 15 percent.

Coventry

HumanaAmerigroup


Sunshine

United

All Plans

Source for Figures 45-48: Florida Medicaid Managed Information System (FLMMIS) Encounter Data,

March 2014 – February 2015, and FLMMIS FFS Claims Data for American ElderCare, March 2014 –

August 2014.

25

A larger percentage

of comprehensive

enrollees used home

health care services

than non-

comprehensive

enrollees. A larger

percentage of non-

comprehensive than

comprehensive

enrollees used the

other four services.

Non-comprehensive enrollees were more than twice as likely to receive personal emergency response

and adult companion care as enrollees in comprehensive plans.

Home Health Care services are medically necessary services, which can be effectively and efficiently provided in the place of residence of an enrollee. Services include home health visits (nurse and home health aide), private duty nursing and personal care services for children, therapy services, medical supplies, and durable medical equipment.

Adult Companion Care services provide

assistance or supervision for functionally

impaired enrollees with tasks such as meal

preparation, laundry, or shopping. This service

may include light housekeeping tasks incidental

to the care and supervision of enrollees but

does not include hands-on nursing care.

Coventry

HumanaAmerigroup


Sunshine

United

All Plans

0%

5%

10%

15%


(5.52%)

Figure 50: Percentage of LTC Enrollees Receiving Home Health Services by Plan, March 2014 - February 2015

Figure 51: Percentage of LTC Enrollees Receiving Adult Companion Care by Plan, March 2014 - February 2015

0%

5%

10%

15%

Home HealthCare Services

(5.91%)

At 14 percent,

Sunshine had the

largest percentage

of enrollees who

received home

health care services.


enrollees who were

provided with adult

companion care services

ranged from 10.5 percent for

Molina to 3.9 percent for

Coventry.

Figure 49: Percentage of LTC Enrollees Receiving at Least One of the Other Widely Used Community Services by Service and Comprehensive Status, March 2014 - February 2015

5.5%

5.9%

9.2%

5.1%

5.4%

2.2%

3.3%

4.5%

5.0%

6.5%

10% 5% 0% 5% 10%


Respite Care

Personal EmergencyResponse System

Hospice Community

Home HealthCare Services




26

Less Widely Used Community Services

Five community services were

used by half-of-a-percent to five

percent of all LTC enrollees.

These services include adult day

care, medication management,

assistive care services,

attendant care, and home

accessibility adaptation.

Adult Day Health Care services are health and

social services needed to ensure optimal

functioning of an enrollee, including social

services to help with personal and family

problems as well as planned group therapeutic

activities. These services are provided only in a

Community setting.

Medication Management services are provided by a licensed nurse or pharmacist who reviews all prescriptions and over-the-counter medications taken by an enrollee, in conjunction with the enrollee’s physician on at least an annual basis or upon a significant change in the enrollee’s condition. The purpose of the review is to assess whether the enrollee’s medication is accurate, valid, non-duplicative and correct for the diagnosis; that doses are at an optimum level; that there is appropriate laboratory monitoring and follow-up taking place; and that drug interactions, allergies and contraindications are being assessed and prevented.

Coventry

HumanaAmerigroup


Sunshine

United

All Plans

(26.91%)

(1.73%)


0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

22%

24%

26%

28%

30%

(3.72%)

0%

2%

4%

6%

8%

10%


0.6%

0.7%

1.6%

1.7%

3.7%

0.0% 1.0% 2.0% 3.0% 4.0% 5.0%

Home Accessibility Adaptation

Attendant Care





enrollees who were

provided with adult day

health care services

ranged from 8 percent for

Molina to 3 percent for

Sunshine.

Although 2 percent of all LTC enrollees received

medication management, over a quarter (26.9%)

of Amerigroup’s enrollees received this service.

Figure 52: Percentage of LTC Enrollees Receiving at Least One of the Less Widely Used Community Services by Service, March 2014 - February 2015

Figure 54: Percentage of LTC Enrollees Receiving Adult Day Health Care by Plan, March 2014 - February 2015

Figure 53: Percentage of LTC Enrollees Receiving Medication Management by Plan, March 2014 - February 2015

Source for Figures 52-54: Florida Medicaid Managed Information System (FLMMIS)

Encounter Data, March 2014 – February 2015, and FLMMIS FFS Claims Data for American


27

Non-comprehensive enrollees

were more than twice as

likely to receive each of these

5 services as enrollees in

comprehensive plans.

