Florida Senate - 2010 CS for CS for SB 1484
By the Policy and Steering Committee on Ways and Means; the
Committee on Health and Human Services Appropriations; and
Senator Peaden
576-03795-10 20101484c2
1 A bill to be entitled
2 An act relating to Medicaid; amending s. 409.912,
3 F.S.; authorizing the Agency for Health Care
4 Administration to contract with an entity for the
5 provision of comprehensive behavioral health care
6 services to certain Medicaid recipients who are not
7 enrolled in a Medicaid managed care plan or a Medicaid
8 provider service network under certain circumstances;
9 requiring the agency to impose a fine against a person
10 under contract with the agency who violates certain
11 provisions; requiring an entity that contracts with
12 the agency as a managed care plan to post a surety
13 bond with the agency or maintain an account of a
14 specified sum; requiring the agency to pursue the
15 entity if the entity terminates the contract with the
16 agency before the end date of the contract; amending
17 s. 409.91211, F.S.; extending by 3 years the statewide
18 implementation of an enhanced service delivery system
19 for the Florida Medicaid program; providing for the
20 expansion of the pilot project into counties that have
21 two or more plans and the capacity to serve the
22 designated population; requiring that the agency
23 provide certain specified data to the recipient when
24 selecting a capitated managed care plan; revising
25 certain requirements for entities performing choice
26 counseling for recipients; requiring the agency to
27 provide behavioral health care services to Medicaid
28 eligible children; extending a date by which the
29 behavioral health care services will be delivered to
30 children; deleting a provision under which certain
31 Medicaid recipients who are not currently enrolled in
32 a capitated managed care plan upon implementation are
33 not eligible for specified services for the amount of
34 time that the recipients do not enroll in a capitated
35 managed care network; authorizing the agency to extend
36 the time to continue operation of the pilot program;
37 requiring that the agency seek public input on
38 extending and expanding the managed care pilot program
39 and post certain information on its website; amending
40 s. 409.9122, F.S.; providing that time allotted to any
41 Medicaid recipient for the selection of, enrollment
42 in, or disenrollment from a managed care plan or
43 MediPass is tolled throughout any month in which the
44 enrollment broker or choice counseling provider
45 adversely affects a beneficiary’s ability to access
46 choice counseling or enrollment broker services by its
47 failure to comply with the terms and conditions of its
48 contract with the agency or has otherwise acted or
49 failed to act in a manner that the agency deems likely
50 to jeopardize its ability to perform certain assigned
51 responsibilities; requiring the agency to incorporate
52 certain provisions after a specified date in its
53 contracts related to sanctions or fines for any action
54 or the failure to act on the part of an enrollment
55 broker or choice counselor provider; providing an
56 effective date.
57
58 Be It Enacted by the Legislature of the State of Florida:
59
60 Section 1. Paragraph (b) of subsection (4) of section
61 409.912, Florida Statutes, is amended, paragraph (d) of
62 subsection (4) of that section is reenacted, present subsections
63 (23) through (53) of that section are renumbered as subsections
64 (24) through (54), respectively, a new subsection (23) is added
65 to that section, and present subsections (21) and (22) of that
66 section are amended, to read:
67 409.912 Cost-effective purchasing of health care.—The
68 agency shall purchase goods and services for Medicaid recipients
69 in the most cost-effective manner consistent with the delivery
70 of quality medical care. To ensure that medical services are
71 effectively utilized, the agency may, in any case, require a
72 confirmation or second physician’s opinion of the correct
73 diagnosis for purposes of authorizing future services under the
74 Medicaid program. This section does not restrict access to
75 emergency services or poststabilization care services as defined
76 in 42 C.F.R. part 438.114. Such confirmation or second opinion
77 shall be rendered in a manner approved by the agency. The agency
78 shall maximize the use of prepaid per capita and prepaid
79 aggregate fixed-sum basis services when appropriate and other
80 alternative service delivery and reimbursement methodologies,
81 including competitive bidding pursuant to s. 287.057, designed
82 to facilitate the cost-effective purchase of a case-managed
83 continuum of care. The agency shall also require providers to
84 minimize the exposure of recipients to the need for acute
85 inpatient, custodial, and other institutional care and the
86 inappropriate or unnecessary use of high-cost services. The
87 agency shall contract with a vendor to monitor and evaluate the
88 clinical practice patterns of providers in order to identify
89 trends that are outside the normal practice patterns of a
90 provider’s professional peers or the national guidelines of a
91 provider’s professional association. The vendor must be able to
92 provide information and counseling to a provider whose practice
93 patterns are outside the norms, in consultation with the agency,
94 to improve patient care and reduce inappropriate utilization.
95 The agency may mandate prior authorization, drug therapy
96 management, or disease management participation for certain
97 populations of Medicaid beneficiaries, certain drug classes, or
98 particular drugs to prevent fraud, abuse, overuse, and possible
99 dangerous drug interactions. The Pharmaceutical and Therapeutics
100 Committee shall make recommendations to the agency on drugs for
101 which prior authorization is required. The agency shall inform
102 the Pharmaceutical and Therapeutics Committee of its decisions
103 regarding drugs subject to prior authorization. The agency is
104 authorized to limit the entities it contracts with or enrolls as
105 Medicaid providers by developing a provider network through
106 provider credentialing. The agency may competitively bid single
107 source-provider contracts if procurement of goods or services
108 results in demonstrated cost savings to the state without
109 limiting access to care. The agency may limit its network based
110 on the assessment of beneficiary access to care, provider
111 availability, provider quality standards, time and distance
112 standards for access to care, the cultural competence of the
113 provider network, demographic characteristics of Medicaid
114 beneficiaries, practice and provider-to-beneficiary standards,
115 appointment wait times, beneficiary use of services, provider
116 turnover, provider profiling, provider licensure history,
117 previous program integrity investigations and findings, peer
118 review, provider Medicaid policy and billing compliance records,
119 clinical and medical record audits, and other factors. Providers
120 shall not be entitled to enrollment in the Medicaid provider
121 network. The agency shall determine instances in which allowing
122 Medicaid beneficiaries to purchase durable medical equipment and
123 other goods is less expensive to the Medicaid program than long
124 term rental of the equipment or goods. The agency may establish
125 rules to facilitate purchases in lieu of long-term rentals in
126 order to protect against fraud and abuse in the Medicaid program
127 as defined in s. 409.913. The agency may seek federal waivers
128 necessary to administer these policies.
