HB 7131

1	A bill to be entitled
2	An act relating to Medicaid; amending s. 409.907, F.S.;
3	requiring Medicaid provider agreements to require full
4	compliance with the Agency for Health Care
5	Administration's medical encounter data system and report
6	actions that provide incentives for healthy behaviors;
7	requiring the agency to submit an annual report to the
8	Governor and Legislature that summarizes data regarding
9	the agency's medical encounter data system; amending s.
10	409.908, F.S.; requiring the agency to adjust alternative
11	health plan, health maintenance organization, and prepaid
12	health plan capitation rates based on aggregate risk
13	scores; providing a limitation on risk score variance for
14	a specified time period; requiring the agency to phase in
15	risk-adjusted capitation rates; providing for a technical
16	advisory panel to advise the agency during the transition
17	to risk-adjusted capitation rates; amending s. 409.912,
18	F.S.; authorizing the agency to contract with certain
19	health centers that are federally qualified or supported
20	to provide comprehensive behavioral health care services
21	through a capitated, prepaid arrangement; requiring the
22	agency to integrate acute care and behavioral health
23	services in the public-hospital-operated managed care
24	model; requiring an entity contracting on a prepaid or
25	fixed-sum basis to meet the surplus requirements of health
26	maintenance organizations; creating s. 409.91207, F.S.;
27	requiring the agency to establish a medical home pilot
28	project in Alachua and Hillsborough Counties; requiring
29	each county to be served by at least one medical home
30	network consisting of specified entities; authorizing
31	managed care organizations to seek designation as a
32	medical home network; requiring each medical home network
33	to provide specified services and comply with specified
34	principles of operation; specifying procedures for
35	enrollment of Medicaid recipients in a medical home
36	network; requiring a medical home network to document
37	capacity for coordinated systems of care; requiring
38	medical home network services to be reimbursed based on
39	Medicaid fee-for-service claims; authorizing specified
40	enhanced benefits for entities participating in a medical
41	home network; specifying that a medical home network is
42	eligible for shared savings under certain circumstances;
43	requiring a medical home network to maintain certain
44	medical records and clinical data; requiring the agency to
45	contract with the University of Florida for initial and
46	final evaluations of the pilot project; requiring the
47	agency to submit reports on medical home network
48	performance to the Governor and Legislature; amending s.
49	409.91211, F.S.; requiring a Medicaid provider who
50	receives low-income pool funds to serve Medicaid
51	recipients regardless of the recipient's county of
52	residence; extending the phasing in of risk-adjusted
53	capitated rates for provider service networks; amending s.
54	409.9122, F.S.; specifying that individuals currently
55	enrolled in a disease management or specialized HIV/AIDS
56	plan stay in their plan unless they opt out; providing for
57	mandatory assignment of certain Medicaid recipients to a
58	medical home network in Alachua and Hillsborough Counties
59	who are eligible for managed care plan enrollment;
60	providing a definition; requiring the agency to convene a
61	workgroup to evaluate the status and future viability of
62	Medicaid managed care; requiring the agency to collect
63	encounter data for services provided to patients enrolled
64	in managed care plans; amending s. 409.9124, F.S.;
65	requiring managed care rates to be based on a risk-
66	adjusted methodology; requiring the agency to submit an
67	annual report to the Governor and Legislature regarding
68	the financial condition and trends affecting Medicaid
69	managed care plans; providing an effective date.
70
71	Be It Enacted by the Legislature of the State of Florida:
72
73	Section 1.  Paragraphs (k) and (l) are added to subsection
74	(3) of section 409.907, Florida Statutes, and subsection (13) is
75	added to that section, to read:
76	409.907  Medicaid provider agreements.--The agency may make
77	payments for medical assistance and related services rendered to
78	Medicaid recipients only to an individual or entity who has a
79	provider agreement in effect with the agency, who is performing
80	services or supplying goods in accordance with federal, state,
81	and local law, and who agrees that no person shall, on the
82	grounds of handicap, race, color, or national origin, or for any
83	other reason, be subjected to discrimination under any program
84	or activity for which the provider receives payment from the
85	agency.
