hidden

hidden

hidden text

Overview

In Florida, the Statewide Medicaid Managed Care (SMMC) delivers services to most Medicaid eligible individuals.  The Statewide Medicaid Managed Care program was implemented in 2013-2014.  Phase one, implemented in 2014, fully integrated medical, dental, behavior and transportation into Managed Care. Phase two was implemented in 2019 and fully integrated medical care, long-term care, behavioral and transportation into managed care.

The 2016 Florida Legislature directed the state to implement a dental component of the SMMC program for children and adults separate from the Medicaid MMA Program.  As a result, AHCA contracted with three dental plans to provide statewide dental services under SMMC beginning in December 2018.  The dental plans are responsible for providing scheduled Medicaid dental services to most Medicaid recipients who are currently in the fee for service and SMMC delivery, while the health plans remain responsible for transportation to dental appointments, prescriptions drugs for dental care, and for non-scheduled hospital dental visits.  The dental plans were made available based on a phased roll out schedule beginning December 1, 2018. This resulted in a drastic decline in Dental claims received by HMS during 2019.

Today, there are three different programs that makeup the Statewide Medicaid Managed Care:

Managed Medical Assistance (MMA) Program

Long-term Care (LTC) Program

Dental Program

hidden

hidden

This is a hidden content

Eligibility

In Florida, Medicaid recipients may receive services from fee for service (FFS) providers because certain Medicaid populations are either not eligible or not required to participate in managed care.

Medicaid recipients who receive services under the FFS payment methodology (not eligible for the MMA Program) include (3):

  • Women eligible only for family planning services via a waiver;
  • Women eligible through the breast and cervical cancer services program;
  • Persons eligible for emergency Medicaid for aliens;
  • Medically Needy, which allows for Medicaid eligibility for over income individuals with significant medical expenses.
  • Recipients who are either enrolled, or waiting for services, in the developmental disability home and community based service waiver (iBudget)
  • Medicaid-Medicare dual eligible whose Medicaid benefits are limited; QMB (Qualified Medicare Beneficiary), SLMB, Specified Low-Income Medicare Beneficiary program, and QI (Qualifying Individual)

In addition, there are Medicaid recipients in Florida who may choose to enroll in MMA but are not required to participate. In instances where the recipient does not elect to participate In MMA, services will be paid as FFS where covered. These include:
• Recipients who have other credible health care coverage excluding Medicare;
• Persons eligible for refugee assistance;
• Recipients who are residents of a developmental disability center;
• Children receiving prescribed pediatric extended care center services;
• Recipients residing in a group home facility licensed under Ch. 393, Florida Statutes.

hidden

hidden

hidden

hidden

hidden text

Data Considerations

HMS does not receive Managed Care Organization (MCO) claims with encounter data under its contract with the Florida Agency for Health Care Administration, as the MCO entities are responsible for coordination of benefits and recovery.

Because of the MCO migration, the FFS claims data HMS receives as declined in the past five years as more and more of Florida’s Medicaid recipients migrated to its SMMC program.   

The managed care dental plans rolled out beginning December 1, 2018 resulted in a drastic decline in Dental claims received by HMS during 2019.

The FFS population represents the claim data universe HMS receives under its contract with the Florida Agency for Health Care Administration.

 

 

Sources

Subscribe to our newsletter