129 (4) The agency may contract with:
130 (b) An entity that is providing comprehensive behavioral
131 health care services to certain Medicaid recipients through a
132 capitated, prepaid arrangement pursuant to the federal waiver
133 provided for by s. 409.905(5). Such entity must be licensed
134 under chapter 624, chapter 636, or chapter 641, or authorized
135 under paragraph (c) or paragraph (d), and must possess the
136 clinical systems and operational competence to manage risk and
137 provide comprehensive behavioral health care to Medicaid
138 recipients. As used in this paragraph, the term “comprehensive
139 behavioral health care services” means covered mental health and
140 substance abuse treatment services that are available to
141 Medicaid recipients. The secretary of the Department of Children
142 and Family Services shall approve provisions of procurements
143 related to children in the department’s care or custody before
144 enrolling such children in a prepaid behavioral health plan. Any
145 contract awarded under this paragraph must be competitively
146 procured. In developing the behavioral health care prepaid plan
147 procurement document, the agency shall ensure that the
148 procurement document requires the contractor to develop and
149 implement a plan to ensure compliance with s. 394.4574 related
150 to services provided to residents of licensed assisted living
151 facilities that hold a limited mental health license. Except as
152 provided in subparagraph 8., and except in counties where the
153 Medicaid managed care pilot program is authorized pursuant to s.
154 409.91211, the agency shall seek federal approval to contract
155 with a single entity meeting these requirements to provide
156 comprehensive behavioral health care services to all Medicaid
157 recipients not enrolled in a Medicaid managed care plan
158 authorized under s. 409.91211, a provider service network
159 authorized under paragraph (d), or a Medicaid health maintenance
160 organization in an AHCA area. In an AHCA area where the Medicaid
161 managed care pilot program is authorized pursuant to s.
162 409.91211 in one or more counties, the agency may procure a
163 contract with a single entity to serve the remaining counties as
164 an AHCA area or the remaining counties may be included with an
165 adjacent AHCA area and are subject to this paragraph. Each
166 entity must offer a sufficient choice of providers in its
167 network to ensure recipient access to care and the opportunity
168 to select a provider with whom they are satisfied. The network
169 shall include all public mental health hospitals. To ensure
170 unimpaired access to behavioral health care services by Medicaid
171 recipients, all contracts issued pursuant to this paragraph must
172 require 80 percent of the capitation paid to the managed care
173 plan, including health maintenance organizations and capitated
174 provider service networks, to be expended for the provision of
175 behavioral health care services. If the managed care plan
176 expends less than 80 percent of the capitation paid for the
177 provision of behavioral health care services, the difference
178 shall be returned to the agency. The agency shall provide the
179 plan with a certification letter indicating the amount of
180 capitation paid during each calendar year for behavioral health
181 care services pursuant to this section. The agency may reimburse
182 for substance abuse treatment services on a fee-for-service
183 basis until the agency finds that adequate funds are available
184 for capitated, prepaid arrangements.
185 1. By January 1, 2001, the agency shall modify the
186 contracts with the entities providing comprehensive inpatient
187 and outpatient mental health care services to Medicaid
188 recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
189 Counties, to include substance abuse treatment services.
190 2. By July 1, 2003, the agency and the Department of
191 Children and Family Services shall execute a written agreement
192 that requires collaboration and joint development of all policy,
193 budgets, procurement documents, contracts, and monitoring plans
194 that have an impact on the state and Medicaid community mental
195 health and targeted case management programs.
196 3. Except as provided in subparagraph 8., by July 1, 2006,
197 the agency and the Department of Children and Family Services
198 shall contract with managed care entities in each AHCA area
199 except area 6 or arrange to provide comprehensive inpatient and
200 outpatient mental health and substance abuse services through
201 capitated prepaid arrangements to all Medicaid recipients who
202 are eligible to participate in such plans under federal law and
203 regulation. In AHCA areas where eligible individuals number less
204 than 150,000, the agency shall contract with a single managed
205 care plan to provide comprehensive behavioral health services to
206 all recipients who are not enrolled in a Medicaid health
207 maintenance organization, a provider service network authorized
208 under paragraph (d), or a Medicaid capitated managed care plan
209 authorized under s. 409.91211. The agency may contract with more
210 than one comprehensive behavioral health provider to provide
211 care to recipients who are not enrolled in a Medicaid capitated
212 managed care plan authorized under s. 409.91211, a provider
213 service network authorized under paragraph (d), or a Medicaid
214 health maintenance organization in AHCA areas where the eligible
215 population exceeds 150,000. In an AHCA area where the Medicaid
216 managed care pilot program is authorized pursuant to s.
217 409.91211 in one or more counties, the agency may procure a
218 contract with a single entity to serve the remaining counties as
219 an AHCA area or the remaining counties may be included with an
220 adjacent AHCA area and shall be subject to this paragraph.
221 Contracts for comprehensive behavioral health providers awarded
222 pursuant to this section shall be competitively procured. Both
223 for-profit and not-for-profit corporations are eligible to
224 compete. Managed care plans contracting with the agency under
225 subsection (3) or paragraph (d), shall provide and receive
226 payment for the same comprehensive behavioral health benefits as
227 provided in AHCA rules, including handbooks incorporated by
228 reference. In AHCA area 11, the agency shall contract with at
229 least two comprehensive behavioral health care providers to
230 provide behavioral health care to recipients in that area who
231 are enrolled in, or assigned to, the MediPass program. One of
232 the behavioral health care contracts must be with the existing
233 provider service network pilot project, as described in
234 paragraph (d), for the purpose of demonstrating the cost
235 effectiveness of the provision of quality mental health services
236 through a public hospital-operated managed care model. Payment
237 shall be at an agreed-upon capitated rate to ensure cost
238 savings. Of the recipients in area 11 who are assigned to
239 MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
240 MediPass-enrolled recipients shall be assigned to the existing
241 provider service network in area 11 for their behavioral care.
242 4. By October 1, 2003, the agency and the department shall
243 submit a plan to the Governor, the President of the Senate, and
244 the Speaker of the House of Representatives which provides for
245 the full implementation of capitated prepaid behavioral health
246 care in all areas of the state.
247 a. Implementation shall begin in 2003 in those AHCA areas
248 of the state where the agency is able to establish sufficient
249 capitation rates.
250 b. If the agency determines that the proposed capitation
251 rate in any area is insufficient to provide appropriate
252 services, the agency may adjust the capitation rate to ensure
253 that care will be available. The agency and the department may
254 use existing general revenue to address any additional required
255 match but may not over-obligate existing funds on an annualized
256 basis.
257 c. Subject to any limitations provided in the General
258 Appropriations Act, the agency, in compliance with appropriate
259 federal authorization, shall develop policies and procedures
260 that allow for certification of local and state funds.
