Medicaid – Florida Politics

Humana makes changes in Capitol, parting ways with Jon Bussey

After scoring a big victory in a statewide Medicaid managed-care procurement, Humana and Jon Bussey, who served as its regional director of corporate affairs, have parted ways.

Humana Director of Corporate Communications Mark Mathis confirmed the separation in an email to The News Service of Florida, saying the company made a decision last year to “restructure our Tallahassee government affairs team to align with new business strategies.”

According to his LinkedIn profile, Bussey was the health insurance company’s principal representative before state executive, legislative and regulatory bodies, including departments of insurance as well as state health and Medicaid agencies, in Florida, Louisiana, Mississippi, Texas, North Carolina and South Carolina. In the profile, he said he was responsible for providing strategic support on policy, political, public-sector procurement and regulatory matters, including commercial, long-term-care, Medicaid and Medicare and specialty insurance products.

The Florida Agency for Health Care Administration announced April 24 its decision to enter into five-year Medicaid contracts worth up to $90 billion with nine Medicaid managed care plans. If the decision stands, Humana will operate statewide.

Twelve managed care companies have filed petitions with the state notifying Medicaid officials of their intent to legally fight the decisions if changes aren’t made.

AHCA Secretary Justin Senior, Medicaid director Beth Kidder, and three other agency staff members have been meeting with the companies this week in hopes of avoiding litigation.

Bill Nelson, Democrats blast proposed Medicaid cuts

U.S. Sen. Bill Nelson and Democratic U.S. House members Thursday called for the federal Centers for Medicare & Medicaid Services to reject a move by Gov. Rick Scott’s administration to cut $98 million by trimming the length of time people have to apply for the Medicaid program.

“I rise here today because the state of Florida has again proposed to harm thousands of seniors and folks with disabilities who rely on Medicaid for their health care,” Nelson, a Democrat who faces an election challenge this year from Scott, said on the Senate floor.

Nelson, along with U.S. Rep. Kathy Castor and 10 other Democratic members of Florida’s congressional delegation sent a letter to CMS Director Seema Verma urging her to reject a proposed amendment to a state Medicaid “waiver” that would exempt Florida from a federal requirement that gives people up to 90 days following a health problem to apply for Medicaid coverage.

The Scott administration proposed — and the Republican-led Legislature agreed — to require people to apply for Medicaid during the same month of the health event.

“Retroactive eligibility is designed to protect Medicaid beneficiaries — including seniors, pregnant women, individuals with disabilities, and parents — and their families from the steep costs of medical services and long-term care. Importantly, this protection was also designed to minimize uncompensated care costs faced by hospitals and other health care providers who take care of our neighbors and are already challenged by the state’s low reimbursement rates,” the letter said.

The state Agency for Health Care Administration estimates that 39,000 people could be impacted by the change. Hospitals and nursing homes, though, say the numbers could be much higher.

The change has become a flashpoint between Democrats and Scott.

“It is our duty to ensure eligible individuals have access to care without going into debt to obtain it, which is why retroactive eligibility is so vital. This proposal would not only wipe out many families’ pocketbooks, but it would also place a financial burden on health care providers, the state and indeed all Florida taxpayers through increased uncompensated care costs,” the letter said. “We fail to see how this proposal will ‘enhance fiscal predictability’ as the state claims when it will increase costs across the board.”

But Mallory McManus, a spokeswoman for the Agency for Health Care Administration, issued a statement Thursday saying it is “categorically false to assert that this change impacts the care” provided to Medicaid beneficiaries.

“Florida continues to focus on quickly enrolling Florida’s most vulnerable people including children, frail elders, those with disabilities and pregnant women,” the statement said. “By enrolling individuals quickly, you ensure better-coordinated fully integrated care, as well as access to preventative services.”

Health plans mount challenges over Medicaid contracts

Twelve managed-care companies challenging the state’s award of tens of billions of dollars in Medicaid contracts have spelled out their arguments about why Florida officials were wrong in the handling of the coveted multi-year deals.

