Anne Swerlick
|
December 14, 2018

Florida Amends Medicaid 'Good Cause' Rule to Include Important Consumer Protections

The state Agency for Health Care Administration (AHCA) has adopted crucial protections for residents who seek to disenroll from their health care plans for “good cause.” The Florida Policy Institute pushed for these protections in comments submitted to AHCA back in October.

This month, Florida started a statewide roll-out of new Medicaid managed care plans. Over 3 million beneficiaries are affected. Nearly 600,000 will be required to change plans because AHCA is no longer contracting with their current plan.

Once a beneficiary selects a new plan and the time for making a change expires, they are “locked in” for 12 months. However, by law, beneficiaries can disenroll sooner for “good cause.” This is a particularly important consumer protection for people who have a serious illness or disability. They are the ones with the most to lose if they are locked into a plan that cannot meet their needs.

AHCA implements the good cause protections through an administrative rule. In an earlier blog we outlined our concerns with AHCA’s proposed changes to the rule —notably, that they were being pushed out  shortly before the statewide roll out of the new plans. This is a time of transition, when beneficiaries are particularly at risk of disruptions in care. During the public notice and comment period, FPI shared these concerns with AHCA and made specific recommendations for improvements.

On November 26, 2018, AHCA published a Notice of Change made in their proposed rule, which includes some of FPI’s key recommendations:

  • An exception for emergencies – Generally, consumers seeking to disenroll for good cause must first pursue their plan’s internal grievance process. This process can be cumbersome and time-consuming, taking up to 90 days. Now, under the final version of the rule, there’s an exception for consumers “when immediate risk of permanent damage to the enrollee’s health is alleged.” This means that in these emergency circumstances consumers can go directly to AHCA for authorization to disenroll from their plan.
  • Access to specialists and specialty services – Access problems are often prompted by a sudden illness or diagnosis requiring a specialty provider and/or treatment not available from the enrollee’s plan. In the proposed rule, the burden would have been on the enrollee to identify another plan that could provide this care before they could disenroll. This put an unreasonable load on the consumer, typically at a point of severe illness. Even under normal circumstances, it would be extremely difficult and time consuming for them to gather this information. Under the final rule, the enrollee no longer shoulders this burden and should be able to look to AHCA for help in identifying a plan that can meet their needs.
  • Inclusion of fraud as a good cause for disenrollment – The proposed rule had initially excluded this reason under the disenrollment for a good cause umbrella. Under the final rule, a beneficiary can promptly change their plan — and get out of the 12 month lock-in period, for example — if their enrollment was based on misleading information or other plan marketing abuses.

These changes are a win for Florida Medicaid consumers. We applaud AHCA for making these improvements.