I am elder law attorney, but more importantly, I am an advocate for the elderly.

As we all know, this waiver request seeks to expand the pilot project to include Florida’s seniors under a long term care managed care model.  Within this model, the managed care organizations will be paid a capitated rate to cover any and all health care needs of these seniors.  I am here to tell you that Florida has failed to do its homework.  It is NOT ready to enroll this population into long term care managed care plan for (3) main reasons summed up as “No Data.  Wrong Data.  And, Bad Data”


Reason Number 1: Face it Florida …  You have NO DATA!  Technically speaking, any hope for success depends upon setting the capitated rate CORRECTLY.   The Kaiser Commission on Medicaid reported that reduced quality of care is more likely with a capitated rate system.  Why?  If the data is not based on (1) the population to be covered and (2) the services to be furnished, then you can NOT set an actuarially sound capitated rate.  If it is set too low, the managed care organizations adapt by cutting back on the quality and quantity of care furnished.

Because seniors were NOT included in the pilot project, Florida has NO historical data for the utilization of long term care services to give to CMS.  And, no cost data exists for them either.  Without data, federal regulations requiring all payments to be actuarially sound are not met in Florida’s waiver request.

Reason Number 2: Of the data that has been collected from the pilot project on Medicaid beneficiaries OTHER THAN seniors, it is the WRONG data.  AHCA cannot apply WRONG data from one set of Medicaid beneficiaries to seniors on whom no data has been collected.  Although AHCA was required by law to use “risk-adjusted capitated rates” to determine the most accurate rate for those with the greatest health care needs, Florida used a statistical model in the pilot project that cannot accurately predict a beneficiary’s health care costs.  Even HMOs disfavor this particular model because of its inaccuracy.  Because of the lack of reliable and sufficient encounter data, AHCA admitted not being able to use a more accurate model until 3 months ago, some 56 months into the 60 month pilot project.

Reason Number 3:  In addition to “No Data” and “Wrong Data”, there’s also been “Bad Data”.   So far, AHCA must collect “encounter data” which shows the health services provided to beneficiaries in the managed care plans.  The data must be accurate and complete.  As recent as 5 months ago, AHCA reported it had “poor and insufficient” reporting by plan providers.  And, this “encounter data” is the foundation for detecting managed care fraud and abuse! Assurance of quality of care and plan accountability is not possible without Medical loss ratios, not even included this waiver request!  This is a flaw in the waiver request which leads to bad data that cannot adequately ensure quality of care provided to the Medicaid enrollees nor render plans accountable for services rendered.


In conclusion, Florida should not be like another State that rushed into managed care for its Medicaid long term care beneficiaries without adequate data to set its capitated rate and paid the price with a Medicaid budget which literally exploded rather than shrunk.


Think about it this way ….. if I asked Wal-mart, Target and Publix to price adult diapers like Depends, they would tell me it “depends” upon the amount of customers and the cost per item from the manufacturer to arrive at an appropriate price or outcome, including profit.  Here, you do not know the number of customers, the cost per item and so…..you cannot depend upon the HMO to accurately predict the outcome, unless you depend upon their undependable representations.

As long as Florida lacks accurate and reliable data, seniors should be excluded from the waiver expansion.  Otherwise, No Data, Wrong Data, Bad Data, spells Disaster for seniors and Florida’s taxpayers.


It is most important that people write to CMS directly (they are the ones that will approve or disapprove the plan that AHCA is suggesting be put into place – which are mandates from the FL legislature:


CMS:   cynthia.mann@cms.hhs.gov

AHCA:  FLMedicaidManagedCare@ahca.myflorida.com


Richard Jensen, Director

Division of State Demonstrations and Waivers Centers for Medicare and Medicaid Services Center for Medicaid and State Operations

7500 Security Blvd., Mail Stop S2-01-16

Baltimore, MD 21244-1850.


Statewide Medicaid Managed Care Program Office of the Deputy Secretary for Medicaid Agency for Health Care Administration

2727 Mahan Drive, MS #8

Tallahassee, Florida 32308


To learn more about Florida Elder Law, Medicaid Laws,  and issues affecting seniors, please contact the Law Offices of Laurie Ohall.