SB 1988 First Engrossed
20121988e1
1 A bill to be entitled
2 An act relating to Medicaid; amending s. 381.79, F.S.;
3 increasing the amount that may be available to the
4 University of Florida and the University of Miami for
5 brain and spinal cord injury research; amending s.
6 383.15, F.S.; revising legislative intent relating to
7 funding for regional perinatal intensive care centers;
8 amending s. 409.8132, F.S.; revising a cross
9 reference; amending s. 409.814, F.S.; deleting a
10 prohibition preventing children who are eligible for
11 coverage under a state health benefit plan from being
12 eligible for services provided through the subsidized
13 program; revising cross-references; requiring a
14 completed application, including a clinical screening,
15 for enrollment in the Children’s Medical Services
16 Network; amending s. 409.902, F.S.; providing for the
17 creation of an Internet-based system for determining
18 eligibility for the Medicaid and Kidcare programs,
19 contingent on the appropriation; providing system
20 business objectives and requirements; requiring the
21 Department of Children and Family Services to develop
22 the system; requiring the system to be completed and
23 implemented by specified dates; providing a governance
24 structure pending implementation of the program,
25 including an executive steering committee and a
26 project management team; amending s. 409.905, F.S.;
27 limiting the number of paid hospital emergency
28 department visits for nonpregnant adults; authorizing
29 the Agency for Health Care Administration to request
30 approval by the Legislative Budget Commission of
31 hospital rate adjustments; providing components for
32 the agency’s plan to convert inpatient hospital rates
33 to a prospective payment system; revising dates for
34 submitting the plan and implementing the system;
35 amending s. 409.908, F.S.; conforming a cross
36 reference; authorizing the Agency for Health Care
37 Administration to accept voluntary intergovernmental
38 transfers of local taxes and other qualified revenue
39 from counties, municipalities, or special taxing
40 districts in order to fund certain costs; limiting the
41 use of intergovernmental transfer funds for hospital
42 reimbursements; prohibiting the inclusion of certain
43 hospital costs in the capitation rates for prepaid
44 health plans; providing for the inclusion of certain
45 hospital costs in capitation rates for prepaid health
46 plans if funded by intergovernmental transfers;
47 incorporating a transferred provision; amending s.
48 409.911, F.S.; updating references to data used for
49 calculations in the disproportionate share program;
50 repealing s. 409.9112, F.S., relating to the
51 disproportionate share program for regional perinatal
52 intensive care centers; amending s. 409.9113, F.S.;
53 conforming a cross-reference; authorizing the agency
54 to distribute moneys in the disproportionate share
55 program for teaching hospitals; repealing s. 409.9117,
56 F.S., relating to the primary care disproportionate
57 share program; amending s. 409.912, F.S.; revising the
58 conditions for contracting with certain managed care
59 plans for behavioral health care services; deleting
60 requirements for assigning certain MediPass recipients
61 to managed care plans for behavioral health care
62 services; requiring the assignment of recipients to
63 provider service networks; amending s. 409.9121, F.S.;
64 revising legislative findings relating to the Medicaid
65 program; amending s. 409.9122, F.S.; providing
66 criteria and procedures relating to recipient
67 enrollment choice and assignment among Medicaid
68 managed care plans and MediPass; deleting transferred
69 provisions relating to school districts; amending s.
70 409.9123, F.S.; revising provisions relating to the
71 publication of quality measures for managed care
72 plans; reenacting s. 409.9126, F.S., relating to
73 children with special health care needs; amending s.
74 409.915, F.S.; specifying criteria for determining a
75 county’s eligible recipients; providing for payment of
76 billings that have been denied by the county from the
77 county’s tax revenues; providing for refunds;
78 providing for the transfer of certain refunds to the
79 Lawton Chiles Endowment Fund; amending ss. 409.979 and
80 430.04, F.S.; deleting references to the Adult Day
81 Health Care Waiver in provisions relating to Medicaid
82 eligibility and duties and responsibilities of the
83 Department of Elderly Affairs; amending s. 31, chapter
84 2009-223, Laws of Florida, as amended, and
85 redesignating that section as s. 409.9132, F.S.;
86 expanding the home health agency monitoring pilot
87 project statewide; amending s. 32, chapter 2009-223,
88 Laws of Florida, and redesignating that section as s.
89 409.9133, F.S.; expanding the comprehensive care
90 management pilot project for home health services
91 statewide and including private-duty nursing and
92 personal care services; providing an additional site
93 in Broward County for the Program of All-Inclusive
94 Care for the Elderly; providing that a public hospital
95 located in trauma service area 2 which has local funds
96 available for intergovernmental transfers may have its
97 reimbursement rates adjusted after a certain date;
98 providing effective dates.
99
100 Be It Enacted by the Legislature of the State of Florida:
101
102 Section 1. Subsection (3) of section 381.79, Florida
103 Statutes, is amended to read:
104 381.79 Brain and Spinal Cord Injury Program Trust Fund.—
105 (3) Annually, 5 percent of the revenues deposited monthly
106 into in the fund pursuant to s. 318.21(2)(d) shall be
107 appropriated to the University of Florida and 5 percent to the
108 University of Miami for spinal cord injury and brain injury
109 research. The amount to be distributed to the universities shall
110 be calculated based on the deposits into the fund for each
111 quarter in the fiscal year, but may not exceed $750,000 $500,000
112 per university per year. Funds distributed under this subsection
113 shall be made in quarterly payments at the end of each quarter
114 during the fiscal year.
115 Section 2. Section 383.15, Florida Statutes, is amended to
116 read:
117 383.15 Legislative intent; perinatal intensive care
118 services.—The Legislature finds and declares that many perinatal
119 diseases and disabilities have debilitating, costly, and often
120 fatal consequences if left untreated. Many of these debilitating
121 conditions could be prevented or ameliorated if services were
122 available to the public through a regional perinatal intensive
123 care centers program. Perinatal intensive care services are
124 critical to the well-being and development of a healthy society
125 and represent a constructive, cost-beneficial, and essential
126 investment in the future of our state. Therefore, it is the
127 intent of the Legislature to develop a regional perinatal
128 intensive care centers program. The Legislature further intends
129 that development of such a regional perinatal intensive care
130 centers program shall not reduce or dilute the current financial
131 commitment of the state, as indicated through appropriation, to
132 the existing regional perinatal intensive care centers. It is
133 also the intent of the Legislature that any additional centers
134 regional perinatal intensive care center authorized under s.
135 383.19 after July 1, 1993, shall not receive payments under a
136 disproportionate share program for regional perinatal intensive
137 care centers authorized under chapter 409 s. 409.9112 unless
138 specific appropriations are provided to expand such payments to
139 additional hospitals.
140 Section 3. Paragraph (b) of subsection (6) of section
141 409.8132, Florida Statutes, is amended to read:
142 409.8132 Medikids program component.—
143 (6) ELIGIBILITY.—
144 (b) The provisions of s. 409.814 apply 409.814(3), (4),
145 (5), and (6) shall be applicable to the Medikids program.
146 Section 4. Section 409.814, Florida Statutes, is amended to
147 read:
148 409.814 Eligibility.—A child who has not reached 19 years
149 of age whose family income is equal to or below 200 percent of
150 the federal poverty level is eligible for the Florida Kidcare
151 program as provided in this section. For enrollment in the
152 Children’s Medical Services Network, a complete application
153 includes the medical or behavioral health screening. If,
154 subsequently, an enrolled individual is determined to be
155 ineligible for coverage, he or she must be immediately be
156 disenrolled from the respective Florida Kidcare program
157 component.
158 (1) A child who is eligible for Medicaid coverage under s.
159 409.903 or s. 409.904 must be enrolled in Medicaid and is not
160 eligible to receive health benefits under any other health
161 benefits coverage authorized under the Florida Kidcare program.
162 (2) A child who is not eligible for Medicaid, but who is
163 eligible for the Florida Kidcare program, may obtain health
164 benefits coverage under any of the other components listed in s.
165 409.813 if such coverage is approved and available in the county
166 in which the child resides.
167 (3) A Title XXI-funded child who is eligible for the
168 Florida Kidcare program who is a child with special health care
169 needs, as determined through a medical or behavioral screening
170 instrument, is eligible for health benefits coverage from and
171 shall be assigned to and may opt out of the Children’s Medical
172 Services Network.
173 (4) The following children are not eligible to receive
174 Title XXI-funded premium assistance for health benefits coverage
175 under the Florida Kidcare program, except under Medicaid if the
176 child would have been eligible for Medicaid under s. 409.903 or
177 s. 409.904 as of June 1, 1997:
178 (a) A child who is eligible for coverage under a state
179 health benefit plan on the basis of a family member’s employment
180 with a public agency in the state.
181 (a)(b) A child who is covered under a family member’s group
182 health benefit plan or under other private or employer health
183 insurance coverage, if the cost of the child’s participation is
184 not greater than 5 percent of the family’s income. If a child is
185 otherwise eligible for a subsidy under the Florida Kidcare
186 program and the cost of the child’s participation in the family
187 member’s health insurance benefit plan is greater than 5 percent
188 of the family’s income, the child may enroll in the appropriate
189 subsidized Kidcare program.
190 (b)(c) A child who is seeking premium assistance for the
191 Florida Kidcare program through employer-sponsored group
192 coverage, if the child has been covered by the same employer’s
193 group coverage during the 60 days before the family submitted
194 prior to the family’s submitting an application for
195 determination of eligibility under the program.
196 (c)(d) A child who is an alien, but who does not meet the
197 definition of qualified alien, in the United States.
198 (d)(e) A child who is an inmate of a public institution or
199 a patient in an institution for mental diseases.
200 (e)(f) A child who is otherwise eligible for premium
201 assistance for the Florida Kidcare program and has had his or
202 her coverage in an employer-sponsored or private health benefit
203 plan voluntarily canceled in the last 60 days, except those
204 children whose coverage was voluntarily canceled for good cause,
205 including, but not limited to, the following circumstances:
206 1. The cost of participation in an employer-sponsored
207 health benefit plan is greater than 5 percent of the family’s
208 income;
209 2. The parent lost a job that provided an employer
210 sponsored health benefit plan for children;
211 3. The parent who had health benefits coverage for the
212 child is deceased;
213 4. The child has a medical condition that, without medical
214 care, would cause serious disability, loss of function, or
215 death;
216 5. The employer of the parent canceled health benefits
217 coverage for children;
218 6. The child’s health benefits coverage ended because the
219 child reached the maximum lifetime coverage amount;
220 7. The child has exhausted coverage under a COBRA
221 continuation provision;
222 8. The health benefits coverage does not cover the child’s
223 health care needs; or
224 9. Domestic violence led to loss of coverage.
225 (5) A child who is otherwise eligible for the Florida
226 Kidcare program and who has a preexisting condition that
227 prevents coverage under another insurance plan as described in
228 paragraph (4)(a) (4)(b) which would have disqualified the child
229 for the Florida Kidcare program if the child were able to enroll
230 in the plan is shall be eligible for Florida Kidcare coverage
231 when enrollment is possible.
232 (6) A child whose family income is above 200 percent of the
233 federal poverty level or a child who is excluded under the
234 provisions of subsection (4) may participate in the Florida
235 Kidcare program as provided in s. 409.8132 or, if the child is
236 ineligible for Medikids by reason of age, in the Florida Healthy
237 Kids program, subject to the following provisions:
238 (a) The family is not eligible for premium assistance
239 payments and must pay the full cost of the premium, including
240 any administrative costs.
241 (b) The board of directors of the Florida Healthy Kids
242 Corporation may offer a reduced benefit package to these
243 children in order to limit program costs for such families.
244 (7) Once a child is enrolled in the Florida Kidcare
245 program, the child is eligible for coverage under the program
246 for 12 months without a redetermination or reverification of
247 eligibility, if the family continues to pay the applicable
248 premium. Eligibility for program components funded through Title
249 XXI of the Social Security Act terminates shall terminate when a
250 child attains the age of 19. A child who has not attained the
251 age of 5 and who has been determined eligible for the Medicaid
252 program is eligible for coverage for 12 months without a
253 redetermination or reverification of eligibility.
254 (8) When determining or reviewing a child’s eligibility
255 under the Florida Kidcare program, the applicant shall be
256 provided with reasonable notice of changes in eligibility which
257 may affect enrollment in one or more of the program components.