The filings allege a long list of errors by the Agency from Health Care Administration ranging from math mistakes, to not finishing reviews on time, to awarding a contract to a vendor that submitted the wrong bid.

In some cases, the petitions allege wrongdoing by rival health plans.

The challenges by the managed-care companies reflect the high stakes surrounding Florida’s massive Medicaid program. If the initial contracting decisions stand, some companies will be shut out of the managed-care program for the next five years.

The 12 plans filed challenges in 11 regions across the state for decisions involving a variety of health care services, including comprehensive care and specialty care such as providing services to people with mental-health issues or HIV and AIDS. In all, the companies filed 88 petitions by a Monday deadline.

Chief among the companies protesting the state’s handling of the contracts is Molina Healthcare, which currently has a footprint in eight of the state’s 11 Medicaid regions. The health plan applied for openings — through a process formally known as an invitation to negotiate — in all 11 regions but wasn’t among the top-scoring plans chosen by AHCA for negotiations.

Lawyers for Molina argue, among other things, that agency staff made mathematical errors throughout the scoring process. They contend the state was required to average scores of three different evaluators to determine top-ranking health plans but, instead, used aggregate scores.

Tallahassee attorney Robert Vezina wrote that AHCA’s alleged failure to follow criteria about scoring and ranking was “clearly erroneous, contrary to competition, and arbitrary and capricious” and made the “entire procurement process fundamentally and fatally flawed.”

Molina is requesting that if the disputes cannot be amicably resolved that the state be required to start over with a new procurement process.

The Agency for Health Care Administration went through a lengthy process before it announced its April 24 decisions to award five-year contracts to nine managed care plans. For contracting purposes, the state is divided into 11 regions. State law establishes a minimum and maximum number of plans that can operate in each of the 11 areas.

This is the second such procurement since the Florida Legislature passed a law in 2011 mandating that most Medicaid patients enroll in managed-care plans. A top Medicaid official has said that the new contracts, in aggregate, could be worth up to $90 billion.

The new contracts also have the potential to upend parts of the existing Medicaid program because, in some instances, existing providers would be eliminated. Magellan, a long-standing Medicaid provider specializing in mental-health services, would be locked out of the managed-care program if the agency decisions remain intact.

Attorneys for Magellan allege in filings that numerous mistakes and errors were made during the procurement process. The plan argues that competitor Staywell was awarded a Medicaid contract to provide mental-health services to patients in Medicaid Region 2 despite not submitting a bid for the area, which stretches across 14 counties in Northwest Florida, including Leon County.

Magellan’s attorneys argue that Staywell erroneously responded to the invitation to negotiate in Region 2 by submitting its response to the so-called ITN for Region 5, which covers Pasco and Pinellas counties.

State evaluators “noted the discrepancies,” according to Magellan’s petition, but “there is no evidence that AHCA requested, or that Staywell submitted, a corrected Region 2 response.”

Magellan’s attorneys are asking that AHCA award a contract to Magellan or, alternatively, reject all specialty-plan submissions and conduct a new procurement.

Not all plans that filed petitions with the state would be locked out of the Medicaid program in the coming years. For instance, UnitedHealthcare was awarded contracts in Medicaid Regions 6 and 11 for comprehensive care, which includes long-term care services as well as traditional health care covered under Medicaid.

But United also wanted contracts statewide to provide services to people with serious mental illnesses and was shut out of that market. United filed 11 petitions — one in each region — challenging those decisions. United alleges in its petitions that AHCA agreed to extend an internal deadline for a trio of evaluators to complete their work but that time ran short before one of them — “evaluator No. 3” — could finish the review.

