Implementing Florida Medicaid Managed Care Redesign. Justin Senior Deputy Secretary for Medicaid Florida Agency for Health Care Administration

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1 Implementing Florida Medicaid Managed Care Redesign Justin Senior Deputy Secretary for Medicaid Florida Agency for Health Care Administration

2 Implementing Medicaid Program Redesign: Overview 1. Steps Once Legislation is Adopted 2. Florida s Mature Managed Care Market 3. Florida Medicaid Managed Care Redesign: Key Phases a) Medicaid Managed Care Pilot Program ( ) b) Statewide Medicaid Managed Care Program (2013/2014) 4. Transitioning Resources/ Administrative Reorganization 2

3 Implementing Medicaid Program Redesign: Steps Once Legislation Adopted State Legislature directs Medicaid redesign Steps for implementation of redesign: Initiate Program/Policy Development Negotiate with CMS Establish Project Management Structure Competitive Procurement Plan Selection Systems Readiness Staff Reorganization 3

4 Implementing Medicaid Program Redesign: Initiate Program/Policy Development Develop Clear Understanding of Federal Authorities Waiver Request 1915(b)? 1915(c)? 1115? Benefit: Allows mandatory assignment of additional populations, including duals State Plan Amendment 1932? 1937? Benefit: Guaranteed approval 4

5 Implementing Medicaid Program Redesign: Negotiate with Federal CMS Important to have experienced staff at state level. Important to have experienced staff at federal level. Maintain open lines of communication. Conduct regular calls with CMS Regular in-person meetings with CMS Inform CMS of interconnectivity of states ongoing/new waivers and the effect on Medicaid and CMS workload. 5

6 Implementing Medicaid Program Redesign: Project Management Project Management Utilized to meet deadlines Establish and maintain governance structure Manage high level milestones and deliverables within and outside individual team tasks Help identify and mitigate project risks Oversee escalation of project issues Utilize project management principles and tools to manage project and teams 6

7 Implementing Medicaid Program Redesign: Project Governance Process 7

8 Implementing Medicaid Program Redesign: Project Phases Initiation Phase Initiate Project Submit Requests for Federal Authority Design Phase Design Key Program Elements Prepare Systems and Operational Processes for Implementation Process Competitive Procurements and Select Plans Obtain Federal Authority Implementation Phase Execute Plan Contracts Enroll Recipients Transition obsolete programs 8

9 Florida s Mature Managed Care Market: Evolution of Florida Medicaid Delivery Systems Fee-for-Service HMOs Since 1984 MediPass (PCCM) Since 1991 Prepaid Mental Health Plans Since 1996 Fee-for-Service PSNs Since 2000 [Must be majority provider owned] Disease Management Long Term Care Management [Nursing Home Diversion Program] Other Alternative Plans Since 2001 Improvements in: Integrated Care Management/Care Coordination Outcomes Management/Improved Clinical Decision Making Quality Assurance, Marketing Restrictions Enhancements to Fraud and Abuse Controls New: Medicaid Reform Specialty Plans Medicaid Encounter Data Capitated PSNs Since

10 Florida s Mature Managed Care Market Enrollment As of October 2012 Medicaid Reform Enrollment As of October 2012 HMO (Reform): 162,100 PSN (Reform) 150,574 Total (Reform) 312,674 Medicaid Non- Reform Enrollment As of October 2012 Nursing Home Diversion 19,716 HMO 1,055,533 PSN 110,226 MediPass (PCCM) 590,875 Fee-For-Service 1,092,976 Total 2,869,326 10

11 Florida s Medicaid Managed Care Redesign: Key Phases Medicaid Managed Care Pilot Program July 1, 2006 through June 30, 2014 Statewide Medicaid Managed Care Program Beginning 2013/

12 Florida s Medicaid Managed Care Redesign: Goals Improve access to health care services. Provide more choices (plans and services) for Medicaid recipients. Provide opportunities for recipients to take a more active role in their health care decisions. Reduce the administrative complexity of managing the Florida Medicaid Program. Slow the rate of growth of expenditures: Better care coordination Reduction of over-utilization Reduction of fraud 12

13 Medicaid Managed Care Pilot Program (July 1, 2006 June 30, 2014) The Agency for Health Care Administration (Agency) was directed by the 2005 Florida Legislature, through Section , Florida Statutes, to implement the Medicaid Managed Care Pilot Program. ~ 1115 Demonstration Waiver

14 Medicaid Managed Care Pilot Program ( ): Choice of Plan Types HMO HMO: Agency contracts with HMOs on a prepaid fixed monthly rate per member (e.g. capitation rate) for which the HMO assumes all risk for providing covered services to their enrollees. PSN Provider Service Network (PSN) is a network established or organized and operated by a health care provider, or group of affiliated health care providers, which provides a substantial proportion of the health care items and services under a contract directly through the provider or group of affiliated providers. Specialty Plans The Agency currently contracts with two HIV/AIDS specialty plans. 14

15 Medicaid Managed Care Pilot Program ( ): Choice of Benefit Packages Expanded Benefits: Health plans can choose to provide benefits in addition to the state plan benefit package Over the Counter Drug Benefits Preventative Dental Care for Adults Adult Eyeglass Upgrades Circumcision Respite Care Nutrition Therapy Health and Wellness Benefit Meals on Wheels for families of newborns 15

