Download Palm Beach County Medical Society Services

Palm Beach County Medical Society
Legislative Wrap Up
May 22, 2014
Boca Raton Regional Hospital
Ronald Zelnick, MD
President,
Palm Beach County Medical Society
Shawn Baca, MD
Secretary, PBCMS
Boca Raton Regional Hospital
Douglas Dedo, MD
President,
Palm Beach County Medical Society Services
Jeff Scott, Esq.
General Council
Florida Medical Association
FMA LEGISLATIVE UPDATE
POST SESSION 2014
2014 LEGISLATIVE SESSION
The Players:
• Governor Rick Scott
•
•
•
Will be seeking a second term
Pending election will affect legislative priorities and budget proposals
Friend of Medicine
• Senate President Don Gaetz
•
•
Final year of 2-year term as Senate President, will have 2 remaining
years in Senate after
Friend of Medicine
• Speaker of the House Will Weatherford
•
•
Final year of 2-year term as Speaker
Friend of Medicine
HELPING PHYSICIANS PRACTICE MEDICINE
2014 LEGISLATIVE SESSION
TOTAL NUMBER OF BILLS
FILED:
1989
BILLS TRACKED BY THE FMA:
317
HELPING PHYSICIANS PRACTICE MEDICINE
POST 2014 SESSION
WRAP UP
HELPING PHYSICIANS PRACTICE MEDICINE
LEGISLATION THAT FAILED
• Most everything health care related
HELPING PHYSICIANS PRACTICE MEDICINE
PLAYING DEFENSE - SCOPE
A majority of the 2014 legislative session
focused on fighting off legislation that was
not physician friendly.
• This legislation included scope of practice
expansion that would have allowed:
1.
2.
3.
ARNP’s to practice independent of a physician
ARNP’s to prescribe controlled substances
CRNA’s to practice with no physician supervision
THE FMA WAS ABLE TO STOP THIS LEGISLATON
FROM PASSING AND BECOMING LAW.
HELPING PHYSICIANS PRACTICE MEDICINE
HB 7113: The Train from Hell
•
•
•
•
ARNP Independent Practice
ARNP Controlled Substance Prescribing
Telemedicine – No Florida license required
Mandatory Checking of the PDMP
HELPING PHYSICIANS PRACTICE MEDICINE
REDUCING BURDENSOME
REGULATIONS
• The FMA fought hard to ease the regulatory burdens
faced by physicians when dealing with insurance
companies.
• This legislation would have removed the insurance
company from the physician/patient relationship
• This legislation had 4 main components:
1.
2.
3.
4.
Fail First / Step Therapy
Grace Period
Prior Authorization
Bait and Switch/ Provider Registries
HB 1001 by Rep. Jason Brodeur / SB 1354 by Sen. Denise
Grimsley
HELPING PHYSICIANS PRACTICE MEDICINE
REDUCING BURDENSOME
REGULATIONS
FAIL FIRST / STEP THERAPY
• This section of the legislation placed strict limitations on
the use of fail first protocols by insurance companies.
• Insurance companies should not practice medicine and
dictate treatment plans to physicians.
• If a physician believes, based on sound medical
judgment, that fail first protocol is likely to be ineffective,
cause an adverse reaction, or result in physical harm, an
override of the fail first protocol should be granted within
24 hours.
HELPING PHYSICIANS PRACTICE MEDICINE
REDUCING BURDENSOME
REGULATIONS
PRIOR AUTHORIZATION
• The portion of the legislation made it unlawful for an
insurance company or other third party payer to interfere
with a licensed MD/DO’s valid order for a medical test or
procedure.
• This created a standardized prior authorization claims
form, which all insurance companies and managed care
plans would be required to use in Florida.
HELPING PHYSICIANS PRACTICE MEDICINE
REDUCING BURDENSOME
REGULATIONS
RETROACTIVE DENIALS /GRACE PERIOD
• A glitch in the ACA requires patients who have purchased coverage
through an insurance exchange be given 90 days before their policy is
canceled for non-payment of premiums. After the first 30 days of nonpayment of premiums, there is no obligation for insurers to reimburse
providers for services rendered.
• To help limit the negative effects of this provision of the ACA, the FMA
filed legislation that would prevent health insurers from retroactively
denying claims if subscriber eligibility has been confirmed prior to the
delivery of care.
HELPING PHYSICIANS PRACTICE MEDICINE
REDUCING BURDENSOME
REGULATIONS
BAIT AND SWITCH
• Health insurers should not be able to entice people to
buy their coverage by advertising long-outdated
preferred provider networks that list physicians who are
no longer participating.
• This bill required insurers to maintain an accurate list on
their website, and to make any changes within 24 hours.
HELPING PHYSICIANS PRACTICE MEDICINE
TELEMEDICINE
Although this legislation did not pass this session, the
FMA will continue to support the expanded use of
telemedicine to modernize the delivery of healthcare.
Uniform standards should be established for
physicians to maintain patient safety through four (4)
key components:
1.
