More than two years after Florida lawmakers passed a controversial plan to transform the Medicaid system, it’s showtime.

As of Thursday, about 9,300 central Florida residents who need long-term care — the vast majority of them seniors — will become the first participants in a statewide move to enroll almost all Medicaid beneficiaries in HMOs and other types of managed-care plans.

The transformation will not happen quickly: Region by region, low-income people will gradually move into the managed-care system during the rest of this year and throughout most of 2014, with the changes first affecting people who need long-term care and later the broader Medicaid population.

But after years of debate, planning and gaining federal approval, Thursday is a pivotal day in a Medicaid system that serves more than 3 million Floridians.

“We’re almost not believing it’s here,” said Liz Dudek, secretary of the Agency for Health Care Administration, which oversees the Medicaid program.

Dudek, Medicaid Director Justin Senior and state Elder Affairs Secretary Charles Corley will take part Thursday in a launch event in the Brevard County community of Rockledge. The first phase of the changes will affect long-term care beneficiaries in Brevard, Orange, Seminole and Osceola counties.

Broadly, the goal is to use managed care to provide services that will help as many seniors as possible stay in their homes or communities, rather than going into nursing facilities. But the changes have been controversial — and remain so as the state moves forward.

Jack McRay, advocacy manager for AARP Florida, said Wednesday the four-county region in central Florida will be the “guinea pig” for long-term care changes that his organization has questioned. He said AARP wanted the state to conduct a pilot program before starting the shift to a statewide managed-care system for seniors, but was rebuffed by lawmakers.

“We want reform to succeed, but we have many doubts about it,” McRay said.

Republican lawmakers and Gov. Rick Scott approved the move to the managed-care system in 2011, but federal officials did not sign off on the changes until this year. After long arguing that Medicaid is fragmented, plagued by fraud and too expensive, GOP leaders say managed care will better coordinate services for beneficiaries while also helping control costs.

Making the changes, however, has required a massive amount of planning. AHCA has contracted with managed-care plans in 11 separate regions of the state to provide long-term care services and is in the midst of a similar contracting process for plans that will serve the broader Medicaid population.

As an example of the issues involved, Senior, the Medicaid director, said the state has needed to ensure that managed-care plans have adequate networks of providers.

With older and disabled beneficiaries unable to go without services such as home health care, Senior said “continuity of care became job one.” That has led to the state allowing beneficiaries to continue receiving services for 60 days from their already-existing providers, if those providers are not in the beneficiaries’ new managed-care plans.

Another example of a major planning issue has been the state’s use of what is known as “choice counseling” to help long-term care beneficiaries choose managed-care plans. The process is critical, at least in part, because managed-care plans can offer different benefits. The choice-counseling process has included home visits to help seniors, Dudek said.

AHCA has contracted with varying numbers of managed-care plans in the 11 regions of the state. That includes four plans — American Eldercare, Coventry Health Plan, Sunshine State Health Plan and UnitedHealthcare of Florida — in the central Florida region where the program will start Thursday.

In the coming months, AHCA will expand the program to other regions. On Sept. 1, the program will start in a region of southwest Florida and in a region that includes Palm Beach County and the Treasure Coast. On Nov. 1, it will move into the Big Bend area of north Florida and to Broward County.

The long-term care changes are expected to be in effect statewide on March 1, 2014, and AHCA then will turn to enrolling the broader Medicaid population in managed-care plans.

But skeptics have long questioned the reliance on managed care and whether that would lead to cutting corners on services provided to Medicaid beneficiaries.

McRay, who has closely followed the issues for AARP, pointed to questions, for example, about what standards the state has used to determine that managed-care networks are adequate. He also said questions remain about the effectiveness of the choice counseling program, particularly when some people needing long-term care might have cognitive problems that make it hard to understand the plan choices.

“We’re going to be watching this (program) very closely,” McRay said.

This <a target="_blank" href="/news/thursday-marks-start-of-florida-shift-to-medicaid-managed-care/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

TALLAHASSEE – The federal government gave final approval Friday to Florida’s long-debated proposal to overhaul the Medicaid system by requiring beneficiaries statewide to enroll in HMOs and other types of managed-care plans.

