HB 7187

1	A bill to be entitled
2	An act relating to Medicaid; amending s. 409.907, F.S.;
3	revising the requirements of a Medicaid provider agreement
4	to include compliance with the Medicaid Encounter Data
5	System; requiring the Agency for Health Care
6	Administration to submit an annual report on the system to
7	the Governor and Legislature; amending s. 409.908, F.S.;
8	requiring the agency to adjust capitation rates for
9	certain Medicaid providers; providing criteria for the
10	adjustments; providing a phase-in schedule; requiring the
11	Secretary of Health Care Administration to establish a
12	technical advisory panel to advise the agency in the area
13	of risk-adjusted rate setting; providing membership and
14	duties; amending s. 409.912, F.S.; providing instructions
15	to the agency regarding seeking federal approval for
16	certain contracts that provide behavioral health care
17	services; providing for certain contracts to remain in
18	effect until a specified date; prohibiting the
19	cancellation of certain contracts with provider service
20	networks without specified notice; providing additional
21	terms for cancellation; requiring contracts for Medicaid
22	services that are on a prepaid or fixed-sum basis to meet
23	certain medical loss ratios; providing for the agency to
24	recoup and redistribute payments under certain
25	circumstances; amending s. 409.91207, F.S.; providing
26	purposes and principles for creating medical homes;
27	providing definitions; providing for the organization of
28	medical home networks and provider service networks
29	certified as medical homes; requiring a provider service
30	network to provide certain notice to the agency prior to
31	ceasing participation as a medical home; requiring each
32	medical home to provide specified services; providing for
33	abolishment of a task force upon the creation of a
34	statewide advisory panel; providing for the establishment
35	of the statewide advisory panel; providing membership,
36	terms, and duties; directing the agency to provide staff
37	support to the panel; directing the panel to establish a
38	medical advisory group to assist in the establishment of
39	medical home networks and provider service networks
40	certified as medical homes; providing for travel expenses
41	and per diem for members of the panel and the medical
42	advisory group; providing for enrollment of MediPass
43	beneficiaries in medical homes; providing for financing of
44	medical home networks; providing duties of the agency;
45	providing for distribution of savings achieved by network
46	providers under certain circumstances; requiring the
47	agency to collaborate with the Office of Insurance
48	Regulation to encourage licensed insurers to incorporate
49	the principles of the medical home network into insurance
50	plans; requiring the Department of Management Services to
51	develop a medical home option in the state group insurance
52	program; requiring medical home network providers to
53	maintain certain records and data; amending s. 409.91211,
54	F.S.; requiring a provider that receives low-income pool
55	funds to serve Medicaid recipients regardless of county of
56	residence; revising the period for phasing in financial
57	risk for certain provider service networks; amending s.
58	409.9122, F.S.; revising the assignment of Medicaid
59	recipients eligible for managed care plan enrollment who
60	are subject to mandatory assignment but who fail to make a
61	choice; providing an effective date.
62
63	Be It Enacted by the Legislature of the State of Florida:
64
65	Section 1.  Paragraph (k) is added to subsection (3) of
66	section 409.907, Florida Statutes, and subsection (13) is added
67	to that section, to read:
68	409.907  Medicaid provider agreements.-The agency may make
69	payments for medical assistance and related services rendered to
70	Medicaid recipients only to an individual or entity who has a
71	provider agreement in effect with the agency, who is performing
72	services or supplying goods in accordance with federal, state,
73	and local law, and who agrees that no person shall, on the
74	grounds of handicap, race, color, or national origin, or for any
75	other reason, be subjected to discrimination under any program
76	or activity for which the provider receives payment from the
77	agency.
78	(3)  The provider agreement developed by the agency, in
79	addition to the requirements specified in subsections (1) and
80	(2), shall require the provider to:
81	(k)  Fully comply with the agency's Medicaid Encounter Data
82	System.
83	(13)  By January 1, 2011, and annually thereafter until
84	full compliance is reached, the agency shall submit to the
85	Governor, the President of the Senate, and the Speaker of the
86	House of Representatives a report that summarizes data regarding
87	the agency's Medicaid Encounter Data System, including the
88	number of participating providers, the level of compliance of
89	each provider, and an analysis of service utilization, service
90	trends, and specific problem areas.
91	Section 2.  Subsection (4) of section 409.908, Florida
92	Statutes, is amended to read:
93	409.908  Reimbursement of Medicaid providers.-Subject to
94	specific appropriations, the agency shall reimburse Medicaid
95	providers, in accordance with state and federal law, according
96	to methodologies set forth in the rules of the agency and in
97	policy manuals and handbooks incorporated by reference therein.
98	These methodologies may include fee schedules, reimbursement
99	methods based on cost reporting, negotiated fees, competitive
100	bidding pursuant to s. 287.057, and other mechanisms the agency
101	considers efficient and effective for purchasing services or
102	goods on behalf of recipients. If a provider is reimbursed based
103	on cost reporting and submits a cost report late and that cost
104	report would have been used to set a lower reimbursement rate
105	for a rate semester, then the provider's rate for that semester
106	shall be retroactively calculated using the new cost report, and
107	full payment at the recalculated rate shall be effected
108	retroactively. Medicare-granted extensions for filing cost
109	reports, if applicable, shall also apply to Medicaid cost
110	reports. Payment for Medicaid compensable services made on
111	behalf of Medicaid eligible persons is subject to the
112	availability of moneys and any limitations or directions
113	provided for in the General Appropriations Act or chapter 216.
