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Florida Statewide Medicaid Managed Care (SMMC) Awards

This week, our In Focus section comes to us from Principal Elaine Peters (HMA – Florida), who reviews the recent re-procurement by the Florida Agency for Health Care Administration (AHCA) of its Statewide Medicaid Managed Care (SMMC) health and dental plans.  The SMMC program currently has two key program components:  Long-Term Care (LTC) and Managed Medical Assistance (MMA).  The new SMMC program changes the two components to: Integrated MMA and LTC and Dental.  The 2016 Legislature “carved out” dental services from MMA plans and new dental plans will be responsible for providing dental services to eligible members.

The SMMC program was fully implemented on August 1, 2014 under 5-year contracts ending December 2018.  The Medicaid program currently serves 3.9 million beneficiaries of which approximately 3.1 million are enrolled in 16 Medicaid managed care plans.  Estimated total Medicaid program spending is $27.6 billion, of which $17.7 billion is for services provided through managed care plans during FY 2018-19.

SMMC Health Plans

AHCA released the rebid Invitation to Negotiate (ITN) on July 14, 2017, for 5-year contracts (contract term through September 30, 2023).  The ITN included separate and simultaneous regional procurements for each of the 11 regions for managed care health plans.  The ITN described the following three goals:

  • Reduce potentially preventable inpatient and outpatient hospital events, and unnecessary ancillary services
  • Improve birth outcomes
  • Rebalance long-term services and supports systems by increasing the percentage of enrollees receiving services in the community instead of an institution

The ITN included four types of plans and corresponding contracts.  The initial SMMC program had separate MMA and LTC programs. Under the rebid ITN, enrollees with both LTC and MMA service needs will now receive all services through one health plan.  The four types of contracts under the rebid ITN are Comprehensive plans, LTC Plus plans, MMA plans, and Specialty plans. See table below for services provided and populations served.

Type of Plan Description
Comprehensive MMA to all members, LTC to LTC eligible members
LTC Plus Serves only LTC members providing all MMA and LTC services
MMA Serves MMA eligible only members
Specialty Serves MMA eligible only members within defined specialty populations

Source:  Agency for Health Care Administration

Additionally, the SMMC program statutorily requires at least one plan in a region be a Provider Service Network (PSN) if any PSN submits a responsive bid as determined by AHCA.

There will be a wide range of expanded benefits available at no cost to the state, a commitment to higher performance by plans, and enhanced access to providers through expanded telemedicine services.  Plans must also provide the following newly covered services that were previously fee-for-service:

  • Early Intervention Services (EIS)/ Early Steps
  • Medical Foster Care
  • Targeted Case Management (TCM)
  • Nursing Facility Services for Managed Medical Assistance

Responses from health plans were due November 2017 and were evaluated, scored and ranked.  They were ranked by plan type with AHCA selecting a predetermined number of top-ranked respondents to enter into negotiation with the state.  Negotiations occurred over a three-month period from January 16, 2018 through March 30, 2018.  The negotiation team did not use the evaluation scores to determine best value.  Negotiations resulted in contract terms and conditions determined to be the best value to the state, including but not limited to price/cost, quality, design, and service delivery.  Initial contract awards were announced on April 24, 2018.  Additional awards were made pursuant to settlement agreements on May 31, 2018, June 12, 2018, June 19, 2018 and September 7, 2018.

The following table reflects the awards by plan type and region.  There are several new plans, Florida Community Care (LTC Plus), Lighthouse Health Plan (MMA), Miami Children’s (MMA) and Vivida Health (MMA).

Source:  Agency for Health Care Administration

Dental Health Plans

AHCA released the ITN on October 16, 2017, to provide services under the SMMC Dental Health Program.  All dental services will be provided through managed care and there will no longer be fee-for-service dental services.

All Medicaid beneficiaries (with very limited exceptions) will be required to enroll in a dental health plan with limited exceptions.  Like SMMC health plans, dental health plans are 5-year contracts (contract term through September 30, 2023).  Dental health plans will operate statewide with each dental plan operating in all eleven regions of the state.  The ITN described the following two goals:

  • Reduce potentially preventable dental-related hospital events
  • Improve access to preventive dental services

Proposals from dental plans were due January 12, 2018.  The state used an evaluation process similar to the one used for health plans plan selection to evaluate, score and rank dental health plans.  AHCA’s intent was to invite the top six ranking respondents to negotiation.  A total of eight dental health plans submitted responses.  Negotiations occurred over a one-month period from May 1 through May 31, 2018 resulting in the award of three statewide dental health plan contracts on June 28, 2018.

