Presentation Transcript

1. Palm Beach County Medical Society Legislative Wrap Up May 22, 2014 Boca Raton Regional Hospital

2. Ronald Zelnick, MD

   President, Palm Beach County Medical Society

3. Shawn Baca, MD

   Secretary, PBCMS Boca Raton Regional Hospital

4. Douglas Dedo, MD

   President, Palm Beach County Medical Society Services

5. Jeff Scott, Esq.

   General Council Florida Medical Association

6. FMA LEGISLATIVE UPDATEPOST SESSION 2014

7. 2014 LEGISLATIVE SESSION The Players: Governor Rick Scott Will be seeking a second term Pending election will affect legislative priorities and budget proposals Friend of Medicine Senate President Don Gaetz Final year of 2-year term as Senate President, will have 2 remaining years in Senate after Friend of Medicine Speaker of the House Will Weatherford Final year of 2-year term as Speaker Friend of Medicine
8. 2014 LEGISLATIVE SESSION TOTAL NUMBER OF BILLS FILED: 1989 BILLSTRACKED BY THE FMA: 317
9. POST 2014 SESSION WRAP UP
10. LEGISLATION THAT FAILED Most everything health care related
11. PLAYING DEFENSE - SCOPE A majority of the 2014 legislative session focused on fighting off legislation that was not physician friendly. This legislation included scope of practice expansion that would have allowed: ARNP’s to practice independent of a physician ARNP’s to prescribe controlled substances CRNA’s to practice with no physician supervision THE FMA WAS ABLE TO STOP THIS LEGISLATON FROM PASSING AND BECOMING LAW.
12. HB 7113: The Train from Hell ARNP Independent Practice ARNP Controlled Substance Prescribing Telemedicine – No Florida license required Mandatory Checking of the PDMP
13. REDUCING BURDENSOME REGULATIONS The FMA fought hard to ease the regulatory burdens faced by physicians when dealing with insurance companies. This legislation would have removed the insurance company from the physician/patient relationship This legislation had 4 main components: Fail First / Step Therapy Grace Period Prior Authorization Bait and Switch/ Provider Registries HB 1001 by Rep. Jason Brodeur / SB 1354 by Sen. Denise Grimsley
14. REDUCING BURDENSOME REGULATIONS FAIL FIRST / STEP THERAPY This section of the legislation placed strict limitations on the use of fail first protocols by insurance companies. Insurance companies should not practice medicine and dictate treatment plans to physicians. If a physician believes, based on sound medical judgment, that fail first protocol is likely to be ineffective, cause an adverse reaction, or result in physical harm, an override of the fail first protocol should be granted within 24 hours.
15. REDUCING BURDENSOME REGULATIONS PRIOR AUTHORIZATION The portion of the legislation made it unlawful for an insurance company or other third party payer to interfere with a licensed MD/DO’s valid order for a medical test or procedure. This created a standardized prior authorization claims form, which all insurance companies and managed care plans would be required to use in Florida.
16. REDUCING BURDENSOME REGULATIONS RETROACTIVE DENIALS /GRACE PERIOD A glitch in the ACA requires patients who have purchased coverage through an insurance exchange be given 90 days before their policy is canceled for non-payment of premiums. After the first 30 days of non-payment of premiums, there is no obligation for insurers to reimburse providers for services rendered.   To help limit the negative effects of this provision of the ACA, the FMA filed legislation that would prevent health insurers from retroactively denying claims if subscriber eligibility has been confirmed prior to the delivery of care.
17. REDUCING BURDENSOME REGULATIONS BAIT AND SWITCH Health insurers should not be able to entice people to buy their coverage by advertising long-outdated preferred provider networks that list physicians who are no longer participating. This bill required insurers to maintain an accurate list on their website, and to make any changes within 24 hours.
18. TELEMEDICINE Although this legislation did not pass this session, the FMA will continue to support the expanded use of telemedicine to modernize the delivery of healthcare. Uniform standards should be established for physicians to maintain patient safety through four (4) key components: Definition Accountability Education Parity in Reimbursement
19. TELEMEDICINE DEFINITION: Telemedicine is the health care delivery, diagnosis, consultation, treatment, monitoring, or the transfer of medical data via the use of telecommunications to establish a physician-patient relationship, to evaluate a patient, or to treat a patient. It should be conducted with the appropriate technology and encryption to comply with HIPAAand with the patient’s informed consent. ACCOUNTABILITY: Physicians practicing telemedicine in Florida must be licensed in Florida.
