Florida Senate - 2012 COMMITTEE AMENDMENT
Bill No. CS for SB 1884
Senate . House
Comm: WD .
The Committee on Budget Subcommittee on Health and Human
Services Appropriations (Gaetz) recommended the following:
1 Senate Amendment (with title amendment)
3 Delete lines 2332 - 2353
4 and insert:
5 Section 49. Effective upon this act becoming a law,
6 subsection (1) of section 409.975, Florida Statutes, is amended
7 to read:
8 409.975 Managed care plan accountability.—In addition to
9 the requirements of s. 409.967, plans and providers
10 participating in the managed medical assistance program shall
11 comply with the requirements of this section.
12 (1) PROVIDER NETWORKS.—Managed care plans must develop and
13 maintain provider networks that meet the medical needs of their
14 enrollees in accordance with standards established pursuant to
15 s. 409.967(2)(b). Except as provided in this section, managed
16 care plans may limit the providers in their networks based on
17 credentials, quality indicators, and price.
18 (a)1. Plans must include all providers in the region that
19 are classified by the agency as essential Medicaid providers for
20 the essential services they provide, unless the agency approves,
21 in writing, an alternative arrangement for securing the types of
22 services offered by the essential providers. Providers are
23 essential for serving Medicaid enrollees if they offer services
24 that are not available from any other provider within a
25 reasonable access standard, or if they provided a substantial
26 share of the total units of a particular service used by
27 Medicaid patients within the region during the last 3 years and
28 the combined capacity of other service providers in the region
29 is insufficient to meet the total needs of the Medicaid
30 patients. The agency may not classify physicians and other
31 practitioners as essential providers. The agency, at a minimum,
32 shall determine which providers in the following categories are
33 essential Medicaid providers:
1. Federally qualified health centers.
35 b. 2. Statutory teaching hospitals as defined in s.
37 c. 3. Hospitals that are trauma centers as defined in s.
39 d. 4. Hospitals located at least 25 miles from any other
40 hospital with similar services.
41 2. Before the selection of managed care plans as specified
42 in s. 409.966, each essential Medicaid provider and each
43 hospital that is necessary in order for a managed care plan to
44 demonstrate an adequate network, as determined by the agency,
45 are deemed a part of that managed care plan’s network for
46 purposes of the plan’s enrollment or expansion in the Medicaid
47 program. A hospital that is necessary for a managed care plan to
48 demonstrate an adequate network is an essential hospital. An
49 essential Medicaid provider is deemed a part of a managed care
50 plan’s network for the essential services it provides for
51 purposes of the plan’s enrollment or expansion in the Medicaid
52 program. The managed care plan, each essential Medicaid
53 provider, and each essential hospital shall negotiate in good
54 faith to enter into a provider network contract. During the plan
55 selection process, the managed care plan is not required to have
56 written agreements or contracts with essential Medicaid
57 providers or essential hospitals.
58 3. Managed care plans that have not contracted with all
59 essential Medicaid providers or essential hospitals in the
60 region as of the first date of recipient enrollment, or with
61 whom an essential Medicaid provider or essential hospital has
62 terminated its contract, must continue to negotiate in good
63 faith with such essential Medicaid providers or essential
64 hospitals for 1 year, or until an agreement is reached, or a
65 complaint is resolved as provided in paragraph (e), whichever is
66 first. Each essential Medicaid provider must continue to
67 negotiate in good faith during that year to enter into a
68 provider network contract for at least the essential services it
69 provides. Each essential hospital must continue to negotiate in
70 good faith during that year to enter into a provider network
71 contract. Payments for services rendered by a nonparticipating
72 essential Medicaid provider or essential hospital shall be made
73 at the applicable Medicaid rate as of the first day of the
74 contract between the agency and the plan. A rate schedule for
75 all essential Medicaid providers and essential hospitals shall
76 be attached to the contract between the agency and the plan.
