Senate Bill 0484
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Florida Senate - 1998 SB 484
By the Committee on Health Care
317-535A-98
1 A bill to be entitled
2 An act relating to public assistance; amending
3 s. 409.908, F.S.; requiring the agency to
4 establish a reimbursement methodology for
5 long-term-care services for Medicaid-eligible
6 nursing home residents; specifying requirements
7 for the methodology; providing legislative
8 intent; providing certain limitations on
9 payments made by the agency for Medicare
10 services rendered to Medicaid-eligible persons;
11 amending s. 409.912, F.S.; authorizing the
12 agency to include disease-management
13 initiatives in providing and monitoring
14 Medicaid services; authorizing the agency to
15 competitively negotiate home health services;
16 authorizing the agency to seek necessary
17 federal waivers that relate to the competitive
18 negotiation of such services; amending s.
19 409.9122, F.S.; specifying the departments that
20 are required to make certain information
21 available to Medicaid recipients; extending the
22 period during which a Medicaid recipient may
23 disenroll from a managed care plan or MediPass
24 provider; deleting authorization for the agency
25 to request a federal waiver from the
26 requirement that a Medicaid managed care plan
27 include a specified ratio of enrollees;
28 amending s. 409.910, F.S.; requiring that
29 certain third-party benefits received by a
30 Medicaid recipient be remitted within a
31 specified period; amending s. 414.28, F.S.;
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1 revising the order under which a claim may be
2 made against the estate of a recipient of
3 public assistance; amending s. 198.30, F.S.;
4 requiring that each circuit judge provide a
5 report of decedents to the Agency for Health
6 Care Administration; amending s. 733.212, F.S.;
7 requiring that a personal representative serve
8 a copy of the notice of administration on the
9 agency; providing an effective date.
10
11 Be It Enacted by the Legislature of the State of Florida:
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13 Section 1. Subsections (2) and (13) of section
14 409.908, Florida Statutes, are amended to read:
15 409.908 Reimbursement of Medicaid providers.--Subject
16 to specific appropriations, the agency shall reimburse
17 Medicaid providers, in accordance with state and federal law,
18 according to methodologies set forth in the rules of the
19 agency and in policy manuals and handbooks incorporated by
20 reference therein. These methodologies may include fee
21 schedules, reimbursement methods based on cost reporting,
22 negotiated fees, competitive bidding pursuant to s. 287.057,
23 and other mechanisms the agency considers efficient and
24 effective for purchasing services or goods on behalf of
25 recipients. Payment for Medicaid compensable services made on
26 behalf of Medicaid eligible persons is subject to the
27 availability of moneys and any limitations or directions
28 provided for in the General Appropriations Act or chapter 216.
29 Further, nothing in this section shall be construed to prevent
30 or limit the agency from adjusting fees, reimbursement rates,
31 lengths of stay, number of visits, or number of services, or
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1 making any other adjustments necessary to comply with the
2 availability of moneys and any limitations or directions
3 provided for in the General Appropriations Act, provided the
4 adjustment is consistent with legislative intent.
5 (2)(a)1. Reimbursement to nursing homes licensed under
6 part II of chapter 400 and state-owned-and-operated
7 intermediate care facilities for the developmentally disabled
8 licensed under chapter 393 must be made prospectively.
9 2. Unless otherwise limited or directed in the General
10 Appropriations Act, reimbursement to hospitals licensed under
11 part I of chapter 395 for the provision of swing-bed nursing
12 home services must be made on the basis of the average
13 statewide nursing home payment, and reimbursement to a
14 hospital licensed under part I of chapter 395 for the
15 provision of skilled nursing services must be made on the
16 basis of the average nursing home payment for those services
17 in the county in which the hospital is located. When a
18 hospital is located in a county that does not have any
19 community nursing homes, reimbursement must be determined by
20 averaging the nursing home payments, in counties that surround
21 the county in which the hospital is located. Reimbursement to
22 hospitals, including Medicaid payment of Medicare copayments,
23 for skilled nursing services shall be limited to 30 days,
24 unless a prior authorization has been obtained from the
25 agency. Medicaid reimbursement may be extended by the agency
26 beyond 30 days, and approval must be based upon verification
27 by the patient's physician that the patient requires
28 short-term rehabilitative and recuperative services only, in
29 which case an extension of no more than 15 days may be
30 approved. Reimbursement to a hospital licensed under part I of
31 chapter 395 for the temporary provision of skilled nursing
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1 services to nursing home residents who have been displaced as
2 the result of a natural disaster or other emergency may not
3 exceed the average county nursing home payment for those
4 services in the county in which the hospital is located and is
5 limited to the period of time which the agency considers
6 necessary for continued placement of the nursing home
7 residents in the hospital.