261 5. Children residing in a statewide inpatient psychiatric
262 program, or in a Department of Juvenile Justice or a Department
263 of Children and Family Services residential program approved as
264 a Medicaid behavioral health overlay services provider may not
265 be included in a behavioral health care prepaid health plan or
266 any other Medicaid managed care plan pursuant to this paragraph.
267 6. In converting to a prepaid system of delivery, the
268 agency shall in its procurement document require an entity
269 providing only comprehensive behavioral health care services to
270 prevent the displacement of indigent care patients by enrollees
271 in the Medicaid prepaid health plan providing behavioral health
272 care services from facilities receiving state funding to provide
273 indigent behavioral health care, to facilities licensed under
274 chapter 395 which do not receive state funding for indigent
275 behavioral health care, or reimburse the unsubsidized facility
276 for the cost of behavioral health care provided to the displaced
277 indigent care patient.
278 7. Traditional community mental health providers under
279 contract with the Department of Children and Family Services
280 pursuant to part IV of chapter 394, child welfare providers
281 under contract with the Department of Children and Family
282 Services in areas 1 and 6, and inpatient mental health providers
283 licensed pursuant to chapter 395 must be offered an opportunity
284 to accept or decline a contract to participate in any provider
285 network for prepaid behavioral health services.
286 8. All Medicaid-eligible children, except children in area
287 1 and children in Highlands County, Hardee County, Polk County,
288 or Manatee County of area 6, that are open for child welfare
289 services in the HomeSafeNet system, shall receive their
290 behavioral health care services through a specialty prepaid plan
291 operated by community-based lead agencies through a single
292 agency or formal agreements among several agencies. The
293 specialty prepaid plan must result in savings to the state
294 comparable to savings achieved in other Medicaid managed care
295 and prepaid programs. Such plan must provide mechanisms to
296 maximize state and local revenues. The specialty prepaid plan
297 shall be developed by the agency and the Department of Children
298 and Family Services. The agency may seek federal waivers to
299 implement this initiative. Medicaid-eligible children whose
300 cases are open for child welfare services in the HomeSafeNet
301 system and who reside in AHCA area 10 are exempt from the
302 specialty prepaid plan upon the development of a service
303 delivery mechanism for children who reside in area 10 as
304 specified in s. 409.91211(3)(dd).
305 (d) A provider service network may be reimbursed on a fee
306 for-service or prepaid basis. A provider service network which
307 is reimbursed by the agency on a prepaid basis shall be exempt
308 from parts I and III of chapter 641, but must comply with the
309 solvency requirements in s. 641.2261(2) and meet appropriate
310 financial reserve, quality assurance, and patient rights
311 requirements as established by the agency. Medicaid recipients
312 assigned to a provider service network shall be chosen equally
313 from those who would otherwise have been assigned to prepaid
314 plans and MediPass. The agency is authorized to seek federal
315 Medicaid waivers as necessary to implement the provisions of
316 this section. Any contract previously awarded to a provider
317 service network operated by a hospital pursuant to this
318 subsection shall remain in effect for a period of 3 years
319 following the current contract expiration date, regardless of
320 any contractual provisions to the contrary. A provider service
321 network is a network established or organized and operated by a
322 health care provider, or group of affiliated health care
323 providers, including minority physician networks and emergency
324 room diversion programs that meet the requirements of s.
325 409.91211, which provides a substantial proportion of the health
326 care items and services under a contract directly through the
327 provider or affiliated group of providers and may make
328 arrangements with physicians or other health care professionals,
329 health care institutions, or any combination of such individuals
330 or institutions to assume all or part of the financial risk on a
331 prospective basis for the provision of basic health services by
332 the physicians, by other health professionals, or through the
333 institutions. The health care providers must have a controlling
334 interest in the governing body of the provider service network
335 organization.
336 (21) Any entity contracting with the agency pursuant to
337 this section to provide health care services to Medicaid
338 recipients is prohibited from engaging in any of the following
339 practices or activities:
340 (a) Practices that are discriminatory, including, but not
341 limited to, attempts to discourage participation on the basis of
342 actual or perceived health status.
343 (b) Activities that could mislead or confuse recipients, or
344 misrepresent the organization, its marketing representatives, or
345 the agency. Violations of this paragraph include, but are not
346 limited to:
347 1. False or misleading claims that marketing
348 representatives are employees or representatives of the state or
349 county, or of anyone other than the entity or the organization
350 by whom they are reimbursed.
351 2. False or misleading claims that the entity is
352 recommended or endorsed by any state or county agency, or by any
353 other organization which has not certified its endorsement in
354 writing to the entity.
355 3. False or misleading claims that the state or county
356 recommends that a Medicaid recipient enroll with an entity.
357 4. Claims that a Medicaid recipient will lose benefits
358 under the Medicaid program, or any other health or welfare
359 benefits to which the recipient is legally entitled, if the
360 recipient does not enroll with the entity.
361 (c) Granting or offering of any monetary or other valuable
362 consideration for enrollment, except as authorized by subsection
363 (25) (24).
364 (d) Door-to-door solicitation of recipients who have not
365 contacted the entity or who have not invited the entity to make
366 a presentation.
367 (e) Solicitation of Medicaid recipients by marketing
368 representatives stationed in state offices unless approved and
369 supervised by the agency or its agent and approved by the
370 affected state agency when solicitation occurs in an office of
371 the state agency. The agency shall ensure that marketing
372 representatives stationed in state offices shall market their
373 managed care plans to Medicaid recipients only in designated
374 areas and in such a way as to not interfere with the recipients’
375 activities in the state office.
376 (f) Enrollment of Medicaid recipients.
377 (22) The agency shall may impose a fine for a violation of
378 this section or the contract with the agency by a person or
379 entity that is under contract with the agency. With respect to
380 any nonwillful violation, such fine shall not exceed $2,500 per
381 violation. In no event shall such fine exceed an aggregate
382 amount of $10,000 for all nonwillful violations arising out of
383 the same action. With respect to any knowing and willful
384 violation of this section or the contract with the agency, the
385 agency may impose a fine upon the entity in an amount not to
386 exceed $20,000 for each such violation. In no event shall such
387 fine exceed an aggregate amount of $100,000 for all knowing and
388 willful violations arising out of the same action.
389 (23) Any entity that contracts with the agency on a prepaid
390 or fixed-sum basis as a managed care plan as defined in s.
