Florida Senate - 2007 CONFERENCE COMMITTEE AMENDMENT
Bill No. HB 7065, 1st Eng.
Barcode 323714
CHAMBER ACTION
Senate House
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05/03/2007 02:43 PM .
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11 The Conference Committee on HB 7065, 1st Eng. recommended the
12 following amendment:
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14 Conference Committee Amendment (with title amendment)
15 Delete everything after the enacting clause
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17 and insert:
18 Section 1. Subsection (5) of section 409.912, Florida
19 Statutes, is amended to read:
20 409.912 Cost-effective purchasing of health care.--The
21 agency shall purchase goods and services for Medicaid
22 recipients in the most cost-effective manner consistent with
23 the delivery of quality medical care. To ensure that medical
24 services are effectively utilized, the agency may, in any
25 case, require a confirmation or second physician's opinion of
26 the correct diagnosis for purposes of authorizing future
27 services under the Medicaid program. This section does not
28 restrict access to emergency services or poststabilization
29 care services as defined in 42 C.F.R. part 438.114. Such
30 confirmation or second opinion shall be rendered in a manner
31 approved by the agency. The agency shall maximize the use of
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Bill No. HB 7065, 1st Eng.
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1 prepaid per capita and prepaid aggregate fixed-sum basis
2 services when appropriate and other alternative service
3 delivery and reimbursement methodologies, including
4 competitive bidding pursuant to s. 287.057, designed to
5 facilitate the cost-effective purchase of a case-managed
6 continuum of care. The agency shall also require providers to
7 minimize the exposure of recipients to the need for acute
8 inpatient, custodial, and other institutional care and the
9 inappropriate or unnecessary use of high-cost services. The
10 agency shall contract with a vendor to monitor and evaluate
11 the clinical practice patterns of providers in order to
12 identify trends that are outside the normal practice patterns
13 of a provider's professional peers or the national guidelines
14 of a provider's professional association. The vendor must be
15 able to provide information and counseling to a provider whose
16 practice patterns are outside the norms, in consultation with
17 the agency, to improve patient care and reduce inappropriate
18 utilization. The agency may mandate prior authorization, drug
19 therapy management, or disease management participation for
20 certain populations of Medicaid beneficiaries, certain drug
21 classes, or particular drugs to prevent fraud, abuse, overuse,
22 and possible dangerous drug interactions. The Pharmaceutical
23 and Therapeutics Committee shall make recommendations to the
24 agency on drugs for which prior authorization is required. The
25 agency shall inform the Pharmaceutical and Therapeutics
26 Committee of its decisions regarding drugs subject to prior
27 authorization. The agency is authorized to limit the entities
28 it contracts with or enrolls as Medicaid providers by
29 developing a provider network through provider credentialing.
30 The agency may competitively bid single-source-provider
31 contracts if procurement of goods or services results in
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Florida Senate - 2007 CONFERENCE COMMITTEE AMENDMENT
Bill No. HB 7065, 1st Eng.
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1 demonstrated cost savings to the state without limiting access
2 to care. The agency may limit its network based on the
3 assessment of beneficiary access to care, provider
4 availability, provider quality standards, time and distance
5 standards for access to care, the cultural competence of the
6 provider network, demographic characteristics of Medicaid
7 beneficiaries, practice and provider-to-beneficiary standards,
8 appointment wait times, beneficiary use of services, provider
9 turnover, provider profiling, provider licensure history,
10 previous program integrity investigations and findings, peer
11 review, provider Medicaid policy and billing compliance
12 records, clinical and medical record audits, and other
13 factors. Providers shall not be entitled to enrollment in the
14 Medicaid provider network. The agency shall determine
15 instances in which allowing Medicaid beneficiaries to purchase
16 durable medical equipment and other goods is less expensive to
17 the Medicaid program than long-term rental of the equipment or
18 goods. The agency may establish rules to facilitate purchases
19 in lieu of long-term rentals in order to protect against fraud
20 and abuse in the Medicaid program as defined in s. 409.913.
21 The agency may seek federal waivers necessary to administer
22 these policies.
23 (5) By December 1, 2005, The Agency for Health Care
24 Administration, in partnership with the Department of Elderly
25 Affairs, shall create an integrated, fixed-payment delivery
26 program system for Medicaid recipients who are 60 years of age
27 or older or dually eligible for Medicare and Medicaid. The
28 Agency for Health Care Administration shall implement the
29 integrated program system initially on a pilot basis in two
30 areas of the state. The pilot areas shall be Area 7 and Area
31 11 of the Agency for Health Care Administration. In one of the
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Florida Senate - 2007 CONFERENCE COMMITTEE AMENDMENT
Bill No. HB 7065, 1st Eng.
