Consumer-directed care demonstrations (include number of beneficiaries served now and in any expansion plans)

In 2000, Florida, as one of three states participating in the Robert Wood Johnson Foundation’s National Cash and Counseling Demonstration and Evaluation project, started its “Consumer-Directed Care (CDC)” waiver program. CDC consumers exchange their current home and community based long-term care services for a monthly budget. Program enrollees are allowed to “cash out” services on their current care and support plans and receive a monthly budget allowance to pay for the services and supports they choose. Services may be provided by non-traditional caregivers such as family members. The consumers’ budgets are equivalent to the value of the services they received in the Medicaid home and community based service (HCBS) waiver program. This budget provides the individual with flexibility and choice in managing and directing his/her own care. Consumers’ allowable purchases can include items and services such as: personal care, homemaking service, consumable medical and personal care supplies. Consumers eligible for the program include elders, adults with brain or spinal cord injuries, and adults and children with developmental disabilities.

Mathematica Policy Research, Incorporated, an independent research group, was contracted by the federal government to evaluate the Cash and Counseling demonstration. The study showed that consumers participating in CDC+ are more likely to have their needs met and be satisfied with their care as opposed to traditional care. Due to the project’s many benefits for consumers, Florida sought expansion of CDC and changes to its experimental design. Florida implemented the Consumer-Directed Care Plus (CDC+) program in January, 2004 under the authority of an Independence Plus 1115 Waiver amendment granted by the Centers for Medicare and Medicaid Services (CMS).  In March 2008 the 1115 waiver ended, and the program received authority to operate under a 1915(j) state plan amendment.  There are currently 1,090 consumers being served on CDC+.

Medicaid Managed Care Pilot Program:  Florida has been working for several years on its Medicaid Managed Care Pilot Program.  Florida's 1115 Medicaid Reform Waiver is a comprehensive demonstration that seeks to improve the value of the Medicaid delivery system.  The program is operated under an 1115 Research and Demonstration Waiver approved by the Centers for Medicare and Medicaid Services (CMS) on October 19, 2005.  State authority to operate the program is located in Section 409.91211, Florida Statutes, which provides authorization for a statewide pilot program with implementation that began in Broward and Duval Counties on July 1, 2006.  The program expanded to Baker, Clay and Nassau Counties on July 1, 2007. 

Through mandatory participation for specified populations in managed care plans that offer customized benefit packages and an emphasis on individual involvement in selecting private health plan options, the State expects to gain valuable information about the effects of allowing market-based approaches to assist the state in its service to Medicaid beneficiaries. A more detailed description of the 1115 waiver can be accessed at: http://ahca.myflorida.com/Medicaid/medicaid_reform/index.shtml.

The first goal of the Pilot is to improve access to healthcare, but also to provide more choices for plans and services and to provide opportunities for beneficiaries to take a more active role in their health.  Reforms will also reduce the administrative complexity of the Medicaid program.  New options include customized plans and enhanced benefits.

As plan choices continue to expand, certified choice counselors work with beneficiaries to help them select the plan most appropriate for them and their families.  Counselors encourage beneficiaries to consider provider, pharmacy, co-pay, and network hospitals.  The coordinated systems of care offered include HMOs and PSNs (Provider Service Networks).  The percentage of beneficiaries actively choosing their plans has increased in recent years.

A customized benefits package, available in five counties thus far.  Plans within the Pilot can add services not currently covered under Medicaid state plans, though they must have the same value as the current Medicaid benefit package.  Examples of expanded benefits include over-the-counter drugs, preventative dental care, circumcision, and respite care.
Florida has also rolled out an Enhanced Benefits program to promote self-involvement in healthcare.  This programs rewards healthy behaviors by giving Medicaid beneficiaries credit money that they can then use to purchase health-related products and supplies, at a maximum of $125 per year.  Healthy behaviors include dental exams, wellness visits, PAP smears, colorectal screenings, disease management participation, weight loss programs, and smoking cessation.  The money earned is then used for products such as over-the-counter medicines, vitamins, diapers, sunscreens, and dental supplies.

The program has been well-received among beneficiaries.  Over 204,243 beneficiaries have received credit, totaling $15,055,548.  As of September 2008, 61,600 unique beneficiaries have used $3,592,547 in credits, and 17,615 have hit the annual cap of $125.

