Florida Medicaid 1915(b) Managed Care Waiver Renewal

Transcription

1 Section 1915(b) MCO, PIHP, PAHP, and PCCM Waiver Programs Waiver Renewal Florida Medicaid 1915(b) Managed Care Waiver Renewal Effective Dates: 02/01/ /31/2014 US DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid and State Operations

2 Table of Contents ACRONYMS / ABBREVIATIONS USED THROUGHOUT THE 1915(B) WAIVER SUBMITTAL 1 FACESHEET... 2 SECTION A. WAIVER DESCRIPTION... 1 Part 1. Waiver Overview... 1 Part 2. Waiver Operations...17 B-I. HEALTH MAINTENANCE ORGANIZATION... 1 Part 1. Program Overview... 1 Part 2. Access...10 Part 3. Quality...12 Part 4. Program Operations...13 Part 5. Monitoring Plan...22 Part 6. Monitoring Results...34 B-II. FRAIL / ELDERLY PROGRAM... 1 Part 1. Program Overview... 1 Part 2. Access... 9 Part 3. Quality...11 Part 4. Program Operations...12 Part 5. Monitoring Plan...20 Part 6. Monitoring Results...30 B-III. MEDIPASS... 1 Part 1. Program Overview... 1 Part 2. Access... 9 Part 3. Quality...13 Part 4. Program Operations...15 Part 5. Monitoring Plan...22 Part 6. Monitoring Results...28 B-IV. CHILDREN S MEDICAL SERVICES NETWORK... 1 Part 1. Program Overview... 1 Part 2. Access...12 Part 3. Quality...17 Part 4. Program Operations...21 Part 5. Monitoring Plan...31 Part 6. Monitoring Results...32 B-V. PROVIDER SERVICE NETWORK... 1 Part 1. Program Overview... 1 Part 2. Access...11 Part 3. Quality...14 Part 4. Program Operations...15 Part 5. Monitoring Plan...25 Part 6. Monitoring Results...37 i

3 B-VI. PREPAID MENTAL HEALTH PLAN... 1 Part 1. Program Overview... 1 Part 2. Access...14 Part 3. Quality...19 Part 4. Program Operations...21 Part 5. Monitoring Plan...30 Part 6. Monitoring Results...37 B-VIII. HEALTHY START COORDINATED SYSTEM OF CARE... 1 Part 1. Program Overview... 1 Part 2. Access...12 Part 3. Quality...15 Part 4. Program Operations...16 Part 5. Monitoring Plan...24 Part 6. Monitoring Results...29 B-I. DISEASE MANAGEMENT... 1 Part 1. Program Overview... 1 Part 2. Access... 9 Part 3. Quality...11 Part 4. Program Operations...12 Part 5. Monitoring Plan...19 Part 6. Monitoring Results...24 B-. COMPREHENSIVE HEMOPHILIA MANAGEMENT PROGRAM... 1 Part 1. Program Overview... 1 Part 2. Access... 9 Part 3. Quality...11 Part 4. Program Operations...12 Part 5. Monitoring Plan...19 Part 6. Monitoring Results...24 SECTION C. COST-EFFECTIVENESS... 1 Part I: State Completion Section... 1 Part II: Appendices C ii

4 Acronyms / Abbreviations used throughout the 1915(b) Waiver Submittal CMS CMS Network DM ER FFS HMO MCO PAHP PCCM PCP PDHP PIHP PMHP PSN SSI TANF The Act Centers for Medicare and Medicaid Services Children s Medical Services Network Disease Management Emergency Room Fee-for-Service Health Maintenance Organization Managed Care Organization Prepaid Ambulatory Health Plan Primary Care Case Management Primary Care Provider Prepaid Dental Health Program Prepaid Inpatient Health Plan Prepaid Mental Health Program Provider Services Network Supplemental Security Income Temporary Assistance for Needy Families Social Security Act 1

5 Proposal for a Section 1915(b) Waiver MCO, PIHP, PAHP, and/or PCCM Program Facesheet Please fill in and submit this Facesheet with each waiver proposal, renewal, or amendment request. The State of Florida requests a waiver under the authority of section 1915(b) of the Act. The Medicaid agency will directly operate the waiver. The name of the waiver program is the State of Florida 1915(b) Medicaid Managed Care Waiver. (Please list each program name if the waiver authorizes more than one program.) Health Maintenance Organizations Frail / Elderly Program MediPass CMS Network Provider Service Networks Prepaid Mental Health Plan Prepaid Dental Health Plan Healthy Start Coordinated Care System Disease Management Program Medicaid Comprehensive Hemophilia Management Type of request. This is an: initial request for new waiver amendment request for existing waiver, which modifies Section/Part Replacement pages are attached for specific Section/Part being amended Document is replaced in full, with changes highlighted renewal request This is the first time the State is using this waiver format to renew an existing waiver. The full preprint (i.e. Sections A through D) is filled out. Due to the number of programs in the waiver renewal, the preprint has been modified. Section A of the preprint provides general waiver information. Section B provides program description information that includes: program overview, access, quality, program operations, monitoring plan, monitoring results for each program in the waiver. Section D of the preprint is renumbered to Section C and provides cost effectiveness information. The State has used this waiver format for its previous waiver period. Due to the number of programs in the waiver, the State is replacing: Section A is replaced in full The State assures the same Program Description from the previous waiver period will be used, with the exception of changes noted in the summary of changes document. The majority of the changes are technical and were made to update the renewal waiver application. 2

