HB 7065

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
27	Be It Enacted by the Legislature of the State of Florida:
28
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.

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