evaluation of florida’s...component 4, evaluation questions and hypotheses this report addresses...

Contract MED180

Evaluation of Florida’s

Managed Medical Assistance (MMA) Program

Demonstration:

Project 3 Final Interim Report

Contract Deliverable No. 13, Managed Medical Assistance

Final Interim Report – Project 3 DY10: Component 4, Low Income Pool (LIP) Evaluation

Presented to:

Prepared by:

Department of Health Outcomes and Biomedical Informatics College of Medicine University of Florida

and Department of Behavioral Sciences and Social Medicine

College of Medicine Florida State University

April 13, 2018

Prepared by: 2 Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida Department of Behavioral Sciences & Social Medicine, College of Medicine, Florida State University

Contract MED180 Evaluation of Florida’s Managed Medical Assistance (MMA) Program Demonstration

Table of Contents

Executive Summary ...................................................................................................... 1

Introduction ................................................................................................................................ 1

Background and Methods .......................................................................................................... 1

Key Findings .............................................................................................................................. 2

Introduction ................................................................................................................... 3

Background ................................................................................................................... 3

Component 4, Evaluation Questions and Hypotheses .............................................. 4

Data and Methods ......................................................................................................... 4

Results ........................................................................................................................... 6

Research Question 4A ............................................................................................................ 6

Research Question 4B ...........................................................................................................10

Summary and Conclusions ........................................................................................ 17

References ................................................................................................................... 18

Appendix. DY10 MMA Evaluation Components and Research Questions ............. 19

List of Tables

Table 1. Number of Individuals Served and Change in Number of Individuals Served by

Reporting Hospital Providers, DY9 and DY10 ...........................................................................10

Table 2. Number of Encounters for Specific Services and Percentage Change in Number of

Encounters Reported by Hospital Providers in DY9 and DY10 ..................................................14

Table 3. Number of Hospitals Providing Specific Services in DY9 and DY10 ...........................17

List of Figures Figure 1. Number of Individuals Served by Reporting Hospital Providers in DY9 and DY10....... 9

Figure 2. Number of Encounters for Specific Services Reported by Hospital Providers in DY9

and DY10 ..................................................................................................................................12

Figure 3. Number of Hospitals Providing Specific Services in DY9 and DY10 ...........................16

List of Acronyms

Agency Agency for Health Care Administration CMS Centers for Medicare and Medicaid Services CY Calendar Year DY Demonstration Year FPL Federal Poverty Level LIP Low Income Pool MMA Managed Medical Assistance MUP Medically Underserved Populations SFY State Fiscal Year SMMC Statewide Medicaid Managed Care STC Special Terms and Conditions UC Uncompensated Care



Executive Summary

Introduction

The purpose of the Low Income Pool (LIP) program is to ensure continuing support for the safety-net providers that furnish uncompensated care (UC) to Florida’s Medicaid, uninsured, and underinsured populations. More specifically, the LIP extends government support to safety-net providers for providing uncompensated care to low-income individuals eligible for charity care or those without insurance (Florida Agency for Health Care Administration 2017, p.29).

This document reports on Project 3 of the Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) Program waiver evaluation and focuses on the LIP program from July 2015 through June 2016. The report addresses the impact of LIP funding on access to care for Medicaid, uninsured, and underinsured individuals as required under the Centers for Medicare & Medicaid Services (CMS) Special Terms and Conditions for the waiver amendment approved in December 2017. The report also provides information relevant to the two Demonstration Year 10 (DY10) research questions associated with Component 4 of the evaluation of Florida’s MMA program:

4A. What is the impact of LIP funding on access to care for Medicaid, uninsured, and underinsured recipients served in hospitals? That is, how many Medicaid, uninsured, and underinsured recipients receive services in LIP-funded hospitals?

4B. What types of services are being provided to Medicaid, uninsured, and underinsured

recipients receiving care in LIP-funded hospitals?

Background and Methods

Florida’s Low Income Pool (LIP) program was implemented on July 1, 2006 as part of a broad Medicaid Reform demonstration project. The LIP program consists of a capped annual allotment (the “pool”) funded primarily by intergovernmental transfers from local governments matched by federal funds.

In October 2015, CMS authorized amendments related to the LIP program for the period of July 1, 2015 through June 30, 2016. During this period, the state authorized supplemental funding for hospitals to provide stability and offset uncompensated care costs with a maximum amount of $1 billion (Florida Agency for Health Care Administration, 2015).