20. TELEMEDICINE EDUCATION: All telemedicine physicians must comply with current Florida laws and rules. The best way to maintain this knowledge is through continuing medical education. PARITY REIMBURSEMENT: Parity for face-to-face consults and telemedicine consults must apply in the private insurance market as well as in Medicaid. Physicians expend the same amount of time, skill, and expertise when conducting a consult whether it be face-to-face or through telecommunications.
21. TELEMEDICINE The FMA strongly believes telemedicine is the practice of medicine, and as such should be provided only by Florida licensed MDs and DOs.  The legislation proposed by both the House and Senate was far reaching and overly broad. These bills allowed for physician extenders as well as out of state licensed practitioners to practice telemedicine on Florida patients. The FMA opposed this legislation as it effectively served as a back door scope of practice expansion and failed to protect the safety of Floridians.
22. THE FIVE PILLARS OF EXPANDED ACCESS TO CARE The FMA has identified how to effectively and immediately address the shortage of primary care and family physicians in Florida and will continue pursuing legislation to expand on these: Increasing the in-state residency slots for family practice Redirecting funds for loan forgiveness to family practitioners Expanding collaboration between PAs, ARNPs and MDs/DOs Fully enacting fair payment for Medicaid services Codifying and regulating telemedicine
23. HOSPITAL OBSTETRIC DEPARTMENT CLOSURES The FMA sought legislation requiring a hospital to notify physicians with privileges in their obstetric department at least 120 days prior to closing that department, in order to allow physicians ample time to notify their pregnant patients. SB 380 by Sen. Aaron Bean / HB 373 by Rep. Kathleen Peters
24. PRIMARY CARE MEDICAID REIMBURSEMENT The FMA fought to extend the 2 year Medicaid reimbursement increase for primary care. If the Legislature does not act, the current rate increase is set to expire on Jan. 1, 2015.
25. Graduate Medical Education HB 7109 (no Senate companion) Called for a survey of the state’s medical schools and accredited GME institutions No additional money provided
26. Accuracy in Medical Damages Main priority of Publix and Disney Initial version would have placed arbitrary limits on physician reimbursement Would have functionally abolished letters of protection Were able to work out a compromise, but bill ultimately did not pass
27. NEEDLE & SYRINGE EXCHANGE PILOT PROGRAM The FMA assisted the FMA’s Medical Student Section (MSS) in seeking legislation authorizing a five-year needle & syringe exchange pilot program in Miami-Dade County. This legislation passed all committees in the House and Senate but got caught up on the floor. This pilot program offered the exchange of free, clean, and unused needles/syringes for used needles/syringes as a means to prevent the transmission of HIV/AIDS and other blood-borne diseases among intravenous drug users. The program was to make available to program participants educational materials, HIV counseling and testing services, referral services targeted to education programs. SB 408 by Sen. Oscar Braynon / HB 491 by Rep. Mark Pafford.
28. Patient Compensation System HB 739 (Rep. Brodeur) SB 1362 (Sen. Grimsley) A “no fault” medical malpractice compensation system riddled with problems.
29. WHAT PASSED? SB 1030 (Rep. Gaetz): Compassionate use of Medical Cannabis HB 225 (Rep. Perry): Child Safety Devices in Motor Vehicles
30. FMA PAC – YOUR VEHICLE TO POLITICS IN MEDICINE
31. FMA PAC The FMA PAC is the political arm of the Florida Medical Association The mission of the FMA PAC is to elect pro-medicine candidates into the Florida Legislature Contributing to the FMA PAC is the single most powerful thing you can do for the medical profession in Florida.  Everything the FMA PAC does makes the medical profession stronger.
32. HOW MUCH DO CAMPAIGNS COST? State Senate $500,000 -$1,500,000+ State House $300,000-$500,000 This includes party money, soft money (large ECO contributions), and hard money (the individual contributions).
33. 96% of FMA PAC endorsed candidates won their election in 2010. 90% of FMA PAC endorsed candidates won their election in 2012.We hope to continue this success this year.
34. THANK YOU Because of the generous support of hospital medical staffs & large groups throughout the state, the FMA PAC is one of the most successful medical PACs in the country. Join the FMA PAC and MD 1000 Club if you are not already a member. Everyone here should be a member of both. We need your support in 2014!