According to United’s petition, “evaluator No. 3” completed 20 percent of the task by the Dec. 29 extended deadline and executed what is known as an “independent evaluators certification.” The certification stated that any plan that scored a zero “was intended to score a zero”

But United attorney Seann Frazier argued that a score of zero should only be given if the vendor didn’t provide a response. Frazier said that “in reality,” a large number of the components in the ITN were scored by two, and not the required three, evaluators.

Not all of the allegations of wrongdoing were leveled against the state, though. In filings for Simply Healthcare, attorney Robert Hosay accused competing health plans of not following rules.

For instance, the ITN required health plans to disclose their largest out-of-state Medicaid contracts. But Hosay argued that Humana — which could operate statewide if the agency’s decisions stand — failed to disclose an out-of-state contract it has in Wisconsin or report on how the plan performed on certain quality-of-care measurements.

The contract is with a company called iCare, which is a joint venture between Humana and the Centers for Independence, a Milwaukee-based non-profit rehabilitation provider.

Hosay also alleged in the petitions that Staywell was not truthful when it disclosed that its Medicaid contract had been terminated in Iowa in December 2015. Staywell attributed the termination to bid protest proceedings, but Hosay argued the disclosure was misleading.

“In reality, WellCare’s Iowa contract was terminated as a result of unfair bidding practices on WellCare’s part being discovered, including a violation of bidding rules and an attempt to acquire an unfair advantage over competing bidders,” wrote Hosay, referring to Staywell’s parent company.

Democrats say Medicaid cut information wrong

Incoming Florida Senate Minority Leader Audrey Gibson sent a letter Monday to the federal government accusing Gov. Rick Scott’s administration of falsifying the record to show support for a $98 million Medicaid reduction and asked for a “thorough review” of the proposed cut, which would impact an estimated 39,000 people.

“I felt compelled to ensure (the federal Centers for Medicare & Medicaid Services) has no misunderstanding as to opposition on this ill-advised move targeting seniors and families facing catastrophic health care emergencies,” Gibson, a Jacksonville Democrat , wrote to CMS Administrator Seema Verma.

Florida is asking the federal government to approve limiting the length of time people have to qualify for the Medicaid program. The issue is known as Medicaid retroactive eligibility. Federal law has long required states to give people 90 days to apply for the program following a health issue.

At the behest of the Scott administration, the Legislature during the 2018 Session approved requiring adults who aren’t pregnant to apply for the Medicaid program the month they required the health services. Florida submitted the request to the federal government last month.

State Medicaid Director Beth Kidder sent a letter to CMS Project Officer Vanessa Khoo last month accompanying the request, saying she was not “not aware of any concern or opposition raised by any member of either party regarding this provision during extensive budget debate.”

Kidder also went on to say that the $98 million reduction “cannot accurately be described as a cut.”

In her letter Monday to Veema, though, Gibson noted that several Democrats flagged the $98 million cut while raising questions on the Senate floor about who would be impacted and what would happen to them.

“AHCA’s proposal to cut off an entire population of powerless citizens and their families in the midst of a catastrophic medical emergency lacks innovation for improving outcomes and ultimately may push more costs to largely safety net hospitals who already bear a tremendous cost burden, particularly in light of rejection of Medicaid expansion in Florida,” Gibson wrote in her letter.

This is not the first time the agency’s correspondence regarding the change has come under fire.

In a March 2017 letter to the federal government, state Agency for Health Care Administration Secretary Justin Senior said reducing Medicaid retroactive eligibility could save as much as $500 million annually. But that figure was reduced to $98 million months later.

AHCA said the $500 million estimate included health care costs for pregnant women and children and that the $98 million figure was only for non-pregnant adults.

Joan Alker, executive director of the Georgetown University Center for Children and Families who has extensively studied Florida’s Medicaid program said the explanation can’t be right. That’s because children account for only 20 percent of total spending in the program.

Report targets AHCA over nursing home verifications

The state Agency for Health Care Administration failed to verify that nursing homes properly corrected deficiencies cited by agency staff in 2015, according to a report issued Friday by the U.S. Department of Health and Human Services inspector general’s office.

