Florida’s Medicaid Reform

Follow Up WorkshopBeneficiaries / Advocates

BrowardNovember 2, 2006

6:00 – 9:00 pm

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Introductions

Gail WilkField Office Manager

Medicaid Area 10

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Medicaid Reform Update

Thomas W. ArnoldDeputy Secretary for Medicaid

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Medicaid Reform

April – November 2004: Stakeholder meetings and Provider workshops.May 2005: Reform authorized by Florida Legislature in SB 838.October 2005: Waiver request approved by CMS.December 2005: Approved by the Legislature.July 2006: Choice counseling hotline available for beneficiaries in Broward and Duval Counties.September 2006: Enrollment began for Broward and Duval Counties.November 2006: Approximately 90,000 beneficiaries participating in Reform.

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How does Medicaid Reform Effect the Beneficiary?

Coordinated Systems of Care (HMOs and PSNs).

Health Plan Choices.

Customized Benefit Packages.

Option to Opt-out of Medicaid into Employer Sponsored Health Plan.Premium Based Financing.

Choice Counseling.

Enhanced Benefits Accounts.

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Coordinated Systems of Care:Types of Reform Plans

Health Maintenance Organization (HMO):A Health Maintenance Organization (HMO) is an entity licensed under Chapter 641, Florida Statutes.

The Agency contracts with HMOs on prepaid a fixed monthly rate per member (e.g. capitation rate) for which the HMO assumes all risk for providing covered services to their enrollees.

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Coordinated Systems of Care:Types of Reform Plans

Provider Service Network (PSN):Provider Service Network (PSN) is defined in 409.912, Florida Statutes as a network established or organized and operated by a health care provider, or group of affiliated health care providers, which provides a substantial proportion of the health care items and services under a contract directly through the provider or group of affiliated providers.

Under Reform, PSN's may be reimbursed on a capitated or fee-for-service basis for up to three years.

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HMOs in Broward County:– AMERIGROUP.– Buena Vista.– HealthEase.– Humana.– Preferred Medical Plan.– Staywell.– Total Health Choice.– UnitedHealthcare.– Vista Healthplan of South Florida.

PSNs in Broward County:– Florida NetPass.– Pediatric Associates.– Access Health Solutions.– South Florida Community Care Network.

Health Plan Choices:Current Reform Plans

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Health Plan Choices:Current Reform Plans

HMOs Duval County:– HealthEase.– UnitedHealthcare.– Staywell.

PSNs in Duval County:– Access Health Solutions.– Shands Jacksonville d/b/a First Coast Advantage.

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Enrollment in Reform Plans

Beneficiaries enrolled in Reform Plans:– 7,604 beginning September 1, 2006;– 39,916 beginning October 1, 2006;– Approximately 40,000 beginning November 1,

2006.Approximately 90,000 beneficiaries now enrolled in reform plans.Enrollment by County as of November 1, 2006:– Approximately 53,000 in Broward County.– Approximately 37,000 in Duval County.

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Enrollment in Reform Plans

Anticipated total enrollment of approximately 210,000 beneficiaries in Broward and Duval Counties.

Eligible beneficiaries not yet enrolled in a Reform plan will be phased in by April 1, 2007.

Enrollment of new eligibles monthly thereafter.

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Customized Benefit Packages

Levels of amount, scope and duration are flexible.– Certain services must be provided at least to current

State Plan coverage levels.– Other services must be provided at least to meet

benefit sufficiency standards.– Remaining services must be offered, but amount,

scope and duration are flexible. Reform plans have enhanced services above current State Plan levels.Reform plans have added services not currently covered under the State Plan.

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Customized Benefit PackagesNew services offered by reform health plans include:– Over-the-counter drug benefit from $10-$25 per

household, per month.– Adult Preventative Dental, including x-rays, cleanings

and fillings.– Acupuncture/Medicinal Massage.– Additional Adult Vision – up to $125 per year for

upgrades such as scratch resistant lenses.– Additional Hearing – up to $500 per year for upgrades

to digital, canal hearing aid.– Home-delivered meals for a period of time after

surgery, providing nutrition essential for proper recovery for the elderly and disabled.

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The Opt-Out program

If you are employed by a company that offers health insurance, you will have the choice of applying your premium towards the purchase of this insurance.The state will pay up to the amount it would have paid a Medicaid Plan for the employee’s share of the premium.Families can combine premiums to purchase family coverage through their employer.