The decision was not a surprise: Federal officials signaled earlier this year that they would grant approval. Also, the Obama administration had already signed off on requiring managed care for tens of thousands of Florida seniors who need Medicaid-funded long-term care.

But Friday’s announcement was a victory for Gov. Rick Scott and Republican lawmakers who approved the proposal to move to statewide Medicaid managed care in 2011, amid controversy about whether the changes would best serve the needs of low-income Floridians.

Scott this year lobbied U.S. Department of Health and Human Services Secretary Kathleen Sebelius for approval and said the managed-care changes will lead to improved coordination of care for beneficiaries. Republicans also have argued that the changes will help control rising Medicaid costs.

The approval of what is known as a Medicaid “waiver” came in a letter from the federal Centers for Medicare & Medicaid Services, which is part of Sebelius’ department.Florida is leading the nation in improving cost, quality and access in the Medicaid program,” Scott said in a prepared statement. “CMS’s final approval of our Medicaid managed care waiver is a huge win for Florida families because it will improve the coordination of care throughout the Medicaid system. Health-care providers can now more effectively manage chronic conditions and work with families to provide preventative treatments.”

Florida CHAIN, a patient-advocacy group that has been among the most-vocal critics of the managed-care requirement, issued a news release that said the federal government had included safeguards that will help protect beneficiaries. Among those safeguards: HMOs will have to spend at least 85 percent of the money they receive on patient care, a concept known in the insurance industry as a “medical loss ratio.”

But Florida CHAIN also said patients and advocates will have to remain “vigilant” and pointed, in part, to controversies about a Medicaid managed-care pilot program that began in 2006 and 2007 in Broward, Duval, Clay, Baker and Nassau counties.

Despite these federal safeguards, the focus now shifts to the state and its efforts to implement this program that will affect access to care for millions of patients in all 67 counties,” Florida CHAIN’s statement said. “The countless reports of disrupted, delayed and denied care streaming in from the original five counties are still very fresh in the minds of all stakeholders.”

The state Agency for Health Care Administration said the plan approved Friday ultimately could affect 2.9 million people, with enrollment in managed-care plans tentatively scheduled to start in April 2014. The related move to enroll seniors in managed-care plans is slated to start this August in central Florida.

In the approval letter, federal officials also signed off on the continuation of a $1-billion-a-year program that helps hospitals and other providers care for uninsured and low-income people. That program, known as the Low Income Pool, is closely watched by the state’s hospital industry.

Along with people in the five pilot counties, hundreds of thousands of Medicaid beneficiaries already get care through HMOs. But others are part of a health-care payment system known as “fee for service” that critics have long derided as fragmented.

Scott and Republican lawmakers in 2011 approved making managed-care enrollment mandatory for almost all beneficiaries statewide and set up a process that involves HMOs and other types of plans, known as provider-service networks, competing for contracts in 11 different regions. The state needed federal approval before it could move forward with the changes, and the process crept slowly as AHCA and Obama administration officials negotiated details.

Even though final approval did not come until Friday, AHCA has already started the process of selecting managed-care plans to serve the 2.9 million people. It is expected to award contracts in September and has received proposals from about 20 managed-care plans, including major industry players such as Coventry Health Care of Florida, Humana Medical Plan, WellCare of Florida, Sunshine State Health Plan and UnitedHealthcare of Florida.

This <a target="_blank" href="/news/floridas-win-feds-grant-medicaid-managed-care-waiver/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

But Scott offered few details about their discussion on another major issue — how, or if, the state will carry out key parts of the federal Affordable Care Act.

Speaking to reporters in Washington, Scott reiterated his oft-repeated concern about the costs of the 2010 law, commonly known as Obamacare. In the coming months, state lawmakers are expected to consider whether Florida should take part in running a health-insurance exchange and expand eligibility for Medicaid, two pieces of the law aimed at helping more people get health coverage.

“Growing government, it’s never free,” Scott said. “It always costs money.”

