Welcome back to Diagnosis, a vertical that focuses on the crossroads of health care policy and politics.
Sunshine Health, the state’s largest managed care vendor operating in its Medicaid program, has remained relatively quiet since it was revealed last week that the Agency for Health Care Administration (AHCA) had levied more than $9 million in fines and sanctions on the company.
Sunshine has not said whether it plans to contest the fine. The fine would be a record since Florida shifted the operation of the mammoth health care safety net over from a fee-for-service model to one that relies on private managed-care companies to coordinate care for the majority of more than 5 million people enrolled in Medicaid.
But it may be worth looking at how Sunshine has fared in other disputes of late.
A recently released report shows that a statewide claims dispute panel reviewed six cases against Sunshine Health in 2021 and found in favor of the provider in five of the disputes. Ultimately, the company was ordered to pay Jackson Memorial an aggregate of more than $380,000 for the five disputed claims. The sixth claim was withdrawn.
The panel was initially created 20 years ago to consider reimbursement claim disputes between health care providers and managed care plans. Over the years, the program has been broadened. And in 2018, the state required Medicaid managed care organizations to use the arbitration process for disputed claims.
AHCA administers the program, but Maximus Inc. is the company the state contracts with to mediate the billing disputes. Users bear the program costs, with the losing party picking up both its costs of the claim review and the prevailing party’s costs. In instances where Maximus favors both parties, the review costs are shared.
In all, the panel agreed to review 73 of the 111 claims filed with it for review.
The largest Medicaid dispute the panel heard in 2021 involved Molina Healthcare of Florida and Children’s National Medical Center. The provider’s case alleged $2.3 million in underpayments. Maximus agreed, according to the report.
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— PARTING GIFT —
State workers, legislators, and other top state officials got a little going away present, courtesy of the Florida Legislature.
Earlier this Session, Diagnosis flagged proposed changes to the state’s group health insurance program. Many changes wound up passing in the waning days of the 2022 Session with scant questioning or debate.
One notable change approved allows state employees with group health insurance who step down from their job on or after July 1 of this year to be eligible for enrollment in the state group health insurance plan for another two years following their departure. There is a caveat: only state employees who have been cumulatively employed for six years could take advantage of the health insurance option.
But this also means that someone who has been in and out of state government — but worked at least six years in a state government job — would get a chance to do this. Initially, the House wanted to have a limited two-month special open enrollment period where this option would be available for former employees. But the final bill (HB 5009) that passed unanimously allows former employees to join the state group health insurance plan for up to two years following their departure.
The premiums, however, would not be at the active employee rate. Instead, the bill clarifies that these departing state employees would pay the same rate as early retirees, which currently is $813.46 a month for individual coverage through a standard PPO/HMO and $1,831.08 for family coverage.
— BUT WAIT, THERE’S MORE —
As they have done for many years now, lawmakers kept the health insurance premium rates for state workers (and themselves) unchanged. But the same bill that opened coverage options for departing state workers did two other things of note.
The measure finally repealed the tiered-coverage system, pushed through by House Republicans in 2017, that kept getting delayed.
That law directed the Department of Management Services (DMS) to offer state employees access to one of four health insurance plans — named after metals with different actuarial values, like Obamacare’s bronze, silver, gold and platinum plans. Employees who chose less expensive plans than what the state paid toward the premium could be used to increase their salary. An actuarial analysis showed that the law, if implemented, would have increased costs by $525 million annually.
The bill that will be sent to Gov. Ron DeSantis, however, would create for the first time a dedicated “anti-fraud” unit inside DMS where workers would investigate claims as well as any fraudulent actions by vendors that work with the state group health insurance program. The newly approved budget sets aside money for three positions in the new unit.
In other moves involving state workers, legislators ordered DMS to hire an outside company to create a “wellness program to treat, reduce and prevent obesity and obesity-related conditions.” Lawmakers say that those employees who enroll in the program would gain access to U.S. Food and Drug Administration-approved medications to treat chronic weight management problems. But the language, which was tucked in the back of the budget bill, says this treatment would not become available until 2024.
DMS has until March 2023 to produce a draft contract and provide costs on how much the wellness program would cost.
Legislators also have OK’d spending more than $2 million for a “new case management and analytics solution for health care fraud,” as well as $600,000 to hire an outside independent benefits consultant to do a “comprehensive cost containment analysis of state employee and retiree health benefits.” By mid-January, DMS must submit a report with recommendations needed to implement any cost containment measures.
These moves came nearly two months after economists revised the fiscal outlook for the state employee health insurance program, which is projected to spend $3.1 billion in the next fiscal year. But the fund, a combination of employees’ monthly premiums and state tax dollars, is projected to have a $61.8 million deficit in the Fiscal Year 2023-24. The deficit is due to a decline in health plan enrollment in the Fiscal Year 2021-22 and higher than anticipated expenses for those covered. Data show 3,312 fewer state employees in the health plan in the current fiscal year than projected.