HB 1869

1	A bill to be entitled
2	An act relating to Medicaid; providing for the Agency for
3	Health Care Administration to expand certain pilot and
4	demonstration project waivers under certain conditions;
5	providing for integration of state funding to persons who
6	are dually eligible for Medicare and Medicaid; requiring
7	the agency to provide a choice of managed care plans to
8	recipients; providing requirements for managed care plans;
9	permitting the agency to withhold certain funding
10	contingent upon the performance of a plan; requiring the
11	plan to rebate certain profits to the agency; authorizing
12	the agency to limit the number of enrollees in a plan
13	under certain circumstances; providing for certain
14	services in demonstration areas; providing for imposition
15	of liquidated damages; permitting a modification of
16	certificate-of-need conditions to nursing homes under
17	certain circumstances; requiring integration of Medicare
18	and Medicaid services; providing legislative intent;
19	providing for awarding of funds for managed care delivery,
20	contingent upon an appropriation; granting rulemaking
21	authority to the agency; requiring legislative authority
22	to implement the waiver; providing for future review and
23	repeal of the act; providing an effective date.
24
25	Be It Enacted by the Legislature of the State of Florida:
26
27	Section 1.  Managed care delivery systems.--
28	(1)  INCLUSION OF MANAGED CARE FOR DUALLY ELIGIBLE
29	PERSONS.--
30	(a)  Contingent upon federal approval, the Agency for
31	Health Care Administration may revise or apply for a waiver
32	pursuant to s. 1915 of the Social Security Act or apply for a
33	demonstration project waiver pursuant to s. 1115 of the Social
34	Security Act to reform Florida's Medicaid program in order to
35	integrate all state funding for Medicaid services to persons who
36	are dually eligible for Medicare and Medicaid. Rates shall be
37	developed in accordance with 42 C.F.R. s. 438.6, certified by an
38	actuary, and submitted for approval to the Centers for Medicare
39	and Medicaid Services. The funds to be integrated shall include:
40	1.  All Medicaid home-based and community-based waiver
41	services funds.
42	2.  All funds for all Medicaid services, including Medicaid
43	nursing home services.
44	3.  Funds paid for Medicare premiums, coinsurance, and
45	deductibles for persons dually eligible for Medicaid and
46	Medicare, for which the state is responsible, but not to exceed
47	federal limits of liability specified in the state plan.
48	(b)  When the agency integrates the funding for Medicaid
49	services for dually eligible recipients into a managed care
50	delivery system under paragraph (a) in any area of the state,
51	the agency shall provide to dually eligible recipients a choice
52	of plans which shall include:
53	1.  An entity licensed under chapter 627 or chapter 641,
54	Florida Statutes; or
55	2.  A state-certified provider, including entities eligible
56	to participate in the nursing home diversion program, other
57	qualified providers as defined in s. 430.703(7), Florida
58	Statutes, and community care for the elderly lead agencies that
59	meet the requirements set forth in s. 430.705(2)(a) and (b),
60	Florida Statutes, as determined by the Department of Financial
61	Services.
62	(c)  The agency shall select managed care plans through
63	competitive procurements in order to ensure a choice of no more
64	than three plans for Medicaid eligible recipients in each of the
65	11 agency areas in the state.
66	(d)  When the agency integrates the funding for Medicaid
67	nursing home and community-based care services into a managed
68	care delivery system, the agency shall ensure that a plan, in
69	addition to other requirements:
70	1.  Allows an enrollee to select any provider with whom the
71	plan has a contract.
72	2.  Makes a good faith effort to develop contracts with
73	qualified providers currently under contract with the Department
74	of Elderly Affairs, area agencies on aging, or community care
75	for the elderly lead agencies.
76	3.  Secures subcontracts with providers of nursing home and
77	community-based long-term care services sufficient to ensure
78	access to and choice of providers.
79	4.  Develops and uses a service provider qualification
80	system that describes the quality-of-care standards that
81	providers of medical, health, and long-term care services must
82	meet in order to obtain a contract from the plan and that do not
83	duplicate other requirements of federal or state law.
84	5.  Contracts with all qualified nursing homes located in
85	the area that are served by the plan, including those designated
86	as Gold Seal.
87	6.  Ensures that a Medicaid recipient integrated into a
88	plan who is a resident of a facility licensed under chapter 400,
89	Florida Statutes, and who does not choose to move to another
90	setting is allowed to remain in the facility in which he or she
91	is currently receiving care.