2.
3.
4.
Definition
Accountability
Education
Parity in Reimbursement
HELPING PHYSICIANS PRACTICE MEDICINE
TELEMEDICINE
DEFINITION:
• Telemedicine is the health care delivery, diagnosis,
consultation, treatment, monitoring, or the transfer of
medical data via the use of telecommunications to
establish a physician-patient relationship, to evaluate a
patient, or to treat a patient. It should be conducted with
the appropriate technology and encryption to comply
with HIPAA and with the patient’s informed consent.
ACCOUNTABILITY:
• Physicians practicing telemedicine in Florida must be
licensed in Florida.
HELPING PHYSICIANS PRACTICE MEDICINE
TELEMEDICINE
EDUCATION:
• All telemedicine physicians must comply with current Florida
laws and rules. The best way to maintain this knowledge is
through continuing medical education.
PARITY REIMBURSEMENT:
• Parity for face-to-face consults and telemedicine consults
must apply in the private insurance market as well as in
Medicaid.
• Physicians expend the same amount of time, skill, and
expertise when conducting a consult whether it be face-toface or through telecommunications.
HELPING PHYSICIANS PRACTICE MEDICINE
TELEMEDICINE
• The FMA strongly believes telemedicine is the
practice of medicine, and as such should be
provided only by Florida licensed MDs and DOs.
• The legislation proposed by both the House and
Senate was far reaching and overly broad. These
bills allowed for physician extenders as well as out
of state licensed practitioners to practice
telemedicine on Florida patients.
• The FMA opposed this legislation as it effectively
served as a back door scope of practice expansion
and failed to protect the safety of Floridians.
HELPING PHYSICIANS PRACTICE MEDICINE
THE FIVE PILLARS OF
EXPANDED ACCESS TO CARE
The FMA has identified how to effectively and
immediately address the shortage of primary care and
family physicians in Florida and will continue pursuing
legislation to expand on these:
1. Increasing the in-state residency slots for family practice
2. Redirecting funds for loan forgiveness to family practitioners
3. Expanding collaboration between PAs, ARNPs and
MDs/DOs
4. Fully enacting fair payment for Medicaid services
5. Codifying and regulating telemedicine
HELPING PHYSICIANS PRACTICE MEDICINE
HOSPITAL OBSTETRIC
DEPARTMENT CLOSURES
• The FMA sought legislation requiring a hospital to
notify physicians with privileges in their obstetric
department at least 120 days prior to closing that
department, in order to allow physicians ample time
to notify their pregnant patients.
• SB 380 by Sen. Aaron Bean / HB 373 by Rep.
Kathleen Peters
HELPING PHYSICIANS PRACTICE MEDICINE
PRIMARY CARE MEDICAID
REIMBURSEMENT
• The FMA fought to extend the 2 year Medicaid
reimbursement increase for primary care.
• If the Legislature does not act, the current rate
increase is set to expire on Jan. 1, 2015.
HELPING PHYSICIANS PRACTICE MEDICINE
Graduate Medical Education
• HB 7109 (no Senate companion)
• Called for a survey of the state’s medical
schools and accredited GME institutions
• No additional money provided
HELPING PHYSICIANS PRACTICE MEDICINE
Accuracy in Medical Damages
• Main priority of Publix and Disney
• Initial version would have placed arbitrary
limits on physician reimbursement
• Would have functionally abolished letters
of protection
• Were able to work out a compromise, but
bill ultimately did not pass
HELPING PHYSICIANS PRACTICE MEDICINE
NEEDLE & SYRINGE
EXCHANGE PILOT PROGRAM
• The FMA assisted the FMA’s Medical Student Section (MSS) in seeking
legislation authorizing a five-year needle & syringe exchange pilot
program in Miami-Dade County. This legislation passed all committees
in the House and Senate but got caught up on the floor.
• This pilot program offered the exchange of free, clean, and unused
needles/syringes for used needles/syringes as a means to prevent the
transmission of HIV/AIDS and other blood-borne diseases among
intravenous drug users.
• The program was to make available to program participants educational
materials, HIV counseling and testing services, referral services
targeted to education programs.
• SB 408 by Sen. Oscar Braynon / HB 491 by Rep. Mark Pafford.
HELPING PHYSICIANS PRACTICE MEDICINE
Patient Compensation System
• HB 739 (Rep. Brodeur)
• SB 1362 (Sen. Grimsley)
• A “no fault” medical malpractice
compensation system riddled with
problems.
HELPING PHYSICIANS PRACTICE MEDICINE
WHAT PASSED?
• SB 1030 (Rep. Gaetz): Compassionate
use of Medical Cannabis
• HB 225 (Rep. Perry): Child Safety
Devices in Motor Vehicles
HELPING PHYSICIANS PRACTICE MEDICINE
FMA PAC –
YOUR VEHICLE TO
POLITICS IN MEDICINE
HELPING PHYSICIANS PRACTICE MEDICINE
FMA PAC
• The FMA PAC is the political arm of the Florida
Medical Association
• The mission of the FMA PAC is to elect promedicine candidates into the Florida Legislature
• Contributing to the FMA PAC is the single
most powerful thing you can do for the
medical profession in Florida. Everything
the FMA PAC does makes the medical
profession stronger.