8 (b) Subject to any limitations or directions provided
9 for in the General Appropriations Act, the agency shall
10 establish and implement a Florida Title XIX Long-Term Care
11 Reimbursement Plan (Medicaid) for nursing home care in order
12 to provide care and services in conformance with the
13 applicable state and federal laws, rules, regulations, and
14 quality and safety standards and to ensure that individuals
15 eligible for medical assistance have reasonable geographic
16 access to such care. Effective not later than the rate-setting
17 period beginning January 1, 1999, the agency shall establish a
18 case-mix reimbursement methodology for the rate of payment for
19 long-term-care services for nursing home residents. The agency
20 shall compute a per diem rate for Medicaid residents, adjusted
21 for case mix, which is based on a resident classification
22 system that accounts for the relative resource utilization by
23 different types of residents and which is based on
24 level-of-care data and other appropriate data. In developing
25 the reimbursement methodology, the agency shall evaluate and
26 modify other aspects of the reimbursement plan as necessary to
27 improve the overall effectiveness of the plan with respect to
28 the costs of patient care, operating costs, and property
29 costs. The agency shall work with the Department of Elderly
30 Affairs, the Florida Health Care Association, and the Florida
31 Association of Homes for the Aging in developing the
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1 methodology. It is the intent of the Legislature that the
2 reimbursement plan achieve the goal of providing access to
3 health care for nursing home residents who require large
4 amounts of care while encouraging diversion services as an
5 alternative to nursing home care for residents who can be
6 served within the community. The agency shall base the
7 establishment of any maximum rate of payment, whether overall
8 or component, on the available moneys as provided for in the
9 General Appropriations Act. The agency may base the maximum
10 rate of payment on the results of scientifically valid
11 analysis and conclusions derived from objective statistical
12 data pertinent to the particular maximum rate of payment.
13 (13) Premiums, deductibles, and coinsurance for
14 Medicare services rendered to Medicaid-eligible Medicaid
15 eligible persons shall be reimbursed in accordance with fees
16 established by Title XVIII of the Social Security Act.
17 However, any payment by the agency for deductibles,
18 coinsurance, or copayments for a Medicare service rendered to
19 a Medicaid-eligible person may not exceed the amount that may
20 be made for such service under the Medicaid state plan.
21 Section 2. Subsection (13) of section 409.912, Florida
22 Statutes, is amended, and subsection (34) is added to that
23 section, to read:
24 409.912 Cost-effective purchasing of health care.--The
25 agency shall purchase goods and services for Medicaid
26 recipients in the most cost-effective manner consistent with
27 the delivery of quality medical care. The agency shall
28 maximize the use of prepaid per capita and prepaid aggregate
29 fixed-sum basis services when appropriate and other
30 alternative service delivery and reimbursement methodologies,
31 including competitive bidding pursuant to s. 287.057, designed
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1 to facilitate the cost-effective purchase of a case-managed
2 continuum of care. The agency shall also require providers to
3 minimize the exposure of recipients to the need for acute
4 inpatient, custodial, and other institutional care and the
5 inappropriate or unnecessary use of high-cost services.
6 (13) The agency shall identify health care utilization
7 and price patterns within the Medicaid program which that are
8 not cost-effective or medically appropriate and assess the
9 effectiveness of new or alternate methods of providing and
10 monitoring service, and may implement such methods as it
11 considers appropriate. Such methods may include
12 disease-management initiatives, an integrated and systematic
13 approach for managing the health care needs of recipients who
14 are at risk of or diagnosed with a specific disease by using
15 best practices, prevention strategies, clinical-practice
16 improvement, clinical interventions and protocols, outcomes
17 research, information technology, and other tools and
18 resources to reduce overall costs and improve measurable
19 outcomes.
