Presentation on theme: "Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) Program 2."— Presentation transcript:
Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) Program 2
Why are changes being made to Florida’s Medicaid program? Because of the Statewide Medicaid Managed Care (SMMC) program, the Agency is changing how a majority of individuals receive most health care services from Florida Medicaid. 2 Statewide Medicaid Managed Care program Managed Medical Assistance program (implementation May 2014 – August 2014 ) Long-term Care program (implementation Aug. 2013 – March 2014)
The SMMC program does not/is not: The program does not limit medically necessary services. The program is not linked to changes in the Medicare program and does not change Medicare benefits or choices. The program is not linked to National Health Care Reform, or the Affordable Care Act passed by the U.S. Congress. –It does not contain mandates for individuals to purchase insurance. –It does not contain mandates for employers to purchase insurance. –It does not expand Medicaid coverage or cost the state or federal government any additional money. 3
Discontinued Programs Once the MMA program is implemented, some programs that were previously part of the Medicaid program will be discontinued. This includes the following programs: –MediPass –Prepaid Mental Health Program (PMHP) –Prepaid Dental Health Plan (PDHP) 4
5 Who WILL NOT participate? The following groups are excluded from program enrollment: –Individuals eligible for emergency services only due to immigration status; –Family planning waiver eligible; –Individuals eligible as women with breast or cervical cancer; and –Children receiving services in a prescribed pediatric extended care facility. –Individuals eligible and enrolled in the Medically Needy program with a Share of Cost. Note: The Agency has applied to federal CMS for permission to enroll this population in managed care. Until approval is granted, this population will be served in fee for service.
Who MAY participate? The following individuals may choose to enroll in program: –Individuals who have other creditable health care coverage, excluding Medicare; –Individuals age 65 and over residing in a mental health treatment facility meeting the Medicare conditions of participation for a hospital or nursing facility; –Individuals in an intermediate care facility for individuals with intellectual disabilities (ICF-IID); and –Individuals with intellectual disabilities enrolled in the home and community based waiver pursuant to state law, and Medicaid recipients. 6
MMA Program & DD Waiver (iBudget) Services Medicaid recipients enrolled in the DD Waiver (iBudget) are not required to enroll in an MMA plan. DD Waiver (iBudget) enrollees may choose to enroll in an MMA plan when the program begins in their region in 2014. Enrollment in an MMA plan will NOT affect the recipient’s DD Waiver (iBudget) services. –Recipients can be enrolled in the DD Waiver (iBudget) and an MMA plan at the same time. 7
Managed Medical Assistance Services Minimum Required Covered Services: Managed Medical Assistance Plans Advanced registered nurse practitioner servicesMedical supplies, equipment, prostheses and orthoses Ambulatory surgical treatment center servicesMental health services Birthing center servicesNursing care Chiropractic servicesOptical services and supplies Dental servicesOptometrist services Early periodic screening diagnosis and treatment services for recipients under age 21 Physical, occupational, respiratory, and speech therapy Emergency servicesPhysician services, including physician assistant services Family planning services and supplies (some exception)Podiatric services Healthy Start Services (some exception )Prescription drugs Hearing servicesRenal dialysis services Home health agency servicesRespiratory equipment and supplies Hospice servicesRural health clinic services Hospital inpatient servicesSubstance abuse treatment services Hospital outpatient servicesTransportation to access covered services Laboratory and imaging services 8
Expanded Benefits List of Expanded Benefits Amerigroup Better Coventry First Coast Humana Integral Molina Preferred Prestige SFCCN Simply Staywell Sunshine United Adult dental services (Expanded)YYY YYYYYYY YYY Adult hearing services (Expanded)YY Y YYY YYYY Adult vision services (Expanded)YYYYYYYYY YYYY Art therapyY Y Y YY Equine therapy Y Home health care for non-pregnant adults (Expanded) YYYYY Y YY YYYY Influenza vaccineYYYYYYYYY YYYY Medically related lodging & food Y Y Y Y YYY Newborn circumcisionsYYYYYYY YY YYYY Nutritional counselingYY YYYY YYY Outpatient hospital services (Expanded)YY Y YYY YYYY Over the counter medication and suppliesYYY YYYYY YYYY Pet therapy Y Y Y Physician home visitsYY Y Y Y YYYY Pneumonia vaccineYYY YYYYY YYYY Post-discharge mealsYY YYYY YYYY Prenatal/Perinatal visits (Expanded)YY YYYYY YYYY Primary care visits for non-pregnant adults (Expanded) YYYYYYYYYY YYYY Shingles vaccineYYYYY Y Y YYYY Waived co-paymentsYY YYYYYY YYYY NOTE: Details regarding scope of covered benefit may vary by managed care plan. 9
Several types of health plans will offer services through the MMA program: –Standard Health Plan Health Maintenance Organizations (HMOs) Provider Service Networks (PSNs) –Specialty Plans –Comprehensive Plans –Children’s Medical Services Network Health plans were selected through a competitive bid for each of 11 regions of the state. 10 Where will recipients receive services?
