Medicaid Overview Better Health Care for all Floridians.
Medicaid Overview Medicaid is a state and federally funded program that provides health care coverage for certain low-income populations who meet requirements related to age, disability or other specific health conditions.
Escambia Santa Rosa Okaloosa Area 1 160 Governmental Center RM510 Pensacola, FL 32502 850-595-2300 1-800-303-2422 Walton Holmes Bay Calhoun Area 2A 651 West 14 th St, Suite K Panama City, FL 32401 850-767-3400 1-800-226-7690 Jackson Gulf Medicaid Area Offices May 22, 2012 Liberty Washington Gadsden Leon Franklin Wakulla Jefferson Lafayette Union Gilchrist Columbia Hamilton Madison Taylor Bradford Area 2B 2727 Mahan Drive, MS #42 Tallahassee, FL 32308 850-412-4002 1-800-248-2243 Area 3A 14101 NW Hwy 441 Suite 600 Alachua, FL 32615 386-462-6200 1-800-803-3245 Area 5 525 Mirror Lake Drive, N Suite 510 St. Petersburg, FL 33701 727-552-1900 1-800-299-4844 Dixie Pinellas Sumter Hernando Pasco Suwannee Levy Sarasota Area 6 6800 N. Dale Mabry Hwy Suite 220 Tampa, FL 33614 813-350-4800 1-800-226-2316 Alachua Citrus Charlotte Baker Marion Nassau Clay Putnam Polk Manatee Hardee Lee Area 8 2295 Victoria Ave. Suite 309 Fort Myers, FL 33901 239-335-1300 1-800-226-6735 DeSoto Lake Volusia Orange Collier Area 4 921 N. Davis St. Bldg. A Suite 160 Jacksonville, FL 32209 904-798-4200 1-800-273-5880 Osceola Glades Hendry St. Johns Flagler Seminole Indian River St. Lucie Palm Beach Dade Area 3B 2441 W. Silver Spgs Blvd Ocala, FL 34475 352-840-5720 1-877-724-2358 Martin Broward Area 7 400 W. Robinson St. Suite S 309 Orlando, FL 32801 407-420-2500 1-877-254-1055 Area 9 1655 Palm Beach Lakes Blvd., Suite 300 W. Palm Beach, FL 33401 561-712-4400 1-800-226-5082 Area 10 1400 W Commercial Blvd Suite 110 Ft. Lauderdale, FL 33309 954-958-6500 1-866-875-9131 Area 11 8333 NW 53 rd St. Suite 200 Doral, Fl 33166 305-593-3000 1-800-953-0555
Medicaid Vs. Medicare Medicaid For people with low incomes and limited resources Some age limitations by eligibility category Administered by federal and state government Coverage varies by state Medicare For people who have paid into the program through social security taxes Serves people age 65 and older or disabled Administered by federal government Coverage same in every state 4
Medicaid Structure Federal Medicaid laws mandate certain benefits for certain populations Medicaid programs vary considerably from state to state, and within states over time State Medicaid programs vary because of differences in: Optional service coverage Limits on mandatory and optional services Optional eligibility groups Income and asset limits to eligibility coverage Provider reimbursement levels Medicaid does not cover all low income individuals 5
Medicaid Program Medicaid Eligibility Social Security Administration (SSA) Department of Children and Families (DCF) Medicaid Services Agency for Health Care Administration (AHCA) 6
Gold Card FLORIDA MEDICAID Identification Card 11111111 Florida Citizen Not proof of eligibility Card control number-not Medicaid ID number One card per eligible recipient including unborn Card mailed at time of eligibility determination Replacement cards obtained through Department of Children and Families 7
MANDATORY MEDICAID COVERED SERVICES Services required of the state by Title XIX of the Social Security Act Advanced Registered Nurse Practitioner Services Child Health Check-Up Family Planning Services Home Health Services Hospital Services - Inpatient Hospital Services - Outpatient Independent Laboratory Services Nursing Facility Services Physician Services Portable X-ray Services Rural Health Clinic Services Transportation Services 8
OPTIONAL MEDICAID COVERED SERVICES Services which are optional to the state under Title XIX of the Social Security Act Ambulatory Surgical Centers Assistive Care Services Birth Center Services Chiropractic Services Community Mental Health Services Dental Services Dialysis Facility Services Durable Medical Equipment Healthy Start Services Hearing Services Home and Community-Based Services Hospice Services Intermediate Care Facility Services for the Developmentally Disabled Optometric Services Physician Assistant Services Podiatry Services Prescribed Drug Services Registered Nurse First Assistant Services School-Based Services State Mental Hospital Services Subacute Inpatient Psychiatric Program for children Targeted Case Management Vision Services 9
Pharmacy Services Information Medications listed on the Medicaid Preferred Drug List (PDL) must be used before requesting approval to use non-pdl medications No limit on the number of generic or brand-name drugs if they are on the Preferred Drug List Mental Health drugs are not exempt from Preferred Drug List requirements Nursing home residents are not exempt from Preferred Drug List requirements All HIV anti-retroviral are on the Preferred Drug List 10