Florida’s Agency for Health Care Administration (the Agency) provided data on the facilities, payments, and reporting documents used to analyze the impact of LIP funding on access to care and the provision of healthcare services to underserved populations such as Medicaid, uninsured, and underinsured individuals in DY10. The analysis included the number of individuals served, the types of services provided, and the number of encounters for all hospital providers receiving LIP supplemental payments that had submitted milestone data as of December 2016. To make meaningful comparisons to the number of individuals served and services provided by hospitals in DY9, this report is based on data for 134 hospital providers that received LIP funding in DY10 (SFY 2015–16). For Component 4, the evaluation team



performed an independent review and analysis of documentation related to the DY10 LIP Milestone Statistics and Findings Report.

Key Findings

In DY10, the 134 hospitals that received LIP supplemental payments for Medicaid, uninsured, and underinsured individuals reported approximately

713,000 individuals served in inpatient settings (9 percent increase from DY9)

3.9 million individuals served in outpatient settings (8 percent increase from DY9)

15.7 million service encounters across six service categories (discharges,

inpatient days, emergency room visits, outpatient visits, affiliated encounters, and

filled prescriptions).

From DY9 to DY10, hospital providers that received LIP supplemental funding in either year for Medicaid, uninsured, and underinsured individuals reported

An 8 percent increase in the total number of individuals served in inpatient and

outpatient settings.

A 12 percent increase in the total encounters for specific hospital services.



Introduction

Project 3 is part of the Florida Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) Program Evaluation, conducted by the Department of Health Outcomes and Biomedical Informatics in the College of Medicine at the University of Florida, the Department of Behavioral Sciences and Social Medicine at Florida State University, and the Department of Health Services Administration at the University of Alabama-Birmingham.

This report presents the findings from Component 4, “The impact of LIP funding on hospital charity care programs.” For DY10, the research team evaluated two research questions focused on types of services provided to Medicaid recipients and uninsured and underinsured individuals receiving care in LIP-funded hospitals; and the impact of LIP funding on access to care for Medicaid, uninsured and underinsured individuals served in hospitals. Component 4 has four additional research questions that will be addressed starting in DY11. All the research questions for Project 3 and all the components and research questions for the DY10 MMA evaluation are presented in the Appendix.

Background

Florida’s Low Income Pool (LIP) program was implemented on July 1, 2006 as part of a broad Medicaid Reform demonstration project. The LIP program consists of a capped annual allotment (the “pool”) funded primarily by intergovernmental transfers from local governments matched by federal funds.

In October 2015, CMS authorized amendments related to the LIP program for the period of July 1, 2015 through June 30, 2016. During this period, the state authorized supplemental funding for hospitals to provide stability and offset uncompensated care costs with a maximum amount of $1 billion (Florida Agency for Health Care Administration, 2015).

In DY9, the evaluation team assessed the impact of LIP funding and Tier One Milestone Initiatives on access to care, the provision of health services to uninsured or underinsured populations and population health. The evaluation found that, overall, LIP funding and Tier One Milestone Initiatives:

Increased access to and utilization of services for pregnant women, children, Hispanic, and migrant populations, individuals with poor dental health, persons with chronic medical and behavioral health conditions such as diabetes, hypertension, congestive heart failure (CHF) and asthma, among others.

Increased access to and utilization of outpatient primary care services, specialty services, and dental services in both urban and rural locations for patients with limited access to care. For instance, approximately three-quarters of the Tier-One initiatives were located in or increased access to services in urban areas of Florida, including Miami-Dade, Broward, Palm Beach, Hillsborough, Pinellas, and Brevard counties. Rural areas in which access to services increased included Franklin, Liberty, and Walton counties among others.

Provided primary medical, dental, behavioral health, care coordination, and disease management services to approximately 83,300 recipients. Four of the Tier-One



Milestone initiatives that were specifically designed to encourage outpatient service use (as opposed to seeking care in the emergency department) saw more than 600 patients in DY9. In addition, there were more than 255,000 visits for primary medical, dental, and behavioral services for underserved patients.

One of the Tier-One programs that increased access to primary care by expanding clinic hours had approximately 23,000 medical encounters in DY9.

Component 4, Evaluation Questions and Hypotheses

This report addresses Project 3 (Component 4 ) and the associated research questions concerning LIP funding as part of Florida’s MMA evaluation for Demonstration Year (DY) 10 (SFY 2015-16).

For DY10, the state is evaluating the impact of LIP funding on access to care for Medicaid uninsured and underinsured individuals. Beginning in DY11, the evaluation team will evaluate the impact of LIP funding on access to care for uncompensated charity care recipients.

