Florida Medicaid: Looking Forward to 2019 Tom Wallace Assistant - PowerPoint PPT Presentation

Florida Medicaid: Looking Forward to 2019 Tom Wallace Assistant Deputy Secretary for Medicaid Finance and Data, Florida Medicaid January 29, 2019

Presentation Overview • Florida Medicaid and Phase two of the Florida Statewide Medicaid Managed Care Program – Pushing Towards New Quality Goals: 2019-2023 • Completing Florida Medicaid’s Transition to Prospective Payment Methodologies to Align With Managed Care System. • Supplemental Funding Streams for Medicaid Participating Hospitals • Continued Focus on Opioid Coverage and Treatment 2

Florida Medicaid – A Snapshot • Fourth largest Medicaid population in the nation. • Approximately 4 million Floridians enrolled in the Medicaid Eligibles program: o 1.7 million adults - parents, aged and disabled o 47% of children in Florida. o 63% of birth deliveries in Florida. o 61% nursing home days in Florida. • Fifth largest nationwide in Medicaid expenditures. Expenditures • $26.8 billion expenditures in Fiscal Year 2017-18 o Federal-state matching program o 61.62% federal, 38.38% state. o Average spending: $6,619 per eligible. • $17.5 billion expenditure for managed care in 2017-2018 Delivery • Statewide Medicaid Managed Care program implemented in System 2013-2014 o Most of Florida’s Medicaid population receives their services through a managed care delivery system. 3

Florida’s Statewide Medicaid Managed Care Programs

What is Changing? December 2017-2018 2013 2018 First Re-procurement SMMC Program New of Health Plans; Begins Contracts Procurement of (5 year contracts with (MMA, LTC & plans) Dental Plans Dental) Begin Two Program Components : Two Program Components : • Managed Medical Assistance • Integrated MMA and LTC • Dental (MMA) Program • Long-term Care (LTC) Program 5

New SMMC Program Goals The Agency has established goals to build on the success of the SMMC program and to ensure continued quality improvement: Reduce potentially Improve birth outcomes: preventable hospital Increase the percentage Reduce Primary C-Section events (PPEs): of enrollees receiving Rate long-term care services in Admissions their own home or the Pre-term Birth Rate Readmissions community instead of a Rate of Neonatal nursing facility Emergency department Abstinence Syndrome visits 6

Regional Benchmarks: Potentially Preventable Events Potentially Preventable Region Region Region Region Region Region Region Region Region Region Region Admissions (PPAs) 1 2 3 4 5 6 7 8 9 10 11 Average Year 1 % Reduction -17.22% -9.75% -9.84% -10.68% -5.28% -16.74% -13.00% -8.46% -4.00% -12.57% -17.49% -11.37% Overall % Reduction -23.65% -19.02% -20.25% -24.14% -24.05% -25.15% -23.82% -18.44% -14.89% -21.74% -29.87% -22.28% * PPAs per 1,000 Enrollee Months Potentially Preventable Region Region Region Region Region Region Region Region Region Region Region Readmissions (PPRs) 1 2 3 4 5 6 7 8 9 10 11 Average Year 1 % Reduction -5.76% -7.91% -7.78% -8.21% -6.78% -9.45% -6.15% -7.21% -5.00% -5.51% -9.58% -7.21% Overall % Reduction -22.78% -19.36% -21.16% -23.11% -24.88% -20.05% -18.33% -16.11% -20.39% -19.25% -22.54% -20.73% * PPRs per 1,000 Hospital Admissions Potentially Preventable Emergency Room Visits Region Region Region Region Region Region Region Region Region Region Region (PPVs) 1 2 3 4 5 6 7 8 9 10 11 Average Year 1 % Reduction -2.79% -1.05% -2.37% -0.93% -5.78% -1.19% -2.36% -2.45% -2.50% -2.51% -2.28% -2.38% Overall % Reduction -16.06% -12.19% -14.30% -14.04% -21.00% -11.01% -13.91% -10.61% -11.87% -14.10% -16.45% -14.14% * PPVs per 1,000 Enrollee Months 7