86	(3)  The provider agreement developed by the agency, in
87	addition to the requirements specified in subsections (1) and
88	(2), shall require the provider to:
89	(k)  Fully comply with the agency's medical encounter data
90	system.
91	(l)  Report specific actions by the plan to provide
92	incentives for healthy behaviors.
93	(13)  By January 1, 2010, and annually thereafter until
94	full compliance is reached, the agency shall submit to the
95	Governor, the President of the Senate, and the Speaker of the
96	House of Representatives a report that summarizes data regarding
97	the agency's medical encounter data system, including the number
98	of participating plans, the level of compliance of each plan,
99	and specific problem areas. The report shall include issues and
100	recommendations developed by the technical assistance panel
101	created in s. 409.908(4)(b).
102	Section 2.  Subsection (4) of section 409.908, Florida
103	Statutes, is amended to read:
104	409.908  Reimbursement of Medicaid providers.--Subject to
105	specific appropriations, the agency shall reimburse Medicaid
106	providers, in accordance with state and federal law, according
107	to methodologies set forth in the rules of the agency and in
108	policy manuals and handbooks incorporated by reference therein.
109	These methodologies may include fee schedules, reimbursement
110	methods based on cost reporting, negotiated fees, competitive
111	bidding pursuant to s. 287.057, and other mechanisms the agency
112	considers efficient and effective for purchasing services or
113	goods on behalf of recipients. If a provider is reimbursed based
114	on cost reporting and submits a cost report late and that cost
115	report would have been used to set a lower reimbursement rate
116	for a rate semester, then the provider's rate for that semester
117	shall be retroactively calculated using the new cost report, and
118	full payment at the recalculated rate shall be effected
119	retroactively. Medicare-granted extensions for filing cost
120	reports, if applicable, shall also apply to Medicaid cost
121	reports. Payment for Medicaid compensable services made on
122	behalf of Medicaid eligible persons is subject to the
123	availability of moneys and any limitations or directions
124	provided for in the General Appropriations Act or chapter 216.
125	Further, nothing in this section shall be construed to prevent
126	or limit the agency from adjusting fees, reimbursement rates,
127	lengths of stay, number of visits, or number of services, or
128	making any other adjustments necessary to comply with the
129	availability of moneys and any limitations or directions
130	provided for in the General Appropriations Act, provided the
131	adjustment is consistent with legislative intent.
132	(4)  Subject to any limitations or directions provided for
133	in the General Appropriations Act, alternative health plans,
134	health maintenance organizations, and prepaid health plans shall
135	be reimbursed a fixed, prepaid amount negotiated, or
136	competitively bid pursuant to s. 287.057, by the agency and
137	prospectively paid to the provider monthly for each Medicaid
138	recipient enrolled. The amount may not exceed the average amount
139	the agency determines it would have paid, based on claims
140	experience, for recipients in the same or similar category of
141	eligibility. The agency shall calculate capitation rates on a
142	regional basis and, beginning September 1, 1995, shall include
143	age-band differentials in such calculations.
144	(a)  Beginning September 1, 2011, the agency shall begin a
145	budget-neutral adjustment of capitation rates based on aggregate
146	risk scores for each plan's enrollees. During the first 2 years
147	of the adjustment, the agency shall ensure that no plan has an
148	aggregate risk score that varies by more than 10 percent from
149	the aggregate weighted average for all plans. The risk-adjusted
150	capitation rates shall be phased in as follows:
151	1.  In the first fiscal year, 75 percent of the capitation
152	rate shall be based on the current methodology and 25 percent
153	shall be based on the risk-adjusted capitation rate methodology.
154	2.  In the second fiscal year, 50 percent of the capitation
155	rate shall be based on the current methodology and 50 percent
156	shall be based on the risk-adjusted rate methodology.
157	3.  In the third fiscal year, the risk-adjusted capitation
158	methodology shall be fully implemented.
159	(b)  The secretary of the agency shall convene a technical
160	advisory panel to advise the agency in the area of risk-adjusted
161	rate-setting during the transition to risk-adjusted capitation
162	rates described in paragraph (a). The panel shall include
163	representatives of prepaid plans in counties not included in the
164	demonstration sites established under s. 409.91211(1). The panel
165	shall advise the agency regarding:
166	1.  The selection of a base year of encounter data to be
167	used to set risk-adjusted rates.
