HB 1261

1	A bill to be entitled
2	An act relating to Medicaid reform; requiring the Agency
3	for Health Care Administration to establish a legislative
4	workgroup on Medicaid reform; providing for membership,
5	meetings, and duties; requiring a report to the Governor
6	and Legislature; providing for expiration of the
7	workgroup; amending s. 395.1041, F.S.; providing
8	legislative intent with respect to access to nonemergency
9	medical services; amending s. 408.910, F.S.; eliminating
10	the opt-out provision for Medicaid reform participants in
11	the Florida Health Choices Program; amending s. 409.8132,
12	F.S.; eliminating the choice counseling option for
13	applicants for the Medikids program component; amending s.
14	409.912, F.S.; conforming a cross-reference; amending s.
15	409.91211, F.S., relating to the Medicaid managed care
16	pilot program; authorizing the agency to seek changes to
17	the current Medicaid reform waiver; revising objectives
18	for distribution of certain Medicaid program funds;
19	requiring the agency to provide plan recipients with
20	reform plan encounter data and a toll-free complaint
21	telephone number; deleting references to a choice
22	counseling system and the opt-out option for Medicaid
23	recipients; requiring the agency to post certain standards
24	and policies on its Internet website; authorizing the
25	agency to develop financial incentives for community-based
26	care providers for certain purposes; amending s.
27	409.91213, F.S., relating to the agency's quarterly
28	progress and annual reports to the Legislature; deleting
29	references to Medicaid choice counseling services, the
30	opt-out program, and the enhanced benefit accounts
31	program; amending s. 409.9122, F.S., relating to mandatory
32	Medicaid managed care enrollment; deleting references to
33	the opt-out program and certain contracts for choice
34	counseling services; providing an effective date.
35
36	Be It Enacted by the Legislature of the State of Florida:
37
38	Section 1.  Legislative workgroup on Medicaid reform;
39	duties.--
40	(1)  The Agency for Health Care Administration shall
41	establish a legislative workgroup to review the Medicaid managed
42	care pilot program established under s. 409.91211, Florida
43	Statutes. The workgroup shall:
44	(a)  Review the patient-encounter data, review the
45	independent studies performed during the course of the pilot
46	program, and assess to what extent the current Medicaid reform
47	pilot program meets the requirements of the current waivers
48	granted by the federal Centers for Medicare and Medicaid
49	Services.
50	(b)  Examine the cost-effectiveness and impact of the
51	enhanced benefit accounts program, particularly in rural
52	counties.
53	(c)  Examine the opt-out option established under s.
54	409.91211(4)(g), Florida Statutes, that permits Medicaid
55	enrollees to purchase health care coverage through an employer-
56	sponsored health insurance plan.
57	(d)  Explore whether the implementation of low-income pool
58	plans has resulted in innovative changes to improve the
59	effectiveness of community-based services and the impact that
60	these plans have had on inpatient hospital utilization and
61	access to Medicaid-funded transportation, including requests for
62	urgent care.
63	(e)  Review the impact of low-income pool plans on
64	behavioral health care and the ability of consumers to access
65	appropriate care, including whether the 80:20 rule should be
66	imposed as a method to ensure that mental health services remain
67	a priority for the plans. For purposes of this section, the term
68	"80:20 rule" means the requirement that contracts issued
69	pursuant to s. 409.912(4)(b), Florida Statutes, spend at least
70	80 percent of the capitation paid to the managed care plan for
71	behavioral health care services and not more than 20 percent on
72	overhead and administrative costs.
73	(f)  Examine how plans have utilized downward substitution
74	of care and whether this practice has led to greater innovation
75	and more cost-effective provision of care. For purposes of this
76	section, the term "downward substitution" means the use of less
77	restrictive, lower cost, and medically appropriate services
78	provided as an alternative to higher cost state plan services.
79	Downward substitution of care may include private practice
80	psychologists and social workers, inpatient care in institutions
81	for mental illness, and other services the plan considers to be
82	more cost-effective than hospital inpatient care.
83	(g)  Review the use of risk-adjusted rates, especially for
84	rural counties.
85	(h)  Review the grievance resolution process and the
86	procedure for filing complaints with the agency regarding access
87	to care and consider alternative approaches.
88	(i)  Consider changes to the federal waiver to respond to
89	identified problems and consider new methods or approaches,
90	which may include physician direct-care models, specialty
91	behavioral health plans, county-based models, and hospital-based
92	systems of care in addition to the managed care delivery models
93	currently authorized.
94	(j)  Consider changes to create financial incentives that
95	reward risk taking and innovation and expand the use of downward
96	substitution strategies, which shall not be limited to
97	treatment-only services but shall include access to cost-
98	effective approaches including providing custodial care for
99	persons with chronic diseases.
100	(2)  The workgroup shall include representatives from the
101	Department of Children and Family Services, the Department of
102	Elderly Affairs, the Agency for Health Care Administration, the
103	Department of Health, the Medicaid Fraud Control Unit, and trade
104	associations and consumer advocates.
105	(3)  Members of the workgroup shall serve at without
106	compensation. The workgroup shall conduct at least four meetings
107	and shall submit a final report recommending changes to the
108	Medicaid managed care pilot program to the Governor, the
109	President of the Senate, and the Speaker of the House of
110	Representatives by January 1, 2010.
111	(4)  The workgroup shall expire January 1, 2010.
112	Section 2.  Subsection (1) of section 395.1041, Florida
113	Statutes, is amended to read:
114	395.1041  Access to emergency services and care.--
115	(1)  LEGISLATIVE INTENT.--The Legislature finds and
116	declares it to be of vital importance that emergency services
117	and care be provided by hospitals and physicians to every person
118	in need of such care. The Legislature finds that persons have
119	been denied emergency services and care by hospitals. It is the
120	intent of the Legislature that the agency vigorously enforce the
121	ability of persons to receive all necessary and appropriate
122	emergency services and care and that the agency act in a
123	thorough and timely manner against hospitals and physicians
124	which deny persons emergency services and care. It is further
125	the intent of the Legislature that hospitals, emergency medical
126	services providers, and other health care providers work
127	together in their local communities to enter into agreements or
128	arrangements to ensure access to emergency services and care. It
129	is further the intent of the Legislature that hospitals develop
130	a placement and referral system for persons in need of
131	nonemergency medical services to have access to appropriate
132	licensed settings that are capable of providing those services.
133	The Legislature further recognizes that appropriate emergency
134	services and care often require followup consultation and
135	treatment in order to effectively care for emergency medical
136	conditions.
137	Section 3.  Paragraph (b) of subsection (4) of section
138	408.910, Florida Statutes, is amended to read:
139	408.910  Florida Health Choices Program.--
140	(4)  ELIGIBILITY AND PARTICIPATION.--Participation in the
141	program is voluntary and shall be available to employers,
142	individuals, vendors, and health insurance agents as specified
143	in this subsection.
144	(b)  Individuals eligible to participate in the program
145	include:
146	1.  Individual employees of enrolled employers.
147	2.  State employees not eligible for state employee health
148	benefits.
149	3.  State retirees.
150	4.  Medicaid reform participants who select the opt-out
151	provision of reform.
152	4.5.  Statutory rural hospitals.
