April 10, 2017

Transparency is Key to the State's Medicaid Block Grant Request: Will Floridians be Given the Opportunity for Public Review and Comment?

Last week Florida’s Medicaid agency, the Agency for Health Care Administration, sent a letter to the new U.S. Health and Human Services Secretary, Tom Price, requesting changes to its Medicaid demonstration waiver. The current waiver provides the framework for Florida’s statewide Medicaid managed care program.

It has been the practice of Florida’s Medicaid agency to vet proposed waiver requests with the public and actively seek recommendations from interested stakeholders prior to submitting these requests to the federal government.  This has included a publicized formal request for review and comment. Is the state now veering from this practice and if so, why?

The letter lays out broad and somewhat vague requests to the federal government, including:

  • A block grant of supplemental federal Medicaid payments to the state;
  • Flexibility to set eligibility criteria and eliminate retroactive Medicaid eligibility;
  • Undefined initiatives to “discourage” uncoordinated and inappropriate emergency room visits; and
  • Waiver of federal protections to ensure Medicaid HMO compliance with “network adequacy” standards.

But the devil is truly in the details. The proposal raises many unanswered questions both for Medicaid beneficiaries and Florida taxpayers at large. How will these requests impact beneficiaries? Safety net providers? Local government budgets?

For example:

Request: Block grant supplemental Medicaid payments

Charitable and safety net hospitals have long provided uncompensated care to low-income and underserved individuals. To help offset the cost of this care, many of these hospitals are eligible to receive supplemental payments.  Under the Affordable Care Act, these funds decreased based on the assumption that there would be less uncompensated care due to Medicaid expansion. It was recognized that supplemental payments are no substitute for health care coverage. But in 19 states, including Florida, Medicaid expansion has not happened and 800,000 vulnerable Floridians remain uninsured.

So why does the state now want a “block grant” of these supplemental payments? What does the state want to do with these funds that it is not currently able to do? Use them for something other than health care for the poor or underserved? What impact will this waiver have on Florida’s uninsured being able to access charity care? Will this increase uncompensated care and/or shift more costs to local government?

Request: Elimination of retroactive Medicaid

Retroactive Medicaid provides coverage up to 3 months before the month in which someone applies for Medicaid. It protects struggling families when they incur enormous medical bills due to unexpected health care disasters like an accident, a heart attack or cancer; it also protects elderly patients in nursing homes, who — after exhausting their own funds for care — incur substantial nursing home charges before they or their families can submit a Medicaid application. Under the state Medicaid agency’s proposal, on top of dealing with the suffering from a major health disaster or decline, these families will now face staggering debt and financial insecurity. What is the state’s rationale for making this change?

Request: Waiver of federal managed care rules on network adequacy

Managed care rules go to the heart of major complaints from beneficiaries enrolled in managed care plans; they can’t find a doctor or the only doctor available is hundreds of miles away. There is a long history of Medicaid plans having sham provider networks. For example, a physician may be listed in the plan’s provider directory, but they don’t have a contract with the plan or are not seeing new patients. Federal regulations require that the state set time and distance standards to ensure that patients can find a doctor nearby and that key information (such as whether the provider is seeing new patients or whether their offices are accessible) be included in a provider directory.  Although the state Medicaid agency has critical plan oversight responsibilities, under its proposal, the agency would not know there is an access/network adequacy problem until a plan report is made months after a beneficiary has an “avoidable” hospitalization. Looking at these health “outcomes” after the fact is important, but it doesn’t address in real-time problems families face when seeking care from a plan with an insufficient network of providers.

There are valuable consumer protections and policies underlying the legal requirements the state seeks to waive. The public has a right to know the details of what the state wants to do, the rationale behind their waiver requests and the health and economic impact on beneficiaries, safety net providers and local governments.

Florida’s Medicaid agency has taken a publicly responsible path in the past, and we urge them to continue this trend of sunshine, transparency and accountability.

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