258 If When a transition from one program component to another is
259 authorized, there shall be cooperation between the program
260 components and the affected family which promotes continuity of
261 health care coverage. Any authorized transfers must be managed
262 within the program’s overall appropriated or authorized levels
263 of funding. Each component of the program shall establish a
264 reserve to ensure that transfers between components will be
265 accomplished within current year appropriations. These reserves
266 shall be reviewed by each convening of the Social Services
267 Estimating Conference to determine the adequacy of such reserves
268 to meet actual experience.
269 (9) In determining the eligibility of a child, an assets
270 test is not required. Each applicant shall provide documentation
271 during the application process and the redetermination process,
272 including, but not limited to, the following:
273 (a) Each applicant’s Proof of family income, which must
274 shall be verified electronically to determine financial
275 eligibility for the Florida Kidcare program. Written
276 documentation, which may include wages and earnings statements
277 or pay stubs, W-2 forms, or a copy of the applicant’s most
278 recent federal income tax return, is shall be required only if
279 the electronic verification is not available or does not
280 substantiate the applicant’s income.
281 (b) Each applicant shall provide A statement from all
282 applicable, employed family members that:
283 1. Their employers do not sponsor health benefit plans for
284 employees;
285 2. The potential enrollee is not covered by an employer
286 sponsored health benefit plan; or
287 3. The potential enrollee is covered by an employer
288 sponsored health benefit plan and the cost of the employer
289 sponsored health benefit plan is more than 5 percent of the
290 family’s income.
291 (c) To enroll in the Children’s Medical Services Network, a
292 completed application, including a clinical screening.
293 (10) Subject to paragraph (4)(a) (4)(b), the Florida
294 Kidcare program shall withhold benefits from an enrollee if the
295 program obtains evidence that the enrollee is no longer
296 eligible, submitted incorrect or fraudulent information in order
297 to establish eligibility, or failed to provide verification of
298 eligibility. The applicant or enrollee shall be notified that
299 because of such evidence program benefits will be withheld
300 unless the applicant or enrollee contacts a designated
301 representative of the program by a specified date, which must be
302 within 10 working days after the date of notice, to discuss and
303 resolve the matter. The program shall make every effort to
304 resolve the matter within a timeframe that will not cause
305 benefits to be withheld from an eligible enrollee.
306 (11) The following individuals may be subject to
307 prosecution in accordance with s. 414.39:
308 (a) An applicant obtaining or attempting to obtain benefits
309 for a potential enrollee under the Florida Kidcare program if
310 when the applicant knows or should have known that the potential
311 enrollee does not qualify for the Florida Kidcare program.
312 (b) An individual who assists an applicant in obtaining or
313 attempting to obtain benefits for a potential enrollee under the
314 Florida Kidcare program if when the individual knows or should
315 have known that the potential enrollee does not qualify for the
316 Florida Kidcare program.
317 Section 5. Section 409.902, Florida Statutes, is amended to
318 read:
319 409.902 Designated single state agency; eligibility
320 determinations payment requirements; program title; release of
321 medical records.—
322 (1) The Agency for Health Care Administration is designated
323 as the single state agency authorized to make payments for
324 medical assistance and related services under Title XIX of the
325 Social Security Act. These payments shall be made, subject to
326 any limitations or directions provided for in the General
327 Appropriations Act, only for services included in the program,
328 shall be made only on behalf of eligible individuals, and shall
329 be made only to qualified providers in accordance with federal
330 requirements for Title XIX of the Social Security Act and the
331 provisions of state law. This program of medical assistance is
332 designated the “Medicaid program.”
333 (2) The Department of Children and Family Services is
334 responsible for determining Medicaid eligibility determinations,
335 including, but not limited to, policy, rules, and the agreement
336 with the Social Security Administration for Medicaid eligibility
337 determinations for Supplemental Security Income recipients, as
338 well as the actual determination of eligibility. As a condition
339 of Medicaid eligibility, subject to federal approval, the agency
340 for Health Care Administration and the department must of
341 Children and Family Services shall ensure that each recipient of
342 Medicaid consents to the release of her or his medical records
343 to the agency for Health Care Administration and the Medicaid
344 Fraud Control Unit of the Department of Legal Affairs.
345 (3)(2) Eligibility is restricted to United States citizens
346 and to lawfully admitted noncitizens who meet the criteria
347 provided in s. 414.095(3).
348 (a) Citizenship or immigration status must be verified. For
349 noncitizens, this includes verification of the validity of
350 documents with the United States Citizenship and Immigration
351 Services using the federal SAVE verification process.
352 (b) State funds may not be used to provide medical services
353 to individuals who do not meet the requirements of this
354 subsection unless the services are necessary to treat an
355 emergency medical condition or are for pregnant women. Such
356 services are authorized only to the extent provided under
357 federal law and in accordance with federal regulations as
358 provided in 42 C.F.R. s. 440.255.
359 (4) To the extent funds are appropriated, the department
360 shall collaborate with the agency to develop an Internet-based
361 system for determining eligibility for the Medicaid and Kidcare
362 programs which complies with all applicable federal and state
363 laws and requirements.
364 (a) The system must accomplish the following primary
365 business objectives:
366 1. Provide individuals and families with a single access
367 point to information that explains benefits, premiums, and cost
368 sharing available through Medicaid, Kidcare, or any other state
369 or federal health insurance exchange.
370 2. Enable timely, accurate, and efficient enrollment of
371 eligible persons into available assistance programs.
372 3. Prevent eligibility fraud.
373 4. Allow for detailed financial analysis of eligibility
374 based cost drivers.
375 (b) The system must include, but need not be limited to,
376 the following business and functional requirements:
377 1. Allowing for the completion and submission of an online
378 application for determining eligibility which accepts the use of
379 electronic signatures.
380 2. Including a process that enables automatic enrollment of
381 qualified individuals into Medicaid, Kidcare, or any other state
382 or federal exchange that offers cost-sharing benefits for the
383 purchase of health insurance.
384 3. Allowing for the determination of Medicaid eligibility
385 based on modified adjusted gross income by using information
386 submitted in the application and information accessed and
387 verified through automated and secure interfaces with authorized
388 databases.
389 4. Including the ability to determine specific categories
390 of Medicaid eligibility and interface with the Florida Medicaid
391 Management Information System to support such determination,
392 using federally approved assessment methodologies, of state and
393 federal financial participation rates for persons in each
394 eligibility category.
395 5. Allowing for the accurate and timely processing of
396 eligibility claims and adjudications.
397 6. Aligning with and incorporating all applicable state and
398 federal laws, requirements, and standards, including the
399 information technology security requirements established under
400 s. 282.318 and the accessibility standards established under
401 part II of chapter 282.
402 7. Producing transaction data, reports, and performance
403 information that contributes to an evaluation of the program,
404 continuous improvement in business operations, and increased
405 transparency and accountability.
406 (c) The department shall develop the system subject to
407 approval by the Legislative Budget Commission and as required by
408 the General Appropriations Act for the 2012-2013 fiscal year.
409 (d) The system must be completed by October 1, 2013, and
410 ready for implementation by January 1, 2014.
411 (e) The department shall implement the following project
412 governance structure until the system is implemented:
413 1. The director of the department’s Economic Self
414 Sufficiency Services Program Office shall have overall
415 responsibility for the project.
416 2. The project shall be governed by an executive steering
417 committee composed of three department staff members appointed
418 by the Secretary of Children and Family Services; three agency
419 staff members, including at least two state Medicaid program
420 staff members, appointed by the Secretary of Health Care
421 Administration; and one staff member from Children’s Medical
422 Services within the Department of Health appointed by the
423 Surgeon General.
424 3. The executive steering committee shall have overall
425 responsibility for ensuring that the project meets its primary
426 business objectives and shall:
427 a. Provide management direction and support to the project
428 management team.
429 b. Review and approve any changes to the project’s scope,
430 schedule, and budget.
431 c. Review, approve, and determine whether to proceed with
432 any major deliverable project.
433 d. Recommend suspension or termination of the project to
434 the Governor, the President of the Senate, and the Speaker of
435 the House of Representatives if the committee determines that
436 the primary business objectives cannot be achieved.
437 4. A project management team shall be appointed by and work
438 under the direction of the executive steering committee. The
439 project management team shall:
440 a. Provide planning, management, and oversight of the
441 project.
442 b. Submit an operational work plan and provide quarterly
443 updates to the plan to the executive steering committee. The
444 plan must specify project milestones, deliverables, and
445 expenditures.
446 c. Submit written monthly project status reports to the
447 executive steering committee.
448 Section 6. Subsection (5) of section 409.905, Florida
449 Statutes, is amended to read:
450 409.905 Mandatory Medicaid services.—The agency may make
451 payments for the following services, which are required of the
452 state by Title XIX of the Social Security Act, furnished by
453 Medicaid providers to recipients who are determined to be
454 eligible on the dates on which the services were provided. Any
455 service under this section shall be provided only when medically
456 necessary and in accordance with state and federal law.
457 Mandatory services rendered by providers in mobile units to
458 Medicaid recipients may be restricted by the agency. Nothing in
459 this section shall be construed to prevent or limit the agency
460 from adjusting fees, reimbursement rates, lengths of stay,
461 number of visits, number of services, or any other adjustments
462 necessary to comply with the availability of moneys and any
463 limitations or directions provided for in the General
464 Appropriations Act or chapter 216.
465 (5) HOSPITAL INPATIENT SERVICES.—The agency shall pay for
466 all covered services provided for the medical care and treatment
467 of a Medicaid recipient who is admitted as an inpatient by a
468 licensed physician or dentist to a hospital licensed under part
469 I of chapter 395. However, the agency shall limit the payment
470 for inpatient hospital services for a nonpregnant Medicaid
471 recipient 21 years of age or older to 45 days per fiscal year or
472 the number of days necessary to comply with the General
473 Appropriations Act. Effective August 1, 2012, the agency shall
474 limit payment for hospital emergency department visits for a
475 nonpregnant recipient 21 years of age or older to six visits per
476 fiscal year.
477 (a) The agency may is authorized to implement reimbursement
478 and utilization management reforms in order to comply with any
479 limitations or directions in the General Appropriations Act,
480 which may include, but are not limited to: prior authorization
481 for inpatient psychiatric days; prior authorization for
482 nonemergency hospital inpatient admissions for individuals 21
483 years of age and older; authorization of emergency and urgent
484 care admissions within 24 hours after admission; enhanced
485 utilization and concurrent review programs for highly utilized
486 services; reduction or elimination of covered days of service;
487 adjusting reimbursement ceilings for variable costs; adjusting
488 reimbursement ceilings for fixed and property costs; and
489 implementing target rates of increase. The agency may limit
490 prior authorization for hospital inpatient services to selected
491 diagnosis-related groups, based on an analysis of the cost and
492 potential for unnecessary hospitalizations represented by
493 certain diagnoses. Admissions for normal delivery and newborns
494 are exempt from requirements for prior authorization
495 requirements. In implementing the provisions of this section
496 related to prior authorization, the agency must shall ensure
497 that the process for authorization is accessible 24 hours per
498 day, 7 days per week and authorization is automatically granted
499 if when not denied within 4 hours after the request.
500 Authorization procedures must include steps for the review of
501 denials. Upon implementing the prior authorization program for
502 hospital inpatient services, the agency shall discontinue its
503 hospital retrospective review program.
504 (b) A licensed hospital maintained primarily for the care
505 and treatment of patients having mental disorders or mental
506 diseases is not eligible to participate in the hospital
507 inpatient portion of the Medicaid program except as provided
508 under in federal law. However, the department shall apply for a
509 waiver, within 9 months after June 5, 1991, designed to provide
510 hospitalization services for mental health reasons to children
511 and adults in the most cost-effective and lowest cost setting
512 possible. Such waiver must shall include a request for the
513 opportunity to pay for care in hospitals known under federal law
514 as “institutions for mental disease” or “IMD’s.” The waiver
515 proposal may not shall propose no additional aggregate cost to
516 the state or Federal Government, and shall be conducted in
517 Hillsborough County, Highlands County, Hardee County, Manatee
518 County, and Polk County. The waiver proposal may incorporate
519 competitive bidding for hospital services, comprehensive
520 brokering, prepaid capitated arrangements, or other mechanisms
521 deemed by the department to show promise in reducing the cost of
522 acute care and increasing the effectiveness of preventive care.
