Medicaid Reform Organizational Analyses

Medicaid Reform Organizational Analyses: April 2008 – March 2009

Christy Harris Lemak, PhD*; Amy Yarbrough Landry, PhD†; Lori Bilello, MHA, MBA‡; Lilliana Bell, MHA‡; Patricia A. Van Wert‡

July 2009

* University of Michigan

† University of Alabama at Birmingham

‡ University of Florida

Prepared by the Department of Health Services Research, Management and Policy at the University of Florida under contract to AHCA for Health Care Administration Bureau of Medicaid Quality Management.

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TABLE OF CONTENTS

EXECUTIVE SUMMARY ........................................................................................................................................... 1 INTRODUCTION ..................................................................................................................................................... 4

FLORIDA’S MEDICAID REFORM INITIATIVE ............................................................................................................................. 4 EVALUATING MEDICAID REFORM IN FLORIDA ........................................................................................................................ 7

RESEARCH METHODS ............................................................................................................................................. 9 INFORMANT INTERVIEWS ................................................................................................................................................. 9 PROCESS OF IDENTIFYING THEMES ................................................................................................................................... 11

REFORM PLANS & NETWORKS ............................................................................................................................. 12 REFORM ORGANIZATIONS .............................................................................................................................................. 12 REFORM MARKET SHARE ............................................................................................................................................... 19

REFORM BENEFITS ............................................................................................................................................... 25 FINDINGS .................................................................................................................................................................... 25 SUMMARY ................................................................................................................................................................... 36

CHOICE COUNSELING ........................................................................................................................................... 37 ELIGIBILITY DATA ................................................................................................................................................. 43 OVERARCHING THEMES ....................................................................................................................................... 45

A CHANGING ORGANIZATIONAL LANDSCAPE ...................................................................................................................... 45 Evolving Organizational Forms ............................................................................................................................ 45 New Plans Entering Market ................................................................................................................................. 45 Existing Plans Exiting Market ............................................................................................................................... 46 Enrollment Freezes............................................................................................................................................... 46 Rural Managed Care Presence ............................................................................................................................. 47

NEW EVALUATION OF ORGANIZATIONAL PERFORMANCE ...................................................................................................... 47 CONTINUING EVOLUTION OF REFORM ELEMENTS ............................................................................................................... 48

EBR Program ........................................................................................................................................................ 48 Choice Counseling ................................................................................................................................................ 49 Opt Out Program ................................................................................................................................................. 49 Modified Plan Benefits ......................................................................................................................................... 49

OPERATIONAL SUCCESSES AND CHALLENGES ...................................................................................................................... 50 Successes ............................................................................................................................................................. 50 Challenges ............................................................................................................................................................ 50

LOOKING AHEAD .......................................................................................................................................................... 51 APPENDIX A: INTERVIEW PROTOCOLS ................................................................................................................. 52

INTERVIEW PROTOCOL: REFORM HEALTH PLANS AND NETWORKS—MAY 2009 ....................................................................... 52 INTERVIEW PROTOCOL: AHCA MEDICAID LEADERSHIP AND STAFF IN TALLAHASSEE AND IN DEMONSTRATION AREA OFFICES—DECEMBER 2008 ......................................................................................................................................................... 54

APPENDIX B: PLAN BENEFIT COMPARISON METHODOLOGY ................................................................................ 56 DATA SOURCES ............................................................................................................................................................ 56 ANALYSIS .................................................................................................................................................................... 57

APPENDIX C: ENROLLMENT TABLES ..................................................................................................................... 58 SOURCES .............................................................................................................................................................. 82

REFERENCES ................................................................................................................................................................ 82 CITATIONS ................................................................................................................................................................ 85

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LIST OF TABLES

Table 1: Key Informant Interview Summary .................................................................................................................. 9

Table 2: Medicaid Reform Plans and Networks for Baker, Broward, Clay, Duval, and Nassau Counties as of March

2009 ............................................................................................................................................................................. 12

Table 3: Organizational Characteristics of Reform Plans by County as of March 2009 ............................................... 14

Table 4: Medicaid Reform Market Share, Broward County, April 2008 – March 2009 ............................................... 16

Table 5: Medicaid Reform Market Share, Duval County, April 2008 – March 2009 .................................................... 17

Table 6: Medicaid Reform Market Share, Baker County, April 2008 – March 2009 .................................................... 17

Table 7: Medicaid Reform Market Share, Clay County, April 2008 – March 2009 ...................................................... 18

Table 8: Medicaid Reform Market Share, Nassau County, April 2008 – March 2009 ................................................. 18

Table 9: Number of Expanded Benefits, October 2006, October 2007, and October 2008 ........................................ 21

Table 10: Durable Medical Equipment Plan Limits, October 2006, October 2007, and October 2008 ....................... 23

Table 11: Hospital Inpatient Co-payments, October 2006, October 2007, and October 2008 ................................... 25

Table 12: Podiatrist Services Co-payments, October 2006, October 2007, and October 2008 ................................... 26

Table 13: Enrollment Activity Report, All Reform Counties, April 2008 – March 2009 ............................................... 29

Table 14: Reform Plan Voluntary Disenrollment Change Reason Summary ............................................................... 31

Table 15: Choice Counseling Brochures: October 2006, October 2007, and October 2008........................................ 47

Table 16: Total Enrollment by Plan, Broward County .................................................................................................. 48

Table 17: Total Enrollment by Plan, Duval County ...................................................................................................... 54

Table 18: Total Enrollment by Plan, Baker County ...................................................................................................... 57

Table 19: Total Enrollment by Plan, Clay County ......................................................................................................... 59

Table 20: Total Enrollment by Plan, Nassau County .................................................................................................... 61

LIST OF FIGURES

Figure 1: Medicaid Eligibles in Broward and Duval Counties from December 31, 2001, to December 31, 2008........ 33 Figure 2: Medicaid Eligibles in Baker, Clay, and Nassau Counties from December 31, 2001, to December 31, 2008 34

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Evaluating Medicaid Reform in Florida: MED027 (UF Project # 58750) Deliverable IX.B: Medicaid Reform Organizational Analyses: April 2008 – March 2009 July 2009

EXECUTIVE SUMMARY

This report summarizes organizational aspects of Florida’s Medicaid Reform pilot*, covering the time period of approximately April 2008 to March 2009. The report examines the third full year of Medicaid Reform in Broward and Duval Counties and the second year of Medicaid Reform in Baker, Clay, and Nassau Counties. Research Methods Through a combination of quantitative and qualitative study designs, the organizational analyses address a broad range of organizational and policy issues raised by the demonstration process. For this report, data were collected from the following sources: the Florida Agency for Health Care Administration (AHCA) Medicaid website, other AHCA sources, informant interviews, and a community stakeholder survey. In total, over 195 in-person informant interviews have been completed. Data from interview transcripts were organized into categories based on themes using content analysis.1 Many of the findings reported here reflect the views described by interviewees. Reform Plans and Networks Increased consumer choice through a competitive market is one goal of the Reform demonstration. As of March 2009, approximately 217,678 Floridians were enrolled in Medicaid Reform health plans. There are 14 health plans operating in Reform, including 5 Provider Service Networks (PSNs) and 9 Health Maintenance Organizations (HMOs). Most Medicaid enrollees are enrolled in HMOs, except in the rural counties where one PSN has a large market share. Of the plans participating in Reform, seven have a multi-state presence, while the remaining plans operate only in Florida. The seven multi-state plans are all HMOs, and three of these operate in Broward and Duval Counties, while one operates in four of the five counties. With regard to plan ownership, five of the participating plans are publicly traded, three are for-profit but privately owned, and six of the plans are not-for-profit organizations. The organizational missions of the plans also vary, with six of the participating plans serving mixed or diversified populations, seven of the plans serving the Florida Medicaid population exclusively, and two plans operated by a state agency for children with chronic conditions who meet the clinical criteria for enrollment in government-sponsored programs.

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The majority of Medicaid Reform participants in Broward County are enrolled in HMOs (73% in March 2009). Broward County saw three plans exit the demonstration and two PSNs consolidate with other plans. In Duval County, the majority of Medicaid Reform participants are enrolled in HMOs (69% in March 2009). One HMO accounts for almost 50% of total Duval Medicaid Reform participants. The majority (over 70%) of participants in Baker, Clay, and Nassau Counties were enrolled in a PSN. Most Medicaid Reform plans did not change their benefits between October 2007 and October 2008, but some reductions were observed. The overall trend for October 2006 through October 2008 was to decrease the additional benefits offered by the Reform plans that are not traditionally offered in Medicaid and add co-payments. Empowering Enrollees Empowering enrollees to take control of their health is one goal of the demonstration pilot. Three strategies were implemented to facilitate this empowerment: choice counseling, the Enhanced Benefits Reward$ (EBR) program, and the Opt-Out program. Most agree that Medicaid Reform’s Choice Counseling is working very well. A clear majority of Medicaid-eligible individuals in the demonstration are self-selecting their health plans. From April 2008 to March 2009, monthly voluntary enrollment fluctuated significantly from as high as 83% to as low as 46%. However, AHCA stopped calculating the voluntary enrollment rate in July 2008 due to errors during the transition process with the new fiscal agent. During the same time period, very few members voluntarily disenrolled from plans they selected or were assigned. Enrollee awareness and participation in the EBR program has significantly increased since the beginning of the demonstration. In the aggregate, enrollees are now spending as much as they earn and AHCA continues to promote the program. While the EBR program is regarded as innovative, its organizational design and goal to promote healthy behaviors need to be evaluated in greater detail. A detailed analysis of the EBR program is currently underway and will be described in a separate report. Fewer than one percent (30 individuals) of Medicaid Reform eligibles expressed interest or chose to participate in the “Opt Out Program,” Reform’s mechanism for Medicaid eligibles to pursue private insurance through their employers should they choose to do so. Overarching Themes and Observations The following overarching themes emerged from our analysis of quantitative and qualitative data, with an emphasis on the organizational aspects of Medicaid Reform implementation and operations:

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1. Changing Organizational Landscape 2. New Evaluation of Organizational Performance 3. Continuing Evolution of Reform Elements 4. Operational Successes and Challenges 5. Looking Ahead

Conclusions At this point in the Reform process, Medicaid has moved from formal implementation to ongoing operations in all five demonstration counties. The evaluation team will focus on progress and challenges experienced during the rest of the demonstration period.

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INTRODUCTION

FLORIDA’S MEDICAID REFORM INITIATIVE

Medicaid is the principal state and federal program that finances the health and medical care of low-income families, the elderly, and people with disabilities, who meet eligibility requirements, do not have health insurance, and otherwise cannot pay for their health care. Florida’s Medicaid program, implemented on January 1, 1970, was modeled after the healthcare financing and delivery of the private sector at that time. However, the healthcare market in which Medicaid operates has experienced dramatic changes since the program’s creation almost four decades ago, and the needs of the population it serves are constantly evolving. Medicaid has grown to become the single largest healthcare program in the United States. In Fiscal Year (FY)* 2006, Medicaid served 58.7 million people in the U.S.,2 with expenditures of $310.8 billion.3† In FY 2006, Florida Medicaid served 3 million people,2 with expenditures of approximately $14 billion.4 For State Fiscal Year (SFY) 0809,‡ it is estimated that Florida Medicaid will spend approximately $6,619 per eligible enrollee for a total of $15 billion.5,6 Payments to hospitals, nursing homes, and Intermediate Care Facilities for the Developmentally Disabled, along with Low-Income Pool and Disproportionate Share payments comprise 45% of all Florida Medicaid expenditures. Twenty-three managed care plans and approximately 80,000 fee-for-service (FFS) providers serve Medicaid enrollees, and are the recipients of the remaining expenditures.5 As a state, Florida has a history of making changes to its Medicaid program. These changes have varied in scope, intensity, and results. Some have been described in detail,§ others are ongoing, and some have effectively been discontinued. However, each of these prior initiatives had its origin in an idea or cluster of ideas about how Medicaid might be improved. That is certainly the case in Florida’s current Medicaid Reform initiative, in which Florida continues to develop innovative strategies to enhance the availability of quality healthcare services.

* “FY” denotes Federal Fiscal Year which runs from October 1 through September 30. For example, FY 2006 refers

to the period October 1, 2005, through September 30, 2006. † Adjusted expenditures exclude all prescription drug spending for dual eligibles to remove the effect of their

transition to Medicare Part D in 2006. ‡ “SFY” denotes State Fiscal Year which runs from July 1 through June 30. For example, SFY0809 refers to the

period July 1, 2008, through June 30, 2009. § For an analysis of Florida’s Medicaid Provider Service Network Demonstration, see Duncan, R. P., Lemak, C. H.,

Vogel, B., Johnson, C., & Porter, C. K. (2004). Evaluating Florida’s Medicaid Provider Service Network Demonstration Project. Gainesville, Florida: University of Florida, Department of Health Services Research, Management and Policy.

