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Medicaid patients win right to leave HMO for good cause

By Christine Jordan Sexton
1/22/2009 © Florida Health News

TALLAHASSEE—Medicaid HMO patients will be allowed to drop out of their health plans and switch their care to other doctors under a pair of administrative and legal actions recently approved by the state. Medicaid HMO patients will be told that they can leave their health plan if their doctors aren’t in the network of the managed care organization or if their care is poor, denied or unreasonably delayed, among other things. 

As part of a November settlement of a class action lawsuit, the Agency for Health Care Administration promised to tell patients enrolled in HMOs in the five counties that are part of a “Medicaid Reform” pilot about their rights to disenroll from their HMO or managed care plan.  Last month the Agency for Health Care Administration adopted a rule defining what constitutes a “good cause” reason to leave their HMO.
“As the state moves more and more to managed care, these rights become more critical,” said Florida Legal Services attorney Miriam Harmatz, lead counsel on the class-action suit filed a year ago in Fort Lauderdale.

Allowing people to change HMOs for good cause makes sense, says Michael Garner, president and CEO of the Florida Association of Health Plans. "Health plans do not wish for members that have valid reasons for disenrollment to be forced to remain in the plan,” said Garner, whose association represents 11 Medicaid HMOs that provide care for 1 million beneficiaries. “We very much want to make sure our customers and the patients we have in our health plans get the services they want and the provider they want.” 

The FAHP is concerned, though, that the recently adopted good cause rule is too broad. For instance, he said the rule allows patients to leave the HMO if their doctors are no longer part of the plan’s network. Garner said the language is vague and would cover people whose doctors have retired. “Is that really good cause for someone to switch health plans?” Garner asked. 

Health plans hope the new good-cause policy doesn’t undermine the state’s “lock-in” requirement for Medicaid beneficiaries and lead to a mass exodus of members. Garner doesn’t think that will happen. 

Florida requires all Medicaid patients to have a care manager. In Medicaid Reform counties (Broward, Duval, Baker, Clay and Nassau) that can be an HMO or an organized network of health-care providers. In other counties, a primary-care physician can act as the care manager – an option called MediPass. 

Either way, when the beneficiary makes a decision, the state locks it in for a year, except for good cause. The lock-in policy, said Garner, is no different than the one that follows the open-enrollment process in commercial insurance. It offers financial predictability to the health plan and provides the patient with a medical home.

Garner’s group will be closely watching the rule’s impact. If problems do occur, “We may have to ask for it to be modified or come back and look at it some other way,” Garner said, alluding to a legislative fix. 

Meanwhile, Harmatz said she’s “very pleased” that the AHCA settlement agreement requires the state to include information about good-cause disenrollment in the letters it sends to new Medicaid Reform enrollees and those whose annual open-enrollment period is approaching. 

Harmatz represented David Reed, David Mitchell and Joann Brown, three Medicaid recipients who filed a class action suit last year on behalf of the 200,000 Medicaid beneficiaries enrolled in the Medicaid Reform counties. The suit alleged that AHCA violated their rights and federal law by failing to let them know they could leave their managed-care plan at any time if they had a good reason.

AHCA tried unsuccessfully to dismiss the case. On Nov. 20, the agency signed a settlement agreement with Florida Legal Services and Broward Legal Aid.

The new information is being included in form letters that go out to patients, AHCA spokesman Fernando Senra said. The settlement also requires Medicaid Reform HMOs to include the good-cause disenrollment information in their member handbooks. Operators who work for the choice-counseling hotline for Medicaid patients must be given information on patient rights. 

Contact the reporter: Christine Jordan Sexton.