HB 7223

1
A bill to be entitled
2An act relating to Medicaid managed care; creating pt. IV
3of ch. 409, F.S.; creating s. 409.961, F.S.; providing for
4statutory construction; providing applicability of
5specified provisions throughout the part; providing
6rulemaking authority for specified agencies; creating s.
7409.962, F.S.; providing definitions; creating s. 409.963,
8F.S.; designating the Agency for Health Care
9Administration as the single state agency to administer
10the Medicaid program; providing for specified agency
11responsibilities; requiring client consent for release of
12medical records; creating s. 409.964, F.S.; establishing
13the Medicaid program as the statewide, integrated managed
14care program for all covered services; authorizing the
15agency to apply for and implement waivers; providing for
16public notice and comment; creating s. 409.965, F.S.;
17providing for mandatory enrollment; providing for
18exemptions; creating s. 409.966, F.S.; providing
19requirements for qualified plans that provide services in
20the Medicaid managed care program; providing for a medical
21home network to be designated as a qualified plan;
22establishing provider service network requirements for
23qualified plans; providing for qualified plan selection;
24requiring the agency to use an invitation to negotiate;
25requiring the agency to compile and publish certain
26information; establishing regions for separate procurement
27of plans; providing quality selection criteria for plan
28selection; establishing quality selection criteria;
29providing limitations on serving recipients during the
30pendency of litigation; providing that a qualified plan
31that participates in an invitation to negotiate in more
32than one region may not serve Medicaid recipients until
33all administrative challenges are finalized; creating s.
34409.967, F.S.; providing for managed care plan
35accountability; establishing contract terms; providing for
36contract extension under certain circumstances;
37establishing payments to noncontract providers;
38establishing requirements for access; requiring plans to
39establish and maintain an electronic database;
40establishing requirements for the database; requiring
41plans to provide encounter data; requiring the agency to
42establish performance standards for plans; providing
43program integrity requirements; establishing a grievance
44resolution process; providing for penalties for early
45termination of contracts or reduction in enrollment
46levels; creating s. 409.968, F.S.; establishing managed
47care plan payments; providing payment requirements for
48provider service networks; creating s. 409.969, F.S.;
49requiring enrollment in managed care plans by specified
50Medicaid recipients; creating requirements for plan
51selection by recipients; providing for choice counseling;
52establishing choice counseling requirements; authorizing
53disenrollment under certain circumstances; defining the
54term "good cause" for purposes of disenrollment; providing
55time limits on an internal grievance process; providing
56requirements for agency determination regarding
57disenrollment; requiring recipients to stay in plans for a
58specified time; creating s. 409.970, F.S.; requiring the
59agency to maintain an encounter data system; providing
60requirements for prepaid plans to submit data; creating s.
61409.971, F.S.; creating the managed medical assistance
62program; providing deadlines to begin and finalize
63implementation of the program; creating s. 409.972, F.S.;
64providing for mandatory and voluntary enrollment; creating
65s. 409.973, F.S.; establishing minimum benefits for
66managed care plans to cover; authorizing plans to
67customize benefit packages; requiring plans to establish
68enhanced benefits programs; providing terms for enhanced
69benefits package; establishing reserve requirements for
70plans to fund enhanced benefits programs; creating s.
71409.974, F.S.; establishing a specified number of
72qualified plans to be selected in each region;
73establishing a deadline for issuing invitations to
74negotiate; establishing quality selection criteria;
75establishing the Children's Medical Service Network as a
76qualified plan; creating s. 409.975; establishing managed
77care plan accountability; creating a medical loss ratio
78requirement; authorizing plans to limit providers in
79networks; mandating certain providers be offered contracts
80in the first year; requiring certain provider types to
81participate in plans; requiring plans to monitor the
82quality and performance history of providers; requiring
83specified programs and procedures be established by plans;
84establishing provider payments for hospitals; establishing
85conflict resolution procedures; establishing the Medicaid
86Resolution Board for specified purposes; establishing plan
87requirements for medically needy recipients; creating s.
88409.976, F.S.; providing for managed care plan payment;
89requiring the agency to establish a methodology to ensure
90certain types of payments to specified providers;
91establishing eligibility for payments; requiring the
92agency to establish payment rates for statewide inpatient
93psychiatric programs; requiring payments to managed care
94plans to be reconciled to reimburse actual payments to
95statewide inpatient psychiatric programs; creating s.
96409.977, F.S.; providing for enrollment; establishing
97choice counseling requirements; providing for automatic
98enrollment of certain recipients; establishing opt-out
99opportunities for recipients; creating s. 409.978, F.S.;
100requiring the Agency for Health Care Administration be
101responsible for administering the long-term care managed
102care program; providing implementation dates for the long-
103term care managed care program; providing duties for the
104Department of Elderly Affairs relating to assisting the
105agency in implementing the program; creating s. 409.979,
106F.S.; providing eligibility requirements for the long-term
107care managed care program; creating s. 409.980, F.S.;
108providing the benefits that a managed care plan shall
109provide when participating in the long-term care managed
110care program; creating s. 409.981, F.S.; providing
111criteria for qualified plans; designating regions for plan
112implementation throughout the state; providing criteria
113for the selection of plans to participate in the long-term
114care managed care program; creating s. 409.982, F.S.;
115providing the agency shall establish a uniform accounting
116and reporting methods for plans; providing spending
117thresholds and consequences relating to spending
118thresholds; providing for mandatory participation in plans
119of certain service providers; providing providers can be
120excluded from plans for failure to meet quality or
121performance criteria; providing the plans must monitor
122participating providers using specified criteria;
123providing certain providers that must be included in plan
124networks; providing provider payment specifications for
125nursing homes and hospices; creating s. 409.983, F.S.;
126providing for negotiation of rates between the agency and
127the plans participating in the long-term care managed care
128program; providing specific criteria for calculating and
129adjusting plan payments; allowing the CARES program to
130assign plan enrollees to a level of care ; providing
131incentives for adjustments of payment rates; providing the
132agency shall establish nursing facility-specific and
133hospice services payment rates; creating s. 409.984, F.S.;
134providing that prior to contracting with another vender,
135the agency shall offer to contract with the aging resource
136centers to provide choice counseling for the long-term
137care managed care program; providing criteria for
138automatic assignments of plan enrollees who fail to chose
139a plan; creating s. 409.985, F.S.; providing that the
140agency shall operate the Comprehensive Assessment and
141Review for Long-Term Care Services program through an
142interagency agreement with the Department of Elderly
143Affairs; providing duties of the program; defining  the
144term "nursing facility care"; creating s. 409.986, F.S.;
145providing authority and agency duties related to long-term
146care plans; creating s. 409.987, F.S.; providing
147eligibility requirements for long-term care plans;
148creating s. 409.988, F.S.; providing benefits for long-
149term care plans; creating s. 409.989, F.S.; establishing
150criteria for qualified plans; specifying minimum and
151maximum number of plans and selection criteria; creating
152s. 409.990, F.S.; providing requirements for managed care
153plan accountability; specifying limitations on providers
154in plan networks; providing for evaluation and payment of
155network providers; creating s. 409.991, F.S.; providing
156for payment of managed care plans; providing duties for
157the Agency for Persons with Disabilities to assign plan
158enrollees into a payment rate level of care; establishing
159level of care criteria; providing payment requirements for
160intensive behavior residential habilitation providers and
161intermediate care facilities for the developmentally
162disabled; creating s. 409.992, F.S.; providing
163requirements for enrollment and choice counseling;
164specifying enrollment exceptions for certain Medicaid
165recipients; providing an effective date.
166
167Be It Enacted by the Legislature of the State of Florida:
168
169     Section 1.  Sections 409.961 through 409.992, Florida
170Statutes, are designated as part IV of chapter 409, Florida
171Statutes, entitled "Medicaid Managed Care."
172     Section 2.  Section 409.961, Florida Statutes, is created
173to read:
174     409.961  Statutory construction; applicability; rules.-It
175is the intent of the Legislature that if any conflict exists
176between the provisions contained in this part and provisions
177contained in other parts of this chapter, the provisions
178contained in this part shall control. The provisions of ss.
179409.961-409.970 apply only to the Medicaid managed medical
180assistance program, long-term care managed care program, and
181managed long-term care for persons with developmental
182disabilities program, as provided in this part. The agency shall
183adopt any rules necessary to comply with or administer this part
184and all rules necessary to comply with federal requirements. In
185addition, the department shall adopt and accept the transfer of
186any rules necessary to carry out the department's
187responsibilities for receiving and processing Medicaid
188applications and determining Medicaid eligibility and for
189ensuring compliance with and administering this part, as those
190rules relate to the department's responsibilities, and any other
191provisions related to the department's responsibility for the
192determination of Medicaid eligibility.
193     Section 3.  Section 409.962, Florida Statutes, is created
194to read:
195     409.962  Definitions.-As used in this part, except as
196otherwise specifically provided, the term:
197     (1)  "Agency" means the Agency for Health Care
198Administration. The agency is the Medicaid agency for the state,
199as provided under federal law.
200     (2)  "Benefit" means any benefit, assistance, aid,
201obligation, promise, debt, liability, or the like, related to
202any covered injury, illness, or necessary medical care, goods,
203or services.
204     (3)  "Direct care management" means care management
205activities that involve direct interaction between providers and
206patients.
207     (4)  "Long-term care comprehensive plan" means a long-term
208care plan that also provides the services described in s.
209409.973.
210     (5)  "Long-term care plan" means a specialty plan that
211provides institutional and home and community-based services.
212     (6)  "Long term care provider service network" means an
213entity certified pursuant to s. 409.912(4)(d), of which a
214controlling interest is owned by one or more licensed nursing
215homes, assisted living facilities with 17 or more beds, home
216health agencies, community care for the elderly lead agencies,
217or hospices.
218     (7)  "Managed care plan" means a qualified plan under
219contract with the agency to provide services in the Medicaid
220program.
221     (8)  "Medicaid" means the medical assistance program
222authorized by Title XIX of the Social Security Act, 42 U.S.C. s.
2231396 et seq., and regulations thereunder, as administered in
224this state by the agency.
225     (9)  "Medicaid recipient" or "recipient" means an
226individual who the department or, for Supplemental Security
227Income, the Social Security Administration determines is
228eligible pursuant to federal and state law to receive medical
229assistance and related services for which the agency may make
230payments under the Medicaid program. For the purposes of
231determining third-party liability, the term includes an
232individual formerly determined to be eligible for Medicaid, an
233individual who has received medical assistance under the
234Medicaid program, or an individual on whose behalf Medicaid has
235become obligated.
236     (10)  "Medical home network" means a qualified plan
237designated by the agency as a medical home network in accordance
238with the criteria established in s. 409.91207.
