Medicaid Managed Care in Florida: Federal Approval

and Implementation

Joan Alker and Jack HoadleyGeorgetown University Health Policy

InstituteOctober 9, 2013

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Florida’s Medicaid program

• 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%

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Timeline

10/2005 Waiver

approved that

results in 5-county

pilot

5/2011 FL

legislation to seek

statewide waiver

8/2011 MMA and LTC waiver requests

submitted

2/2013 Long-term

care waiver

approved

6/2013 Statewide

waiver approved

8/2013 Start of

enrollment in LTC waiver

Mid-2014 Projected

start of enrollment

in MMA program

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Approval June 14, 2013o CMS approves statewide waiver extension with

new terms; some are built off the 5-county pilot. Waiver approval period ends 6/30/2014.

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Renewal: Just around the corner

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

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

o Low Income Pool for safety-net providersoNot addressed in negotiations, but merely

extended to this date

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Long term care waiver

o Was approved on a separate track o Program implementation occurring

nowo Not addressed in this briefo Forthcoming brief and webinar,

sponsored by a group of Florida funders, expected in November from Georgetown Health Policy Institute

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How has Florida’s waiver changed?

o Does not affect eligibility and never dido Now largely about delivery system change

o Some benefits flexibility for adultso Original waiver authorities and programs

that are now goneo EPSDT waivero Premiums never approvedo Enhanced benefits program changingo Premium assistance

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Why was a waiver still needed?

o Some populations can be required to move into managed care without a waiveroOthers cannot: dual eligibles, children on SSI,

long term care serviceso Adult benefit is based on an actuarial

equivalency standard that requires a waiver (though actuarial equivalency now allowed)

o Geographic phase-in requires a waiver

Findings on pilot programo Five counties (Broward, Duval, Baker, Clay,

Nassau) starting in 2006 and 2007o High levels of market disruption

o Withdrawal of plans with large enrollment shareo Little evidence on access improvement

o Early evidence: low provider participationo Benefit flexibility had little effecto Inconclusive on whether pilot saved moneyo Opt-out program had minimal take-up

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Managed care in Florida today

Population Current % in MCOsTOTAL MEDICAID POPULATION 47%TANF: Low-Income Children and Parents 63%SSI: Person receiving disability payments 47%Dually eligible for Medicare and Medicaid 9%Other populations <1%

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

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Does managed care vary by region?

Region Counties Current % in MCOs

1 Escambia, Okaloosa, Santa Rosa, Walton 28%

2 Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, Washington

34%

3 Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrest, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwanee, Union

36%

4 Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia 59%5 Pasco, Pinellas 50%

6 Hardee, Highlands, Hillsborough, Manatee, Polk 55%7 Brevard, Orange, Osceola, Seminole 53%8 Charlotte, Collier, DeSoto, Glades, Hendry, Lee, Sarasota 38%9 Indian River, Martin, Okeechobee, Palm Beach, St. Lucie 42%

10 Broward 66%11 Miami-Dade, Monroe 36%

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Who must participate?o Most Medicaid populations will be required to enroll in a

managed-care plano Voluntary for those:

o With another source of health care, except Medicareo Age ≥65, residing in a mental health treatment facilityo In intermediate care facility for intellectual disabilitieso With developmental disabilities, using home & community-based

serviceso Excluded are those:

o Eligible for emergency services due to immigration statuso Participating in family planning waiver programo Eligible as women with breast or cervical cancero Children receiving services in a pediatric extended care facilityo Dual eligibles, with only premium or cost-sharing assistance

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What plans will be participating?

o Bids solicited, December 2012o 27 plan bids, 20 organizations

o Winners announced, September 2013o 6 HMOS and 4 PSNs selected for general

populationo No organization will serve all regionso 5 companies selected to offer specialty plans

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

o Some non-selected plans are protesting

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Transition to the new system

o All selected plans are in FL Medicaid today

o But not all will continue in all regionso Broward County: half of current MCO

enrollees will be required to select new plans

o How will transitions and potential disruptions be addressed?

o What role will specialty plans play?

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PSNs vs. HMOs

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

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

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PSNs vs. HMOs in pilot counties

Children and Families People with Disabilities

59%46%

41%54%

PSNs

HMOs

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PSNs vs. HMOs – worth monitoring

• HMOs have had higher rates of complaints

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

7/12-6/13 HMOs PSNs

Enrollment 52% 48%

Complaints 75% 25%

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What is the transition timeline?

o 10/31/2013: Implementation plan due, with plan for readiness reviewo Basic timeline for implementationo Assessment of plan capacity and

solvency, access protectionso Mid-2014: Enrollment phase-in

o Implementation by regionoOutreach starts 90 days in advanceo Potential for “pauses” if issues arise

HOW WILL MANAGED CARE OPERATE? WHAT CONSUMER PROTECTIONS ARE THERE?

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Medical loss ratio (MLR)

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

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

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

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Medical loss ratio in waiver

o FL Healthy Kids has an 85% MLRo Florida’s 2011 pilot waiver extension

included an 85% MLR for five-county pilot

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

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

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Comprehensive quality strategy

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

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

o Quality improvement projectso Improved prenatal careo Well-child visits to age of 15 monthso Preventive dental care for children

o Health plan report cards for consumers

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Network adequacyo Concern about shortages of specialists,

dentists, other providers; pilot experienceo State required to report on network policies

o Availability of routine, urgent appointmentso Travel time and distance standardso Access outside of networko Access for those with special needs, cultural

considerationso This will need a lot of monitoring!

o Secret shopper studies a good tool

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Ensuring plan stability

o Pilot experience: high rate of plan turnovero 11 of 14 HMOs from Year 1 later

withdrewoBut only 1 of PSNs withdrew

o Policies in waivero Five-year commitment to programo Penalties for withdrawaloMaximum number of plans per region

o Issues to monitor

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Enrollment procedureso Letter with enrollment informationo 30 days to select a plan

o 90 days to change the selectiono Those not selecting will be auto-enrolled

o Based on history with plan or providerso Chance to switch away from assigned plan

o Issues to monitor:o Do beneficiaries understand options?o How many pick? How many are auto-enrolled?

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Stakeholder involvemento Medical Care Advisory Committee

o Minimum of 4 beneficiarieso Smaller advisory committees to monitor

impact on specific subpopulationso Persons with HIV/AIDSo Children, especially those in foster careo Children with dental care needso Persons receiving behavioral health, SA

serviceso Issues to monitor

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Concluding thoughts

o Will imminent waiver renewal change anything?

o Will ongoing Medicaid expansion debate intersect?o Future of LIP

o Education, oversight and monitoring is essential….

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For more information

o Joan Alker and Jack Hoadleyo jca25@georgetown.edu;

jfh7@georgetown.edu o Twitter @joanalker1

o Georgetown University project websiteo http://hpi.georgetown.edu/floridamedicaid

o Georgetown Center for Children and Families http://ccf.georgetown.edu/