Amendment
Bill No. 6003

Amendment No. 171861

CHAMBER ACTION
Senate		House
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1	Representative(s) Gannon and Joyner offered the following:
2
3	Amendment to Amendment (317791)
4	Remove line(s) 69-247 and insert:
5	pursuant to s. 409.9128, Florida Statutes. Notwithstanding any
6	other provision of law, all plans shall be required to provide
7	mammogram testing coverage at least once annually to all women
8	over 40 years of age.
9	1.  Mandatory and optional services as delineated in s.
10	409.905, and s. 409.906, Florida Statutes may vary in amount,
11	duration and scope based on actuarial analysis and determination
12	of service utilization among a categorical or predetermined risk
13	group served by the plan.
14	2.  A plan shall provide all mandatory and optional
15	services as delineated in ss. 409.905, and 409.906, Florida
16	Statutes, to a level of amount, duration and scope based on the
17	actuarial analysis and corresponding capitation rate.
18	Contractual stipulations for each risk or categorical group
19	shall not vary among plans.
20	3.  A plan shall be at risk for all services as defined in
21	this section needed by a recipient up to a monetary catastrophic
22	threshold pursuant to this section.
23	4.  Catastrophic coverage pursuant to this section shall
24	not release the plan from continued care management of the
25	recipient and providing other services as stipulated in the
26	contract with the agency.
27	(h)  "Provider service network" means an incorporated
28	network:
29	1.  Established or organized, and operated, by a health
30	care provider or group of affiliated health care providers;
31	2.  That provides a substantial proportion of the health
32	care items and services under a contract directly through the
33	provider or affiliated group;
34	3.  That may make arrangements with physicians, other
35	health care professionals, and health care institutions, to
36	assume all or part of the financial risk on a prospective basis
37	for the provision of basic health services; and
38	4.  Within which health care providers have a controlling
39	interest in the governing body of the provider service network
40	organization, as authorized by s. 409.912, Florida Statutes.
41	(i)  "Shall" means the agency must include the provision of
42	a subsection as delineated in this section in the waiver
43	application and implement the provision to the extent allowed in
44	the demonstration project sites by the Centers for Medicare and
45	Medicaid Services and as approved by the Legislature pursuant to
46	this section.
47	(j)  "State-certified contractor" means an entity not
48	authorized under part I, part II, or part III of chapter 641,
49	Florida Statutes, or under chapter 624, chapter 627, or chapter
50	636, Florida Statutes, qualified by the agency to be certified
51	as a managed care plan. The agency shall develop the standards
52	necessary to authorize an entity to become a state-certified
53	contractor.
54	(5)  ELIGIBILITY.--
55	(a)  The agency shall pursue waivers to reform Medicaid for
56	the following categorical groups:
57	1.  Temporary Assistance for Needy Families, consistent
58	with ss. 402 and 1931 of the Social Security Act and chapter
59	409, chapter 414, or chapter 445, Florida Statutes.
60	2.  Supplemental Security Income recipients as defined in
61	Title XVI of the Social Security Act, except for persons who are
62	dually eligible for Medicaid and Medicare, individuals 60 years
63	of age or older, individuals who have developmental
64	disabilities, and residents of institutions or nursing homes.
65	3.  All children covered pursuant to Title XIX of the
66	Social Security Act.
67	(b)  The agency may pursue any appropriate federal waiver
68	to reform Medicaid for the populations not identified by this
69	subsection, including Title XXI children, if authorized by the
70	Legislature.
71	(6)  CHOICE COUNSELING.--
72	(a)  At the time of eligibility determination, the agency
73	shall provide the recipient with all the Medicaid health care
74	options available in that community to assist the recipient in
75	choosing health care coverage. The recipient shall choose a plan
76	within 30 days after the recipient is eligible unless the
77	recipient loses eligibility. Failure to choose a plan within 30
78	days will result in the recipient being assigned to a managed
79	care plan.
80	(b)  After a recipient has chosen a plan or has been
81	assigned to a plan, the recipient shall have 90 days in which to
82	voluntarily disenroll and select another managed care plan.
83	After 90 days, no further changes may be made except for cause.
84	Cause shall include, but not be limited to, poor quality of
85	care, lack of access to necessary specialty services, an
86	unreasonable delay or denial of service, inordinate or
87	inappropriate changes of primary care providers, service access
88	impairments due to significant changes in the geographic
89	location of services, or fraudulent enrollment. The agency may
90	require a recipient to use the managed care plan's grievance
91	process prior to the agency's determination of cause, except in
92	cases in which immediate risk of permanent damage to the
93	recipient's health is alleged. The grievance process, when used,
94	must be completed in time to permit the recipient to disenroll
95	no later than the first day of the second month after the month
96	the disenrollment request was made. If the capitated managed
97	care network, as a result of the grievance process, approves an