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On May 6, 2005, the Florida Legislature authorized Medicaid Reform in Senate Bill 838. In accordance with Senate Bill 838, the Agency for Health Care Administration (AHCA) formally submitted an application for an 1115 Research and Demonstration Waiver to the U.S. Department of Health and Human Service’s Centers for Medicare and Medicaid Services (CMS) on October 3, 2005. That application was approved by CMS on October 19, 2005. On December 8, 2005, the Florida Legislature passed legislation (House Bill 3B) to authorize the design and implementation of the reforms described in the waiver application.* Effective July 1, 2006, AHCA began implementing Medicaid Reform by means of demonstration pilots in Broward and Duval Counties. Broward County is located in the southeast section of Florida and includes the city of Fort Lauderdale. Duval County is located in the northeast section of Florida and includes the city of Jacksonville. The transition of eligible enrollees to the demonstration started on September 1, 2006, and, as of June 1, 2009, approximately 208,051 Floridians were enrolled in participating managed care organizations in these two counties. At the end of the first year of implementation, the demonstration was extended to Baker, Clay, and Nassau Counties, all of which are somewhat more sparsely populated counties with extensive rural areas. All are in northeast Florida, adjacent to Duval County. As of June 1, 2009, approximately 17,698 Floridians were enrolled in Reform in the expansion counties. Overall, the total number enrolled in Medicaid Reform managed care organizations as of June 1, 2009, was 225,749. As envisioned by those responsible for designing and implementing the changes, Medicaid Reform would transform Florida’s Medicaid program by empowering consumers to take control of their health care, providing more choices for consumers, and enhancing the health status of Medicaid enrollees through increased health literacy and incentives to engage in healthy behaviors. Furthermore, a key objective of Medicaid Reform in Florida includes the goal of making the delivery of medical care in Medicaid more reflective of the processes and approaches operative in the private sector.

* For a summary of Florida’s Medicaid Reform Section 1115 Waiver process, see Duncan, R. P., Lemak, C. H.,

McKay, N. M., Hall, A. G., & Bell, L. L. (2006). Summary report on section 1115 waiver process. Gainesville, Florida:

University of Florida, Department of Health Services Research, Management and Policy.

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The expressed principles governing Medicaid Reform are patient responsibility and empowerment, marketplace decisions, bridging public and private coverage, and sustainable growth rate.

These principles were manifested in several specifically identifiable activities. Participating Health Maintenance Organizations (HMOs) and Provider Service Networks (PSNs) can offer customized benefit packages. The plans can design their own benefit package (within a specified amount, scope, and duration) subject to tests of actuarial equivalency and benefit sufficiency.* These plan attributes are affirmed by contract with AHCA. Eligible Medicaid enrollees must enroll in a participating HMO or PSN, but may choose the plan that is best suited to meet their specific needs. HMOs participating in Medicaid Reform are paid a capitation payment that is risk adjusted to reflect the relative healthcare status of their enrollees. Reform capitation rates are based on specific principles and policies of Reform applied to fee-for-service historical data in identifiable areas. That rate is then risk adjusted to reflect the medical circumstances of a particular plan’s enrollees, based on their enrollees’ age, gender, and use of prescription medications, which serves as an indicator of certain chronic diseases. The technical approach to this adjustment is based on the calculation of risk scores using the Medicaid Rx risk adjustment model devised by researchers at the University of California San Diego.7 The risk adjustment work is performed under contract by an external, nationally prominent healthcare consulting and actuarial firm. For the first two years of Reform, a risk corridor was mandated so that risk adjustment was limited to plus or minus 10% of the original base rate noted previously.† PSNs are paid on a FFS basis.‡ In order to facilitate enrollee selection of a health plan, a Choice Counseling process was created. Choice Counseling is a comprehensive counseling program designed to provide the education and outreach necessary to assist Medicaid enrollees with making a health plan choice that best fits their specific needs. Choice Counselors also provide information aimed at enhancing health literacy and the promotion of healthy lifestyles in order to reduce minority health disparities.

* As a general principle, Reform plans must offer services consistent with the state Medicaid plan; variation is in

the form of additional benefits. † Further technical details on the underlying mathematical and statistical processes involved are available online at

http://ahca.myflorida.com/Medicaid/meds/index.shtml ‡ AHCA also develops risk scores for each PSN and compares the amount the plan was paid using the FFS payment

methodology, to what they would have been paid had they been paid a risk adjusted capitated rate. On May 27, 2009, Florida Governor Charlie Crist approved CS/SB 1658 which delays the requirement that PSNs move from FFS to risk adjustment capitated payment by two years (or the 6

th year of the demonstration: 2011).

http://ahca.myflorida.com/Medicaid/meds/index.shtml

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Another key element was the creation of the Enhanced Benefits Reward$ (EBR) program. In this program, enrollees are offered financial incentives to participate in specific health promotion and illness prevention activities such as dental visits, vision exams, wellness visits, PAP screening, mammography screening, and colorectal screening.8 When enrollees complete an EBR activity, funds are placed in their account and can be utilized for purchasing certain over-the-counter items at any Florida Medicaid participating pharmacy.*

EVALUATING MEDICAID REFORM IN FLORIDA

It is critically important that any program change of this magnitude be independently evaluated. Such assessment will assist in achieving an understanding of the Reform pilot, including the challenges of program design and implementation, costs, quality, the impact on program enrollees, and the like. Indeed, federal approval of the waiver includes a requirement for a comprehensive, independent evaluation. The evaluation is intended not only to provide information to assist the Florida Legislature as it considers possible expansion of Medicaid Reform, but also to inform Medicaid programs in other states and other interested parties as they pursue their own reform initiatives. To accomplish these goals, the health services research team at the University of Florida is gathering data and conducting the research activities necessary to complete a series of analyses. In the first year of the evaluation, the research team examined the evolution of Medicaid Reform, including the earliest expressions of interest, the initial legislation, the waiver application process, the subsequent legislation, the program design, and the initial implementation in Broward and Duval Counties. Through the evaluation process, the research team will continue to pursue answers to the questions included in Florida’s “Application for 1115 Research and Demonstration Waiver.”9 The research team is conducting its analysis through inquiry in five major project areas: (1) organizational analyses, (2) enrollee experiences analyses, (3) fiscal analyses, (4) Low-Income Pool (LIP) program analysis, and (5) mental health analyses. The organizational analyses are focused on the Reform implementation process, the Reform health plans, the Choice Counseling organization, and the EBR program. The enrollee experiences analyses are measuring the changes in enrollee experiences, primarily their satisfaction with care. The fiscal analyses are assessing pre- and post-Reform Medicaid utilization and expenditures for both Reform and non-Reform plans. The LIP analysis is examining the impact of the new financing mechanism that provides reimbursement for the provision of services to the uninsured and

* This program has been described in detail in Greene, J. (2007). Medicaid Efforts to Incentivize Health Behaviors.

Hamilton, New Jersey: Center for Health Care Strategies, Inc.

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underinsured. The mental health analyses are examining the impact of the demonstration Reform on mental health services and experiences.

In this report, “health plan,” “managed care plan,” and “network” include both HMO

(capitated) and PSN (fee-for-service) entities. This report summarizes data and information

collected and analyzed by the University of Florida Organizational Analysis Team as part of the

larger Medicaid Reform Evaluation project. The report presents information and findings

detailing the ongoing organizational analysis of health plans that are participating in Medicaid

Reform in Broward, Duval, Baker, Clay, and Nassau Counties for the time period of April 2008 to

March 2009.

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RESEARCH METHODS

Through a combination of quantitative and qualitative study designs, the organizational analyses address a broad range of structural and policy issues raised by the demonstration process. For this report, data were collected from the following sources: the AHCA Medicaid website, other AHCA sources, and informant interviews. Sources are noted for each table. A complete list of references is included at the end of the report. Unless otherwise noted, data are the most recently available, typically April 2008 to March 2009, inclusive.

INFORMANT INTERVIEWS

The research team conducted the first round of key informant interviews during the summer of 2006. Second round interviews were conducted between December 2006 and May 2007. The third round of interviews took place during the period of summer 2007 through May 2008 and the fourth round from December 2008 through June 2009. The interviews have included AHCA officials at headquarters and in Medicaid Area Offices, representatives from Medicaid Reform Plans, and legislators and their staff, as well as other stakeholders. In total, 195 interviews have been completed. Table 1 summarizes the interviews conducted to date by classification and time frame. With some exceptions, interviews were conducted in person and a minimum of two members of the evaluation team were present for each interview.

Table 1: Key Informant Interview Summary

Health Plans and

Networks AHCA (Tallahassee and Area Offices)

Other Organizations

Other Individuals

Total

Round 1 May – Aug. 06

23 24 7 0 54

Round 2 Dec. 06 – May 07

29 16 0 8 53

Round 3 June 07 – May 08

15 27 1 0 43

Round 4 Dec 08 – June 09

28 17 0 0 45

Total Interviewed 95 84 8 8 195 Note. Other organizations and individual interviews include interviews with the Choice Counseling organization, legislators, and other key stakeholders.

The interview questions that guided the most recent rounds of informant interviews are provided in Appendix A.

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PROCESS OF IDENTIFYING THEMES

All interview notes and audio tapes were transcribed. Data from interview transcripts were organized into categories based on themes using content analysis as a thematic coding technique. The investigators identified overarching themes through a collaborative analytic process based on their interview experiences. Interview transcripts were then coded using the initially identified themes, and confirmatory quotations were selected from the text. After the coding process was completed, the investigators compared their findings to assure reliability of the themes. The investigators then merged their findings to create a summary of overarching themes and supporting documentation.

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REFORM PLANS & NETWORKS

REFORM ORGANIZATIONS

Increased consumer choice through a competitive market is one goal of Florida’s Medicaid demonstration pilot program. This portion of the report will describe the managed care organizations participating in the demonstration. This description of the participating plans both examines the progress to date in stimulating choice in the demonstration counties and allows us to answer one of the proposed research questions for the evaluation: Will the number, types, and distribution of health plans participating in Medicaid increase? Plan participation in the demonstration continues to be dynamic. As shown in Table 2, there were 14 plans participating in Medicaid Reform as of March 2009. Of the participating plans, 13 began enrolling patients at the beginning of Reform,10 while the others began participating at a later time. Access Health Solutions and United Healthcare are the only plans participating in Baker, Clay, and Nassau Counties. During previous months, two health plans left Medicaid Reform (Vista and Buena Vista), Pediatric Associates PSN merged with Access Health Solutions PSN, and United Healthcare withdrew from Broward County but continued in Baker, Clay, Duval, and Nassau Counties. HealthEase, Staywell, and Florida NetPass have given notice to AHCA to withdraw from Medicaid Reform within the next several months. AHCA has approved new health plans to participate in Medicaid Reform but they were not operational by March 2009. Of those plans participating as of March 2009, five were PSNs. Two of these PSNs are operated by safety-net hospitals (First Coast Advantage and South Florida Community Care Network), one specialty plan is operated by the Florida Department of Health for children with chronic conditions, and the others are physician networks. The remaining plans are HMOs.

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Evaluating Medicaid Reform in Florida: MED027 (UF project # 58750) Deliverable IX.B: Medicaid Reform Organizational Analyses: April 2008 – March 2009 July 2009

Table 2: Medicaid Reform Plans and Networks for Baker, Broward, Clay, Duval, and Nassau Counties as of March 2009

Plan Name Baker Broward Clay Duval Nassau Type Broward & Duval First

Enrollment

Clay, Baker, & Nassau First Enrollment

Plan Merger or Withdrawal

Access Health Solutionsa X X X X X PSN 09/01/2006 09/01/2007 Transitioning to Sunshine State Health

Plan (HMO) in all five counties prior to 09/01/2009

Amerigroup Florida, Inc. X HMO 09/01/2006

CMSN – Broward X PSN 12/01/2006

CMS –Duval X PSN 05/01/2007

First Coast Advantage X PSN 09/01/2006

Florida NetPassb X PSN 09/01/2006 Transitioning to Molina Health Plan

(HMO) 08/01/2009

Freedom Health Plan X HMO 12/01/2007

HealthEase X X HMO 09/01/2006 Withdrawing from Broward and Duval Counties in 07/2009

Humana Family X HMO 09/01/2006

Pediatric Associates PSN 10/01/2006 Merged with Access 02/01/2009

Preferred Medical Plan, Inc. X HMO 09/01/2006

South Florida Community Care Network

X PSN 09/01/2006

Staywell X X HMO 09/01/2006 Withdrawing from Broward and Duval Counties in 06/2009

Total Health Choice, Inc. X HMO 09/01/2006

United Healthcare X X X X HMO 09/01/2006 09/01/ 2007 Withdrew from Broward County only on 11/01/2008

Universal Health Carec X X HMO 01/01/2007

Vista Health Plan of S. Florida, Inc.

d

HMO 09/01/2006 Withdrew 12/01/2008

Vista Health Plan: Buena Vista

d

HMO 09/01/2006 Withdrew 12/01/2008

Note. Adapted from AHCA Monthly Enrollment Reports and AHCA Correspondence aSunshine State Health Plan is applying to become a Reform plan. bFlorida NetPass is accepting voluntary enrollment until June 2009. cTo ensure that enrollees have two plan choices in Baker, Clay, and Nassau Counties, United will only accept enrollees who self-select their plan. AHCA will assign all enrollees who do not self-select United to Access Health Solutions. dVista Health Plan of South Florida, Inc., and Vista Health Plan: Buena Vista only operated in Broward County.

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Table 3 shows the Reform plans by county as of March 2009. Twelve Reform plans are operating in Broward County, seven are operating in Duval County, and two plans are in Baker, Clay, and Nassau Counties. Of the plans operating in Broward County, four are PSNs. Duval has three PSNs in operation, and Baker, Clay, and Nassau have one PSN and one HMO. Table 3 also describes the plans participating in Reform (as of March 2009) based on their organizational characteristics. Of the plans participating in Reform, seven have a multi-state presence, while the remaining plans operate only in Florida. The seven multi-state plans are all HMOs; three of these operate in both Broward and Duval Counties (HealthEase, Staywell, and Universal) and one operates in four of the five counties (United). With regard to plan ownership, five of the participating plans are publicly traded, three are for-profit but privately owned, and six of the plans are not-for-profit organizations. The organizational missions of the plans also vary, with six of the participating plans serving a diversified/mixed population, and six of the plans serving the Medicaid population exclusively. Of these plans, two are operated by a state agency for children with chronic conditions who meet the clinical criteria for enrollment in government-sponsored programs. Additionally, two plans focus on governmental payers not limited to Medicaid.

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Table 3: Organizational Characteristics of Reform Plans by County as of March 2009

Plan Name Plan Type

Area Served Ownership Mission

Multi-State

Florida Only

Publicly Traded

For Profit (Not

Public)

Not-for-

Profit Diversified

Medicaid Only

Govt. Payers

Broward County

Amerigroup HMO X X X

HealthEase HMO X X X

Humana HMO X X X

Preferred HMO X X X

Staywell HMO X X X

Total Health HMO X X X

Universal HMO X X X

Freedom Health HMO X X X

Florida NetPass PSN X X X

Access Health PSN X X X

SFCCN PSN X X X

CMS PSN X X X

Duval County

HealthEase HMO X X X

Staywell HMO X X X

United HMO X X X

Universal HMO X X X


First Coast Advantage PSN X X X

CMS PSN X X X

Baker, Clay, and Nassau Counties


United HMO X X X Note. Adapted from Reform plan websites. Area served, ownership, and mission defined for parent company, not individual plans.

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REFORM MARKET SHARE

Tables 4 – 8 describe market share by plan for each Reform county for the time period of April 2008 to March 2009. As of March 2009, the majority of Medicaid Reform participants in Broward County were enrolled in HMOs which is the predominant plan type in Broward County (Table 4). In fact, three of Broward County’s 11 HMOs (Amerigroup, HealthEase, and Staywell) account for almost 50% of total county enrollment. Overall, HMO market share decreased slightly, from 79% in April 2008 to 73% in March 2009. Alternately, it is noted that overall PSN market share increased from 21% in April 2008 to 27% in March 2009. A portion of these changes may have resulted from plan departures from Broward County. United Healthcare (HMO) left Broward County in November; Buena Vista and Vista of S. Florida left in December. Over this time, Humana and Total Health Choice (both HMOs) reported 5% increases in market share. However, Access Health solutions (PSN) experienced the greatest market share increase (8%). In Duval County, the majority of Medicaid Reform participants are enrolled in HMOs (Table 5). The market share held by HMOs in Duval County remained relatively constant at around 69% from April 2008 to August 2008. From September 2008 through March 2009, HMOs experienced a slight decline to 57%. One HMO, HealthEase, continues to account for almost 50% of total Medicaid Reform participants in Duval County; however, it did see its market share decrease from 49% to 41% during this time period. PSN market share remained relatively steady at 31% in Duval County until September 2008 when there was a slight increase. By March 2009, the PSN market share had risen to 43%; Access Health Solutions (PSN) nearly doubled its market share, from 8% to 14%. Enrollees in Baker, Clay, and Nassau (Table 6, Table 7, and Table 8) are primarily enrolled in Access Health Solutions (PSN). In Nassau County, PSN market share increased from 65% in April 2008 to 73% in March 2009. The PSN market share in Clay County increased from 63% to 66% during this time period, and from 73% to 74% in Baker County.

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Table 4: Medicaid Reform Market Share, Broward County, April 2008 – March 2009

Broward County Plans Type 2008 2009

April May June July Aug Sept Oct Nov Dec Jan Feb March

Amerigroup HMO 11.6% 11.6% 11.7% 11.7% 11.7% 11.9% 12.5% 13.1% 14.2% 13.5% 13.6% 13.4%

Freedom Health Plan HMO 0.2% 0.2% 0.2% 0.3% 0.3% 0.4% 0.4% 0.8% 1.0% 1.7% 1.4% 1.2%

HealthEase HMO 13.2% 13.0% 13.0% 12.9% 12.9% 12.7% 12.0% 12.0% 12.9% 11.6% 11.1% 10.4%

Humana Family HMO 8.6% 8.5% 8.4% 8.4% 8.4% 8.7% 9.1% 10.2% 11.5% 12.4% 13.2% 13.8%

Preferred Medical Plan HMO 1.5% 1.5% 1.4% 1.5% 1.5% 1.6% 1.7% 2.1% 2.4% 3.0% 3.1% 3.0%

Staywell HMO 25.5% 25.7% 25.8% 25.6% 25.5% 25.0% 24.1% 24.4% 26.9% 24.8% 24.3% 22.8%

Total Health Choice HMO 1.5% 1.5% 1.5% 1.6% 1.7% 1.9% 2.2% 2.9% 3.5% 4.5% 5.2% 6.2%

United Healthcare HMO 6.8% 6.9% 7.0% 7.0% 7.1% 6.3% 5.2% 0.0% 0.0% 0.0% 0.0% 0.0%

Universal Health Care* HMO 0.2% 0.2% 0.2% 0.2% 0.3% 0.4% 0.4% 0.7% 0.8% 1.5% 1.7% 2.0%

Buena Vista HMO 5.4% 5.4% 5.4% 5.3% 5.3% 5.3% 5.4% 4.6% 0.0% 0.0% 0.0% 0.0%

Vista Healthplan S. Florida HMO 4.4% 4.6% 4.8% 4.9% 5.0% 5.3% 5.8% 4.9% 0.0% 0.0% 0.0% 0.0%

HMO Totals 78.8% 79.0% 79.4% 79.5% 79.5% 79.4% 78.7% 75.9% 73.1% 73.0% 73.7% 72.8%

Access Health Solutions PSN 2.4% 2.3% 2.2% 2.2% 2.2% 2.2% 2.2% 2.6% 2.8% 3.3% 10.3% 10.3%

CMS North Broward PSN 1.5% 1.5% 1.5% 1.5% 1.6% 1.6% 1.6% 1.7% 1.9% 1.8% 1.7% 1.8%

CMS South Broward PSN 0.5% 0.5% 0.5% 0.6% 0.5% 0.5% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6%

Florida NetPass PSN 3.6% 3.5% 3.3% 3.3% 3.3% 3.3% 3.4% 4.2% 4.9% 5.5% 5.4% 5.8%

Pediatric Associates PSN 8.2% 8.2% 8.0% 7.9% 7.8% 7.6% 7.8% 8.2% 8.8% 7.7% 0.0% 0.0%

SFCCN PSN 5.1% 5.0% 4.9% 5.0% 3.0% 3.2% 3.4% 4.0% 4.5% 4.5% 4.6% 4.9%

SFCC Memorial PSN 2.1% 2.2% 2.3% 2.9% 3.4% 3.6% 3.6% 3.7%

PSN Totals 21.2% 21.0% 20.6% 20.5% 20.5% 20.6% 21.3% 24.1% 26.9% 27.0% 26.3% 27.2%

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Note. Adapted from AHCA Monthly Enrollment Reports.

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Table 5: Medicaid Reform Market Share, Duval County, April 2008 – March 2009

Duval County Plans Type 2008 2009


HealthEase HMO 48.8% 48.3% 48.0% 47.5% 47.1% 47.0% 45.2% 44.4% 44.6% 44.3% 43.5% 41.4%

Staywell HMO 4.1% 4.1% 4.0% 4.1% 4.1% 4.1% 3.7% 3.5% 3.3% 3.2% 3.1% 2.8%


Universal HMO 0.5% 0.6% 0.7% 0.9% 1.0% 1.8% 2.3% 2.8% 3.3% 3.4% 3.5% 4.1%

HMO Totals 69.3% 69.5% 69.7% 69.6% 69.4% 68.2% 65.5% 63.5% 63.0% 61.5% 59.8% 56.9%


CMS Duval/Ped-I-Care PSN 2.1% 2.1% 2.2% 2.3% 2.2% 2.3% 2.3% 2.3% 2.4% 2.4% 2.4% 2.4%

First Coast Advantage PSN 20.8% 20.8% 20.6% 20.7% 20.9% 21.5% 23.1% 24.0% 23.8% 24.1% 24.9% 26.7%

PSN Totals 30.7% 30.5% 30.3% 30.4% 30.6% 31.8% 34.5% 36.5% 37.0% 38.5% 40.2% 43.1%

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Note. Adapted from AHCA Monthly Enrollment Reports.

Table 6: Medicaid Reform Market Share, Baker County, April 2008 – March 2009

Baker County Plans Type 2008 2009




Total 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Note. Adapted from AHCA Monthly Enrollment Reports.

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Table 7: Medicaid Reform Market Share, Clay County, April 2008 – March 2009

Clay County Plans Type 2008 2009

April May June July August Sept Oct Nov Dec Jan Feb March




Table 8: Medicaid Reform Market Share, Nassau County, April 2008 – March 2009

Nassau County Plans Type 2008 2009

April May June July August Sept Oct Nov Dec Jan Feb March




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REFORM BENEFITS

The benefits offered by the plans participating in Reform are described in this section of the report. This description of the benefits offered in the first three years of Reform will assist in answering the following research question: Do plans provide additional services not previously covered by Medicaid when given the option? If so, what types of services? Tables 9 – 12 compare plan benefits and limits for October 2006, October 2007, and October 2008 for four different areas; Number of Expanded Benefits, Plan Limits for Durable Medical Equipment, Hospital Inpatient-Services Co-payments, and Podiatrist Services Co-payments. AHCA Choice Counseling brochures effective in October 2006, October 2007, and October 2008 were used to compare the benefit plans for each of the three years. In September 2006, the Reform benefits became effective for the Medicaid Reform enrollees. While Reform health plans have the opportunity to revise their benefit structure every year, consultation with AHCA determined that the brochures produced in October of each year were the most relevant for this comparison. Plans may vary benefits by eligibility category (aged and disabled or children and families). PSNs are reimbursed on a fee-for-service basis and so have the same benefit package as traditionally offered under Medicaid. Since all PSNs who are currently operating in Reform are paid on a fee-for service basis, they are not included in these Reform benefits analyses. HMOs in the demonstration have the ability to change the benefit package as long as they can verify the sufficiency and actuarial equivalency of their benefit packages to what is traditionally offered in Medicaid. All HMO plans available in October 2006 in Broward and Duval, and October 2007 and October 2008 in Broward, Duval, Baker, Clay, and Nassau Counties (for both Adult/Disabled and Children/Families) were included in the tables. A detailed methodology for this analysis is provided in Appendix C.

FINDINGS

Even though there was an increase in expanded benefits from October 2006 to October 2007, there was a significant decrease in extra benefits in October 2008 (Table 9). The total number of expanded benefits from 2007 to 2008 decreased from 84 to 59 partly due to the withdrawal of three managed care organizations (6 health plan options) in Broward County.* Of the remaining active plans in Medicaid Reform, three plans reduced their benefits (Preferred Medical Plan,

* For a description of Medicaid Reform plan changes, see Table 2: Medicaid Reform Plans and Networks for Baker,

Broward, Clay, Duval, and Nassau Counties as of March 2009.

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United Healthcare and Vista Health Plan) in 2008. No plans added benefits; however, Freedom Health Plan became active in Broward in 2008 and they had two extra benefits for both the aged/disabled population and children/families population. The remaining 16 plans kept the same benefit structure in 2008 as they had in 2007. While the number of expanded benefits increased from 2006 to 2007 (63 to 84), the number of expanded benefits decreased to 59 in 2008.

