HB 1403

1	A bill to be entitled
2	An act relating to Medicaid managed care; providing a
3	short title; creating the "Independence at Home Act";
4	providing legislative findings; directing the Agency for
5	Health Care Administration to establish an Independence at
6	Home Chronic Care Coordination Pilot Project; providing
7	for Independence at Home programs within the pilot
8	project; specifying objectives of the programs; providing
9	for implementation and independent evaluation of the pilot
10	project; providing eligibility criteria for participation;
11	providing rulemaking authority to the agency; providing
12	for best-practices teleconferences; providing definitions;
13	providing for enrollment of program participants;
14	providing program requirements; providing requirements for
15	plan development; providing terms and conditions of
16	agreements between the agency and Independence at Home
17	organizations; requiring a report to the Legislature;
18	establishing quality, performance, and participation
19	standards; providing for terms, modification, termination,
20	and nonrenewal of agreements; requiring mandatory minimum
21	savings and for computation thereof; providing a waiver of
22	coinsurance for house calls; providing an effective date.
23
24	Be It Enacted by the Legislature of the State of Florida:
25
26	Section 1.  Short title.-This act may be cited as the
27	"Independence at Home Act."
28	Section 2.  Legislative findings.-The Legislature finds,
29	pursuant to the November 2007 Congressional Budget Office's
30	Long-Term Outlook for Health Care Spending, that:
31	(1)  Unless changes are made to the way health care is
32	delivered, the growing demand for resources caused by rising
33	health care costs and, to a lesser extent, the nation's
34	expanding elderly and chronically ill population will confront
35	Floridians with increasingly difficult choices between health
36	care and other priorities. However, opportunities exist to
37	constrain health care costs without adverse health care
38	consequences.
39	(2)  Medicaid beneficiaries with multiple chronic
40	conditions account for a disproportionate share of Medicaid
41	spending compared to their representation in the overall
42	Medicaid population, and evidence suggests that such patients
43	often receive poorly coordinated care, including conflicting
44	information from health providers and different diagnoses of the
45	same symptoms.
46	(3)  People with chronic conditions account for 76 percent
47	of all hospital admissions, 88 percent of all prescriptions
48	filled, and 72 percent of physician visits.
49	(4)  Hospital utilization and emergency room visits for
50	patients with multiple chronic conditions can be reduced and
51	significant savings can be achieved through the use of
52	interdisciplinary teams of health care professionals caring for
53	patients in their places of residence.
54	Section 3.  Independence at Home Act; purpose.-The purpose
55	of the Independence at Home Act is to:
56	(1)  Create a chronic care coordination pilot project to
57	bring primary care medical services to the highest cost Medicaid
58	beneficiaries with multiple chronic conditions in their home or
59	place of residence so that they may be as independent as
60	possible for as long as possible in a comfortable setting.
61	(2)  Generate savings by providing better, more coordinated
62	care across all treatment settings to the highest cost Medicaid
63	beneficiaries with multiple chronic conditions, reducing
64	duplicative and unnecessary services, and avoiding unnecessary
65	hospitalizations, nursing home admissions, and emergency room
66	visits.
67	(3)  Hold providers accountable for improving beneficiary
68	outcomes, ensuring patient and caregiver satisfaction, and
69	achieving cost savings to Medicaid on an annual basis.
70	(4)  Create incentives for practitioners and providers to
71	develop methods and technologies for providing better and lower
72	cost health care to the highest cost Medicaid beneficiaries with
73	the greatest incentives provided in the case of highest cost
74	Medicaid beneficiaries.
75	(5)  Contain the central elements of proven home-based
76	primary care delivery models that have been utilized for years
77	by the United States Department of Veterans Affairs and its
78	house calls program to deliver coordinated care for chronic
79	conditions in the comfort of the patient's home or place of
80	residence.
81	Section 4.  Independence at Home Chronic Care Coordination
82	Pilot Project.-
83	(1)  IMPLEMENTATION BY THE AGENCY FOR HEALTH CARE
84	ADMINISTRATION.-The Secretary of Health Care Administration
85	shall provide for the phased-in development, implementation, and
86	evaluation of the Independence at Home Chronic Care Coordination
87	Pilot Project described in this section to meet the following
88	objectives:
89	(a)  To improve patient outcomes, compared to outcomes
90	achieved by comparable beneficiaries who do not participate in
91	such a program, through reduced hospitalizations, nursing home
92	admissions, and emergency room visits and increased symptom
93	self-management and other similar results.
