Christine Jordan Sexton
Welcome back to Diagnosis, a vertical that focuses on the crossroads of health care policy and politics.
— They’ve only just begun —
As lawmakers officially started working on the budget Wednesday the Agency for Health Care Administration (AHCA) started meeting with the Medicaid managed care entities that told the state they want to operate in Florida’s statewide Medicaid managed care program.
Sources tell Florida Politics that AHCA started notifying the entities via letter late last week.
The letters give the managed care entities six days’ notice they will be required to appear in Tallahassee to meet with Medicaid officials.
Sources tell Florida Politics that AHCA appears to have sent the letters to companies based on the on alphabetical order of the companies’ names. At least seven letters had been sent out according to those familiar with the process.
AHCA issued its invitation to negotiate (ITN) for the statewide Medicaid managed care program in April 2023.
Eleven vendors submitted responses to the ITN: Aetna Better Health of Florida, AmeriHealth Caritas of Florida, Florida Community Care, Molina Healthcare of Florida, Humana Medical Plan, ImagineCare, Sentara Care Alliance, Simply Healthcare Plans, South Florida Community Care Network (dba Community Care Plan), Sunshine Health, and United Healthcare of Florida. Nine of those providers currently have Medicaid managed care contracts with the state but Sentara Care Alliance and ImagineCare do not.
Sentara made news recently for a Department of Justice investigation into whether a company subsidiary, Optima Health, bilked the government of $665 million in 2018 and 2019 for health insurance subsidies associated with the Affordable Care Act, often called Obamacare.
The DOJ’s False Claims Act investigation became public after the government in November asked a Virginia circuit court judge to force the company to comply with the government’s requests for information about its Obamacare rate filings during the two-year period.
Meanwhile, Centene, the parent company of Sunshine Health, was awarded a five-year, multi-billion Medicaid managed care contract in New Hampshire. The new contract takes effect Sept. 1 and remains in place through Aug. 31, 2029.
Centene has operated in the New Hampshire Medicaid managed care market since 2013 through its subsidiary, NH Healthy Families.
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— Senate budget—
The Senate Health Appropriations Committee on Wednesday released a proposed budget that directs $45.9 billion in spending on health care-related services and programs administered by a spate of different state agencies and departments.
“This is 40% of the budget,” Appropriations Committee on Health and Human Services Chair Gayle Harrell said as she explained the proposed spending plan. “We have been working weeks on this.”
AHCA is targeted to receive about $34 billion in the Senate’s proposed spending plan.
Some of the big ticket items in the proposed budget for ACHA include about $48 million for a Medicaid managed care pilot program for people with intellectual and developmental disabilities; $15.1 million to increase payments for inpatient psychiatric care; $10.5 million to increase graduate medical education program and $5.5 million to increase payments to the emergency medical service (EMS) ground ambulance providers.
Harrell noted that the investments were in addition to the funds the Senate has included in its Live Healthy plan, SB 7016 and SB 7018.
Worth noting, the Senate budget also contains a $1.6 million increase for AHCA to hire the information technology (IT) staff it needs to continue the redesign of the Medicaid Management Information System, known as FMMIS, into the FX or Florida Heath Care Connections. The state recently had to halt additional contract work on FX because it was falling behind, a reality that the agency placed on a lack of critical resources.
The Senate budget directs $2.3 billion to the Agency for Persons with Disabilities (APD) including $64.7 million to help reduce a lengthy wait list for Medicaid iBudget waiver services and $2.7 million for the iConnect system providers must use to bill the state for services.
The Department of Children and Families (DCF), the agency charged with determining Medicaid eligibility as well as running many of the mental health and substance abuse services that aren’t covered by Medicaid would have a $4.6 billion budget under the Senate’s proposal. The Senate includes $15.1 billion to address the long wait times Medicaid beneficiaries have been complaining about during the Medicaid redetermination eligibility process.
The Department of Elder Affairs (DOEA) would have a $467.8 million budget with the Senate proposing that $4 million be spent on the Alzheimer’s Disease Initiative $6 million on Community Care for the Elder and $3.6 million on Home Care for the Elderly.