239     (11)  "Prepaid plan" means a qualified plan that is
240licensed or certified as a risk-bearing entity in the state and
241is paid a prospective per-member, per-month payment by the
242agency.
243     (12)  "Provider service network" means an entity certified
244pursuant to s. 409.912(4)(d) of which a controlling interest is
245owned by a health care provider, or group of affiliated
246providers, or a public agency or entity that delivers health
247services. Health care providers include Florida-licensed health
248care professionals or licensed health care facilities, federally
249qualified health care centers, and home health care agencies.
250     (13)  "Qualified plan" means a health insurer authorized
251under chapter 624, an exclusive provider organization authorized
252under chapter 627, a health maintenance organization authorized
253under chapter 641, or a provider service network authorized
254under s. 409.912(4)(d) that is eligible to participate in the
255statewide managed care program.
256     (14)  "Specialty plan" means a qualified plan that serves
257Medicaid recipients who meet specified criteria based on age,
258medical condition, or diagnosis.
259     Section 4.  Section 409.963, Florida Statutes, is created
260to read:
261     409.963  Single state agency.-The Agency for Health Care
262Administration is designated as the single state agency
263authorized to manage, operate, and make payments for medical
264assistance and related services under Title XIX of the Social
265Security Act. Subject to any limitations or directions provided
266for in the General Appropriations Act, these payments shall be
267made only for services included in the program, only on behalf
268of eligible individuals, and only to qualified providers in
269accordance with federal requirements for Title XIX of the Social
270Security Act and the provisions of state law. This program of
271medical assistance is designated as the "Medicaid program." The
272department is responsible for Medicaid eligibility
273determinations, including, but not limited to, policy, rules,
274and the agreement with the Social Security Administration for
275Medicaid eligibility determinations for Supplemental Security
276Income recipients, as well as the actual determination of
277eligibility. As a condition of Medicaid eligibility, subject to
278federal approval, the agency and the department shall ensure
279that each Medicaid recipient consents to the release of her or
280his medical records to the agency and the Medicaid Fraud Control
281Unit of the Department of Legal Affairs.
282     Section 5.  Section 409.964, Florida Statutes is created to
283read:
284     409.964  Managed care program; state plan; waivers.-The
285Medicaid program is established as a statewide, integrated
286managed care program for all covered services, including long-
287term care services. The agency shall apply for and implement
288state plan amendments or waivers of applicable federal laws and
289regulations necessary to implement the program. Prior to seeking
290a waiver, the agency shall provide public notice and the
291opportunity for public comment and shall include public feedback
292in the waiver application. The agency shall include the public
293feedback in the application. The agency shall hold one public
294meeting in each of the regions described in s. 409.966(2) and
295the time period for public comment for each region shall end no
296sooner than 30 days after the completion of the public meeting
297in that region.
298     Section 6.  Section 409.965, Florida Statutes, is created
299to read:
300     409.965  Mandatory enrollment.-All Medicaid recipients
301shall receive covered services through the statewide managed
302care program, except as provided by this part pursuant to an
303approved federal waiver. The following Medicaid recipients are
304exempt from participation in the statewide managed care program:
305     (1)  Women who are only eligible for family planning
306services.
307     (2)  Women who are only eligible for breast and cervical
308cancer services.
309     (3)  Persons who are eligible for emergency Medicaid for
310aliens.
311     Section 7.  Section 409.966, Florida Statutes, is created
312to read:
313     409.966  Qualified plans; selection.-
314     (1)  QUALIFIED PLANS.-Services in the Medicaid managed care
315program shall be provided by qualified plans.
316     (a)  A qualified plan may request the agency to designate
317the plan as a medical home network if it meets the criteria
318established in s. 409.91207.
319     (b)  A provider service network must be capable of
320providing all covered services to a mandatory Medicaid managed
321care enrollee or may limit the provision of services to a
322specific target population based on the age, chronic disease
323state, or the medical condition of the enrollee to whom the
324network will provide services. A specialty provider service
325network must be capable of coordinating care and delivering or
326arranging for the delivery of all covered services to the target
327population. A provider service network may partner with an
328insurer licensed under chapter 627 or a health maintenance
329organization licensed under chapter 641 to meet the requirements
330of a Medicaid contract.
331     (2)  QUALIFIED PLAN SELECTION.-The agency shall select a
332limited number of qualified plans to participate in the Medicaid
333program using invitations to negotiate in accordance with s.
334287.057(3)(a). At least 30 days prior to issuing an invitation
335to negotiate, the agency shall compile and publish a databook
336consisting of a comprehensive set of utilization and spending
337data for the 3 most recent contract years consistent with the
338rate-setting periods for all Medicaid recipients by region or
339county. The source of the data in the report shall include both
340historic fee-for-service claims and validated data from the
341Medicaid Encounter Data System. The report shall be made
342available in electronic form and shall delineate utilization use
343by age, gender, eligibility group, geographic area, and
344aggregate clinical risk score. Separate and simultaneous
345procurements shall be conducted in each of the following
346regions:
347     (a)  Region I, which shall consist of Bay, Calhoun,
348Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson,
349Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla,
350Walton, and Washington Counties.
351     (b)  Region II, which shall consist of Alachua, Baker,
352Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler,
353Gilchrist, Hamilton, Lafayette, Levy, Marion, Nassau, Putnam,
354St. Johns, Suwannee, Union, and Volusia Counties.
355     (c)  Region III, which shall consist of Charlotte, DeSoto,
356Hardee, Hernando, Highlands, Hillsborough, Lee, Manatee, Pasco,
357Pinellas, Polk, and Sarasota Counties.
358     (d)  Region IV, which shall consist of Brevard, Indian
359River, Lake, Orange, Osceola, Seminole, and Sumter Counties.
360     (e)  Region V, which shall consist of Broward, Glades,
361Hendry, Martin, Okeechobee, Palm Beach, and St. Lucie Counties.
362     (f)  Region VI, which shall consist of Collier, Dade, and
363Monroe Counties.
364     (3)  QUALITY SELECTION CRITERIA.-The invitation to
365negotiate must specify the criteria and the relative weight of
366the criteria that will be used for determining the acceptability
367of the reply and guiding the selection of the organizations with
368which the agency negotiates. In addition to criteria established
369by the agency, the agency shall consider the following factors
370in the selection of qualified plans:
371     (a)  Accreditation by the National Committee for Quality
372Assurance or another nationally recognized accrediting body.
373     (b)  Experience serving similar populations, including the
374organization's record in achieving specific quality standards
375with similar populations.
376     (c)  Availability and accessibility of primary care and
377specialty physicians in the provider network.
378     (d)  Establishment of community partnerships with providers
379that create opportunities for reinvestment in community-based
380services.
381     (e)  Organization commitment to quality improvement and
382documentation of achievements in specific quality improvement
383projects, including active involvement by organization
384leadership.
385     (f)  Provision of additional benefits, particularly dental
386care and disease management, and other enhanced-benefit
387programs.
388     (g)  History of voluntary or involuntary withdrawal from
389any state Medicaid program or program area.
390     (h)  Evidence that a qualified plan has written agreements
391or signed contracts or has made substantial progress in
392establishing relationships with providers prior to the plan
393submitting a response. The agency shall evaluate and give
394special weight to such evidence, and the evaluation shall be
395based on the following factors:
396     1.  Contracts with primary and specialty physicians in
397sufficient numbers to meet the specific standards established
398pursuant to s. 409.967(2)(b).
399     2.  Specific arrangements that provide evidence that the
400compensation offered is sufficient to retain primary and
401specialty physicians in sufficient numbers to continue to comply
402with the standards established pursuant to s. 409.967(2)
403throughout the 5-year contract term.
404     3.  Contracts with community pharmacies located in rural
405areas; contracts with community pharmacies servicing specialty
406disease populations, including, but not limited to, HIV/AIDS
407patients, hemophiliacs, patients suffering from end-stage renal
408disease, diabetes, or cancer; community pharmacies located
409within distinct cultural communities that reflect the unique
410cultural dynamics of such communities, including, but not
411limited to, languages spoken, ethnicities served, unique disease
412states serviced, and geographic location within neighborhoods of
413such culturally distinct populations; and community pharmacies
414providing value-added services to patients, such as free
415delivery, immunizations, disease management, diabetes education,
416and medication utilization review.
417     4.  Contracts with multiple and diverse suppliers of home
418medical equipment and supplies distributed throughout the region
419that ensure patient choice, continuity of services, and
420redundant capacity to prevent service disruption during disaster
421response. The network of home medical equipment and supply
422providers shall include fully accredited and locally owned and
423operated companies with a proven ability to provide quality
424products, personalized service, 24-hour access to service, and
425appropriate response time.
426
427After negotiations are conducted, the agency shall select the
428qualified plans that are determined to be responsive and provide
429the best value to the state. Preference shall be given to
430organizations designated as medical home networks pursuant to s.
431409.91207 or organizations with the greatest number of primary
432care providers that are recognized as patient-centered medical
433homes by the National Committee for Quality Assurance or
434organizations with networks that reflect recruitment of minority
435physicians and other minority providers.
436     (4)  ADMINISTRATIVE CHALLENGE.-Any qualified plan that
437participates in an invitation to negotiate in more than one
438region and is selected in at least one region may not begin
439serving Medicaid recipients in any region for which it was
440selected until all administrative challenges to procurements
441required by this section to which the qualified plan is a party
442have been finalized. For purposes of this subsection, an
443administrative challenge is finalized if an order granting
444voluntary dismissal with prejudice has been entered by any court
445established under Article V of the State Constitution or by the
446Division of Administrative Hearings, a final order has been
447entered into by the agency and the deadline for appeal has
448expired, a final order has been entered by the First District
449Court of Appeal and the time to seek any available review by the
450Florida Supreme Court has expired, or a final order has been
451entered by the Florida Supreme Court and a warrant has been
452issued.
453     Section 8.  Section 409.967, Florida Statutes, is created
454to read:
455     409.967  Managed care plan accountability.-
456     (1)  The agency shall establish a 5-year contract with each
457of the qualified plans selected through the procurement process
458described in s. 409.966. A plan contract may not be renewed;
459however, the agency may extend the terms of a plan contract to
460cover any delays in transition to a new plan.
461     (2)  The agency shall establish such contract requirements
462as are necessary for the operation of the statewide managed care
463program. In addition to any other provisions the agency may deem
464necessary, the contract shall require:
465     (a)  Emergency services.-Plans shall pay for services
466required by ss. 395.1041 and 401.45 and rendered by a
467noncontracted provider within 30 days after receipt of a
468complete and correct claim. Plans must give providers of these
469services a specific explanation for each claim denied for being
470incomplete or incorrect. Providers shall have an opportunity to
471resubmit corrected claims for reconsideration within 30 days
472after receiving notice from the managed care plans of the claims
473being incomplete or incorrect. Payments for noncontracted
474emergency services and care shall be made at the rate the agency
475would pay for such services from the same provider. Claims from
476noncontracted providers shall be accepted by the qualified plan
477for at least 1 year after the date the services are provided.