16 Medicaid Managed Care Pilot Program ( ): Choice of Benefit Packages Flexible Benefits: Plans can vary some benefits within an actuarially sound range: Plan offering aged and disabled population $4,250 in outpatient hospital/ therapy benefits (vs. $1,500 state plan limit) while placing a limit on durable medical equipment of $3,300 per year (vs. no state plan limit). Plan offering children and families $25 per month over the counter pharmacy benefit (vs. no coverage under state plan), while placing a limit on prescriptions of 10 per month (limits do not apply to chemotherapy or HIV/AIDs drugs). Specialty plan for HIV/AIDs limiting home health benefit to 20 visits per year (vs. state plan limit of 4 visits per day), while including coverage of respite care up to 3 hours per week (vs. no coverage under the state plan). 16

17 Medicaid Managed Care Pilot Program ( ): Choice Counseling Choice Counseling is designed to assist Medicaid recipients to choose a health care plan that meets their needs. 96% express high satisfaction with Choice Counseling services 70% of new enrollees made a voluntary plan choice from July 2010 to June 2012 Features unique to Pilot: Online enrollment Comprehensive plan comparison information Home visits available upon request Services available in many languages Plan prescription Drug Formulary comparison tool Special Needs Unit staffed with nurses to assist the medically complex 17

18 Medicaid Managed Care Pilot Program ( ): Enhanced Benefits Participation in healthy behaviors that have positive outcomes and can improve one s health status are rewarded. Rewards are in the form of credit dollars that may be used to purchase health related products and supplies. Recipients may earn up to a maximum of $125 per year in credit dollars. Recipients can use credits for up three years after losing Medicaid eligibility if the credits were earned before January 1, or for up to 1 year after losing Medicaid eligibility if the credits were earned after January 1,

19 Medicaid Managed Care Pilot Program ( ): Enhanced Benefits As of June 2012, over 499,000 recipients have received credits for healthy behaviors, totaling $53,810,936 in credit dollars. As of June 2012, 277,531 unique recipients have used $29,512,503 in credits. Top 10 Healthy Behaviors Office Visit Child Childhood Preventative Care Maintenance Drug Dental Eye Adult/Child PAP Smear Preventative Care Child/Adult Diabetes Management Preventative Care Adult Mammogram Top 10 Frequently Purchased Items Diapers Baby Wipes Mouthwash Feminine supplies Isopropyl alcohol Children s Ibuprofen Baby Shampoo Toothpaste Ibuprofen Multivitamins 19

20 Medicaid Managed Care Pilot Program ( ): Risk Adjusted Rates Risk Adjusted Rates: A process to predict health care expenses based on chronic diagnoses. Distributes capitation payments across health plans based on the health risk of the members enrolled in each health plan. Captures adverse selection without using experience rating (health status, not health use). Rate allocation, not rate setting. Risk Adjustment Process: Better matches payment to risk. Pay for the risk associated with each plan s enrolled population. 20

21 Statewide Medicaid Managed Care (Beginning 2013/2014) During the 2011 Florida Legislative Session, the House and Senate passed House Bill 7107 and HB 7109, which require the state Medicaid program to implement a Statewide Medicaid Managed Care Program. ~ 1915 (b)(c) ~ 1115 Demonstration Waiver ~ State Plan Amendment

22 Statewide Medicaid Managed Care (2013/2014): Maintains Elements from Pilot Plan Choice Choice of Benefit Package Choice Counseling Healthy Behaviors (formerly enhanced benefits) Risk Adjusted Rates 22

23 Statewide Medicaid Managed Care (2013/2014): New Elements Integrates long-term Care for a more comprehensive and coordinated delivery system Long-term care managed care program component Will begin in the fall of 2013 Managed Medical Assistance program component Will begin in mid-2014 Legislation establishes 11 regions in the state Plans will contract to provide services in all counties within a region Competitive Procurement for Plan Selection Only the highest performing plans will participate Limited Number of Plans Ensuring Adequate Market Share for participating plans 23

24 Statewide Medicaid Managed Care (2013/2014): Program Enhancements Increases access to quality providers Increases access to quality services Increases emphasis on Home and Community Based (HCB) Services Increases accountability Increases predictability for recipients and providers 24

25 Statewide Medicaid Managed Care (2013/2014): Federal Authorities Requested Long-term Care Managed Care program: Seeking 1915b/c Combination Waiver Managed Medical Assistance Program: Amend 1115 Medicaid Reform Pilot Demonstration Waiver Mandatorily enroll most Medicaid recipients Allow health plans to develop customized benefits packages. Implement program on a statewide basis. Allow qualified individuals to receive home and community based care services in lieu of nursing home care services. Allow for selective contracting of health plans Medically Needy Program: Seeking Section 1115 Research and Demonstration Waiver Mandatorily enroll medically needy recipient Implement a premium payment that would not exceed the share of cost. Change the program to provide additional months of coverage and a grace period of 90 days before the recipient can be dis-enrolled for non-payment of the premium. State Plan Amendment To authorize the Health Insurance Premium Payment Program 25

26 Implementing Medicaid Program Redesign: Transitioning Resources - Administrative Reorganization Analyzing Current Program Organization Identifying Program Structure / Functions / Staffing Determine resource needs for transition period Identify timing of new program initiation and current program phase out Allocate resources in order to maintain current programs while implementing and developing new program Implement a phased program reorganization throughout the transition period 26

27 Implementing Medicaid Program Redesign: Transitioning Resources - Administrative Reorganization Shifting Responsibilities to MCOs Prior Authorization Utilization Management Program Monitoring Provider Monitoring Responsibilities Maintained by Medicaid Program Staff Contracting Contract Compliance/Monitoring Policy-related Functions Systems Maintenance Data Collection and Analysis Provider and Recipient Assistance 27

28 Questions? 28

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