The Department of Health (DOH) meanwhile would have a $3.8 billion budget under the Senate’s proposal. Of that $30 million would be used to increase the Cancer Innovation Fund and another $5 million would be used to beef up the DOH”s medical quality assurance program, which is in charge of investigating health care providers. The Department of Veterans Affairs, meanwhile would have a $311 million budget under Harrell’s proposed plan.
— House budget—
The Agency for Health Care Administration, which houses the Medicaid program, is slated to receive $34.4 billion in state and federal dollars. Some of the larger ticket items the House has proposed funding in AHCA’s budget include: appropriating $123.9 million to increase reimbursement rates for nursing homes and directing $43 million to increase the rates paid to increase payments for pediatric services
Florida Health Care Association Chief Executive Officer Emmet Reed said the increase translates to roughly a 4% rate increase for nursing homes.
“If we do not make bold investments to strengthen our long-term care workforce, we will be left with the question of ‘who will care’ for Florida’s aging population,” Reed said in a statement.
“This increase is good first step toward rebuilding a workforce that has faced many challenges since the pandemic and is critical to ensure quality care for our state’s growing senior population. The Florida Health Care Association looks forward to working with the Legislature over these next few weeks to build upon these investments so that our nursing centers may continue to deliver high-quality care today and into the future.”
The House also is proposing to spend $8.56 million to implement a tiered reimbursement model for a Statewide Inpatient Psychiatric Program. The goal is to increase Medicaid reimbursement for more difficult-to-treat patients and to reimburse behavioral health providers who collaborate with primary care providers when providing care to patients.
The Agency for Persons with Disabilities is slated to receive $2.3 billion, including $29.4 million to fund participation in a pilot project that tests whether managed care is an appropriate model to deliver home and community-based services to people with intellectual and developmental disabilities. The pilot program currently is authorized to operate in two of the state’s Medicaid Regions.
The House budget directs $4.5 billion to the Department of Children and Families, the agency charged with determining Medicaid eligibility as well as running many of the mental health and substance abuse services that aren’t covered by Medicaid.
The House targets nearly $465 million for the Department of Elder Affairs, including $4 million to the Alzheimer’s Disease Initiative to provide services to another 418 people. The House budget also appropriates $6 million for the Community Care for the Elderly program which will provide service to an additional 540 clients. The House also wants to send $2 million to the Home Care for the Elderly program to serve an additional 540 clients.
The House budget earmarks $4 billion for the Department of Health. Some of the larger line items in the DOH budget include $80 million to expand the Florida Cancer Innovation Fund to promote emerging cancer research grants. The Hosue budget targets $10 million to further sickle cell research and to provide enhancements for the treatment of the disease. The House budget also includes $7 million to fund capital outlay needs for rural hospitals.
The Department of Veterans Affairs has the smallest budget of the health care-related agencies, with the House proposing to spend nearly $203 million to the agency.
— Garrison: Hospital DPP taxes not optional —
The House Health Care Appropriations Subcommittee approved a four-page bill Wednesday that could result in hospitals in Pasco and Pinellas counties losing hundreds of millions of dollars in supplemental Medicaid payments.
HCA 1 would ban private hospitals that don’t participate in what’s called the Direct Payment Program (DPP) from tapping into two additional supplemental Medicaid payment streams: Low-Income Pool (LIP) dollars and Indirect Graduate Medical Education (IGME) payments.
Combined the DPP, LIP and IGME account for $5 billion in supplemental Medicaid payments made to Florida hospitals that provide care to the poor, elderly and disabled.
“This is serious. Health care matters to the communities that rely on these institutions, especially folks that do high Medicaid and lots of charity care,” Rep. Sam Garrison, the Chair of the House Health Care Appropriations Subcommittee told Florida Politics.
The bill sends a strong message to privately operated hospitals in Pasco and Pinellas counties that have been unable to reach an agreement on the self-imposed tax necessary for them to participate since the DPP’s inception in 2021.
Florida doesn’t contribute any state general revenue funds to the DPP. Instead, it is funded by local dollars. Public hospitals provide the necessary local funds through intergovernmental transfers or IGTs. Private hospitals, though, don’t have access to IGTs and must agree to a self-imposed tax to raise the required local revenue. The assessments cannot exceed 6% of net patient revenue and all private hospitals in the Medicaid region must agree to the assessment for it to take effect.