HELPING PHYSICIANS PRACTICE MEDICINE
HOW MUCH DO CAMPAIGNS
COST?
• State Senate $500,000 -$1,500,000+
• State House $300,000-$500,000
– This includes party money, soft
money (large ECO contributions),
and hard money (the individual
contributions).
HELPING PHYSICIANS PRACTICE MEDICINE
96% of FMA PAC endorsed
candidates won their election in
2010. 90% of FMA PAC
endorsed candidates won their
election in 2012.
We hope to continue this
success this year.
HELPING PHYSICIANS PRACTICE MEDICINE
THANK YOU
•Because of the generous support of hospital
medical staffs & large groups throughout the state,
the FMA PAC is one of the most successful
medical PACs in the country.
•Join the FMA PAC and MD 1000 Club if you are
not already a member. Everyone here should be a
member of both.
We need your support in 2014!
HELPING PHYSICIANS PRACTICE MEDICINE
THANK YOU!
Questions?
For more info visit www.flmedical.org
Melanie Brown-Woofter
Director of Community Relations
Medicaid
Agency of Health Care Administration
Statewide Medicaid
Managed Care (SMMC)
Managed Medical Assistance (MMA)
Program
Palm Beach County Medical Society
Member Meeting
May 22, 2014
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.
Long-term Care program
Statewide Medicaid
Managed Care
program
(implementation Aug. 2013 –
March 2014)
Managed Medical Assistance
program
(implementation May 2014 –
August 2014)
38
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.
39
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)
40
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 eligibles;
– 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.
41
MMA Program
• The following individuals may choose to enroll in the
MMA program, but are not required to enroll:
– 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 developmental disabilities enrolled in the
home and community based waiver and Medicaid
recipients waiting for developmental disabilities waiver
services.
42
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.
43
The Managed Medical
Assistance (MMA) Program
Most Medicaid recipients are required to
enroll in the MMA program.
Medicaid recipients who qualify and
become enrolled in the MMA program
receive medical services from a managed
care plan.
∙ Recipients who have chosen an LTC plan
may need to also choose an MMA plan.
44
Managed Medical Assistance Services
(All MMA Plans will provide these services)
Minimum Required Covered Services: Managed Medical Assistance Plans
Advanced registered nurse practitioner services
Medical supplies, equipment, prostheses and orthoses
Ambulatory surgical treatment center services
Mental health services
Birthing center services
Nursing care
Chiropractic services
Optical services and supplies
Dental services
Optometrist services
Early periodic screening diagnosis and treatment services for
recipients under age 21
Physical, occupational, respiratory, and speech therapy
Emergency services
Physician services, including physician assistant services
Family planning services and supplies (some exception)
Podiatric services
Healthy Start Services (some exception )
Prescription drugs
Hearing services
Renal dialysis services
Home health agency services
Respiratory equipment and supplies
Hospice services
Rural health clinic services
Hospital inpatient services
Substance abuse treatment services
Hospital outpatient services
Transportation to access covered services
Laboratory and imaging services
45
Art therapy
Y
United
Y
Sunshine
Y
Staywell
Adult vision services (Expanded)
Simply
Y
SFCCN
Y
Prestige
Adult hearing services (Expanded)
Preferred
Y
Molina
Y
Integral
Coventry
Y
Humana
Better
Adult dental services (Expanded)
List of Expanded Benefits
First Coast
Amerigroup
Expanded Benefits
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Equine therapy
Y
Home health care for non-pregnant
adults (Expanded)
Influenza vaccine
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Medically related lodging & food
Y
Newborn circumcisions
Y
Y
Nutritional counseling
Y
Outpatient hospital services (Expanded)
Over the counter medication and supplies
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Pet therapy
Physician home visits
Y
Y
Pneumonia vaccine
Y
Y
Post-discharge meals
Y
Prenatal/Perinatal visits (Expanded)
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Primary care visits for non-pregnant
adults (Expanded)
Y
Y
Y
Y
Y
Y
Y
Y
Y
Shingles vaccine
Y
Y
Y
Y
Y
Waived co-payments
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
NOTE: Details regarding scope of covered benefit may vary by managed care plan.
46
Where will recipients receive
services?
• 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.
47
Children’s Medical Services Network
• 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.
• Recipient statewide may enroll in the CMS
Network until May 22, 2014.
48
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.
