Senate Bill sb0012Cc1
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By the Committee on Health and Human Services Appropriations;
and Senator Peaden
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1 A bill to be entitled
2 An act relating to health care; amending s.
3 393.0661, F.S.; providing for additional hours
4 to be authorized under the personal care
5 assistance services provided pursuant to a
6 federal waiver program and administered by the
7 Agency for Health Care Administration;
8 repealing proviso language contained in
9 Specific Appropriation 270 in chapter 2007-72,
10 Laws of Florida, to conform; amending s.
11 395.701, F.S.; clarifying provisions imposing
12 an assessment on hospital outpatient services;
13 specifying assessment amounts; amending s.
14 409.912, F.S.; providing for certain children
15 who are eligible for Medicaid and who reside
16 within a specified service area of the Agency
17 for Health Care Administration to be served
18 under a service delivery mechanism other than
19 the HomeSafeNet system; amending s. 409.9122,
20 F.S.; requiring that the agency give certain
21 providers priority with respect to the
22 assignment of enrollees under the Medicaid
23 managed prepaid health plan; deleting a
24 requirement that certain recipients of
25 comprehensive behavioral health services be
26 assigned to MediPass or a managed care plan;
27 amending s. 409.91211, F.S.; clarifying the
28 duties of the agency for implementing service
29 delivery mechanisms for certain children who
30 are eligible for Medicaid; providing effective
31 dates.
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1 Be It Enacted by the Legislature of the State of Florida:
2
3 Section 1. Paragraph (f) of subsection (3) of section
4 393.0661, Florida Statutes, is amended to read:
5 393.0661 Home and community-based services delivery
6 system; comprehensive redesign.--The Legislature finds that
7 the home and community-based services delivery system for
8 persons with developmental disabilities and the availability
9 of appropriated funds are two of the critical elements in
10 making services available. Therefore, it is the intent of the
11 Legislature that the Agency for Persons with Disabilities
12 shall develop and implement a comprehensive redesign of the
13 system.
14 (3) The Agency for Health Care Administration, in
15 consultation with the agency, shall seek federal approval and
16 implement a four-tiered waiver system to serve clients with
17 developmental disabilities in the developmental disabilities
18 and family and supported living waivers. The agency shall
19 assign all clients receiving services through the
20 developmental disabilities waiver to a tier based on a valid
21 assessment instrument, client characteristics, and other
22 appropriate assessment methods. All services covered under the
23 current developmental disabilities waiver shall be available
24 to all clients in all tiers where appropriate, except as
25 otherwise provided in this subsection or in the General
26 Appropriations Act.
27 (f) The agency shall seek federal waivers and amend
28 contracts as necessary to make changes to services defined in
29 federal waiver programs administered by the agency as follows:
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1 1. Supported living coaching services shall not exceed
2 20 hours per month for persons who also receive in-home
3 support services.
4 2. Limited support coordination services shall be the
5 only type of support coordination service provided to persons
6 under the age of 18 who live in the family home.
7 3. Personal care assistance services shall be limited
8 to no more than 180 hours per calendar month and shall not
9 include rate modifiers. Additional hours may be authorized for
10 persons who have intensive medical or adaptive needs and if
11 such hours are essential for avoiding institutionalization, or
12 for persons who possess behavioral problems that are
13 exceptional in intensity, duration, or frequency and present a
14 substantial risk of harming themselves or others. Additional
15 hours may be authorized only if a substantial change in
16 circumstances occurs for the individual.
17 4. Residential habilitation services shall be limited
18 to 8 hours per day. Additional hours may be authorized for
19 persons who have intensive medical or adaptive needs and if
20 such hours are essential for avoiding institutionalization, or
21 for persons who possess behavioral problems that are
22 exceptional in intensity, duration, or frequency and present a
23 substantial risk of harming themselves or others. This
24 restriction shall be in effect until the four-tiered waiver
25 system is fully implemented.
26 5. Chore Services, nonresidential support services,
27 and homemaker services shall be eliminated. The agency shall
28 expand the definition of in-home support services to enable
29 the provider of the service to include activities previously
30 provided in these eliminated services.
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1 6. Massage therapy and psychological assessment
2 services shall be eliminated.