To date, the DPP currently operates in 10 of the 11 Medicaid regions. The only exception is Medicaid Region 5 which is comprised of Pasco and Pinellas counties. Region 5 is a competitive two-county area that includes the likes of All Children’s Hospital, Baycare and Bayfront. There also are HCA and Advent Health-owned hospitals in the region.
While private hospitals in Region 5 are the only ones that don’t currently qualify for DPP, Garrison stressed that HCA 1 isn’t targeting any of those hospitals per se.
The funding agreements necessary to raise the required local dollars are 12-month agreements that require annual approval from the Centers for Medicare & Medicaid Services (CMS), the state, and even the participating hospitals.
That, Garrison said, can make the state’s Medicaid hospital financing system somewhat tenuous.
“If any region, for whatever reason, decides they are not going to participate in DPP now or in the future, it has an adverse effect on not only hospitals in that region, but the state as a whole,” Garrison said. “Because what happens then is people come in and start asking for money.”
To that end, in the FY 2021-22 state budget, then-House Speaker Chris Sprowls included money for Tampa General Hospital which is located in Medicaid Region 6 and at the time didn’t qualify for DPP supplemental payments.
To punctuate his point, Garrison said the House isn’t planning to make special appropriations in the 2024-25 budget to hospitals that are locked out of the DPP.
“This is a new page in the supplemental payments chapter of the Florida health care book. We want consistency and I think the other thing is we want to make sure those institutions get to know that they don’t get to pick and choose as it relates to DPP.”
— Additional CMS approval? —
Cutting non-DPP participating hospitals off from LIP funds, though, could bring on additional challenges and require CMS approval.
Like DPP, LIP is a supplemental payment opportunity that is funded through IGTs that are matched by federal funds.
Based on statutory requirements, ownership status and the ratio of charity care to commercial costs, hospitals are placed in different tiers.
Similar to DPP, LIP operates only with federal approval and with the state abiding by the required special terms and conditions required by the federal government.
One of those special terms and conditions is that hospitals in the same LIP distribution tier be treated equally.
Banning some hospitals from collecting LIP funds based on DPP participation could, some say, run amok of that federal requirement and may require the feds to revisit the special terms and conditions.
Garrison said he wasn’t sure that was the case.
“I guess it kinda depends on how you look at the question. What I personally think is the House’s position is if you have a situation where institutions are choosing to exercise LIP but not participate in DPP, that creates an inherent difference in terms of how we are handling not only charity care, but our heavy Medicaid providers,” Garrison said. “This is chapter one.”
The Legislature meanwhile also created the IGME program in the FY 2021-22 budget. IGME covers ancillary costs associated with the educational process and the higher case-mix intensity of teaching hospitals with residency programs.
— RULES —
—The Board of Psychology proposes amending Rule 64B19-11.005 to provide additional information regarding supervised experience requirements in light of recent statutory changes involving telehealth. More here
—The Board of Psychology proposes amending Rule 64B19-13.006 to provide continuing education credits in units smaller than one hour. More here.
—The Board of Podiatric Medicine proposes amending Rule 64B18-17.005 to update the language for continuing education required after initial licensure. More here.
—The Board of Podiatric Medicine proposes amending Rule 64B18-17.001 to update the language for continuing education required for license renewal. More here.
— LOBBYISTS —
Kimberly Diggers, Driggers Law: Florida Chiropractic Association
Nathan Gorman, The Gorman Group: National Health Freedom Action
Elnatan Rudolph, Converge Public Strategies: Milan Laser Hair Removal
John White, Shumaker Advisors Florida: Gracepoint Wellness
— ETC —
—The federal government said this week that it is taking steps to educate the public about their rights to emergency medical care and treatment at hospitals. The federal Emergency Medical Treatment and Labor Act (EMTALA) requires
Medicare-participating hospitals with emergency departments are required to provide emergency medical screenings and treatment for emergency medical conditions, which include labor as well as pregnancy loss. EMTALA also requires hospitals to provide stabilizing treatment for patients with emergency medical conditions.
