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State Faces Shortfall In Children's Medical Program

Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.
Nick Evans/WFSU
The Florida Channel
Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.

A Medicaid program that pays health-care costs for some of the sickest children in the state has an estimated $25 million budget shortfall, a key lawmaker said Monday night.

House Health Care Appropriations Chairman Jason Brodeur, R-Sanford, told The News Service of Florida that the estimated deficit in Children’s Medical Services funding for fiscal year 2016-2017 was caused by higher-than-anticipated medical costs of the children served in the program. The costs, he said, exceeded projected estimates and will have to be addressed when lawmakers draw up a budget during the 2018 session.

Mallory McManus, a spokeswoman for the Agency for Health Care Administration, said costs for inpatient and outpatient hospital care, nursing care and home health care were higher than initially anticipated.

The Children’s Medical Services Network plan, which is a type of managed-care program, enrolls about 51,000 children.

It is based on a per-member, per-month cost estimate and paid in advance for each eligible child. The state reconciles the CMS network plan bills a year after the end of each fiscal-year quarter and submits a budget amendment to the Legislature for approval. Legislative leaders recently approved a $141 million budget amendment for the period from October 2016 through December 2016.

McManus said the state this year adjusted its estimates upward by nearly 17 percent and that it doesn't anticipate any shortfalls for the current fiscal year, which provides funding from July 1, 2017 through June 30, 2018.

“Ensuring that children get the services they need is our number one priority, and AHCA has taken aggressive action to update our processes for calculating these payments,” she said in a prepared statement to The News Service of Florida.

The state has grappled with the costs of caring for children who are medically complex and who have special health-care needs and, as a result, qualify for the Children's Medical Services program.

CMS, before the creation of the managed-care plan, was a network of specialists across the state who agreed to treat children with conditions such as heart disease, cleft palates or spina bifida.

Reorganizing the Children's Medical Services program was a priority for the Scott administration after costs began to soar, increasing by nearly $100 million between 2010 and 2014.

To reduce enrollment, the Department of Health in 2015 started using a five-question parental screening tool. One of the questions asked, "Is your child limited or prevented in any way in his or her ability to do the things most children of the same age can do?" If parents answered “no,” their children were removed from the program and placed into an HMO instead.

More than 9,000 children were removed from the CMS program and placed into traditional Medicaid managed-care plans before a judge ordered the state to stop.

The state subsequently adopted a new screening tool and started using a form that allowed for input from physicians.

Children who were not screened out remained in the CMS program, which was transformed into the CMS Specialty Medical Services Network plan. But enrollment in the program has dipped from more than 61,000 in July 2015 to less than 51,000 in November 2017, according to state enrollment figures.

Brodeur said the state did the right thing to screen healthier children out of the program.

“Children of lower acuity that shouldn't have been in that program as they should have never qualified for the program in the first place,” he said. ” Many who have moved back to managed Medicaid are doing better because that's the more appropriate plan.”

Tallahassee pediatric cardiologist, Louis St. Petery, though, said some unnecessary obstacles and delays to enrollment remain. He currently is trying to get eight newborns who are in a Medicaid HMO into the CMS network plan.

St. Petery maintains that the CMS network plan provides a better medical home for sick children than the traditional managed care plans and makes it easier to treat them.

As a cardiologist, St. Petery often orders echocardiograms for his patients. The traditional Medicaid managed-care plans require prior authorization before the tests can be conducted, but the CMS plan does not.

“They approve the test 100 percent of the time, but they make me run through a mother-may-I-hoop,” St. Petery said of the Medicaid HMO plans. And while Medicaid officials say that managed-care plans provide nurse case managers to their patients, St. Petery said that he has “never seen or even talked to such a person in those plans.”