As required by state law, the Agency for Health Care Administration has phased in a method that pays Medicaid Reform capitated plans monthly rates that are risk-adjusted to reflect the health status of plans' beneficiaries. With risk-adjusted rates, the agency pays higher rates to plans that serve beneficiaries who are sicker and have greater health care needs than plans that serve healthier beneficiaries. The agency currently uses the Medicaid Rx model which uses pharmacy claims and demographic data to calculate these rates. By 2009, it expects to begin phasing in another model, the CDPS that will rely on diagnostic data from the agency's newly developed encounter data system and may continue using pharmacy data as well.
The advantage of risk-adjusted rates is that they better match capitated plan payments to the health status and costs of each beneficiary. Regardless of whether Medicaid Reform expands beyond the pilot counties, once AHCA gains experience using encounter data to set risk-adjusted rates, the Legislature should consider directing the agency to also use risk-adjusted rates to pay non-Reform capitated plans.

Medicaid Reform: Legislature Should Delay Expansion Until More Information Is Available to Evaluate Success
Report 09-29 June 2009
Medicaid Reform: Reform Provider Network Requirements Same as Traditional Medicaid; Improvements Needed to Ensure Beneficiaries Have Access to Specialty Providers
Report 08-64 November 2008
Medicaid Reform: Oversight to Ensure Beneficiaries Receive Needed Prescription Drugs Can Be Improved; Information Difficult for Beneficiaries to Locate and Compare
Report 08-55 September 2008
Medicaid Reform: Two-Thirds of the Initial Pilot Counties' Beneficiaries Are Enrolled in Reform Plans
Report 08-40 June 2008

Copies of this report in print or alternate accessible format may be obtained by email OPPAGA@oppaga.fl.gov, telephone (850) 488-0021, or mail 111 W. Madison St., Room 312 Tallahassee, FL 32399-1475.