Florida Medicaid Managed Care Contract


Florida Medicaid Dental Plan Continuity Of Care

Judge Rules Against State On Medicaid Contract

The Agency for Health Care Administration contracts with Medicaid Dental Plans to provide dental services to dental plan enrollees in the Statewide Medicaid Managed Care program. The Agency recently entered into a contract with LIBERTY Dental Plan as one of three statewide Medicaid Dental Plans.

LIBERTY Dental Plan is required to ensure continuity of care during the transition period for Medicaid recipients enrolled in the SMMC program. The transition will occur by Region in 3 Phases, beginning with Regions 9 through 11 on December 1st:

COC requirements ensure that when enrollees transition from one health or dental plan to another, one service provider to another, or one service delivery system to another , their services continue seamlessly throughout their transition. The Agency has instituted the following COC provisions under its contract with LIBERTY:

More information about COC provisions can be referenced on the COC program highlight document, which is posted on the Agencys website at www.ahca.myflorida.com/smmc . Once on the page, click Program Changes, then the Outreach and Presentations link.

Member Dental Home Assignments

LIBERTY Dental Plan is temporarily removing the requirement of Member Dental Home Assignment.

Effective immediately your office will only need to verify Eligibility prior to scheduling and treating our Medicaid enrollees. The enrollee does not need to appear on your roster in order to be seen. Additionally, based on claims received LIBERTY will transfer your patients to your office for you.

Members DO NOT need to call to transfer, if they require a transfer they can complete the transfer on our website.

Please refer to the provider alert Florida Medicaid Dental Home Assignment Relief sent on 1-23-2019 and posted on your secure provider portal for waiver period in your Region.

Health Plans And Program

In Florida, most Medicaid recipients are enrolled in the Statewide Medicaid Managed Care program. The program has three parts: Managed Medical Assistance, Long-Term Care, and Dental. People on Medicaid will get services using one or more of these plan types:

Managed Medical Assistance : Provides Medicaid covered medical services like doctor visits, hospital care, prescribed drugs, mental health care, and transportation to these services. Most people on Medicaid will receive their care from a plan that covers MMA services.

Long-Term Care : Provides Medicaid LTC services like care in a nursing facility, assisted living, or at home. To get LTC you must be at least 18 years old and meet nursing home level of care .

Dental: Provides all Medicaid dental services for children and adults. All people on Medicaid must enroll in a dental plan.

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State Guide To Cms Criteria For Medicaid Managed Care Contract Review And Approval

This guide covers the standards that are used by the Centers for Medicare & Medicaid Services Division of Managed Care Operations staff to review and approve State contracts with Medicaid managed care organizations , prepaid inpatient health plans , prepaid ambulatory health plans , non-emergency medical transportation prepaid ambulatory health plans , primary care case management entities , and health insuring organizations .

Florida Medicaid Officials Assessed More Than $1 Million In Damages Against All 11 Managed Health Care Plans That Have Contracts With The State As Well As Three Managed Dental Care Companies

Centene awarded most contracts in Florida Medicaid bidding ...

Florida relies on managed-care companies to provide Medicaid coverage to 3.7 million low-income and elderly residents, but a review of data assembled by regulators shows that the companies have been hit with dozens of complaints that have resulted in the state requesting millions of dollars in payments.

In the first three months of 2021, Florida Medicaid officials assessed more than $1 million in liquidated damages against managed-care plans, according to Agency for Health Care Administration data updated last week.

The state imposed the damages because of 91 alleged violations of Medicaid contracts. The damages were imposed against all 11 managed health-care plans that have contracts with the state, as well as three managed dental-care companies.

The state also imposed damages against Magellan Health for alleged violations during the time frame. Magellan Health offers a Medicaid managed-care specialty plan for people with serious mental illness.

Sunshine Health Plan, which is owned by Centene, had the most complaints — 11 — from January to March, resulting in the state assessing $116,500 in damages. A review of the information shows that four of the allegations focused on the adequacy of the plans provider network.