The Department of Health and Human Services and CMS have posted information about patients’ rights under federal law and information on how to file a complaint if they are denied emergency medical care. The government also plans to meet with hospital and health care provider associations to discuss best practices and challenges in ensuring compliance with EMTALA.
The government launched the educational campaign in response to what it said is a growing number of inquiries to CMS from patients and providers who have been pressing for additional information about how EMTALA is being enforced.
—AHCA announced it intends to its request for a new title XXI section 1115 demonstration to CMS in order to accommodate the income eligibility changes made to the federal children’s health insurance program, in Florida, known as KidCare, to include children living in families with incomes up to 300% of the federal poverty level.
—AHCA received three expedited certificate of need (CON) applications to review this week. PruittHealth Citrus County is requesting the state transfer the CON from PruittHealth Citrus Hills it to establish a 93-bed community nursing home.
PruittHealth Brevard County is requesting to transfer a CON from PruittHealth Viera to it to establish a new 98-bed community nursing home.
PruittHealth Orange County is requesting the state transfer CON from PruittHealth Windermere to it to establish a new 120-bed community nursing home.
— ROSTER —
—Centene announced that Michael A. Carson has been named President and CEO of the company’s Medicare business, which operates under the Wellcare moniker. Carson succeeds Richard Fisher, who was appointed to the company’s operation’s leadership team.
—Kindred Hospitals of South Florida named David O’Brien Market Chief Executive Officer. Kindred’s four specialty hospitals in South Florida are Kindred Hospital South Florida in Coral Gables; Kindred Hospital South Florida in Fort Lauderdale; Kindred Hospital South Florida in Hollywood; and Kindred Hospital The Palm Beaches in Riviera Beach.
— ICYMI —
In case you missed them, here is a recap of other critical health care policy stories covered in Florida Politics this past week.
“Senate judiciary panel OK’s reintroduction of med mal caps in wrongful death bill” via Christine Jordan Sexton of Florida Politics — Saying his proposal strikes a compromise, Sen. Clay Yarborough agreed to amend language onto his proposed legislation (SB 248) that would cap noneconomic damages in medical malpractice cases. As amended, SB 248 caps non-economic damages for practitioners at $500,000 per claimant regardless of the number of health care practitioners who are liable. The limit would be $750,000 on “non-practitioners” who are liable, such as hospitals and health care facilities. The cap would drop to $150,000 for health care practitioners in emergency medical cases. “Because efforts over the last several years to do a clean repeal have not garnered enough support to pass the Legislature, I knew we needed to find a way to thread the needle and strike a balance to try to help impacted individuals,” Yarborough said.
“Senate trims $116M from Live Healthy proposal before passing it unanimously” via Christine Jordan Sexton of Florida Politics — After agreeing to slash proposed spending by roughly $116 million, Senators approved a pair of bills comprising Senate President Kathleen Passidomo’s Live Healthy proposal. The plan proposes hundreds of millions in Medicaid rate increases and would pump tens of millions in more money into graduate medical education as a way to help fortify the state’s health care workforce. Senators tagged six amendments onto SB 7016, including one that trimmed back Medicaid spending in the bill by about $96 million, and another amendment that modified the requirements for hospitals to have nonemergent care access plans before passing the measure unanimously. The Senate also tagged an amendment onto SB 7018 that reduced funding for the low-interest revolving loan program established in the bill by $25 million.
“Clay Yarborough amendment is a prescription for physician compromise” via Peter Schorsch of Florida Politics — Amid this Legislative Session, Senate President Passidomo is laser-focused on reversing the state’s historic doctor shortage. But along came SB 248, threatening to derail the President’s priority by sending doctors packing their stethoscopes and leaving Florida for more physician-friendly states — all by expanding the Florida Wrongful Death Act and potentially sending doctors’ already sky-high medical malpractice premiums into the stratosphere. Let me say right off that I absolutely believe victims of malpractice mistakes deserve fair compensation. In times like this, compromise is needed: holding negligent health care providers accountable while not derailing efforts to fix our state’s doctor shortage. Enter Sen. Yarborough, who navigated this emotional minefield with a finesse that deserves more than a polite nod. His strike-all amendment to SB 248 wasn’t a legislative maneuver but a tightrope walk over a canyon of competing interests.
