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Dana McHugh
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THE SMMC NEWLY COVERED SERVICES AND AGENCY PROVIDED PROGRAM SNAPSHOT

SMMC New Contract Period Started December 1, 2018 for Regions 9, 10, 11


Based on feedback from the health plans and providers, it appears the rollout has progressed relatively smoothly. Please ensure the eligibility of all residents with Medicaid LTC coverage is checked and were assigned as expected. Including those who were previously assigned to health plans continuing to do business in the region. Read more


ASSIST YOUR RESIDENTS WITH THE SMMC ROLL-OUT ENROLLMENT PROCESS

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.


 

EXPANDED BENEFITS OFFERED IN NEW SMMC CONTRACT YEAR

Medicaid New SMMC Five-Year Contract Begins January 1, 2019

The rollout transition to the new SMMC contract period begins soon. Recipient letters will be mailed out by the Agency approximately 45 days prior to each phase going live. According to the Agency, “under the new contracts, recipients enrolled in the SMMC health plans will have access to the richest benefit package ever offered by Florida Medicaid.”

Expanded benefits are offered in addition to the standard benefit package offered by Medicaid. These expanded benefits are provided by the plans at no additional cost to the state.  Read more...



NEW SMMC PROGRAM GOALS

Medicaid New Five-Year Contract Begins January 1, 2019


Please review previous newsletter articles on our ongoing analysis of the upcoming new Statewide Medicaid Managed Care contract effective January 1, 2019. This week is focused on the published Agency New SMMC Program goal related to the percentage of enrollees receiving long-term care services in their own home or community instead of a nursing home.

This is a goal of the current SMMC contract but, has been given further emphasis within the new SMMC contract. It is evident by the requirements of the contract and the negotiation and award process the Agency will place special emphasis on this goal. Further, the health plans are offering additional expanded benefits related to the transitioning of appropriately approved nursing home residents into HCBS. Some of this increase in HCBS will be realized through Assisted Living placement or the ability to age in place due to increased services to the home. These services include home delivered meals, housing assistance, home care services, aide services, home health and other expanded benefits.

Below is a snapshot of the current percentages of Medicaid LTC enrollees residing in a nursing home or within a HCBS setting.

The overall state Medicaid LTC average for those residing in a nursing home is 43% with 57% residing in a HCBS setting. South Florida has the highest percentage of Medicaid LTC within the HCBS setting. The HCBS participation percentage has steadily increased since the inception of the SMMC program in 2013.

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


July 22, 2016

Reducing Antipsychotic Usage in Long Term Care Facilities
By Ken Brummel-Smith, MD
FAHA H&S Medical Director


For a number of years, experts in geriatric medicine and psychiatry have been questioning the use of antipsychotic medication in persons with dementia. Symptoms that look like those seen in non-demented psychotic patients are commonly seen in persons with dementia – hallucinations, delusions, resistance to care, irritability, and many others. It seems natural that antipsychotic drugs would be used for these symptoms. However, as the problem was more closely studied, it became apparent that not only were these drugs often ineffective, they actually increased the harm experienced by patients with dementia. Over-sedation, parkinsonian movements, and falls are common. More concerning, these drugs increase the death rate of people on them. At first, we thought this may be due to using older drugs, like thorazine or haloperidol. But then studies showed the newer drugs had the same effects. For this reason, the American Geriatrics Society released this “Choosing Wisely” recommendation: “Do not use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.”  READ MORE

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June 3, 2016

Why Everyone Should Care About Managed Care

According to the latest data, about one in five Floridians is 65 or over, and nearly one out of two of them are choosing Medicare Advantage plans. That number has been rising for some time.


Since the transition of Florida’s Medicaid program to managed care, LeadingAge Florida’s Medicaid provider members have been acutely aware of the impact of that change, and the need to stay informed about the ways it is altering long-term care system.

Increasingly, though, managed care is no longer just a Medicaid issue for aging services providers.