92	7.  Includes persons who are in nursing homes and who
93	convert from non-Medicaid payment sources to Medicaid. Plans
94	shall be at risk for serving persons who convert to Medicaid.
95	The agency shall ensure that persons who choose community
96	alternatives instead of nursing home care and who meet the level
97	of care and financial eligibility standards continue to receive
98	Medicaid.
99	8.  Demonstrates a quality assurance and quality
100	improvement system that is satisfactory to the agency.
101	9.  Develops a system to identify recipients who have
102	special health care needs such as polypharmacy, mental health
103	and substance abuse problems, falls, chronic pain, nutritional
104	deficits, or cognitive deficits or who are ventilator-dependent
105	in order to respond to and meet these needs.
106	10.  Ensures a multidisciplinary team approach to recipient
107	management that facilitates the sharing of information among
108	providers responsible for delivering care to a recipient.
109	11.  Ensures medical oversight of care plans and service
110	delivery, regular medical evaluation of care plans, and the
111	availability of medical consultation for care managers and
112	service coordinators.
113	12.  Develops, monitors, and enforces quality-of-care
114	requirements using existing Agency for Health Care
115	Administration survey and certification data, whenever possible,
116	to avoid duplication of survey or certification activities
117	between the plans and the agency.
118	13.  Ensures a system of care coordination that includes
119	educational and training standards for care managers and service
120	coordinators.
121	14.  Develops a business plan that demonstrates the ability
122	of the contractor to organize and operate a risk-bearing entity.
123	15.  Furnishes evidence of liability insurance coverage or
124	a self-insurance plan that is determined by the Office of
125	Insurance Regulation to be adequate to respond to claims for
126	injuries arising out of the furnishing of health care.
127	16.  Complies with the prompt payment of claims
128	requirements of s. 641.3155, Florida Statutes.
129	17.  Provides for a periodic review of its facilities as
130	required by the agency, which does not duplicate other
131	requirements of federal or state law. The agency shall provide
132	provider survey results to the plan.
133	18.  Provides enrollees the ability, to the extent
134	possible, to choose care providers, including nursing home,
135	assisted living, and adult day care service providers affiliated
136	with a person's religious faith or denomination, nursing home
137	and assisted living facility providers that are part of a
138	retirement community in which an enrollee resides, and nursing
139	homes and assisted living facilities that are geographically
140	located as close as possible to an enrollee's family, friends,
141	and social support system.
142	(e)  In addition to other quality assurance standards
143	required by law or by rule or in an approved federal waiver, and
144	in consultation with the Department of Elderly Affairs and area
145	agencies on aging, the agency shall develop quality assurance
146	standards that are specific to the care needs of elderly
147	individuals and that measure enrollee outcomes and satisfaction
148	with care management, nursing home services, and other services
149	that are provided to dually eligible recipients by managed care
150	plans pursuant to this section. The agency shall contract with
151	area agencies on aging to perform initial and ongoing
152	measurement of the appropriateness, effectiveness, and quality
153	of services that are provided to dually eligible recipients by
154	managed care plans and to collect and report the resolution of
155	enrollee grievances and complaints. The agency and the
156	department shall coordinate the quality measurement activities
157	performed by area agencies on aging with other quality assurance
158	activities required by this section in a manner that promotes
159	efficiency and avoids duplication.
160	(f)  If there is not a contractual relationship between a
161	nursing home provider and a plan in an area in which the
162	demonstration project operates, the nursing home shall cooperate
163	with the efforts of the administrator of a plan to determine if
164	a recipient would be more appropriately served in a community
165	setting, and payments shall be made in accordance with Medicaid
166	nursing home rates as calculated in the Medicaid state plan.
167	(g)  The agency may develop innovative risk-sharing
168	agreements that limit the level of custodial nursing home risk
169	that the plan assumes, consistent with the intent of the
170	Legislature to reduce the use and cost of nursing home care.
171	Under risk-sharing agreements, the agency may reimburse the
172	administering entity or a nursing home for the cost of providing
173	nursing home care for Medicaid-eligible recipients who have been
174	permanently placed and remain in nursing home care.
175	(h)  The agency shall withhold a percentage of the
176	capitation rate that would otherwise have been paid to a plan in
177	order to create a quality reserve fund, which shall be annually
178	disbursed to those contracted plans that deliver high-quality
179	services, have a low rate of enrollee complaints, have
180	successful enrollee outcomes, are in compliance with quality
181	improvement standards, and demonstrate other indicators
182	determined by the agency to be consistent with high-quality
183	service delivery.