94	(b)  To improve patient and caregiver satisfaction, as
95	demonstrated through a quantitative pretest and posttest survey
96	developed by the agency that measures patient and caregiver
97	satisfaction relating to coordination of care, provision of
98	educational information, timeliness of response, and similar
99	care features.
100	(c)  To achieve a minimum of 5 percent cost savings
101	associated with the care of Medicaid beneficiaries served under
102	this program who suffer from multiple high-cost chronic
103	diseases.
104	(2)  INITIAL IMPLEMENTATION; PHASE I.-
105	(a)  For the purpose of carrying out this section and to
106	the extent possible, the Agency for Health Care Administration
107	shall enter into agreements with at least two unaffiliated
108	Independence at Home organizations in each county in the state
109	to provide chronic care coordination services for a period of 3
110	years or until those agreements are terminated by the agency.
111	Agreements under this paragraph shall continue in effect until
112	the agency makes a determination pursuant to subsection (3) or
113	until those agreements are supplanted by new agreements entered
114	into under subsection (3).
115	(b)  In selecting an Independence at Home organization
116	under this subsection, the agency shall give a preference to the
117	extent practicable to an organization that:
118	1.  Has documented experience in furnishing the types of
119	services covered under this subsection to eligible beneficiaries
120	in their home or place of residence using qualified teams of
121	health care professionals who are under the direction of a
122	qualified Independence at Home physician or, in a case when such
123	direction is provided by an Independence at Home physician to a
124	physician assistant who has at least 1 year of experience
125	providing medical and related services for chronically ill
126	individuals in their homes, or other similar qualifications as
127	determined by the agency to be appropriate for the Independence
128	at Home program, by the physician assistant acting under the
129	supervision of an Independence at Home physician and as
130	permitted under state law, or by an Independence at Home nurse
131	practitioner;
132	2.  Has the capacity to provide services covered by this
133	section to at least 150 eligible Medicaid beneficiaries; and
134	3.  Uses electronic medical records, health information
135	technology, and individualized plans of care.
136	(3)  EXPANDED IMPLEMENTATION; PHASE II.-
137	(a)  For periods beginning after the end of the 3-year
138	initial implementation period under subsection (2), and subject
139	to paragraph (b), the agency shall renew agreements described in
140	subsection (2) with an Independence at Home organization that
141	has met all the objectives specified in subsection (1) and enter
142	into agreements described in subsection (2) with any other
143	organization located in the state that was not an Independence
144	at Home organization during the initial implementation period
145	and meets the qualifications for an Independence at Home
146	organization under this section. The agency may terminate and
147	decline to renew an agreement with an organization that has not
148	met those objectives during the initial implementation period.
149	(b)  The expanded implementation under paragraph (a) may
150	not occur if the agency finds, not later than 60 days after the
151	date of issuance of the independent evaluation under subsection
152	(5), that continuation of the Independence at Home Chronic Care
153	Coordination Pilot Project is not in the best interest of
154	Medicaid beneficiaries participating under this section.
155	(4)  ELIGIBILITY.-An organization is not prohibited from
156	participating under this section during the expanded
157	implementation phase under subsection (3) and, to the extent
158	practicable, during the initial implementation phase under
159	subsection (2) because of its small size as long as it meets the
160	eligibility requirements of this section.
161	(5)  INDEPENDENT EVALUATIONS.-
162	(a)  The agency shall contract for an independent
163	evaluation of the initial implementation phase under subsection
164	(2) and provide an interim report to the Legislature regarding
165	the evaluation as soon as practicable after the first year of
166	phase I and provide a final report to the Legislature as soon as
167	practicable following the conclusion of the phase I, but not
168	later than 6 months following the end of phase I. The evaluation
169	shall be conducted by individuals with knowledge of chronic care
170	coordination programs for the targeted patient population and
171	prior experience in the evaluation of such programs.
172	(b)  Each report shall include an assessment of the
173	following factors and shall identify the characteristics of
174	individual Independence at Home programs that are the most
175	effective in producing improvements in:
176	1.  Beneficiary, caregiver, and provider satisfaction.
177	2.  Health outcomes appropriate for patients with multiple
178	chronic diseases.
179	3.  Cost savings to the program under this section, such as
180	reductions in:
181	a.  Hospital and skilled nursing facility admission rates
182	and lengths of stay.
