(LATE FILED)	Amendment
Bill No. 7065

Amendment No. 488687

CHAMBER ACTION
Senate		House
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1	Representative(s) Zapata, R. Garcia, Seiler, Schwartz, Ausley,
2	and Bean offered the following:
3
4	Substitute Amendment for Amendment (001575) (with title
5	amendment)
6	Remove line(s) 96-223 and insert:
7	program system for Medicaid recipients who are 60 years of age
8	or older or dually eligible for Medicare and Medicaid. The
9	Agency for Health Care Administration shall implement the
10	integrated program system initially on a pilot basis in two
11	areas of the state. The pilot areas shall be Area 7 and Area 11
12	of the Agency for Health Care Administration. In one of the
13	areas Enrollment in the pilot areas shall be on a voluntary
14	basis and in accordance with approved federal waivers and this
15	section. The agency and its program contractors and providers
16	shall not enroll any individual in the integrated program
17	because the individual or the person legally responsible for the
18	individual fails to choose to enroll in the integrated program.
19	Enrollment in the integrated program shall be exclusively by
20	affirmative choice of the eligible individual or by the person
21	legally responsible for the individual. The integrated program
22	must transfer all Medicaid services for eligible elderly
23	individuals who choose to participate into an integrated-care
24	management model designed to serve Medicaid recipients in the
25	community. The integrated program must combine all funding for
26	Medicaid services provided to individuals who are 60 years of
27	age or older or dually eligible for Medicare and Medicaid into
28	the integrated program system, including funds for Medicaid home
29	and community-based waiver services; all Medicaid services
30	authorized in ss. 409.905 and 409.906, excluding funds for
31	Medicaid nursing home services unless the agency is able to
32	demonstrate how the integration of the funds will improve
33	coordinated care for these services in a less costly manner; and
34	Medicare coinsurance and deductibles for persons dually eligible
35	for Medicaid and Medicare as prescribed in s. 409.908(13).
36	(a)  Individuals who are 60 years of age or older or dually
37	eligible for Medicare and Medicaid and enrolled in the
38	developmental disabilities waiver program, the family and
39	supported-living waiver program, the project AIDS care waiver
40	program, the traumatic brain injury and spinal cord injury
41	waiver program, the consumer-directed care waiver program, and
42	the program of all-inclusive care for the elderly program, and
43	residents of institutional care facilities for the
44	developmentally disabled, must be excluded from the integrated
45	program system.
46	(b)  The integrated program shall must use a competitive
47	procurement process to select managed care entities who meet or
48	exceed the agency's minimum standards to operate the integrated
49	program system. For the purpose of this section, managed care
50	entities shall be considered prepaid health plans as provided in
51	s. 408.7056(1)(e). Entities eligible to submit bids include
52	managed care organizations licensed under chapter 641, including
53	entities eligible to participate in the nursing home diversion
54	program, other qualified providers as defined in s. 430.703(7),
55	community care for the elderly lead agencies, and other state-
56	certified community service networks that meet comparable
57	standards as defined by the agency, in consultation with the
58	Department of Elderly Affairs and the Office of Insurance
59	Regulation, to be financially solvent and able to take on
60	financial risk for managed care. Community service networks that
61	are certified pursuant to the comparable standards defined by
62	the agency are not required to be licensed under chapter 641.
63	Eligible entities shall choose to serve enrollees who are dually
64	eligible for Medicare and Medicaid, enrollees who are 60 years
65	of age or older, or both.
66	(c)  The agency must ensure that the capitation-rate-
67	setting methodology for the integrated program system is
68	actuarially sound and reflects the intent to provide quality
69	care in the least restrictive setting. The agency must also
70	require integrated-program integrated-system providers to
71	develop a credentialing system for service providers and to
72	contract with all Gold Seal nursing homes, where feasible, and
73	exclude, where feasible, chronically poor-performing facilities
74	and providers as defined by the agency. The integrated program
75	must develop and maintain an informal provider grievance system
76	that addresses provider payment and contract problems. The
77	agency shall also establish a formal grievance system to address
78	those issues that were not resolved through the informal
79	grievance system. The integrated program system must provide
80	that if the recipient resides in a noncontracted residential
81	facility licensed under chapter 400 or chapter 429 at the time
82	of enrollment in the integrated program system is initiated, the
83	recipient must be permitted to continue to reside in the
84	noncontracted facility as long as the recipient desires. The
85	integrated program system must also provide that, in the absence
86	of a contract between the integrated-program integrated-system
87	provider and the residential facility licensed under chapter 400
88	or chapter 429, current Medicaid rates must prevail. The
89	integrated-program provider must ensure that electronic nursing
90	home claims that contain sufficient information for processing
91	are paid within 10 business days after receipt. Alternately, the
92	integrated-program provider may establish a capitated payment
93	mechanism to prospectively pay nursing homes at the beginning of
94	each month. The agency and the Department of Elderly Affairs
95	must jointly develop procedures to manage the services provided
96	through the integrated program system in order to ensure quality
97	and recipient choice.
98	(d)  Within 24 months after implementation, The Office of
99	Program Policy Analysis and Government Accountability, in
100	consultation with the Auditor General, shall comprehensively
101	evaluate the pilot project for the integrated, fixed-payment
102	delivery program system for Medicaid recipients created under
103	this subsection who are 60 years of age or older. The evaluation
104	shall begin as soon as Medicaid recipients are enrolled in the
105	managed care pilot program plans and shall continue for 24
106	months thereafter. The evaluation must include assessments of
107	each managed care plan in the integrated program with regard to
108	cost savings; consumer education, choice, and access to
109	services; coordination of care; and quality of care. The
110	evaluation must describe administrative or legal barriers to the
111	implementation and operation of the pilot program and include
112	recommendations regarding statewide expansion of the pilot
113	program. The office shall submit its an evaluation report to the
114	Governor, the President of the Senate, and the Speaker of the
115	House of Representatives no later than December 31, 2009 June
116	30, 2008.
117	(e)  The agency may seek federal waivers or Medicaid state
118	plan amendments and adopt rules as necessary to administer the
119	integrated program system. The agency may implement the approved
120	federal waivers and other provisions as specified in this
121	subsection must receive specific authorization from the
122	Legislature prior to implementing the waiver for the integrated
123	system.
124	(f)  No later than December 31, 2007, the agency shall
125	provide a report to the President of the Senate and the Speaker
126	of the House of Representatives containing an analysis of the
127	merits and challenges of seeking a waiver to implement a
128	voluntary program that integrates payments and services for
129	dually enrolled Medicare and Medicaid recipients who are 65
130	years of age or older.
131	Section 2.  Paragraph (d) of subsection (1) of section
132	408.040, Florida Statutes, is amended to read:
133	408.040  Conditions and monitoring.--
134	(1)
135	(d)  If a nursing home is located in a county in which a
136	long-term care community diversion pilot project has been
137	implemented under s. 430.705 or in a county in which an
138	integrated, fixed-payment delivery program system for Medicaid
139	recipients who are 60 years of age or older or dually eligible
140	for Medicare and Medicaid has been implemented
141
142	=========== T I T L E  A M E N D M E N T ========
143	Remove line(s) 6-11 and insert:
144	years of age or older or dually eligible for Medicare and
145	Medicaid; providing for voluntary enrollment in the program in
146	specified locations, in accordance with certain requirements;
147	requiring selection of managed care entities to operate the
148	program; providing that such managed care entities shall be
149	considered prepaid health plans; providing for entities to
150	choose to serve certain enrollees; providing for the
151	establishment of informal and

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