153	Section 4.  Subsection (7) of section 409.8132, Florida
154	Statutes, is amended to read:
155	409.8132  Medikids program component.--
156	(7)  ENROLLMENT.--Enrollment in the Medikids program
157	component may occur at any time throughout the year. A child may
158	not receive services under the Medikids program until the child
159	is enrolled in a managed care plan or MediPass. Once determined
160	eligible, an applicant may receive choice counseling and select
161	a managed care plan or MediPass. The agency may initiate
162	mandatory assignment for a Medikids applicant who has not chosen
163	a managed care plan or MediPass provider after the applicant's
164	voluntary choice period ends. An applicant may select MediPass
165	under the Medikids program component only in counties that have
166	fewer than two managed care plans available to serve Medicaid
167	recipients and only if the federal Health Care Financing
168	Administration determines that MediPass constitutes "health
169	insurance coverage" as defined in Title XXI of the Social
170	Security Act.
171	Section 5.  Paragraph (b) of subsection (4) of section
172	409.912, Florida Statutes, is amended to read:
173	409.912  Cost-effective purchasing of health care.--The
174	agency shall purchase goods and services for Medicaid recipients
175	in the most cost-effective manner consistent with the delivery
176	of quality medical care. To ensure that medical services are
177	effectively utilized, the agency may, in any case, require a
178	confirmation or second physician's opinion of the correct
179	diagnosis for purposes of authorizing future services under the
180	Medicaid program. This section does not restrict access to
181	emergency services or poststabilization care services as defined
182	in 42 C.F.R. part 438.114. Such confirmation or second opinion
183	shall be rendered in a manner approved by the agency. The agency
184	shall maximize the use of prepaid per capita and prepaid
185	aggregate fixed-sum basis services when appropriate and other
186	alternative service delivery and reimbursement methodologies,
187	including competitive bidding pursuant to s. 287.057, designed
188	to facilitate the cost-effective purchase of a case-managed
189	continuum of care. The agency shall also require providers to
190	minimize the exposure of recipients to the need for acute
191	inpatient, custodial, and other institutional care and the
192	inappropriate or unnecessary use of high-cost services. The
193	agency shall contract with a vendor to monitor and evaluate the
194	clinical practice patterns of providers in order to identify
195	trends that are outside the normal practice patterns of a
196	provider's professional peers or the national guidelines of a
197	provider's professional association. The vendor must be able to
198	provide information and counseling to a provider whose practice
199	patterns are outside the norms, in consultation with the agency,
200	to improve patient care and reduce inappropriate utilization.
201	The agency may mandate prior authorization, drug therapy
202	management, or disease management participation for certain
203	populations of Medicaid beneficiaries, certain drug classes, or
204	particular drugs to prevent fraud, abuse, overuse, and possible
205	dangerous drug interactions. The Pharmaceutical and Therapeutics
206	Committee shall make recommendations to the agency on drugs for
207	which prior authorization is required. The agency shall inform
208	the Pharmaceutical and Therapeutics Committee of its decisions
209	regarding drugs subject to prior authorization. The agency is
210	authorized to limit the entities it contracts with or enrolls as
211	Medicaid providers by developing a provider network through
212	provider credentialing. The agency may competitively bid single-
213	source-provider contracts if procurement of goods or services
214	results in demonstrated cost savings to the state without
215	limiting access to care. The agency may limit its network based
216	on the assessment of beneficiary access to care, provider
217	availability, provider quality standards, time and distance
218	standards for access to care, the cultural competence of the
219	provider network, demographic characteristics of Medicaid
220	beneficiaries, practice and provider-to-beneficiary standards,
221	appointment wait times, beneficiary use of services, provider
222	turnover, provider profiling, provider licensure history,
223	previous program integrity investigations and findings, peer
224	review, provider Medicaid policy and billing compliance records,
225	clinical and medical record audits, and other factors. Providers
226	shall not be entitled to enrollment in the Medicaid provider
227	network. The agency shall determine instances in which allowing
228	Medicaid beneficiaries to purchase durable medical equipment and
229	other goods is less expensive to the Medicaid program than long-
230	term rental of the equipment or goods. The agency may establish
231	rules to facilitate purchases in lieu of long-term rentals in
232	order to protect against fraud and abuse in the Medicaid program
233	as defined in s. 409.913. The agency may seek federal waivers
234	necessary to administer these policies.
235	(4)  The agency may contract with:
236	(b)  An entity that is providing comprehensive behavioral
237	health care services to certain Medicaid recipients through a
238	capitated, prepaid arrangement pursuant to the federal waiver
239	provided for by s. 409.905(5). Such an entity must be licensed
240	under chapter 624, chapter 636, or chapter 641 and must possess
241	the clinical systems and operational competence to manage risk
242	and provide comprehensive behavioral health care to Medicaid
243	recipients. As used in this paragraph, the term "comprehensive
244	behavioral health care services" means covered mental health and
245	substance abuse treatment services that are available to
246	Medicaid recipients. The secretary of the Department of Children
247	and Family Services shall approve provisions of procurements
248	related to children in the department's care or custody prior to
249	enrolling such children in a prepaid behavioral health plan. Any
250	contract awarded under this paragraph must be competitively
251	procured. In developing the behavioral health care prepaid plan
252	procurement document, the agency shall ensure that the
253	procurement document requires the contractor to develop and
254	implement a plan to ensure compliance with s. 394.4574 related
255	to services provided to residents of licensed assisted living
256	facilities that hold a limited mental health license. Except as
257	provided in subparagraph 8., and except in counties where the
258	Medicaid managed care pilot program is authorized pursuant to s.
259	409.91211, the agency shall seek federal approval to contract
260	with a single entity meeting these requirements to provide
261	comprehensive behavioral health care services to all Medicaid
262	recipients not enrolled in a Medicaid managed care plan
263	authorized under s. 409.91211 or a Medicaid health maintenance
264	organization in an AHCA area. In an AHCA area where the Medicaid
265	managed care pilot program is authorized pursuant to s.
266	409.91211 in one or more counties, the agency may procure a
267	contract with a single entity to serve the remaining counties as
268	an AHCA area or the remaining counties may be included with an
269	adjacent AHCA area and shall be subject to this paragraph. Each
270	entity must offer sufficient choice of providers in its network
271	to ensure recipient access to care and the opportunity to select
272	a provider with whom they are satisfied. The network shall
273	include all public mental health hospitals. To ensure unimpaired
274	access to behavioral health care services by Medicaid
275	recipients, all contracts issued pursuant to this paragraph
276	shall require 80 percent of the capitation paid to the managed
277	care plan, including health maintenance organizations, to be
278	expended for the provision of behavioral health care services.
279	In the event the managed care plan expends less than 80 percent
280	of the capitation paid pursuant to this paragraph for the
281	provision of behavioral health care services, the difference
282	shall be returned to the agency. The agency shall provide the
283	managed care plan with a certification letter indicating the
284	amount of capitation paid during each calendar year for the
285	provision of behavioral health care services pursuant to this
286	section. The agency may reimburse for substance abuse treatment
287	services on a fee-for-service basis until the agency finds that
288	adequate funds are available for capitated, prepaid
289	arrangements.
290	1.  By January 1, 2001, the agency shall modify the
291	contracts with the entities providing comprehensive inpatient
292	and outpatient mental health care services to Medicaid
293	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
294	Counties, to include substance abuse treatment services.
295	2.  By July 1, 2003, the agency and the Department of
296	Children and Family Services shall execute a written agreement
297	that requires collaboration and joint development of all policy,
298	budgets, procurement documents, contracts, and monitoring plans
299	that have an impact on the state and Medicaid community mental
300	health and targeted case management programs.
301	3.  Except as provided in subparagraph 8., by July 1, 2006,
302	the agency and the Department of Children and Family Services
303	shall contract with managed care entities in each AHCA area
304	except area 6 or arrange to provide comprehensive inpatient and
305	outpatient mental health and substance abuse services through
306	capitated prepaid arrangements to all Medicaid recipients who
307	are eligible to participate in such plans under federal law and
308	regulation. In AHCA areas where eligible individuals number less
309	than 150,000, the agency shall contract with a single managed
310	care plan to provide comprehensive behavioral health services to
311	all recipients who are not enrolled in a Medicaid health
312	maintenance organization or a Medicaid capitated managed care
313	plan authorized under s. 409.91211. The agency may contract with
314	more than one comprehensive behavioral health provider to
315	provide care to recipients who are not enrolled in a Medicaid
316	capitated managed care plan authorized under s. 409.91211 or a
317	Medicaid health maintenance organization in AHCA areas where the
318	eligible population exceeds 150,000. In an AHCA area where the
319	Medicaid managed care pilot program is authorized pursuant to s.
320	409.91211 in one or more counties, the agency may procure a
321	contract with a single entity to serve the remaining counties as
322	an AHCA area or the remaining counties may be included with an
323	adjacent AHCA area and shall be subject to this paragraph.
324	Contracts for comprehensive behavioral health providers awarded
325	pursuant to this section shall be competitively procured. Both
326	for-profit and not-for-profit corporations shall be eligible to
327	compete. Managed care plans contracting with the agency under
328	subsection (3) shall provide and receive payment for the same
329	comprehensive behavioral health benefits as provided in AHCA
330	rules, including handbooks incorporated by reference. In AHCA
331	area 11, the agency shall contract with at least two
332	comprehensive behavioral health care providers to provide
333	behavioral health care to recipients in that area who are
334	enrolled in, or assigned to, the MediPass program. One of the
335	behavioral health care contracts shall be with the existing
336	provider service network pilot project, as described in
337	paragraph (d), for the purpose of demonstrating the cost-
338	effectiveness of the provision of quality mental health services
339	through a public hospital-operated managed care model. Payment
340	shall be at an agreed-upon capitated rate to ensure cost
341	savings. Of the recipients in area 11 who are assigned to
342	MediPass under the provisions of s. 409.9122(2)(k), a minimum of
343	50,000 of those MediPass-enrolled recipients shall be assigned
344	to the existing provider service network in area 11 for their
345	behavioral care.
346	4.  By October 1, 2003, the agency and the department shall
347	submit a plan to the Governor, the President of the Senate, and
348	the Speaker of the House of Representatives which provides for
349	the full implementation of capitated prepaid behavioral health
350	care in all areas of the state.
351	a.  Implementation shall begin in 2003 in those AHCA areas
352	of the state where the agency is able to establish sufficient
353	capitation rates.
354	b.  If the agency determines that the proposed capitation
355	rate in any area is insufficient to provide appropriate
356	services, the agency may adjust the capitation rate to ensure
357	that care will be available. The agency and the department may
358	use existing general revenue to address any additional required
359	match but may not over-obligate existing funds on an annualized
360	basis.
361	c.  Subject to any limitations provided for in the General
362	Appropriations Act, the agency, in compliance with appropriate
363	federal authorization, shall develop policies and procedures
364	that allow for certification of local and state funds.
365	5.  Children residing in a statewide inpatient psychiatric
366	program, or in a Department of Juvenile Justice or a Department
367	of Children and Family Services residential program approved as
368	a Medicaid behavioral health overlay services provider shall not
369	be included in a behavioral health care prepaid health plan or
370	any other Medicaid managed care plan pursuant to this paragraph.
371	6.  In converting to a prepaid system of delivery, the
372	agency shall in its procurement document require an entity
373	providing only comprehensive behavioral health care services to
374	prevent the displacement of indigent care patients by enrollees
375	in the Medicaid prepaid health plan providing behavioral health
376	care services from facilities receiving state funding to provide
377	indigent behavioral health care, to facilities licensed under
378	chapter 395 which do not receive state funding for indigent
379	behavioral health care, or reimburse the unsubsidized facility
380	for the cost of behavioral health care provided to the displaced
381	indigent care patient.
382	7.  Traditional community mental health providers under
383	contract with the Department of Children and Family Services
384	pursuant to part IV of chapter 394, child welfare providers
385	under contract with the Department of Children and Family
386	Services in areas 1 and 6, and inpatient mental health providers
387	licensed pursuant to chapter 395 must be offered an opportunity
388	to accept or decline a contract to participate in any provider
389	network for prepaid behavioral health services.
390	8.  All Medicaid-eligible children, except children in area
391	1 and children in Highlands County, Hardee County, Polk County,
392	or Manatee County of area 6, who are open for child welfare
393	services in the HomeSafeNet system, shall receive their
394	behavioral health care services through a specialty prepaid plan
395	operated by community-based lead agencies either through a
396	single agency or formal agreements among several agencies. The
397	specialty prepaid plan must result in savings to the state
398	comparable to savings achieved in other Medicaid managed care
399	and prepaid programs. Such plan must provide mechanisms to
400	maximize state and local revenues. The specialty prepaid plan
401	shall be developed by the agency and the Department of Children
402	and Family Services. The agency is authorized to seek any
403	federal waivers to implement this initiative. Medicaid-eligible
404	children whose cases are open for child welfare services in the
405	HomeSafeNet system and who reside in AHCA area 10 are exempt
406	from the specialty prepaid plan upon the development of a
407	service delivery mechanism for children who reside in area 10 as
408	specified in s. 409.91211(3)(z)(dd).
409	Section 6.  Section 409.91211, Florida Statutes, is amended
410	to read:
411	409.91211  Medicaid managed care pilot program.--
412	(1)(a)  The agency is authorized to seek and implement
413	experimental, pilot, or demonstration project waivers, pursuant
414	to s. 1115 of the Social Security Act, and to seek changes to
415	the current federal Medicaid reform waiver, to create a
416	statewide initiative to provide for a more efficient and
417	effective service delivery system that enhances quality of care
418	and client outcomes in the Florida Medicaid program pursuant to
419	this section. Phase one of the demonstration shall be
420	implemented in two geographic areas. One demonstration site
421	shall include only Broward County. A second demonstration site
422	shall initially include Duval County and shall be expanded to
423	include Baker, Clay, and Nassau Counties within 1 year after the
424	Duval County program becomes operational. The agency shall
425	implement expansion of the program to include the remaining
426	counties of the state and remaining eligibility groups in
427	accordance with the process specified in the federally approved
428	special terms and conditions numbered 11-W-00206/4, as approved
429	by the federal Centers for Medicare and Medicaid Services on
430	October 19, 2005, with a goal of full statewide implementation
431	by June 30, 2011.
432	(b)  This waiver authority is contingent upon federal
433	approval to preserve the upper-payment-limit funding mechanism
434	for hospitals, including a guarantee of a reasonable growth
435	factor, a methodology to allow the use of a portion of these
436	funds to serve as a risk pool for demonstration sites,
437	provisions to preserve the state's ability to use
438	intergovernmental transfers, and provisions to protect the
439	disproportionate share program authorized pursuant to this
440	chapter. Upon completion of the evaluation conducted under s. 3,
441	ch. 2005-133, Laws of Florida, the agency may request statewide
442	expansion of the demonstration projects. Statewide phase-in to
443	additional counties shall be contingent upon review and approval
444	by the Legislature. Under the upper-payment-limit program, or
445	the low-income pool as implemented by the Agency for Health Care
446	Administration pursuant to federal waiver, the state matching
447	funds required for the program shall be provided by local
448	governmental entities through intergovernmental transfers in
449	accordance with published federal statutes and regulations. The
450	Agency for Health Care Administration shall distribute upper-
451	payment-limit, disproportionate share hospital, and low-income
452	pool funds according to published federal statutes, regulations,
453	and waivers and the low-income pool methodology approved by the
454	federal Centers for Medicare and Medicaid Services.
455	(c)  It is the intent of the Legislature that the low-
456	income pool plan required by the terms and conditions of the
457	Medicaid reform waiver and submitted to the federal Centers for
458	Medicare and Medicaid Services propose the distribution of the
459	above-mentioned program funds based on the following objectives:
460	1.  Assure a broad and fair distribution of available funds
461	based on the access provided by Medicaid participating
462	hospitals, regardless of their ownership status, through their
463	delivery of inpatient or outpatient care for Medicaid
464	beneficiaries and uninsured and underinsured individuals;
465	2.  Assure accessible emergency inpatient and outpatient
466	care for Medicaid beneficiaries and uninsured and underinsured
467	individuals;
468	3.  Enhance primary, preventive, and other ambulatory care
469	coverages for uninsured individuals;
470	4.  Promote teaching and specialty hospital programs;
471	5.  Promote the stability and viability of statutorily
472	defined rural hospitals and hospitals that serve as sole
473	community hospitals;
474	6.  Recognize the extent of hospital uncompensated care
475	costs;
476	7.  Maintain and enhance essential community hospital care;
477	8.  Maintain incentives for local governmental entities to
478	contribute to the cost of uncompensated care;
479	9.  Promote measures to avoid preventable hospitalizations;
480	10.  Account for hospital efficiency; and
481	11.  Contribute to a community's overall health system.
