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

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