Assistive Care services provide assistance with

daily living tasks for enrollees. These services

are available only to individuals who are

assessed to need at least two components of

supports for daily living. These include

grooming, mobility, bathing, reporting health

related changes to health care providers, and

self-administration of medication.

Attendant Care services provide hands-on care in the form of skilled nursing care and housekeeping activities for medically stable, disabled enrollees. These services substitute for the absence, loss, diminution, or impairment of a physical or cognitive function. Home Accessibility Adaptation services include

physical adaptations to the home which are

necessary to ensure the health, welfare, and

safety of the enrollee or which enable an

enrollee to live at home as opposed to an

institutional setting. Such adaptations may

include the installation of ramps and grab-bars,

widening of doorways, modification of

bathroom facilities, or installation of specialized

electric and plumbing systems to accommodate

medical equipment and supplies.

(1.62%)

0%

2%

4%

6%

8%

10%

Assistive Care Services(0.73%)

0%

2%

4%

6%

8%

10%

Attendant Care

Figure 56: Percentage of LTC Enrollees Receiving Assistive Care Services by Plan, March 2014 - February 2015

Figure 57: Percentage of LTC Enrollees Receiving Attendant Care by Plan, March 2014 - February 2015

Figure 58: Percentage of LTC Enrollees Receiving Home Accessibility Adaptation by Plan, March 2014 - February 2015

(0.59%)0%

2%

4%

6%

8%

10%

Home Accessibility

Adaptation

As with medication

management, one plan

provided a much larger

percentage of its enrollees

with assistive care services

than other plans.

Figure 55: Percentage of LTC Enrollees Receiving at Least One of the Less Widely Used Community Services by Service and Comprehensive Status, March 2014 - February 2015

Coventry

HumanaAmerigroup


Sunshine

United

All Plans

1.7%

0.6%

0.7%

1.6%

3.7%

0.1%

0.1%

0.2%

0.6%

1.7%

4.0% 2.0% 0.0% 2.0% 4.0%


Home AccessibilityAdaptation

Attendant Care


Adult DayHealth Care




28

Least Widely Used Community Services

Four community services were used by less than a quarter-of-a-percent of all

LTC enrollees. These services include nutritional assessment, skilled nursing,

medication administration, and caregiver training.

Nutritional Assessment services teach caregivers and enrollees to follow dietary specifications that are essential to enrollees’ health and physical functioning and to prepare and eat nutritionally appropriate meals. Intermittent and Skilled Nursing services

include home health services as well as skilled

nursing services. Home health services are

provided by a registered professional nurse, or

a licensed practical or vocational nurse under

the supervision of a registered nurse. Skilled

nursing services require the direct care skills of

a licensed nurse. In this report, intermittent

and skilled nursing services are reported

separately as home health services and skilled

nursing services. The services categorized as

skilled nursing services are those that home

health aides must not perform.

Coventry

HumanaAmerigroup


Sunshine

United

All Plans

Nutritional Assessment0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

0.60%

0.70%

0.80%

0.90%

1.00%

1.10%

1.20%

1.30%

1.40%

1.50%

1.60%

1.70%

1.80%

1.90%

2.00%(2.00%)

(0.11%)

0.01%

0.06%

0.07%

0.11%

0.00% 0.05% 0.10% 0.15% 0.20% 0.25%

Caregiver Training


Skilled Nursing

Nutritional Assessment

0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

Skilled Nursing

(0.07%)

Only two plans

provided any

nutritional

assessments,

Amerigroup and

Sunshine.

United did not provide skilled nursing

services to its enrollees during the

review period.

Figure 59: Percentage of LTC Enrollees Receiving at Least One of the Least Widely Used Community Services by Service, March 2014 - February 2015

Figure 60: Percentage of LTC Enrollees Receiving Nutritional Assessment by Plan, March 2014 - February 2015

Figure 61: Percentage of LTC Enrollees Receiving Skilled Nursing Services by Plan, March 2014 - February 2015

Source for Figures 59-61: Florida Medicaid Managed Information System (FLMMIS) Encounter

Data, March 2014 – February 2015, and FLMMIS FFS Claims Data for American ElderCare, March

2014 – August 2014.

29


non-comprehensive than

comprehensive enrollees

used each service with the

exception of nutritional

assessment.