183	b.  Hospital readmission rates.
184	c.  Emergency department visits.
185	(c)  Each report shall include data on the performance of
186	Independence at Home organizations in responding to the needs of
187	eligible Medicaid beneficiaries with specific chronic conditions
188	and combinations of conditions and responding to the needs of
189	the overall eligible beneficiary population.
190	(6)  AGREEMENTS.-
191	(a)  Beginning not later than July 1, 2012, the agency
192	shall enter into agreements with Independence at Home
193	organizations that meet the participation requirements of this
194	section, including minimum performance standards developed under
195	subsection (17), in order to provide access by eligible Medicaid
196	beneficiaries to Independence at Home programs under this
197	section.
198	(b)  If the agency deems it necessary to serve the best
199	interest of the Medicaid beneficiaries under this section, the
200	agency may:
201	1.  Require screening of all potential Independence at Home
202	organizations, including owners, using fingerprinting, licensure
203	checks, site visits, or other database checks before entering
204	into an agreement.
205	2.  Require a provisional period during which a new
206	Independence at Home organization is subject to enhanced
207	oversight that may include prepayment review, unannounced site
208	visits, and payment caps.
209	3.  Require applicants to disclose any previous affiliation
210	with entities that have uncollected Medicaid debt and authorize
211	the denial of enrollment if the agency determines that these
212	affiliations pose undue risk to the program.
213	(7)  RULEMAKING.-At least 3 months before entering into the
214	first agreement under this section, the agency shall publish in
215	the Florida Administrative Weekly the specifications for
216	implementing this section. Such specifications shall describe
217	the implementation process from the initial through the final
218	implementation phases, including how the agency will identify
219	and notify potential enrollees and how and when a Medicaid
220	beneficiary may enroll, disenroll, of change enrollment in an
221	Independence at Home program.
222	(8)  PERIODIC PROGRESS REPORTS.-Semiannually during the
223	first year, and annually thereafter, during the period of
224	implementation of this section, the agency shall submit to the
225	appropriate committees of the House of Representatives and the
226	Senate a report that describes the progress of the
227	implementation of the pilot project and explains any variation
228	from the Independence at Home program model as described in this
229	section.
230	(9)  ANNUAL BEST PRACTICES TELECONFERENCE.-During the
231	initial implementation phase and to the extent practicable at
232	intervals thereafter, the agency shall provide for an annual
233	Independence at Home teleconference for Independence at Home
234	organizations to share best practices and review treatment
235	interventions and protocols that were successful in meeting the
236	objectives specified in subsection (1).
237	(10)  DEFINITIONS.-As used in this section, the term:
238	(a)  "Activities of daily living" means bathing, dressing,
239	grooming, transferring, feeding, or toileting.
240	(b)  "Caregiver" means, with respect to an individual with
241	a qualifying functional impairment, a family member, friend, or
242	neighbor who provides assistance to the individual.
243	(c)  "Chronic conditions" includes the following:
244	1.  Congestive heart failure.
245	2.  Diabetes.
246	3.  Chronic obstructive pulmonary disease.
247	4.  Ischemic heart disease.
248	5.  Peripheral arterial disease.
249	6.  Stroke.
250	7.  Alzheimer's disease and other forms of dementia
251	designated by the agency.
252	8.  Pressure ulcers.
253	9.  Hypertension.
254	10.  Myasthenia gravis.
255	11.  Neurodegenerative diseases designated by the agency
256	that result in high costs to the program, including amyotrophic
257	lateral sclerosis (ALS), multiple sclerosis, and Parkinson's
258	disease.
259	12.  Any other chronic condition that the agency identifies
260	as likely to result in high costs when such condition is present
261	in combination with one or more of the chronic conditions
262	specified in this paragraph.
263	(d)  "Disqualification" does not include an individual:
264	1.  Who resides in a setting that presents a danger to the
265	safety of in-home health care providers and primary caregivers;
266	or
267	2.  Whose enrollment in an Independence at Home program is
268	determined by the agency to be inappropriate.
