1. Medicaid Managed Care in Florida: Federal Approval and Implementation Joan Alker and Jack Hoadley Georgetown University Health Policy Institute October 9, 2013

2. Florida’s Medicaid program 3.3 million enrollees Primary source of care for children, pregnant women, people with HIV/AIDS, long term care Expenditures -- 31% of state budget, 18% of state general funds Matching rate: 58.08% 2

3. Timeline 3 10/2005 Waiver approved that results in 5-county pilot 5/2011 FL legislation to seek statewide waiver 8/2011 MMA and LTC waiver requests submitted 2/2013 Long-term care waiver approved 6/2013 Statewide waiver approved 8/2013 Start of enrollment in LTC waiver Mid-2014 Projected start of enrollment in MMA program

4. Approval June 14, 2013 o CMS approves statewide waiver extension with new terms; some are built off the 5-county pilot. Waiver approval period ends 6/30/2014. 4

5. Renewal: Just around the corner o Because negotiations took so long, the waiver amendment term runs out 6/30/2014 o Public comment process already under way as AHCA must submit extension request by end of the year o Low Income Pool for safety-net providers o Not addressed in negotiations, but merely extended to this date 5

6. Long term care waiver o Was approved on a separate track o Program implementation occurring now o Not addressed in this brief o Forthcoming brief and webinar, sponsored by a group of Florida funders, expected in November from Georgetown Health Policy Institute 6

7. How has Florida’s waiver changed? o Does not affect eligibility and never did o Now largely about delivery system change o Some benefits flexibility for adults o Original waiver authorities and programs that are now gone o EPSDT waiver o Premiums never approved o Enhanced benefits program changing o Premium assistance 7

8. Why was a waiver still needed? o Some populations can be required to move into managed care without a waiver o Others cannot: dual eligibles, children on SSI, long term care services o Adult benefit is based on an actuarial equivalency standard that requires a waiver (though actuarial equivalency now allowed) o Geographic phase-in requires a waiver 8

9. Findings on pilot program o Five counties (Broward, Duval, Baker, Clay, Nassau) starting in 2006 and 2007 o High levels of market disruption o Withdrawal of plans with large enrollment share o Little evidence on access improvement o Early evidence: low provider participation o Benefit flexibility had little effect o Inconclusive on whether pilot saved money o Opt-out program had minimal take-up

10. Managed care in Florida today 10 PopulationCurrent % in MCOs TOTAL MEDICAID POPULATION 47% TANF: Low-Income Children and Parents 63% SSI: Person receiving disability payments 47% Dually eligible for Medicare and Medicaid 9% Other populations <1% o Varying use of managed care today by different FL Medicaid populations

11. Does managed care vary by region? 11 RegionCountiesCurrent % in MCOs 1 Escambia, Okaloosa, Santa Rosa, Walton 28% 2 Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, Washington 34% 3 Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrest, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwanee, Union 36% 4 Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia 59% 5 Pasco, Pinellas 50% 6 Hardee, Highlands, Hillsborough, Manatee, Polk 55% 7 Brevard, Orange, Osceola, Seminole 53% 8 Charlotte, Collier, DeSoto, Glades, Hendry, Lee, Sarasota 38% 9 Indian River, Martin, Okeechobee, Palm Beach, St. Lucie 42% 10 Broward 66% 11 Miami-Dade, Monroe 36%

12. Who must participate? o Most Medicaid populations will be required to enroll in a managed-care plan o Voluntary for those: o With another source of health care, except Medicare o Age ≥ 65, residing in a mental health treatment facility o In intermediate care facility for intellectual disabilities o With developmental disabilities, using home & community-based services o Excluded are those: o Eligible for emergency services due to immigration status o Participating in family planning waiver program o Eligible as women with breast or cervical cancer o Children receiving services in a pediatric extended care facility o Dual eligibles, with only premium or cost-sharing assistance 12

