Florida Medicaid and Managed Care

Justin M. Senior Deputy Secretary for Medicaid

Agency for Health Care Administration May 7, 2013

Florida Medicaid – A Snapshot

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Expenditures

•  $20.7 billion estimated spending in Fiscal Year 2012-13 •  Federal-state matching program – 57.73% federal, 42.27% state. •  Florida will spend approximately $6,208 per eligible in Fiscal Year

2012-2013. •  42% of all Medicaid expenditures cover hospitals, nursing homes,

Intermediate Care Facilities for the Developmentally Disabled (ICF/DD’s); Low Income Pool and Disproportionate Share Payments.

•  10% of all Medicaid expenditures cover drugs. •  Fifth largest nationwide in Medicaid expenditures.

•  New York, California, Texas and Pennsylvania spend more.

Eligibles

•  3.35 million eligibles. •  Elders, disabled, families, pregnant women, children in families below

poverty. •  Fourth largest Medicaid population in the nation.

•  California, New York and Texas have higher enrollment.

Providers/Plans •  Approximately 76,000 Fee-For-Service providers; 29 Medicaid Managed Care plans (20 HMOs and 9 PSNs).

Florida Medicaid and Managed Care •  Managed Care has existed as a delivery system in Florida since the

mid-1980s. •  47% of recipients currently receive their care through a managed

care plan. (Includes those enrolled in HMOs, PSNs and Nursing Home Diversion)

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Medicaid  Enrollment    As  of  April  2013  

%  of  Total  Enrollment  

HMO   1,226,484   37.5%  

PSN          283,594   8.7%  

Nursing  Home  Diversion  (NHD)  

         18,425      .56%  

MediPass  (PCCM)        588,548   18.1%  

Fee-­‐for-­‐Service   1,195,587   36.58%  

Current Acute Care Managed Care

•  Managed Care in Florida is operated under two waivers •  1915(b) Managed Care waiver

•  1,194,606 enrollees •  1115 Medicaid Reform Demonstration waiver

•  317,335 enrollees

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Current Long-term Care Managed Care: Nursing Home Diversion (NHD) Program

•  Operates under 1915(c) waiver authority. •  Services are provided by managed care plans. •  Eligibility - Medicaid Institutional Care Program,

Medicare parts A & B, and meet additional clinical impairment criteria

•  Services - Case management, and 20 other home and community-based services, 11 acute care services, Medicare co-payments and co-insurance, and unlimited nursing facility care

•  20 NHD plans offering services in 66 of Florida’s 67 counties.

Statewide Medicaid Managed Care Program

•  In 2011, the Florida Legislature created a new program: Statewide Medicaid Managed Care (SMMC) •  Chapter 409, Part IV, Florida Statutes

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Statewide  Medicaid  Managed  Care  Program  

Key  Components:   Managed  Medical  Assistance  Program    

(2014)  

 Long-­‐term  Care  (LTC)  Program    

(Implemented  First)    (2013)  

SMMC: Selecting Managed Care Plans

•  Statutorily required to select Managed care plans through a competitive bid process (Invitation to Negotiate)

•  Plans must bid separately for Long-term Care and Managed Medical Assistance programs

•  State is divided into 11 regions

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Walton

Holmes

Wakulla

MadisonLeon

Gadsden

Jackson

Bay

Liberty

Gulf Franklin

Taylor

Lafayette

Hamilton

Baker

Nassau

Duv al

Flagler

Putnam

Clay

Dixie Alachua

Lev yMarion

Volusia

Citrus Lake

Orange

Seminole

OsceolaPolk

Pasco

Manatee Hardee

HighlandsSt. Lucie

SarasotaDe Soto

Charlotte Glades

Martin

LeeHendry Palm Beach

CollierBroward

Dade

Hernando

Region 4

Region 2

Region 1

Region 5

Region 3Region 7

Region 11

Region 9

Region 10

Region 6

Region 8

Region 1: Escambia, Okaloosa, Santa Rosa, and Walton Region 2: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington Region 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suw annee, and Union Region 4: Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia Region 5: Pasco and Pinellas Region 6: Hardee, Highlands, Hillsborough, Manatee, and Polk Region 7: Brevard, Orange, Osceola, and Seminole Region 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota Region 9: Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie Region 10: Brow ard Region 11: Miami-Dade and Monroe

Statewide  Medicaid  Managed  Care  Region  Map  

Federal Authorities and ITN for LTC Program

•  Obtained a 1915(b) and 1915(c) combination waiver. •  To identify and allow qualified individuals to receive

home and community based care services in lieu of nursing home care services.

•  To enroll individuals in managed care plans statewide, and to allow for selective contracting of those plans.

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Seven Plans Selected for Participation in LTC Managed Care Program

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 Region  

Healthcare  Plans  American  Eldercare,  Inc.  

Amerigroup  Florida,  Inc.  

Coventry  Health    Plan    

Humana  Medical  Plan,  Inc.    

Molina  Healthcare  of  Florida,  Inc.    

Sunshine  State  Health  Plan  

United  Healthcare  of  Florida,  Inc.    