49
Plans Selected for Managed Medical Assistance Program Participation
(General, Non-specialty Plans)
Note: Formal protest pending in Region 11 for MMA Standard Plans
2
X
3
X
4
X
6
X
7
X
X
X
X
X
8
X
9
X
10
X
X
X
X
X
Staywell
United
Healthcare
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Sunshine State
Simply
X
X
5
11
SFCCN
Prestige
X
Preferred
X
Molina
Integral
1
Humana
First Coast
Advantage
Coventry
Better Health
Region
Amerigroup
MMA Plans
X
X
X
X
X
X
X
X
X
50
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 State
Health Plan
Freedom Health
(Dual Eligibles Only)
HIV/AIDS
HIV/AIDS
Children with
Chronic
Conditions
Serious
Mental
Illness
Child Welfare
Cardiovascular Disease; Chronic
Obstructive Pulmonary Disease;
Congestive Heart Failure; &
Diabetes
1
X
X
2
X
X
3
X
X
4
X
X
X
X
X
X
X
X
5
X
X
X
X
X
6
X
X
X
X
X
7
X
X
X
X
X
8
X
X
X
X
9
X
X
X
X
X
10
X
X
X
X
X
X
11
X
X
X
X
X
X
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
51
Which Plans are Comprehensive?
Region
Comprehensive Plans Available
1
2
3
4
5
6
7
8
9
10
11
None available
None available
Sunshine, United
Sunshine, United
Sunshine
Sunshine
Molina, Sunshine, United
Sunshine
Sunshine
Humana, Sunshine
Amerigroup, Coventry, Humana, Molina, Sunshine, United
52
Long-term Care Plans by Region
LTC Plans
Region
American
Eldercare, Inc.
(PSN)
1
X
2
X
3
X
4
X
5
X
6
X
X
7
X
X
8
X
9
X
10
X
X
11
X
X
Amerigroup
Florida, Inc.
Coventry
Health Plan
Humana
Medical Plan,
Inc.
Molina
Healthcare of
Florida, Inc.
Sunshine
State Health
Plan (“Tango”)
United
Healthcare of
Florida, Inc.
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
53
Statewide Medicaid Managed Care
Regions Map
Region 2
Holmes
Jackson
Nassau
Gadsden
W alton
Leon
Bay
Hamilton
Madison
Duval
Baker
Liberty
Region 1
Gulf
W akulla
Taylor
Franklin
Clay
Lafayette
Alachua
Dixie
Region 4
Putnam
Flagler
Levy
Marion
Region 3
Volusia
Region 7
Lake
Citrus
Seminole
Hernando
Orange
Pasco
Region 5
Osceola
Polk
Region 6
Manatee
Hardee
St. Lucie
Highlands
Sarasota
Region 1: Escambia, Okaloosa, Santa Rosa, and Walton
Region 2: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon,
Liberty, Madison, Taylor, Wakulla, and Washington
Region 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando,
Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union
Region 4: Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia
Region 5: Pasco and Pinellas
Region 6: Hardee, Highlands, Hillsborough, Manatee, and Polk
Region 7: Brevard, Orange, Osceola, and Seminole
Region 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota
Region 9: Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie
Region 10: Broward
Region 11: Miami-Dade and Monroe
De Soto
Charlotte
Lee
Martin
Glades
Hendry
Region 8
Palm Beach
Broward
Collier
Region 9
Region 10
Dade
Region 11
54
Managed Medical Assistance Program
Roll Out Schedule
Implementation Schedule
Regions
Plans
Enrollment
Date
2, 3 and 4
•
•
Standard Plans
Specialty Plans:
o HIV/AIDS
o Child Welfare
May 1, 2014
5, 6 and 8
•
•
Standard Plans
Specialty Plans:
o HIV/AIDS
o Child Welfare
June 1, 2014
10 and 11
•
•
Standard Plans
Specialty Plans:
o HIV/AIDS
o Child Welfare
o Serious Mental Illness
July 1, 2014
1, 7 and 9
•
•
Standard Plans
Specialty Plans:
o HIV/AIDS
o Child Welfare
August 1, 2014
Statewide
•
Children’s Medical Services Network
August 1, 2014
55
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.
56
Mixed Services in SMMC
57
What are mixed services?
• Mixed services are services that are available under
both the Long-term Care (LTC) program and the
Managed Medical Assistance (MMA) program. These
services are:
–
–
–
–
–
–
Assistive care services
Case management
Home health
Hospice
Durable medical equipment and supplies
Therapy services (physical, occupational, respiratory, and
speech-language pathology)
– Non-emergency transportation
58
Mixed Services Reimbursement
• If an enrollee has other insurance coverage, such
as Medicare, the provider must bill the primary
insurer prior to billing Medicaid.
– For dually eligible Medicare and Medicaid recipients,
Medicare is the primary payor.
– The MMA and LTC plans are responsible for services
not covered by Medicare (including any Medicare coinsurance and co-payments).
• If the enrollee only has Medicaid coverage and is
enrolled in an MMA and an LTC plan, the LTC
plan is responsible for paying for the mixed
services.