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Table 9: Number of Expanded Benefits, October 2006, October 2007, and October 2008

Plan Name

a

Number of Expanded Benefits

Oct. 2006

Oct. 2007

Change 06 – 07

Oct. 2007

Oct. 2008

Change 07 – 08

Change 06 – 08

Preferred Medical Plan – Broward 2 2 0 2 0 -2 -2

Preferred Medical Plan – Broward 2 2 0 2 0 -2 -2

Universal Health Care – Broward Began enrollment on Jan. 1, 2007; was

not operational in Oct. 2006

1 Began enrollment on Jan. 1, 2007; was


1 1 0 Began enrollment on Jan. 1, 2007; was


Universal Health Care – Broward 1 1 1 0

Universal Health Care – Duval 1 1 1 0

Universal Health Care – Duval 1 1 1 0

Total Health Choice – Broward 2 4 +2 4 4 0 +2

Total Health Choice – Broward 2 4 +2 4 4 0 +2

Buena Vista – Broward 1 3 +2 3 Left the Broward Reform on Dec. 1, 2008, and was not listed in the Choice Counseling

brochure on Oct. 2008 Buena Vista – Broward 0 2 +2 2

HealthEase – Duval 4 5 +1 5 5 0 +1

HealthEase – Duval 3 3 0 3 3 0 0

HealthEase – Broward 4 5 +1 5 5 0 +1

HealthEase – Broward 3 3 0 3 3 0 0

Staywell – Broward 4 5 +1 5 5 0 +1

Staywell – Broward 3 3 0 3 3 0 0

Staywell – Duval 4 5 +1 5 5 0 +1

Staywell – Duval 3 3 0 3 3 0 0

Amerigroup Comm Care – Broward 6 7 +1 7 5 -2 -1

Amerigroup Comm Care – Broward 3 4 +1 4 1 -3 -2

Humana Medical Plan – Broward 2 1 -1 1 1 0 -1

Humana Medical Plan – Broward 1 1 0 1 1 0 0

United Healthcare FL – Broward 4 4 0 4 Left the Broward Reform on Nov. 1, 2008 and was not listed in the Choice Counseling

brochure on Oct. 2008 United Healthcare FL – Broward 3 3 0 3

United Healthcare FL – Duvalb 3 3 0 3 1 -2 -2

United Healthcare FL – Duval b

3 3 0 3 2 -1 -1

Vista Health Plan S FL – Broward 1 3 +2 3 Left the Broward Reform on Dec. 1, 2008 and was not listed in the Choice Counseling

brochure on Oct. 2008 Vista Health Plan S FL – Broward 0 2 +2 2

Freedom Health – Broward Began enrollment on Dec. 1, 2007; was not operational in Oct. 2006 or Oct. 2007

2 Began enrollment on Dec. 1, 2007; was not operational in Oct. 2006 or Oct. 2007 Freedom Health – Broward 2

Total Number of Benefits By Year 63 84 84 59

Comparison +17 -12 -3

Note. Adapted from AHCA Medicaid Reform Choice Counseling Brochures aUnshaded areas denote plans serving the Aged/Disabled population and shaded areas denote plans serving Children/Families.

bIncludes Baker, Clay, and Nassau Counties as well as Duval for 2007 and 2008.

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Table 10 indicates that, of the plans listed in October 2008, 3 plans added a stated Durable Medical Equipment (DME) limit: United, for both Aged/Disabled and Children/Families plans in Duval, and Amerigroup Community Care, for Aged/Disabled in Broward. One plan increased their plan limit for DME (Amerigroup Community Care in Broward for Children/Families). Eighteen plans did not change their DME plan limits and six plan options left Medicaid Reform in Broward. Preferred Medical Plan implemented a plan limit in 2007 and kept the plan limit in 2008. For the three years overall, the plans which had a plan limit in 2006 either increased or eliminated them in 2007 and 2008.

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Table 10: Durable Medical Equipment Plan Limits, October 2006, October 2007, and October 2008

Plan Name

a

DME Plan Limits b

Oct. 2006

Oct. 2007

Change 06 – 07

Oct. 2007

Oct. 2008

Change 07 – 08

Change 06 – 08

Preferred Medical Plan – Broward $5,000 ↑ $5,000 $5,000 - ↑

Preferred Medical Plan – Broward $200 ↑ $200 $200 - ↑

Universal Health Care – Browardc Began

enrollment on Jan. 1, 2007; was


Began enrollment on Jan. 1, 2007; was


Universal Health Care – Browardc

Universal Health Care – Duvalc

Universal Health Care – Duvalc

Total Health Choice – Broward

Total Health Choice – Broward

Buena Vista – Broward Left the Broward Reform on Dec. 1, 2008; was not listed in the Choice Counseling

brochure on October 2008 Buena Vista – Broward

HealthEase – Duval

HealthEase – Duval

HealthEase – Broward

HealthEase – Broward

Staywell – Broward

Staywell – Broward

Staywell – Duval

Staywell – Duval

Amerigroup Comm Care – Broward $3,675 ↓ $4,275 ↑ ↑

Amerigroup Comm Care – Broward $60 $60 - $60 $600 ↑ ↑

Humana Medical Plan – Broward $5,500 ↓ ↓

Humana Medical Plan – Broward $200 ↓ ↓

United Healthcare FL – Broward $4,000 $4,500 ↑ $4,500 Left the Broward Reform on Nov. 1, 2008; was not listed in the Choice Counseling

brochure on Oct. 2008 United Healthcare FL – Broward $100 $100 - $100

United Healthcare FL – Duvalc $4,000 ↓ $3,300 ↑ ↓

United Healthcare FL – Duvalc $100 ↓ $100 ↑ -

Vista Health Plan S FL – Broward Left the Broward Reform on Dec. 1, 2008; was not listed in the Choice Counseling

brochure on Oct. 2008 Vista Health Plan S FL – Broward

Freedom Health – Broward Began enrollment on Dec. 1, 2007; was not operational in Oct. 2006 or Oct. 2007

Freedom Health – Broward

Note. Adapted from AHCA Medicaid Reform Choice Counseling Brochures. aUnshaded areas denote plans serving the Aged/Disabled population and shaded areas denote plans serving Children/Families.

bBlank cells indicate “No Stated Limit.” In the benefit charts, this benefit is annotated at the bottom of the chart page as a

covered benefit and states that “prior authorization & other limits may apply.” cIncludes Baker, Clay, and Nassau Counties as

well as Duval for 2007 and 2008.

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In 2006, co-payments were separated for inpatient services for behavioral health versus physical health but in subsequent years, they were combined in the Choice Counseling brochures. According to Table 11, from 2007 to 2008, nineteen plans did not change their co-payment requirements and three added co-payments (Amerigroup for Children/ Families and United Healthcare in Duval for both Aged/Disabled and Children/Families). In 2007, six plans eliminated co-payments compared to 2006, and in 2008, three of those plans reinstated copayments.

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Table 11: Hospital Inpatient Co-payments, October 2006, October 2007, and October 2008

Plan Name

a

Hospital Inpatient Co-Payments

Oct. 2006

b

Oct. 2007

b

Change 06 – 07

Oct. 2007

b

Oct. 2008

Change 07 – 08

Change 06 – 08

Beh

avio

ral

Hea

lth

Ph

ysic

al

Hea

lth

Ho

spit

al

Inp

atie

nt

Ho

spit

al

Inp

atie

nt

Ho

spit

al

Inp

atie

nt

Preferred Medical Plan – Broward $0 $0 $0 - $0 $0 - -

Preferred Medical Plan – Broward $0 $0 $0 - $0 $0 - -

Universal Health Care – Broward Began enrollment on Jan. 1, 2007; was not operational in Oct.

2006

$0 - $0 $0 - -

Universal Health Care – Broward $0 - $0 $0 - -

Universal Health Care – Duval $0 - $0 $0 - -

Universal Health Care – Duval $0 - $0 $0 - -

Total Health Choice – Broward $0 $0 $0 - $0 $0 - -

Total Health Choice – Broward $0 $0 $0 - $0 $0 - -

Buena Vista – Broward $0 $0 $0 - $0 Left the Broward Reform on Dec. 1, 2008; was not listed in the Choice Counseling

brochure on Oct. 2008 Buena Vista – Broward $0 $0 $0 - $0

HealthEase – Duval $0 $0 $0 - $0 $0 - -

HealthEase – Duval $0 $0 $0 - $0 $0 - -

HealthEase – Broward $0 $0 $0 - $0 $0 - -

HealthEase – Broward $0 $0 $0 - $0 $0 - -

Staywell – Broward $0 $0 $0 - $0 $0 - -

Staywell – Broward $0 $0 $0 - $0 $0 - -

Staywell – Duval $0 $0 $0 - $0 $0 - -

Staywell – Duval $0 $0 $0 - $0 $0 - -

Amerigroup Comm Care – Broward $3 $3 $0 ↓ $0 $0 - ↓

Amerigroup Comm Care – Broward $3 $3 $0 ↓ $0 $3 ↑ -

Humana Medical Plan – Broward $0 $0 $0 - $0 $0 - -

Humana Medical Plan – Broward $3 $3 $3 - $3 $3 - -

United Healthcare FL – Broward $3 $0 $0 ↓ $0 Left the Broward Reform on Nov. 1, 2008; was not listed in the Choice Counseling

brochure on Oct. 2008 United Healthcare FL – Broward $3 $0 $0 ↓ $0

United Healthcare FL – Duvalc $3 $0 $0 ↓ $0 $3 ↑ -

United Healthcare FL – Duvalc $3 $0 $0 ↓ $0 $3 ↑ -

Vista Health Plan S FL – Broward $0 $0 $0 - $0 Left the Broward Reform on Dec. 1, 2008; was not listed in the Choice Counseling

brochure on Oct. 2008 Vista Health Plan S FL – Broward $0 $0 $0 - $0

Freedom Health – Broward Began enrollment on Dec. 1, 2007; was not operational in Oct. 2007

$0

Freedom Health – Broward $0

Note. Adapted from AHCA Medicaid Reform Choice Counseling Brochures. aUnshaded areas denote plans serving the Aged/Disabled population and shaded areas denote plans serving Children/Families.

bThe October 2006 AHCA benefit comparison charts show behavioral and physical inpatient co-pays, but in the benefit

comparison charts for October 2007 and 2008 these co-pays are combined under one “hospital inpatient” category. cIncludes

Duval, Baker, Clay, and Nassau Counties for 2007 and 2008.

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As shown in Table 12, from 2007 to 2008, three plans added co-payments for podiatrist services (Humana Medical Plan – Broward for Children/Families and United Healthcare FL – Duval for both Aged/Disabled and Children/Families). The remaining plans have no podiatrist co-payments, which was the same in 2007. From 2006 to 2008, one plan increased co-payments, and two plans decreased co-payments.

Table 12: Podiatrist Services Co-payments, October 2006, October 2007, and October 2008

Plan Name

a

Podiatrist Service Co-Payments

Oct. 2006

Oct. 2007

Change 06 – 07

Oct. 2007

Oct. 2008

Change 07 – 08

Change 06 – 08

Preferred Medical Plan – Broward $0 $0 - $0 $0 - -

Preferred Medical Plan – Broward $0 $0 - $0 $0 - -

Universal Health Care – Browardb Began

enrollment on Jan. 1, 2007; was


$0 $0 $0 -

Universal Health Care – Browardb $0 $0 $0 -

Universal Health Care – Duvalb $0 $0 $0 -

Universal Health Care – Duvalb $0 $0 $0 -

Total Health Choice – Broward $0 $0 - $0 $0 - -

Total Health Choice – Broward $0 $0 - $0 $0 - -

Buena Vista – Broward $0 $0 - $0 Left the Broward Reform on Dec. 1, 2008; was not listed in the Choice Counseling

brochure on Oct. 2008 Buena Vista – Broward $0 $0 - $0

HealthEase – Duval $0 $0 - $0 $0 - -

HealthEase – Duval $0 $0 - $0 $0 - -

HealthEase – Broward $0 $0 - $0 $0 - -

HealthEase – Broward $0 $0 - $0 $0 - -

Staywell – Broward $0 $0 - $0 $0 - -

Staywell – Broward $0 $0 - $0 $0 - -

Staywell – Duval $0 $0 - $0 $0 - -

Staywell – Duval $0 $0 - $0 $0 - -

Amerigroup Comm Care – Broward $2 $0 ↓ $0 $0 - ↓

Amerigroup Comm Care – Broward $2 $0 ↓ $0 $0 - ↓

Humana Medical Plan – Broward $0 $0 - $0 $0 - -

Humana Medical Plan – Broward $0 $0 - $0 $2 ↑ ↑

United Healthcare FL – Broward $2 $0 ↓ $0 Left the Broward Reform on Nov. 1, 2008; was not listed in the Choice Counseling

brochure on Oct. 2008 United Healthcare FL – Broward $2 $0 ↓ $0

United Healthcare FL – Duvalb $2 $0 ↓ $0 $2 ↑ -

United Healthcare FL – Duvalb $2 $0 ↓ $0 $2 ↑ -

Vista Health Plan S FL – Broward $0 $0 - $0 Left the Broward Reform on Dec. 1, 2008; was not listed in the Choice Counseling

brochure on Oct. 2008 Vista Health Plan S FL – Broward $0 $0 - $0

Freedom Health – Broward Began enrollment on Dec. 1, 2007; was not operational in Oct. 2007

$0

Freedom Health – Broward $0

Note. Adapted from AHCA Medicaid Reform Choice Counseling Brochures aUnshaded areas denote plans serving the Aged/Disabled population and shaded areas denote plans serving

Children/Families.bIncludes Baker, Clay, and Nassau Counties as well as Duval for 2007 and 2008.

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SUMMARY

In general, most Reform plans did not change their benefits between October 2007 and October 2008; however, the overall three-year trend was to decrease benefits and add co-payments. In 2008, no plans increased the number of expanded benefits and six plans reduced benefits. While the number of expanded benefits increased from 2006 to 2007 (63 to 84), the number of expanded benefits decreased to 59 in 2008. In 2008, three plans added a stated limit for durable medical equipment and one plan increased its limits. However, for the three years overall, the plans which had a plan limit for durable medical equipment in 2006, either increased the limit so more services were covered or eliminated the limits completely in 2007 and 2008. With regards to co-payments, nineteen plans did not change their hospital co-payment requirements, three added co-payments for hospital services, and three plans added co-payments for podiatrist services. In 2007, six plans eliminated hospital co-payments compared to 2006, and in 2008, three of those plans reinstated co-payments. From 2006 to 2008, one plan increased podiatrist co-payments, and two plans decreased their podiatrist co-payments.