391 409.9122(2)(f) or s. 409.91211 shall post a surety bond with the
392 agency in an amount that is equivalent to a 1-year guaranteed
393 savings amount as specified in the contract. In lieu of a surety
394 bond, the agency may establish an irrevocable account in which
395 the vendor funds an equivalent amount over a 6-month period. The
396 purpose of the surety bond or account is to protect the agency
397 if the entity terminates its contract with the agency before the
398 scheduled end date for the contract. If the contract is
399 terminated by the vendor for any reason, the agency shall pursue
400 a claim against the surety bond or account for an early
401 termination fee. The early termination fee must be equal to
402 administrative costs incurred by the state due to the early
403 termination and the differential of the guaranteed savings based
404 on the original contract term and the corresponding termination
405 date. The agency shall terminate a vendor who does not reimburse
406 the state within 30 days after any early termination involving
407 administrative costs and requiring reimbursement of lost savings
408 from the Medicaid program.
409 Section 2. Subsections (1) through (6) of section
410 409.91211, Florida Statutes, are amended to read:
411 409.91211 Medicaid managed care pilot program.—
412 (1)(a) The agency is authorized to seek and implement
413 experimental, pilot, or demonstration project waivers, pursuant
414 to s. 1115 of the Social Security Act, to create a statewide
415 initiative to provide for a more efficient and effective service
416 delivery system that enhances quality of care and client
417 outcomes in the Florida Medicaid program pursuant to this
418 section. Phase one of the demonstration shall be implemented in
419 two geographic areas. One demonstration site shall include only
420 Broward County. A second demonstration site shall initially
421 include Duval County and shall be expanded to include Baker,
422 Clay, and Nassau Counties within 1 year after the Duval County
423 program becomes operational. The agency shall implement
424 expansion of the program to include the remaining counties of
425 the state and remaining eligibility groups in accordance with
426 the process specified in the federally approved special terms
427 and conditions numbered 11-W-00206/4, as approved by the federal
428 Centers for Medicare and Medicaid Services on October 19, 2005,
429 with a goal of full statewide implementation by June 30, 2014
430 2011.
431 (b) This waiver extension shall authority is contingent
432 upon federal approval to preserve the low-income pool upper
433 payment-limit funding mechanism for providers and hospitals,
434 including a guarantee of a reasonable growth factor, a
435 methodology to allow the use of a portion of these funds to
436 serve as a risk pool for demonstration sites, provisions to
437 preserve the state’s ability to use intergovernmental transfers,
438 and provisions to protect the disproportionate share program
439 authorized pursuant to this chapter. Upon completion of the
440 evaluation conducted under s. 3, ch. 2005-133, Laws of Florida,
441 The agency shall expand may request statewide expansion of the
442 demonstration to counties that have two or more plans and that
443 have capacity to serve the designated population projects. The
444 agency may expand to additional counties as plan capacity is
445 developed. Statewide phase-in to additional counties shall be
446 contingent upon review and approval by the Legislature. Under
447 the upper-payment-limit program, or the low-income pool as
448 implemented by the Agency for Health Care Administration
449 pursuant to federal waiver, the state matching funds required
450 for the program shall be provided by local governmental entities
451 through intergovernmental transfers in accordance with published
452 federal statutes and regulations. The Agency for Health Care
453 Administration shall distribute upper-payment-limit,
454 disproportionate share hospital, and low-income pool funds
455 according to published federal statutes, regulations, and
456 waivers and the low-income pool methodology approved by the
457 federal Centers for Medicare and Medicaid Services.
458 (c) It is the intent of the Legislature that the low-income
459 pool plan required by the terms and conditions of the Medicaid
460 reform waiver and submitted to the federal Centers for Medicare
461 and Medicaid Services propose the distribution of the above
462 mentioned program funds based on the following objectives:
463 1. Assure a broad and fair distribution of available funds
464 based on the access provided by Medicaid participating
465 hospitals, regardless of their ownership status, through their
466 delivery of inpatient or outpatient care for Medicaid
467 beneficiaries and uninsured and underinsured individuals;
468 2. Assure accessible emergency inpatient and outpatient
469 care for Medicaid beneficiaries and uninsured and underinsured
470 individuals;
471 3. Enhance primary, preventive, and other ambulatory care
472 coverages for uninsured individuals;
473 4. Promote teaching and specialty hospital programs;
474 5. Promote the stability and viability of statutorily
475 defined rural hospitals and hospitals that serve as sole
476 community hospitals;
477 6. Recognize the extent of hospital uncompensated care
478 costs;
479 7. Maintain and enhance essential community hospital care;
480 8. Maintain incentives for local governmental entities to
481 contribute to the cost of uncompensated care;
482 9. Promote measures to avoid preventable hospitalizations;
483 10. Account for hospital efficiency; and
484 11. Contribute to a community’s overall health system.
485 (2) The Legislature intends for the capitated managed care
486 pilot program to:
487 (a) Provide recipients in Medicaid fee-for-service or the
488 MediPass program a comprehensive and coordinated capitated
489 managed care system for all health care services specified in
490 ss. 409.905 and 409.906.
491 (b) Stabilize Medicaid expenditures under the pilot program
492 compared to Medicaid expenditures in the pilot area for the 3
493 years before implementation of the pilot program, while
494 ensuring:
495 1. Consumer education and choice.
496 2. Access to medically necessary services.
497 3. Coordination of preventative, acute, and long-term care.
498 4. Reductions in unnecessary service utilization.
499 (c) Provide an opportunity to evaluate the feasibility of
500 statewide implementation of capitated managed care networks as a
501 replacement for the current Medicaid fee-for-service and
502 MediPass systems.
503 (3) The agency shall have the following powers, duties, and
504 responsibilities with respect to the pilot program:
505 (a) To implement a system to deliver all mandatory services
506 specified in s. 409.905 and optional services specified in s.
507 409.906, as approved by the Centers for Medicare and Medicaid
508 Services and the Legislature in the waiver pursuant to this
509 section. Services to recipients under plan benefits shall
510 include emergency services provided under s. 409.9128.
511 (b) To implement a pilot program, including Medicaid
512 eligibility categories specified in ss. 409.903 and 409.904, as
513 authorized in an approved federal waiver.
514 (c) To implement the managed care pilot program that
515 maximizes all available state and federal funds, including those
516 obtained through intergovernmental transfers, the low-income
517 pool, supplemental Medicaid payments, and the disproportionate
518 share program. Within the parameters allowed by federal statute
519 and rule, the agency may seek options for making direct payments
520 to hospitals and physicians employed by or under contract with
521 the state’s medical schools for the costs associated with
522 graduate medical education under Medicaid reform.
523 (d) To implement actuarially sound, risk-adjusted
524 capitation rates for Medicaid recipients in the pilot program
525 which cover comprehensive care, enhanced services, and
526 catastrophic care.