6 Section B is replaced in full The State assures the same Monitoring Plan from the previous waiver period will be used, with exceptions noted in the summary of changes document. The majority of the changes are technical and were made to update the renewal waiver application. Effective Dates: This waiver renewal is requested for a period of 2 years; effective July 1, 2011 and ending June 30, (For beginning date for an initial or renewal request, please choose first day of a calendar quarter, if possible, or if not, the first day of a month. For an amendment, please identify the implementation date as the beginning date, and end of the waiver period as the end date) State Contact: The State contact person for this waiver is Linda Macdonald and can be reached by telephone at (850) , or fax at (850) , or at Linda.Macdonald@ahca.myflorida.com. (Please list for each program) 3

7 Section A. Waiver Description

8 Section A. Waiver Description Part 1. Waiver Overview Tribal Consultation For initial and renewal waiver requests, please describe the efforts the State has made to ensure Federally recognized tribes in the State are aware of and have had the opportunity to comment on this waiver proposal. The State has notified the two Tribal Organizations in the State of Florida prior to submitting this waiver renewal request. This notification provided the Tribal Organizations with an opportunity to obtain additional information on Florida s managed care programs or to provide comments regarding the managed care programs. The State did not receive any written or verbal comments from the tribes regarding the renewal of this waiver. Waiver History For renewal waivers, please provide a brief history of the program(s) authorized under the waiver. Include implementation date and major milestones (phase-in timeframe; new populations added; major new features of existing program; new programs added). Medicaid managed care in Florida originated in 1981, when Palm Beach County Public Health Unit began operating Florida s first Medicaid managed care plan. In 1984, Florida was selected as one of five states to receive a grant from Health Care Financing Administration (HCFA) to implement a demonstration program. Between 1984 and 1990 eligible Medicaid recipients were provided with the opportunity to enroll in Medicaid Health Maintenance Organizations (HMOs). Since Medicaid HMOs were not available statewide, many areas of the State were initially left uncovered. In response, Florida developed a primary care case management (PCCM) program as an alternative strategy to expand managed care throughout the state and to provide Medicaid recipients with another managed care option. The State submitted the original 1915(b) waiver proposal to the HCFA (now known as Centers for Medicare and Medicaid Services or CMS) in March 1989; it was approved in January That initial 1915(b) waiver allowed for the implementation of the Medicaid Physician Access System (MediPass), designed to be a managed care alternative for Florida Medicaid recipients. MediPass provides health care services to Medicaid eligibles under a primary care case management model. Since the first submission, the 1915(b) waiver has evolved into a variety of managed care plans including Managed Care Organizations (MCOs), Primary Care Case Management Programs, Prepaid Inpatient Health Plans (PIHPs), and Prepaid Ambulatory Health Plans (PAHPs). In general, the State has created a menu of managed care options from which an individual may enroll (HMO, PCCM, PSN, CMS, etc.) The State has also created special programs specifically for individuals enrolled in MediPass (PCCM). These programs include the Prepaid Mental Health Plans and the Disease Management Program. A-1. Waiver Overview 1

9 The history for each program in the 1915(b) waiver is included in Section B as listed in the following chart. This proposal represents the eighth renewal request for the State of Florida s 1915(b) Medicaid Managed Care Waiver. Delivery System MCO PCCM PIHP PAHP Program Name Health Maintenance Organizations Frail / Elderly Program Prepaid Provider Service Network MediPass CMS Network Fee-for Service Provider Service Network Prepaid Mental Health Plan Prepaid Dental Health Plan Healthy Start Coordinated Care System Disease Management Initiative Medicaid Comprehensive Hemophilia Management 1115 Medicaid Reform Waiver On October 19, 2005, CMS approved Florida s 1115 Medicaid Reform Research and Demonstration Waiver for a period of five years, from July 1, 2006, through June 30, The initial five year 1115 Medicaid Reform Waiver was implemented in phases with the goal of statewide expansion. The initial phase of implementation began July 1, 2006, in two counties: Broward and Duval. Within a year of implementation in Duval County, the Medicaid Reform Wavier was expanded to include three rural contiguous counties to Duval County: Baker, Clay and Nassau. This expansion occurred July 1, Participation in the demonstration waiver is mandatory for two eligibility groups. The first group is the 1931 eligibles and related group (described below as the TANF and TANF-related eligibility group). The second group is the Aged and Disabled group. Mandatory Participant Populations 1115 Medicaid Reform Waiver TANF (1931 Eligibles) and TANF-Related Groups (1902 Eligibles): Families whose income is below the TANF limit (20% of the FPL or $303 per month for a family of 3) with assets less than $2,000. Poverty-related children whose family incomes exceed the TANF limit as follows: - Up to age one, family income up to 200% FPL. - Age 1 through age 6, family income up to 133% of FPL. - Age 6 through age 18, family income up to 100% FPL. A-1. Waiver Overview 2