482	12.  Develop physician-directed health care plans,
483	specialty behavioral health care plans, and county-based health
484	care plans for rural areas;
485	13.  Develop a plan to provide nonemergency transportation
486	for individuals who reside in licensed assisted living
487	facilities, mental health residential facilities, and adult
488	family-care homes. The plan shall include cooperative agreements
489	between the plan and the facility administrators and shall
490	detail how the plan will make transportation available for
491	qualified plan enrollees at these facilities to include access
492	to urgent care transportation, time standards for pick up and
493	returns, and the provision of escorts, if required;
494	14.  Create a standardization process for quality assurance
495	purposes that all plans will utilize to help providers
496	streamline and reduce redundancy associated with processing
497	claims;
498	15.  Create an accreditation standard for provider agencies
499	that will be recognized by all reform plans for compliance
500	purposes; and
501	16.  Create financial incentives for plans to pursue
502	innovative approaches to the provision of care for adversely
503	affected subgroups that include individuals with chronic mental
504	illnesses who have been committed under the Baker Act,
505	individuals who have HIV/AIDS, and individuals with
506	developmental disabilities.
507	(2)  The Legislature intends for the capitated managed care
508	pilot program to:
509	(a)  Provide recipients in Medicaid fee-for-service or the
510	MediPass program a comprehensive and coordinated capitated
511	managed care system for all health care services specified in
512	ss. 409.905 and 409.906.
513	(b)  Stabilize Medicaid expenditures under the pilot
514	program compared to Medicaid expenditures in the pilot area for
515	the 3 years before implementation of the pilot program, while
516	ensuring:
517	1.  Consumer education and choice.
518	2.  Access to medically necessary services.
519	3.  Coordination of preventative, acute, and long-term
520	care.
521	4.  Reductions in unnecessary service utilization.
522	(c)  Provide an opportunity to evaluate the feasibility of
523	statewide implementation of capitated managed care networks as a
524	replacement for the current Medicaid fee-for-service and
525	MediPass systems.
526	(3)  The agency shall have the following powers, duties,
527	and responsibilities with respect to the pilot program:
528	(a)  To implement a system to deliver all mandatory
529	services specified in s. 409.905 and optional services specified
530	in s. 409.906, as approved by the Centers for Medicare and
531	Medicaid Services and the Legislature in the waiver pursuant to
532	this section. Services to recipients under plan benefits shall
533	include emergency services provided under s. 409.9128.
534	(b)  To implement a pilot program, including Medicaid
535	eligibility categories specified in ss. 409.903 and 409.904, as
536	authorized in an approved federal waiver.
537	(c)  To implement the managed care pilot program that
538	maximizes all available state and federal funds, including those
539	obtained through intergovernmental transfers, the low-income
540	pool, supplemental Medicaid payments, and the disproportionate
541	share program. Within the parameters allowed by federal statute
542	and rule, the agency may seek options for making direct payments
543	to hospitals and physicians employed by or under contract with
544	the state's medical schools for the costs associated with
545	graduate medical education under Medicaid reform.
546	(d)  To implement actuarially sound, risk-adjusted
547	capitation rates for Medicaid recipients in the pilot program
548	which cover comprehensive care, enhanced services, and
549	catastrophic care.
550	(e)  To implement policies and guidelines for phasing in
551	financial risk for approved provider service networks over a 3-
552	year period. These policies and guidelines must include an
553	option for a provider service network to be paid fee-for-service
554	rates. For any provider service network established in a managed
555	care pilot area, the option to be paid fee-for-service rates
556	shall include a savings-settlement mechanism that is consistent
557	with s. 409.912(44). This model shall be converted to a risk-
558	adjusted capitated rate no later than the beginning of the
559	fourth year of operation, and may be converted earlier at the
560	option of the provider service network. Federally qualified
561	health centers may be offered an opportunity to accept or
562	decline a contract to participate in any provider network for
563	prepaid primary care services.
564	(f)  To implement stop-loss requirements and the transfer
565	of excess cost to catastrophic coverage that accommodates the
566	risks associated with the development of the pilot program.
567	(g)  To recommend a process to be used by the Social
568	Services Estimating Conference to determine and validate the
569	rate of growth of the per-member costs of providing Medicaid
570	services under the managed care pilot program.
571	(h)  To implement program standards and credentialing
572	requirements for capitated managed care networks to participate
573	in the pilot program, including those related to fiscal
574	solvency, quality of care, and adequacy of access to health care
575	providers. It is the intent of the Legislature that, to the
576	extent possible, any pilot program authorized by the state under
577	this section include any federally qualified health center,
578	federally qualified rural health clinic, county health
579	department, the Children's Medical Services Network within the
580	Department of Health, or other federally, state, or locally
581	funded entity that serves the geographic areas within the
582	boundaries of the pilot program that requests to participate.
583	This paragraph does not relieve an entity that qualifies as a
584	capitated managed care network under this section from any other
585	licensure or regulatory requirements contained in state or
586	federal law which would otherwise apply to the entity. The
587	standards and credentialing requirements shall be based upon,
588	but are not limited to:
589	1.  Compliance with the accreditation requirements as
590	provided in s. 641.512.
591	2.  Compliance with early and periodic screening,
592	diagnosis, and treatment screening requirements under federal
593	law.
594	3.  The percentage of voluntary disenrollments.
595	4.  Immunization rates.
596	5.  Standards of the National Committee for Quality
597	Assurance and other approved accrediting bodies.
598	6.  Recommendations of other authoritative bodies.
599	7.  Specific requirements of the Medicaid program, or
600	standards designed to specifically meet the unique needs of
601	Medicaid recipients.
602	8.  Compliance with the health quality improvement system
603	as established by the agency, which incorporates standards and
604	guidelines developed by the Centers for Medicare and Medicaid
605	Services as part of the quality assurance reform initiative.
606	9.  The network's infrastructure capacity to manage
607	financial transactions, recordkeeping, data collection, and
608	other administrative functions.
609	10.  The network's ability to submit any financial,
610	programmatic, or patient-encounter data or other information
611	required by the agency to determine the actual services provided
612	and the cost of administering the plan.
613	(i)  To implement a mechanism for providing information to
614	Medicaid recipients for the purpose of selecting a capitated
615	managed care plan. For each plan available to a recipient, the
616	agency, at a minimum, shall ensure that the recipient is
617	provided with:
618	1.  A list and description of the benefits provided and
619	patient-encounter data from the reform plans.
620	2.  Information about cost sharing.
621	3.  Plan performance data, if available.
622	4.  An explanation of benefit limitations.
623	5.  Contact information, including identification of
624	providers participating in the network, geographic locations,
625	and transportation limitations, and a toll-free telephone number
626	to report complaints.
627	6.  Any other information the agency determines would
628	facilitate a recipient's understanding of the plan or insurance
629	that would best meet his or her needs.
630	(j)  To implement a system to ensure that there is a record
631	of recipient acknowledgment that choice counseling has been
632	provided.
633	(k)  To implement a choice counseling system to ensure that
634	the choice counseling process and related material are designed
635	to provide counseling through face-to-face interaction, by
636	telephone, and in writing and through other forms of relevant
637	media. Materials shall be written at the fourth-grade reading
638	level and available in a language other than English when 5
639	percent of the county speaks a language other than English.
640	Choice counseling shall also use language lines and other
641	services for impaired recipients, such as TTD/TTY.
642	(j)(l)  To implement a system that prohibits capitated
643	managed care plans, their representatives, and providers
644	employed by or contracted with the capitated managed care plans
645	from recruiting persons eligible for or enrolled in Medicaid,
646	from providing inducements to Medicaid recipients to select a
647	particular capitated managed care plan, and from prejudicing
648	Medicaid recipients against other capitated managed care plans.
649	The system shall require the entity performing choice counseling
650	to determine if the recipient has made a choice of a plan or has
651	opted out because of duress, threats, payment to the recipient,
652	or incentives promised to the recipient by a third party. If the
653	choice counseling entity determines that the decision to choose
654	a plan was unlawfully influenced or a plan violated any of the
655	provisions of s. 409.912(21), the choice counseling entity shall
656	immediately report the violation to the agency's program
657	integrity section for investigation. Verification of choice
658	counseling by the recipient shall include a stipulation that the
659	recipient acknowledges the provisions of this subsection.