168	2.  The completeness and accuracy of the encounter data.
169	3.  The effect of risk-adjusted rates on prepaid plans
170	based on a review of a simulated rate-setting process.
171	Section 3.  Paragraph (b) of subsection (4) and subsection
172	(17) of section 409.912, Florida Statutes, are 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, or authorized
241	under paragraph (c), and must possess the clinical systems and
242	operational competence to manage risk and provide comprehensive
243	behavioral health care to Medicaid recipients. As used in this
244	paragraph, the term "comprehensive behavioral health care
245	services" means covered mental health and substance abuse
246	treatment services that are available to Medicaid recipients.
247	The secretary of the Department of Children and Family Services
248	shall approve provisions of procurements related to children in
249	the department's care or custody prior to enrolling such
250	children in a prepaid behavioral health plan. Any contract
251	awarded under this paragraph must be competitively procured. In
252	developing the behavioral health care prepaid plan procurement
253	document, the agency shall ensure that the procurement document
254	requires the contractor to develop and implement a plan to
255	ensure compliance with s. 394.4574 related to services provided
256	to residents of licensed assisted living facilities that hold a
257	limited mental health license. Except as provided in
258	subparagraph 8., and except in counties where the Medicaid
259	managed care pilot program is authorized pursuant to s.
260	409.91211, the agency shall seek federal approval to contract
261	with a single entity meeting these requirements to provide
262	comprehensive behavioral health care services to all Medicaid
263	recipients not enrolled in a Medicaid managed care plan
264	authorized under s. 409.91211 or a Medicaid health maintenance
265	organization in an AHCA area. In an AHCA area where the Medicaid
266	managed care pilot program is authorized pursuant to s.
267	409.91211 in one or more counties, the agency may procure a
268	contract with a single entity to serve the remaining counties as
269	an AHCA area or the remaining counties may be included with an
270	adjacent AHCA area and shall be subject to this paragraph. Each
271	entity must offer sufficient choice of providers in its network
272	to ensure recipient access to care and the opportunity to select
273	a provider with whom they are satisfied. The network shall
274	include all public mental health hospitals. To ensure unimpaired
275	access to behavioral health care services by Medicaid
276	recipients, all contracts issued pursuant to this paragraph
277	shall require 80 percent of the capitation paid to the managed
278	care plan, including health maintenance organizations, to be
279	expended for the provision of behavioral health care services.
280	In the event the managed care plan expends less than 80 percent
281	of the capitation paid pursuant to this paragraph for the
282	provision of behavioral health care services, the difference
283	shall be returned to the agency. The agency shall provide the
284	managed care plan with a certification letter indicating the
285	amount of capitation paid during each calendar year for the
286	provision of behavioral health care services pursuant to this
287	section. The agency may reimburse for substance abuse treatment
288	services on a fee-for-service basis until the agency finds that
289	adequate funds are available for capitated, prepaid
290	arrangements.
291	1.  By January 1, 2001, the agency shall modify the
292	contracts with the entities providing comprehensive inpatient
293	and outpatient mental health care services to Medicaid
294	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
295	Counties, to include substance abuse treatment services.
296	2.  By July 1, 2003, the agency and the Department of
297	Children and Family Services shall execute a written agreement
298	that requires collaboration and joint development of all policy,
299	budgets, procurement documents, contracts, and monitoring plans
300	that have an impact on the state and Medicaid community mental
301	health and targeted case management programs.
302	3.  Except as provided in subparagraph 8., by July 1, 2006,
303	the agency and the Department of Children and Family Services
304	shall contract with managed care entities in each AHCA area
305	except area 6 or arrange to provide comprehensive inpatient and
306	outpatient mental health and substance abuse services through
307	capitated prepaid arrangements to all Medicaid recipients who
308	are eligible to participate in such plans under federal law and
309	regulation. In AHCA areas where eligible individuals number less
310	than 150,000, the agency shall contract with a single managed
311	care plan to provide comprehensive behavioral health services to
312	all recipients who are not enrolled in a Medicaid health
313	maintenance organization or a Medicaid capitated managed care
314	plan authorized under s. 409.91211. The agency may contract with
315	more than one comprehensive behavioral health provider to
316	provide care to recipients who are not enrolled in a Medicaid
317	capitated managed care plan authorized under s. 409.91211 or a
318	Medicaid health maintenance organization in AHCA areas where the
319	eligible population exceeds 150,000. In an AHCA area where the
320	Medicaid managed care pilot program is authorized pursuant to s.
321	409.91211 in one or more counties, the agency may procure a
322	contract with a single entity to serve the remaining counties as
323	an AHCA area or the remaining counties may be included with an
324	adjacent AHCA area and shall be subject to this paragraph.
