October 12, 2018

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

This post was last updated on December 8, 2021. As new policies are announced, FPI will update this page.

As Florida’s response to COVID-19 takes front and center, concern grows for low-income families who struggle to take precautions against the spread of the virus. Although Congress has passed the Families First Coronavirus Response Act to address, at least in part,  the public health crisis and economic fallout from COVID-19, many barriers continue to keep struggling families from accessing the assistance they need during the pandemic. As Florida initiates policies implementing the Act and addressing other barriers to the safety net, FPI will update this form. When available, hyperlinks are provided to agency documents or statements that provide greater detail  about the new policy.

On March 22, 2020, FPI and 44 other organizations sent a letter to Governor DeSantis, leadership in the Legislature and agency heads to urge action on 47 specific policy changes to reduce unnecessary barriers for Florida’s safety net programs in response to the COVID-19 pandemic. See the letter here.

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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