20 (34) The agency may provide for cost-effective
21 purchasing of home health services through competitive
22 negotiation pursuant to s. 287.057. The agency may request
23 appropriate waivers from the federal Health Care Financing
24 Administration in order to competitively bid home health
25 services.
26 Section 3. Subsection (2) of section 409.9122, Florida
27 Statutes, is amended to read:
28 409.9122 Mandatory Medicaid managed care enrollment;
29 programs and procedures.--
30 (2)(a) The agency shall enroll in a managed care plan
31 or MediPass all Medicaid recipients, except those Medicaid
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1 recipients who are: in an institution; enrolled in the
2 Medicaid medically needy program; or eligible for both
3 Medicaid and Medicare. However, to the extent permitted by
4 federal law, the agency may enroll in a managed care plan or
5 MediPass a Medicaid recipient who is exempt from mandatory
6 managed care enrollment, provided that:
7 1. The recipient's decision to enroll in a managed
8 care plan or MediPass is voluntary;
9 2. If the recipient chooses to enroll in a managed
10 care plan, the agency has determined that the managed care
11 plan provides specific programs and services which address the
12 special health needs of the recipient; and
13 3. The agency receives any necessary waivers from the
14 federal Health Care Financing Administration.
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16 The agency shall develop rules to establish policies by which
17 exceptions to the mandatory managed care enrollment
18 requirement may be made on a case-by-case basis. The rules
19 shall include the specific criteria to be applied when making
20 a determination as to whether to exempt a recipient from
21 mandatory enrollment in a managed care plan or MediPass.
22 School districts participating in the certified school match
23 program pursuant to ss. 236.0812 and 409.908(21) shall be
24 reimbursed by Medicaid, subject to the limitations of s.
25 236.0812(1) and (2), for a Medicaid-eligible child
26 participating in the services as authorized in s. 236.0812, as
27 provided for in s. 409.9071, regardless of whether the child
28 is enrolled in MediPass or a managed care plan. Managed care
29 plans shall make a good faith effort to execute agreements
30 with school districts and county health departments regarding
31 the coordinated provision of services authorized under s.
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1 236.0812. To ensure continuity of care for Medicaid patients,
2 the agency and the Department of Education shall develop
3 procedures for ensuring that a student's managed care plan or
4 MediPass provider receives information relating to services
5 provided in accordance with ss. 236.0812 and 409.9071.
6 (b) A Medicaid recipient shall not be enrolled in or
7 assigned to a managed care plan or MediPass unless the managed
8 care plan or MediPass has complied with the quality-of-care
9 standards specified in paragraphs (3)(a) and (b),
10 respectively.
11 (c) Medicaid recipients shall have a choice of managed
12 care plans or MediPass. The Agency for Health Care
13 Administration, the Department of Health and Rehabilitative
14 Services, the Department of Children and Family Services, and
15 the Department of Elderly Affairs shall cooperate to ensure
16 that each Medicaid recipient receives clear and easily
17 understandable information that meets the following
18 requirements:
19 1. Explains the concept of managed care, including
20 MediPass.
21 2. Provides information on the comparative performance
22 of managed care plans and MediPass in the areas of quality,
23 credentialing, preventive health programs, network size and
24 availability, and patient satisfaction.
25 3. Explains where additional information on each
26 managed care plan and MediPass in the recipient's area can be
27 obtained.
28 4. Explains that recipients have the right to choose
29 their own managed care plans or MediPass. However, if a
30 recipient does not choose a managed care plan or MediPass, the
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1 agency will assign the recipient to a managed care plan or
2 MediPass according to the criteria specified in this section.
3 5. Explains the recipient's right to complain, file a
4 grievance, or change managed care plans or MediPass providers
5 if the recipient is not satisfied with the managed care plan
6 or MediPass.
