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Medicaid Managed Care in Florida: Federal Approval and Implementation. Joan Alker and Jack Hoadley Georgetown University Health Policy Institute October 9, 2013. Florida’s Medicaid program. 3.3 million enrollees

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Medicaid managed care in florida federal approval and implementation

Medicaid Managed Care in Florida: Federal Approval and Implementation

Joan Alker and Jack Hoadley

Georgetown University Health Policy Institute

October 9, 2013

Florida s medicaid program
Florida’s Medicaid program Implementation

  • 3.3 million enrollees

  • Primary source of care for children, pregnant women, people with HIV/AIDS, long term care

  • Expenditures -- 31% of state budget, 18% of state general funds

  • Matching rate: 58.08%

Timeline Implementation

Approval june 14 2013
Approval June 14, 2013 Implementation

  • CMS approves statewide waiver extension with new terms; some are built off the 5-county pilot. Waiver approval period ends 6/30/2014.

Renewal j ust around the corner
Renewal: ImplementationJust around the corner

  • Because negotiations took so long, the waiver amendment term runs out 6/30/2014

  • Public comment process already under way as AHCA must submit extension request by end of the year

  • Low Income Pool for safety-net providers

    • Not addressed in negotiations, but merely extended to this date

Long term care waiver
Long term care waiver Implementation

  • Was approved on a separate track

  • Program implementation occurring now

  • Not addressed in this brief

  • Forthcoming brief and webinar, sponsored by a group of Florida funders, expected in November from Georgetown Health Policy Institute

How has florida s waiver changed
How has Florida’s waiver changed? Implementation

  • Does not affect eligibility and never did

  • Now largely about delivery system change

    • Some benefits flexibility for adults

  • Original waiver authorities and programs that are now gone

    • EPSDT waiver

    • Premiums never approved

    • Enhanced benefits program changing

    • Premium assistance

Why was a waiver still needed
Why was a waiver still needed? Implementation

  • Some populations can be required to move into managed care without a waiver

    • Others cannot: dual eligibles, children on SSI, long term care services

  • Adult benefit is based on an actuarial equivalency standard that requires a waiver (though actuarial equivalency now allowed)

  • Geographic phase-in requires a waiver

Findings on pilot program
Findings on pilot program Implementation

  • Five counties (Broward, Duval, Baker, Clay, Nassau) starting in 2006 and 2007

  • High levels of market disruption

    • Withdrawal of plans with large enrollment share

  • Little evidence on access improvement

    • Early evidence: low provider participation

  • Benefit flexibility had little effect

  • Inconclusive on whether pilot saved money

  • Opt-out program had minimal take-up

Managed care in florida today
Managed care in Florida today Implementation

  • Varying use of managed care today by different FL Medicaid populations

Who must participate
Who must participate? Implementation

  • Most Medicaid populations will be required to enroll in a managed-care plan

  • Voluntary for those:

    • With another source of health care, except Medicare

    • Age ≥65, residing in a mental health treatment facility

    • In intermediate care facility for intellectual disabilities

    • With developmental disabilities, using home& community-based services

  • Excluded are those:

    • Eligible for emergency services due to immigration status

    • Participating in family planning waiver program

    • Eligible as women with breast or cervical cancer

    • Children receiving services in a pediatric extended care facility

    • Dual eligibles, with only premium or cost-sharing assistance

What plans will be participating
What plans will be participating? Implementation

  • Bids solicited, December 2012

    • 27 plan bids, 20 organizations

  • Winners announced, September 2013

    • 6 HMOS and 4 PSNs selected for general population

    • No organization will serve all regions

    • 5 companies selected to offer specialty plans

      • Children in child welfare system, people with HIV/AIDS, severe mental illness, cardiovascular disease, COPD, congestive heart failure, diabetes

  • Some non-selected plans are protesting

Transition to the new system
Transition to the new system Implementation

  • All selected plans are in FL Medicaid today

  • But not all will continue in all regions

    • Broward County: half of current MCO enrollees will be required to select new plans

  • How will transitions and potential disruptions be addressed?

  • What role will specialty plans play?

Psns vs hmos
PSNs vs. HMOs Implementation

  • Selected PSNs: based in local hospital systems, clinics, or primary care groups

  • PSNs have been popular in pilot counties, especially for those with more health conditions and existing relationships with providers

Psns vs hmos worth monitoring
PSNs vs. HMOs – worth monitoring Implementation

  • HMOs have had higher rates of complaints

  • PSNs moving to capitation is a risk point with sicker population

What is the transition timeline
What is the transition timeline? Implementation

  • 10/31/2013: Implementation plan due, with plan for readiness review

    • Basic timeline for implementation

    • Assessment of plan capacity and solvency, access protections

  • Mid-2014: Enrollment phase-in

    • Implementation by region

    • Outreach starts 90 days in advance

    • Potential for “pauses” if issues arise

Medical loss ratio mlr
Medical loss ratio (MLR) there?

  • Requires insurers to spend a minimum percentage of premium dollars on services

  • ACA included an MLR on private insurers, but does not apply to Medicaid

  • 11 states have some kind of Medicaid MLR on some or all of their expenditures

Medical loss ratio in waiver
Medical loss ratio in waiver there?

  • FL Healthy Kids has an 85% MLR

  • Florida’s 2011 pilot waiver extension included an 85% MLR for five-county pilot

  • This was extended statewide in waiver terms and conditions approved in June

  • First and only time CMS has included an MLR in a waiver agreement

Comprehensive quality strategy
Comprehensive quality strategy there?

  • State strategy for quality improvement at state, plan, provider levels

  • Develop, adopt quality metrics; achieve at least 75th percentile of national Medicaid

  • Quality improvement projects

    • Improved prenatal care

    • Well-child visits to age of 15 months

    • Preventive dental care for children

  • Health plan report cards for consumers

Network adequacy
Network adequacy there?

  • Concern about shortages of specialists, dentists, other providers; pilot experience

  • State required to report on network policies

    • Availability of routine, urgent appointments

    • Travel time and distance standards

    • Access outside of network

    • Access for those with special needs, cultural considerations

  • This will need a lot of monitoring!

    • Secret shopper studies a good tool

Ensuring plan stability
Ensuring plan stability there?

  • Pilot experience: high rate of plan turnover

    • 11 of 14 HMOs from Year 1 later withdrew

    • But only 1 of PSNs withdrew

  • Policies in waiver

    • Five-year commitment to program

    • Penalties for withdrawal

    • Maximum number of plans per region

  • Issues to monitor

Enrollment procedures
Enrollment procedures there?

  • Letter with enrollment information

  • 30 days to select a plan

    • 90 days to change the selection

  • Those not selecting will be auto-enrolled

    • Based on history with plan or providers

    • Chance to switch away from assigned plan

  • Issues to monitor:

    • Do beneficiaries understand options?

    • How many pick? How many are auto-enrolled?

Stakeholder involvement
Stakeholder involvement there?

  • Medical Care Advisory Committee

    • Minimum of 4 beneficiaries

  • Smaller advisory committees to monitor impact on specific subpopulations

    • Persons with HIV/AIDS

    • Children, especially those in foster care

    • Children with dental care needs

    • Persons receiving behavioral health, SA services

  • Issues to monitor

Concluding thoughts
Concluding thoughts there?

  • Will imminent waiver renewal change anything?

  • Will ongoing Medicaid expansion debate intersect?

    • Future of LIP

  • Education, oversight and monitoring is essential….

For more information
For more information there?

  • Joan Alker and Jack Hoadley


    • Twitter @joanalker1

  • Georgetown University project website


  • Georgetown Center for Children and Families