HB 1411

1	A bill to be entitled
2	An act relating to Medicaid managed care programs;
3	amending s. 409.9122, F.S.; revising criteria that the
4	Agency for Health Care Administration is required to
5	consider when assigning a Medicaid recipient to a managed
6	care plan or MediPass provider; requiring the agency to
7	consider a managed care plan's performance and compliance
8	with network adequacy requirements and whether it meets
9	certain needs; requiring the agency to establish, monitor,
10	and evaluate network adequacy standards for managed care
11	plans; expanding the basis for such standards to include
12	patient access standards for specialty care providers and
13	network adequacy standards established by contract, rule,
14	and statute; requiring the agency to encourage the
15	development of public and private partnerships to foster
16	the growth of managed care plans rather than health
17	maintenance organizations; authorizing the agency to enter
18	into contracts with traditional providers of health care
19	to low-income persons subject to a specific appropriation;
20	requiring managed care plans and MediPass providers to
21	demonstrate and document plans to ensure that Medicaid
22	recipients receive health care service in a timely manner;
23	authorizing the agency to extend eligibility for Medicaid
24	recipients enrolled in contracted managed care plans
25	rather than health maintenance organizations; requiring
26	the agency to verify patient load certifications if the
27	agency determines that access to primary care is being
28	compromised; defining the term "Medicaid rate" or
29	"Medicaid reimbursement rate"; requiring the agency to
30	include exemption payments and low-income pool payments in
31	its calculation of the hospital inpatient component of a
32	Medicaid health maintenance organization's capitation
33	rate; amending s. 409.9124, F.S.; conforming provisions
34	regarding managed care reimbursement to changes made by
35	the act; amending s. 409.9128, F.S.; prohibiting a managed
36	care plan or MediPass provider from withholding payment
37	for emergency services and care; providing an effective
38	date.
39
40	Be It Enacted by the Legislature of the State of Florida:
41
42	Section 1.  Paragraphs (f) and (k) of subsection (2),
43	paragraph (a) of subsection (3), subsection (8), paragraph (c)
44	of subsection (9), and subsections (11), (12), and (14) of
45	section 409.9122, Florida Statutes, as amended by chapter 2007-
46	331, Laws of Florida, are amended to read:
47	409.9122  Mandatory Medicaid managed care enrollment;
48	programs and procedures.--
49	(2)
50	(f)  When a Medicaid recipient does not choose a managed
51	care plan or MediPass provider, the agency shall assign the
52	Medicaid recipient to a managed care plan or MediPass provider.
53	Medicaid recipients who are subject to mandatory assignment but
54	who fail to make a choice shall be assigned to managed care
55	plans until an enrollment of 35 percent in MediPass and 65
56	percent in managed care plans, of all those eligible to choose
57	managed care, is achieved. Once this enrollment is achieved, the
58	assignments shall be divided in order to maintain an enrollment
59	in MediPass and managed care plans which is in a 35 percent and
60	65 percent proportion, respectively. Thereafter, assignment of
61	Medicaid recipients who fail to make a choice shall be based
62	proportionally on the preferences of recipients who have made a
63	choice in the previous period. Such proportions shall be revised
64	at least quarterly to reflect an update of the preferences of
65	Medicaid recipients. The agency shall disproportionately assign
66	Medicaid-eligible recipients who are required to but have failed
67	to make a choice of managed care plan or MediPass, including
68	children, and who are to be assigned to the MediPass program to
69	children's networks as described in s. 409.912(4)(g), Children's
70	Medical Services Network as defined in s. 391.021, exclusive
71	provider organizations, provider service networks, minority
72	physician networks, and pediatric emergency department diversion
73	programs authorized by this chapter or the General
74	Appropriations Act, in such manner as the agency deems
75	appropriate, until the agency has determined that the networks
76	and programs have sufficient numbers to be economically
77	operated. For purposes of this paragraph, when referring to
78	assignment, the term "managed care plans" includes health
79	maintenance organizations, exclusive provider organizations,
80	provider service networks, minority physician networks,
81	Children's Medical Services Network, and pediatric emergency
82	department diversion programs authorized by this chapter or the
83	General Appropriations Act. When making assignments, the agency
84	shall take into account the following criteria:
85	1.  A managed care plan maintains has sufficient network
86	capacity to meet the need of members.