325	Contracts for comprehensive behavioral health providers awarded
326	pursuant to this section shall be competitively procured. Both
327	for-profit and not-for-profit corporations shall be eligible to
328	compete. Managed care plans contracting with the agency under
329	subsection (3) shall provide and receive payment for the same
330	comprehensive behavioral health benefits as provided in AHCA
331	rules, including handbooks incorporated by reference. In AHCA
332	area 11, the agency shall contract with at least two
333	comprehensive behavioral health care providers to provide
334	behavioral health care to recipients in that area who are
335	enrolled in, or assigned to, the MediPass program. One of the
336	behavioral health care contracts shall be with the existing
337	provider service network pilot project, as described in
338	paragraph (d), for the purpose of demonstrating the cost-
339	effectiveness of the provision of quality mental health services
340	through a public hospital-operated managed care model. The
341	agency is directed to integrate the provision of acute care and
342	behavioral health services in the public hospital-operated
343	managed care model to the extent feasible and consistent with
344	continuity of care and patient choice. Payment shall be at an
345	agreed-upon capitated rate to ensure cost savings. Of the
346	recipients in area 11 who are assigned to MediPass under the
347	provisions of s. 409.9122(2)(k), a minimum of 50,000 of those
348	MediPass-enrolled recipients shall be assigned to the existing
349	provider service network in area 11 for their behavioral care.
350	4.  By October 1, 2003, the agency and the department shall
351	submit a plan to the Governor, the President of the Senate, and
352	the Speaker of the House of Representatives which provides for
353	the full implementation of capitated prepaid behavioral health
354	care in all areas of the state.
355	a.  Implementation shall begin in 2003 in those AHCA areas
356	of the state where the agency is able to establish sufficient
357	capitation rates.
358	b.  If the agency determines that the proposed capitation
359	rate in any area is insufficient to provide appropriate
360	services, the agency may adjust the capitation rate to ensure
361	that care will be available. The agency and the department may
362	use existing general revenue to address any additional required
363	match but may not over-obligate existing funds on an annualized
364	basis.
365	c.  Subject to any limitations provided for in the General
366	Appropriations Act, the agency, in compliance with appropriate
367	federal authorization, shall develop policies and procedures
368	that allow for certification of local and state funds.
369	5.  Children residing in a statewide inpatient psychiatric
370	program, or in a Department of Juvenile Justice or a Department
371	of Children and Family Services residential program approved as
372	a Medicaid behavioral health overlay services provider shall not
373	be included in a behavioral health care prepaid health plan or
374	any other Medicaid managed care plan pursuant to this paragraph.
375	6.  In converting to a prepaid system of delivery, the
376	agency shall in its procurement document require an entity
377	providing only comprehensive behavioral health care services to
378	prevent the displacement of indigent care patients by enrollees
379	in the Medicaid prepaid health plan providing behavioral health
380	care services from facilities receiving state funding to provide
381	indigent behavioral health care, to facilities licensed under
382	chapter 395 which do not receive state funding for indigent
383	behavioral health care, or reimburse the unsubsidized facility
384	for the cost of behavioral health care provided to the displaced
385	indigent care patient.
386	7.  Traditional community mental health providers under
387	contract with the Department of Children and Family Services
388	pursuant to part IV of chapter 394, child welfare providers
389	under contract with the Department of Children and Family
390	Services in areas 1 and 6, and inpatient mental health providers
391	licensed pursuant to chapter 395 must be offered an opportunity
392	to accept or decline a contract to participate in any provider
393	network for prepaid behavioral health services.
