HB 1525

1	A bill to be entitled
2	An act relating to elderly affairs; amending s. 430.205,
3	F.S.; deleting provisions relating to implementation plans
4	to integrate certain functions of the Agency for Health
5	Care Administration; providing for development of uniform
6	case management standards within the Aged and Disabled
7	Adult Medicaid waiver program; authorizing, rather than
8	requiring, coordination of acute and chronic medical
9	service between the agency and the Department of Elderly
10	Affairs to be included in the capitated rate for case
11	management services; requiring the agency to consult with
12	the department before adopting rules relating to
13	reimbursement of providers and case management standards;
14	revising provisions relating to certain reimbursement
15	rates; deleting obsolete provisions; providing that
16	evaluation of a specified pilot project relating to elder
17	care is subject to an appropriation; amending s. 430.7031,
18	F.S.; deleting provision that requires the department and
19	agency to review the case files of a specified percentage
20	of Medicaid nursing home residents annually for the
21	purpose of determining whether the residents are able to
22	move to community placements; amending s. 430.705, F.S.;
23	revising eligibility requirements relating to financial
24	solvency for entities that provide services under the
25	long-term care community diversion pilot projects;
26	providing definitions; authorizing the department to make
27	rules; amending s. 430.707, F.S.; requiring project
28	providers to report quarterly to the department regarding
29	compliance with financial requirements; providing an
30	effective date.
31
32	Be It Enacted by the Legislature of the State of Florida:
33
34	Section 1.  Paragraphs (b) and (c) of subsection (6) of
35	section 430.205, Florida Statutes, are amended to read:
36	430.205  Community care service system.--
37	(6)  Notwithstanding other requirements of this chapter,
38	the Department of Elderly Affairs and the Agency for Health Care
39	Administration shall develop an integrated long-term-care
40	delivery system.
41	(b)  During the 2004-2005 state fiscal year:
42	1.  The agency, in consultation with the department, shall
43	develop an implementation plan to integrate the Frail Elder
44	Option into the Nursing Home Diversion pilot project and each
45	program's funds into one capitated program serving the aged.
46	Beginning July 1, 2004, the agency may not enroll additional
47	individuals in the Frail Elder Option.
48	2.  The agency, in consultation with the department, shall
49	integrate the Aged and Disabled Adult Medicaid waiver program
50	and the Assisted Living for the Elderly Medicaid waiver program
51	and each program's funds into one fee-for-service Medicaid
52	waiver program serving the aged and disabled. Once the programs
53	are integrated, funding to provide care in assisted-living
54	facilities under the new waiver may not be less than the amount
55	appropriated in the 2003-2004 fiscal year for the Assisted
56	Living for the Elderly Medicaid waiver.
57	a.  The agency shall seek federal waivers necessary to
58	integrate these waiver programs.
59	b.  The agency and the department shall reimburse providers
60	for case management services on a capitated basis and develop
61	uniform standards for case management within the Aged and
62	Disabled Adult in this fee-for-service Medicaid waiver program.
63	The coordination of acute and chronic medical services for
64	individuals may shall be included in the capitated rate for case
65	management services.
66	c.  The agency, in consultation with and the department,
67	shall adopt any rules necessary to comply with or administer
68	these requirements, effect and implement interagency agreements
69	between the department and the agency, and comply with federal
70	requirements.
71	2.3.  The Legislature finds that preservation of the
72	historic aging network of lead agencies is essential to the
73	well-being of Florida's elderly population. The Legislature
74	finds that the Florida aging network constitutes a system of
75	essential community providers which should be nurtured and
76	assisted to develop systems of operations which allow the
77	gradual assumption of responsibility and financial risk for
78	managing a client through the entire continuum of long-term care
79	services within the area the lead agency is currently serving,
80	and which allow lead agency providers to develop managed systems
81	of service delivery. The department, in consultation with the
82	agency, shall therefore:
83	a.  Develop a demonstration project in which existing
84	community care for the elderly lead agencies are assisted in
85	transferring their business model and the service delivery
86	system within their current community care service area to
87	enable assumption, over a period of time, of full risk as a
88	community diversion pilot project contractor providing long-term
89	care services in the areas of operation. The department, in
90	consultation with the agency and the Department of Children and
91	Family Services, shall develop an implementation plan for no
92	more than three lead agencies by October 31, 2004.
93	b.  In the demonstration area, a community care for the
94	elderly lead agency shall be initially reimbursed on a prepaid
95	or fixed-sum basis for all home and community-based services
96	provided under the long-term care community diversion pilot
97	project newly integrated fee-for-service Medicaid waiver. By the
98	end of the third year of operation, the lead agency shall be
99	reimbursed on a prepaid or fixed-sum basis for demonstration
100	project shall include all services under the long-term care
101	community diversion pilot project.