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

LTC Timelines: Recipient Enrollment Schedule

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Region  Plan  Readiness  

Deadline  Enrollment  EffecDve  

Date  Total  Eligible  PopulaDon  

7   May  1,  2013   August  1,  2013   Region  7:  9,338  

8  &  9   June  1,  2013   September  1,  2013  Region  8:  5,596;  Region  9:  7,854  Total  =  13,450  

2  &  10   August  1,  2013   November  1,  2013  Region  2,  4058;  Region  10,  7,877  Total  =  14,853  

11   September  1,  2013   December  1,  2013   Region  11:    17,257  

5  &  6   November  1,  2013   February  1,  2014  Region  5:  9,963;  Region  6,  9,575  Total  =  19,538  

1,  3  ,  4   December  1,  2013   March  1,  2014  Region  1:  2,973;    Region  3:  6,911;  Region  4:  9,087  Total  =  18,971  

Program Enrollment: •  Individuals must enroll in LTC managed care if they are 18

and older and enrolled in: •  Nursing Facility

•  Aged and Disabled Adult Waiver

•  Consumer-Directed Care Plus for individuals in the A/DA waiver

•  Assisted Living Waiver

•  Channeling Services for Frail Elders Waiver

•  Nursing Home Diversion Waiver

•  Frail Elder Option

•  Waivers listed above will end with implementation of the SMMC program

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Covered Services

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Adult  companion  care       Hospice      

Adult  day  health  care       Intermi\ent  and  skilled  nursing      

Assisted  living       Medical  equipment  and  supplies      

Assis_ve  care  services       Medica_on  administra_on      

A\endant  care       Medica_on  management      

Behavioral  management       Nursing  facility      

Care  coordina_on/Case  management       Nutri_onal  assessment/Risk  reduc_on      

Caregiver  training       Personal  care      

Home  accessibility  adapta_on     Personal  emergency  response  system  (PERS)    

Home-­‐delivered  meals       Respite  care      

Homemaker       Therapies,  occupa_onal,  physical,  respiratory,  and  speech    

Transporta_on,  non-­‐emergency  

SMMC Impact on Assisted Living Facilities (ALF) and & Adult Family Care Homes (ADCH) •  ALFs are eligible to provide Assisted Living Service. •  AFCHs are eligible to provide Assistive Care

Services. •  ALFs & AFCHs will bill managed care plans for

service payments based upon terms of subcontract with the plan.

•  Managed care plans must offer a contract to any ALF that was billing for Medicaid waiver services as of July 2012.

•  After the first year of contract, plans can exclude ALFs for not meeting quality or performance standards.

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Program Enhancements: Increased Recipient and Provider Predictability

•  Five year contracting period - less confusion for providers and recipients.

•  Penalties for plan withdrawals. •  Maintenance of role of critical community-based

providers (ADRCs and Aging Network providers). •  Parameters for payments to certain providers

(nursing facilities, hospice). Parameters for participation of certain providers (nursing facilities, hospice)

Program Enhancements: Case Management, PDO, and Expanded Benefits

•  New services and options such as: •  Case Management for nursing facility residents •  Participant Directed Option

•  Plans are offering expanded benefits. •  Some expanded benefits include adult dental

services, over the counter medication, additional nursing home transition services, and non-medical transportation.

Program Enhancements: Incentives for Home and Community Based Care

•  The law requires that managed care plan rates be adjusted annually to provide an incentive to shift services from nursing facilities to community based care.

•  Payment incentives are in place until no more than 35% of the plan’s enrollees are in institutional settings.

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Provider Participation Requirements

•  Although health plans may limit the providers in their networks based on credentials, quality indicators, and price, plans are required to offer initial contracts to certain providers within their region.

•  During the first year of the program, each selected plan must offer a network contract to all nursing facilities, hospices and aging network services providers in their region. Examples of aging network service providers include, but are not limited to, home health, durable medical equipment, therapy, and homemaker providers.

•  After 12 months of active participation in a health plan’s network, the plan may exclude any of the providers listed above from the network for failure to meet quality or performance criteria.

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Participation of Nursing Facilities and Hospices

Nursing facilities and hospices that are enrolled Medicaid providers must participate in all eligible plans selected by the Agency in the region in which the provider is located [Section 409.982(2), F.S.].

Plans are required to pay nursing homes an amount equal to the nursing facility-specific payment rates set by the Agency; however, higher rates mutually acceptable to the plan and the provider may be negotiated for medically complex care.

Plans shall pay hospice providers through a prospective system for each enrollee an amount equal to the per diem rate set by the Agency.

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Program Challenges •  Home-Like Environment requirements

•  Requires providers that serve Medicaid recipients in the community maintain home and community-based characteristics, which includes person-centered services and a home-like environment

•  Community Integration •  Access to the greater community is facilitated by the ALF or

AFCH based on the resident’s abilities, needs and preferences •  The ALF or AFCH setting must offer meaningful community

participation opportunities for their residents at times, frequencies and with persons of their choosing

•  Timing of Transition •  Plan terminations and transitions

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Resources

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  Questions can be emailed to: FLMedicaidManagedCare@ahca.my!orida.com

  Information about the Long-term Care procurement is available via the Florida Vendor Bid System: http://my!orida.com/apps/vbs/vbs_www.main_menu

  Updates about the Statewide Medicaid Managed Care program are posted at: http://ahca.my!orida.com/SMMC

  Upcoming events and news can be found on the “News and Events” tab on the SMMC website.

a.  Keep up to date on information by signing up to receive program updates by clicking the red “Sign Up for Program Updates” box on the right hand side of the page.

  For information about the enrollment process and enhanced bene"ts of each plan, recipients and enrollees may visit http://wwwFLMedicaidManagedCare.com.

You can find more information on the SMMC program at:

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Youtube.com/AHCAFlorida  

Facebook.com/AHCAFlorida  

Twi\er.com/AHCA_FL