35. THANK YOU! Questions?For more info visit www.flmedical.org

36. Melanie Brown-Woofter

    Director of Community Relations Medicaid Agency of Health Care Administration

37. Statewide Medicaid Managed Care (SMMC)

    Managed Medical Assistance (MMA) Program Palm Beach County Medical Society Member Meeting May 22, 2014
38. Why are changes being made to Florida’s Medicaid program? Because of the Statewide Medicaid Managed Care (SMMC) program, the Agency is changing how a majority of individuals receive most health care services from Florida Medicaid.
39. The SMMC program does not/is not: The program does not limit medically necessary services. The program is notlinked to changes in the Medicare program and does not change Medicare benefits or choices. The program is not linked to National Health Care Reform, or the Affordable Care Act passed by the U.S. Congress. It does not contain mandates for individuals to purchase insurance. It does not contain mandates for employers to purchase insurance. It does not expand Medicaid coverage or cost the state or federal government any additional money.
40. Discontinued Programs Once the MMA program is implemented, some programs that were previously part of the Medicaid program will be discontinued. This includes the following programs: MediPass Prepaid Mental Health Program (PMHP) Prepaid Dental Health Plan (PDHP)
41. Who WILL NOT participate? The following groups are excluded from program enrollment: Individuals eligible for emergency services only due to immigration status; Family planning waiver eligibles; Individuals eligible as women with breast or cervical cancer; and Children receiving services in a prescribed pediatric extended care facility.** Individuals eligible and enrolled in the Medically Needy program with a Share of Cost.** Note: The Agency has applied to federal CMS for permission to enroll this population in managed care. Until approval is granted, this population will be served in fee for service.
42. MMA Program The following individuals may choose to enroll in the MMA program, but are not required to enroll: Individuals who have other creditable health care coverage, excluding Medicare; Individuals age 65 and over residing in a mental health treatment facility meeting the Medicare conditions of participation for a hospital or nursing facility; Individuals in an intermediate care facility for individuals with intellectual disabilities (ICF-IID); and Individuals with developmental disabilities enrolled in the home and community based waiver and Medicaid recipientswaiting for developmental disabilities waiver services.
43. MMA Program &DD Waiver (iBudget) Services Medicaid recipients enrolled in the DD Waiver (iBudget) are not requiredto enroll in an MMA plan. DD Waiver (iBudget) enrollees may choose to enroll in an MMA plan when the program begins in their region in 2014. Enrollment in an MMA plan will NOT affect the recipient’s DD Waiver (iBudget) services. Recipients can be enrolled in the DD Waiver (iBudget) and an MMA plan at the same time.
44. The Managed Medical Assistance (MMA) Program
45. Managed Medical Assistance Services(All MMA Plans will provide these services)
46. Expanded Benefits
47. Where will recipients receive services? Several types of health plans will offer services through the MMA program: Standard Health Plan Health Maintenance Organizations (HMOs) Provider Service Networks (PSNs) Specialty Plans Comprehensive Plans Children’s Medical Services Network Health plans were selected through a competitive bid for each of 11 regions of the state.
48. Children’s Medical Services Network Enrollment into the Children’s Medical Services plan will occur statewide on August 1, 2014. Children currently enrolled in Title XXI CMS will transition to Title XIX CMS statewide plan on August 1, 2014, if family income is under 133% of the federal poverty level. Recipient statewide may enroll in the CMS Network until May 22, 2014.
49. Managed Medical Assistance Program Implementation The Agency has selected 14 companies to serve as general, non-specialty MMA plans. Five different companies were selected to provide specialty plans that will serve populations with a distinct diagnosis or chronic condition; these plans are tailored to meet the specific needs of the specialty population. The selected health plans are contracted with the Agency to provide services for 5 years.
50. Plans Selected for Managed Medical Assistance Program Participation (General, Non-specialty Plans)Note: Formal protest pending in Region 11 for MMA Standard Plans First Coast Advantage United Healthcare Better Health Amerigroup Sunshine State Simply Prestige SFCCN Preferred Staywell Humana Coventry Molina Integral
51. What Specialty Plans are Available? Note: Magellan Complete Care will not begin operation until July 1, 2014 Children’s Medical Services Network plan will not begin operations until August 1, 2014 Freedom Health will not begin operations until January 1, 2015
52. Which Plans are Comprehensive?
53. Long-term Care Plans by Region
54. Statewide Medicaid Managed CareRegions Map
55. Managed Medical Assistance Program Roll Out Schedule
56. What providers will be included in the MMA plans? Plans must have a sufficient provider network to serve the needs of their plan enrollees, as determined by the State. Managed Medical Assistance plans may limit the providers in their networks based on credentials, quality indicators, and price, but they must include the following statewide essential providers: Faculty plans of Florida Medical Schools; Regional Perinatal Intensive Care Centers (RPICCs); Specialty Children's Hospitals; and Health care providers serving medically complex children, as determined by the State.