10 Aged and Disabled Group: The aged and disabled, comprising persons receiving SSI cash assistance whose eligibility is determined by SSA (income limit approximately 75% of the federal poverty level (FPL); asset limit for an individual is $2,000). Children eligible under SSI. Exception: The above groups are mandatory Medicaid eligibles under Florida s 1115 Medicaid Reform Waiver, with the exception of poverty level children up to age one whose family incomes are above 185 percent of FPL but below 200 percent of FPL. 3-Year Waiver Extension Request On April 30, 2010, the Florida Legislature passed Senate Bill 1484 and the Governor signed the bill into law (Chapter , Laws of Florida) on May 28, The law directs the Agency to seek approval of a 3-year waiver extension in order to continue operation of the 1115 waiver in Baker, Broward, Clay, Duval and Nassau Counties. On June 30, 2010, the State submitted to CMS a three year waiver extension request as the waiver was scheduled to expire on June 30, CMS temporarily extended the waiver from June 30, 2011, until December 15, 2011, to maintain program operations and provide additional time to finalize the special terms and conditions of the waiver. On December 15, 2011, CMS approved the 3-year waiver extension request that the Agency submitted on June 30, Florida s Section 1115 Research and Demonstration Waiver extension period begins December 16, 2011 and ends June 30, The federal approval packet including the new Special Terms and Conditions of the waiver are posted on the Agency s website: Legislation Statewide Managed Medical Assistance Program The 2011 Florida Legislature passed legislation (House Bill 7107) and the Governor signed the bill into law (Chapter , Laws of Florida) on June 2, This law directs the Agency to apply for and implement state plan amendments and waivers of applicable federal laws and regulations necessary to implement the Statewide Medicaid Managed Care program including the Statewide Managed Medical Assistance program (SMMAP). On August 1, 2011, the Agency submitted the required documents requesting the necessary authorities to implement the program as required by state law. The submission included an amendment to the 1115 demonstration waiver to expand geographic operation of the program statewide and to transition the following populations: Medicare dual eligibles, children with chronic conditions, children in foster care and adoption subsidy to mandated participation in the SMMAP. The SMMAP will begin implementation in January 1, 2013 and end October 1, The SMMAP implementation schedule can be viewed by clicking on the following link: A-1. Waiver Overview 3

11 Exempted & Voluntary Populations - Statewide Managed Medical Assistance Program Exempted Populations Pursuant to state law, Florida Medicaid recipients will be required to enroll in the SMMAP for their primary and acute medical services unless exempt. Exempt recipients include: Women who are eligible only for family planning services. Women who are eligible only 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 facility. Voluntary Populations Additional provisions of the law establish that certain individuals who are exempt may voluntarily choose to participate in the SMMAP. Additional exempt recipients who may voluntarily enroll include: Medicaid recipients who have other creditable health care coverage, excluding Medicare. Medicaid recipients residing in residential commitment facilities operated through the Department of Juvenile Justice or mental health treatment facilities, as defined in state law. Persons eligible for refugee assistance. Medicaid recipients who are residents of a developmental disabilities center. Medicaid recipients with developmental disabilities enrolled in the home and community based waiver pursuant to state law, and Medicaid recipients waiting for waiver services. The state law also provides that persons eligible for Medicaid but exempt from mandatory participation who do not choose to enroll in managed care shall be served in the Medicaid feefor-service program. Covered and Excluded Services - Statewide Managed Medical Assistance Program The managed care plans will be required to cover, at a minimum, the following services: (a) Advanced registered nurse practitioner (b) Ambulatory surgical treatment center (c) Birthing center (d) Chiropractic (e) Dental (f) Early periodic screening diagnosis and treatment services for recipients under age 21 (g) Emergency (h) Family planning services and supplies. Pursuant to 42 C.F.R. s , plans may elect to not provide these services due to an objection on moral or religious grounds, and must notify the Agency of that election when submitting a reply to an invitation to negotiate. (i) Healthy Start services, except as provided in Florida Statutes (j) Hearing (k) Home health agency (l) Hospice A-1. Waiver Overview 4

12 (m) Hospital inpatient (n) Hospital outpatient (o) Laboratory and imaging (p) Medical supplies, equipment, prostheses, and orthotics (q) Mental health (r) Nursing care (s) Optical services and supplies (t) Optometrist (u) Physical, occupational, respiratory, and speech therapy (v) Physician services, including physician assistant (w) Podiatric (x) Prescription drugs (y) Renal dialysis (z) Respiratory equipment and supplies (aa) Rural health clinic (bb) Substance abuse treatment (cc) Transportation to access covered services In addition, plans are authorized to customize their benefit packages to non-pregnant adults, vary cost sharing provisions, and provide coverage for additional services. The Agency is required to evaluate the proposed benefit package to ensure that services are sufficient to meet the needs of the plans enrollees and to verify actuarial equivalence. Certain services are excluded from the plan benefit packages, and are carved out to remain under the fee-forservice system. Those services include services provided in a prescribed pediatric extended care facility, and the provision of anti-hemophilic factor replacement products to recipients diagnosed with hemophilia through the Agency s hemophilia disease management program. Transition As the 1115 demonstration waiver expands into additional counties, the mandatory managed care populations for the SMMAP will be transitioned from the 1915(b) Managed Care Waiver programs to health plans approved to operate under the 1115 demonstration waiver. The voluntary populations for the SMMAP may choose to transition to a plan or receive their services through the fee-for-service system. All mandatory managed care populations will be given 30 days to select a health plan, and provided a 90-day period to change their health plan choice without cause. A. Statutory Authority 1. Waiver Authority. Florida's waiver program is authorized under section 1915(b) of the Act, which permits the Secretary to waive provisions of section 1902 for certain purposes. Specifically, Florida is relying upon authority provided in the subsection(s) listed below of the section 1915(b) of the Act. Programs included under this waiver authority will be operated directly by the Medicaid agency, the Agency for Health Care Administration (AHCA). A-1. Waiver Overview 5

