Impact of the MMA on Existing Disease Management Programs and Managed Care Initiatives for the Aged and Disabled Center for State Health Policy Rutgers, The State University of New Jersey Roberta Kelley Chief, Bureau of Health Systems Development Florida Agency for Health Care Administration

MMA and Florida Medicaid Florida: Over Age 65 Population 15.2 Million Residents 15.2 Million Residents 17.6 percent over age 65 versus 12.4 percent nationally 17.6 percent over age 65 versus 12.4 percent nationally 2.9 Million Medicare Beneficiaries 2.9 Million Medicare Beneficiaries

MMA and Florida Medicaid Medicaid Enrollment (Estimated FY ) 2.1 Million Eligibles 2.1 Million Eligibles  Approximately 480,000 are dual eligibles $13 Billion in Expenditures $13 Billion in Expenditures  Dual eligible account for 40% of total expenditures  Dual eligible drug costs account for 55.5% of total drug spend Exempt from Managed Care Exempt from Managed Care

MMA and Florida Medicaid Disease Management Initial Statutory Direction Medicaid Reform Task Force Legislative Authorization (HIV, Asthma, Diabetes, Hemophilia) Legislative Authorization (ESRD, Heart Failure) Asthma Agreement ITNs for HIV, Diabetes and Hemophilia ITNs for ESRD and Heart Failure Diabetes Contract HIV/AIDS (except S. FL) and Hemophilia Contracts Legislative Authority to Expand to Other Diseases as Necessary COPD Pilot Contract ESRD and Heart Failure Contracts Legislative Authorization for ‘Value-Added’ Programs Pfizer Agreement (Asthma, Diabetes, Hypertension, Heart Failure) Bristol-Myers Squibb Agreement (Diabetes, Depression) Autoimmune Center Contract HIV/AIDS (S. FL) Contract July 1997 July 1998 July 1999 July 2000 July 2001

MMA and Florida Medicaid DM Initiative HistoryDates Disease State(s) DMO(s) 8/98–2/00Asthma -Integrated Therapeutics Group 5/99-6/02Diabetes -Coordinated Care Solutions 6/99-6/04HIV/AIDS -AIDS Health Care Foundation (With Public Health Trust of Miami-Dade/N. Broward Hospital District in S.FL) 6/99-7/019/00-1/03Hemophilia -Accordant (S. FL) -Caremark (N. FL) 9/01-8/03ESRD/CKD -RMS Disease Management 9/01-8/05CHF -Lifemasters Supported SelfCare 8/00-12/01COPD -CyberCare Technologies 1/02-6/04 Autoimmune Disorders -University of Florida 7/01-9/05 Diabetes, Asthma, CHF, HTN -Pfizer/Pfizer Health Solutions 5/02-6/03 Diabetes, Depression -Bristol Myers Squibb Spring 04 Evaluation of Initiative -Contract with CorSolutions

MMA and Florida Medicaid DM Initiative Currently Florida: A Healthy State Florida: A Healthy State  Asthma, Diabetes, Hypertension statewide; CHF Areas 8-11 Positive Healthcare Positive Healthcare  AIDS Healthcare Foundation, HIV/AIDS statewide Diabetik Smart Promotora Diabetes Program Diabetik Smart Promotora Diabetes Program  Health Choice Network, Dade and Broward counties LifeMasters Supported Self Care, Inc. LifeMasters Supported Self Care, Inc.  CHF Areas 1-7 University of Florida University of Florida  Center for Orphan Autoimmune Disorders

MMA and Florida Medicaid Medicaid DM Enrollment Process Claims Based Disease State Algorithms: Claims Based Disease State Algorithms:  ICD-9 codes  NDC codes  Utilization Beneficiaries assigned to DM program based on Disease State Hierarchy Beneficiaries assigned to DM program based on Disease State Hierarchy Duals excluded from DM except for PAC Duals excluded from DM except for PAC

MMA and Florida Medicaid DM and Long Term Care HIV/AIDs DM works with Home Community Based Waiver Program HIV/AIDs DM works with Home Community Based Waiver Program Approximately 3,200 of 5,880 enrollees are dual eligible Approximately 3,200 of 5,880 enrollees are dual eligible Responsible for utilization review and assessments Responsible for utilization review and assessments Reduction in Home Health and Skilled Nursing Reduction in Home Health and Skilled Nursing

MMA and Florida Medicaid Part D Drug Coverage and Impact on FL DM Availability of Claims Data (medical and pharmacy) to identify beneficiaries Availability of Claims Data (medical and pharmacy) to identify beneficiaries Coordination of Benefits Coordination of Benefits  Medicare only providers Lack of UR/UM measures for population Lack of UR/UM measures for population Education of Drug Coverage Education of Drug Coverage

MMA and Florida Medicaid Enrollment in Part D States have not been given authority to ensure that duals are enrolled. States have not been given authority to ensure that duals are enrolled. Duals are expected to secure Part D coverage. Duals are expected to secure Part D coverage. … but enrollment is voluntary; non selection = assignment; and … but enrollment is voluntary; non selection = assignment; and although automatically enrolled, they may opt out although automatically enrolled, they may opt out

MMA and Florida Medicaid Chronic Care Improvement Program Coverage of CHF and Diabetes Coverage of CHF and Diabetes Participation is Voluntary Participation is Voluntary Florida is a possible site Florida is a possible site Strong Evaluation Component Strong Evaluation Component Scalability of Program Scalability of Program

MMA and Florida Medicaid Medicare Advantage Encouraged to provide DM Encouraged to provide DM Creation of Specialty Health Plans Creation of Specialty Health Plans  May increase DM and enhance coordination of Medicare covered services  Medicaid services are unmanaged

MMA and Florida Medicaid Conclusion Short Term Short Term  Enrollment and Coverage of Prescription Drugs  Fragmentation as CCIP becomes operational Long Term Long Term  Scalability of DM Programs  Decision to better manage duals and integration with long term care

Roberta Kelley Chief, Bureau of Health Systems Development Florida Agency for Health Care Administration Ph Medicaid: