Although they're not expanding Medicaid under the Affordable Care Act, Texas, Florida and other states are expanding managed care, bringing insurers opportunities as well as challenges, including competition from provider-based health plans.
In Texas, the unduplicated enrollment numbers in Medicaid managed care programs total approximately 2.84 million residents, and Superior HealthPlan, a subsidiary of Centene, and Amerigroup, a subsidiary of WellPoint, have received the bulk of managed care organization contracts over the past few years.
The Texas Health and Human Services Commission's managed care contracts include requirements that organizations have sufficient capacity to serve the expected enrollment, meet service area needs with geographic distribution of preventative, primary care, and specialty service providers, and report how often members go out of network.
In Florida, the Statewide Medicaid Managed Care program is being rolled out in two phases. The first phase, the Long-term Care program, serves recipients who are disabled and/or over the age of 65, and was completed on March 1, 2014, enrolling approximately 90,000 residents.
The second phase, the Managed Medical Assistance program, provides acute care services such as inpatient and outpatient hospital services or prescription drug coverage to eligible recipients of all ages. The rollout for the Managed Medical Assistance program began in early May and should be completed on August 1, 2014 -- and is anticipated to cover more than three million.
During its competitive procurement process, the Florida Agency for Health Care Administration negotiated with and is requiring managed care plans to have robust provider networks, with the requirements being the state Medicaid program's most comprehensive ever, said Jamie Sowers, outreach coordinator at the Florida Agency for Health Care Administration.
"We are confident that the provisions of the SMMC program will provide recipients with better access to both primary care physicians and specialists than they had under the previous fee-for-service delivery system," Sowers said. If a managed care plan violates any portion of the contract, including network adequacy standards, it may be sanctioned or have liquidated damages imposed for lack of compliance."
In addition, Sowers said Florida managed care plans must enter into provider contracts with at least one full-time equivalent (FTE) primary care physician per 1,500 enrollees. The managed care plan may increase the ratio by 750 enrollees for each FTE advanced registered nurse practitioner or physician's assistant affiliated with a primary care physician.
Patient advocacy concerns
In Texas, the expansion of managed care into new areas have brought concerns about the adequacy of some health plan networks, as well as fears that health plans would deny or reduce benefits. Some advocates also worry that patients may not understand the changes.
"There are many more regulations we have to comply with; I wish they were uniform," said Yasser Fahmy Zeid, MD, an OB/GYN at Zeid Women's Health Center in Longview, Texas. "But there are still a few patients on traditional Medicaid, which are easiest to take care of."
"One problem is that patients can change from one managed care company to another almost on a monthly basis," Zeid said. "Each company has its own rules and regulations to comply with. Oftentimes, you don't know which company a patient is insured by until they arrive for an appointment. It takes a lot more staff time to verify which company they are with."
Texas Health and Human Services Commission spokesperson Linda Edwards Gockel said the agency "works closely with providers, clients, and advocates to address concerns and explain everything the state does related to client outreach, measurement of network adequacy, and transitions of prior authorizations and benefits from the fee-for-service system to managed care."
"HHSC staff travel to cities across the state and present information sessions for providers and consumers. And we continue to meet with stakeholders on a regular basis to work through questions and concerns," Gockel said.
The Florida Agency for Health Care Administration has worked closely with advocacy groups to answer questions and provide information as it works to implement both the Long-term Care and Managed Medical Assistance components of the SMMC program.
Sowers said the primary questions from advocacy groups are about managed care plan assignment; whom to contact if patients want to change plans or if they have questions on being required to enroll in a plan; eligibility for specialty plan enrollment; and, for long-term care program enrollees, care plan development.
And in Florida, in addition to established managed care insurers like Amerigroup, Centene, Humana and UnitedHealth, some providers are starting to directly cover Medicaid beneficiaries through their own health plans.
The Jessie Trice Community Health Center, an FQHC with 16 facilities, is covering Medicaid beneficiaries in eight of Florida's eleven Medicaid regions, including greater Miami, through a for-profit plan, Prestige Health Choice, that it created in 2008.
The Jessie Trice Community Health Center's move to launch its own Medicaid plan -- officially called a provider service network, as opposed to an HMO -- has garnered a fair amount of interest from other Florida health payers and providers.
Florida Blue and AmeriHealth Caritas ended up buying a 40 percent stake in Jessie Trice's Prestige Health Choice through a partnership called Florida TrueHealth, while Florida Health Choice Network, a consortium of 23 community health centers and FQHCs, took a 13 percent stake.
Three other provider service network Medicaid plans are taking part in the managed care transition, including First Coast Advantage, a Medicaid plan created by University of Florida Health, in the region serving greater Jacksonville, and Integral Health Plan, sponsored by Healthcare Network of Southwest Florida and the Association of Area Delivery Systems, a group of FQHCs, in two regions on the southwest coast of Florida.