Key takeaways from Florida’s SMMC reprocurement RFI

The Agency for Health Care Administration (AHCA) continues to prepare for the reprocurement process for its Statewide Medicaid Managed Care (SMMC) program this year. Enrollment in Florida Medicaid has continued to increase throughout the pandemic, with over 5.3 million beneficiaries as of June 2022. 

In early June, 58 health care organizations including health plans, providers, and community-based organizations, responded to a request for information (RFI) released by AHCA. The RFI was meant to gather information “regarding best practices and innovations in business models as well as service delivery for Medicaid managed care,” according to the document.

 

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The RFI outlined several areas to improve in the world of managed care, which respondents were encouraged to include in their responses. Here are a few of the most common priorities from Florida’s top health care organizations, based on their responses: 

Promoting economic self-sufficiency and addressing SDOH

One of the SMMC priorities outlined in the RFI was to “leverage the managed care delivery system, either through expanded benefits or other mechanisms, to promote sustainable economic self-sufficiency among Medicaid recipients in the short and long term.” Several managed care organizations (MCOs) highlighted the need to expand benefits and improve health outcomes among the Medicaid population. 

In their recommendations, plans said one way to improve health outcomes is by focusing on services that address individuals’ and families’ housing needs, food and employment security, and other social determinants of health. In their RFI response, Molina Healthcare suggested AHCA should require MCOs to provide Community Engagement Plans as part of the reprocurement process. 

“[A Community Engagement Plan] describes how we identify and mitigate unique SDOH barriers that contribute to health disparities and prevent economic self-sufficiency at the community level and at individual member cohorts,” Molina said in their response. 

Molina also recommended AHCA give MCOs the flexibility to tailor benefit offerings for additional non-medical, SDOH-focused supports, such as financial literacy and workforce development. AHCA already has the authority to allow this flexibility under its current 1115 waiver, Molina noted. 

Other recommendations for AHCA, made by Aetna Better Health of Florida, include standardizing methods to document a participant’s SDOH information during the Medicaid intake process, and using a state plan amendment or other method to recognize a wider range of community provider types. 

“The many benefits that peer support specialists, community health workers, and doula services complement a comprehensive, culturally sensitive, system of care approach—resulting in enhanced quality outcomes that empower the recipient in management of care and reduce overall program costs,” Aetna said through their response. 

Improve SMMC provider experience

Organizations representing Medicaid providers advocated for ways to streamline the process for credentialing providers, prior authorization requests, addressing claims payment delays, and holding third-party vendors accountable. 

“The Medicaid program should identify a standard list of procedures to require prior authorization and update at least semi-annually based on the review of data on the types of requests for prior authorization and the resulting approval and denial rates,” the Florida Hospital Association wrote in its response

The National Community Pharmacists Association (NCPA), which represents over 1,100 independent community pharmacies in Florida, noted in its response that “opaque reimbursement practices” often lead to under-reimbursements for pharmacies in MCOs. NCPA suggests Florida’s SMMC adopt a reimbursement methodology similar to the fee-for-service model, a process already established in other states such as Michigan, Kentucky, and Louisiana. This change would improve transparency because it would establish clear reimbursement rates for pharmacies within the MCOs. 

Improving home and community-based services (HCBS)

Many MCOs and community-based organizations agreed that Florida can do more to improve HCBS and aging-in-place services under Medicaid. 

 

Image: Molina Healthcare

 

Molina cited data in its response showing a higher utilization of HCBS since the implementation of the SMMC, but a majority of Medicaid long-term care recipients in certain regions are still in nursing facilities—particularly in rural counties. 

CareSource provided recommendations for this issue in its response. They suggest including the use of CMS’ first-ever set of HCBS quality measures, which are set to release in late 2022, in the procurement process. 

Care coordination company UniteUs also included recommendations to improve HCBS in its response, such as improving social needs screening, closed-loop referrals, and building capacity among providers. 

Other priorities

Other common priorities among respondents included implementing value-based payment models to improve quality and reduce costs, addressing maternal health and mental health needs, and aligning quality metrics with the Florida State Health Improvement Plan (SHIP). SHIP, which covers 2022-2026, outlines a plan of action focusing on health areas such as chronic disease, maternal health, mental well-being and substance abuse prevention, and Alzheimer’s Disease. 

A full list of responses to the RFI are available here