Florida Senate - 2009 SB 2690
By Senator Baker
20-01804-09 20092690__
1 A bill to be entitled
2 An act relating to Medicaid reform; requiring the
3 Agency for Health Care Administration to establish a
4 legislative workgroup on Medicaid reform; providing
5 for membership, meetings, and duties; requiring a
6 report to the Governor and Legislature; providing for
7 expiration of the workgroup; amending s. 395.1041,
8 F.S.; providing legislative intent with respect to
9 access to nonemergency medical services; amending s.
10 408.910, F.S.; eliminating the opt-out provision for
11 Medicaid reform participants in the Florida Health
12 Choices Program; amending s. 409.8132, F.S.;
13 eliminating the choice counseling option for
14 applicants for the Medikids program component;
15 amending s. 409.912, F.S.; conforming a cross
16 reference; amending s. 409.91211, F.S., relating to
17 the Medicaid managed care pilot program; authorizing
18 the agency to seek changes to the current Medicaid
19 reform waiver; revising objectives for distribution of
20 certain Medicaid program funds; requiring the agency
21 to provide plan recipients with reform plan encounter
22 data and a toll-free complaint telephone number;
23 deleting references to a choice counseling system and
24 the opt-out option for Medicaid recipients; requiring
25 the agency to post certain standards and policies on
26 its Internet website; authorizing the agency to
27 develop financial incentives for community-based care
28 providers for certain purposes; amending s. 409.91213,
29 F.S., relating to the agency’s quarterly progress and
30 annual reports to the Legislature; deleting references
31 to Medicaid choice counseling services, the opt-out
32 program, and the enhanced benefit accounts program;
33 amending s. 409.9122, F.S., relating to mandatory
34 Medicaid managed care enrollment; deleting references
35 to the opt-out program and certain contracts for
36 choice counseling services; providing an effective
37 date.
38
39 Be It Enacted by the Legislature of the State of Florida:
40
41 Section 1. Legislative workgroup on Medicaid reform;
42 duties.—
43 (1) The Agency for Health Care Administration shall
44 establish a legislative workgroup to review the Medicaid managed
45 care pilot program established under s. 409.91211, Florida
46 Statutes. The workgroup shall:
47 (a) Review the patient-encounter data, review the
48 independent studies performed during the course of the pilot
49 program, and assess to what extent the current Medicaid reform
50 pilot program meets the requirements of the current waivers
51 granted by the federal Centers for Medicare and Medicaid
52 Services.
53 (b) Examine the cost-effectiveness and impact of the
54 enhanced benefit accounts program, particularly in rural
55 counties.
56 (c) Examine the opt-out option established under s.
57 409.91211(4)(g), Florida Statutes, that permits Medicaid
58 enrollees to purchase health care coverage through an employer
59 sponsored health insurance plan.
60 (d) Explore whether the implementation of low-income pool
61 plans has resulted in innovative changes to improve the
62 effectiveness of community-based services and the impact that
63 these plans have had on inpatient hospital utilization and
64 access to Medicaid-funded transportation, including requests for
65 urgent care.
66 (e) Review the impact of low-income pool plans on
67 behavioral health care and the ability of consumers to access
68 appropriate care, including whether the 80:20 rule should be
69 imposed as a method to ensure that mental health services remain
70 a priority for the plans. For purposes of this section, the term
71 “80:20 rule” means the requirement that contracts issued
72 pursuant to s. 409.912(4)(b), Florida Statutes, spend at least
73 80 percent of the capitation paid to the managed care plan for
74 behavioral health care services and not more than 20 percent on
75 overhead and administrative costs.
76 (f) Examine how plans have utilized downward substitution
77 of care and whether this practice has led to greater innovation
78 and more cost-effective provision of care. For purposes of this
79 section, the term “downward substitution” means the use of less
80 restrictive, lower cost, and medically appropriate services
81 provided as an alternative to higher cost state plan services.
82 Downward substitution of care may include private practice
83 psychologists and social workers, inpatient care in institutions
84 for mental illness, and other services the plan considers to be
85 more cost-effective than hospital inpatient care.
86 (g) Review the use of risk-adjusted rates, especially for
87 rural counties.
88 (h) Review the grievance resolution process and the
89 procedure for filing complaints with the agency regarding access
90 to care and consider alternative approaches.
91 (i) Consider changes to the federal waiver to respond to
92 identified problems and consider new methods or approaches,
93 which may include physician direct-care models, specialty
94 behavioral health plans, county-based models, and hospital-based
95 systems of care in addition to the managed care delivery models
96 currently authorized.
97 (j) Consider changes to create financial incentives that
98 reward risk taking and innovation and expand the use of downward
99 substitution strategies, which shall not be limited to
100 treatment-only services but shall include access to cost
101 effective approaches including providing custodial care for
102 persons with chronic diseases.
103 (2) The workgroup shall include representatives from the
104 Department of Children and Family Services, the Department of
105 Elderly Affairs, the Agency for Health Care Administration, the
106 Department of Health, the Medicaid Fraud Control Unit, and trade
107 associations and consumer advocates.
108 (3) Members of the workgroup shall serve at without
109 compensation. The workgroup shall conduct at least four meetings
110 and shall submit a final report recommending changes to the
111 Medicaid managed care pilot program to the Governor, the
112 President of the Senate, and the Speaker of the House of
113 Representatives by January 1, 2010.
114 (4) The workgroup shall expire January 1, 2010.
115 Section 2. Subsection (1) of section 395.1041, Florida
116 Statutes, is amended to read:
117 395.1041 Access to emergency services and care.—
118 (1) LEGISLATIVE INTENT.—The Legislature finds and declares
119 it to be of vital importance that emergency services and care be
120 provided by hospitals and physicians to every person in need of
121 such care. The Legislature finds that persons have been denied
122 emergency services and care by hospitals. It is the intent of
123 the Legislature that the agency vigorously enforce the ability
124 of persons to receive all necessary and appropriate emergency
125 services and care and that the agency act in a thorough and
126 timely manner against hospitals and physicians which deny
127 persons emergency services and care. It is further the intent of
128 the Legislature that hospitals, emergency medical services
129 providers, and other health care providers work together in
130 their local communities to enter into agreements or arrangements
131 to ensure access to emergency services and care. It is further
132 the intent of the Legislature that hospitals develop a placement
133 and referral system for persons in need of nonemergency medical
134 services to have access to appropriate licensed settings that
135 are capable of providing those services. The Legislature further
136 recognizes that appropriate emergency services and care often
137 require followup consultation and treatment in order to
138 effectively care for emergency medical conditions.
139 Section 3. Paragraph (b) of subsection (4) of section
140 408.910, Florida Statutes, is amended to read:
141 408.910 Florida Health Choices Program.—
142 (4) ELIGIBILITY AND PARTICIPATION.—Participation in the
143 program is voluntary and shall be available to employers,
144 individuals, vendors, and health insurance agents as specified
145 in this subsection.
146 (b) Individuals eligible to participate in the program
147 include:
148 1. Individual employees of enrolled employers.
149 2. State employees not eligible for state employee health
150 benefits.
151 3. State retirees.
152 4. Medicaid reform participants who select the opt-out
153 provision of reform.
154 4.5. Statutory rural hospitals.