13 a. 1915(b)(1) The State requires enrollees to obtain medical care through a primary care case management (PCCM) system or specialty physician services arrangements. This includes mandatory capitated programs. b. 1915(b)(2) A locality will act as a central broker (agent, facilitator, negotiator) in assisting eligible individuals in choosing among PCCMs or competing MCOs/PIHPs/PAHPs in order to provide enrollees with more information about the range of health care options open to them. c. 1915(b)(3) The State will share cost savings resulting from the use of more cost-effective medical care with enrollees by providing them with additional services. The savings must be expended for the benefit of the Medicaid beneficiary enrolled in the waiver. Note: this can only be requested in conjunction with section 1915(b)(1) or (b)(4) authority. d. 1915(b)(4) The State requires enrollees to obtain services only from specified providers who undertake to provide such services and meet reimbursement, quality, and utilization standards which are consistent with access, quality, and efficient and economic provision of covered care and services. The State assures it will comply with 42 CFR (f). The 1915(b)(4) waiver applies to the following programs: PIHP PAHP PCCM (Note: please check this item if this waiver is for a PCCM program that limits who is eligible to be a primary care case manager. That is, a program that requires PCCMs to meet certain quality/utilization criteria beyond the minimum requirements required to be a fee-for-service Medicaid contracting provider.) Other (please identify programs) The following chart provides information on what authority is required for each program under this waiver: Waiver Programs Delivery System 1915(b)(1) 1915(b)(3) 1915(b)(4) HMOs MCO Frail / Elderly Program MCO MediPass PCCM CMS Networks PCCM * FFS Provider Service Networks Prepaid Provider Service Networks PIHP MCO Prepaid Mental Health Plan PIHP Prepaid Dental Health Plan PAHP Healthy Start Coordinated Care System PAHP Disease Management Initiative PAHP Comprehensive Hemophilia Management PAHP * This authority applies to pediatric palliative care services only ** This authority applies to SFCCN contract only ** A-1. Waiver Overview 6

14 2. Sections Waived. Relying upon the authority of the above section(s), the State requests a waiver of the following sections of 1902 of the Act (if this waiver authorizes multiple programs, please list program(s) separately under each applicable statute): Waiver Programs Delivery System 1902(a)(1) Statewideness 1902(a)(10)(B) Comparability of Service 1902(a)(23) Freedom of Choice HMOs MCO Frail / Elderly Program MCO MediPass PCCM CMS Networks PCCM FFS PSNs* Prepaid PSNs* PIHP MCO 1902(a)(4) Mandate into Single PAHP/PIHP & Restrict Disenrollment PMHPs PIHP Prepaid Dental Health Plans* PAHP * Healthy Start Coordinated Care System PAHP Disease Management Initiative PAHP Hemophilia Management PAHP * The State will expand these programs into additional geographic areas or implement them statewide upon contract completion during the next waiver period. Please see Section B for specific information regarding expansion or statewide implementation of these programs. a. Section 1902(a)(1) Statewideness This section of the Act requires a Medicaid State plan to be in effect in all political subdivisions of the State. Not all waiver programs are available throughout the State. b. Section 1902(a)(10)(B) Comparability of Services This section of the Act requires all services for categorically needy individuals to be equal in amount, duration, and scope. Some waiver programs include additional benefits such as case management and health education that will not be available to other Medicaid beneficiaries not enrolled in the waiver program. c. Section 1902(a)(23) Freedom of Choice This Section of the Act requires Medicaid State plans to permit all individuals eligible for Medicaid to obtain medical assistance from any qualified provider in the State. Under most programs in the waiver, freedom of choice of providers is restricted. That is, beneficiaries enrolled in this program must receive certain services through an MCO, PIHP, PAHP, or PCCM. d. Section 1902(a)(4) To permit the State to mandate beneficiaries into a single PIHP or PAHP, and restrict disenrollment from them. (If state seeks waivers of additional managed care provisions, please list here). A-1. Waiver Overview 7

15 The State seeks a waiver of 42 CFR on choice of plans and 42 CFR on enrollment and disenrollment for the following programs in the waiver: Prepaid Mental Health Plans, Prepaid Dental Health Plans, and Medicaid Comprehensive Hemophilia Program. The State seeks a waiver of 42 CFR on choice of plans on enrollment for the Disease Management Program. The State requests a waiver of 42 CFR on choice of plan on enrollment for the MomCare component of the Healthy Start Coordinated System of Care Program. The State assures that the Healthy Start Coordinated System of Care, other MomCare component regarding enrollment, is in compliance with section 1932(a)(3) of the Act and 42 CFR The Healthy Start Healthy Start Coordinated System of Care, including the MomCare component, permits enrollees to voluntary disenroll at any time. Please see Section B for program-specific information regarding each of these waiver programs. e. Other Statutes and Relevant Regulations Waived Please list any additional section(s) of the Act the State requests to waive, and include an explanation of the request. B. Delivery Systems 1. Delivery Systems. The State will be using the following systems to deliver services: a. MCO: Risk-comprehensive contracts are fully-capitated and require that the contractor be an MCO or HIO. Comprehensive means that the contractor is at risk for inpatient hospital services and any other mandatory State plan service in section 1905(a), or any three or more mandatory services in that section. References in this preprint to MCOs generally apply to these risk-comprehensive entities. The HMOs and prepaid PSNs are paid on comprehensive risk basis and responsible for the provision of substantial health care services to enrollees. Please see Section B for programspecific information. b. PIHP: Prepaid Inpatient Health Plan means an entity that: (1) provides medical services to enrollees under contract with the State agency, and on the basis of prepaid capitation payments or other payment arrangements that do not use State Plan payment rates; (2) provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its enrollees; and (3) does not have a comprehensive risk contract. Note: this includes MCOs paid on a non-risk basis. The PIHP is paid on a risk basis. The Prepaid Mental Health Plan, the fee-for-service (FFS) Provider Service Networks, and the Disease Management Program are paid on a risk basis. Please see Section B for programspecific information. A-1. Waiver Overview 8