59
Mixed Services Reimbursement
Recipient Coverage
Who Pays for Mixed Services
Medicare and Medicaid
Medicare (if it is a covered
service)
Medicaid LTC Plan
Medicaid LTC and Fee-for
Service
Medicaid LTC and MMA Plan
Medicaid LTC Plan
Medicaid MMA Plan only (not
enrolled in LTC)
Medicaid MMA Plan
Medicaid Fee-for-Service
Medicaid Fee-for-Service
60
Medicare Coinsurance and
Deductibles
and Crossover Claims
61
Medicare Crossover Claims: Plan
Responsibilities
• The Managed Care Plan is responsible for Medicare coinsurance and deductibles for covered services.
• The Managed Care Plan must reimburse providers or
enrollees for Medicare deductibles and co-insurance
payments made by the providers or enrollees, according
to guidelines referenced in the Florida Medicaid Provider
General Handbook.
• The Managed Care Plan must not deny Medicare
crossover claims solely based on the period between the
date of service and the date of clean claim submission,
unless that period exceeds three years.
62
Medicare Crossover Claims: Plan
Responsibilities
• Plans are responsible for processing and payment
of all Medicare Part A and B coinsurance
crossover claims for dates of service from the date
of enrollment until the date of disenrollment from
the plan.
• Fee-For-Service Medicaid will continue to be
responsible for processing and payment of
Medicare Part A and B (level of care X) crossover
coinsurance claims for dates of service from the
date of eligibility until the date of enrollment with
the LTC plan.
63
Medicare Crossover Claims: Plan
Responsibilities
• LTC plans are responsible for paying crossovers (if
any) for the following services:
–
–
–
–
nursing facility
durable medical equipment
home health, and
therapies (occupational, physical, speech or respiratory)
• MMA plans are responsible for paying crossovers (if
any) for all covered services.
• If a recipient is also in an LTC plan, the LTC plan is
responsible for crossovers for the services above.
64
Medicare Crossover Claims: Provider
Responsibilities
• Medicare crossover claims will not be automatically
submitted to the LTC or MMA plans.
• Providers will bill the LTC plans for co-payments
due for Medicaid covered LTC services for
individuals who are dually eligible for Medicare
and Medicaid after receiving the Medicare
Explanation of Benefits (EOB) for the coinsurance payments.
• Providers will need to submit the claim to the
enrollees’ MMA plan in order to be reimbursed
for any co-insurance or deductibles.
65
Medicare Crossover Claims: Recipient
Responsibilities
• Except for patient responsibility for long-term care
services, the plan members should have no costs to
pay or be reimbursed.
66
Are the plans
responsible for
payment of Part A
coinsurance and
deductible?
Are the plans
responsible for
payment of Part B
coinsurance and
deductibles?
LONG-TERM CARE
MANAGED
MEDICAL
ASSISTANCE
Yes
Yes*
Yes
Yes*
*Note: If member is also enrolled in an LTC plan, the LTC plan
must pay any coinsurance and deductibles on services listed in
slide 36.
67
Do providers submit
crossover claims to
the health plan for
payment?
Should the provider
wait to receive the
EOB before
submitting the
crossover to the
plan?
LONG-TERM CARE
MANAGED
MEDICAL
ASSISTANCE
Yes
Yes
Yes
Yes
68
Will Comprehensive plan cover Medicare
services?
• In 2015, recipients enrolled in Medicare Advantage plans will
have the ability to choose a comprehensive Medicaid plan
where the recipients’ Medicare and Medicaid plans are the
same entity.
• Medicaid recipients currently enrolled in a Medicare
Advantage plan that offers the full set of MMA benefits will
not be required to enroll in a Medicaid MMA plan.
– Please see the Agency’s guidance statement about Medicare
Advantage plans at:
http://ahca.myflorida.com/MEDICAID/statewide_
mc/pdf/Guidance_Statements/SMMC_Guidance_S
tatement_enrollment_in_Medicare_Advantage_Pla
ns.pdf
69
Choice Counseling
70
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.
71
The Choice Counseling Cycle
Recipient determined
eligible for enrollment
or enters open
enrollment
Newly eligible
recipients are allowed
90 days to “try” the
plan out, before
becoming locked-in
Enrollment or change
is processed during
monthly processing
and becomes effective
the following month
Recipient receives
communication
informing him of
choices
Recipient may enroll
or change via phone,
online or in person
72
How Do Recipients Choose an MMA
Plan?
•
Recipients may enroll in an MMA plan or change plans:
─ Online at: www.flmedicaidmanagedcare.com
Or
─ By calling 1-877-711-3662 (toll free) or 1-866-467-4970
(TTY) 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.
73
When Can Recipients Change
Plans?
• Recipient who are required to enroll in
MMA plans will have 90 days after joining
a plan 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.