57. Mixed Services in SMMC

58. What are mixed services? Mixed services are services that are available under both the Long-term Care (LTC) program and the Managed Medical Assistance (MMA) program. These services are: Assistive care services Case management Home health Hospice Durable medical equipment and supplies Therapy services (physical, occupational, respiratory, and speech-language pathology) Non-emergency transportation
59. Mixed Services Reimbursement If an enrollee has other insurance coverage, such as Medicare, the provider must bill the primary insurer prior to billing Medicaid. For dually eligible Medicare and Medicaid recipients, Medicare is the primary payor. The MMA and LTC plans are responsible for services not covered by Medicare (including any Medicare co-insurance and co-payments). If the enrollee only has Medicaid coverage and is enrolled in an MMA and an LTC plan, the LTC plan is responsible for paying for the mixed services.
60. Mixed Services Reimbursement
61. Medicare Coinsurance and Deductibles and Crossover Claims
62. Medicare Crossover Claims: Plan Responsibilities The Managed Care Plan is responsible for Medicare co-insurance and deductibles for covered services. The Managed Care Plan must reimburse providers or enrollees for Medicare deductibles and co-insurance payments made by the providers or enrollees, according to guidelines referenced in the Florida Medicaid Provider General Handbook. The Managed Care Plan must not deny Medicare crossover claims solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds three years.
63. Medicare Crossover Claims: Plan Responsibilities Plans are responsible for processing and payment of all Medicare Part A and B coinsurance crossover claims for dates of service from the date of enrollment until the date of disenrollment from the plan. Fee-For-Service Medicaid will continue to be responsible for processing and payment of Medicare Part A and B (level of care X) crossover coinsurance claims for dates of service from the date of eligibility until the date of enrollment with the LTC plan. 
64. Medicare Crossover Claims: Plan Responsibilities LTC plans are responsible for paying crossovers (if any) for the following services: nursing facility durable medical equipment home health, and therapies (occupational, physical, speech or respiratory) MMA plans are responsible for paying crossovers (if any) for all covered services. If a recipient is also in an LTC plan, the LTC plan is responsible for crossovers for the services above.
65. Medicare Crossover Claims: Provider Responsibilities Medicare crossover claims will not be automatically submitted to the LTC or MMA plans. Providers will bill the LTC plans for co-payments due for Medicaid covered LTC services for individuals who are dually eligible for Medicare and Medicaid after receiving the Medicare Explanation of Benefits (EOB) for the co-insurance payments. Providers will need to submit the claim to the enrollees’ MMA plan in order to be reimbursed for any co-insurance or deductibles.
66. Medicare Crossover Claims: Recipient Responsibilities Except for patient responsibility for long-term care services, the plan members should have no costs to pay or be reimbursed.
67. *Note: If member is also enrolled in an LTC plan, the LTC plan must pay any coinsurance and deductibles on services listed in slide 36.
68. Will Comprehensive plan cover Medicare services? In 2015, recipients enrolled in Medicare Advantage plans will have the ability to choose a comprehensive Medicaid plan where the recipients’ Medicare and Medicaid plans are the same entity. Medicaid recipients currently enrolled in a Medicare Advantage plan that offers the full set of MMA benefits will not be required to enroll in a Medicaid MMA plan. Please see the Agency’s guidance statement about Medicare Advantage plans at: http://ahca.myflorida.com/MEDICAID/statewide_mc/pdf/Guidance_Statements/SMMC_Guidance_Statement_enrollment_in_Medicare_Advantage_Plans.pdf
69. Choice Counseling
70. Choice Counseling Defined Choice counseling is a service offered by the Agency for Health Care Administration (AHCA), through a contracted enrollment broker, to assist recipients in understanding: managed care available plan choices and plan differences the enrollment and plan change process. Counseling is unbiased and objective.