Non-standard Health Plans Specialty Plan –A specialty plan is a managed care plan that serves Medicaid recipients who meet specified criteria based on age, medical condition, or diagnosis. Comprehensive Plan –Comprehensive plans are managed care plans that offer both Long-term Care and Acute Care services. Children’s Medical Services Network –Children’s Medical Services is the statewide managed care plan for children with special healthcare needs. 11
Children’s Medical Services Network Children’s Medical Services is the statewide managed care plan for children with special healthcare needs. Enrollment into the Children’s Medical Services plan will occur statewide on August 1, 2014. Children currently enrolled in Title XXI CMS will transition to Title XIX CMS statewide plan on August 1, 2014, if family income is under 133% of the federal poverty level. 12
Managed Medical Assistance Program Implementation The Agency has selected 14 companies to serve as general, non-specialty MMA plans. Five different companies were selected to provide specialty plans that will serve populations with a distinct diagnosis or chronic condition; these plans are tailored to meet the specific needs of the specialty population. The selected health plans are contracted with the Agency to provide services for 5 years. 13
Plans Selected for Managed Medical Assistance Program Participation (General, Non-specialty Plans) Note: Formal protest pending in Region 11 for MMA Standard Plans 14 Region MMA Plans 1XX 2XX 3XXXX 4XXXX 5XXXX 6XXXXXXX 7XXXXXX 8XXXX 9XXXX 10XXXX 11XXXXXXXXXX Amerigroup Better Health Coventry First Coast Advantage Humana Integral Molina Preferred Prestige Simply Sunshine United Healthcare Staywell SFCCN
Plans Selected for Managed Medical Assistance Program Participation (Specialty Plans) 15 Region MMA Plans Positive Healthcare Florida HIV/AIDS Magellan Complete Care Serious Mental Illness Freedom Health, Inc. Cardiovascular Disease Freedom Health, Inc. Chronic Obstructive Pulmonary Disease Freedom Health, Inc. Congestive Heart Failure Freedom Health, Inc. Diabetes Clear Health Alliance HIV/AIDS Sunshine Health Plan, Inc. Child Welfare 1XX 2XXX 3XXXXXX 4XX 5XXXXXXX 6XXXXXXX 7XXXXXXX 8XXXXXX 9XXXXXXX 10XXXXXXXX 11XXXXXXXX
Managed Medical Assistance Program Roll Out Schedule Implementation Schedule RegionsPlans Enrollment Date 2, 3 and 4Standard Plans Specialty Plans: o HIV/AIDS o Child Welfare May 1, 2014 5, 6 and 8Standard Plans Specialty Plans: o HIV/AIDS o Child Welfare June 1, 2014 10 and 11Standard Plans Specialty Plans: o HIV/AIDS o Child Welfare o Serious Mental Illness July 1, 2014 1, 7 and 9Standard Plans Specialty Plans: o HIV/AIDS o Child Welfare August 1, 2014 StatewideChildren’s Medical Services NetworkAugust 1, 2014 17
What providers will be included in the MMA plans? Plans must have a sufficient provider network to serve the needs of their plan enrollees, as determined by the State. Managed Medical Assistance plans may limit the providers in their networks based on credentials, quality indicators, and price, but they must include the following statewide essential providers: – Faculty plans of Florida Medical Schools; – Regional Perinatal Intensive Care Centers (RPICCs); – Specialty Children's Hospitals; and – Health care providers serving medically complex children, as determined by the State. 18
20 Choice Counseling Defined Choice counseling is a service offered by the Agency for Health Care Administration (AHCA), through a contracted enrollment broker, to assist recipients in understanding: –managed care –available plan choices and plan differences –the enrollment and plan change process. Counseling is unbiased and objective.