394	8.  All Medicaid-eligible children, except children in area
395	1 and children in Highlands County, Hardee County, Polk County,
396	or Manatee County of area 6, who are open for child welfare
397	services in the HomeSafeNet system, shall receive their
398	behavioral health care services through a specialty prepaid plan
399	operated by community-based lead agencies either through a
400	single agency or formal agreements among several agencies. The
401	specialty prepaid plan must result in savings to the state
402	comparable to savings achieved in other Medicaid managed care
403	and prepaid programs. Such plan must provide mechanisms to
404	maximize state and local revenues. The specialty prepaid plan
405	shall be developed by the agency and the Department of Children
406	and Family Services. The agency is authorized to seek any
407	federal waivers to implement this initiative. Medicaid-eligible
408	children whose cases are open for child welfare services in the
409	HomeSafeNet system and who reside in AHCA area 10 are exempt
410	from the specialty prepaid plan upon the development of a
411	service delivery mechanism for children who reside in area 10 as
412	specified in s. 409.91211(3)(dd).
413	(c)  A federally qualified health center or an entity owned
414	by one or more federally qualified health centers or an entity
415	owned by other migrant and community health centers receiving
416	non-Medicaid financial support from the Federal Government to
417	provide health care services on a prepaid or fixed-sum basis to
418	recipients. A federally qualified health center or an entity
419	that is owned by one or more federally qualified health centers
420	and is reimbursed by the agency on a prepaid basis is exempt
421	from parts I and III of chapter 641, but must comply with the
422	solvency requirements in s. 641.2261(2) and meet the appropriate
423	requirements governing financial reserve, quality assurance, and
424	patients' rights established by the agency.
425	(17)  An entity contracting on a prepaid or fixed-sum basis
426	shall meet the, in addition to meeting any applicable statutory
427	surplus requirements of s. 641.225, also maintain at all times
428	in the form of cash, investments that mature in less than 180
429	days allowable as admitted assets by the Office of Insurance
430	Regulation, and restricted funds or deposits controlled by the
431	agency or the Office of Insurance Regulation, a surplus amount
432	equal to one-and-one-half times the entity's monthly Medicaid
433	prepaid revenues. As used in this subsection, the term "surplus"
434	means the entity's total assets minus total liabilities. If an
435	entity's surplus falls below an amount equal to the surplus
436	requirements of s. 641.225 one-and-one-half times the entity's
437	monthly Medicaid prepaid revenues, the agency shall prohibit the
438	entity from engaging in marketing and preenrollment activities,
439	shall cease to process new enrollments, and shall not renew the
440	entity's contract until the required balance is achieved. The
441	requirements of this subsection do not apply:
442	(a)  Where a public entity agrees to fund any deficit
443	incurred by the contracting entity; or
444	(b)  Where the entity's performance and obligations are
445	guaranteed in writing by a guaranteeing organization which:
446	1.  Has been in operation for at least 5 years and has
447	assets in excess of $50 million; or
448	2.  Submits a written guarantee acceptable to the agency
449	which is irrevocable during the term of the contracting entity's
450	contract with the agency and, upon termination of the contract,
451	until the agency receives proof of satisfaction of all
452	outstanding obligations incurred under the contract.
453	Section 4.  Section 409.91207, Florida Statutes, is created
454	to read:
455	409.91207  Medical Home Pilot Projects.--
456	(1)  PURPOSE.--The agency shall establish pilot projects in
457	Alachua and Hillsborough Counties to test the potential for
458	coordinated and cost-effective care in a fee-for-service
459	environment and to compare performance of these pilot projects
460	with other managed care models.
461	(2)  ORGANIZATION.--
462	(a)  Each pilot project shall be served by at least one
463	medical home network, which shall consist of federally qualified
464	health centers for primary care and disease management; primary
465	care clinics owned or operated by medical schools or teaching
466	hospitals for primary care and disease management; programs
467	serving children with special health care needs currently
468	authorized as a network under an existing Medicaid waiver;
469	medical school faculty for specialty care; and hospitals that
470	agree to participate in the pilot projects. A medical home
471	network shall coordinate with other providers, as necessary, to
472	ensure that Medicaid participants receive efficient and
473	effective access to services specified in subsection (3).