523 When developing the waiver proposal, the department shall take
524 into account price, quality, accessibility, linkages of the
525 hospital to community services and family support programs,
526 plans of the hospital to ensure the earliest discharge possible,
527 and the comprehensiveness of the mental health and other health
528 care services offered by participating providers.
529 (c) The agency shall implement a methodology for
530 establishing base reimbursement rates for each hospital based on
531 allowable costs, as defined by the agency. Rates shall be
532 calculated annually and take effect July 1 of each year based on
533 the most recent complete and accurate cost report submitted by
534 each hospital. Adjustments may not be made to the rates after
535 September 30 of the state fiscal year in which the rate takes
536 effect, except that the agency may request that adjustments be
537 approved by the Legislative Budget Commission when needed due to
538 insufficient commitments or collections of intergovernmental
539 transfers under s. 409.908(1) or s. 409.908(4). Errors in cost
540 reporting or calculation of rates discovered after September 30
541 must be reconciled in a subsequent rate period. The agency may
542 not make any adjustment to a hospital’s reimbursement rate more
543 than 5 years after a hospital is notified of an audited rate
544 established by the agency. The prohibition against requirement
545 that the agency making may not make any adjustment to a
546 hospital’s reimbursement rate more than 5 years after a hospital
547 is notified of an audited rate established by the agency is
548 remedial and applies shall apply to actions by providers
549 involving Medicaid claims for hospital services. Hospital rates
550 shall be subject to such limits or ceilings as may be
551 established in law or described in the agency’s hospital
552 reimbursement plan. Specific exemptions to the limits or
553 ceilings may be provided in the General Appropriations Act.
554 (d) The agency shall implement a comprehensive utilization
555 management program for hospital neonatal intensive care stays in
556 certain high-volume participating hospitals, select counties, or
557 statewide, and replace existing hospital inpatient utilization
558 management programs for neonatal intensive care admissions. The
559 program shall be designed to manage the lengths of stay for
560 children being treated in neonatal intensive care units and must
561 seek the earliest medically appropriate discharge to the child’s
562 home or other less costly treatment setting. The agency may
563 competitively bid a contract for the selection of a qualified
564 organization to provide neonatal intensive care utilization
565 management services. The agency may seek federal waivers to
566 implement this initiative.
567 (e) The agency may develop and implement a program to
568 reduce the number of hospital readmissions among the non
569 Medicare population eligible in areas 9, 10, and 11.
570 (f) The agency shall develop a plan to convert Medicaid
571 inpatient hospital rates to a prospective payment system that
572 categorizes each case into diagnosis-related groups (DRG) and
573 assigns a payment weight based on the average resources used to
574 treat Medicaid patients in that DRG. To the extent possible, the
575 agency shall propose an adaptation of an existing prospective
576 payment system, such as the one used by Medicare, and shall
577 propose such adjustments as are necessary for the Medicaid
578 population and to maintain budget neutrality for inpatient
579 hospital expenditures.
580 1. The plan must:
581 a. Define and describe DRGs for inpatient hospital care
582 specific to Medicaid in this state;
583 b. Develop the use of resources needed for each DRG;
584 c. Apply current statewide levels of funding to DRGs based
585 on the associated resource value of DRGs. Current statewide
586 funding levels shall be calculated both with and without the use
587 of intergovernmental transfers;
588 d. Calculate the current number of services provided in the
589 Medicaid program based on DRGs defined under this subparagraph;
590 e. Estimate the number of cases in each DRG for future
591 years based on agency data and the official workload estimates
592 of the Social Services Estimating Conference;
593 f. Estimate potential funding for each hospital with a
594 Medicaid provider agreement, based on the DRGs and estimated
595 workload;
596 g. Propose supplemental DRG payments to augment hospital
597 reimbursements based on patient acuity and individual hospital
598 characteristics, including classification as a children’s
599 hospital, rural hospital, trauma center, burn unit, and other
600 characteristics that could warrant higher reimbursements; and
601 h. Estimate potential funding for each hospital with a
602 Medicaid provider agreement for DRGs defined pursuant to this
603 subparagraph and supplemental DRG payments using current funding
604 levels, calculated both with and without the use of
605 intergovernmental transfers.
606 2. The agency, through a competitive procurement pursuant
607 to chapter 287, shall engage a consultant with expertise and
608 experience in the implementation of DRG systems for hospital
609 reimbursement to develop the DRG plan under subparagraph 1.
610 3. The agency shall submit the Medicaid DRG plan,
611 identifying all steps necessary for the transition and any costs
612 associated with plan implementation, to the Governor, the
613 President of the Senate, and the Speaker of the House of
614 Representatives no later than December 1, 2012 January 1, 2013.
615 Upon receiving legislative authorization, the agency shall begin
616 making the necessary changes to fiscal agent coding by June 1,
617 2013, with a target date of November 1, 2013, for full
618 implementation of the DRG system of hospital reimbursement. If,
619 during implementation of this paragraph, the agency determines
620 that these timeframes might not be achievable, the agency shall
621 report to the Legislative Budget Commission the status of its
622 implementation efforts, the reasons the timeframes might not be
623 achievable, and proposals for new timeframes.
624 Section 7. Paragraph (c) of subsection (1) of section
625 409.908, Florida Statutes, is amended, paragraph (e) is added to
626 that subsection, and subsections (4) and (21) of that section
627 are amended, to read:
628 409.908 Reimbursement of Medicaid providers.—Subject to
629 specific appropriations, the agency shall reimburse Medicaid
630 providers, in accordance with state and federal law, according
631 to methodologies set forth in the rules of the agency and in
632 policy manuals and handbooks incorporated by reference therein.
633 These methodologies may include fee schedules, reimbursement
634 methods based on cost reporting, negotiated fees, competitive
635 bidding pursuant to s. 287.057, and other mechanisms the agency
636 considers efficient and effective for purchasing services or
637 goods on behalf of recipients. If a provider is reimbursed based
638 on cost reporting and submits a cost report late and that cost
639 report would have been used to set a lower reimbursement rate
640 for a rate semester, then the provider’s rate for that semester
641 shall be retroactively calculated using the new cost report, and
642 full payment at the recalculated rate shall be effected
643 retroactively. Medicare-granted extensions for filing cost
644 reports, if applicable, shall also apply to Medicaid cost
645 reports. Payment for Medicaid compensable services made on
646 behalf of Medicaid eligible persons is subject to the
647 availability of moneys and any limitations or directions
648 provided for in the General Appropriations Act or chapter 216.
649 Further, nothing in this section shall be construed to prevent
650 or limit the agency from adjusting fees, reimbursement rates,
651 lengths of stay, number of visits, or number of services, or
652 making any other adjustments necessary to comply with the
653 availability of moneys and any limitations or directions
654 provided for in the General Appropriations Act, provided the
655 adjustment is consistent with legislative intent.
656 (1) Reimbursement to hospitals licensed under part I of
657 chapter 395 must be made prospectively or on the basis of
658 negotiation.
659 (c) Hospitals that provide services to a disproportionate
660 share of low-income Medicaid recipients, or that participate in
661 the regional perinatal intensive care center program under
662 chapter 383, or that participate in the statutory teaching
663 hospital disproportionate share program may receive additional
664 reimbursement. The total amount of payment for disproportionate
665 share hospitals shall be fixed by the General Appropriations
666 Act. The computation of these payments must be made in
667 compliance with all federal regulations and the methodologies
668 described in ss. 409.911, 409.9112, and 409.9113.
669 (e) The agency may accept voluntary intergovernmental
670 transfers of local taxes and other qualified revenue from
671 counties, municipalities, or special taxing districts under
672 paragraphs (a) and (b) or the General Appropriations Act for the
673 purpose of funding the costs of special Medicaid payments to
674 hospitals, the costs of exempting hospitals from reimbursement
675 ceilings, or the costs of buying back hospital Medicaid trend
676 adjustments authorized under the General Appropriations Act,
677 except that the use of these intergovernmental transfers for
678 fee-for-service payments to hospitals is limited to the
679 proportionate use of such funds accepted by the agency under
680 subsection (4). As used in this paragraph, the term
681 “proportionate use” means that the use of intergovernmental
682 transfer funds under this subsection must be in the same
683 proportion to the use of such funds under subsection (4)
684 relative to the need for funding hospital costs under each
685 subsection.
686 (4) Subject to any limitations or directions provided for
687 in the General Appropriations Act, alternative health plans,
688 health maintenance organizations, and prepaid health plans,
689 including health maintenance organizations, prepaid provider
690 service networks, and other capitated managed care plans, shall
691 be reimbursed a fixed, prepaid amount negotiated, or
692 competitively bid pursuant to s. 287.057, by the agency and
693 prospectively paid to the provider monthly for each Medicaid
694 recipient enrolled. The amount may not exceed the average amount
695 the agency determines it would have paid, based on claims
696 experience, for recipients in the same or similar category of
697 eligibility. The agency shall calculate capitation rates on a
698 regional basis and, beginning September 1, 1995, shall include
699 age-band differentials in such calculations.
700 (a) Effective September 1, 2012:
701 1. The costs of special Medicaid payments to hospitals, the
702 costs of exempting hospitals from reimbursement ceilings, and
703 the costs of buying back hospital Medicaid trend adjustments
704 authorized under the General Appropriations Act, which are
705 funded through intergovernmental transfers, may not be included
706 as inpatient or outpatient costs in the calculation of prepaid
707 health plan capitations under this part. This provision must be
708 construed so that inpatient hospital costs included in the
709 calculation of prepaid health plan capitations are identical to
710 those represented by county billing rates under s. 409.915.
711 2. Prepaid health plans may not reimburse hospitals for the
712 costs described in subparagraph 1., except that plans may
713 contract with hospitals to pay inpatient per diems that are
714 between 95 percent and 105 percent of the county billing rate.
715 Hospitals and prepaid health plans may negotiate mutually
716 acceptable higher rates for medically complex care.
717 (b) Notwithstanding paragraph (a):
718 1. In order to fund the inclusion of costs described in
719 paragraph (a) in the calculation of capitations paid to prepaid
720 health plans, the agency may accept voluntary intergovernmental
721 transfers of local taxes and other qualified revenue from
722 counties, municipalities, or special taxing districts. After
723 securing commitments from counties, municipalities, or special
724 taxing districts to contribute intergovernmental transfers for
725 that purpose, the agency shall develop capitation payments for
726 prepaid health plans which include the costs described in
727 paragraph (a) if those components of the capitation are funded
728 through intergovernmental transfers and not with general
729 revenue. The rate-setting methodology must preserve federal
730 matching funds for the intergovernmental transfers collected
731 under this paragraph and result in actuarially sound rates. The
732 agency has the discretion to perform this function using
733 supplemental capitation payments.
734 2. The amounts included in a prepaid health plan’s
735 capitations or supplemental capitations under this paragraph for
736 funding the costs described in paragraph (a) must be used
737 exclusively by the prepaid health plan to enhance hospital
738 payments and be calculated by the agency as accurately as
739 possible to equal the costs described in paragraph (a) which the
740 prepaid health plan actually incurs and for which
741 intergovernmental transfers have been secured.
742 (21) The agency shall reimburse school districts that which
743 certify the state match pursuant to ss. 409.9071 and 1011.70 for
744 the federal portion of the school district’s allowable costs to
745 deliver the services, based on the reimbursement schedule. The
746 school district shall determine the costs for delivering
747 services as authorized in ss. 409.9071 and 1011.70 for which the
748 state match will be certified.
749 (a) School districts participating in the certified school
750 match program pursuant to this subsection and s. 1011.70 shall
751 be reimbursed by Medicaid, subject to the limitations of s.
752 1011.70(1), for a Medicaid-eligible child participating in the
753 services, as authorized under s. 1011.70 and as provided in s.