155 Section 4. Subsection (7) of section 409.8132, Florida
156 Statutes, is amended to read:
157 409.8132 Medikids program component.—
158 (7) ENROLLMENT.—Enrollment in the Medikids program
159 component may occur at any time throughout the year. A child may
160 not receive services under the Medikids program until the child
161 is enrolled in a managed care plan or MediPass. Once determined
162 eligible, an applicant may receive choice counseling and select
163 a managed care plan or MediPass. The agency may initiate
164 mandatory assignment for a Medikids applicant who has not chosen
165 a managed care plan or MediPass provider after the applicant’s
166 voluntary choice period ends. An applicant may select MediPass
167 under the Medikids program component only in counties that have
168 fewer than two managed care plans available to serve Medicaid
169 recipients and only if the federal Health Care Financing
170 Administration determines that MediPass constitutes “health
171 insurance coverage” as defined in Title XXI of the Social
172 Security Act.
173 Section 5. Paragraph (b) of subsection (4) of section
174 409.912, Florida Statutes, is amended to read:
175 409.912 Cost-effective purchasing of health care.—The
176 agency shall purchase goods and services for Medicaid recipients
177 in the most cost-effective manner consistent with the delivery
178 of quality medical care. To ensure that medical services are
179 effectively utilized, the agency may, in any case, require a
180 confirmation or second physician’s opinion of the correct
181 diagnosis for purposes of authorizing future services under the
182 Medicaid program. This section does not restrict access to
183 emergency services or poststabilization care services as defined
184 in 42 C.F.R. part 438.114. Such confirmation or second opinion
185 shall be rendered in a manner approved by the agency. The agency
186 shall maximize the use of prepaid per capita and prepaid
187 aggregate fixed-sum basis services when appropriate and other
188 alternative service delivery and reimbursement methodologies,
189 including competitive bidding pursuant to s. 287.057, designed
190 to facilitate the cost-effective purchase of a case-managed
191 continuum of care. The agency shall also require providers to
192 minimize the exposure of recipients to the need for acute
193 inpatient, custodial, and other institutional care and the
194 inappropriate or unnecessary use of high-cost services. The
195 agency shall contract with a vendor to monitor and evaluate the
196 clinical practice patterns of providers in order to identify
197 trends that are outside the normal practice patterns of a
198 provider’s professional peers or the national guidelines of a
199 provider’s professional association. The vendor must be able to
200 provide information and counseling to a provider whose practice
201 patterns are outside the norms, in consultation with the agency,
202 to improve patient care and reduce inappropriate utilization.
203 The agency may mandate prior authorization, drug therapy
204 management, or disease management participation for certain
205 populations of Medicaid beneficiaries, certain drug classes, or
206 particular drugs to prevent fraud, abuse, overuse, and possible
207 dangerous drug interactions. The Pharmaceutical and Therapeutics
208 Committee shall make recommendations to the agency on drugs for
209 which prior authorization is required. The agency shall inform
210 the Pharmaceutical and Therapeutics Committee of its decisions
211 regarding drugs subject to prior authorization. The agency is
212 authorized to limit the entities it contracts with or enrolls as
213 Medicaid providers by developing a provider network through
214 provider credentialing. The agency may competitively bid single
215 source-provider contracts if procurement of goods or services
216 results in demonstrated cost savings to the state without
217 limiting access to care. The agency may limit its network based
218 on the assessment of beneficiary access to care, provider
219 availability, provider quality standards, time and distance
220 standards for access to care, the cultural competence of the
221 provider network, demographic characteristics of Medicaid
222 beneficiaries, practice and provider-to-beneficiary standards,
223 appointment wait times, beneficiary use of services, provider
224 turnover, provider profiling, provider licensure history,
225 previous program integrity investigations and findings, peer
226 review, provider Medicaid policy and billing compliance records,
227 clinical and medical record audits, and other factors. Providers
228 shall not be entitled to enrollment in the Medicaid provider
229 network. The agency shall determine instances in which allowing
230 Medicaid beneficiaries to purchase durable medical equipment and
231 other goods is less expensive to the Medicaid program than long
232 term rental of the equipment or goods. The agency may establish
233 rules to facilitate purchases in lieu of long-term rentals in
234 order to protect against fraud and abuse in the Medicaid program
235 as defined in s. 409.913. The agency may seek federal waivers
236 necessary to administer these policies.
237 (4) The agency may contract with:
238 (b) An entity that is providing comprehensive behavioral
239 health care services to certain Medicaid recipients through a
240 capitated, prepaid arrangement pursuant to the federal waiver
241 provided for by s. 409.905(5). Such an entity must be licensed
242 under chapter 624, chapter 636, or chapter 641 and must possess
243 the clinical systems and operational competence to manage risk
244 and provide comprehensive behavioral health care to Medicaid
245 recipients. As used in this paragraph, the term “comprehensive
246 behavioral health care services” means covered mental health and
247 substance abuse treatment services that are available to
248 Medicaid recipients. The secretary of the Department of Children
249 and Family Services shall approve provisions of procurements
250 related to children in the department’s care or custody prior to
251 enrolling such children in a prepaid behavioral health plan. Any
252 contract awarded under this paragraph must be competitively
253 procured. In developing the behavioral health care prepaid plan
254 procurement document, the agency shall ensure that the
255 procurement document requires the contractor to develop and
256 implement a plan to ensure compliance with s. 394.4574 related
257 to services provided to residents of licensed assisted living
258 facilities that hold a limited mental health license. Except as
259 provided in subparagraph 8., and except in counties where the
260 Medicaid managed care pilot program is authorized pursuant to s.
261 409.91211, the agency shall seek federal approval to contract
262 with a single entity meeting these requirements to provide
263 comprehensive behavioral health care services to all Medicaid
264 recipients not enrolled in a Medicaid managed care plan
265 authorized under s. 409.91211 or a Medicaid health maintenance
266 organization in an AHCA area. In an AHCA area where the Medicaid
267 managed care pilot program is authorized pursuant to s.
268 409.91211 in one or more counties, the agency may procure a
269 contract with a single entity to serve the remaining counties as
270 an AHCA area or the remaining counties may be included with an
271 adjacent AHCA area and shall be subject to this paragraph. Each
272 entity must offer sufficient choice of providers in its network
273 to ensure recipient access to care and the opportunity to select
274 a provider with whom they are satisfied. The network shall
275 include all public mental health hospitals. To ensure unimpaired
276 access to behavioral health care services by Medicaid
277 recipients, all contracts issued pursuant to this paragraph
278 shall require 80 percent of the capitation paid to the managed
279 care plan, including health maintenance organizations, to be
280 expended for the provision of behavioral health care services.
281 In the event the managed care plan expends less than 80 percent
282 of the capitation paid pursuant to this paragraph for the
283 provision of behavioral health care services, the difference
284 shall be returned to the agency. The agency shall provide the
285 managed care plan with a certification letter indicating the
286 amount of capitation paid during each calendar year for the
287 provision of behavioral health care services pursuant to this
288 section. The agency may reimburse for substance abuse treatment
289 services on a fee-for-service basis until the agency finds that
290 adequate funds are available for capitated, prepaid
291 arrangements.
292 1. By January 1, 2001, the agency shall modify the
293 contracts with the entities providing comprehensive inpatient
294 and outpatient mental health care services to Medicaid
295 recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
296 Counties, to include substance abuse treatment services.
297 2. By July 1, 2003, the agency and the Department of
298 Children and Family Services shall execute a written agreement
299 that requires collaboration and joint development of all policy,
300 budgets, procurement documents, contracts, and monitoring plans
301 that have an impact on the state and Medicaid community mental
302 health and targeted case management programs.
