Amendment
Bill No. 6003

Amendment No. 099881

CHAMBER ACTION
Senate		House
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1	Representative(s) A. Gibson offered the following:
2
3	Amendment to Amendment (317791) (with directory and title
4	amendments)
5	Remove line(s) 88-247 and insert:
6	5.  Notwithstanding any other provision of law, however,
7	all plans shall be required to cover prenatal care for pregnant
8	women. The usage of this prenatal care coverage cannot eliminate
9	or reduce other coverage areas for enrollees as designed within
10	the plans.
11	(h)  "Provider service network" means an incorporated
12	network:
13	1.  Established or organized, and operated, by a health
14	care provider or group of affiliated health care providers;
15	2.  That provides a substantial proportion of the health
16	care items and services under a contract directly through the
17	provider or affiliated group;
18	3.  That may make arrangements with physicians, other
19	health care professionals, and health care institutions, to
20	assume all or part of the financial risk on a prospective basis
21	for the provision of basic health services; and
22	4.  Within which health care providers have a controlling
23	interest in the governing body of the provider service network
24	organization, as authorized by s. 409.912, Florida Statutes.
25	(i)  "Shall" means the agency must include the provision of
26	a subsection as delineated in this section in the waiver
27	application and implement the provision to the extent allowed in
28	the demonstration project sites by the Centers for Medicare and
29	Medicaid Services and as approved by the Legislature pursuant to
30	this section.
31	(j)  "State-certified contractor" means an entity not
32	authorized under part I, part II, or part III of chapter 641,
33	Florida Statutes, or under chapter 624, chapter 627, or chapter
34	636, Florida Statutes, qualified by the agency to be certified
35	as a managed care plan. The agency shall develop the standards
36	necessary to authorize an entity to become a state-certified
37	contractor.
38	(5)  ELIGIBILITY.--
39	(a)  The agency shall pursue waivers to reform Medicaid for
40	the following categorical groups:
41	1.  Temporary Assistance for Needy Families, consistent
42	with ss. 402 and 1931 of the Social Security Act and chapter
43	409, chapter 414, or chapter 445, Florida Statutes.
44	2.  Supplemental Security Income recipients as defined in
45	Title XVI of the Social Security Act, except for persons who are
46	dually eligible for Medicaid and Medicare, individuals 60 years
47	of age or older, individuals who have developmental
48	disabilities, and residents of institutions or nursing homes.
49	3.  All children covered pursuant to Title XIX of the
50	Social Security Act.
51	(b)  The agency may pursue any appropriate federal waiver
52	to reform Medicaid for the populations not identified by this
53	subsection, including Title XXI children, if authorized by the
54	Legislature.
55	(6)  CHOICE COUNSELING.--
56	(a)  At the time of eligibility determination, the agency
57	shall provide the recipient with all the Medicaid health care
58	options available in that community to assist the recipient in
59	choosing health care coverage. The recipient shall choose a plan
60	within 30 days after the recipient is eligible unless the
61	recipient loses eligibility. Failure to choose a plan within 30
62	days will result in the recipient being assigned to a managed
63	care plan.
64	(b)  After a recipient has chosen a plan or has been
65	assigned to a plan, the recipient shall have 90 days in which to
66	voluntarily disenroll and select another managed care plan.
67	After 90 days, no further changes may be made except for cause.
68	Cause shall include, but not be limited to, poor quality of
69	care, lack of access to necessary specialty services, an
70	unreasonable delay or denial of service, inordinate or
71	inappropriate changes of primary care providers, service access
72	impairments due to significant changes in the geographic
73	location of services, or fraudulent enrollment. The agency may
74	require a recipient to use the managed care plan's grievance
75	process prior to the agency's determination of cause, except in
76	cases in which immediate risk of permanent damage to the
77	recipient's health is alleged. The grievance process, when used,
78	must be completed in time to permit the recipient to disenroll
79	no later than the first day of the second month after the month
80	the disenrollment request was made. If the capitated managed
81	care network, as a result of the grievance process, approves an
82	enrollee's request to disenroll, the agency is not required to
83	make a determination in the case. The agency must make a
84	determination and take final action on a recipient's request so
85	that disenrollment occurs no later than the first day of the
86	second month after the month the request was made. If the agency
87	fails to act within the specified timeframe, the recipient's
88	request to disenroll is deemed to be approved as of the date