A Health and Human Services official, speaking on background, said Sebelius noted during the meeting that Florida has the third-highest rate of uninsured residents in the country. Sebelius encouraged Scott to work in partnership with the federal government on an insurance exchange and also said the law would lead to the federal government paying 100 percent of the costs of a Medicaid eligibility expansion during the first three years and 90 percent of the costs later.

Scott, who made his fortune as a hospital-company executive, helped hatch his political career by being a vocal opponent of President Obama’s efforts to overhaul the health-care system. Scott and other Florida Republican leaders fought the Affordable Care Act in the courts as well as politically. But in recent months — following a landmark U.S. Supreme Court decision and Obama’s re-election — they have grappled with how to move forward with the law.

At the same time, Florida has been seeking federal approval of proposals that would ultimately lead to Medicaid beneficiaries statewide signing up with HMOs and other types of managed-care plans. Scott and Republican lawmakers approved the proposals in 2011 but have waited more than a year for decisions by the federal Centers for Medicare & Medicaid Services, which is under Sebelius. 

Florida Medicaid director Justin Senior said last month he expects a February decision about one of the proposals, which would lead to managed care for seniors who need long-term care services. It is unclear, however, when the federal government will make a decision about another proposal that would affect the broader Medicaid population.

“I’ve asked the secretary if she would expedite those and get those finished,” Scott said after the meeting with Sebelius, a former Kansas governor and insurance commissioner.

But state Rep. Mark Pafford, a West Palm Beach Democrat who is critical of shifting beneficiaries into HMOs, issued a statement Monday that warned Scott against trying to link the managed-care proposals and the Affordable Care Act in discussions with Sebelius. Pafford said he hopes Scott “isn’t demanding that expansion of the Medicaid program (under the Affordable Care Act) be contingent upon federal approval of a controversial Medicaid HMO-managed experiment.”

After more than two years of largely refusing to carry out the Affordable Care Act, the state House and Senate have formed committees that will study the law during the upcoming legislative session. While the law has various implications for the state, much of the discussion centers on a health insurance exchange and the potential expansion of Medicaid eligibility.

Under the Affordable Care Act, each state will have an online exchange aimed at helping individuals and small groups shop for insurance coverage. Depending on their income levels, many people will qualify for federal subsidies to help afford coverage. The federal government is expected in January 2014 to begin running an exchange for Florida, though the state could enter into a partnership or eventually run an exchange itself.

Florida does not have to carry out the Medicaid expansion, which would increase income thresholds and also open the program to many childless adults who currently do not qualify. Supporters, such as Pafford, say the expansion would reduce the amount of uncompensated care provided by hospitals and health professionals and would prevent thousands of deaths each year.

While the federal government says it would cover virtually all of the expansion costs in the initial years, Scott has repeatedly warned that the increased eligibility and other changes in the Affordable Care Act would lead to hefty costs for Florida’s Medicaid program.

Scott on Monday pointed to an estimate by his Agency for Health Care Administration of $26 billion over 10 years, though that is substantially higher than other estimates. The governor said he was trying to look out for Florida families.

“We want good access to health care, quality health care but (at) a price that they can afford,” Scott said.

This <a target="_blank" href="/insurance/florida-medicaid-scott-sebelius/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Both issues are highly complex and politically controversial.

Gov. Rick Scott and Republican legislative leaders want to require almost all Medicaid beneficiaries statewide to enroll in managed-care plans, an effort that has drawn opposition from Democratic lawmakers and some patient advocates. Meanwhile, after waging a legal and political battle, Scott and his GOP colleagues face the reality that the Affordable Care Act — better known as Obamacare — is here to stay.

Lawmakers in 2011 approved the Medicaid overhaul, but it requires approval from the federal government. State Medicaid director Justin Senior told lawmakers this month that he expects a decision from federal officials in February about the first part of the overhaul.

That part would lead to managed-care enrollment for seniors who need long-term care. If approved by federal officials, those changes would start taking effect by Oct. 1. Broadly, the idea is that HMOs and other types of managed-care plans could provide services that would allow seniors to stay in their homes and communities instead of having to live in costly nursing facilities.

The state Agency for Health Care Administration has been seeking approval from the federal Centers for Medicare & Medicaid Services for more than a year and also has started the contracting process for managed-care plans that want to take part in the long-term care system. The state would be split into 11 regions, with a limited number of plans receiving contracts in each region.