114	Further, nothing in this section shall be construed to prevent
115	or limit the agency from adjusting fees, reimbursement rates,
116	lengths of stay, number of visits, or number of services, or
117	making any other adjustments necessary to comply with the
118	availability of moneys and any limitations or directions
119	provided for in the General Appropriations Act, provided the
120	adjustment is consistent with legislative intent.
121	(4)  Subject to any limitations or directions provided for
122	in the General Appropriations Act, alternative health plans,
123	health maintenance organizations, and prepaid health plans shall
124	be reimbursed a fixed, prepaid amount negotiated, or
125	competitively bid pursuant to s. 287.057, by the agency and
126	prospectively paid to the provider monthly for each Medicaid
127	recipient enrolled. The amount may not exceed the average amount
128	the agency determines it would have paid, based on claims
129	experience, for recipients in the same or similar category of
130	eligibility. The agency shall calculate capitation rates on a
131	regional basis and, beginning September 1, 1995, shall include
132	age-band differentials in such calculations.
133	(a)  Beginning October 1, 2010, the agency shall begin a
134	budget-neutral adjustment of capitation rates based on aggregate
135	risk scores for each provider's enrollees. During the first 2
136	years of the adjustment, the agency shall ensure that no
137	provider has an aggregate risk score that varies by more than 10
138	percent from the aggregate weighted average for all providers.
139	The risk-adjusted capitation rates shall be phased in as
140	follows:
141	1.  In the first contract year, 75 percent of the
142	capitation rate shall be based on the current methodology and 25
143	percent shall be based on the risk-adjusted capitation rate
144	methodology.
145	2.  In the second contract year, 50 percent of the
146	capitation rate shall be based on the current methodology and 50
147	percent shall be based on the risk-adjusted capitation rate
148	methodology.
149	3.  In the third contract year, the risk-adjusted
150	capitation rate methodology shall be fully implemented.
151	(b)  The Secretary of Health Care Administration shall
152	convene a technical advisory panel to advise the agency in the
153	area of risk-adjusted rate setting during the transition to
154	risk-adjusted capitation rates described in paragraph (a). The
155	panel shall include representatives of prepaid plans in counties
156	that are not included as demonstration sites under s.
157	409.91211(1). The panel shall advise the agency regarding:
158	1.  The selection of a base year of encounter data to be
159	used to set risk-adjusted capitation rates.
160	2.  The completeness and accuracy of the encounter data
161	set.
162	3.  The effect of risk-adjusted capitation rates on prepaid
163	plans based on a review of a simulated rate-setting process.
164	Section 3.  Paragraphs (b) and (d) of subsection (4) of
165	section 409.912, Florida Statutes, are amended, and subsection
166	(54) is added to that section, to read:
167	409.912  Cost-effective purchasing of health care.-The
168	agency shall purchase goods and services for Medicaid recipients
169	in the most cost-effective manner consistent with the delivery
170	of quality medical care. To ensure that medical services are
171	effectively utilized, the agency may, in any case, require a
172	confirmation or second physician's opinion of the correct
173	diagnosis for purposes of authorizing future services under the
174	Medicaid program. This section does not restrict access to
175	emergency services or poststabilization care services as defined
176	in 42 C.F.R. part 438.114. Such confirmation or second opinion
177	shall be rendered in a manner approved by the agency. The agency
178	shall maximize the use of prepaid per capita and prepaid
179	aggregate fixed-sum basis services when appropriate and other
180	alternative service delivery and reimbursement methodologies,
181	including competitive bidding pursuant to s. 287.057, designed
182	to facilitate the cost-effective purchase of a case-managed
183	continuum of care. The agency shall also require providers to
184	minimize the exposure of recipients to the need for acute
185	inpatient, custodial, and other institutional care and the
186	inappropriate or unnecessary use of high-cost services. The
187	agency shall contract with a vendor to monitor and evaluate the
188	clinical practice patterns of providers in order to identify
189	trends that are outside the normal practice patterns of a
190	provider's professional peers or the national guidelines of a
191	provider's professional association. The vendor must be able to
192	provide information and counseling to a provider whose practice
193	patterns are outside the norms, in consultation with the agency,
194	to improve patient care and reduce inappropriate utilization.
195	The agency may mandate prior authorization, drug therapy
196	management, or disease management participation for certain
197	populations of Medicaid beneficiaries, certain drug classes, or
198	particular drugs to prevent fraud, abuse, overuse, and possible
199	dangerous drug interactions. The Pharmaceutical and Therapeutics
200	Committee shall make recommendations to the agency on drugs for
201	which prior authorization is required. The agency shall inform
202	the Pharmaceutical and Therapeutics Committee of its decisions
203	regarding drugs subject to prior authorization. The agency is
204	authorized to limit the entities it contracts with or enrolls as
205	Medicaid providers by developing a provider network through
206	provider credentialing. The agency may competitively bid single-
207	source-provider contracts if procurement of goods or services
208	results in demonstrated cost savings to the state without
209	limiting access to care. The agency may limit its network based
210	on the assessment of beneficiary access to care, provider
211	availability, provider quality standards, time and distance
212	standards for access to care, the cultural competence of the
213	provider network, demographic characteristics of Medicaid
214	beneficiaries, practice and provider-to-beneficiary standards,
215	appointment wait times, beneficiary use of services, provider
216	turnover, provider profiling, provider licensure history,
217	previous program integrity investigations and findings, peer
218	review, provider Medicaid policy and billing compliance records,
219	clinical and medical record audits, and other factors. Providers
220	shall not be entitled to enrollment in the Medicaid provider
221	network. The agency shall determine instances in which allowing
222	Medicaid beneficiaries to purchase durable medical equipment and
223	other goods is less expensive to the Medicaid program than long-
224	term rental of the equipment or goods. The agency may establish
225	rules to facilitate purchases in lieu of long-term rentals in
226	order to protect against fraud and abuse in the Medicaid program
227	as defined in s. 409.913. The agency may seek federal waivers
228	necessary to administer these policies.
