October 18, 2021

Florida's Medicaid Managed Care Program Falls Far Short on Providing Quality Behavioral Health Care

This post was last updated on September 29, 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.

The findings of a recent independent evaluation of behavioral health services provided through Florida's Statewide Medicaid Managed Care (SMMC) program are alarming. They show that statewide average performance on all 16 measures related to behavioral health failed to meet targets set by the Agency for Health Care Administration (AHCA).  Even more troubling is that for half of these measures, performance ranked below minimum targets set by AHCA.

Over 3 million Floridians covered by Medicaid are required to enroll in and receive services — both physical and behavioral health — through the SMMC program. Through this program AHCA contracts with managed care organizations (MCOs or plans) — primarily for-profit health maintenance organizations — to provide these services.  MCOs are paid on a “capitated” basis, meaning they receive a flat monthly payment per enrollee, regardless of actual services provided to the enrollee.

Many Medicaid enrollees encounter problems accessing needed services because MCOs may have insufficient provider networks, onerous prior authorization requirements, and other roadblocks to obtaining care. And notably, MCOs may have a financial incentive to deny care. If enrollees use fewer services, the MCOs can keep a chunk of unused funds as profit.

By federal law, AHCA is required to contract annually with an “external quality review organization (EQRO)” to do an assessment and prepare a report detailing plan performance on various quality metrics. Florida's April 2021 report, as well as older ones, can be found on AHCA’s website. They provide a wealth of information on how the SMMC program is doing overall, as well as plan specific data. 

In 2021, the EQRO assessed the following behavioral health quality measures:

  • Follow-up care after emergency department (ED) visits or hospitalizations for mental illness or alcohol/drug abuse
  • Antidepressant medication management
  • Adherence to antipsychotic medications for individuals with schizophrenia
  • Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medications
  • Metabolic monitoring for children & adolescents on antipsychotics

(For more detail on why these measures matter, see explanations here from the National Committee on Quality Assurance, the organization responsible for development of plan performance measures referred to as "HEDIS"-Healthcare Effectiveness Data and Information Set.) 

The EQRO findings paint a very bleak picture. For example: In only 6.19 percent of the instances when people went to the ED due to alcohol or drug abuse did they have a follow-up outpatient visit with a mental health practitioner within seven days. This percentage minimally increased to 9.42 percent in looking at 30-day follow-ups. These numbers are particularly troubling given recent news that over 7,500 Floridians died in 2020 from opioid overdoses — the second highest number in the nation.

The rate of follow-up care within 30 days after an ED visit for mental illness, 43.03 percent, is better, yet still shows that most beneficiaries are not getting follow-up within that time frame, if at all. (See Fig. 1.)

Financially, 2020 was a banner year for the five largest health insurance companies in the national Medicaid managed care market, four of which are part of Florida's SMMC program. Notably, in the 2021-22 fiscal year, the Legislature has appropriated a record $22 billion to the SMMC program.

However, how much of this multi-billion appropriation translates into behavioral health services is far from transparent. Before Medicaid managed care, there was a separate line item in the General Appropriations Act (GAA) for Medicaid-funded community mental health services. Now there are just two large lump sums, designated in the GAA for “Prepaid Health Plans” and “Prepaid Health Plan/Long Term Care.” These sums are appropriated to AHCA for contracting with MCOs to deliver a broad range of services, not just behavioral health.

On national rankings Florida has consistently ranked in the bottom on per-capita state investments in behavioral health. A common retort by legislators has been that these rankings do not look at the state's Medicaid funding for behavioral health. .   

Well, it's high time to do that. Not only to look at what the state spends, but also to look at what the managed care plans are actually spending for these services.

AHCA collects “encounter data” from the Medicaid plans. This is a record of specific services delivered to plan enrollees for which the plans pay. The Legislature has directed the agency to use this data to “identify possible cases of systemic underutilization or denials of claims and inappropriate service utilization such as higher than expected emergency department encounters.” Without this data, “what goes on inside MCOs is essentially a black box.”

The EQRO report findings should be a red flag for policymakers to further look at what is happening in the black box. Linking information on the actual services provided and public dollars paid to the MCOs to deliver behavioral health services is critical. This analysis needs to be done in a way that is transparent and accessible for the public and legislators and is desperately needed before Florida's next multi-billion dollar investment in the SMMC.  

Downloadable Resources

There are no attachments currently.
This is some text inside of a div block.

Fully Funding Mental and Behavioral Health Services

Florida has historically underinvested in mental health

Learn More