71. The Choice Counseling Cycle
72. How Do Recipients Choose an MMA Plan? Recipients may enroll in an MMA plan or change plans: Online at: www.flmedicaidmanagedcare.com Or By calling 1-877-711-3662 (toll free) or 1-866-467-4970(TTY) and speaking with a choice counselor OR using the Interactive Voice Response system (IVR) Choice counselors are available to assist recipients in selecting a plan that best meets their needs. This assistance will be provided by phone, however recipients with special needs can request a face-to-face meeting.
73. When Can Recipients Change Plans? Recipient who are required to enroll in MMA plans will have 90 days after joining a plan to choose a different plan in their region. After 90 days, recipients will be locked in and cannot change plans without a state approved good cause reason or until their annual open enrollment.
74. Choice Counseling
75. Recipient Notification and Enrollment Note: The dates above are when mailings begin. Due to the volume, letters are mailed over several days.
76. Auto-Assignment Process If a Recipient does not Make a Plan Choice, how will the Agency determine which MMA plan recipients will be auto assigned to? For Recipients who are required to enroll in an MMA plan: Recipient is identified as eligible for a specialty plan. The recipients prior Medicaid managed care plan is also an MMA plan. Recipient is already enrolled (or has asked to be enrolled) in a long term care plan with a sister MMA plan. The recipient has a family member(s) already enrolled in, or with a pending enrollment, in an MMA plan.
77. If a recipient qualifies for enrollment in more than one of the available specialty plan types, and does not make a voluntary plan choice, they will be assigned to the plan for which they qualify that appears highest in the chart below: Children’s Medical Services HIV/AIDS Serious Mental Illness Freedom Health specialty plans Child Welfare specialty plan
78. Specialty Plan Enrollment Criteria
79. Expanded Benefits NOTE: Details regarding scope of covered benefit may vary by managed care plan. Children’s Medical Services and the specialty plan for dual eligibles with chronic conditions do not offer Expanded Benefits.
80. Choice Counseling Available in English, Spanish and Creole
81. Information about making a plan selection
82. Step by Step On-Line Enrollment
83. Your Address Medicaid is mailing important information to you regarding the MMA program to your home. Make sure we have your current address! To check, Please call the ACCESS Customer Call Center (866) 762-2237 OR Visit http://www.myflorida.com/accessflorida/
84. Continuity of Care
85. Agency Goals for a Successful MMA Rollout Preserve continuity of care, and to greatest extent possible: Recipients keep primary care provider Recipients keep current prescriptions Ongoing course of treatment will go uninterrupted Plans must have the ability to pay providers fully and promptly to ensure no provider cash flow or payroll issues.
86. Agency Goals for a Successful MMA Rollout Plans must have sufficient and accurate provider networks under contract and taking patients. Allows an informed choice of providers for recipients and the ability to make appointments. Choice Counseling call center and website must be able to handle volume of recipients engaged in plan choice at any one time. Regional roll out to ensure success
87. Continuity of Care During TransitionPlan Responsibility MMA plans are responsible for the coordination of care for new enrollees transitioning into the plan MMA plans are required to cover any ongoing course of treatment (services that were previously authorized or prescheduled prior to the enrollee’s enrollment in the plan) with the recipient’s provider during the 60 day continuity of care period, even if that provider is not enrolled in the plan’s network. The following services may extend beyond the continuity of care period and as such, the MMA plans are responsible for continuing the entire course of treatment with the recipient’s current provider: Prenatal and postpartum care (until six weeks after birth) Transplant services (through the first year post-transplant) Radiation and/or chemotherapy services (for the current round of treatment).
