HB 1525CS

CHAMBER ACTION



1The Health Care Appropriations Committee recommends the
2following:
3
4     Council/Committee Substitute
5     Remove the entire bill and insert:
6
A bill to be entitled
7An act relating to elderly affairs; amending s. 430.205,
8F.S.; deleting provisions relating to implementation plans
9to integrate certain functions of the Agency for Health
10Care Administration; providing for development of uniform
11case management standards within the Aged and Disabled
12Adult Medicaid waiver program; authorizing, rather than
13requiring, coordination of acute and chronic medical
14service between the agency and the Department of Elderly
15Affairs to be included in the capitated rate for case
16management services; requiring the agency to consult with
17the department before adopting rules relating to
18reimbursement of providers and case management standards;
19revising provisions relating to certain reimbursement
20rates; deleting obsolete provisions; providing that
21evaluation of a specified pilot project relating to elder
22care is subject to an appropriation; amending s. 430.7031,
23F.S.; deleting provision that requires the department and
24agency to review the case files of a specified percentage
25of Medicaid nursing home residents annually for the
26purpose of determining whether the residents are able to
27move to community placements; amending s. 430.705, F.S.;
28revising eligibility requirements relating to financial
29solvency for entities that provide services under the
30long-term care community diversion pilot projects;
31providing definitions; authorizing the department to make
32rules; amending s. 430.707, F.S.; requiring project
33providers to report quarterly to the department regarding
34compliance with financial requirements; providing an
35effective date.
36
37Be It Enacted by the Legislature of the State of Florida:
38
39     Section 1.  Paragraphs (b) and (c) of subsection (6) of
40section 430.205, Florida Statutes, are amended to read:
41     430.205  Community care service system.--
42     (6)  Notwithstanding other requirements of this chapter,
43the Department of Elderly Affairs and the Agency for Health Care
44Administration shall develop an integrated long-term-care
45delivery system.
46     (b)  During the 2004-2005 state fiscal year:
47     1.  The agency, in consultation with the department, shall
48develop an implementation plan to integrate the Frail Elder
49Option into the Nursing Home Diversion pilot project and each
50program's funds into one capitated program serving the aged.
51Beginning July 1, 2004, the agency may not enroll additional
52individuals in the Frail Elder Option.
53     2.  The agency, in consultation with the department, shall
54integrate the Aged and Disabled Adult Medicaid waiver program
55and the Assisted Living for the Elderly Medicaid waiver program
56and each program's funds into one fee-for-service Medicaid
57waiver program serving the aged and disabled. Once the programs
58are integrated, funding to provide care in assisted-living
59facilities under the new waiver may not be less than the amount
60appropriated in the 2003-2004 fiscal year for the Assisted
61Living for the Elderly Medicaid waiver.
62     a.  The agency shall seek federal waivers necessary to
63integrate these waiver programs.
64     b.  The agency and the department shall reimburse providers
65for case management services on a capitated basis and develop
66uniform standards for case management within the Aged and
67Disabled Adult in this fee-for-service Medicaid waiver program.
68The coordination of acute and chronic medical services for
69individuals may shall be included in the capitated rate for case
70management services.
71     c.  The agency, in consultation with and the department,
72shall adopt any rules necessary to comply with or administer
73these requirements, effect and implement interagency agreements
74between the department and the agency, and comply with federal
75requirements.
76     2.3.  The Legislature finds that preservation of the
77historic aging network of lead agencies is essential to the
78well-being of Florida's elderly population. The Legislature
79finds that the Florida aging network constitutes a system of
80essential community providers which should be nurtured and
81assisted to develop systems of operations which allow the
82gradual assumption of responsibility and financial risk for
83managing a client through the entire continuum of long-term care
84services within the area the lead agency is currently serving,
85and which allow lead agency providers to develop managed systems
86of service delivery. The department, in consultation with the
87agency, shall therefore:
88     a.  Develop a demonstration project in which existing
89community care for the elderly lead agencies are assisted in
90transferring their business model and the service delivery
91system within their current community care service area to
92enable assumption, over a period of time, of full risk as a
93community diversion pilot project contractor providing long-term
94care services in the areas of operation. The department, in
95consultation with the agency and the Department of Children and
96Family Services, shall develop an implementation plan for no
97more than three lead agencies by October 31, 2004.
98     b.  In the demonstration area, a community care for the
99elderly lead agency shall be initially reimbursed on a prepaid
100or fixed-sum basis for all home and community-based services
101provided under the long-term care community diversion pilot
102project newly integrated fee-for-service Medicaid waiver. By the
103end of the third year of operation, the lead agency shall be
104reimbursed on a prepaid or fixed-sum basis for demonstration
105project shall include all services under the long-term care
106community diversion pilot project.
