Florida Medicaid Reform Pilot
Welcome to the Agency for Health Care Administration’s (the Agency’s) Medicaid reform website. Florida is leading the nation in changing the Medicaid program. For the first time, we will offer true flexibility in the program so health plans can better target the needs of the program’s participants. We believe this innovative approach will better match health care services with the needs of the citizens we serve. Together, we can create a better Medicaid program.
We encourage you to visit the reform website frequently for information on upcoming meetings, updates on the status of reform implementation and other relevant information.
Florida's Medicaid Reform is a comprehensive demonstration that seeks to improve the value of the Medicaid delivery system. The program is operated under an 1115 Research and Demonstration Waiver initially approved by the Centers for Medicare and Medicaid Services (Federal CMS) on October 19, 2005. State authority to operate the program is located in Section (s.) 409.91211, Florida Statutes (F.S.), which provides authorization for a statewide pilot program with implementation that began in Broward and Duval Counties on July 1, 2006. The program expanded to Baker, Clay and Nassau Counties on July 1, 2007.
Florida expects to gain valuable information about the effects of allowing market-based approaches to assist the state in its service to Medicaid recipients. Key components of the demonstration include:
- Comprehensive choice counseling,
- Customized benefit packages,
- Enhanced benefits for participating in healthy behaviors,
- Risk-adjusted premiums based on enrollee health status, and
- Low Income Pool.
The following Agency web pages are available to view for more information on some of the key components of the demonstration.
Choice Counseling and Other Recipient Information
- Medicaid Reform Choice Counseling
- Medicaid Reform Training for Recipient
- Medicaid Reform Brochure for Medicaid Recipient
For more information on the topics above, please refer to the Choice Counseling and Other Recipient Information web page.
Enhanced Benefits Reward$ Program
Florida Medicaid wants to encourage you to make healthy choices and participate in activities that will help keep you from getting sick. Recipients in Florida Medicaid Reform plans will be eligible for enhanced benefits if they take part in specific activities. The goal is to reward your healthy behavior.
- Enhanced Benefits Products
- Universal Form (English and Spanish)
- Enhanced Benefits Reward$ Program Welcome Letter (English and Spanish)
- Frequently Asked Questions
- Monthly Enhanced Benefits Report
- Enhanced Benefits Panel Meetings
- EBIS Health Plan Credit File Validator
Low Income Pool (LIP)
The Low Income Pool (LIP) is established to ensure continued government support for the provision of health care services to Medicaid, underinsured and uninsured populations.
Florida Medicaid Reform (2011-2014)
On December 15, 2011, the Centers for Medicare and Medicaid Services (Federal CMS) approved the 3-year waiver extension request the Agency submitted on June 30, 2010. The waiver extension period for Florida’s Section 1115 Research and Demonstration Waiver is December 16, 2011 through June 30, 2014. The following are links to the federal approval documents for the 3-Year waiver extension request.
Approved 3-Year Extension of the 1115 Research and Demonstration Waiver
- CMS Approval Letter, 12/15/11 [298KB PDF]
- CMS’s Waiver Authorities and Special Terms and Conditions, 12/15/11 [200KB PDF]
To view the Waiver Extension Request and related Documents for 06/30/10-12/15/11, please go to the 1115 Research and Demonstration Waiver Extension Request web page.
The following is a link to view the clarification from CMS regarding Low Income Pool Tier-One Milestone, 12/13/11.
Florida Medicaid Reform (2005-2011)
Approved 1115 Research and Demonstration Waiver Initial 5-Year Application
In 2005, the Florida Legislature passed Senate Bill (SB) 838, authorizing the Agency to seek an experimental, pilot, or demonstration project waiver, pursuant to section 1115 of the Social Security Act (SSA) to create a statewide initiative to provide a more efficient and effective service delivery system that enhances quality of care and outcomes in the Florida Medicaid program. To effectively implement the program, the Agency submitted a draft application to Federal CMS on August 30, 2005, requesting a section 1115 Research and Demonstration Waiver in order to waive statutory provisions under section 1902 of the SSA. The draft 1115 waiver application was posted on Agency's website on August 31, 2005.