Research Questions:

The following questions are addressed in the evaluation of DY10 (SFY 2015-16):

4A. What is the impact of LIP funding on access to care for Medicaid, uninsured, and underinsured recipients served in hospitals? That is, how many Medicaid, uninsured, and underinsured recipients receive services in LIP-funded hospitals?

Hypothesis 4A. There will be no impact of LIP funding on access to care for Medicaid, uninsured, and underinsured recipients served in hospitals.

4B. What types of services are being provided to Medicaid, uninsured, and underinsured recipients receiving care in LIP-funded hospitals?

Research question 4B is included to provide context (description of types of services provided thorough LIP) for this component. Therefore, there is no hypothesis to test for this research question.

Data and Methods

The Agency provided data on the facilities, payments, and reporting documents used to report on the impact of LIP funding on access to care and the provision of health care services to underserved populations such as Medicaid, uninsured, and underinsured individuals in DY10. The analysis included data on the number of individuals served, the types of services provided, and the number of encounters for all hospital providers receiving LIP supplemental payments that had submitted milestone data as of December 2016. To make meaningful comparisons to the number of individuals served and services provided by hospitals in DY9, this report is based on data for 134 hospital providers that received LIP funding in DY10 (SFY 2015-16). The evaluation team conducted an independent review and analysis of documentation related to the DY10 LIP Milestone Statistics and Findings Report.



Key terms used throughout this report are defined as follows:

Individuals served: The most comprehensive measure of services is the number of individuals served. Hospitals must provide an unduplicated count of individuals served in the following categories: Medicaid (inpatient and outpatient) and uninsured/underinsured (inpatient and outpatient). In addition to including information separately for Medicaid and uninsured/underinsured, this report uses the number of “Medicaid, uninsured, and underinsured” individuals as a summary measure.

Medicaid: Enacted in 1965 through amendments to the Social Security Act, Medicaid is a health care and long-term care coverage program that is jointly financed by states and the federal government. Each state establishes and administers its own Medicaid program and determines the type, amount, duration, and scope of services covered within broad federal guidelines. States must cover certain mandatory benefits and may choose to provide other optional benefits.

Federal law also requires states to cover certain mandatory eligibility groups, including qualified parents, children, and pregnant women with low income, as well as older adults and people with disabilities with low income. States have the flexibility to cover other optional eligibility groups and set eligibility criteria within the federal standards. The Affordable Care Act of 2010 creates a new voluntary national Medicaid minimum eligibility level that covers most Americans with household income up to 133 percent of the Federal Poverty Level (FPL). This new eligibility requirement is effective January 1, 2014, but states may choose whether or not to expand coverage before this date [or at all] (Centers for Medicare & Medicaid Services, 2013).

Services provided: Information about the type and amount of specific services provided is also important in understanding the link between LIP payments and the provision of health services to Medicaid, uninsured, and underinsured patients. For hospitals, measures of services provided include hospital discharges, hospital inpatient days, emergency care encounters, outpatient encounters, affiliated encounters, primary care or preventive care clinic visits, specialist visits, surgical care furnished in a physician’s office, home health services, durable medical equipment, prosthetic or orthotic devices not associated with outpatient therapy visits, nursing home care, and the number of prescriptions filled. For each type of service, the amount provided is reported separately for Medicaid and uninsured or underinsured individuals, then aggregated to a total summary measure of services provided to Medicaid, uninsured, and underinsured individuals.

Underinsured: These are persons without third-party coverage for a particular service rendered on the date(s) of service captured within a defined cost reporting period. This means a patient had third-party coverage, but the particular service provided was not covered as part of the individual’s benefit package. For example, a patient had insurance coverage for inpatient hospital services but his or her covered benefit package did not include outpatient hospital services. In this example, the individual would be considered insured for any inpatient hospital services received. This person would be considered underinsured for any outpatient hospital services received and, accordingly, costs associated with a particular outpatient hospital service could be included (to the extent it was otherwise eligible) as a cost when calculating underinsured uncompensated care costs for the LIP. Similarly, a patient with coverage in which a lifetime or annual benefit cap is applied would be considered underinsured for services furnished beyond that cap. Before reporting any expenditure as an eligible cost in calculating the uncompensated care for the underinsured for the purpose of claiming LIP funding, the State



expects providers to employ their standard practices for billing and payment collection from any individual and/or legally liable third-party payer for services provided. The cost of uncompensated care specifically excludes charges/cost associated with any unpaid service costs, including unpaid deductible and coinsurance amounts for services covered by a patient’s insurance plan. While these amounts may be written off as bad debts or charity care, they are not eligible costs that may be claimed through the LIP. In reporting a patient’s liability, the provider must distinguish between amounts due for copays and deductibles and amounts due for services not covered by a third-party payer. The cost of uncompensated care eligible for the LIP may not include any cost shortfalls for services covered by other liable third parties (Florida Agency for Health Care Administration, 2012, pp. 6-7).

