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Center for State Health Policy Rutgers, The State University of New Jersey Roberta Kelley

Impact of the MMA on Existing Disease Management Programs and Managed Care Initiatives for the Aged and Disabled. Center for State Health Policy Rutgers, The State University of New Jersey Roberta Kelley Chief, Bureau of Health Systems Development Florida Agency for Health Care Administration.

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Center for State Health Policy Rutgers, The State University of New Jersey Roberta Kelley

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  1. Impact of the MMA on Existing Disease Management Programs andManaged Care Initiatives for the Aged and Disabled Center for State Health Policy Rutgers, The State University of New Jersey Roberta Kelley Chief, Bureau of Health Systems Development Florida Agency for Health Care Administration

  2. MMA and Florida MedicaidFlorida: Over Age 65 Population • 15.2 Million Residents • 17.6 percent over age 65 versus 12.4 percent nationally • 2.9 Million Medicare Beneficiaries

  3. MMA and Florida MedicaidMedicaid Enrollment (Estimated FY2003-04) • 2.1 Million Eligibles • Approximately 480,000 are dual eligibles • $13 Billion in Expenditures • Dual eligible account for 40% of total expenditures • Dual eligible drug costs account for 55.5% of total drug spend • Exempt from Managed Care

  4. MMA and Florida MedicaidDisease Management Initial Statutory Direction July 1997 • Medicaid Reform Task Force • Legislative Authorization (HIV, Asthma, Diabetes, Hemophilia) • Legislative Authorization (ESRD, Heart Failure) • Asthma Agreement • ITNs for HIV, Diabetes and Hemophilia • ITNs for ESRD and Heart Failure • Diabetes Contract • HIV/AIDS (except S. FL) and Hemophilia Contracts • Legislative Authority to Expand to Other Diseases as Necessary • COPD Pilot Contract • ESRD and Heart Failure Contracts • Legislative Authorization for ‘Value-Added’ Programs • Pfizer Agreement (Asthma, Diabetes, Hypertension, Heart Failure) • Bristol-Myers Squibb Agreement (Diabetes, Depression) • Autoimmune Center Contract • HIV/AIDS (S. FL) Contract July 1998 July 1999 July 2000 July 2001

  5. MMA and Florida MedicaidDM Initiative History

  6. MMA and Florida MedicaidDM Initiative Currently • Florida: A Healthy State • Asthma, Diabetes, Hypertension statewide; CHF Areas 8-11 • Positive Healthcare • AIDS Healthcare Foundation, HIV/AIDS statewide • Diabetik Smart Promotora Diabetes Program • Health Choice Network, Dade and Broward counties • LifeMasters Supported Self Care, Inc. • CHF Areas 1-7 • University of Florida • Center for Orphan Autoimmune Disorders

  7. MMA and Florida MedicaidMedicaid DM Enrollment Process • Claims Based Disease State Algorithms: • ICD-9 codes • NDC codes • Utilization • Beneficiaries assigned to DM program based on Disease State Hierarchy • Duals excluded from DM except for PAC

  8. MMA and Florida MedicaidDM and Long Term Care • HIV/AIDs DM works with Home Community Based Waiver Program • Approximately 3,200 of 5,880 enrollees are dual eligible • Responsible for utilization review and assessments • Reduction in Home Health and Skilled Nursing

  9. MMA and Florida MedicaidPart D Drug Coverage and Impact on FL DM • Availability of Claims Data (medical and pharmacy) to identify beneficiaries • Coordination of Benefits • Medicare only providers • Lack of UR/UM measures for population • Education of Drug Coverage

  10. MMA and Florida MedicaidEnrollment in Part D • States have not been given authority to ensure that duals are enrolled. • Duals are expected to secure Part D coverage. • … but enrollment is voluntary; non selection = assignment; and • although automatically enrolled, they may opt out

  11. MMA and Florida MedicaidChronic Care Improvement Program • Coverage of CHF and Diabetes • Participation is Voluntary • Florida is a possible site • Strong Evaluation Component • Scalability of Program

  12. MMA and Florida MedicaidMedicare Advantage • Encouraged to provide DM • Creation of Specialty Health Plans • May increase DM and enhance coordination of Medicare covered services • Medicaid services are unmanaged

  13. MMA and Florida MedicaidConclusion • Short Term • Enrollment and Coverage of Prescription Drugs • Fragmentation as CCIP becomes operational • Long Term • Scalability of DM Programs • Decision to better manage duals and integration with long term care

  14. Roberta Kelley Chief, Bureau of Health Systems Development Florida Agency for Health Care Administration kelleyro@fdhc.state.fl.us Ph. 850-487-2355 Medicaid: http://www.fdhc.state.fl.us/Medicaid/index.shtml

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