“Lawmakers advance bills to block, remove harmful chemicals from drinking water” via Jesse Scheckner of Florida Politics — Lawmakers are again working to reduce the prevalence in Florida’s drinking water of long-lasting chemicals with bad bearings on human health through two bills that may unite before the end of Session. One focuses on the source of chemicals: industrial producers of common, everyday-used products. The other concerns itself with what comes out of the tap. Both cleared the first legislative hurdles Tuesday when the Senate Environmental and Natural Resources Committee gave unanimous approval. The first bill (SB 1692) heard Tuesday would create the not-so-catchily named “PFAS and 1,4-Dixoane Pretreatment Initiative” within the Florida Department of Environmental Protection (DEP). As its name suggests, the program’s purpose would be to work with companies to keep the chemicals out of the water.
“Bill seeks to regulate sales of legal vapor products in state” via Florida Daily — Supporters of Florida Senate Bill 1006 and House Bill 1007 support the legislation they say would create a well-regulated marketplace for the sale of legal vapor products in Florida. JUUL Labs, an American electronic cigarette company, favors the legislation. JUUL says the bill focuses on the key areas that companies like theirs would uphold and participate in, such as well-regulated nicotine in the marketplace across Florida and the rest of the country. Florida is the No. 1 destination for sales of illegal vapor products in the U.S., most of which are imported illegally via Florida ports from China and are sold with youth-appealing packaging and flavors.
“Florida Hospital leaders gather to advocate for priority health care policies” via Peter Schorsch of Florida Politics — Hospital leaders from across the Sunshine State assembled last week in Florida’s capital city for the Florida Hospital Association’s annual Hospital Days event. This two-day advocacy event provided an opportunity for hospital leaders to engage with state lawmakers on hospital policy matters during the 2024 Legislative Session. Gino Santorio, Chair of the Florida Hospital Association Board of Trustees and president and CEO of Mount Sinai Medical Center, expressed his optimism about the prominence of health care on this year’s Session agenda. Santorio highlighted the significance of the Live Healthy package, emphasizing legislative leaders’ unwavering commitment to hospitals, patients and the health care workforce.
— FOR YOUR RADAR —
Aside from coverage by Florida Politics, these stories are worth your time.
“More background checks for health care workers? A physician lawmaker calls them humiliating” via Jackie Llanos of the Florida Phoenix — Republican Rep. Joel Rudman, a family medicine physician in the Panhandle, voted against a proposal to expand background checks to all health care workers, calling his experience going through the process humiliating. He was the only one who voted against the bipartisan bill. Some health care workers, such as physicians, nurses and massage therapists, have to undergo a criminal background screening to get their license. But Republican Rep. Dana Trabulsy and Democratic Rep. Allison Tant want to make that a requirement for all health care workers before licensure, including dietitians, dentists and optometrists.
“Some foreign-trained physicians could skip residency to practice medicine in Florida” via Jackie Llanos of Florida Phoenix — One of the ways the Senate’s ‘Live Healthy’ initiative could increase the supply of doctors is by creating another licensure pathway for physicians trained outside of the U.S. As lawmakers started looking into the state of Florida’s health care workforce ahead of this year’s Legislative Session, it became apparent that physicians would not be able to keep up with the growing and aging population. Part of the problem is that Florida’s physicians are also aging. Nearly 34% of them are over 60 years and one in 10 plan to retire in the next five years, according to an analysis from Florida TaxWatch, a nonprofit research institute. That’s where the proposed new path for foreign-trained physicians comes in. To get an unrestricted license, someone who went to a medical school outside of the U.S. must complete a one-year residency, regardless of whether they practiced medicine in another country.
“Florida may force transgender people to put birth sex on driver’s licenses” via Tribune Wire Services — Transgender people would be forced to put their birth sex on their Florida driver’s licenses under a bill that gained a House Committee approval on Monday, the latest effort by state Republicans to target the LGBTQ community. The bill also would require health plans that cover treatments such as hormone-replacement therapy and surgeries for people with gender dysphoria also to cover the cost of “de-transitioning.” The House Select Committee on Health Innovation approved the bill (HB 1639) along party lines, despite opposition from transgender people and their allies. The Department of Highway Safety and Motor Vehicles currently identifies a person’s “gender” on licenses. The bill would require licenses to reflect a person’s sex, based on “the person’s sex chromosomes, naturally occurring sex hormones, and internal and external genitalia present at birth.”