269	(e)  "Eligible beneficiary" means, with respect to an
270	Independence at Home program, an individual who:
271	1.  Is entitled to benefits under the Florida Medicaid
272	program;
273	2.  Has a qualifying functional impairment and has been
274	diagnosed with two or more of the chronic conditions described
275	in paragraph (c); and
276	3.  Within the 12 months prior to the individual first
277	enrolling with an Independence at Home program under this
278	section, has received benefits under Medicare Part A for the
279	following services:
280	a.  Nonelective inpatient hospital services;
281	b.  Services in the emergency department of a hospital;
282	c.  Skilled nursing or subacute rehabilitation services in
283	a Medicaid-certified nursing facility;
284	d.  Comprehensive acute rehabilitation facility or
285	comprehensive outpatient rehabilitation facility services; or
286	e.  Skilled nursing or rehabilitation services through a
287	Medicaid-certified home health agency.
288	(f)  "Independence at Home assessment" means a
289	determination of eligibility of an individual for an
290	Independence at Home program as an eligible beneficiary and
291	includes a comprehensive medical history, physical examination,
292	and assessment of the beneficiary's clinical and functional
293	status that is conducted in person by an Independence at Home
294	physician or an Independence at Home nurse practitioner or by a
295	physician assistant, nurse practitioner, or clinical nurse
296	specialist who is employed by an Independence at Home
297	organization and is supervised by an Independence at Home
298	physician or Independence at Home nurse practitioner. The
299	individual conducting the assessment may not have an ownership
300	interest in the Independence at Home organization unless the
301	agency determines that it is impracticable to preclude such
302	individual's involvement. The assessment shall include an
303	evaluation of:
304	1.  Activities of daily living and other comorbidities.
305	2.  Medications and the client's adherence to medication
306	plans.
307	3.  Affect, cognition, executive function, and presence of
308	mental disorders.
309	4.  Functional status, including mobility, balance, gait,
310	risk of falling, and sensory function.
311	5.  Social functioning and social integration.
312	6.  Environmental needs and a safety assessment.
313	7.  The ability of the beneficiary's primary caregiver to
314	assist with the beneficiary's care as well as the caregiver's
315	own physical and emotional capacity, education, and training.
316	8.  Whether, in the professional judgment of the individual
317	conducting the assessment, the beneficiary is likely to benefit
318	from an Independence at Home program.
319	9.  Whether the conditions in the beneficiary's home or
320	place of residence would permit the safe provision of services
321	in the home or residence, respectively, under an Independence at
322	Home program.
323	10.  Whether the beneficiary has a designated primary care
324	physician whom the beneficiary has seen in an office-based
325	setting within the previous 12 months.
326	11.  Other factors determined appropriate for consideration
327	by the agency.
328	(g)  "Independence at Home care team" means a team of
329	qualified individuals that provides services to the participant
330	as part of an Independence at Home program. The term includes a
331	team consisting of an Independence at Home physician or an
332	Independence at Home nurse practitioner, working with an
333	Independence at Home coordinator, who may also be an
334	Independence at Home physician or an Independence at Home nurse
335	practitioner.
336	(h)  "Independence at Home coordinator" means an individual
337	who:
338	1.  Is employed by an Independence at Home organization and
339	is responsible for coordinating all of the services of the
340	participant's Independence at Home plan;
341	2.  Is a licensed health professional, such as a physician,
342	registered nurse, nurse practitioner, clinical nurse specialist,
343	physician assistant, or other health care professional as the
344	agency determines appropriate, who has at least 1 year of
345	experience providing and coordinating medical and related
346	services for individuals in their homes; and
347	3.  Serves as the primary point of contact responsible for
348	communications with the participant and for facilitating
349	communications with other health care providers under the plan.
350	(k)  "Independence at Home nurse practitioner" means a
351	nurse practitioner who:
352	1.  Is employed by or affiliated with an Independence at
353	Home organization or has another contractual relationship with
354	the Independence at Home organization that requires the nurse
355	practitioner to make in-home visits and to be responsible for
356	the plans of care for the nurse practitioner's patients;
357	2.  Practices in accordance with state law regarding scope
358	of practice for nurse practitioners;
359	3.  Is certified as:
360	a.  A gerontological nurse practitioner by the American
361	Academy of Nurse Practitioners Certification Program or the
362	American Nurses Credentialing Center; or
363	b.  A family nurse practitioner or adult nurse practitioner
364	by the American Academy of Nurse Practitioners Certification
365	Program or the American Nurses Credentialing Center and holds a
366	Certificate of Added Qualification in gerontology, elder care,
367	or care of the older adult provided by the American Academy of
368	Nurse Practitioners Certification Program, the American Nurses
369	Credentialing Center, or a national nurse practitioner
370	certification board deemed by the agency to be appropriate for
371	an Independence at Home program; and
372	4.  Has furnished services during the previous 12 months
373	for which payment is made under this section.