Underserved: Medically Underserved Populations (MUPs), or the “underserved,” are specific sub-groups of populations living in a defined geographic area with a shortage of primary care health services. These groups of individuals may face economic, cultural, or linguistic barriers to health care (HRSA, 2016).

Uninsured: Persons with no source of third-party coverage on the date of service captured within a defined cost reporting period (Florida Agency for Health Care Administration, 2012, p. 6).

Results

Results focus on the numbers of individuals served in both Medicaid and uninsured/underinsured categories by type of service (e.g., discharges and outpatient visits for hospital services), along with the number of reporting providers by type who receive LIP funds.

Research Question 4A

What is the impact of LIP funding on access to care for Medicaid, uninsured, and underinsured recipients served in hospitals? That is, how many Medicaid, uninsured, and underinsured recipients receive services in LIP-funded hospitals?

Number of Individuals Served

As shown in Figure 1 and Table 1, the 134 reporting hospitals out of 135 hospital providers that received LIP supplemental payments in DY10 reported providing inpatient and outpatient services to those with Medicaid, the uninsured, and underinsured as follows:

Medicaid

Inpatient services were provided to approximately 404,000 individuals.

Outpatient services were provided to approximately 2.1 million individuals.

Uninsured and Underinsured





Total Medicaid, Uninsured and Underinsured


Outpatient services were provided to approximately 4 million individuals.

Overall inpatient and outpatient services were provided to approximately 4.7 million

individuals.

Also shown in Table 1, in DY9, 124 hospitals that received LIP supplemental payments reported providing inpatient and outpatient services to those with Medicaid, the uninsured, and underinsured as follows:

Medicaid






Total Medicaid, Uninsured, and Underinsured



Overall inpatient and outpatient services were provided to approximately 4.3 million

individuals.

Table 1 also provides a summary of the change in the number of individuals served from DY9 to DY10 for all reporting hospitals.

Medicaid

From DY 9 to DY 10:

The number of Medicaid individuals served by hospital providers in inpatient settings

increased by approximately 26,000 (7 percent).

The number of Medicaid individuals served in outpatient settings increased by

approximately 165,000. (9 percent)


From DY9 to DY10:

The number of uninsured and underinsured individuals served by reporting hospital

providers on an inpatient basis increased by approximately 31,000 (11 percent).

The number of uninsured and underinsured individuals served by reporting hospital

providers on an outpatient basis increased by approximately 143,000 (8 percent).



Total Medicaid, Uninsured, and Underinsured

For both inpatient and outpatient services, from DY9 to DY10, the total number of

Medicaid, uninsured, and underinsured individuals served increased by approximately

366,000 (8 percent).



Figure 1. Number of Individuals Served by Reporting Hospital Providers in DY9 and DY10*

* The number of individuals served in DY9 and DY10 are not mutually exclusive.



Table 1. Number of Individuals Served and Change in Number of Individuals Served by Reporting Hospital Providers, DY9 and DY10

DY9 DY10 DY9 to DY10

Service Type and Payer Number of

Individuals

Served

Number of

Hospitals

Reporting

Number of

Individuals

Served

Number of

Hospitals

Reporting

Change in

Number of

Individuals

Served

Percent

Change in

Number of

Individuals

Served

INPATIENT

Medicaid

377,983 124 404,187 133 26,204 7%

Uninsured/Underinsured 277,067 123 308,641 134 31,574 11%

Total Medicaid,

Uninsured, and

Underinsured

655,050 124 712,828 134 57,778 9%

OUTPATIENT

Medicaid 1,929,912 124 2,095,272 134 165,360 9%

Uninsured/Underinsured 1,741,932 124 1,884,943 134 143,011 8%

Total Medicaid,

Uninsured, and

Underinsured

3,671,844 124 3,980,215 134 308,371 8%

TOTAL INPATIENT & OUTPATIENT

Medicaid 2,307,895 124 2,499,459 134 191,564 8%

Uninsured/Underinsured 2,018,999 124 2,193,584 134 174,585 9%

Total Medicaid,

Uninsured, and

Underinsured

4,326,894 124 4,693,043 134 366,149 8%

Note: Calculations based only on hospitals reporting both milestone data for DY9 and DY10 and nonzero services provided by given

category.