On October 3, 2005, the Agency submitted the official waiver application to Federal CMS after posting the draft application for 30 days as required by SB 838. Federal CMS reviewed the application and after intensive negotiations with Florida, granted approval on October 19, 2005, to waive certain federal statutory provisions and move forward in reforming Medicaid as authorized by SB 838. To view the Approved 1115 Waiver Application, as well as the draft waiver application, you may visit the Approved 1115 Research and Demonstration Waiver Application web page.
In December 2005, the Agency submitted an implementation plan to the Florida Legislature, which summarized the implementation milestones and activities that had been undertaken and would be completed before beginning operation of the waiver on July 1, 2006, and, if legislative approval had been obtained, expansion statewide by 2011. To view the Implementation Plan, you may visit the Florida Medicaid Reform Implementation Plan web page.
Beginning in January 2006 through June 2008, the Agency held a series of informational meetings/workshops on Medicaid Reform for providers, beneficiaries, and advocates in the demonstration counties of Broward, Duval, Baker, Clay, and Nassau prior to implementation of the waiver on July 1, 2006. To view the meetings/workshop schedules and handouts, you may visit the Medicaid Reform Meetings/Workshops web page.
The reporting requirements are specified in the Special Terms and Conditions (STCs) for the 1115 Medicaid Reform Waiver and can be viewed in the above drop down menu named, “Waiver History.” The following are links to view documents submitted by the Agency to Federal CMS in compliance with the STCs of the waiver extension period December 16, 2011 – June 30, 2014.
Special Term and Condition #17
On September 12, 2013, the Agency submitted to Federal CMS Florida’s Medicaid managed care policies as required by newly amended STC #17 of Florida’s Section 1115 Managed Medical Assistance Waiver. The following is a link to view the letter to Federal CMS and the Medicaid managed care policies.
1115 Medicaid Reform Evaluation Plan 12/16/2011 – 6/30/2014
With the renewal of the demonstration on December 15, 2011, the Agency is required to conduct an evaluation of the demonstration during the renewal period, December 16, 2011 – June 30, 2014. In accordance with STC #80 of the waiver, the Agency submitted a draft evaluation plan to Federal CMS within 120 days after receiving approval to renew the demonstration. Federal CMS provided comments and the Agency submitted the final evaluation plan to Federal CMS on August 9, 2012, as required by STC #81 of the waiver. On October 30, 2012, Federal CMS approved the final evaluation plan, which can be viewed at the following link:
Special Term and Condition #14
On March 13, 2012, the Agency submitted to Federal CMS Florida’s Medicaid managed care policies as required by STC #14 of Florida’s Section 1115 Research and Demonstration Waiver.
The following is a link to view the letter to CMS and the Medicaid managed care policies.
Medicaid Reform Quarterly Reports
The quarterly progress reports provide an analysis and the status of the various operational areas of the 1115 Research and Demonstration waiver. The quarterly reports are completed and made available 60 days after the end of each quarter.
Medicaid Reform Annual Reports
The annual report documents accomplishments, project status, quantitative and case-study findings, utilization data, and policy and administrative issues in the operation of the 1115 Research and Demonstration Waiver for each year of the waiver. The annual reports are completed and made available 120 days after the end of each demonstration year.
As part of the Agency’s commitment to enhancing the implementation of reform, the Agency continues to expand its communication with providers that are considering developing a benefit package and submitting an application as a Medicaid HMO or Provider Service Network. This web page is one of many ways that the Agency communicates with potential plan applicants and current health plan contractors to provide the tools needed to complete the application and contracting processes. We encourage you to visit this site regularly.
Current Year: 2012 - 2013
Previous Years: 2006 - 2012
The State of Florida purchases health care services from commercially licensed HMOs. The Bureau of Managed Health Care, along with the Bureau of Health Systems Development, is responsible for the approval and monitoring of all Medicaid HMO contracts in the state. Bureau staff conduct desk and on-site reviews throughout the year to ensure contract compliance.