98	enrollee's request to disenroll, the agency is not required to
99	make a determination in the case. The agency must make a
100	determination and take final action on a recipient's request so
101	that disenrollment occurs no later than the first day of the
102	second month after the month the request was made. If the agency
103	fails to act within the specified timeframe, the recipient's
104	request to disenroll is deemed to be approved as of the date
105	agency action was required. Recipients who disagree with the
106	agency's finding that cause does not exist for disenrollment
107	shall be advised of their right to pursue a Medicaid fair
108	hearing to dispute the agency's finding.
109	(c)  In the managed care demonstration projects, the
110	Medicaid recipients who are already enrolled in a managed care
111	plan shall remain with that plan until their next eligibility
112	determination. The agency shall develop a method whereby newly
113	eligible Medicaid recipients, Medicaid recipients with renewed
114	eligibility, and Medipass enrollees shall enroll in managed care
115	plans certified pursuant to this section.
116	(d)  A Medicaid recipient receiving services under this
117	section is eligible for only emergency services until the
118	recipient enrolls in a managed care plan.
119	(e)  The agency shall ensure that the recipient is provided
120	with:
121	1.  A list and description of the benefits provided.
122	2.  Information about cost sharing.
123	3.  Plan performance data, if available.
124	4.  An explanation of benefit limitations.
125	5.  Contact information, including identification of
126	providers participating in the network, geographic locations,
127	and transportation limitations.
128	6.  Any other information the agency determines would
129	facilitate a recipient's understanding of the plan or insurance
130	that would best meet his or her needs.
131	(f)  The agency shall ensure that there is a record of
132	recipient acknowledgment that choice counseling has been
133	provided.
134	(g)  To accommodate the needs of recipients, the agency
135	shall ensure that the choice counseling process and related
136	material are designed to provide counseling through face-to-face
137	interaction, by telephone, and in writing and through other
138	forms of relevant media. Materials shall be written at the
139	fourth-grade reading level and available in a language other
140	than English when 5 percent of the county speaks a language
141	other than English. Choice counseling shall also utilize
142	language lines and other services for impaired recipients, such
143	as TTD/TTY.
144	(h)  The agency shall require the entity performing choice
145	counseling to determine if the recipient has made a choice of a
146	plan or has opted out because of duress, threats, payment to the
147	recipient, or incentives promised to the recipient by a third
148	party. If the choice counseling entity determines that the
149	decision to choose a plan was unlawfully influenced or a plan
150	violated any of the provisions of s. 409.912(21), Florida
151	Statutes, the choice counseling entity shall immediately report
152	the violation to the agency's program integrity section for
153	investigation. Verification of choice counseling by the
154	recipient shall include a stipulation that the recipient
155	acknowledges the provisions of this subsection.
156	(i)  It is the intent of the Legislature, within the
157	authority of the waiver and within available resources, that the
158	agency promote health literacy and partner with the Department
159	of Health to provide information aimed to reduce minority health
160	disparities through outreach activities for Medicaid recipients.
161	(j)  The agency is authorized to contract with entities to
162	perform choice counseling and may establish standards and
163	performance contracts, including standards requiring the
164	contractor to hire choice counselors representative of the
165	state's diverse population and to train choice counselors in
166	working with culturally diverse populations.
167	(k)  The agency shall develop processes to ensure that
168	demonstration sites have sufficient levels of enrollment to
169	conduct a valid test of the managed care demonstration project
170	model within a 2-year timeframe.
171	(7)  PLANS.--
172	(a)  Plan benefits.--The agency shall develop a capitated
173	system of care that promotes choice and competition. Plan
174	benefits shall include the mandatory services delineated in
175	federal law and specified in s. 409.905, Florida Statutes;
176	behavioral health services specified in s. 409.906(8), Florida
177	Statutes; pharmacy services specified in s. 409.906(20), Florida
178	Statutes; and other services including, but not limited to,
179	Medicaid optional services specified in s. 409.906, Florida
180	Statutes, for which a plan is receiving a risk-adjusted
181	capitation rate. Plans shall provide all mandatory services and
182	may cover optional services to attract recipients and provide
183	needed care. Mandatory and optional services may vary in amount,
184	duration, and scope of benefits. Services to recipients under
185	plan benefits shall include emergency services pursuant to s.
186	409.9128, Florida Statutes. Notwithstanding any other provision
187	of law, all plans shall be required to provide mammogram testing
188	coverage at least once annually to all women over 40 years of
189	age.

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