Additional components of the Medicaid Managed Care Pilot include:
• Comprehensive Choice Counseling;
• Enhanced Benefits for participating in healthy behaviors;
• Risk Adjusted Premiums based on enrollee health status;
• Catastrophic Component of the premium (i.e., state reinsurance to encourage development of provider service networks and health maintenance organizations in rural and underserved areas of the State); and
• Low-Income Pool.

Delivering high quality, coordinated, long term care for the disabled and/or the infirm

The Florida Medicaid Nursing Home Diversion program is a 1915(c) home and community-based waiver that offers both acute and long-term care services to frail elders, as an alternative to nursing home care. Contracted managed care organizations receive a monthly capitated rate and provide, manage, and coordinate each member’s care. By receiving integrated acute and long-term care services, members are better able to remain in the community. The Nursing Home Diversion waiver program began in 1998 and included four counties. The program has expanded to 25 counties, and has received recent waiver approval for expansion into an additional 26 counties, for a total of 51 approved counties. Participation in the Nursing Home Diversion program is limited to frail elders to ensure those served meet program impairment criteria and are at risk of nursing home placement. Members must be 65 years of age and over, be dually eligible for Medicare and Medicaid, and live in the program service area. As of June 1, 2008, 9,912 elders were enrolled in the program.

Florida Senior Care will provide health care services to all Medicaid participants 60 years of age or older, and individuals dually eligible for both Medicaid and Medicare age 21 years or older.  Statute provides that the program will be implemented in the Central Florida (Brevard, Orange, Osceola, and Seminole counties) and South Florida (Miami-Dade and Monroe counties) areas of the state.

Florida Senior Care will provide and coordinate all Medicaid services—acute, primary, and long-term care (including nursing facility and home and community based services) --to enrolled Medicaid participants. Eligible providers will include a broad range of managed care organizations, including state certified community service networks, health maintenance organizations, and other qualified providers who will assume full risk for nursing home care. Florida Senior Care will provide plans with much needed flexibility to deliver care to Florida’s Medicaid participants in the home and community as an alternative to nursing home care. In this way, Florida Senior Care will allow elders and younger adults with disabilities to maintain their independence longer by creating incentives for managed care plans to provide medically necessary home and community-based services before they become very frail. This integrated, long term care program will coordinate care across all health care settings including primary care doctors, specialists, hospital care, and when needed, long term care in the home or in a nursing home. The provision of a care coordinator for all beneficiaries will be especially beneficial for seniors who receive services through both the Medicaid and Medicare programs.  The Agency for Health Care Administration has an approved 1915(c) waiver from the Centers for Medicare and Medicaid Services. Implementation of the program is currently on hold awaiting further direction from the Florida Legislature, which will convene in March 2009..

Use of health information technology (electronic health records, e-prescribing, electronic billing,etc)

Florida uses wireless technology to make 90 days of our recipients’ prescription drug history available to practitioners at the point of service which permits immediate utilization and compliance review as well as providing information about coverage and restrictions. The system also incorporates an e-prescribing function that permits immediate transmission of prescription authorization to the patient’s pharmacy.

Expanding coverage through private sector initiatives

As a component of Medicaid reform, the state is creating a new option for beneficiaries that are employed. Specifically, the State has created the Opt Out Program in which employed beneficiaries can use the premiums the State would have paid to a Medicaid HMO to pay their portion of an employer sponsored plan. Individuals will have coverage, including cost sharing, through the employer plan only. This option is completely voluntary and individuals will be able to reenter Medicaid, at their redeterimination date, open enrollment, employer’s open enrollment period or if they lose their job. One of the advantages to the program is that family will be able to pool their premiums and obtain coverage for the entire family. For example, if a mother has two children on Medicaid, but she is not eligible, the premiums will be available to her and with the combined premium she may be able to purchase family coverage through her employer sponsored insurance plan.

Transparent and publicly-accessible measurements of patients outcomes and/or quality improvements

In November 2005, through the introduction of the www.FloridaCompareCare.gov website Florida became the first state in the country to publicly report infection rates and mortality rates in each of our hospitals. In July 2006, Florida will again be the first state to publicly report pediatric quality of care data. By giving consumers the tools to compare hospitals and ambulatory (outpatient) surgery centers, they will become the most informed health care consumers in the nation.