3 7. The agency shall conduct supplemental cost plan
4 reviews to verify the medical necessity of authorized services
5 for plans that have increased by more than 8 percent during
6 either of the 2 preceding fiscal years.
7 8. The agency shall implement a consolidated
8 residential habilitation rate structure to increase savings to
9 the state through a more cost-effective payment method and
10 establish uniform rates for intensive behavioral residential
11 habilitation services.
12 9. Pending federal approval, the agency is authorized
13 to extend current support plans for clients receiving services
14 under Medicaid waivers for 1 year beginning July 1, 2007, or
15 from the date approved, whichever is later. Clients who have a
16 substantial change in circumstances which threatens their
17 health and safety may be reassessed during this year in order
18 to determine the necessity for a change in their support plan.
19 Section 2. The following proviso associated with
20 Specific Appropriation 270 in chapter 2007-72, Laws of
21 Florida, is repealed: "Personal Care Assistance services shall
22 be limited to no more than 180 hours per calendar month and
23 shall not include rate modifiers. Additional hours may be
24 authorized only if a substantial change in circumstances
25 occurs for the individual."
26 Section 3. Subsection (2) of section 395.701, Florida
27 Statutes, is amended to read:
28 395.701 Annual assessments on net operating revenues
29 for inpatient and outpatient services to fund public medical
30 assistance; administrative fines for failure to pay
31 assessments when due; exemption.--
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1 (2)(a) There is imposed upon each hospital an
2 assessment in an amount equal to 1.5 percent of the annual net
3 operating revenue for inpatient services for each hospital,
4 such revenue to be determined by the agency, based on the
5 actual experience of the hospital as reported to the agency.
6 Within 6 months after the end of each hospital fiscal year,
7 the agency shall certify the amount of the assessment for each
8 hospital. The assessment shall be payable to and collected by
9 the agency in equal quarterly amounts, on or before the first
10 day of each calendar quarter, beginning with the first full
11 calendar quarter that occurs after the agency certifies the
12 amount of the assessment for each hospital. All moneys
13 collected pursuant to this subsection shall be deposited into
14 the Public Medical Assistance Trust Fund.
15 (b) There is imposed upon each hospital an assessment
16 in an amount equal to 1 percent of the annual net operating
17 revenue for outpatient services for each hospital, such
18 revenue to be determined by the agency, based on the actual
19 experience of the hospital as reported to the agency. While
20 prior year report worksheets may be reconciled to the
21 hospital's audited financial statements, no additional audited
22 financial components may be required for the purposes of
23 determining the amount of the assessment imposed pursuant to
24 this section other than those in effect on July 1, 2000.
25 Within 6 months after the end of each hospital fiscal year,
26 the agency shall certify the amount of the assessment for each
27 hospital. The assessment shall be payable to and collected by
28 the agency in equal quarterly amounts, on or before the first
29 day of each calendar quarter, beginning with the first full
30 calendar quarter that occurs after the agency certifies the
31 amount of the assessment for each hospital. All moneys
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1 collected pursuant to this subsection shall be deposited into
2 the Public Medical Assistance Trust Fund.
3 (c) The reduced assessment on hospital outpatient
4 services contained in section 16 of chapter 2000-256, Laws of
5 Florida, shall be imposed upon the annual net operating
6 revenue for outpatient services for each hospital for each
7 hospital fiscal year beginning on or after July 1, 2000. For
8 each hospital fiscal year beginning before July 1, 2000, an
9 assessment in an amount equal to 1.5 percent, as required by
10 s. 395.701, Florida Statutes (2000), shall be imposed. This
11 paragraph clarifies the law as it has existed since July 1,
12 2000.