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The Opt-Out program

You may enroll in your employer’s plan at any time, even after you enroll in a reform health plan.If you Opt-Out, you will still have the option to reenroll in Medicaid at the time of your Medicaid open enrollment period, your employer’s open enrollment period, or due to loss of your job.This option is completely voluntary.Program is up and running and beneficiaries are participating.Contact your Choice Counselor for more information.

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Risk Adjusted Rates

Risk Adjusted Rates:

– A process to predict health care expenses based on chronic diagnoses.

– Better matches payment to risk.

– Pay for the risk enrolled.

– Risk Adjusted rates are now being paid to Reform Plans.

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Florida Medicaid Reform Choice Counseling

Scott EttaroOutreach Manager, ACS

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ACS Call Center ActivitiesJuly 24 – October 19, 2006

51,163 Inbound calls.

13,473 Outbound calls.

Average talk time 8.2 minutes.

844 calls abandoned.

No calls blocked.

Average time in queue was 126.1 seconds.

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Voluntary Enrollment Rates (October 1, 2006 effective date)

New Eligibles:– 68 percent made a voluntary choice.– Contract standard was 65 percent.

Uncommitted MediPass:– 78 percent made a voluntary choice.

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Reasons for Choice

Tracked the top 4 reasons for choice.

The percentage of calls by reason:

– Provider: 65.6%.

– Co-Pay: 16.5%.

– Hospital: 6.6%.

– Pharmacy Benefit: 11.2%.

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Beneficiary Focus Groups

Purpose: To allow beneficiaries who have accessed Choice Counseling to provide feedback on their experience. When:– October 17 in Duval County.– October 26 in Broward County.

Topics Covered:– Materials.– Choice Counseling Experience.– Information Provided.– Provider Selection.– Benefit Package Information.– Information Choice Counselor could not provide.

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Choice Counseling

Public Seminars.

Private Seminars.

One-on-One Counseling.

Home Visits.

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Choice Counseling

ACS Field Activities July 24 - September 30, 2006:

– Group Sessions 816– Private and One on One Sessions 205

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Outreach Activities

Field visits to beneficiaries without phone service.

Telephone follow up with beneficiaries who have received a mandatory plan assignment to ensure they are aware of their option to choose.

Participation in Health Fairs.

Media campaign.

Flyer Distribution.

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Community Based Organizations

Choice Counselors are presently involved with the following Community Based Organizations in Broward County providing ongoing counseling and enrollment services:– Minority Development and Empowerment Inc. – Hope Outreach Center.– Susan B. Anthony Recovery Center.– South Regional Family Success Center.– Mt. Olive Development Corp.– Henderson Mental Health.– Family Success Refugee Services Center.

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Ongoing Weekly Counseling

Regularly Scheduled weekly sessions with Choice Counselors are held in Broward County :

– Sunshine Health Center.

– Broward Community and Family Health Center.

– 7th Avenue Family Health Center.

– Department of Children & Families: Sheridan Street.

– Department of Children & Families: Plantation.

– Memorial Primary Care.

– Coast to Coast Legal Aid.

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Break

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Enhanced Benefits Account Program

Michele HudsonSMA Supervisor

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Enhanced Benefits Account Program

Goal: Promote more involvement in leading Healthy Lifestyles.

Healthy Behaviors that lead to positive outcomes and better health will be rewarded.

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Enhanced Benefits Overview

The program began September 1, 2006.

Beneficiaries may earn up to a maximum of $125 per year in “credit dollars.”

“Credit dollars” may be used to purchase health related OTC products and supplies.

The current Medicaid Gold card can be used to access the accounts and may be used at any Medicaid participating pharmacy.

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Enhanced Benefits Account Program: Getting Involved

Brochure and introductory letter sent to all beneficiaries once enrolled in a Reform plan.

Statements with information about credits earned and used will be mailed at least once a month.

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Enhanced Benefits Account Program: Who is eligible

Everyone enrolled in a Florida Medicaid Reform Health Plan is eligible to earn and use credits in the Enhanced Benefits Program.

There is no application process.

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Enhanced Benefits Account Program: How do you earn credits?

Earn credits by taking part in Healthy Behaviors.

Healthy behaviors may be offered by:– Your Reform Health Plan,– Community center,– Other not-for-profit organization.