527 (e) To implement policies and guidelines for phasing in
528 financial risk for approved provider service networks that, for
529 purposes of this paragraph, include the Children’s Medical
530 Services Network, over a 5-year period. These policies and
531 guidelines must include an option for a provider service network
532 to be paid fee-for-service rates. For any provider service
533 network established in a managed care pilot area, the option to
534 be paid fee-for-service rates must include a savings-settlement
535 mechanism that is consistent with s. 409.912(44). This model
536 must be converted to a risk-adjusted capitated rate by the
537 beginning of the sixth year of operation, and may be converted
538 earlier at the option of the provider service network. Federally
539 qualified health centers may be offered an opportunity to accept
540 or decline a contract to participate in any provider network for
541 prepaid primary care services.
542 (f) To implement stop-loss requirements and the transfer of
543 excess cost to catastrophic coverage that accommodates the risks
544 associated with the development of the pilot program.
545 (g) To recommend a process to be used by the Social
546 Services Estimating Conference to determine and validate the
547 rate of growth of the per-member costs of providing Medicaid
548 services under the managed care pilot program.
549 (h) To implement program standards and credentialing
550 requirements for capitated managed care networks to participate
551 in the pilot program, including those related to fiscal
552 solvency, quality of care, and adequacy of access to health care
553 providers. It is the intent of the Legislature that, to the
554 extent possible, any pilot program authorized by the state under
555 this section include any federally qualified health center,
556 federally qualified rural health clinic, county health
557 department, the Children’s Medical Services Network within the
558 Department of Health, or other federally, state, or locally
559 funded entity that serves the geographic areas within the
560 boundaries of the pilot program that requests to participate.
561 This paragraph does not relieve an entity that qualifies as a
562 capitated managed care network under this section from any other
563 licensure or regulatory requirements contained in state or
564 federal law which would otherwise apply to the entity. The
565 standards and credentialing requirements shall be based upon,
566 but are not limited to:
567 1. Compliance with the accreditation requirements as
568 provided in s. 641.512.
569 2. Compliance with early and periodic screening, diagnosis,
570 and treatment screening requirements under federal law.
571 3. The percentage of voluntary disenrollments.
572 4. Immunization rates.
573 5. Standards of the National Committee for Quality
574 Assurance and other approved accrediting bodies.
575 6. Recommendations of other authoritative bodies.
576 7. Specific requirements of the Medicaid program, or
577 standards designed to specifically meet the unique needs of
578 Medicaid recipients.
579 8. Compliance with the health quality improvement system as
580 established by the agency, which incorporates standards and
581 guidelines developed by the Centers for Medicare and Medicaid
582 Services as part of the quality assurance reform initiative.
583 9. The network’s infrastructure capacity to manage
584 financial transactions, recordkeeping, data collection, and
585 other administrative functions.
586 10. The network’s ability to submit any financial,
587 programmatic, or patient-encounter data or other information
588 required by the agency to determine the actual services provided
589 and the cost of administering the plan.
590 (i) To implement a mechanism for providing information to
591 Medicaid recipients for the purpose of selecting a capitated
592 managed care plan. For each plan available to a recipient, the
593 agency, at a minimum, shall ensure that the recipient is
594 provided with:
595 1. A list and description of the benefits provided.
596 2. Information about cost sharing.
597 3. A list of providers participating in the plan networks.
598 4.3. Plan performance data, if available.
599 4. An explanation of benefit limitations.
600 5. Contact information, including identification of
601 providers participating in the network, geographic locations,
602 and transportation limitations.
603 6. Any other information the agency determines would
604 facilitate a recipient’s understanding of the plan or insurance
605 that would best meet his or her needs.
606 (j) To implement a system to ensure that there is a record
607 of recipient acknowledgment that plan choice counseling has been
608 provided.
609 (k) To implement a choice counseling system to ensure that
610 the choice counseling process and related material are designed
611 to provide counseling through face-to-face interaction, by
612 telephone or, and in writing and through other forms of relevant
613 media. Materials shall be written at the fourth-grade reading
614 level and available in a language other than English when 5
615 percent of the county speaks a language other than English.
616 Choice counseling shall also use language lines and other
617 services for impaired recipients, such as TTD/TTY.
618 (l) To implement a system that prohibits capitated managed
619 care plans, their representatives, and providers employed by or
620 contracted with the capitated managed care plans from recruiting
621 persons eligible for or enrolled in Medicaid, from providing
622 inducements to Medicaid recipients to select a particular
623 capitated managed care plan, and from prejudicing Medicaid
624 recipients against other capitated managed care plans. The
625 system shall require the entity performing choice counseling to
626 determine if the recipient has made a choice of a plan or has
627 opted out because of duress, threats, payment to the recipient,
628 or incentives promised to the recipient by a third party. If the
629 choice counseling entity determines that the decision to choose
630 a plan was unlawfully influenced or a plan violated any of the
631 provisions of s. 409.912(21), the choice counseling entity shall
632 immediately report the violation to the agency’s program
633 integrity section for investigation. Verification of choice
634 counseling by the recipient shall include a stipulation that the
635 recipient acknowledges the provisions of this subsection.
636 (m) To implement a choice counseling system that promotes
637 health literacy, uses technology effectively, and provides
638 information intended aimed to reduce minority health disparities
639 through outreach activities for Medicaid recipients.
640 (n) To contract with entities to perform choice counseling.
641 The agency may establish standards and performance contracts,
642 including standards requiring the contractor to hire choice
643 counselors who are representative of the state’s diverse
644 population and to train choice counselors in working with
645 culturally diverse populations.
646 (o) To implement eligibility assignment processes to
647 facilitate client choice while ensuring pilot programs of
648 adequate enrollment levels. These processes shall ensure that
649 pilot sites have sufficient levels of enrollment to conduct a
650 valid test of the managed care pilot program within a 2-year
651 timeframe.
652 (p) To implement standards for plan compliance, including,
653 but not limited to, standards for quality assurance and
654 performance improvement, standards for peer or professional
655 reviews, grievance policies, and policies for maintaining
656 program integrity. The agency shall develop a data-reporting
657 system, seek input from managed care plans in order to establish
658 requirements for patient-encounter reporting, and ensure that
659 the data reported is accurate and complete.
660 1. In performing the duties required under this section,
661 the agency shall work with managed care plans to establish a
662 uniform system to measure and monitor outcomes for a recipient
663 of Medicaid services.
664 2. The system shall use financial, clinical, and other
665 criteria based on pharmacy, medical services, and other data
666 that is related to the provision of Medicaid services,
667 including, but not limited to:
668 a. The Health Plan Employer Data and Information Set
669 (HEDIS) or measures that are similar to HEDIS.
670 b. Member satisfaction.
671 c. Provider satisfaction.
672 d. Report cards on plan performance and best practices.