7 (d) The agency shall develop a mechanism for providing
8 information to Medicaid recipients for the purpose of making a
9 managed care plan or MediPass selection. Examples of such
10 mechanisms may include, but not be limited to, interactive
11 information systems, mailings, and mass marketing materials.
12 Managed care plans and MediPass providers are prohibited from
13 providing inducements to Medicaid recipients to select their
14 plans or from prejudicing Medicaid recipients against other
15 managed care plans or MediPass providers.
16 (e) Prior to requesting a Medicaid recipient who is
17 subject to mandatory managed care enrollment to make a choice
18 between a managed care plan or MediPass, the agency shall
19 contact and provide choice counseling to the recipient.
20 Medicaid recipients who are already enrolled in a managed care
21 plan or MediPass shall be offered the opportunity to change
22 managed care plans or MediPass providers on a staggered basis,
23 as defined by the agency. All Medicaid recipients shall have
24 90 days in which to make a choice of managed care plans or
25 MediPass providers. Those Medicaid recipients who do not make
26 a choice shall be assigned to a managed care plan or MediPass
27 in accordance with paragraph (f). To facilitate continuity of
28 care, for a Medicaid recipient who is also a recipient of
29 Supplemental Security Income (SSI), prior to assigning the SSI
30 recipient to a managed care plan or MediPass, the agency shall
31 determine whether the SSI recipient has an ongoing
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1 relationship with a MediPass provider or managed care plan,
2 and if so, the agency shall assign the SSI recipient to that
3 MediPass provider or managed care plan. Those SSI recipients
4 who do not have such a provider relationship shall be assigned
5 to a managed care plan or MediPass provider in accordance with
6 paragraph (f).
7 (f) When a Medicaid recipient does not choose a
8 managed care plan or MediPass provider, the agency shall
9 assign the Medicaid recipient to a managed care plan or
10 MediPass provider. In the first period that assignment
11 begins, the assignments shall be divided equally between the
12 MediPass program and managed care plans. Thereafter,
13 assignment of Medicaid recipients who fail to make a choice
14 shall be based proportionally on the preferences of recipients
15 who have made a choice in the previous period. Such
16 proportions shall be revised at least quarterly to reflect an
17 update of the preferences of Medicaid recipients. When making
18 assignments, the agency shall take into account the following
19 criteria:
20 1. A managed care plan has sufficient network capacity
21 to meet the need of members.
22 2. The managed care plan or MediPass has previously
23 enrolled the recipient as a member, or one of the managed care
24 plan's primary care providers or MediPass providers has
25 previously provided health care to the recipient.
26 3. The agency has knowledge that the member has
27 previously expressed a preference for a particular managed
28 care plan or MediPass provider as indicated by Medicaid
29 fee-for-service claims data, but has failed to make a choice.
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1 4. The managed care plan's or MediPass primary care
2 providers are geographically accessible to the recipient's
3 residence.
4 (g) When more than one managed care plan or MediPass
5 provider meets the criteria specified in paragraph (f), the
6 agency shall make recipient assignments consecutively by
7 family unit.
8 (h) The agency may not engage in practices that are
9 designed to favor one managed care plan over another or that
10 are designed to influence Medicaid recipients to enroll in
11 MediPass rather than in a managed care plan or to enroll in a
12 managed care plan rather than in MediPass. This subsection
13 does not prohibit the agency from reporting on the performance
14 of MediPass or any managed care plan, as measured by
15 performance criteria developed by the agency.
16 (i) After a recipient has made a selection or has been
17 enrolled in a managed care plan or MediPass, the recipient
18 shall have 90 60 days in which to voluntarily disenroll and
19 select another managed care plan or MediPass provider. After
20 90 60 days, no further changes may be made except for cause.
21 Cause shall include, but not be limited to, poor quality of
22 care, lack of access to necessary specialty services, an
23 unreasonable delay or denial of service, or fraudulent
24 enrollment. The agency shall develop criteria for good cause
25 disenrollment for chronically ill and disabled populations who
26 are assigned to managed care plans if more appropriate care is
27 available through the MediPass program. The agency must make
28 a determination as to whether cause exists. However, the
29 agency may require a recipient to use the managed care plan's
30 or MediPass grievance process prior to the agency's
31 determination of cause, except in cases in which immediate
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1 risk of permanent damage to the recipient's health is alleged.