Federal officials are recommending that the state improve practices for verifying that deficiencies have been corrected.

The Agency for Health Care Administration did not agree with the Office of Inspector General’s findings and asked that federal officials change the name of the audit titled, “Florida Did Not Always Verify Correction of Deficiencies Identified During Surveys of Nursing Homes Participating in Medicare and Medicaid.”

The inspector general reviewed 100 deficiencies at nursing homes across Florida that were flagged by regulators in 2015 and found that the agency verified the correction of 82 deficiencies.

According to the report, the state agency did not obtain evidence of correction — or sufficient evidence of correction — for the remaining 18 deficiencies. Based on those findings, the Office of Inspector General estimated that the state agency failed to obtain evidence of corrections for 455 of 2,381 deficiencies cited at facilities that participated in Medicare and Medicaid.

Moreover, the report estimated that the state didn’t provide sufficient evidence that corrections had been properly made for another 130 deficiencies.

Agency for Health Care Administration spokeswoman Mallory McManus downplayed the findings, saying the report involves a small number of “isolated incidents in 2015 at nursing facilities that did not involve patient harm” and said the agency has since changed its operations.

Federal regulations require nursing homes that participate in Medicare and Medicaid to submit correction plans to the federal Centers for Medicare & Medicaid Services or to the proper state agency. State agencies must verify the correction of deficiencies by obtaining evidence or through onsite reviews.

But according to the report released Friday, a state official told a federal auditor that AHCA’s practice for less-serious deficiencies was to accept the nursing homes’ correction plans as confirmation of substantial compliance. The report noted that an AHCA official cited a section of a federal manual that allowed for the practice.

But the inspector-general report said the cited section of the manual “is not applicable to nursing homes. …  Without verification of evidence of correction, the state agency cannot ensure CMS that nursing homes have complied with federal participation requirements and that residents are adequately protected.”

AHCA Secretary Justin Senior wrote a three-page letter in February on the findings and recommendations. In it, Senior said the “18 deficiencies in question were isolated incidents (not patterns or widespread), and none of them involved patient harm or immediate jeopardy. We are therefore concerned that the title significantly misrepresents the findings for Florida.”

A copy of the report is here.

Child care, health insurance and housing are ‘fiscal cliffs’ for Florida families

State and federal programs aimed at helping low-income Florida families aren’t working, according to a new report from the Florida Children’s Council.

“Positive child and youth outcomes, financial stability for families, and economic vitality for businesses are interrelated goals. There is clear need to rethink social service policy and align work-based solutions with child and family supports,” said Dr. Brittany Birken, CEO of the Florida Children’s Council. “These two-generational strategies provide a framework for developing systems that support strong child and youth outcomes within the context of family.”

The report, released Monday, studied the impact of Temporary Assistance for Needy Families, Supplemental Nutrition Assistance Program, block grants for school readiness, the Earned Income Tax Credit, Medicaid/Florida CHIP, and Section 8 housing vouchers on household budgets.

The combination of social programs were found to be lacking in the report, which concluded that if “children from low-income homes are to reach their full potential, there is a significant need to eliminate the current silos addressing adult-oriented and child-oriented programs separately.”

The Council report demonstrated the financial “break even” points for single adults without children and compared them to a household with a single working parent who has two children. Both models assumed the households were in Miami-Dade County.

The report found a household where a single parent earns $11,000 a year could “break even” through the use of social program, and the same was true as the parent’s income increased to about $40,000 a year.

Once past that mark however, net resources plummet – a single parent earning between $40,000 a year and $53,000 is likely to see negative income between $3,200 and $8,000 each year.

Single adults start to break even at about $15,000 a year in earnings, with incomes over $25,000 a year generally allowing them to have cash left over once their expenses are paid.