474	(b)  A managed care organization may seek designation by
475	the agency as a medical home network by documenting policies and
476	procedures consistent with the principles provided in subsection
477	(4). A managed care organization designated as a medical home
478	network may receive capitated rates that reflect enhanced
479	payments to fee-for-service medical home networks, as authorized
480	in the General Appropriations Act.
481	(3)  SERVICE CAPABILITIES.--A medical home network shall
482	provide primary care, coordinated services to control chronic
483	illnesses, pharmacy services, outpatient specialty physician
484	services, and inpatient services.
485	(4)  PRINCIPLES.--A medical home network shall modify the
486	processes and patterns of health care service delivery by
487	applying the following principles:
488	(a)  A personal medical provider shall lead an
489	interdisciplinary team of professionals who share the
490	responsibility for ongoing care to a specific panel of patients.
491	(b)  The personal medical provider shall identify the
492	patient's health care needs and respond to those needs either
493	through direct care or arrangements with other qualified
494	providers.
495	(c)  Care shall be coordinated or integrated across all
496	areas of health service delivery.
497	(d)  Information technology shall be integrated into
498	delivery systems to enhance clinical performance and monitor
499	patient outcomes.
500	(5)  ENROLLMENT.--Each Medicaid recipient receiving primary
501	care at a participating federally qualified health center or
502	primary care clinic owned and operated by a medical school or
503	teaching hospital shall be enrolled in the program if the
504	recipient does not opt out of enrollment. Other Medicaid
505	recipients shall be enrolled consistent with s. 409.9122(2)(e)1.
506	(6)  ACCESS STANDARDS AND NETWORK ADEQUACY.--A medical home
507	network shall document the capacity for coordinated systems of
508	care through written agreements among providers that establish
509	arrangements for referral, access to medical records, and
510	followup care.
511	(7)  FINANCING.--Services provided by a medical home
512	network shall be reimbursed based on claims filed for Medicaid
513	fee-for-service payments. In addition, the following entities
514	participating in a medical home network shall be eligible to
515	receive an enhanced payment:
516	(a)  A federally qualified health center or primary care
517	clinic owned and operated by a medical school or teaching
518	hospital shall be eligible to receive enhanced primary care case
519	management fees as authorized in the General Appropriations Act.
520	(b)  A medical school shall be eligible to receive enhanced
521	payments through the supplemental physician payment program
522	using such certified funds as authorized in the General
523	Appropriations Act.
524	(c)  An outpatient primary or specialty clinic shall be
525	eligible to bill Medicaid for facility costs, in addition to
526	professional services.
527	(d)  A hospital shall be eligible to receive supplemental
528	Medicaid payments through the low-income pool, as authorized by
529	the General Appropriations Act, and shall receive exempt fee-
530	for-service rates.
531	(8)  SHARED SAVINGS.--The agency shall analyze spending for
532	enrolled medical home network patients compared to capitation
533	rates that would have been paid for the same population in the
534	same region during the same year. The agency shall report the
535	results of this comparison as part of the Social Services
536	Estimating Conference. Each medical home network that achieves
537	savings equal to the prepaid health plan area discount factor is
538	eligible for an appropriation of the shared savings. When the
539	savings exceed the area discount factor, the medical home
540	network shall be eligible for an appropriation of the full
541	amount of the excess savings. To the extent possible, savings
542	shared with the medical home network shall be distributed as
543	bonus payments for quality performance.
544	(9)  QUALITY ASSURANCE AND ACCOUNTABILITY.--A medical home
545	network shall maintain medical records and clinical data as
546	necessary to assess the utilization, cost, and outcome of
547	services provided to enrollees.
