1. Update on Statewide Medicaid Managed Care Program and Florida Medicaid Mental Health and Substance Abuse Services Justin M. Senior Deputy Secretary for Medicaid Agency for Health Care Administration Florida Council for Community Mental Health August 4, 2015

2. The Statewide Medicaid Managed Care Program In 2011, the Florida Legislature required the Agency to expand managed care statewide for most Medicaid recipients. The Agency successfully implemented the Statewide Medicaid Managed Care (SMMC) program August 1, 2013, through August 1, 2014. The program has two components: the Long-Term Care (LTC) program and the Managed Medical Assistance (MMA) program. –MMA covers most recipients of any age who are eligible to receive full Medicaid benefits. –LTC covers most recipients 18 years of age or older who need nursing facility level of care. 2

3. SMMC Program Goals The goals of the Statewide Medicaid Managed Care Program are: –To improve coordination of care –Improve the health of recipients, not just paying claims when people are sick –Enhance accountability –Allow recipients a choice of plans and benefit packages –Allow plans the flexibility to offer services not otherwise covered –Enhance prevention of fraud and abuse through contract requirements. 3

4. SMMC Program Elements Plan Choice HMOs and PSNs (provider service networks) Comprehensive Plans in LTC Specialty Plans in MMA Choice of Benefit Package Choice Counseling Risk Adjusted Rates Low Income Pool 4

5. SMMC Program Enhancements: Expanded Benefits The Agency negotiated with health plans to provide extra benefits at no cost to the state. These benefits include: –Adult dental –Hearing and vision coverage –Outpatient hospital coverage –Physician coverage, among many others. 5

6. SMMC Program Enhancements: Network Adequacy Standards Time and distance standards Ratios of patients to providers Increasing the number of primary care and specialist providers accepting new Medicaid enrollees Increasing the number of primary care providers that offer appointments after normal business hours Extremely low level of complaints/issues. 6

7. SMMC Program Enhancements: Types of MMA Plans Standard Plan –Offers most Medicaid services Comprehensive Plan –Offers both Long-term Care and Managed Medical Assistance services Specialty Plan –Serves Medicaid recipients who meet specified criteria based on age, medical condition, or diagnosis. 7

8. SMMC Program Enhancements: MMA Plan Accreditation Each health plan must be accredited by the National Committee for Quality Assurance, the Joint Commission, or another nationally recognized accrediting body, or have initiated the accreditation process, within 1 year after the contract is executed. For any plan not accredited within 18 months after executing the contract, the agency shall suspend automatic assignment. 8

9. SMMC Program Enhancements: Claims Processing The Agency negotiated more timely claims processing timeframes than are required in state and federal regulations. –Examples: Health plans will pay, deny, or contest electronic claims within 15 calendar days. Health plans will pay, deny, or contest paper claims within 20 calendar days. Health plans agree to pay 50% all clean claims within 7 calendar days of receipt. 9

10. SMMC Program Enhancements: Prior Authorization Health plans agreed to process standard and expedited prior authorization requests more timely. For many of the standards, the timeframes for processing the authorization request have been reduced by almost half. 10

11. SMMC Program Enhancements: Enrollee/Provider Help Line Health plans agreed to adhere to more stringent call center performance standards. Areas where we achieved added value include: –reduced time for the average speed to answer, –reduced call blockage rates, –reduced call abandonment rates, and –reduced wait times for calls placed in the queue. 11

12. Selecting SMMC Plans Health plan contracts were competitively procured in each of 11 regions. The Agency received bids and awarded contracts to HMOs and Provider Service Networks (PSNs). Contracts are for a five-year contract period. 12

14. *Specialty Plan Managed Medical Assistance Plan Enrollment by Region as of July 1, 2015 Plan Name Region 01 Region 02 Region 03 Region 04 Region 05 Region 06 Region 07 Region 08 Region 09 Region 10 Region 11 Total by Plan Amerigroup 73,121126,78480,637 54,527335,069 Better Health 19,662 73,191 92,853 CMSN1,5274,7166,4275,2703,8978,1207,9994,0395,7357,3056,33561,370 Coventry 49,000 Humana62,564 35,119 71,48163,94487,426320,534 Integral32,785 16,684 41,521 90,990 Molina 61,995 11,948 66,029 26,972166,944 Preferred Medical 24,929 Prestige 49,46162,980 22,36026,49933,62754,54943,782 14,466307,724 SFCCN 42,111 Simply Healthcare 80,314 Staywell 54,26190,78362,44448,096124,958146,74588,848 61,693677,828 Sunshine State 34,56379,72627,02544,02555,20818,82367,16862,06925,907414,514 United Healthcare 56,87978,241 47,226 87,921270,267 AHF / Positive* 7771,0321,809 Freedom Health* 20 918111220072 Magellan* 2,014 6,0653,6346,5047,475 3,9023,1356,23838,967 Clear Health Alliance*219282525 9079231,1934481,2869342,5119,228 Sunshine Health Child Welfare*8626742,3312,5391,6052,9672,5981,4921,9752,3562,06421,463 Total by Region97,957111,408254,508296,280180,654412,263394,667209,732261,360255,822531,3353,005,986 14