Such losses as a parent’s income rises were attributed to three “fiscal cliffs” –  children’s health insurance, child care, and housing. Each of those cost categories contributes to what the report calls “parking,” where a working parent is disincentivized from earning more money due tin order to maintain eligibility for social programs.

“Florida is a vibrant and growing state that has its share of opportunities and challenges.  To ensure that we secure paths to prosperity for all Floridians, especially the nearly one million kids living in poverty, we must focus on bold and broad strategies that consider two-generation approaches,” said Tony Carvajal, Executive Vice President of the Florida Chamber Foundation.  “Targeting policies that trap families in fiscal cliffs or create hurdles to self-sufficiency should be job one.”

Of the three cliffs, quality child care stood out as “perhaps the singularly most important social service in recognition of its impact on the entire family while providing clear economic benefit to employers and communities.”

“There are systemic barriers that hinder a family’s ability to become economically self-sufficient,” said Cindy Arenberg Seltzer, chair of the Florida Children’s Council and Executive Director of the Children’s Services Council of Broward County. “By strategically aligning systems of care, we can ensure that all children live in stable and nurturing environments.”

The Council’s findings will be addressed during the upcoming Florida Business Leaders’ Summit on Prosperity And Economic Opportunity being put on by the Florida Chamber. The event will be held in Orlando on Wednesday and Thursday.

Health plans challenge Medicaid contract decisions

With tens of billions of dollars in contracts at stake, a dozen health plans have told Florida officials they are challenging newly awarded Medicaid contracts.

The challenges could complicate plans by the state Agency for Health Care Administration to transition to new five-year contracts for Florida’s massive Medicaid program by Jan. 1. Medicaid is Florida’s safety-net health program that provides care for nearly 4 million poor, elderly and disabled people, with 85 percent of beneficiaries enrolled in managed-care plans.

Some of the bid protests filed late last week were expected because several managed-care plans currently providing Medicaid services would not have their contracts renewed. Some of those who filed challenges included Molina Healthcare of Florida, Prestige Health Choice and UnitedHealthcare of Florida.

“There’s a lot of investment that has happened over the last five years, so I don’t find it surprising there would be protests,’’ said Audrey Brown, president and CEO of the Florida Association of Health Plans, which represents the managed-care industry.

The health plans challenged contracts ranging from providing the full range of Medicaid services to specialized contracts for long-term care, services for HIV/AIDS patients and mental-health services.

The Agency for Health Care Administration has gone through a lengthy process of awarding contracts in 11 regions of the state, with contracts going to varying numbers of plans in the regions. Several health plans filed protests for all 11 regions, while others filed protests for specific parts of the state.

This is the second such procurement since the Florida Legislature passed a law in 2011 mandating that most Medicaid patients enroll in managed-care plans.

The protest notices start a legal process for the plans to challenge the agency decisions. The notices submitted Friday did not provide the rationale behind the challenges. The companies have 10 days to file formal written protests that spell out why they think the agency erred.

AHCA last week announced the names of nine managed-care plans that won contracts.

Florida Medicaid Director Beth Kidder said earlier this year that the contracts could be worth as much as $90 billion over a five year-period. The state first issued its invitation to negotiate for the latest round of contracts in July 2017.

If the agency’s decisions stand, Sunshine Health Plan would operate in all 11 regions of the state. Sunshine Health would offer Medicaid beneficiaries access to a traditional plan as well as a separate “child welfare” specialty plan.

Simply Healthcare Plans, meanwhile, would offer a specialty plan for people with HIV and AIDS in all 11 regions.

Humana was picked by the state as a provider in 10 of the 11 regions across the state but did not win a bid in Medicaid Region 1, which includes Escambia, Okaloosa, Santa Rosa and Walton counties.

But by winning a contract in Region 2, which also includes parts of the Panhandle, Humana would be able to serve Medicaid beneficiaries in Region 1. To encourage managed-care participation in the Panhandle, lawmakers agreed in 2011 to provide health plans an incentive to participate in regions 1 and 2. A law requires AHCA to award additional contracts in any other regions where plans bid if they have contracts in Region 1 or Region 2.

