SEBRING — The majority of Medicaid recipients in Highlands County have until Aug. 1 to enroll into managed care plans under Florida’s massive overhaul to privatize its Medicaid program.
The change comes three years after the Legislature voted to privatize the program, saying the roughly $23 billion a year bill was consuming the state budget.
The transition to the Statewide Medicaid Managed Care program is broken up into two components.
The long-term care population, which includes those 65 and over who reside in nursing homes, recently completed enrollment.
Enrollment in Managed Medical Assistance or the second part of the phase is underway in Highlands County, which is a part of Region 6. Many of these are children.
As of June 1, 14,381 Medicaid recipients were enrolled in a MMA plan in Highlands County, said Shelisha Coleman, Agency for Health Care Administration spokeswoman.
Those who don’t enroll in a plan by the deadline don’t lose coverage. The state will chose a plan for them but experts warn they may not be the right one for their health needs.
Coleman said they don’t have the long-term care enrollment by county readily available as of yet, but as of June 1, there are 8,710 recipients enrolled in a plan in Region 6.
Avon Park’s Oaks at Avon was one of the area’s nursing homes whose patients had to choose plans.
Its administrator Melissa Fijalkowski said the transition went smoothly.
“We needed to educate our patients and their families”on plan choices, she said. Compared to some other regions, she felt Highlands County had a relatively higher number of plans offered, which, she said, was a good thing.
One big change under the managed care system is that their Medicaid recipients will get a personal case manager, who will be able to decide if patients are able to, say, move up to an assisted living facility.
“The personal case manager will be able to decide what’s more appropriate for them (the recipients),” she said.
John Gountas, The Florida Department of Health in Highlands and DeSoto County spokesman, said the most common question their clients have asked is what kind of insurance the health department accepts.
In Highlands County there are seven plans being offered, which is a blend between the PPO and HMO systems, said the health department’s Penny Kurtz.
“We let them know which ones we accept, and if they are on a plan that we do not accept, we let them know that on their insurance card it has the Primary Care Provider’s (PCP) name and office number that they have been assigned to,” Gountas said.
The health department has also encountered some confusion over how to change providers or plans.
If clients want to receive services at the Florida Department of Health in Highlands County, they have 90 days after enrollment to switch their plan to one the health department accepts by calling their Medicaid plan or 1-877-711-3662 or by going to www.flmedicaidmanagedcare.com.
Kurtz said it is important that Medicaid recipients be “educated consumers.” One of the first things they may want to find out is if their existing doctors are on the plans they are looking at, should they want to continue seeing them.
Gountas advised recipients to review all the mail they receive from Medicaid “as it gives them the steps that they need to take in order to choose a plan/provider.”
Medicaid recipients need to be aware of the provider they are assigned to. This information can be found on their card, he said.
They also need to have a better understanding of the services that their new plan covers, he said. Services that where covered in the past may not be covered under their new plan, he added.
More than three million Medicaid recipients around the state are transitioning into managed care under the privatization.
Health advocates have worried about lapses in care during the transition, especially because the program is built on a controversial five-county pilot where many insurance companies dropped out and patients struggled to access doctors and treatments.
Under the new agreements, insurance companies are required to honor appointments or treatments that were already scheduled under another insurance company even if the provider is out of network. The lists of provider networks are also closely monitored — a huge problem with the federal health law — and uncompliant insurers can face financial penalties or potentially lose their contract.
Other states have privatized their Medicaid program but the Sunshine State is one of the first to enroll the more vulnerable long-term care group. Experts say this was also the first time federal officials required certain oversight components, including requiring insurers to spend 85 percent on patients.
“On paper, I think this is one of the stronger agreements that we’ve seen with the federal government and I think that reflected the very high level of concern with Florida’s Medicaid managed care,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families.
Medicaid privatization has also been politically factious as federal health officials had to approve the state’s request, a lengthy negotiation after the bungled pilot program. Some experts predicted that if the feds approved the program that Republican Gov. Rick Scott would support expanding Medicaid coverage to nearly 1 million additional Floridians under the Affordable Care Act. Scott backed expansion in 2013 but did little to promote the cause and the Legislature rejected it.
The statewide privatization, a victory for state Republicans, meant Florida had to convince federal health officials that mistakes from the pilot wouldn’t be repeated. Federal officials said Florida needed to address quality-of-care and transparency issues and is requiring the state to report data that captures what services are being provided and denied.
Under Medicaid privatization, the state gives insurance companies a set amount of money each month (between $300 and $428 a month for a woman between 14 and 54-years-old) to care for a patient, giving the insurer broad authority to care for the patients, including which doctors they can see and what treatments can be prescribed.
The state says insurance companies were required to have a larger network of doctors, hospitals and providers compared to the number of consumers.
Critics worry the state is abdicating care of its most vulnerable residents to for-profit companies with little oversight of how the money is being spent and say there’s little evidence the pilot program improved patient care or saved money.
Insurance companies say they have an incentive to control costs by linking patients up with primary care doctors early on instead of treating them in more expensive setting like emergency rooms.
The Associated Press contributed to the report: