Rollout of Statewide Medicaid Managed Care: Some Things Advocates Need to Know and Do

1. Rollout of Statewide Medicaid Managed Care:Some Things AdvocatesNeed to Know and Do Florida CHAIN May 29, 2014

2. Statewide Medicaid Managed Care (SMMC) Generally • Has nothing to do with who is eligible for Medicaid - Only affects how services are delivered to those already in Medicaid. • Medicaid is a state-federal partnership. States administer the program but are subject to federal rules. To implement SMMC, Florida obtained a Demonstration Waiver from federal HHS that rewrites some of those rules. • Virtually eliminates state’s direct role of authorizing services for recipients and paying claims from providers. • Assigns responsibility instead to managed care plans such as HMOs and Provider Service Networks selected through competitive bidding process.

3. How Did We Get Here? • 1990s: Managed care plans enter Florida Medicaid • 2006: “Medicaid Reform” Waiver (“free market experiment”) approved by HHS under Bush administration; Launched in 2 Pilot counties with goal of expanding statewide in 4 years • 2007: Pilot expanded to 5 counties • 2008: Horror stories abound; plans begin fleeing Pilot • 2009: Medicaid Reform experiment almost collapses; statewide expansion blocked, but Reform not fixed by Legislature • Jun 2010: Florida requests extension of Medicaid Reform Waiver, 12 months before expiration, HHS announces it will review the request like a brand new application

4. How Did We Get Here? (cont.) • Apr 2011: Reform renamed, reworked, passed by Legislature (Statewide Medicaid Managed Care= SMMC) • Aug 2011: Florida submits request for new SMMC experiment to feds, but as an amendment to the old Reform experiment • Dec 2011: After almost 18 months, HHS approves extension of old Reform waiver through June 2014 with much stricter conditions and much less experimentation allowed • 2012-2013: Florida and HHS negotiate terms of new SMMC waiver; Florida agrees to several new requirements; other problematic elements rejected by HHS • Jun 2013: HHS approves SMMC, replacing Reform waiver • May 2014: SMMC begins rolling out over 4 months

5. What is Statewide Medicaid Managed Care? • Consists of2 separate but related components: - Managed Long-Term Care (Rollout recently completed) - Managed Medical Assistance (all other services) • In all 67 counties, most recipients must now enroll in a managed care plan: - Some will lose “Fee-for-Service” Medicaid - Many will lose access to MediPass Note: In general, Florida did not need a high-powered waiver to do this.

6. More About Statewide Medicaid Managed Care (SMMC) • Consists of2 separate but related components: - Managed Long-Term Care (Rollout recently completed) - Managed Medical Assistance (all other services) • In all 67 counties, most recipients must now enroll in a managed care plan: - Some will lose “Fee-for-Service” Medicaid - Many will lose access to MediPass Note: In general, Florida did not need a high-powered Demonstration Waiver to do this.

7. Statewide Medicaid Managed Carevs. Medicaid Reform • Provides better, more consistent,more manageable plan choices • Reduces threat from giving plans too much flexibility, too little oversight (benefit and consumer protections) • Significantly increasesaccountability and transparency (some only on paper so far) • Eliminates worst experimental features and addressed worst problems

8. If It’s Just Managed Care, What’s the Concern? • For the first time, almost all of the ultimate decision-makers re: patient care report to investors or shareholders. • Capitated managed care: Plans receive paid (some now, some soon) a fixed amount per recipient for care. • Some flexibility in benefit design, though so far appears to be used only to add optional benefits • Medicaid recipients are very low-income and face many barriers to participation. They are also less likely to speak up.

9. Rollout of Managed Medical Assistance • HAPPENING REGIONALLY: 11 Regions in 4 Flights • HAPPENING FAST: Over 4 months: May 1, June 1, July 1, Aug 1 • HAPPENING TO MOST GROUPS (FAST, REGIONALLY): Exempt: Those with limited Medicaid coverage Voluntary: e.g., DD waiver services or waiting list Some groups using specialty plans are delayed (e.g., Children’s Medical Services)

11. Statewide MMA Rollout Schedule July:Broward, Miami-Dade and the Keys August: Western Panhandle, Central Florida & Brevard, Treasure Coast and Palm Beach

12. Between 2 and 10 Plan Choices, Depending on Region (excluding Specialty Plans)

13. Before the Switch • Recipients should receive information about options at least 60 days before the switch date - several different communications. • For recipients enrolled in managed care plans already, those plans must continue to serve them, even if the plans were not selected to serve the region where the recipient lives. • Each recipient must selecteda managed care plan, or (s)he will be assigned to one (based on criteria). • Recipients are encouraged to work with choice counselors that are supposed to equip them to select the plan that best meets their needs.

14. During the Transition • Recipients must be able to continue getting the services and medications they’ve relied on from their new plan. • Recipients must be able to access providers they need in their new plans. Networks must be adequate and network info must be accurate

15. After the Switch • After 60 days (and presumably after evaluation), recipients may see access to services or medications changed/limited • Recipients have 90 days to change plans for any reason…or for no reason at all. • After 90 days, recipients are “locked in” to plan for 12 months, except for good cause • Recipients must be able to access providers and services without delays or denials

16. We Need to Be on the Lookout for Recipients Who… • Did not receive information about the switch, their options or their rights • Received misinformation or insufficient info from choice counselors • Have special needs that were not addressed or accommodated • Were assigned to a plan they did not choose or want • Experienced a disruption in care • Encountered inadequate plan network/Loss of provider access • Faced delays or denials of needed care

17. Important Links Official Statewide Medicaid Managed Care Site: http://ahca.myflorida.com/medicaid/statewide_mc/ Official State Complaint Form: http://ahca.myflorida.com/medicaid/statewide_mc/mmahome.shtml Choice Counseling Services: http://www.flmedicaidmanagedcare.com/ Florida CHAIN (Submit Stories or Ask Questions): http://floridachain.org/contact-florida-chain/