Medicaid Managed Care in Florida: Federal Approval and Implementation

1. Medicaid Managed Care in Florida: Federal Approval and Implementation Joan Alker and Jack Hoadley Georgetown 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. Timeline

4. Approval June 14, 2013 • 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 corner • Because negotiations took so long, the waiver amendment term runs out 6/30/2014 • Public comment process already under way as AHCA must submit extension request by end of the year • Low Income Pool for safety-net providers • Not addressed in negotiations, but merely extended to this date

6. Long term care waiver • Was approved on a separate track • Program implementation occurring now • Not addressed in this brief • 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? • Does not affect eligibility and never did • Now largely about delivery system change • Some benefits flexibility for adults • Original waiver authorities and programs that are now gone • EPSDT waiver • Premiums never approved • Enhanced benefits program changing • Premium assistance

8. Why was a waiver still needed? • Some populations can be required to move into managed care without a waiver • Others cannot: dual eligibles, children on SSI, long term care services • Adult benefit is based on an actuarial equivalency standard that requires a waiver (though actuarial equivalency now allowed) • Geographic phase-in requires a waiver

9. Findings on pilot program • Five counties (Broward, Duval, Baker, Clay, Nassau) starting in 2006 and 2007 • High levels of market disruption • Withdrawal of plans with large enrollment share • Little evidence on access improvement • Early evidence: low provider participation • Benefit flexibility had little effect • Inconclusive on whether pilot saved money • Opt-out program had minimal take-up

10. Managed care in Florida today • Varying use of managed care today by different FL Medicaid populations

11. Does managed care vary by region?

12. Who must participate? • Most Medicaid populations will be required to enroll in a managed-care plan • Voluntary for those: • With another source of health care, except Medicare • Age ≥65, residing in a mental health treatment facility • In intermediate care facility for intellectual disabilities • With developmental disabilities, using home& community-based services • Excluded are those: • Eligible for emergency services due to immigration status • Participating in family planning waiver program • Eligible as women with breast or cervical cancer • Children receiving services in a pediatric extended care facility • Dual eligibles, with only premium or cost-sharing assistance

13. What plans will be participating? • Bids solicited, December 2012 • 27 plan bids, 20 organizations • Winners announced, September 2013 • 6 HMOS and 4 PSNs selected for general population • No organization will serve all regions • 5 companies selected to offer specialty plans • Children in child welfare system, people with HIV/AIDS, severe mental illness, cardiovascular disease, COPD, congestive heart failure, diabetes • Some non-selected plans are protesting

14. Transition to the new system • All selected plans are in FL Medicaid today • But not all will continue in all regions • Broward County: half of current MCO enrollees will be required to select new plans • How will transitions and potential disruptions be addressed? • What role will specialty plans play?

15. PSNs vs. HMOs • Selected PSNs: based in local hospital systems, clinics, or primary care groups • 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

17. PSNs vs. HMOs – worth monitoring • HMOs have had higher rates of complaints • PSNs moving to capitation is a risk point with sicker population

18. What is the transition timeline? • 10/31/2013: Implementation plan due, with plan for readiness review • Basic timeline for implementation • Assessment of plan capacity and solvency, access protections • Mid-2014: Enrollment phase-in • Implementation by region • Outreach starts 90 days in advance • Potential for “pauses” if issues arise

19. How will managed care operate? What consumer protections are there?

20. Medical loss ratio (MLR) • Requires insurers to spend a minimum percentage of premium dollars on services • ACA included an MLR on private insurers, but does not apply to Medicaid • 11 states have some kind of Medicaid MLR on some or all of their expenditures

21. Medical loss ratio in waiver • FL Healthy Kids has an 85% MLR • Florida’s 2011 pilot waiver extension included an 85% MLR for five-county pilot • This was extended statewide in waiver terms and conditions approved in June • First and only time CMS has included an MLR in a waiver agreement

22. Comprehensive quality strategy • State strategy for quality improvement at state, plan, provider levels • Develop, adopt quality metrics; achieve at least 75th percentile of national Medicaid • Quality improvement projects • Improved prenatal care • Well-child visits to age of 15 months • Preventive dental care for children • Health plan report cards for consumers

23. Network adequacy • Concern about shortages of specialists, dentists, other providers; pilot experience • State required to report on network policies • Availability of routine, urgent appointments • Travel time and distance standards • Access outside of network • Access for those with special needs, cultural considerations • This will need a lot of monitoring! • Secret shopper studies a good tool

24. Ensuring plan stability • Pilot experience: high rate of plan turnover • 11 of 14 HMOs from Year 1 later withdrew • But only 1 of PSNs withdrew • Policies in waiver • Five-year commitment to program • Penalties for withdrawal • Maximum number of plans per region • Issues to monitor

25. Enrollment procedures • Letter with enrollment information • 30 days to select a plan • 90 days to change the selection • Those not selecting will be auto-enrolled • Based on history with plan or providers • Chance to switch away from assigned plan • Issues to monitor: • Do beneficiaries understand options? • How many pick? How many are auto-enrolled?

26. Stakeholder involvement • Medical Care Advisory Committee • Minimum of 4 beneficiaries • Smaller advisory committees to monitor impact on specific subpopulations • Persons with HIV/AIDS • Children, especially those in foster care • Children with dental care needs • Persons receiving behavioral health, SA services • Issues to monitor

27. Concluding thoughts • Will imminent waiver renewal change anything? • Will ongoing Medicaid expansion debate intersect? • Future of LIP • Education, oversight and monitoring is essential….

28. For more information • Joan Alker and Jack Hoadley • jca25@georgetown.edu; jfh7@georgetown.edu • Twitter @joanalker1 • Georgetown University project website • http://hpi.georgetown.edu/floridamedicaid • Georgetown Center for Children and Families http://ccf.georgetown.edu/