Office of the Deputy Secretary for Medicaid

Dyke Snipes
Deputy Secretary for Medicaid
2727 Mahan Drive, Mail Stop 8
Tallahassee, FL 32308

A Message from the Deputy Secretary for Medicaid

Think of Medicaid as a large insurance company. It operates nationwide, but the benefits are slightly different in each state. Florida is the fifth largest state in Medicaid spending over $13 billion in this fiscal year.

Over two million Floridians are eligible for Medicaid coverage. They are elders, disabled people, families, pregnant women, and children in low-income families. It is the fourth largest Medicaid population in the country.

To meet the needs of Medicaid participants, we have approximately 82,000 Florida Medicaid enrolled individuals and facilities offering health care services as of the end of 2006. ACS "processed approximately 406,000 claim lines every day in 2006." Some people are confused about the difference between Medicaid and Medicare. Both are health care programs, and both were created in 1965 through the federal Social Security Act. Medicare is fully funded and operated by the federal government and offers the nation's primary insurance program for retirees.

Medicaid is a partnership between the states and the federal government, with each paying about half the cost. Each state operates its own Medicaid program under a state plan that must be approved by the federal Centers for Medicare and Medicaid Services or CMS, the new name for what used to be called the Health Care Financing Administration or HCFA.

Certain services must be offered by all states, but each can place some limits on the services. There are also optional services that a state may choose to offer, variations in eligibility groups, different limits on income and assets to decide eligibility, and differences in how much states pay their Medicaid providers.

In Florida the Agency for Health Care Administration (AHCA) is responsible for Medicaid. We are the equivalent of the corporate head office. The Department of Children and Families acts as our agent by enrolling people in Medicaid. We contract with other state agencies and private organizations to provide the broad range of services that Medicaid offers its participants.

Any service offered under Medicaid must be medically necessary. When Medicaid pays for a service, the health care provider must accept that as payment in full, meaning he or she cannot bill the Medicaid participant any additional amount for that service. Medicaid also is the last payer. If a person has any other kind of benefit, it must pay first before Medicaid will pay. This includes Medicare, private insurance, settlements from accidents and judgments in legal actions. If Medicaid has already paid before these benefits are discovered, Medicaid recovers from the liable third party.

Required Medicaid services include those offered by physicians, laboratories and x-ray facilities, rural health clinics, hospitals, and skilled nursing homes. Medicaid also offers home health care, family planning, child health check-ups, transportation, nurse midwife and nurse practitioner services. Florida offers more than 30 optional services, including prescription drugs.

Medicaid always tries to hold down costs. The pharmacy program, which previously represented almost 15 percent of the Medicaid budget, now represents less than 8 percent. This cost savings occurred as a result of the Preferred Drug List and movement of dually eligible beneficiaries to Part D Medicare.

If a state wants to deviate from federal Medicaid requirements, it must get a waiver from the Centers for Medicare and Medicaid Services. Usually waivers relate to getting recipients into managed care plans, setting up alternatives to institutional care, and conducting demonstration projects. Florida offers a number of waiver programs in home and community based services and in disease management.

To manage a program of this size requires more than 600 positions in the Division of Medicaid, two thirds of which are in the 11 Medicaid area offices. It is in the field offices where personal contact takes place between Agency staff, our providers, and our enrollees.

Headquarters staff handle planning and policy issues through four bureaus: Program Analysis, Medicaid Services, Health Systems Development, Pharmacy Services, Quality Management, and Contract Management.

• Program Analysis does fiscal planning, institutional cost reimbursement, systems support and audit services.
• Medicaid Services handles institutional and non-institutional services, long-term care, children's health services, and the waivers.
• Health Systems Development handles MediPass and managed care programs.
• Pharmacy Services administers the prescription drug program, including working with outside professionals who make changes to the preferred drug list.
• Quality Management consists of three offices that focus on optimizing and improving quality in our policies and programs, the implementations of projects and research.
• Contract Management oversees the fiscal agent to ensure claims are paid.

Like any large corporation, Medicaid constantly reviews its methods of operation, monitors contractors and providers, conducts audits, and pursues those who appear to be abusing the program or trying to commit fraud. These efforts are just one part of the broader cost containment measures that overlay all of Medicaid.