102	c.  During the first year of operation, the department, in
103	consultation with the agency, may place providers at risk to
104	provide nursing home services for the enrolled individuals who
105	are participating in the demonstration project. During the 3-
106	year development period, the agency and the department may limit
107	the level of custodial nursing home risk that the administering
108	entities assume. Under risk-sharing arrangements, during the
109	first 3 years of operation, the department, in consultation with
110	the agency, may reimburse the administering entity for the cost
111	of providing nursing home care for Medicaid-eligible
112	participants who have been permanently placed and remain in a
113	nursing home for more than 1 year, or may disenroll such
114	participants from the demonstration project.
115	d.  The agency, in consultation with the department, shall
116	develop reimbursement rates based on the federally approved,
117	actuarially certified rate methodology for the long-term care
118	community diversion pilot project historical cost experience of
119	the state in providing long-term care and nursing home services
120	under Medicaid waiver programs to the population 65 years of age
121	and older in the area served by the pilot project.
122	e.  The department, in consultation with the agency, shall
123	ensure that the entity or entities receiving prepaid or fixed-
124	sum reimbursement are assisted in developing internal management
125	and financial control systems necessary to manage the risk
126	associated with providing services under a prepaid or fixed-sum
127	rate system.
128	f.  If the department and the agency share risk of
129	custodial nursing home placement, payment rates during the first
130	3 years of operation shall be set at not more than 100 percent
131	of the costs to the agency and the department of providing
132	equivalent services to the population within the area of the
133	pilot project for the year prior to the year in which the pilot
134	project is implemented, adjusted forward to account for
135	inflation and policy changes in the Medicaid program. In
136	subsequent years, the rate shall be negotiated, based on the
137	cost experience of the entity in providing contracted services,
138	but may not exceed 95 percent of the amount that would have been
139	paid in the pilot project area absent the prepaid or fixed sum
140	reimbursement methodology.
141	g.  Community care for the elderly lead agencies that have
142	operated for a period of at least 20 years, which provide
143	Medicare-certified services to elders, and which have developed
144	a system of service provision by health care volunteers shall be
145	given priority in the selection of the pilot project if they
146	meet the minimum requirements specified in the competitive
147	procurement.
148	h.  The agency and the department shall adopt rules
149	necessary to comply with or administer these requirements,
150	effect and implement interagency agreements between the agency
151	and the department, and comply with federal requirements.
152	i.  The department and the agency shall seek federal
153	waivers necessary to implement the requirements of this section.
154	j.  The Department of Elderly Affairs shall conduct or
155	contract for an evaluation of the demonstration project. The
156	department shall submit the evaluation to the Governor and the
157	Legislature by January 1, 2007. The evaluation must address the
158	effectiveness of the pilot project in providing a comprehensive
159	system of appropriate and high-quality, long-term care services
160	to elders in the least restrictive setting and make
161	recommendations on expanding the project to other parts of the
162	state. This subparagraph is subject to an appropriation by the
163	Legislature.
164	4.  The department, in consultation with the agency, shall
165	study the integration of the database systems for the
166	Comprehensive Assessment and Review of Long-Term Care (CARES)
167	program and the Client Information and Referral Tracking System
168	(CIRTS) and develop a plan for database integration. The
169	department shall submit the plan to the Governor, the President
170	of the Senate, and the Speaker of the House of Representatives
171	by December 31, 2004.
172	3.5.  The agency, in consultation with the department,
173	shall work with the fiscal agent for the Medicaid program to
174	develop a service utilization reporting system that operates
175	through the fiscal agent for the capitated plans.
176	(c)  During the 2005-2006 state fiscal year:
177	1.  The agency, in consultation with the department, shall
178	monitor the newly integrated programs and report on the progress
179	of those programs to the Governor, the President of the Senate,
180	and the Speaker of the House of Representatives by June 30,
181	2006. The report must include an initial evaluation of the
182	programs in their early stages following the evaluation plan
183	developed by the department, in consultation with the agency and
184	the selected contractor.
185	2.  The department shall monitor the pilot projects for
186	resource centers on aging and report on the progress of those
187	projects to the Governor, the President of the Senate, and the
188	Speaker of the House of Representatives by June 30, 2006. The
189	report must include an evaluation of the implementation process
190	in its early stages.
191	3.  The department, in consultation with the agency, shall
192	integrate the database systems for the Comprehensive Assessment
193	and Review for of Long-Term Care Services (CARES) program and
194	the Client Information and Referral Tracking System (CIRTS) into
195	a single operating assessment information system by June 30,
196	2006.
197	4.  The agency, in consultation with the department, shall
198	integrate the Frail Elder Option into the Nursing Home Diversion
199	pilot project and each program's funds into one capitated
200	program serving the aged.
201	a.  The department, in consultation with the agency, shall
202	develop uniform standards for case management in this newly
203	integrated capitated system.
204	b.  The agency shall seek federal waivers necessary to
205	integrate these programs.
206	c.  The department, in consultation with the agency, shall
207	adopt any rules necessary to comply with or administer these
208	requirements, effect and implement interagency agreements
209	between the department and the agency, and comply with federal
210	requirements.