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CHOICE COUNSELING

A number of plan choices are available under Reform with a variety of benefit packages. Enrollees who do not voluntarily select a health plan are enrolled in a plan through an auto-enrollment process. The Choice Counseling program was created to assist enrollees in voluntarily selecting a health plan. Choice Counselors aid enrollees in making informed decisions by providing plan-specific information on benefits and providers. The choice counseling process can be completed in person or over the phone. Table 13 describes the voluntary enrollment activities of enrollees under Reform. From April 2008 to March 2009, voluntary enrollment fluctuated significantly from a high of 83% in May 2008 to a low of 27% in March 2009. However, AHCA stopped calculating the voluntary enrollment rate in July 2008 due to errors during the transition process with the new fiscal agent. Pending HMO and PSN assignments also varied greatly, particularly toward the end of this reporting period. Yet the method of voluntary enrollments remained consistent. The majority of voluntary enrollments, approximately 64%, took place over the phone during this time period.

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Table 13: Enrollment Activity Report, All Reform Counties, April 2008 – March 2009

Activity Types April 2008 May 2008 June 2008 July 2008* August 2008* September 2008

Count % Count % Count % Count % Count % Count %

% Voluntary Enrollment Activities 7,283 76.80% 8,918 82.90% 6,734 69.40% n/a n/a n/a n/a 7562 63.00%

% Assignment Activities 2,205 23.20% 1,835 17.10% 2,975 30.60% n/a n/a n/a n/a 4,444 37.00%

Total 9,488 100% 10,753 100% 9,709 100% 12,006 100%

Mandatory Assignments

Pending HMO Assignments 1,534 69.60% 1,222 66.60% 1,891 63.60% n/a n/a n/a n/a 1,899 42.70%

Pending PSN Assignments 671 30.40% 613 33.40% 1,084 36.40% n/a n/a n/a n/a 2,545 57.30%

Total 2,205 100% 1,835 100% 2,975 100% 4,444 100%

Voluntary Enrollment

Fax Enrollment 6 0.08% 10 0.10% 2 0.00% n/a n/a n/a n/a 5 0.10%

Interview/Session Enrollment 2,429 33.40% 2,648 29.70% 1,980 29.40% n/a n/a n/a n/a 2,806 37.10%

Mail Enrollment 248 3.40% 253 2.80% 223 3.30% n/a n/a n/a n/a 126 1.70%

Outbound Enrollment 43 0.60% 66 0.70% 38 0.60% n/a n/a n/a n/a 40 0.50%

Phone Enrollment 4,557 62.60% 5,941 66.60% 4,491 66.70% n/a n/a n/a n/a 4,585 60.60%

Total 7,283 100% 8,918 100% 6,734 100% n/a n/a n/a n/a 7,562 100%

Activity Types October 2008 November 2008 December 2008 January 2009 February 2009 March 2009

Count % Count % Count % Count % Count % Count %

% Voluntary Enrollment Activities 6,296 45.70% 8,230 72.20% 9,143 47.50% 8,970 63.50% 8,155 54.00% 7,942 27.34%

% Assignment Activities 7,485 54.30% 3,168 27.80% 10,127 52.60% 5,158 36.50% 6,939 46.00% 21,104 72.66%

Total 13,781 100% 11,398 100% 19,270 100% 14,128 100% 15,094 100% 29,046 100%

Mandatory Assignments

Pending HMO Assignments 3,480 46.50% 1,448 45.70% 5,605 55.40% 1,400 27.10% 2,852 41.10% 7,433 35.22%

Pending PSN Assignments 4,005 53.50% 1,720 54.30% 4,522 44.70% 3,758 72.90% 4,087 58.90% 13,671 64.78%

Total 7,485 100% 3,168 100% 10,127 100% 5,158 100% 6,939 100% 21,104 100%

Voluntary Enrollment

Fax Enrollment 2 0.00% 5 0.10% 13 0.10% 5 0.10% 12 0.20% 27 0.34%

Interview/Session Enrollment 2,102 33.40% 2,756 33.50% 2,636 28.80% 2,935 32.70% 2,221 27.20% 1,982 24.95%

Mail Enrollment 287 4.60% 397 4.80% 302 3.30% 352 3.90% 214 2.60% 562 7.08%

Outbound Enrollment 19 0.30% 33 0.40% 118 1.30% 38 0.40% 18 0.20% 34 0.43%

Phone Enrollment 3,886 61.70% 5,039 61.20% 6,074 66.40% 5,640 62.90% 5,690 69.80% 5,337 67.20%

Total 6,296 100% 8,230 100% 9,143 100% 8,970 100% 8,155 100% 7,942 100% Note. Adapted from AHCA Enrollment Activity Reports April 2008 – March 2009. *According to AHCA, Voluntary Enrollment Reports are unavailable due to the new fiscal agent transition which began July 2008.

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Table 14 compares reasons for voluntary plan disenrollment or change for Reform enrollees for April 2008 – March 2009 (current reporting period) to April 2007 – March 2008 (previous reporting period).* The top two reasons for disenrollment/change remained the same for both years (“Other” and “Personal care physician *PCP+ is not in the Plan”). The category titled “Other” encompasses any other reason for disenrollment that is not listed in the table. Approximately 28% of Reform enrollees this year cited this reason for disenrollment/change compared to 39% from the previous year. It is noteworthy that for the reporting period (not indicated here) April 2006 – March 2007, over 60% of Reform enrollees cited “Other” as their reason for disenrollment/change. This decrease in change reason indicated as “Other” may be attributed to AHCA policy changes in what Choice Counselors are allowed to determine as “Other.” The percentage of enrollees who cited “PCP is not in the Plan” as the reason for disenrollment/change remained about the same (18.7% for the current year compared to 19.1% for the previous year). The recent changes in Reform plan availability are reflected in the 18% of enrollees who cited that their reason for changing plans as “Plan Left/Leaving County.” This reason was ranked 39th in the previous year. “Provider no longer with plan” was given as a reason for disenrollment/change by about 8% of Reform enrollees this year, compared to 3% of enrollees the previous year. These four reasons for disenrollment/change accounted for 73% of changes among Reform enrollees this year.

* We are unable to compare voluntary disenrollment or change reason for Reform to non-Reform this year as the

non-Reform data are unavailable. AHCA indicates that issues with the June 2008 fiscal agent transition has delayed

or prevented the development of the data reports.

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Table 14: Reform Plan Voluntary Disenrollment Change Reason Summary

Reason Reform 4/08–3/09 Reform 4/07–3/08

# % of total # % of total

Other 9,663 28.36% 10,260 39.20%

PCP is not in the Plan 6,365 18.68% 5,003 19.11%

GC11 - Plan Left/Leaving County 6,039 17.73% 4 0.02%

GC01 - Provider no longer with Plan 2,685 7.88% 683 2.61%

Moved/Moving out of Service Area 1,306 3.83% 1,324 5.06%

Extra Benefits Offered by Another Plan 1,200 3.52% 2,499 9.55%

IR Moved out of Service Area 1,120 3.29% 1,342 5.13%

GC10 - 90 Day Change Period/System Limitation 972 2.85% 391 1.49%

Specialist Not in Plan 964 2.83% 973 3.72%

GC09 - Active Relationship with Provider 844 2.48% 314 1.20%

Enrolling in CMS Network 466 1.37% 735 2.81%

GC05 - Incorrect Address/Moved out of Service 366 1.07% 1,028 3.93%

No Reason Given 336 0.99% 197 0.75%

Problems getting Prescriptions 295 0.87% 239 0.91%

Plan’s Providers are too far away 264 0.77% 226 0.86%

GC17 - Move to Specialty Plan 199 0.58% 196 0.75%

Dissatisfaction with PCP 96 0.28% 137 0.52%

PCP Quality of Care Problem 95 0.28% 61 0.23%

Accidentally Chose the Wrong Plan 87 0.26% 60 0.23%

Medicare Entitled 81 0.24% 81 0.31%

GC18 - Reform Plan Benefit Reduction-FLCC Only 79 0.23% 8 0.03%

Denial of Services or Payment for Services 76 0.22% 88 0.34%

IR Enrollee Ineligible for Plan Enrollment 70 0.21% 85 0.32%

Not Eligible for Plan Enrollment (ACWM Code) 67 0.20% 53 0.20%

GC02 - Member ineligible for Enrollment in Plan 53 0.16% 20 0.08%

Unable to get Referral 50 0.15% 39 0.15%

Language Barriers with Providers 42 0.12% 13 0.05%

Processing Error 36 0.11% 18 0.07%

Continuous Rude Treatment by Plan 31 0.09% 22 0.08%

GC12 - Reinstated - Missed OE Period 29 0.09% 8 0.03%

Wait too long at doctor’s office or for appt. 19 0.06% 19 0.07%

Discriminatory Treatment 18 0.05% 3 0.01%

IR Enrollee Death 14 0.04% 19 0.07%

Continuous Rude Treatment by Provider Staff 11 0.03% 11 0.04%

Problems getting Durable Medical Equipment 9 0.03% 3 0.01%

Unsanitary office conditions 5 0.01% 0 0.00%

Alleged Marketing Misrepresentation 4 0.01% 0 0.00%

GC16 - State-special case by case approvals 3 0.01% 5 0.02%

GC14 - Rel svc needed not avail in same plan ntwk 2 0.01% 0 0.00%

Residing in Skilled Nursing Facility 2 0.01% 1 0.00%

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Reason Reform 4/08–3/09 Reform 4/07–3/08

# % of total # % of total

Alleged Enrollment Fraud 1 0.00% 5 0.02%

GC04 - Inability to provide effective care 1 0.00% 2 0.01%

GC08 - Unable to access PCP/No translation svcs 1 0.00% 0 0.00%

GC13 - Svc not covered-moral/religious reasons 1 0.00% 0 0.00%

GC03 - Marketing Violation 0 0.00% 0 0.00%

GC07 - Not allowed to help in treatment plan 0 0.00% 0 0.00%

Total 34,067 100% 26,175 100%

Note. Adapted from AHCA Disenrollment and Plan Change From Summary Count by Reason Code, April 2007 – March 2009

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ELIGIBILITY DATA

Figure 1 indicates the Medicaid eligibility trend in Broward and Duval Counties from December 2001 – December 2008. During this time period, Broward had an overall increase of about 38,000 Medicaid eligibles, or 25%, while Duval had an overall increase of about 26,000 eligibles, or 27%. Broward had a spike of about 50,000 (a 31% increase) from 2003 to 2004. However, in 2005 and 2006, the number of eligibles greatly decreased. The number of eligibles then remained stable from 2006 to 2007. Between 2007 and 2008, both counties experienced increases in eligibles. Broward’s number rose by 13,817, or 7%, and Duval increased by 11,586, or 10%, likely attributable to economic conditions. It is important to note that Reform did not impact eligibility. Figure 1: Medicaid Eligibles in Broward and Duval Counties from December 31, 2001, to

December 31, 2008

Note. AHCA Number of Medicaid Eligibles by Program-Group by County, December 2001 – December 2008.

97,350

105,496 102,849 102,480

113,418 111,717 111,917

123,503

149,059

168,360 170,140

223,031

189,398

172,615 173,911

186,828

85,000

105,000

125,000

145,000

165,000

185,000

205,000

225,000

245,000

12/31/01 12/31/02 12/31/03 12/31/04 12/31/05 12/31/06 12/31/07 12/31/08

Nu

mb

er

of

Eli

gib

les

DUVAL BROWARD

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Figure 2 illustrates the Medicaid eligibility trends in the Reform expansion counties from December 2001 – December 2008. Throughout this time period, Clay County had the largest amount of Medicaid eligibles among the expansion counties with 15,985. Both Clay and Nassau Counties had a significant spike in eligibles between 2004 and 2005. Clay saw an increase of 3529 eligibles, or 35%, while Nassau had an increase of 36%, or 1626 eligibles. All three expansion counties saw a stabilization of numbers between 2005 and 2007. Overall, from 2001 to 2008, Clay County had the greatest increase of 103%, or 8188 eligibles. Nassau County also had a large increase of 82%, or 3173 eligibles, while Baker County reported an increase of 28%. Figure 2: Medicaid Eligibles in Baker, Clay, and Nassau Counties from December 31, 2001, to

December 31, 2008

Note. AHCA Number of Medicaid Eligibles by Program-Group by County, December 2001 – December 2008.

3,568 3,611 3,773 3,969 3,677 3,7474,260

7,8678,491

8,802

10,020

13,54913,920

14,196

15,985

4,002 4,1674,559

6,185 6,049 6,117

7,025

3,328

3,852

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

12/31/01 12/31/02 12/31/03 12/31/04 12/31/05 12/31/06 12/31/07 12/31/08

Nu

mb

er o

f E

lig

ible

s

BAKER CLAY NASSAU

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OVERARCHING THEMES

The overarching goals of the Reform demonstration are to (1) improve health outcomes of Medicaid enrollees and (2) achieve budget predictability. The defining principles of the demonstration pilot include (1) increasing Medicaid patient responsibility and empowerment, (2) supporting marketplace decisions, (3) bridging public and private coverage, and (4) achieving a sustainable growth rate in Medicaid expenditures. The following five overarching themes emerged from our analysis of quantitative and qualitative data, with an emphasis on the organizational aspects of Medicaid Reform implementation and operations: (1) a changing organizational landscape, (2) a new evaluation of organizational performance, (3) continuing evolution of Reform elements, (4) operational successes and challenges, and (5) looking ahead.