89	agency action was required. Recipients who disagree with the
90	agency's finding that cause does not exist for disenrollment
91	shall be advised of their right to pursue a Medicaid fair
92	hearing to dispute the agency's finding.
93	(c)  In the managed care demonstration projects, the
94	Medicaid recipients who are already enrolled in a managed care
95	plan shall remain with that plan until their next eligibility
96	determination. The agency shall develop a method whereby newly
97	eligible Medicaid recipients, Medicaid recipients with renewed
98	eligibility, and Medipass enrollees shall enroll in managed care
99	plans certified pursuant to this section.
100	(d)  A Medicaid recipient receiving services under this
101	section is eligible for only emergency services until the
102	recipient enrolls in a managed care plan.
103	(e)  The agency shall ensure that the recipient is provided
104	with:
105	1.  A list and description of the benefits provided.
106	2.  Information about cost sharing.
107	3.  Plan performance data, if available.
108	4.  An explanation of benefit limitations.
109	5.  Contact information, including identification of
110	providers participating in the network, geographic locations,
111	and transportation limitations.
112	6.  Any other information the agency determines would
113	facilitate a recipient's understanding of the plan or insurance
114	that would best meet his or her needs.
115	(f)  The agency shall ensure that there is a record of
116	recipient acknowledgment that choice counseling has been
117	provided.
118	(g)  To accommodate the needs of recipients, the agency
119	shall ensure that the choice counseling process and related
120	material are designed to provide counseling through face-to-face
121	interaction, by telephone, and in writing and through other
122	forms of relevant media. Materials shall be written at the
123	fourth-grade reading level and available in a language other
124	than English when 5 percent of the county speaks a language
125	other than English. Choice counseling shall also utilize
126	language lines and other services for impaired recipients, such
127	as TTD/TTY.
128	(h)  The agency shall require the entity performing choice
129	counseling to determine if the recipient has made a choice of a
130	plan or has opted out because of duress, threats, payment to the
131	recipient, or incentives promised to the recipient by a third
132	party. If the choice counseling entity determines that the
133	decision to choose a plan was unlawfully influenced or a plan
134	violated any of the provisions of s. 409.912(21), Florida
135	Statutes, the choice counseling entity shall immediately report
136	the violation to the agency's program integrity section for
137	investigation. Verification of choice counseling by the
138	recipient shall include a stipulation that the recipient
139	acknowledges the provisions of this subsection.
140	(i)  It is the intent of the Legislature, within the
141	authority of the waiver and within available resources, that the
142	agency promote health literacy and partner with the Department
143	of Health to provide information aimed to reduce minority health
144	disparities through outreach activities for Medicaid recipients.
145	(j)  The agency is authorized to contract with entities to
146	perform choice counseling and may establish standards and
147	performance contracts, including standards requiring the
148	contractor to hire choice counselors representative of the
149	state's diverse population and to train choice counselors in
150	working with culturally diverse populations.
151	(k)  The agency shall develop processes to ensure that
152	demonstration sites have sufficient levels of enrollment to
153	conduct a valid test of the managed care demonstration project
154	model within a 2-year timeframe.
155	(7)  PLANS.--
156	(a)  Plan benefits.--The agency shall develop a capitated
157	system of care that promotes choice and competition. Plan
158	benefits shall include the mandatory services delineated in
159	federal law and specified in s. 409.905, Florida Statutes;
160	behavioral health services specified in s. 409.906(8), Florida
161	Statutes; pharmacy services specified in s. 409.906(20), Florida
162	Statutes; and other services including, but not limited to,
163	Medicaid optional services specified in s. 409.906, Florida
164	Statutes, for which a plan is receiving a risk-adjusted
165	capitation rate. Plans shall provide all mandatory services and
166	may cover optional services to attract recipients and provide
167	needed care. Mandatory and optional services may vary in amount,
168	duration, and scope of benefits. Services to recipients under
169	plan benefits shall include emergency services pursuant to s.
170	409.9128, Florida Statutes. Notwithstanding any other provision
171	of law, however, all plans shall be required to cover prenatal
172	care for pregnant women. The usage of this prenatal care
173	coverage cannot eliminate or reduce other coverage areas for
174	enrollees as designed within the plans.

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