88. Continuity of Care During Transition If the services were prearranged prior to enrollment with the plan, written documentation includes the following: Prior existing orders; Provider appointments, e.g., dental appointments, surgeries, etc.; Prescriptions (including prescriptions at non-participating pharmacies); and Behavioral health services. MMA plans cannot require additional authorization for any ongoing course of treatment. If a provider contacts the plan to obtain prior authorization during the continuity of care period, the MMA plan cannot delay service authorization if written documentation is not available in a timely manner. The plan must approve the service. However, the MMA plan may require the submission of written document (as described above) before paying the claim.
89. How Will Providers Know Whether to Continue Services? Providers should keep previously scheduled appointments with recipients during transition
90. Continuity of Care During TransitionProvider Responsibility Service providers should continue providing services to MMA enrollees during the 60-day continuity of care period for any services that were previously authorized or prescheduled prior to the MMA implementation, regardless of whether the provider is participating in the plan’s network. Providers should notify the enrollee’s MMA plan as soon as possible of any prior authorized ongoing course of treatment (existing orders, prescriptions, etc.) or prescheduled appointments.
91. How Will Providers Be Paid? Providers will receive payment for services provided during the transition.
92. Continuity of Care During Transition Provider Reimbursement MMA plans are responsible for the costs of continuing any ongoing course of treatment without regard to whether such services are being provided by participating or non-participating providers. The MMA plan must pay non-participating providers at the rate they received for services rendered to the enrollee immediately prior to the enrollee transitioning for a minimum of thirty (30) days, unless the provider agrees to an alternative rate.Providers will need to follow the process established by the managed care plans for getting these claims paid appropriately. Providers may be required to submit written documentation (as described above) of any prior authorized ongoing care, along with their claim(s) in order to receive payment from the plan.
93. Continuity of Care During Transition Do the managed care plans have to honor prior authorizations that were issued (either through one of the Agency’s contracted vendors or a managed care plan) prior to the recipient’s enrollment in the MMA plan? Examples include: Home health Dental Behavioral Health Durable medical equipment (rent-to-purchase equipment, ongoing rentals, etc.) Prescribed drugs Yes. During the continuity of care period, the MMA plan must continue to pay for any prior approved services, regardless of whether the provider is in the plan’s network. During this timeframe, the plan should be working with the enrollee and their treating practitioner to obtain any information needed to continue authorization after the continuity of care period (if the service is still medically necessary). After the continuity of care period, if the provider is not a part of the plan’s network, the enrollee may be required to switch to a participating provider.
94. Continuity of Care During TransitionPharmacy For the first year of operation, MMA plans are required to use the Medicaid Preferred Drug List (PDL) in order to ensure an effective transition of enrollees during implementation. For the first 60 days after implementation in a region, MMA plans or Pharmacy Benefit Managers (PBMs) are required to operate open pharmacy networks so that enrollees may continue to receive their prescriptions through their current pharmacy providers until their prescriptions are transferred to in-network providers. MMA plans and/or PBMs must reimburse non-participating providers at established open network reimbursement rates. For new plan enrollees (i.e., enrolled after the implementation), MMA plans must meet continuity of care requirements for prescription drug benefits, but are not required to do so through an open pharmacy network. During the continuity of care period MMA plans are required to educate new enrollees on how to access their prescription drug benefits through their MMA plan provider network.
