Medicaid patients and their doctors in 31 rural counties will soon get their first taste of real managed care -- the kind that requires permission to spend.
The state has chosen the company that will be making the decisions: Better Health, a Coral Gables-based firm that sponsors a provider-service network in Broward County. It has signed a $36-million contract with the Agency for Health Care Administration.
Better Health's task is to transform the Medicaid program known as MediPass into a standard managed-care program that requires “prior authorization” – permission -- for hospital stays and many other services.
According to the contract, the company could handle up to 35,000 requests annually. It isn’t clear when the requirement will begin.
“Early fall is all I can shoot for,” said Lourdes Rivas, chief operating officer for Better Health. “A lot needs to happen before we can go live.”
The company already participates in the Medicaid Pilot in Broward, one of five counties in which managed care already is required for most Medicaid patients. Rivas said Better Health will apply what it has learned in its existing PSN to its new contract areas.
First, Better Health officials must meet with the doctors who participate in Medicaid in the 31 counties and train them in the use of case managers to coordinate care.
For a number of years, doctors who treat Medicaid patients but are not part of a network have received a modest monthly fee through a state program called MediPass to manage their patients’ care. They have not borne financial risk for patients’ treatment expenses, as HMOs do.
Rivas said MediPass doctors will get to keep the monthly fee and will not be required to join a network. Patients – “members” -- may not even notice a difference.
“This is meant to work with MediPass,” Rivas said. “We are trying to make this invisible to the member.”
In addition to hospitalization, physicians will have to seek pre-authorization for MRI scans, home health care, and physical, speech and occupational therapy.
The Legislature in 2011 changed Florida’s Medicaid program, which pays for care of low-income children, pregnant women, disabled persons and the frail elderly. The new rules require nearly all patients, even those who qualify for nursing-home care, to enter managed-care plans.
To save money, the state will take bids on its Medicaid patient population from PSNs and HMOs that meet qualifications. While the plan is supposed to be in effect statewide by 2014, Florida is still waiting for federal approval.
While most Florida Medicaid patients in urban areas are already enrolled in managed care, HMOS haven’t been practical in the rural areas of the Panhandle and Central Florida. Patients in those regions have continued to have direct access to doctors and health care services, with little coordination.
As part of the 2011 overhaul, the Legislature directed AHCA to smooth the transition to managed care by contracting with a PSN in 2012 to better manage MediPass. Better Health will be paid $7.65 monthly for each MediPass patient in the first year of the two-year contract.