Research Question 4B

What types of services are being provided to Medicaid, uninsured, and underinsured recipients receiving care in LIP-funded hospitals?

This section describes the volume and types of services provided to those with Medicaid, and uninsured or underinsured individuals by reporting hospital providers that received LIP supplemental funding. Specific services include discharges, inpatient days, emergency care services, hospital-based outpatient services, affiliated services (primary care or preventive care clinic visits, specialist visits, surgical care furnished in a physician’s office, home health services, durable medical equipment, prosthetic or orthotic devices not associated with outpatient therapy visits, and nursing home care), and prescriptions filled.

Hospital Encounters

The analysis of hospital service encounters does not include all services provided to Medicaid, uninsured, and underinsured individuals in Florida. Only those services for which the provider received a LIP supplemental payment in DY10 and submitted milestone data as of December 2016 are included in the analysis.



Figure 2 and Table 2 present the number and change in the number of encounters for specific services reported by hospital providers in DY9 and DY10. In DY10, for all categories of encounters, 134 reporting hospitals receiving LIP payments provided approximately 15.7 million encounters for specific services.

Hospitals reported almost 879,000 encounters for discharges for Medicaid, uninsured, and underinsured individuals in DY10, an increase of approximately 42,000 encounters (5 percent) compared to DY9. When measured in terms of inpatient days, reporting hospitals provided approximately 3.8 million days in total to Medicaid, uninsured, and underinsured individuals in DY10, approximately 193,000 (5 percent) more than the number provided in DY9.

In DY10, reporting hospitals provided approximately 4.3 million emergency room encounters to Medicaid, uninsured, and underinsured individuals, nearly 461,000 (12 percent) more than in DY9.

Reporting hospitals also provided approximately 3.2 million encounters for outpatient services to Medicaid, uninsured, and underinsured individuals in DY10, about 432,000 (15 percent) more than in DY9. In DY10, hospital providers reported approximately 2.0 million encounters for affiliated services, including primary care/preventive care clinic visits, specialist visits, surgical care furnished in a physician’s office, home health services, durable medical equipment, prosthetic/orthotic devices (not associated with outpatient therapy visits), and nursing home care (skilled or intermediate), an increase of approximately 425,000 encounters (26 percent) from DY9.

Approximately 1.3 million filled prescriptions were furnished to Medicaid, uninsured, and underinsured individuals in DY10—about 138,000 (12 percent) more prescriptions than the number filled in DY9. Overall, hospital providers reported an increase of more than 1.6 million (12 percent) in total encounters for all services, with approximately 717,000 (11 percent) more encounters for individuals that were uninsured and underinsured in DY10 compared to DY9.



Figure 2. Number of Encounters for Specific Services Reported by Hospital Providers in DY9 and DY10



Figure 2 (cont’d). Number of Encounters for Specific Services Reported by Hospital Providers in DY9 and DY10



Table 2. Number of Encounters for Specific Services and Percentage Change in Number of Encounters Reported by Hospital Providers in DY9 and DY10

