1 | A bill to be entitled |
2 | An act relating to Medicaid; amending s. 409.912, F.S.; |
3 | requiring the Agency for Health Care Administration to |
4 | implement federal waivers to administer an integrated, |
5 | fixed-payment delivery program for Medicaid recipients 60 |
6 | years of age or older; providing for voluntary enrollment |
7 | in the program in specified locations, in accordance with |
8 | certain requirements; requiring selection of managed care |
9 | entities to operate the program; providing that such |
10 | managed care entities shall be considered prepaid health |
11 | plans; providing for the establishment of informal and |
12 | formal provider grievance systems; requiring payment of |
13 | certain nursing home claims within a time certain; |
14 | providing a timeframe for evaluation of the program by the |
15 | Office of Program Policy Analysis and Government |
16 | Accountability; extending the deadline for submission of |
17 | the evaluation report; authorizing the agency to seek |
18 | Medicaid state plan amendments; requiring the agency to |
19 | submit a report to the Legislature; amending s. 408.040, |
20 | F.S.; conforming terminology to changes made by the act; |
21 | amending s. 409.915, F.S.; requiring counties to |
22 | participate in Medicaid payments for certain nursing home |
23 | or intermediate facilities care for both health |
24 | maintenance members and fee-for-service beneficiaries; |
25 | providing an effective date. |
26 |
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27 | Be It Enacted by the Legislature of the State of Florida: |
28 |
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29 | Section 1. Subsection (5) of section 409.912, Florida |
30 | Statutes, is amended to read: |
31 | 409.912 Cost-effective purchasing of health care.--The |
32 | agency shall purchase goods and services for Medicaid recipients |
33 | in the most cost-effective manner consistent with the delivery |
34 | of quality medical care. To ensure that medical services are |
35 | effectively utilized, the agency may, in any case, require a |
36 | confirmation or second physician's opinion of the correct |
37 | diagnosis for purposes of authorizing future services under the |
38 | Medicaid program. This section does not restrict access to |
39 | emergency services or poststabilization care services as defined |
40 | in 42 C.F.R. part 438.114. Such confirmation or second opinion |
41 | shall be rendered in a manner approved by the agency. The agency |
42 | shall maximize the use of prepaid per capita and prepaid |
43 | aggregate fixed-sum basis services when appropriate and other |
44 | alternative service delivery and reimbursement methodologies, |
45 | including competitive bidding pursuant to s. 287.057, designed |
46 | to facilitate the cost-effective purchase of a case-managed |
47 | continuum of care. The agency shall also require providers to |
48 | minimize the exposure of recipients to the need for acute |
49 | inpatient, custodial, and other institutional care and the |
50 | inappropriate or unnecessary use of high-cost services. The |
51 | agency shall contract with a vendor to monitor and evaluate the |
52 | clinical practice patterns of providers in order to identify |
53 | trends that are outside the normal practice patterns of a |
54 | provider's professional peers or the national guidelines of a |
55 | provider's professional association. The vendor must be able to |
56 | provide information and counseling to a provider whose practice |
57 | patterns are outside the norms, in consultation with the agency, |
58 | to improve patient care and reduce inappropriate utilization. |
59 | The agency may mandate prior authorization, drug therapy |
60 | management, or disease management participation for certain |
61 | populations of Medicaid beneficiaries, certain drug classes, or |
62 | particular drugs to prevent fraud, abuse, overuse, and possible |
63 | dangerous drug interactions. The Pharmaceutical and Therapeutics |
64 | Committee shall make recommendations to the agency on drugs for |
65 | which prior authorization is required. The agency shall inform |
66 | the Pharmaceutical and Therapeutics Committee of its decisions |
67 | regarding drugs subject to prior authorization. The agency is |
68 | authorized to limit the entities it contracts with or enrolls as |
69 | Medicaid providers by developing a provider network through |
70 | provider credentialing. The agency may competitively bid single- |
71 | source-provider contracts if procurement of goods or services |
72 | results in demonstrated cost savings to the state without |
73 | limiting access to care. The agency may limit its network based |
74 | on the assessment of beneficiary access to care, provider |
75 | availability, provider quality standards, time and distance |
76 | standards for access to care, the cultural competence of the |
77 | provider network, demographic characteristics of Medicaid |
78 | beneficiaries, practice and provider-to-beneficiary standards, |
79 | appointment wait times, beneficiary use of services, provider |
80 | turnover, provider profiling, provider licensure history, |
81 | previous program integrity investigations and findings, peer |
82 | review, provider Medicaid policy and billing compliance records, |
83 | clinical and medical record audits, and other factors. Providers |
84 | shall not be entitled to enrollment in the Medicaid provider |
85 | network. The agency shall determine instances in which allowing |