374	(i)  "Independence at Home organization" means a provider
375	of services, a physician or physician group practice which
376	receives payment for services furnished under Title XVIII of the
377	Social Security Act, rather than only under this section, and
378	which:
379	1.  Has entered into an agreement under subsection (6) to
380	provide an Independence at Home program under this section;
381	2.a.  Provides all of the services of the Independence at
382	Home plan in a participant's home or place of residence; or
383	b.  If the organization is not able to provide all such
384	services in the participant's home or residence, has adequate
385	mechanisms for ensuring the provision of such services by one or
386	more qualified entities;
387	3.  Has Independence at Home physicians, clinical nurse
388	specialists, nurse practitioners, or physician assistants
389	available to respond to patient emergencies 24 hours a day, 7
390	days a week;
391	4.  Accepts all eligible Medicaid beneficiaries from the
392	organization's service area, as determined under the agreement
393	with the agency under this section, except to the extent that
394	qualified staff are not available; and
395	5.  Meets other requirements for such an organization under
396	this section.
397	(j)  "Independence at Home physician" means a physician
398	who:
399	1.  Is employed by or affiliated with an Independence at
400	Home organization or has another contractual relationship with
401	the Independence at Home organization that requires the
402	physician to make in-home visits and be responsible for the
403	plans of care for the physician's patients;
404	2.  Is certified by:
405	a.  The American Board of Family Physicians, the American
406	Board of Internal Medicine, the American Osteopathic Board of
407	Family Physicians, the American Osteopathic Board of Internal
408	Medicine, the American Board of Emergency Medicine, or the
409	American Board of Physical Medicine and Rehabilitation; or
410	b.  A board recognized by the American Board of Medical
411	Specialties and determined by the agency to be appropriate for
412	the Independence at Home program;
413	3.  Has a certification in geriatric medicine as provided
414	by the American Board of Medical Specialties or has passed the
415	clinical competency examination of the American Academy of Home
416	Care Physicians and has substantial experience in the delivery
417	of medical care in the home, including at least 2 years of
418	experience in the management of Medicare or Medicaid patients
419	and 1 year of experience in home-based medical care, including
420	at least 200 house calls; and
421	4.  Has furnished services during the previous 12 months
422	for which payment is made under this section.
423	(l)  "Independence at Home plan" means a plan established
424	under subsection (13) for a specific participant in an
425	Independence at Home program.
426	(m)  "Independence at Home program" means a program
427	described in subsection (12) that is operated by an Independence
428	at Home organization.
429	(n)  "Participant" means an eligible beneficiary who has
430	voluntarily enrolled in an Independence at Home program.
431	(o)  "Qualified entity" means a person or organization that
432	is licensed or otherwise legally permitted to provide the
433	specific service provided under an Independence at Home plan
434	that the entity has agreed to provide.
435	(p)  "Qualified individual" means an individual who is
436	licensed or otherwise legally permitted to provide the specific
437	service under an Independence at Home plan that the individual
438	has agreed to provide.
439	(q)  "Qualifying functional impairment" means an inability
440	to perform, without the assistance of another person, three or
441	more activities of daily living.
442	(11)  IDENTIFICATION AND ENROLLMENT OF PROSPECTIVE PROGRAM
443	PARTICIPANTS.-
444	(a)  The agency shall develop a model notice to be made
445	available by participating providers and Independence at Home
446	programs to Medicaid beneficiaries, and their caregivers, who
447	are potentially eligible for an Independence at Home program.
448	The notice shall include the following information:
449	1.  A description of the potential advantages to the
450	beneficiary participating in an Independence at Home program.
451	2.  A description of the eligibility requirements to
452	participate.
453	3.  Notice that participation is voluntary.
454	4.  A statement that all other Medicaid benefits remain
455	available to Medicaid beneficiaries who enroll in an
456	Independence at Home program.
457	5.  Notice that those who enroll in an Independence at Home
458	program are responsible for copayments for house calls made by
459	Independence at Home physicians, physician assistants, or
460	Independence at Home nurse practitioners, except that such
461	copayments may be reduced or eliminated at the discretion of the
462	Independence at Home physician, physician assistant, or
463	Independence at Home nurse practitioner.
464	6.  A description of the services that may be provided.
465	7.  A description of the method for participating or
466	withdrawing from participation in an Independence at Home
467	program or becoming ineligible to participate.