478     (b)  Access.-The agency shall establish specific standards
479for the number, type, and regional distribution of providers in
480plan networks to ensure access to care. Each plan must maintain
481a region-wide network of providers in sufficient numbers to meet
482the access standards for specific medical services for all
483recipients enrolled in the plan. Each plan shall establish and
484maintain an accurate and complete electronic database of
485contracted providers, including information about licensure or
486registration, locations and hours of operation, specialty
487credentials and other certifications, specific performance
488indicators, and such other information as the agency deems
489necessary. The database shall be available online to both the
490agency and the public and shall have the capability to compare
491the availability of providers to network adequacy standards and
492to accept and display feedback from each provider's patients.
493Each plan shall submit quarterly reports to the agency
494identifying the number of enrollees assigned to each primary
495care provider.
496     (c)  Encounter data.-Each prepaid plan must comply with the
497agency's reporting requirements for the Medicaid Encounter Data
498System. The agency shall develop methods and protocols for
499ongoing analysis of the encounter data that adjusts for
500differences in characteristics of plans' enrollees to allow
501comparison of service utilization among plans and against
502expected levels of use. The analysis shall be used to identify
503possible cases of systemic under-utilization or denials of
504claims and inappropriate service utilization such as higher than
505expected emergency department encounters. The analysis shall
506provide periodic feedback to the plans and enable the agency to
507establish corrective action plans when necessary. One of the
508primary focus areas for the analysis shall be the use of
509prescription drugs.
510     (d)  Continuous improvement.-The agency shall establish
511specific performance standards and expected milestones or
512timelines for improving performance over the term of the
513contract. Each plan shall establish an internal health care
514quality improvement system, including enrollee satisfaction and
515disenrollment surveys. The quality improvement system shall
516include incentives and disincentives for network providers.
517     (e)  Program integrity.-Each plan shall establish program
518integrity functions and activities to reduce the incidence of
519fraud and abuse, including, at a minimum:
520     1.  A provider credentialing system and ongoing provider
521monitoring;
522     2.  An effective prepayment and postpayment review process
523including, but not limited to, data analysis, system editing,
524and auditing of network providers;
525     3.  Procedures for reporting instances of fraud and abuse
526pursuant to chapter 641;
527     4.  Administrative and management arrangements or
528procedures, including a mandatory compliance plan, designed to
529prevent fraud and abuse; and
530     5.  Designation of a program integrity compliance officer.
531     (f)  Grievance resolution.-Each plan shall establish and
532the agency shall approve an internal process for reviewing and
533responding to grievances from enrollees consistent with the
534requirements of s. 641.511. Each plan shall submit quarterly
535reports on the number, description, and outcome of grievances
536filed by enrollees. The agency shall maintain a process for
537provider service networks consistent with s. 408.7056.
538     (g)  Penalties.-Plans that reduce enrollment levels or
539leave a region prior to the end of the contract term shall
540reimburse the agency for the cost of enrollment changes and
541other transition activities, including the cost of additional
542choice counseling services. If more than one plan leaves a
543region at the same time, costs shall be shared by the departing
544plans proportionate to their enrollments. In addition to the
545payment of costs, departing plans shall pay a per enrollee
546penalty not to exceed 5 percent of 1 month's payment. Plans
547shall provide the agency notice no less than 180 days prior to
548withdrawing from a region.
549     (h)  Prompt payment.-All managed care plans shall comply
550with ss. 641.315, 641.3155, and 641.513.
551     (i)  Electronic claims.-Plans shall accept electronic
552claims in compliance with federal standards.
553     (j)  Medical home development.-The managed care plan, if
554not designated as a medical home network pursuant to s.
555409.91207, must develop a plan to assist and to provide
556incentives for its primary care providers to become recognized
557as patient-centered medical homes by the National Committee for
558Quality Assurance.
559     Section 9.  Section 409.968, Florida Statutes, is created
560to read:
561     409.968  Managed care plan payment.-
562     (1)  Prepaid plans shall receive per-member, per-month
563payments negotiated pursuant to the procurements described in s.
564409.966. Payments shall be risk-adjusted rates based on
565historical utilization and spending data, projected forward, and
566adjusted to reflect the eligibility category, geographic area,
567and the clinical risk profile of the recipients.
568     (2)  Beginning September 1, 2010, the agency shall update
569the rate-setting methodology by initiating a transition to rates
570based on statewide encounter data submitted by Medicaid managed
571care plans pursuant to s. 409.970. Prior to this transition, the
572agency shall conduct appropriate tests and establish specific
573milestones in order to determine that the Medicaid Encounter
574Data system consists of valid, complete, and sound data for a
575sufficient period of time to provide a reliable basis for
576establishing actuarially sound payment rates. The transition
577shall be implemented within 3 years or less, and shall utilize
578such other data sources as necessary and reliable to make
579appropriate adjustments during the transition. The agency shall
580establish a technical advisory panel to obtain input from the
581prepaid plans regarding the incorporation of encounter data in
582the rate setting process.
583     (3)  Provider service networks may be prepaid plans and
584receive per-member, per-month payments negotiated pursuant to
585the procurement process described in s. 409.966. Provider
586service networks that choose not to be prepaid plans shall
587receive fee-for-service rates with a shared savings settlement.
588The fee-for-service option shall be available to a provider
589service network only for the first 5 years of the plan's
590operation in a given region or until the contract year that
591begins on October 1, 2015, whichever is later. The agency shall
592annually conduct cost reconciliations to determine the amount of
593cost savings achieved by fee-for-service provider service
594networks for the dates of service within the period being
595reconciled. Only payments for covered services for dates of
596service within the reconciliation period and paid within 6
597months after the last date of service in the reconciliation
598period shall be included. The agency shall perform the necessary
599adjustments for the inclusion of incurred but not reported
600claims within the reconciliation period for claims that could be
601received and paid by the agency after the 6-month claims
602processing time lag. The agency shall provide the results of the
603reconciliations to the fee-for-service provider service networks
604within 45 days after the end of the reconciliation period. The
605fee-for-service provider service networks shall review and
606provide written comments or a letter of concurrence to the
607agency within 45 days after receipt of the reconciliation
608results. This reconciliation shall be considered final.
609     Section 10.  Section 409.969, Florida Statutes, is created
610to read:
611     409.969  Enrollment; choice counseling; automatic
612assignment; disenrollment.-
613     (1)  ENROLLMENT.-All Medicaid recipients shall be enrolled
614in a managed care plan unless specifically exempted in this
615part. Each recipient shall have a choice of plans and may select
616any available plan unless that plan is restricted by contract to
617a specific population that does not include the recipient.
618Medicaid recipients shall have 30 days in which to make a choice
619of plans. All recipients shall be offered choice counseling
620services in accordance with this section.
621     (2)  CHOICE COUNSELING.-The agency shall provide choice
622counseling for Medicaid recipients. The agency may contract for
623the provision of choice counseling. Any such contract shall be
624for a period of 5 years. The agency may renew a contract for an
625additional 5-year period; however, prior to renewal of the
626contract the agency shall hold at least one public meeting in
627each of the regions covered by the choice counseling vendor. The
628agency may extend the term of the contract to cover any delays
629in transition to a new contractor. Printed choice information
630and choice counseling shall be offered in the native or
631preferred language of the recipient, consistent with federal
632requirements. The manner and method of choice counseling shall
633be modified as necessary to assure culturally competent,
634effective communication with people from diverse cultural
635backgrounds. The agency shall maintain a record of the
636recipients who receive such services, identifying the scope and
637method of the services provided. The agency shall make available
638clear and easily understandable choice information to Medicaid
639recipients that includes:
640     (a)  An explanation that each recipient has the right to
641choose a managed care plan at the time of enrollment in Medicaid
642and again at regular intervals set by the agency, and that if a
643recipient does not choose a plan, the agency will assign the
644recipient to a plan according to the criteria specified in this
645section.
646     (b)  A list and description of the benefits provided in
647each plan.
648     (c)  An explanation of benefit limits.
649     (d)  A current list of providers participating in the
650network, including location and contact information.
651     (e)  Plan performance data.
652     (3)  DISENROLLMENT; GRIEVANCES.-After a recipient has
653enrolled in a managed care plan, the recipient shall have 90
654days to voluntarily disenroll and select another plan. After 90
655days, no further changes may be made except for good cause. Good
656cause includes, but is not limited to, poor quality of care,
657lack of access to necessary specialty services, an unreasonable
658delay or denial of service, or fraudulent enrollment. The agency
659must make a determination as to whether good cause exists. The
660agency may require a recipient to use the plan's grievance
661process prior to the agency's determination of good cause,
662except in cases in which immediate risk of permanent damage to
663the recipient's health is alleged.
664     (a)  The managed care plan internal grievance process, when
665utilized, must be completed in time to permit the recipient to
666disenroll by the first day of the second month after the month
667the disenrollment request was made. If the result of the
668grievance process is approval of an enrollee's request to
669disenroll, the agency is not required to make a determination in
670the case.
671     (b)  The agency must make a determination and take final
672action on a recipient's request so that disenrollment occurs no
673later than the first day of the second month after the month the
674request was made. If the agency fails to act within the
675specified timeframe, the recipient's request to disenroll is
676deemed to be approved as of the date agency action was required.
677Recipients who disagree with the agency's finding that good
678cause does not exist for disenrollment shall be advised of their
679right to pursue a Medicaid fair hearing to dispute the agency's
680finding.
681     (c)  Medicaid recipients enrolled in a managed care plan
682after the 90-day period shall remain in the plan for the
683remainder of the 12-month period. After 12 months, the recipient
684may select another plan. However, nothing shall prevent a
685Medicaid recipient from changing primary care providers within
686the plan during that period.
687     (d)  On the first day of the next month after receiving
688notice from a recipient that the recipient has moved to another
689region, the agency shall automatically disenroll the recipient
690from the plan the recipient is currently enrolled in and treat
691the recipient as if the recipient is a new Medicaid enrollee. At
692that time, the recipient may choose another plan pursuant to the
693enrollment process established in this section.
694     Section 11.  Section 409.970, Florida Statutes, is created
695to read:
696     409.970  Encounter data.-The agency shall maintain and
697operate the Medicaid Encounter Data System to collect, process,
698store, and report on covered services provided to all Medicaid
699recipients enrolled in prepaid plans. Prepaid plans shall submit
700encounter data electronically in a format that complies with the
701Health Insurance Portability and Accountability Act provisions
702for electronic claims and in accordance with deadlines
703established by the agency. Prepaid plans must certify that the
704data reported is accurate and complete. The agency is
705responsible for validating the data submitted by the plans. The
706agency shall make encounter data available to those plans
707accepting enrollees who are assigned to them from other plans
708leaving a region.
