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November 27, 2018


SMMC new contract period goes live December 1, 2018 for Regions 9, 10, 11

According to the Agency for Health Care Administration enrollees will be assigned to their existing health plan if that health plan continues to do business in their region. Otherwise, the enrollee will be assigned to a new health plan offered in the region they reside. It is recommended to check the eligibility of all the Medicaid long-term care residents in December to ensure they are assigned to the health plan they are expecting.

If there is a discrepancy in the health plan assigned or your resident is interested in changing their health plan there is an online solution(Member Portal) in addition to Choice Counseling to assist with this choice.

The Agency is providing a Member Portal, so enrollees can manage their health and dental care plans. This Member Portal can be accessed by individuals currently eligible for Medicaid and authorized representatives of Medicaid recipients can sign up for the portal.

There are several reasons why this Member Portal is useful:
• Ability to check Medicaid eligibility and plan enrollment status
• Compare available plans
• Enroll in a plan and change plans online
• Review plans’ member materials

Further detail on Member Portal can be found here.

If you have questions, please contact Dana McHugh via email or by calling her at (850) 339-2909.


SMMC Medicaid LTC Health Plan In-Service Webinar

Join us for an update of the policy and procedures and expectations of the health plans for the new SMMC contract period. This webinar will include expectations of case management and authorization requirements. Information about provider portals, billing and payment parameters. Including how and when to contact health plans along with important contact and phone number information.

Please join the webinar December 11 at 2:00pm offered free to FAHA H&S members. Further detail on the webinar will be available prior for registration.

The Role of Medical Care in Assisted Living
How Medicaid Managed Long Term Care May Change the Game

Ken Brummel-Smith, MD
Medical Director, FAHA H&S

A stated goal of Medicaid managed long term care is to reduce the number of residents in nursing homes. Clearly, this is a goal of many residents in nursing homes as well. The two most obvious ways to accomplish this goal is to increase the number of persons receiving care in the home and increasing the number of nursing home residents discharged to assisted living. Added to these initiatives is the goal of Medicare and health plans to reduce the number of readmissions to hospitals after discharge. Finally, there is a strong push from Medicare, Medicaid and health plans to reduce the number of medications older people consume, especially antipsychotic medications. A perfect storm!

All of this means that assisted living facilities will be facing greater expectations, and scrutiny, to meet these goals. Clearly, a desire to care for residents who were formally in a nursing home, and to limit hospitalizations, means that more medically complex residents will be among the assisted living population. In addition, given many older person’s desire to “age in place,” conditions which before were managed in nursing homes are already becoming common in assisted living.

Unfortunately, the experience of trying to coordinate care in assisted living has been frustrating on both sides. Facilities are frequently stymied by having difficulty accessing physicians, forced to wait long times for physicians to visit or respond to requests, or having physicians who refuse to see residents in the facility. Physicians often feel that communication is difficult with ALFs, and in one study (Sloane and Zimmerman, Journal of the American Geriatrics Society, December 2011) felt that the “hassle factor” of dealing with ALFs exceeded that of nursing homes and even home-based patients. Perhaps that is why in this sample of geriatric and long-term care physicians, only 40% saw residents in the facility and 60% required them to come to the office.

What are the options for assisted living facilities to enhance the quality of medical care for its residents? There are a number – including using protocols such as the INTERACT guidelines for assisted living, having a part-time nurse on staff, developing contracts with visiting nurse associations, having contacts with specific physicians to provide care on site, and having a medical director to oversee care for all residents. There may be others that FAHA members are using that we would like to hear about.

INTERACT for some time has been a leader in developing guidelines for nursing home care. Many studies have shown improved quality of care when using the guidelines. INTERACT also includes tools for documenting transfers and readmissions. Implementation requires, though, a high degree of support from administration and does cost money. Many facilities contract with specific visiting nurse groups or geriatric nurse managers to provide oversight to care provided in the facility. Such contracts may be a “bargaining chip” when competing for health plan contracts, in that the plans bear significant financial risk for not achieving benchmark outcomes.

Large facilities, and multiple level organizations such as continuing care communities, often have physicians on contract. Whether this is economically feasible for smaller facilities is questionable. A recent article by Paul Katz, MD, FAHA H & S’s other medical director, recently outlined the critical need for high-quality medical care for residents in ALFs. (Journal of the American Medical Directors Association, Feb. 2018)

Whether to have a medical director is even more controversial. Dr. Katz and his fellow authors suggested it was time to consider this possibility. In his article he stated:

"We believe that the cost attributed to the creation of such a position will be covered many times over through enhanced quality of care, resident satisfaction, longer lengths of stay, higher occupancy rates, and reduced staff turnover."

I spoke with Leonard Hock, DO, President of the Florida Medical Directors Association (now called the Society for Post-Acute and Long-Term Care Medicine) about this. He said the Society has been looking at this question for some time. Interestingly, AMDA published a white paper in 2009 on the physician’s role in assisted living but it did not address the idea of a medical director.

So, the jury is still out. What is not uncertain is that health plans in long-term care will continue to search for ways to reduce the number of residents in nursing homes, and assisted living facilities will continue to see a rise in the number of residents with complex medical conditions and dementia. How facilities will balance the desire for improved quality of care and continued creation of a home-like environment will be challenging.


New Medicare Advantage Telehealth Rules Signal Growing Skilled Nursing Opportunity - New Guidelines that could open up telehealth under Medicare Advantage represent a serious opportunity for the industry, according to multiple technology providers – especially as the moves signal growing support for remote care from key federal officials.  Read more...

New Brief Examines Potential Changes to Medicaid Long-Term Care “Spousal Impoverishment” Rules - A new brief from KFF (the Kaiser Family Foundation) examines potential changes to “spousal impoverishment” rules in Medicaid that allow married couples to protect a portion of their income and assets should one spouse seek Medicaid coverage for long-term care. Read more...

Health plan updates

Comprehensive plan award. Amerigroup merged with and into Simply Healthcare Plans in October 2017. Our Amerigroup network is being rebranded as Simply in the state of Florida. Read more...

Simply Healthcare Provider Bulletin. Electronic Claim Submissions – as we continue to streamline the process for the Florida market, we are changing the way that providers submit electronic claims to the health plan. Read more...

Copyright 2018 — Publication of FAHA H&S
Chair: Brian Robare
President/CEO: Steve Bahmer
Principal/Editor: Dana McHugh

Copyright Information: Copies of the articles and other information in this publication may be non-commercially reproduced for the purpose of educational or scientific advancement. Otherwise, no part of this publication may be reproduced or utilized in any form, or by any means, mechanical or electronic, including photocopying, microfilm and recording, or by any information storage and retrieval system, without the written permission of the managing editor. For permission to reproduce, contact the principal/editor via email or phone at (850) 999-6034. 

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