16 c. PAHP: Prepaid Ambulatory Health Plan means an entity that: (1) provides medical services to enrollees under contract with the State agency, and on the basis of prepaid capitation payments, or other payment arrangements that do not use State Plan payment rates; (2) does not provide or arrange for, and is not otherwise responsible for the provision of any inpatient hospital or institutional services for its enrollees; and (3) does not have a comprehensive risk contract. This includes capitated PCCMs. The PAHP is paid on a risk basis. The PAHP is paid on a non-risk basis. d. PCCM: A system under which a primary care case manager contracts with the State to furnish case management services. Reimbursement is on a fee-forservice basis. Note: a capitated PCCM is a PAHP. e. Other: (Please provide a brief narrative description of the model.) 2. Procurement. The State selected the contractor in the following manner (required by 42 CFR Part 74 if contract over $100,000). Please complete for each type of managed care entity utilized (e.g. procurement for MCO; procurement for PIHP, etc): Competitive procurement process (e.g. Request for Proposal or Invitation for Bid that is formally advertised and targets a wide audience). The State uses a competitive procurement process for the following waiver programs: Prepaid Mental Health Plans Healthy Start Coordinated System of Care Disease Management Programs Comprehensive Hemophilia Management Program Prepaid Dental Health Plans beginning January 2012 The PDHPs that currently operate in Dade County were selected by using an open cooperative procurement process as noted below. On July 26, 2011, the State selected two PDHP contractors using the competitive procurement process for the provision of PDHP services statewide excluding Miami-Dade, Broward, Baker, Clay, Duval and Nassau Counties. Implementation for the competitively procured PDHPs begins January See Section B-VII, Part 4, C.2.c for the Statewide PDHP implementation schedule. Eligible recipients (children up to age 21) will be given 30 days to select a PDHP or the recipient will be assigned to one of the PDHP s. Enrolled recipients will be able to change to the other PDHP at any time. See Section B-VII for specific information regarding the PDHPs. Open cooperative procurement process (in which any qualifying contractor may participate). A-1. Waiver Overview 9

17 The State has used an open cooperative procurement process for the following waiver programs: Health Maintenance Organizations Frail / Elderly Program MediPass CMS Networks Provider Service Networks Prepaid Dental Health Plan these contracts will terminate prior to implementation of new contracts (target implementation date for the new PDHP contracts is January 2012) Sole source procurement. CMS Regional Office prior approval required. C. Choice of MCOs, PIHPs, PAHPs, and PCCMs 1. Assurances. The State assures CMS that it complies with section 1932(a)(3) of the Act and 42 CFR , which require that a State that mandates Medicaid beneficiaries to enroll in an MCO or PCCM must give those beneficiaries a choice of at least two entities. The State seeks a waiver of section 1902(a)(4) of the Act, which requires States to offer a choice of more than one PIHP or PAHP per 42 CFR Please describe how the State will ensure this lack of choice of PIHP or PAHP is not detrimental to beneficiaries ability to access services. The State seeks a waiver of 42 CFR on choice of plans and 42 CFR on enrollment and disenrollment for the following programs in the waiver: Prepaid Mental Health Plans Prepaid Dental Health Plans Medicaid Comprehensive Hemophilia Program The State seeks a waiver of 42 CFR on choice of plans on enrollment for the Disease Management Programs. The State requests a waiver of 42 CFR on choice of plan on enrollment for the MomCare component of the Healthy Start Coordinated System of Care Program. The State assures that the Healthy Start Coordinated System of Care, other than MomCare component regarding enrollment, is in compliance with section 1932(a)(3) of the Act and 42 CFR The Healthy Start Healthy Start Coordinated System of Care, including the MomCare component, permits enrollees to voluntary disenroll at any time. In all of the above PIHP and PAHP programs the State monitors access and quality of services to ensure that it s equivalent to fee-for-service. The State has contracts with all the above PIHPs and PAHP programs which details access, coverage, and quality. Please see Section B for program-specific information regarding each of the programs in the waiver. A-1. Waiver Overview 10

18 2. Details. The State will provide enrollees with the following choices (please replicate for each program in waiver): Two or more MCOs Two or more primary care providers within one PCCM system. A PCCM or one or more MCOs Two or more PIHPs. Two or more PAHPs, where available Other: (please describe) In most areas of the State, enrollees have a choice of MCOs (HMOs) or PCCMs (MediPass and CMS Network). In areas where MCOs are not available, enrollees have a choice of PCCMs (MediPass or CMS Network). Where available, enrollees also have a choice of an alternative managed care options such as PIHP (FFS PSN), or MCO (prepaid PSN). Please note that information in this section is general across all programs. Where programs have different requirements, please see Section B for program-specific description. Specifically, Section B provides details regarding waiver of 1904(a)(4) and 42 CFR and for PIHP and PAHPs. 3. Rural Exception. The State seeks an exception for rural area residents under section 1932(a)(3)(B) of the Act and 42 CFR (b), and assures CMS that it will meet the requirements in that regulation, including choice of physicians or case managers, and ability to go out of network in specified circumstances. The State will use the rural exception in the following areas ("rural area" must be defined as any area other than an "urban area" as defined in 42 CFR (f)(1)(ii)): D. Geographic Areas Served by the Waiver 1. General. Please indicate the area of the State where the waiver program will be implemented. (If the waiver authorizes more than one program, please list applicable programs below item(s) the State checks.) Please note that information in this section is general across all programs. Where programs have different requirements, please see Section B for program-specific description. Statewide all counties, zip codes, or regions of the State All areas of the State have managed care; however, not all programs under this waiver are available statewide. Please see Section B for program-specific information on geographical availability. The Agency divides the State into 11 areas in order to facilitate operation of its programs. The following chart details the service areas in which Medicaid managed care programs operate throughout Florida. A-1. Waiver Overview 11