13 Section 4. Paragraph (b) of subsection (4) of section
14 409.912, Florida Statutes, is amended to read:
15 409.912 Cost-effective purchasing of health care.--The
16 agency shall purchase goods and services for Medicaid
17 recipients in the most cost-effective manner consistent with
18 the delivery of quality medical care. To ensure that medical
19 services are effectively utilized, the agency may, in any
20 case, require a confirmation or second physician's opinion of
21 the correct diagnosis for purposes of authorizing future
22 services under the Medicaid program. This section does not
23 restrict access to emergency services or poststabilization
24 care services as defined in 42 C.F.R. part 438.114. Such
25 confirmation or second opinion shall be rendered in a manner
26 approved by the agency. The agency shall maximize the use of
27 prepaid per capita and prepaid aggregate fixed-sum basis
28 services when appropriate and other alternative service
29 delivery and reimbursement methodologies, including
30 competitive bidding pursuant to s. 287.057, designed to
31 facilitate the cost-effective purchase of a case-managed
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1 continuum of care. The agency shall also require providers to
2 minimize the exposure of recipients to the need for acute
3 inpatient, custodial, and other institutional care and the
4 inappropriate or unnecessary use of high-cost services. The
5 agency shall contract with a vendor to monitor and evaluate
6 the clinical practice patterns of providers in order to
7 identify trends that are outside the normal practice patterns
8 of a provider's professional peers or the national guidelines
9 of a provider's professional association. The vendor must be
10 able to provide information and counseling to a provider whose
11 practice patterns are outside the norms, in consultation with
12 the agency, to improve patient care and reduce inappropriate
13 utilization. The agency may mandate prior authorization, drug
14 therapy management, or disease management participation for
15 certain populations of Medicaid beneficiaries, certain drug
16 classes, or particular drugs to prevent fraud, abuse, overuse,
17 and possible dangerous drug interactions. The Pharmaceutical
18 and Therapeutics Committee shall make recommendations to the
19 agency on drugs for which prior authorization is required. The
20 agency shall inform the Pharmaceutical and Therapeutics
21 Committee of its decisions regarding drugs subject to prior
22 authorization. The agency is authorized to limit the entities
23 it contracts with or enrolls as Medicaid providers by
24 developing a provider network through provider credentialing.
25 The agency may competitively bid single-source-provider
26 contracts if procurement of goods or services results in
27 demonstrated cost savings to the state without limiting access
28 to care. The agency may limit its network based on the
29 assessment of beneficiary access to care, provider
30 availability, provider quality standards, time and distance
31 standards for access to care, the cultural competence of the
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1 provider network, demographic characteristics of Medicaid
2 beneficiaries, practice and provider-to-beneficiary standards,
3 appointment wait times, beneficiary use of services, provider
4 turnover, provider profiling, provider licensure history,
5 previous program integrity investigations and findings, peer
6 review, provider Medicaid policy and billing compliance
7 records, clinical and medical record audits, and other
8 factors. Providers shall not be entitled to enrollment in the
9 Medicaid provider network. The agency shall determine
10 instances in which allowing Medicaid beneficiaries to purchase
11 durable medical equipment and other goods is less expensive to
12 the Medicaid program than long-term rental of the equipment or
13 goods. The agency may establish rules to facilitate purchases
14 in lieu of long-term rentals in order to protect against fraud
15 and abuse in the Medicaid program as defined in s. 409.913.
16 The agency may seek federal waivers necessary to administer
17 these policies.
18 (4) The agency may contract with:
19 (b) An entity that is providing comprehensive
20 behavioral health care services to certain Medicaid recipients
21 through a capitated, prepaid arrangement pursuant to the
22 federal waiver provided for by s. 409.905(5). Such an entity
23 must be licensed under chapter 624, chapter 636, or chapter
24 641 and must possess the clinical systems and operational
25 competence to manage risk and provide comprehensive behavioral
26 health care to Medicaid recipients. As used in this paragraph,
27 the term "comprehensive behavioral health care services" means
28 covered mental health and substance abuse treatment services
29 that are available to Medicaid recipients. The secretary of
30 the Department of Children and Family Services shall approve
31 provisions of procurements related to children in the
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1 department's care or custody prior to enrolling such children
2 in a prepaid behavioral health plan. Any contract awarded
3 under this paragraph must be competitively procured. In
4 developing the behavioral health care prepaid plan procurement
5 document, the agency shall ensure that the procurement
6 document requires the contractor to develop and implement a
7 plan to ensure compliance with s. 394.4574 related to services
8 provided to residents of licensed assisted living facilities
9 that hold a limited mental health license. Except as provided
10 in subparagraph 8., and except in counties where the Medicaid
11 managed care pilot program is authorized pursuant to s.