A CHANGING ORGANIZATIONAL LANDSCAPE

Changes in the organizational landscape of the demonstration counties have been documented over the past year. Market changes include evolving organizational forms, plan entrances and exits, enrollment freezes, and the development of a rural managed care presence.

Evolving Organizational Forms Consolidation in the managed care market has been observed in the demonstration pilot counties. Reform PSNs are consolidating, and some PSNs are either converting to or considering alignment with HMOs. One reason cited for such change is a lack of infrastructure needed to meet reporting and other administrative requirements of Reform. PSNs are seeking partners who can provide existing infrastructures (e.g., information technology systems) that support Reform requirements. Another reason that PSNs are exploring conversion is perceived adverse selection in the patient population. Due to the severity of illness among PSN enrollees who were previously in MediPass, some PSNs are not optimistic that they could survive a transition to capitation in their current organizational form.

New Plans Entering Market New plans are entering the pilot counties. The main reason cited for their entrance is that they want a presence in the Florida Medicaid managed care arena. Some plans are entering the market through the acquisition of PSNs. These plans view such partnerships as opportunities to work with existing provider networks, while providing the infrastructure and managed care experience necessary to meet the requirements of the demonstration.

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Existing Plans Exiting Market Plans have exited the Reform counties over the past year and others will leave soon. Plans indicate that the combination of reduced rates, increased administrative burden, and sicker, expensive patients resulted in an unsustainable financial model for HMOs. Although recent legislatively mandated rate cuts affect all Medicaid managed care plans, the additional 2% “taken off the top” for the EBR program and perceived excessive administrative burden make the Reform financial picture particularly risky for plans. One respondent noted about the reduced rate,

The 3% base rate cut was the final straw for us. In addition, plans indicated that the risk adjustment methodology used to determine rates (e.g., MedRx) does not adequately reflect the morbidity of their Medicaid patient population. For example,

People were sicker than indicated by the pharmacy-based risk adjustment.

The morbidity of our patients is not changing just because rates go down. Difficulty contracting with hospital providers and, specifically, negotiating rates that would not result in losses, was another reason plans said they were leaving the demonstration pilot. For example,

When your competition owns the hospital, you don’t have a lot of options.

It is hard to negotiate reasonable rates with hospital monopolies in Broward County. Finally, some plans reported leaving the demonstration because other plans were leaving and “the future looked bleak.”

Enrollment Freezes Many existing HMOs participating in the Reform have decided to freeze enrollment. The primary reason cited for these decisions is financial performance. Plans suggested that low rates, coupled with resource-intensive patients, make them hesitant to grow enrollment quickly in Reform areas.

We don’t want to develop a large footprint in Reform and have to pull out later because it is unsustainable.

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Many plans want to stabilize their enrollment and enhance their administrative capacity; others are making business decisions and looking at medical loss ratios to decide where they want to go with their plans.

While plans are freezing enrollment, many reported that if they can improve their financial picture in the pilot counties, they will be open to expanding enrollment again in the future.

Rural Managed Care Presence Two plans continue to operate in the rural pilot counties (Baker, Clay, and Nassau). These plans report very high disease management utilization. According to these plans, rural patients are sicker because they have been “unmanaged” for a long time. While managing the care of patients in these areas is challenging because patients are spread over a large geographic area, the plans intend to use more physician extenders in the rural areas to better meet healthcare needs. Plans operating in these counties have no immediate plans to leave the Reform.

NEW EVALUATION OF ORGANIZATIONAL PERFORMANCE

For the first time, Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Healthcare Effectiveness Data and Information Set (HEDIS) Data on Reform plan performance were made available in 2008. This has resulted in increased collaboration between plans and AHCA in efforts to improve quality. Plans demonstrated adequate performance on CAHPS indicators. However, the initial performance of Florida Medicaid health plans on HEDIS and HEDIS-like performance indicators is very low compared to national Medicaid benchmarks. This poor performance is observed in all Florida Medicaid health plans, including Reform and non-Reform plans. Despite their initial performance, both the plans and AHCA report positive outcomes of meetings held with the Secretary and other AHCA staff regarding plan performance compared to peers and strategies for improvement. Plans are submitting goals and operational plans to AHCA and will be meeting regularly with AHCA to discuss progress. More specifically, plans are creating corrective action plans, with a mandated goal of achieving the 75th percentile of the national Medicaid average in 3 years. While plan representatives state that “no one can argue with striving for improvement,” the 75% threshold set by AHCA is viewed by some plans as a “stretch” goal. Plan representatives indicate that certain performance indicators are beyond their control. For example, the number of dental visits is limited by a lack of available Medicaid dental providers. Another challenge cited is the difficulty obtaining accurate addresses and phone numbers of enrollees, making it difficult to contact enrollees to encourage physician visits. Finally, plans state that no additional funding is provided for quality improvement activities and they are limited by AHCA with regard to marketing and incentivizing patients.

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Some plans suggest that using the benchmark choice of nationally reporting Medicaid plans is not appropriate. Some plan representatives cite a “spike upward” in the 2007 national HEDIS data which makes the Florida plan performance look particularly poor. Additionally, the national benchmark scores come from a database of self-reported, voluntary plans. Some suggest that it is unlikely that poorly performing plans would report to such a database. Finally, plan representatives argue that plans in the southeastern United States historically perform poorly on HEDIS measures, so it is more appropriate to benchmark against Medicaid Plans in other southern states. A detailed analysis of the available HEDIS data is currently underway and will be described in a separate report.

CONTINUING EVOLUTION OF REFORM ELEMENTS

Several elements of the pilot program were established with the goals of empowering enrollees and increasing choice, including the EBR program, Choice Counseling, the Opt-Out program, and modified benefits. Since the beginning of Reform, these elements have continued to evolve, with input from, and actions of, various stakeholders, including AHCA, plans, enrollees, advocates, and healthcare providers.

EBR Program Enrollee awareness and participation in the EBR program has significantly increased since the beginning of the Reform. Although the program had a slow start, the EBR program was recently moved to a specific AHCA bureau and has benefited from the additional attention. Enrollees are now spending as much as they earn, and AHCA is working to make enrollees aware of their benefits. Additionally, point of sale issues that previously hampered the spending of EBR credits have been resolved. The list of items that can be purchased has been simplified and pharmacists have been educated about the EBR program. However, some plans indicate that, although the EBR concept is innovative, it may not be appropriate for the Medicaid population. Plans cite low EBR participation among members and no evidence that the program affects outcomes. Some plans question whether selected EBR credit-earning behaviors are appropriate. For example, enrollees receiving credits for a primary care visit probably would have visited their primary care physician anyway. Others question the effectiveness of such a program in the Medicaid population. One plan suggested that many Medicaid patients are in “survival mode,” focusing on ensuring food and shelter for their families. Thus, preventive care and changing behaviors for more “long term” benefits may be a low priority for them.

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Plans also cite specific EBR operational challenges. The administrative processes required to reward an enrollee credit are perceived as a “hassle” for all parties. Perceptions of lag time between EBR activity and reward also limit the program, and make the linkage between behavior and rewards unclear. Additionally, plans question the 2% financial rate commitment to EBR, particularly given the recent rate cuts and current state fiscal climate. Some plans suggest that punitive action for beneficiary non-compliance, rather than rewarding compliant behavior, would be more effective. A frequent statement was that unless enrollees have “skin in the game,” they are not going to change behaviors.

Choice Counseling Both AHCA and some health plans report that the Choice Counseling program is working well. For example, one plan representative said, AHCA should be proud of how well this worked. Plan choice among enrollees was over 80%, and getting people engaged enough to choose is considered by some as a victory. Many think that Choice Counseling gives enrollees a sense that they are driving their care. However, some plans indicated new challenges with Choice Counseling. The inability to get through to a counselor was the most frequently noted issue. Plans said that enrollees call the Choice Counseling number, and the phone rings without an answer. One plan even confirmed this through several “secret shopper” exercises. Other issues cited by some plans include misinformation provided in the counseling process that resulted in future enrollee grievances. Plans appreciated the Choice Counseling reports provided to them in the beginning of the Reform; however, they no longer receive these reports. Finally, some plan respondents question the benefit of the Choice Counseling program relative to its expense.

Opt Out Program While the Opt-Out program has increased its enrollment (30 enrollees now, up from 10), the future of this program is uncertain. Some sources indicate that Opt-Out uptake may increase if the demonstration goes statewide. However, some predict that the program is unlikely to continue. For now, this Reform element continues to operate.

Modified Plan Benefits In the pilot, plans still have limited discretion to modify benefits. Although benefits remained relatively stable over the past year, in general, benefits were decreased. Some plans report dropping certain “extras” due to rate cuts and financial constraints.

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OPERATIONAL SUCCESSES AND CHALLENGES

Over the past year, both successes and challenges with the Reform were reported from both AHCA and health plan perspectives.

Successes Plans continue to use innovative tools to manage the care of enrollees that were not available under MediPass. Examples include a dental program that is tied to the EBR program, a postpartum discharge program, and an emergency room follow-up program. Plans cite demonstrated success using outreach to improve preventive care. One plan increased well-child visits from 55% to 73% by working with doctors’ offices and sending out mailings. From AHCA’s perspective, the increase in participation in the EBR program, the implementation of a complaint tracking system, and maintaining a voluntary choice level of 80% among enrollees are all deemed successes. The Reform is fully operational, and “business as usual” is described as positive. Probably the greatest success from AHCA’s perspective is how certain components of the pilot will be expanded to all Medicaid managed care (even without Reform expansion). For example, the new emphasis on quality among all Medicaid health plans can be attributed to the Reform. Although performance data has been reported in the past, this is the first time AHCA has compared Florida plans to national averages. Collaboration among health plans and AHCA to improve quality was facilitated by the Reform. AHCA hopes to include enrollment incentives and sanctions on health plans, depending on health plan compliance with corrective action plans. These will not be specific to Reform, but were developed and refined in the demonstration. Additionally, the use of risk-adjusted rates in Florida came about through the Reform, and this may be extended to all Medicaid managed care plans.

Challenges Plans and AHCA cite the conversion of the fiscal agent as one of the biggest challenges faced in overall Medicaid this year (including non-Reform areas). The change has delayed the processing of encounter data, and, in turn, prevented AHCA from moving to a full diagnostic model of rate setting. Plans also cite difficulty gaining provider compliance with the reporting of encounter data. Many Medicaid providers do not have electronic medical records or office staff who are qualified to do the reporting. However, plans report that they “are just glad the doctors are seeing Medicaid patients.”

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Both AHCA and the plans acknowledge how challenging the recent rate cuts have been for everyone. Several plans are exiting the market, and others are freezing their enrollments in Reform counties. Plans express uncertainty about participating in Reform in the future, and some report “struggling mightily” in the Reform counties. The rate cuts have also resulted in challenges for AHCA. From a manpower perspective, transitioning enrollees from plans leaving Reform has been very difficult. Additionally, as plans leave and join Reform at the same time, AHCA experiences a huge workload.

LOOKING AHEAD

The future of the Medicaid Reform program in Florida depends on several things, including support of the Legislature and the fiscal condition of the state. The decision to expand the demonstration is highly political, and some respondents note that a true “champion” for the Reform does not currently exist in the Legislature. Also, some noted that the Governor’s office does not back Reform to the same degree as the previous administration and also notes Reform has various supporters and nay-sayers. From AHCA’s perspective, however, despite certain issues, the pilot is operating in a more efficient manner than fee-for-service Medicaid. One of the major factors that may determine the future of Medicaid Reform is the state’s fiscal situation. Health plans continue to question Reform’s future based on the current financial model and risk adjustment methodology. While certain plans are leaving the pilot, others continue to join. The state budget is strained, and additional rate cuts might drive out health plans that are participating in the program. The concept of having “choice” is already being challenged by plan withdrawals and frozen enrollments. If plans continue to withdraw and/or freeze, enrollee choice, one of the major tenets of the program, will be severely limited. Despite these challenges, some health plans and the provider community remain committed to providing care to the Medicaid population. Regardless of the Reform’s expansion state-wide, certain processes and programs are already being applied to Florida’s Medicaid program statewide. Risk adjustment and a heavy emphasis on quality improvement are evolving into permanent fixtures for the state’s Medicaid program. Also, AHCA’s new approaches to collaborating with various stakeholders (e.g., Technical Advisory Panel) appear to be here to stay.