The Choice Counseling Cycle Recipient determined eligible for enrollment or enters open enrollment Recipient receives communication informing him of choices Recipient may enroll or change via phone, online or in person Enrollment or change is processed during monthly processing and becomes effective the following month Newly eligible recipients are allowed 90 days to “try” the plan out, before becoming locked-in 21
Recipient Notification and Enrollment 22 Region Pre-Welcome Letter Welcome Letter Reminder Letter Last Day to Choose a Plan Before Initial Enrollment Date Enrolled in MMA Plans 14/1/20145/26/20146/23/20147/17/20148/1/2014 21/2/20142/17/20143/24/20144/17/20145/1/2014 31/1/20142/17/20143/24/20144/17/20145/1/2014 41/2/20142/17/20143/24/20144/17/20145/1/2014 52/3/20143/24/20144/21/20145/22/20146/1/2014 62/3/20143/24/20144/21/20145/22/20146/1/2014 74/1/20145/26/20146/23/20147/17/20148/1/2014 82/3/20143/24/20144/21/20145/22/20146/1/2014 94/1/20145/26/20146/23/20147/17/20148/1/2014 103/3/20144/21/20145/26/20146/19/20147/1/2014 113/3/20144/21/20145/26/20146/19/20147/1/2014 Note: The dates above are when mailings begin. Due to the volume, letters are mailed over several days.
When will recipients be notified and be required to enroll? Approximately 60 days prior to each region’s start date, eligible Medicaid recipients will receive a letter with enrollment information, including information on how to enroll. Eligible recipients who must enroll will have a minimum of 30 days from the date they receive their welcome letter to choose from the plans available in their region. 23
How Do Recipients Choose an MMA Plan? Recipients may enroll in an MMA plan or change plans: – Online at :www.flmedicaidmanagedcare.comwww.flmedicaidmanagedcare.com Or – By calling 1-877-711-3662 (toll free) and speaking with a choice counselor OR using the Interactive Voice Response system (IVR) Choice counselors are available to assist recipients in selecting a plan that best meets their needs. This assistance will be provided by phone, however recipients with special needs can request a face-to-face meeting. 24
90 days to change plans After joining a plan, recipients will have 90 days to choose a different plan in their region. After 90 days, recipients will be locked in and cannot change plans without a state approved good cause reason or until their annual open enrollment. 25
Your Address Medicaid is mailing important information to you regarding the MMA program to your home. Make sure we have your current address! To check, Please call the ACCESS Customer Call Center (866) 762-2237 OR Visit http://www.myflorida.com/accessflorida/http://www.myflorida.com/accessflorida/ 29
Auto-Assignment Process If a Recipient does not Make a Plan Choice, how will the Agency determine which MMA plan recipients will be auto assigned to? For Recipients who are required to enroll in an MMA plan: –Recipient is identified as eligible for a specialty plan. –The recipients prior Medicaid managed care plan is also an MMA plan. –Recipient is already enrolled (or has asked to be enrolled) in a long term care plan with a sister MMA plan. –The recipient has a family member(s) already enrolled in, or with a pending enrollment, in an MMA plan. 30
Specialty Plans Can recipients choose to be in or identify themselves as eligible for a specialty plan? Yes, recipients can inform their choice counselor during their choice period that they would like to enroll in a specialty plan if they believe they are eligible for a specialty plan available in their region. The specialty plan will be responsible for confirming that the recipient meets the eligibility criteria for the plan. 31
What Specialty Plans are Available? Managed Medical Assistance Specialty Plans Region Clear Health Alliance Positive Healthcare Children’s Medical Services Network Magellan Complete Care Sunshine Health Plan Freedom Health (Dual Eligibles Only) HIV/AIDS Children with Chronic Conditions Serious Mental Illness Child WelfareCardiovascular Disease; Chronic Obstructive Pulmonary Disease; Congestive Heart Failure; & Diabetes 1XXX 2XXXX 3XXXX 4XXX 5XXXXX 6XXXXX 7XXXXX 8XXXX 9XXXXX 10XXXXXX 11XXXXXX 32 Note: Magellan Complete Care will not begin operation until July 1, 2014 Children’s Medical Services Network plan will not begin operations until August 1, 2014 Freedom Health will not begin operations until January 1, 2015