229	(4)  The agency may contract with:
230	(b)  An entity that is providing comprehensive behavioral
231	health care services to certain Medicaid recipients through a
232	capitated, prepaid arrangement pursuant to the federal waiver
233	provided for by s. 409.905(5). Such entity must be licensed
234	under chapter 624, chapter 636, or chapter 641, or authorized
235	under paragraph (c), and must possess the clinical systems and
236	operational competence to manage risk and provide comprehensive
237	behavioral health care to Medicaid recipients. As used in this
238	paragraph, the term "comprehensive behavioral health care
239	services" means covered mental health and substance abuse
240	treatment services that are available to Medicaid recipients.
241	The secretary of the Department of Children and Family Services
242	shall approve provisions of procurements related to children in
243	the department's care or custody before enrolling such children
244	in a prepaid behavioral health plan. Any contract awarded under
245	this paragraph must be competitively procured. In developing the
246	behavioral health care prepaid plan procurement document, the
247	agency shall ensure that the procurement document requires the
248	contractor to develop and implement a plan to ensure compliance
249	with s. 394.4574 related to services provided to residents of
250	licensed assisted living facilities that hold a limited mental
251	health license. Except as provided in subparagraph 8., and
252	except in counties where the Medicaid managed care pilot program
253	is authorized pursuant to s. 409.91211, the agency shall seek
254	federal approval to contract with a single entity meeting these
255	requirements to provide comprehensive behavioral health care
256	services to all Medicaid recipients not enrolled in a Medicaid
257	managed care plan authorized under s. 409.91211, a Medicaid
258	provider service network authorized under paragraph (d), or a
259	Medicaid health maintenance organization in an AHCA area. In an
260	AHCA area where the Medicaid managed care pilot program is
261	authorized pursuant to s. 409.91211 in one or more counties, the
262	agency may procure a contract with a single entity to serve the
263	remaining counties as an AHCA area or the remaining counties may
264	be included with an adjacent AHCA area and are subject to this
265	paragraph. Each entity must offer a sufficient choice of
266	providers in its network to ensure recipient access to care and
267	the opportunity to select a provider with whom they are
268	satisfied. The network shall include all public mental health
269	hospitals. To ensure unimpaired access to behavioral health care
270	services by Medicaid recipients, all contracts issued pursuant
271	to this paragraph must require 80 percent of the capitation paid
272	to the managed care plan, including health maintenance
273	organizations or provider service networks, to be expended for
274	the provision of behavioral health care services. If the managed
275	care plan expends less than 80 percent of the capitation paid
276	for the provision of behavioral health care services, the
277	difference shall be returned to the agency. The agency shall
278	provide the plan with a certification letter indicating the
279	amount of capitation paid during each calendar year for
280	behavioral health care services pursuant to this section. The
281	agency may reimburse for substance abuse treatment services on a
282	fee-for-service basis until the agency finds that adequate funds
283	are available for capitated, prepaid arrangements.
284	1.  By January 1, 2001, the agency shall modify the
285	contracts with the entities providing comprehensive inpatient
286	and outpatient mental health care services to Medicaid
287	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
288	Counties, to include substance abuse treatment services.
289	2.  By July 1, 2003, the agency and the Department of
290	Children and Family Services shall execute a written agreement
291	that requires collaboration and joint development of all policy,
292	budgets, procurement documents, contracts, and monitoring plans
293	that have an impact on the state and Medicaid community mental
294	health and targeted case management programs.
295	3.  Except as provided in subparagraph 8., by July 1, 2006,
296	the agency and the Department of Children and Family Services
297	shall contract with managed care entities in each AHCA area
298	except area 6 or arrange to provide comprehensive inpatient and
299	outpatient mental health and substance abuse services through
300	capitated prepaid arrangements to all Medicaid recipients who
301	are eligible to participate in such plans under federal law and
302	regulation. In AHCA areas where eligible individuals number less
303	than 150,000, the agency shall contract with a single managed
304	care plan to provide comprehensive behavioral health services to
305	all recipients who are not enrolled in a Medicaid health
306	maintenance organization or a Medicaid capitated managed care
307	plan authorized under s. 409.91211. The agency may contract with
308	more than one comprehensive behavioral health provider to
309	provide care to recipients who are not enrolled in a Medicaid
310	capitated managed care plan authorized under s. 409.91211 or a
311	Medicaid health maintenance organization in AHCA areas where the
312	eligible population exceeds 150,000. In an AHCA area where the
313	Medicaid managed care pilot program is authorized pursuant to s.
314	409.91211 in one or more counties, the agency may procure a
315	contract with a single entity to serve the remaining counties as
316	an AHCA area or the remaining counties may be included with an
317	adjacent AHCA area and shall be subject to this paragraph.
318	Contracts for comprehensive behavioral health providers awarded
319	pursuant to this section shall be competitively procured. Both
320	for-profit and not-for-profit corporations are eligible to
321	compete. Managed care plans contracting with the agency under
322	subsection (3) shall provide and receive payment for the same
323	comprehensive behavioral health benefits as provided in AHCA
324	rules, including handbooks incorporated by reference. In AHCA
325	area 11, the agency shall contract with at least two
326	comprehensive behavioral health care providers to provide
327	behavioral health care to recipients in that area who are
328	enrolled in, or assigned to, the MediPass program. One of the
329	behavioral health care contracts must be with the existing
330	provider service network pilot project, as described in
331	paragraph (d), for the purpose of demonstrating the cost-
332	effectiveness of the provision of quality mental health services
333	through a public hospital-operated managed care model. Payment
334	shall be at an agreed-upon capitated rate to ensure cost
335	savings. Of the recipients in area 11 who are assigned to
336	MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
337	MediPass-enrolled recipients shall be assigned to the existing
338	provider service network in area 11 for their behavioral care.