660	(m)  To implement a choice counseling system that promotes
661	health literacy and provides information aimed to reduce
662	minority health disparities through outreach activities for
663	Medicaid recipients.
664	(n)  To contract with entities to perform choice
665	counseling. The agency may establish standards and performance
666	contracts, including standards requiring the contractor to hire
667	choice counselors who are representative of the state's diverse
668	population and to train choice counselors in working with
669	culturally diverse populations.
670	(k)(o)  To implement eligibility assignment processes to
671	facilitate client choice while ensuring pilot programs of
672	adequate enrollment levels. These processes shall ensure that
673	pilot sites have sufficient levels of enrollment to conduct a
674	valid test of the managed care pilot program within a 2-year
675	timeframe.
676	(l)(p)  To implement standards for plan compliance,
677	including, but not limited to, standards for quality assurance
678	and performance improvement, standards for peer or professional
679	reviews, grievance policies, and policies for maintaining
680	program integrity. The agency shall develop a data-reporting
681	system, seek input from managed care plans in order to establish
682	requirements for patient-encounter reporting, and ensure that
683	the data reported is accurate and complete, and post the data on
684	its Internet website.
685	1.  In performing the duties required under this section,
686	the agency shall work with managed care plans to establish a
687	uniform system to measure and monitor outcomes for a recipient
688	of Medicaid services.
689	2.  The system shall use financial, clinical, and other
690	criteria based on pharmacy, medical services, and other data
691	that is related to the provision of Medicaid services,
692	including, but not limited to:
693	a.  The Health Plan Employer Data and Information Set
694	(HEDIS) or measures that are similar to HEDIS.
695	b.  Member satisfaction.
696	c.  Provider satisfaction.
697	d.  Report cards on plan performance and best practices.
698	e.  Compliance with the requirements for prompt payment of
699	claims under ss. 627.613, 641.3155, and 641.513.
700	f.  Utilization and quality data for the purpose of
701	ensuring access to medically necessary services, including
702	underutilization or inappropriate denial of services.
703	3.  The agency shall require the managed care plans that
704	have contracted with the agency to establish a quality assurance
705	system that incorporates the provisions of s. 409.912(27) and
706	any standards, rules, and guidelines developed by the agency.
707	4.  The agency shall establish an encounter database in
708	order to compile data on health services rendered by health care
709	practitioners who provide services to patients enrolled in
710	managed care plans in the demonstration sites. The encounter
711	database shall:
712	a.  Collect the following for each type of patient
713	encounter with a health care practitioner or facility,
714	including:
715	(I)  The demographic characteristics of the patient.
716	(II)  The principal, secondary, and tertiary diagnosis.
717	(III)  The procedure performed.
718	(IV)  The date and location where the procedure was
719	performed.
720	(V)  The payment for the procedure, if any.
721	(VI)  If applicable, the health care practitioner's
722	universal identification number.
723	(VII)  If the health care practitioner rendering the
724	service is a dependent practitioner, the modifiers appropriate
725	to indicate that the service was delivered by the dependent
726	practitioner.
727	b.  Collect appropriate information relating to
728	prescription drugs for each type of patient encounter.
729	c.  Collect appropriate information related to health care
730	costs and utilization from managed care plans participating in
731	the demonstration sites.
732	5.  To the extent practicable, when collecting the data the
733	agency shall use a standardized claim form or electronic
734	transfer system that is used by health care practitioners,
735	facilities, and payors.
736	6.  Health care practitioners and facilities in the
737	demonstration sites shall electronically submit, and managed
738	care plans participating in the demonstration sites shall
739	electronically receive, information concerning claims payments
740	and any other information reasonably related to the encounter
741	database using a standard format as required by the agency.
742	7.  The agency shall establish reasonable deadlines for
743	phasing in the electronic transmittal of full encounter data.
744	8.  The system must ensure that the data reported is
745	accurate and complete.
746	(m)(q)  To implement a grievance resolution process for
747	Medicaid recipients enrolled in a capitated managed care network
748	under the pilot program modeled after the subscriber assistance
749	panel, as created in s. 408.7056. This process shall include a
750	mechanism for an expedited review of no greater than 24 hours
751	after notification of a grievance if the life of a Medicaid
752	recipient is in imminent and emergent jeopardy.
753	(n)(r)  To implement a grievance resolution process for
754	health care providers employed by or contracted with a capitated
755	managed care network under the pilot program in order to settle
756	disputes among the provider and the managed care network or the
757	provider and the agency.
758	(o)(s)  To implement criteria in an approved federal waiver
759	to designate health care providers as eligible to participate in
760	the pilot program. These criteria must include at a minimum
761	those criteria specified in s. 409.907.
762	(p)(t)  To use health care provider agreements for
763	participation in the pilot program.
764	(q)(u)  To require that all health care providers under
765	contract with the pilot program be duly licensed in the state,
766	if such licensure is available, and meet other criteria as may
767	be established by the agency. These criteria shall include at a
768	minimum those criteria specified in s. 409.907.
769	(r)(v)  To ensure that managed care organizations work
770	collaboratively with other state or local governmental programs
771	or institutions for the coordination of health care to eligible
772	individuals receiving services from such programs or
773	institutions.
774	(s)(w)  To implement procedures to minimize the risk of
775	Medicaid fraud and abuse in all plans operating in the Medicaid
776	managed care pilot program authorized in this section.
777	1.  The agency shall ensure that applicable provisions of
778	this chapter and chapters 414, 626, 641, and 932 which relate to
779	Medicaid fraud and abuse are applied and enforced at the
780	demonstration project sites.
781	2.  Providers must have the certification, license, and
782	credentials that are required by law and waiver requirements.
783	3.  The agency shall ensure that the plan is in compliance
784	with s. 409.912(21) and (22).
785	4.  The agency shall require that each plan establish
786	functions and activities governing program integrity in order to
787	reduce the incidence of fraud and abuse. Plans must report
788	instances of fraud and abuse pursuant to chapter 641.
789	5.  The plan shall have written administrative and
790	management arrangements or procedures, including a mandatory
791	compliance plan, which are designed to guard against fraud and
792	abuse. The plan shall designate a compliance officer who has
793	sufficient experience in health care.
794	6.a.  The agency shall require all managed care plan
795	contractors in the pilot program to report all instances of
796	suspected fraud and abuse. A failure to report instances of
797	suspected fraud and abuse is a violation of law and subject to
798	the penalties provided by law.
799	b.  An instance of fraud and abuse in the managed care
800	plan, including, but not limited to, defrauding the state health
801	care benefit program by misrepresentation of fact in reports,
802	claims, certifications, enrollment claims, demographic
803	statistics, or patient-encounter data; misrepresentation of the
804	qualifications of persons rendering health care and ancillary
805	services; bribery and false statements relating to the delivery
806	of health care; unfair and deceptive marketing practices; and
807	false claims actions in the provision of managed care, is a
808	violation of law and subject to the penalties provided by law.
809	c.  The agency shall require that all contractors make all
810	files and relevant billing and claims data accessible to state
811	regulators and investigators and that all such data is linked
812	into a unified system to ensure consistent reviews and
813	investigations.
814	(t)(x)  To develop and provide actuarial and benefit design
815	analyses that indicate the effect on capitation rates and
816	benefits offered in the pilot program over a prospective 5-year
817	period based on the following assumptions:
818	1.  Growth in capitation rates which is limited to the
819	estimated growth rate in general revenue.
820	2.  Growth in capitation rates which is limited to the
821	average growth rate over the last 3 years in per-recipient
822	Medicaid expenditures.
823	3.  Growth in capitation rates which is limited to the
824	growth rate of aggregate Medicaid expenditures between the 2003-
825	2004 fiscal year and the 2004-2005 fiscal year.