673 e. Compliance with the requirements for prompt payment of
674 claims under ss. 627.613, 641.3155, and 641.513.
675 f. Utilization and quality data for the purpose of ensuring
676 access to medically necessary services, including
677 underutilization or inappropriate denial of services.
678 3. The agency shall require the managed care plans that
679 have contracted with the agency to establish a quality assurance
680 system that incorporates the provisions of s. 409.912(27) and
681 any standards, rules, and guidelines developed by the agency.
682 4. The agency shall establish an encounter database in
683 order to compile data on health services rendered by health care
684 practitioners who provide services to patients enrolled in
685 managed care plans in the demonstration sites. The encounter
686 database shall:
687 a. Collect the following for each type of patient encounter
688 with a health care practitioner or facility, including:
689 (I) The demographic characteristics of the patient.
690 (II) The principal, secondary, and tertiary diagnosis.
691 (III) The procedure performed.
692 (IV) The date and location where the procedure was
693 performed.
694 (V) The payment for the procedure, if any.
695 (VI) If applicable, the health care practitioner’s
696 universal identification number.
697 (VII) If the health care practitioner rendering the service
698 is a dependent practitioner, the modifiers appropriate to
699 indicate that the service was delivered by the dependent
700 practitioner.
701 b. Collect appropriate information relating to prescription
702 drugs for each type of patient encounter.
703 c. Collect appropriate information related to health care
704 costs and utilization from managed care plans participating in
705 the demonstration sites.
706 5. To the extent practicable, when collecting the data the
707 agency shall use a standardized claim form or electronic
708 transfer system that is used by health care practitioners,
709 facilities, and payors.
710 6. Health care practitioners and facilities in the
711 demonstration sites shall electronically submit, and managed
712 care plans participating in the demonstration sites shall
713 electronically receive, information concerning claims payments
714 and any other information reasonably related to the encounter
715 database using a standard format as required by the agency.
716 7. The agency shall establish reasonable deadlines for
717 phasing in the electronic transmittal of full encounter data.
718 8. The system must ensure that the data reported is
719 accurate and complete.
720 (q) To implement a grievance resolution process for
721 Medicaid recipients enrolled in a capitated managed care network
722 under the pilot program modeled after the subscriber assistance
723 panel, as created in s. 408.7056. This process shall include a
724 mechanism for an expedited review of no greater than 24 hours
725 after notification of a grievance if the life of a Medicaid
726 recipient is in imminent and emergent jeopardy.
727 (r) To implement a grievance resolution process for health
728 care providers employed by or contracted with a capitated
729 managed care network under the pilot program in order to settle
730 disputes among the provider and the managed care network or the
731 provider and the agency.
732 (s) To implement criteria in an approved federal waiver to
733 designate health care providers as eligible to participate in
734 the pilot program. These criteria must include at a minimum
735 those criteria specified in s. 409.907.
736 (t) To use health care provider agreements for
737 participation in the pilot program.
738 (u) To require that all health care providers under
739 contract with the pilot program be duly licensed in the state,
740 if such licensure is available, and meet other criteria as may
741 be established by the agency. These criteria shall include at a
742 minimum those criteria specified in s. 409.907.
743 (v) To ensure that managed care organizations work
744 collaboratively with other state or local governmental programs
745 or institutions for the coordination of health care to eligible
746 individuals receiving services from such programs or
747 institutions.
748 (w) To implement procedures to minimize the risk of
749 Medicaid fraud and abuse in all plans operating in the Medicaid
750 managed care pilot program authorized in this section.
751 1. The agency shall ensure that applicable provisions of
752 this chapter and chapters 414, 626, 641, and 932 which relate to
753 Medicaid fraud and abuse are applied and enforced at the
754 demonstration project sites.
755 2. Providers must have the certification, license, and
756 credentials that are required by law and waiver requirements.
757 3. The agency shall ensure that the plan is in compliance
758 with s. 409.912(21) and (22).
759 4. The agency shall require that each plan establish
760 functions and activities governing program integrity in order to
761 reduce the incidence of fraud and abuse. Plans must report
762 instances of fraud and abuse pursuant to chapter 641.
763 5. The plan shall have written administrative and
764 management arrangements or procedures, including a mandatory
765 compliance plan, which are designed to guard against fraud and
766 abuse. The plan shall designate a compliance officer who has
767 sufficient experience in health care.
768 6.a. The agency shall require all managed care plan
769 contractors in the pilot program to report all instances of
770 suspected fraud and abuse. A failure to report instances of
771 suspected fraud and abuse is a violation of law and subject to
772 the penalties provided by law.
773 b. An instance of fraud and abuse in the managed care plan,
774 including, but not limited to, defrauding the state health care
775 benefit program by misrepresentation of fact in reports, claims,
776 certifications, enrollment claims, demographic statistics, or
777 patient-encounter data; misrepresentation of the qualifications
778 of persons rendering health care and ancillary services; bribery
779 and false statements relating to the delivery of health care;
780 unfair and deceptive marketing practices; and false claims
781 actions in the provision of managed care, is a violation of law
782 and subject to the penalties provided by law.
783 c. The agency shall require that all contractors make all
784 files and relevant billing and claims data accessible to state
785 regulators and investigators and that all such data is linked
786 into a unified system to ensure consistent reviews and
787 investigations.
788 (x) To develop and provide actuarial and benefit design
789 analyses that indicate the effect on capitation rates and
790 benefits offered in the pilot program over a prospective 5-year
791 period based on the following assumptions:
792 1. Growth in capitation rates which is limited to the
793 estimated growth rate in general revenue.
794 2. Growth in capitation rates which is limited to the
795 average growth rate over the last 3 years in per-recipient
796 Medicaid expenditures.
797 3. Growth in capitation rates which is limited to the
798 growth rate of aggregate Medicaid expenditures between the 2003
799 2004 fiscal year and the 2004-2005 fiscal year.
800 (y) To develop a mechanism to require capitated managed
801 care plans to reimburse qualified emergency service providers,
802 including, but not limited to, ambulance services, in accordance
803 with ss. 409.908 and 409.9128. The pilot program must include a
804 provision for continuing fee-for-service payments for emergency
805 services, including, but not limited to, individuals who access
806 ambulance services or emergency departments and who are
807 subsequently determined to be eligible for Medicaid services.