95. How to get Ready for the MMA Program One month before the MMA program starts, ask your pharmacy for a list of your prescriptions filled in the last four months. If you need to change pharmacies, take your prescription bottles and the list of your last four months of prescriptions to your new pharmacy. You can continue to receive the same medications for up to 60 days after you are in your new MMA plan. This gives you time to see your doctor if you need to update your prescriptions or to have your new plan approve your medications.
96. Continuity of Care- Reimbursement Providers will receive payment for services provided during the transition.
97. Resources Questions can be emailed to: FLMedicaidManagedCare@ahca.myflorida.com Updates about the Statewide Medicaid Managed Care program are posted at: www.ahca.myflorida.com/SMMC Upcoming events and news can be found on the “News and Events” link. You may sign up for our mailing list by clicking the red “Program Updates” box on the right hand side of the page.
98. http://apps.ahca.myflorida.com/smmc_cirts/ If you have a complaint or issue about Medicaid Managed Care services, please complete the online form found at: http://ahca.myflorida.com/smmc Click on the “Report a Complaint” blue button. If you need assistance completing this form or wish to verbally report your issue, please contact your local Medicaid area office. Find contact information for the Medicaid area offices at:http://www.mymedicaid-florida.com/
99. Resources Weekly provider informational calls regarding the rollout of the Managed Medical Assistance program will be held. Please refer to our SMMC page, ahca.myflorida.com/smmc, for dates, times, and calling instructions. Calls will address issues specific to the following provider groups: Mental Health and Substance Abuse Dental Therapy Durable Medical Equipment Home Health Physicians / MediPass Pharmacy Hospitals and Hospice Skilled Nursing Facilities / Assisted Living Facilities / Adult Family Care Homes
100. Other Components of MMA:Physician Pay Increase Managed care plans are expected to coordinate care, manage chronic disease, and prevent the need for more costly services. This efficiency allows plans to redirect resources and increase compensation for physicians. Plans achieve this performance standard when physician payment rates equal or exceed Medicare rates for similar services. (Section 409.967 (2)(a), F.S.) The Agency may impose fines or other sanctions including liquidated damages on a plan that fails to meet this performance standard after 2 years of continuous operation.
101. Other Components of MMA:Achieved Savings Rebate The achieved savings rebate program is established to allow for income sharing between the health plan and the state, and is calculated by applying the following income sharing ratios: 100% of income up to and including 5% of revenue shall be retained by the plan. 50% of income above 5% and up to 10% shall be retained by the plan, and the other 50% refunded to the state. 100% of income above 10% of revenue shall be refunded to the state. Incentives are included for plans that exceed Agency defined quality measures. Plans that exceed such measures during a reporting period may retain an additional 1% of revenue.
102. Other Components of MMA:Low Income Pool (LIP) The LIP program was initially implemented effective July 1, 2006. The LIP program currently consists of an annual allotment of $1 billion, funded primarily by intergovernmental transfers from local governments matched by federal funds. Payments are made to qualifying Provider Access Systems, including hospitals, federally qualified health centers and county health departments working with community partners. The objective of LIP program is to ensure support for the provision of health care services to Medicaid, underinsured and uninsured population.
103. Youtube.com/AHCAFlorida