754 409.9071, regardless of whether the child is enrolled in
755 MediPass or a managed care plan. Managed care plans and school
756 districts shall make good faith efforts to execute agreements
757 regarding the coordinated provision of services authorized under
758 s. 1011.70. County health departments delivering school-based
759 services pursuant to ss. 381.0056 and 381.0057 shall be
760 reimbursed by Medicaid for the federal share for a Medicaid
761 eligible child who receives Medicaid-covered services in a
762 school setting, regardless of whether the child is enrolled in
763 MediPass or a managed care plan. Managed care plans and county
764 health departments shall make good faith efforts to execute
765 agreements regarding the coordinated provision of services to a
766 Medicaid-eligible child. To ensure continuity of care for
767 Medicaid patients, the agency, the Department of Health, and the
768 Department of Education shall develop procedures for ensuring
769 that a student’s managed care plan or MediPass primary care
770 provider receives information relating to services provided in
771 accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
772 (b) Reimbursement of school-based providers is contingent
773 on such providers being enrolled as Medicaid providers and
774 meeting the qualifications contained in 42 C.F.R. s. 440.110,
775 unless otherwise waived by the federal Centers for Medicare and
776 Medicaid Services Health Care Financing Administration. Speech
777 therapy providers who are certified through the Department of
778 Education pursuant to rule 6A-4.0176, Florida Administrative
779 Code, are eligible for reimbursement for services that are
780 provided on school premises. An Any employee of the school
781 district who has been fingerprinted and has received a criminal
782 background check in accordance with Department of Education
783 rules and guidelines is shall be exempt from any agency
784 requirements relating to criminal background checks.
785 Section 8. Subsection (1), paragraphs (a) and (b) of
786 subsection (2), and paragraph (d) of subsection (4) of section
787 409.911, Florida Statutes, are amended to read:
788 409.911 Disproportionate share program.—Subject to specific
789 allocations established within the General Appropriations Act
790 and any limitations established pursuant to chapter 216, the
791 agency shall distribute, pursuant to this section, moneys to
792 hospitals providing a disproportionate share of Medicaid or
793 charity care services by making quarterly Medicaid payments as
794 required. Notwithstanding the provisions of s. 409.915, counties
795 are exempt from contributing toward the cost of this special
796 reimbursement for hospitals serving a disproportionate share of
797 low-income patients.
798 (1) DEFINITIONS.—As used in this section, s. 409.9112, and
799 the Florida Hospital Uniform Reporting System manual:
800 (a) “Adjusted patient days” means the sum of acute care
801 patient days and intensive care patient days as reported to the
802 agency for Health Care Administration, divided by the ratio of
803 inpatient revenues generated from acute, intensive, ambulatory,
804 and ancillary patient services to gross revenues.
805 (b) “Actual audited data” or “actual audited experience”
806 means data reported to the agency for Health Care Administration
807 which has been audited in accordance with generally accepted
808 auditing standards by the agency or representatives under
809 contract with the agency.
810 (c) “Charity care” or “uncompensated charity care” means
811 that portion of hospital charges reported to the agency for
812 Health Care Administration for which there is no compensation,
813 other than restricted or unrestricted revenues provided to a
814 hospital by local governments or tax districts, regardless of
815 the method of payment, for care provided to a patient whose
816 family income for the 12 months preceding the determination is
817 less than or equal to 200 percent of the federal poverty level,
818 unless the amount of hospital charges due from the patient
819 exceeds 25 percent of the annual family income. However, in no
820 case shall the hospital charges for a patient whose family
821 income exceeds four times the federal poverty level for a family
822 of four may not be considered charity.
823 (d) “Charity care days” means the sum of the deductions
824 from revenues for charity care minus 50 percent of restricted
825 and unrestricted revenues provided to a hospital by local
826 governments or tax districts, divided by gross revenues per
827 adjusted patient day.
828 (e) “Hospital” means a health care institution licensed as
829 a hospital pursuant to chapter 395, but does not include
830 ambulatory surgical centers.
831 (f) “Medicaid days” means the number of actual days
832 attributable to Medicaid recipients patients as determined by
833 the agency for Health Care Administration.
834 (2) The agency for Health Care Administration shall use the
835 following actual audited data to determine the Medicaid days and
836 charity care to be used in calculating the disproportionate
837 share payment:
838 (a) The average of the 2004, 2005, and 2006 audited
839 disproportionate share data to determine each hospital’s
840 Medicaid days and charity care for the 2012-2013 2011-2012 state
841 fiscal year.
842 (b) If the agency for Health Care Administration does not
843 have the prescribed 3 years of audited disproportionate share
844 data as noted in paragraph (a) for a hospital, the agency shall
845 use the average of the years of the audited disproportionate
846 share data as noted in paragraph (a) which is available.
847 (4) The following formulas shall be used to pay
848 disproportionate share dollars to public hospitals:
849 (d) Any nonstate government owned or operated hospital
850 eligible for payments under this section on July 1, 2011,
851 remains eligible for payments during the 2012-2013 2011-2012
852 state fiscal year.
853 Section 9. Section 409.9112, Florida Statutes, is repealed.
854 Section 10. Section 409.9113, Florida Statutes, is amended
855 to read:
856 409.9113 Disproportionate share program for teaching
857 hospitals.—In addition to the payments made under s. ss. 409.911
858 and 409.9112, the agency shall make disproportionate share
859 payments to teaching hospitals, as defined in s. 408.07, for
860 their increased costs associated with medical education programs
861 and for tertiary health care services provided to the indigent.
862 This system of payments must conform to federal requirements and
863 distribute funds in each fiscal year for which an appropriation
864 is made by making quarterly Medicaid payments. Notwithstanding
865 s. 409.915, counties are exempt from contributing toward the
866 cost of this special reimbursement for hospitals serving a
867 disproportionate share of low-income patients. For the 2011-2012
868 state fiscal year, The agency shall distribute the moneys
869 provided in the General Appropriations Act to statutorily
870 defined teaching hospitals and family practice teaching
871 hospitals, as defined in s. 395.805, pursuant to this section.
872 The funds provided for statutorily defined teaching hospitals
873 shall be distributed as provided in the General Appropriations
874 Act. The funds provided for family practice teaching hospitals
875 shall be distributed equally among family practice teaching
876 hospitals.
877 (1) On or before September 15 of each year, the agency
878 shall calculate an allocation fraction to be used for
879 distributing funds to statutory teaching hospitals. Subsequent
880 to the end of each quarter of the state fiscal year, the agency
881 shall distribute to each statutory teaching hospital an amount
882 determined by multiplying one-fourth of the funds appropriated
883 for this purpose by the Legislature times such hospital’s
884 allocation fraction. The allocation fraction for each such
885 hospital shall be determined by the sum of the following three
886 primary factors, divided by three:
887 (a) The number of nationally accredited graduate medical
888 education programs offered by the hospital, including programs
889 accredited by the Accreditation Council for Graduate Medical
890 Education and the combined Internal Medicine and Pediatrics
891 programs acceptable to both the American Board of Internal
892 Medicine and the American Board of Pediatrics at the beginning
893 of the state fiscal year preceding the date on which the
894 allocation fraction is calculated. The numerical value of this
895 factor is the fraction that the hospital represents of the total
896 number of programs, where the total is computed for all
897 statutory teaching hospitals.
898 (b) The number of full-time equivalent trainees in the
899 hospital, which comprises two components:
900 1. The number of trainees enrolled in nationally accredited
901 graduate medical education programs, as defined in paragraph
902 (a). Full-time equivalents are computed using the fraction of
903 the year during which each trainee is primarily assigned to the
904 given institution, over the state fiscal year preceding the date
905 on which the allocation fraction is calculated. The numerical
906 value of this factor is the fraction that the hospital
907 represents of the total number of full-time equivalent trainees
908 enrolled in accredited graduate programs, where the total is
909 computed for all statutory teaching hospitals.
910 2. The number of medical students enrolled in accredited
911 colleges of medicine and engaged in clinical activities,
912 including required clinical clerkships and clinical electives.
913 Full-time equivalents are computed using the fraction of the
914 year during which each trainee is primarily assigned to the
915 given institution, over the course of the state fiscal year
916 preceding the date on which the allocation fraction is
917 calculated. The numerical value of this factor is the fraction
918 that the given hospital represents of the total number of full
919 time equivalent students enrolled in accredited colleges of
920 medicine, where the total is computed for all statutory teaching
921 hospitals.
922
923 The primary factor for full-time equivalent trainees is computed
924 as the sum of these two components, divided by two.
925 (c) A service index that comprises three components:
926 1. The Agency for Health Care Administration Service Index,
927 computed by applying the standard Service Inventory Scores
928 established by the agency to services offered by the given
929 hospital, as reported on Worksheet A-2 for the last fiscal year
930 reported to the agency before the date on which the allocation
931 fraction is calculated. The numerical value of this factor is
932 the fraction that the given hospital represents of the total
933 index values, where the total is computed for all statutory
934 teaching hospitals.
935 2. A volume-weighted service index, computed by applying
936 the standard Service Inventory Scores established by the agency
937 to the volume of each service, expressed in terms of the
938 standard units of measure reported on Worksheet A-2 for the last
939 fiscal year reported to the agency before the date on which the
940 allocation factor is calculated. The numerical value of this
941 factor is the fraction that the given hospital represents of the
942 total volume-weighted service index values, where the total is
943 computed for all statutory teaching hospitals.
944 3. Total Medicaid payments to each hospital for direct
945 inpatient and outpatient services during the fiscal year
946 preceding the date on which the allocation factor is calculated.
947 This includes payments made to each hospital for such services
948 by Medicaid prepaid health plans, whether the plan was
949 administered by the hospital or not. The numerical value of this
950 factor is the fraction that each hospital represents of the
951 total of such Medicaid payments, where the total is computed for
952 all statutory teaching hospitals.
953
954 The primary factor for the service index is computed as the sum
955 of these three components, divided by three.
956 (2) By October 1 of each year, the agency shall use the
957 following formula to calculate the maximum additional
958 disproportionate share payment for statutory teaching hospitals:
959
960 TAP = THAF x A
961
962 Where:
963 TAP = total additional payment.
964 THAF = teaching hospital allocation factor.
965 A = amount appropriated for a teaching hospital
966 disproportionate share program.
967 Section 11. Section 409.9117, Florida Statutes, is
968 repealed.
969 Section 12. Paragraphs (b) and (d) of subsection (4) of
970 section 409.912, Florida Statutes, are amended to read:
971 409.912 Cost-effective purchasing of health care.—The
972 agency shall purchase goods and services for Medicaid recipients
973 in the most cost-effective manner consistent with the delivery
974 of quality medical care. To ensure that medical services are
975 effectively utilized, the agency may, in any case, require a
976 confirmation or second physician’s opinion of the correct
977 diagnosis for purposes of authorizing future services under the
978 Medicaid program. This section does not restrict access to
979 emergency services or poststabilization care services as defined
980 in 42 C.F.R. part 438.114. Such confirmation or second opinion
981 shall be rendered in a manner approved by the agency. The agency
982 shall maximize the use of prepaid per capita and prepaid
983 aggregate fixed-sum basis services when appropriate and other
984 alternative service delivery and reimbursement methodologies,
985 including competitive bidding pursuant to s. 287.057, designed
986 to facilitate the cost-effective purchase of a case-managed
987 continuum of care. The agency shall also require providers to
988 minimize the exposure of recipients to the need for acute
989 inpatient, custodial, and other institutional care and the
990 inappropriate or unnecessary use of high-cost services. The
991 agency shall contract with a vendor to monitor and evaluate the
992 clinical practice patterns of providers in order to identify
993 trends that are outside the normal practice patterns of a
994 provider’s professional peers or the national guidelines of a
995 provider’s professional association. The vendor must be able to
996 provide information and counseling to a provider whose practice
997 patterns are outside the norms, in consultation with the agency,
998 to improve patient care and reduce inappropriate utilization.
999 The agency may mandate prior authorization, drug therapy
1000 management, or disease management participation for certain
1001 populations of Medicaid beneficiaries, certain drug classes, or
1002 particular drugs to prevent fraud, abuse, overuse, and possible
1003 dangerous drug interactions. The Pharmaceutical and Therapeutics
1004 Committee shall make recommendations to the agency on drugs for
1005 which prior authorization is required. The agency shall inform
1006 the Pharmaceutical and Therapeutics Committee of its decisions
1007 regarding drugs subject to prior authorization. The agency is
1008 authorized to limit the entities it contracts with or enrolls as
1009 Medicaid providers by developing a provider network through
1010 provider credentialing. The agency may competitively bid single
1011 source-provider contracts if procurement of goods or services
1012 results in demonstrated cost savings to the state without
1013 limiting access to care. The agency may limit its network based
1014 on the assessment of beneficiary access to care, provider
1015 availability, provider quality standards, time and distance
1016 standards for access to care, the cultural competence of the
1017 provider network, demographic characteristics of Medicaid
1018 beneficiaries, practice and provider-to-beneficiary standards,
1019 appointment wait times, beneficiary use of services, provider
1020 turnover, provider profiling, provider licensure history,
1021 previous program integrity investigations and findings, peer
1022 review, provider Medicaid policy and billing compliance records,
1023 clinical and medical record audits, and other factors. Providers
1024 are not entitled to enrollment in the Medicaid provider network.
