florida medicaid: looking forward to 2019

Florida Medicaid: Looking

Forward to 2019

Tom WallaceAssistant Deputy Secretary for Medicaid

Finance and Data, Florida MedicaidJanuary 29, 2019

Presentation Overview

• Florida Medicaid and Phase two of the Florida Statewide Medicaid Managed Care Program – Pushing Towards New Quality Goals: 2019-2023

• Completing Florida Medicaid’s Transition to Prospective Payment Methodologies to Align With Managed Care System.

• Supplemental Funding Streams for Medicaid Participating Hospitals

• Continued Focus on Opioid Coverage and Treatment

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Florida Medicaid – A Snapshot

Eligibles

• Fourth largest Medicaid population in the nation.

• Approximately 4 million Floridians enrolled in the Medicaid program:

o 1.7 million adults - parents, aged and disabled

o 47% of children in Florida.

o 63% of birth deliveries in Florida.

o 61% nursing home days in Florida.

Expenditures• Fifth largest nationwide in Medicaid expenditures.

• $26.8 billion expenditures in Fiscal Year 2017-18

o Federal-state matching program

o 61.62% federal, 38.38% state.

o Average spending: $6,619 per eligible.

• $17.5 billion expenditure for managed care in 2017-2018

Delivery System • Statewide Medicaid Managed Care program implemented in

2013-2014

o Most of Florida’s Medicaid population receives their

services through a managed care delivery system.3

Florida’s Statewide Medicaid Managed

Care Programs

What is Changing?

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2013SMMC Program

Begins(5 year contracts with

plans)

2017-2018First Re-procurement

of Health Plans; Procurement of

Dental Plans

December 2018New

Contracts (MMA, LTC & Dental) Begin

Two Program Components:

• Managed Medical Assistance (MMA) Program

• Long-term Care (LTC) Program

Two Program Components:

• Integrated MMA and LTC• Dental

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New SMMC Program Goals

The Agency has established goals to build on the success of the SMMC program and to ensure continued quality improvement:

Reduce potentially preventable hospital

events (PPEs):

Admissions

Readmissions

Emergency department visits

Improve birth outcomes:

Reduce Primary C-Section Rate

Pre-term Birth Rate

Rate of Neonatal Abstinence Syndrome

Increase the percentage of enrollees receiving

long-term care services in their own home or the community instead of a

nursing facility

Regional Benchmarks: Potentially Preventable Events

Potentially Preventable Admissions (PPAs)

Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

Region 7

Region 8

Region 9

Region 10

Region 11 Average

Year 1 % Reduction -17.22% -9.75% -9.84% -10.68% -5.28% -16.74% -13.00% -8.46% -4.00% -12.57% -17.49% -11.37%

Overall % Reduction -23.65% -19.02% -20.25% -24.14% -24.05% -25.15% -23.82% -18.44% -14.89% -21.74% -29.87% -22.28%

* PPAs per 1,000 Enrollee Months

Potentially Preventable Readmissions (PPRs)

Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

Region 7

Region 8

Region 9

Region 10

Region 11 Average

Year 1 % Reduction -5.76% -7.91% -7.78% -8.21% -6.78% -9.45% -6.15% -7.21% -5.00% -5.51% -9.58% -7.21%


* PPRs per 1,000 Hospital Admissions

Potentially Preventable Emergency Room Visits

(PPVs)Region

1Region

2Region

3Region

4Region

5Region

6Region

7Region

8Region

9Region

10Region

11 Average

Year 1 % Reduction -2.79% -1.05% -2.37% -0.93% -5.78% -1.19% -2.36% -2.45% -2.50% -2.51% -2.28% -2.38%

Overall % Reduction -16.06% -12.19% -14.30% -14.04% -21.00% -11.01% -13.91% -10.61% -11.87% -14.10% -16.45% -14.14%* PPVs per 1,000 Enrollee Months

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Regional Benchmarks: Birth Outcomes