Medication Administration offers assistance

with self-administration of medications in the

home or a facility. The service includes taking

the medication from where it is stored and

delivering it to the enrollee; removing a

prescribed amount of medication from the

container and placing it in the enrollee’s hand

or another container; helping the enrollee by

lifting the container to their mouth; applying

topical medications; and keeping a record of

when an enrollee receives assistance with self-

administration of their medications.

Caregiver Training provides training and

counseling services for individuals who provide

unpaid care to enrollees. This service is not

available to paid caregivers. Training services

include instruction about treatment regimens

and use of equipment. Counseling services

assist the unpaid caregiver in meeting the needs

of the enrollee.

0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

Caregiver Training

(0.01%)

0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

M edication Administration

(0 .06%)

Figure 63: Percentage of LTC Enrollees Receiving Medication Administration by Plan, March 2014 - February 2015

Figure 64: Percentage of LTC Enrollees Receiving Caregiver Training by Plan, March 2014 - February 2015

Caregiver training was the least

widely used service among

community services offered to LTC

Enrollees. American ElderCare,

Coventry, and Molina did not report

any caregiver training.

Figure 62: Percentage of LTC Enrollees Receiving at Least One of the Least Widely Used Community Services by Service and Comprehensive Status, March 2014 - February 2015

Coventry

HumanaAmerigroup


Sunshine

United

All Plans



0.012%

0.07%

0.05%

0.09%

0.002%

0.01%

0.04%

0.09%

0.15% 0.10% 0.05% 0.00% 0.05% 0.10% 0.15%

Caregiver Training

Skilled Nursing




30

General Services General services, those available in an institutional or community setting, were used by 58 percent of

LTC enrollees during the review period. General Services are divided into Therapy and Other General

Services

Therapy Services

Therapy services include

physical, occupational,

speech and respiratory

therapies.

Physical Therapy services treat impaired

physical functions through physical activity,

massage, exercise, or chemical properties of

heat, light, electricity, or sound when an

assessment indicates the services will improve

an enrollee’s capacity to live safely at home.

Occupational Therapy services treat impaired

functions to increase or maintain enrollees’

ability to perform tasks required for

independent functioning when an assessment

indicates the services will improve an enrollee’s

capacity to live safely at home.

0.8%

7.0%

10.9%

12.5%

0% 5% 10% 15%

Respiratory Therapy

Speech Therapy


Physical Therapy

(12.46%)

0%

4%

8%

12%

16%

Physical Therapy

(10.91%)

0.00%

4.00%

8.00%

12.00%

16.00%


Figure 66: Percentage of LTC Enrollees Receiving Physical Therapy by Plan, March 2014 - February 2015

Figure 67: Percentage of LTC Enrollees Receiving Occupational Therapy by Plan, March 2014 - February 2015

Figure 65: Percentage of LTC Enrollees Receiving at Least One Therapy Service by Service, March 2014 - February 2015

Coventry

HumanaAmerigroup


Sunshine

United

All Plans



31

A larger percentage of non-comprehensive than comprehensive enrollees used each therapy service with the exception of respiratory therapy.

Speech Therapy services evaluate and treat problems related to an oral motor dysfunction when an assessment determines the services will improve an enrollee’s capacity to live safely at home. Respiratory Therapy services treat

conditions that interfere with respiratory

functions or other deficiencies of the

cardiopulmonary system. Services include

evaluation and treatment of pulmonary

dysfunction.

(6.96%)

0%

4%

8%

12%

16%

Speech Therapy

(0.81%)0%

4%

8%

12%

16%

Respiratory Therapy

Figure 69: Percentage of LTC Enrollees Receiving Speech Therapy by Plan, March 2014 - February 2015

Figure 70: Percentage of LTC Enrollees Receiving Respiratory Therapy by Plan, March 2014 - February 2015

Coventry

HumanaAmerigroup


Sunshine

United

All Plans

Figure 68: Percentage of LTC Enrollees Receiving at Least One Therapy Service by Service and Comprehensive Status, March 2014 - February 2015

0.6%

5.9%

9.4%

10.5%

0.6%

4.5%

7.2%

9.4%

15% 10% 5% 0% 5% 10% 15%

Respiratory Therapy

Speech Therapy


Physical Therapy




32

Other General Services

Medical Equipment and Supplies include devices, controls, appliances, ancillary supplies, and equipment that increase enrollees’ ability to perform activities of daily living, manage their environment, or address physical conditions. Transportation services include non-emergency transportation to and from sites to receive services offered by the LTC Plan, including expanded benefits. Behavioral Management services reduce behaviors attributed to mental health or substance abuse problems of enrollees. The services include an evaluation of the origin and trigger of the presenting behavior; development of strategies to address the behavior; implementation of an intervention by the provider; and assistance for the caregiver in being able to intervene and maintain the improved behavior.

