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Dana McHugh
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Medicare Advantage Plans Look for SNFs with the Ability to Accept Higher Level of Acuity Members

More than previous years, the Medicare Advantage health plans are specifically interested in skilled nursing facilities with the ability to accept higher acuity patients. Some health plans are requesting questionnaires as an entry point for negotiations that include specific questions related to clinical capabilities. Read More...


Ensure all Medicaid LTC Residents are Assigned to Health Plan after Medicaid Re-Certification

Always confirm the eligibility and health plan assignment of your Medicaid LTC residents after the Medicaid re-certification process. Recently, a FAHA H&S member experienced a situation that resulted in their resident be assigned to a different health plan after the Medicaid re-certification process. Read More...


Ensure all Requested Documentation is Submitted Timely to the Health Plans

Always obtain prior authorization from the health plans before accepting an admission to your skilled nursing facility (SNF) to ensure claims payment. The health plans require medical documentation as part of the prior- authorization process. Sometimes this process can be daunting, time consuming and frustrating. Read More...


Ensure all Health Plan Claims and Appeal Processes are Followed

In a previous March 21, 2019, newsletter we’ve discussed the option to file a complaint with AHCA to address an outstanding claims issue for resolution. The article addressed claims issues related to an MMA enrollee transitioning to Medicaid LTC while residing in the nursing home. The MMA health plan is responsible for paying the claim during that transition period. This is the time-period previously billed to the state while the resident becomes Medicaid LTC eligible. Read More...


NOMNC Process Training and Review

The health plans are providing additional training and clarification on the NOMNC process to FAHA H&S members. Last week, Florida Blue provided a NOMNC training session with a FAHA H&S member. This training addressed Florida Blue’s NOMNC policy as well as an agreement to improved communication and accountability processes. Because this session was considered successful, Florida Blue has offered to repeat the training session for all FAHA H&S members. We are in the process of scheduling this session and will send out an invitation in the coming weeks. Read More...


The Importance of Eligibility and Enrollment Processes

The SMMC rollout has completed and membership has been assigned to the health plans. Providers are billing these health plans for the services provided and issues are now beginning to bubble up. One of these issues is related to enrollment and eligibility. Read More...


Residents Assigned Incorrectly to an MMA plan vs Comprehensive or LTC+ Health Plans

The final phase of the SMMC rollout occurred in February. The health plans new to the Medicaid LTC space have received new enrollees throughout the state. This process has been relatively smooth with a few items that have caused some confusion in the rollout. These items have included some health plan provider portal and claims systems alignment issues. And, what appears to be some long-term care enrollees being assigned to an MMA plan versus a comprehensive or LTC+ health plan. Read More...


Non-Emergent Transportation Back to Nursing Home after Hospital Stay

Recently, a FAHA H&S member experienced a frustrating situation regarding transportation for a resident returning home from a hospital stay. It was a complex issue that included a hospital refusing to coordinate transportation back to the nursing home after a hospital stay, an AHCA complaint, the transportation company billing the FAHA H&S member and all of these were unintended consequences of a health plan terminating a hospital’s contract. This issue has since been resolved and through that process we have obtained clarification on the transportation benefit. Read More...


Medicare Advantage Plans Review Requirements and Expectations

The Medicare Advantage plans are highly regulated with stringent reporting requirements via their contract with the federal government. Because of these requirements the health plans are diligent about requesting data and responses in a timely fashion. One such requirement, is the NOMNC (Notice of Medicare Non-Coverage) completed form that must be delivered to beneficiaries receiving covered skilled nursing services at lease two calendar days prior to the Medicare covered services ending. Read More...


The Rollout of the SMMC Finalizes in February 2019

February 1 marks the final phase of the SMMC rollout process. Regions 1, 2, 3 and 4 are included in this final phase and consist of approximately 3,270 Medicaid LTC enrollees and 105,567 MMA enrollees. Read More...


Nursing Facility Services Payment in Statewide Medicaid Managed Care

According to the January 22 AHCA alert, the new SMMC contracts for 2019-2023 require the health plans to cover nursing facility services for health plan enrollees who are not yet enrolled in Long-Term Care (LTC) program.

Nursing facility services for health plan enrollees who are not yet enrolled in the LTC program can no longer be directly billed to the Agency (fee-for-service). Providers must seek reimbursement for these services from health plans in accordance with the Agency’s rollout schedule. This AHCA document provides detailed information on this update.


Medicare Advantage 2019 Enrollment Continues to Increase

According to the Kaiser Family Foundation, more than 20 million Medicare beneficiaries (34%) are enrolled in Medicare Advantage plans nationally. Additionally, more Medicare Advantage plans are available in 2019 than any year since 2009. Read more


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


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.



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...


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


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


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







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 or (850) 999-6034.  Additional information can also be found at the CMS Innovation Center:


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


Aventura Hospital and Medical Center



Flagler Hospital


St. Augustine

Florida Health Sciences Center dba Tampa General Hospital



Halifax Hospital Medical Center


Daytona Beach

JFK Medical Center



Jupiter Medical Center



Lakeland Regional Medical Center, Inc



Lakewood Ranch Medical Center


Lakewood Ranch

Manatee Memorial Hospital LP



Memorial Hospital Jacksonville



North Brevard County Hospital District dba Parrish Medical Center



Orlando Health



Physicians of Central Florida PA


Mount Dora

St Vincent’s Healthcare



Wellington Regional Medical Center



West Palm Beach Physician Group



Westside Regional Medical Center




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


Brooks Health System



Chatsworth at Wellington Green, LLC


Palm Beach Gardens

Jupiter Medical Center Pavilion



Westchester Gardens




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


Florida Hospital




For more information on any of the specific bundled payment awardees, please go to the following website:


June 20, 2019

June 5, 2019

May 16, 2019

May 1, 2019

April 18, 2019

April 3, 2019

March 21, 2019

March 7 ,2019

February 21, 2019

February 7, 2019

January 24, 2019

January 9, 2019

December 14, 2018

November 27, 2018

November 7, 2018

October 18, 2018

October 3, 2018

September 19, 2018

September 6, 2018

August 23, 2018

August 9, 2018

July 26, 2018

July 12, 2018

June 13, 2018

May 24, 2018

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