1025 The agency shall determine instances in which allowing Medicaid
1026 beneficiaries to purchase durable medical equipment and other
1027 goods is less expensive to the Medicaid program than long-term
1028 rental of the equipment or goods. The agency may establish rules
1029 to facilitate purchases in lieu of long-term rentals in order to
1030 protect against fraud and abuse in the Medicaid program as
1031 defined in s. 409.913. The agency may seek federal waivers
1032 necessary to administer these policies.
1033 (4) The agency may contract with:
1034 (b) An entity that is providing comprehensive behavioral
1035 health care services to certain Medicaid recipients through a
1036 capitated, prepaid arrangement pursuant to the federal waiver
1037 provided for by s. 409.905(5). Such entity must be licensed
1038 under chapter 624, chapter 636, or chapter 641, or authorized
1039 under paragraph (c) or paragraph (d), and must possess the
1040 clinical systems and operational competence to manage risk and
1041 provide comprehensive behavioral health care to Medicaid
1042 recipients. As used in this paragraph, the term “comprehensive
1043 behavioral health care services” means covered mental health and
1044 substance abuse treatment services that are available to
1045 Medicaid recipients. The secretary of the Department of Children
1046 and Family Services shall approve provisions of procurements
1047 related to children in the department’s care or custody before
1048 enrolling such children in a prepaid behavioral health plan. Any
1049 contract awarded under this paragraph must be competitively
1050 procured. In developing the behavioral health care prepaid plan
1051 procurement document, the agency must shall ensure that the
1052 procurement document requires the contractor to develop and
1053 implement a plan that ensures to ensure compliance with s.
1054 394.4574 related to services provided to residents of licensed
1055 assisted living facilities that hold a limited mental health
1056 license. Except as provided in subparagraph 5., and except in
1057 counties where the Medicaid managed care pilot program is
1058 authorized pursuant to s. 409.91211, the agency shall seek
1059 federal approval to contract with a single entity meeting these
1060 requirements to provide comprehensive behavioral health care
1061 services to all Medicaid recipients not enrolled in a Medicaid
1062 managed care plan authorized under s. 409.91211, a provider
1063 service network authorized under paragraph (d), or a Medicaid
1064 health maintenance organization in an AHCA area. In an AHCA area
1065 where the Medicaid managed care pilot program is authorized
1066 pursuant to s. 409.91211 in one or more counties, the agency may
1067 procure a contract with a single entity to serve the remaining
1068 counties as an AHCA area or the remaining counties may be
1069 included with an adjacent AHCA area and are subject to this
1070 paragraph. Each entity must offer a sufficient choice of
1071 providers in its network to ensure recipient access to care and
1072 the opportunity to select a provider with whom they are
1073 satisfied. The network must shall include all public mental
1074 health hospitals. To ensure unimpaired access to behavioral
1075 health care services by Medicaid recipients, all contracts
1076 issued pursuant to this paragraph must require 80 percent of the
1077 capitation paid to the managed care plan, including health
1078 maintenance organizations and capitated provider service
1079 networks, to be expended for the provision of behavioral health
1080 care services. If the managed care plan expends less than 80
1081 percent of the capitation paid for the provision of behavioral
1082 health care services, the difference shall be returned to the
1083 agency. The agency shall provide the plan with a certification
1084 letter indicating the amount of capitation paid during each
1085 calendar year for behavioral health care services pursuant to
1086 this section. The agency may reimburse for substance abuse
1087 treatment services on a fee-for-service basis until the agency
1088 finds that adequate funds are available for capitated, prepaid
1089 arrangements.
1090 1. The agency shall modify the contracts with the entities
1091 providing comprehensive inpatient and outpatient mental health
1092 care services to Medicaid recipients in Hillsborough, Highlands,
1093 Hardee, Manatee, and Polk Counties, to include substance abuse
1094 treatment services.
1095 2. Except as provided in subparagraph 5., the agency and
1096 the Department of Children and Family Services shall contract
1097 with managed care entities in each AHCA area except area 6 or
1098 arrange to provide comprehensive inpatient and outpatient mental
1099 health and substance abuse services through capitated prepaid
1100 arrangements to all Medicaid recipients who are eligible to
1101 participate in such plans under federal law and regulation. In
1102 AHCA areas where eligible individuals number less than 150,000,
1103 the agency shall contract with a single managed care plan to
1104 provide comprehensive behavioral health services to all
1105 recipients who are not enrolled in a Medicaid health maintenance
1106 organization, a provider service network authorized under
1107 paragraph (d), or a Medicaid capitated managed care plan
1108 authorized under s. 409.91211. The agency may contract with more
1109 than one comprehensive behavioral health provider to provide
1110 care to recipients who are not enrolled in a Medicaid capitated
1111 managed care plan authorized under s. 409.91211, a provider
1112 service network authorized under paragraph (d), or a Medicaid
1113 health maintenance organization in AHCA areas where the eligible
1114 population exceeds 150,000. In an AHCA area where the Medicaid
1115 managed care pilot program is authorized pursuant to s.
1116 409.91211 in one or more counties, the agency may procure a
1117 contract with a single entity to serve the remaining counties as
1118 an AHCA area or the remaining counties may be included with an
1119 adjacent AHCA area and shall be subject to this paragraph.
1120 Contracts for comprehensive behavioral health providers awarded
1121 pursuant to this section shall be competitively procured. Both
1122 for-profit and not-for-profit corporations are eligible to
1123 compete. Managed care plans contracting with the agency under
1124 subsection (3) or paragraph (d) shall provide and receive
1125 payment for the same comprehensive behavioral health benefits as
1126 provided in AHCA rules, including handbooks incorporated by
1127 reference. In AHCA area 11, prior to any fiscal year for which
1128 the agency expects the number of MediPass enrollees in that area
1129 to exceed 150,000, the agency shall seek to contract with at
1130 least two comprehensive behavioral health care providers to
1131 provide behavioral health care to recipients in that area who
1132 are enrolled in, or assigned to, the MediPass program, and the
1133 agency must offer one. One of the behavioral health care
1134 contracts to must be with the existing public hospital-operated
1135 provider service network pilot project, as described in
1136 paragraph (d), for the purpose of demonstrating the cost
1137 effectiveness of the provision of quality mental health services
1138 through a public hospital-operated managed care model. Payment
1139 shall be at an agreed-upon capitated rate to ensure cost
1140 savings. Of the recipients in area 11 who are assigned to
1141 MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
1142 MediPass-enrolled recipients shall be assigned to the existing
1143 provider service network in area 11 for their behavioral care.
1144 3. Children residing in a statewide inpatient psychiatric
1145 program, or in a Department of Juvenile Justice or a Department
1146 of Children and Family Services residential program approved as
1147 a Medicaid behavioral health overlay services provider may not
1148 be included in a behavioral health care prepaid health plan or
1149 any other Medicaid managed care plan pursuant to this paragraph.
1150 4. Traditional community mental health providers under
1151 contract with the Department of Children and Family Services
1152 pursuant to part IV of chapter 394, child welfare providers
1153 under contract with the Department of Children and Family
1154 Services in areas 1 and 6, and inpatient mental health providers
1155 licensed pursuant to chapter 395 must be offered an opportunity
1156 to accept or decline a contract to participate in a any provider
1157 network for prepaid behavioral health services.
1158 5. All Medicaid-eligible children, except children in area
1159 1 and children in Highlands County, Hardee County, Polk County,
1160 or Manatee County of area 6, which that are open for child
1161 welfare services in the statewide automated child welfare
1162 information system, shall receive their behavioral health care
1163 services through a specialty prepaid plan operated by community
1164 based lead agencies through a single agency or formal agreements
1165 among several agencies. The agency shall work with the specialty
1166 plan to develop clinically effective, evidence-based
1167 alternatives as a downward substitution for the statewide
1168 inpatient psychiatric program and similar residential care and
1169 institutional services. The specialty prepaid plan must result
1170 in savings to the state comparable to savings achieved in other
1171 Medicaid managed care and prepaid programs. Such plan must
1172 provide mechanisms to maximize state and local revenues. The
1173 specialty prepaid plan shall be developed by the agency and the
1174 Department of Children and Family Services. The agency may seek
1175 federal waivers to implement this initiative. Medicaid-eligible
1176 children whose cases are open for child welfare services in the
1177 statewide automated child welfare information system and who
1178 reside in AHCA area 10 shall be enrolled in a capitated provider
1179 service network or other capitated managed care plan, which, in
1180 coordination with available community-based care providers
1181 specified in s. 409.1671, must shall provide sufficient medical,
1182 developmental, and behavioral health services to meet the needs
1183 of these children.
1184
1185 This paragraph expires October 1, 2014.
1186 (d)1. A provider service network, which may be reimbursed
1187 on a fee-for-service or prepaid basis. Prepaid provider service
1188 networks shall receive per-member, per-month payments. A
1189 provider service network that does not choose to be a prepaid
1190 plan shall receive fee-for-service rates with a shared savings
1191 settlement. The fee-for-service option shall be available to a
1192 provider service network only for the first 2 years of the
1193 plan’s operation or until the contract year beginning September
1194 1, 2014, whichever is later. The agency shall annually conduct
1195 cost reconciliations to determine the amount of cost savings
1196 achieved by fee-for-service provider service networks for the
1197 dates of service in the period being reconciled. Only payments
1198 for covered services for dates of service within the
1199 reconciliation period and paid within 6 months after the last
1200 date of service in the reconciliation period shall be included.
1201 The agency shall perform the necessary adjustments for the
1202 inclusion of claims incurred but not reported within the
1203 reconciliation for claims that could be received and paid by the
1204 agency after the 6-month claims processing time lag. The agency
1205 shall provide the results of the reconciliations to the fee-for
1206 service provider service networks within 45 days after the end
1207 of the reconciliation period. The fee-for-service provider
1208 service networks shall review and provide written comments or a
1209 letter of concurrence to the agency within 45 days after receipt
1210 of the reconciliation results. This reconciliation shall be
1211 considered final.
1212 2. A provider service network that which is reimbursed by
1213 the agency on a prepaid basis is shall be exempt from parts I
1214 and III of chapter 641, but must comply with the solvency
1215 requirements in s. 641.2261(2) and meet appropriate financial
1216 reserve, quality assurance, and patient rights requirements as
1217 established by the agency.
1218 3. The agency shall assign Medicaid recipients assigned to
1219 a provider service network in accordance with s. 409.9122 or s.
1220 409.91211, as applicable shall be chosen equally from those who
1221 would otherwise have been assigned to prepaid plans and
1222 MediPass. The agency may is authorized to seek federal Medicaid
1223 waivers as necessary to implement the provisions of this
1224 section. This subparagraph expires October 1, 2014.
1225 4. A provider service network is a network established or
1226 organized and operated by a health care provider, or group of
1227 affiliated health care providers, including minority physician
1228 networks and emergency room diversion programs that meet the
1229 requirements of s. 409.91211, which provides a substantial
1230 proportion of the health care items and services under a
1231 contract directly through the provider or affiliated group of
1232 providers and may make arrangements with physicians or other
1233 health care professionals, health care institutions, or any
1234 combination of such individuals or institutions to assume all or
1235 part of the financial risk on a prospective basis for the
1236 provision of basic health services by the physicians, by other
1237 health professionals, or through the institutions. The health
1238 care providers must have a controlling interest in the governing
1239 body of the provider service network organization.