 

Why Bundled Payments?

During the holiday shopping season many of us are looking for a good deal on products and services.  One way to accomplish the good deal is by purchasing several accompanying products or services wrapped into one lower negotiated package price. This is a simple example of what CMS is hoping to accomplish with the Bundled Payment initiative. 

Why Bundled Payments?  According to CMS, Medicare’s traditional fee-for-service can result in fragmented care with minimal coordination across providers and health care settings. CMS believes this approach rewards quantity of services versus quality of care.   Their research suggests bundled payments can align incentives for hospitals, post-acute care, physicians, and other practitioners – allowing them to work together closely across all specialties and settings.   

The CMS bundled payments initiative known as Bundled Payment for Care Improvement (BPCI) is made up of four broadly defined models of care.  These models, described in the table below, link payments for multiple services received by Medicare beneficiaries within an episode of care as defined by clusters of DRG’s such as:  total joint; CHF, etc. 

 

Model 1

Model 2

Model 3

Model 4

Episode

All acute patients, all DRGs

Selected DRGs, hospital plus post-acute period

Selected DRGs, post-acute period only

Selected DRGs, hospital plus readmissions

Services included in the bundle

All Part A services paid as part of the MS-DRG payment

All non-hospice Part A and B services during the initial inpatient stay, post-acute period and readmissions

All non-hospice Part A and B services during the post-acute period and readmissions

All non-hospice Part A and B services (including the hospital and physician) during initial inpatient stay and readmissions

Payment

Retrospective

Retrospective

Retrospective

Prospective

 

Florida is represented with 22 Participant Awardees in Models 2, 3, and 4 with the most participation in Model 2.  

How is it implemented?  The first set of Awardees for Models 2, 3, and 4 began in January 2013 and the Model 1 Awardees began in April 2013. The initiative includes two phases for Models 2, 3, and 4. Phase 1, is referred to as the “preparation” period, which the participants prepare for the implementation and financial risk of the initiative. Those approved by CMS and agree to assume financial risk will be allowed to enter Phase 2 of the initiative.  Phase 2 is considered the “risk-bearing” period. By October 2013, some Awardees entered into Phase 2. Please see footnotes for further detail on those participating Awardee hospitals and the number of episodes awarded in Phase 2.

Relationships matter in all things and this is especially true with your local hospital or physician Bundled Payment Awardee. As explained in the footnotes portion of this article, “any reduction in payments beyond the target price is paid to the participant and may be shared among their provider partners.” Please consider meeting with your local Awardee (hospital or physician) to understand their participation and your potential partnership in the bundled payment initiative.   

For further information or questions, please contact Dana McHugh at fahahs@leadingageflorida.org or (850) 999-6034.  Additional information can also be found at the CMS Innovation Center: https://innovation.cms.gov

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Keeping up with the various types of health care reform initiatives in your region is critical.  We have prepared the following detailed information on the bundled payment models and which entities have been selected in the State of Florida.

BPCI Model 1: Retrospective Acute Care Hospital Stay Only

In Model 1, the episode of care is defined as the inpatient stay in the acute care hospital.   Medicare pays the hospital a discounted amount based on the payment rates established under the Inpatient Prospective Payment System used in the original Medicare program.   Medicare continues to pay physicians separately for their services under the Medicare Physician Fee Schedule.

                No Florida hospitals awarded this Model 1 effective July 1, 2015

BPCI Model 2:  Retrospective Acute & Post Acute Care Episode (678 awardees nationally)

In Model 2, the episode of care includes a Medicare beneficiary’s inpatient stay in the acute care hospital, post-acute care and all related services during the episode of care, which ends either 30, 60, or 90 days after hospital discharge. Awardees select up to 48 different clinical episodes to test in the model.

