Statewide Medicaid Managed
Care Overview
Presented to Commission for Transportation
Disadvantaged
April 11, 2012
Beth Kidder
Assistant Deputy Secretary
for Medicaid Operations
Overview of 2011 Legislation
• In 2011, the Florida Legislature created a new
program, Statewide Medicaid Managed Care
(SMMC) (Part IV of Chapter 409, Florida Statutes).
• Statewide Medicaid Managed Care has two program
components:
 Long Term Care Managed Care Program
o Implementation begins 7/1/12 with release of ITN
o Certain recipients will be required to enroll
 Managed Medical Assistance Program
o Implementation begins 1/1/13 with release of ITN
o All Medicaid recipients will be required to enroll in a managed care
plan unless specifically exempted
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Statewide Medicaid Managed Care Goals
The Statewide Medicaid Managed Care Program is
designed to:
• Emphasize patient centered care, personal
responsibility and active patient participation;
• Coordinate fully integrated long-term care and
health care in different health care settings;
• Provide a choice of the best long-term care and
managed care plans to meet recipients’ needs;
• Implement innovations in reimbursement
methodologies, plan quality and plan
accountability.
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Other Key Program Elements
• Changes to the Medically Needy Program relating to plan
enrollment and premium requirements
 Medically Needy recipients meet the share of cost by paying the
plan premium, up to the share of cost amount, pending Federal
approval
• Changes to Home and Community Based Services waiver
programs relating to premium requirements for families
of certain enrollees
• Opt-out and premium assistance for Medicaid eligibles
with access to other insurance
• Cost-sharing requirements, including increased
copayments for non-emergency use of hospital emergency
rooms.
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Current Status of Statewide Medicaid
Managed Care Implementation
• The Agency for Health Care Administration has requested
federal authority, including waiver amendments and a new
waiver, to implement key SMMC program provisions:
 To mandatorily enroll most Medicaid recipients in managed care
plans
 To allow health plans to develop customized benefits packages
 To implement SMMC on a statewide basis
 To impose additional premiums and co-payments
 To make changes to the Medically Needy Program
 To develop a program that will enable Medicaid recipients to
participate in employer-sponsored health insurance
 To implement the Long Term Care component
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Current Status of Statewide Medicaid
Managed Care Implementation
• Federal CMS (Centers for Medicare and
Medicaid Services) has begun to negotiate
program approval with the Agency.
• The Agency is responding to informal
questions and formal requests from CMS for
additional information.
• AHCA has implemented project management
and planning teams to ensure timely, effective
program implementation.
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Statewide Medicaid Managed Care
Implementation
• The Statewide Medicaid Managed Care
Program will be implemented statewide.
• The State has been divided into 11 regions
that coincide with the existing Medicaid
areas.
• Each region will have a certain number of
managed care plans to ensure that
enrollees have a choice of plans.
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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
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Number of Plans Per Region
Region
Counties
Number of Plans
1
Escambia, Okaloosa, Santa Rosa and Walton
2
2
Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson,
Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and
Washington
2
3
Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist,
Hamilton, Hernando, Lafayette, Lake, Levy, Marion,
Putnam, Sumter, Suwannee, and Union
3-5
4
Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia
3-5
5
Pasco and Pinellas
2-4
6
Hardee, Highlands, Hillsborough, Manatee, and Polk
4-7
7
Brevard, Orange, Osceola, and Seminole
3-6
8
Charlotte, Collier, DeSoto, Glades, Hendry, Lee and
Sarasota
2-4
9
Indian River, Martin, Okeechobee, Palm Beach and St.
Lucie
2-4
10
Broward
2-4
11
Miami-Dade and Monroe
5-10
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Long-Term Care Managed Care Program
• Medicaid recipients who qualify and become enrolled in the
Long-Term Care Managed Care Program will receive long-term
care services from long-term care managed care plans.
• The Long-Term Care Managed Care Program will not change
Medicare benefits.
• AHCA will use competitive procurement to select long-term
care managed care plans for each region.
• Each recipient will have a choice of plans and may select any
available plan.
• Long-term care managed care plans will only provide long-term
care services. The Florida Managed Medical Assistance
Program will provide all health care services other than longterm care services to eligible recipients.
