Legal challenges continue to mount over the state’s Medicaid managed-care program. Lighthouse Health Plan filed a petition in state administrative court last week challenging state decisions that it says will lead to the automatic assignment of Medicaid patients in Northwest Florida to a competitor, Humana.
Attorneys for Lighthouse, a type of managed-care plan known as a provider-sponsored network, argue that the patient-assignment policy is an unadopted rule.
They also argue that the policy violates Florida law and a federal Medicaid waiver that allows Florida to operate a statewide managed-care program.
The challenge has been assigned to Administrative Law Judge Robert J Telfer III. Lighthouse, which is affiliated with Pensacola-based Baptist Health Care, was awarded a contract this year to provide Medicaid “managed medical assistance” services in Medicaid regions 1 and 2. Combined, the regions stretch across 18 counties in Northwest Florida. Medicaid managed-medical assistance plans cover acute care and other traditional health services.
Humana Medical Plan also was awarded a Medicaid contract in regions 1 and 2. It was awarded a “comprehensive” contract, which means it is responsible for managed medical-assistance services as well as long-term care.
Florida lawmakers in 2011 approved a major revamp of the Medicaid program that requires most beneficiaries to enroll in managed-care plans.
The state contracted with various numbers of plans in 11 regions. But with the initial contracts ending, the state went through a procurement process that led to AHCA this spring awarding a new set of contracts.
The Lighthouse challenge comes about four months before the state transitions the Northwest Florida counties to newly contracted health plans in February.
In the challenge, attorneys for Lighthouse argue that state law requires assigning patients based on a number of criteria, including whether plans have sufficient networks, whether patients previously received care from plans’ providers and whether primary care providers in plans are more geographically accessible to patients.
Specifically, the law precludes the agency from "engag(ing) in practices that are designed to favor one managed care plan over another," Lighthouse attorneys wrote in their petition.
The Lighthouse case comes after other health plans filed administrative challenges about contract awards. While some of those case have been resolved, the AIDS Healthcare Foundation and the South Florida Community Care Network, which did not reach settlements with the state, are pursuing challenges.