Statewide Medicaid Managed Care Overview

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Statewide Medicaid ManagedCare OverviewPresented bySheri Powers, Project Manager

Role of the Commission The role of the Commission for the TransportationDisadvantaged is to provide all Medicaid NonEmergency Transportation pursuant to the existingcontract with the Agency for Health CareAdministration (AHCA). There are no anticipated changes in transportationservices during the next fiscal year 2012-13. Provide assistance to AHCA as they develop theirtransition plans.

Purpose of this Session To provide an overview of Medicaid Reform andthe tentative implementation schedule. Engage in discussions with providers who haveexperience working within the Medicaid reformpilot area or other HMO programs. Request feedback on ways to make this a smoothtransition for the beneficiaries.

Overview of 2011 Legislation In 2011, the Florida Legislature created a newprogram, Statewide Medicaid Managed Care (SMMC)(Part IV of Chapter 409, Florida Statutes). Statewide Medicaid Managed Care has two programcomponents: Long Term Care Managed Care Programo Implementation begins 7/1/12 with release of ITNo Certain recipients will be required to enroll Managed Medical Assistance Programo Implementation begins 1/1/13 with release of ITNo All Medicaid recipients will be required to enroll in a managed careplan unless specifically exempted

Statewide Medicaid Managed CareGoalsThe Statewide Medicaid Managed Care Program isdesigned to: Emphasize patient centered care, personalresponsibility and active patient participation; Coordinate fully integrated long-term care andhealth care in different health care settings; Provide a choice of the best long-term care andmanaged care plans to meet recipients’ needs; Implement innovations in reimbursementmethodologies, plan quality and planaccountability.

Other Key Program Elements Changes to the Medically Needy Program relating toplan enrollment and premium requirements Medically Needy recipients meet the share of cost by payingthe plan premium, up to the share of cost amount, pendingFederal approval Changes to Home and Community Based Serviceswaiver programs relating to premium requirements forfamilies of certain enrollees Opt-out and premium assistance for Medicaid eligibleswith access to other insurance Cost-sharing requirements, including increasedcopayments for non-emergency use of hospitalemergency rooms.

Potential Providersof Long Term CareAetna Better HealthAmerican Elder CareAvanteGroupBrevard Alzheimer’sFoundationCatholic Health ServicesGnot Capital LLCFlorida Health Care Plus, Inc.Freedom HealthHumanaMiami-Jewish Health SystemsMolinaNeighborly Care NetworkPrestige Health ChoiceSimply HealthcareSunshine State Health PlanTri-County Life CareUniversalUnitedWellCareWorldnet Services Corp

Current Status of Statewide MedicaidManaged Care (SMMC) Implementation AHCA has requested federal authority, including waiveramendments and a new waiver, to implement key SMMCprogram provisions: To mandatorily enroll most Medicaid recipients in managed careplans To allow health plans to develop customized benefits packages To implement SMMC on a statewide basis To impose additional premiums and co-payments To make changes to the Medically Needy Program To develop a program that will enable Medicaid recipients toparticipate in employer-sponsored health insurance To implement the Long Term Care component

Current Status of Statewide MedicaidManaged Care Implementation Federal CMS (Centers for Medicare and Medicaid Services) hasbegun to negotiate program approval with AHCA. AHCA is responding to informal questions and formal requestsfrom CMS for additional information. AHCA has implemented project management and planningteams to ensure timely, effective program implementation. The Statewide Medicaid Managed Care Program will beimplemented statewide. The State has been divided into 11 regions that coincide with theexisting Medicaid areas. Each region will have a certain number of managed care plans toensure that enrollees have a choice of plans.

Statewide Medicaid Managed Care Regions MapRegion 2HolmesJacksonNassauGadsdenW altonLeonBayHamiltonMadisonDuvalBakerLibertyRegion 1GulfW n 4PutnamFlaglerLevyMarionRegion 3VolusiaRegion 7LakeCitrusSeminoleHernandoOrangePascoRegion 5OsceolaPolkRegion 6ManateeHardeeSt. LucieHighlandsSarasotaRegion 1: Escambia, Okaloosa, Santa Rosa, and WaltonRegion 2: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon,Liberty, Madison, Taylor, Wakulla, and WashingtonRegion 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando,Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and UnionRegion 4: Baker, Clay, Duval, Flagler, Nassau, St. Johns, and VolusiaRegion 5: Pasco and PinellasRegion 6: Hardee, Highlands, Hillsborough, Manatee, and PolkRegion 7: Brevard, Orange, Osceola, and SeminoleRegion 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and SarasotaRegion 9: Indian River, Martin, Okeechobee, Palm Beach, and St. LucieRegion 10: BrowardRegion 11: Miami-Dade and MonroeDe SotoCharlotteLeeMartinGladesHendryRegion 8Palm BeachBrowardCollierDadeRegion 11Region 9Region 10