12 409.91211, the agency shall seek federal approval to contract
13 with a single entity meeting these requirements to provide
14 comprehensive behavioral health care services to all Medicaid
15 recipients not enrolled in a Medicaid managed care plan
16 authorized under s. 409.91211 or a Medicaid health maintenance
17 organization in an AHCA area. In an AHCA area where the
18 Medicaid managed care pilot program is authorized pursuant to
19 s. 409.91211 in one or more counties, the agency may procure a
20 contract with a single entity to serve the remaining counties
21 as an AHCA area or the remaining counties may be included with
22 an adjacent AHCA area and shall be subject to this paragraph.
23 Each entity must offer sufficient choice of providers in its
24 network to ensure recipient access to care and the opportunity
25 to select a provider with whom they are satisfied. The network
26 shall include all public mental health hospitals. To ensure
27 unimpaired access to behavioral health care services by
28 Medicaid recipients, all contracts issued pursuant to this
29 paragraph shall require 80 percent of the capitation paid to
30 the managed care plan, including health maintenance
31 organizations, to be expended for the provision of behavioral
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1 health care services. In the event the managed care plan
2 expends less than 80 percent of the capitation paid pursuant
3 to this paragraph for the provision of behavioral health care
4 services, the difference shall be returned to the agency. The
5 agency shall provide the managed care plan with a
6 certification letter indicating the amount of capitation paid
7 during each calendar year for the provision of behavioral
8 health care services pursuant to this section. The agency may
9 reimburse for substance abuse treatment services on a
10 fee-for-service basis until the agency finds that adequate
11 funds are available for capitated, prepaid arrangements.
12 1. By January 1, 2001, the agency shall modify the
13 contracts with the entities providing comprehensive inpatient
14 and outpatient mental health care services to Medicaid
15 recipients in Hillsborough, Highlands, Hardee, Manatee, and
16 Polk Counties, to include substance abuse treatment services.
17 2. By July 1, 2003, the agency and the Department of
18 Children and Family Services shall execute a written agreement
19 that requires collaboration and joint development of all
20 policy, budgets, procurement documents, contracts, and
21 monitoring plans that have an impact on the state and Medicaid
22 community mental health and targeted case management programs.
23 3. Except as provided in subparagraph 8., by July 1,
24 2006, the agency and the Department of Children and Family
25 Services shall contract with managed care entities in each
26 AHCA area except area 6 or arrange to provide comprehensive
27 inpatient and outpatient mental health and substance abuse
28 services through capitated prepaid arrangements to all
29 Medicaid recipients who are eligible to participate in such
30 plans under federal law and regulation. In AHCA areas where
31 eligible individuals number less than 150,000, the agency
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1 shall contract with a single managed care plan to provide
2 comprehensive behavioral health services to all recipients who
3 are not enrolled in a Medicaid health maintenance organization
4 or a Medicaid capitated managed care plan authorized under s.
5 409.91211. The agency may contract with more than one
6 comprehensive behavioral health provider to provide care to
7 recipients who are not enrolled in a Medicaid capitated
8 managed care plan authorized under s. 409.91211 or a Medicaid
9 health maintenance organization in AHCA areas where the
10 eligible population exceeds 150,000. In an AHCA area where the
11 Medicaid managed care pilot program is authorized pursuant to
12 s. 409.91211 in one or more counties, the agency may procure a
13 contract with a single entity to serve the remaining counties
14 as an AHCA area or the remaining counties may be included with
15 an adjacent AHCA area and shall be subject to this paragraph.
16 Contracts for comprehensive behavioral health providers
17 awarded pursuant to this section shall be competitively
18 procured. Both for-profit and not-for-profit corporations
19 shall be eligible to compete. Managed care plans contracting
20 with the agency under subsection (3) shall provide and receive
21 payment for the same comprehensive behavioral health benefits
22 as provided in AHCA rules, including handbooks incorporated by
23 reference. In AHCA area 11, the agency shall contract with at
24 least two comprehensive behavioral health care providers to
25 provide behavioral health care to recipients in that area who
26 are enrolled in, or assigned to, the MediPass program. One of
27 the behavioral health care contracts shall be with the
28 existing provider service network pilot project, as described
29 in paragraph (d), for the purpose of demonstrating the
30 cost-effectiveness of the provision of quality mental health
31 services through a public hospital-operated managed care
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1 model. Payment shall be at an agreed-upon capitated rate to
2 ensure cost savings. Of the recipients in area 11 who are
3 assigned to MediPass under the provisions of s.