In addition to the www.FloridaCompareCare.gov website, the Agency for Health Care Administration has two other premier websites that are dedicated to providing a transparent health care system Florida’s health care consumer:

The Agency for Health Care Administration's (AHCA) redesigned website is the first step in an ambitious program. This site will ultimately give Florida’s health care consumers, purchasers and professionals an unprecedented degree of easy-to-access and understandable information on quality, pricing and performance. Good information is key to making sure our health care system works well and in everyone’s interests. We are committed to delivering information that is practical and useful, can play an important role in driving improvements in quality, and can help reduce exploding health costs.

Most pharmacies do not advertise or even display drug prices. This website was developed by the Florida Attorney General and the Agency for Health Care Administration (AHCA) to help consumers shop for the lowest price in their area for their prescription drugs. The Florida Prescription Drug Price website www.MyFloridaRx.com provides pricing information for the 100 most commonly used prescription drugs in Florida. The prices are the “usual and customary prices,” also known as retail prices, reported monthly by pharmacies. This is the price that an uninsured consumer, with no discount or supplemental plan, would normally pay. Prices at your local pharmacy may change daily, so this website is only meant to help you compare prices at different pharmacies and are not a guaranteed price. For questions or comments regarding any of Florida’s consumer websites, please contact, Christina Nye, Bureau Chief of the Florida Center for Health Information and Policy Analysis at  (850) 922-7036 .

Efforts to combat Fraud and abuse

In the fight against fraud and abuse in the Medicaid program, Florida’s best practices start with the best professionals.  From relying on an in-house doctor or nurse to help interpret the data who, in turn, support experienced investigators and data analysts who present a compelling case for the Agency attorneys to pursue, only then can the best practices designed on paper bring about results in the practical world.
One of the most effective tools to prevent fraud and abuse within the Medicaid program is to prevent potential fraudulent providers from enrolling.
Florida has a very proactive enrollment process, and has instituted the following pre-enrollment requirements:
• Random and targeted provider onsite visits
• Criminal background screening
• Surety bonds
• Accreditation

These measures may vary depending on the provider type.  In addition, Florida has established a re-enrollment program aimed at maintaining a current provider database.

Florida balances its fight against fraud and abuse between preventing the improper behavior and recovering the monies upon discovery of an overpayment.  One of the keys to controlling fraud and abuse in health care is early detection.  Florida uses unique algorithms to detect and quantify overpayments to providers.  These algorithms are developed by hypothesizing how providers could possibly “misbill” the Medicaid program.  Another initiative which results in several million in recoveries annually is paid claims reversal.  These recoveries are the result of pharmacists reviewing current billing patterns of pharmacies.  These trained individuals can immediately spot inappropriate dosages that are being billed to the Medicaid program.  The pharmacies are contacted and requested to reverse (void) the claims(s). 

As with most fee-for-service payment environments, the ability to truly impact fraud and abuse is dependent on prevention.  Florida has been aggressive in this area through the implementation of prior authorization programs for Medicaid inpatient medical/surgical services, inpatient psychiatric services, pharmacy, and home health services.  Technology also plays an important role in the effort to prevent overpayments.  Through contracted partnerships, Florida utilizes early detection software that flags providers presenting with aberrant billing compared to their peers as well as compared with historical billing.

Finally, no truly successful program for combating fraud and abuse can be achieved without strong intergovernmental partnerships.  Very often the regulation of the activities of one medical provider will fall under several different jurisdictions.  Florida has taken great strides to ensure all the relevant agencies; local, state and federal, including the executive and the legislative branches of those jurisdictions, are speaking to one another regarding the providers or policies that they oversee.  An example of this success is in the establishment of the South Florida Health Care Fraud Task Force, which meets on a quarterly basis.  The working group consists of representatives from state health care regulatory agencies, Medicaid Fraud Control Unit, US Attorney’s Office, Federal Bureau of Investigations, Centers for Medicare and Medicaid Services and other federal agencies.  This task force has been successful in opening lines of communication, which has resulted in an increase in the sharing of information and an enhanced coordination of fraud and abuse activities.  This type of open dialogue enables stakeholders to be more proactive in combating fraud and abuse at levels.

What changes would you make to the federal Title XIX so that you could provide better services to individuals and families on Medicaid in your state?

Provide a new state plan option that would allow some of the flexibility of a waiver. DRA included many provisions as a State Plan amendment, however, it would be helpful if the provisions did not vary by income level as this is difficult to administer.

What are your future plans?

The State is working with the Administration and the Legislature regarding potential expansions or changes in the Medicaid delivery system.