184	(i)  The agency shall implement a system of profit rebates
185	that require a plan to rebate a portion of the plan's profits
186	that exceed 3 percent. The portion of profit above 3 percent
187	that is to be rebated shall be determined by the agency on a
188	sliding scale; however, no profits above 15 percent may be
189	retained by the plan. Rebates shall be paid to the agency.
190	(j)  The agency may limit the number of persons enrolled in
191	a plan who are not nursing home facility residents but who would
192	be Medicaid eligible as defined under s. 409.904(3), Florida
193	Statutes, if served in an approved home-based or community-based
194	waiver program.
195	(k)  In the demonstration areas, the area agency on aging
196	shall serve as the aging resource center, shall be the entry
197	point for eligibility determination for dually eligible persons,
198	and shall provide choice counseling to assist recipients in
199	choosing a managed care plan.
200	(l)  The agency, in cooperation with the Florida Health
201	Care Association, the Florida Association of Homes for the
202	Aging, and the Department of Elderly Affairs, is directed to
203	create a task force for the purpose of developing a system of
204	monitoring and enforcing quality-of-care requirements and
205	managing and responding to enrollee grievances and complaints,
206	which is specific to long-term care service delivery in a
207	managed care environment.
208	(m)  In the event that a managed care plan does not meet
209	its obligations under its contract with the agency or under the
210	requirements of this section, the agency may impose liquidated
211	damages. Such liquidated damages shall be calculated by the
212	agency as reasonable estimates of the agency's financial loss
213	and are not to be used to penalize the plan. If the agency
214	imposes liquidated damages, the agency may collect those damages
215	by reducing the amount of any monthly premium payments otherwise
216	due to the plan by the amount of the damages. Liquidated damages
217	are forfeited and will not be subsequently paid to a plan upon
218	compliance or cure of default unless a determination is made
219	after appeal that the damages should not have been imposed.
220	(n)  In any area of the state in which the agency has
221	implemented a demonstration project pursuant to this section,
222	the agency shall grant a modification of certificate-of-need
223	conditions related to Medicaid participation to a nursing home
224	that has experienced decreased Medicaid patient day utilization
225	due to a transition to a managed care delivery system.
226	(o)  Notwithstanding any other law to the contrary, the
227	agency shall ensure that, to the extent possible, Medicare and
228	Medicaid services are integrated. When possible, persons served
229	by the managed care delivery system who are eligible for
230	Medicare shall be enrolled in a Medicare managed health care
231	plan operated by the same entity that is placed at risk for
232	Medicaid services.
233	(p)  It is the intent of the Legislature that the agency
234	begin discussions with the federal Centers for Medicare and
235	Medicaid Services regarding the inclusion of Medicare in an
236	integrated long-term care system.
237	(2)  FUNDING DEVELOPMENT COSTS OF ESSENTIAL COMMUNITY
238	PROVIDERS.--It is the intent of the Legislature to facilitate
239	development of managed care delivery systems by networks of
240	essential community providers, including current community care
241	for the elderly lead agencies and other networks as defined in
242	this section. To allow the assumption of responsibility and
243	financial risk for managing a recipient through the entire
244	continuum of Medicaid services, the agency shall, subject to
245	appropriations included in the General Appropriations Act, award
246	up to $500,000 per applicant for the purpose of funding managed
247	care delivery system development costs. The terms of repayment
248	may not extend beyond 6 years after the date when the funding
249	begins and must include payment in full with a rate of interest
250	equal to or greater than the federal funds rate. The agency
251	shall establish a grant application process for awards.
252	(3)  RULEMAKING.--The Agency for Health Care Administration
253	is authorized to adopt rules in consultation with the
254	appropriate state agencies to implement the provisions of this
255	section.
256	(4)  IMPLEMENTATION.--Upon approval of a waiver by the
257	Centers for Medicare and Medicaid Services, the Agency for
258	Health Care Administration shall report the provisions and
259	structure of the approved waiver and any deviations from this
260	section to the Legislature. The agency shall implement the
261	waiver after authority to implement the waiver is granted by the
262	Legislature.
263	(5)  REVIEW AND REPEAL.--This section shall stand repealed
264	on July 1, 2010, unless reviewed and saved from repeal through
265	reenactment by the Legislature.
266	Section 2.  This act shall take effect July 1, 2005.

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