(19.90%)

0%

10%

20%

30%

40%

Medical Equipmentand Supplies

(4.99%)

0%

10%

20%

30%

40%

Transportation

Figure 73: Percentage of LTC Enrollees Receiving Transportation by Plan, March 2014 - February 2015

(0.46%)

0%

1%

2%

3%

4%


Figure 74: Percentage of LTC Enrollees Receiving Behavioral Management Services by Plan, March 2014 - February 2015

Coventry

HumanaAmerigroup


Sunshine

United

All Plans

Less than 1 percent of all LTC

enrollees received behavioral

management services. Nearly two

percent of Amerigroup’s enrollees

received the service.

Overall, 20 percent of LTC

enrollees received some

medical equipment and

supplies during the review

period. Forty percent of

Amerigroup’s enrollees

received medical

equipment and supplies.

< 0.1%

5.0%

19.9%

0% 5% 10% 15% 20%


Transportation


Amerigroup provided

transportation services to

twenty-one percent of their

LTC enrollees.

Figure 75: Percentage of LTC Enrollees Receiving at Least One Therapy Service by Service and Comprehensive Status, March 2014 - February 2015

0.4%

4.2%

19.7%

0.1%

3.3%

12.5%

25% 15% 5% 5% 15% 25%


Transportation

Medical Equipmentand Supplies


Figure 71: Percentage of LTC Enrollees Receiving at Least One Other General Service by Service, March 2014 - February 2015

Figure 72: Percentage of LTC Enrollees Receiving Medical Equipment and Supplies by Plan, March 2014 - February 2015

Source for Figures 71-75: Florida Medicaid Managed Information System (FLMMIS)

Encounter Data, March 2014 – February 2015, and FLMMIS FFS Claims Data for American


33

Participant Directed Option

The Participant Directed Option (PDO) is a delivery system available to an enrollee who lives at home or in a family home and who has a plan of care that includes one or more of the following services: adult companion care, attendant care, homemaker, intermittent and skilled nursing, and personal care. LTC Plans are required to offer the PDO to eligible enrollees, but the enrollee chooses whether or not to participate in each of the eligible PDO services. LTC Plan enrollees who choose the Participant Directed Option can hire, train, supervise, and dismiss their direct service workers. A direct service worker is a person eighteen years of age or older who has direct, face-to-face contact with an LTC enrollee while providing services to the enrollee and has access to the enrollee’s living areas, funds, personal property, or personal identification information as defined in Florida Statutes. Direct service workers include any qualified individual chosen by the participant, including a neighbor, family member, or friend, and are paid by the Managed Care Plan based on a set rate. (See s. 817.568, F.S. and s. 430.0402(1)(b), F.S.) The LTC Plan must assign enrollees who choose the PDO (participants) to case managers with specialized training. The case managers, extensively trained in PDO, are responsible for providing training and documents to enrollees and their direct service workers. The LTC Plan enrollee and provider call centers must include PDO-trained staff to assist participants and direct service workers. A Participant Directed Option Roster Report must be submitted to the Agency on a monthly basis by each LTC plan. The report provides a list of enrollees participating in PDO and identifies which of the five available services the participant has elected as a PDO service. A small but growing number of LTC enrollees participate in the PDO program.

LTC Enrollees Not in PDO

83,307

LTC Enrollees in PDO 1,956 Community

LTC Enrollees Not in PDO

40,907

Community LTC Enrollees

in PDO 1,956

PDO participants represent five

percent of LTC enrollees who live in

community settings in February 2015.

Figure 76: Number and Percentage of LTC Enrollees by PDO Status, July 2015

Figure 77: Number of LTC Enrollees in the Community by PDO Status, July 2015

Source for Figures 76-77: Plan Submitted PDO Report, March 2014 – July 2015, and Florida Medicaid Managed Information System


34

By July 2015,

almost 2,000 LTC

enrollees were

PDO participants.

