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

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