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State Looks to Managed Care as Answer in Legal Battle


 Pointing to a new managed-care system, the state is seeking to scuttle a long-running lawsuit that challenges the adequacy of care provided to children in Florida's Medicaid program.

A federal judge will hold a hearing Tuesday in Miami, with attorneys for the state Agency for Health Care Administration expected to argue that the lawsuit, spearheaded by the Florida Pediatric Society, is moot.

In documents filed during the past week, the agency contended that a new statewide Medicaid managed-care system will ensure adequate networks of doctors for children and that the system includes safeguards for quality of care. The managed-care system, approved by lawmakers in 2011, is expected to fully take effect Aug. 1.

"In light of all of the many changes to the Florida Medicaid program's service delivery system, the statutory changes which evidence significant changes in policy, and the (federal Centers for Medicare & Medicaid Services) approvals and oversight …this case is moot, and should be dismissed,'' a filing last week said.

But attorneys for the Florida Pediatric Society, in a June 23 filing, took a far different stance. They said state lawmakers this spring did not set aside money for an extension of increased Medicaid payment rates for physicians.

A key issue in the lawsuit has been whether payment rates were so low that physicians would not treat patients, limiting access to care for children. The federal Affordable Care Act led to the federal government temporarily increasing payment rates for primary-care physicians, but that will end Dec. 31.

State lawmakers did not include money in the new 2014-15 budget to help continue the increased payments after that date, though they earmarked $8.4 million for a separate pediatrician rate hike. Attorneys for the pediatric society said that amount is far below the amount needed to make up for the Affordable Care Act increases, which were designed to bring Medicaid payment rates to the same level as higher rates in the Medicare program.

"Simply put, Florida children on Medicaid face the loss as of the end of this year of most of the temporary improvements in physician reimbursement rates enacted through the Affordable Care Act, and this aspect of the case is even more clearly not moot than when (a judge rejected a mootness argument last year),'' the June 23 filing said.

Judge Adalberto Jordan has scheduled the Tuesday hearing in the case, which dates to 2005. Jordan has already heard extensive testimony and arguments on the overall issues but has not ruled.

The state adamantly denies allegations that it has failed to comply with federal requirements about medical services for children. But the shift to a statewide Medicaid managed-care system --- an issue that, in itself, has been controversial --- is another argument to try to end the case.

Under the system, almost all Medicaid beneficiaries throughout the state will enroll in HMOs or another type of managed care known as provider-service networks. Health plans have been selected in 11 different regions of the state and are required to show they have adequate networks of doctors and other types of health providers.

AHCA has gradually put the new system into place, and the changes are expected to take effect in the final three regions Aug. 1.

In the filing last week, AHCA's attorneys argued that the new managed-care system is a dramatic change from what was known in the past as a "fee for service" system of paying doctors to care for children. If the lawsuit is not dismissed as moot, the agency's attorneys wrote that the court should hear more testimony and evidence about the effects of the changes.

"Alternatively, the record is so stale and dated that it cannot provide the basis for relief (and certainly is inadequate to establish an ongoing violation of federal law),'' the filing said. "An evidentiary hearing would be required to determine whether an ongoing violation of federal law exists, in light of these changes to the way that services have been delivered to Medicaid recipient children."

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