Services

Total

Encounters

DY9

Total

Encounters

DY10

Change in

Number of

Encounters

DY9 to

DY10

Percent

Change in

Number of

Encounters

DY9 to

DY10

DISCHARGES

Medicaid 491,943 500,308 8,365 2%

Uninsured and Underinsured 344,812 378,457 33,645 10%

Total Medicaid, Uninsured, and

Underinsured 836,755 878,765 42,010 5%

INPATIENT DAYS

Medicaid 2,230,442 2,310,506 80,064 4%

Uninsured and Underinsured 1,440,858 1,553,512 112,654 8%


Underinsured 3,671,300 3,864,018 192,718 5%

EMERGENCY ROOM ENCOUNTERS

Medicaid 2,246,194 2,476,739 230,545 10%



Underinsured 3,857,774 4,319,483 461,709 12%

OUTPATIENT ENCOUNTERS

Medicaid 1,360,864 1,731,937 371,073 27%



Underinsured 2,814,172 3,246,654 432,482 15%

AFFILIATED ENCOUNTERS

Medicaid 1,046,898 1,290,043 243,145 23%



Underinsured 1,623,886 2,048,978 425,092 26%

NUMBER OF PRESCRIPTIONS FILLED

Medicaid 302,264 344,265 42,001 14%



Underinsured 1,204,060 1,342,833 138,773 12%



TOTAL ENCOUNTERS FOR ALL SERVICES

Medicaid 7,678,605 8,653,798 975,193 13%



Underinsured 14,007,947 15,700,731 1,692,784 12%

Hospital Services

Types of Services

Each facility that received LIP funding for the corresponding year is required to report to the Agency certain outpatient and affiliated services provided. Outpatient care includes diagnostic X-ray and laboratory services; surgical care in an outpatient facility; outpatient facility care; and speech, physical, and occupational therapies. The affiliated services hospitals must report primary care or preventive care visits, specialist visits, surgical care services in a provider’s office, home health care, durable medical equipment, prosthetic and orthotic devices, and nursing home care. In addition to the data reported by hospitals previously mentioned in this report, hospitals are required to supply a list of any other services provided using LIP funds.

Proportion of Facilities that Provide Each Type of Service

In DY9 and DY10, 124 and 134 hospitals, respectively, provided certain outpatient and affiliated services. Figure 3 and Table 3 display the proportion of reporting facilities that provided specific types of services. Among hospital outpatient care services, approximately 99 percent of the reporting facilities in DY10 and 98 percent in DY9 provided diagnostic laboratory and radiology services. For outpatient speech, physical, and occupational therapy services, 96 percent of facilities provided these services in DY10 compared to 94 percent in DY9. Approximately 73 percent and 82 percent of reporting hospitals receiving LIP payments in DY10 indicated providing outpatient surgeries and outpatient facility care, respectively, an increase of 3 percentage points for both types of services compared to DY9.

For affiliated services, 38 percent of the reporting hospitals in DY10 and DY9 provided primary care or preventive care clinic visits. In DY10, 32 percent of the reporting facilities provided specialist visits and 27 percent of hospital facilities indicated providing surgical care services in physicians’ offices, an increase of 2 percentage points and 3 percentage points from DY9, respectively. In DY10, 20 percent of hospitals provided home health services, a decrease of 1 percentage point from DY9. Ten percent of reporting hospitals provided durable medical equipment in DY10, an increase of 1 percentage point from DY9. Prosthetic or orthotic devices (not associated with outpatient therapy visits) were provided by 12 percent of the reporting facilities in DY10, a decrease of 5 percentage points from DY9. Ten percent of the hospitals provided nursing home care (skilled or intermediate) services in DY10, a 2 percentage point increase from DY9.



Figure 3. Number of Hospitals Providing Specific Services in DY9 and DY10



Table 3. Number of Hospitals Providing Specific Services in DY9 and DY10

Hospital-Affiliated Services Hospital Outpatient Care

Pri

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ry C

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/

Pre

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tive

Ca

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Vis

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Sp

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Vis

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Th

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s

Number of Hospitals

Providing Services,

DY9 (N=124) 47 37 30 26 11 21 10 121 87 98 117

Percent of Reporting

Hospitals 38% 30% 24% 21% 9% 17% 8% 98% 70% 79% 94%

Number of Hospitals

Providing Services,

DY10 (N=134)

51 43 36 27 13 16 13 132 98 110 128

Percent of Reporting

Hospitals

38% 32% 27% 20% 10% 12% 10% 99% 73% 82% 96%

Note: Calculations based only on hospitals that (1) received a LIP payment (2) reported milestone data in DY10 (n = 134) or DY9 (n

= 124), and (3) reported nonzero services provided for a given category.

Summary and Conclusions

In DY10, the 134 hospitals that received LIP supplemental payments for Medicaid, uninsured, and underinsured individuals reported approximately

713,000 indiviudals served in inpatient settings (9 percent increase from DY9).

3.9 million individuals served in outpatient settings (8 percent increase from

DY9).

An 8 percent increase in the total number of individuals served (inpatient and

outpatient).

15.7 million total service encounters across six service categories (12 percent

increase from DY9).

Both the DY9 and DY10 MMA evaluations documented increases in the total number of individuals served and in total service encounters (across six service categories) in hospitals that received LIP funding. These findings suggest that the LIP program has had a positive impact on access to care for Medicaid, uninsured, and underinsured recipients served in hospitals.



References Centers for Medicare & Medicaid Services. (2013). Medicaid. Retrieved from

http://medicaid.gov/

Florida Agency for Health Care Administration. (2014) Centers for Medicare & Medicaid

Services special terms and conditions. Approved July 31, 2014. Tallahassee, FL. Retrieved

from

http://www.fdhc.state.fl.us/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waive

rs/docs/mma/SpecialTermsandConditionsCMSApprovedJuly312014.pdf

Florida Agency for Health Care Administration. (2015). Centers for Medicare & Medicaid

Services special terms and conditions. CMS amended October 15, 2015. Tallahassee, FL.

