Statewide Medicaid Managed Care (SMMC)

1. Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) Program

2. 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.

3. 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.

4. 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)

5. 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 eligible; • 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.

6. Who MAY participate? • The following individuals may choose to enroll in program: • 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 intellectual disabilities enrolled in the home and community based waiver pursuant to state law, and Medicaid recipients.

7. 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.

8. Managed Medical Assistance Services

9. Expanded Benefits

10. 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.

11. Non-standard Health Plans • Specialty Plan • A specialty plan is a managed care plan that serves Medicaid recipients who meet specified criteria based on age, medical condition, or diagnosis. • Comprehensive Plan • Comprehensive plans are managed care plans that offer both Long-term Care and Acute Care services. • Children’s Medical Services Network • Children’s Medical Services is the statewide managed care plan for children with special healthcare needs.

12. Children’s Medical Services Network Children’s Medical Services is the statewide managed care plan for children with special healthcare needs. 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.

13. 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.

14. 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 Simply Prestige SFCCN Preferred Staywell Humana Coventry Molina Integral

15. Plans Selected for Managed Medical Assistance Program Participation (Specialty Plans)

16. Statewide Medicaid Managed CareRegions Map

17. Managed Medical Assistance Program Roll Out Schedule

18. 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.

19. Choice Counseling

20. 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.

21. The Choice Counseling Cycle

22. Recipient Notification and Enrollment Note: The dates above are when mailings begin. Due to the volume, letters are mailed over several days.

23. When will recipients be notified and be required to enroll? • Approximately 60 days prior to each region’s start date, eligible Medicaid recipients will receive a letter with enrollment information, including information on how to enroll. • Eligible recipients who must enroll will have a minimum of 30 days from the date they receive their welcome letter to choose from the plans available in their region.

24. 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) 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.

25. 90 days to change plans After joining a plan, recipients will have 90 days 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.

26. Information about making a plan selection

27. Step by Step On-Line Enrollment

28. Choice Counseling

29. 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/

30. 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.

31. Specialty Plans Can recipients choose to be in or identify themselves as eligible for a specialty plan? • Yes, recipients can inform their choice counselor during their choice period that they would like to enroll in a specialty plan if they believe they are eligible for a specialty plan available in their region. • The specialty plan will be responsible for confirming that the recipient meets the eligibility criteria for the plan.

32. 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

33. Specialty Plan Assignment The Agency is required by Florida law to automatically enroll Medicaid recipients into a managed care plan if they do not voluntarily choose a plan. When a specialty plan is available to serve a specific condition or diagnosis of a recipient, the Agency is required to assign the recipient to that plan. The Agency employs a hierarchy for assignment to specialty plans in those instances where a recipient qualifies for enrollment into more than one specialty plan.

34. 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 Network HIV/AIDS Serious Mental Illness Dual Eligibles with Chronic Conditions Child Welfare

35. Who can Enroll in a Specialty Plan? Each specialty plan is designed to serve a unique population. Each population must have defined specified criteria based on age, medical condition, or diagnosis, per Florida law. A recipient must meet the specified criteria in order to enroll in a specific specialty plan. For the most part, the Agency will identify recipients who are eligible to enroll in a specialty plan. However, specialty plans may develop and implement policies and procedures (subject to Agency approval) to screen recipients meeting the specialty plan eligibility criteria and who have not been identified by the Agency.

36. Specialty Plan Enrollment Criteria

37. Expanded Benefits • All managed care plans participating in the SMMC program have the opportunity to offer expanded benefits to their enrollees. Expanded benefits are services that are offered in addition to those available through the Medicaid program. Plans can: • Exceed the limits stated in Medicaid policy for certain services; or • Offer additional services not covered under the Medicaid state plan (e.g., art therapy, post discharge meals, etc.). • Specialty plans can choose to offer expanded benefits tailored to their unique population.

38. Expanded Benefits

39. 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.

40. Which Plans are Comprehensive?

41. Partnership • Choice Counseling wants to partner with the agencies, organizations and providers that serve Medicaid recipients. • Public and Private Enrollment Sessions • Partner Staff Training • Educational only presentations • Health Fairs

42. Continuity of Care

43. 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.

44. 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

45. Continuity of Care During the Transition to MMA • Heath care providers should not cancel appointments with current patients.  MMA plans must honor any ongoing treatment, for up to 60 days after MMA starts in each Region, that was authorized prior to the recipient’s enrollment into the plan.  • Providers will be paid.  Providers should continue providing any services that were previously authorized, regardless of whether the provider is participating in the plan’s network.  Plans must pay for previously authorized services for up to 60 days after MMA starts in each Region, and must pay providers at the rate previously received for up to 30 days. • Prescriptions will be honored.  Plans must allow recipients to continue to receive their prescriptions through their current provider, for up to 60 days after MMA starts in each Region, until their prescriptions can be transferred to a provider in the plan’s network.

46. 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/

47. 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.

48. Youtube.com/AHCAFlorida Additional Information Facebook.com/AHCAFlorida Twitter.com/AHCA_FL SlideShare.net/AHCAFlorida

49. Questions?