808 (z) To ensure that school districts participating in the
809 certified school match program pursuant to ss. 409.908(21) and
810 1011.70 shall be reimbursed by Medicaid, subject to the
811 limitations of s. 1011.70(1), for a Medicaid-eligible child
812 participating in the services as authorized in s. 1011.70, as
813 provided for in s. 409.9071, regardless of whether the child is
814 enrolled in a capitated managed care network. Capitated managed
815 care networks must make a good faith effort to execute
816 agreements with school districts regarding the coordinated
817 provision of services authorized under s. 1011.70. County health
818 departments and federally qualified health centers delivering
819 school-based services pursuant to ss. 381.0056 and 381.0057 must
820 be reimbursed by Medicaid for the federal share for a Medicaid
821 eligible child who receives Medicaid-covered services in a
822 school setting, regardless of whether the child is enrolled in a
823 capitated managed care network. Capitated managed care networks
824 must make a good faith effort to execute agreements with county
825 health departments and federally qualified health centers
826 regarding the coordinated provision of services to a Medicaid
827 eligible child. To ensure continuity of care for Medicaid
828 patients, the agency, the Department of Health, and the
829 Department of Education shall develop procedures for ensuring
830 that a student’s capitated managed care network provider
831 receives information relating to services provided in accordance
832 with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
833 (aa) To implement a mechanism whereby Medicaid recipients
834 who are already enrolled in a managed care plan or the MediPass
835 program in the pilot areas shall be offered the opportunity to
836 change to capitated managed care plans on a staggered basis, as
837 defined by the agency. All Medicaid recipients shall have 30
838 days in which to make a choice of capitated managed care plans.
839 Those Medicaid recipients who do not make a choice shall be
840 assigned to a capitated managed care plan in accordance with
841 paragraph (4)(a) and shall be exempt from s. 409.9122. To
842 facilitate continuity of care for a Medicaid recipient who is
843 also a recipient of Supplemental Security Income (SSI), prior to
844 assigning the SSI recipient to a capitated managed care plan,
845 the agency shall determine whether the SSI recipient has an
846 ongoing relationship with a provider or capitated managed care
847 plan, and, if so, the agency shall assign the SSI recipient to
848 that provider or capitated managed care plan where feasible.
849 Those SSI recipients who do not have such a provider
850 relationship shall be assigned to a capitated managed care plan
851 provider in accordance with paragraph (4)(a) and shall be exempt
852 from s. 409.9122.
853 (bb) To develop and recommend a service delivery
854 alternative for children having chronic medical conditions which
855 establishes a medical home project to provide primary care
856 services to this population. The project shall provide
857 community-based primary care services that are integrated with
858 other subspecialties to meet the medical, developmental, and
859 emotional needs for children and their families. This project
860 shall include an evaluation component to determine impacts on
861 hospitalizations, length of stays, emergency room visits, costs,
862 and access to care, including specialty care and patient and
863 family satisfaction.
864 (cc) To develop and recommend service delivery mechanisms
865 within capitated managed care plans to provide Medicaid services
866 as specified in ss. 409.905 and 409.906 to persons with
867 developmental disabilities sufficient to meet the medical,
868 developmental, and emotional needs of these persons.
869 (dd) To implement service delivery mechanisms within a
870 specialty plan in area 10 capitated managed care plans to
871 provide behavioral health care services Medicaid services as
872 specified in ss. 409.905 and 409.906 to Medicaid-eligible
873 children whose cases are open for child welfare services in the
874 HomeSafeNet system. These services must be coordinated with
875 community-based care providers as specified in s. 409.1671,
876 where available, and be sufficient to meet the medical,
877 developmental, behavioral, and emotional needs of these
878 children. Children in area 10 who have an open case in the
879 HomeSafeNet system shall be enrolled into the specialty plan.
880 These service delivery mechanisms must be implemented no later
881 than July 1, 2011 2008, in AHCA area 10 in order for the
882 children in AHCA area 10 to remain exempt from the statewide
883 plan under s. 409.912(4)(b)8. An administrative fee may be paid
884 to the specialty plan for the coordination of services based on
885 the receipt of the state share of that fee being provided
886 through intergovernmental transfers.
887 (4)(a) A Medicaid recipient in the pilot area who is not
888 currently enrolled in a capitated managed care plan upon
889 implementation is not eligible for services as specified in ss.
890 409.905 and 409.906, for the amount of time that the recipient
891 does not enroll in a capitated managed care network. If a
892 Medicaid recipient has not enrolled in a capitated managed care
893 plan within 30 days after eligibility, the agency shall assign
894 the Medicaid recipient to a capitated managed care plan based on
895 the assessed needs of the recipient as determined by the agency
896 and the recipient shall be exempt from s. 409.9122. When making
897 assignments, the agency shall take into account the following
898 criteria:
899 1. A capitated managed care network has sufficient network
900 capacity to meet the needs of members.
901 2. The capitated managed care network has previously
902 enrolled the recipient as a member, or one of the capitated
903 managed care network’s primary care providers has previously
904 provided health care to the recipient.
905 3. The agency has knowledge that the member has previously
906 expressed a preference for a particular capitated managed care
907 network as indicated by Medicaid fee-for-service claims data,
908 but has failed to make a choice.
909 4. The capitated managed care network’s primary care
910 providers are geographically accessible to the recipient’s
911 residence.
912 5. Plan performance as designed by the agency.
913 (b) When more than one capitated managed care network
914 provider meets the criteria specified in paragraph (3)(h), the
915 agency shall make recipient assignments consecutively by family
916 unit.
917 (c) If a recipient is currently enrolled with a Medicaid
918 managed care organization that also operates an approved reform
919 plan within a demonstration area and the recipient fails to
920 choose a plan during the reform enrollment process or during
921 redetermination of eligibility, the recipient shall be
922 automatically assigned by the agency into the most appropriate
923 reform plan operated by the recipient’s current Medicaid managed
924 care plan. If the recipient’s current managed care plan does not
925 operate a reform plan in the demonstration area which adequately
926 meets the needs of the Medicaid recipient, the agency shall use
927 the automatic assignment process as prescribed in the special
928 terms and conditions numbered 11-W-00206/4. All enrollment and
929 choice counseling materials provided by the agency must contain
930 an explanation of the provisions of this paragraph for current
931 managed care recipients.
932 (d) Except for plan performance as provided for in
933 paragraph (a), the agency may not engage in practices that are
934 designed to favor one capitated managed care plan over another
935 or that are designed to influence Medicaid recipients to enroll
936 in a particular capitated managed care network in order to
937 strengthen its particular fiscal viability.