1240 Section 13. Section 409.9121, Florida Statutes, is amended
1241 to read:
1242 409.9121 Legislative findings and intent.—The Legislature
1243 hereby finds that the Medicaid program has experienced an annual
1244 growth rate of approximately 28 percent per year for the past 5
1245 years, and is consuming more than half of all new general
1246 revenue growth. The present Medicaid system must be reoriented
1247 to emphasize, to the maximum extent possible, the delivery of
1248 health care through entities and mechanisms that which are
1249 designed to contain costs, to emphasize preventive and primary
1250 care, and to promote access and continuity of care. The
1251 Legislature further finds that the concept of “managed care”
1252 best encompasses these multiple goals. The Legislature also
1253 finds that, with the cooperation of the physician community,
1254 MediPass, the Medicaid primary care case management program, is
1255 responsible for ensuring that there is a sufficient supply of
1256 primary care to provide access to preventive and primary care
1257 services to Medicaid recipients. Therefore, the Legislature
1258 declares its intent that the Medicaid program require, to the
1259 maximum extent practicable and permitted by federal law, that
1260 all Medicaid recipients be enrolled in a managed care program.
1261 Section 14. Subsections (1), (2), (4), (5), and (12) of
1262 section 409.9122, Florida Statutes, are amended to read:
1263 409.9122 Mandatory Medicaid managed care enrollment;
1264 programs and procedures.—
1265 (1) It is the intent of the Legislature that Medicaid
1266 managed care the MediPass program be cost-effective, provide
1267 quality health care, and improve access to health services, and
1268 that the program be implemented statewide. Medicaid managed care
1269 shall consist of the enrollment of Medicaid recipients in the
1270 MediPass program or managed care plans for comprehensive medical
1271 services. This subsection expires October 1, 2014.
1272 (2)(a) The agency shall enroll all Medicaid recipients in a
1273 managed care plan or MediPass all Medicaid recipients, except
1274 those Medicaid recipients who are: in an institution,; enrolled
1275 in the Medicaid medically needy program,; or eligible for both
1276 Medicaid and Medicare. Upon enrollment, recipients may
1277 individuals will be able to change their managed care option
1278 during the 90-day opt out period required by federal Medicaid
1279 regulations. The agency may is authorized to seek the necessary
1280 Medicaid state plan amendment to implement this policy. However,
1281 (a) To the extent permitted by federal law, the agency may
1282 enroll a recipient in a managed care plan or MediPass a Medicaid
1283 recipient who is exempt from mandatory managed care enrollment
1284 if, provided that:
1285 1. The recipient’s decision to enroll in a managed care
1286 plan or MediPass is voluntary;
1287 2. If The recipient chooses to enroll in a managed care
1288 plan and, the agency has determined that the managed care plan
1289 provides specific programs and services that which address the
1290 special health needs of the recipient; and
1291 3. The agency receives any necessary waivers from the
1292 federal Centers for Medicare and Medicaid Services.
1293
1294 School districts participating in the certified school match
1295 program pursuant to ss. 409.908(21) and 1011.70 shall be
1296 reimbursed by Medicaid, subject to the limitations of s.
1297 1011.70(1), for a Medicaid-eligible child participating in the
1298 services as authorized in s. 1011.70, as provided for in s.
1299 409.9071, regardless of whether the child is enrolled in
1300 MediPass or a managed care plan. Managed care plans shall make a
1301 good faith effort to execute agreements with school districts
1302 regarding the coordinated provision of services authorized under
1303 s. 1011.70. County health departments delivering school-based
1304 services pursuant to ss. 381.0056 and 381.0057 shall be
1305 reimbursed by Medicaid for the federal share for a Medicaid
1306 eligible child who receives Medicaid-covered services in a
1307 school setting, regardless of whether the child is enrolled in
1308 MediPass or a managed care plan. Managed care plans shall make a
1309 good faith effort to execute agreements with county health
1310 departments regarding the coordinated provision of services to a
1311 Medicaid-eligible child. To ensure continuity of care for
1312 Medicaid patients, the agency, the Department of Health, and the
1313 Department of Education shall develop procedures for ensuring
1314 that a student’s managed care plan or MediPass provider receives
1315 information relating to services provided in accordance with ss.
1316 381.0056, 381.0057, 409.9071, and 1011.70.
1317 (b) A Medicaid recipient may shall not be enrolled in or
1318 assigned to a managed care plan or MediPass unless the managed
1319 care plan or MediPass has complied with the quality-of-care
1320 standards specified in paragraphs (3)(a) and (b), respectively.
1321 (c) A Medicaid recipient eligible for managed care
1322 enrollment recipients shall have a choice of managed care
1323 options plans or MediPass. The Agency for Health Care
1324 Administration, the Department of Health, the Department of
1325 Children and Family Services, and the Department of Elderly
1326 Affairs shall cooperate to ensure that each Medicaid recipient
1327 receives clear and easily understandable information that meets
1328 the following requirements:
1329 1. Explains the concept of managed care, including
1330 MediPass.
1331 2. Provides information on the comparative performance of
1332 managed care options available to the recipient plans and
1333 MediPass in the areas of quality, credentialing, preventive
1334 health programs, network size and availability, and patient
1335 satisfaction.
1336 3. Explains where additional information on each managed
1337 care option plan and MediPass in the recipient’s area can be
1338 obtained.
1339 4. Explains that recipients have the right to choose their
1340 managed care coverage at the time they first enroll in Medicaid
1341 and again at regular intervals set by the agency. However, if a
1342 recipient does not choose a managed care option plan or
1343 MediPass, the agency shall will assign the recipient to a
1344 managed care plan or MediPass according to the criteria
1345 specified in this section.
1346 5. Explains the recipient’s right to complain, file a
1347 grievance, or change his or her managed care option as specified
1348 in this section plans or MediPass providers if the recipient is
1349 not satisfied with the managed care plan or MediPass.
1350 (d) The agency shall develop a mechanism for providing
1351 information to Medicaid recipients for the purpose of choosing
1352 making a managed care option plan or MediPass selection.
1353 Examples of such mechanisms may include, but are not be limited
1354 to, interactive information systems, mailings, and mass
1355 marketing materials. Managed care plans and MediPass providers
1356 may not provide are prohibited from providing inducements to
1357 Medicaid recipients to select their plans or prejudice from
1358 prejudicing Medicaid recipients against other managed care plans
1359 or MediPass providers.
1360 (e) Medicaid recipients who are already enrolled in a
1361 managed care plan or MediPass shall be offered the opportunity
1362 to change managed care plans or MediPass providers, as
1363 applicable, on a staggered basis, as defined by the agency. All
1364 Medicaid recipients shall have 30 days in which to choose a
1365 managed care option make a choice of managed care plans or
1366 MediPass providers. Those Medicaid recipients who do not make a
1367 choice shall be assigned in accordance with paragraph (f). To
1368 facilitate continuity of care, for a Medicaid recipient who is
1369 also a recipient of Supplemental Security Income (SSI), prior to
1370 assigning the SSI recipient to a managed care plan or MediPass,
1371 the agency shall determine whether the SSI recipient has an
1372 ongoing relationship with a MediPass provider or managed care
1373 plan, and if so, the agency shall assign the SSI recipient to
1374 that MediPass provider or managed care plan. Those SSI
1375 recipients who do not have such a provider relationship shall be
1376 assigned to a managed care plan or MediPass provider in
1377 accordance with paragraph (f).
1378 1. During the 30-day choice period:
1379 a. A recipient residing in a county in which two or more
1380 managed care plans are eligible to accept Medicaid enrollees,
1381 including a recipient who was enrolled in MediPass at the
1382 commencement of his or her 30-day choice period, shall choose
1383 from those managed care plans. A recipient may opt out of his or
1384 her choice and choose a different managed care plan during the
1385 90-day opt out period.
1386 b. A recipient residing in a county in which only one
1387 managed care plan is eligible to accept Medicaid enrollees shall
1388 choose the managed care plan or a MediPass provider. A recipient
1389 who chooses the managed care plan may opt out of the plan and
1390 choose a MediPass provider during the 90-day opt out period.
1391 c. A recipient residing in a county in which no managed
1392 care plan is accepting Medicaid enrollees shall choose a
1393 MediPass provider.
1394 2. For the purposes of recipient choice, if a managed care
1395 plan reaches its enrollment capacity, as determined by the
1396 agency, the plan may not accept additional Medicaid enrollees
1397 until the agency determines that the plan’s enrollment is
1398 sufficiently less than its enrollment capacity, due to a decline
1399 in enrollment or by an increase in enrollment capacity. If a
1400 managed care plan notifies the agency of its intent to exit a
1401 county, the plan may not accept additional Medicaid enrollees in
1402 that county before the exit date.
1403 3. As used in this paragraph, when referring to recipient
1404 choice, the term “managed care plans” includes health
1405 maintenance organizations, exclusive provider organizations,
1406 provider service networks, minority physician networks,
1407 Children’s Medical Services Networks, and pediatric emergency
1408 department diversion programs authorized by this chapter or the
1409 General Appropriations Act.
1410 4. The agency shall seek federal waiver authority or a
1411 state plan amendment consistent with 42 U.S.C. 1396u-2(a)(1), as
1412 needed, to implement this paragraph.
1413 (f) If a Medicaid recipient does not choose a managed care
1414 option:
1415 1. If the recipient resides in a county in which two or
1416 more managed care plans are accepting Medicaid enrollees, the
1417 agency shall assign the recipient, including a recipient who was
1418 enrolled in MediPass at the commencement of his or her 30-day
1419 choice period, to one of those managed care plans. A recipient
1420 assigned to a managed care plan under this subparagraph may opt
1421 out of the managed care plan and enroll in a different managed
1422 care plan during the 90-day opt out period. The agency shall
1423 seek to make assignments among the managed care plans on an even
1424 basis under the criteria in subparagraph 6.
1425 2. If the recipient resides in a county in which only one
1426 managed care plan is accepting Medicaid enrollees, the agency
1427 shall assign the recipient, including a recipient who was
1428 enrolled in MediPass at the commencement of his or her 30-day
1429 choice period, to the managed care plan. A recipient assigned to
1430 a managed care plan under this subparagraph may opt out of the
1431 managed care plan and choose a MediPass provider during the 90
1432 day opt out period.
1433 3. If the recipient resides in a county in which no managed
1434 care plan is accepting Medicaid enrollees, the agency shall
1435 assign the recipient to a MediPass provider.
1436 4. For the purpose of assignment, if a managed care plan
1437 reaches its enrollment capacity, as determined by the agency,
1438 the plan may not accept additional Medicaid enrollees until the
1439 agency determines that the plan’s enrollment is sufficiently
1440 less than its enrollment capacity, due to a decline in
1441 enrollment or by an increase in enrollment capacity. If a
1442 managed care plan notifies the agency of its intent to exit a
1443 county, the agency may not assign additional Medicaid enrollees
1444 to the plan in that county before the exit date. plan or
1445 MediPass provider, the agency shall assign the Medicaid
1446 recipient to a managed care plan or MediPass provider. Medicaid
1447 recipients eligible for managed care plan enrollment who are
1448 subject to mandatory assignment but who fail to make a choice
1449 shall be assigned to managed care plans until an enrollment of
1450 35 percent in MediPass and 65 percent in managed care plans, of
1451 all those eligible to choose managed care, is achieved. Once
1452 this enrollment is achieved, the assignments shall be divided in
1453 order to maintain an enrollment in MediPass and managed care
1454 plans which is in a 35 percent and 65 percent proportion,
1455 respectively. Thereafter, assignment of Medicaid recipients who
1456 fail to make a choice shall be based proportionally on the
1457 preferences of recipients who have made a choice in the previous
1458 period. Such proportions shall be revised at least quarterly to
1459 reflect an update of the preferences of Medicaid recipients. The
1460 agency shall disproportionately assign Medicaid-eligible
1461 recipients who are required to but have failed to make a choice
1462 of managed care plan or MediPass to the Children’s Medical
1463 Services Network as defined in s. 391.021, exclusive provider
1464 organizations, provider service networks, minority physician
1465 networks, and pediatric emergency department diversion programs
1466 authorized by this chapter or the General Appropriations Act, in
1467 such manner as the agency deems appropriate, until the agency
1468 has determined that the networks and programs have sufficient
1469 numbers to be operated economically.
1470 5. As used in For purposes of this paragraph, when
1471 referring to assignment, the term “managed care plans” includes
1472 health maintenance organizations, exclusive provider
1473 organizations, provider service networks, minority physician
1474 networks, Children’s Medical Services Network, and pediatric
1475 emergency department diversion programs authorized by this
1476 chapter or the General Appropriations Act.