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Enhanced Benefits Account Program:Approved Healthy Behaviors and Credits

Claims Data or Universal Form

Claims Data

Claims Data

Claims Data

Claims Data

Claims Data

Claims Data

Claims Data

Claims Data

Reporting Process

2$ 15.00 Adult Dental Exam

1$ 25.00 Adult Vision Exam

1$ 25.00 Colorectal Screening

1$ 25.00 PAP Smear

1$ 25.00 Mammogram

2$ 15.00 Keeps all primary care appointments

Annual Occurrence Limit

Credit Amount Per OccurrenceAdults: Behavior Name

$ 25.00 Keeps all primary care appointments

$ 25.00 Childhood wellness visitAny combination, up to

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$ 25.00 Childhood preventive care (age-appropriate screenings and immunizations)

1$ 25.00 Childhood vision exam

2$ 25.00 Childhood dental exam

Annual Occurrence Limit

Credit Amount Per OccurrenceChildren: Behavior Name

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Claims Data

Claims Data or Universal Form

Universal Form

Universal Form

Universal Form

Universal Form

Universal Form

Universal Form

Universal Form

Universal Form

Universal Form

Reporting Process

4$7.50 Compliance with prescribed maintenance medications

1$25.00 Flu Shot when recommended by physician

2$15.00 Exercise program 6 month success

1$25.00 Exercise program participation

2$15.00 Weight loss program 6 month success

1$25.00 Weight loss program participation

2$15.00 Smoking cessation program 6 month success

1$25.00 Smoking cessation program participation

2$15.00 Alcohol and/or drug treatment program 6 month success

1$25.00 Alcohol and/or drug treatment program participation

1$ 25.00 Disease management participation

Annual Occurrence

LimitCredit Amount Per OccurrenceALL: Behavior Name

Enhanced Benefits Account Program:Approved Healthy Behaviors and Credits

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Enhanced Benefits Account Program:

How do you buy items using your credits?

At any participating Medicaid pharmacy:– You must provide:

• Florida Medicaid ID number;• Medicaid Gold Care, AND• Picture ID.

– Take items to the pharmacy counter for check out.

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Enhanced Benefits Account Program:

What can you buy with the credits you earn?

Approved health related items such as:– First aid supplies,– Cough and cold medication,– Dental supplies, and – Many other over the counter items.

Where can you use your credits?Any Florida Medicaid participating pharmacy.

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Enhanced Benefits Account Program: Approved Health Related Products and Supplies

Toothpaste, Tooth brushes, Mouthwash, Floss, etc.Dental Supplies

Vitamin A, Vitamin B, Vitamin C, Multi-vitamin tablet(s), Stress B tablet(s)Vitamin

Summers Eve Cream, VagasilTopical Vaginal

Clotrimazole, Desenex, LamisilTopical Antifungal

Sunscreens, medicated shampoos, lotionTopical

Arthritis Relief Gloves, Arch Supports, Heating PadOrthopedic aids

Simple Saline, Sinus Nasal SprayNose

Phillip's Milk of Magnesia, Metamucil Fiber WaferLaxatives

Antacids, Pepto-Bismol, Prilosec OTCGastrointestinal

Bandages, braces, ointmentsFirst Aid Products

Visine, Refresh, Tears NaturaleEye

Debrox, Ear drops, Nurine ear dropsEar

Cough and Cold Medications that require a prescription and are not covered by MedicaidCough and Cold by Rx only

Cough and Cold Medications that do not require a prescriptionCough and Cold OTC

Advil, AspirinAnalgesics/anti-inflammatory agents

ExamplesCategory

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Enhanced Benefits Account Program:

Four Easy Steps to Earn credits:

1. Participate in approved healthy behavior.2. Your health plan reports the behavior to the Agency.3. The Agency approves the credit, updates the

account and mails you a statement.4. You may begin using the credits you have earned!

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Enhanced Benefits Call Center:

The call center will be able to provide the following information:– General information about the program.– Send out brochures and universal forms.– List of approved healthy behaviors.– List of approved products available for purchase under

the program.– Specific account information, including balance and

recent transactions.

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Enhanced Benefits Call Center:

Contact Information:– Beneficiaries may contact the call center at:

1-866-421-8474

– Or visit the Medicaid Reform Website at:

http://ahca.myflorida.com/Medicaid/medicaid_reform/index.shtml

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Florida’s Medicaid Reform

Questions and Answers