709     Section 12.  Section 409.971, Florida Statutes, is created
710to read:
711     409.971  Managed medical assistance program.-The agency
712shall make payments for primary and acute medical assistance and
713related services using a managed care model. By January 1, 2012,
714the agency shall begin implementation of the statewide managed
715medical assistance program, with full implementation in all
716regions by October 1, 2013.
717     Section 13.  Section 409.972, Florida Statutes, is created
718to read:
719     409.972  Mandatory and voluntary enrollment.-
720     (1)  Persons eligible for the program known as "medically
721needy" pursuant to s. 409.904(2)(a) shall enroll in managed care
722plans. Medically needy recipients shall meet the share of cost
723by paying the plan premium, up to the share of cost amount,
724contingent upon federal approval.
725     (2)  The following Medicaid-eligible persons are exempt
726from mandatory managed care enrollment required by s. 409.965,
727and may voluntarily choose to participate in the managed medical
728assistance program:
729     (a)  Medicaid recipients who have other creditable health
730care coverage, excluding Medicare.
731     (b)  Medicaid recipients residing in residential commitment
732facilities operated through the Department of Juvenile Justice,
733group care facilities operated by the Department of Children and
734Families, and treatment facilities funded through the Substance
735Abuse and Mental Health program of the Department of Children
736and Families.
737     (c)  Persons eligible for refugee assistance.
738     (d)  Medicaid recipients who are residents of a
739developmental disability center including Sunland Center in
740Marianna and Tacachale in Gainesville.
741     (3)  Persons eligible for Medicaid but exempt from
742mandatory participation who do not choose to enroll in managed
743care shall be served in the Medicaid fee-for-service program as
744provided in part III of this chapter.
745     Section 14.  Section 409.973, Florida Statutes, is created
746to read:
747     409.973  Benefits.-
748     (1)  MINIMUM BENEFITS.-Managed care plans shall cover, at a
749minimum, the following services:
750     (a)  Advanced registered nurse practitioner services.
751     (b)  Ambulatory surgical treatment center services.
752     (c)  Birthing center services.
753     (d)  Chiropractic services.
754     (e)  Dental services.
755     (f)  Early periodic screening diagnosis and treatment
756services for recipients under age 21.
757     (g)  Emergency services.
758     (h)  Family planning services and supplies.
759     (i)  Healthy start services.
760     (j)  Hearing services.
761     (k)  Home health agency services.
762     (l)  Hospice services.
763     (m)  Hospital inpatient services.
764     (n)  Hospital outpatient services.
765     (o)  Laboratory and imaging services.
766     (p)  Medical supplies, equipment, prostheses, and orthoses.
767     (q)  Mental health services.
768     (r)  Nursing care.
769     (s)  Optical services and supplies.
770     (t)  Optometrist services.
771     (u)  Physical, occupational, respiratory, and speech
772therapy services.
773     (v)  Physician services.
774     (w)  Podiatric services.
775     (x)  Prescription drugs.
776     (y)  Renal dialysis services.
777     (z)  Respiratory equipment and supplies.
778     (aa)  Rural health clinic services.
779     (bb)  Substance abuse treatment services.
780     (cc)  Transportation to access covered services.
781     (2)  CUSTOMIZED BENEFITS.-Managed care plans may customize
782benefit packages for nonpregnant adults, vary cost-sharing
783provisions, and provide coverage for additional services. The
784agency shall evaluate the proposed benefit packages to ensure
785services are sufficient to meet the needs of the plans'
786enrollees and to verify actuarial equivalence.
787     (3)  ENHANCED BENEFITS.-Each plan operating in the managed
788medical assistance program shall establish an incentive program
789that rewards specific healthy behaviors with credits in a
790flexible spending account.
791     (a)  At the discretion of the recipient, credits shall be
792used to purchase otherwise uncovered health and related services
793during the entire period of, and for a maximum of 3 years after,
794the recipient's Medicaid eligibility, whether or not the
795recipient remains continuously enrolled in the plan in which the
796credits were earned.
797     (b)  Enhanced benefits shall be structured to provide
798greater incentives for those diseases linked with lifestyle and
799conditions or behaviors associated with avoidable utilization of
800high-cost services.
801     (c)  To fund these credits, each plan must maintain a
802reserve account in an amount of up to 2 percent of the plan's
803Medicaid premium revenue, or benchmark premium revenue in the
804case of provider service networks, based on an actuarial
805assessment of the value of the enhanced benefits program.
806     Section 15.  Section 409.974, Florida Statutes, is created
807to read:
808     409.974  Qualified plans.-
809     (1)  QUALIFIED PLAN SELECTION.-The agency shall select
810qualified plans through the procurement described in s. 409.966.
811The agency shall notice invitations to negotiate no later than
812January 1, 2012.
813     (a)  The agency shall procure three plans for Region I. At
814least one plan shall be a provider service network, if any
815provider service network submits a responsive bid.
816     (b)  The agency shall procure at least four and no more
817than seven plans for Region II. At least one plan shall be a
818provider service network, if any provider service network
819submits a responsive bid.
820     (c)  The agency shall procure at least five plans and no
821more than ten plans for Region III. At least two plans shall be
822provider service networks, if any two provider service networks
823submit a responsive bid.
824     (d)  The agency shall procure at least four plans and no
825more than eight plans for Region IV. At least one plan shall be
826a provider service network if any provider service network
827submits a responsive bid.
828     (e)  The agency shall procure at least four plans and no
829more than seven plans for Region V. At least one plan shall be a
830provider service network, if any provider service network
831submits a responsive bid.
832     (f)  The agency shall procure at least five plans and no
833more than ten plans for Region VI. At least two plans shall be
834provider service networks, if any two provider service networks
835submit a responsive bid.
836If no provider service network submits a responsive bid, the
837agency shall procure no more than one less than the maximum
838number of qualified plans permitted in that region. Within 12
839months after the initial invitation to negotiate, the agency
840shall attempt to procure a qualified plan that is a provider
841service network. The agency shall notice another invitation to
842negotiate only with provider service networks in such region
843where no provider service network has been selected.
844     (2)  QUALITY SELECTION CRITERIA.-In addition to the
845criteria established in s. 409.966, the agency shall consider
846evidence that a qualified plan has written agreements or signed
847contracts or has made substantial progress in establishing
848relationships with providers prior to the plan submitting a
849response. The agency shall evaluate and give special weight to
850evidence of signed contracts with providers of critical services
851pursuant to s. 409.975(3)(a)-(d). The agency shall also consider
852whether the organization is a specialty plan. When all other
853factors are equal, the agency shall consider whether the
854organization has a contract to provide managed long-term care
855services in the same region and shall exercise a preference for
856such plans.  
857     (3)  CHILDREN'S MEDICAL SERVICES NETWORK.-The Children's
858Medical Services Network authorized under chapter 391 is a
859qualified plan for purposes of the managed medical assistance
860program. Participation by the Children's Medical Services
861Network shall be pursuant to a single, statewide contract with
862the agency that is not subject to the procurement requirements
863or regional plan number limits of this section. The Children's
864Medical Services Network must meet all other plan requirements
865for the managed medical assistance program.
866     Section 16.  Section 409.975, Florida Statutes, is created
867to read:
868     409.975  Managed care plan accountability.-In addition to
869the requirements of s. 409.967, plans and providers
870participating in the managed medical assistance program shall
871comply with the requirements of this section.
872     (1)  MEDICAL LOSS RATIO.-The agency shall establish and
873implement managed care plans that shall use a uniform method of
874accounting for and reporting medical, direct care management,
875and nonmedical costs. The agency shall evaluate plan spending
876patterns beginning after the plan completes 2 full years of
877operation and at least annually thereafter. The agency shall
878implement the following thresholds and consequences of various
879spending patterns:
880     (a)  Plans that spend less than 75 percent of Medicaid
881premium revenue on medical services and direct care management
882as determined by the agency shall be excluded from automatic
883enrollments and shall be required to pay back the amount between
884actual spending and 85 percent of the Medicaid premium revenue.
885     (b)  Plans that spend less than 85 percent of Medicaid
886premium revenue on medical services and direct care management
887as determined by the agency shall be required to pay back the
888amount between actual spending and 85 percent of the Medicaid
889premium revenue.
890     (c)  Plans that spend more than 92 percent of Medicaid
891premium revenue on medical services and direct care management
892as determined by the agency shall be evaluated by the agency to
893determine whether higher expenditures are the result of failures
894in care management.
895     (d)  Plans that spend 95 percent or more of Medicaid
896premium revenue on medical services and direct care management
897and are determined to be failing to appropriately manage care
898shall be excluded from automatic enrollments.
899     (2)  PROVIDER NETWORKS.-Plans may limit the providers in
900their networks based on credentials, quality indicators, and
901price. However, in the first contract period after a qualified
902plan is selected in a region by the agency, the plan must offer
903a network contract to the following providers in the region:
904     (a)  Federally qualified health centers.
905     (b)  Primary care providers certified as medical homes.
906     (c)  Providers listed in paragraphs (3)(a)-(d).
907
908After 12 months of active participation in a plan's network, the
909plan may exclude any of the above-named providers from the
910network for failure to meet quality or performance criteria. If
911the plan excludes a provider from the plan, the plan must
912provide written notice to all recipients who have chosen that
913provider for care. The notice shall be provided at least 30 days
914prior to the effective date of the exclusion.
915     (3)  SELECT PROVIDER PARTICIPATION.-Providers may not be
916required to participate in any qualified plan selected by the
917agency except as provided in this subsection. The following
918providers must agree to participate with each qualified plan
919selected by the agency in the regions where they are located:
920     (a)  Statutory teaching hospitals as defined in s.
921408.07(45).
922     (b)  Hospitals that are trauma centers as defined in s.
923395.4001(14).
924     (c)  Hospitals that are regional perinatal intensive care
925centers as defined in s. 383.16(2).
926     (d)  Hospitals licensed as specialty children's hospitals
927as defined in s. 395.002(28).
928     (e)  Hospitals with both an active Medicaid provider
929agreement under s. 409.907 and a certificate of need.
930
931The hospitals described in paragraphs (a)-(d) shall make
932adequate arrangements for medical staff sufficient to fulfill
933their contractual obligations with the plans.
934     (4)  PERFORMANCE MEASUREMENT.-Each plan shall monitor the
935quality and performance of each participating provider. At the
936beginning of the contract period, each plan shall notify all its
937network providers of the metrics used by the plan for evaluating
938the provider's performance and determining continued
939participation in the network.
