Advocates Provide Guides and Tips for New Florida MLTSS Program

In September, the National Senior Citizens Law Center (NSCLC), along with the Academy of Florida Elder Law Attorneys and Florida Legal Services Inc., released guides and tips for beneficiaries regarding Florida’s transition from fee for service (FFS) to managed long-term services and supports (MLTSS). This program is called the Statewide Medicaid Managed Care Long-term Care Program (the Program), has an effective date of July 1, 2013 and will last for three years.  Enrollment started on August 1, and The Centers for Medicare & Medicaid (CMS) had approved the Program in February.  The National Council on Medicaid Home Care – a NAHC Affiliate - discusses some of the highlights of the guides and tips, along with other information about the Program.   

Scope and Start Dates

The Program is divided into eleven (11) regions, with enrollment start dates varying between August 2013 and March 2014.  Central Florida, including Orlando, came online first, with 9,300 enrollees on August 1.  Counties in Southwest (5,600 enrollees) and Southeast (7,900 enrollees) Florida including Sarasota and Palm Beach counties followed on September 1.    Total statewide enrollment in the Program will exceed 90,000 beneficiaries.  For a complete map of the regions and their enrollment dates, and enrollee populations, click here.  For a full list of the regions, counties, and enrollment dates, click here. 

MCOs

The Program incorporates both health maintenance organizations (HMOs) and Provider Service Networks (PSNs) (collectively, managed care organizations, or MCOs).  Seven MCOs are participating in the Program to varying degrees.  American Elder Care will be in all 11 regions of the Program, with Sunshine Health in 10 regions, United HealthCare of Florida in 9 regions, Coventry Health Care in 4 regions, Humana and Molina Healthcare of Florida each in 3 regions, and Amerigroup in 2 regions.  Payment will be provided either through a capitated monthly rate, in the case of the HMOs, or a FFS rate in the case of the PSNs. 

Rebalancing Goal

The Program aims to reduce costs and coordinate care for Medicaid’s long-term care population, while emphasizing rebalancing from nursing home services to home and community based services (HCBS). 

Currently, beneficiaries using long-term care comprise just over one third of all Medicaid enrollees in Florida, but consume over two-thirds of Florida’s $22 billion annual Medicaid budget.  Given that nursing home costs to Florida Medicaid amounted to $2.7 billion in 2010, and constituted Medicaid’s highest expense, analysts estimate that the Program can save the state up to $2 billion over its first 10 years, according to the Herald-Tribune.  

As an incentive to support rebalancing, the MCOs gets bonuses for decreasing their share of nursing home enrollees by 2 percent by shifting them to either assisted-living facilities or the home and community.

Covered Services

The Program covers a range of services, including: adult companion care, adult day health care, assisted living, assistive care services, attendant care, behavioral management, care coordination/case management, caregiver training, home accessibility adaptation, home-delivered meals, homemaker, hospice, intermittent and skilled nursing, medical equipment and supplies, medication administration, medication management, nursing facility, nutritional assessment/risk reduction, personal care, personal emergency response system (PERS), respite care, therapies (occupational, physical, respiratory and speech), and non-emergency transportation.  For the full list of services, along with descriptions, see pages 1-3, here.  According to the state, all LTSS currently available through HCBS waivers will be provided under the Program, but terminology may change.

Enrollees

Required Enrollees: With limited exceptions (see Optional Participants, below), the Program is mandatory for beneficiaries of LTSS across the state.  Individuals who are mandatorily enrolled in the Program include: those aged 65 or older with nursing facility needs, and those aged 18 years or older with nursing facility needs that are eligible for Medicaid due to a disability.  Also, those mandatorily enrolled include those enrolled in any of four waiver programs (Aged and Disabled Adult or A/DA, Consumer-Directed Care Plus enrollees in the A/DA, Assisted Living, Frail Ender Option, and Nursing Home Diversion).  These four waivers will be phased out as a part of the Program.

Optional Enrollees: There are several groups that may, but are not required to, enroll in the Program.  Those groups include those enrolled in the Developmental Disabilities Waiver program, and the Program of All-Inclusive Care for the Elderly (PACE).  For a full list of optional participants, click here.  Further instances of Medicaid recipients who may be exempted include those receiving hospice care from an organization not part of a MCO, and those residing in specific nursing facilities.  For details of exemptions, see page 3, here. 

