Government Program Summaries
Last update 6/28/2019

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Agency for Health Care Administration

Medicaid Health Care Services

What is the purpose of the program?

Florida’s Medicaid Program provides access to health care for eligible low-income persons and assists aged and disabled people with the cost of long-term care.  Medicaid is administered by the Agency for Health Care Administration while program eligibility is determined either by the Department of Children and Families, the Social Security Administration, or the Florida Healthy Kids Corporation.  As of March 31, 2019, there were 3.9 million Medicaid recipients, which included 108,808 that were in Medicaid Managed Care Long Term Care Program; 57% of individuals eligible for Medicaid are children and adolescents 20 years of age or younger.

Who is eligible for Medicaid services in Florida?

To receive federal Medicaid funds, Florida must adhere to federal requirements related to recipient eligibility.  For example, federal guidelines require Florida to provide health care coverage to low-income families with children who receive cash assistance, children in foster care, and low-income elderly, or disabled recipients.  In addition to the mandatory eligibility groups, Florida also has expanded Medicaid coverage to include several additional groups.

What services are covered under Florida Medicaid?

Florida must ensure that Medicaid recipients receive the health care services required by federal guidelines.  For managed care plans mandatory services include physician visits, family planning, laboratory tests, x-rays, health screening services for individuals under age 21, and transportation to access covered services.  Currently, Florida's Medicaid Managed Care Program covers over 29 mandatory services.

How are Medicaid services delivered in Florida?

With the enactment of Ch. 2011-134, Laws of Florida, the Legislature expanded Medicaid Managed Care statewide.  Statewide Medicaid Managed Care (SMMC) consists of the Managed Medical Assistance Program (MMA) for primary and acute care and the Long Term Care (LTC) Program for residential and home and community-based care.  The agency completed the transition to statewide managed LTC March 1, 2014, and to statewide MMA August 1, 2014.

AHCA contracts with managed care plans by geographic regions for both the MMA and LTC programs.  As part of the MMA program, AHCA also contracts with specialty plans tailored to meet the needs of specialty populations.

The Legislature established the number of plans that each region is required to have.

The Number of MMA and LTC Plans Allowed by Region

Region

Plans Allowed1

Counties in Service Region

1

2

Escambia, Okaloosa, Santa Rosa, and Walton

2

2

Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington

3

3 to 5

Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrest, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union

4

3 to 5

Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia

5

2 to 4

Pasco and Pinellas

6

4 to 7

Hardee, Highlands, Hillsborough, Manatee, and Polk

7

3 to 6

Brevard, Orange, Osceola, and Seminole

8

2 to 4

Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota

9

2 to 4

Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie

10

2 to 4

Broward

11

5 to 10

Miami-Dade and Monroe

1 Children’s Medical Services Network is a separate plan in addition to the number of Managed Medical Assistance plans listed.
Source:  Section 409.966, Florida Statutes, and s. 409.974, Florida Statutes.

The 2016 Legislature directed AHCA to implement a dental component of the SMMC program for children and adults separate from the Medicaid MMA Program.  As a result, AHCA contracted with three dental plans to provide statewide dental services under SMMC beginning in December 2018.  The dental plans are responsible for providing scheduled Medicaid dental services to most Medicaid recipients who are currently in the fee for service and SMMC delivery, while the health plans remain responsible for transportation to dental appointments, prescriptions drugs for dental care, and for non-scheduled hospital dental visits.  The dental plans were made available based on a phased roll out schedule beginning December 1, 2018.

As of March 31, 2019, 22% of Medicaid recipients were receiving service from fee for service providers because certain Medicaid populations are either not eligible or not required to participate in managed care.  Medicaid recipients not eligible for MMA include women eligible only for family planning services; women eligible through the breast and cervical cancer services program; persons eligible for emergency Medicaid for aliens; and Medicaid-Medicare dual eligible whose Medicaid benefits are limited.

Medicaid recipients who may enroll in MMA but are not required to participate include recipients who have other credible health care coverage excluding Medicare; persons eligible for refugee assistance; recipients who are residents of a developmental disability center; recipients who are either enrolled, or waiting for services, in the developmental disability home and community based service waiver; children receiving prescribed pediatric extended care center services; and recipients residing in a group home facility licensed under Ch. 393, Florida Statutes.

How is the program administered?

AHCA’s Division of Medicaid administers the state Medicaid Program, ensures that managed care plans meet contract requirements, pays fee-for-service medical claims, recruits and monitors health care providers, and plans and evaluates Medicaid service delivery.  The Tallahassee central office directs the field offices in carrying out a number of functions related to implementing and administering the Medicaid Program.

The agency also coordinates Medicaid overpayment and abuse prevention, detection, and recovery efforts.  The Bureau of Medicaid Program Integrity identifies and investigates Medicaid providers suspected of overbilling and abusing the program, recovers overpayments, issues administrative sanctions, and refers cases of suspected fraud for criminal investigation.  The Attorney General’s Office investigates and prosecutes Medicaid fraud.

Is the program preventing unnecessary hospitalizations?

In Fiscal Year 2017-18, the Medicaid-approved standard for hospitalizations due to conditions that should have been prevented by good ambulatory care in full service capitated managed health care plans for individuals age 1 to 20 years was 25% and for individuals age 21 years and older, 20%.  For Fiscal Year 2017-18, the agency reported a much lower rate of unnecessary hospitalizations, 2.92% for individuals age 1 to 20 years and 6.22% for individuals age 21 and older.

How well is the program providing prenatal care?