Under this payment model, Medicare continues to make fee-for-service (FFS) payments to providers and suppliers furnishing services to beneficiaries in Model 2 episodes. The total expenditures for a beneficiary’s episode is later reconciled against a bundled payment amount (the target price) determined by CMS.  his target price is set based on historical fee-for-service payments for the participant’s Medicare beneficiaries in the episode including a discount.  A payment or recoupment amount is then made by Medicare reflecting the aggregate performance compared to the target price. Any reduction in expenditures beyond the target price is paid to the participant and may be shared among their provider partners.   Any expenditure paid above the target price is to be repaid to Medicare by the participant.

The information below represents the Florida BPCI Model 2 Awardees as of October 1, 2015 which are actively testing BPCI in Phase 2 at one or more episode-initiating sites:

Model 2 Awardees

Phase 2

Number of Episodes

Location

Aventura Hospital and Medical Center

22

Aventura

Flagler Hospital

3

St. Augustine

Florida Health Sciences Center dba Tampa General Hospital

1

Tampa

Halifax Hospital Medical Center

1

Daytona Beach

JFK Medical Center

22

Atlantis

Jupiter Medical Center

4

Jupiter

Lakeland Regional Medical Center, Inc

1

Lakeland

Lakewood Ranch Medical Center

1

Lakewood Ranch

Manatee Memorial Hospital LP

5

Bradenton

Memorial Hospital Jacksonville

19

Jacksonville

North Brevard County Hospital District dba Parrish Medical Center

3

Titusville

Orlando Health

5

Orlando

Physicians of Central Florida PA

1

Mount Dora

St Vincent’s Healthcare

5

Jacksonville

Wellington Regional Medical Center

37

Wellington

West Palm Beach Physician Group

35

Sunrise

Westside Regional Medical Center

18

Plantation

 

BPCI Model 3:  Retrospective Post Acute Care Only (1,353 awardees nationally)

In Model 3, the Episode of Care is triggered by a Medicare beneficiary’s acute care hospital stay and begins at initiation of post-acute care services with a participating skilled nursing facility, inpatient rehabilitation facility, long-term care hospital or home health agency.  The post-acute care services included in the episode of care must begin within 30 days of discharge from the inpatient stay and end 30, 60, or 90 days after the initiation of the episode of care. Participants can select up to 48 different clinical condition episodes to test in the model.

Under this model, Medicare continues to make fee-for-service (FFS) payments to providers and suppliers furnishing services to beneficiaries in Model 3 episodes. The total expenditures for a beneficiary’s episode is later reconciled against a bundled payment amount (the target price) determined by CMS. A payment or recoupment amount is then made by Medicare reflecting the aggregate performance compared to the target price.  

The information below represents Florida BPCI Model 3 Awardees as of October 2015 which are actively testing BPCI in Phase 2 at one or more episode-initiating sites:

Model 3 Awardees

Phase 2 Number of Episodes

Location

Brooks Health System

27

Jacksonville

Chatsworth at Wellington Green, LLC

15

Palm Beach Gardens

Jupiter Medical Center Pavilion

4

Jupiter

Westchester Gardens

1

Clearwater

 

BPCI Model 4:  Prospective Acute Care Hospital Stay Only  (10 participants nationally)

 

Model 4, CMS makes a single, prospectively determined bundled payment to the hospital that  encompasses all services furnished by the hospital, physicians, and other practitioners during the Episode of Care, which lasts the entire inpatient stay. Physicians and other practitioners submit “no-pay” claims to Medicare and are paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge are included in the bundled payment amount. Participants can select up to 48 different clinical condition episodes to test in the model.

 

The information below represents FLORIDA BPCI Model 4 Awardees as of October 2015 which are actively testing BPCI in Phase 2 at one or more episode-initiating sites:

 

Model 4 Awardees

Phase 2 Number of Episodes

Location

Florida Hospital

2

Orlando

 

For more information on any of the specific bundled payment awardees, please go to the following website:  https://innovation.cms.gov

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