468	(b)  An eligible beneficiary may participate in an
469	Independence at Home program through enrollment in the program
470	on a voluntary basis and may terminate participation at any
471	time. The beneficiary may also receive Independence at Home
472	services from the Independence at Home organization of the
473	beneficiary's choice but may not receive Independence at Home
474	services from more than one Independence at Home organization at
475	a time.
476	(12)  INDEPENDENCE at HOME PROGRAM REQUIREMENTS.-Each
477	Independence at Home program shall, for each participant
478	enrolled in the program:
479	(a)  Designate an Independence at Home coordinator and
480	either an Independence at Home physician or an Independence at
481	Home nurse practitioner.
482	(b)  Have a process to ensure that the participant receives
483	an Independence at Home assessment before enrollment in the
484	program.
485	(c)  With the participation of the participant, or the
486	participant's representative or caregiver, an Independence at
487	Home physician, a physician assistant under the supervision of
488	an Independence at Home physician, and, as permitted under state
489	law, an Independence at Home nurse practitioner, or the
490	Independence at Home coordinator, develop an Independence at
491	Home plan for the participant in accordance with subsection
492	(13).
493	(d)  Ensure that the participant receives an Independence
494	at Home assessment at least every 6 months after the original
495	assessment to ensure that the Independence at Home plan for the
496	participant remains current and appropriate.
497	(e)  Implement all of the services under the participant's
498	Independence at Home plan and, in instances in which the
499	Independence at Home organization does not provide specific
500	services within the Independence at Home plan, ensure that
501	qualified entities successfully provide those specific services.
502	(f)  Provide for an electronic medical record and
503	electronic health information technology to coordinate the
504	participant's care and to exchange information with the Medicaid
505	program and electronic monitoring and communication technologies
506	and mobile diagnostic and therapeutic technologies as
507	appropriate and accepted by the participant.
508	(13)  INDEPENDENCE at HOME PLAN.-
509	(a)  An Independence at Home plan for a participant shall
510	be developed with the participant, an Independence at Home
511	physician, a physician assistant under the supervision of an
512	Independence at Home physician and, as permitted under state
513	law, an Independence at Home nurse practitioner or an
514	Independence at Home coordinator, and, if appropriate, one or
515	more of the participant's caregivers and shall:
516	1.  Document the chronic conditions, comorbidities, and
517	other health needs identified in the participant's Independence
518	at Home assessment.
519	2.  Determine which services under an Independence at Home
520	plan described in paragraph (c) are appropriate for the
521	participant.
522	3.  Identify the qualified entity responsible for providing
523	each service under such plan.
524	(b)  If the individual responsible for conducting the
525	participant's Independence at Home assessment and developing the
526	Independence at Home plan is not the participant's Independence
527	at Home coordinator, the Independence at Home physician or
528	Independence at Home nurse practitioner is responsible for
529	ensuring that the participant's Independence at Home coordinator
530	has that plan, is familiar with the requirements of the plan,
531	and has the appropriate contact information for all of the
532	members of the Independence at Home care team.
533	(c)  An Independence at Home organization shall coordinate
534	and make available through referral to a qualified entity the
535	services described in subparagraphs 1.-3. to the extent they are
536	needed and covered under this section and shall provide the care
537	coordination services described in subparagraph 4. to the extent
538	they are appropriate and accepted by a participant. The services
539	provided are:
540	1.  Primary care services, such as physician visits and
541	diagnosis, treatment, and preventive services.
542	2.  Home health services, such as skilled nursing care and
543	physical and occupational therapy.
544	3.  Phlebotomy and ancillary laboratory and imaging
545	services, including point-of-care laboratory and imaging
546	diagnostics.
547	4.  Coordination of care services, consisting of:
548	a.  Monitoring and management of medications by a
549	pharmacist who is certified in geriatric pharmacy by the
550	Commission for Certification in Geriatric Pharmacy or possesses
551	other comparable certification demonstrating knowledge and
552	expertise in geriatric or chronic disease pharmacotherapy and
553	providing assistance to participants and their caregivers with
554	respect to selection of a prescription drug plan that best meets
555	the needs of the participant's chronic conditions.
556	b.  Coordination of all medical treatment furnished to the
557	participant, regardless of whether that treatment is covered and
558	available to the participant under this section.
559	c.  Self-care education and preventive care consistent with
560	the participant's condition.