548	(10)  EVALUATION.--The agency shall report medical home
549	network performance on a quarterly basis. The agency shall
550	contract with the University of Florida to comprehensively
551	evaluate the pilot projects created under this section,
552	including a comparison of the medical home network to other
553	models of managed care. An initial evaluation shall cover a 24-
554	month period beginning with the implementation of the pilot
555	projects in all pilot project counties. A final evaluation shall
556	cover a 60-month period beginning with the implementation of the
557	pilot projects in all pilot project counties. The initial
558	evaluation shall be submitted to the Governor, the President of
559	the Senate, and the Speaker of the House of Representatives by
560	June 30, 2012. The final evaluation shall be submitted to the
561	Governor, the President of the Senate, and the Speaker of the
562	House of Representatives by June 30, 2015.
563	Section 5.  Paragraph (b) of subsection (1) and paragraph
564	(e) of subsection (3) of section 409.91211, Florida Statutes,
565	are amended to read:
566	409.91211  Medicaid managed care pilot program.--
567	(1)
568	(b)  This waiver authority is contingent upon federal
569	approval to preserve the upper-payment-limit funding mechanism
570	for hospitals, including a guarantee of a reasonable growth
571	factor, a methodology to allow the use of a portion of these
572	funds to serve as a risk pool for demonstration sites,
573	provisions to preserve the state's ability to use
574	intergovernmental transfers, and provisions to protect the
575	disproportionate share program authorized pursuant to this
576	chapter. Upon completion of the evaluation conducted under s. 3,
577	ch. 2005-133, Laws of Florida, the agency may request statewide
578	expansion of the demonstration projects. Statewide phase-in to
579	additional counties shall be contingent upon review and approval
580	by the Legislature. Under the upper-payment-limit program, or
581	the low-income pool as implemented by the Agency for Health Care
582	Administration pursuant to federal waiver, the state matching
583	funds required for the program shall be provided by local
584	governmental entities through intergovernmental transfers in
585	accordance with published federal statutes and regulations. The
586	Agency for Health Care Administration shall distribute upper-
587	payment-limit, disproportionate share hospital, and low-income
588	pool funds according to published federal statutes, regulations,
589	and waivers and the low-income pool methodology approved by the
590	federal Centers for Medicare and Medicaid Services. A provider
591	who receives low-income pool funds shall serve Medicaid
592	recipients regardless of their county of residence in this state
593	and may not restrict access to care based on residency in a
594	county in this state other than the one in which the provider is
595	located.
596	(3)  The agency shall have the following powers, duties,
597	and responsibilities with respect to the pilot program:
598	(e)  To implement policies and guidelines for phasing in
599	financial risk for approved provider service networks over a 5-
600	year 3-year period. These policies and guidelines must include
601	an option for a provider service network to be paid fee-for-
602	service rates. For any provider service network established in a
603	managed care pilot area, the option to be paid fee-for-service
604	rates shall include a savings-settlement mechanism that is
605	consistent with s. 409.912(44). This model shall be converted to
606	a risk-adjusted capitated rate no later than the beginning of
607	the sixth fourth year of operation, and may be converted earlier
608	at the option of the provider service network. Federally
609	qualified health centers may be offered an opportunity to accept
610	or decline a contract to participate in any provider network for
611	prepaid primary care services.
612	Section 6.  Paragraph (e) of subsection (2) and subsection
613	(7) of section 409.9122, Florida Statutes, are amended, and
614	subsection (15) is added to that section, to read:
615	409.9122  Mandatory Medicaid managed care enrollment;
616	programs and procedures.--
617	(2)
618	(e)  Medicaid recipients who are already enrolled in a
619	managed care plan or MediPass shall be offered the opportunity
620	to change managed care plans or MediPass providers on a
621	staggered basis, as defined by the agency. All Medicaid
622	recipients shall have 30 days in which to make a choice of
623	managed care plans or MediPass providers. Enrolled Medicaid
624	recipients who have a known diagnosis consistent with HIV/AIDS
625	shall be offered the opportunity to change plans on a staggered
626	basis; however, these individuals shall remain in their current
627	disease management or specialized HIV/AIDS plan unless they
628	actively choose to opt out of that plan. In counties that have
629	two or more managed care plans, a recipient already enrolled in
630	MediPass who fails to make a choice during the annual period
631	shall be assigned to a managed care plan if he or she is
632	eligible for enrollment in the managed care plan. The agency
633	shall apply for a state plan amendment or federal waiver
634	authority, if necessary, to implement the provisions of this
635	paragraph. All newly eligible Medicaid recipients shall have 30
636	days in which to make a choice of managed care plans or MediPass
637	providers. Those Medicaid recipients who do not make a choice
638	shall be assigned in accordance with paragraph (f). To
639	facilitate continuity of care, for a Medicaid recipient who is
640	also a recipient of Supplemental Security Income (SSI), prior to
641	assigning the SSI recipient to a managed care plan or MediPass,
642	the agency shall determine whether the SSI recipient has an
643	ongoing relationship with a MediPass provider or managed care
644	plan. If the SSI recipient has an ongoing relationship with a
645	managed care plan, the agency shall assign the recipient to that
646	managed care plan. Those SSI recipients who do not have such a
647	provider relationship shall be assigned to a managed care plan
648	or MediPass provider in accordance with paragraph (f).