Regional Benchmarks: Birth Outcomes Region Region Region Region Region Region Region Region Region Region Region Primary C-section 1 2 3 4 5 6 7 8 9 10 11 Average Year 1 % Reduction -8.94% -2.60% -2.01% -2.05% -2.26% -2.12% -2.07% -1.43% -3.22% -4.65% -3.61% -3.18% Overall % Reduction -16.00% -12.06% -9.50% -9.71% -11.38% -10.11% -9.99% -7.69% -14.53% -15.74% -16.92% -12.15% Region Region Region Region Region Region Region Region Region Region Region Pre-term Delivery 1 2 3 4 5 6 7 8 9 10 11 Average Year 1 % Reduction -2.65% -1.95% -1.82% -2.49% -1.91% -1.80% -2.23% -1.29% -1.87% -5.72% -1.68% -2.31% Overall % Reduction -12.56% -9.84% -9.42% -11.69% -9.33% -7.72% -9.31% -7.38% -8.56% -18.69% -7.84% -10.21% Neonatal Abstinence Region Region Region Region Region Region Region Region Region Region Region Syndrome (NAS) 1 2 3 4 5 6 7 8 9 10 11 Average Year 1 % Reduction -2.49% -2.25% -2.81% -4.12% -5.25% -2.22% -2.49% -1.82% -2.55% -2.25% -2.01% -2.75% Overall % Reduction -15.12% -11.47% -15.57% -21.05% -27.36% -14.81% -13.26% -10.63% -14.11% -12.25% -6.29% -14.72% * NAS per 1,000 live births 8

LTC Plans Commit to Higher Performance LTC Transitions to Community The law requires that base rates be adjusted to provide an incentive for plans to transition enrollees from nursing facilities (NF) to the community (HCBS). Current Contracts Required Transition Incentive Until 35% NF 9

LTC Plans Commit to Higher Performance LTC Transitions to Community Negotiated New Benchmarks: New Contracts NF 25% Required Transition Incentive Until 25% NF HCBS 75% 10

Gains for Recipients Health Plans Dental Plans Access to Care When you Need it :  Double the primary care providers in each network Access to Care When you Need it :   Guaranteed access to after hours care and telemedicine where available Improved Transportation : New level of  accountability with benchmarks to ensure recipients arrive and are picked up from appointments in a timely manner. 11

Gains for Recipients Health Plans Dental Plans Best Benefit Package Ever : Additional benefits at   no extra cost to the state. More than 55 benefits offered by health plans and extensive adult dental benefits offered by dental plans. Model Enrollee Handbook :   Information and content has been standardized across all health plans’ enrollee handbooks for greater ease of use. 12

Gains for Providers Health Plans Dental Plans Better Pay :  More pediatric physicians will be eligible to receive Medicare level of reimbursement through the Medicaid Physician Incentive Program Less Administrative Burden:   High performing providers can bypass prior authorization Less Administrative Burden :   Plans will complete credentialing for network contracts in 60 days 13

Gains for Providers Health Plans Dental Plans Prompt Authorization of Services :   Health plans will provide authorization decisions: • Within 7 days of receipt of standard request. • Within 2 days of an expedited request. Smoother Process for Complaints, Grievances,   and Appeals : Health plans agreed not to delegate any aspect of the grievance system to subcontractors. 14

SMMC Plan Roll Out Schedule SMMC Health and Dental Plan Roll-out Schedule Regions Transition Date Counties Included 9 Indian River, Martin, Okeechobee, Palm Beach, St. Lucie Phase 1 December 1, 2018 10 Broward 11 Miami-Dade, Monroe 5 Pasco, Pinellas 6 Hardee, Highlands, Hillsborough, Manatee, Polk Phase 2 January 1, 2019 7 Brevard, Orange, Osceola, Seminole 8 Charlotte, Collier, DeSoto, Glades, Hendry, Lee, Sarasota 1 Escambia, Okaloosa, Santa Rosa, Walton Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, 2 Madison, Taylor, Wakulla, Washington Phase 3 February 1, 2019 Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, 3 Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, Union 4 Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia 15

Florida’s Statewide Medicaid Managed Care Programs • Next Steps? 16

Florida Medicaid: Completing the Transition to Prospective Payment Systems

Transition to Prospective Payment Systems • Historically, under the Medicaid program, rates for institutional providers, such as hospitals and nursing homes, are set on a facility specific basis, based on each facility’s reported costs. • Florida has transitioned major institutional providers to prospective payment systems to better align with the managed care environment. 18

Transition to Prospective Payment Systems • Date Legislative Date Provider Type Methodology Implemented Direction Implemented Received Inpatient Hospital Diagnosis Related Groups 2012 July 1, 2013 Enhanced Ambulatory Outpatient Hospital 2016 July 1, 2017 Payment Groups Nursing Home Prospective October 1, Nursing Home 2017 Payment System (NPPS) 2018 19

Hospital Inpatient Payment Method • Utilize one DRG base rate: 1. Apply a provider policy adjustor for: • Rural hospitals, • Long-Term Care Acute Care (LTAC) hospitals, • Hospitals with unusually high percentage of their inpatient utilization coming from Medicaid recipients and a high percentage of stays hitting an outlier status 2. Apply automatic rate enhancements through supplemental payments (outside of the base rate) - $265 million for 28 providers in SFY 2018-2019 20