RegionCountiesNumber of Plans1Escambia, Okaloosa, Santa Rosa and Walton22Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson,Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, andWashington23Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist,Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam,Sumter, Suwannee, and Union3-54Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia3-55Pasco and Pinellas2-46Hardee, Highlands, Hillsborough, Manatee, and Polk4-77Brevard, Orange, Osceola, and Seminole3-68Charlotte, Collier, DeSoto, Glades, Hendry, Lee and Sarasota2-49Indian River, Martin, Okeechobee, Palm Beach and St. Lucie2-410Broward2-411Miami-Dade and Monroe5-10

Long Term Care Managed CareProgram Medicaid recipients who qualify and become enrolled in theLong-Term Care Managed Care Program will receive long-termcare services from long-term care managed care plans. The Long-Term Care Managed Care Program will not changeMedicare benefits. AHCA will use competitive procurement to select long-termcare managed care plans for each region. Each recipient will have a choice of plans and may select anyavailable plan. Long-term care managed care plans will only provide longterm care services. The Florida Managed Medical AssistanceProgram will provide all health care services other than longterm care services to eligible recipients.

Who Will Enroll in the Long-TermCare Managed Care Program? Individuals who are: 65 years of age or older AND need nursing facility care 18 years of age or older AND are eligible for Medicaid by reasonof a disability AND need nursing facility care Individuals who live in a nursing facility Individuals enrolled in: Aged and Disabled Adult Waiver; Consumer-Directed Care Plus for individuals in the A/DA waiver; Assisted Living Waiver; Channeling Services for Frail Elders Waiver Program of All-inclusive Care for the Elderly (PACE); Nursing Home Diversion Waiver.

Long Term Care Managed CareEnrollment Process Department of Elder Affairs’ ComprehensiveAssessment and Review for Long-Term Care Services(CARES) Program will determine clinical eligibility. CARES will complete an assessment including: What kinds of services an individual needs; If a nurse or other health care professional is the bestperson to help with the individual’s needs; Whether a physician agrees that the individual is in needof nursing facility care; and Whether the individual has any other way to receive carein the community.

Long-Term Care Managed CareEnrollment Process (cont.) Individuals have 30 days to choose one of the long-termcare plans available in their region If they do not choose, they will be assigned to a plan Once enrolled, will have 90 days to choose a differentplan After 90 days, individuals must remain in their plan forthe rest of the year, unless they have good cause tochange plans. Examples of good cause include:o Poor quality of careo Cannot access necessary specialty serviceso Were unreasonably denied services

Managed Medical AssistanceProgram Medicaid recipients enrolled in the Managed Medical AssistanceProgram will receive all health care services other than longterm care through a managed care plan. AHCA will use competitive procurement to select managed careplans for each region. It is anticipated that there will be nearly 1.2 million newenrollees in the Managed Medical Assistance component for atotal of 2.5 million enrolled recipients. When fully implemented, Medicaid enrollment is expected toshift from the current level of 43% enrolled in managed care tonearly 85% in managed care.

Who Will Enroll in the ManagedMedical Assistance Program?Medicaid recipients not required, but may choose to enroll: Recipients who have other comprehensive health carecoverage, excluding Medicare Recipients residing in residential commitment facilitiesoperated through the Dept. of Juvenile Justice or mentalhealth treatment facilities Recipients eligible for refugee assistance Recipients who are residents of a developmental disabilitycenter, including Sunland Center and Tacachale Recipients enrolled in a Developmental Disabilities Home andCommunity Based Waiver and recipients on the waiting list forDD waiver services

Managed Medical AssistanceEnrollment Eligible recipients will receive a letter with enrollment information. Eligible recipients who must enroll will have 30 days to choose amanaged care plan from the plans available in their region. Enrollees will have 90 days after enrollment to choose a differentplan. After 90 days, enrollees will remain in their plans for theremainder of their 12 month period unless they meet certaincriteria. If a recipient who is required to enroll does not choose a planwithin 30 days, AHCA will automatically enroll the recipient into amanaged care plan. Enrollees can change primary care providers within their managedcare plan at any time.

For More InformationUpdates about the Statewide Medicaid Managed Care Program areposted on the AHCA’s website at: http://ahca.myflorida.com Sign up to receive email updates about the program

Discussion Clay County Council on Aging, Inc., operates within the “pilotarea” for Medicaid Reform. What have they experienced in thisprocess? Any others who have similar experience?

Ideas for SmoothTransition

QuestionsTHANK YOU!

program, Statewide Medicaid Managed Care (SMMC) (Part IV of Chapter 409, Florida Statutes). Statewide Medicaid Managed Care has two program components: Long Term Care Managed Care Program oImplementation begins 7/1/12 with release of ITN oCertain recipients will be required to e

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