561	d.  Education for primary caregivers and family members.
562	e.  Caregiver counseling services and information about and
563	referral to other caregiver support and health care services in
564	the community.
565	f.  Referral to social services that provide personal care,
566	meals, volunteers, and individual and family therapy.
567	g.  Information about and access to hospice care.
568	h.  Pain and palliative care and end-of-life care,
569	including information about developing advance directives and
570	physicians orders for life-sustaining treatment.
571	(14)  PRIMARY TREATMENT ROLE WITHIN AN INDEPENDENCE AT HOME
572	CARE TEAM.-An Independence at Home physician, a physician
573	assistant under the supervision of an Independence at Home
574	physician, and, as permitted under state law, an Independence at
575	Home nurse practitioner may assume the primary treatment role as
576	permitted under state law.
577	(15)  ADDITIONAL RESPONSIBILITIES.-
578	(a)  Each Independence at Home organization offering an
579	Independence at Home program shall monitor and report to the
580	agency, in a manner specified by the agency, on:
581	1.  Patient outcomes.
582	2.  Beneficiary, caregiver, and provider satisfaction with
583	respect to coordination of the participant's care.
584	3.  The achievement of mandatory minimum savings described
585	in subsection (21).
586	(b)  Each Independence at Home organization shall provide
587	the agency with listings of individuals employed by the
588	organization, including contract employees and individuals with
589	an ownership interest in the organization, and comply with such
590	additional requirements as the agency may specify.
591	(16)  TERMS AND CONDITIONS.-
592	(a)  An agreement under this section with an Independence
593	at Home organization shall contain such terms and conditions as
594	the agency may specify consistent with this section.
595	(b)  The agency may not enter into an agreement with an
596	Independence at Home organization under this section for the
597	operation of an Independence at Home program unless:
598	1.  The program and organization meet the requirements of
599	subsection (12), minimum quality and performance standards
600	developed under subsection (17), and such clinical, quality
601	improvement, financial, program integrity, and other
602	requirements as the agency deems to be appropriate for
603	participants to be served.
604	2.  The organization demonstrates to the satisfaction of
605	the agency that the organization is able to assume financial
606	risk for performance under the agreement with respect to
607	payments made to the organization under the agreement through
608	available reserves, reinsurance, or withholding of funding
609	provided under this section or through such other means as the
610	agency deems appropriate.
611	(17)  MINIMUM QUALITY AND PERFORMANCE STANDARDS.-The agency
612	shall develop mandatory minimum quality and performance
613	standards for Independence at Home organizations and programs
614	that are no more stringent that those established by the Centers
615	for Medicare and Medicaid Services. The standards shall require:
616	(a)  Improvement in participant outcomes and beneficiary,
617	caregiver, and provider satisfaction.
618	(b)  Cost savings consistent with the requirements of
619	subsection (20).
620	(c)  For any year after the first year, and except for a
621	program provided by the agency to serve a rural area, an average
622	of at least 150 participants during the previous year.
623	(18)  TERM OF AGREEMENT AND MODIFICATION.-The agreement
624	under this section shall be, subject to paragraph (17)(c) and
625	subsection (19), for a period of 3 years and the terms and
626	conditions may be modified during the contract period by the
627	agency as necessary to serve the best interest of the Medicaid
628	beneficiaries under this section or the best interest of federal
629	health care programs or upon the request of the Independence at
630	Home organization.
631	(19)  TERMINATION AND NONRENEWAL OF AGREEMENT.-
632	(a)  If the agency determines that an Independence at Home
633	organization has failed to meet the minimum performance
634	standards under paragraph (17)(c) or other requirements under
635	this section, or if the agency determines it necessary to serve
636	the best interest of the Medicaid beneficiaries under this
637	section or the best interest of federal health care programs,
638	the agency may terminate the agreement of the organization at
639	the end of the contract year.
640	(b)  The agency shall terminate an agreement with an
641	Independence at Home organization if the agency determines that
642	the care being provided by that organization poses a threat to
643	the health and safety of a participant.
644	(c)  Notwithstanding any other provision of this section,
645	an Independence at Home organization may terminate an agreement
646	with the agency to provide an Independence at Home program at
647	the end of a contract year if the organization provides
648	notification of the termination to the agency and the Medicaid
649	beneficiaries participating in the program at least 90 days
650	before the end of that contract year. Subsections (20) and (23)
651	and paragraphs (24)(b) and (c) shall apply to the organization
652	until the date of termination.