107     c.  During the first year of operation, the department, in
108consultation with the agency, may place providers at risk to
109provide nursing home services for the enrolled individuals who
110are participating in the demonstration project. During the 3-
111year development period, the agency and the department may limit
112the level of custodial nursing home risk that the administering
113entities assume. Under risk-sharing arrangements, during the
114first 3 years of operation, the department, in consultation with
115the agency, may reimburse the administering entity for the cost
116of providing nursing home care for Medicaid-eligible
117participants who have been permanently placed and remain in a
118nursing home for more than 1 year, or may disenroll such
119participants from the demonstration project.
120     d.  The agency, in consultation with the department, shall
121develop reimbursement rates based on the federally approved,
122actuarially certified rate methodology for the long-term care
123community diversion pilot project historical cost experience of
124the state in providing long-term care and nursing home services
125under Medicaid waiver programs to the population 65 years of age
126and older in the area served by the pilot project.
127     e.  The department, in consultation with the agency, shall
128ensure that the entity or entities receiving prepaid or fixed-
129sum reimbursement are assisted in developing internal management
130and financial control systems necessary to manage the risk
131associated with providing services under a prepaid or fixed-sum
132rate system.
133     f.  If the department and the agency share risk of
134custodial nursing home placement, payment rates during the first
1353 years of operation shall be set at not more than 100 percent
136of the costs to the agency and the department of providing
137equivalent services to the population within the area of the
138pilot project for the year prior to the year in which the pilot
139project is implemented, adjusted forward to account for
140inflation and policy changes in the Medicaid program. In
141subsequent years, the rate shall be negotiated, based on the
142cost experience of the entity in providing contracted services,
143but may not exceed 95 percent of the amount that would have been
144paid in the pilot project area absent the prepaid or fixed sum
145reimbursement methodology.
146     g.  Community care for the elderly lead agencies that have
147operated for a period of at least 20 years, which provide
148Medicare-certified services to elders, and which have developed
149a system of service provision by health care volunteers shall be
150given priority in the selection of the pilot project if they
151meet the minimum requirements specified in the competitive
152procurement.
153     h.  The agency and the department shall adopt rules
154necessary to comply with or administer these requirements,
155effect and implement interagency agreements between the agency
156and the department, and comply with federal requirements.
157     i.  The department and the agency shall seek federal
158waivers necessary to implement the requirements of this section.
159     j.  The Department of Elderly Affairs shall conduct or
160contract for an evaluation of the demonstration project. The
161department shall submit the evaluation to the Governor and the
162Legislature by January 1, 2007. The evaluation must address the
163effectiveness of the pilot project in providing a comprehensive
164system of appropriate and high-quality, long-term care services
165to elders in the least restrictive setting and make
166recommendations on expanding the project to other parts of the
167state. This subparagraph is subject to an appropriation by the
168Legislature.
169     4.  The department, in consultation with the agency, shall
170study the integration of the database systems for the
171Comprehensive Assessment and Review of Long-Term Care (CARES)
172program and the Client Information and Referral Tracking System
173(CIRTS) and develop a plan for database integration. The
174department shall submit the plan to the Governor, the President
175of the Senate, and the Speaker of the House of Representatives
176by December 31, 2004.
177     3.5.  The agency, in consultation with the department,
178shall work with the fiscal agent for the Medicaid program to
179develop a service utilization reporting system that operates
180through the fiscal agent for the capitated plans.
181     (c)  During the 2005-2006 state fiscal year:
182     1.  The agency, in consultation with the department, shall
183monitor the newly integrated programs and report on the progress
184of those programs to the Governor, the President of the Senate,
185and the Speaker of the House of Representatives by June 30,
1862006. The report must include an initial evaluation of the
187programs in their early stages following the evaluation plan
188developed by the department, in consultation with the agency and
189the selected contractor.
190     2.  The department shall monitor the pilot projects for
191resource centers on aging and report on the progress of those
192projects to the Governor, the President of the Senate, and the
193Speaker of the House of Representatives by June 30, 2006. The
194report must include an evaluation of the implementation process
195in its early stages.
196     3.  The department, in consultation with the agency, shall
197integrate the database systems for the Comprehensive Assessment
198and Review for of Long-Term Care Services (CARES) program and
199the Client Information and Referral Tracking System (CIRTS) into
200a single operating assessment information system by June 30,
2012006.
202     4.  The agency, in consultation with the department, shall
203integrate the Frail Elder Option into the Nursing Home Diversion
204pilot project and each program's funds into one capitated
205program serving the aged.
206     a.  The department, in consultation with the agency, shall
207develop uniform standards for case management in this newly
208integrated capitated system.
209     b.  The agency shall seek federal waivers necessary to
210integrate these programs.
211     c.  The department, in consultation with the agency, shall
212adopt any rules necessary to comply with or administer these
213requirements, effect and implement interagency agreements
214between the department and the agency, and comply with federal
215requirements.