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Who Will Enroll in the Long-Term Care
Managed Care Program?
• Individuals who are:
 65 years of age or older AND need nursing facility care
 18 years of age or older AND are eligible for Medicaid by reason
of a disability AND need nursing facility care
• Individuals who live in a nursing facility
• Individuals enrolled in:
 Aged and Disabled Adult Waiver;
 Consumer-Directed Care Plus for individuals in the A/DA
waiver;
 Assisted Living Waiver;
 Channeling Services for Frail Elders Waiver
 Program of All-inclusive Care for the Elderly (PACE);
 Nursing Home Diversion Waiver.
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Long-Term Care Managed Care
Enrollment Process
• Department of Elder Affairs’ Comprehensive
Assessment and Review for Long-Term Care Services
(CARES) Program will determine clinical eligibility.
• CARES will complete an assessment including:
 What kinds of services an individual needs;
 If a nurse or other health care professional is the best
person to help with the individual’s needs;
 Whether a physician agrees that the individual is in need of
nursing facility care; and
 Whether the individual has any other way to receive care in
the community.
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Long-Term Care Managed Care
Enrollment Process (cont.)
• Individuals have 30 days to choose one of the long-term
care plans available in their region
• If they do not choose, they will be assigned to a plan
• Once enrolled, will have 90 days to choose a different
plan
• After 90 days, individuals must remain in their plan for
the rest of the year, unless they have good cause to change
plans.
 Examples of good cause include:
• Poor quality of care
• Cannot access necessary specialty services
• Were unreasonably denied services
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Managed Medical Assistance Program
• Medicaid recipients enrolled in the Managed Medical
Assistance Program will receive all health care services
other than long-term care through a managed care plan.
• AHCA will use competitive procurement to select
managed care plans for each region.
• It is anticipated that there will be nearly 1.2 million new
enrollees in the Managed Medical Assistance component
for a total of 2.5 million enrolled recipients.
• When fully implemented, Medicaid enrollment is
expected to shift from the current level of 43% enrolled in
managed care to nearly 85% in managed care.
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Who Will Enroll in the Managed Medical
Assistance Program?
Recipients required to enroll in Managed Medical Assistance:
• Low income families with children (Temporary Assistance
for Needy Families (TANF) and TANF-related
• Children with chronic medical conditions
• Children in foster care
• Children in adoption subsidy
• Pregnant women
• Medically Needy recipients
• Individuals with full Medicaid and Medicare coverage
(where Medicare is secondary payer)
• Recipients who are elderly, blind or disabled excluding the
developmentally disabled population
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Who Will Enroll in the Managed Medical
Assistance Program?
Medicaid recipients not required, but may choose to enroll:
• Recipients who have other comprehensive health care coverage,
excluding Medicare
• Recipients residing in residential commitment facilities operated
through the Dept. of Juvenile Justice or mental health treatment
facilities
• Recipients eligible for refugee assistance
• Recipients who are residents of a developmental disability center,
including Sunland Center and Tacachale
• Recipients enrolled in a Developmental Disabilities Home and
Community Based Waiver and recipients on the waiting list for DD
waiver services
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Who Will Enroll in the Managed Medical
Assistance Program?
Recipients not allowed to enroll:
• Women who are eligible only for family
planning services
• Women who are eligible through the breast and
cervical cancer services program
• Persons who are eligible for emergency
Medicaid for aliens
• Children receiving services in a prescribed
pediatric extended care center
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Managed Medical Assistance Enrollment
• Eligible recipients will receive a letter with enrollment
information.
• Eligible recipients who must enroll will have 30 days to choose a
managed care plan from the plans available in their region.
• Enrollees will have 90 days after enrollment to choose a different
plan.
• After 90 days, enrollees will remain in their plans for the
remainder of their 12 month period unless they meet certain
criteria.
• If a recipient who is required to enroll does not choose a plan
within 30 days, AHCA will automatically enroll the recipient into a
managed care plan.
• Enrollees can change primary care providers within their managed
care plan at any time.
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For More Information
• Updates about the Statewide Medicaid Managed
Care Program will be posted on the Agency
website at:
http://ahca.myflorida.com/Medicaid/statewide_mc/index.
shtml#tab1
• Sign up to receive email updates about the
program at this website.
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