Update on Statewide Medicaid Managed Care Program and Florida

MedicaidMental Health and Substance Abuse

Services

Justin M. SeniorDeputy Secretary for Medicaid

Agency for Health Care Administration

Florida Council for Community Mental Health

August 4, 2015

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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.

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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. 

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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 73,121 126,784 80,637 54,527 335,069

Better Health 19,662 73,191 92,853

CMSN 1,527 4,716 6,427 5,270 3,897 8,120 7,999 4,039 5,735 7,305 6,335 61,370

Coventry 49,000 49,000

Humana 62,564 35,119 71,481 63,944 87,426 320,534

Integral 32,785 16,684 41,521 90,990

Molina 61,995 11,948 66,029 26,972 166,944

Preferred Medical 24,929 24,929

Prestige 49,461 62,980 22,360 26,499 33,627 54,549 43,782 14,466 307,724

SFCCN 42,111 42,111

Simply Healthcare 80,314 80,314

Staywell 54,261 90,783 62,444 48,096 124,958 146,745 88,848 61,693 677,828

Sunshine State 34,563 79,726 27,025 44,025 55,208 18,823 67,168 62,069 25,907 414,514

United Healthcare 56,879 78,241 47,226 87,921 270,267

AHF / Positive* 777 1,032 1,809

Freedom Health* 20 9 18 11 12 2 0 0 72

Magellan* 2,014 6,065 3,634 6,504 7,475 3,902 3,135 6,238 38,967Clear Health Alliance* 219 282 525 907 923 1,193 448 1,286 934 2,511 9,228Sunshine Health Child Welfare* 862 674 2,331 2,539 1,605 2,967 2,598 1,492 1,975 2,356 2,064 21,463Total by Region 97,957 111,408 254,508 296,280 180,654 412,263 394,667 209,732 261,360 255,822 531,335 3,005,986

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Long-term Care Plan Enrollment by Region as of July 1, 2015Plan 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 Eldercare 1,368 1,344 654 2,579 1,613 1,009 2,180 960 1,347 1,919 3,525 18,498

Amerigroup Florida 1,645 2,906 4,551

Coventry Healthcare 1,041 970 1,381 1,362 4,754

Humana 1 1

Molina 1,490 1,257 2,891 5,638

Sunshine State 1,629 3,905 3,793 4,105 3,853 3,312 3,182 3,571 2,706 4,531 34,587

United Healthcare 2,411 1,872 2,181 2,280 1,949 2,148 1,240 1,453 4,028 19,562

Total by Region 2,997 3,755 6,431 8,554 9,488 9,109 8,610 5,382 7,752 6,270 19,243 87,591

Florida MedicaidMental Health and

Substance Abuse Services

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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

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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

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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

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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

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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

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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).

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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

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Serious Mental Illness Specialty Plan: Enhanced Provider Network

Provider Type Specialty Plan Enhanced Network Adequacy Ratios

Standard Plan Network Adequacy Ratios

Primary Care Provider 1:750 1:1500

24-Hour Pharmacy 2: County n/a

Board Certified or Board Eligible Adult Psychiatrist

1:375 1:1500

Fully accredited Psychiatric Community Hospital (Adult) or Crisis Stabilization Units/ Freestanding Psychiatric Specialty Hospital

1 bed:500 enrollees 1 bed:2000 enrollees

Inpatient Substance Abuse Detoxification Units 1 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

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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.

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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.

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Report a Medicaid Complaint

• If you have a complaint or issue about Medicaid please complete the online form at: http://ahca.myflorida.com/smmc

• Click on the “Report a Complaint” blue button.

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Questions?