940     (5)  PREGNANCY AND INFANT HEALTH.-Each plan shall establish
941specific programs and procedures to improve pregnancy outcomes
942and infant health, including, but not limited to, coordination
943with the Healthy Start program, immunization programs, and
944referral to the Special Supplemental Nutrition Program for
945Women, Infants, and Children, and the Children's Medical
946Services program for children with special health care needs.
947     (6)  SCREENING RATE.-Each plan shall achieve an annual
948Early and Periodic Screening, Diagnosis, and Treatment Service
949screening rate of at least 80 percent of those recipients
950continuously enrolled for at least 8 months.
951     (7)  PROVIDER PAYMENT.-Plans and hospitals shall negotiate
952mutually acceptable rates, methods, and terms of payment. At a
953minimum, plans shall pay hospitals the Medicaid rate. Payments
954to hospitals shall not exceed 150 percent of the rate the agency
955would have paid on the first day of the contract between the
956provider and the plan, unless specifically approved by the
957agency. Payment rates may be updated periodically.
958     (8)  CONFLICT RESOLUTION.-In order to protect the continued
959statewide operation of the Medicaid managed care program, the
960Medicaid Resolution Board is established to resolve disputes
961between managed care plans and hospitals and between managed
962care plans and the medical staff of the providers listed in s.
963409.975(3)(a)-(d). The board shall consist of two members
964appointed by the Speaker of the House of Representatives, two
965members appointed by the President of the Senate, and three
966members appointed by the Governor. The costs of the board's
967activities to review and resolve disputes shall be shared
968equally by the parties to the dispute. Any managed care plan or
969above-named provider may initiate a review by the board for any
970conflict related to payment rates, contract terms, or other
971conditions. The board shall make recommendations to the agency
972regarding payment rates, procedures, or other contract terms to
973resolve such conflicts. The agency may amend the terms of the
974contracts with the parties to ensure compliance with these
975recommendations. This process shall not be used to review and
976reverse any managed care plan decision to exclude any provider
977that fails to meet quality standards.
978     (9)  MEDICALLY NEEDY ENROLLEES.-Each selected plan shall
979accept any medically needy recipient who selects or is assigned
980to the plan and provide that recipient with continuous
981enrollment for 12 months. After the first month of qualifying as
982a medically needy recipient and enrolling in a plan, and
983contingent upon federal approval, the enrollee shall pay the
984plan a portion of the monthly premium equal to the enrollee's
985share of the cost as determined by the department. The agency
986shall pay the remainder of the monthly premium. Plans must
987provide a grace period of at least 120 days before disenrolling
988recipients who fail to pay their shares of the premium.
989     Section 17.  Section 409.976, Florida Statutes, is created
990to read:
991     409.976  Managed care plan payment.-In addition to the
992payment provisions of s. 409.968, the agency shall provide
993payment to plans in the managed medical assistance program
994pursuant to this section.
995     (1)  Prepaid payment rates shall be negotiated between the
996agency and the qualified plans as part of the procurement
997described in s. 409.966.
998     (2)  The agency shall develop a methodology to ensure the
999availability of intergovernmental transfers in the statewide
1000integrated managed care program to support providers that have
1001historically served Medicaid recipients. Such providers include,
1002but are not limited to, safety net providers, trauma hospitals,
1003children's hospitals, statutory teaching hospitals, and medical
1004and osteopathic physicians employed by or under contract with a
1005medical school in this state. The agency may develop a
1006supplemental capitation rate, risk pool, or incentive payment to
1007plans that contract with these providers. A plan is eligible for
1008a supplemental payment only if there are sufficient
1009intergovernmental transfers available from allowable sources and
1010the plan can demonstrate that it pays a reimbursement rate not
1011less than the equivalent fee-for-service rate. The agency may
1012develop the supplemental capitation rate to consider rates
1013higher than the fee-for-service Medicaid rate when needed to
1014ensure access and supported by funds provided by a locality. The
1015agency shall evaluate the development of the rate cell to
1016accurately reflect the underlying utilization to the maximum
1017extent possible. This methodology may include interim rate
1018adjustments as permitted under federal regulations. Any such
1019methodology shall preserve federal funding to these entities and
1020must be actuarially sound. In the absence of federal approval
1021for the above methodology, the agency is authorized to set an
1022enhanced rate and require that plans pay the enhanced rate, if
1023the agency determines the enhanced rate is necessary to ensure
1024access to care by the providers described in this subsection.
1025The amount paid to the plans to make supplemental payments or to
1026enhance provider rates pursuant to this subsection shall be
1027reconciled to the exact amounts the plans are required to pay to
1028providers. The plans shall make the designated payments to
1029providers within 15 business days of notification by the agency
1030regarding provider-specific distributions.
1031     (3)  The agency shall establish payment rates for statewide
1032inpatient psychiatric programs. Payments to managed care plans
1033shall be reconciled to reimburse actual payments to statewide
1034inpatient psychiatric programs.
1035     Section 18.  Section 409.977, Florida Statutes, is created
1036to read:
1037     409.977  Choice counseling and enrollment.-
1038     (1)  CHOICE COUNSELING.-In addition to the choice
1039counseling information required by s. 409.969, the agency shall
1040make available clear and easily understandable choice
1041information to Medicaid recipients that includes:
1042     (a)  Information about earning credits in the plan's
1043enhanced benefit program.
1044     (b)  Information about cost sharing requirements of each
1045plan.
1046     (2)  AUTOMATIC ENROLLMENT.-The agency shall automatically
1047enroll into a managed care plan those Medicaid recipients who do
1048not voluntarily choose a plan pursuant to s. 409.969. The agency
1049shall automatically enroll recipients in plans that meet or
1050exceed the performance or quality standards established pursuant
1051to s. 409.967, and shall not automatically enroll recipients in
1052a plan that is deficient in those performance or quality
1053standards. When a specialty plan is available to accommodate a
1054specific condition or diagnosis of a recipient, the agency shall
1055assign the recipient to that plan. The agency may not engage in
1056practices that are designed to favor one managed care plan over
1057another. When automatically enrolling recipients in plans, the
1058agency shall automatically enroll based on the following
1059criteria:
1060     (a)  Whether the plan has sufficient network capacity to
1061meet the needs of the recipients.
1062     (b)  Whether the recipient has previously received services
1063from one of the plan's primary care providers.
1064     (c)  Whether primary care providers in one plan are more
1065geographically accessible to the recipient's residence than
1066those in other plans.
1067     (3)  OPT-OUT OPTION.-The agency shall develop a process to
1068enable any recipient with access to employer-sponsored insurance
1069to opt out of all qualified plans in the Medicaid program and to
1070use Medicaid financial assistance to pay for the recipient's
1071share of the cost in any such plan. Contingent upon federal
1072approval, the agency shall also enable recipients with access to
1073other insurance or related products providing access to health
1074care services created pursuant to state law, including any
1075product available under the Cover Florida Health Access Program,
1076the Florida Health Choices Program, or any health exchange, to
1077opt out. The amount of financial assistance provided for each
1078recipient may not exceed the amount of the Medicaid premium that
1079would have been paid to a plan for that recipient.
1080     Section 19.  Section 409.978, Florida Statutes, is created
1081to read:
1082     409.978  Long-term care managed care program.-
1083     (1)  Pursuant to s. 409.963, the agency shall administer
1084the long-term care managed care program described in ss.
1085409.978-409.985, but may delegate specific duties and
1086responsibilities for the program to the Department of Elderly
1087Affairs and other state agencies. By July 1, 2011, the agency
1088shall begin implementation of the statewide long-term care
1089managed care program, with full implementation in all regions by
1090October 1, 2012.
1091     (2)  The agency shall make payments for long-term care,
1092including home and community-based services, using a managed
1093care model. Unless otherwise specified, the provisions of ss.
1094409.961-409.970 apply to the long-term care managed care
1095program.
1096     (3)  The Department of Elderly Affairs shall assist the
1097agency to develop specifications for use in the invitation to
1098negotiate and the model contract; determine clinical eligibility
1099for enrollment in managed long-term care plans; monitor plan
1100performance and measure quality of service delivery; assist
1101clients and families to address complaints with the plans;
1102facilitate working relationships between plans and providers
1103serving elders and disabled adults; and perform other functions
1104specified in a memorandum of agreement.
1105     Section 20.  Section 409.979, Florida Statutes, is created
1106to read:
1107     409.979  Eligibility.-
1108     (1)  Medicaid recipients who meet all of the following
1109criteria are eligible to participate in the long-term care
1110managed care program. The recipient must be:
1111     (a)  Sixty-five years of age or older or eligible for
1112Medicaid by reason of a disability.
1113     (b)  Determined by the Comprehensive Assessment Review and
1114Evaluation for Long-Term Care Services (CARES) Program to
1115require nursing facility care.
1116     (2)  Medicaid recipients who on the date long-term care
1117managed care plans becomes available in the recipient's region,
1118are residing in a nursing home facility or enrolled in one of
1119the following long-term care Medicaid waiver programs are
1120eligible to participate in the long-term care managed care
1121program:
1122     (a)  The Assisted Living for the Frail Elderly Waiver.
1123     (b)  The Aged and Disabled Adult Waiver.
1124     (c)  The Adult Day Health Care Waiver.
1125     (d)  The Consumer-Directed Care Plus Program as described
1126in s. 409.221.
1127     (e)  The Program of All-inclusive Care for the Elderly.
1128     (f)  The Long-Term Care Community-Based Diversion Pilot
1129Project as described in s. 430.705.
1130     (g)  The Channeling Services Waiver for Frail Elders.
1131     Section 21.  Section 409.980, Florida Statutes, is created
1132to read:
1133     409.980  Benefits.-Managed care plans shall cover, at a
1134minimum, the following services:
1135     (1)  Nursing facility.
1136     (2)  Assisted living facility.
1137     (3)  Hospice.
1138     (4)  Adult day care.
1139     (5)  Medical equipment and supplies, including incontinence
1140supplies.
1141     (5)  Personal care.
1142     (7)  Home accessibility adaptation.
1143     (9)  Behavior management.
1144     (9)  Home delivered meals.
1145     (10)  Case management.
1146     (11)  Therapies:
1147     (a)  Occupational therapy
1148     (b)  Speech therapy
1149     (c)  Respiratory therapy
1150     (d)  Physical therapy.
1151     (12)  Intermittent and skilled nursing.
1152     (13)  Medication administration.
1153     (14)  Medication management.
1154     (15)  Nutritional assessment and risk reduction.
1155     (16)  Caregiver training.
1156     (17)  Respite care.
1157     (18)  Transportation.
1158     (19)  Personal emergency response system.