Deadline looms for managed-care protests

Managed care organizations that want to challenge the award of upward of $90 billion in Medicaid contracts to nine health plans across the state have until late Friday afternoon to launch protests.

Organizations that don’t agree with the state Agency for Health Care Administration’s contracting decisions, announced Tuesday, must file what is called a notice of intent to protest within 72 hours of the agency posting its decision.

That gives the managed care plans until 4:15 p.m. Friday to file notices with the state.

Any managed care plan that files a notice of intent to protest must also post a bond in an amount equal to 1 percent of the estimated contract amount, which the state must provide within 72 hours of the filing of notice of intent to protest.

Medicaid Director Beth Kidder previously said the five-year contracts could be worth upward of $90 billion in the aggregate. The managed-care plans that receive the contracts will provide health care to nearly 4 million poor, elderly and disabled residents.

If the agency’s decisions stand, Sunshine Health Plan, Humana, and Florida Community Care will operate in all 11 regions of the state.

Also statewide, Sunshine Health and Simply Healthcare Plans will offer specialty managed-care plans catered to people in the “child welfare” system and people living with HIV and AIDS, respectively.

WellCare of Florida, which operates as Staywell Health Plan of Florida, also will offer a specialty plan statewide for people with serious mental illnesses.

Republished with permission of the News Service of Florida.

Rick Scott’s Medicaid numbers come under fire

When it comes to health-care math, sometimes the numbers don’t add up for Florida Gov. Rick Scott.

As Scott’s administration this week submits a request to the federal government to trim the amount of time people have to apply for Medicaid coverage, the state’s estimate of $98 million in savings associated with the change has come under fire from health-care providers who contend the impact is much greater. Providers also allege that the number of people impacted will exceed the 39,000 projected by the state.

The providers’ arguments are bolstered by a 2017 letter sent to the federal government by the secretary of Scott’s Agency for Health Care Administration. The letter described savings associated with the change as high as $500 million.

That contradiction, however, is not the first time that a Medicaid cost analysis by the Scott administration has been called into question since he became Florida’s chief executive officer in 2011.

“I would say that Governor Scott’s Medicaid numbers should be carefully and independently analyzed,” said Joan Alker, executive director of the Georgetown University Center for Children and Families who has extensively studied Florida’s Medicaid program. “I certainly regard them with a healthy degree of skepticism.”

Scott, who is running this year for U.S. Senate, made his fortune in health care and understands its many nuances. He led the Columbia/HCA hospital company before it forced him out amid an investigation into federal health care fraud. Scott was never charged in the case, but the company paid a then-record $1.7 billion fine.

John Tupps, a Scott spokesman, defended the governor’s handling of the Medicaid program, which will total about $28.3 billion in the upcoming year.

“The bottom line is that Florida’s Medicaid program is operating at the highest level of quality in its history,” Tupps said. “These claims are unfounded and have zero impact on the services that Florida delivers to patients.”

But the Scott administration’s cost analyses sometimes have not made sense to Medicaid experts or health and social-service providers in the trenches.

Florida’s disabled community cried foul just months after Scott’s election after the governor ordered his chief inspector general to conduct a review of what is known as the home and community-based waiver program at the state Agency for Persons with Disabilities. The March 2011 report included budget information which, critics maintain, inflated a deficit at the agency by $75 million.

In 2012, Scott contended Florida’s Medicaid costs would increase by $1.9 billion if the state were to expand Medicaid under the federal Affordable Care Act. The contention was disputed at the time by state economists and was later revised.

In 2017, Scott announced Florida had been approved for $1.5 billion in each of the next five years for the Low Income Pool program, which funnels additional money to hospitals that serve large numbers or poor and uninsured patients. Scott also praised President Donald Trump’s administration for its willingness to work with the state.

