Q & A – CATEGORY - GENERAL:

** Is this a Medicaid or Medicare Plan?
ADVANTAGE FLORIDA HEALTH PLAN will work with both Medicaid and Medicare funded programs. The PLAN will be Medicaid, but the provider network will also enjoy the opportunity of participating in Medicare Special Needs Plans where provider rates will be at least 100% of Medicare rates.

** Is this a Fee-For-Service (FFS) or Prepaid (Capitated) Plan?
ADVANTAGE FLORIDA HEALTH PLAN will initially start as a Medicaid FFS plan and will transition to a Prepaid Plan as soon as possible, probably within the year, in order to participate in the “Florida Senior Care” pilot which will exist in some of our targeted counties.

** What is “Florida Senior Care” pilot?
Florida Senior Care see http://ahca.myflorida.com/Medicaid/long_term_care/index.shtml and the recently passed legislation, HB 7065, requires the Agency for Health Care Administration (AHCA) or (Agency) to implement federal waivers to administer integrated, fixed-payment delivery program for Medicaid recipients 60 years of age or older or dually eligible for Medicare & Medicaid. ADVANTAGE FLORIDA HEALTH PLAN will work to prepare the provider network for the opportunity to participate. The program will pilot in PSA 11 which is Dade and Monroe counties. as well as PSA 7 which is Brevard, Orange, Osceola, and Seminole counties.

** What is the Fee Schedule for Medicaid?
ADVANTAGE FLORIDA HEALTH PLAN will initially start as a Medicaid FFS plan and will thus pay the Medicaid Fee Schedule. As the Plan transitions to a Prepaid (Capitated) Plan we will have some additional flexibility in rates and services.

** What is the Fee Schedule for Medicare Special Needs Plans (SNP)?
ADVANTAGE FLORIDA HEALTH PLAN anticipates the Plan Network will be used by Medicare SNP with the payment to Plan providers to be 100% or more of Medicare rate schedules.

** How does a PSN make money?

1. ADVANTAGE FLORIDA HEALTH PLAN will be paid an administrative fee by AHCA. There may also be some cost savings as calculated by AHCA.  ADVANTAGE FLORIDA HEALTH PLAN proposes to allocate a portion of the savings to improve the total revenue to Primary Care Physicians and Hospitals.
2. The Plan also anticipates administrative income from network participation with Medicare Special Needs Plans.

** What is “Nursing Home Diversion Waiver”?
Nursing Home Diversion Waiver is also known as Long Term Care Community Diversion.  Diversion Waiver information is available at http://elderaffairs.state.fl.us/english/longtermcared.html. The Diversion Program is designed to provide community-based services to people who would qualify for Medicaid nursing home placement. Services provided include long-term care services, and Medicaid-covered medical services. The objective is to provide frail elders with safe, appropriate community-based care alternatives in lieu of nursing home placement at a cost less than Medicaid nursing home care. Eligible individuals are over 64; dually eligible for Medicaid and Medicare; live in authorized counties; and have been determined by DOEA CARES to be need services and meet a nursing home level of care.

Independent Living Systems, LLC, our Third Party Administrator (TPA), manages a network of Home & Community Based Providers used by Nursing Home Diversion Contractors.  ILS is expanding this network in the rural areas as a step in the Diversion Waiver becoming active. This program could bring approximately $1500 a month per member to your community. We will explore how the Plan and the Plan network could provide services in this or other existing and developing waivers.