Adriana DeJesus doesn't remember getting a letter.
Her kids - 6-year-old Angel, and son, Christian – have been covered by Medicaid plans since birth. Her son’s asthma and ADHD keep her regularly connected to his doctors and make her diligent about understanding his health coverage.
But the St.Petersburg daycare worker says she missed seeing a notice that Florida is moving 3.5 million residents in its medical insurance program for the poor to a new managed care system.
She stumbled onto the news only after she looked for a dentist for a daughter, and a counselor filled her in on the changes.
“I didn’t even know,” she said.
She’s not alone. For months, the Agency for Health Care Administration has been asking 1.5 million Floridians with fee-for-service Medicaid medical coverage to pick a plan from thirteen pre-approved insurers.
Another 1.4 million Medicaid recipients, including DeJesus, already were signed up with private insurers as part of a pilot program. They also got letters from the state, asking if they want to stay or change.
Justin Senior, ACHA’s deputy secretary for Medicaid, said he knows most people worry about health insurance only when they get sick.
“The typical Medicaid recipient is a healthy 9-year-old or 10-year-old. They’re not receiving medical care on a daily basis,” he said. “They may have doctor’s appointments. But ultimately they don’t receive medical care on day one of the rollout.”
Reaching recipients is one of the biggest challenges of this Medicaid managed care rollout. Most of North Central and North Florida made the transition May 1, and the greater Tampa Bay area launches Monday. By August first, nearly all Medicaid recipient plans will be run by private insurers, Senior said.
So far, 25 percent of Medicaid enrollees have chosen a plan, and 40 percent failed to pick one; so a state computer assigned them to one. The remaining 35 percent, who already were enrolled in a managed care plan, opted to stay with that insurer.
Senior said the computer algorithm that auto-selects a Medicaid managed care plan takes into account a participant’s location, current medical status and other needs.
“We try to figure out which plans have their primary care physicians or specialists in them, or cover their drugs, let’s say,” he said. “And we try to match them up with the plan that is best for them.”
Rosy Cozad is CEO of Amerigroup Florida, which offers plans along the state's I-4 corridor. Many families with Medicaid coverage move a lot, making them difficult to find.
“One of the challenges is finding the member in the first place. We find that where we have an opportunity to connect with the member, to connect them with a care manager, and or to educate the member, we are able to influence change,” she said. “So finding them is our first order of business.”
More than half of those enrolled in Florida Medicaid are younger than 21. So it’s up to moms, dads or grandparents to make these decisions. DeJesus said she scrambled to decide whether to keep her current plan or find another that includes Christian's and Angel's doctors.
“What happens if you do change?” she asked. “Do I stay with the same doctor?”
This transition to Medicaid managed care started in 2011, to save money in a program costing the state $22 billion dollars a year. While the amount the state will pay to insurers isn’t increasing, the private companies will be judged more on preventative care performance, such as seeing that enrollees get regular checkups.
“We want every member to see their primary care physician. We want every member to see their dentist,” said Chris Paterson, CEO of Sunshine Health, which has managed care contracts in all but two of the state’s 11 Medicaid regions. “We want people to have more utilization of services that could help them manage a chronic illness or prevent a condition.”
Cozad says insurers also are required to provide counselors who monitor members' health, something people with commercial insurance might envy.
“Care coordination is something that does not exist in fee-for-service,” Cozad said. “Dare I say that even in some commercial plans - I would love to have a concierge service where I have a case manager who knows all my health care needs, all about my providers and can help me navigate the health care system.”
Not everyone involved in this transition is a kid with minor medical needs. Some Medicaid enrollees have chronic conditions handled by the state's Children's Medical Services program. Some pediatricians are worried the financial incentives could hurt the quality of these life-saving services.
Sunshine Health will be handling the medically fragile children in Florida's foster care system. Paterson said Sunshine is partnering with social workers in the state's Community-Based Care network - or CBCs. This new coordination will improve attention to these vulnerable children, he said.
“So the health care now will be integrated,” he said. “And the information that everyone needs to make sure that the children’s health care needs are being met, are being orchestrated in this relationship between the CBCs and Sunshine Health.”
Sunshine Health, like others involved in the managed care transition, are not new to Medicaid, Senior said. But in order to attract more business, the new managed care plans offer more options for treatment and a longer list of health providers accepting patients with Medicaid coverage.
“The networks now that those plans have are significantly broader than the networks that they used to have,” Senior said. “And (members) may notice that there are additional benefits that weren’t available to them before.”
The list of added benefits includes options never available before in Florida’s Medicaid system. Certain vaccines, adult dental, hearing and vision, newborn circumcisions and nutrition counseling are among the benefits offered. Paterson said the extras can attract business, but more importantly, they promote better health.
“Many of us felt like we needed to add this extra enhancement to the program to be competitive,” he said. “And it is true though that some of these benefits that we are offering could lead to reduction (in illness), because they are more preventative in nature.”
Right now, Adriana DeJesus isn't excited by these extras. She just hopes the new system makes it easier for her to take care of her kids’ health.
“Just to call Medicaid sometimes, I mean you wait on hold forever" just to ask one question, she said. “So maybe the commercial ones will be quicker.”
--Health News Florida is part of WUSF Public Media. Contact Reporter Mary Shedden at (813) 974-8636, on Twitter @MaryShedden, or email at shedden@wusf.org. For more health news, visit HealthNewsFlorida.org.