1159     Section 22.  Section 409.981, Florida Statutes, is created
1160to read:
1161     409.981  Qualified plans.-
1162     (1)  QUALIFIED PLANS.-For purposes of the long-term care
1163managed care program, qualified plans also include entities who
1164are qualified under 42 C.F.R. part 422 as Medicare Advantage
1165Preferred Provider Organizations, Medicare Advantage Provider-
1166sponsored Organizations, and Medicare Advantage Special Needs
1167Plans. Such plans are eligible to participate in the statewide
1168long-term care managed care program. Qualified plans that are
1169provider service networks must be long-term care provider
1170service networks. Qualified plans may either be long-term care
1171plans that cover benefits pursuant to s. 409.980, or
1172comprehensive long-term care plans that cover benefits pursuant
1173to ss. 409.973 and 409.980.
1174     (2) QUALIFIED PLAN SELECTION.-The agency shall select
1175qualified plans through the procurement described in s. 409.966.
1176The agency shall notice invitations to negotiate no later than
1177July 1, 2011.
1178     (a)  The agency shall procure three plans for Region I. At
1179least one plan shall be a provider service network, if any
1180submit a responsive bid.
1181     (b)  The agency shall procure at least four and no more
1182than seven plans for Region II. At least one plan shall be a
1183provider service network, if any submit a responsive bid.
1184     (c)  The agency shall procure at least five plans and no
1185more than ten plans for Region III. At least two plans shall be
1186provider service networks, if any two submit a responsive bid.
1187     (d)  The agency shall procure at least four plans and no
1188more than eight plans for Region IV. At least one plan shall be
1189a provider service network if any submit a responsive bid.
1190     (e)  The agency shall procure at least four plans and no
1191more than seven plans for Region V. At least one plan shall be a
1192provider service network, if any submit a responsive bid.
1193     (f)  The agency shall procure at least five plans and no
1194more than ten plans for Region VI. At least two plans shall be
1195provider service networks, if any two submit a responsive bid.
1196If no provider service network submits a responsive bid, the
1197agency shall procure one less qualified plan in each of the
1198regions. Within 12 months after the initial invitation to
1199negotiate, the agency shall attempt to procure a qualified plan
1200that is a provider service network. The agency shall notice
1201another invitation to negotiate only with provider service
1202networks in such region where no provider service network has
1203been selected.
1204     (3) QUALITY SELECTION CRITERIA.-In addition to the criteria
1205established in s. 409.966, the agency shall consider the
1206following factors in the selection of qualified plans:
1207     (a)  Specialized staffing. Plan employment of executive
1208managers with expertise and experience in serving aged and
1209disabled persons who require long-term care.
1210     (b)  Network qualifications. Plan establishment of a
1211network of service providers dispersed throughout the region and
1212in sufficient numbers to meet specific service standards
1213established by the agency for specialty services for persons
1214receiving home and community-based care.
1215     (c)  Whether a plan is proposing to establish a
1216comprehensive long-term care plan and whether the qualified plan
1217has a contract to provide managed medical assistance services in
1218the same region. The agency shall exercise a preference for such
1219plans.
1220     (d)  Whether a plan is designated as a medical home network
1221pursuant to s. 409.91207 or offers consumer-directed care
1222services to enrollees pursuant to s. 409.221. Consumer-directed
1223care services provide a flexible budget which is managed by
1224enrolled individuals and their families or representatives and
1225allows them to choose providers of services, determine provider
1226rates of payment and direct the delivery of services to best
1227meet their special long-term care needs. When all other factors
1228are equal among competing qualified plans, the agency shall
1229exercise a preference for such plans.
1230     (e)  Evidence that a qualified plan has written agreements
1231or signed contracts or has made substantial progress in
1232establishing relationships with providers prior to the plan
1233submitting a response. The agency shall evaluate and give
1234special weight to evidence of signed contracts with providers of
1235critical services pursuant to s. 409.982(2)(a)-(c).
1236     (4)  PROGRAM FOR ALL-INCLUSIVE CARE FOR THE ELDERLY.-The
1237Program for All-Inclusive Care for the Elderly (PACE) is a
1238qualified plan for purposes of the long-term care managed care
1239program. Participation by PACE shall be pursuant to a contract
1240with the agency and not subject to the procurement requirements
1241or regional plan number limits of this section. PACE plans may
1242continue to provide services to individuals at such levels and
1243enrollment caps as authorized by the General Appropriations Act.
1244     Section 23.  Section 409.982, Florida Statutes, is created
1245to read:
1246     409.982  Managed care plan accountability.-In addition to
1247the requirements of s. 409.967, plans and providers
1248participating in the long-term care managed care program shall
1249comply with the requirements of this section.
1250     (1)  MEDICAL LOSS RATIO.-The agency shall establish and
1251plans shall use a uniform method of accounting and reporting
1252long-term care service costs, direct care management costs, and
1253administrative costs. The agency shall evaluate plan spending
1254patterns beginning after the plan completes 2 full years of
1255operation and at least annually thereafter. The agency shall
1256implement the following thresholds and consequences of various
1257spending patterns:
1258     (a)  Plans that spend less than 75 percent of Medicaid
1259premium revenue on long-term care services, including direct
1260care management as determined by the agency shall be excluded
1261from automatic enrollments and shall be required to pay back the
1262amount between actual spending and 85 percent of the Medicaid
1263premium revenue.
1264     (b)  Plans that spend less than 85 percent of Medicaid
1265premium revenue on long-term care services, including direct
1266care management as determined by the agency shall be required to
1267pay back the amount of the difference between actual spending
1268and 85 percent of Medicaid premium revenue.
1269     (c)  Plans that spend more than 92 percent of Medicaid
1270premium revenue on long-term care services, including direct
1271care management as determined by the agency, shall be evaluated
1272by the agency to determine whether higher expenditures are the
1273result of failures in care management.
1274     (d)  Plans that spend 95 percent or more of Medicaid
1275premium revenue on long-term care services, including direct
1276care management as determined by the agency, and are determined
1277to be failing to appropriately manage care shall be excluded
1278from automatic enrollments.
1279     (2)  PROVIDER NETWORKS.-Plans may limit the providers in
1280their networks based on credentials, quality indicators, and
1281price. However, in the first contract period after a qualified
1282plan is selected in a region by the agency, the plan must offer
1283a network contract to the following providers in the region:
1284     (a)  Nursing homes.
1285     (b)  Hospices.
1286     (c)  Aging network service providers that have previously
1287participated in home and community-based waivers serving elders
1288or community-service programs administered by the Department of
1289Elderly Affairs.
1290
1291After 12 months of active participation in a plan's network, the
1292plan may exclude any of the providers named in this subsection
1293from the network for failure to meet quality or performance
1294criteria. If the plan excludes a provider from the plan, the
1295plan must provide written notice to all recipients who have
1296chosen that provider for care. The notice shall be provided at
1297least 30 days prior to the effective date of the exclusion.
1298     (3)  SELECT PROVIDER PARTICIPATION.-Except as provided in
1299this subsection, providers may limit the plans they join.
1300Nursing homes and hospices must participate in all qualified
1301plans selected by the agency in the region in which the provider
1302is located.
1303     (4) PERFORMANCE MEASUREMENT.-Each plan shall monitor the
1304quality and performance of each participating provider. At the
1305beginning of the contract period, each plan shall notify all its
1306network providers of the metrics used by the plan for evaluating
1307the provider's performance and determining continued
1308participation in the network.
1309     (5)  PROVIDER NETWORK STANDARDS.-The agency shall establish
1310and each plan must comply with specific standards for the
1311number, type, and regional distribution of providers in the
1312plan's network, which must include:
1313     (a)  Adult day centers.
1314     (b)  Adult family care homes.
1315     (c)  Assisted living facilities.
1316     (d)  Health care services pools.
1317     (e)  Home health agencies.
1318     (f)  Homemaker and companion services.
1319     (g)  Hospices.
1320     (h)  Community Care for the Elderly Lead Agencies.
1321     (i)  Nurse registries.
1322     (j)  Nursing homes.
1323     (6) PROVIDER PAYMENT.-Plans and providers shall negotiate
1324mutually acceptable rates, methods, and terms of payment. Plans
1325shall pay nursing homes an amount equal to the nursing facility-
1326specific payment rates set by the agency. Plans shall pay
1327hospice providers an amount equal to the per diem rate set by
1328the agency. For recipients residing in a nursing facility and
1329receiving hospice services, the plan shall pay the hospice
1330provider the per diem rate set by the agency minus the nursing
1331facility component and shall pay the nursing facility the
1332appropriate state rate.
1333     Section 24.  Section 409.983, Florida Statutes, is created
1334to read:
1335     409.983  Managed care plan payment.-In addition to the
1336payment provisions of s. 409.968, the agency shall provide
1337payment to plans in the long-term care managed care program
1338pursuant to this section.
1339     (1)  Prepaid payment rates for long-term care managed care
1340plans shall be negotiated between the agency and the qualified
1341plans as part of the procurement described in s. 409.966.
1342     (2)  Payment rates for comprehensive long-term care plans
1343covering services described in s. 409.973 shall be combined with
1344rates for long-term care plans for services specified in s.
1345409.980.
1346     (3)  Payment rates for plans shall reflect historic
1347utilization and spending for covered services projected forward
1348and adjusted to reflect the level of care profile for enrollees
1349of each plan. The payment shall be adjusted to provide an
1350incentive for reducing institutional placements and increasing
1351the utilization of home and community-based services.
1352     (4)  The initial assessment of an enrollee's level of care
1353shall be made by the Comprehensive Assessment and Review for
1354Long-Term-Care Services (CARES) program, which shall assign the
1355recipient into one of the following levels of care:
1356     (a)  Level of care 1 consists of recipients residing in
1357nursing homes or needing immediate placement in a nursing home.
1358     (b)  Level of care 2 consists of recipients who require the
1359constant availability of routine medical and nursing treatment
1360and care, and require extensive health-related care and services
1361because of mental or physical incapacitation.
1362     (c)  Level of care 3 consists of recipients who require the
1363constant availability of routine medical and nursing treatment
1364and care, have a limited need for health-related care and
1365services, are mildly medically or physically incapacitated, and
1366have a priority score of 5 or above.
1367
1368The agency shall periodically adjust payment rates to account
1369for changes in the level of care profile for each plan based on
1370encounter data.
1371     (5)  The incentive adjustment for reducing institutional
1372placements shall be modified in each successive rate period
1373during the contract in order to encourage a progressive
1374rebalancing of the spending distribution for institutional and
1375community services. The expected change toward more home and
1376community-based services shall be at least a 3 percent, up to a
13775 percent, annual increase in the ratio of home and community-
1378based service expenditures compared to nursing facility
1379expenditures.
