Rollout of Statewide Medicaid Managed Care: Some Things Advocates Need to Know and Do Florida CHAIN May 29, 2014

Statewide Medicaid Managed Care (SMMC) Generally Has nothing to do with who is eligible for Medicaid - Only affects how services are delivered to those already in Medicaid. Medicaid is a state-federal partnership. States administer the program but are subject to federal rules. To implement SMMC, Florida obtained a Demonstration Waiver from federal HHS that rewrites some of those rules. Virtually eliminates state’s direct role of authorizing services for recipients and paying claims from providers. Assigns responsibility instead to managed care plans such as HMOs and Provider Service Networks selected through competitive bidding process.

How Did We Get Here? 1990s: Managed care plans enter Florida Medicaid 2006:“Medicaid Reform” Waiver (“free market experiment”) approved by HHS under Bush administration; Launched in 2 Pilot counties with goal of expanding statewide in 4 years 2007: Pilot expanded to 5 counties 2008: Horror stories abound; plans begin fleeing Pilot 2009:Medicaid Reform experiment almost collapses; statewide expansion blocked, but Reform not fixed by Legislature Jun 2010: Florida requests extension of Medicaid Reform Waiver, 12 months before expiration, HHS announces it will review the request like a brand new application

How Did We Get Here? (cont.) Apr 2011: Reform renamed, reworked, passed by Legislature (Statewide Medicaid Managed Care = SMMC) Aug 2011: Florida submits request for new SMMC experiment to feds, but as an amendment to the old Reform experiment Dec 2011: After almost 18 months, HHS approves extension of old Reform waiver through June 2014 with much stricter conditions and much less experimentation allowed : Florida and HHS negotiate terms of new SMMC waiver; Florida agrees to several new requirements; other problematic elements rejected by HHS Jun 2013: HHS approves SMMC, replacing Reform waiver May 2014: SMMC begins rolling out over 4 months

What is Statewide Medicaid Managed Care? Consists of 2 separate but related components: - Managed Long-Term Care (Rollout recently completed) - Managed Medical Assistance (all other services) In all 67 counties, most recipients must now enroll in a managed care plan: - Some will lose “Fee-for-Service” Medicaid - Many will lose access to MediPass Note: In general, Florida did not need a high-powered waiver to do this.

More About Statewide Medicaid Managed Care (SMMC) Consists of 2 separate but related components: - Managed Long-Term Care (Rollout recently completed) - Managed Medical Assistance (all other services) In all 67 counties, most recipients must now enroll in a managed care plan: - Some will lose “Fee-for-Service” Medicaid - Many will lose access to MediPass Note: In general, Florida did not need a high-powered Demonstration Waiver to do this.

Statewide Medicaid Managed Care vs. Medicaid Reform Provides better, more consistent, more manageable plan choices Reduces threat from giving plans too much flexibility, too little oversight (benefit and consumer protections) Significantly increases accountability and transparency (some only on paper so far) Eliminates worst experimental features and addressed worst problems

If It’s Just Managed Care, What’s the Concern? For the first time, almost all of the ultimate decision-makers re: patient care report to investors or shareholders. Capitated managed care: Plans receive paid (some now, some soon) a fixed amount per recipient for care. Some flexibility in benefit design, though so far appears to be used only to add optional benefits Medicaid recipients are very low-income and face many barriers to participation. They are also less likely to speak up.

Rollout of Managed Medical Assistance HAPPENING REGIONALLY: 11 Regions in 4 Flights HAPPENING FAST: Over 4 months: May 1, June 1, July 1, Aug 1 HAPPENING TO MOST GROUPS (FAST, REGIONALLY): Exempt: Those with limited Medicaid coverage Voluntary: e.g., DD waiver services or waiting list Some groups using specialty plans are delayed (e.g., Children’s Medical Services)

Statewide MMA Rollout Schedule July: Broward, Miami-Dade and the Keys August: Western Panhandle, Central Florida & Brevard, Treasure Coast and Palm Beach

Between 2 and 10 Plan Choices, Depending on Region (excluding Specialty Plans)

Before the Switch Recipients should receive information about options at least 60 days before the switch date - several different communications. For recipients enrolled in managed care plans already, those plans must continue to serve them, even if the plans were not selected to serve the region where the recipient lives. Each recipient must selected a managed care plan, or (s)he will be assigned to one (based on criteria). Recipients are encouraged to work with choice counselors that are supposed to equip them to select the plan that best meets their needs.

During the Transition Recipients must be able to continue getting the services and medications they’ve relied on from their new plan. Recipients must be able to access providers they need in their new plans. Networks must be adequate and network info must be accurate

After the Switch After 60 days (and presumably after evaluation), recipients may see access to services or medications changed/limited Recipients have 90 days to change plans for any reason…or for no reason at all. After 90 days, recipients are “locked in” to plan for 12 months, except for good cause Recipients must be able to access providers and services without delays or denials

We Need to Be on the Lookout for Recipients Who… Did not receive information about the switch, their options or their rights Received misinformation or insufficient info from choice counselors Have special needs that were not addressed or accommodated Were assigned to a plan they did not choose or want Experienced a disruption in care Encountered inadequate plan network/Loss of provider access Faced delays or denials of needed care

Important Links Official Statewide Medicaid Managed Care Site: Official State Complaint Form: ome.shtml Choice Counseling Services: Florida CHAIN (Submit Stories or Ask Questions):