Specialty Plan Assignment The Agency is required by Florida law to automatically enroll Medicaid recipients into a managed care plan if they do not voluntarily choose a plan. When a specialty plan is available to serve a specific condition or diagnosis of a recipient, the Agency is required to assign the recipient to that plan. The Agency employs a hierarchy for assignment to specialty plans in those instances where a recipient qualifies for enrollment into more than one specialty plan. 33
34 Child Welfare Children’s Medical Services Network HIV/AIDS Serious Mental Illness If a recipient qualifies for enrollment in more than one of the available specialty plan types, and does not make a voluntary plan choice, they will be assigned to the plan for which they qualify that appears highest in the chart below: Dual Eligibles with Chronic Conditions
Who can Enroll in a Specialty Plan? Each specialty plan is designed to serve a unique population. Each population must have defined specified criteria based on age, medical condition, or diagnosis, per Florida law. A recipient must meet the specified criteria in order to enroll in a specific specialty plan. For the most part, the Agency will identify recipients who are eligible to enroll in a specialty plan. However, specialty plans may develop and implement policies and procedures (subject to Agency approval) to screen recipients meeting the specialty plan eligibility criteria and who have not been identified by the Agency. 35
Specialty Plan Enrollment Criteria Specialty Plan Eligibility Criteria Child Welfare (Sunshine Health Plan) Medicaid recipients under the age of 21 who have an open case for child welfare services in the Department of Children and Families’ Florida Safe Families Network database. Serious Mental Illness (Magellan Complete Care) Medicaid recipients diagnosed with Schizophrenia, Bipolar Disorder, Major Depressive Disorder, or Obsessive Compulsive Disorder The Agency will identify the eligible population using specific diagnosis codes and/or medications used to treat the diagnoses specified above. Children’s Medical Services Network Medicaid recipients under the age of 21 who meet the Department of Health’s clinical screening criteria for chronic conditions. NOTE: Will begin operations in August 1, 2014 HIV/AIDS (Positive and Clear Health Alliance) Medicaid recipients diagnosed with HIV or AIDS. The Agency will identify the eligible population using specific diagnosis codes, laboratory procedure codes, and/or medications commonly used to treat HIV or AIDS. Chronic Conditions (Freedom Health, Inc.) Medicaid recipients aged 21 and older eligible for both Medicare and full Medicaid benefits with a diagnosis of Diabetes, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF) or Cardiovascular Disease (CVD). NOTE: Will begin operations in January 1, 2015
Expanded Benefits All managed care plans participating in the SMMC program have the opportunity to offer expanded benefits to their enrollees. Expanded benefits are services that are offered in addition to those available through the Medicaid program. Plans can: –Exceed the limits stated in Medicaid policy for certain services; or –Offer additional services not covered under the Medicaid state plan (e.g., art therapy, post discharge meals, etc.). Specialty plans can choose to offer expanded benefits tailored to their unique population. 37
Expanded Benefits List of Expanded Benefits Amerigroup Better Coventry First Coast Humana Integral Molina Preferred Prestige SFCCN Simply Staywell Sunshine United Adult dental services (Expanded)YYY YYYYYYY YYY Adult hearing services (Expanded)YY Y YYY YYYY Adult vision services (Expanded)YYYYYYYYY YYYY Art therapyY Y Y YY Equine therapy Y Home health care for non-pregnant adults (Expanded) YYYYY Y YY YYYY Influenza vaccineYYYYYYYYY YYYY Medically related lodging & food Y Y Y Y YYY Newborn circumcisionsYYYYYYY YY YYYY Nutritional counselingYY YYYY YYY Outpatient hospital services (Expanded)YY Y YYY YYYY Over the counter medication and suppliesYYY YYYYY YYYY Pet therapy Y Y Y Physician home visitsYY Y Y Y YYYY Pneumonia vaccineYYY YYYYY YYYY Post-discharge mealsYY YYYY YYYY Prenatal/Perinatal visits (Expanded)YY YYYYY YYYY Primary care visits for non-pregnant adults (Expanded) YYYYYYYYYY YYYY Shingles vaccineYYYYY Y Y YYYY Waived co-paymentsYY YYYYYY YYYY NOTE: Details regarding scope of covered benefit may vary by managed care plan. 38