Retrieved from

http://ahca.myflorida.com/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waiver

s/docs/mma/FL_MMA_STCs_CMS_Approved_2015-10-15.pdf

Florida Agency for Health Care Administration. (2017). Centers for Medicare & Medicaid

Services special terms and conditions. CMS amended December 21, 2017. Tallahassee, FL.

Retrieved from

http://ahca.myflorida.com/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waiver

s/docs/mma/FL_MMA_STCs_CMS_APPROVED_2017-12-21.pdf.

Health Resources and Services Administration (HRSA). HRSA Health Workforce. Medically

Underserved Areas and Populations (MUA/Ps). (2016). Retrieved from

https://bhw.hrsa.gov/shortage-designation/muap.

http://medicaid.gov/

http://www.fdhc.state.fl.us/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/mma/SpecialTermsandConditionsCMSApprovedJuly312014.pdf

http://www.fdhc.state.fl.us/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/mma/SpecialTermsandConditionsCMSApprovedJuly312014.pdf

https://bhw.hrsa.gov/shortage-designation/muap



Appendix. DY10 MMA Evaluation Components and

Research Questions

Component Research Questions

1. The effect of managed care on access to care, quality and efficiency of care, and the cost of care

1A. What barriers do enrollees encounter when accessing primary care and preventive services? 1B. What changes in the accessibility of services occur with MMA implementation, comparing the accessibility in pre-MMA implementation plans (Reform plans and 1915(b) waiver plans) to MMA plans? 1C. What changes in the utilization of services for enrollees are evident post-MMA implementation, comparing: 1) utilization of services in the pre-MMA period (FFS, Reform plans and pre-MMA 1915(b) waiver plans) to utilization of services in post-MMA implementation; 2) utilization of services in specialty MMA plans versus standard MMA plans for enrollees eligible for enrollment in a specialty plan (e.g., enrollees with HIV or SMI) who are enrolled in standard MMA plans versus enrollees in the specialty plans? 1D. What changes in quality of care for enrollees are evident post MMA implementation, comparing: 1) quality of care in pre-MMA implementation plans (Reform plans and 1915(b) waiver plans) to quality of care in MMA plans in the MMA period; 2) quality of care in specialty MMA plans versus standard MMA plans for enrollees eligible for enrollment in a specialty plan (e.g. enrollees with HIV or SMI) who are enrolled in standard plans versus enrollees in the specialty plans (to the extent possible)? 1E. What strategies are standard MMA and specialty MMA plans using to improve quality of care? Which of these strategies are most effective in improving quality and why? 1F. What changes in timeliness of services occur with MMA implementation, comparing timeliness of services in pre-MMA implementation plans (Reform plans and 1915(b) waiver plans) to post-MMA implementation plans? 1G. What is the difference in per-enrollee cost by eligibility group pre-MMA implementation (FFS,



Reform plans and pre-MMA 1915(b) waiver plans) compared to per-enrollee costs in the MMA period (MMA plans as a whole, standard MMA plans and specialty MMA plans)?

2. The effect of customized benefit plans on beneficiaries’ choice of plans, access to care, or quality of care

Note: Since the MMA plans do not offer customized benefit plans, the state will evaluate the effect of expanded benefits on enrollees’ utilization of services, access to care, and quality of care.

2A. What is the difference in the types of expanded benefits offered by standard MMA and specialty MMA plans? How do plans tailor the types of expanded benefits to particular populations? 2B. How many enrollees utilize expanded benefits and which ones are most commonly used? 2C. How does Emergency Department (ED) and inpatient hospital utilization differ for those enrollees who use expanded benefits (e.g. additional vaccines, physician home visits, extra outpatient services, extra primary care and prenatal/perinatal visits, and over-the-counter drugs/supplies) vs. those enrollees who do not? 2D. How do enrollees rate their experiences and satisfaction with the expanded benefits that are offered by their health plan?