826	(u)(y)  To develop a mechanism to require capitated managed
827	care plans to reimburse qualified emergency service providers,
828	including, but not limited to, ambulance services, in accordance
829	with ss. 409.908 and 409.9128. The pilot program must include a
830	provision for continuing fee-for-service payments for emergency
831	services, including, but not limited to, individuals who access
832	ambulance services or emergency departments and who are
833	subsequently determined to be eligible for Medicaid services.
834	(v)(z)  To ensure that school districts participating in
835	the certified school match program pursuant to ss. 409.908(21)
836	and 1011.70 shall be reimbursed by Medicaid, subject to the
837	limitations of s. 1011.70(1), for a Medicaid-eligible child
838	participating in the services as authorized in s. 1011.70, as
839	provided for in s. 409.9071, regardless of whether the child is
840	enrolled in a capitated managed care network. Capitated managed
841	care networks must make a good faith effort to execute
842	agreements with school districts regarding the coordinated
843	provision of services authorized under s. 1011.70. County health
844	departments and federally qualified health centers delivering
845	school-based services pursuant to ss. 381.0056 and 381.0057 must
846	be reimbursed by Medicaid for the federal share for a Medicaid-
847	eligible child who receives Medicaid-covered services in a
848	school setting, regardless of whether the child is enrolled in a
849	capitated managed care network. Capitated managed care networks
850	must make a good faith effort to execute agreements with county
851	health departments and federally qualified health centers
852	regarding the coordinated provision of services to a Medicaid-
853	eligible child. To ensure continuity of care for Medicaid
854	patients, the agency, the Department of Health, and the
855	Department of Education shall develop procedures for ensuring
856	that a student's capitated managed care network provider
857	receives information relating to services provided in accordance
858	with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
859	(w)(aa)  To implement a mechanism whereby Medicaid
860	recipients who are already enrolled in a managed care plan or
861	the MediPass program in the pilot areas shall be offered the
862	opportunity to change to capitated managed care plans on a
863	staggered basis, as defined by the agency. All Medicaid
864	recipients shall have 30 days in which to make a choice of
865	capitated managed care plans. Those Medicaid recipients who do
866	not make a choice shall be assigned to a capitated managed care
867	plan in accordance with paragraph (4)(a) and shall be exempt
868	from s. 409.9122. To facilitate continuity of care for a
869	Medicaid recipient who is also a recipient of Supplemental
870	Security Income (SSI), prior to assigning the SSI recipient to a
871	capitated managed care plan, the agency shall determine whether
872	the SSI recipient has an ongoing relationship with a provider or
873	capitated managed care plan, and, if so, the agency shall assign
874	the SSI recipient to that provider or capitated managed care
875	plan where feasible. Those SSI recipients who do not have such a
876	provider relationship shall be assigned to a capitated managed
877	care plan provider in accordance with paragraph (4)(a) and shall
878	be exempt from s. 409.9122.
879	(x)(bb)  To develop and recommend a service delivery
880	alternative for children having chronic medical conditions which
881	establishes a medical home project to provide primary care
882	services to this population. The project shall provide
883	community-based primary care services that are integrated with
884	other subspecialties to meet the medical, developmental, and
885	emotional needs for children and their families. This project
886	shall include an evaluation component to determine impacts on
887	hospitalizations, length of stays, emergency room visits, costs,
888	and access to care, including specialty care and patient and
889	family satisfaction.
890	(y)(cc)  To develop and recommend service delivery
891	mechanisms within capitated managed care plans to provide
892	Medicaid services as specified in ss. 409.905 and 409.906 to
893	persons with developmental disabilities sufficient to meet the
894	medical, developmental, and emotional needs of these persons.
895	(z)(dd)  To implement service delivery mechanisms within
896	capitated managed care plans to provide Medicaid services as
897	specified in ss. 409.905 and 409.906 to Medicaid-eligible
898	children whose cases are open for child welfare services in the
899	HomeSafeNet system. These services must be coordinated with
900	community-based care providers as specified in s. 409.1671,
901	where available, and be sufficient to meet the medical,
902	developmental, behavioral, and emotional needs of these
903	children. These service delivery mechanisms must be implemented
904	no later than July 1, 2008, in AHCA area 10 in order for the
905	children in AHCA area 10 to remain exempt from the statewide
906	plan under s. 409.912(4)(b)8.
907	(4)(a)  A Medicaid recipient in the pilot area who is not
908	currently enrolled in a capitated managed care plan upon
909	implementation is not eligible for services as specified in ss.
910	409.905 and 409.906, for the amount of time that the recipient
911	does not enroll in a capitated managed care network. If a
912	Medicaid recipient has not enrolled in a capitated managed care
913	plan within 30 days after eligibility, the agency shall assign
914	the Medicaid recipient to a capitated managed care plan based on
915	the assessed needs of the recipient as determined by the agency
916	and the recipient shall be exempt from s. 409.9122. When making
917	assignments, the agency shall take into account the following
918	criteria:
919	1.  A capitated managed care network has sufficient network
920	capacity to meet the needs of members.
921	2.  The capitated managed care network has previously
922	enrolled the recipient as a member, or one of the capitated
923	managed care network's primary care providers has previously
924	provided health care to the recipient.
925	3.  The agency has knowledge that the member has previously
926	expressed a preference for a particular capitated managed care
927	network as indicated by Medicaid fee-for-service claims data,
928	but has failed to make a choice.
929	4.  The capitated managed care network's primary care
930	providers are geographically accessible to the recipient's
931	residence.
932	(b)  When more than one capitated managed care network
933	provider meets the criteria specified in paragraph (3)(h), the
934	agency shall make recipient assignments consecutively by family
935	unit.
936	(c)  If a recipient is currently enrolled with a Medicaid
937	managed care organization that also operates an approved reform
938	plan within a demonstration area and the recipient fails to
939	choose a plan during the reform enrollment process or during
940	redetermination of eligibility, the recipient shall be
941	automatically assigned by the agency into the most appropriate
942	reform plan operated by the recipient's current Medicaid managed
943	care plan. If the recipient's current managed care plan does not
944	operate a reform plan in the demonstration area which adequately
945	meets the needs of the Medicaid recipient, the agency shall use
946	the automatic assignment process as prescribed in the special
947	terms and conditions numbered 11-W-00206/4. All enrollment and
948	choice counseling materials provided by the agency must contain
949	an explanation of the provisions of this paragraph for current
950	managed care recipients.
951	(d)  The agency may not engage in practices that are
952	designed to favor one capitated managed care plan over another
953	or that are designed to influence Medicaid recipients to enroll
954	in a particular capitated managed care network in order to
955	strengthen its particular fiscal viability.
956	(e)  After a recipient has made a selection or has been
957	enrolled in a capitated managed care network, the recipient
958	shall have 90 days in which to voluntarily disenroll and select
959	another capitated managed care network. After 90 days, no
960	further changes may be made except for cause. Cause shall
961	include, but not be limited to, poor quality of care, lack of
962	access to necessary specialty services, an unreasonable delay or
963	denial of service, inordinate or inappropriate changes of
964	primary care providers, service access impairments due to
965	significant changes in the geographic location of services, or
966	fraudulent enrollment. The agency may require a recipient to use
967	the capitated managed care network's grievance process as
968	specified in paragraph (3)(m)(q) prior to the agency's
969	determination of cause, except in cases in which immediate risk
970	of permanent damage to the recipient's health is alleged. The
971	grievance process, when used, must be completed in time to
972	permit the recipient to disenroll no later than the first day of
973	the second month after the month the disenrollment request was
974	made. If the capitated managed care network, as a result of the
975	grievance process, approves an enrollee's request to disenroll,
976	the agency is not required to make a determination in the case.
