Hometown Health
Managed Medical Assistance
State Goals
Statewide Medicaid Managed Care enacted in June 2011 required Florida to competitively procure
Plans to provide both health and long term care services for Medicaid recipients in Florida.
(s. 409.964, 409.965, 409.966, F.S.)
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Coordinated health care across different health care settings
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A choice of the best managed care plans to meet recipients’ needs
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The ability for health care plans to offer different, or more, services
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The opportunity for recipients to become more involved in their health care
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Emphasize patient centered care, personal responsibility and active patient
participation
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Provide for fully integrated care through alternative delivery models with access
to providers and services through a uniform statewide program
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Implement innovations in reimbursement methodologies, plan quality and plan
accountability
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Provide increased predictability
Who is Sunshine State Health Plan
LTC Counties Served
Services: Medicaid, Healthy Kids, Long Term Care,
ABD, Medicare SNP
Number of Local Employees: 270
First Year of FL Operations: 2009
Average Claim Paid (w/i 30 days of receipt): 98%
Number of Providers: 10,869
Counties Served
Newly Active
- Statewide LTC Applicant
Membership: 208,000
Scope: 2nd Largest Medicaid Company today
Sunshine Health’s core philosophy is that quality healthcare is best delivered locally.
We are committed to building collaborative partnerships with hospitals, physicians, and other service providers.
Centene Corporation
23,700
208,000
16,300
TPA
298,300
206,900
180,700
35,700
31,600
159,900
82,900
503,800
78,000
Sunshine Health’s core philosophy is that quality healthcare is best delivered locally.
We are committed to building collaborative partnerships with hospitals, physicians, and other service providers.
7/1/12
Centene’s Suite of Solutions
Sunshine Health Differentiators
National Plan with a Local Philosophy
• Only National Plan with Corporate Philosophy of Local Plans (Sunshine Health, Peach State, Buckeye)
• Significant Community Involvement
• Backing & Resources of National Plan Known for Successful State Partnerships
• Invested in local plans when entering Florida (Access Health, a Minority owned PSN)
• Still locally staffed today
Quality and Business Philosophy
• High Degree of Regulatory Compliance
• Strong Relationships with State Partners
• Judge ourselves based on member outcomes
Innovative Responses to State Needs
• Centene plans differ in each State and/or Region according to the needs of that population
• We refuse to force a cookie-cutter approach if it’s not going to work for that demographic
• Willingness to re-asses during the life of a program and change approach if needed
• Innovative partnerships with providers
• Strong Hospital Relationships (HMA, Tenet, Florida Hospital, HCA & Robust Local Hospital Networks)
Successful National Comprehensive Performance
• Other plans may have national experience in various lines of business but we have SUCCESSFUL experience
serving Long Term Care, Medicaid, Medicare, & Foster Care members in these types of programs in other States
Medicaid Expansion Timeline
Florida Medicaid Reform Regions
MMA Requirements
1. Categories of Medicaid Recipients Required to Enroll:
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Low-income families with children (TANF)
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Children with chronic conditions
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Children in foster care
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Children in adoption subsidy
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Pregnant women
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Medically Needy recipients
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Individuals with full Medicaid and Medicare coverage
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Elderly, blind or disabled excluding the (DD) population
2. Not required to enroll, but may do so on voluntary basis:
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Persons with other creditable coverage (excluding Medicare)
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Residents in DJJ Facilities and State Mental Hospitals
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Persons eligible for refugee assistance
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Recipients in Developmental Disabilities centers
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Persons in Developmental Disabilities waivers and on the waiting list
3. Not eligible:
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Women who are eligible only for family planning services
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Women who are eligible through the breast and cervical cancer
program
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Persons who are eligible for emergency Medicaid for aliens
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Children receiving services in a prescribed pediatric extended care
center
Min #
Max #
# of
PSNs
Region 1
2
2
1
Region 2
2
2
1
Region 3
3
5
1
Region 4
3
5
1
Region 5
2
4
1
Region 6
4
7
1
Region 7
3
6
1
Region 8
2
4
1
Region 9
2
4
1
Region 10
2
4
1
Region 11
5
10
1
Essential Providers
Statewide essential providers required within the MMA ITN include:
(1) Faculty plans of Florida medical schools
(2) Regional perinatal intensive care centers (RPICCs) as defined in s. 383.16(2), F.S.,
(3) Hospitals licensed as specialty children's hospitals as defined in s. 395.002(28), F.S.,
(4) Accredited and integrated systems serving medically complex children that are comprised of
separately licensed, but commonly owned, health care providers delivering at least the following
services: medical group home, in-home and outpatient nursing care and therapies, pharmacy
services, durable medical equipment, and Prescribed Pediatric Extended Care
Statue allows AHCA to determine which providers in the following are essential Medicaid providers:
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Federally qualified health centers
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Statutory teaching hospitals as defined in s. 408.07(45).
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Hospitals that are trauma centers as defined in s. 395.4001(14)
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Hospitals located at least 25 miles from any other hospital with similar services
Statute provides guidance on essential provider & Plan negotiations:
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Plans without contracts as of enrollment must negotiate in good faith for 1 year while paying nonpar essential providers at the applicable Medicaid rate
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After 1 year w/o agreement, the plan shall propose an alternative arrangement for securing the
essential services for Medicaid enrollees.
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If alternative arrangement approved by the agency, payments to nonpar essential providers
decrease to 90 percent of Medicaid rate. If alternative arrangement not approved, payment to
nonparticipating essential providers increases to 110 percent of Medicaid rate.
Highlights of MMA Legislation
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Statewide Medicaid Managed Care enacted in June 2011 required Florida to competitively procure
plans to provide both health and long term care services for Medicaid recipients in Florida (s.
409.964, 409.965, 409.966, F.S.)
•
Procurement is phased: Long term care service procurement begins July 2012; implementation
concluded by October 2013. Acute care procurement begins January 2013 and concludes October
2014 (ss. 409.974, 409.978, F.S.)
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Phase 1 – Long Term Care (LTC): Recommended Awards Announced Yesterday
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Phase 2 – Managed Medical Assistance (MMA): ITN Responses Due March 15th
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Hospital rates set annually preparing for conversion to DRG Model
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Applicable Physicians must be paid Medicare rates or better within two years
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Related entities may not bid in the same region
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Winners in Region One or Two receive a bonus region
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Aggregate savings guarantee is 5% off baseline rates
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Severe plan withdrawal penalties, including termination of all contracts
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MMA Roll Out Schedule is yet to be determined
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Contingent upon Waiver Approvals from CMS
Q&A
Sunshine Health’s core philosophy is that quality healthcare is best delivered locally.
We are committed to building collaborative partnerships with hospitals, physicians, and other service providers.