77 4. After 1 year, managed care plans that are unable to
78 contract with essential Medicaid providers and essential
79 hospitals shall notify the agency and propose an alternative
80 arrangement for securing the essential services for Medicaid
81 enrollees. The arrangement must rely on contracts with other
82 participating providers, regardless of whether those providers
83 are located within the same region as the nonparticipating
84 essential service provider. If the alternative arrangement is
85 approved by the agency, payments to nonparticipating essential
86 Medicaid providers and essential hospitals after the date of the
87 agency’s approval shall equal 90 percent of the applicable
88 Medicaid rate. If the alternative arrangement is not approved by
89 the agency, payment to nonparticipating essential Medicaid
90 providers and essential hospitals shall equal 110 percent of the
91 applicable Medicaid rate.
92 (b)1. Certain providers are statewide resources and
93 essential providers for all managed care plans in all regions.
94 All managed care plans must include these essential providers in
95 their networks for the essential services they provide.
96 Statewide essential providers include:
97 a. 1. Faculty plans of Florida medical schools.
98 b. 2. Regional perinatal intensive care centers as defined
99 in s. 383.16(2).
100 c. 3. Hospitals licensed as specialty children’s hospitals
101 as defined in s. 395.002(28).
102 d. 4. Accredited and integrated systems serving medically
103 complex children that are comprised of separately licensed, but
104 commonly owned, health care providers delivering at least the
105 following services: medical group home, in-home and outpatient
106 nursing care and therapies, pharmacy services, durable medical
107 equipment, and Prescribed Pediatric Extended Care.
108 2. Before the selection of managed care plans as specified
109 in s. 409.966, each statewide essential provider is deemed a
110 part of that managed care plan’s network for the essential
111 services they provide and for purposes of the plan’s enrollment
112 or expansion in the Medicaid program. The managed care plan and
113 each statewide essential provider shall negotiate in good faith
114 to enter into a provider network contract. During the plan
115 selection process, the managed care plan is not required to have
116 written agreements or contracts with statewide essential
117 providers or essential hospitals.
118 3. Managed care plans that have not contracted with all
119 statewide essential providers in all regions as of the first
120 date of recipient enrollment and all statewide essential
121 providers that have not entered into a contract with each
122 managed care plan must continue to negotiate in good faith . to
123 enter into a provider network contract for at least the
124 essential services. As of the first day of the contract between
125 the agency and the plan, and until a provider network contract
126 is signed, payments: Payments
127 a. To physicians on the faculty of nonparticipating Florida
128 medical schools shall be made at the applicable Medicaid rate.
130 b. For services rendered by regional perinatal intensive
131 care centers shall be made at the applicable Medicaid rate as of
132 the first day of the contract between the agency and the plan.
134 c. To nonparticipating specialty children’s hospitals shall
135 equal the highest rate established by contract between that
136 provider and any other Medicaid managed care plan.
137 (c) After 12 months of active participation in a plan’s
138 network, the plan may exclude any essential provider from the
139 network for failure to meet quality or performance criteria. If
140 the plan excludes an essential provider from the plan, the plan
141 must provide written notice to all recipients who have chosen
142 that provider for care. The notice shall be provided at least 30
143 days before the effective date of the exclusion.
144 (d) Each managed care plan must offer a network contract to
145 each home medical equipment and supplies provider in the region
146 which meets quality and fraud prevention and detection standards
147 established by the plan and which agrees to accept the lowest
148 price previously negotiated between the plan and another such
150 (e) 1. At any time during negotiations a managed care plan,
151 an essential Medicaid provider, an essential hospital, or a
152 statewide essential provider may file a complaint with the
153 agency alleging that, in provider network negotiations, the
154 other party is not negotiating in good faith. The agency shall
155 review each complaint and make a determination whether or not
156 one or both parties have failed to negotiate in good faith. If
157 the agency determines that:
158 a. The managed care plan was not negotiating in good faith,
159 payment to the nonparticipating essential Medicaid provider,
160 essential hospital, or statewide essential provider shall equal
161 110 percent of the applicable Medicaid rate or the highest
162 contracted rate the provider has with a plan, whichever is
164 b. The essential Medicaid provider, essential hospital, or
165 statewide essential provider was not negotiating in good faith,
166 payment to the nonparticipating provider shall equal 90 percent
167 of the applicable Medicaid rate or the lowest contracted rate
168 the provider has with a plan, whichever is lower.