3. Participation in the Healthy Behaviors programs and its effect on participant behavior or health status

3A. What Healthy Behaviors programs do MMA plans offer? What types of programs and how many are offered in addition to the three required programs (the medically approved smoking cessation program, the medically directed weight loss program, and the medically approved alcohol or substance abuse treatment program)? 3B. What incentives and rewards do MMA plans offer to their enrollees for participating in Healthy Behaviors programs? 3C. How many enrollees participate in each Healthy Behaviors program? How many enrollees complete Healthy Behaviors programs? Which types of Healthy Behaviors programs attract higher numbers of participants? 3D. How does participation in Healthy Behaviors programs vary by gender, age, race/ethnicity and health status of enrollees (DY13 and beyond)? 3E. What differences in service utilization occur over the course of the demonstration for enrollees participating in Healthy Behaviors programs versus enrollees not participating (DY13 and beyond)?



4. The impact of LIP funding on hospital charity care programs

4A. What is the impact of LIP funding on access to care for Medicaid, uninsured, and underinsured recipients served in hospitals? That is, how many Medicaid, uninsured, and underinsured recipients receive services in LIP-funded hospitals? 4B. What types of services are being provided to Medicaid, uninsured, and underinsured recipients receiving care in LIP-funded hospitals? 4C. What is the impact of LIP funding on access to care for uncompensated charity care recipients served in hospitals? That is, how many uncompensated charity care recipients receive services in LIP-funded hospitals? How does this compare among hospitals in different tiers of LIP finding? 4D. What types of services are being provided to uncompensated charity care recipients receiving care in LIP-funded hospitals? 4E. What is the difference in the type and number of services offered to uncompensated charity care patients in hospitals receiving LIP funding? 4F. What is the impact of LIP funding on the number of uncompensated charity care patients served and the types of services provided in FQHCs, RHCs, and medical school physician practices?

5. The effect of having separate managed care programs for acute care and LTC services on access to care, care coordination, quality, efficiency of care, and the cost of care1

5A. How many enrollees are enrolled in separate Medicaid managed care programs for acute (medical) care and LTC services? 5B. How many enrollees are enrolled in comprehensive plans for both acute (medical) care and LTC services? 5C. Are there differences in service utilization, as well as in the appropriateness of service utilization (to the extent this can be measured), between enrollees who are in a comprehensive plan for both MMA and LTC services versus those who are enrolled in separate MMA and LTC plans?

6. The impact of efforts to align with Medicare and

6A. How many MMA enrollees are also Medicare recipients (dual-eligibles) and to what extent do dual-

1 Component 5 will sunset following the evaluation of DY12 (SFY 2017-18).



improving beneficiary experiences and outcomes for dual-eligible individuals

eligible enrollees utilize behavioral health and non-emergency transportation services? 6B. What specific care coordination strategies and practices are most effective for ensuring access to and quality of care for behavioral health services and non-emergency transportation services for dual-eligible enrollees? 6C. How do dual-eligible enrollees rate their experience and satisfaction with delivery of care they received related to behavioral health and non-emergency transportation services?

7. The effectiveness of enrolling individuals into a managed care plan upon eligibility determination in connecting beneficiaries with care in a timely manner

7A. How quickly do new enrollees access services, including expanded benefits in excess of State Plan covered benefits, after becoming Medicaid eligible and enrolling in a health plan? 7B. Among new enrollees, what is the time to access services for enrollees who are enrolled under Express Enrollment compared to enrollees who were enrolled prior to the implementation of Express Enrollment?

8. The effect the Statewide Medicaid Prepaid Dental Health Program has on accessibility, quality, utilization, and cost of dental health care services

8A. How does enrollee utilization of dental health services vary by age, gender, race/ethnicity, and geographic area? 8B. What changes in dental health service utilization occur with the implementation of the Statewide Medicaid Prepaid Dental Health Program?

8C. What changes in quality of dental health services occur with the implementation of the Statewide Medicaid Prepaid Dental Health Program? 8D. What changes in the accessibility of dental services occur with the implementation of the Statewide Medicaid Prepaid Dental Health Program? 8E. What barriers do enrollees encounter when accessing dental health services? 8F. How many enrollees utilize expanded benefits provided by the dental health plans and which ones are most commonly used?

8G. How does enrollee utilization of dental health services impact dental-related hospital events (e.g., Emergency Department, Inpatient hospitalization)?



How does utilization of expanded benefits offered by the dental health plans impact dental-related hospital events? 8H. What changes in per-enrollee cost for dental health services occur with the implementation of the Statewide Medicaid Prepaid Dental Health Program? 8I. How do enrollees rate their experiences and satisfaction with dental health services, including timeliness of dental health services, provided by their dental health plans? 8J. How do enrollees rate their experiences and satisfaction with the expanded benefits offered by their dental health plans?

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