74
Choice Counseling
75
Recipient Notification and Enrollment
Region
Pre-Welcome
Letter
Welcome
Letter
Reminder
Letter
Last Day to
Choose a Plan
Before Initial
Enrollment
1
4/1/2014
5/26/2014
6/23/2014
7/17/2014
8/1/2014
2
1/2/2014
2/17/2014
3/24/2014
4/17/2014
5/1/2014
3
1/1/2014
2/17/2014
3/24/2014
4/17/2014
5/1/2014
4
1/2/2014
2/17/2014
3/24/2014
4/17/2014
5/1/2014
5
2/3/2014
3/24/2014
4/21/2014
5/22/2014
6/1/2014
6
2/3/2014
3/24/2014
4/21/2014
5/22/2014
6/1/2014
7
4/1/2014
5/26/2014
6/23/2014
7/17/2014
8/1/2014
8
2/3/2014
3/24/2014
4/21/2014
5/22/2014
6/1/2014
9
4/1/2014
5/26/2014
6/23/2014
7/17/2014
8/1/2014
10
3/3/2014
4/21/2014
5/26/2014
6/19/2014
7/1/2014
11
3/3/2014
4/21/2014
5/26/2014
6/19/2014
7/1/2014
Date Enrolled
in MMA Plans
Note: The dates above are when mailings begin. Due to the volume,
letters are mailed over several days.
76
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.
77
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:
Child Welfare specialty plan
Children’s Medical Services
HIV/AIDS
Serious Mental Illness
Freedom Health specialty
plans
78
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.
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
NOTE: Will begin operations in August 1, 2014
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
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Child
Welfare
Expanded Benefits
HIV/AIDS
(Clear
Health)
Expanded Benefits
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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.
80
Choice Counseling Available in English,
Spanish and Creole
81
Information about making a plan selection
82
Step by Step On-Line Enrollment
83
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/
84
Continuity of Care
85
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.
86
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
87
Continuity of Care During Transition
Plan Responsibility
•
MMA plans are responsible for the coordination of care for new
enrollees transitioning into the plan
• MMA plans are required to cover any ongoing course of treatment
(services that were previously authorized or prescheduled prior to
the enrollee’s enrollment in the plan) with the recipient’s provider
during the 60 day continuity of care period, even if that provider is
not enrolled in the plan’s network.
•
– The following services may extend beyond the continuity of care period
and as such, the MMA plans are responsible for continuing the entire
course of treatment with the recipient’s current provider:
• Prenatal and postpartum care (until six weeks after birth)
• Transplant services (through the first year post-transplant)
• Radiation and/or chemotherapy services (for the current round of treatment).
88
Continuity of Care During Transition
If the services were prearranged prior to enrollment with the plan, written
documentation includes the following:
• Prior existing orders;
• Provider appointments, e.g., dental appointments, surgeries, etc.;
• Prescriptions (including prescriptions at non-participating pharmacies);
and
• Behavioral health services.
• MMA plans cannot require additional authorization for any ongoing course
of treatment. If a provider contacts the plan to obtain prior authorization
during the continuity of care period, the MMA plan cannot delay service
authorization if written documentation is not available in a timely manner.
The plan must approve the service.
• However, the MMA plan may require the submission of written document
(as described above) before paying the claim.
89
How Will Providers Know Whether to
Continue Services?
Providers should keep
previously scheduled
appointments with recipients
during transition
90
Continuity of Care During Transition
Provider Responsibility
• Service providers should continue providing
services to MMA enrollees during the 60-day
continuity of care period for any services that
were previously authorized or prescheduled
prior to the MMA implementation, regardless of
whether the provider is participating in the plan’s
network.
• Providers should notify the enrollee’s MMA plan
as soon as possible of any prior authorized
ongoing course of treatment (existing orders,
prescriptions, etc.) or prescheduled
appointments.
91
How Will Providers Be Paid?
Providers will receive payment for
services provided during the
transition.
92
Continuity of Care During Transition
Provider Reimbursement
• MMA plans are responsible for the costs of continuing any ongoing
course of treatment without regard to whether such services are
being provided by participating or non-participating providers.
• The MMA plan must pay non-participating providers at the rate they
received for services rendered to the enrollee immediately prior to
the enrollee transitioning for a minimum of thirty (30) days, unless
the provider agrees to an alternative rate. Providers will need to
follow the process established by the managed care plans for
getting these claims paid appropriately.
• Providers may be required to submit written documentation (as
described above) of any prior authorized ongoing care, along with
their claim(s) in order to receive payment from the plan.
93
Continuity of Care During Transition
•
Do the managed care plans have to honor prior authorizations that were issued
(either through one of the Agency’s contracted vendors or a managed care plan)
prior to the recipient’s enrollment in the MMA plan? Examples include:
–
–
–
–
Home health
Dental
Behavioral Health
Durable medical equipment (rent-to-purchase equipment, ongoing rentals,
etc.)
– Prescribed drugs
•
Yes. During the continuity of care period, the MMA plan must continue to
pay for any prior approved services, regardless of whether the provider is in
the plan’s network. During this timeframe, the plan should be working with
the enrollee and their treating practitioner to obtain any information needed
to continue authorization after the continuity of care period (if the service is
still medically necessary). After the continuity of care period, if the provider
is not a part of the plan’s network, the enrollee may be required to switch to
a participating provider.
94
Continuity of Care During Transition
Pharmacy
•
For the first year of operation, MMA plans are required to use the Medicaid
Preferred Drug List (PDL) in order to ensure an effective transition of
enrollees during implementation.