15. Long-term Care Plan Enrollment by Region as of July 1, 2015 Plan Name Region 01 Region 02 Region 03 Region 04 Region 05 Region 06 Region 07 Region 08 Region 09 Region 10 Region 11 Total by Plan American Eldercare1,3681,3446542,5791,6131,0092,1809601,3471,9193,52518,498 Amerigroup Florida 1,6452,9064,551 Coventry Healthcare 1,041970 1,381 1,3624,754 Humana 1 1 Molina 1,4901,257 2,8915,638 Sunshine State1,629 3,9053,7934,1053,8533,3123,1823,5712,7064,53134,587 United Healthcare 2,4111,8722,1812,2801,9492,1481,2401,453 4,02819,562 Total by Region2,9973,7556,4318,5549,4889,1098,6105,3827,7526,27019,24387,591 15

16. Florida Medicaid Mental Health and Substance Abuse Services

17. Medicaid-Covered Mental Health and Substance Abuse Services –Community mental health and substance abuse treatment services –Mental health targeted case management –Inpatient/ residential psychiatric treatment –Child welfare-related mental health and substance abuse services 17

18. Medicaid-Covered Mental Health and Substance Abuse Services (cont.) Community mental health and substance abuse services: –Assessments –Treatment planning –Individual, group, and family therapies –Community support and rehabilitative services –Therapeutic behavioral on-site services for children and adolescents Mental health targeted case management: –Assists recipients in gaining access to needed medical, social, educational, and other services 18

19. Medicaid-Covered Mental Health and Substance Abuse Services (cont.) Inpatient/ residential psychiatric treatment: –State Mental Health Hospital: over age 65 –Statewide Inpatient Psychiatric Program (SIPP): under age 21. Specialized service for children in child welfare: –Behavioral health overlay services –Comprehensive behavioral health assessment –Specialized therapeutic foster care –Therapeutic group care services 19

20. Provider Network Adequacy Network adequacy requirements are in place for: –Board Certified or Board Eligible Adult and Child Psychiatrists –Licensed Practitioners of the Healing Arts –Licensed Community Substance Abuse Treatment Centers –Inpatient Substance Abuse Detoxification Units –Fully Accredited Psychiatric Community Hospital (Adult and Children) or Crisis Stabilization Units/ Freestanding Psychiatric Specialty Hospital 20

21. Performance Measures Plans must report on mental health and substance abuse- related performance measures: –Antidepressant Medication Management –Follow-up Care for Children Prescribed ADHD Medication –Initiation and Engagement of Alcohol and other Drug Dependence Treatment –Follow-up after Hospitalization for Mental Illness –Mental Health Readmission Rate 21

22. Serious Mental Illness Specialty Plan Magellan Complete Care is the specialty health plan Serves recipients ages six and older who are diagnosed with or in treatment for a serious mental illness: –Schizophrenia –Schizoaffective Disorder –Delusional Disorder –Bipolar Disorder –Major Depression –Obsessive Compulsive Disorder; or –Recipients who are treated with a medication commonly used to treat a disorder listed above. 38,967 recipients are enrolled in this plan (July 2015). 22

23. Serious Mental Illness Specialty Plan Expanded benefit: medically necessary intensive outpatient therapy for substance abuse Additional performance measures: –Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotics –Diabetes monitoring for people with diabetes and schizophrenia –Cardiovascular monitoring for people with cardiovascular disease and schizophrenia –Adherence to antipsychotic medications for individuals with schizophrenia 23

24. Serious Mental Illness Specialty Plan: Enhanced Provider Network 24 Provider TypeSpecialty Plan Enhanced Network Adequacy Ratios Standard Plan Network Adequacy Ratios Primary Care Provider1:7501:1500 24-Hour Pharmacy2: Countyn/a Board Certified or Board Eligible Adult Psychiatrist 1:3751:1500 Fully accredited Psychiatric Community Hospital (Adult) or Crisis Stabilization Units/ Freestanding Psychiatric Specialty Hospital 1 bed:500 enrollees1 bed:2000 enrollees Inpatient Substance Abuse Detoxification Units1 bed:1000 enrollees 1 bed:4000 enrollees Fully accredited Psychiatric Community Hospital (Child) or Crisis Stabilization Units/ Freestanding Psychiatric Specialty Hospital 1 bed:2000 enrollees 1 bed:4000 enrollees

25. Community Behavioral Health Provider Rates During 2015 Special Session A, the Agency, in consultation with the Department of Children and Families, was authorized to seek approval from the federal Centers for Medicare and Medicaid Services to implement a certified public expenditure or similar mechanism to increase reimbursement rates for services reimbursed to community behavioral health care providers. 25

26. Medicaid Help Line Medicaid recipients and providers can call (877) 254-1055 to ask questions about Medicaid and Medicaid services. Please note: This line cannot be used for help with Medicaid eligibility questions. The Department of Children and Families handles those issues. 26

27. Report a Medicaid Complaint If you have a complaint or issue about Medicaid please complete the online form at: http://ahca.myflorida.com/smmc http://ahca.myflorida.com/smmc Click on the “Report a Complaint” blue button. 27

28. Stay Connected 28 Youtube.com/AHCAFlorida Facebook.com/AHCAFlorida Twitter.com/AHCA_FL SlideShare.net/AHCAFlorida

29. Questions? 29