Public Health
Three-Year Extension of Medicaid Reform Pilot with Mandated Changes
Federal Centers for Medicare & Medicaid Services (CMS)
December 14, 2011
Under a waiver from the federal Medicaid Act, Florida has operated a pilot project in five counties that requires most Medicaid recipients to enroll in a managed care plan. When the five-year authorization for this project ran out last year, AHCA requested a three-year extension from CMS. After more than a year of negotiations and temporary extensions, CMS issued it approval, but requires additional assurances and commitments, including:
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At least 85% of taxpayer-generated Medicaid payments must be spent on patient care or direct care quality improvement
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A minimum standard for Medicaid benefit plans must be defined that meet the needs of 98.5% of enrollees
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MCOs should be held accountable for access to care and quality of care
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Patient continuity of care is required, along with additional assurances to prevent MCOs from pulling out of a geographic area
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Choice counseling needs to expand
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The same rules for eligibility and co-payments as apply elsewhere in Medicaid should apply to MCO enrollees
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Medicaid recipients who “opt out” to use an employer’s plan should be protected from deficient plans
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The State must begin planning for expansion of Medicaid in 2014 under the Affordable Care Act
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The State must obtain federal approval for any statewide expansion (either geographically, or beyond the current patient population of SSI participants and families with children)
Federal Denial of Florida Request for Waiver of Medical Loss Ratio
Federal CMS, Center for Consumer Information and Insurance Oversight
December 15, 2011
The mandated Medical Loss Ratio for the individual health insurance market under the Affordable Care Act is 80% for medical claims and 20% for administrative expenses. If the MLR isn’t met, the law requires the insurance company to send subscribers rebates. The law permits an adjustment to the 80 percent MLR standard for a State’s individual health insurance market if it is determined that applying this standard “may destabilize the individual market in such State.” The State of Florida applied for a waiver to adjust the standard to 68% for 2011, 72% for 2012 and 76% for 2013. This request was denied by CMS. Based on figures from 2010, reports suggest that failure to adhere to the MLR could result in consumer rebates of about $60 million for the next three years, with United Healthcare and Humana the companies most likely impacted.
Preliminary Injunction Against AHCA Cut in Payments to ICF/DDs
Circuit Court Judge Valerie Manno-Schurr, Miami-Dade County
January 4, 2010
In a lawsuit filed by 19 providers and one Medicaid recipient, the Circuit Court issued a preliminary injunction to keep provider rates at “status quo” pending the outcome of the suit. The plaintiffs are arguing, among other things, that AHCA exceeded its legislative authority because the rate cuts resulted in less funding than the amount specified in the appropriations bill.
Permanent Injunction Issued for Nursing Home Resident Seeking Medicaid Payment of Home Based Services, But Class Action Decertified
Lee v. Dudek, Case No. 4:08cv26-RH/WCS
District Court Judge Robert Hinkle, Federal Northern District of Florida
January 3, 2011
In a case filed in 2008 under the Olmstead doctrine of the Americans with Disabilities Act, Medicaid recipients who were currently residing in nursing homes sued AHCA and Department of Elder Affairs to allow them to use Medicaid funds for services to live within the community. The court originally certified as a class action, but a stay was entered when the State passed legislation that would allow diversion of funds for Medicaid nursing home care to transition participants into the home or community. Of the seven named plaintiffs, five died in the interim and one chose not to transition when his family moved away.
After litigation concerning the impact and implementation of this “diversion,” the Court recognized “flaws and weaknesses” in the transition program, including an eligibility standard that screened out any candidate who needed 24-hour care, was cognitively impaired, or did not have friends or family willing to provide housing or support. Assuming that these admitted errors had been corrected by the State, the Court decertified the class. Nonetheless, despite the fact that state agreed to continue benefits, the remaining plaintiff was granted a permanent injunction to assure that he receive services to allow him to live at home.
US Supreme Court Set Oral Argument for Challenge to Affordable Care Act
December 19, 2011
Florida, along with 25 other states and the National Federation of Independent Businesses, has challenged the constitutionality of the federal Affordable Care Act, particularly the provision that requires individuals to procure health insurance or face a penalty (the so-called “individual mandate“). The Circuits have split on this issue.
Oral argument is scheduled for three days – from March 26, 2012 through March 28th. The Court will rule on four key questions: whether the individual mandates are constitutional, whether the Medicaid expansions are constitutional, whether challenges to the law are premature under a provision known as the Anti-injunction Act and whether overturning the individual mandate would topple the entire law.
Reported by: Nancy E. Wright