1477 6. When making assignments, the agency shall consider take
1478 into account the following criteria, as applicable:
1479 a.1. Whether a managed care plan has sufficient network
1480 capacity to meet the need of members.
1481 b.2. Whether the managed care plan or MediPass has
1482 previously enrolled the recipient as a member, or one of the
1483 managed care plan’s primary care providers or a MediPass primary
1484 care provider providers has previously provided health care to
1485 the recipient.
1486 c.3. Whether the agency has knowledge that the recipient
1487 member has previously expressed a preference for a particular
1488 managed care plan or MediPass primary care provider as indicated
1489 by Medicaid fee-for-service claims data, but has failed to make
1490 a choice.
1491 d.4. Whether the managed care plan’s or MediPass primary
1492 care providers are geographically accessible to the recipient’s
1493 residence.
1494 e. If the recipient was already enrolled in a managed care
1495 plan at the commencement of his or her 30-day choice period and
1496 fails to choose a different option, the recipient must remain
1497 enrolled in that same managed care plan.
1498 f. To facilitate continuity of care for a Medicaid
1499 recipient who is also a recipient of Supplemental Security
1500 Income (SSI), before assigning the SSI recipient, the agency
1501 shall determine whether the SSI recipient has an ongoing
1502 relationship with a managed care plan or a MediPass primary care
1503 provider, and if so, the agency shall assign the SSI recipient
1504 to that managed care plan or MediPass provider, as applicable.
1505 However, if the recipient has an ongoing relationship with a
1506 MediPass primary care provider who is included in the provider
1507 network of one or more managed care plans, the agency shall
1508 assign the recipient to one of those managed care plans.
1509 g. If the recipient is diagnosed with HIV/AIDS and resides
1510 in Broward County, Miami-Dade County, or Palm Beach County, the
1511 agency shall assign the Medicaid recipient to a managed care
1512 plan that is a health maintenance organization authorized under
1513 chapter 641, that was under contract with the agency on July 1,
1514 2011, and that offers a delivery system in partnership with a
1515 university-based teaching and research-oriented organization
1516 specializing in providing health care services and treatment for
1517 individuals diagnosed with HIV/AIDS. Recipients not diagnosed
1518 with HIV/AIDS may not be assigned under this paragraph to a
1519 managed care plan that specializes in HIV/AIDS.
1520 7. The agency shall seek federal waiver authority or a
1521 state plan amendment consistent with 42 U.S.C. 1396u-2(a)(4)(D),
1522 as needed, to implement this paragraph.
1523 (g) When more than one managed care plan or MediPass
1524 provider meets the criteria specified in paragraph (f), the
1525 agency shall make recipient assignments consecutively by family
1526 unit.
1527 (h) The agency may not engage in practices that are
1528 designed to favor one managed care plan over another or that are
1529 designed to influence Medicaid recipients to enroll in MediPass
1530 rather than in a managed care plan or to enroll in a managed
1531 care plan rather than in MediPass, as applicable. This
1532 subsection does not prohibit the agency from reporting on the
1533 performance of MediPass or any managed care plan, as measured by
1534 performance criteria developed by the agency.
1535 (i) After a recipient has made his or her selection or has
1536 been enrolled in a managed care plan or MediPass, the recipient
1537 shall have 90 days to exercise the opportunity to voluntarily
1538 disenroll and select another managed care option plan or
1539 MediPass. After 90 days, no further changes may be made except
1540 for good cause. Good cause includes, but is not limited to, poor
1541 quality of care, lack of access to necessary specialty services,
1542 an unreasonable delay or denial of service, or fraudulent
1543 enrollment. The agency shall develop criteria for good cause
1544 disenrollment for chronically ill and disabled populations who
1545 are assigned to managed care plans if more appropriate care is
1546 available through the MediPass program. The agency must make a
1547 determination as to whether good cause exists. However, the
1548 agency may require a recipient to use the managed care plan’s or
1549 MediPass grievance process prior to the agency’s determination
1550 of good cause, except in cases in which immediate risk of
1551 permanent damage to the recipient’s health is alleged. The
1552 grievance process, if used when utilized, must be completed in
1553 time to permit the recipient to disenroll by the first day of
1554 the second month after the month the disenrollment request was
1555 made. If the managed care plan or MediPass, as a result of the
1556 grievance process, approves an enrollee’s request to disenroll,
1557 the agency is not required to make a determination in the case.
1558 The agency must make a determination and take final action on a
1559 recipient’s request so that disenrollment occurs by no later
1560 than the first day of the second month after the month the
1561 request was made. If the agency fails to act within the
1562 specified timeframe, the recipient’s request to disenroll is
1563 deemed to be approved as of the date agency action was required.
1564 Recipients who disagree with the agency’s finding that good
1565 cause does not exist for disenrollment shall be advised of their
1566 right to pursue a Medicaid fair hearing to dispute the agency’s
1567 finding.
1568 (j) Consistent with 42 U.S.C. 1396u-2(a)(4)(A) or under
1569 federal waiver authority, as needed, the agency shall apply for
1570 a federal waiver from the Centers for Medicare and Medicaid
1571 Services to lock eligible Medicaid recipients into a managed
1572 care plan or MediPass for 12 months after an open enrollment
1573 period, except for the 90-day opt out period and good cause
1574 disenrollment. After 12 months’ enrollment, a recipient may
1575 select another managed care plan or MediPass provider. However,
1576 nothing shall prevent a Medicaid recipient may not be prevented
1577 from changing primary care providers within the managed care
1578 plan or MediPass program, as applicable, during the 12-month
1579 period.
1580 (k) The agency shall maintain MediPass provider networks in
1581 all counties, including those counties in which two or more
1582 managed care plans are accepting Medicaid enrollees. When a
1583 Medicaid recipient does not choose a managed care plan or
1584 MediPass provider, the agency shall assign the Medicaid
1585 recipient to a managed care plan, except in those counties in
1586 which there are fewer than two managed care plans accepting
1587 Medicaid enrollees, in which case assignment shall be to a
1588 managed care plan or a MediPass provider. Medicaid recipients in
1589 counties with fewer than two managed care plans accepting
1590 Medicaid enrollees who are subject to mandatory assignment but
1591 who fail to make a choice shall be assigned to managed care
1592 plans until an enrollment of 35 percent in MediPass and 65
1593 percent in managed care plans, of all those eligible to choose
1594 managed care, is achieved. Once that enrollment is achieved, the
1595 assignments shall be divided in order to maintain an enrollment
1596 in MediPass and managed care plans which is in a 35 percent and
1597 65 percent proportion, respectively. For purposes of this
1598 paragraph, when referring to assignment, the term “managed care
1599 plans” includes exclusive provider organizations, provider
1600 service networks, Children’s Medical Services Network, minority
1601 physician networks, and pediatric emergency department diversion
1602 programs authorized by this chapter or the General
1603 Appropriations Act. When making assignments, the agency shall
1604 take into account the following criteria:
1605 1. A managed care plan has sufficient network capacity to
1606 meet the need of members.
1607 2. The managed care plan or MediPass has previously
1608 enrolled the recipient as a member, or one of the managed care
1609 plan’s primary care providers or MediPass providers has
1610 previously provided health care to the recipient.
1611 3. The agency has knowledge that the member has previously
1612 expressed a preference for a particular managed care plan or
1613 MediPass provider as indicated by Medicaid fee-for-service
1614 claims data, but has failed to make a choice.
1615 4. The managed care plan’s or MediPass primary care
1616 providers are geographically accessible to the recipient’s
1617 residence.
1618 5. The agency has authority to make mandatory assignments
1619 based on quality of service and performance of managed care
1620 plans.
1621 (l) If the Medicaid recipient is diagnosed with HIV/AIDS
1622 and resides in Broward County, Miami-Dade County, or Palm Beach
1623 County, the agency shall assign the Medicaid recipient to a
1624 managed care plan that is a health maintenance organization
1625 authorized under chapter 641, is under contract with the agency
1626 on July 1, 2011, and which offers a delivery system through a
1627 university-based teaching and research-oriented organization
1628 that specializes in providing health care services and treatment
1629 for individuals diagnosed with HIV/AIDS.
1630 (l)(m) Notwithstanding the provisions of chapter 287, the
1631 agency may, at its discretion, renew cost-effective contracts
1632 for choice counseling services once or more for such periods as
1633 the agency may decide. However, all such renewals may not
1634 combine to exceed a total period longer than the term of the
1635 original contract.
1636
1637 This subsection expires October 1, 2014.
1638 (4)(a) Each female recipient may select as her primary care
1639 provider an obstetrician/gynecologist who has agreed to
1640 participate within a managed care plan’s provider network or as
1641 a MediPass primary care case manager, as applicable.
1642 (b) The agency shall establish a complaints and grievance
1643 process to assist Medicaid recipients enrolled in the MediPass
1644 program to resolve complaints and grievances. The agency shall
1645 investigate reports of quality-of-care grievances which remain
1646 unresolved to the satisfaction of the enrollee.
1647
1648 This subsection expires October 1, 2014.
1649 (5)(a) The agency shall work cooperatively with the Social
1650 Security Administration to identify recipients beneficiaries who
1651 are jointly eligible for Medicare and Medicaid and shall develop
1652 cooperative programs to encourage these recipients beneficiaries
1653 to enroll in a Medicare participating health maintenance
1654 organization or prepaid health plans.
1655 (b) The agency shall work cooperatively with the Department
1656 of Elderly Affairs to assess the potential cost-effectiveness of
1657 providing managed care enrollment MediPass to recipients
1658 beneficiaries who are jointly eligible for Medicare and Medicaid
1659 on a voluntary choice basis. If the agency determines that
1660 enrollment of these recipients beneficiaries in managed care
1661 MediPass has the potential for being cost-effective for the
1662 state, the agency shall offer managed care enrollment MediPass
1663 to these recipients beneficiaries on a voluntary choice basis in
1664 the counties where managed care is available MediPass operates.
1665
1666 This subsection expires October 1, 2014.
1667 (12) The agency shall include in its calculation of the
1668 hospital inpatient component of a Medicaid health maintenance
1669 organization’s capitation rate any special payments, including,
1670 but not limited to, upper payment limit or disproportionate
1671 share hospital payments, made to qualifying hospitals through
1672 the fee-for-service program. The agency may seek federal waiver
1673 approval or state plan amendment as needed to implement this
1674 adjustment. This subsection expires September 1, 2012.
1675 Section 15. Section 409.9123, Florida Statutes, is amended
1676 to read:
1677 409.9123 Quality-of-care reporting.—In order to promote
1678 competition between Medicaid managed care plans and MediPass
1679 based on quality-of-care indicators, The agency shall annually
1680 develop and publish a set of measures of managed care plan
1681 performance based on quality-of-care indicators. This
1682 information shall be made available to each Medicaid recipient
1683 who makes a choice of a managed care plan in her or his area.
1684 This information must shall be easily understandable to the
1685 Medicaid recipient and shall use nationally recognized standards
1686 wherever possible. In formulating this information, the agency
1687 shall, at a minimum, consider take into account at least the
1688 following:
1689 (1) The recommendations of the National Committee for
1690 Quality Assurance Medicaid HEDIS Task Force.
1691 (2) Requirements and recommendations of the Centers for
1692 Medicare and Medicaid Services Health Care Financing
1693 Administration.
1694 (3) Recommendations of the managed care industry.
1695 Section 16. For the purpose of incorporating the amendment
1696 made by this act to section 409.9122, Florida Statutes, in a
1697 reference thereto, subsection (1) of section 409.9126, Florida
1698 Statutes, is reenacted to read:
1699 409.9126 Children with special health care needs.—
1700 (1) Except as provided in subsection (4), children eligible
1701 for Children’s Medical Services who receive Medicaid benefits,
1702 and other Medicaid-eligible children with special health care
1703 needs, shall be exempt from the provisions of s. 409.9122 and
1704 shall be served through the Children’s Medical Services network
1705 established in chapter 391.
1706 Section 17. Effective upon this act becoming a law,
1707 subsections (4) through (6) of section 409.915, Florida
1708 Statutes, are amended, and subsections (7) through (11) are
1709 added to that section, to read:
1710 409.915 County contributions to Medicaid.—Although the
1711 state is responsible for the full portion of the state share of
1712 the matching funds required for the Medicaid program, in order
1713 to acquire a certain portion of these funds, the state shall
1714 charge the counties for certain items of care and service as
1715 provided in this section.