339	4.  By October 1, 2003, the agency and the department shall
340	submit a plan to the Governor, the President of the Senate, and
341	the Speaker of the House of Representatives which provides for
342	the full implementation of capitated prepaid behavioral health
343	care in all areas of the state.
344	a.  Implementation shall begin in 2003 in those AHCA areas
345	of the state where the agency is able to establish sufficient
346	capitation rates.
347	b.  If the agency determines that the proposed capitation
348	rate in any area is insufficient to provide appropriate
349	services, the agency may adjust the capitation rate to ensure
350	that care will be available. The agency and the department may
351	use existing general revenue to address any additional required
352	match but may not over-obligate existing funds on an annualized
353	basis.
354	c.  Subject to any limitations provided in the General
355	Appropriations Act, the agency, in compliance with appropriate
356	federal authorization, shall develop policies and procedures
357	that allow for certification of local and state funds.
358	5.  Children residing in a statewide inpatient psychiatric
359	program, or in a Department of Juvenile Justice or a Department
360	of Children and Family Services residential program approved as
361	a Medicaid behavioral health overlay services provider may not
362	be included in a behavioral health care prepaid health plan or
363	any other Medicaid managed care plan pursuant to this paragraph.
364	6.  In converting to a prepaid system of delivery, the
365	agency shall in its procurement document require an entity
366	providing only comprehensive behavioral health care services to
367	prevent the displacement of indigent care patients by enrollees
368	in the Medicaid prepaid health plan providing behavioral health
369	care services from facilities receiving state funding to provide
370	indigent behavioral health care, to facilities licensed under
371	chapter 395 which do not receive state funding for indigent
372	behavioral health care, or reimburse the unsubsidized facility
373	for the cost of behavioral health care provided to the displaced
374	indigent care patient.
375	7.  Traditional community mental health providers under
376	contract with the Department of Children and Family Services
377	pursuant to part IV of chapter 394, child welfare providers
378	under contract with the Department of Children and Family
379	Services in areas 1 and 6, and inpatient mental health providers
380	licensed pursuant to chapter 395 must be offered an opportunity
381	to accept or decline a contract to participate in any provider
382	network for prepaid behavioral health services.
383	8.  All Medicaid-eligible children, except children in area
384	1 and children in Highlands County, Hardee County, Polk County,
385	or Manatee County of area 6, that are open for child welfare
386	services in the HomeSafeNet system, shall receive their
387	behavioral health care services through a specialty prepaid plan
388	operated by community-based lead agencies through a single
389	agency or formal agreements among several agencies. The
390	specialty prepaid plan must result in savings to the state
391	comparable to savings achieved in other Medicaid managed care
392	and prepaid programs. Such plan must provide mechanisms to
393	maximize state and local revenues. The specialty prepaid plan
394	shall be developed by the agency and the Department of Children
395	and Family Services. The agency may seek federal waivers to
396	implement this initiative. Medicaid-eligible children whose
397	cases are open for child welfare services in the HomeSafeNet
398	system and who reside in AHCA area 10 are exempt from the
399	specialty prepaid plan upon the development of a service
400	delivery mechanism for children who reside in area 10 as
401	specified in s. 409.91211(3)(dd).
402	(d)  A provider service network may be reimbursed on a fee-
403	for-service or prepaid basis. A provider service network that
404	which is reimbursed by the agency on a prepaid basis shall be
405	exempt from parts I and III of chapter 641, but must comply with
406	the solvency requirements in s. 641.2261(2) and meet appropriate
407	financial reserve, quality assurance, and patient rights
408	requirements as established by the agency. Medicaid recipients
409	assigned to a provider service network shall be chosen equally
410	from those who would otherwise have been assigned to prepaid
411	plans and MediPass. The agency may is authorized to seek federal
412	Medicaid waivers as necessary to implement the provisions of
413	this section. Any contract previously awarded to a provider
414	service network operated by a hospital pursuant to this
415	subsection shall remain in effect through June 30, 2015 for a
416	period of 3 years following the current contract expiration
417	date, regardless of any contractual provisions to the contrary.
418	A contract awarded or renewed on or after July 1, 2010, to a
419	provider service network shall prohibit the cancellation of the
420	contract unless the network provides the agency with at least 90
421	days' notice. All members of the network must continue to
422	provide services to Medicaid recipients assigned to that network
423	during that 90-day period. A provider service network is a
424	network established or organized and operated by a health care
425	provider, or group of affiliated health care providers,
426	including minority physician networks and emergency room
427	diversion programs that meet the requirements of s. 409.91211,
428	which provides a substantial proportion of the health care items
429	and services under a contract directly through the provider or
430	affiliated group of providers and may make arrangements with
431	physicians or other health care professionals, health care
432	institutions, or any combination of such individuals or
433	institutions to assume all or part of the financial risk on a
434	prospective basis for the provision of basic health services by
435	the physicians, by other health professionals, or through the
436	institutions. The health care providers must have a controlling
437	interest in the governing body of the provider service network
438	organization.
