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A bill to be entitled

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An act relating to Medicaid managed care programs;

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amending s. 409.9122, F.S.; revising criteria that the

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Agency for Health Care Administration is required to

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consider when assigning a Medicaid recipient to a managed

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care plan or MediPass provider; requiring the agency to

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consider a managed care plan's performance and compliance

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with network adequacy requirements and whether it meets

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certain needs; requiring the agency to establish, monitor,

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and evaluate network adequacy standards for managed care

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plans; expanding the basis for such standards to include

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patient access standards for specialty care providers and

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network adequacy standards established by contract, rule,

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and statute; requiring the agency to encourage the

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development of public and private partnerships to foster

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the growth of managed care plans rather than health

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maintenance organizations; authorizing the agency to enter

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into contracts with traditional providers of health care

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to low-income persons subject to a specific appropriation;

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requiring managed care plans and MediPass providers to

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demonstrate and document plans to ensure that Medicaid

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recipients receive health care service in a timely manner;

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authorizing the agency to extend eligibility for Medicaid

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recipients enrolled in contracted managed care plans

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rather than health maintenance organizations; requiring

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the agency to verify patient load certifications if the

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agency determines that access to primary care is being

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compromised; defining the term "Medicaid rate" or

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"Medicaid reimbursement rate"; requiring the agency to

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include exemption payments and low-income pool payments in

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its calculation of the hospital inpatient component of a

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Medicaid health maintenance organization's capitation

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rate; amending s. 409.9124, F.S.; conforming provisions

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regarding managed care reimbursement to changes made by

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the act; amending s. 409.9128, F.S.; prohibiting a managed

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care plan or MediPass provider from withholding payment

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for emergency services and care; providing an effective

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date.

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Be It Enacted by the Legislature of the State of Florida:

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     Section 1.  Paragraphs (f) and (k) of subsection (2),

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paragraph (a) of subsection (3), subsection (8), paragraph (c) of

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subsection (9), and subsections (11), (12), and (14) of section

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409.9122, Florida Statutes, are amended to read:

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     409.9122  Mandatory Medicaid managed care enrollment;

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programs and procedures.--

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     (2)

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     (f)  When a Medicaid recipient does not choose a managed

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care plan or MediPass provider, the agency shall assign the

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Medicaid recipient to a managed care plan or MediPass provider.

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Medicaid recipients who are subject to mandatory assignment but

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who fail to make a choice shall be assigned to managed care plans

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until an enrollment of 35 percent in MediPass and 65 percent in

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managed care plans, of all those eligible to choose managed care,

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is achieved. Once this enrollment is achieved, the assignments

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shall be divided in order to maintain an enrollment in MediPass

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and managed care plans which is in a 35 percent and 65 percent

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proportion, respectively. Thereafter, assignment of Medicaid

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recipients who fail to make a choice shall be based

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proportionally on the preferences of recipients who have made a

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choice in the previous period. Such proportions shall be revised

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at least quarterly to reflect an update of the preferences of

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Medicaid recipients. The agency shall disproportionately assign

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Medicaid-eligible recipients who are required to but have failed

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to make a choice of managed care plan or MediPass, including

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children, and who are to be assigned to the MediPass program to

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children's networks as described in s. 409.912(4)(g), Children's

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Medical Services Network as defined in s. 391.021, exclusive

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provider organizations, provider service networks, minority

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physician networks, and pediatric emergency department diversion

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programs authorized by this chapter or the General Appropriations

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Act, in such manner as the agency deems appropriate, until the

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agency has determined that the networks and programs have

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sufficient numbers to be economically operated. For purposes of

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this paragraph, when referring to assignment, the term "managed

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care plans" includes health maintenance organizations, exclusive

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provider organizations, provider service networks, minority

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physician networks, Children's Medical Services Network, and

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pediatric emergency department diversion programs authorized by

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this chapter or the General Appropriations Act. When making

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assignments, the agency shall take into account the following

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criteria:

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     1. A managed care plan maintains has sufficient network

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capacity to meet the need of members.

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     2.  The managed care plan or MediPass has previously

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enrolled the recipient as a member, or one of the managed care

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plan's primary care providers or MediPass providers has

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previously provided health care to the recipient.

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     3.  The agency has knowledge that the member has previously

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expressed a preference for a particular managed care plan or

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MediPass provider as indicated by Medicaid fee-for-service claims

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data, but has failed to make a choice.

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     4.  The managed care plan's or MediPass primary care

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providers are geographically accessible to the recipient's

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residence.

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     5. The managed care plan's performance and compliance with

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the network adequacy requirements, which the agency shall

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validate annually.

