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Senator Wilson moved the following amendment:

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     Senate Amendment (with title amendment)

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     Between lines 1219 and 1220,

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insert:

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     Section 10.  Paragraphs (ee), (ff), (gg), and (hh) are added

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to subsection (3) of section 409.91211, Florida Statutes, as

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amended by chapter 2007-331, Laws of Florida, to read:

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     409.91211  Medicaid managed care pilot program.--

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     (3)  The agency shall have the following powers, duties, and

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responsibilities with respect to the pilot program:

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     (ee) To implement contractual requirements and adopt rules

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that will require capitated managed care plans and provider

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services networks to continue providing any current services,

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including those services subject to prior authorization, during

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the period of time in which prior authorization is being

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requested, processed, or appealed. Services must be continued at

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the current level until a notice conforming with 42 C.F.R. s.

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431.200 is sent and at least 10 days after the date of the notice

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has passed and a hearing is not requested or, if a hearing is

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requested, the hearing decision affirms the adverse action.

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     (ff) To adopt rules to establish policies by which

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exceptions to mandatory Medicaid reform enrollment may be made on

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a case-by-case basis, in addition to those groups specified in

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paragraph (1)(a). The rules shall include the specific criteria

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to be applied when making a determination regarding whether to

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exempt a recipient from mandatory enrollment.

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     (gg) To develop improvement benchmarks in the areas of

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health plan and system readiness, timely claims processing,

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implementation of a consolidated complaint-tracking system that

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has analytical capabilities for producing trending reports, and

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receipt and validations of encounter data, including paid and

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denied claims. Before the program may be expanded beyond the

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pilot project counties, the improvement benchmarks must be met,

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encounter data sufficient to conduct assessments of cost-

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effectiveness and quality of care must be available, and access

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to care must be available. Future audits or evaluations of cost-

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effectiveness must examine indicators of cost-shifting,

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including, but not limited to, increases in emergency room

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admissions, incarceration rates, use of indigent drug program

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funds, outsourcing, and administrative costs.

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     (hh) To perform monthly audits of reports of health plan

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provider networks by comparing them with enrollee handbooks for

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discrepancies and contacting a statistically significant sample

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of providers to ensure accuracy.

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================ T I T L E  A M E N D M E N T ================

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And the title is amended as follows:

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     On line 42, after the first semicolon,

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insert:

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amending s. 409.91211, F.S.; requiring that the Agency for

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Health Care Administration implement certain contractual

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requirements concerning the Medicaid managed care pilot

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program; requiring that the agency adopt certain rules

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concerning the program; requiring that the agency develop

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certain benchmarks and perform certain audits concerning

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the program;

4/9/2008  7:44:00 AM     33-07060-08