87	2.  The managed care plan or MediPass has previously
88	enrolled the recipient as a member, or one of the managed care
89	plan's primary care providers or MediPass providers has
90	previously provided health care to the recipient.
91	3.  The agency has knowledge that the member has previously
92	expressed a preference for a particular managed care plan or
93	MediPass provider as indicated by Medicaid fee-for-service
94	claims data, but has failed to make a choice.
95	4.  The managed care plan's or MediPass primary care
96	providers are geographically accessible to the recipient's
97	residence.
98	5.  The managed care plan's performance and compliance with
99	the network adequacy requirements, which the agency shall
100	validate annually.
101	(k)  When a Medicaid recipient does not choose a managed
102	care plan or MediPass provider, the agency shall assign the
103	Medicaid recipient to a managed care plan, except in those
104	counties in which there are fewer than two managed care plans
105	accepting Medicaid enrollees, in which case assignment shall be
106	to a managed care plan or a MediPass provider. Medicaid
107	recipients in counties with fewer than two managed care plans
108	accepting Medicaid enrollees who are subject to mandatory
109	assignment but who fail to make a choice shall be assigned to
110	managed care plans until an enrollment of 35 percent in MediPass
111	and 65 percent in managed care plans, of all those eligible to
112	choose managed care, is achieved. Once that enrollment is
113	achieved, the assignments shall be divided in order to maintain
114	an enrollment in MediPass and managed care plans which is in a
115	35 percent and 65 percent proportion, respectively. For purposes
116	of this paragraph, when referring to assignment, the term
117	"managed care plans" includes exclusive provider organizations,
118	provider service networks, Children's Medical Services Network,
119	minority physician networks, and pediatric emergency department
120	diversion programs authorized by this chapter or the General
121	Appropriations Act. When making assignments, the agency shall
122	take into account the following criteria:
123	1.  A managed care plan has sufficient network capacity to
124	meet the urgent, emergency, acute, and chronic needs need of its
125	members and has consistently maintained compliance with the
126	network adequacy requirements over the previous 12-month period.
127	2.  The managed care plan or MediPass has previously
128	enrolled the recipient as a member, or one of the managed care
129	plan's primary care providers or MediPass providers has
130	previously provided health care to the recipient.
131	3.  The agency has knowledge that the member has previously
132	expressed a preference for a particular managed care plan or
133	MediPass provider as indicated by Medicaid fee-for-service
134	claims data, but has failed to make a choice.
135	4.  The managed care plan's or MediPass primary care
136	providers are geographically accessible to the recipient's
137	residence.
138	5.  The agency shall has authority to make mandatory
139	assignments based on quality of service and performance of
140	managed care plans.
141	(3)(a)  The agency shall establish quality-of-care and
142	network adequacy standards for managed care plans, which the
143	agency shall monitor quarterly and evaluate annually. These
144	standards shall be based upon, but are not limited to:
145	1.  Compliance with the accreditation requirements as
146	provided in s. 641.512.
147	2.  Compliance with Early and Periodic Screening,
148	Diagnosis, and Treatment screening requirements.
149	3.  The percentage of voluntary disenrollments.
150	4.  Immunization rates.
151	5.  Standards of the National Committee for Quality
152	Assurance and other approved accrediting bodies.
153	6.  Recommendations of other authoritative bodies.
154	7.  Specific requirements of the Medicaid program and
155	network adequacy, or standards designed to specifically meet
156	assist the unique needs of Medicaid recipients, including
157	patient access standards for specialty care providers.