So-called LIP funding is a supplemental Medicaid program and, like other programs, requires local matching dollars to draw down federal funds. In Florida, that match has come from counties and local hospital taxing districts whose interest in continuing to put up the funding waned after the Barack Obama administration restricted how LIP dollars could be spent.

At a press conference following the announcement, Scott dismissed concerns that the local matching money would fall short and that the full $1.5 billion wouldn’t be available, saying at the time Florida would “get more flexibility in a lot of things with regard to the Medicaid program.”

But the final tally of LIP funding in fiscal year 2017-2018 is about $731 million, less than half of what is available, because of a lack of matching money.

Tupps dismissed the criticisms and placed blame on hospitals. He said Scott negotiated the $1.5 billion LIP program and “it’s up to them to draw down the federal funding.”

Moreover, Tupps said the announcement that Florida would have $1.5 billion isn’t inaccurate because “this is year one of a five-year commitment.”

The latest dispute centers on a proposal to trim a length of time people have to apply for the Medicaid program from the current 90 days to a maximum of 30 days.

Federal law requires states to cover the costs of medical bills incurred up to three months prior to the time people apply for Medicaid. So long as people qualify for Medicaid and the services are covered, the hospital, doctor and nursing-home bills that accrue during that period will be absorbed.

The longstanding policy, officially known as “retroactive eligibility,” protects the poor from unpaid medical bills that they cannot afford and helps ensure that hospitals and nursing homes are paid for services they offer to Medicaid-eligible people.

Earlier this month, AHCA said 39,000 people would be impacted by a switch to a 30-day period and that it should save $98 million. That’s a drastic reduction from the $500 million in savings that AHCA Secretary Justin Senior said could be saved in a March 2017 letter he sent to former U.S. Department of Health and Human Services Secretary Tom Price.

Senior said claims that accrue during the 90-day period are paid outside of the state’s Medicaid managed-care system. That means Florida pays for “uncoordinated and potentially inappropriate utilization of medical services.”

Months later, the Scott administration floated the proposal to the Legislature for consideration during the 2018 Session. Ultimately, the $98 million reduction was included in the new state budget that begins July 1.

At two public meetings this month, health-care providers testified that they believe the change in policy will lead to much larger reductions in spending than the $98 million the agency cited.

“It does appear low from what we’re seeing anecdotally, but I don’t have the numbers to back that,” said Stephen Harris, vice-president of payor and government affairs for Tampa General Hospital.

What Harris does know is that Tampa General discharged 4,200 “straight Medicaid” patients last year, meaning they were not enrolled in Medicaid HMOs. And while he hasn’t conducted an analysis of each of those patients to determine when they applied for Medicaid, Harris suspects many of them were enrolled retroactively.

Mallory McManus, a spokeswoman for the Agency for Health Care Administration, defended the $98 million figure and distributed backup details showing how the agency reached those conclusions.

But the agency provided no backup data on how it reached the $500 million estimate it touted as savings in 2017. Moreover, the agency now says the figure is irrelevant.

But when pressed for an answer, McManus attributed the huge difference to the Legislature’s decision to exclude pregnant women and children from the policy change.

“As you know, the majority of the Florida Medicaid population is children,” she added.

But the chances of McManus’ explanation being accurate are nil because excluding pregnant women and children wouldn’t lead to such a large reduction in the estimate, Alker said.

“While children account for about half of Florida’s Medicaid enrollment, they constitute only 20 percent of total spending. And the good news is that most kids don’t spend time in the hospital or in nursing homes — both of which are very expensive and likely the drivers of retroactive eligibility spending,” Alker said. “Thus, the likelihood of a huge chunk of retroactive eligibility spending being due to children is close to zero.”