19 Medicaid Area / Counties* Medicaid Area 1: Counties include Escambia, Okaloosa, Santa Rosa, and Walton (Pensacola) Medicaid Area 2: Counties include Bay, Franklin, Gulf, Holmes, Jackson, Washington, Calhoun, Gadsden, Jefferson, Leon, Liberty, Madison, Taylor, and Wakulla (Tallahassee and Panama City) Medicaid Area 3: Counties include Alachua, Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette, Levy, Putnam, Suwannee, Union, Citrus, Hernando, Lake, Marion, and Sumter (Gainesville and Ocala) Medicaid Area 4: Counties include Baker, Clay, Duval, Nassau, St. Johns, Flagler, and Volusia (Jacksonville and Daytona Beach) Medicaid Area 5: Counties include Pasco and Pinellas (St. Petersburg) Medicaid Area 6: Counties include Hardee, Highlands, Hillsborough, Manatee, and Polk (Tampa) Medicaid Area 7: Counties include Brevard, Orange, Osceola, and Seminole (Orlando) Medicaid Area 8: Counties include Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota (Ft. Myers) Medicaid Area 9: Counties include Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie (West Palm Beach) Medicaid Area 10: Broward County (Ft. Lauderdale) Medicaid Area 11: Miami/Dade and Monroe Counties (Miami and Florida Keys) Less than Statewide The State plans to expand the PIHP and the PAHP listed below into additional geographic areas or implement them statewide, excluding areas where Florida s 1115 Medicaid Reform Waiver is operational, upon contract completion during the next waiver period. Delivery System PIHP PSNs PAHP Waiver Program Prepaid Dental Health Plans (Beginning January 2012, this program will operate statewide, excluding Miami-Dade, Broward, Baker, Clay, Duval and Nassau Counties.) 2. Details. [Regardless of whether item 1 or 2 is checked above, please list in the chart below the areas (i.e., cities, counties, and/or regions) and the name and type of entity or program (MCO, PIHP, PAHP, HIO, PCCM or other entity) with which the State will contract.] Please see Section B for program-specific information for the name and type of entity with which the State will contract including the geographic area served. E. Populations Included in Waiver Please see Section B for program-specific information regarding what populations are included and excluded from each program in the waiver. The following chart provides a summary of the populations included in each of the waiver programs. Please note: Pursuant to the Special Terms and Conditions of the 1115 New MEDS AD Waiver, recipients eligible for Medicaid under the 1115 New MEDS AD Waiver will not be eligible for enrollment into any other waiver program including the 1915(b) Managed Care Waiver. MEDS AD recipients who would otherwise be eligible for enrollment in the approved 1915(b) Managed Care Waiver, under guidelines set forth by the waiver program design, will be able to receive the same services through the authority of the 1115 New MEDS AD Waiver in the same manner as those enrolled in the approved 1915(b) Managed Care Waiver. A-1. Waiver Overview 12

20 Section 1915(b) Waiver Programs Section 1931 Children & Related Populations Section 1931 Adults & Related Populations Populations included in the 1915(b) Waiver Blind/Disabled Adults & Related Populations Blind/Disabled Children & Related Populations Aged & Related Populations * Foster Care Children TITLE I SCHIP Mandatory Voluntary Mandatory Voluntary Mandatory Voluntary Mandatory Voluntary Mandatory Voluntary Mandatory Voluntary Mandatory Voluntary HMOs Frail / Elderly Program MediPass CMS Network PSN PMHPs PDHPs (age 18 to 20 only) Healthy Start Coordinated Care System Disease Management Hemophilia Management * Please note that Medicare dual eligibles are an excluded population but may voluntarily enroll in some programs. See Section B for program-specific information regarding what populations are included in each program in the waiver. A-1. Waiver Overview 13

21 F. Services The chart below provides a summary of the services covered by each waiver program. Please see Section B for specific information regarding the services offered by each program in the waiver as covered by the State Plan. All services offered under the waiver are provided in Appendices C2.S. and C2.A of Section C, Cost-Effectiveness. Florida Medicaid Managed Care Waiver Services* State Plan Covered Services Covered by HMOs and PSNs Covered by MediPass and CMS Network Covered by PMHPs Covered by PDHPs Covered by Hemophilia Management Advanced Registered Nurse Practitioner Services Ambulatory Surgical Centers Services Birth Center Services Child Health Check-Up Services Chiropractic Services Community Mental Health Services County Health Department Services Dialysis Services Durable Medical Equipment and Medical Supplies Emergency Services Family Planning Services Federally Qualified Health Centers Services Freestanding Dialysis Centers Hearing Services Home Health Care Services Hospice Care Services Hospital Services Inpatient Hospital Services Outpatient Immunizations Independent Laboratory Services Licensed Midwife Services Optometric Services Physician Services Physician Assistant Services Podiatry Services Portable -ray Services Prescribed Drugs Rural Health Clinic Services Targeted Case Management (Mental Health) Therapy Services Occupational, Physical, Respiratory, Speech Transplant Services Visual Services * The HMO and Capitated PSN services cannot be more restrictive than those provided under Medicaid fee-for-service system. Services provided under contract are negotiated with each contractor. However, contractors must provide, at a minimum, the services listed in this table. In addition, specific quality and benefit enhancement services are contractually required. Contractors may choose to provide dental services as an optional Medicaid service and other services not covered under the State Plan with prior approval from the State. Transportation services can only be provided by certain HMOs (statutorily authorized) located in Dade County. The State does not reimburse the HMOs or PSNs for services not covered under the State Plan. Transplant services are covered excluding liver, heart, and lung transplants which are available through fee-for-service system. A-1. Waiver Overview 14