Senior said much of the state’s negotiations with federal officials have focused on safeguards to make sure that the program would be based on providing services in people’s homes and communities and would not be a “nursing home light” system.

‘We Will Really Start To Negotiate With The Federal Government’

The state also is seeking approval to require the broader Medicaid population, such as low-income women and children, to enroll in managed-care plans. Those changes would start to take effect by October 2014, though Senior said the state has focused first on getting approval for the long-term care portion of the overhaul.

“As we get that approval, I think our guns will turn, if you will, onto the (proposal dealing with the broader Medicaid population), and we will really start to negotiate with the federal government to get to the best possible product there as well and do it in a timely fashion,” Senior told the House Health & Human Services Committee.

Supporters of the overhaul contend that it will help hold down costs in the Medicaid program and better coordinate care for beneficiaries. Medicaid serves more than 3.2 million people in Florida, and is expected to spend about $20.8 billion this fiscal year.

But critics of the overhaul have long raised concerns that for-profit HMOs will scrimp on care for the beneficiaries. Rep. Elaine Schwartz, D-Hollywood, pointedly asked Senior about whether the state will have enough oversight of the managed-care organizations.

“I don’t hear from you that there is a beefing up in these programs to oversee these managed-care companies who could easily be diverting that money to the wrong purposes,” Schwartz said.

Senior said AHCA is aware it will have to be a “watchdog” over managed-care organizations, looking at such things as the health plans’ finances and medical data. But while Schwartz is concerned about the overhaul, other state officials want to get federal approval of what are known as “waivers” and move forward quickly with the changes.

“I’m very concerned about the length of time it’s taken us to get the waiver,” said Rep. Gayle Harrell, a Republican who has long been involved in health issues.

Health Insurance Exchange Decisions Looming

As AHCA works to get approval, lawmakers this spring also will debate whether the state should play an active role in carrying out the Affordable Care Act.

Scott and Republican legislative leaders largely refused over the past two years to move forward with the law, which President Obama and congressional Democrats approved in 2010. But after a U.S. Supreme Court ruling in June and Obama’s re-election in November, it became clear that the Affordable Care Act will not be tossed out or repealed.

The House and Senate have formed select committees that will study issues such as whether the state should create what is known as a health-insurance exchange, which is a key part of the law’s attempt to expand coverage to millions of more Americans. Also, the committees will study issues such as a potential expansion of Medicaid eligibility in Florida.

Scott, whose opposition to the Affordable Care Act helped propel his political career, is scheduled to meet Jan. 7 with U.S. Health and Human Services Secretary Kathleen Sebelius.

He and other Republican leaders say they need more information about issues such as the insurance exchanges, which are designed to be online marketplaces where people can shop for coverage. Depending on income levels, many people will be able to receive subsidies to buy the coverage.

Florida has already missed a deadline for states that plan to operate exchanges starting in January 2014. That means, at least initially, the federal government will run an exchange in the state.

But lawmakers during the spring session will look at the possibility of operating an exchange in the future or entering into a partnership with the federal government.

The House and Senate also will discuss a series of other issues stemming from the Affordable Care Act, including whether to expand Medicaid eligibility to offer coverage to more people. The federal government would pay for the eligibility expansion from 2014 to 2016, with the state gradually picking up some of the costs after that.

In grappling with the Affordable Care Act, Scott and Republican lawmakers likely will face pressure from conservatives to avoid taking part in an exchange and the Medicaid expansion. That political pressure was evident early this month when a meeting of the Senate select committee turned raucous after a group of activists pleaded with lawmakers to not carry out the law.

But Sen. Eleanor Sobel, a Hollywood Democrat who is vice chairwoman of the select committee, said the state has to abide by the law and pointed out that Florida has one of the largest uninsured populations in the country.

“I think that needs to be reckoned with, and we need to adjust our attitudes so we make sure that everybody has health insurance and a health care policy that’s affordable and accessible,” Sobel said.

This <a target="_blank" href="/insurance/florida-medicaid/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">