439	(54)  An entity that contracts with the agency on a prepaid
440	or fixed-sum basis for the provision of Medicaid services shall
441	spend 85 percent of the Medicaid capitation revenue for health
442	services to enrollees. The agency shall monitor medical loss
443	ratios for all prepaid plans on a county-by-county basis. When a
444	plan's 3-year average medical loss ratio in a county is less
445	than 85 percent, the agency may recoup an amount equivalent to
446	the difference between 85 percent of the capitation paid to the
447	plan and the amount the plan paid for provision of services over
448	the 3-year period. These recouped funds shall be dispersed in
449	proportionate amounts to plans that have spent in excess of 85
450	percent of their capitation on the provision of medical
451	services.
452	Section 4.  Section 409.91207, Florida Statutes, is amended
453	to read:
454	(Substantial rewording of section. See
455	s. 409.91207, F.S., for present text.)
456	409.91207  Medical homes.-
457	(1)  PURPOSE AND PRINCIPLES.-The agency shall develop a
458	method for recognizing the certification of a primary care
459	provider or a provider service network as a medical home. The
460	purpose of this certification is to foster and support improved
461	care management through enhanced primary care case management
462	and dissemination of best practices for coordinated and cost-
463	effective care. The medical home modifies the processes and
464	patterns of health care service delivery by applying the
465	following principles:
466	(a)  A personal medical provider leads an interdisciplinary
467	team of professionals who share the responsibility of providing
468	ongoing care to a specific panel of patients.
469	(b)  The personal medical provider identifies a patient's
470	health care needs and responds to those needs through direct
471	care or arrangements with other qualified providers.
472	(c)  Care is coordinated or integrated across all areas of
473	health service delivery.
474	(d)  Information technology is integrated into delivery
475	systems to enhance clinical performance and monitor patient
476	outcomes.
477	(2)  DEFINITIONS.-As used in this section, the term:
478	(a)  "Case manager" means a person or persons employed by a
479	medical home network or provider service network, or a member of
480	such network, to work with primary care providers in the
481	delivery of outreach, support services, and care coordination
482	for medical home patients.
483	(b)  "Medical home network" means a group of primary care
484	providers and other health professionals and facilities who
485	agree to cooperate with one another in order to coordinate care
486	for Medicaid beneficiaries assigned to primary care providers in
487	the network.
488	(c)  "Primary care provider" means a health professional
489	practicing in the field of family medicine, general internal
490	medicine, geriatric medicine, or pediatric medicine who is
491	licensed as a physician under chapter 458 or chapter 459, a
492	physician's assistant performing services delegated by a
493	supervising physician pursuant to s. 458.347 or s. 459.022, or a
494	registered nurse certified as an advanced registered  nurse
495	practitioner performing services pursuant to a protocol
496	established with a supervising physician in accordance with s.
497	464.012. The term "primary care provider" also means a federally
498	qualified health center.
499	(d)  "Principal network provider" means a member of a
500	medical home network or a provider service network who serves as
501	the principal liaison between the agency and that network and
502	who accepts responsibility for communicating the agency's
503	directives concerning the project to all other network members.
504	(e)  "Provider service network" has the same meaning as
505	provided in s. 409.912(4)(d).
506	(f)  "Tier One medical home" means:
507	1.  A primary care provider that certifies to the agency
508	that the provider meets the service capabilities established in
509	paragraph (4)(a); or
510	2.  A provider service network that certifies to the agency
511	that all of its members who are primary care providers meet the
512	service capabilities established in paragraph (4)(a).
513	(g)  "Tier Two medical home" means:
514	1.  A primary care provider that certifies to the agency
515	that the provider meets the service capabilities established in
516	paragraph (4)(b); or
517	2.  A provider service network that certifies to the agency
518	that at least 85 percent of its members who are primary care
519	providers meet the service capabilities established in paragraph
520	(4)(b) and the remainder of the primary care providers meet the
521	service capabilities established in paragraph (4)(a).
522	(h)  "Tier Three medical home" means:
523	1.  A primary care provider that certifies to the agency
524	that the provider meets the service capabilities established in
525	paragraph (4)(c); or
526	2.  A provider service network that certifies to the agency
527	that at least 85 percent of its members who are primary care
528	providers meet the service capabilities established in paragraph
529	(4)(c) and the remainder of the primary care providers meet the
530	service capabilities established in paragraph (4)(b).
531	(3)  ORGANIZATION.-
532	(a)  Each participating primary care provider shall be a
533	member of a medical home network or a provider service network
534	and shall be classified by the agency as a Tier One, Tier Two,
535	or Tier Three medical home upon certification by the provider of
536	compliance with the service capabilities for that tier. A
537	primary care provider or a provider service network may change
538	classification by certifying service capabilities consistent
539	with the standards for another tier. Certifications shall be
540	made annually.
541	(b)  Each participating provider service network shall be
542	classified by the agency as a Tier One, Tier Two, or Tier Three
543	medical home upon certification by the network that the
544	network's primary care providers meet the service capabilities
545	for that tier. The provider service network may also certify to
546	the agency that it intends to serve a specific target population
547	based on disease, condition, or age.
548	(c)  The members of each medical home network or provider
549	service network shall designate a principal network provider who
550	shall be responsible for maintaining an accurate list of
551	participating providers, forwarding this list to the agency,
552	updating the list as requested by the agency, and facilitating
553	communication between the agency and the participating
554	providers.
555	(d)  A provider service network may only cease
556	participation as a medical home after providing at least 90
557	days' notice to the agency. All members of the provider service
558	network must continue to serve the enrollees during this 90-day
559	period. A provider service network that is reimbursed by the
560	agency on a prepaid basis may not receive any additional
561	reimbursements for this 90-day period.