     Additional Information

     Facebook.com/AHCAFlorida Twitter.com/AHCA_FL SlideShare.net/AHCAFlorida

104. Kevin Kearns

     Health Choice Network President and CEO
105. Kevin Kearns, CEO prestigehealthchoice.com
106. Prestige Health Choice Founded in 2008 as a Capitated Provider Service Network (PSN) Formed by FQHCs and CMHCs – 48 owners Important Strategic initiative for our safety net providers Partnership with Florida True Health
107. Medicaid Managed Care Statewide Medicaid Manage Care has two program components Long-Term Care MC Program Implementation began 7/1/12 with ITN release Implementation completed April 2014 – 7 Plans Managed Medical Assistance Program
108. Medicaid Managed Care Statewide Medicaid Managed Care Managed Medical Assistance (MMA) program Types of managed care plans - Health Maintenance Organizations - Provider Service Networks - Children’s Medical Services Network Most Medicaid recipients must enroll in the MMA program
109. Managed Medical Assistance Program Invitation To Negotiate (ITN) Timeline Release of ITN – 12/28/12 Responses Deadline 3/15/13 Negotiation Period - 7/1/13 – 8/31/13 Awards Notification – 9/23/14 Contracts signed - 1/31/14
110. Medicaid Overview As of April 2014 – 3,471,421 Medicaid Recipients Pre ITN 20 HMOs 3 Capitated PSNs 4 FFS PSNs Post ITN 10 HMOs 4 PSNs
111. Rollout Timeline & Notices Region 1, 7, and 9 – roll out August 1, 2014 Region 9 expected enrollment – 290K & 4 Plans AHCA timeline: April 1, 2014: MMA pre-welcome letters sent June 1, 2014: Welcome letter & enrollment process July 1, 2014: Auto assignment notification letter Members can switch plans during rollout and 90 days after roll out - 8/1/14
112. Prestige Health Choice Active in 8 Regions 2, 3, 5, 6, 7, 8, 9, 11 Projecting to serve 330K Members Region 9 – Preparations begin 6/1/14 Inservicing all Primary Care Physicians Conducting town hall orientations for par Specialists Conducting Hospital orientations for par Hospitals
113. Projected Prestige Health Choice Enrollment by AHCA Area: August 1, 2014 Today, 8,634 Members
114. Region 9Provider Network Strong Provider Network Hospitals - 17 PCPs - 262 Specialists - 1,235
115. Service Level Commitments Accepting new Medicaid enrollees 85% par PCPs 90% par Specialist 40% of PCPs offer after hours appointment availability No more than 5% of hospital admissions occur in non-participating facilities No more than 10% of enrollee specialty care shall occur with non-par providers
116. Service Level Commitments Electronic Health Records 60% of eligible professionals and hospitals are using certified EHR Meaningful manner Exchange of health information to improve quality of health care; and Submit clinical quality measures and other measures selected by the Secretary under HITECH Act
117. Service Level Commitments Pay or notify the provider that the claim is denied or contested within 15 days for electronic claims and 20 days for paper claims Enrollee Help Line Average speed of answer not to exceed 30 seconds Abandonment rate not to exceed 3 percent
118. The Road Ahead Historic transition from FFS to managed care Significant cost savings are expected Strong focus on quality & continuity of care Innovative approaches and use of health technology A strong partnership with community providers is essential
119. We look forward to working with YOU!

120. Ron Wiewora, MD

     CEO, Health Care District Palm Beach County

121. Legislative Update and the Health Care District

     R. J. Wiewora, MD, MPH 5/22/14
122. Legislative session outcomes No Medicaid expansion for now There are an estimated 260,000 uninsured people (25% of the population) There are an estimated 88,000 who would be eligible for Medicaid expansion LIP (Low Income Pool) unchanged for now $34M of local tax dollars comes back to hospitals as $80M
123. Other related issues “Woodwork effect” State Medicaid changes Vita Health changes HCD gap coverage
124. “Woodwork Effect”
125. On August 1st, all Medicaid recipients will be transitioned to four managed care Medicaid programs: Humana, Molina, Sunshine and Prestige Personal Health Plan (District’s HMO) goes away Vita Health membership is frozen and transition begun to exchange products Gap coverage Option 2 (clinic and pharmacy only) Up to 300% of FPGL One time only as members will be expected to enroll in an exchange
126. Some proposed programs for the future Local exchange product Narrow network PB County providers only Marketplace assistance program Affordability of premiums CMS has given some guidelines for how this could be done

127. Questions and Answers