303 3. Except as provided in subparagraph 8., by July 1, 2006,
304 the agency and the Department of Children and Family Services
305 shall contract with managed care entities in each AHCA area
306 except area 6 or arrange to provide comprehensive inpatient and
307 outpatient mental health and substance abuse services through
308 capitated prepaid arrangements to all Medicaid recipients who
309 are eligible to participate in such plans under federal law and
310 regulation. In AHCA areas where eligible individuals number less
311 than 150,000, the agency shall contract with a single managed
312 care plan to provide comprehensive behavioral health services to
313 all recipients who are not enrolled in a Medicaid health
314 maintenance organization or a Medicaid capitated managed care
315 plan authorized under s. 409.91211. The agency may contract with
316 more than one comprehensive behavioral health provider to
317 provide care to recipients who are not enrolled in a Medicaid
318 capitated managed care plan authorized under s. 409.91211 or a
319 Medicaid health maintenance organization in AHCA areas where the
320 eligible population exceeds 150,000. In an AHCA area where the
321 Medicaid managed care pilot program is authorized pursuant to s.
322 409.91211 in one or more counties, the agency may procure a
323 contract with a single entity to serve the remaining counties as
324 an AHCA area or the remaining counties may be included with an
325 adjacent AHCA area and shall be subject to this paragraph.
326 Contracts for comprehensive behavioral health providers awarded
327 pursuant to this section shall be competitively procured. Both
328 for-profit and not-for-profit corporations shall be eligible to
329 compete. Managed care plans contracting with the agency under
330 subsection (3) shall provide and receive payment for the same
331 comprehensive behavioral health benefits as provided in AHCA
332 rules, including handbooks incorporated by reference. In AHCA
333 area 11, the agency shall contract with at least two
334 comprehensive behavioral health care providers to provide
335 behavioral health care to recipients in that area who are
336 enrolled in, or assigned to, the MediPass program. One of the
337 behavioral health care contracts shall be with the existing
338 provider service network pilot project, as described in
339 paragraph (d), for the purpose of demonstrating the cost
340 effectiveness of the provision of quality mental health services
341 through a public hospital-operated managed care model. Payment
342 shall be at an agreed-upon capitated rate to ensure cost
343 savings. Of the recipients in area 11 who are assigned to
344 MediPass under the provisions of s. 409.9122(2)(k), a minimum of
345 50,000 of those MediPass-enrolled recipients shall be assigned
346 to the existing provider service network in area 11 for their
347 behavioral care.
348 4. By October 1, 2003, the agency and the department shall
349 submit a plan to the Governor, the President of the Senate, and
350 the Speaker of the House of Representatives which provides for
351 the full implementation of capitated prepaid behavioral health
352 care in all areas of the state.
353 a. Implementation shall begin in 2003 in those AHCA areas
354 of the state where the agency is able to establish sufficient
355 capitation rates.
356 b. If the agency determines that the proposed capitation
357 rate in any area is insufficient to provide appropriate
358 services, the agency may adjust the capitation rate to ensure
359 that care will be available. The agency and the department may
360 use existing general revenue to address any additional required
361 match but may not over-obligate existing funds on an annualized
362 basis.
363 c. Subject to any limitations provided for in the General
364 Appropriations Act, the agency, in compliance with appropriate
365 federal authorization, shall develop policies and procedures
366 that allow for certification of local and state funds.
367 5. Children residing in a statewide inpatient psychiatric
368 program, or in a Department of Juvenile Justice or a Department
369 of Children and Family Services residential program approved as
370 a Medicaid behavioral health overlay services provider shall not
371 be included in a behavioral health care prepaid health plan or
372 any other Medicaid managed care plan pursuant to this paragraph.
373 6. In converting to a prepaid system of delivery, the
374 agency shall in its procurement document require an entity
375 providing only comprehensive behavioral health care services to
376 prevent the displacement of indigent care patients by enrollees
377 in the Medicaid prepaid health plan providing behavioral health
378 care services from facilities receiving state funding to provide
379 indigent behavioral health care, to facilities licensed under
380 chapter 395 which do not receive state funding for indigent
381 behavioral health care, or reimburse the unsubsidized facility
382 for the cost of behavioral health care provided to the displaced
383 indigent care patient.
384 7. Traditional community mental health providers under
385 contract with the Department of Children and Family Services
386 pursuant to part IV of chapter 394, child welfare providers
387 under contract with the Department of Children and Family
388 Services in areas 1 and 6, and inpatient mental health providers
389 licensed pursuant to chapter 395 must be offered an opportunity
390 to accept or decline a contract to participate in any provider
391 network for prepaid behavioral health services.
392 8. All Medicaid-eligible children, except children in area
393 1 and children in Highlands County, Hardee County, Polk County,
394 or Manatee County of area 6, who are open for child welfare
395 services in the HomeSafeNet system, shall receive their
396 behavioral health care services through a specialty prepaid plan
397 operated by community-based lead agencies either through a
398 single agency or formal agreements among several agencies. The
399 specialty prepaid plan must result in savings to the state
400 comparable to savings achieved in other Medicaid managed care
401 and prepaid programs. Such plan must provide mechanisms to
402 maximize state and local revenues. The specialty prepaid plan
403 shall be developed by the agency and the Department of Children
404 and Family Services. The agency is authorized to seek any
405 federal waivers to implement this initiative. Medicaid-eligible
406 children whose cases are open for child welfare services in the
407 HomeSafeNet system and who reside in AHCA area 10 are exempt
408 from the specialty prepaid plan upon the development of a
409 service delivery mechanism for children who reside in area 10 as
410 specified in s. 409.91211(3)(z)(dd).
411 Section 6. Section 409.91211, Florida Statutes, is amended
412 to read:
413 409.91211 Medicaid managed care pilot program.—
414 (1)(a) The agency is authorized to seek and implement
415 experimental, pilot, or demonstration project waivers, pursuant
416 to s. 1115 of the Social Security Act, and to seek changes to
417 the current federal Medicaid reform waiver, to create a
418 statewide initiative to provide for a more efficient and
419 effective service delivery system that enhances quality of care
420 and client outcomes in the Florida Medicaid program pursuant to
421 this section. Phase one of the demonstration shall be
422 implemented in two geographic areas. One demonstration site
423 shall include only Broward County. A second demonstration site
424 shall initially include Duval County and shall be expanded to
425 include Baker, Clay, and Nassau Counties within 1 year after the
426 Duval County program becomes operational. The agency shall
427 implement expansion of the program to include the remaining
428 counties of the state and remaining eligibility groups in
429 accordance with the process specified in the federally approved
430 special terms and conditions numbered 11-W-00206/4, as approved
431 by the federal Centers for Medicare and Medicaid Services on
432 October 19, 2005, with a goal of full statewide implementation
433 by June 30, 2011.