22 The following chart is a summary of the 1915(b)(3) services provided by program. Please see Section B for detailed information regarding the provision of these services and Section C for information on reimbursement. 1915(b)(3) Waiver Program Program Name Program Type Geographic Availability Reimbursement Method 1915(b)(3) Services Provided Frail/Elderly Program HMO Evercare (MCO) Dade County Only Capitated Method of Reimbursement is specified in Section B-II and Section C Adaptive Equipment - These services are physical adaptations to the home that include grab bars, cushioned grips, ramps, modification of bathroom facilities and other minor adaptations and equipment which assist the member's caregiver in providing supportive care and allow the member to remain independent, able to perform ADLs, and/or reduces the risk of falls without which the enrollee's safety in the home may be at risk. Adult Day Health Care - The Frail/Elderly Program is a center-based program, which assures a protective environment for frail elders and disabled adults. It provides preventive, remedial, and restorative services, in addition to therapeutic recreation and nutrition services. Homemaker/Personal Care - These are services which help the member manage activities of daily living (ADLs) and instrumental ADLs. This service includes preparation of meals, but not the cost of meals themselves. This service may also include housekeeping chores such as bed making, dusting and vacuuming, which are incidental to the care furnished or are essential to the health and welfare of the enrollee rather than the enrollee's family. Supplies -These include items like disposable diapers, pads, ointments, or other items as deemed necessary by the plan. Home Health Services - These are services, which provide medically necessary care to an eligible Medicaid recipient whose medical condition, illness or injury requires the care to be delivered in the recipient s place of residence. Caregiver Training - Services designed to increase the ability of family and caregivers to care for the member. Emergency Alert Response Services - Such services monitor the safety of individuals in their own homes, which will alert and dispatch qualified assistance to the member when in need. Expanded Home Health - Services incorporating health and medical services, including nutrition, occupational, physical, and speech therapies, supervised by a health professional including a registered nurse or a medical doctor. Financial Education - Services which include training, counseling and assistance with personal financial management particularly to help the member avoid financial exploitation. Identity Bracelets - A bracelet which identifies the member and includes a phone number to call to get additional information about the member. A-1. Waiver Overview 15

23 Program Name Program for All- Inclusive Care for Children (PACC) Healthy Start Coordinated System of Care Program Type Component of CMS Network (PCCM) PAHP Geographic Availability Statewide Statewide Disease Management PAHP Statewide 1915(b)(3) Waiver Program Reimbursement Method Fee-for-Service Method of Reimbursement is Specified in Section B-III and Section C Method of Reimbursement is specified in Section B-VIII and Section C Fee-for-Service Method of Reimbursement is Specified in Section B-III and Section C 1915(b)(3) Services Provided Support Counseling - Face-to-face support counseling for child and family unit in the home, school or hospice facility, provided by a licensed therapist with documented pediatric training and experience. Expressive Therapies - Music, art and play therapies relating to the care and treatment of the child and provided by registered or board certified providers with pediatric training and experience. Respite Support - Inpatient respite in a licensed hospice facility or in-home respite for patients who require justified supervision and care provided by RN. LPN, or HHA with pediatric experience. This service is limited to 168 hours per year. Hospice Nursing Services - Assessment, pain and symptom management and in-home nursing when the experience, skill and knowledge of a trained pediatric hospice nurse is justified. Personal Care -This service is to be used when a hospice trained provider is justified and requires specialized experience, skill and knowledge to benefit the child who is experiencing pain or emotional trauma due to their medical condition. Pain and Symptom Management - Consultation provided by a CMS Network approved physician with experience and training in pediatric pain and symptom management. MomCare - Initial outreach to facilitate enrollment with a qualified prenatal care provider for early and continuous health care, Healthy Start prenatal risk screening and WIC services. In addition, the MomCare program assists and facilitates the provision of any additional identified needs of the Medicaid beneficiary, including referral to community resources, family planning services, Medicaid coverage for the infant and the need to select a primary care physician for the infant. Healthy Start Care Coordination - Information, education and referral on identified risks, assessment, care coordination, childbirth education, parenting education, tobacco cessation, breastfeeding education, nutritional counseling and psychosocial counseling. The disease management services are care management. Disease management care management is currently for MediPass eligible beneficiaries meeting the criteria for the following disease states: AIDS, congestive heart failure, hypertension, diabetes, chronic obstructive pulmonary disease, sickle cell, renal disease and asthma. These programs are available statewide and nurse care managers provide services. A-1. Waiver Overview 16

