Medicaid managed long-term care complaints are increasing in Florida

MM Curator summary

[MM Curator Summary]: Centene’s and Molina complaint trends are going down; Aetna and Humana’s are going up.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



The number of complaints concerning Florida’s Medicaid managed long-term care program have risen in recent months, members of a statewide medical care advisory panel were told Tuesday.

Paula James, the administrator for the Agency for Health Care Administration (AHCA) Bureau of Plan Management Operations, presented data showing there were 312 calls in May complaining about the contracted managed care plans that provide long-term care services in the state.

“The complaints, unfortunately, have been going up in the last three months. in some areas it’s gone down a little, but we do have a trending rate that has gone up in some of the complaints,” she said.

About a third of the calls were made about Sunshine Health Plan, the largest managed care provider in the state.

James attributed the 111 call complaints regarding Sunshine Health Plan to the company’s acquisition of StayWell and subsequent merger. The state hit Sunshine Health Plan with a record-breaking $9 million sanction in March for not making payments or delaying payment on 121,277 claims.


While Sunshine Health Plan had more complaints than any other provider, there is a downward trend in the number of complaints being made to the state about the health plan, according to James’ presentation to the Medicaid Managed Medical Care Long Term Care Advisory Subcommittee.

Sunshine and Molina Healthcare were the only two plans providing long-term care services to see a downward trend in complaints over the three-month period between March and May.

Humana Medical Plan, second only to Sunshine in the number of long-term care enrollees, with 28,739 members, had 59 complaints in May. That’s a continued upward increase in complaints over the three-month period.

Aetna Better Health
was the subject of 59 calls into the agency in May, which exceeds the number of complaints made against the insurer in March or April. Additionally, the number of complaints against Simply Healthcare Plan (43) also was up from the previous two months.

The calls came from providers and from Medicaid beneficiaries, but the state didn’t provide a further breakdown of the numbers.


James’ presentation did, though, provide details about what drives complaints about both groups.

Half of the complaints the state received in May from enrollees stemmed from an inability to access medical or dental benefits.

“In many instances, it’s a case of the recipient not knowing how to access the information or the fact that they have not gone back to the plan and requested assistance with this,” she said. “Or it could be a situation where they have asked for a particular provider and that provider is not in their network. So, a lot of it is education for the recipients.”

However, transportation, which is also classified as an access-to-care issue, continues to be an area where the state sees complaints from beneficiaries and providers, she said.

A snapshot of the providers’ complaints for May shows that 72% of the calls involve claims. While claims processing accounts for the overwhelming majority of the providers’ calls, the AHCA presentation showed that 15% of the calls from providers in May involve disputes between the plans and the providers over the accuracy of the information given to them by health plans.

The agency report also relayed that as of June 12 there were 372 unresolved complaints against Medicaid managed care plans. More than half of the pending claims involved allegations against Sunshine Health Plan.

James acknowledged to panel members that the number of unresolved claims “may” seem high. But she said that allegations involving claim payments are reviewed by a research team before health plans are notified. Moreover, she said the report includes information on complaints that her office received Monday and that some of the complaints “may” involve allegations about unpaid claims.

Medicaid is a safety net program for the poor, elderly and disabled that is funded and administered jointly between states and the federal government. There are more than 5 million people in the program as of the end of May.

Federal regulations require states to have a Medical Care Advisory panel that meets quarterly. The managed long-term care panel that met Tuesday is one of a handful of subcommittees that were created to examine issues.

There is a subcommittee for dental care as well as subcommittees that examine services for people with HIV/AIDS and children.

James said the other subcommittees will be meeting in the coming weeks.

The meetings come as Florida Medicaid officials begin work on a new procurement for the mandatory Medicaid managed care program.

The current Medicaid contracts the state has with selected managed care plans are set to expire on Dec. 31, 2023.

To have new contracts in effect by Jan. 1, 2024, the state wants to advertise the Medicaid bid by the end of the year.

While the number of complaints regarding the managed long-term care program are on the rise, not all the news James delivered Tuesday was bad.

She noted that in March 2018, 54% of the 100,209 people enrolled in the Medicaid managed long-term care program were receiving care in nursing homes.

Today, 62% of the 123,052 Medicaid managed long-term care enrollees are receiving services they need to keep living in a community setting and outside an institution. These services include adult companion care, attendant care, homemaker services, intermittent and skilled nursing, or personal care services.

“So, we are right where the agency has wanted to be all along. We are increasing the population that is able to receive services in their home or in a less restrictive environment like an assisted living facility rather than in a skilled nursing facility,” James said of the roughly 76,000 people on the waiver receiving home- and community-based services.

In addition to seeing a shift from non-institutional care to home and community-based services, James said there also has been an uptick in the number of people who are participating in what’s known as the Participant Directed Option (PDO).

PDO allows Medicaid beneficiaries who require assistance such as assistance with eating, bathing, grooming and homemaker services to hire workers providing certain long-term care services. The PDO is available to all long-term care enrollees who live in their own home or family home who hire friends, family members and even neighbors to provide the care.

The Medicaid managed care plan remains responsible for paying the providers the beneficiary chooses. Only services that are medically necessary can be covered through the PDO plan

Of the 67,875 people who qualified for PDO participation in March, about 16% were enrolled in the program.

Sunshine Health Plan Vice President of Long-Term Care and panel member Brad Shapiro asked James whether that was an increase from past years.

“My hope is it’s on the rise,” he said.

James didn’t have the comparison data but said participation had increased.

Sunshine Health Plan and Simply Health Care Plan have PDO participating rates of 19.1% and 18.7%, respectively.

Conversely, Molina, which has contracts in two of the 11 regions, had the lowest participation rates with just 9% of its eligible enrollees participating in the program.

But James said that plan size should not impact participation rates.

Simply has contracts in six regions and is second to Sunshine, which has contracts statewide, in the number of enrollees in the PDO program.

Humana has long-term care contracts in 11 regions but only 14% of its eligible enrollees participate in the program. That’s on par with Aetna Better Health which operates in three Medicaid regions and has an average PDO participation rate of 14%.

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