Christine Jordan Sexton
Who’s in charge?
State Medicaid officials are moving ahead with some changes to Medicaid managed-care rules that would make it harder for people in the safety-net program to shift to different health plans.
The Agency for Health Care Administration is eliminating a provision in a rule that allows certain Medicaid beneficiaries to disenroll from their managed care plans if they are receiving a ”medically necessary, active and continuing course of treatment” from out-of-network providers who are participating in other managed care plans’ provider networks.
At an online rule workshop Thursday, AHCA’s Devona “D.D.” Pickle said the current rule creates a disincentive for health plans to create complete and robust networks that meet the needs of patients.
But when asked why the change was being sought, Pickle said AHCA, which oversees the statewide Medicaid managed-care program, said: “The changes came about for two reasons. One was just the process of individuals requesting disenrollment. This is a reason for disenrollment that we were seeing overutilized, and our emphasis is on developing robust provider networks.”
“The second reason was really validated back at the Legislature who agreed with the agency’s assessment that this did not motivate managed care plans to develop the appropriate networks,” she continued.
Pickle did not disclose at the virtual meeting the names of the legislative staff members or committees discussing the policy with AHCA. But her comments underscored the continued legislative interest in the statewide Medicaid managed-care program, most notably by the House of Representatives, and in the program’s operations. And it is interesting that an executive agency would pursue changes at the behest of someone in another branch of government.
As of Nov. 30, 4.47 million people were enrolled in Medicaid. The majority of them (3.44 million) were enrolled in the managed care program and must enroll in one of 16 health plans (which includes three dental companies). AHCA initially announced it would alter its Medicaid disenrollment rules in August but didn’t release a specific plan until late last month.
One company — Centene Corp. — dominates Florida’s Medicaid managed-care market after the acquisition of Tampa-based WellCare Health Plans. Centene operates as Sunshine Health, while WellCare’s Florida Medicaid business has continued to operate as Staywell Health Plan after the merger. Combined, the companies account for more than 40% of the Medicaid “managed medical assistance” and the managed-long-term care market.
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Republished with permission of The News Service of Florida.