Primary C-sectionRegion

1Region

2Region

3Region

4Region

5Region

6Region

7Region

8Region

9Region

10Region

11 Average

Year 1 % Reduction -8.94% -2.60% -2.01% -2.05% -2.26% -2.12% -2.07% -1.43% -3.22% -4.65% -3.61% -3.18%


Pre-term DeliveryRegion

1Region

2Region

3Region

4Region

5Region

6Region

7Region

8Region

9Region

10Region

11 Average

Year 1 % Reduction -2.65% -1.95% -1.82% -2.49% -1.91% -1.80% -2.23% -1.29% -1.87% -5.72% -1.68% -2.31%


Neonatal Abstinence Syndrome (NAS)

Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

Region 7

Region 8

Region 9

Region 10

Region 11 Average

Year 1 % Reduction -2.49% -2.25% -2.81% -4.12% -5.25% -2.22% -2.49% -1.82% -2.55% -2.25% -2.01% -2.75%


* NAS per 1,000 live births

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LTC Plans Commit to Higher Performance

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LTC Transitions to Community

The law requires that base rates be adjusted to provide an incentive for plans to transition enrollees from nursing facilities (NF) to the community (HCBS).

Current Contracts

Required Transition Incentive Until 35% NF

LTC Plans Commit to Higher Performance

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LTC Transitions to Community

Negotiated New Benchmarks:

New Contracts

Required Transition Incentive Until 25% NF

NF25%

HCBS75%

Gains for Recipients

Health Plans Dental Plans

Access to Care When you Need it:Double the primary care providers in each network

Access to Care When you Need it: Guaranteed access to after hours care and telemedicine where available

Improved Transportation: New level of accountability with benchmarks to ensure recipients arrive and are picked up from appointments in a timely manner.

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Gains for Recipients


Best Benefit Package Ever: Additional benefits at no extra cost to the state. More than 55 benefits offered by health plans and extensive adult dental benefits offered by dental plans.

Model Enrollee Handbook: Information and content has been standardized across all health plans’ enrollee handbooks for greater ease of use.

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Gains for Providers


Better Pay: More pediatric physicians will be eligible to receive Medicare level of reimbursement through the Medicaid Physician Incentive Program

Less Administrative Burden:High performing providers can bypass prior authorization

Less Administrative Burden: Plans will complete credentialing for network contracts in 60 days

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Gains for Providers


Prompt Authorization of Services: Health plans will provide authorization decisions: • Within 7 days of receipt of standard request.• Within 2 days of an expedited request.

Smoother Process for Complaints, Grievances, and Appeals: Health plans agreed not to delegate any aspect of the grievance system to subcontractors.

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SMMC Plan Roll Out Schedule

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SMMC Health and Dental Plan Roll-out Schedule

Transition DateRegions Included

Counties

Phase 1 December 1, 2018

9 Indian River, Martin, Okeechobee, Palm Beach, St. Lucie

10 Broward

11 Miami-Dade, Monroe

Phase 2 January 1, 2019

5 Pasco, Pinellas

6 Hardee, Highlands, Hillsborough, Manatee, Polk

7 Brevard, Orange, Osceola, Seminole

8 Charlotte, Collier, DeSoto, Glades, Hendry, Lee, Sarasota

Phase 3 February 1, 2019

1 Escambia, Okaloosa, Santa Rosa, Walton

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

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

4 Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia

Florida’s Statewide Medicaid Managed Care

Programs

• Next Steps?

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Florida Medicaid: Completing the Transition to

Prospective Payment Systems

Transition to Prospective Payment Systems

• Historically, under the Medicaid program, rates for institutional providers, such as hospitals and nursing homes, are set on a facility specific basis, based on each facility’s reported costs.

• Florida has transitioned major institutional providers to prospective payment systems to better align with the managed care environment.