Records kept by AHCA show that regulators assessed nearly $7 million in liquidated damages against Medicaid managed-care plans between July 1, 2020, and March 30 for 214 alleged contract violations in the first nine months of the 2020-21 fiscal year.

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Medicaid Managed Care Contracts

  • Carol Gentry,Univita Health, which gained control of the entire Florida Medicaid home-care market a year ago, has suddenly lost all of its HMO contracts.The Florida
  • Associated Press,A state health care official has criticized a proposed rate increase by private health plans that cover Florida’s poorest residents.The Tampa Bay Times Listen 0:48
  • Carol Gentry,Medicaid health plans, which lost $543 million in the first half-year of Floridas Statewide Medicaid Managed Care program, have been hoping for major
  • ,Take a look at the top health care stories in Florida in 2014, and its clear that the business of Medicare and Medicaid continued to dominate the
  • Carol Gentry,Its much too soon to say whether this summers flood of Florida Medicaid patients into private managed-care plans will accomplish the states goals of
  • Health News Florida ,A South Florida health plan ramped up its legal challenge to the states decision to award a Medicaid managed-care contract to a competitor, the News
  • ,Milagros Medina rents a room in a quiet subdivision on the outskirts of Lakeland. At 68, her arthritis, high blood pressure and chronic back pain are not Listen 4:52

Your Medicaid Fair Hearing Rights

Under Federal and State Law you have the right to file a Medicaid Fair Hearing request. Below are times when you can file a Medicaid Fair Hearing request:

  • If you disagree with the denial, reduction, suspension or termination of Medicaid service or services made by AHCA for regular Medicaid or your Statewide Medicaid Managed Care Plan.
  • If you disagree with AHCAs denial of a For Cause plan change request.
  • How to file a Medicaid Fair Hearing
  • Deadlines for filing a Medicaid Fair Hearing

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Provider Service Network Rebid

The SMMC program requires at least one plan in a region be a Provider Service Network if any PSN submits a responsive bid. If AHCA determines that there was no PSN responsive bid, they are to reserve one less than the maximum number of eligible plans permitted in that region. Within 12 months after the initial ITN, the AHCA is required to attempt to procure a PSN.

Because there were no responsive bids in regions 3, 4, 5, 6, and 7, AHCA recently released another ITN for MMA PSN services on September 25, 2018. Binding letters of intent were due October 19, 2018 with responses due December 17, 2018. Negotiations will occur over a one-month period in March 2019 with awards anticipated March 26, 2019.

For further information and presentations regarding SMMC MMA, LTC and dental program changes see:

Please contact Elaine Peters:

What Are My Florida Medicaid Waiver Long

Webinar on Medicaid Managed Care Contract Provisions for Health Care Transition

The Statewide Medicaid Managed Care program providers can be found on the Florida Medicaid Managed Care website. Some of the Florida Statewide Medicaid Managed Care LTC Plan Choices are :

  • mobile personal emergency response system
  • non-medical transportation
  • OTC – over the counter medications and supplies
  • vision services
  • Waiting lists / waiting times for home and community based care are not expected to change. Priority is given to individuals based on their level of need for services.

    LTC providers will provide personal care services for those who qualify, and if specified in the enrolleeâs plan of care , including: pest control, homemaker, companion, chore, enhanced chore, and home delivered meals. Through the Participant Direction Option the participant can sometimes choose who will provide their services . Rates for PDO services are set by the LTC plans.

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    Florida Hits Medicaid Plans With $2m In Contract Breach Sanctions

    News Service of Florida

    TALLAHASSEE, Fla. Managed care plans were sanctioned 187 times and paid more than $2 million in damages during the 2019-2020 state fiscal year for breach of Medicaid contracts, according to information released by the state.

    The Florida Agency for Health Care Administration website shows that during the fiscal year, which ended June 30, 13 Medicaid managed-care health plans, one Medicaid specialty plan and three managed dental plans faced sanctions for failing to adhere to contract requirements.

