Office of Program Policy Analysis and Government Accountability
Office of Program Policy Analysis and Government Accountability

Agency for Health Care Administration

Medicaid Health Care Services

For assistance, call 1-877-254-1055 or visit https://ahca.myflorida.com/Medicaid/complaints/

What is the purpose of the program?

Florida's Medicaid Program provides access to health care for eligible low-income persons and assists aged and disabled people with the cost of long-term care. Medicaid is administered by the Agency for Health Care Administration while program eligibility is determined either by the Department of Children and Families or the Social Security Administration. As of September 30, 2023, there were 5.2 million Medicaid recipients, with 133,990 in Medicaid Managed Care Long Term Care Program. Half of individuals eligible for Medicaid are children and adolescents 20 years of age or younger.

What services are covered under Florida Medicaid?

The federal government and the states jointly finance Medicaid which delivers primary and acute medical services, as well as long-term services and supports to low-income populations including children, pregnant women, adults, individuals with disabilities, and those age 65 and older. While the federal government requires states to cover certain mandatory populations and services, the Social Security Act (the underlying statute for Medicaid) gives states flexibility in determining eligibility, covered benefits and provider payment rates. For managed care plans mandatory services include physician visits, family planning, laboratory tests, portable x-ray services, health screening services for individuals under age 21, and transportation to access covered services. Currently, Florida's Medicaid Managed Care Program covers over 29 mandatory services.

How are Medicaid services delivered in Florida?

Most Medicaid recipients are enrolled in the Statewide Medicaid Managed Care (MMC) which has three parts: Managed Medical Assistance (MMA), Long-Term Care (LTC) and Dental. People on Medicaid will obtain services using one or more of these plans.

  • Managed Medical Assistance (MMA) plans include doctor visits, hospital care, prescribed medication, mental health care, and transportation.  Most people on Medicaid receive care from a plan that covers MMA services.
  • Long-Term Care (LTC) includes care in a nursing facility, assisted living or at home. An individual must be at least 18 years old and meet nursing home level of care or meet hospital level care for those with Cystic Fibrosis.
  • Dental services are provided to all recipients. All children and adults must enroll in a dental plan.

AHCA contracts with managed care plans by geographic regions for the MMA, LTC and Dental programs. AHCA also contracts with specialty plans tailored to meet the needs of specialty populations.

 The Legislature established the number of plans that each region is required to have.

The Number of MMA, LTC and Dental Plans Allowed by Region

Region

Plans Allowed1

Counties in Service Region

1 2 Escambia, Okaloosa, Santa Rosa, and Walton
2 2 Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington
3 3 to 5 Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrest, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union
4 3 to 5 Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia
5 2 to 4 Pasco and Pinellas
6 4 to 7 Hardee, Highlands, Hillsborough, Manatee, and Polk
7 3 to 6 Brevard, Orange, Osceola, and Seminole
8 2 to 4 Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota
9 2 to 4 Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie
10 2 to 4 Broward
11 5 to 10 Miami-Dade and Monroe
1Children's Medical Services Network is a separate plan in addition to the number of Managed Medical Assistance plans listed.
Source: Sections 409.966 and 409.974, Florida Statutes.

 

As of September 2023, 26.7% of Medicaid recipients were receiving services from fee for service providers because certain Medicaid populations are either not eligible or not required to participate in managed care. Medicaid recipients not eligible for MMA care include family planning waivers enrollees; breast and cervical cancer program enrollees; presumptive eligible pregnant women; residents of a Department of Juvenile Justice commitment facility; and residents of a state mental hospital.

Medicaid recipients who may enroll in MMA but are not required to participate include recipients who have other health care coverage excluding Medicare; persons eligible for refugee assistance; recipients who are residents of a developmental disability center; iBudget enrollees and waitlist population; children receiving prescribed pediatric extended care center services; and recipients residing in a group home facility licensed under Ch. 393, Florida Statutes.

Who is eligible for Medicaid services in Florida?

To receive federal Medicaid funds, Florida must adhere to federal requirements related to recipient eligibility. For example, federal guidelines require Florida to provide health care coverage to low-income children and their families, low-income seniors, low-income people with disabilities, pregnant women, and people age 65 and older.

How is the program administered?

The Agency for Health Care Administration's Division of Medicaid plans, develops, organizes and monitors program planning, coverage and reimbursement policies, and oversees provider and consumer relations. The division also administers the Medicaid fiscal agent contract and formulates long-term plans for service delivery.

Under AHCA's Medicaid Policy, Quality and Operations, the Bureau of Plan Management Operations is responsible for the primary oversight of Medicaid's management care programs, with a focus on the Statewide Medicaid Managed Care (SMMC) program. The bureau's contract managers ensure that the managed care plans meet Medicaid contractual requirements such as the timely provision of medically needed services and provider payment for such services.

The Bureau of Medical Field Operations has 11 field offices that carry out a number of functions such as monitoring the implementation of Medicaid policies and procedures; providing technical assistance, consulting and training to providers, governmental agencies, and community organizations. Field offices also coordinate the primary care case management program (MediPass) and assists Medicaid enrollees and providers with issues related to Medicaid services.

The Office of the Inspector General oversees the Office of Medicaid Program Integrity whose responsibility is to perform audits and investigation Medicaid providers suspected of overbilling or defrauding Florida's Medicaid program, recover overpayments, issues administrative sanctions and refers cases of suspected fraud for criminal investigation.