Medicaid Co-payments A co-payment may not be charged to recipients in any of the following categories: Recipients under 21 years of age Recipients who are pregnant or receiving family planning services Recipients in a hospice, nursing home, ICF/DD Recipients being treated for an emergency in an emergency facility Recipient currently enrolled in a Medicaid HMO/prepaid health plan 11
What is Share of Cost? Program eligibility category is called Medically Needy Share of Cost is the amount of medical bills a recipient must have before Medicaid can pay any other medical bills Share of Cost is based on the amount of the recipient s monthly income Share of Cost works like a deductible on any health insurance policy Share of Cost must be met, on a monthly basis, before a recipient becomes eligible for Medicaid Medicaid will begin by paying the bill that meets or goes over the Share of Cost Recipients have to take proof of expenses to DCF Proof should include: - amount of the expense (medical bills) - date expense incurred - date and amount of any payment (receipts or cancelled checks) 12
Medicaid Rules Medically Necessary Medicaid Payment is Payment in Full Medicaid is Payer of Last Resort 13
Reimbursement Hierarchy Third Party Liability Medicare Medicaid State Plan Waiver 14
Managed Care Provision of health care services through a contracted delivery system Medicaid Options, a private contracted company, helps recipients enroll in a managed care plan Recipients have 30 days from the date Medicaid eligibility begins to select a managed care option Recipients have 90 days, from the date of enrollment, to try the plan and request change 15
Why Managed Care? Emphasizes Preventative Health Care Facilitates Cost Effectiveness Encourages Patient/Provider Relationship Helps Reduce Fraud and Over-utilization 16
Who is Exempt from Mandatory Assignment? Most Medicaid recipients are required to participate in some form of managed care Exemptions include those who: Have Medicare or another major medical policy as their primary insurance (must have proof) Receive services through Hospice Reside in a Skilled Nursing Facility, Intermediate Care Facility for the Developmentally Disabled (ICF/DD), or in a Sub-Acute Inpatient Psychiatric Program (SIPP) Are under age 21 and enrolled in Children s Medical Services or attend a Prescribed Pediatric Extended Care center Are only eligible for limited Medicaid under such programs as the Family Planning waiver, Medically Needy or Qualified Medicare Beneficiary (QMB) groups 17
Florida Medicaid Reform Senate Bill 838, passed by the Florida Legislature in 2005, gave AHCA permission to reform Medicaid Referred to as a waiver, because it seeks federal permission to waive certain federal Medicaid requirements that govern the regular Medicaid Program Began in Broward and Duval Counties in July 2006 Expanded to Baker, Clay and Nassau Counties Expand statewide upon legislative approval 18
Florida Medicaid Reform (continued) Healthcare provider networks formed to create benefit packages to meet needs of patients Participants, with the help of counselors, choose the plan that best meets their needs Participants can earn enhanced benefit credits by participating in healthy lifestyle choices Enhanced benefit credits give participants extra funds to purchase healthcare goods and services not covered by their plan 19
Who Are You Going to Call? Medicaid Options Educates new recipients on differences between managed care plans Assists current recipients wishing to make a plan change Educates recipients on open enrollment policy Enrolls, disenrolls and processes health plan changes 1-888-367-6554 20
Who Are You Going to Call? To ask questions about MediPass Medicaid Beneficiary Unit To change from one MediPass provider to another MediPass provider To inquire about finding a Medicaid Provider (until enrolled in a Medicaid Health Maintenance Organization) To report a problem, such as inappropriate provider billing for covered services or refusal to provide services (due to Third Party Insurance on file) To ask questions about Medicaid copayments To ask questions about Medicaid-covered services 407-420-2500 Toll Free: 1-877-254-1055 21
Who Are You Going to Call? Department of Children & Families Toll Free 1-866-762-2237 Fix Medicaid file problems (recipient not on file, incorrect date of birth on file, etc.) Change any information on FMMIS Assist with eligibility issues such as: (a) Changes in coverage groups (b) Medically Needy bill tracking (c) Questions about Share of Cost (d) Adding household members to Medicaid (e) Medicaid denial or termination of benefits (f) Temporary proofs of eligibility Issue duplicate Medicaid gold cards Apply for Medicaid through DCF website: www.dcf.state.fl.us/programs/access 22
For More Information... Visit our web sites at: http://ahca.myflorida.com http://mymedicaid-florida.com 23
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