Enrollment Process

Enrollees receive notices to enroll in a plan approximately four months prior to the enrollment start date of their region.  The enrollees then receive a second notice two months prior to the effective date, which lists available managed care plans along with the procedure for selecting a plan.  After this second notice, enrollees have 30 days to review the material and consult with their case managers from their existing waiver programs, where applicable.  If enrollees do not actively choose a plan after those 30 days, the Program will automatically enroll them in a plan.

Enrollees can switch plans within 90 days of enrollment for “good cause,” which includes: enrollment in error, lack of access to covered services and/or providers experienced with the beneficiary’s medical needs, a marketing violation by the MCO, poor quality of care, or state-imposed intermediate sanction.

Enrollment Cap

The provision of HCBS under the Program faces an enrollment cap.  The Program will limit HCBS enrollment to 35,852 at any one time, which is equal to the total enrollment cap of all four waivers being phased out under the Program. According to the NSCLC, this cap will result in waiting lists, and some beneficiaries not able to receive HCBS under the Program may seek services in a nursing home.  This could ironically result in a reversal of re-balancing in some instances.  

Current Providers and Previously Authorized Services

Enrollees are not guaranteed the ability to continue to see their current provider under the Program, unless that provider is included in the plan selected by the enrollee. 

Previously authorized services must continue after the effective date of enrollment, until completion of a new assessment and care plan.  However, the right to continue these services does not exceed beyond 60 days, regardless of whether or not the new care plan has been prepared.

Network Adequacy

Every plan until September 30, 2014 is required to include all aging service providers, hospices, and nursing homes in the region in its network.  For a full definition of aging service provider, see page 3, here.  Following September 30, 2014, these providers are allowed to stay in network, but they can be excluded if they fail to meet quality or performance standards.

Care Planning

The State estimates that 10 percent of enrollees will opt to self-direct their care under the Program.  While Florida’s approved application for the Program mentions that care will be enrollee directed, stakeholders such as the NSCLC are skeptical.  For example, while the application states that the enrollee will direct care with the assistance of the case manager (and others the enrollee chooses to include), the case manager is given the responsibility of developing the care plan (albeit in consultation with the enrollee and others).  Self-direction will be an option with: adult companion, attendant care, home maker, intermittent and skilled nursing care, and personal care services. 

Providers of HCBS services cannot monitor service plan implementation under the Program, to avoid potential conflicts of interest.  However, the NSCLC commented that there are not specific safeguards for this in the Program, as the State’s approved application merely states that “The State requires that responsibility for monitoring plan of care implementation and enrollee health and welfare within the plan be independent of any direct waiver services to avoid conflict of interest issues.”

For NSCLC’s September guides and tips on the Program, click here.  For the NSCLC’s March report on the Program, click here.   For articles on the Program, click here and here.

Analysis

The Council supports the Program and its efforts to re-balance LTSS away from the institution and towards HCBS.  That said, the Council calls on Florida to monitor the enrollment cap, and its potential effect on the reversal of that trend.  The Council also supports Florida funding programs to reduce or eliminate any waitlist for HCBS that may result as a byproduct of the Program.

The Council commends Florida in having a voluntary enrollment period followed by a passive enrollment period, which is what stakeholders advocated for in California’s dual demonstration program.  For more specifics, see the Council’s brief on the matter here.  The Council believes that a hybrid voluntary/passive enrollment, rather than passive enrollment alone, will more positively impact the efficacy of the Program.   

While the Program will transform the way that LTSS users receive care, many unknowns remain for providers, and home care providers specifically.  Concerns remain as to the degree to which care planning is self-directed, and it is unclear specifically to what degree home care providers will be involved in that process.  While the Program contains performance measures for the MCO’s care planning, there is no clear mention of quality standards to which home care providers will be held as part of the Program.

That said, home care providers can look to the Program as an opportunity to increased clinical coordination among the long-term care population. In addition, the Program will give home care providers rebalancing opportunities, as a stronger emphasis, along with financial incentives, is placed on community based systems over institutional settings. Home care providers are encouraged to keep abreast of Program developments on Florida Medicaid’s website, and to contact the Council with any questions or concerns.

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