977	The agency must make a determination and take final action on a
978	recipient's request so that disenrollment occurs no later than
979	the first day of the second month after the month the request
980	was made. If the agency fails to act within the specified
981	timeframe, the recipient's request to disenroll is deemed to be
982	approved as of the date agency action was required. Recipients
983	who disagree with the agency's finding that cause does not exist
984	for disenrollment shall be advised of their right to pursue a
985	Medicaid fair hearing to dispute the agency's finding.
986	(f)  The agency shall apply for federal waivers from the
987	Centers for Medicare and Medicaid Services to lock eligible
988	Medicaid recipients into a capitated managed care network for 12
989	months after an open enrollment period. After 12 months of
990	enrollment, a recipient may select another capitated managed
991	care network. However, nothing shall prevent a Medicaid
992	recipient from changing primary care providers within the
993	capitated managed care network during the 12-month period.
994	(g)  The agency shall apply for federal waivers from the
995	Centers for Medicare and Medicaid Services to allow recipients
996	to purchase health care coverage through an employer-sponsored
997	health insurance plan instead of through a Medicaid-certified
998	plan. This provision shall be known as the opt-out option.
999	1.  A recipient who chooses the Medicaid opt-out option
1000	shall have an opportunity for a specified period of time, as
1001	authorized under a waiver granted by the Centers for Medicare
1002	and Medicaid Services, to select and enroll in a Medicaid-
1003	certified plan. If the recipient remains in the employer-
1004	sponsored plan after the specified period, the recipient shall
1005	remain in the opt-out program for at least 1 year or until the
1006	recipient no longer has access to employer-sponsored coverage,
1007	until the employer's open enrollment period for a person who
1008	opts out in order to participate in employer-sponsored coverage,
1009	or until the person is no longer eligible for Medicaid,
1010	whichever time period is shorter.
1011	2.  Notwithstanding any other provision of this section,
1012	coverage, cost sharing, and any other component of employer-
1013	sponsored health insurance shall be governed by applicable state
1014	and federal laws.
1015	(5)  This section does not authorize the agency to
1016	implement any provision of s. 1115 of the Social Security Act
1017	experimental, pilot, or demonstration project waiver to reform
1018	the state Medicaid program in any part of the state other than
1019	the two geographic areas specified in this section unless
1020	approved by the Legislature.
1021	(6)  The agency shall develop and submit for approval
1022	applications for waivers of applicable federal laws and
1023	regulations as necessary to implement the managed care pilot
1024	project as defined in this section. The agency may develop
1025	financial incentives for community-based care providers to
1026	develop systems of care that prevent or divert the need for
1027	inpatient hospital care. The agency shall post all waiver
1028	applications under this section on its Internet website 30 days
1029	before submitting the applications to the United States Centers
1030	for Medicare and Medicaid Services. All waiver applications
1031	shall be provided for review and comment to the appropriate
1032	committees of the Senate and House of Representatives for at
1033	least 10 working days prior to submission. All waivers submitted
1034	to and approved by the United States Centers for Medicare and
1035	Medicaid Services under this section must be approved by the
1036	Legislature. Federally approved waivers must be submitted to the
1037	President of the Senate and the Speaker of the House of
1038	Representatives for referral to the appropriate legislative
1039	committees. The appropriate committees shall recommend whether
1040	to approve the implementation of any waivers to the Legislature
1041	as a whole. The agency shall submit a plan containing a
1042	recommended timeline for implementation of any waivers and
1043	budgetary projections of the effect of the pilot program under
1044	this section on the total Medicaid budget for the 2006-2007
1045	through 2009-2010 state fiscal years. This implementation plan
1046	shall be submitted to the President of the Senate and the
1047	Speaker of the House of Representatives at the same time any
1048	waivers are submitted for consideration by the Legislature. The
1049	agency may implement the waiver and special terms and conditions
1050	numbered 11-W-00206/4, as approved by the federal Centers for
1051	Medicare and Medicaid Services. If the agency seeks approval by
1052	the Federal Government of any modifications to these special
1053	terms and conditions, the agency must provide written
1054	notification of its intent to modify these terms and conditions
1055	to the President of the Senate and the Speaker of the House of
1056	Representatives at least 15 days before submitting the
1057	modifications to the Federal Government for consideration. The
1058	notification must identify all modifications being pursued and
1059	the reason the modifications are needed. Upon receiving federal
1060	approval of any modifications to the special terms and
1061	conditions, the agency shall provide a report to the Legislature
1062	describing the federally approved modifications to the special
1063	terms and conditions within 7 days after approval by the Federal
1064	Government.
1065	(7)(a)  The Secretary of Health Care Administration shall
1066	convene a technical advisory panel to advise the agency in the
1067	areas of risk-adjusted-rate setting and, benefit design, and
1068	choice counseling. The panel shall include representatives from
1069	the Florida Association of Health Plans, representatives from
1070	provider-sponsored networks, a Medicaid consumer representative,
1071	and a representative from the Office of Insurance Regulation.
1072	(b)  The technical advisory panel shall advise the agency
1073	concerning:
1074	1.  The risk-adjusted rate methodology to be used by the
1075	agency, including recommendations on mechanisms to recognize the
1076	risk of all Medicaid enrollees and for the transition to a risk-
1077	adjustment system, including recommendations for phasing in risk
1078	adjustment and the use of risk corridors.
1079	2.  Implementation of an encounter data system to be used
1080	for risk-adjusted rates.
1081	3.  Administrative and implementation issues regarding the
1082	use of risk-adjusted rates, including, but not limited to, cost,
1083	simplicity, client privacy, data accuracy, and data exchange.
1084	4.  Issues of benefit design, including the actuarial
1085	equivalence and sufficiency standards to be used.
1086	5.  The implementation plan for the proposed choice-
1087	counseling system, including the information and materials to be
1088	provided to recipients, the methodologies by which recipients
1089	will be counseled regarding choice, criteria to be used to
1090	assess plan quality, the methodology to be used to assign
1091	recipients into plans if they fail to choose a managed care
1092	plan, and the standards to be used for responsiveness to
1093	recipient inquiries.
1094	(c)  The technical advisory panel shall continue in
1095	existence and advise the agency on matters outlined in this
1096	subsection.
1097	(8)  The agency must ensure, in the first two state fiscal
1098	years in which a risk-adjusted methodology is a component of
1099	rate setting, that no managed care plan providing comprehensive
1100	benefits to TANF and SSI recipients has an aggregate risk score
1101	that varies by more than 10 percent from the aggregate weighted
1102	mean of all managed care plans providing comprehensive benefits
1103	to TANF and SSI recipients in a reform area. The agency's
1104	payment to a managed care plan shall be based on such revised
1105	aggregate risk score.
1106	(9)  After any calculations of aggregate risk scores or
1107	revised aggregate risk scores in subsection (8), the capitation
1108	rates for plans participating under this section shall be phased
1109	in as follows:
1110	(a)  In the first year, the capitation rates shall be
1111	weighted so that 75 percent of each capitation rate is based on
1112	the current methodology and 25 percent is based on a new risk-
1113	adjusted capitation rate methodology.
1114	(b)  In the second year, the capitation rates shall be
1115	weighted so that 50 percent of each capitation rate is based on
1116	the current methodology and 50 percent is based on a new risk-
1117	adjusted rate methodology.
1118	(c)  In the following fiscal year, the risk-adjusted
1119	capitation methodology may be fully implemented.
1120	(10)  Subsections (8) and (9) do not apply to managed care
1121	plans offering benefits exclusively to high-risk, specialty
1122	populations. The agency may set risk-adjusted rates immediately
1123	for such plans.
1124	(11)  Before the implementation of risk-adjusted rates, the
1125	rates shall be certified by an actuary and approved by the
1126	federal Centers for Medicare and Medicaid Services.
1127	(12)  For purposes of this section, the term "capitated
1128	managed care plan" includes health insurers authorized under
1129	chapter 624, exclusive provider organizations authorized under
1130	chapter 627, health maintenance organizations authorized under
1131	chapter 641, the Children's Medical Services Network under
1132	chapter 391, and provider service networks that elect to be paid
1133	fee-for-service for up to 3 years as authorized under this
1134	section.
