Amendment
Bill No. 7065

Amendment No. 001575

CHAMBER ACTION
Senate		House
.
.
.

---

---

1	Representative(s) Zapata, R. Garcia, Seiler, Schwartz, and
2	Ausley offered the following:
3
4	Amendment (with title amendment)
5	Remove line(s) 96-223 and insert:
6	program system for Medicaid recipients who are 60 years of age
7	or older or dually eligible for Medicare and Medicaid. The
8	Agency for Health Care Administration shall implement the
9	integrated program system initially on a pilot basis in two
10	areas of the state. The pilot areas shall be Area 7 and Area 11
11	of the Agency for Health Care Administration. In one of the
12	areas Enrollment in the pilot areas shall be on a voluntary
13	basis and in accordance with approved federal waivers and this
14	section. The agency and its program contractors and providers
15	shall not enroll any individual in the integrated program
16	because the individual or the person legally responsible for the
17	individual fails to choose to enroll in the integrated program.
18	Enrollment in the integrated program shall be exclusively by
19	affirmative choice of the eligible individual or by the person
20	legally responsible for the individual. The integrated program
21	must transfer all Medicaid services for eligible elderly
22	individuals who choose to participate into an integrated-care
23	management model designed to serve Medicaid recipients in the
24	community. The integrated program must combine all funding for
25	Medicaid services provided to individuals who are 60 years of
26	age or older or dually eligible for Medicare and Medicaid into
27	the integrated program system, including funds for Medicaid home
28	and community-based waiver services; all Medicaid services
29	authorized in ss. 409.905 and 409.906, excluding funds for
30	Medicaid nursing home services unless the agency is able to
31	demonstrate how the integration of the funds will improve
32	coordinated care for these services in a less costly manner; and
33	Medicare coinsurance and deductibles for persons dually eligible
34	for Medicaid and Medicare as prescribed in s. 409.908(13).
35	(a)  Individuals who are 60 years of age or older or dually
36	eligible for Medicare and Medicaid and enrolled in the
37	developmental disabilities waiver program, the family and
38	supported-living waiver program, the project AIDS care waiver
39	program, the traumatic brain injury and spinal cord injury
40	waiver program, the consumer-directed care waiver program, and
41	the program of all-inclusive care for the elderly program, and
42	residents of institutional care facilities for the
43	developmentally disabled, must be excluded from the integrated
44	program system.
45	(b)  The integrated program shall must use a competitive
46	procurement process to select managed care entities who meet or
47	exceed the agency's minimum standards to operate the integrated
48	program system. For the purpose of this section, managed care
49	entities shall be considered prepaid health plans as provided in
50	s. 408.7056(1)(e). Entities eligible to submit bids include
51	managed care organizations licensed under chapter 641, including
52	entities eligible to participate in the nursing home diversion
53	program, other qualified providers as defined in s. 430.703(7),
54	community care for the elderly lead agencies, and other state-
55	certified community service networks that meet comparable
56	standards as defined by the agency, in consultation with the
57	Department of Elderly Affairs and the Office of Insurance
58	Regulation, to be financially solvent and able to take on
59	financial risk for managed care. Community service networks that
60	are certified pursuant to the comparable standards defined by
61	the agency are not required to be licensed under chapter 641.
62	(c)  The agency must ensure that the capitation-rate-
63	setting methodology for the integrated program system is
64	actuarially sound and reflects the intent to provide quality
65	care in the least restrictive setting. The agency must also
66	require integrated-program integrated-system providers to
67	develop a credentialing system for service providers and to
68	contract with all Gold Seal nursing homes, where feasible, and
69	exclude, where feasible, chronically poor-performing facilities
70	and providers as defined by the agency. The integrated program
71	must develop and maintain an informal provider grievance system
72	that addresses provider payment and contract problems. The
73	agency shall also establish a formal grievance system to address
74	those issues that were not resolved through the informal
75	grievance system. The integrated program system must provide
76	that if the recipient resides in a noncontracted residential
77	facility licensed under chapter 400 or chapter 429 at the time
78	of enrollment in the integrated program system is initiated, the
79	recipient must be permitted to continue to reside in the
80	noncontracted facility as long as the recipient desires. The
81	integrated program system must also provide that, in the absence
82	of a contract between the integrated-program integrated-system
83	provider and the residential facility licensed under chapter 400
84	or chapter 429, current Medicaid rates must prevail. The
85	integrated-program provider must ensure that electronic nursing
86	home claims that contain sufficient information for processing
87	are paid within 10 business days after receipt. Alternately, the
88	integrated-program provider may establish a capitated payment
89	mechanism to prospectively pay nursing homes at the beginning of
90	each month. The agency and the Department of Elderly Affairs
91	must jointly develop procedures to manage the services provided
92	through the integrated program system in order to ensure quality
93	and recipient choice.
94	(d)  Within 24 months after implementation, The Office of
95	Program Policy Analysis and Government Accountability, in
96	consultation with the Auditor General, shall comprehensively
97	evaluate the pilot project for the integrated, fixed-payment
98	delivery program system for Medicaid recipients created under
99	this subsection who are 60 years of age or older. The evaluation
100	shall begin as soon as Medicaid recipients are enrolled in the
101	managed care pilot program plans and shall continue for 24
102	months thereafter. The evaluation must include assessments of
103	each managed care plan in the integrated program with regard to
104	cost savings; consumer education, choice, and access to
105	services; coordination of care; and quality of care. The
106	evaluation must describe administrative or legal barriers to the
107	implementation and operation of the pilot program and include
108	recommendations regarding statewide expansion of the pilot
109	program. The office shall submit its an evaluation report to the
110	Governor, the President of the Senate, and the Speaker of the
111	House of Representatives no later than December 31, 2009 June
112	30, 2008.
113	(e)  The agency may seek federal waivers or Medicaid state
114	plan amendments and adopt rules as necessary to administer the
115	integrated program system. The agency may implement the approved
116	federal waivers and other provisions as specified in this
117	subsection must receive specific authorization from the
118	Legislature prior to implementing the waiver for the integrated
119	system.
120	(f)  No later than December 31, 2007, the agency shall
121	provide a report to the President of the Senate and the Speaker
122	of the House of Representatives containing an analysis of the
123	merits and challenges of seeking a waiver to implement a
124	voluntary program that integrates payments and services for
125	dually enrolled Medicare and Medicaid recipients who are 65
126	years of age or older.
127	Section 2.  Paragraph (d) of subsection (1) of section
128	408.040, Florida Statutes, is amended to read:
129	408.040  Conditions and monitoring.--
130	(1)
131	(d)  If a nursing home is located in a county in which a
132	long-term care community diversion pilot project has been
133	implemented under s. 430.705 or in a county in which an
134	integrated, fixed-payment delivery program system for Medicaid
135	recipients who are 60 years of age or older or dually eligible
136	for Medicare and Medicaid has been implemented
137
138	======= T I T L E  A M E N D M E N T =======
139
140	Remove line 6 and insert:
141	years of age or older or dually eligible for Medicare and
142	Medicaid; providing for voluntary enrollment

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