158	8.  Compliance with the health quality improvement system
159	as established by the agency, which incorporates standards and
160	guidelines developed by the Medicaid Bureau of the Health Care
161	Financing Administration as part of the quality assurance reform
162	initiative.
163	9.  Network adequacy as established by contract, rule, and
164	statute for urgent, emergency, acute, and chronic care.
165	(8)(a)  The agency shall encourage the development of
166	public and private partnerships to foster the growth of managed
167	care plans health maintenance organizations and prepaid health
168	plans that will provide high-quality health care to Medicaid
169	recipients.
170	(b)  Subject to a specific appropriation the availability
171	of moneys and any limitations established by the General
172	Appropriations Act or chapter 216, the agency is authorized to
173	enter into contracts with traditional providers of health care
174	to low-income persons to assist such providers with the
175	technical aspects of cooperatively developing Medicaid prepaid
176	health plans.
177	1.  The agency may contract with disproportionate share
178	hospitals, county health departments, federally initiated or
179	federally funded community health centers, and counties that
180	operate either a hospital or a community clinic.
181	2.  A contract may not be for more than $100,000 per year,
182	and no contract may be extended with any particular provider for
183	more than 2 years. The contract is intended only as seed or
184	development funding and requires a commitment from the
185	interested party.
186	3.  A contract must require participation by at least one
187	community health clinic and one disproportionate share hospital.
188	(9)
189	(c)  The agency shall require managed care plans and
190	MediPass providers to demonstrate and document plans and
191	activities, as defined by rule, including outreach and followup,
192	undertaken to ensure that Medicaid recipients receive the health
193	care service to which they are entitled in a timely manner.
194	(11)  The agency may extend eligibility for Medicaid
195	recipients enrolled in contracted managed care plans licensed
196	and accredited health maintenance organizations for the duration
197	of the enrollment period or for 6 months, whichever is earlier,
198	provided the agency certifies that such an offer will not
199	increase state expenditures.
200	(12)  A managed care plan that has a Medicaid contract
201	shall at least annually review each primary care physician's
202	active patient load and shall ensure that additional Medicaid
203	recipients are not assigned to physicians who have a total
204	active patient load of more than 3,000 patients. As used in this
205	subsection, the term "active patient" means a patient who is
206	seen by the same primary care physician, or by a physician
207	assistant or advanced registered nurse practitioner under the
208	supervision of the primary care physician, at least three times
209	within a calendar year. Each primary care physician shall
210	annually certify to the managed care plan whether or not his or
211	her patient load exceeds the limits established under this
212	subsection and the managed care plan shall accept such
213	certification on face value as compliance with this subsection.
214	The agency shall accept the managed care plan's representations
215	that it is in compliance with this subsection based on the
216	certification of its primary care physicians, unless the agency
217	has an objective indication that access to primary care is being
218	compromised, such as failure to maintain network adequacy or
219	receiving complaints or grievances relating to access to care.
220	If the agency determines that an objective indication exists
221	that access to primary care is being compromised, it shall may
222	verify the patient load certifications submitted by the managed
223	care plan's primary care physicians and that the managed care
224	plan is not assigning Medicaid recipients to primary care
225	physicians who have an active patient load of more than 3,000
226	patients.
227	(14)  As used in this section and ss. 409.912(19),
228	409.9128(5)(d), and 641.513(6)(d), the term "Medicaid rate" or
229	"Medicaid reimbursement rate" is equivalent to the amount paid
230	directly to a hospital by the agency for providing inpatient or
231	outpatient services to a Medicaid recipient on a fee-for-service
232	basis. The agency shall include in its calculation of the
233	hospital inpatient component of a Medicaid health maintenance
234	organization's capitation rate any special payments, including,
235	but not limited to, upper payment limit, exemption payments,
236	low-income pool payments, or disproportionate share hospital
237	payments, made to qualifying hospitals through the fee-for-
238	service program. The agency may seek federal waiver approval or
239	state plan amendments amendment as needed to implement this
240	adjustment.