    Staywell Health Plan, which has the largest market share in the states Medicaid managed-care system, had the most sanctions with 24 and the largest amount of liquidated damages with $668,150, according to the data, which was made publicly available Friday.

    Eight of the sanctions against the company stemmed from provider services violations, which included issues related to network adequacy, payment, credentialing and contracting and untimely or inaccurate reporting.

    For those eight violations, Staywell paid $261,750 in damages.

    Overall, provider services accounted for nearly one-third of the total number of sanctions during the fiscal year, with the state assessing $673,250 in liquidated damages against plans for 61 violations.

    In terms of dollars, though, state regulators assessed $732,050 in damages when managed care plans failed to follow contract requirements for covered services and authorizations.

    News Service of Florida

    What Is The Role Of Area Agencies On Aging

    The local AAAs provide education about the long-term care programs , screen individuals for the HCBS waiting list and assist with the completion of medical and financial eligibility.

    Related Florida Medicaid Resources

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    Medicaid Managed Ltss Program & State Initiative To Integrate Care For Dual Eligible Individuals

    The Florida Long-Term Care Community Diversion Program, operating under §1915 and §1915 waiver authorities, provided community-based services to people who would otherwise qualify for Medicaid nursing home placement. The LTC Community Diversion Program was phased out in 2014.

    The 2011 Florida Legislature passed HB 7107 which directed the state to restructure its Medicaid program into an integrated managed care program requiring almost all Medicaid recipients to receive covered services through the Statewide Medicaid Managed Care program. In August 2011, in accordance with this legislation, the state submitted to CMS concurrent §1915 and §1915 waiver applications to implement the Florida Long Term Care Managed Care Program. §1915 waiver application

    In February 2013, CMS approved the states §1915 Florida Long Term Care Managed Care Program combination waiver, effective July 1, 2013 through June 30, 2016. From August 2013 through March 2014, the state regionally phased out five of its current HCBS waivers and transitioned eligible recipients from its LTC Community Diversion Program into its new Statewide Medicaid Managed Care Long-Term Care Program. Mandatory enrollment populations include dual eligibles . A Snapshot of the Florida Medicaid Long-term Care Program

    Medicaid Managed Care Market Tracker

    Magellan To Challenge Loss Of Medicaid Contract

    Medicaid MCO State-Level Enrollment Data

    about this data collection

    This Data Collection, the Medicaid Managed Care Market Tracker, provides information related to risk-based Medicaid managed care organizations that provide comprehensive services, including acute care services and, in some cases, long-term services and supports as well, to Medicaid enrollees. In addition, the Tracker provides information on parent firms that own Medicaid MCOs in two or more states.

    The data in the Medicaid Managed Care Tracker are current to the date or period specified in the sources for each table.

    The information in this Tracker is public information and may be reproduced with appropriate citation.

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    Achieved Savings Rebate Rule

    The Standards for Independence document is provided for any plan who intends to participate in the Statewide Medicaid Managed Care program. This document outlines the standards of independence for audits conducted by independent certified public accountants. These standards of independence are incorporated by reference in Rule 59G-8.800: Financial Compliance Audits of Medicaid Prepaid Plans.

    Obtaining Information From Ahca Regarding A Medicaid Fair Hearing Request:

    AHCAs Office of Fair Hearings , is responsible for acknowledging Medicaid Fair Hearing requests filed with AHCA. The Office will assign a Hearing Officer who will schedule a hearing, or take other appropriate action, on the hearing request pursuant to Rule 59G-1.100, F.A.C. Contact information for the AHCA Office of Fair Hearings is:Agency for Health Care AdministrationOffice of Fair Hearings2727 Mahan Drive, MS#11Tallahassee, Florida 32308E-mail:

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    What Is The Florida Statewide Medicaid Managed Care

    Medicaid recipients who reside in a nursing facility or receiving home and community based services must participate in the Statewide Medicaid Managed Care – Long Term Care Program .

    Anyone who meets the financial level of care as determined by DCF and medical level of care criteria as determined by the will be able to receive services in their nursing home of choice. So, if a long-term care plan enrollee is denied a service that is needed, the Medicaid recipient can appeal through the planâs grievance process or through the Fair Hearing Process.