562	(4)  SERVICE CAPABILITIES.-A medical home network or a
563	provider service network certified as a medical home shall
564	provide primary care; coordinate services to control chronic
565	illnesses; provide disease management and patient education;
566	provide or arrange for pharmacy, outpatient diagnostic, and
567	specialty physician services; and provide for or coordinate with
568	inpatient facilities and behavioral health, mental health, and
569	rehabilitative service providers. The network shall place a
570	priority on methods to manage pharmacy and behavioral health
571	services.
572	(a)  Tier One medical homes shall have the capability to:
573	1.  Maintain a written copy of the mutual agreement between
574	the medical home and the patient in the patient's medical
575	record.
576	2.  Supply all medically necessary primary and preventive
577	services and provide all scheduled immunizations.
578	3.  Organize clinical data in paper or electronic form
579	using a patient-centered charting system.
580	4.  Maintain and update patients' medication lists and
581	review all medications during each office visit.
582	5.  Maintain a system to track diagnostic tests and provide
583	followup services regarding test results.
584	6.  Maintain a system to track referrals, including self-
585	referrals by members.
586	7.  Supply care coordination and continuity of care through
587	proactive contact with members and encourage family
588	participation in care.
589	8.  Supply education and support using various materials
590	and processes appropriate for individual patient needs.
591	(b)  Tier Two medical homes shall have all of the
592	capabilities of a Tier One medical home and shall have the
593	additional capability to:
594	1.  Communicate electronically.
595	2.  Supply voice-to-voice telephone coverage to panel
596	members 24 hours per day, 7 days per week, to enable patients to
597	speak to a licensed health care professional who triages and
598	forwards calls, as appropriate.
599	3.  Maintain an office schedule of at least 30 scheduled
600	hours per week.
601	4.  Use scheduling processes to promote continuity with
602	clinicians, including providing care for walk-in, routine, and
603	urgent care visits.
604	5.  Implement and document behavioral health and substance
605	abuse screening procedures and make referrals as needed.
606	6.  Use data to identify and track patients' health and
607	service use patterns.
608	7.  Coordinate care and followup for patients receiving
609	services in inpatient and outpatient facilities.
610	8.  Implement processes to promote access to care and
611	member communication.
612	(c)  Tier Three medical homes shall have all of the
613	capabilities of Tier One and Tier Two medical homes and shall
614	have the additional capability to:
615	1.  Maintain electronic medical records.
616	2.  Develop a health care team that provides ongoing
617	support, oversight, and guidance for all medical care received
618	by the patient and documents contact with specialists and other
619	health care providers caring for the patient.
620	3.  Supply postvisit followup care for patients.
621	4.  Implement specific evidence-based clinical practice
622	guidelines for preventive and chronic care.
623	5.  Implement a medication reconciliation procedure to
624	avoid interactions or duplications.
625	6.  Use personalized screening, brief intervention, and
626	referral to treatment procedures for appropriate patients
627	requiring specialty treatment.
628	7.  Offer at least 4 hours per week of after-hours care to
629	patients.
630	8.  Use health assessment tools to identify patient needs
631	and risks.
632	(5)  TASK FORCE; ADVISORY PANEL.-
633	(a)  The Secretary of Health Care Administration shall
634	appoint a task force by August 1, 2009, to assist the agency in
635	the development and implementation of the medical home pilot
636	project. The task force must include, but is not limited to,
637	representatives of providers who could potentially participate
638	in a medical home network, Medicaid recipients, and existing
639	MediPass and managed care providers. Members of the task force
640	shall serve without compensation but are may be reimbursed for
641	per diem and travel expenses as provided in s. 112.061. When the
642	statewide advisory panel created pursuant to paragraph (b) has
643	been appointed, the task force shall dissolve.
644	(b)  A statewide advisory panel shall be established to
645	advise and assist the agency in developing a methodology for an
646	annual evaluation of each medical home network and provider
647	service network certified as a medical home. The panel shall
648	promote communication among medical home networks and provider
649	service networks certified as medical homes. The panel shall
650	consist of seven members, as follows:
651	1.  Two members appointed by the Speaker of the House of
652	Representatives, one of whom shall be a primary care physician
653	licensed under chapter 458 or chapter 459 and one of whom shall
654	be a representative of a hospital licensed under chapter 395.
655	2.  Two members appointed by the President of the Senate,
656	one of whom shall be a physician licensed under chapter 458 or
657	chapter 459 who is a board-certified specialist and one of whom
658	shall be a representative of a Florida medical school.
659	3.  Two members appointed by the Governor, one of whom
660	shall be a representative of an insurer licensed to do business
661	in this state or a health maintenance organization licensed
662	under part I of chapter 641 and one of whom shall be a
663	representative of Medicaid consumers.
664	4.  The Secretary of Health Care Administration or his or
665	her designee.
666	(c)  Appointed members of the panel shall serve 4-year
667	terms, except that the initial terms shall be staggered as
668	follows:
669	1.  The Governor shall appoint one member for a term of 2
670	years and one member for a term of 4 years.
671	2.  The President of the Senate shall appoint one member
672	for a term of 2 years and one member for a term of 4 years.
673	3.  The Speaker of the House of Representatives shall
674	appoint one member for a term of 2 years and one member for a
675	term of 4 years.
676	(d)  A vacancy in an appointed member's position shall be
677	filled by appointment by the original appointing authority for
678	the unexpired portion of the term.
679	(e)  Members of the statewide advisory panel shall serve
680	without compensation but may be reimbursed for per diem and
681	travel expenses as provided in s. 112.061.
682	(f)  The agency shall provide staff support to assist the
683	panel in the performance of its duties.