211	Section 2.  Subsection (2) of section 430.7031, Florida
212	Statutes, is amended to read:
213	430.7031  Nursing home transition program.--The department
214	and the Agency for Health Care Administration:
215	(2)  Shall collaboratively work to identify nursing home
216	residents who are able to move to community placements, and to
217	provide case management and supportive services to such
218	individuals while they are in nursing homes to assist such
219	individuals to move in moving to less expensive and less
220	restrictive settings. CARES program staff shall annually review
221	at least 20 percent of the case files for nursing home residents
222	who are Medicaid recipients to determine which nursing home
223	residents are able to move to community placements.
224	Section 3.  Subsection (2) of section 430.705, Florida
225	Statutes, is amended, and subsection (10) is added to said
226	section, to read:
227	430.705  Implementation of the long-term care community
228	diversion pilot projects.--
229	(2)(a)  The department shall select projects whose design
230	and providers demonstrate capacity to maximize the placement of
231	participants in the least restrictive appropriate care setting.
232	(b)  The department shall select providers that meet all of
233	the following criteria. Providers shall:
234	1.  Have a plan administrator who is dedicated to the
235	diversion pilot project and project staff who perform the
236	necessary project administrative functions, including data
237	collection, reporting, and analysis. The department shall select
238	providers that:
239	2.  Demonstrate the ability to provide program enrollees
240	with a choice of care provider by contracting with multiple
241	providers that provide the same type of service.
242	3.  Demonstrate through performance or other documented
243	means the capacity for prompt payment of claims as specified
244	under s. 641.3155.
245	4.  Maintain an insolvency protection account in a bank or
246	savings and loan association located in the state with a balance
247	of at least $100,000 into which monthly deposits equal to at
248	least 5 percent of premiums received under the project are made
249	until the balance equals 2 percent of the total contract amount.
250	The account shall be established with such terms as to ensure
251	that funds may only be withdrawn with the signature approval of
252	designated department representatives.
253	5.  Maintain a surplus of at least $1.5 million as
254	determined by the department. Each applicant and each provider
255	shall furnish to the department initial and annual unqualified
256	audited financial statements prepared by a certified public
257	accountant that expressly confirm that the applicant or provider
258	satisfies this surplus requirement. The department may approve a
259	waiver of compliance with the surplus requirement for an
260	existing diversion provider. The department's approval of this
261	waiver must be contingent on the provider demonstrating proof to
262	the department that the entity has posted and maintains a $1.5
263	million performance bond, which is written by an insurer
264	licensed to transact insurance in this state, in lieu of meeting
265	the surplus requirement. The department may not approve a waiver
266	of compliance with the surplus requirement that extends beyond
267	June 30, 2006. As used in this subparagraph, the term:
268	a.  "Existing diversion provider" means an entity that is
269	approved by the department on or before June 30, 2005, to
270	provide services to consumers through any long-term care
271	community diversion pilot project authorized under ss. 430.701-
272	430.709.
273	b.  "Surplus" has the same meaning as in s. 641.19(19).
274	(c)  The requirements of paragraph (b) do not apply to
275	entities selected to provide services to the pilot projects
276	authorized under s. 430.205(6)(b)2. The department, in
277	consultation with the agency, shall develop by rule minimum
278	financial solvency and reporting standards for these providers
279	that are reflective of the amount of risk the provider will
280	assume under the pilot project. The standards adopted by rule
281	shall ensure safety for the pilot project enrollees and
282	financial protection for the state in the event of a provider's
283	inability to continue providing services to the project.
284	(a)  Are determined by the Department of Financial Services
285	to:
286	1.  Meet surplus requirements specified in s. 641.225;
287	2.  Demonstrate the ability to comply with the standards
288	for financial solvency specified in s. 641.285;
289	3.  Demonstrate the ability to provide for the prompt
290	payment of claims as specified in s. 641.3155; and
291	4.  Demonstrate the ability to provide technology with the
292	capability for data collection that meets the security
293	requirements of the federal Health Insurance Portability and
294	Accountability Act of 1996, 42 C.F.R. ss. 160 and 164.
295	(b)  Demonstrate the ability to contract with multiple
296	providers that provide the same type of service.
297	(10)  The department, in consultation with the agency, is
298	authorized to adopt any rules necessary to implement and
299	administer the long-term care community diversion pilot projects
300	authorized under ss. 430.701-430.709.
301	Section 4.  Subsection (1) of section 430.707, Florida
302	Statutes, is amended to read:
303	430.707  Contracts.--
304	(1)  The department, in consultation with the agency, shall
305	select and contract with managed care organizations and, on a
306	prepaid basis, with other qualified providers as defined in s.
307	430.703(7) to provide long-term care within community diversion
308	pilot project areas. All providers The agency shall evaluate and
309	report quarterly to the department regarding the entity's
310	compliance by other qualified providers with all the financial
311	and quality assurance requirements of the contract.
312	Section 5.  This act shall take effect upon becoming a law.

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