    There is no waiting list for nursing facility services under the Florida Statewide Medicaid Managed Care Long-Term Care Program . However, there is a waitlist for Home and Community Based Medicaid .

    While there are no âco-pays,â those enrolled in a managed care program may have a âpatient responsibilityâ amount for nursing facility or home and community based services.

    The SMMC-LTC plans are paid a rate depending on the region in Florida where the Medicaid-recipient is located:

    • Region #10: Broward County
    • Region #11: Miami-Dadeand Monroe Counties

    Skilled Nursing Facilities must contract with all LTC programs in its region â and cannot discharge a patient because of their choice of plan and must work with the patientâs desired LTC plan to arrange for payment.

    ALFs will only receive reimbursement for home and community-based services, not for room and board charges.

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    Christine VestalWhat is Medicaid managed care?Is managed care new?How much are states using managed care now?Why are states expanding managed care?Is the federal health care overhaul a factor?Why is managed care controversial?Is there a down side for states?Are all Medicaid managed care plans the same?Do managed care plans really save money for states?study

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    Guidance To States Regarding Inclusion Of Contract Language Addressing Managed Care Activities That May Be Vacated By The Court

    This document outlines expectations for States to include specific contract language in their Medicaid and Childrens Health Insurance Program managed care plan contracts to address situations where managed care activities have been vacated by the court. States should execute contract amendments to include the additional language in their managed care plan contracts no later than December 31, 2020. We are issuing this guidance as part of our ongoing effort to provide greater transparency and consistency across CMS managed care plan contract review process.

    Special Supplemental Nutrition Program For Women Infants And Children

    Congress allows increased fruit and vegetable benefits. At present, WIC provides $9 for children and $11 for women monthly for fruits and vegetables. The American Rescue Plan Act makes funding available for a four-month increase in the benefit of up to $35 monthly, if a state chooses to do so.

    DOH attains waiver allowing remote issuance: Department of Health obtained a waiver of the requirement that participants pick up their EBT cards in person at recertification or during nutritional education appointments.

    âWIC participants allowed to substitute certain food. Under a waiver from USDA, WIC participants in Florida are allowed to substitute milk of any available fat content and whole wheat or whole grain bread in package sizes up to 24 oz. when 16 oz. packages are unavailable.

    âUSDA waived physical presence requirements: Although the scope and logistics are unclear at this time, USDA has given DOH permission to waive the requirement that persons be physically present at each certification or recertification determination in order to determine eligibility under the program through May 31, 2020.

    USDA extends certification periods through May 31, 2020, for some participants.

    For a list of current WIC waivers for Florida from USDA, go here.

    For a list of current child nutrition program waivers for Florida from USDA, go here.

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    State Levies $950k In Liquidated Damages Against Medicaid Managed Care Plans

    Tuesday, October 5, 2021

    Florida health officials assessed $949,250 in liquidated damages in the first quarter of fiscal year 2021-2022, issuing final orders in 36 complaints against Medicaid managed care plans, Agency for Health Care Administration information shows.

    Simply Healthcare was fined $422,250 in liquidated damages for the first quarter, more than any other health plan, and was responsible for about 44% of the overall amount of damages assessed in the three-month time frame. The damages were assessed in state-issued final orders settling four complaints.

    While Simply Healthcare leads the Medicaid managed care plan pack in terms of the amount of liquidated damages assessed, Humana Medical Plan had seven final orders issued for the quarter, more than any other plan.

    The state issued the orders between July 1 and Sept. 30 for Humana Medical Plan and levied $258,000 in liquidated damages against the health plan. Humana offers comprehensive health plans to Medicaid managed care enrollees throughout the state.

    Staywell Health Plan had two final orders for the quarter and was levied $40,000 in liquidated damages. The managed care plan was acquired last year by Centene Corporation. Medicaid enrollment reports show that as of Aug. 31 Staywell had 23.5% of the Medicaid managed medical assistance market share.


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