2 The grievance process, when utilized, must be completed in
3 time to permit the recipient to disenroll no later than the
4 first day of the second month after the month the
5 disenrollment request was made. If the managed care plan or
6 MediPass, as a result of the grievance process, approves an
7 enrollee's request to disenroll, the agency is not required to
8 make a determination in the case. The agency must make a
9 determination and take final action on a recipient's request
10 so that disenrollment occurs no later than the first day of
11 the second month after the month the request was made. If the
12 agency fails to act within the specified timeframe, the
13 recipient's request to disenroll is deemed to be approved as
14 of the date agency action was required. Recipients who
15 disagree with the agency's finding that cause does not exist
16 for disenrollment shall be advised of their right to pursue a
17 Medicaid fair hearing to dispute the agency's finding.
18 (j) The agency shall apply for a federal waiver from
19 the Health Care Financing Administration to lock eligible
20 Medicaid recipients into a managed care plan or MediPass for
21 12 months after an open enrollment period. After 12 months'
22 enrollment, a recipient may select another managed care plan
23 or MediPass provider. However, nothing shall prevent a
24 Medicaid recipient from changing primary care providers within
25 the managed care plan or MediPass program during the 12-month
26 period.
27 (k) In order to provide increased access to managed
28 care, the agency may request from the Health Care Financing
29 Administration a waiver of the regulation requiring health
30 maintenance organizations to have one commercial enrollee for
31 each three Medicaid enrollees.
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1 Section 4. Subsection (18) of section 409.910, Florida
2 Statutes, is amended to read:
3 409.910 Responsibility for payments on behalf of
4 Medicaid-eligible persons when other parties are liable.--
5 (18) A recipient or his or her legal representative or
6 any person representing, or acting as agent for, a recipient
7 or the recipient's legal representative, who has notice,
8 excluding notice charged solely by reason of the recording of
9 the lien pursuant to paragraph (6)(d), or who has actual
10 knowledge of the department's rights to third-party benefits
11 under this section, who receives any third-party benefit or
12 proceeds therefrom for a covered illness or injury, is
13 required either to pay the department the full amount of the
14 third-party benefits, but not in excess of the total medical
15 assistance provided by Medicaid within 30 days after
16 settlement, or to place the full amount of the third-party
17 benefits in an interest-bearing a trust account for the
18 benefit of the department pending judicial or administrative
19 determination of the department's right thereto. Proof that
20 any such person had notice or knowledge that the recipient had
21 received medical assistance from Medicaid, and that
22 third-party benefits or proceeds therefrom were in any way
23 related to a covered illness or injury for which Medicaid had
24 provided medical assistance, and that any such person
25 knowingly obtained possession or control of, or used,
26 third-party benefits or proceeds and failed either to pay the
27 department the full amount required by this section or to hold
28 the full amount of third-party benefits or proceeds in trust
29 pending judicial or administrative determination, unless
30 adequately explained, gives rise to an inference that such
31 person knowingly failed to credit the state or its agent for
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1 payments received from social security, insurance, or other
2 sources, pursuant to s. 414.39(4)(b), and acted with the
3 intent set forth in s. 812.014(1).
4 (a) The department is authorized to investigate and to
5 request appropriate officers or agencies of the state to
6 investigate suspected criminal violations or fraudulent
7 activity related to third-party benefits, including, without
8 limitation, ss. 409.325 and 812.014. Such requests may be
9 directed, without limitation, to the Medicaid Fraud Control
10 Unit of the Office of the Attorney General, or to any state
11 attorney. Pursuant to s. 409.913, the Attorney General has
12 primary responsibility to investigate and control Medicaid
13 fraud.
14 (b) In carrying out duties and responsibilities
15 related to Medicaid fraud control, the department may subpoena
16 witnesses or materials within or outside the state and,
17 through any duly designated employee, administer oaths and
18 affirmations and collect evidence for possible use in either
19 civil or criminal judicial proceedings.