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•

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Provider Type Methodology Implemented

Date

Legislative

Direction

Received

Date

Implemented

Inpatient Hospital Diagnosis Related Groups 2012 July 1, 2013

Outpatient HospitalEnhanced Ambulatory

Payment Groups2016 July 1, 2017

Nursing HomeNursing Home Prospective

Payment System (NPPS)2017

October 1,

2018

Hospital Inpatient Payment Method

• Utilize one DRG base rate:

1. Apply a provider policy adjustor for:

• Rural hospitals,

• Long-Term Care Acute Care (LTAC) hospitals,

• Hospitals with unusually high percentage of their inpatient utilization coming from Medicaid recipients and a high percentage of stays hitting an outlier status

2. Apply automatic rate enhancements through supplemental payments (outside of the base rate) - $265 million for 28 providers in SFY 2018-2019

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Hospital Outpatient Payment Method

• Utilize two EAPG base rates (one for hospitals and one for ASCs)

1. Apply a provider policy adjustor for:

• Rural hospitals,

• Hospitals with unusually high percentage of their inpatient utilization coming from Medicaid recipients and a high percentage of stays hitting an outlier status

2. Apply automatic rate enhancements through supplemental payments (outside of the base rate) - $53 million for 26 providers in SFY 2018-2019

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Medicaid Nursing Facility Reimbursement

• Florida Medicaid reimburses 61% of Florida nursing facility days.

• Rates are facility-specific, all inclusive, per diems that reimburse for all necessary care and services including:

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Nursing Facility Services include:

Room and Board Medical supplies

On-site physician services Dietary services

General nursing services Rehabilitative services

Personal hygiene care and items

Social services

Laundry Activity services

Medicaid Nursing Facility Prospective Payment System

• The Nursing Facility Prospective Payment System includes the following components effective October 1, 2018:

– Patient Care

– Quality Incentive

– Fair Rental Value

– Additional Factors:

• Supplemental Add-On

• Transitional Period

• Exempt Providers

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• Next Steps?

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Medicaid Hospital Supplemental

Payments

Supplemental Payments

• Low Income Pool (LIP)

• Disproportionate Share Hospital (DSH)

• Graduate Medical Education (GME)

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LIP: How it Works

• Local government entities put money into the pool through Intergovernmental Transfers (IGTs).

– The Agency draws matching funds from the federal government based on the Federal Medical Assistance Percentage.

• The Agency distributes the combined local and federal funds to qualified providers based on a legislatively approved distribution model.

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History of LIP Funding

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State Fiscal Year (SFY) Total LIP Allotment

SFY 2006-2007 through SFY

2013-2014$ 1 billion

SFY 2014-2015 $ 2.17 billion

SFY 2015-2016 $ 1 billion

SFY 2016-2017 $ 608 million

SFY 2017-2018 $1.5 billion

SFY 2018-2019 $1.5 billion

Special Terms and Conditions:

Additional Flexibility• Providers that can participate:

– Hospitals– Federally Qualified Health Centers and Rural Health Clinics– Medical School Faculty Physician Practices– Community Behavioral Health providers

• Each group may be divided in up to five tiered subgroups, any of which may be based on:

– Ownership

• Publically Owned, Privately Owned, statutory teaching, and freestanding children’s hospital status

– Uncompensated Charity Care Ratio

– Combination of ownership and Uncompensated Charity Care ratio

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Participation Requirements

• All providers must be enrolled in Medicaid

• Hospitals must:

– Contract with:

– At least 50% of the standard Medicaid health plans in their region.

– At least one Medicaid specialty plan for each target population that is served by a specialty plan in their region.

– Participate in the Encounter Notification System

– Have at least 1% Medicaid utilization

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Participation Requirements

• Medical School Physician Practices:

– Must participate in the Florida Medical Schools Quality Network.

– Must have at least 1% Medicaid utilization.

• Federally Qualified Health Centers/Rural Health Clinics:

– Must contract with at least 50 % of the health plans in their region.

• Community Behavioral Health Providers

– Must be a designated Central Receiving System.

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Disproportionate Share Hospital

• There are currently eight DSH categories in Florida:

– Public DSH

– Provider Service Network DSH

– Graduate Medical Education DSH

– Family Practice DSH

– Specialty DSH

– Mental Health DSH

– Rural DSH

– Specialty Hospitals for Children DSH

• Currently there are 74 Hospitals participating.