241	Section 2.  Subsection (6) of section 409.9124, Florida
242	Statutes, is amended to read:
243	409.9124  Managed care reimbursement.--The agency shall
244	develop and adopt by rule a methodology for reimbursing managed
245	care plans.
246	(6)  As used in this section and ss. 409.912(19),
247	409.9128(5)(d), and 641.513(6)(d), the term "Medicaid rate" or
248	"Medicaid reimbursement rate" is equivalent to the amount paid
249	directly to a hospital by the agency for providing inpatient or
250	outpatient services to a Medicaid recipient on a fee-for-service
251	basis. The agency shall include in its calculation of the
252	hospital inpatient component of a Medicaid health maintenance
253	organization's capitation rate any special payments, including,
254	but not limited to, upper payment limit, exemption payments,
255	low-income pool payments, or disproportionate share hospital
256	payments, made to qualifying hospitals through the fee-for-
257	service program. The agency may seek federal waiver approval or
258	state plan amendments as needed to implement this adjustment.
259	For the 2005-2006 fiscal year only, the agency shall make an
260	additional adjustment in calculating the capitation payments to
261	prepaid health plans, excluding prepaid mental health plans.
262	This adjustment must result in an increase of 2.8 percent in the
263	average per-member, per-month rate paid to prepaid health plans,
264	excluding prepaid mental health plans, which are funded from
265	Specific Appropriations 225 and 226 in the 2005-2006 General
266	Appropriations Act.
267	Section 3.  Paragraph (d) of subsection (1), paragraph (b)
268	of subsection (3), and subsection (5) of section 409.9128,
269	Florida Statutes, are amended to read:
270	409.9128  Requirements for providing emergency services and
271	care.--
272	(1)  In providing for emergency services and care as a
273	covered service, neither a managed care plan nor the MediPass
274	program may:
275	(d)  Deny or withhold payment based on the enrollee's or
276	the hospital's failure to notify the managed care plan or
277	MediPass primary care provider in advance or within a certain
278	period of time after the care is given.
279	(3)
280	(b)  If a determination has been made that an emergency
281	medical condition exists and the enrollee has notified the
282	hospital, or the hospital emergency personnel otherwise has
283	knowledge that the patient is an enrollee of the managed care
284	plan or the MediPass program, the hospital must make a
285	reasonable attempt to notify the enrollee's primary care
286	physician, if known, or the managed care plan, if the managed
287	care plan had previously requested in writing that the
288	notification be made directly to the managed care plan, of the
289	existence of the emergency medical condition. If the primary
290	care physician is not known, or has not been contacted, the
291	hospital must:
292	1.  Notify the managed care plan or the MediPass provider
293	as soon as possible prior to discharge of the enrollee from the
294	emergency care area; or
295	2.  Notify the managed care plan or the MediPass provider
296	within 24 hours or on the next business day after admission of
297	the enrollee as an inpatient to the hospital.
298
299	If notification required by this paragraph is not accomplished,
300	the hospital must document its attempts to notify the managed
301	care plan or the MediPass provider or the circumstances that
302	precluded attempts to notify the managed care plan or the
303	MediPass provider. Neither a managed care plan nor the Medicaid
304	program on behalf of MediPass patients may deny or withhold
305	payment for emergency services and care based on a hospital's
306	failure to comply with the notification requirements of this
307	paragraph.
308	(5)  Reimbursement for services provided to an enrollee of
309	a managed care plan under this section by a provider who does
310	not have a contract with the managed care plan shall be the
311	lesser of:
312	(a)  The provider's billed charges;
313	(b)  The usual and customary provider charges for similar
314	services in the community where the services were provided;
315	(c)  The charge mutually agreed to by the entity and the
316	provider within 60 days after submittal of the claim; or
317	(d)  The Medicaid rate defined as equivalent to the amount
318	paid directly to a hospital by the agency for providing
319	inpatient and outpatient services to a Medicaid recipient on a
320	fee-for-service basis.
321	Section 4.  This act shall take effect July 1, 2008.

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