434 (b) This waiver authority is contingent upon federal
435 approval to preserve the upper-payment-limit funding mechanism
436 for hospitals, including a guarantee of a reasonable growth
437 factor, a methodology to allow the use of a portion of these
438 funds to serve as a risk pool for demonstration sites,
439 provisions to preserve the state’s ability to use
440 intergovernmental transfers, and provisions to protect the
441 disproportionate share program authorized pursuant to this
442 chapter. Upon completion of the evaluation conducted under s. 3,
443 ch. 2005-133, Laws of Florida, the agency may request statewide
444 expansion of the demonstration projects. Statewide phase-in to
445 additional counties shall be contingent upon review and approval
446 by the Legislature. Under the upper-payment-limit program, or
447 the low-income pool as implemented by the Agency for Health Care
448 Administration pursuant to federal waiver, the state matching
449 funds required for the program shall be provided by local
450 governmental entities through intergovernmental transfers in
451 accordance with published federal statutes and regulations. The
452 Agency for Health Care Administration shall distribute upper
453 payment-limit, disproportionate share hospital, and low-income
454 pool funds according to published federal statutes, regulations,
455 and waivers and the low-income pool methodology approved by the
456 federal Centers for Medicare and Medicaid Services.
457 (c) It is the intent of the Legislature that the low-income
458 pool plan required by the terms and conditions of the Medicaid
459 reform waiver and submitted to the federal Centers for Medicare
460 and Medicaid Services propose the distribution of the above
461 mentioned program funds based on the following objectives:
462 1. Assure a broad and fair distribution of available funds
463 based on the access provided by Medicaid participating
464 hospitals, regardless of their ownership status, through their
465 delivery of inpatient or outpatient care for Medicaid
466 beneficiaries and uninsured and underinsured individuals;
467 2. Assure accessible emergency inpatient and outpatient
468 care for Medicaid beneficiaries and uninsured and underinsured
469 individuals;
470 3. Enhance primary, preventive, and other ambulatory care
471 coverages for uninsured individuals;
472 4. Promote teaching and specialty hospital programs;
473 5. Promote the stability and viability of statutorily
474 defined rural hospitals and hospitals that serve as sole
475 community hospitals;
476 6. Recognize the extent of hospital uncompensated care
477 costs;
478 7. Maintain and enhance essential community hospital care;
479 8. Maintain incentives for local governmental entities to
480 contribute to the cost of uncompensated care;
481 9. Promote measures to avoid preventable hospitalizations;
482 10. Account for hospital efficiency; and
483 11. Contribute to a community’s overall health system.
484 12. Develop physician-directed health care plans, specialty
485 behavioral health care plans, and county-based health care plans
486 for rural areas;
487 13. Develop a plan to provide nonemergency transportation
488 for individuals who reside in licensed assisted living
489 facilities, mental health residential facilities, and adult
490 family-care homes. The plan shall include cooperative agreements
491 between the plan and the facility administrators and shall
492 detail how the plan will make transportation available for
493 qualified plan enrollees at these facilities to include access
494 to urgent care transportation, time standards for pick up and
495 returns, and the provision of escorts, if required;
496 14. Create a standardization process for quality assurance
497 purposes which all plans will utilize to help providers
498 streamline and reduce redundancy associated with processing
499 claims;
500 15. Create an accreditation standard for provider agencies
501 which will be recognized by all reform plans for compliance
502 purposes; and
503 16. Create financial incentives for plans to pursue
504 innovative approaches to the provision of care for adversely
505 affected subgroups that include individuals with chronic mental
506 illnesses who have been committed under the Baker Act,
507 individuals who have HIV/AIDS, and individuals with
508 developmental disabilities.
509 (2) The Legislature intends for the capitated managed care
510 pilot program to:
511 (a) Provide recipients in Medicaid fee-for-service or the
512 MediPass program a comprehensive and coordinated capitated
513 managed care system for all health care services specified in
514 ss. 409.905 and 409.906.
515 (b) Stabilize Medicaid expenditures under the pilot program
516 compared to Medicaid expenditures in the pilot area for the 3
517 years before implementation of the pilot program, while
518 ensuring:
519 1. Consumer education and choice.
520 2. Access to medically necessary services.
521 3. Coordination of preventative, acute, and long-term care.
522 4. Reductions in unnecessary service utilization.
523 (c) Provide an opportunity to evaluate the feasibility of
524 statewide implementation of capitated managed care networks as a
525 replacement for the current Medicaid fee-for-service and
526 MediPass systems.
527 (3) The agency shall have the following powers, duties, and
528 responsibilities with respect to the pilot program:
529 (a) To implement a system to deliver all mandatory services
530 specified in s. 409.905 and optional services specified in s.
531 409.906, as approved by the Centers for Medicare and Medicaid
532 Services and the Legislature in the waiver pursuant to this
533 section. Services to recipients under plan benefits shall
534 include emergency services provided under s. 409.9128.
535 (b) To implement a pilot program, including Medicaid
536 eligibility categories specified in ss. 409.903 and 409.904, as
537 authorized in an approved federal waiver.
538 (c) To implement the managed care pilot program that
539 maximizes all available state and federal funds, including those
540 obtained through intergovernmental transfers, the low-income
541 pool, supplemental Medicaid payments, and the disproportionate
542 share program. Within the parameters allowed by federal statute
543 and rule, the agency may seek options for making direct payments
544 to hospitals and physicians employed by or under contract with
545 the state’s medical schools for the costs associated with
546 graduate medical education under Medicaid reform.
547 (d) To implement actuarially sound, risk-adjusted
548 capitation rates for Medicaid recipients in the pilot program
549 which cover comprehensive care, enhanced services, and
550 catastrophic care.
551 (e) To implement policies and guidelines for phasing in
552 financial risk for approved provider service networks over a 3
553 year period. These policies and guidelines must include an
554 option for a provider service network to be paid fee-for-service
555 rates. For any provider service network established in a managed
556 care pilot area, the option to be paid fee-for-service rates
557 shall include a savings-settlement mechanism that is consistent
558 with s. 409.912(44). This model shall be converted to a risk
559 adjusted capitated rate no later than the beginning of the
560 fourth year of operation, and may be converted earlier at the
561 option of the provider service network. Federally qualified
562 health centers may be offered an opportunity to accept or
563 decline a contract to participate in any provider network for
564 prepaid primary care services.
565 (f) To implement stop-loss requirements and the transfer of
566 excess cost to catastrophic coverage that accommodates the risks
567 associated with the development of the pilot program.
568 (g) To recommend a process to be used by the Social
569 Services Estimating Conference to determine and validate the
570 rate of growth of the per-member costs of providing Medicaid
571 services under the managed care pilot program.
572 (h) To implement program standards and credentialing
573 requirements for capitated managed care networks to participate
574 in the pilot program, including those related to fiscal
575 solvency, quality of care, and adequacy of access to health care
576 providers. It is the intent of the Legislature that, to the
577 extent possible, any pilot program authorized by the state under
578 this section include any federally qualified health center,
579 federally qualified rural health clinic, county health
580 department, the Children’s Medical Services Network within the
581 Department of Health, or other federally, state, or locally
582 funded entity that serves the geographic areas within the
583 boundaries of the pilot program that requests to participate.
584 This paragraph does not relieve an entity that qualifies as a
585 capitated managed care network under this section from any other
586 licensure or regulatory requirements contained in state or
587 federal law which would otherwise apply to the entity. The
588 standards and credentialing requirements shall be based upon,
589 but are not limited to:
590 1. Compliance with the accreditation requirements as
591 provided in s. 641.512.