13. What plans will be participating? o Bids solicited, December 2012 o 27 plan bids, 20 organizations o Winners announced, September 2013 o 6 HMOS and 4 PSNs selected for general population o No organization will serve all regions o 5 companies selected to offer specialty plans o Children in child welfare system, people with HIV/AIDS, severe mental illness, cardiovascular disease, COPD, congestive heart failure, diabetes o Some non-selected plans are protesting 13

14. Transition to the new system o All selected plans are in FL Medicaid today o But not all will continue in all regions o Broward County: half of current MCO enrollees will be required to select new plans o How will transitions and potential disruptions be addressed? o What role will specialty plans play? 14

15. PSNs vs. HMOs o Selected PSNs: based in local hospital systems, clinics, or primary care groups o PSNs have been popular in pilot counties, especially for those with more health conditions and existing relationships with providers 15

16. PSNs vs. HMOs in pilot counties 16

17. PSNs vs. HMOs – worth monitoring HMOs have had higher rates of complaints PSNs moving to capitation is a risk point with sicker population 7/12-6/13HMOsPSNs Enrollment52%48% Complaints75%25% 17

18. What is the transition timeline? o 10/31/2013: Implementation plan due, with plan for readiness review o Basic timeline for implementation o Assessment of plan capacity and solvency, access protections o Mid-2014: Enrollment phase-in o Implementation by region o Outreach starts 90 days in advance o Potential for “pauses” if issues arise 18

19. HOW WILL MANAGED CARE OPERATE? WHAT CONSUMER PROTECTIONS ARE THERE? 19

20. Medical loss ratio (MLR) o Requires insurers to spend a minimum percentage of premium dollars on services o ACA included an MLR on private insurers, but does not apply to Medicaid o 11 states have some kind of Medicaid MLR on some or all of their expenditures 20

21. Medical loss ratio in waiver o FL Healthy Kids has an 85% MLR o Florida’s 2011 pilot waiver extension included an 85% MLR for five-county pilot o This was extended statewide in waiver terms and conditions approved in June o First and only time CMS has included an MLR in a waiver agreement 21

22. Comprehensive quality strategy o State strategy for quality improvement at state, plan, provider levels o Develop, adopt quality metrics; achieve at least 75 th percentile of national Medicaid o Quality improvement projects o Improved prenatal care o Well-child visits to age of 15 months o Preventive dental care for children o Health plan report cards for consumers 22

23. Network adequacy o Concern about shortages of specialists, dentists, other providers; pilot experience o State required to report on network policies o Availability of routine, urgent appointments o Travel time and distance standards o Access outside of network o Access for those with special needs, cultural considerations o This will need a lot of monitoring! o Secret shopper studies a good tool 23

24. Ensuring plan stability o Pilot experience: high rate of plan turnover o 11 of 14 HMOs from Year 1 later withdrew o But only 1 of PSNs withdrew o Policies in waiver o Five-year commitment to program o Penalties for withdrawal o Maximum number of plans per region o Issues to monitor 24

25. Enrollment procedures o Letter with enrollment information o 30 days to select a plan o 90 days to change the selection o Those not selecting will be auto-enrolled o Based on history with plan or providers o Chance to switch away from assigned plan o Issues to monitor: o Do beneficiaries understand options? o How many pick? How many are auto-enrolled? 25

26. Stakeholder involvement o Medical Care Advisory Committee o Minimum of 4 beneficiaries o Smaller advisory committees to monitor impact on specific subpopulations o Persons with HIV/AIDS o Children, especially those in foster care o Children with dental care needs o Persons receiving behavioral health, SA services o Issues to monitor 26

27. Concluding thoughts o Will imminent waiver renewal change anything? o Will ongoing Medicaid expansion debate intersect? o Future of LIP o Education, oversight and monitoring is essential…. 27

28. For more information o Joan Alker and Jack Hoadley o jca25@georgetown.edu; jfh7@georgetown.edu jca25@georgetown.edu jfh7@georgetown.edu o Twitter @joanalker1 o Georgetown University project website o http://hpi.georgetown.edu/floridamedicaid http://hpi.georgetown.edu/floridamedicaid o Georgetown Center for Children and Families http://ccf.georgetown.edu/http://ccf.georgetown.edu/ 28