Senate Bill sb1828
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Florida Senate - 2007 SB 1828
By Senator Fasano
11-1206A-07 See HB
1 A bill to be entitled
2 An act relating to the Medicaid managed care
3 pilot program; amending s. 409.91211, F.S.;
4 requiring the Agency for Health Care
5 Administration to develop a methodology for
6 calculating risk-adjusted capitation rates
7 based on information in the encounter database;
8 requiring that specified criteria be met prior
9 to implementation of the methodology; providing
10 for use of an interim risk-adjusted
11 methodology; providing a phase-in schedule for
12 the encounter-based methodology for
13 participating managed care plans; requiring the
14 phase-in schedule to be applied anew for
15 counties into which the program expands;
16 providing an effective date.
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18 Be It Enacted by the Legislature of the State of Florida:
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20 Section 1. Subsections (8) and (9) of section
21 409.91211, Florida Statutes, are amended to read:
22 409.91211 Medicaid managed care pilot program.--
23 (8)(a) The agency shall develop a methodology for
24 calculating risk-adjusted capitation rates using comprehensive
25 encounter and diagnosis data pursuant to subparagraph (3)(p)4.
26 for all acute Medicaid services. Prior to the implementation
27 of the risk-adjusted capitation rate methodology, the agency
28 shall ensure that all of the following criteria are met:
29 1. Agency staff is sufficiently educated and trained
30 regarding issues and methods related to compiling encounter
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Florida Senate - 2007 SB 1828
11-1206A-07 See HB
1 data to implement and maintain the Florida Medicaid encounter
2 data system.
3 2. The Florida Medicaid Management Information System
4 has the capacity to house, maintain, and manage the
5 anticipated volume of encounter data records that will be
6 produced.
7 3. The agency has ensured that the encounter data
8 system is secure, protects personal health information, and is
9 in compliance with 45 C.F.R. ss. 160.102, 160.103, and 164,
10 subpart A, commonly referred to as the HIPAA Privacy
11 Regulation.
12 4. The agency has implemented a validation system to
13 ensure the encounter data is accurate; has been screened for
14 completeness, logic, and consistency; and is standardized to
15 facilitate the use of various models for the payment of claims
16 and submission of data.
17 5. The agency has compiled no less than 1 year's worth
18 of complete encounter and diagnostic data to permit the
19 adjustment of capitation rates for health risk differences and
20 has ensured, through validation by an independent actuary,
21 that the data are of sufficient integrity to be used for
22 risk-adjustment purposes in accordance with actuarial
23 standards of practice that are generally recognized as sound
24 and appropriate.
25 6. The agency has consulted with the technical
26 advisory panel regarding the development and implementation of
27 the comprehensive encounter and diagnosis data system and
28 sought input from the panel.
29 7. The risk-adjusted capitation rates have been
30 certified by an independent actuary and approved by the
31 Centers for Medicare and Medicaid Services.
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Florida Senate - 2007 SB 1828
11-1206A-07 See HB
1 (b) The agency must ensure, in the first two state
2 fiscal years in which a risk-adjusted methodology is a
3 component of rate setting, that, under any risk-adjustment
4 methodology, no managed care plan providing comprehensive
5 benefits to TANF and SSI recipients under this section has an
6 aggregate risk score that varies by more than 10 percent from
7 the aggregate weighted mean of all managed care plans
8 providing comprehensive benefits to TANF and SSI recipients in
9 a reform area. A risk-adjusted capitation paid by the agency
10 The agency's payment to a managed care plan shall be based on
11 an such revised aggregate risk score revised in accordance
12 with the provisions of this paragraph.
13 (c) The agency may implement an interim risk-adjusted
14 capitation rate methodology to be used before a fully
15 functional encounter and diagnostic data system has been in
16 operation for no less than 12 months pursuant to paragraph
17 (a). If the agency implements an interim methodology, the
18 capitation rates during the interim period shall be weighted
19 so that 75 percent of each capitation rate is based on the
20 methodology developed under s. 409.9124 and 25 percent is
21 based on the interim risk-adjusted capitation rate
22 methodology.
23 (9) After any calculations of aggregate risk scores or
24 revised aggregate risk scores in subsection (8) and after a
25 fully functional encounter and diagnostic data system has been
26 in operation for no less than 12 months, the capitation rates
27 for plans participating under this section shall be phased in,
28 and this phase-in schedule shall be applied anew, in its
29 entirety, in any county in which the risk-adjusted capitation
30 rate methodology is implemented, as follows:
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Florida Senate - 2007 SB 1828
11-1206A-07 See HB
1 (a) For managed care plan contracts taking effect in
2 the first and second state fiscal years after a fully
3 functional encounter and diagnostic data system has been in
4 operation for no less than 12 months, the capitation rates
5 shall be weighted so that 75 percent of each capitation rate
6 is based on the methodology developed under s. 409.9124 and 25
7 percent is based on the risk-adjusted capitation rate
8 methodology developed under subsection (8). In the first year,
9 the capitation rates shall be weighted so that 75 percent of
10 each capitation rate is based on the current methodology and
11 25 percent is based on a new risk-adjusted capitation rate
12 methodology.
13 (b) For managed care plan contracts taking effect in
14 the third state fiscal year after a fully functional encounter
15 and diagnostic data system has been in operation for no less
16 than 12 months, the capitation rates shall be weighted so that
17 70 percent of each capitation rate is based on the methodology
18 developed under s. 409.9124 and 30 percent is based on the
19 risk-adjusted capitation rate methodology developed under
20 subsection (8). In the second year, the capitation rates shall
21 be weighted so that 50 percent of each capitation rate is
22 based on the current methodology and 50 percent is based on a
23 new risk-adjusted rate methodology.
24 (c) For managed care plan contracts taking effect in
25 the fourth state fiscal year after a fully functional
26 encounter and diagnostic data system has been in operation for
27 no less than 12 months, the capitation rates shall be weighted
28 so that 50 percent of each capitation rate is based on the
29 methodology developed under s. 409.9124 and 50 percent is
30 based on the risk-adjusted capitation rate methodology
31 developed under subsection (8).
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CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2007 SB 1828
11-1206A-07 See HB
1 (d) For managed care plan contracts taking effect in
2 the fifth state fiscal year after a fully functional encounter
3 and diagnostic data system has been in operation for no less
4 than 12 months, the capitation rates shall be weighted so that
5 25 percent of each capitation rate is based on the methodology
6 developed under s. 409.9124 and 75 percent is based on the
7 risk-adjusted capitation rate methodology developed under
8 subsection (8).
9 (e) For managed care plan contracts taking effect in
10 the sixth state fiscal year after a fully functional encounter
11 and diagnostic data system has been in operation for no less
12 than 12 months In the following fiscal year, the risk-adjusted
13 capitation methodology may be fully implemented.
14 Section 2. This act shall take effect July 1, 2007.
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