592 2. Compliance with early and periodic screening, diagnosis,
593 and treatment screening requirements under federal 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 as
603 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 counseling.
665 The agency may establish standards and performance contracts,
666 including standards requiring the contractor to hire choice
667 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 ensuring
701 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 encounter
713 with a health care practitioner or facility, including:
714 (I) The demographic characteristics of the patient.
715 (II) The principal, secondary, and tertiary diagnosis.
716 (III) The procedure performed.
717 (IV) The date and location where the procedure was
718 performed.
719 (V) The payment for the procedure, if any.
720 (VI) If applicable, the health care practitioner’s
721 universal identification number.
722 (VII) If the health care practitioner rendering the service
723 is a dependent practitioner, the modifiers appropriate to
724 indicate that the service was delivered by the dependent
725 practitioner.
726 b. Collect appropriate information relating to prescription
727 drugs for each type of patient encounter.
728 c. Collect appropriate information related to health care
729 costs and utilization from managed care plans participating in
730 the demonstration sites.
731 5. To the extent practicable, when collecting the data the
732 agency shall use a standardized claim form or electronic
733 transfer system that is used by health care practitioners,
734 facilities, and payors.
735 6. Health care practitioners and facilities in the
736 demonstration sites shall electronically submit, and managed
737 care plans participating in the demonstration sites shall
738 electronically receive, information concerning claims payments
739 and any other information reasonably related to the encounter
740 database using a standard format as required by the agency.
741 7. The agency shall establish reasonable deadlines for
742 phasing in the electronic transmittal of full encounter data.
743 8. The system must ensure that the data reported is
744 accurate and complete.
745 (m)(q) To implement a grievance resolution process for
746 Medicaid recipients enrolled in a capitated managed care network
747 under the pilot program modeled after the subscriber assistance
748 panel, as created in s. 408.7056. This process shall include a
749 mechanism for an expedited review of no greater than 24 hours
750 after notification of a grievance if the life of a Medicaid
751 recipient is in imminent and emergent jeopardy.
752 (n)(r) To implement a grievance resolution process for
753 health care providers employed by or contracted with a capitated
754 managed care network under the pilot program in order to settle
755 disputes among the provider and the managed care network or the
756 provider and the agency.
757 (o)(s) To implement criteria in an approved federal waiver
758 to designate health care providers as eligible to participate in
759 the pilot program. These criteria must include at a minimum
760 those criteria specified in s. 409.907.
761 (p)(t) To use health care provider agreements for
762 participation in the pilot program.
763 (q)(u) To require that all health care providers under
764 contract with the pilot program be duly licensed in the state,
765 if such licensure is available, and meet other criteria as may
766 be established by the agency. These criteria shall include at a
767 minimum those criteria specified in s. 409.907.
768 (r)(v) To ensure that managed care organizations work
769 collaboratively with other state or local governmental programs
770 or institutions for the coordination of health care to eligible
771 individuals receiving services from such programs or
772 institutions.
773 (s)(w) To implement procedures to minimize the risk of
774 Medicaid fraud and abuse in all plans operating in the Medicaid
775 managed care pilot program authorized in this section.
776 1. The agency shall ensure that applicable provisions of
777 this chapter and chapters 414, 626, 641, and 932 which relate to
778 Medicaid fraud and abuse are applied and enforced at the
779 demonstration project sites.
780 2. Providers must have the certification, license, and
781 credentials that are required by law and waiver requirements.
782 3. The agency shall ensure that the plan is in compliance
783 with s. 409.912(21) and (22).
784 4. The agency shall require that each plan establish
785 functions and activities governing program integrity in order to
786 reduce the incidence of fraud and abuse. Plans must report
787 instances of fraud and abuse pursuant to chapter 641.
788 5. The plan shall have written administrative and
789 management arrangements or procedures, including a mandatory
790 compliance plan, which are designed to guard against fraud and
791 abuse. The plan shall designate a compliance officer who has
792 sufficient experience in health care.
793 6.a. The agency shall require all managed care plan
794 contractors in the pilot program to report all instances of
795 suspected fraud and abuse. A failure to report instances of
796 suspected fraud and abuse is a violation of law and subject to
797 the penalties provided by law.
798 b. An instance of fraud and abuse in the managed care plan,
799 including, but not limited to, defrauding the state health care
800 benefit program by misrepresentation of fact in reports, claims,
801 certifications, enrollment claims, demographic statistics, or
802 patient-encounter data; misrepresentation of the qualifications
803 of persons rendering health care and ancillary services; bribery
804 and false statements relating to the delivery of health care;
805 unfair and deceptive marketing practices; and false claims
806 actions in the provision of managed care, is a violation of law
807 and subject to the penalties provided by law.
808 c. The agency shall require that all contractors make all
809 files and relevant billing and claims data accessible to state
810 regulators and investigators and that all such data is linked
811 into a unified system to ensure consistent reviews and
812 investigations.
813 (t)(x) To develop and provide actuarial and benefit design
814 analyses that indicate the effect on capitation rates and
815 benefits offered in the pilot program over a prospective 5-year
816 period based on the following assumptions:
817 1. Growth in capitation rates which is limited to the
818 estimated growth rate in general revenue.
819 2. Growth in capitation rates which is limited to the
820 average growth rate over the last 3 years in per-recipient
821 Medicaid expenditures.
822 3. Growth in capitation rates which is limited to the
823 growth rate of aggregate Medicaid expenditures between the 2003
824 2004 fiscal year and the 2004-2005 fiscal year.
825 (u)(y) To develop a mechanism to require capitated managed
826 care plans to reimburse qualified emergency service providers,
827 including, but not limited to, ambulance services, in accordance
828 with ss. 409.908 and 409.9128. The pilot program must include a
829 provision for continuing fee-for-service payments for emergency
830 services, including, but not limited to, individuals who access
831 ambulance services or emergency departments and who are
832 subsequently determined to be eligible for Medicaid services.
833 (v)(z) To ensure that school districts participating in the
834 certified school match program pursuant to ss. 409.908(21) and
835 1011.70 shall be reimbursed by Medicaid, subject to the
836 limitations of s. 1011.70(1), for a Medicaid-eligible child
837 participating in the services as authorized in s. 1011.70, as
838 provided for in s. 409.9071, regardless of whether the child is
839 enrolled in a capitated managed care network. Capitated managed
840 care networks must make a good faith effort to execute
841 agreements with school districts regarding the coordinated
842 provision of services authorized under s. 1011.70. County health
843 departments and federally qualified health centers delivering
844 school-based services pursuant to ss. 381.0056 and 381.0057 must
845 be reimbursed by Medicaid for the federal share for a Medicaid
846 eligible child who receives Medicaid-covered services in a
847 school setting, regardless of whether the child is enrolled in a
848 capitated managed care network. Capitated managed care networks
849 must make a good faith effort to execute agreements with county
850 health departments and federally qualified health centers
851 regarding the coordinated provision of services to a Medicaid
852 eligible child. To ensure continuity of care for Medicaid
853 patients, the agency, the Department of Health, and the
854 Department of Education shall develop procedures for ensuring
855 that a student’s capitated managed care network provider
856 receives information relating to services provided in accordance
857 with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
858 (w)(aa) To implement a mechanism whereby Medicaid
859 recipients who are already enrolled in a managed care plan or
860 the MediPass program in the pilot areas shall be offered the
861 opportunity to change to capitated managed care plans on a
862 staggered basis, as defined by the agency. All Medicaid
863 recipients shall have 30 days in which to make a choice of
864 capitated managed care plans. Those Medicaid recipients who do
865 not make a choice shall be assigned to a capitated managed care
866 plan in accordance with paragraph (4)(a) and shall be exempt
867 from s. 409.9122. To facilitate continuity of care for a
868 Medicaid recipient who is also a recipient of Supplemental
869 Security Income (SSI), prior to assigning the SSI recipient to a
870 capitated managed care plan, the agency shall determine whether
871 the SSI recipient has an ongoing relationship with a provider or
872 capitated managed care plan, and, if so, the agency shall assign
873 the SSI recipient to that provider or capitated managed care
874 plan where feasible. Those SSI recipients who do not have such a
875 provider relationship shall be assigned to a capitated managed
876 care plan provider in accordance with paragraph (4)(a) and shall
877 be exempt from s. 409.9122.