20 (c) All information obtained and documents prepared
21 pursuant to an investigation of a Medicaid recipient, the
22 recipient's legal representative, or any other person relating
23 to an allegation of recipient fraud or theft is confidential
24 and exempt from s. 119.07(1):
25 1. Until such time as the department takes final
26 agency action;
27 2. Until such time as the Attorney General refers the
28 case for criminal prosecution;
29 3. Until such time as an indictment or criminal
30 information is filed by a state attorney in a criminal case;
31 or
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1 4. At all times if otherwise protected by law.
2 Section 5. Subsection (1) of section 414.28, Florida
3 Statutes, is amended to read:
4 414.28 Public assistance payments to constitute debt
5 of recipient.--
6 (1) CLAIMS.--The acceptance of public assistance
7 creates a debt of the person accepting assistance, which debt
8 is enforceable only after the death of the recipient. The
9 debt thereby created is enforceable only by claim filed
10 against the estate of the recipient after his or her death or
11 by suit to set aside a fraudulent conveyance, as defined in
12 subsection (3). After the death of the recipient and within
13 the time prescribed by law, the department may file a claim
14 against the estate of the recipient for the total amount of
15 public assistance paid to or for the benefit of such
16 recipient, reimbursement for which has not been made. Claims
17 so filed shall take priority as class 3 class 7 claims as
18 provided by s. 733.707(1)(g).
19 Section 6. Section 198.30, Florida Statutes, is
20 amended to read:
21 198.30 Circuit judge to furnish department with names
22 of decedents, etc.--Each circuit judge of this state shall, on
23 or before the 10th day of every month, notify the department
24 of the names of all decedents; the names and addresses of the
25 respective personal representatives, administrators, or
26 curators appointed; the amount of the bonds, if any, required
27 by the court; and the probable value of the estates, in all
28 estates of decedents whose wills have been probated or
29 propounded for probate before the circuit judge or upon which
30 letters testamentary or upon whose estates letters of
31 administration or curatorship have been sought or granted,
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1 during the preceding month; and such report shall contain any
2 other information which the circuit judge may have concerning
3 the estates of such decedents. In addition, a copy of this
4 report shall be provided to the Agency for Health Care
5 Administration. A circuit judge shall also furnish forthwith
6 such further information, from the records and files of the
7 circuit court in regard to such estates, as the department may
8 from time to time require.
9 Section 7. Subsection (3) of section 733.212, Florida
10 Statutes, is amended to read:
11 733.212 Notice of administration; filing of objections
12 and claims.--
13 (3) The personal representative shall serve a copy of
14 the notice on the following persons who are known to the
15 personal representative:
16 (a) The decedent's surviving spouse;
17 (b) Beneficiaries; and
18 (c) The trustee of any trust described in s.
19 733.707(3), of which the decedent was grantor; and
20 (d) The Agency for Health Care Administration
21
22 in the manner provided for service of formal notice, unless
23 served under s. 733.2123. The personal representative may
24 similarly serve a copy of the notice on any devisees under a
25 known prior will or heirs.
26 Section 8. This act shall take effect July 1, 1998.
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2 SENATE SUMMARY
3 Requires that the Agency for Health Care Administration
establish a methodology for reimbursing providers under
4 the Medicaid program. Provides certain limitations on the
amount of payment that may be made for a Medicare service
5 on behalf of a person who is also eligible for Medicaid.
Authorizes the agency to competitively negotiate the
6 purchase of home health services for Medicaid recipients.
Provides that a Medicaid recipient has 90 days rather
7 than 60 days within which to select another managed care
plan or MediPass provider after voluntarily disenrolling
8 from a managed care plan or MediPass. Requires that
third-party benefits received by a Medicaid recipient
9 must be remitted to the agency within 30 days after
settlement. Provides for public assistance payments to
10 take priority in recovery against the estate of a
deceased person as a class 3 claim rather than as a class
11 7 claim. Requires circuit judges and personal
representatives to notify the Agency for Health Care
12 Administration on the administration of estates. (See
bill for details.)
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