The larger plans

serve a larger

number of PDO

participants.

A small number of PDO participants

disenrolled from the PDO program during

the review period. Participant lack of

ability to employ or manage direct service

workers is a barrier to the participant’s

continuing to successfully use the

program.

617 701

799 884

950 992 1,117

1,223 1,331

1,410 1,472 1,552

1,629 1,689 1,791

1,897 1,956

0

500

1,000

1,500

2,000

Figure 78: Number of LTC Enrollees in PDO by Month, March 2014 July 2015

0

500

1,000

1,500

2,000

2,500

Molina

Amerigroup

American Eldercare

Coventry

Humana

United

Sunshine

Figure 79: Number of LTC Enrollees in PDO by Month and Plan, March 2014 - July 2015

*Humana enrollees are included with American ElderCare from February 2015 forward.

Beginning February 2015, Humana began operating its LTC plan as Humana American Eldercare.

Expired 45

Unable to employ/manage

direct service worker(s)

40

Requested to discontinue

participation in the PDO

36

Admitted into a facility (nursing

home, group home, ALF, etc.)

25

No longer eligible for Medicaid

14

No longer eligible for the

Long-Term Care Waiver

4

At risk for health or safety reasons

2

Moved out of the state of

Florida 2

Figure 80: Number of Disenrollments from PDO by Reason for Disenrollment, March 2014 - July 2015

Source for Figures 78-80: Plan Submitted PDO Report, March 2014 –

July 2015, and Florida Medicaid Managed Information System


35

A larger percentage of PDO

participants chose to direct their

personal care and homemaker

services than other services.

LTC enrollees participate in PDO throughout the state. Three counties do

not have any PDO participants. These counties are Jackson, Franklin, and

Glades. In three counties, Taylor, Suwannee, and Hendry, PDO enrollees

account for between 18 and 22 percent of all LTC enrollees living in the

community.

87.1%

75.9%

32.4%

0.8% 0.6% 0%

25%

50%

75%

100%

PersonalCare

Homemaker AdultCompanion

Care

AttendantCare

SkilledNursing Care

Figure 81: Percentage of PDO Enrollees Who Elected Specific Services by Service Category, July 2015

Figure 82: Percentage of LTC Enrollees in the Community Who Are in PDO by County, July 2015

Esc

ambia

SantaRosa

Okalo

osa Walton

Holmes

Wash-ington

Bay

Jackson

Gadsden

Liberty

Franklin

Leon

Wakulla

Je

f fers

on

Taylor

MadisonCal-houn

Gulf

Hamilton

Colu

mbia

Union

Brad-ford

Suwannee

Lafayette

Gil-christ Alachua

Dixie

Levy

Putnam

Marion

Citrus

Hernando

Lake

Sum

ter

Pasco

Pi n

ell a

s

Hillsborough

Highlands

HardeeManatee

Polk

Orange

Osceola

Seminole

Bre

vard

SarasotaDesoto

Charlotte

Lee

Collier

Hendry

Glades

Indian River

Martin

St. Lucie

Palm Beach

Oke

echob

ee

Broward

Miami-Dade

Monroe

Baker

Nassau

Duval

Clay

St . Jo

hns

Flagler

Volusia

No PDO Enrollees

Less than 3.00

3.99 to 6.99

7.00 to 12.99

13.00 to 17.99

Percentage of Community Enrollees in PDO

18.00 to 21.99

Source for Figures 81-82: Plan Submitted PDO Report, March 2014 – July 2015, and Florida Medicaid Managed Information System


36

Services Received by PDO Participants

Over 80 percent of PDO

participants receive personal

care as a regular service

rather than a PDO service.

Two-thirds of PDO

participants receive

homemaker services as a PDO

service.

Thirty percent of PDO

participants receive

Home Delivered Meals,

and over 20 percent use

a Personal Emergency

Response System.

Over 70 percent of PDO

participants use medical

equipment and supplies,

and 6 percent receive

transportation services.