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Graduate Medical Education

• Graduate Medical Education (GME) consists of two programs.• Statewide Medicaid Residency Program is established to

improve the quality of care and access to care for Medicaid recipients, expand graduate medical education on an equitable basis, and increase the supply of highly trained physicians statewide.– Funded by General Revenue and the Medical Care Trust

Fund.• Startup Bonus Program provides funding to hospitals with

newly accredited physician residency positions or programs in the statewide supply-and-demand deficit specialties or subspecialties.– Funded by IGTs and the Medical Care Trust Fund.– Began in SFY 2013-2014

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Medicaid Hospital Supplemental Payments

• Next Steps?

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Florida Medicaid: Opioid Coverage and

Treatment

Coverage of Pain Management

• The Florida Medicaid program covers:

– A variety of opioids to treat the therapeutic needs of recipients.

– Alternative Pain Management Services such as chiropractic services and physical therapy.

– Health Plans provide additional services through our Expanded Benefits program, including massage therapy, acupuncture, and additional chiropractic services to treat pain and outpatient detoxification services

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Coverage of Opioids

• Florida Medicaid covers a variety of opioids to ensure providers have options to treat the therapeutic need of recipients.

• These drugs are listed on the Florida Medicaid Preferred Drug List (PDL).

• In general, drugs on the PDL do not require prior authorization. Health plans must follow the PDL.

• As it relates to opioids, the Agency requires prior authorization for some controlled substances. Some examples of opioids that require prior authorization are Morphine Extended Release, OxyContin, and Methadone.

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Treatment for Opioid Addiction

• Florida Medicaid covers medicine that reverses an opioid overdose including Narcan or its generic equivalent

• Administration of these drugs is covered in a hospital setting. Narcan and Naloxone are also available to recipients who are prescribed Narcan or Naloxone by a physician, ARNP, or physician assistant.

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• Most Florida Medicaid recipients are enrolled in the MMA program and receive their care through a health plan. These plans are required to cover the services listed below:– Psychiatric physician services – Individual, group, and family therapy services – Assessment services – Support/rehabilitative services – Mental health targeted case management– Inpatient hospital services (psychiatric and medical detoxification services)– Substance abuse county match services– Medication-assisted treatments (MAT)

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• Medication-Assisted Treatment

– Florida Medicaid covers medically necessary MAT services delivered in state licensed programs that are certified by the federal Substance Abuse and Mental Health Services Administration.

– The Agency has a number of options available for MAT on the current Preferred Drug List (PDL).

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Florida Medicaid: Opioid Coverage and Treatment

• Next Steps?

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Transforming Medicaid Systems

Transforming Medicaid Systems

• Centers for Medicare & Medicaid Services (CMS) issued a rule in 2016 requiring states to follow a modular approach to Medicaid Information Technology (IT) acquisition. To accomplish this goal, the Agency selected a Strategic Enterprise Advisory Services (SEAS) Vendor.

• Encouraged by the CMS modular rule, the state and Agency responded to the changing health care and technology trends and initiated plans to replace the existing monolithic Florida Medicaid Management Information System (FMMIS) with a modular IT system.

• This Multi-year project is known as Florida Health Care Connections, or “FX”.health care and technology trends and initiated plans to replace the existing monolithic Florida Medicaid Management Information System (FMMIS) with a modular IT system.

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TRANSFORMING AHCA THROUGH MODULARITY

Agency leadership recognized the need to leverage the Medicaid modular infrastructure to improve overall Agency functionality and build better connections to other data sources and programs and rebranded this transformation as Florida Health Care Connections (FX).

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➢ Smaller system components to:

▪ Upgrade components with fewer enterprise-

wide disruptions

▪ Avoid vendor lock-in

➢ Greater vendor choice to:

▪ Source best-in-class solutions to meet

specific requirements

▪ Benefit from market innovation

▪ Receive higher levels of service

DESIRED OUTCOMES FROM MODULARITYCURRENT STATE

Questions?

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Email questions to the SMMC Inbox at [email protected]

mailto:[email protected]

florida medicaid: looking forward to 2019

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