1380     (6)  The agency shall establish nursing facility-specific
1381payment rates for each licensed nursing home based on facility
1382costs adjusted for inflation and other factors. Payments to
1383long-term care managed care plans shall be reconciled to
1384reimburse actual payments to nursing facilities.
1385     (7)  The agency shall establish hospice payment rates.
1386Payments to long-term care managed care plans shall be
1387reconciled to reimburse actual payments to hospices.
1388     Section 25.  Section 409.984, Florida Statutes, is created
1389to read:
1390     409.984  Choice counseling; enrollment.-
1391     (1) CHOICE COUNSELING.-Before contracting with a vendor to
1392provide choice counseling as authorized under s. 409.969, the
1393agency shall offer to contract with aging resource centers
1394established under s. 430.2053 for choice counseling services. If
1395the aging resource center is determined not to be the vendor
1396that provides choice counseling, the agency shall establish a
1397memorandum of understanding with the aging resource center to
1398coordinate staffing and collaborate with the choice counseling
1399vendor.
1400     (2)  AUTOMATIC ENROLLMENT.-The agency shall automatically
1401enroll into a long-term care managed care plan those Medicaid
1402recipients who do not voluntarily choose a plan pursuant to s.
1403409.969. The agency shall automatically enroll recipients in
1404plans that meet or exceed the performance or quality standards
1405established pursuant to s. 409.967, and shall not automatically
1406enroll recipients in a plan that is deficient in those
1407performance or quality standards. The agency shall assign
1408individuals who are deemed dually eligible for Medicaid and
1409Medicare to a plan that provides both Medicaid and Medicare
1410services. The agency may not engage in practices that are
1411designed to favor one managed care plan over another. When
1412automatically enrolling recipients in plans, the agency shall
1413take into account the following criteria:
1414     (a)  Whether the plan has sufficient network capacity to
1415meet the needs of the recipients.
1416     (b)  Whether the recipient has previously received services
1417from one of the plan's home and community-based service
1418providers.
1419     (c)  Whether the home and community-based providers in one
1420plan are more geographically accessible to the recipient's
1421residence than those in other plans.
1422     (3)  Notwithstanding the provisions of s. 409.969(3)(c),
1423when a recipient is referred for hospice services, the recipient
1424shall have a 30-day period during which the recipient may select
1425to enroll in another plan to access the hospice provider of the
1426recipient's choice.
1427     Section 26.  Section 409.985, Florida Statutes, is created
1428to read:
1429     409.985  Comprehensive Assessment and Review for Long-Term
1430Care Services (CARES) Program.-
1431     (1)  The agency shall operate the Comprehensive Assessment
1432and Review for Long-Term Care Services (CARES) preadmission
1433screening program to ensure that only individuals whose
1434conditions require long-term care services are enrolled in the
1435long-term care managed care program.
1436     (2)  The agency shall operate the CARES program through an
1437interagency agreement with the Department of Elderly Affairs.
1438The agency, in consultation with the Department of Elderly
1439Affairs, may contract for any function or activity of the CARES
1440program, including any function or activity required by 42
1441C.F.R. part 483.20, relating to preadmission screening and
1442review.
1443     (3)  The CARES program shall determine if an individual
1444requires nursing facility care and, if the individual requires
1445such care, assign the individual to a level of care as described
1446in s. 409.983(4). For the purposes of the long-term care managed
1447care program, "nursing facility care" means the individual:
1448     (a)  Requires the constant availability of routine medical
1449and nursing treatment and care, and requires extensive health-
1450related care and services because of mental or physical
1451incapacitation; or
1452     (b)  Requires the constant availability of routine medical
1453and nursing treatment and care, has a limited need for health-
1454related care and services, is mildly medically or physically
1455incapacitated, and has a priority score of 5 or above.
1456     (4)  For individuals whose nursing home stay is initially
1457funded by Medicare and Medicare coverage is being terminated for
1458lack of progress towards rehabilitation, CARES staff shall
1459consult with the person making the determination of progress
1460toward rehabilitation to ensure that the recipient is not being
1461inappropriately disqualified from Medicare coverage. If, in
1462their professional judgment, CARES staff believes that a
1463Medicare beneficiary is still making progress toward
1464rehabilitation, they may assist the Medicare beneficiary with an
1465appeal of the disqualification from Medicare coverage. The use
1466of CARES teams to review Medicare denials for coverage under
1467this section is authorized only if it is determined that such
1468reviews qualify for federal matching funds through Medicaid. The
1469agency shall seek or amend federal waivers as necessary to
1470implement this section.
1471     Section 27.  Section 409.986, Florida Statutes, is created
1472to read:
1473     409.986  Managed long-term care for persons with
1474developmental disabilities.-
1475     (1)  Pursuant to s. 409.963, the agency is responsible for
1476administering the long-term care managed care program for
1477persons with developmental disabilities described in ss.
1478409.986-409.992, but may delegate specific duties and
1479responsibilities for the program to the Agency for Persons with
1480Disabilities and other state agencies. By January 1, 2014, the
1481agency shall begin implementation of statewide long-term care
1482managed care for persons with developmental disabilities, with
1483full implementation in all regions by October 1, 2015.
1484     (2)  The agency shall make payments for long-term care for
1485persons with developmental disabilities, including home and
1486community-based services, using a managed care model. Unless
1487otherwise specified, the provisions of ss. 409.961-409.970 apply
1488to the long-term care managed care program for persons with
1489developmental disabilities.
1490     (3)  The Agency for Persons with Disabilities shall assist
1491the agency to develop the specifications for use in the
1492invitations to negotiate and the model contract; determine
1493clinical eligibility for enrollment in long-term care plans for
1494persons with developmental disabilities; assist the agency to
1495monitor plan performance and measure quality; assist clients and
1496families to address complaints with the plans; facilitate
1497working relationships between plans and providers serving
1498persons with developmental disabilities; and perform other
1499functions specified in a memorandum of agreement.
1500     Section 28.  Section 409.987, Florida Statutes, is created
1501to read:
1502     409.987  Eligibility.-
1503     (1)  Medicaid recipients who meet all of the following
1504criteria are eligible to be enrolled in a developmental
1505disabilities comprehensive long-term care plan or developmental
1506disabilities long-term care plan:
1507     (a)  Medicaid eligible pursuant to income and asset tests
1508in state and federal law.
1509     (b)  A Florida resident who has a developmental disability
1510as defined in s. 393.063.
1511     (c)  Meets the level of care need including:
1512     1.  The recipient's intelligence quotient is 59 or less;
1513     2.  The recipient's intelligence quotient is 60-69,
1514inclusive, and the recipient has a secondary handicapping
1515condition that includes cerebral palsy, spina bifida, Prader-
1516Willi syndrome, epilepsy, or autism; or ambulation, sensory,
1517chronic health, and behavioral problems;
1518     3.  The recipient's intelligence quotient is 60-69,
1519inclusive, and the recipient has severe functional limitations
1520in at least three major life activities including self-care,
1521learning, mobility, self-direction, understanding and use of
1522language, and capacity for independent living; or
1523     4.  The recipient is eligible under a primary disability of
1524autism, cerebral palsy, spina bifida, or Prader-Willi syndrome.
1525In addition, the condition must result in substantial functional
1526limitations in three or more major life activities, including
1527self-care, learning, mobility, self-direction, understanding and
1528use of language, and capacity for independent living.
1529     (d)  Meets the level of care need for services in an
1530intermediate care facility for the developmentally disabled.
1531     (e)  Is enrolled or has been offered enrollment in one of
1532the four tier waivers established in s. 393.0661(3) or the
1533recipient is a Medicaid-funded resident of a private
1534intermediate care facility for the developmentally disabled on
1535the date the managed long-term care plans for persons with
1536disabilities become available in the recipient's region or the
1537recipient has been offered enrollment in a developmental
1538disabilities comprehensive long-term care plan or developmental
1539disabilities long-term care plan.
1540     (2)  Unless specifically exempted, all eligible persons
1541must be enrolled in a developmental disabilities comprehensive
1542long-term care plan or a developmental disabilities long-term
1543care plan. Medicaid recipients who are residents of a
1544developmental disability center, including Sunland Center in
1545Marianna and Tacachale Center in Gainesville, are exempt from
1546mandatory enrollment but may voluntarily enroll in a long-term
1547care plan.
1548     Section 29.  Section 409.988, Florida Statutes, is created
1549to read:
1550     409.988  Benefits.-Managed care plans shall cover, at a
1551minimum, the services in this section. Plans may customize
1552benefit packages or offer additional benefits to meet the needs
1553of enrollees in the plan.
1554     (1)  Intermediate care for the developmentally disabled.
1555     (2)  Alternative residential services, including, but not
1556limited to:
1557     (a)  Group homes and foster care homes licensed pursuant to
1558chapters 393 and 409.
1559     (b)  Comprehensive transitional education programs licensed
1560pursuant to chapter 393.
1561     (c)  Residential habilitation centers licensed pursuant to
1562chapter 393.
1563     (d)  Assisted living facilities, and transitional living
1564facilities licensed pursuant to chapters 400 and 429.
1565     (3)  Adult day training.
1566     (4)  Behavior analysis services.
1567     (5)  Companion services.
1568     (6)  Consumable medical supplies.
1569     (7)  Durable medical equipment and supplies.
1570     (8)  Environmental accessibility adaptations.
1571     (9)  In-home support services.
1572     (10)  Therapies, including occupational, speech,
1573respiratory, and physical therapy.
1574     (11)  Personal care assistance.
1575     (12)  Residential habilitation services.
1576     (13)  Intensive behavioral residential habilitation
1577services.
1578     (14)  Behavior focus residential habilitation services.
1579     (15)  Residential nursing services.
1580     (16)  Respite care.
1581     (17)  Case management.
1582     (18)  Supported employment.
1583     (19)  Supported living coaching.
1584     (20)  Transportation.
1585     Section 30.  Section 409.989, Florida Statutes, is created
1586to read:
1587     409.989  Qualified plans.-
1588     (1)  QUALIFIED PLANS.-Qualified plans that are a provider
1589service network or the Children's Medical Services Network
1590authorized under chapter 391 may be either developmental
1591disabilities long-term care plans that cover benefits pursuant
1592to s. 409.988, or developmental disabilities comprehensive long-
1593term care plans that cover benefits pursuant to ss. 409.973 and
1594409.988. Other qualified plans may only be developmental
1595disabilities comprehensive long-term care plans that cover
1596benefits pursuant to ss. 409.973 and 409.988.
1597     (2)  SPECIALTY PROVIDER SERVICE NETWORKS.-Provider service
1598networks targeted to serve persons with disabilities must
1599include one or more owners licensed pursuant to s. 393.067 or s.
1600400.962 and with at least 10 years experience in serving this
1601population.