649	1.  Notwithstanding this paragraph and paragraph (f), a
650	Medicaid recipient who resides in Alachua County or Hillsborough
651	County who is eligible for managed care plan enrollment and
652	subject to mandatory assignment because the recipient failed to
653	make a choice shall be assigned by the agency to a medical home
654	network operated pursuant to s. 409.91207 using a method that
655	enrolls 50 percent of those recipients in medical home networks
656	and 50 percent in managed care plans. In making these
657	assignments, the agency shall consider the capability of the
658	networks to meet patient needs. Thereafter, assignment of
659	Medicaid recipients shall continue in accordance with paragraph
660	(f).
661	2.  For purposes of subparagraph 1., the term "managed care
662	plans" includes health maintenance organizations, exclusive
663	provider organizations, provider service networks, minority
664	physician networks, the Children's Medical Services Network, and
665	pediatric emergency department diversion programs authorized by
666	this chapter or the General Appropriations Act.
667	(7)  The agency shall convene a workgroup to evaluate the
668	current status and future viability of Medicaid managed care.
669	The workgroup shall complete a report by January 1, 2010, that
670	considers the following issues investigate the feasibility of
671	developing managed care plan and MediPass options for the
672	following groups of Medicaid recipients:
673	(a)  The performance of managed care plans in achieving
674	access to care, quality services, and cost containment. Pregnant
675	women and infants.
676	(b)  The effect of recent changes to payment rates for
677	managed care plans. Elderly and disabled recipients, especially
678	those who are at risk of nursing home placement.
679	(c)  The status of contractual relationships between
680	managed care plans and providers, especially providers
681	critically necessary for compliance with network adequacy
682	standards. Persons with developmental disabilities.
683	(d)  The availability of other models for managed care that
684	may improve performance, ensure stability, and contain costs in
685	the future. Qualified Medicare beneficiaries.
686	(e)  Adults who have chronic, high-cost medical conditions.
687	(f)  Adults and children who have mental health problems.
688	(g)  Other recipients for whom managed care plans and
689	MediPass offer the opportunity of more cost-effective care and
690	greater access to qualified providers.
691	(15)  The agency shall collect encounter data in conformity
692	with s. 409.91211(3)(p)4. on services provided to patients
693	enrolled in managed care plans. The agency shall collect
694	financial and utilization encounter data in a uniform manner
695	based on common definitions delineated by category of service
696	and eligibility group.
697	Section 7.  Subsection (4) of section 409.9124, Florida
698	Statutes, is amended, and paragraph (d) is added to subsection
699	(1) of that section, to read:
700	409.9124  Managed care reimbursement.--The agency shall
701	develop and adopt by rule a methodology for reimbursing managed
702	care plans.
703	(1)  Final managed care rates shall be published annually
704	prior to September 1 of each year, based on methodology that:
705	(d)  Is risk adjusted in accordance with s. 409.908(4).
706	(4)  The agency shall quarterly examine the financial
707	condition of each managed care plan, and its performance in
708	serving Medicaid patients, and shall utilize examinations
709	performed by the Office of Insurance Regulation wherever
710	possible. No later than January 1, 2010, and at least annually
711	thereafter, the agency shall submit a report to the Governor,
712	the President of the Senate, and the Speaker of the House of
713	Representatives regarding the financial condition and trends
714	affecting Medicaid managed care plans in order to assess the
715	viability of these plans, identify any specific risks to future
716	performance, assess overall rate adequacy, and recommend any
717	changes necessary to ensure a resilient and effective managed
718	care program that meets the needs of Medicaid participants.
719	Section 8.  This act shall take effect July 1, 2009.

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