The Agency for Health Care Administration used 2015 data in coming up with the $98 million projection. A News Service of Florida analysis of the 2015 data shows that bills for poor and elderly people who don’t qualify for Social Security account for about half of that total. Another $31 million is attributed to bills for elderly patients who qualify for both Medicare and Medicaid.

That’s not surprising to Tampa General’s Harris, who also worries that, if the retroactivity change is approved by the Trump administration, it would become more difficult for hospitals to find skilled nursing facilities that are willing to accept patients that hospitals want to discharge.

“Knowing that the patient is Medicaid eligible is a big deal,” he said. “If we can’t tell them (nursing homes) that, it makes it more difficult for us to place them.”

AIDS foundation fights getting shut out of Medicaid

The largest nonprofit AIDS health care provider in the nation is at risk of being blocked out of South Florida’s Medicaid market.

AIDS Healthcare Foundation attorneys filed a written protest and requested a hearing after its managed-care division was not among the health plans selected to negotiate with state Medicaid officials to continue providing care in Miami-Dade, Broward and Monroe counties beginning in 2019.

As of March 1, nearly 2,000 people in South Florida with HIV or AIDS were enrolled in Positive Healthcare, the managed-care plan.

“It is inconceivable that such an experienced plan would have its proposal to continue operating as an HIV/AIDS specialty plan scored so low compared to other plans without the same experience or provider network,” Jeffrey Blend, Positive Healthcare assistant general counsel, wrote, noting that it scored well below other plans that responded to a state contracting process known as an “invitation to negotiate.”

Agency for Health Care Administration Secretary Justin Senior denied the request for a hearing this week, saying the issues weren’t ripe for challenge because the state hadn’t finalized negotiations.

The dispute comes as part of a broader process by the Agency for Health Care Administration to award new contracts in the state’s Medicaid managed-care system. Total five-year contracts could be worth up to $90 billion, with contracts awarded to health plans in different regions of the state.

The state issued its invitation to negotiate, the second under the Medicaid managed-care program, in July 2017. The winning bids are expected to be announced on April 16. The state will transition from current health plans under contract to new plans at the end of 2018, according to state documents.

In its protest, Positive Healthcare alleged that “upon information and belief” the state is negotiating with two other specialty plans for the treatment of HIV-positive people in the South Florida regions 10 and 11: Clear Health Alliance and United Healthcare of Florida Inc.

Like Positive Healthcare, Clear Health Alliance already is a contracted specialty health plan that’s available for HIV-positive people. United Healthcare has contracts for long-term care services and traditional managed care but not specialty care, such as HIV or AIDS.

Michael Rajner, an activist living with HIV in Broward County, said he wasn’t aware that Positive Healthcare was at risk of losing its Medicaid contract but said that “could be harmful for people living with HIV that have enjoyed access to that plan and particular providers because it could force them to establish a new relationship with a new physician, and that doesn’t benefit patients.”

The Legislature passed a sweeping rewrite of the state’s Medicaid program in 2011, requiring nearly all beneficiaries, from the cradle to the grave, to enroll in managed-care plans. Eleven managed-care organizations, including Positive Healthcare, were awarded contracts after the state’s first invitation to negotiate.

For contracting purposes, the state is divided into 11 regions. State law establishes a minimum and maximum number of plans that can operate in each of the 11 regions. Positive Healthcare operates only in Broward, Miami Dade and Monroe counties.

Positive Healthcare isn’t the only managed care plan currently under contract that has been snubbed in the second round of bidding. Molina Healthcare disclosed in a recent Securities and Exchange Commission filing that its Florida subsidiary, Molina Healthcare of Florida, was invited to negotiate a new contract only in the Miami-Dade region.

Molina Healthcare of Florida currently has contracts in eight regions, and Medicaid premiums from the plan accounted for 8 percent of Molina Healthcare’s projected revenues in 2018.

The filing noted that the company “intends to take all appropriate actions to both protect its rights and ensure continuity of care for its members,” according to the filing.

Republished with permission of the News Service of Florida.

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