1602     (3)  QUALIFIED PLAN SELECTION.-The agency shall select
1603qualified plans through the procurement described in s. 409.966.
1604The agency shall notice invitations to negotiate no later than
1605January 1, 2014.
1606     (a)  The agency shall procure two plans for Region I. At
1607least one plan shall be a provider service network, if any
1608submit a responsive bid.
1609     (b)  The agency shall procure at least two and no more than
1610five plans for Region II. At least one plan shall be a provider
1611service network, if any submit a responsive bid.
1612     (c)  The agency shall procure at least three plans and no
1613more than six plans for Region III. At least one plan shall be a
1614provider service network, if any submit a responsive bid.
1615     (d)  The agency shall procure at least three plans and no
1616more than six plans for Region IV. At least one plan shall be a
1617provider service network if any submit a responsive bid.
1618     (e)  The agency shall procure at least three plans and no
1619more than six plans for Region V. At least one plan shall be a
1620provider service network, if any submit a responsive bid.
1621     (f)  The agency shall procure at least three plans and no
1622more than six plans for Region VI. At least one plan shall be a
1623provider service network, if any submit a responsive bid.
1624If no provider service network submits a responsive bid, the
1625agency shall procure no more than one less than the maximum
1626number of qualified plans permitted in that region. Within 12
1627months after the initial invitation to negotiate, the agency
1628shall attempt to procure a qualified plan that is a provider
1629service network. The agency shall notice another invitation to
1630negotiate only with provider service networks in such region
1631where no provider service network has been selected.
1632     (4)  QUALITY SELECTION CRITERIA.-In addition to the
1633criteria established in s. 409.966, the agency shall consider
1634the following factors in the selection of qualified plans:
1635     (a)  Specialized staffing. Plan employment of executive
1636managers with expertise and experience in serving persons with
1637developmental disabilities.
1638     (b)  Network qualifications. Plan establishment of a
1639network of service providers dispersed throughout the region and
1640in sufficient numbers to meet specific accessibility standards
1641established by the agency for specialty services for persons
1642with developmental disabilities.
1643     (c)  Whether the plan has proposed to be a developmental
1644disabilities comprehensive long-term care plan and has a
1645contract to provide managed medical assistance services in the
1646same region. The agency shall exercise a preference for such
1647plans.
1648     (d)  Whether the plan offers consumer-directed care
1649services to enrollees pursuant to s. 409.221. Consumer-directed
1650care services provide a flexible budget which is managed by
1651enrolled individuals and their families or representatives and
1652allows them to choose providers of services, determine provider
1653rates of payment and direct the delivery of services to best
1654meet their special long-term care needs. When all other factors
1655are equal among competing qualified plans, the agency shall
1656exercise a preference for such plans.
1657     (e)  Evidence that a qualified plan has written agreements
1658or signed contracts or has made substantial progress in
1659establishing relationships with providers prior to the plan
1660submitting a response. The agency shall evaluate and give
1661special weight to evidence of signed contracts with providers of
1662critical services pursuant to s. 409.990(2)a)-(b).
1663     (5)  CHILDREN'S MEDICAL SERVICES NETWORK.-The Children's
1664Medical Services Network authorized under chapter 391 is a
1665qualified plan for purposes of the developmental disabilities
1666long-term care plans and developmental disabilities
1667comprehensive long-term care plans. Participation by the
1668Children's Medical Services Network shall be pursuant to a
1669single, statewide contract with the agency not subject to the
1670procurement requirements or regional plan number limits of this
1671section. The Children's Medical Services Network must meet all
1672other plan requirements.
1673     Section 31.  Section 409.990, Florida Statutes, is created
1674to read:
1675     409.990  Managed care plan accountability.-In addition to
1676the requirements of s. 409.967, qualified plans and providers
1677shall comply with the requirements of this section.
1678     (1)  MEDICAL LOSS RATIO.-The agency shall establish and
1679plans shall use a uniform method of accounting and reporting
1680long-term care service costs, direct care management costs, and
1681administrative costs. The agency shall evaluate plan spending
1682patterns beginning after the plan completes 2 full years of
1683operation and at least annually thereafter. The agency shall
1684implement the following thresholds and consequences of various
1685spending patterns:
1686     (a)  Plans that spend less than 75 percent of Medicaid
1687premium revenue on long-term care services, including direct
1688care management as determined by the agency shall be excluded
1689from automatic enrollments and shall be required to pay back the
1690amount between actual spending and 92 percent of the Medicaid
1691premium revenue.
1692     (b)  Plans that spend less than 92 percent of Medicaid
1693premium revenue on long-term care services, including direct
1694care management as determined by the agency shall be required to
1695pay back the amount between actual spending and 92 percent of
1696the Medicaid premium revenue.
1697     (2)  PROVIDER NETWORKS.-Plans may limit the providers in
1698their networks based on credentials, quality indicators, and
1699price. However, in the first contract period after a qualified
1700plan is selected in a region by the agency, the plan must offer
1701a network contract to the following providers in the region:
1702     (a)  Providers with licensed institutional care facilities
1703for the developmentally disabled.
1704     (b)  Providers of alternative residential facilities
1705specified in s.409.988.
1706
1707After 12 months of active participation in a plan's network, the
1708plan may exclude any of the above-named providers from the
1709network for failure to meet quality or performance criteria. If
1710the plan excludes a provider from the plan, the plan must
1711provide written notice to all recipients who have chosen that
1712provider for care. The notice shall be issued at least 90 days
1713before the effective date of the exclusion.
1714     (3)  SELECT PROVIDER PARTICIPATION.-Except as provided in
1715this subsection, providers may limit the plans they join.
1716Licensed institutional care facilities for the developmentally
1717disabled with an active Medicaid provider agreement must agree
1718to participate in any qualified plan selected by the agency in
1719the region in which the provider is located.
1720     (4)  PERFORMANCE MEASUREMENT.-Each plan shall monitor the
1721quality and performance of each participating provider. At the
1722beginning of the contract period, each plan shall notify all its
1723network providers of the metrics used by the plan for evaluating
1724the provider's performance and determining continued
1725participation in the network.
1726     (5)  PROVIDER PAYMENT.-Plans and providers shall negotiate
1727mutually acceptable rates, methods, and terms of payment. Plans
1728shall pay intermediate care facilities for the developmentally
1729disabled an amount equal to the facility-specific payment rate
1730set by the agency.
1731     (6)  CONSUMER AND FAMILY INVOLVEMENT.-Plans must establish
1732a family advisory committee to participate in program design and
1733oversight.
1734     Section 32.  Section 409.991, Florida Statutes, is created
1735to read:
1736     409.991  Managed care plan payment.-In addition to the
1737payment provisions of s. 409.968, the agency shall provide
1738payment to developmental disabilities comprehensive long-term
1739care plans and developmental disabilities long-term care plans
1740pursuant to this section.
1741     (1)  Prepaid payment rates shall be negotiated between the
1742agency and the qualified plans as part of the procurement
1743described in s. 409.966.
1744     (2)  Payment for developmental disabilities comprehensive
1745long-term care plans covering services pursuant to s. 409.973
1746shall be combined with payments for developmental disabilities
1747long-term care plans for services specified in s. 409.988.
1748     (3)  Payment rates for plans covering service specified in
1749s. 409.988 shall be based on historical utilization and spending
1750for covered services projected forward and adjusted to reflect
1751the level of care profile of each plan's enrollees.
1752     (4)  The Agency for Persons with Disabilities shall conduct
1753the initial assessment of an enrollee's level of care. The
1754evaluation of level of care shall be based on assessment and
1755service utilization information from the most recent version of
1756the Questionnaire for Situational Information and encounter
1757data.
1758     (5)  Payment rates for developmental disabilities long-term
1759care plans shall be classified into five levels of care to
1760account for variations in risk status and service needs among
1761enrollees.
1762     (a)  Level of care 1 consists of individuals receiving
1763services in an intermediate care facility for the
1764developmentally disabled.
1765     (b)  Level of care 2 consists of individuals with intensive
1766medical or adaptive needs and that are essential for avoiding
1767institutionalization, or who possess behavioral problems that
1768are exceptional in intensity, duration, or frequency and present
1769a substantial risk of harm to themselves or others.
1770     (c)  Level of care 3 consists of individuals with service
1771needs, including a licensed residential facility and a moderate
1772level of support for standard residential habilitation services
1773or a minimal level of support for behavior focus residential
1774habilitation services, or individuals in supported living who
1775require more than 6 hours a day of in-home support services.
1776     (d)  Level of care 4 consists of individuals requiring less
1777than moderate level of residential habilitation support in a
1778residential placement, or individuals in independent or
1779supported living situations, or who live in their family home.
1780     (e)  Level of care 5 consists of individuals requiring
1781minimal support services while living in independent or
1782supported living situations and individuals who live in their
1783family home.
1784
1785The agency shall periodically adjust payment rates to account
1786for changes in the level of care profile of each plan's
1787enrollees based on encounter data.
1788     (6)  The agency shall establish intensive behavior
1789residential habilitation rates for providers approved by the
1790agency to provide this service. The agency shall also establish
1791intermediate care facility for the developmentally disabled-
1792specific payment rates for each licensed intermediate care
1793facility based on facility costs adjusted for inflation and
1794other factors. Payments to intermediate care facilities for the
1795developmentally disabled and providers of intensive behavior
1796residential habilitation service shall be reconciled to
1797reimburse the plan's actual payments to the facilities.
1798     Section 33.  Section 409.992, Florida Statutes, is created
1799to read:
1800     409.992  Automatic enrollment.-
1801     (1)  The agency shall automatically enroll into a
1802developmental disabilities comprehensive long-term care plan or
1803a developmental disabilities long-term care plan those Medicaid
1804recipients who do not voluntarily choose a plan pursuant to s.
1805409.969. The agency shall automatically enroll recipients in
1806plans that meet or exceed the performance or quality standards
1807established pursuant to s. 409.967, and shall not automatically
1808enroll recipients in a plan that is deficient in those
1809performance or quality standards. The agency shall assign
1810individuals who are deemed dually eligible for Medicaid and
1811Medicare, to a plan that provides both Medicaid and Medicare
1812services. The agency may not engage in practices that are
1813designed to favor one managed care plan over another. When
1814automatically enrolling recipients in plans, the agency shall
1815take into account the following criteria:
1816     (a)  Whether the plan has sufficient network capacity to
1817meet the needs of the recipients.
1818     (b)  Whether the recipient has previously received services
1819from one of the plan's home and community-based service
1820providers.
1821     (c)  Whether home and community-based providers in one plan
1822are more geographically accessible to the recipient's residence
1823than those in other plans.
1824     Section 34.  This act shall take effect July 1, 2010.


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