Statewide Medicaid Managed Care Overview

Presented by Sheri Powers, Project Manager

• The role of the Commission for the Transportation Disadvantaged is to provide all Medicaid Non-Emergency Transportation pursuant to the existing contract with the Agency for Health Care Administration (AHCA).

• There are no anticipated changes in transportation services during the next fiscal year 2012-13.

• Provide assistance to AHCA as they develop their transition plans.

Role of the Commission

Purpose of this Session

• To provide an overview of Medicaid Reform and the tentative implementation schedule.

• Engage in discussions with providers who have experience working within the Medicaid reform pilot area or other HMO programs.

• Request feedback on ways to make this a smooth transition for the beneficiaries.

Overview of 2011 Legislation

• In 2011, the Florida Legislature created a new program, Statewide Medicaid Managed Care (SMMC) (Part IV of Chapter 409, Florida Statutes).

• Statewide Medicaid Managed Care has two program components: Long Term Care Managed Care Program

o Implementation begins 7/1/12 with release of ITN o Certain recipients will be required to enroll

Managed Medical Assistance Program o Implementation begins 1/1/13 with release of ITN o All Medicaid recipients will be required to enroll in a managed care

plan unless specifically exempted

Statewide Medicaid Managed Care Goals

The Statewide Medicaid Managed Care Program is designed to:

• Emphasize patient centered care, personal responsibility and active patient participation;

• Coordinate fully integrated long-term care and health care in different health care settings;

• Provide a choice of the best long-term care and managed care plans to meet recipients’ needs;

• Implement innovations in reimbursement methodologies, plan quality and plan accountability.

Other Key Program Elements • Changes to the Medically Needy Program relating to

plan enrollment and premium requirements Medically Needy recipients meet the share of cost by paying

the plan premium, up to the share of cost amount, pending Federal approval

• Changes to Home and Community Based Services waiver programs relating to premium requirements for families of certain enrollees

• Opt-out and premium assistance for Medicaid eligibles with access to other insurance

• Cost-sharing requirements, including increased copayments for non-emergency use of hospital emergency rooms.

Potential Providers of Long Term Care

Aetna Better Health American Elder Care AvanteGroup Brevard Alzheimer’sFoundation Catholic Health Services Gnot Capital LLC Florida Health Care Plus, Inc. Freedom Health Humana Miami-Jewish Health Systems

Molina Neighborly Care Network Prestige Health Choice Simply Healthcare Sunshine State Health Plan Tri-County Life Care Universal United WellCare Worldnet Services Corp

Current Status of Statewide Medicaid

Managed Care (SMMC) Implementation • AHCA has requested federal authority, including waiver

amendments and a new waiver, to implement key SMMC program provisions: To mandatorily enroll most Medicaid recipients in managed care

plans To allow health plans to develop customized benefits packages To implement SMMC on a statewide basis To impose additional premiums and co-payments To make changes to the Medically Needy Program To develop a program that will enable Medicaid recipients to

participate in employer-sponsored health insurance To implement the Long Term Care component

Current Status of Statewide Medicaid Managed Care Implementation

• Federal CMS (Centers for Medicare and Medicaid Services) has begun to negotiate program approval with AHCA.

• AHCA is responding to informal questions and formal requests from CMS for additional information.

• AHCA has implemented project management and planning teams to ensure timely, effective program implementation.

• The Statewide Medicaid Managed Care Program will be implemented statewide.

• The State has been divided into 11 regions that coincide with the existing Medicaid areas.

• Each region will have a certain number of managed care plans to ensure that enrollees have a choice of plans.

Statewide Medicaid Managed Care Regions Map

W alton

Holmes

W akulla

MadisonLeon

Gadsden

Jackson

Bay

Liberty

Gulf Franklin

Taylor

Lafayette

Hamilton

Baker

Nassau

Duval

Flagler

Putnam

Clay

Dixie Alachua

LevyMarion

Volusia

Citrus Lake

Orange

Seminole

OsceolaPolk

Pasco

Manatee Hardee

HighlandsSt. Lucie

SarasotaDe Soto

Charlotte Glades

Martin

LeeHendry Palm Beach

CollierBroward

Dade

Hernando

Region 4

Region 2

Region 1

Region 5

Region 3Region 7

Region 11

Region 9

Region 10

Region 6

Region 8

Region 1: Escambia, Okaloosa, Santa Rosa, and Walton Region 2: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington Region 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union Region 4: Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia Region 5: Pasco and Pinellas Region 6: Hardee, Highlands, Hillsborough, Manatee, and Polk Region 7: Brevard, Orange, Osceola, and Seminole Region 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota Region 9: Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie Region 10: Broward Region 11: Miami-Dade and Monroe