86 | Medicaid beneficiaries to purchase durable medical equipment and |
87 | other goods is less expensive to the Medicaid program than long- |
88 | term rental of the equipment or goods. The agency may establish |
89 | rules to facilitate purchases in lieu of long-term rentals in |
90 | order to protect against fraud and abuse in the Medicaid program |
91 | as defined in s. 409.913. The agency may seek federal waivers |
92 | necessary to administer these policies. |
93 | (5) By December 1, 2005, The Agency for Health Care |
94 | Administration, in partnership with the Department of Elderly |
95 | Affairs, shall create an integrated, fixed-payment delivery |
96 | program system for Medicaid recipients who are 60 years of age |
97 | or older. The Agency for Health Care Administration shall |
98 | implement the integrated program system initially on a pilot |
99 | basis in two areas of the state. The pilot areas shall be Area 7 |
100 | and Area 11 of the Agency for Health Care Administration. In one |
101 | of the areas Enrollment in the pilot areas shall be on a |
102 | voluntary basis and in accordance with approved federal waivers |
103 | and this section. The agency and its program contractors and |
104 | providers shall not enroll any individual in the integrated |
105 | program because the individual or the person legally responsible |
106 | for the individual fails to choose to enroll in the integrated |
107 | program. Enrollment in the integrated program shall be |
108 | exclusively by affirmative choice of the eligible individual or |
109 | by the person legally responsible for the individual. The |
110 | integrated program must transfer all Medicaid services for |
111 | eligible elderly individuals who choose to participate into an |
112 | integrated-care management model designed to serve Medicaid |
113 | recipients in the community. The integrated program must combine |
114 | all funding for Medicaid services provided to individuals 60 |
115 | years of age or older into the integrated program system, |
116 | including funds for Medicaid home and community-based waiver |
117 | services; all Medicaid services authorized in ss. 409.905 and |
118 | 409.906, excluding funds for Medicaid nursing home services |
119 | unless the agency is able to demonstrate how the integration of |
120 | the funds will improve coordinated care for these services in a |
121 | less costly manner; and Medicare coinsurance and deductibles for |
122 | persons dually eligible for Medicaid and Medicare as prescribed |
123 | in s. 409.908(13). |
124 | (a) Individuals who are 60 years of age or older and |
125 | enrolled in the developmental disabilities waiver program, the |
126 | family and supported-living waiver program, the project AIDS |
127 | care waiver program, the traumatic brain injury and spinal cord |
128 | injury waiver program, the consumer-directed care waiver |
129 | program, and the program of all-inclusive care for the elderly |
130 | program, and residents of institutional care facilities for the |
131 | developmentally disabled, must be excluded from the integrated |
132 | program system. |
133 | (b) The integrated program shall must use a competitive |
134 | procurement process to select managed care entities who meet or |
135 | exceed the agency's minimum standards to operate the integrated |
136 | program system. For the purpose of this section, managed care |
137 | entities shall be considered prepaid health plans as provided in |
138 | s. 408.7056(1)(e). Entities eligible to submit bids include |
139 | managed care organizations licensed under chapter 641, including |
140 | entities eligible to participate in the nursing home diversion |
141 | program, other qualified providers as defined in s. 430.703(7), |
142 | community care for the elderly lead agencies, and other state- |
143 | certified community service networks that meet comparable |
144 | standards as defined by the agency, in consultation with the |
145 | Department of Elderly Affairs and the Office of Insurance |
146 | Regulation, to be financially solvent and able to take on |
147 | financial risk for managed care. Community service networks that |
148 | are certified pursuant to the comparable standards defined by |
149 | the agency are not required to be licensed under chapter 641. |
150 | (c) The agency must ensure that the capitation-rate- |
151 | setting methodology for the integrated program system is |
152 | actuarially sound and reflects the intent to provide quality |
153 | care in the least restrictive setting. The agency must also |
154 | require integrated-program integrated-system providers to |
155 | develop a credentialing system for service providers and to |
156 | contract with all Gold Seal nursing homes, where feasible, and |
157 | exclude, where feasible, chronically poor-performing facilities |
158 | and providers as defined by the agency. The integrated program |
159 | must develop and maintain an informal provider grievance system |
160 | that addresses provider payment and contract problems. The |
161 | agency shall also establish a formal grievance system to address |
162 | those issues that were not resolved through the informal |
163 | grievance system. The integrated program system must provide |
164 | that if the recipient resides in a noncontracted residential |
165 | facility licensed under chapter 400 or chapter 429 at the time |
166 | of enrollment in the integrated program system is initiated, the |
