State admits goofs but seeks dismissal of Medicaid lawsuit

2/4/2008 © Florida Health News
By Christine Jordan Sexton and Carol Gentry
Florida Medicaid reform was ushered in with the promise that it would improve access to care for the poor, elderly and disabled. If they were enrolled in managed-care networks, the thinking went, they would have no trouble finding good doctors. 
That’s not how it worked out for David Reid, a 61-year-old Broward resident who was one of the first enrolled in the pilot program two years ago.  He cannot see the doctors who were listed in the HMO’s directory, he said, and can’t get coverage for the prescriptions that work best for him.
Those are no small matters, given that he has been disabled for 26 years, since suffering a brain aneurysm. He must use a cane to walk, is losing his eyesight to glaucoma and has trouble sleeping.
“Since Medicaid reform, everything is downhill,” Reid told Florida Heath News.  “In the last two years my deterioration has been rapid.”
With help from Florida Legal Services, Reid and two others filed suit in federal court in Broward County last month against the state Agency for Health Care Administration on behalf of the 200,000 Medicaid enrollees who are part of the pilot project in Broward and metro Jacksonville. The class-action suit argues that AHCA violated their rights by failing to let them know they could leave their managed-care plan at any time if they had a good reason.
The suit thrusts AHCA Secretary Andrew Agwunobi into the awkward position of defending a program he didn’t create and that his own inspector general has criticized. But defend it he has.
Late Monday, AHCA moved to dismiss the lawsuit, arguing that its actions in Medicaid reform were approved ahead of time by the federal government, which shares in the funding of state Medicaid programs. The waiver granted to Florida for the pilot project allowed the state to assign beneficiaries to managed-care programs even if they didn’t want to be in one and allowed the plans to alter the traditional benefits.
As is common in commercial HMOs, enrollees are locked in until annual enrollment, which begins each year on Sept. 1. However, the lock-in can be overridden “for cause” at any time, AHCA said.
The plaintiffs have no grounds to sue because they could have moved to a different managed-care plan at any time, AHCA argues. “None of the plaintiffs here are actually locked into” a plan, the motion says. “All three, in fact, have been exempted from reform either temporarily or permanently.”
While the motion defends AHCA’s actions, it reveals numerous goofs in the implementation of the Medicaid reform pilot in the fall of 2006 and since then. Specifically:
--Reid and “many others” who thought they were locked into HMOs never actually were because of a computer glitch. AHCA says it’s been corrected but is not being enforced as long as Reid and the others remain in their current health plans. It is not clear from the documents whether the affected Medicaid beneficiariesknow that they are free to switch.
Reid is enrolled in StayWell, a subsidiary of Tampa-based WellCare Health Plans. WellCare spokesperson Amy Knapp said the HMO does not comment on active litigation.
--Joann Brown, an 11-year-old who has asthma and other health problems, is not locked into her HMO because Social Security disability recipients under age 19 are exempt from the lock-in, AHCA says. The child, who is in Preferred Medical Plan, could switch to any other managed-care organization in Broward “at any time, with or without cause.”  
--David Mitchell, a 49-year-old cancer patient, was so ill that AHCA removed him from UnitedHealthcare and returned him to traditional, “fee-for-service” Medicaid. However, the system failed to note that Mitchell had been removed and “automatically re-enrolled” him. He has once again been removed, according to the motion, and AHCA says it won’t happen again.
The conditions under which Medicaid-reform patients can leave their managed-care plans are set out in the HMO handbooks given to each member, AHCA argues. “The law does not require the Agency to provide the notices itself,” the motion says.
Florida Legal Services attorneys, who filed the lawsuit in mid-January, argued that AHCA confused Medicaid recipients by mailing out notices that said they could leave their  managed care plan only within the first 90 days or at the end of a year at renewal. These notices failed to mention the option of leaving for cause.
Ft. Lauderdale attorney Miriam Harmatz said withholding the information harms patients if they are denied access to specialists they need.  That’s what Reid, who suffers from glaucoma, says happened to him.
He chose StayWell because his ophthalmologist was listed as one of the approved providers. However, when he went to make an appointment, he was told the provider never accepted StayWell. He found out that some of his other specialists weren’t in the network, either, and only one of his five prescription drugs was covered under the plan’s formulary.
“Everything has changed,” Reid said. “I’m frustrated.”
 Mistakes in HMOs’ listings of doctors and drugs were among the concerns in a September 2007 report on the Medicaid reform project by AHCA Inspector General Linda Keen. The counselors who help Medicaid enrollees choose a plan that’s a good fit can’t do their jobs because of the errors, she wrote.
Following release of the report, Agwunobi said the state would not expand the reform program into other counties, as planned. The agency is reviewing the managed care plans’ listings of health-care providers for accuracy.
Bob Wychulis, president and chief executive officer of the Florida Association of Health Plans, said his member plans update their provider lists monthly but networks are fluid. They “change almost every day, and not just for Medicaid,” he said.
Florida’s Medicaid reform plan was designed by former Gov. Jeb Bush and former AHCA Secretary Alan Levine, who said they could stretch Medicaid dollars further and provide better access to specialists if patients were in managed-care plans. They obtained a federal waiver of traditional Medicaid regulations in October 2005, and that December they persuaded the Legislature to allow the program to begin in summer 2006 in Broward and Duval counties. Last year it was expanded to Baker, Clay and Nassau counties.