Transcript Statewide Medicaid Managed Care rollout

Rollout of
Statewide Medicaid
Managed Care:
Some Things Advocates
Need to Know and Do
Florida CHAIN
May 29, 2014
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.
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
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
What is Statewide Medicaid
Managed Care?
• Consists of 2 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.
More About Statewide Medicaid
Managed Care (SMMC)
• Consists of 2 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.
Statewide Medicaid Managed Care
vs. 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 increases accountability and
transparency (some only on paper so far)
• Eliminates worst experimental features and
addressed worst problems
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.
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)
Statewide MMA Rollout Schedule
July:
Broward, Miami-Dade and the Keys
August: Western Panhandle, Central Florida & Brevard, Treasure Coast
and Palm Beach
Between 2 and 10 Plan Choices, Depending on
Region (excluding Specialty Plans)
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 selected a 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.
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
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
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
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/mmah
ome.shtml
Choice Counseling Services:
http://www.flmedicaidmanagedcare.com/
Florida CHAIN (Submit Stories or Ask Questions):
http://floridachain.org/contact-florida-chain/