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1 areas Enrollment in the pilot areas shall be on a voluntary
2 basis and in accordance with approved federal waivers and this
3 section. The agency and its program contractors and providers
4 shall not enroll any individual in the integrated program
5 because the individual or the person legally responsible for
6 the individual fails to choose to enroll in the integrated
7 program. Enrollment in the integrated program shall be
8 exclusively by affirmative choice of the eligible individual
9 or by the person legally responsible for the individual. The
10 integrated program must transfer all Medicaid services for
11 eligible elderly individuals who choose to participate into an
12 integrated-care management model designed to serve Medicaid
13 recipients in the community. The integrated program must
14 combine all funding for Medicaid services provided to
15 individuals who are 60 years of age or older or dually
16 eligible for Medicare and Medicaid into the integrated program
17 system, including funds for Medicaid home and community-based
18 waiver services; all Medicaid services authorized in ss.
19 409.905 and 409.906, excluding funds for Medicaid nursing home
20 services unless the agency is able to demonstrate how the
21 integration of the funds will improve coordinated care for
22 these services in a less costly manner; and Medicare
23 coinsurance and deductibles for persons dually eligible for
24 Medicaid and Medicare as prescribed in s. 409.908(13).
25 (a) Individuals who are 60 years of age or older or
26 dually eligible for Medicare and Medicaid and enrolled in the
27 developmental disabilities waiver program, the family and
28 supported-living waiver program, the project AIDS care waiver
29 program, the traumatic brain injury and spinal cord injury
30 waiver program, the consumer-directed care waiver program, and
31 the program of all-inclusive care for the elderly program, and
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Florida Senate - 2007 CONFERENCE COMMITTEE AMENDMENT
Bill No. HB 7065, 1st Eng.
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1 residents of institutional care facilities for the
2 developmentally disabled, must be excluded from the integrated
3 program system.
4 (b) Managed care The program must use a competitive
5 procurement process to select entities who meet or exceed the
6 agency's minimum standards are eligible to operate the
7 integrated program system. Entities eligible to participate
8 submit bids include managed care organizations licensed under
9 chapter 641, including entities eligible to participate in the
10 nursing home diversion program, other qualified providers as
11 defined in s. 430.703(7), community care for the elderly lead
12 agencies, and other state-certified community service networks
13 that meet comparable standards as defined by the agency, in
14 consultation with the Department of Elderly Affairs and the
15 Office of Insurance Regulation, to be financially solvent and
16 able to take on financial risk for managed care. Community
17 service networks that are certified pursuant to the comparable
18 standards defined by the agency are not required to be
19 licensed under chapter 641. Managed care entities who operate
20 the integrated program shall be subject to s. 408.7056.
21 Eligible entities shall choose to serve enrollees who are
22 dually eligible for Medicare and Medicaid, enrollees who are
23 60 years of age or older, or both.
24 (c) The agency must ensure that the
25 capitation-rate-setting methodology for the integrated program
26 system is actuarially sound and reflects the intent to provide
27 quality care in the least restrictive setting. The agency must
28 also require integrated-program integrated-system providers to
29 develop a credentialing system for service providers and to
30 contract with all Gold Seal nursing homes, where feasible, and
31 exclude, where feasible, chronically poor-performing
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Bill No. HB 7065, 1st Eng.
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1 facilities and providers as defined by the agency. The
2 integrated program must develop and maintain an informal
3 provider grievance system that addresses provider payment and
4 contract problems. The agency shall also establish a formal
5 grievance system to address those issues that were not
6 resolved through the informal grievance system. The integrated
7 program system must provide that if the recipient resides in a
8 noncontracted residential facility licensed under chapter 400
9 or chapter 429 at the time of enrollment in the integrated
10 program system is initiated, the recipient must be permitted
11 to continue to reside in the noncontracted facility as long as
12 the recipient desires. The integrated program system must also
13 provide that, in the absence of a contract between the
14 integrated-program integrated-system provider and the
15 residential facility licensed under chapter 400 or chapter
16 429, current Medicaid rates must prevail. The
17 integrated-program provider must ensure that electronic
18 nursing home claims that contain sufficient information for
19 processing are paid within 10 business days after receipt.
20 Alternately, the integrated-program provider may establish a
21 capitated payment mechanism to prospectively pay nursing homes
22 at the beginning of each month. The agency and the Department
23 of Elderly Affairs must jointly develop procedures to manage
24 the services provided through the integrated program system in
25 order to ensure quality and recipient choice.
26 (d) Within 24 months after implementation, The Office
27 of Program Policy Analysis and Government Accountability, in
28 consultation with the Auditor General, shall comprehensively
29 evaluate the pilot project for the integrated, fixed-payment
30 delivery program system for Medicaid recipients created under
31 this subsection who are 60 years of age or older. The
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Bill No. HB 7065, 1st Eng.