Source:  Agency for Health Care Administration

Dental health plans will provide a minimum set of covered services to children and adults.  Additionally, all dental plans are providing expanded benefits for adults that include preventive, diagnostic, restorative, periodontics, oral and maxillofacial surgery and other services.  Enrollees will have enhanced access to providers through expanded teledentistry. Dental plans have also committed to higher performance targets.

Dental plans will coordinate service provision with health plans.  Dental plans cover non-emergency (scheduled) dental services in a facility, dental services with sedation in an office setting and dental services without sedation in an office setting, County Health Department (CHD), or Federally Qualified Health Center (FQHC).  Health plans cover emergency dental services in a facility, non-emergency anesthesiologist and ancillary services in a facility, anesthesiologist when required for sedation, dental services provided by a non-dental provider, pharmacy and transportation.

Implementation of Health and Dental Plans

Implementation of the new contracts will occur over a three-phased schedule:  Phase 1-  December 1, 2018; Phase 2 – January 1, 2019; and Phase 3 – February 1, 2019.  See below schedule by region and county.

Source:  Agency for Health Care Administration

Transition

Medicaid recipients will be sent a letter approximately 45 days prior to the transition date for their region letting them know their plan assignment or they can contact Choice Counseling if they wish to make a different plan choice.

  • Health Plans – Beneficiaries will be assigned to their current health plan if their current health plan was awarded a contract in their region. Beneficiaries will be assigned to a new health plan if their current contract was not awarded a contract. They may accept the assignment or choose a different plan and are given a 120-day change period from the start of the transition to change plans.
  • Dental Plans – All beneficiaries will be assigned to a dental plan. If one of the three awarded dental plans was previously the dental subcontractor for a recipient’s MMA plan, they will be assigned to that dental plan. They may change plans if they choose and will have approximately 45 days to contact Choice Counseling if they wish to make a different plan choice.  Beneficiaries are also given a 120-day change period from the start of the transition to change plans.

Continuity of Care

Health plans are required to honor any ongoing treatment authorized prior to a beneficiary’s enrollment into the plan for up to 60 days after SMMC contracts start in each region. The plans must pay providers for previously authorized services and allow beneficiaries to continue to receive prescriptions through their current provider.  Dental plans must honor any ongoing treatments authorized prior to a beneficiary’s enrollment for at least 90 days after the dental program starts in each region and pay providers for those treatments.

Children’s Medical Services Managed Care Plan

AHCA has a statewide contract with the Department of Health, Children’s Medical Services, to serve children with chronic conditions through the Children’s Medical Services (CMS) Specialty managed care plan.  This contract is statutorily exempt from the SMMC procurement requirements and requires the CMS managed care plan meet all other health plan requirements for the MMA program.

CMS developed a new model going forward and released an ITN on January 30, 2018 to provide services for SMMC and CHIP to serve approximately 62,000 children.  The intent was to award one statewide contract with the ability to award more than one contract based on regional clusters.  The contract term is for 5 years, January 1, 2019 through September 30, 2023.  The ITN described the following goals:

  • Reduce potentially preventable inpatient and outpatient hospital events, and unnecessary ancillary services
  • Culturally competent, linguistically appropriate, family centered, and participant driven care
  • Care that is evidence based, where possible and evidence-informed or based on promising practice when evidence-based approaches are not available

Responses were due April 27, 2018.  Three plans submitted responses: WellCare (dba Staywell Healthplan of Florida); Sunshine Health; and South Florida Community Care Network LLC (dba Community Care Plan).  A similar evaluation process was used as for SMMC health plans.  Negotiations occurred in June 2018. An award to WellCare was announced on June 29, 2018.  There is currently a protest regarding this award which has not been resolved to date.

Provider Service Network Rebid

The SMMC program requires at least one plan in a region be a Provider Service Network (PSN) if any PSN submits a responsive bid.  If AHCA determines that there was no PSN responsive bid, they are to reserve one less than the maximum number of eligible plans permitted in that region.  Within 12 months after the initial ITN, the AHCA is required to attempt to procure a PSN.

Because there were no responsive bids in regions 3, 4, 5, 6, and 7, AHCA recently released another ITN for MMA PSN services on September 25, 2018.  Binding letters of intent were due October 19, 2018 with responses due December 17, 2018.  Negotiations will occur over a one-month period in March 2019 with awards anticipated March 26, 2019.

For further information and presentations regarding SMMC MMA, LTC and dental program changes see: http://ahca.myflorida.com/medicaid/statewide_mc/index.shtml

Please contact Elaine Peters: epeters@healthmanagement.com

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