medicaid managed care in florida: federal approval and implementation
DESCRIPTION
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
Medicaid Managed Care in Florida: Federal Approval
and Implementation
Joan Alker and Jack HoadleyGeorgetown University Health Policy Institute
October 9, 2013
2
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%
3
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
4
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.
5
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
6
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
7
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
8
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
10
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
11
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%
12
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
13
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
14
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?
15
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
16
PSNs vs. HMOs in pilot counties
Children and Families People with Disabilities
59% 46%
41% 54%PSNsHMOs
17
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%
18
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
HOW WILL MANAGED CARE OPERATE? WHAT CONSUMER PROTECTIONS ARE THERE?
19
20
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
21
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
22
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
23
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
24
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
25
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?
26
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
27
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….
28
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/