167 | recipient must be permitted to continue to reside in the |
168 | noncontracted facility as long as the recipient desires. The |
169 | integrated program system must also provide that, in the absence |
170 | of a contract between the integrated-program integrated-system |
171 | provider and the residential facility licensed under chapter 400 |
172 | or chapter 429, current Medicaid rates must prevail. The |
173 | integrated-program provider must ensure that electronic nursing |
174 | home claims that contain sufficient information for processing |
175 | are paid within 10 business days after receipt. Alternately, the |
176 | integrated-program provider may establish a capitated payment |
177 | mechanism to prospectively pay nursing homes at the beginning of |
178 | each month. The agency and the Department of Elderly Affairs |
179 | must jointly develop procedures to manage the services provided |
180 | through the integrated program system in order to ensure quality |
181 | and recipient choice. |
182 | (d) Within 24 months after implementation, The Office of |
183 | Program Policy Analysis and Government Accountability, in |
184 | consultation with the Auditor General, shall comprehensively |
185 | evaluate the pilot project for the integrated, fixed-payment |
186 | delivery program system for Medicaid recipients created under |
187 | this subsection who are 60 years of age or older. The evaluation |
188 | shall begin as soon as Medicaid recipients are enrolled in the |
189 | managed care pilot program plans and shall continue for 24 |
190 | months thereafter. The evaluation must include assessments of |
191 | each managed care plan in the integrated program with regard to |
192 | cost savings; consumer education, choice, and access to |
193 | services; coordination of care; and quality of care. The |
194 | evaluation must describe administrative or legal barriers to the |
195 | implementation and operation of the pilot program and include |
196 | recommendations regarding statewide expansion of the pilot |
197 | program. The office shall submit its an evaluation report to the |
198 | Governor, the President of the Senate, and the Speaker of the |
199 | House of Representatives no later than December 31, 2009 June |
200 | 30, 2008. |
201 | (e) The agency may seek federal waivers or Medicaid state |
202 | plan amendments and adopt rules as necessary to administer the |
203 | integrated program system. The agency may implement the approved |
204 | federal waivers and other provisions as specified in this |
205 | subsection must receive specific authorization from the |
206 | Legislature prior to implementing the waiver for the integrated |
207 | system. |
208 | (f) No later than December 31, 2007, the agency shall |
209 | provide a report to the President of the Senate and the Speaker |
210 | of the House of Representatives containing an analysis of the |
211 | merits and challenges of seeking a waiver to implement a |
212 | voluntary program that integrates payments and services for |
213 | dually enrolled Medicare and Medicaid recipients who are 65 |
214 | years of age or older. |
215 | Section 2. Paragraph (d) of subsection (1) of section |
216 | 408.040, Florida Statutes, is amended to read: |
217 | 408.040 Conditions and monitoring.-- |
218 | (1) |
219 | (d) If a nursing home is located in a county in which a |
220 | long-term care community diversion pilot project has been |
221 | implemented under s. 430.705 or in a county in which an |
222 | integrated, fixed-payment delivery program system for Medicaid |
223 | recipients who are 60 years of age or older has been implemented |
224 | under s. 409.912(5), the nursing home may request a reduction in |
225 | the percentage of annual patient days used by residents who are |
226 | eligible for care under Title XIX of the Social Security Act, |
227 | which is a condition of the nursing home's certificate of need. |
228 | The agency shall automatically grant the nursing home's request |
229 | if the reduction is not more than 15 percent of the nursing |
230 | home's annual Medicaid-patient-days condition. A nursing home |
231 | may submit only one request every 2 years for an automatic |
232 | reduction. A requesting nursing home must notify the agency in |
233 | writing at least 60 days in advance of its intent to reduce its |
234 | annual Medicaid-patient-days condition by not more than 15 |
235 | percent. The agency must acknowledge the request in writing and |
236 | must change its records to reflect the revised certificate-of- |
237 | need condition. This paragraph expires June 30, 2011. |
238 | Section 3. Paragraph (b) of subsection (1) of section |
239 | 409.915, Florida Statutes, is amended to read: |
240 | 409.915 County contributions to Medicaid.--Although the |
241 | state is responsible for the full portion of the state share of |
242 | the matching funds required for the Medicaid program, in order |
243 | to acquire a certain portion of these funds, the state shall |
244 | charge the counties for certain items of care and service as |
245 | provided in this section. |
246 | (1) Each county shall participate in the following items |
247 | of care and service: |
248 | (b) For both health maintenance members and fee-for- |
249 | service beneficiaries, payments for nursing home or intermediate |
250 | facilities care in excess of $170 per month, with the exception |
251 | of skilled nursing care for children under age 21. |
252 | Section 4. This act shall take effect July 1, 2007. |