medicaid managed care in florida: federal approval and implementation
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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 - PowerPoint PPT PresentationTRANSCRIPT
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Medicaid Managed Care in Florida: Federal Approval
and Implementation
Joan Alker and Jack HoadleyGeorgetown University Health Policy Institute
October 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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Timeline10/2005 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 cornero 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 waivero 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
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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, Washington34%
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 2012
o 27 plan bids, 20 organizationso Winners announced, September 2013
o 6 HMOS and 4 PSNs selected for general population
o 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 systemo All selected plans are in FL Medicaid
todayo But not all will continue in all regions
o 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. HMOso 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%PSNsHMOs
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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 reviewoBasic timeline for implementationoAssessment 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
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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 waivero 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 stabilityo 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 services
o Issues to monitor
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Concluding thoughtso 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 informationo Joan Alker and Jack Hoadley
o [email protected]; [email protected]
o Twitter @joanalker1o Georgetown University project website
o http://hpi.georgetown.edu/floridamedicaido Georgetown Center for Children and
Families http://ccf.georgetown.edu/