684	(g)  The statewide advisory panel shall establish a medical
685	advisory group consisting of physicians licensed under chapter
686	458 or chapter 459 who shall act as ambassadors to their
687	communities for the promotion of and assistance in the
688	establishment of medical home networks and provider service
689	networks certified as medical homes. Members of the medical
690	advisory group shall serve without compensation but may be
691	reimbursed for per diem and travel expenses as provided in s.
692	112.061.
693	(6)  ENROLLMENT.-Each MediPass beneficiary served by a
694	certified Tier One, Tier Two, or Tier Three medical home shall
695	be given a choice to enroll in a medical home network or
696	provider service network certified as a medical home. Enrollment
697	shall be effective upon the agency's receipt of a participation
698	agreement signed by the beneficiary.
699	(7)  FINANCING.-
700	(a)  Subject to a specific appropriation provided for in
701	the General Appropriations Act, medical home network members
702	shall be eligible to receive a monthly enhanced case management
703	fee, as follows:
704	1.  Tier One medical homes shall receive $3.58 per child in
705	a panel of enrollees and $5.02 per adult in a panel of
706	enrollees.
707	2.  Tier Two medical homes shall receive $4.65 per child in
708	a panel of enrollees and $6.52 per adult in a panel of
709	enrollees.
710	3.  Tier Three medical homes shall receive $6.12 per child
711	in a panel of enrollees and $8.69 per adult in a panel of
712	enrollees.
713	(b)  Services provided by a medical home network or a
714	provider service network with a fee-for-service contract with
715	the agency shall be reimbursed based on claims filed for
716	Medicaid fee-for-service payments. Services by a provider
717	service network with a contract with the agency for prepaid
718	services shall be paid pursuant to the contract and shall be
719	eligible to receive the credit provided in this subsection.
720	(c)  Any hospital, as defined in s. 395.002(12),
721	participating in a medical home network or service provider
722	network certified as a medical home that employs case managers
723	for the network shall be eligible to receive a credit against
724	the assessment imposed under s. 395.701. The credit is
725	compensation for participating in the network by providing case
726	management and other network services.
727	1.  The credit shall be prorated based on the number of
728	full-time equivalent case managers hired but shall not be more
729	than $75,000 for each full-time equivalent case manager. The
730	total credit may not exceed $450,000 for any hospital for any
731	state fiscal year.
732	2.  To qualify for the credit, the hospital must employ
733	each full-time equivalent case manager for the entire hospital
734	fiscal year for which the credit is claimed.
735	3.  The hospital must certify the number of full-time
736	equivalent case managers for whom it is entitled to a credit
737	using the certification process required under s. 395.701(2)(a).
738	4.  The agency shall calculate the amount of the credit and
739	reduce the certified assessment for the hospital by the amount
740	of the credit.
741	(d)  The enhanced payments to primary care providers shall
742	not affect the calculation of capitated rates under this
743	chapter.
744	(8)  AGENCY DUTIES.-The agency shall:
745	(a)  Maintain a record of certified primary care providers
746	and provider service networks by classification as Tier One,
747	Tier Two, or Tier Three medical homes.
748	(b)  Develop a standard form to be used by primary care
749	providers and provider service networks to certify to the agency
750	that they meet the necessary principles and service capabilities
751	for the tier in which they seek to be classified. The form shall
752	have a check box for each of the three tiers, a line to indicate
753	whether a primary care network intends to specialize in a target
754	population, a line to specify the target population, if any, and
755	a line for the signature of the provider or principal of an
756	entity. Checking the appropriate tier box and signing the form
757	shall be deemed certification for the purposes of this section.
758	(c)  Develop a process for managed care organizations to
759	certify themselves as Tier One, Tier Two, or Tier Three medical
760	homes based on established policies and procedures consistent
761	with the principles and corresponding service capabilities
762	provided under subsections (1) and (4).
763	(d)  Establish a participation agreement to be executed by
764	Medipass recipients who choose to participate in the medical
765	home pilot project.
766	(e)  Track the spending for and utilization of services by
767	all enrolled medical home network patients.
768	(f)  Evaluate each provider service network at least
769	annually to ensure that the network is cost-effective as defined
770	in s. 409.912(44).
771	(9)  ACHIEVED SAVINGS.-Each medical home network or
772	provider service network certified as a medical home that
773	participates on a fee-for-service basis and achieves savings
774	equal to or greater than the spending that would have occurred
775	if its enrollees participated in prepaid health plans is
776	eligible to receive funding based on the identified savings
777	pursuant to a specific appropriation provided for in the General
778	Appropriations Act. The funds must be distributed on a pro rata
779	basis to the physicians who are members of the medical home
780	network so that the compensation for their services is as close
781	as possible to 100 percent of Medicare rates. Subject to a
782	specific appropriation, it is the intent of the Legislature that
783	the savings that result from the implementation of the medical
784	home network model be used to enable Medicaid fees to physicians
785	participating in medical home networks to be equivalent to 100
786	percent of Medicare rates as soon as possible.
787	(10)  COLLABORATION WITH PRIVATE INSURERS.-To enable the
788	state to participate in federal gainsharing initiatives, the
789	agency shall collaborate with the Office of Insurance Regulation
790	to encourage insurers licensed in this state to incorporate
791	medical home network principles into the design of their
792	individual and employment-based plans. The Department of
793	Management Services is directed to develop a medical home option
794	in the state group insurance program.
795	(11)  QUALITY ASSURANCE AND ACCOUNTABILITY.-Each primary
796	care and principal network provider participating in a medical
797	home network or provider service network certified as a medical
798	home shall maintain medical records and clinical data necessary
799	for the network to assess the use, cost, and outcome of services
800	provided to enrollees.
