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Senator Wilson moved the following amendment:

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     Senate Amendment (with title amendment)

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     Between line(s) 1219 and 1220,

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insert:

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     Section 10.  Paragraph (p) of subsection (3) of section

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409.91211, Florida Statutes, as amended by chapter 2007-331, Laws

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of Florida, is amended 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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     (p)  To implement standards for plan compliance, including,

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but not limited to, standards for quality assurance and

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performance improvement, standards for peer or professional

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reviews, grievance policies, and policies for maintaining program

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integrity. The agency shall develop a data-reporting system, seek

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input from managed care plans in order to establish requirements

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for patient-encounter reporting, and ensure that the data

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reported is accurate and complete.

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     1.  In performing the duties required under this section,

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the agency shall work with managed care plans to establish a

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uniform system to measure and monitor outcomes for a recipient of

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Medicaid services.

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     2.  The system shall use financial, clinical, and other

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criteria based on pharmacy, medical services, and other data that

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is related to the provision of Medicaid services, including, but

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not limited to:

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     a.  The Health Plan Employer Data and Information Set

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(HEDIS) or measures that are similar to HEDIS.

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     b.  Member satisfaction.

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     c.  Provider satisfaction.

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     d.  Report cards on plan performance and best practices.

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     e.  Compliance with the requirements for prompt payment of

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claims under ss. 627.613, 641.3155, and 641.513.

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     f.  Utilization and quality data for the purpose of ensuring

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access to medically necessary services, including

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underutilization or inappropriate denial of services.

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     3.  The agency shall require the managed care plans that

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have contracted with the agency to establish a quality assurance

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system that incorporates the provisions of s. 409.912(27) and any

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standards, rules, and guidelines developed by the agency.

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     4.  The agency shall establish an encounter database in

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order to compile data on health services rendered by health care

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practitioners who provide services to patients enrolled in

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managed care plans in the demonstration sites. The encounter

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database shall:

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     a.  Collect the following for each type of patient encounter

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with a health care practitioner or facility, including:

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     (I)  The demographic characteristics of the patient.

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     (II)  The principal, secondary, and tertiary diagnosis.

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     (III)  The procedure performed.

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     (IV)  The date and location where the procedure was

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performed.

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     (V)  The payment for the procedure, if any.

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     (VI)  If applicable, the health care practitioner's

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universal identification number.

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     (VII)  If the health care practitioner rendering the service

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is a dependent practitioner, the modifiers appropriate to

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indicate that the service was delivered by the dependent

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practitioner.

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     b.  Collect appropriate information relating to prescription

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drugs for each type of patient encounter.

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     c.  Collect appropriate information related to health care

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costs and utilization from managed care plans participating in

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the demonstration sites, including, but not limited to:

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     (I) The number of recipients reaching the annual benefit

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maximum cost cap;

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     (II) The number of recipients receiving the maximum

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number of services for each service category;

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     (III) The number of notices sent to recipients meeting

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the plan cap for a specific service advising them that services

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have been terminated due to reaching the cap;

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     (IV) The number of notices sent to recipients meeting the

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plan cap for a specific service and advising them of the

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opportunity to request prior authorization for additional

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services in excess of the plan cap;

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     (V) The number of recipients requesting additional

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services; and

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     (VI) The number of recipients granted services in excess of

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the plan cap.

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     5.  To the extent practicable, when collecting the data the

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agency shall use a standardized claim form or electronic transfer

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system that is used by health care practitioners, facilities, and

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payors.

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     6.  Health care practitioners and facilities in the

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demonstration sites shall electronically submit, and managed care

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plans participating in the demonstration sites shall

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electronically receive, information concerning claims payments

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and any other information reasonably related to the encounter

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database using a standard format as required by the agency.

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     7.  The agency shall establish reasonable deadlines for

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phasing in the electronic transmittal of full encounter data.

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     8.  The system must ensure that the data reported is

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accurate and complete.

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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(s) 42, after the semicolon,

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insert:

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amending s. 409.91211, F.S.; specifying appropriate

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information to be collected by the encounter database

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related to health care costs and utilization of managed

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care plans participating in the demonstration sites;

4/9/2008  7:48:00 AM     33-07038-08