Amendments approved June 2013 and October 2016; an application to extend the waiver from 2017 to 2022 was submitted to the federal government on Dec. 20, 2016.
Waiver Approval Period:
July 31, 2014 through June 30, 2017
June 14, 2013
Key Themes from Waiver:
- Managed Care
- Medical Loss Ratio
- Network Adequacy
- Quality Improvement
- Pediatric palliative care
- In 2006, Florida began implementing this waiver that moved beneficiaries from fee-for-service Medicaid into managed care plans. The pilot began in two counties and then expanded to three additional counties. In 2013, the Centers for Medicare and Medicaid Services (CMS) approved a waiver amendment, which allowed the state to extend managed care for most Medicaid beneficiaries throughout the state. This includes children with disabilities. This agreement was the culmination of many years of negotiations between the state and the federal government. Through these negotiations, CMS dropped many of the initial controversial proposals and included consumer protections. Some of these protections include: a medical-loss ratio, a quality strategy, and network adequacy requirements.
- While most beneficiaries must enroll in managed care, there are some beneficiaries who are not required to participate. These populations include: anyone with some other source of health care coverage (other than Medicare), anyone age 65 or older who resides in a mental health treatment facility, anyone in an intermediate care facility for individuals with intellectual disabilities, and individuals with development disabilities who are enrolled in the home and community-based waiver program or are on the waiting list for such services.
- Eligible beneficiaries will have 30 days to select a plan and another 90 days after enrollment to change their selection. Those who do not select a plan will be enrolled automatically into a plan. The demonstration attempts to ensure auto-enrollment criteria consider network adequacy, access, continuity of care, and preservation of existing patient-provider relationships.
- The state is using a competitive process to select managed-care organizations. Enrollees in each of the 11 regions served by managed care organizations will have a choice of at least two plans.
- The demonstration includes a number of requirements on network adequacy. These include policies on network capacity, travel time and distance standards, and availability of appointments.
- All plans providing acute care services will need to spend 85 percent of premium revenues on medical care and report quarterly on their medical-loss ratios. CMS will determine what corrective action will be taken if plans do not meet their ratios.
- The state must implement a comprehensive quality strategy that focuses on quality improvement at the state, plan, and provider levels. The state will adopt a set of quality metrics for this and set targets on the metrics that equal or exceed the 75th percentile national Medicaid performance level.
- The waiver includes a Program for All Inclusive Care for Children (PACC). The PACC program is voluntary and provides pediatric palliative care services for children who have been diagnosed with potentially life-limiting conditions.
Association Principles: The waiver is consistent with CHA’s principles. However, the Florida Children’s Hospital Association is closely monitoring the implementation of this waiver to ensure that the protections that CMS included in the final waiver are enforced.
Association Contact: Shannon Lovejoy, (202) 753-5385