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     (k)  When a Medicaid recipient does not choose a managed

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care plan or MediPass provider, the agency shall assign the

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Medicaid recipient to a managed care plan, except in those

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counties in which there are fewer than two managed care plans

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accepting Medicaid enrollees, in which case assignment shall be

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to a managed care plan or a MediPass provider. Medicaid

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recipients in counties with fewer than two managed care plans

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accepting Medicaid enrollees who are subject to mandatory

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assignment but who fail to make a choice shall be assigned to

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managed care plans until an enrollment of 35 percent in MediPass

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and 65 percent in managed care plans, of all those eligible to

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choose managed care, is achieved. Once that enrollment is

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achieved, the assignments shall be divided in order to maintain

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an enrollment in MediPass and managed care plans which is in a 35

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percent and 65 percent proportion, respectively. In service areas

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1 and 6 of the Agency for Health Care Administration where the

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agency is contracting for the provision of comprehensive

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behavioral health services through a capitated prepaid

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arrangement, recipients who fail to make a choice shall be

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assigned equally to MediPass or a managed care plan. For purposes

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of this paragraph, when referring to assignment, the term

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"managed care plans" includes exclusive provider organizations,

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provider service networks, Children's Medical Services Network,

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minority physician networks, and pediatric emergency department

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diversion programs authorized by this chapter or the General

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Appropriations Act. When making assignments, the agency shall

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take into account the following criteria:

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     1.  A managed care plan has sufficient network capacity to

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meet the urgent, emergency, acute, and chronic needs need of its

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members and has consistently maintained compliance with the

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network adequacy requirements over the previous 12-month period.

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     2.  The managed care plan or MediPass has previously

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enrolled the recipient as a member, or one of the managed care

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plan's primary care providers or MediPass providers has

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previously provided health care to the recipient.

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     3.  The agency has knowledge that the member has previously

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expressed a preference for a particular managed care plan or

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MediPass provider as indicated by Medicaid fee-for-service claims

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data, but has failed to make a choice.

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     4.  The managed care plan's or MediPass primary care

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providers are geographically accessible to the recipient's

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residence.

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     5. The agency shall has authority to make mandatory

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assignments based on quality of service and performance of

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managed care plans.

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     (3)(a) The agency shall establish quality-of-care and

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network adequacy standards for managed care plans, which the

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agency shall monitor quarterly and evaluate annually. These

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standards shall be based upon, but are not limited to:

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     1.  Compliance with the accreditation requirements as

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provided in s. 641.512.

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     2.  Compliance with Early and Periodic Screening, Diagnosis,

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and Treatment screening requirements.

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     3.  The percentage of voluntary disenrollments.

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     4.  Immunization rates.

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     5.  Standards of the National Committee for Quality

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Assurance and other approved accrediting bodies.

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     6.  Recommendations of other authoritative bodies.

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     7. Specific requirements of the Medicaid program and

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network adequacy, or standards designed to specifically meet

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assist the unique needs of Medicaid recipients, including patient

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access standards for specialty care providers.

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     8.  Compliance with the health quality improvement system as

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established by the agency, which incorporates standards and

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guidelines developed by the Medicaid Bureau of the Health Care

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Financing Administration as part of the quality assurance reform

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initiative.

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     9. Network adequacy as established by contract, rule, and

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statute for urgent, emergency, acute, and chronic care.

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     (8)(a)  The agency shall encourage the development of public

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and private partnerships to foster the growth of managed care

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plans health maintenance organizations and prepaid health plans

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that will provide high-quality health care to Medicaid

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recipients.

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     (b) Subject to a specific appropriation the availability of

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moneys and any limitations established by the General

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Appropriations Act or chapter 216, the agency is authorized to

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enter into contracts with traditional providers of health care to

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low-income persons to assist such providers with the technical

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aspects of cooperatively developing Medicaid prepaid health

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plans.

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     1.  The agency may contract with disproportionate share

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hospitals, county health departments, federally initiated or

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federally funded community health centers, and counties that

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operate either a hospital or a community clinic.

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     2.  A contract may not be for more than $100,000 per year,

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and no contract may be extended with any particular provider for

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more than 2 years. The contract is intended only as seed or

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development funding and requires a commitment from the interested

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party.

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     3.  A contract must require participation by at least one

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community health clinic and one disproportionate share hospital.

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     (9)

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     (c)  The agency shall require managed care plans and

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MediPass providers to demonstrate and document plans and

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activities, as defined by rule, including outreach and followup,

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undertaken to ensure that Medicaid recipients receive the health

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care service to which they are entitled in a timely manner.

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     (11)  The agency may extend eligibility for Medicaid

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recipients enrolled in contracted managed care plans licensed and

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accredited health maintenance organizations for the duration of

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the enrollment period or for 6 months, whichever is earlier,

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provided the agency certifies that such an offer will not

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increase state expenditures.

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     (12)  A managed care plan that has a Medicaid contract shall

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at least annually review each primary care physician's active

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patient load and shall ensure that additional Medicaid recipients

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are not assigned to physicians who have a total active patient

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load of more than 3,000 patients. As used in this subsection, the

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term "active patient" means a patient who is seen by the same

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primary care physician, or by a physician assistant or advanced

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registered nurse practitioner under the supervision of the

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primary care physician, at least three times within a calendar

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year. Each primary care physician shall annually certify to the

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managed care plan whether or not his or her patient load exceeds

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the limits established under this subsection and the managed care

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plan shall accept such certification on face value as compliance

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with this subsection. The agency shall accept the managed care

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plan's representations that it is in compliance with this

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subsection based on the certification of its primary care

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physicians, unless the agency has an objective indication that

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access to primary care is being compromised, such as failure to

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maintain network adequacy or receiving complaints or grievances

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relating to access to care. If the agency determines that an

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objective indication exists that access to primary care is being

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compromised, it shall may verify the patient load certifications

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submitted by the managed care plan's primary care physicians and

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that the managed care plan is not assigning Medicaid recipients

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to primary care physicians who have an active patient load of

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more than 3,000 patients.

