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Medicaid health plans hit $23.1 million in damages and penalties for 208 complaints last year

Florida regulators overseeing the state’s massive Medicaid program have issued 208 final actions against Medicaid managed care plans that breached or breached the terms of their contracts in the past fiscal year.

The results?

More than $23.1 million in damages and/or penalties were levied against the plans, according to recently released data from the state Agency for Health Care Administration (AHCA).

The total is one of the largest amounts of damages and/or penalties over a 12-month period that the state has imposed against projects for violating the terms of their contracts.

The $23.1 million comes as enrollment in Medicaid managed care plans hits an all-time high. There were more than 4.2 million people enrolled in Medicaid managed care programs statewide as of June 30, the end of the state’s 2021-22 fiscal year, according to registration data.

Sun Health Plan and StayWell Health Plan, which are owned by Centene Corporation, were awarded damages and penalties in the amounts of $11,724,810 and $4,911,690, respectively. That’s more than any of the other health plans for the year.

Included in Sunshine’s $11.7 million figure is a whopping $9.1 million penalty, the largest penalty imposed against a plan in the history of the statewide Medicaid managed care program.

Damages and penalties are not the same thing. Damages are not meant to be a penalty. They are meant to be reasonable estimates of the state’s anticipated financial losses and damages that have occurred due to Medicaid’s managed care plan violation of their contractual requirements.

Sanctions are penalties the state assesses when managed care plans violate their contracts.

Meanwhile, Humana Medical Plan leads the pack in the number of state actions finalized against a Medicaid managed care plan for the year, with 24.

The dashboard contains information on actions finalized between July 1, 2020 and June 30, 2021, not when complaints were filed with the state.

State health care regulators divide the complaints they receive about the Medicaid managed care program into one of nine broad categories: administration and management; service coverage and authorization; registered services; financial requirements; complaints and appeals system; marketing; provider services; quality of care; and reports.

According to AHCA data, there were 90 “provider service” complaints, a category that includes, among other things, complaints ranging from the speed of provider payments to network adequacy standards, the speed of transport services.

Meanwhile, nearly a third (29) of the 90 provider complaints were about network adequacy, the data showed. The state collected $1.08 million in damages for breaches of contract.

Another 28 of the 90 supplier complaints stemmed from the speed of payments. But the price to pay for not paying claims on time was far greater than the $1.08 million for inadequate managed care networks.

The data shows the state issued $10,141,525 in damages and assessments for not paying providers on time, a figure that included the $9.1 million penalty against Sunshine Health Plan.

While not the highest number of penalties and liquidated damages assessed against plans in a single year, it is one of the highest amounts, according to a review of data. The AHCA levied $26.5 million in assessments and penalties against plans for 371 contact violations in the 2017-18 fiscal year. The following year, the AHCA levied $23.8 million for 137 breaches of contract or violations.

Conversely, the 2018-2019 fiscal year saw the fewest penalties and damages with 37 actions against managed care plans being finalized that year and $284,750 in assessments.


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