24 Part 2. Waiver Operations A. Marketing Marketing includes indirect MCO/PIHP/PAHP or PCCM administrator marketing (e.g., radio and TV advertising for the MCO/PIHP/PAHP or PCCM in general) and direct MCO/PIHP/PAHP or PCCM marketing (e.g., direct mail to Medicaid beneficiaries). 1. Assurances The State assures CMS that it complies with section 1932(d)(2) of the Act and 42 CFR Marketing activities; in so far as these regulations are applicable. The State seeks a waiver of section 1902(a)(4) of the Act, to waive one or more of these regulatory requirements for PIHP or PAHP programs. Please identify each regulatory requirement waived, the managed care program(s) to which the waiver will apply, and the State s alternative requirement. The CMS Regional Office has reviewed and approved the MCO, PIHP, PAHP, or PCCM contracts for compliance with the provisions of section 1932(d)(2) of the Act and 42 CFR Marketing activities and these contracts are effective for the period specified in the contract. Please note that information in this section is general across all programs. Where programs have different requirements, please see Section B for program-specific description. 2. Details a. Scope of Marketing 1. The State does not permit direct or indirect MCO/PIHP/PAHP or PCCM marketing. 2. The State permits indirect MCO/PIHP/PAHP or PCCM marketing (e.g., radio and TV advertising for the MCO/PIHP/PAHP or PCCM in general). Please list types of indirect marketing permitted. 3. The State permits direct MCO/PIHP/PAHP or PCCM marketing (e.g., direct mail to Medicaid beneficiaries). Please list types of direct marketing permitted. The State does allow the HMOs to participate in community outreach events with prior written approval from the State. b. Description. Please describe the State s procedures regarding direct and indirect marketing by answering the following questions, if applicable. 1. The State prohibits or limits MCOs/PIHPs/PAHPs from offering gifts or other incentives to potential enrollees. Please explain any limitation or prohibition and how the State monitors this. Florida Statutes provides that managed care plans and MediPass providers are prohibited from providing inducements to Medicaid recipients to select their plans or from prejudicing Medicaid recipients against other managed care plans or MediPass providers. The State monitors this prohibition through on-site surveys and Consumer Compliant hotline. A-2. Waiver Operations 17

25 2. The State permits MCOs/PIHPs/PAHPs and PCCMs to pay their marketing representatives based on the number of new Medicaid enrollees he/she recruited into the plan. Please explain how the State monitors marketing to ensure it is not coercive or fraudulent: 3. The State requires MCO/PIHP/PAHP and PCCM to translate marketing materials into the languages listed below (If the State does not translate or require the translation of marketing materials, please explain): The State has chosen these languages because (check any that apply): i. The languages comprise all prevalent languages in the MCO/PIHP/PAHP/PCCM service area. Please describe the methodology for determining prevalent languages. ii. The languages comprise all languages in the MCO/PIHP/PAHP/PCCM service area spoken by approximately five (5) percent or more of the population. iii. Other (please explain): B. Information to Potential Enrollees and Enrollees 1. Assurances. The State assures CMS that it complies with Federal Regulations found at section 1932(a)(5) of the Act and 42 CFR Information requirements; in so far as these regulations are applicable. The State seeks a waiver of section 1902(a)(4) of the Act, to waive one of more of these regulatory requirements for PIHPs and PAHPs. Please identify each regulatory requirement waived, the managed care program(s) to which the waiver will apply, and the State s alternative requirement. The CMS Regional Office has reviewed and approved the MCO, PIHP, PAHP, or PCCM contracts for compliance with the provisions of section 1932(a)(5) of the Act and 42 CFR Information requirements and these contracts and these contracts are effective for the period specified in the contract. Please note that information in this section is general across all programs. Where programs have different requirements, please see Section B for program-specific description. 2. Details. a. Non-English Languages Potential enrollee and enrollee materials will be translated into the prevalent non- English languages listed below (If the State does not require written materials to be translated, please explain): The State defines prevalent non-english languages as: (check any that apply): 1. The languages spoken by significant number of potential enrollees and enrollees. Please explain how the State defines significant. 2. The languages spoken by approximately five (5) percent or more of the potential enrollee/ enrollee population. 3. Other (please explain): A-2. Waiver Operations 18

26 Please describe how oral translation services are available to all potential enrollees and enrollees, regardless of language spoken. The State requires that contractors have a toll-free number available 24-hours per day for questions, assistance, and emergencies. The State requires TTY/TDD for enrollees with hearing and speech impairments and translation services to be provided. The State will have a mechanism in place to help enrollees and potential enrollees understand the managed care program. Please describe. Unless ineligible for managed care enrollment, newly eligible recipients will receive initial notification of the requirement to enroll in a managed care plan from the State s enrollment and disenrollment services contractor. This initial notification includes informational materials about the available managed care options and a letter, which specifies the amount of time available to make a choice and the name of the plan the individual will be assigned to if a plan is not selected in the 30 day choice period. This letter also provides a telephone number that the potential enrollee may call to enroll and obtain answers to any enrollment questions. The enrollment and disenrollment services contractor has a toll-free number available during business days with extended hours to answer questions and provide assistance regarding managed care options. The call center must be staffed with professionals qualified to address the needs of the enrollees and potential enrollees. The State requires TTY/TDD for enrollees with hearing and speech impairments and translation services to be provided. b. Potential Enrollee Information Information is distributed to potential enrollees by: State contractor (please specify) On March 12, 2010, the enrollment broker contract was amended to change the name from EDS Information Services, LLC to HP Enterprise Services, LLC. On June 20, 2011, the State s enrollment broker and choice counseling services will be performed by Automated Health System (AHS). There are no potential enrollees in the following programs. (Check this if State automatically enrolls beneficiaries into a single PIHP or PAHP) The State automatically enrolls beneficiaries into the following PIHP or PAHP waiver programs: Prepaid Mental Health Plans Disease Management Healthy Start Coordinated System of Care (MomCare Component) Comprehensive Hemophilia Management Program c. Enrollee Information The State has designated the following as responsible for providing required information to enrollees: (i) the State (ii) State contractor (please specify): A-2. Waiver Operations 19