878 (x)(bb) To develop and recommend a service delivery
879 alternative for children having chronic medical conditions which
880 establishes a medical home project to provide primary care
881 services to this population. The project shall provide
882 community-based primary care services that are integrated with
883 other subspecialties to meet the medical, developmental, and
884 emotional needs for children and their families. This project
885 shall include an evaluation component to determine impacts on
886 hospitalizations, length of stays, emergency room visits, costs,
887 and access to care, including specialty care and patient and
888 family satisfaction.
889 (y)(cc) To develop and recommend service delivery
890 mechanisms within capitated managed care plans to provide
891 Medicaid services as specified in ss. 409.905 and 409.906 to
892 persons with developmental disabilities sufficient to meet the
893 medical, developmental, and emotional needs of these persons.
894 (z)(dd) To implement service delivery mechanisms within
895 capitated managed care plans to provide Medicaid services as
896 specified in ss. 409.905 and 409.906 to Medicaid-eligible
897 children whose cases are open for child welfare services in the
898 HomeSafeNet system. These services must be coordinated with
899 community-based care providers as specified in s. 409.1671,
900 where available, and be sufficient to meet the medical,
901 developmental, behavioral, and emotional needs of these
902 children. These service delivery mechanisms must be implemented
903 no later than July 1, 2008, in AHCA area 10 in order for the
904 children in AHCA area 10 to remain exempt from the statewide
905 plan under s. 409.912(4)(b)8.
906 (4)(a) A Medicaid recipient in the pilot area who is not
907 currently enrolled in a capitated managed care plan upon
908 implementation is not eligible for services as specified in ss.
909 409.905 and 409.906, for the amount of time that the recipient
910 does not enroll in a capitated managed care network. If a
911 Medicaid recipient has not enrolled in a capitated managed care
912 plan within 30 days after eligibility, the agency shall assign
913 the Medicaid recipient to a capitated managed care plan based on
914 the assessed needs of the recipient as determined by the agency
915 and the recipient shall be exempt from s. 409.9122. When making
916 assignments, the agency shall take into account the following
917 criteria:
918 1. A capitated managed care network has sufficient network
919 capacity to meet the needs of members.
920 2. The capitated managed care network has previously
921 enrolled the recipient as a member, or one of the capitated
922 managed care network’s primary care providers has previously
923 provided health care to the recipient.
924 3. The agency has knowledge that the member has previously
925 expressed a preference for a particular capitated managed care
926 network as indicated by Medicaid fee-for-service claims data,
927 but has failed to make a choice.
928 4. The capitated managed care network’s primary care
929 providers are geographically accessible to the recipient’s
930 residence.
931 (b) When more than one capitated managed care network
932 provider meets the criteria specified in paragraph (3)(h), the
933 agency shall make recipient assignments consecutively by family
934 unit.
935 (c) If a recipient is currently enrolled with a Medicaid
936 managed care organization that also operates an approved reform
937 plan within a demonstration area and the recipient fails to
938 choose a plan during the reform enrollment process or during
939 redetermination of eligibility, the recipient shall be
940 automatically assigned by the agency into the most appropriate
941 reform plan operated by the recipient’s current Medicaid managed
942 care plan. If the recipient’s current managed care plan does not
943 operate a reform plan in the demonstration area which adequately
944 meets the needs of the Medicaid recipient, the agency shall use
945 the automatic assignment process as prescribed in the special
946 terms and conditions numbered 11-W-00206/4. All enrollment and
947 choice counseling materials provided by the agency must contain
948 an explanation of the provisions of this paragraph for current
949 managed care recipients.
950 (d) The agency may not engage in practices that are
951 designed to favor one capitated managed care plan over another
952 or that are designed to influence Medicaid recipients to enroll
953 in a particular capitated managed care network in order to
954 strengthen its particular fiscal viability.
955 (e) After a recipient has made a selection or has been
956 enrolled in a capitated managed care network, the recipient
957 shall have 90 days in which to voluntarily disenroll and select
958 another capitated managed care network. After 90 days, no
959 further changes may be made except for cause. Cause shall
960 include, but not be limited to, poor quality of care, lack of
961 access to necessary specialty services, an unreasonable delay or
962 denial of service, inordinate or inappropriate changes of
963 primary care providers, service access impairments due to
964 significant changes in the geographic location of services, or
965 fraudulent enrollment. The agency may require a recipient to use
966 the capitated managed care network’s grievance process as
967 specified in paragraph (3)(m)(q) prior to the agency’s
968 determination of cause, except in cases in which immediate risk
969 of permanent damage to the recipient’s health is alleged. The
970 grievance process, when used, must be completed in time to
971 permit the recipient to disenroll no later than the first day of
972 the second month after the month the disenrollment request was
973 made. If the capitated managed care network, as a result of the
974 grievance process, approves an enrollee’s request to disenroll,
975 the agency is not required to make a determination in the case.
976 The agency must make a determination and take final action on a
977 recipient’s request so that disenrollment occurs no later than
978 the first day of the second month after the month the request
979 was made. If the agency fails to act within the specified
980 timeframe, the recipient’s request to disenroll is deemed to be
981 approved as of the date agency action was required. Recipients
982 who disagree with the agency’s finding that cause does not exist
983 for disenrollment shall be advised of their right to pursue a
984 Medicaid fair hearing to dispute the agency’s finding.
985 (f) The agency shall apply for federal waivers from the
986 Centers for Medicare and Medicaid Services to lock eligible
987 Medicaid recipients into a capitated managed care network for 12
988 months after an open enrollment period. After 12 months of
989 enrollment, a recipient may select another capitated managed
990 care network. However, nothing shall prevent a Medicaid
991 recipient from changing primary care providers within the
992 capitated managed care network during the 12-month period.
993 (g) The agency shall apply for federal waivers from the
994 Centers for Medicare and Medicaid Services to allow recipients
995 to purchase health care coverage through an employer-sponsored
996 health insurance plan instead of through a Medicaid-certified
997 plan. This provision shall be known as the opt-out option.
998 1. A recipient who chooses the Medicaid opt-out option
999 shall have an opportunity for a specified period of time, as
1000 authorized under a waiver granted by the Centers for Medicare
1001 and Medicaid Services, to select and enroll in a Medicaid
1002 certified plan. If the recipient remains in the employer
1003 sponsored plan after the specified period, the recipient shall
1004 remain in the opt-out program for at least 1 year or until the
1005 recipient no longer has access to employer-sponsored coverage,
1006 until the employer’s open enrollment period for a person who
1007 opts out in order to participate in employer-sponsored coverage,
1008 or until the person is no longer eligible for Medicaid,
1009 whichever time period is shorter.