For Fiscal Year 2017-18, 83.7% of women received adequate prenatal care, slightly below the approved performance standard of 86%.  The neonatal mortality rate (calculated for babies less than 28 days old) for Fiscal Year 2017-18 was 4.9 per 1,000 births, while the approved standard was 4.7% per 1,000 births.

How is the program funded?

Florida’s Medicaid Program is funded through federal and state revenues.  The federal share is funded through Title XIX of the Social Security Act.  States receive federal matching dollars based on reported state Medicaid expenditures.  Funding for the state share of Medicaid expenditures comes from a variety of sources but at least 40 percent must be financed by the state, and up to 60 percent may come from local governments.  The federal share for most Medicaid service costs is determined by the federal medical assistance percentage (FMAP), which is based on a formula that provides higher reimbursement to states with lower per capita incomes relative to the national average (and vice versa).  The state also receives Title XXI funds to provide health care services to certain children not covered by Medicaid through the non-Medicaid components of KidCare.

FISCAL YEAR 2019-20
PROGRAM: HEALTH CARE SERVICESDOLLARSPOSITIONS
CHILDREN'S SPECIAL HEALTH CARE597,986,504 .00
EXECUTIVE DIRECTION AND SUPPORT SERVICES271,512,484 626.00
MEDICAID LONG TERM CARE6,616,342,975 .00
MEDICAID SERVICES TO INDIVIDUALS20,783,828,431 .00
TOTAL28,269,670,394 626.00

Source:  www.transparencyflorida.gov 

Updates

Intergovernmental Transfers to Fund Low Income Pool Program.  The Florida Legislature enacted Chapter 2019-116, Laws of Florida, which authorizes the Agency for Health Care Administration (AHCA) to receive funds from other state entities, including but not limited to, the Department of Health, local government, and other local political subdivisions, for the purpose of making Low Income Pool Program payments.  Unless otherwise amended, this provision expires July 1, 2020.

Medicaid Retroactive Eligibility Time Period Waiver Extended.  The Florida Legislature enacted Chapter 2019-116, Laws of Florida, which extends the waiver of the three-month Medicaid retroactive eligibility period for non-pregnant adults to July 1, 2020.  For eligible non-pregnant adults, the Agency for Health Care Administration (AHCA) shall make payments to Medicaid-covered services retroactive to the first day of the month in which an application for Medicaid is submitted.  The law also directs AHCA, in consultation with the Department of Children and Families, the Florida Hospital Association, the Safety Net Hospital Alliance of Florida, the Florida Health Care Association, and LeadingAge Florida to report on the impact of the waiver of Medicaid retroactive eligibility on beneficiaries and providers.  The report is due to the Governor, the President of the Senate, and the Speaker of the House of Representatives by January 10, 2020.

Where can I get more information?

OPPAGA Reports

AHCA Continues to Expand Medicaid Program Integrity Efforts; Establishing Performance Criteria Would Be Beneficial, Report No. 18-03, January 2018.

Review of Medicaid Dental Services, Report No. 16-07, December 2016.

AHCA Reorganized to Enhance Managed Care Program Oversight and Continues to Recoup Fee-for-Service Overpayments, Report No. 16-03, January 2016.

Florida’s Graduate Medical Education System, Report No. 14-08, February 2014.

Profile of Florida’s Medicaid Home and Community-Based Services Waivers, Report No. 13-07, March 2013.

The Alzheimer’s Disease Waiver Program Does Not Delay Nursing Home Entry More Effectively Than Other Waivers and Costs the State More Per Participant Than Most Waivers That Serve Similar Persons, Report No. 10-23, February 2010.

A complete list of OPPAGA reports pertaining to the agency is available on our website.

Other Reports

Agency For Health Care Administration - Collection and Use of Medicaid Managed Care Encounter Data and Selected Administrative Activities - Operational Audit, Auditor General Report No. 2018-172, March 2018.

Agency For Health Care Administration - Statewide Medicaid Managed Care Program and Prior Audit Follow-Up - Operational Audit, Auditor General Report No. 2018-002, July 2017. 

Medicaid Health Plan Report Card, Florida Health Finder.

Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2019: Findings from a 50-State Survey, Kaiser Family Foundation and Georgetown University Health Policy Institute, March 27, 2019.

Medicaid Financing:  The Basics, Kaiser Commission on Medicaid and the Uninsured, March 21, 2019.

Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State, Kaiser Commission on Medicaid and the Uninsured, March 17, 2019.

10 Things to Know about Medicaid:  Setting the Facts Straight, Kaiser Commission on Medicaid and the Uninsured, March 6, 2019.

States Focus on Quality and Outcomes Amid Waiver Changes:  Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2018 and 2019, Kaiser Commission on Medicaid and the Uninsured, October 25, 2018.

Florida Medicaid Reform Project Reports, University of Florida.

Assessing Florida’s Medicaid Reform Reports, Georgetown University Health Policy Institute.

Websites of Interest

Agency for Health Care Administration, Statewide Medicaid Managed Care Program

Centers for Medicare and Medicaid Services

Kaiser Family Foundation, Medicaid/CHIP

Performance

Performance measures and standards for the agency may be found in its Long Range Program Plan.

What are the applicable statutes?

Title 42, U.S. Code, s. 1396a; Title 42 Part 430, Code of Federal Regulations; and Ch. 409 Parts II, III, and IV, Florida Statutes.

Whom do I contact for help?

Medicaid Consumer Complaint, Publication, and Information Call Center, 1-877-254-1055

Website

Health and Social Services, Children's health services, Health and social services, Health Care Fraud, Health Care Services, HMOs, Medicaid, Medicaid Benefits, Medicaid Fraud


The Florida Legislature

Office of Program Policy Analysis and Government Accountability