Medicaid Quality
The Quality Bureau provides data-driven, focused and systematic feedback on the quality of Florida’s Medicaid program to federal and state agencies, Medicaid recipients, Medicaid managed care plans, and providers. Florida’s 2014 transition from a mix of fee-for-service and managed care to mostly managed care hastened a newly-honed focus on quality: providing more comprehensive care, improving health outcomes, and reducing costs.
The Quality Bureau is responsible for the following:
- Quality measurement and improvement
- Research and evaluation of Medicaid managed care plans
- Monitoring Medicaid managed care clinical outcomes
- Oversight of prior authorization of services
- Management of remaining Medicaid fee-for-service programs
- Providing clinical consultation to the entire Agency
Federal Reports
The State of Florida is required to furnish a written quality strategy to the federal Centers for Medicare and Medicaid Services (CMS) every three years. This report must include a written quality strategy for assessing and improving the quality of health care and services furnished by the managed care organizations and other providers within Florida Medicaid. In 2023, the Medicaid Quality Bureau of the Agency for Health Care Administration (the Agency) compiled a new Comprehensive Quality Strategy (CQS) report, outlining Florida Medicaid’s priorities and goals for continuous quality improvement, the performance improvement efforts that align with and promote these priorities/goals, and the quality metrics and performance targets to be used in measuring performance and improvements to provide “better health care for all Floridians”.
The Agency conducted a 30-day public notice and comment period prior to the submission of the CQS to CMS during February and March of 2024. The CQS was submitted to CMS in April 2024.
A copy of the 2023 report is located at the following link:
Comprehensive Quality Strategy Report
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1.5 MB
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CQS and Statewide Medicaid Managed Care (SMMC) Program Review and Evaluation
In addition to monitoring health and dental plan report submissions, performance measures, and general program activities, the Agency uses a variety of reports and dashboards to review the effectiveness of the Agency’s quality strategy and the SMMC program.
- Annual Health Plan Performance Measure Data: The Agency monitors and evaluates the health plans’ performance through a combination of HEDIS, Adult and Child Core Set, and Agency-defined performance measures. Multiple years of plan performance measures (currently through calendar year 2022) are posted on the Agency’s website and may be accessed at: https://ahca.myflorida.com/medicaid/medicaid-quality-activities-and-projects/performance-measure-data-submissions-for-medicaid.
- E xternal Quality Review Organization (EQRO) Annual Technical Reports: The Agency utilizes the EQRO’s recommendations for improvement from the annual technical reports to continually improve quality of care, timeliness, and access to healthcare services provided by the SMMC health and dental plans. Multiple years of the Annual Technical Reports (currently through the April 2024 version) are posted on the Agency’s website and may be accessed at: https://ahca.myflorida.com/medicaid/medicaid-quality-activities-and-projects/annual-technical-report-of-external-quality-review-results.
- KidCare Evaluation Report: The Agency contracts with the University of Florida’s Institute of Child Health Policy to perform research and analysis to evaluate the effectiveness and quality of children’s health insurance services, the demographics and characteristics of children and families who utilize those services, and an overall assessment of the operation of the Florida KidCare Program, which includes both Medicaid and the Children’s Health Insurance Program (CHIP). This report is done annually and multiple years of reports (currently through the calendar year 2022 version) are posted on the Agency’s website and may be accessed at: ht tps://ahca.myflorida.com/medicaid/medicaid-policy-quality-and-operations/medicaid-policy-and-quality/medicaid-quality/performance-measurement-quality-review/medicaid-research-and-evaluation-contracts/florida-kidcare.
- Quality Initiatives Dashboard: The Agency developed a publicly available dashboard related to Agency goals for reducing Potentially Preventable Hospital Events and improving Birth Outcomes. This dashboard allows users to look at statewide rates as well as by region, health plan, and hospital. The dashboard may be accessed at: https://bi.ahca.myflorida.com/t/FLMedicaid/views/QualityInitiativesDashboard/QualityInitiatives?%3Adisplay_count=n&%3Aembed=y&%3AisGuestRedirectFromVizportal=y&%3Aorigin=viz_share_link&%3AshowAppBanner=false&%3AshowVizHome=n.
As additional review results become available, this information will be updated.
Performance Measurement & Quality Review
- Establishes performance benchmarks for Medicaid managed care plans and analyzes results.
- Leads managed care quality improvements.
- Monitors specific programs for improvement opportunities.
- Produces the Medicaid Health Plan Report Card comparing Medicaid Managed Medical Assistance (MMA) plans.
Clinical Compliance Monitoring
- Provides clinical review of Statewide Medicaid Managed Care program services, policies, procedures, reports and initiatives.
- Performs targeted contractual compliance monitoring of Medicaid Managed Medical Assistance Plans and Dental Plans.
- Monitors Medicaid special population programs including School Match and Administrative Claiming, the Model Waiver and Familial Dysautonomia Waiver.
- Participates in inter-agency child staffing meetings for medical neglect, behavioral health services and the Children’s Multidisciplinary Assessment Team.
Quality Improvement & Evaluation Contracts
- Ensures that Medicaid recipients not enrolled in managed care plans receive medically necessary, quality services in the most cost-effective manner.
- Manages prior authorization and utilization management contracts.
- Conducts monitoring and technical assistance for FFS programs.
