Statewide Medicaid Managed Care Overview

1. Statewide Medicaid Managed Care Overview Presented to Commission for Transportation Disadvantaged April 11, 2012 Beth Kidder Assistant Deputy Secretary for Medicaid Operations

2. 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 • Implementation begins 7/1/12 with release of ITN • Certain recipients will be required to enroll • Managed Medical Assistance Program • Implementation begins 1/1/13 with release of ITN • All Medicaid recipients will be required to enroll in a managed care plan unless specifically exempted

3. 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.

4. 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.

6. Current Status of Statewide Medicaid Managed Care Implementation • The Agency for Health Care Administration 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

7. Current Status of Statewide Medicaid Managed Care Implementation • Federal CMS (Centers for Medicare and Medicaid Services) has begun to negotiate program approval with the Agency. • The Agency 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.

8. Statewide Medicaid Managed Care 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.

9. Statewide Medicaid Managed Care Regions Map

10. Number of Plans Per Region

11. 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.

12. 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.

13. 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.

14. 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: • Poor quality of care • Cannot access necessary specialty services • Were unreasonably denied services

15. 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.

16. Who Will Enroll in the Managed Medical Assistance Program? Recipients required to enroll in Managed Medical Assistance: • Low income families with children (Temporary Assistance for Needy Families (TANF) and TANF-related • Children with chronic medical conditions • Children in foster care • Children in adoption subsidy • Pregnant women • Medically Needy recipients • Individuals with full Medicaid and Medicare coverage (where Medicare is secondary payer) • Recipients who are elderly, blind or disabled excluding the developmentally disabled population

17. 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

18. Who Will Enroll in the Managed Medical Assistance Program? Recipients not allowed to enroll: • Women who are eligible only for family planning services • Women who are eligible through the breast and cervical cancer services program • Persons who are eligible for emergency Medicaid for aliens • Children receiving services in a prescribed pediatric extended care center

19. 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.

20. For More Information • Updates about the Statewide Medicaid Managed Care Program will be posted on the Agency website at: http://ahca.myflorida.com/Medicaid/statewide_mc/index.shtml#tab1 • Sign up to receive email updates about the program at this website.