1010 2. Notwithstanding any other provision of this section,
1011 coverage, cost sharing, and any other component of employer
1012 sponsored health insurance shall be governed by applicable state
1013 and federal laws.
1014 (5) This section does not authorize the agency to implement
1015 any provision of s. 1115 of the Social Security Act
1016 experimental, pilot, or demonstration project waiver to reform
1017 the state Medicaid program in any part of the state other than
1018 the two geographic areas specified in this section unless
1019 approved by the Legislature.
1020 (6) The agency shall develop and submit for approval
1021 applications for waivers of applicable federal laws and
1022 regulations as necessary to implement the managed care pilot
1023 project as defined in this section. The agency may develop
1024 financial incentives for community-based care providers to
1025 develop systems of care that prevent or divert the need for
1026 inpatient hospital care. The agency shall post all waiver
1027 applications under this section on its Internet website 30 days
1028 before submitting the applications to the United States Centers
1029 for Medicare and Medicaid Services. All waiver applications
1030 shall be provided for review and comment to the appropriate
1031 committees of the Senate and House of Representatives for at
1032 least 10 working days prior to submission. All waivers submitted
1033 to and approved by the United States Centers for Medicare and
1034 Medicaid Services under this section must be approved by the
1035 Legislature. Federally approved waivers must be submitted to the
1036 President of the Senate and the Speaker of the House of
1037 Representatives for referral to the appropriate legislative
1038 committees. The appropriate committees shall recommend whether
1039 to approve the implementation of any waivers to the Legislature
1040 as a whole. The agency shall submit a plan containing a
1041 recommended timeline for implementation of any waivers and
1042 budgetary projections of the effect of the pilot program under
1043 this section on the total Medicaid budget for the 2006-2007
1044 through 2009-2010 state fiscal years. This implementation plan
1045 shall be submitted to the President of the Senate and the
1046 Speaker of the House of Representatives at the same time any
1047 waivers are submitted for consideration by the Legislature. The
1048 agency may implement the waiver and special terms and conditions
1049 numbered 11-W-00206/4, as approved by the federal Centers for
1050 Medicare and Medicaid Services. If the agency seeks approval by
1051 the Federal Government of any modifications to these special
1052 terms and conditions, the agency must provide written
1053 notification of its intent to modify these terms and conditions
1054 to the President of the Senate and the Speaker of the House of
1055 Representatives at least 15 days before submitting the
1056 modifications to the Federal Government for consideration. The
1057 notification must identify all modifications being pursued and
1058 the reason the modifications are needed. Upon receiving federal
1059 approval of any modifications to the special terms and
1060 conditions, the agency shall provide a report to the Legislature
1061 describing the federally approved modifications to the special
1062 terms and conditions within 7 days after approval by the Federal
1063 Government.
1064 (7)(a) The Secretary of Health Care Administration shall
1065 convene a technical advisory panel to advise the agency in the
1066 areas of risk-adjusted-rate setting and, benefit design, and
1067 choice counseling. The panel shall include representatives from
1068 the Florida Association of Health Plans, representatives from
1069 provider-sponsored networks, a Medicaid consumer representative,
1070 and a representative from the Office of Insurance Regulation.
1071 (b) The technical advisory panel shall advise the agency
1072 concerning:
1073 1. The risk-adjusted rate methodology to be used by the
1074 agency, including recommendations on mechanisms to recognize the
1075 risk of all Medicaid enrollees and for the transition to a risk
1076 adjustment system, including recommendations for phasing in risk
1077 adjustment and the use of risk corridors.
1078 2. Implementation of an encounter data system to be used
1079 for risk-adjusted rates.
1080 3. Administrative and implementation issues regarding the
1081 use of risk-adjusted rates, including, but not limited to, cost,
1082 simplicity, client privacy, data accuracy, and data exchange.
1083 4. Issues of benefit design, including the actuarial
1084 equivalence and sufficiency standards to be used.
1085 5. The implementation plan for the proposed choice
1086 counseling system, including the information and materials to be
1087 provided to recipients, the methodologies by which recipients
1088 will be counseled regarding choice, criteria to be used to
1089 assess plan quality, the methodology to be used to assign
1090 recipients into plans if they fail to choose a managed care
1091 plan, and the standards to be used for responsiveness to
1092 recipient inquiries.
1093 (c) The technical advisory panel shall continue in
1094 existence and advise the agency on matters outlined in this
1095 subsection.
1096 (8) The agency must ensure, in the first two state fiscal
1097 years in which a risk-adjusted methodology is a component of
1098 rate setting, that no managed care plan providing comprehensive
1099 benefits to TANF and SSI recipients has an aggregate risk score
1100 that varies by more than 10 percent from the aggregate weighted
1101 mean of all managed care plans providing comprehensive benefits
1102 to TANF and SSI recipients in a reform area. The agency’s
1103 payment to a managed care plan shall be based on such revised
1104 aggregate risk score.
1105 (9) After any calculations of aggregate risk scores or
1106 revised aggregate risk scores in subsection (8), the capitation
1107 rates for plans participating under this section shall be phased
1108 in as follows:
1109 (a) In the first year, the capitation rates shall be
1110 weighted so that 75 percent of each capitation rate is based on
1111 the current methodology and 25 percent is based on a new risk
1112 adjusted capitation rate methodology.
1113 (b) In the second year, the capitation rates shall be
1114 weighted so that 50 percent of each capitation rate is based on
1115 the current methodology and 50 percent is based on a new risk
1116 adjusted rate methodology.
1117 (c) In the following fiscal year, the risk-adjusted
1118 capitation methodology may be fully implemented.
1119 (10) Subsections (8) and (9) do not apply to managed care
1120 plans offering benefits exclusively to high-risk, specialty
1121 populations. The agency may set risk-adjusted rates immediately
1122 for such plans.
1123 (11) Before the implementation of risk-adjusted rates, the
1124 rates shall be certified by an actuary and approved by the
1125 federal Centers for Medicare and Medicaid Services.
1126 (12) For purposes of this section, the term “capitated
1127 managed care plan” includes health insurers authorized under
1128 chapter 624, exclusive provider organizations authorized under
1129 chapter 627, health maintenance organizations authorized under
1130 chapter 641, the Children’s Medical Services Network under
1131 chapter 391, and provider service networks that elect to be paid
1132 fee-for-service for up to 3 years as authorized under this
1133 section.
1134 (13) Upon review and approval of the applications for
1135 waivers of applicable federal laws and regulations to implement
1136 the managed care pilot program by the Legislature, the agency
1137 may initiate adoption of rules pursuant to ss. 120.536(1) and
1138 120.54 to implement and administer the managed care pilot
1139 program as provided in this section.
1140 (14) It is the intent of the Legislature that if any
1141 conflict exists between the provisions contained in this section
1142 and other provisions of this chapter which relate to the
1143 implementation of the Medicaid managed care pilot program, the
1144 provisions contained in this section shall control. The agency
1145 shall provide a written report to the Legislature by April 1,
1146 2006, identifying any provisions of this chapter which conflict
1147 with the implementation of the Medicaid managed care pilot
1148 program created in this section. After April 1, 2006, the agency
1149 shall provide a written report to the Legislature immediately
1150 upon identifying any provisions of this chapter which conflict
1151 with the implementation of the Medicaid managed care pilot
1152 program created in this section.