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1 evaluation shall begin as soon as Medicaid recipients are
2 enrolled in the managed care pilot program plans and shall
3 continue for 24 months thereafter. The evaluation must include
4 assessments of each managed care plan in the integrated
5 program with regard to cost savings; consumer education,
6 choice, and access to services; coordination of care; and
7 quality of care. The evaluation must describe administrative
8 or legal barriers to the implementation and operation of the
9 pilot program and include recommendations regarding statewide
10 expansion of the pilot program. The office shall submit its an
11 evaluation report to the Governor, the President of the
12 Senate, and the Speaker of the House of Representatives no
13 later than December 31, 2009 June 30, 2008.
14 (e) The agency may seek federal waivers or Medicaid
15 state plan amendments and adopt rules as necessary to
16 administer the integrated program system. The agency may
17 implement the approved federal waivers and other provisions as
18 specified in this subsection must receive specific
19 authorization from the Legislature prior to implementing the
20 waiver for the integrated system.
21 (f) No later than December 31, 2007, the agency shall
22 provide a report to the Governor, the President of the Senate,
23 and the Speaker of the House of Representatives containing an
24 analysis of the merits and challenges of seeking a waiver to
25 implement a voluntary program that integrates payments and
26 services for dually enrolled Medicare and Medicaid recipients
27 who are 65 years of age or older.
28 Section 2. Paragraph (d) of subsection (1) of section
29 408.040, Florida Statutes, is amended to read:
30 408.040 Conditions and monitoring.--
31 (1)
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Florida Senate - 2007 CONFERENCE COMMITTEE AMENDMENT
Bill No. HB 7065, 1st Eng.
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1 (d) If a nursing home is located in a county in which
2 a long-term care community diversion pilot project has been
3 implemented under s. 430.705 or in a county in which an
4 integrated, fixed-payment delivery program system for Medicaid
5 recipients who are 60 years of age or older or dually eligible
6 for Medicare and Medicaid has been implemented under s.
7 409.912(5), the nursing home may request a reduction in the
8 percentage of annual patient days used by residents who are
9 eligible for care under Title XIX of the Social Security Act,
10 which is a condition of the nursing home's certificate of
11 need. The agency shall automatically grant the nursing home's
12 request if the reduction is not more than 15 percent of the
13 nursing home's annual Medicaid-patient-days condition. A
14 nursing home may submit only one request every 2 years for an
15 automatic reduction. A requesting nursing home must notify the
16 agency in writing at least 60 days in advance of its intent to
17 reduce its annual Medicaid-patient-days condition by not more
18 than 15 percent. The agency must acknowledge the request in
19 writing and must change its records to reflect the revised
20 certificate-of-need condition. This paragraph expires June 30,
21 2011.
22 Section 3. Paragraph (b) of subsection (1) of section
23 409.915, Florida Statutes, is amended to read:
24 409.915 County contributions to Medicaid.--Although
25 the state is responsible for the full portion of the state
26 share of the matching funds required for the Medicaid program,
27 in order to acquire a certain portion of these funds, the
28 state shall charge the counties for certain items of care and
29 service as provided in this section.
30 (1) Each county shall participate in the following
31 items of care and service:
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Florida Senate - 2007 CONFERENCE COMMITTEE AMENDMENT
Bill No. HB 7065, 1st Eng.
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1 (b) For both health maintenance members and
2 fee-for-service beneficiaries, payments for nursing home or
3 intermediate facilities care in excess of $170 per month, with
4 the exception of skilled nursing care for children under age
5 21.
6 Section 4. This act shall take effect July 1, 2007.
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10 And the title is amended as follows:
11 Delete everything before the enacting clause
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13 and insert:
14 A bill to be entitled
15 An act relating to Medicaid; amending s.
16 409.912, F.S.; requiring the Agency for Health
17 Care Administration to implement federal
18 waivers to administer an integrated,
19 fixed-payment delivery program for Medicaid
20 recipients 60 years of age or older or dually
21 eligible for Medicare and Medicaid; providing
22 for voluntary enrollment in the program in
23 specified locations, in accordance with certain
24 requirements; providing eligibility for managed
25 care entities to operate the program; providing
26 for entities to choose to serve certain
27 enrollees; providing for the establishment of
28 informal and formal provider grievance systems;
29 requiring payment of certain nursing home
30 claims within a time certain; providing a
31 timeframe for evaluation of the program by the
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Bill No. HB 7065, 1st Eng.
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1 Office of Program Policy Analysis and
2 Government Accountability; extending the
3 deadline for submission of the evaluation
4 report; authorizing the agency to seek Medicaid
5 state plan amendments; requiring the agency to
6 submit a report to the Governor and the
7 Legislature; amending s. 408.040, F.S.;
8 conforming terminology to changes made by the
9 act; amending s. 409.915, F.S.; requiring
10 counties to participate in Medicaid payments
11 for certain nursing home or intermediate
12 facilities care for both health maintenance
13 members and fee-for-service beneficiaries;
14 providing an effective date.
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