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     (14) As used in this section and ss. 409.912(19),

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409.9128(5)(d), and 641.513(6)(d), the term "Medicaid rate" or

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"Medicaid reimbursement rate" is equivalent to the amount paid

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directly to a hospital by the agency for providing inpatient or

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outpatient services to a Medicaid recipient on a fee-for-service

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basis. The agency shall include in its calculation of the

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hospital inpatient component of a Medicaid health maintenance

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organization's capitation rate any special payments, including,

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but not limited to, upper payment limit, exemption payments, low-

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income pool payments, or disproportionate share hospital

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payments, made to qualifying hospitals through the fee-for-

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service program. The agency may seek federal waiver approval or

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state plan amendments amendment as needed to implement this

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adjustment.

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     Section 2.  Subsection (6) of section 409.9124, Florida

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Statutes, is amended to read:

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     409.9124  Managed care reimbursement.--The agency shall

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develop and adopt by rule a methodology for reimbursing managed

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care plans.

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     (6) As used in this section and ss. 409.912(19),

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409.9128(5)(d), and 641.513(6)(d), the term "Medicaid rate" or

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"Medicaid reimbursement rate" is equivalent to the amount paid

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directly to a hospital by the agency for providing inpatient or

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outpatient services to a Medicaid recipient on a fee-for-service

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basis. The agency shall include in its calculation of the

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hospital inpatient component of a Medicaid health maintenance

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organization's capitation rate any special payments, including,

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but not limited to, upper payment limit, exemption payments, low-

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income pool, or disproportionate share hospital payments made to

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qualifying hospitals through the fee-for-service program. The

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agency may seek federal waiver approval or state plan amendments

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as needed to implement this adjustment. For the 2005-2006 fiscal

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year only, the agency shall make an additional adjustment in

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calculating the capitation payments to prepaid health plans,

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excluding prepaid mental health plans. This adjustment must

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result in an increase of 2.8 percent in the average per-member,

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per-month rate paid to prepaid health plans, excluding prepaid

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mental health plans, which are funded from Specific

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Appropriations 225 and 226 in the 2005-2006 General

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Appropriations Act.

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     Section 3.  Paragraph (d) of subsection (1), paragraph (b)

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of subsection (3), and subsection (5) of section 409.9128,

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Florida Statutes, are amended to read:

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     409.9128  Requirements for providing emergency services and

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care.--

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     (1)  In providing for emergency services and care as a

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covered service, neither a managed care plan nor the MediPass

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program may:

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     (d) Deny or withhold payment based on the enrollee's or the

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hospital's failure to notify the managed care plan or MediPass

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primary care provider in advance or within a certain period of

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time after the care is given.

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     (3)

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     (b)  If a determination has been made that an emergency

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medical condition exists and the enrollee has notified the

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hospital, or the hospital emergency personnel otherwise has

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knowledge that the patient is an enrollee of the managed care

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plan or the MediPass program, the hospital must make a reasonable

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attempt to notify the enrollee's primary care physician, if

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known, or the managed care plan, if the managed care plan had

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previously requested in writing that the notification be made

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directly to the managed care plan, of the existence of the

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emergency medical condition. If the primary care physician is not

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known, or has not been contacted, the hospital must:

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     1.  Notify the managed care plan or the MediPass provider as

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soon as possible prior to discharge of the enrollee from the

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emergency care area; or

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     2.  Notify the managed care plan or the MediPass provider

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within 24 hours or on the next business day after admission of

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the enrollee as an inpatient to the hospital.

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If notification required by this paragraph is not accomplished,

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the hospital must document its attempts to notify the managed

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care plan or the MediPass provider or the circumstances that

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precluded attempts to notify the managed care plan or the

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MediPass provider. Neither a managed care plan nor the Medicaid

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program on behalf of MediPass patients may deny or withhold

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payment for emergency services and care based on a hospital's

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failure to comply with the notification requirements of this

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paragraph.

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     (5)  Reimbursement for services provided to an enrollee of a

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managed care plan under this section by a provider who does not

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have a contract with the managed care plan shall be the lesser

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of:

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     (a) The provider's billed charges;

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     (b)  The usual and customary provider charges for similar

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services in the community where the services were provided;

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     (c)  The charge mutually agreed to by the entity and the

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provider within 60 days after submittal of the claim; or

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     (d) The Medicaid rate defined as equivalent to the amount

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paid directly to a hospital by the agency for providing inpatient

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and outpatient services to a Medicaid recipient on a fee-for-

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service basis.

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     Section 4.  This act shall take effect July 1, 2008.