•
For the first 60 days after implementation in a region, MMA plans or
Pharmacy Benefit Managers (PBMs) are required to operate open
pharmacy networks so that enrollees may continue to receive their
prescriptions through their current pharmacy providers until their
prescriptions are transferred to in-network providers. MMA plans and/or
PBMs must reimburse non-participating providers at established open
network reimbursement rates.
•
For new plan enrollees (i.e., enrolled after the implementation), MMA plans
must meet continuity of care requirements for prescription drug benefits, but
are not required to do so through an open pharmacy network.
•
During the continuity of care period MMA plans are required to educate new
enrollees on how to access their prescription drug benefits through their
MMA plan provider network.
95
How to get Ready for the MMA
Program
• One month before the MMA program starts, ask
your pharmacy for a list of your prescriptions
filled in the last four months.
• If you need to change pharmacies, take your
prescription bottles and the list of your last four
months of prescriptions to your new pharmacy.
• You can continue to receive the same medications
for up to 60 days after you are in your new MMA
plan. This gives you time to see your doctor if
you need to update your prescriptions or to have
your new plan approve your medications.
96
Continuity of Care- Reimbursement
Providers will receive payment for
services provided during the
transition.
97
Resources

Questions can be emailed to:
FLMedicaidManagedCare@ahca
.myflorida.com

Updates about the Statewide
Medicaid Managed Care program
are posted at:
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.
98
http://apps.ahca.myflorida.com/smmc_cirts/
• If you have a complaint or issue
about Medicaid Managed Care
services, please complete the
online form found at:
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.mymedicaidflorida.com/
99
Resources
• Weekly provider informational calls regarding the rollout of the Managed
Medical Assistance program will be held. Please refer to our SMMC page,
ahca.myflorida.com/smmc, for dates, times, and calling instructions.
• Calls will address issues specific to the following provider groups:
‒ Mental Health and Substance Abuse
‒ Dental
‒ Therapy
‒ Durable Medical Equipment
‒ Home Health
‒ Physicians / MediPass
‒ Pharmacy
‒ Hospitals and Hospice
‒ Skilled Nursing Facilities / Assisted Living Facilities / Adult Family Care
Homes
100
Other Components of MMA:
Physician Pay Increase
•
•
Managed care plans are expected to coordinate
care, manage chronic disease, and prevent the
need for more costly services. This efficiency
allows plans to redirect resources and increase
compensation for physicians.
Plans achieve this performance standard when
physician payment rates equal or exceed
Medicare rates for similar services. (Section
409.967 (2)(a), F.S.)
–
The Agency may impose fines or other sanctions including liquidated
damages on a plan that fails to meet this performance standard after 2 years
of continuous operation.
101
Other Components of MMA:
Achieved Savings Rebate
•
The achieved savings rebate program is
established to allow for income sharing between
the health plan and the state, and is calculated by
applying the following income sharing ratios:
–
–
–
•
100% of income up to and including 5% of revenue shall be retained by the
plan.
50% of income above 5% and up to 10% shall be retained by the plan, and
the other 50% refunded to the state.
100% of income above 10% of revenue shall be refunded to the state.
Incentives are included for plans that exceed
Agency defined quality measures. Plans that
exceed such measures during a reporting period
may retain an additional 1% of revenue.
102
Other Components of MMA:
Low Income Pool (LIP)
• The LIP program was initially implemented effective July 1,
2006. The LIP program currently consists of an annual
allotment of $1 billion, funded primarily by
intergovernmental transfers from local governments
matched by federal funds.
• Payments are made to qualifying Provider Access Systems,
including hospitals, federally qualified health centers and
county health departments working with community
partners.
• The objective of LIP program is to ensure support for the
provision of health care services to Medicaid, underinsured
and uninsured population.