1153 Section 7. Section 409.91213, Florida Statutes, is amended
1154 to read:
1155 409.91213 Quarterly progress reports and annual reports.—
1156 (1) The agency shall submit to the Governor, the President
1157 of the Senate, the Speaker of the House of Representatives, the
1158 Minority Leader of the Senate, the Minority Leader of the House
1159 of Representatives, and the Office of Program Policy Analysis
1160 and Government Accountability the following reports:
1161 (a) The quarterly progress report submitted to the United
1162 States Centers for Medicare and Medicaid Services no later than
1163 60 days following the end of each quarter. The intent of this
1164 report is to present the agency’s analysis and the status of
1165 various operational areas. The quarterly progress report must
1166 include, but need not be limited to:
1167 1. Events occurring during the quarter or anticipated to
1168 occur in the near future which affect health care delivery,
1169 including, but not limited to, the approval of and contracts for
1170 new plans, which report must specify the coverage area, phase-in
1171 period, populations served, and benefits; the enrollment;
1172 grievances; and other operational issues.
1173 2. Action plans for addressing any policy and
1174 administrative issues.
1175 3. Agency efforts related to collecting and verifying
1176 encounter data and utilization data.
1177 4. Enrollment data disaggregated by plan and by eligibility
1178 category, such as Temporary Assistance for Needy Families or
1179 Supplemental Security Income; the total number of enrollees;
1180 market share; and the percentage change in enrollment by plan.
1181 In addition, the agency shall provide a summary of voluntary and
1182 mandatory selection rates and disenrollment data.
1183 5. For purposes of monitoring budget neutrality, enrollment
1184 data, member-month data, and expenditures in the format for
1185 monitoring budget neutrality which is provided by the federal
1186 Centers for Medicare and Medicaid Services.
1187 6. Activities and associated expenditures of the low-income
1188 pool.
1189 7. Activities related to the implementation of choice
1190 counseling, including efforts to improve health literacy and the
1191 methods used to obtain public input, such as recipient focus
1192 groups.
1193 8. Participation rates in the enhanced benefit accounts
1194 program, including participation levels; a summary of activities
1195 and associated expenditures; the number of accounts established,
1196 including active participants and individuals who continue to
1197 retain access to funds in an account but who no longer actively
1198 participate; an estimate of quarterly deposits in the accounts;
1199 and expenditures from the accounts.
1200 9. Enrollment data concerning employer-sponsored insurance
1201 which document the number of individuals selecting to opt out
1202 when employer-sponsored insurance is available. The agency shall
1203 include data that identify enrollee characteristics, including
1204 the eligibility category, type of employer-sponsored insurance,
1205 and type of coverage, such as individual or family coverage. The
1206 agency shall develop and maintain disenrollment reports
1207 specifying the reason for disenrollment in an employer-sponsored
1208 insurance program. The agency shall also track and report on
1209 those enrollees who elect the option to reenroll in the Medicaid
1210 reform demonstration.
1211 7.10. Progress toward meeting the demonstration goals.
1212 8.11. Evaluation activities.
1213 (b) An annual report documenting accomplishments, project
1214 status, quantitative and case-study findings, utilization data,
1215 and policy and administrative difficulties in the operation of
1216 the Medicaid waiver demonstration program. The agency shall
1217 submit the draft annual report no later than October 1 after the
1218 end of each fiscal year.
1219 (2) Beginning with the annual report for demonstration year
1220 two, the agency shall include a section concerning the
1221 administration of enhanced benefit accounts, the participation
1222 rates, an assessment of expenditures, and an assessment of
1223 potential cost savings.
1224 (2)(3) Beginning with the annual report for demonstration
1225 year four, the agency shall include a section that provides
1226 qualitative and quantitative data describing the impact the low
1227 income pool has had on the rate of uninsured people in this
1228 state, beginning with the implementation of the demonstration
1229 program.
1230 Section 8. Paragraphs (a) and (l) of subsection (2) of
1231 section 409.9122, Florida Statutes, are amended to read:
1232 409.9122 Mandatory Medicaid managed care enrollment;
1233 programs and procedures.—
1234 (2)(a) The agency shall enroll in a managed care plan or
1235 MediPass all Medicaid recipients, except those Medicaid
1236 recipients who are: in an institution; enrolled in the Medicaid
1237 medically needy program; or eligible for both Medicaid and
1238 Medicare. Upon enrollment, individuals will be able to change
1239 their managed care option during the 90-day opt out period
1240 required by federal Medicaid regulations. The agency is
1241 authorized to seek the necessary Medicaid state plan amendment
1242 to implement this policy. However, to the extent permitted by
1243 federal law, the agency may enroll in a managed care plan or
1244 MediPass a Medicaid recipient who is exempt from mandatory
1245 managed care enrollment, provided that:
1246 1. The recipient’s decision to enroll in a managed care
1247 plan or MediPass is voluntary;
1248 2. If the recipient chooses to enroll in a managed care
1249 plan, the agency has determined that the managed care plan
1250 provides specific programs and services which address the
1251 special health needs of the recipient; and
1252 3. The agency receives any necessary waivers from the
1253 federal Centers for Medicare and Medicaid Services.
1254
1255 The agency shall develop rules to establish policies by which
1256 exceptions to the mandatory managed care enrollment requirement
1257 may be made on a case-by-case basis. The rules shall include the
1258 specific criteria to be applied when making a determination as
1259 to whether to exempt a recipient from mandatory enrollment in a
1260 managed care plan or MediPass. School districts participating in
1261 the certified school match program pursuant to ss. 409.908(21)
1262 and 1011.70 shall be reimbursed by Medicaid, subject to the
1263 limitations of s. 1011.70(1), for a Medicaid-eligible child
1264 participating in the services as authorized in s. 1011.70, as
1265 provided for in s. 409.9071, regardless of whether the child is
1266 enrolled in MediPass or a managed care plan. Managed care plans
1267 shall make a good faith effort to execute agreements with school
1268 districts regarding the coordinated provision of services
1269 authorized under s. 1011.70. County health departments
1270 delivering school-based services pursuant to ss. 381.0056 and
1271 381.0057 shall be reimbursed by Medicaid for the federal share
1272 for a Medicaid-eligible child who receives Medicaid-covered
1273 services in a school setting, regardless of whether the child is
1274 enrolled in MediPass or a managed care plan. Managed care plans
1275 shall make a good faith effort to execute agreements with county
1276 health departments regarding the coordinated provision of
1277 services to a Medicaid-eligible child. To ensure continuity of
1278 care for Medicaid patients, the agency, the Department of
1279 Health, and the Department of Education shall develop procedures
1280 for ensuring that a student’s managed care plan or MediPass
1281 provider receives information relating to services provided in
1282 accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
1283 (l) Notwithstanding the provisions of chapter 287, the
1284 agency may, at its discretion, renew cost-effective contracts
1285 for choice counseling services once or more for such periods as
1286 the agency may decide. However, all such renewals may not
1287 combine to exceed a total period longer than the term of the
1288 original contract.
1289 Section 9. This act shall take effect July 1, 2009.