4 409.9122(2)(k), a minimum of 50,000 of those MediPass-enrolled
5 recipients shall be assigned to the existing provider service
6 network in area 11 for their behavioral care.
7 4. By October 1, 2003, the agency and the department
8 shall submit a plan to the Governor, the President of the
9 Senate, and the Speaker of the House of Representatives which
10 provides for the full implementation of capitated prepaid
11 behavioral health care in all areas of the state.
12 a. Implementation shall begin in 2003 in those AHCA
13 areas of the state where the agency is able to establish
14 sufficient capitation rates.
15 b. If the agency determines that the proposed
16 capitation rate in any area is insufficient to provide
17 appropriate services, the agency may adjust the capitation
18 rate to ensure that care will be available. The agency and the
19 department may use existing general revenue to address any
20 additional required match but may not over-obligate existing
21 funds on an annualized basis.
22 c. Subject to any limitations provided for in the
23 General Appropriations Act, the agency, in compliance with
24 appropriate federal authorization, shall develop policies and
25 procedures that allow for certification of local and state
26 funds.
27 5. Children residing in a statewide inpatient
28 psychiatric program, or in a Department of Juvenile Justice or
29 a Department of Children and Family Services residential
30 program approved as a Medicaid behavioral health overlay
31 services provider shall not be included in a behavioral health
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1 care prepaid health plan or any other Medicaid managed care
2 plan pursuant to this paragraph.
3 6. In converting to a prepaid system of delivery, the
4 agency shall in its procurement document require an entity
5 providing only comprehensive behavioral health care services
6 to prevent the displacement of indigent care patients by
7 enrollees in the Medicaid prepaid health plan providing
8 behavioral health care services from facilities receiving
9 state funding to provide indigent behavioral health care, to
10 facilities licensed under chapter 395 which do not receive
11 state funding for indigent behavioral health care, or
12 reimburse the unsubsidized facility for the cost of behavioral
13 health care provided to the displaced indigent care patient.
14 7. Traditional community mental health providers under
15 contract with the Department of Children and Family Services
16 pursuant to part IV of chapter 394, child welfare providers
17 under contract with the Department of Children and Family
18 Services in areas 1 and 6, and inpatient mental health
19 providers licensed pursuant to chapter 395 must be offered an
20 opportunity to accept or decline a contract to participate in
21 any provider network for prepaid behavioral health services.
22 8. For fiscal year 2004-2005, all Medicaid eligible
23 children, except children in areas 1 and 6, whose cases are
24 open for child welfare services in the HomeSafeNet system,
25 shall be enrolled in MediPass or in Medicaid fee-for-service
26 and all their behavioral health care services including
27 inpatient, outpatient psychiatric, community mental health,
28 and case management shall be reimbursed on a fee-for-service
29 basis. Beginning July 1, 2005, such children, who are open for
30 child welfare services in the HomeSafeNet system, shall
31 receive their behavioral health care services through a
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1 specialty prepaid plan operated by community-based lead
2 agencies either through a single agency or formal agreements
3 among several agencies. The specialty prepaid plan must result
4 in savings to the state comparable to savings achieved in
5 other Medicaid managed care and prepaid programs. Such plan
6 must provide mechanisms to maximize state and local revenues.
7 The specialty prepaid plan shall be developed by the agency
8 and the Department of Children and Family Services. The agency
9 is authorized to seek any federal waivers to implement this
10 initiative. Medicaid-eligible children whose cases are open
11 for child welfare services in the HomeSafeNet system and who
12 reside in AHCA area 10 are exempt from the specialty prepaid
13 plan upon the development of a service delivery mechanism for
14 children who reside in area 10 as specified in s.
15 409.91211(3)(dd).