801	Section 5.  Paragraph (b) of subsection (1) and paragraph
802	(e) of subsection (3) of section 409.91211, Florida Statutes,
803	are amended to read:
804	409.91211  Medicaid managed care pilot program.-
805	(1)
806	(b)  This waiver authority is contingent upon federal
807	approval to preserve the upper-payment-limit funding mechanism
808	for hospitals, including a guarantee of a reasonable growth
809	factor, a methodology to allow the use of a portion of these
810	funds to serve as a risk pool for demonstration sites,
811	provisions to preserve the state's ability to use
812	intergovernmental transfers, and provisions to protect the
813	disproportionate share program authorized pursuant to this
814	chapter. Upon completion of the evaluation conducted under s. 3,
815	ch. 2005-133, Laws of Florida, the agency may request statewide
816	expansion of the demonstration projects. Statewide phase-in to
817	additional counties shall be contingent upon review and approval
818	by the Legislature. Under the upper-payment-limit program, or
819	the low-income pool as implemented by the Agency for Health Care
820	Administration pursuant to federal waiver, the state matching
821	funds required for the program shall be provided by local
822	governmental entities through intergovernmental transfers in
823	accordance with published federal statutes and regulations. The
824	Agency for Health Care Administration shall distribute upper-
825	payment-limit, disproportionate share hospital, and low-income
826	pool funds according to published federal statutes, regulations,
827	and waivers and the low-income pool methodology approved by the
828	federal Centers for Medicare and Medicaid Services. A provider
829	who receives low-income pool funds shall serve Medicaid
830	recipients regardless of the recipient's county of residence in
831	the state and may not restrict access to care based on residency
832	in a county in the state other than the one in which the
833	provider is located.
834	(3)  The agency shall have the following powers, duties,
835	and responsibilities with respect to the pilot program:
836	(e)  To implement policies and guidelines for phasing in
837	financial risk for approved provider service networks that, for
838	purposes of this paragraph, include the Children's Medical
839	Services Network, over the longer of a 5-year period or through
840	October 1, 2015. These policies and guidelines must include an
841	option for a provider service network to be paid fee-for-service
842	rates. For any provider service network established in a managed
843	care pilot area, the option to be paid fee-for-service rates
844	must include a savings-settlement mechanism that is consistent
845	with s. 409.912(44). As of October 1, 2015, or after 5 years of
846	operation, whichever is the longer period, this model must be
847	converted to a risk-adjusted capitated rate by the beginning of
848	the sixth year of operation, and may be converted earlier at the
849	option of the provider service network. Federally qualified
850	health centers may be offered an opportunity to accept or
851	decline a contract to participate in any provider network for
852	prepaid primary care services.
853	Section 6.  Paragraph (f) of subsection (2) of section
854	409.9122, Florida Statutes, is amended to read:
855	409.9122  Mandatory Medicaid managed care enrollment;
856	programs and procedures.-
857	(2)
858	(f)  If a Medicaid recipient does not choose a managed care
859	plan or MediPass provider, the agency shall assign the Medicaid
860	recipient to a managed care plan or MediPass provider. Medicaid
861	recipients eligible for managed care plan enrollment who are
862	subject to mandatory assignment but who fail to make a choice
863	shall be assigned to managed care plans until an enrollment of
864	65 percent in provider service networks certified as medical
865	homes under s. 409.91207 and 35 percent in other managed care
866	plans 35 percent in MediPass and 65 percent in managed care
867	plans, of all those eligible to choose managed care, is
868	achieved. Once this enrollment is achieved, the assignments
869	shall be divided in the same manner order to maintain the same
870	an enrollment ratio in MediPass and managed care plans which is
871	in a 35 percent and 65 percent proportion, respectively.
872	Thereafter, assignment of Medicaid recipients who fail to make a
873	choice shall be based proportionally on the preferences of
874	recipients who have made a choice in the previous period. Such
875	proportions shall be revised at least quarterly to reflect an
876	update of the preferences of Medicaid recipients. The agency
877	shall disproportionately assign Medicaid-eligible recipients who
878	are required to but have failed to make a choice of managed care
879	plan or MediPass, including children, and who would be assigned
880	to the MediPass program to children's networks as described in
881	s. 409.912(4)(g), Children's Medical Services Network as defined
882	in s. 391.021, exclusive provider organizations, provider
883	service networks, minority physician networks, and pediatric
884	emergency department diversion programs authorized by this
885	chapter or the General Appropriations Act, in such manner as the
886	agency deems appropriate, until the agency has determined that
887	the networks and programs have sufficient numbers to be operated
888	economically. For purposes of this paragraph, when referring to
889	assignment, the term "managed care plans" includes health
890	maintenance organizations, exclusive provider organizations,
891	provider service networks, minority physician networks,
892	Children's Medical Services Network, and pediatric emergency
893	department diversion programs authorized by this chapter or the
894	General Appropriations Act. When making assignments, the agency
895	shall take into account the following criteria:
896	1.  A managed care plan has sufficient network capacity to
897	meet the need of members.
898	2.  The managed care plan or MediPass has previously
899	enrolled the recipient as a member, or one of the managed care
900	plan's primary care providers or MediPass providers has
901	previously provided health care to the recipient.
902	3.  The agency has knowledge that the member has previously
903	expressed a preference for a particular managed care plan or
904	MediPass provider as indicated by Medicaid fee-for-service
905	claims data, but has failed to make a choice.
906	4.  The managed care plan's or MediPass primary care
907	providers are geographically accessible to the recipient's
908	residence.
909	Section 7.  This act shall take effect July 1, 2010.

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