169 c. Both parties were not negotiating in good faith, payment
170 to the nonparticipating provider shall be made at the applicable
171 Medicaid rate.
172 2. In making a determination under this paragraph regarding
173 a managed care plan’s good faith efforts to negotiate, the
174 agency shall, at a minimum, consider whether the managed care
175 plan has:
176 a. Offered payment rates that are comparable to other
177 managed care plan rates to the provider or that are comparable
178 to fee-for-service rates for the provider.
179 b. Proposed its prepayment edits and audits and prior
180 authorizations in a manner comparable to other managed care
181 plans or comparable to current fee for service utilization
182 management and prior authorization procedures for non-emergent
184 c. Offered to pay the provider’s undisputed claims faster
185 or equal to existing Medicaid managed care plan contract
186 standards and, if the managed care plan’s claims payment system
187 has been used in other markets, has it failed to meet these
189 d. Offered a provider dispute resolution system that meets
190 or exceeds existing Medicaid managed care plan contract
192 e. If the provider is a hospital essential provider,
193 offered a reasonable payment amount for utilization of the
194 hospital emergency room for non-emergent care, developed
195 referral arrangements with the hospital for non-emergent care,
196 and offered reasonable prior or post authorization requirements
197 for non-emergent care in the emergency room.
198 f. Attempted to work with the provider to assist the
199 provider with any patient volume arrangements and whether
200 patient volume arrangements benefit the provider.
201 g. Demonstrated its financial viability and commitment to
202 meeting its financial obligations.
203 h. Demonstrated its ability to support HIPAA-compliant
204 electronic data interchange transactions.
205 3. In making a determination under this paragraph regarding
206 a provider’s good faith efforts to negotiate, the agency shall,
207 at a minimum, consider whether the provider has:
208 a. Met with the managed care plan at a reasonable frequency
209 and involved empowered decision makers in the meetings.
210 b. Offered reasonable rates that are comparable to other
211 managed care plan rates to the provider or comparable to fee
212 for-service rates to the provider.
213 c. Negotiated managed care plan prepayment edits and audits
214 and prior authorizations in a manner comparable to other managed
215 care plans or comparable to fee for service utilization
216 management and prior authorization procedures for non-emergent
218 d. Negotiated reasonable payment timeframes for payment of
219 undisputed claims that are comparable to existing Medicaid
220 managed care plan standards or comparable to fee-for-service
222 e. Researched other providers’ experience with the managed
223 care plan’s claims payment system for timeliness of payment.
224 f. Negotiated with the managed care plan regarding a
225 provider dispute resolution system that meets or exceeds the
226 managed care plan’s Medicaid contract requirements.
227 g. If the provider is an essential hospital, negotiated
228 with the managed care plan regarding primary care alternatives
229 to non-emergent use of the emergency room.
230 h. Negotiated patient volume arrangements with the managed
231 care plan.
232 i. Developed, or is developing, a hospital-based provider
233 service network.
234 j. Already contracted with other Medicaid managed care
236 4. Either party may appeal a determination by the agency
237 under this paragraph pursuant to chapter 120. The party
238 appealing the agency’s determination shall pay the appellee’s
239 attorney’s fees and costs, in an amount up to $1 million, from
240 the beginning of the agency’s review of the complaint if the
241 appealing party loses the appeal.
244 ================= T I T L E A M E N D M E N T ================
245 And the title is amended as follows:
246 Delete lines 206 - 209
247 and insert:
248 Medicaid program; requiring good faith negotiations
249 between Medicaid managed care plans and essential
250 Medicaid providers; providing that a statewide
251 essential provider is part of a Medicaid managed care
252 plan’s network for purposes of the managed care plan’s
253 application for enrollment or expansion in the
254 Medicaid program; requiring good faith negotiations
255 between Medicaid managed care plans and statewide
256 essential providers; authorizing Medicaid managed care
257 plans and certain Medicaid providers to file a
258 complaint alleging that, in provider network
259 negotiations, the other party is not negotiating in
260 good faith; requiring the Agency for Health Care
261 Administration to review such complaints and make a
262 determination whether or not one or both parties have
263 failed to negotiate in good faith; providing criteria
264 for the agency to consider in making a determination
265 about good faith negotiations; providing financial
266 penalties for parties that do not negotiate in good
267 faith; authorizing appeal of the agency’s
268 determination pursuant to chapter 120, F.S.; providing
269 for payment of attorney’s fees and costs; repealing s.