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APPENDIX A: INTERVIEW PROTOCOLS

INTERVIEW PROTOCOL: REFORM HEALTH PLANS AND NETWORKS—MAY 2009

We are interested in understanding your experience with Medicaid Reform in the Medicaid Reform counties. All your answers are completely confidential, and you do not have to answer any question you do not wish to answer. This interview may be recorded. We will maintain your name for study participation. Please be assured that your identity will be confidential and all interview information will be reported in aggregate. Overall Questions Please describe your organization and provide an overview of your organization’s involvement in Florida Medicaid. Please tell us about your involvement in Medicaid Reform. How is it going so far? What do you believe are the best aspects of Medicaid Reform? What are Medicaid Reform’s biggest challenges? What aspects of Medicaid Reform are you following most closely? Specific Questions What is your enrollment in Medicaid Reform? Is it what you expected? How does your Reform enrollment compare to non-Reform or pre-Reform enrollment (if applicable)? There have been (and will be) many changes to the plans participating in Medicaid Reform. Have you decided to leave Medicaid Reform? If so, why? Describe your organization’s decision about leaving. What were the primary reasons for leaving Reform? For plans that are not leaving or planning to leave: Describe your organization’s decisions to remain in Medicaid Reform. How will the departure of other plans affect your organization? Is this an opportunity for growth? Will you need to make adjustments to your network? Are there other challenges you anticipate with the changing plans in Reform?

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What do you think is the likely future of Medicaid Reform in Florida? What are your views on the Choice Counseling Process? Do you provide additional services not previously covered by Medicaid? If so, what types of services? What has been your experience providing those services? What is your opinion of the Enhanced Benefit Reward$ Program? Describe your case management, utilization management, and disease management program(s). What are the ways that you “manage care” for Medicaid enrollees? What do you think about the health plan quality reporting requirements under the Medicaid Reform? What was your response to the Medicaid plan performance measures that were published in January? What Performance Improvement Programs does your plan currently have in place? What has been your experience with these activities, thus far? What specific operational challenges have you faced with Medicaid Reform? What has been your experience with AHCA during Reform? What has worked well/or not so well? What about Medicaid Reform has surprised you? What lessons have you learned so far? What else would you like us to know about Medicaid Reform? Thank you very much for your participation in this interview.

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INTERVIEW PROTOCOL: AHCA MEDICAID LEADERSHIP AND STAFF IN TALLAHASSEE AND IN DEMONSTRATION AREA OFFICES—DECEMBER 2008

We are interested in understanding the implementation and ongoing operations of Medicaid Reform in Florida, including the components of the current Reform initiatives (e.g., health plans, specialized benefit packages, Choice Counseling, the EBR program, the Low-Income Pool, the Opt-Out program, etc.). All your answers are completely confidential, and you do not have to answer any question you do not wish to answer. This interview may be recorded. We will maintain your name for study participation, but be assured that your identity will be confidential and all interview information will be reported in aggregate. Please briefly describe your role in Medicaid Reform to date. Over the past year, what would you say have been the major Medicaid Reform activities and milestones? What have been the biggest challenges during the past 6–12 months? What have been the biggest successes during the past 6–12 months? Reform Implementation: Since Reform began, what do you think is different for Medicaid recipients in Broward and Duval Counties? For Baker, Clay, and Nassau Counties? What are key indicators that you are tracking? Let’s discuss each Medicaid Reform element separately. In your opinion what has worked particularly well/not so well with respect to:

Reform Plans and Networks o Plans and Networks in Reform o Contracting Process o Risk Adjustment o Providers in Networks o Performance Measures

The Choice Counseling program

The EBR program

The Opt-Out program

Enrollee Satisfaction

Use, Access, Disparities

Low-Income Pool

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Additional Probes for Team Leaders/Others Lessons Learned in Florida: In your opinion, what are key elements to effective operations of Medicaid Reform? What could other states do differently to improve on the process experienced in Florida? Reform Results: Overall, how do various stakeholders (e.g., the State, the legislators, providers, health plans, other community leaders, etc.) view Medicaid Reform? In your opinion is the Reform succeeding? What have been intended and unintended implications of Reform? What are your goals looking ahead? Is there anything else you want us to know about Medicaid Reform? Thank you very much for your participation in this interview.

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APPENDIX B: PLAN BENEFIT COMPARISON METHODOLOGY

In July 2006, Medicaid Reform “went live” in Broward and Duval Counties; however, the transition of enrollees into Reform health plans did not occur until September 2006.11 In July 2007, the demonstration was expanded to Baker, Clay, and Nassau Counties with enrollee transition beginning in September 2007.12 Reform health plans are required to verify the sufficiency and actuarial equivalency of their benefit packages and can only modify their benefit packages annually. Any changes that are made usually become effective in the fall of the same demonstration year.11 AHCA has adopted a continuous review policy in which multiple opportunities are provided for interested parties and individuals to provide feedback on various aspects of the demonstration including the Choice Counseling Brochures (Medicaid Reform Health Plan Benefit Charts). Through these reviews, several iterations of benefit charts have been produced to improve the ease with which enrollees may read and understand the materials and so be able to choose a health plan that is best suited for them. While health plan benefits were unchanged, language revisions, style, and the order in which the materials were presented differed with each issue of the benefit charts.

PSNs are reimbursed on a fee-for-service basis, and so have the same benefit package as traditionally offered under Medicaid. Since all PSNs who are currently operating in Reform are paid on a fee-for-service basis, they are not included in these Reform benefits analyses. Consultation with AHCA determined that the benefit charts from October 2006, 2007, and 2008 were the most relevant to review for this comparison.

DATA SOURCES

Table 15 indicates the Choice Counseling brochures used to conduct the reviews. All data were requested and received through AHCA.

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Table 15: Choice Counseling Brochures: October 2006, October 2007, and October 2008

Month Year Brochure Entitled

Oct. 2006 Welcome to Broward County Florida Medicaid – Broward County Aged and/or Disabled. Rev 10/06.

Oct. 2006 Welcome to Broward County Florida Medicaid – Broward County Children and Families. Rev 10/06.

Oct. 2006 Welcome to Duval County Florida Medicaid – Duval County Aged and/or Disabled. Rev 10/06.

Oct. 2006 Welcome to Duval County Florida Medicaid – Duval County Children and Families. Rev 10/06.



Oct. 2007 Welcome to Duval County Florida Medicaid – Duval County Aged and/or Disabled. Rev 10/07.

Oct. 2007 Welcome to Duval County Florida Medicaid – Duval County Children and Families. Rev 10/07.

Oct. 2007 Welcome to Baker, Clay, and Nassau Counties Florida Medicaid – Baker, Clay, and Nassau Counties Children and Families and Aged and/or Disabled. Rev 10/07.



Oct. 2008 Welcome to Baker, Clay, Duval and Nassau Counties Florida Medicaid – Aged and/or Disabled. Rev 10/08.

Oct. 2008 Welcome to Baker, Clay, Duval and Nassau Counties Florida Medicaid – Children and Families. Rev 10/08.

ANALYSIS

The analysis compared plan benefits and limits for October 2006, 2007, and 2008 for four different services including Plan Limits for Durable Medical Equipment, Number of Expanded Benefits, Hospital Inpatient-Services Co-Payments, and Podiatrist Services Co-payments. AHCA Choice Counseling brochures were used to compare the plan benefits and limits and are found in Tables 9 through 12 of this report.

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APPENDIX C: ENROLLMENT TABLES

Table 16: Total Enrollment by Plan, Broward County

Broward County April 2008 May 2008

Non-Reform Reform Non-Reform Reform

Plan Name Plan Type TANF SSI Total TANF SSI Total TANF SSI Total TANF SSI Total

Amerigroup of Florida, Inc. HMO 190 241 431 11,498 1,696 13,194 192 237 429 11,624 1,720 13,344

Freedom Health Plan HMO 0 0 0 140 32 172 0 0 0 170 33 203

HealthEase of Florida, Inc. HMO 223 165 388 13,363 1,643 15,006 210 166 376 13,341 1,649 14,990

Humana Medical Plan, Inc. HMO 184 479 663 7,727 2,104 9,831 180 468 648 7,703 2,075 9,778

Preferred Medical Plan, Inc. HMO 11 65 76 1,208 459 1,667 10 64 74 1,235 458 1,693

Staywell HMO 370 337 707 26,169 2,883 29,052 360 326 686 26,572 2,951 29,523

Total Health Choice, Inc. HMO 1 5 6 1,372 343 1,715 1 5 6 1,404 333 1,737

United Healthcare of Florida, Inc. HMO 274 264 538 6,499 1,245 7,744 273 262 535 6,619 1,255 7,874

Universal HMO 0 0 0 135 43 178 0 0 0 153 51 204

Vista dba Buena Vista (Vista) HMO 84 109 193 5,414 723 6,137 81 107 188 5,465 725 6,190

Vista Healthplan of S. Florida HMO 0 0 0 4,481 486 4,967 0 00 0 4,726 507 5,233

Access Health Solutions PSN 166 143 309 1,876 826 2,702 156 171 327 1,828 812 2,640

CMS North Broward PSN 74 227 301 669 992 1,661 74 230 304 700 990 1,690

CMS South Broward PSN 0 0 0 266 338 604 0 266 341 607

NetPass PSN 172 296 468 2548 1,508 4,056 179 303 482 2,493 1,496 3,989

Pediatric Associates PSN 323 103 426 8,866 506 9,372 332 103 435 8,891 511 9,402

SFCCN dba North Broward Hospital PSN 0 0 0 3,680 2,119 5,799 0 0 0 3,674 2,126 5,800

SFCCN dba Memorial Healthcare PSN 0 0 0 0 0 0 0 0 0 0 0 0

United Evercare HMO 0 216 216 0 0 0 0 221 221 0 0 0

Total 2,072 2,650 4,722 95,911 17,946 113,857 2,048 2,663 4,711 96,864 18,033 114,897

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Table 16: Total Enrollment by Plan, Broward County (Continued)

Broward County June 2008 July 2008








Staywell HMO 349 321 670 27,110 2,968 30,078 329 288 617 26,849 2,948 29,797



Universal HMO 0 0 0 160 55 215 0 0 0 205 64 269




CMS North Broward PSN 73 226 299 718 1,009 1,727 73 225 298 766 1,029 1,795

CMS South Broward PSN 0 0 0 279 346 625 0 0 0 282 358 640

NetPass PSN 175 310 485 2,394 1,504 3,898 180 311 491 2,348 1,503 3,851



SFCCN dba Memorial Healthcare PSN 0 0 0 0 0 0 0 0 0 0 0 0


Total 2,021 2,639 4,660 98,134 18,304 116,438 1,991 2,466 4,457 97,833 18,412 116,245

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Broward County August 2008 September 2008








Staywell HMO 132 221 353 25,391 2,835 28,226 122 219 341 25,592 2,882 28,474



Universal HMO 0 0 0 225 68 293 0 0 0 279 126 405






NetPass PSN 0 0 0 2,193 1,441 3,634 0 0 0 2,231 1,474 3,705



SFCCN dba Memorial Healthcare PSN 0 0 0 1,585 742 2,327 0 0 0 1,741 785 2,526


Total 661 1,392 2,053 93,005 17,867 110,872 594 1,137 1,731 94,975 18,700 113,675

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Broward County October 2008 November 2008








Staywell HMO 120 220 340 24,622 2,538 27,160 111 204 315 24,694 2,569 27,263


United Healthcare of Florida, Inc. HMO 0 0 0 5,007 874 5,881 156 192 348 0 0 0

Universal HMO 182 201 383 318 130 448 0 0 0 608 194 802






NetPass PSN 0 0 0 2,297 1,500 3,797 0 0 0 3,077 1,603 4,680





Total 560 1,374 1,934 95,383 17,480 112,863 504 1,084 1,588 94,341 17,279 111,620

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Broward County December 2008 January 2009




Freedom Health Plan HMO 0 0 0 850 169 1,019 0 0 0 1,601 284 1,885




Staywell HMO 107 203 310 25,487 2,643 28,130 94 197 291 25,456 2,680 28,136


United Healthcare of Florida, Inc. HMO 137 187 324 0 0 0 131 174 305 0 0 0

Universal HMO 0 0 0 626 184 810 0 0 0 1,435 319 1,754

Vista dba Buena Vista (Vista) HMO 28 64 92 6 0 6 22 60 82 4 0 4

Vista Healthplan of S. Florida HMO 0 0 0 6 0 6 0 0 0 2 0 2




NetPass PSN 0 0 0 3,492 1,646 5,138 213 299 512 4,443 1,778 6,221





Total 460 1,292 1,516 87,982 16,714 104,696 852 1,494 2,346 95,587 17,843 113,430

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Broward County February 2009 March 2009




Freedom Health Plan HMO 0 0 0 1,400 252 1,652 0 0 0 1,188 222 1,410




Staywell HMO 92 194 286 25,313 2,657 27,970 91 187 278 24,517 2,595 27,112

Total Health Choice, Inc. HMO 0 0 0 5,146 869 6,015 0 2 2 6,287 1,078 7,365


Universal HMO 0 0 0 1,641 327 1,968 0 0 0 2,029 403 2,432

Vista dba Buena Vista (Vista) HMO 19 60 79 0 0 0 18 60 78 0 0 0

Vista Healthplan of S. Florida HMO 0 0 0 0 0 0 0 0 0 0 0 0

Access Health Solutions PSN 209 169 378 10,399 1,496 11,895 243 168 411 10,735 1,579 12,314