103
Additional Information
Youtube.com/AHCAFlorida
Facebook.com/AHCAFlorida
Twitter.com/AHCA_FL
SlideShare.net/AHCAFlorida
104
Kevin Kearns
Health Choice Network
President and CEO
Kevin Kearns, CEO
prestigehealthchoice.com
Prestige Health Choice
• Founded in 2008 as a Capitated Provider
Service Network (PSN)
• Formed by FQHCs and CMHCs – 48 owners
• Important Strategic initiative for our safety
net providers
• Partnership with Florida True Health
Medicaid Managed Care
Statewide Medicaid Manage Care has two
program components
• Long-Term Care MC Program
– Implementation began 7/1/12 with ITN release
– Implementation completed April 2014 – 7 Plans
• Managed Medical Assistance Program
Medicaid Managed Care
Statewide Medicaid Managed Care Managed
Medical Assistance (MMA) program
• Types of managed care plans
- Health Maintenance Organizations
- Provider Service Networks
- Children’s Medical Services Network
Most Medicaid recipients must enroll in the
MMA program
Managed Medical Assistance
Program
Invitation To Negotiate (ITN) Timeline
• Release of ITN – 12/28/12
• Responses Deadline 3/15/13
• Negotiation Period - 7/1/13 – 8/31/13
• Awards Notification – 9/23/14
• Contracts signed - 1/31/14
Medicaid Overview
As of April 2014 – 3,471,421 Medicaid Recipients
Fee For Service
Medipass
Managed Care
1,454,017
536,305
1,481,099
Pre ITN
Post ITN
• 20 HMOs
• 3 Capitated PSNs
• 4 FFS PSNs
• 10 HMOs
• 4 PSNs
Rollout Timeline & Notices
• Region 1, 7, and 9 – roll out August 1, 2014
• Region 9 expected enrollment – 290K & 4 Plans
AHCA timeline:
• April 1, 2014: MMA pre-welcome letters sent
• June 1, 2014: Welcome letter & enrollment
process
• July 1, 2014: Auto assignment notification letter
• Members can switch plans during rollout and 90
days after roll out - 8/1/14
Prestige Health Choice
• Active in 8 Regions 2, 3, 5, 6, 7, 8, 9, 11
• Projecting to serve 330K Members
• Region 9 – Preparations begin 6/1/14
– Inservicing all Primary Care Physicians
– Conducting town hall orientations for par
Specialists
– Conducting Hospital orientations for par
Hospitals
Projected Prestige Health Choice Enrollment by AHCA Area:
August 1, 2014
AHCA Area
Tallahassee/Panama
City
Gainesville/Ocala
Projected Enrollment –
August 1, 2014
39,668 (actual)
51,005 (actual)
St. Petersburg
28,689
Tampa
35,898
Orlando
41,829
Ft. Myers/Sarasota
51,313
Palm Beach
50,072
Miami-Dade
35,489
Total Enrollment
Today, 8,634 Members
333,963
3
114
Region 9
Provider Network
Strong Provider Network
• Hospitals - 17
• PCPs - 262
• Specialists - 1,235
Service Level Commitments
• Accepting new Medicaid enrollees
– 85% par PCPs
– 90% par Specialist
• 40% of PCPs offer after hours
appointment availability
• No more than 5% of hospital admissions
occur in non-participating facilities
• No more than 10% of enrollee specialty
care shall occur with non-par providers
Service Level Commitments
Electronic Health Records
• 60% of eligible professionals and hospitals
are using certified EHR
– Meaningful manner
– Exchange of health information to
improve quality of health care; and
– Submit clinical quality measures and other
measures selected by the Secretary under
HITECH Act
Service Level Commitments
• Pay or notify the provider that the claim is
denied or contested within 15 days for
electronic claims and 20 days for paper
claims
• Enrollee Help Line
– Average speed of answer not to exceed 30
seconds
– Abandonment rate not to exceed 3 percent
The Road Ahead
• Historic transition from FFS to managed
care
• Significant cost savings are expected
• Strong focus on quality & continuity of
care
• Innovative approaches and use of health
technology
• A strong partnership with community
providers is essential
We look forward to working with
YOU!
Ron Wiewora, MD
CEO, Health Care District
Palm Beach County
Legislative Update and the
Health Care District
R. J. Wiewora, MD, MPH
5/22/14
Legislative session outcomes
• No Medicaid expansion for now
– There are an estimated 260,000 uninsured people
(25% of the population)
– There are an estimated 88,000 who would be
eligible for Medicaid expansion
• LIP (Low Income Pool) unchanged for now
– $34M of local tax dollars comes back to hospitals
as $80M
Health Coverage Programs Available to the Uninsured in Palm Beach County
300%
$35,010
Exchange Plans
(with Federal Subsidy available up to 400% FPLG)
200%
$23,340
185%
150%
$17,505
138%
100%
$11,670
Medicaid
Health Care District
22%
Federal
Poverty Level
Guidelines
(FPLG)
Pregnant
Women
Infants up to
age 1
Children Ages
1 through 5
Children Ages
6 through 18
Adults Ages
19 and 20
Parent(s)* for
Families with
Children
Adults
without
Children
Income for
Individuals
Notes: Federal subsidies available for incomes greater than 100% of the FPLG. HCD Coordinated Care Plan covers uninsured up to 150% of the FPLG. Medicaid
Other related issues
•
•
•
•
“Woodwork effect”
State Medicaid changes
Vita Health changes
HCD gap coverage
“Woodwork Effect”
• On August 1st, all Medicaid recipients will be
transitioned to four managed care Medicaid
programs: Humana, Molina, Sunshine and
Prestige
• Personal Health Plan (District’s HMO) goes away
• Vita Health membership is frozen and transition
begun to exchange products
• Gap coverage
– Option 2 (clinic and pharmacy only)
– Up to 300% of FPGL
– One time only as members will be expected to enroll
in an exchange
Some proposed programs for the
future
• Local exchange product
– Narrow network
– PB County providers only
• Marketplace assistance program
– Affordability of premiums
– CMS has given some guidelines for how this could
be done
Questions and Answers