1135	(13)  Upon review and approval of the applications for
1136	waivers of applicable federal laws and regulations to implement
1137	the managed care pilot program by the Legislature, the agency
1138	may initiate adoption of rules pursuant to ss. 120.536(1) and
1139	120.54 to implement and administer the managed care pilot
1140	program as provided in this section.
1141	(14)  It is the intent of the Legislature that if any
1142	conflict exists between the provisions contained in this section
1143	and other provisions of this chapter which relate to the
1144	implementation of the Medicaid managed care pilot program, the
1145	provisions contained in this section shall control. The agency
1146	shall provide a written report to the Legislature by April 1,
1147	2006, identifying any provisions of this chapter which conflict
1148	with the implementation of the Medicaid managed care pilot
1149	program created in this section. After April 1, 2006, the agency
1150	shall provide a written report to the Legislature immediately
1151	upon identifying any provisions of this chapter which conflict
1152	with the implementation of the Medicaid managed care pilot
1153	program created in this section.
1154	Section 7.  Section 409.91213, Florida Statutes, is amended
1155	to read:
1156	409.91213  Quarterly progress reports and annual reports.--
1157	(1)  The agency shall submit to the Governor, the President
1158	of the Senate, the Speaker of the House of Representatives, the
1159	Minority Leader of the Senate, the Minority Leader of the House
1160	of Representatives, and the Office of Program Policy Analysis
1161	and Government Accountability the following reports:
1162	(a)  The quarterly progress report submitted to the United
1163	States Centers for Medicare and Medicaid Services no later than
1164	60 days following the end of each quarter. The intent of this
1165	report is to present the agency's analysis and the status of
1166	various operational areas. The quarterly progress report must
1167	include, but need not be limited to:
1168	1.  Events occurring during the quarter or anticipated to
1169	occur in the near future which affect health care delivery,
1170	including, but not limited to, the approval of and contracts for
1171	new plans, which report must specify the coverage area, phase-in
1172	period, populations served, and benefits; the enrollment;
1173	grievances; and other operational issues.
1174	2.  Action plans for addressing any policy and
1175	administrative issues.
1176	3.  Agency efforts related to collecting and verifying
1177	encounter data and utilization data.
1178	4.  Enrollment data disaggregated by plan and by
1179	eligibility category, such as Temporary Assistance for Needy
1180	Families or Supplemental Security Income; the total number of
1181	enrollees; market share; and the percentage change in enrollment
1182	by plan. In addition, the agency shall provide a summary of
1183	voluntary and mandatory selection rates and disenrollment data.
1184	5.  For purposes of monitoring budget neutrality,
1185	enrollment data, member-month data, and expenditures in the
1186	format for monitoring budget neutrality which is provided by the
1187	federal Centers for Medicare and Medicaid Services.
1188	6.  Activities and associated expenditures of the low-
1189	income pool.
1190	7.  Activities related to the implementation of choice
1191	counseling, including efforts to improve health literacy and the
1192	methods used to obtain public input, such as recipient focus
1193	groups.
1194	8.  Participation rates in the enhanced benefit accounts
1195	program, including participation levels; a summary of activities
1196	and associated expenditures; the number of accounts established,
1197	including active participants and individuals who continue to
1198	retain access to funds in an account but who no longer actively
1199	participate; an estimate of quarterly deposits in the accounts;
1200	and expenditures from the accounts.
1201	9.  Enrollment data concerning employer-sponsored insurance
1202	which document the number of individuals selecting to opt out
1203	when employer-sponsored insurance is available. The agency shall
1204	include data that identify enrollee characteristics, including
1205	the eligibility category, type of employer-sponsored insurance,
1206	and type of coverage, such as individual or family coverage. The
1207	agency shall develop and maintain disenrollment reports
1208	specifying the reason for disenrollment in an employer-sponsored
1209	insurance program. The agency shall also track and report on
1210	those enrollees who elect the option to reenroll in the Medicaid
1211	reform demonstration.
1212	7.10.  Progress toward meeting the demonstration goals.
1213	8.11.  Evaluation activities.
1214	(b)  An annual report documenting accomplishments, project
1215	status, quantitative and case-study findings, utilization data,
1216	and policy and administrative difficulties in the operation of
1217	the Medicaid waiver demonstration program. The agency shall
1218	submit the draft annual report no later than October 1 after the
1219	end of each fiscal year.
1220	(2)  Beginning with the annual report for demonstration
1221	year two, the agency shall include a section concerning the
1222	administration of enhanced benefit accounts, the participation
1223	rates, an assessment of expenditures, and an assessment of
1224	potential cost savings.
1225	(2)(3)  Beginning with the annual report for demonstration
1226	year four, the agency shall include a section that provides
1227	qualitative and quantitative data describing the impact the low-
1228	income pool has had on the rate of uninsured people in this
1229	state, beginning with the implementation of the demonstration
1230	program.
1231	Section 8.  Paragraphs (a) and (l) of subsection (2) of
1232	section 409.9122, Florida Statutes, are amended to read:
1233	409.9122  Mandatory Medicaid managed care enrollment;
1234	programs and procedures.--
1235	(2)(a)  The agency shall enroll in a managed care plan or
1236	MediPass all Medicaid recipients, except those Medicaid
1237	recipients who are: in an institution; enrolled in the Medicaid
1238	medically needy program; or eligible for both Medicaid and
1239	Medicare. Upon enrollment, individuals will be able to change
1240	their managed care option during the 90-day opt out period
1241	required by federal Medicaid regulations. The agency is
1242	authorized to seek the necessary Medicaid state plan amendment
1243	to implement this policy. However, to the extent permitted by
1244	federal law, the agency may enroll in a managed care plan or
1245	MediPass a Medicaid recipient who is exempt from mandatory
1246	managed care enrollment, provided that:
1247	1.  The recipient's decision to enroll in a managed care
1248	plan or MediPass is voluntary;
1249	2.  If the recipient chooses to enroll in a managed care
1250	plan, the agency has determined that the managed care plan
1251	provides specific programs and services which address the
1252	special health needs of the recipient; and
1253	3.  The agency receives any necessary waivers from the
1254	federal Centers for Medicare and Medicaid Services.
1255
1256	The agency shall develop rules to establish policies by which
1257	exceptions to the mandatory managed care enrollment requirement
1258	may be made on a case-by-case basis. The rules shall include the
1259	specific criteria to be applied when making a determination as
1260	to whether to exempt a recipient from mandatory enrollment in a
1261	managed care plan or MediPass. School districts participating in
1262	the certified school match program pursuant to ss. 409.908(21)
1263	and 1011.70 shall be reimbursed by Medicaid, subject to the
1264	limitations of s. 1011.70(1), for a Medicaid-eligible child
1265	participating in the services as authorized in s. 1011.70, as
1266	provided for in s. 409.9071, regardless of whether the child is
1267	enrolled in MediPass or a managed care plan. Managed care plans
1268	shall make a good faith effort to execute agreements with school
1269	districts regarding the coordinated provision of services
1270	authorized under s. 1011.70. County health departments
1271	delivering school-based services pursuant to ss. 381.0056 and
1272	381.0057 shall be reimbursed by Medicaid for the federal share
1273	for a Medicaid-eligible child who receives Medicaid-covered
1274	services in a school setting, regardless of whether the child is
1275	enrolled in MediPass or a managed care plan. Managed care plans
1276	shall make a good faith effort to execute agreements with county
1277	health departments regarding the coordinated provision of
1278	services to a Medicaid-eligible child. To ensure continuity of
1279	care for Medicaid patients, the agency, the Department of
1280	Health, and the Department of Education shall develop procedures
1281	for ensuring that a student's managed care plan or MediPass
1282	provider receives information relating to services provided in
1283	accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
1284	(l)  Notwithstanding the provisions of chapter 287, the
1285	agency may, at its discretion, renew cost-effective contracts
1286	for choice counseling services once or more for such periods as
1287	the agency may decide. However, all such renewals may not
1288	combine to exceed a total period longer than the term of the
1289	original contract.
1290	Section 9.  This act shall take effect July 1, 2009.

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