October 12, 2018

AHCA Seeks to Make It Harder for Medicaid Enrollees to Disenroll From Their Health Plans for 'Good Cause'

Nearly 600,000 Florida Medicaid enrollees will be required to move to new health plans because the state Agency for Health Care Administration (AHCA) is no longer contracting with their current plan. Starting in December 2018, these enrollees will be automatically enrolled in new plans, but have a 120-day window to pick a new plan. If they don’t, they will be locked into the plan that AHCA has automatically selected. This means they will not be able to change plans for the next 12 months, until their next open enrollment period, whether or not the plan is meeting their needs.

However, by law, enrollees have the right to change plans sooner if they have “good cause.” This is particularly important for thousands of Medicaid enrollees who live with complex medical conditions and disabilities.  They are more likely to need health services and suffer from disruptions in their care when shifted to new plans and providers. A good cause disenrollment process that is fair, responsive and timely is essential to minimizing disruptions in care.

The good cause process and reasons are spelled out in AHCA rules. But now, just at the time when thousands of beneficiaries will be assigned to new plans, AHCA is proposing changes that will make it more difficult for people to disenroll for good cause. For example, the agency seeks to further restrict the right to disenroll when a provider is no longer in the enrollees’ plan network or when an enrollee can’t access providers experienced in treating their specific medical conditions.

Moreover, current AHCA good cause rules omit a critical protection for enrollees in emergency circumstances. Normally, people are required to pursue the plan’s grievance process before they ask the agency for permission to disenroll for cause. But Florida law makes an exception to this requirement when “immediate risk of permanent damage to the recipient’s health is alleged.”  It’s misleading to not include this exception in AHCA’s rule when it otherwise describes the good cause disenrollment process.

AHCA recently held a public hearing on the proposed changes, during which the Florida Policy Institute and other stakeholders voiced their concerns. The Institute also submitted detailed written comments urging the agency to withdraw the proposed rule amendments. AHCA has until Dec. 5 to make a decision.

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