“Florida needs a law so nurses don’t have too many patients at once” via Sen. Ileana Garcia for the Miami Herald — Nurses are on the front line of delivering and assuring quality care, as they are typically the person that you would interact with most during your time there. While nurses excel at juggling multiple tasks and patients — they seem to be able to do it all — nurses are only human, and they shouldn’t have to shoulder an unreasonable number of patients, even as the state faces a workforce shortage. This creates a difficult working environment for our nurses. This is why I filed Senate Bill 376, the Florida Patient Protection Act, this Legislative Session to establish and implement a healthy minimum staffing level for direct care registered nurses at health care facilities. This legislation will lay out a uniform, minimum nurse-to-patient staffing ratio across the state.
“Florida lab is making a vaccine to live in space. It might help here, too.” via the Miami Herald — Traveling by plane isn’t always easy on the body. And neither is space travel. Astronauts often experience atrophy, the loss of bone and muscle, during their months living in zero gravity. People on Earth also tend to see their bones and muscles weaken as they age, increasing risk of injuries from falls. Companies like Elon Musk’s SpaceX and Jeff Bezos’ Blue Origin are working to open space travel for more people. And figuring out how to reduce atrophy is on the mind of scientists. At the University of Central Florida in Orlando, researchers have received state funding to collaborate with biotech company Vaxxinity, which moved its headquarters from Texas to Cape Canaveral last year, to develop vaccines that can prevent and mitigate muscle and bone weakening, a common health problem for people experiencing long-term spaceflight — and aging seniors.
— PENCIL IT IN —
Thursday
It’s Home Care Advisory Day at the Capitol.
8 a.m. — The Hosue Banking and Insurance Committee meets and will consider HB 161 and HB 659 regarding physician workers compensation payments and a broad managed care bill, respectively. Room 17 House Office Building.
Friday
9 a.m. — The Senate is in Session.
Saturday
Happy birthday to Rep. Christopher Benjamin
Monday
11:30 a.m. — The House Children, Families & Seniors Subcommittee meets. Room 102 House Office Building.
3 p.m. — The House Health Care Appropriations Subcommittee meets. Room 17 House Office Building.
Tuesday
It’s Dentists’ Day on the Hill.
9 a.m. — The Senate Health Policy Committee meets. Room 412 Knott Office Building.
10 a.m. — The House Health & Human Services Committee meets. Room 17 House Office Building.
1 p.m.— The Senate Children, Families, and Elder Affairs Committee meets. Room 37 Senate Office Building.
Wednesday
9:30 a.m. — The Medicaid Medical Care Advisory Committee on Behavioral Health/Substance Use Subcommittee meets via Microsoft Teams. Meeting ID: 214313930942; passcode: Zj5Q4. Contact [email protected] for a copy of the agenda.
9:30 a.m. — The Medicaid Medical Care Advisory Committee (Long Term Care, Managed Care Subcommittee meets via Microsoft Teams. Meeting ID: 231336395870; passcode: 2vYZMC. Contact [email protected] for a copy of the agenda.
10 a.m. — The Medicaid Medical Care Advisory Committee on HIV/AIDS Subcommittee meets via Microsoft Teams. ID: 227044 706326; passcode: EySWkr. Contact [email protected] for a copy of the agenda.
10 a.m. — The Medicaid Medical Care Advisory Committee on Children, Including Foster Care Subcommittee meets via Microsoft Teams. Meeting ID: 220606704136; passcode: fqXWjJ. Contact [email protected] for a copy of the agenda.
10:30 a.m. — The Medicaid Medical Care Advisory Committee (MCAC) Dental Subcommittee meets via Mircosoft Teams. Meeting ID: 231336395870; passcode 2vYZMC. Contact [email protected] for a copy of the agenda.
11 a.m. — The Medicaid Medical Care Advisory Committee meets via Mircosoft Team. ID: 27 249358038; participant code: wSfwzD Contact [email protected] for a copy of the agenda.
Diagnosis is written by Christine Jordan Sexton and edited by Drew Wilson.
