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AIDS Foundation Fights Getting Shut Out Of Medicaid

A new law in effect July 1 makes it easier to get an HIV test in health care settings.
A new law in effect July 1 makes it easier to get an HIV test in health care settings.

The largest nonprofit AIDS health-care provider in the nation is at risk of being blocked out of South Florida’s Medicaid market.

AIDS Healthcare Foundation attorneys filed a written protest and requested a hearing after its managed-care division was not among the health plans selected to negotiate with state Medicaid officials to continue providing care in Miami-Dade, Broward and Monroe counties beginning in 2019.

As of March 1, nearly 2,000 people in South Florida with HIV or AIDS were enrolled in Positive Healthcare, the managed-care plan.

“It is inconceivable that such an experienced plan would have its proposal to continue operating as an HIV/AIDS specialty plan scored so low compared to other plans without the same experience or provider network,” Jeffrey Blend, Positive Healthcare assistant general counsel, wrote, noting that it scored well below other plans that responded to a state contracting process known as an “invitation to negotiate.”

Agency for Health Care Administration Secretary Justin Senior denied the request for a hearing this week, saying the issues weren’t ripe for challenge because the state hadn’t finalized negotiations.

The dispute comes as part of a broader process by the Agency for Health Care Administration to award new contracts in the state’s Medicaid managed-care system. Total five-year contracts could be worth up to $90 billion, with contracts awarded to health plans in different regions of the state.

The state issued its invitation to negotiate, the second under the Medicaid managed-care program, in July 2017. The winning bids are expected to be announced on April 16. The state will transition from current health plans under contract to new plans at the end of 2018, according to state documents.

In its protest, Positive Healthcare alleged that “upon information and belief” the state is negotiating with two other specialty plans for the treatment of HIV-positive people in the South Florida regions 10 and 11: Clear Health Alliance and United Healthcare of Florida Inc.

Like Positive Healthcare, Clear Health Alliance already is a contracted specialty health plan that’s available for HIV-positive people. United Healthcare has contracts for long-term care services and traditional managed care but not specialty care, such as HIV or AIDS.

Michael Rajner, an activist living with HIV in Broward County, said he wasn’t aware that Positive Healthcare was at risk of losing its Medicaid contract but said that “could be harmful for people living with HIV that have enjoyed access to that plan and particular providers because  it could force them to establish a new relationship with a new physician, and that doesn’t benefit patients.”

The Legislature passed a sweeping rewrite of the state's Medicaid program in 2011, requiring nearly all beneficiaries, from the cradle to the grave, to enroll in managed-care plans.  Eleven managed-care organizations, including Positive Healthcare, were awarded contracts after the state’s first invitation to negotiate.

For contracting purposes, the state is divided into 11 regions. State law establishes a minimum and maximum number of plans that can operate in each of the 11 regions. Positive Healthcare operates only in Broward, Miami Dade and Monroe counties.

Positive Healthcare isn’t the only managed care plan currently under contract that has been snubbed in the second round of bidding. Molina Healthcare disclosed in a recent Securities and Exchange Commission filing that its Florida subsidiary, Molina Healthcare of Florida, was invited to negotiate a new contract only in the Miami-Dade region.

Molina Healthcare of Florida currently has contracts in eight regions, and Medicaid premiums from the plan accounted for 8 percent of Molina Healthcare’s projected revenues in 2018.

The filing noted that the company “intends to take all appropriate actions to both protect its rights and ensure continuity of care for its members,” according to the filing.

Copyright 2018 Health News Florida