Review finds AHCA fell short in behavioral health and women’s care in Florida


Nicole Pasia


The Agency for Health Care Administration (AHCA), which administers Florida’s Statewide Medicaid Managed Care (SMMC) program, received several recommendations to improve care delivery for behavioral and women’s health, along with other services as part of its federally-required External Quality Review (EQR).


Stay one step ahead. Join our email list for the latest news.



Health Services Advisory Group (HSAG), an EQR Organization for Medicaid, conducted the assessment for the SMMC program for fiscal year 2020-2021 and published its technical report last month. 

AHCA’s last procurement cycle  in 2017 awarded contracts to several plans including Sunshine Health, Simply Healthcare, and Aetna Better Health, that would last through December 2024. These plans provide services through Managed Medical Assistance (MMA) Program, Long-term Care (LTC) Program, Comprehensive MMA and LTC, Specialty, and Dental Program plans. Over 5.2 million Floridians are now enrolled in Medicaid, according to the most recent data from AHCA.

HSAG used elements of AHCA’s Comprehensive Quality Strategy (CQS) to measure the agency’s performance. These include quality, timeliness, and access to services.

Aside from the above performance measure, HSAG also reviewed AHCA’s Performance Improvement Projects and its compliance with Healthcare Effectiveness Data and Information Set (HEDIS) measures. 

Among MMA plans, the state on average met AHCA’s minimum performance targets for 23 out of 38, or 60.5% of its measure indicators. The performance measures in the EQR were divided into six areas of care: pediatric care, women’s care, living with illness, behavioral health, access/availability of care, and appropriate treatment and utilization.  


Performance Strengths

Strong performance measures include Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication—Continuation and Maintenance Phase. The HEDIS performance measure indicator rate increased from 57.33% in 2020 to 62.67% in 2021, meeting or exceeding the performance target. According to the report, this means Florida providers are following up with children after their ADHD diagnoses and treatments, and ensuring their medication levels are appropriately managed. 

Other strengths include a decrease in the statewide average Asthma Medication Ratio of Total Members. This rate decreased from 74.67% in 2020 to 73.94% in 2021, suggesting that more Floridians with asthma are receiving their recommended care and can better manage their chronic condition. 

The EQR noted 7 of 15 measurement rates in the LTC program met or exceeded AHCA’s 2021 performance targets:

“The results indicate that the plans have established documentation of in-person comprehensive assessments, comprehensive care plans, and shared care plans to promote the coordination of [Long-Term Support Services],” the report said. “The results also indicate that health plans are conducting assessments and creating care plans with their members within [a] specific measure timeline.”


Performance Weaknesses

The report found that during the evaluation period, AHCA did not conduct a comprehensive compliance review every 3 years, which is required by the CMS Medicaid Managed Care Rule. However the report noted that AHCA has since “put into place a process to ensure compliance going forward.” 

The report also cautioned that many negative performance rates may have been impacted by the temporary closure or reduction of non-urgent services due to the COVID pandemic. 

Several women’s care measurements fell below minimum performance targets, according to the report. These include timeliness of prenatal care visits (fell 8 percentage points from 2020 to 2021) and cervical cancer screening (fell 4 percentage points). 

“Early detection of cancer and chlamydia reduces the risk of serious complications or death and can lead to a greater range of treatment options and lower healthcare costs,” the report said. “… Members were not completing recommended screenings, which may indicate a lack of understanding of healthcare or recommended prevention and screening schedules.”

The report identified several weaknesses regarding behavioral health care measures. For example, the measure of medical assistance provided for smoking and tobacco use cessation fell 3 percentage points. Performance rates for follow-up care after an emergency department visit for mental illness or substance misuse did not significantly decrease, and in some cases witnessed a slight increase, but overall remained below AHCA’s performance targets. 

Some of AHCA’s highest performance declines were in relation to LTC services. The measure on minimizing institutional length of stay dropped over 21 percentage points from 2020-2021, while the measure for successful transitions after long-term institutional stays dropped over 11 percentage points. The statewide average for plan of care to prevent a patient’s future injuries from falls also dropped by  over 14 percentage points. 

HSAG outlined several recommendations corresponding to each performance weakness. A common suggestion was that AHCA study social determinants of health impacting the members’ access to services. 

“Health plans should consider if there are disparities within their populations that contributed to lower performance in a particular race or ethnicity, age group, ZIP Code, etc.,” the report said. “Upon identification of a root cause, health plans should implement appropriate interventions to improve utilization.”

The report continues to break down performance measures by plan and highlights some of AHCA’s current actions to improve their service delivery. These include encouraging health plans to improve LTC discharge plans, monitoring data submissions, and setting data submission standards.