938 (e) After a recipient has made a selection or has been
939 enrolled in a capitated managed care network, the recipient
940 shall have 90 days in which to voluntarily disenroll and select
941 another capitated managed care network. After 90 days, no
942 further changes may be made except for cause. Cause shall
943 include, but not be limited to, poor quality of care, lack of
944 access to necessary specialty services, an unreasonable delay or
945 denial of service, inordinate or inappropriate changes of
946 primary care providers, service access impairments due to
947 significant changes in the geographic location of services, or
948 fraudulent enrollment. The agency may require a recipient to use
949 the capitated managed care network’s grievance process as
950 specified in paragraph (3)(q) prior to the agency’s
951 determination of cause, except in cases in which immediate risk
952 of permanent damage to the recipient’s health is alleged. The
953 grievance process, when used, must be completed in time to
954 permit the recipient to disenroll no later than the first day of
955 the second month after the month the disenrollment request was
956 made. If the capitated managed care network, as a result of the
957 grievance process, approves an enrollee’s request to disenroll,
958 the agency is not required to make a determination in the case.
959 The agency must make a determination and take final action on a
960 recipient’s request so that disenrollment occurs no later than
961 the first day of the second month after the month the request
962 was made. If the agency fails to act within the specified
963 timeframe, the recipient’s request to disenroll is deemed to be
964 approved as of the date agency action was required. Recipients
965 who disagree with the agency’s finding that cause does not exist
966 for disenrollment shall be advised of their right to pursue a
967 Medicaid fair hearing to dispute the agency’s finding.
968 (f) The agency shall apply for federal waivers from the
969 Centers for Medicare and Medicaid Services to lock eligible
970 Medicaid recipients into a capitated managed care network for 12
971 months after an open enrollment period. After 12 months of
972 enrollment, a recipient may select another capitated managed
973 care network. However, nothing shall prevent a Medicaid
974 recipient from changing primary care providers within the
975 capitated managed care network during the 12-month period.
976 (g) The agency shall apply for federal waivers from the
977 Centers for Medicare and Medicaid Services to allow recipients
978 to purchase health care coverage through an employer-sponsored
979 health insurance plan instead of through a Medicaid-certified
980 plan. This provision shall be known as the opt-out option.
981 1. A recipient who chooses the Medicaid opt-out option
982 shall have an opportunity for a specified period of time, as
983 authorized under a waiver granted by the Centers for Medicare
984 and Medicaid Services, to select and enroll in a Medicaid
985 certified plan. If the recipient remains in the employer
986 sponsored plan after the specified period, the recipient shall
987 remain in the opt-out program for at least 1 year or until the
988 recipient no longer has access to employer-sponsored coverage,
989 until the employer’s open enrollment period for a person who
990 opts out in order to participate in employer-sponsored coverage,
991 or until the person is no longer eligible for Medicaid,
992 whichever time period is shorter.
993 2. Notwithstanding any other provision of this section,
994 coverage, cost sharing, and any other component of employer
995 sponsored health insurance shall be governed by applicable state
996 and federal laws.
997 (5) This section authorizes does not authorize the agency
998 to seek an extension amendment and to continue operation
999 implement any provision of the s. 1115 of the Social Security
1000 Act experimental, pilot, or demonstration project waiver to
1001 reform the state Medicaid program in any part of the state other
1002 than the two geographic areas specified in this section unless
1003 approved by the Legislature.
1004 (6) The agency shall develop and submit for approval
1005 applications for waivers of applicable federal laws and
1006 regulations as necessary to extend and expand implement the
1007 managed care pilot project as defined in this section. The
1008 agency shall seek public input on the waiver and post all waiver
1009 applications under this section on its Internet website for 30
1010 days before submitting the applications to the United States
1011 Centers for Medicare and Medicaid Services. The 30 days shall
1012 commence with the initial posting and must conclude 30 days
1013 prior to approval by the United States Centers for Medicare and
1014 Medicaid Services. All waiver applications shall be provided for
1015 review and comment to the appropriate committees of the Senate
1016 and House of Representatives for at least 10 working days prior
1017 to submission. All waivers submitted to and approved by the
1018 United States Centers for Medicare and Medicaid Services under
1019 this section must be approved by the Legislature. Federally
1020 approved waivers must be submitted to the President of the
1021 Senate and the Speaker of the House of Representatives for
1022 referral to the appropriate legislative committees. The
1023 appropriate committees shall recommend whether to approve the
1024 implementation of any waivers to the Legislature as a whole. The
1025 agency shall submit a plan containing a recommended timeline for
1026 implementation of any waivers and budgetary projections of the
1027 effect of the pilot program under this section on the total
1028 Medicaid budget for the 2006-2007 through 2009-2010 state fiscal
1029 years. This implementation plan shall be submitted to the
1030 President of the Senate and the Speaker of the House of
1031 Representatives at the same time any waivers are submitted for
1032 consideration by the Legislature. The agency may implement the
1033 waiver and special terms and conditions numbered 11-W-00206/4,
1034 as approved by the federal Centers for Medicare and Medicaid
1035 Services. If the agency seeks approval by the Federal Government
1036 of any modifications to these special terms and conditions, the
1037 agency must provide written notification of its intent to modify
1038 these terms and conditions to the President of the Senate and
1039 the Speaker of the House of Representatives at least 15 days
1040 before submitting the modifications to the Federal Government
1041 for consideration. The notification must identify all
1042 modifications being pursued and the reason the modifications are
1043 needed. Upon receiving federal approval of any modifications to
1044 the special terms and conditions, the agency shall provide a
1045 report to the Legislature describing the federally approved
1046 modifications to the special terms and conditions within 7 days
1047 after approval by the Federal Government.
1048 Section 3. Paragraph (m) is added to subsection (2) of
1049 section 409.9122, Florida Statutes, to read:
1050 409.9122 Mandatory Medicaid managed care enrollment;
1051 programs and procedures.—
1052 (2)
1053 (m)1. Time allotted pursuant to this subsection to any
1054 Medicaid recipient for the selection of, enrollment in, or
1055 disenrollment from a managed care plan or MediPass is tolled
1056 throughout any month in which the enrollment broker or choice
1057 counseling provider, whichever is applicable, has adversely
1058 affected a beneficiary’s ability to access choice counseling or
1059 enrollment broker services by its failure to comply with the
1060 terms and conditions of its contract or has otherwise acted or
1061 failed to act in a manner that the agency deems likely to
1062 jeopardize its ability to perform its assigned responsibilities
1063 as set forth in paragraphs (c) and (d). During any month in
1064 which time is tolled for a recipient, he or she must be afforded
1065 uninterrupted access to benefits and services in the same
1066 delivery system available prior to such tolling.
1067 2. The agency shall incorporate into all pertinent
1068 contracts that are executed or renewed on or after July 1, 2010,
1069 provisions authorizing and requiring the agency to impose
1070 sanctions or fines against an enrollment broker or choice
1071 counselor if a recipient is adversely affected due to any action
1072 or failure to act on the part of the enrollment broker or choice
1073 counselor.
1074 Section 4. This act shall take effect July 1, 2010.