16 Section 5. Subsection (13) of section 409.9122,
17 Florida Statutes, is amended to read:
18 409.9122 Mandatory Medicaid managed care enrollment;
19 programs and procedures.--
20 (13) Effective July 1, 2003, the agency shall adjust
21 the enrollee assignment process of Medicaid managed prepaid
22 health plans for those Medicaid managed prepaid plans
23 operating in Miami-Dade County which have executed a contract
24 with the agency for a minimum of 8 consecutive years in order
25 for the Medicaid managed prepaid plan to maintain a minimum
26 enrollment level of 15,000 members per month. When assigning
27 enrollees pursuant to this subsection, the agency shall give
28 priority to providers that initially qualified under this
29 subsection until such providers reach and maintain an
30 enrollment level of 15,000 members per month. A prepaid health
31 plan that has a statewide Medicaid enrollment of 25,000 or
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1 more members is not eligible for enrollee assignments under
2 this subsection.
3 Section 6. Effective March 1, 2008, paragraph (k) of
4 subsection (2) of section 409.9122, Florida Statutes, is
5 amended to read:
6 409.9122 Mandatory Medicaid managed care enrollment;
7 programs and procedures.--
8 (2)
9 (k) When a Medicaid recipient does not choose a
10 managed care plan or MediPass provider, the agency shall
11 assign the Medicaid recipient to a managed care plan, except
12 in those counties in which there are fewer than two managed
13 care plans accepting Medicaid enrollees, in which case
14 assignment shall be to a managed care plan or a MediPass
15 provider. Medicaid recipients in counties with fewer than two
16 managed care plans accepting Medicaid enrollees who are
17 subject to mandatory assignment but who fail to make a choice
18 shall be assigned to managed care plans until an enrollment of
19 35 percent in MediPass and 65 percent in managed care plans,
20 of all those eligible to choose managed care, is achieved.
21 Once that enrollment is achieved, the assignments shall be
22 divided in order to maintain an enrollment in MediPass and
23 managed care plans which is in a 35 percent and 65 percent
24 proportion, respectively. In service areas 1 and 6 of the
25 Agency for Health Care Administration where the agency is
26 contracting for the provision of comprehensive behavioral
27 health services through a capitated prepaid arrangement,
28 recipients who fail to make a choice shall be assigned equally
29 to MediPass or a managed care plan. For purposes of this
30 paragraph, when referring to assignment, the term "managed
31 care plans" includes exclusive provider organizations,
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1 provider service networks, Children's Medical Services
2 Network, minority physician networks, and pediatric emergency
3 department diversion programs authorized by this chapter or
4 the General Appropriations Act. When making assignments, the
5 agency shall take into account the following criteria:
6 1. A managed care plan has sufficient network capacity
7 to meet the need of members.
8 2. The managed care plan or MediPass has previously
9 enrolled the recipient as a member, or one of the managed care
10 plan's primary care providers or MediPass providers has
11 previously provided health care to the recipient.
12 3. The agency has knowledge that the member has
13 previously expressed a preference for a particular managed
14 care plan or MediPass provider as indicated by Medicaid
15 fee-for-service claims data, but has failed to make a choice.
16 4. The managed care plan's or MediPass primary care
17 providers are geographically accessible to the recipient's
18 residence.
19 5. The agency has authority to make mandatory
20 assignments based on quality of service and performance of
21 managed care plans.
22 Section 7. Paragraph (dd) of subsection (3) of section
23 409.91211, Florida Statutes, is amended to read:
24 409.91211 Medicaid managed care pilot program.--
25 (3) The agency shall have the following powers,
26 duties, and responsibilities with respect to the pilot
27 program:
28 (dd) To implement develop and recommend service
29 delivery mechanisms within capitated managed care plans to
30 provide Medicaid services as specified in ss. 409.905 and
31 409.906 to Medicaid-eligible children whose cases are open for
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1 child welfare services in the HomeSafeNet system in foster
2 care. These services must be coordinated with community-based
3 care providers as specified in s. 409.1671 s. 409.1675, where
4 available, and be sufficient to meet the medical,
5 developmental, behavioral, and emotional needs of these
6 children. These service delivery mechanisms must be
7 implemented no later than July 1, 2008, in AHCA area 10 in
8 order for the children in AHCA area 10 to remain exempt from
9 the statewide plan under s. 409.912(4)(b)8.
10 Section 8. Except as otherwise expressly provided in
11 this act, this act shall take effect upon becoming a law.
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