Expanded Benefits Child Welfare HIV/AIDS ( Clear Health) HIV/AIDS ( Positive) SMI Adult dental services (Expanded) Adult hearing services (Expanded) Adult vision services (Expanded) Art therapy Home and community-based services Home health care for non-pregnant adults (Expanded) Influenza vaccine Medically related lodging & food Intensive Outpatient Therapy Newborn circumcisions Nutritional counseling Outpatient hospital services (Expanded) Over the counter medication and supplies Physician home visits Pneumonia vaccine Post-discharge meals Prenatal/Perinatal visits (Expanded) Primary care visits for non-pregnant adults (Expanded) Shingles vaccine Waived co-payments 39 NOTE: Details regarding scope of covered benefit may vary by managed care plan. Children’s Medical Services and the specialty plan for dual eligibles with chronic conditions do not offer Expanded Benefits.
Partnership Choice Counseling wants to partner with the agencies, organizations and providers that serve Medicaid recipients. –Public and Private Enrollment Sessions –Partner Staff Training –Educational only presentations –Health Fairs 41
Agency Goals for a Successful MMA Rollout Preserve continuity of care, and to greatest extent possible: –Recipients keep primary care provider –Recipients keep current prescriptions –Ongoing course of treatment will go uninterrupted Plans must have the ability to pay providers fully and promptly to ensure no provider cash flow or payroll issues. 43
Agency Goals for a Successful MMA Rollout Plans must have sufficient and accurate provider networks under contract and taking patients. –Allows an informed choice of providers for recipients and the ability to make appointments. Choice Counseling call center and website must be able to handle volume of recipients engaged in plan choice at any one time. –Regional roll out to ensure success 44
Continuity of Care During the Transition to MMA Heath care providers should not cancel appointments with current patients. MMA plans must honor any ongoing treatment, for up to 60 days after MMA starts in each Region, that was authorized prior to the recipient’s enrollment into the plan. Providers will be paid. Providers should continue providing any services that were previously authorized, regardless of whether the provider is participating in the plan’s network. Plans must pay for previously authorized services for up to 60 days after MMA starts in each Region, and must pay providers at the rate previously received for up to 30 days. Prescriptions will be honored. Plans must allow recipients to continue to receive their prescriptions through their current provider, for up to 60 days after MMA starts in each Region, until their prescriptions can be transferred to a provider in the plan’s network. 45
46 If you have a complaint or issue about Medicaid Managed Care services, please complete the online form found at: http://ahca.myflorida.com/smmc http://ahca.myflorida.com/smmc Click on the “Report a Complaint” blue button. If you need assistance completing this form or wish to verbally report your issue, please contact your local Medicaid area office. Find contact information for the Medicaid area offices at: http://www.mymedicaid- florida.com / http://www.mymedicaid- florida.com / http://apps.ahca.myflorida.com/smmc_cirts /
Resources Questions can be emailed to: FLMedicaidManagedCare@ahca.myflorida.com FLMedicaidManagedCare@ahca.myflorida.com Updates about the Statewide Medicaid Managed Care program are posted at: www.ahca.myflorida.com/SMMC www.ahca.myflorida.com/SMMC Upcoming events and news can be found on the “News and Events” link. You may sign up for our mailing list by clicking the red “Program Updates” box on the right hand side of the page. 47
Additional Information Youtube.com/AHCAFlorida Facebook.com/AHCAFlorida Twitter.com/AHCA_FL 48 SlideShare.net/AHCAFlorida
Your consent to our cookies if you continue to use this website.