216     Section 2.  Subsection (2) of section 430.7031, Florida
217Statutes, is amended to read:
218     430.7031  Nursing home transition program.--The department
219and the Agency for Health Care Administration:
220     (2)  Shall collaboratively work to identify nursing home
221residents who are able to move to community placements, and to
222provide case management and supportive services to such
223individuals while they are in nursing homes to assist such
224individuals to move in moving to less expensive and less
225restrictive settings. CARES program staff shall annually review
226at least 20 percent of the case files for nursing home residents
227who are Medicaid recipients to determine which nursing home
228residents are able to move to community placements.
229     Section 3.  Subsection (2) of section 430.705, Florida
230Statutes, is amended, and subsection (10) is added to said
231section, to read:
232     430.705  Implementation of the long-term care community
233diversion pilot projects.--
234     (2)(a)  The department shall select projects whose design
235and providers demonstrate capacity to maximize the placement of
236participants in the least restrictive appropriate care setting.
237     (b)  The department shall select providers that meet all of
238the following criteria. Providers shall:
239     1.  Have a plan administrator who is dedicated to the
240diversion pilot project and project staff who perform the
241necessary project administrative functions, including data
242collection, reporting, and analysis. The department shall select
243providers that:
244     2.  Demonstrate the ability to provide program enrollees
245with a choice of care provider by contracting with multiple
246providers that provide the same type of service.
247     3.  Demonstrate through performance or other documented
248means the capacity for prompt payment of claims as specified
249under s. 641.3155.
250     4.  Maintain an insolvency protection account in a bank or
251savings and loan association located in the state with a balance
252of at least $100,000 into which monthly deposits equal to at
253least 5 percent of premiums received under the project are made
254until the balance equals 2 percent of the total contract amount.
255The account shall be established with such terms as to ensure
256that funds may only be withdrawn with the signature approval of
257designated department representatives.
258     5.  Maintain a surplus of at least $1.5 million as
259determined by the department. Each applicant and each provider
260shall furnish to the department initial and annual unqualified
261audited financial statements prepared by a certified public
262accountant that expressly confirm that the applicant or provider
263satisfies this surplus requirement. The department may approve a
264waiver of compliance with the surplus requirement for an
265existing diversion provider. The department's approval of this
266waiver must be contingent on the provider demonstrating proof to
267the department that the entity has posted and maintains a $1.5
268million performance bond, which is written by an insurer
269licensed to transact insurance in this state, in lieu of meeting
270the surplus requirement. The department may not approve a waiver
271of compliance with the surplus requirement that extends beyond
272June 30, 2006. As used in this subparagraph, the term:
273     a.  "Existing diversion provider" means an entity that is
274approved by the department on or before June 30, 2005, to
275provide services to consumers through any long-term care
276community diversion pilot project authorized under ss. 430.701-
277430.709.
278     b.  "Surplus" has the same meaning as in s. 641.19(19).
279     (c)  The requirements of paragraph (b) do not apply to
280entities selected to provide services to the pilot projects
281authorized under s. 430.205(6)(b)2. The department, in
282consultation with the agency, shall develop by rule minimum
283financial solvency and reporting standards for these providers
284that are reflective of the amount of risk the provider will
285assume under the pilot project. The standards adopted by rule
286shall ensure safety for the pilot project enrollees and
287financial protection for the state in the event of a provider's
288inability to continue providing services to the project.
289     (a)  Are determined by the Department of Financial Services
290to:
291     1.  Meet surplus requirements specified in s. 641.225;
292     2.  Demonstrate the ability to comply with the standards
293for financial solvency specified in s. 641.285;
294     3.  Demonstrate the ability to provide for the prompt
295payment of claims as specified in s. 641.3155; and
296     4.  Demonstrate the ability to provide technology with the
297capability for data collection that meets the security
298requirements of the federal Health Insurance Portability and
299Accountability Act of 1996, 42 C.F.R. ss. 160 and 164.
300     (b)  Demonstrate the ability to contract with multiple
301providers that provide the same type of service.
302     (10)  The department, in consultation with the agency, is
303authorized to adopt any rules necessary to implement and
304administer the long-term care community diversion pilot projects
305authorized under ss. 430.701-430.709.
306     Section 4.  Subsection (1) of section 430.707, Florida
307Statutes, is amended to read:
308     430.707  Contracts.--
309     (1)  The department, in consultation with the agency, shall
310select and contract with managed care organizations and, on a
311prepaid basis, with other qualified providers as defined in s.
312430.703(7) to provide long-term care within community diversion
313pilot project areas. All providers The agency shall evaluate and
314report quarterly to the department regarding the entity's
315compliance by other qualified providers with all the financial
316and quality assurance requirements of the contract.
317     Section 5.  This act shall take effect upon becoming a law.


CODING: Words stricken are deletions; words underlined are additions.