Medicaid waiver coming soon, with patient-protection rules

Medicaid waiver coming soon, with patient-protection rules

By Carol Gentry

This week, federal health officials are expected to give Florida an early Christmas present: an extension on a five-county Medicaid Pilot that requires patients to be enrolled in managed care.

But when state officials unwrap the gift, they’re likely to find a bundle of strings attached. Most of those strings are intended to keep HMOs from shortchanging patients to hike their profits. Some will likely require hospitals to improve quality of care.

Receipt of the waiver extension on the Medicaid Pilot will be a major relief for state lawmakers and the Agency for Health Care Administration, which in Florida governs the joint state-federal program for coverage of low-income patients. AHCA has been negotiating terms of the waiver for more than a year.

But the conditions attached to the waiver also represent some big wins for consumer and medical groups that have protested the program, including Florida CHAIN. Its policy director, Greg Mellowe, obtained a draft copy of the waiver last week and shared a copy with members and Health News Florida.

Among the hard-fought wins he listed:

–At least 85 percent of taxpayer-funded Medicaid payments must go to direct patient care or quality improvements. The Florida Legislature has resisted imposing this requirement on all but a small part of Medicaid HMO funding.

–The benefits that plans offer Medicaid enrollees must meet the needs of at least 98.5 percent of them. One of the arguments in favor of the Pilot had been that it allowed benefit changes that would better fit the needs of enrollees, but consumer groups argued it needed to be clarified and enforced.

–The state must use contract guarantees and other means to assure that plans can’t just pull out of a county, leaving members stranded. Such pull-outs from Pilot counties in the past have led to chaos and made it difficult for patients to find access to care, according to doctors and consumer advocates.

–The state can’t impose co-pays or premiums for Medicaid enrollees in the Pilot that aren’t allowed in traditional Medicaid. As Health News Florida reported last week, a study from Georgetown University concluded that the $10-a-month premiums the state planned to impose would push an estimated 800,000 enrollees out of Medicaid, mostly children.