FLORIDA MEDICAID REFORM

Facts and Flaws Impact on Consumers

Communities & Providers

Why Medicaid Reform Act for Florida

Medicaid Reform proposal by the Governor was based on the rising costs in the budget.

Florida Legislature passed SB 838 in the 2005 session that allowed the Agency for Health Care Administration, AHCA, to apply for a Section 1115 demonstration & research waiver from the federal government that would allow the state the flexibility to change Medicaid outside of current federal rules.

Facts about Medicaid Costs in Florida

Medicaid costs are lower and are growing at less that half the rate of private health insurance on a per-person basis.

Administrative costs for Medicaid are about 5% compared to and average of 15% in the private sector.

Florida’s Medicaid growth has decreased from an aggregate 12.5% annually over a five year period down to 8% in 2004 & now estimated to be as low as 3-4%

Medicaid Today

A key safety-net system that provides vital health care services to nearly 2.2 million children, pregnant women, seniors, and people with severe disabilities.

Coverage for Medically Needy, dual eligible populations, and TANF, Temporary Assistance for Needy Families.

Medicaid is a jointly financed by state and federal funds- federal share 60cents on a $1

What the reform bill and waiver will do to the current Medicaid program

Creates two demonstration pilot sites one in Broward and Duval County with expansion into surrounding rural Counties, Nassau, Clay, and Baker after a year.

Shifts Medicaid recipients into a private managed care system- HMO’s and Provider Service Networks.

Start up for pilot programs July 2006 - Allows managed care plans flexibility to change the

scope, amount, and duration of services provided Sets a “cap” for each recipient based on a “risk

adjusted” premium determined on historical data. .

Who would be included in the pilot programs

Individuals who are recipients of TANF, temporary assistance for needy families, children, and the aged and disabled, SSI

Voluntary populations; individuals residing in nursing homes, children with chronic conditions, foster care children, pregnant women above 27% of poverty, dual eligible who are covered under Medicare-Medicaid.

The voluntary recipients will be included in the next phase of Medicaid reform

Long Term Care Waiver-

The legislation also allows AHCA to apply for an additional 1115 waiver to design an integrated Long Term Care delivery system for individuals aged 60 and over.

Individuals eligible for Medicaid-Medicare, dual eligible, will then be required to participate in Medicaid Reform.

There is no requirement for Legislative approval or public review prior to submitting waiver.

More about the proposed changes

Managed care plans are to offer mandated core Medicaid services, but they may or may not offer the catastrophic coverage in plan.

Plans offer benefits that are actuarial equivalent - not list of specific services like today.

The amount, duration, and scope of services can be changed in plans and will be a way to control costs under state & federal budget limitations-budget neutrality agreement.

Other features/Issues

Enhanced benefit accounts: Beneficiaries that meet certain healthy

behaviors will be rewarded $ in an account they can use to purchase health services not offered in under the plan.

Changes in cost sharing are allowed. Opt-out to buy private insurance/benefits

and cost sharing rules relaxed.

More features issues and facts

Choice counseling provided & 30 days to chose a plan.

If plan not chosen within 30 days, enrollee will be assigned to a plan. After 90 days they can chose another plan if not satisfied. Waiver allows the state to cover only emergency care and nursing home up to 30 days from eligibility to selection of plan.

Under the recently approved waiver there is no longer the provision for a 3 month retroactive coverage for enrollees.

Florida Waiver Approved in Record Time by federal Center for Medicaid and Medicare Services, CMS

Fast Track for Legislative Approval of the AHCA

Implementing Plan

Waiver Implementing Process The Medicaid Reform bill requires that

the agency submit an Implementing Plan to the appropriate Legislative Committees and the full Legislature for approval of the waiver.

AHCA presented the approved waiver and terms and conditions to Health Care Committees during the Interim Committees the week of November 7th

Reasons to Slow Down the Legislative Approval

Process

To Many Questions and Not Enough Time To Make Good Decisions for Bold and Far-

reaching Reforms

Key Issues to be resolved

The waiver lacks necessary operational details needed before moving forward.

Budget information is not available. There is insufficient encounter data

available to project actual savings. Fact: Florida has not been in

compliance with federal law to track managed care encounter data which is necessary to determine savings.

More concerns and questions

The methodology for calculating the risk adjusted premiums is not clear.

The terms and conditions agreement with CMS raises many questions.

A serious concern is how the current safety-net hospitals & providers will be able to collect and distribute reserve funds to care for the uninsured.

Reasons to slow down approval

Need for details and budget information for a complex and comprehensive overhaul of the Florida Medicaid program is essential before responsible policy decisions can be made.

The cap over five years on federal funding would eventually result in reduced services and inability to respond to unforeseen increase in the number of Medicaid recipients.

Caution signs and more concerns

Budget neutrality agreement:Savings to come from the reform pilot

programs but only 10% of recipients will participate in the two pilot areas.

To meet the agreement that the federal government will not provide more funding without the reforms the state would have to look at decreasing services outside of the two pilot programs.

Responsible Medicaid Reform Reality

Alternative cost-savings exist with proven pharmacy cost control models, chronic disease management programs, and expanded fraud and abuse efforts.

Shifting people into managed care does not necessarily result in savings as demonstrated recently in California and the Medicare plus choice failure in 1995

Stop Waiver Legislative Approval

AHCA is proposing to expand into counties outside of the pilot programs prior to the completion for extensive evaluations and required approval by the Legislature for statewide implementation.

There is no guarantee that coverage will be available statewide.

The waiver adds significantly more administrative costs and diverts public funds into private for profit entities

More reasons to slow down decisions

What incentive is there for plans to serve high risk more costly recipients.

Limited state and federal funds will result in cost shifts to counties, tax payers, and providers.

Reform will not address the underlying causes of health care cost increases.

Every Voice Counts -Medicaid Matters

Meet with members of your delegation.

Write letters to the Editor Tell personal stories and link with

other groups & agencies with mutual concern.

Time is of the essence because of the Special Session early December.

Presentation Information by Florida CHAIN

Community Health Action Information Network

For more information visit:www.floridachain.org