0.0%

0.1%

0.1%

0.1%

0.9%

0.9%

5.8%

10.5%

10.9%

15.7%

22.2%

30.5%

0% 5% 10% 15% 20% 25% 30% 35%

Caregiver Training




Hospice Community



Home Accessibility Adaptation

Respite Care

Home Health Care Services

Personal Emergency Response System


0.3%

0.8%

1.5%

1.7%

5.2%

5.6%

72.1%

0% 25% 50% 75%

Respiratory Therapy

Speech Therapy


Physical Therapy


Transportation


Figure 83: Percentage of LTC Enrollees Receiving at Least One PDO Service by Service and Type, March 2014 February 2015

Figure 84: Percentage of LTC PDO Enrollees Receiving at Least One non-PDO Community Service by Service, March 2014 - February 2015

Figure 85: Percentage of LTC PDO Enrollees Receiving at Least One General Service by Service, March 2014 - February 2015

0.2%

1.2%

81.8%

11.5%

34.6%

0.6%

0.9%

3.3%

30.1%

67.1%

100% 50% 0% 50% 100%

Intermittent & Skilled Nursing

Attendant Care

Personal Care

AdultCompanion Care

Homemaker Services

Regular Service PDO Service



37

Coventry

HumanaAmerigroup


Sunshine

United

All Plans

PDO services are only available to PDO participants. Each service is the same as the corresponding non-

PDO service, except the enrollee directs the PDO service by hiring people to perform the service.

Homemaker services

are the most widely

used PDO service

among PDO

participants in six of

the seven LTC plans.

Personal care is the

most widely used

PDO service by

Amerigroup’s PDO

participants.

(0.93%)

0.0%

1.5%

3.0%

4.5%

PDO Attendant Care

(30.13%)

0%

20%

40%

60%

80%

PDO Adult Companion Care

(67.07%)

0%

20%

40%

60%

80%

PDO Homemaker Services

Figure 86: Percentage of PDO Participants Receiving PDO Homemaker Services by Plan, March 2014 - February 2015

Figure 87: Percentage of PDO Participants Receiving PDO Adult Companion Care by Plan, March 2014 - February 2015

(3.32%)0%

20%

40%

60%

80%

PDO Personal Care

(0.64%)

0.0%

1.5%

3.0%

4.5%

PDO Intermittentand Skilled Nursing

Figure 88: Percentage of PDO Participants Receiving PDO Personal Care by Plan, March 2014 - February 2015

Figure 89: Percentage of PDO Participants Receiving PDO Intermittent and Skilled Nursing by Plan, March 2014 - February 2015

Figure 90: Percentage of PDO Participants Receiving PDO Attendant Care by Plan, March 2014 - February 2015



38

Conclusion

A shift of LTC enrollees from institutional to community settings occurred from March 2014 through July

2015. At the beginning of the review period, the three largest plans – Sunshine, United, and American

ElderCare – each had a higher ratio of enrollees in institutional settings as compared to community

settings. The percentage of each plan’s enrollees living in an institutional setting was lower at the end of

the review period than at the beginning. In March 2014, more than half of LTC enrollees lived in an

institutional setting. By July 2015, less than half of enrollees were in an institutional setting. In July

2015, 42,400 LTC enrollees were living in an institutional setting and 42,863 enrollees were living in a

community setting.

Nursing facility transfers demonstrated that a larger percentage of LTC enrollees transferred out of

nursing facilities to the community than into nursing facilities from the community. Six of the seven LTC

plans transferred more enrollees from nursing facilities to the community than into nursing facilities

from the community during the review period.

LTC plans began the review period with different case mixes of enrollees. Sunshine and United had the

largest ratio of enrollees residing in nursing facilities at close to 60 percent for each plan. Less than half

of each of the other five plans’ enrollees lived in nursing facilities, although 44 percent of enrollees in

American ElderCare and Coventry lived in nursing facilities. Less than a quarter of Amerigroup’s

enrollees resided in a nursing facility, the lowest ratio for all plans. Due to the different case mix of

enrollees in each plan, plans vary in whether more of their enrollees receive institutional or community

services. Three quarters of Amerigroup’s enrollees received community services during the review

period. Over 60 percent of Sunshine’s enrollees received institutional services.

Over half of LTC enrollees received institutional services during the review period while forty-nine

percent of LTC enrollees received community services. The most widely received institutional service is

nursing facility services. Among community services, homemaker services, personal care services,

assisted living services, and home delivered meal services are the most widely received services.

Medical equipment and supply services are also widely used by LTC enrollees.

The Participant Directed Option (PDO) is a small but growing program that allows LTC enrollees who live

at home to direct their own service workers for select services. By July 2015, the PDO program had

grown to 1,956 participants. Homemaker services are the most widely received PDO service among PDO

participants.

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