NetPass PSN 211 294 505 4,477 1,782 6,259 205 288 493 5,082 1,858 6,940

Pediatric Associates PSN 0 0 0 0 0 0 0 0 0 0 0 0




Total 807 1,683 2,490 97,038 17,902 114,940 820 1,423 2,243 100,423 18,581 119,004 Note. Adapted from http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/MHMO/med_data.shtml and http://www.fdhc.state.fl.us/Medicaid/MediPass/reports.shtml

http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/MHMO/med_data.shtml

http://www.fdhc.state.fl.us/Medicaid/MediPass/reports.shtml

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Table 17: Total Enrollment by Plan, Duval County

Duval County April 2008 May 2008



HealthEase of Florida, Inc. HMO 616 860 1,476 30,818 4,215 35,033 597 838 1,435 30,718 4,202 34,920

Staywell HMO 0 0 0 2,543 401 2,944 0 0 0 2,521 410 2,931


Universal HMO 0 0 0 305 38 343 0 0 0 399 55 454

Access Health Solutions PSN 292 872 1,164 4,497 1,072 5,569 840 286 1,126 4,413 1,077 5,490

CMS PSN 106 174 280 770 774 1,544 110 174 284 758 774 1,532

Shands/Jax dba First Coast Advantage PSN 0 0 0 11,310 3,629 14,939 0 0 0 11,465 3,610 15,075

Total 60,360 1,924 2,974 60,360 11,488 71,848 1,585 1,318 2,903 60,839 11,528 72,367

Table 17: Total Enrollment by Plan, Duval County (Continued)

Duval County June 2008 July 2008



HealthEase of Florida, Inc. HMO 583 820 1,403 31,111 4,230 35,341 553 712 1,265 31,030 4,245 35,275

Staywell HMO 0 0 0 2,553 411 2,964 0 0 0 2,604 416 3,020


Universal HMO 0 0 0 478 67 545 0 0 0 579 78 657

Access Health Solutions PSN 835 283 1,118 4,431 1,085 5,516 768 290 1,058 4,443 1,085 5,528

CMS PSN 114 169 283 806 809 1,615 109 167 276 865 827 1,692


Total 1,573 1,294 2,867 61,943 11,704 73,647 1,468 1,183 2,651 62,484 11,797 74,281

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Duval County October 2008 November 2008




Staywell HMO 0 0 0 2,444 363 2,807 0 0 0 2,319 331 2,650


Universal HMO 0 0 0 1,513 242 1,755 0 0 0 1,874 242 2,116


CMS PSN 0 0 0 893 833 1,726 0 0 0 946 842 1,788


Total 373 633 1,006 63,767 11,620 75,387 356 583 939 65,002 11,565 76,567

Duval County August 2008 September 2008



HealthEase of Florida, Inc. HMO 386 639 1,025 29,972 4,188 34,160 363 632 995 30,831 4,304 35,135

Staywell HMO 0 0 0 2,525 413 2,938 0 0 0 2,616 448 3,064


Universal HMO 0 0 0 652 91 743 0 0 0 1,087 250 1,337


CMS PSN 0 0 0 798 813 1,611 0 0 0 869 825 1,694


Total 418 650 1,068 60,782 11,694 72,476 390 643 1,033 62,479 12,277 74,756

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Duval County December 2008 January 2009




Staywell HMO 16 8 24 2,252 339 2,591 0 0 0 2,162 334 2,496

United Healthcare of Florida, Inc. HMO 0 0 0 8,031 1,115 9,146 14 7 21 7,300 971 8,271

Universal HMO 0 0 0 2,259 295 2,554 0 0 0 2,365 302 2,667


CMS PSN 0 0 0 997 863 1,860 0 0 0 993 869 1,862


Total 337 576 913 65,864 11,793 77,657 554 645 1,199 65,947 11,912 77,859


Duval County February 2009 March 2009




Staywell HMO 12 7 19 2,137 326 2,463 12 7 19 2,002 324 2,326

United Healthcare of Florida, Inc. HMO 0 0 0 6,801 942 7,743 0 0 0 6,195 834 7,029

Universal HMO 0 0 0 2,489 289 2,778 0 0 0 3,058 324 3,382


CMS PSN 0 0 0 998 880 1,878 0 0 0 1,073 907 1,980


Total 546 628 1,174 67,740 12,017 79,757 542 621 1,163 69,925 12,282 82,207 Note. Adapted from http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/MHMO/med_data.shtml and http://www.fdhc.state.fl.us/Medicaid/MediPass/reports.shtml



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Table 18: Total Enrollment by Plan, Baker County

Baker County April 2008 May 2008





Total 36 119 155 1,946 280 2,226 107 34 141 1,991 280 2,271

Table 18: Total Enrollment by Plan, Baker County (Continued)

Baker County June 2008 July 2008





Total 110 32 142 2,069 278 2,347 112 24 136 2,110 279 2,389


Baker County August 2008 September 2008





Total 0 0 0 2,055 277 2,332 0 0 0 2,144 297 2,441

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Baker County December 2008 January 2009





Total 0 0 0 2,186 295 2,481 0 0 0 0 2,254 2, 5439


Baker County December 2008 January 2009





Total 0 0 0 2,256 295 2,551 45 6 51 2,310 294 2,604


Baker County February 2009 March 2009





Total 43 6 49 2,380 293 2,673 47 5 52 2,481 293 2,774 Note. Adapted from http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/MHMO/med_data.shtml and http://www.fdhc.state.fl.us/Medicaid/MediPass/reports.shtml



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Table 19: Total Enrollment by Plan, Clay County

Clay County April 2008 May 2008





Total 97 224 321 6,788 920 7,708 107 34 141 6,920 940 7,860

Table 19: Total Enrollment by Plan, Clay County (Continued)

Clay County June 2008 July 2008





Total 225 93 318 7,069 943 8,012 230 46 276 7,129 944 8,073


Clay County August 2008 September 2008





Total 0 0 0 6,890 935 7,825 0 0 0 7,271 978 8,249

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Clay County October 2008 November 2008





Total 0 0 0 7,430 965 8,395 0 0 0 7,596 965 8,561


Clay County December 2008 January 2009





Total 0 0 0 7,813 976 8,789 174 47 221 7,943 989 8,932


Clay County February 2009 March 2009





Total 286 108 394 8,148 990 9,138 162 49 211 8,458 1,020 9,478 Note. Adapted from http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/MHMO/med_data.shtml and http://www.fdhc.state.fl.us/Medicaid/MediPass/reports.shtml



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Table 20: Total Enrollment by Plan, Nassau County

Nassau County April 2008 May 2008



United Healthcare of Florida, Inc. HMO 0 0 0 966 177 1,143 0 0 0 983 185 1,168


Total 29 50 79 2,796 437 3,233 48 30 78 2,840 448 3,288

Table 20: Total Enrollment by Plan, Nassau County (Continued)

Nassau County June 2008 July 2008





Total 40 32 72 2,879 454 3,333 40 10 50 2,978 465 3,443


Nassau County August 2008 September 2008



United Healthcare of Florida, Inc. HMO 0 0 0 1,025 182 1,207 0 0 0 960 171 1,131


Total 0 0 0 2,898 457 3,355 0 0 0 3,113 484 3,597

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Nassau County October 2008 November 2008

Non-Reform Reform Non Reform Reform


United Healthcare of Florida, Inc. HMO 0 0 0 945 157 1,102 0 0 0 968 150 1,118


Total 0 0 0 3,140 466 3,606 0 0 0 3,235 458 3,693


Nassau County December 2008 January 2009





Total 0 0 0 3,309 476 3,785 0 0 0 3,452 483 3,935


Nassau County February 2009 March 2009



United Healthcare of Florida, Inc. HMO 0 0 0 1,049 148 1,197 0 0 0 999 142 1,141


Total 0 0 0 3,569 488 4,057 0 0 0 3,715 500 4,215 Note. Adapted from http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/MHMO/med_data.shtml and http://www.fdhc.state.fl.us/Medicaid/MediPass/reports.shtml



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SOURCES

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July 2008. [Data file]. Retrieved April 2009. Available from http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/MHMO/med_data_prev.shtml

Agency for Health Care Administration. Florida MediPass/Medicaid HMO Recipient Enrollment

Report April 2008 – July 2008. [Data file]. Retrieved April 2009. Available from http://ahca.myflorida.com/Medicaid/MediPass/archive.shtml

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Reform 1115 Enrollment Report August 2008 – March 2009. Retrieved June 2009. Available from http://ahca.myflorida.com/MCHQ/Managed_Health_Care/MHMO/med_data.shtml

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Agency for Health Care Administration Medicaid Reform Choice Counseling Brochure, October 2007. Welcome to Broward County Florida Medicaid – Broward County Aged and/or Disabled. Rev 10/07. Received via mail February 2008 from April Cook.


2007. Welcome to Broward County Florida Medicaid – Broward County Children and Families. Rev 10/07. Received via mail February 2008 from April Cook.


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First Coast Advantage. Retrieved June 2009 from http://www.firstcoastadvantage.com Florida NetPass. Retrieved June 2009 from http://www.floridaNetPass.com Freedom Health Plan. Retrieved on June 19, 2009, from www.freedomhealth.com http://www.freedomh.com/aboutus.html HealthEase. Retrieved June 2009 from http://www.wellcare.com/

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CITATIONS

1 Patton, M.Q. (2002). Qualitative research and evaluation methods (3rd ed.). Thousand Oaks, CA: Sage Publications, Inc.

2 Kaiser Commission on Medicaid and the Uninsured. (2007). Total Medicaid Enrollment, FY

2006. (Updated 2009). Retrieved April 14, 2009, from http://www.statehealthfacts.org/comparemaptable.jsp?ind=198&cat=4

3 Kaiser Commission on Medicaid and the Uninsured. (2007). Why did Medicaid Spending

Decline in 2006? A Detailed Look at Program Spending and Enrollment: 2000–2006. Retrieved April 16, 2009, from http://www.kff.org/medicaid/upload/7697.pdf

4 National Association of Budget Office. (2008). Fiscal Year 2007: State Expenditure Report.

Retrieved April 24, 2009, from http://www.nasbo.org/Publications/PDFs/FY07%20State%20Expenditure%20Report.pdf

5 Williams, P. (2009, February 10). Florida Medicaid: Program Overview. Tallahassee, Florida:

Agency for Health Care Administration. PowerPoint presented to the Senate Health and Human Services Appropriations Committee. Retrieved May 14, 2009, from http://ahca.myflorida.com/Medicaid/deputy_secretary/recent_presentations/medicaid_program_overview_shhsa_021009.pdf

6 Agency for Health Care Administration. Florida Medicaid Summary of Services Fiscal Year 08/09.

Retrieved June 2009 from http://ahca.myflorida.com/medicaid/pdffiles/SS_08_080701_SOS.pdf

7 Gilmore, T., Kronick, R., Fishman, P., & Ganiats, T.G. (2001). The Medicaid RX Model:

Pharmacy-Based Risk Adjustment for Public Programs. Medical Care, 39(11), 1188–1202. 8 Agency for Health Care Administration. Healthy Behaviors with Approved Credit Amounts,

March 10, 2009. Retrieved May 2009 from http://ahca.myflorida.com/Medicaid/Enhanced_Benefits/approved_credit_amounts_031009.pdf

9 Agency for Health Care Administration. Florida Medicaid Reform Application for 1115

Research and Demonstration Waiver August 30, 2005. Retrieved May 2009 from http://ahca.myflorida.com/Medicaid/medicaid_Reform/waiver/pdfs/medicaid_Reform_waiver_final_101905.pdf

http://www.statehealthfacts.org/comparemaptable.jsp?ind=198&cat=4

http://www.kff.org/medicaid/upload/7697.pdf

http://www.nasbo.org/Publications/PDFs/FY07%20State%20Expenditure%20Report.pdf

http://ahca.myflorida.com/Medicaid/deputy_secretary/recent_presentations/medicaid_program_overview_shhsa_021009.pdf

http://ahca.myflorida.com/Medicaid/deputy_secretary/recent_presentations/medicaid_program_overview_shhsa_021009.pdf

http://ahca.myflorida.com/medicaid/pdffiles/SS_08_080701_SOS.pdf

http://ahca.myflorida.com/Medicaid/Enhanced_Benefits/approved_credit_amounts_031009.pdf

http://ahca.myflorida.com/Medicaid/Enhanced_Benefits/approved_credit_amounts_031009.pdf

http://ahca.myflorida.com/Medicaid/medicaid_Reform/waiver/pdfs/medicaid_Reform_waiver_final_101905.pdf

http://ahca.myflorida.com/Medicaid/medicaid_Reform/waiver/pdfs/medicaid_Reform_waiver_final_101905.pdf

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10 Lemak, C. H., Bell, L. L, Duncan, R. P., & Hall, A. G. (2006). Medicaid Reform Health Plans and Networks As of July 1, 2006. Prepared by the Department of Health Services Research, Management and Policy. University of Florida, Gainesville.

11 Agency for Health Care Administration. (2006). Florida Medicaid Reform Quarterly Progress

Report July 1, 2006 – September 30, 2006. 12 Agency for Health Care Administration. (2007). Florida Medicaid Reform Quarterly Progress

Report July 1, 2007 – September 30, 2007.

Medicaid Reform Organizational Analyses

Documents

Transcript of Medicaid Reform Organizational Analyses