1716 (4) Each county shall contribute pay into the General
1717 Revenue Fund, unallocated, its pro rata share of the total
1718 county participation based upon statements rendered by the
1719 agency in consultation with the counties. The agency shall
1720 render such statements monthly based on each county’s eligible
1721 recipients. For purposes of this section, each county’s eligible
1722 recipients shall be determined by the recipients’ address
1723 information contained in the federally approved Medicaid
1724 eligibility system within the Department of Children and Family
1725 Services. The process developed under subsection (10) may be
1726 used for cases in which the Medicaid eligibility system’s
1727 address information may indicate a need for revision.
1728 (5) The Department of Financial Services shall withhold
1729 from the cigarette tax receipts or any other funds to be
1730 distributed to the counties the individual county share that has
1731 not been remitted within 60 days after billing.
1732 (5)(6) In any county in which a special taxing district or
1733 authority is located which will benefit from the medical
1734 assistance programs covered by this section, the board of county
1735 commissioners may divide the county’s financial responsibility
1736 for this purpose proportionately, and each such district or
1737 authority must furnish its share to the board of county
1738 commissioners in time for the board to comply with the
1739 provisions of subsection (3). Any appeal of the proration made
1740 by the board of county commissioners must be made to the
1741 Department of Financial Services, which shall then set the
1742 proportionate share of each party.
1743 (6)(7) Counties are exempt from contributing toward the
1744 cost of new exemptions on inpatient ceilings for statutory
1745 teaching hospitals, specialty hospitals, and community hospital
1746 education program hospitals that came into effect July 1, 2000,
1747 and for special Medicaid payments that came into effect on or
1748 after July 1, 2000.
1749 (7) By September 1, 2012, the agency shall certify to the
1750 Department of Revenue, for each county, an amount equal to 85
1751 percent of each county’s billings through April 30, 2012, which
1752 remain unpaid.
1753 (8)(a) Beginning with the October 2012 distribution, the
1754 Department of Revenue shall reduce each county’s distributions
1755 pursuant to s. 218.26 by one thirty-sixth of the amount
1756 certified by the agency under subsection (7) for that county.
1757 However, the amount of the reduction may not exceed 50 percent
1758 of each county’s distribution. If, after 36 months, the
1759 reductions for each county do not equal the total amount
1760 initially certified by the agency, the Department of Revenue
1761 shall continue to reduce each distribution by up to 50 percent
1762 until the total amount certified is reached. The amounts by
1763 which the distributions are reduced shall be transferred to the
1764 General Revenue Fund.
1765 (b) As an assurance to holders of bonds issued before the
1766 effective date of this act to which distributions made pursuant
1767 to s. 218.26 are pledged, or bonds issued to refund such bonds
1768 which mature no later than the bonds they refunded and which
1769 result in a reduction of debt service payable in each fiscal
1770 year, the amount available for distribution to a county shall
1771 remain as provided by law and continue to be subject to any lien
1772 or claim on behalf of the bondholders. The Department of Revenue
1773 must ensure that any reduction in amounts distributed pursuant
1774 to paragraph (a) does not reduce the amount of distribution to a
1775 county below the amount necessary for the payment of principal
1776 and interest on the bonds and the amount necessary to comply
1777 with any covenant under the bond resolution or other documents
1778 relating to the issuance of the bonds.
1779 (9)(a) Beginning May 1, 2012, and each month thereafter,
1780 the agency shall certify to the Department of Revenue the amount
1781 of the monthly statement rendered to each county pursuant to
1782 subsection (4). The department shall reduce each county’s
1783 monthly distribution pursuant to s. 218.61 by the amount
1784 certified. The amounts by which the distributions are reduced
1785 shall be transferred to the General Revenue Fund.
1786 (b) As an assurance to holders of bonds issued before the
1787 effective date of this act to which distributions made pursuant
1788 to s. 218.61 are pledged, or bonds issued to refund such bonds
1789 which mature no later than the bonds they refunded and which
1790 result in a reduction of debt service payable in each fiscal
1791 year, the amount available for distribution to a county shall
1792 remain as provided by law and continue to be subject to any lien
1793 or claim on behalf of the bondholders. The Department of Revenue
1794 must ensure that any reductions in amounts distributed pursuant
1795 to paragraph (a) does not reduce the amount of distribution to a
1796 county below the amount necessary for the payment of principal
1797 and interest on the bonds and the amount necessary to comply
1798 with any covenant under the bond resolution or other documents
1799 relating to the issuance of the bonds.
1800 (10) The Department of Revenue shall pay certified refund
1801 requests in accordance with a process developed by the agency
1802 and the department which:
1803 (a) Allows counties to submit to the agency written
1804 requests for refunds of any amounts by which the distributions
1805 were reduced as provided in subsection (9) and which set forth
1806 the reasons for the refund requests.
1807 (b) Requires the agency to make a determination as to
1808 whether a refund request is appropriate and should be approved,
1809 in which case the agency shall certify the amount of the refund
1810 to the department.
1811 (c) Requires the department to issue the refund for the
1812 certified amount to the county from the General Revenue Fund.
1813 (11) Beginning in the 2013-2014 fiscal year and each year
1814 thereafter until the 2020-2021 fiscal year, the Chief Financial
1815 Officer shall transfer from the General Revenue Fund to the
1816 Lawton Chiles Endowment Fund an amount equal to the amounts
1817 transferred to the General Revenue Fund in the previous fiscal
1818 year pursuant to subsections (8) and (9), reduced by the amount
1819 of refunds paid pursuant to subsection (10), which are in excess
1820 of the official estimate for medical hospital fees for such
1821 previous fiscal year adopted by the Revenue Estimating
1822 Conference on January 12, 2012, as reflected in the conference’s
1823 workpapers. By July 20 of each year, the Office of Economic and
1824 Demographic Research shall certify the amount to be transferred
1825 to the Chief Financial Officer. Such transfers must be made
1826 before July 31 of each year until the total transfers for all
1827 years equal $265 million. The Office of Economic and Demographic
1828 Research shall publish the official estimates reflected in the
1829 conference’s workpapers on its website.
1830 Section 18. Subsection (2) of section 409.979, Florida
1831 Statutes, is amended to read:
1832 409.979 Eligibility.—
1833 (2) Medicaid recipients who, on the date long-term care
1834 managed care plans become available in their region, reside in a
1835 nursing home facility or are enrolled in one of the following
1836 long-term care Medicaid waiver programs are eligible to
1837 participate in the long-term care managed care program for up to
1838 12 months without being reevaluated for their need for nursing
1839 facility care as defined in s. 409.985(3):
1840 (a) The Assisted Living for the Frail Elderly Waiver.
1841 (b) The Aged and Disabled Adult Waiver.
1842 (c) The Adult Day Health Care Waiver.
1843 (c)(d) The Consumer-Directed Care Plus Program as described
1844 in s. 409.221.
1845 (d)(e) The Program of All-inclusive Care for the Elderly.
1846 (e)(f) The long-term care community-based diversion pilot
1847 project as described in s. 430.705.
1848 (f)(g) The Channeling Services Waiver for Frail Elders.
1849 Section 19. Subsection (15) of section 430.04, Florida
1850 Statutes, is amended to read:
1851 430.04 Duties and responsibilities of the Department of
1852 Elderly Affairs.—The Department of Elderly Affairs shall:
1853 (15) Administer all Medicaid waivers and programs relating
1854 to elders and their appropriations. The waivers include, but are
1855 not limited to:
1856 (a) The Assisted Living for the Frail Elderly Waiver.
1857 (b) The Aged and Disabled Adult Waiver.
1858 (c) The Adult Day Health Care Waiver.
1859 (c)(d) The Consumer-Directed Care Plus Program as defined
1860 in s. 409.221.
1861 (d)(e) The Program of All-inclusive Care for the Elderly.
1862 (e)(f) The Long-Term Care Community-Based Diversion Pilot
1863 Project as described in s. 430.705.
1864 (f)(g) The Channeling Services Waiver for Frail Elders.
1865
1866 The department shall develop a transition plan for recipients
1867 receiving services in long-term care Medicaid waivers for elders
1868 or disabled adults on the date eligible plans become available
1869 in each recipient’s region defined in s. 409.981(2) to enroll
1870 those recipients in eligible plans. This subsection expires
1871 October 1, 2014.
1872 Section 20. Section 31 of chapter 2009-223, Laws of
1873 Florida, as amended by section 44 of chapter 2010-151, Laws of
1874 Florida, is redesignated as section 409.9132, Florida Statutes,
1875 and amended to read:
1876 409.9132 Section 31. Pilot project to monitor home health
1877 services.—The agency for Health Care Administration shall expand
1878 the develop and implement a home health agency monitoring pilot
1879 project in Miami-Dade County on a statewide basis effective July
1880 1, 2012, except in counties in which the program will not be
1881 cost-effective, as determined by the agency by January 1, 2010.
1882 The agency shall contract with a vendor to verify the
1883 utilization and delivery of home health services and provide an
1884 electronic billing interface for home health services. The
1885 contract must require the creation of a program to submit claims
1886 electronically for the delivery of home health services. The
1887 program must verify telephonically visits for the delivery of
1888 home health services using voice biometrics. The agency may seek
1889 amendments to the Medicaid state plan and waivers of federal
1890 laws, as necessary, to implement or expand the pilot project.
1891 Notwithstanding s. 287.057(3)(f), Florida Statutes, the agency
1892 must award the contract through the competitive solicitation
1893 process and may use the current contract to expand the home
1894 health agency monitoring pilot project to include additional
1895 counties as authorized under this section. The agency shall
1896 submit a report to the Governor, the President of the Senate,
1897 and the Speaker of the House of Representatives evaluating the
1898 pilot project by February 1, 2011.
1899 Section 21. Section 32 of chapter 2009-223, Laws of
1900 Florida, is redesignated as section 409.9133, Florida Statutes,
1901 and amended to read:
1902 409.9133 Section 32. Pilot project for home health care
1903 management.—The agency for Health Care Administration shall
1904 expand the implement a comprehensive care management pilot
1905 project for home health services statewide and include private
1906 duty nursing and personal care services effective July 1, 2012,
1907 except in counties in which the program will not be cost
1908 effective, as determined by the agency by January 1, 2010. The
1909 program must include, which includes face-to-face assessments by
1910 a nurse licensed pursuant to chapter 464, Florida Statutes,
1911 consultation with physicians ordering services to substantiate
1912 the medical necessity for services, and on-site or desk reviews
1913 of recipients’ medical records in Miami-Dade County. The agency
1914 may enter into a contract with a qualified organization to
1915 implement or expand the pilot project. The agency may use the
1916 current contract to expand the comprehensive care management
1917 pilot project to include the additional services and counties
1918 authorized under this section. The agency may seek amendments to
1919 the Medicaid state plan and waivers of federal laws, as
1920 necessary, to implement or expand the pilot project.
1921 Section 22. Notwithstanding s. 430.707, Florida Statutes,
1922 and subject to federal approval of an additional site for the
1923 Program of All-Inclusive Care for the Elderly (PACE), the Agency
1924 for Health Care Administration shall contract with a current
1925 PACE organization authorized to provide PACE services in
1926 Southeast Florida to develop and operate a PACE program in
1927 Broward County to serve frail elders who reside in Broward
1928 County. The organization shall be exempt from chapter 641,
1929 Florida Statutes. The agency, in consultation with the
1930 Department of Elderly Affairs and subject to an appropriation,
1931 shall approve up to 150 initial enrollee slots in the Broward
1932 program established by the organization.
1933 Section 23. Effective upon this act becoming a law and for
1934 the 2011-2012 state fiscal year only, a public hospital located
1935 in trauma service area 2 which has local funds available for
1936 intergovernmental transfers that allow for exemptions from
1937 inpatient and outpatient reimbursement limitations may,
1938 notwithstanding s. 409.905(5)(c), Florida Statues, have its
1939 reimbursement rates adjusted after September 30 of the state
1940 fiscal year in which the rates take effect.
1941 Section 24. Except as otherwise expressly provided in this
1942 act and except for this section, which shall take effect upon
1943 this act becoming a law, this act shall take effect July 1,
1944 2012.