Region Counties Number of Plans

1 Escambia, Okaloosa, Santa Rosa and Walton 2

2 Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington

2

3 Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union

3-5

4 Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia 3-5

5 Pasco and Pinellas 2-4

6 Hardee, Highlands, Hillsborough, Manatee, and Polk 4-7

7 Brevard, Orange, Osceola, and Seminole 3-6

8 Charlotte, Collier, DeSoto, Glades, Hendry, Lee and Sarasota 2-4

9 Indian River, Martin, Okeechobee, Palm Beach and St. Lucie 2-4

10 Broward 2-4

11 Miami-Dade and Monroe 5-10

Long Term Care Managed Care Program

• Medicaid recipients who qualify and become enrolled in the Long-Term Care Managed Care Program will receive long-term care services from long-term care managed care plans.

• The Long-Term Care Managed Care Program will not change Medicare benefits.

• AHCA will use competitive procurement to select long-term care managed care plans for each region.

• Each recipient will have a choice of plans and may select any available plan.

• Long-term care managed care plans will only provide long-term care services. The Florida Managed Medical Assistance Program will provide all health care services other than long-term care services to eligible recipients.

Who Will Enroll in the Long-Term Care Managed Care Program?

• Individuals who are: 65 years of age or older AND need nursing facility care 18 years of age or older AND are eligible for Medicaid by reason

of a disability AND need nursing facility care • Individuals who live in a nursing facility • Individuals enrolled in: Aged and Disabled Adult Waiver; Consumer-Directed Care Plus for individuals in the A/DA waiver; Assisted Living Waiver; Channeling Services for Frail Elders Waiver Program of All-inclusive Care for the Elderly (PACE); Nursing Home Diversion Waiver.

Long Term Care Managed Care Enrollment Process

• Department of Elder Affairs’ Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program will determine clinical eligibility.

• CARES will complete an assessment including: What kinds of services an individual needs; If a nurse or other health care professional is the best

person to help with the individual’s needs; Whether a physician agrees that the individual is in need

of nursing facility care; and Whether the individual has any other way to receive care

in the community.

Long-Term Care Managed Care Enrollment Process (cont.)

• Individuals have 30 days to choose one of the long-term care plans available in their region

• If they do not choose, they will be assigned to a plan • Once enrolled, will have 90 days to choose a different

plan • After 90 days, individuals must remain in their plan for

the rest of the year, unless they have good cause to change plans. Examples of good cause include:

o Poor quality of care o Cannot access necessary specialty services o Were unreasonably denied services

Managed Medical Assistance Program

• Medicaid recipients enrolled in the Managed Medical Assistance Program will receive all health care services other than long-term care through a managed care plan.

• AHCA will use competitive procurement to select managed care plans for each region.

• It is anticipated that there will be nearly 1.2 million new enrollees in the Managed Medical Assistance component for a total of 2.5 million enrolled recipients.

• When fully implemented, Medicaid enrollment is expected to shift from the current level of 43% enrolled in managed care to nearly 85% in managed care.

Who Will Enroll in the Managed Medical Assistance Program?

Medicaid recipients not required, but may choose to enroll: • Recipients who have other comprehensive health care

coverage, excluding Medicare • Recipients residing in residential commitment facilities

operated through the Dept. of Juvenile Justice or mental health treatment facilities

• Recipients eligible for refugee assistance • Recipients who are residents of a developmental disability

center, including Sunland Center and Tacachale • Recipients enrolled in a Developmental Disabilities Home and

Community Based Waiver and recipients on the waiting list for DD waiver services

Managed Medical Assistance Enrollment

• Eligible recipients will receive a letter with enrollment information. • Eligible recipients who must enroll will have 30 days to choose a

managed care plan from the plans available in their region. • Enrollees will have 90 days after enrollment to choose a different

plan. • After 90 days, enrollees will remain in their plans for the

remainder of their 12 month period unless they meet certain criteria.

• If a recipient who is required to enroll does not choose a plan within 30 days, AHCA will automatically enroll the recipient into a managed care plan.

• Enrollees can change primary care providers within their managed care plan at any time.

For More Information Updates about the Statewide Medicaid Managed Care Program are

posted on the AHCA’s website at: http://ahca.myflorida.com Sign up to receive email updates about the program

Discussion • Clay County Council on Aging, Inc., operates within the “pilot

area” for Medicaid Reform. What have they experienced in this process?

• Any others who have similar experience?

Ideas for SmoothTransition

Questions

THANK YOU!