Is the program preventing unnecessary hospitalizations?

In Fiscal Year2021-22, all hospitalizations for Ambulatory Sensitive Conditions (conditions preventable by good ambulatory care) for ages 1 to 20 who were enrolled in Fee-for-Service, MediPass, and Provider Service Networks was 0.78%. For individuals age 21 and over, 5.05% of all hospitalizations were for Ambulatory Sensitive Conditions.

How well is the program providing prenatal care?

For Fiscal Year 2021-22, 82.7% of women received adequate prenatal care, below the approved performance standard of 86%. The neonatal mortality rate (calculated for babies fewer than 28 days old) for Fiscal Year 2021-22 was 3.8% per 1,000 births, which was lower than the approved standard of 4.7% per 1,000 births.

How are these activities funded?

Funding for Medicaid is a shared responsibility of the federal government and the states. States receive federal matching dollars based on reported state Medicaid expenditures. Funding for the state share of Medicaid expenditures comes from a variety of sources but at least 40% must be financed by the state, and up to 60% may come from local governments. The federal share for most Medicaid service costs is determined by the federal medical assistance percentage (FMAP), which is based on a formula that provides higher reimbursement to states with lower per capita incomes relative to the national average (and vice versa). The state also receives Title XXI funds to provide health care services to certain children not covered by Medicaid through the non-Medicaid components of KidCare.

Fiscal Year: 2023-24
Fund Dollars Positions
PROGRAM: HEALTH CARE SERVICES
CHILDREN'S SPECIAL HEALTH CARE
563,401,290
.00
EXECUTIVE DIRECTION AND SUPPORT SERVICES
440,822,400
623.00
MEDICAID LONG TERM CARE
9,057,889,610
.00
MEDICAID SERVICES TO INDIVIDUALS
30,951,409,414
.00
TOTAL
41,013,522,714
623.00

Updates

Medicaid Coverage of Continuous Glucose Monitors. The 2023 Legislature enacted Ch. 2023-283, Laws of Florida, requiring the Agency for Health Care Administration (AHCA) to provide coverage for continuous glucose monitors for Medicaid recipients diagnosed with diabetes by a primary care physician or another licensed health care practitioner. AHCA must implement requirements for Medicaid recipients to continue receiving coverage for their continuous glucose monitors. Coverage for continuous glucose monitors is subject to the availability of funds and subject to any limitations or directions provided in the General Appropriations Act. If needed, AHCA must seek federal approval for the implementation of this statute. AHCA must also include the rate impact of the program in the Medicaid managed medical assistance program and long-term care managed care program rates.

Where can I find related OPPAGA reports?

Biennial Review of AHCA's Oversight of Fraud and Abuse in Florida's Medicaid Program, Report 24-03, January 2024
Biennial Review of AHCAs Oversight of Fraud, Waste, and Abuse in Florida's Medicaid Program, Report 22-03, January 2022
Review of Services Provided to Medicaid-Eligible Pregnant Women, Infants and Children by Florida Healthy Start and Medicaid Managed Care Plans, Report 21-08, December 2021
AHCA Continues to Improve Medicaid Program Data Quality and Oversight; Additional Improvements Needed in Use of Data, Report 20-04, January 2020

Where can I get more information?

Other Reports
Agency For Health Care Administration, Office of Inspector General - Annual Report FY 2022-23, September 2023
Agency For Health Care Administration - MediKids Program Funding and Selected Administrative Activities- Operational Audit, Auditor General Report No. 2021-198, April 2021
Agency For Health Care Administration -Analysis of Selected Medicaid Claims Data - Operational Audit, Auditor General Report No. 2021-013, August 2020
Medicaid Health Plan Report Card, Florida Health Finder
Analysis of Recent Trends in Medicaid and CHIP Enrollment, Kaiser Family Foundation Issue Brief, April 8, 2021
Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2021: Findings from a 50-State

Survey, Kaiser Family Foundation and Georgetown University Health Policy Institute, March 2021
Medicaid Financing: The Basics, Kaiser Commission on Medicaid and the Uninsured, March 21, 2019
Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State, Kaiser Commission on Medicaid and the Uninsured, April 7, 2021
10 Things to Know about Medicaid: Setting the Facts Straight, Kaiser Commission on Medicaid and the Uninsured, March 6, 2019
Florida Medicaid Maternal & Child Health Status Indicator Report Calendar Years 2018-2021, University of Florida, Family Data Center, Institute for Child Health Policy, College of Medicine, June 2019

Websites of Interest
Agency for Health Care Administration, Statewide Medicaid Managed Care Program

Agency for Health Care Administration Publications

Centers for Medicare and Medicaid Services
Kaiser Family Foundation, Medicaid/CHIP

Performance Information


Performance measures and standards for the department may be found in its Long Range Program Plan.

What are the applicable statutes?

Title 42, U.S. Code, s. 1396a; Title 42 Part 430, Code of Federal Regulations; and Ch. 409 Parts II, III, and IV, Florida Statutes

Whom do I contact for help?

Florida Medicaid Complaints Helpline: 1-877-254-1055 or 1-866-467-4970 (TDD).
Staff are available to help Monday through Friday, 8:00 a.m. to 5:00 p.m. (EST).

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