653	(d)  The agency shall notify the participants in an
654	Independence at Home program as soon as practicable if a
655	determination is made to terminate an agreement with the
656	Independence at Home organization involuntarily as provided in
657	paragraphs (a) and (b). The notice shall inform the beneficiary
658	of any other Independence at Home organizations that might be
659	available to the beneficiary.
660	(20)  MANDATORY MINIMUM SAVINGS.-
661	(a)  Pursuant to an agreement under this subsection, each
662	Independence at Home organization shall ensure that during any
663	year of the agreement for its Independence at Home program,
664	there is an aggregate savings in the cost to the program under
665	this section for participating Medicaid beneficiaries, as
666	calculated under paragraphs (c)-(e), that is not less than 5
667	percent of the product described in paragraph (b) for such
668	participating Medicaid beneficiaries and for that program year.
669	(b)  The product described in this subsection for
670	participating Medicaid beneficiaries in an Independence at Home
671	program for a year is the product of:
672	1.  The estimated average monthly costs that would have
673	been incurred under Florida Medicaid, other than those in the
674	Medicaid reform pilot program counties if those Medicaid
675	beneficiaries had not participated in the Independence at Home
676	program; and
677	2.  The number of participant-months for that year. For
678	purposes of this paragraph, the term "participant-month" means
679	each month or part of a month in a program year that a
680	beneficiary participates in an Independence at Home program.
681	(c)  The agency shall contract with a nongovernmental
682	organization or academic institution to independently develop an
683	analytical model for determining whether an Independence at Home
684	program achieves at least the savings required under paragraphs
685	(a) and (b) relative to costs that would have been incurred by
686	Medicaid in the absence of Independence at Home programs. The
687	analytical model developed by the independent research
688	organization for making these determinations shall utilize
689	state-of-the-art econometric techniques, such as Heckman's
690	selection correction methodologies, to account for sample
691	selection bias, omitted variable bias, or problems with
692	endogeneity.
693	(d)  Using the model developed under paragraph (c), the
694	agency shall compare the actual costs to Medicaid of
695	beneficiaries participating in an Independence at Home program
696	to the predicted costs to Medicaid for such beneficiaries to
697	determine whether an Independence at Home program achieves the
698	savings required under this subsection.
699	(e)  The agency shall require that the model developed
700	under paragraph (c) for determining savings shall be designed
701	according to instructions that control or adjust for inflation
702	and risk factors, including age; race; gender; disability
703	status; socioeconomic status; region of the state, such as
704	county, municipality, or zip code; and such other factors as the
705	agency determines to be appropriate, including adjustment for
706	prior health care utilization. The agency may add to, modify, or
707	substitute for those adjustment factors if the changes will
708	improve the sensitivity or specificity of the calculation of
709	cost savings.
710	(21)  NOTICE OF SAVINGS CALCULATION.-No later than 30 days
711	before the beginning of the first year of the pilot project and
712	120 days before the beginning of any Independence at Home
713	program year after the first year of implementation, the agency
714	shall publish in the Florida Administrative Weekly a description
715	of the model developed under subparagraph (20)(c) and
716	information for calculating savings required under paragraph
717	(20)(a), including any revisions, sufficient to permit
718	Independence at Home organizations to determine the savings they
719	will be required to achieve during the program year to meet the
720	savings requirement under paragraph (20)(a). In order to
721	facilitate this notice, the agency may designate a single annual
722	date for the beginning of all Independence at Home program years
723	that shall not be later than July 1, 2012.
724	(22)  MANNER OF PAYMENT.-Subject to subsection (23),
725	payments shall be made by the agency to an Independence at Home
726	organization at a rate negotiated between the agency and the
727	organization under the agreement for:
728	(a)  Independence at Home assessments.
729	(b)  On a per-participant, per-month basis, the items and
730	services required to be provided or made available under
731	subparagraph (13)(c)4.
732	(23)  ENSURING MANDATORY MINIMUM SAVINGS.-The agency shall
733	require any Independence at Home organization that fails in any
734	year to achieve the mandatory minimum savings described in
735	subsection (20) to provide those savings by refunding payments
736	made to the organization under subsection (22) during that year.
737	(24)  BUDGET-NEUTRAL PAYMENT CONDITION.-
738	(a)  The agency shall ensure that the cumulative, aggregate
739	sum of Medicaid program benefit expenditures for participants in
740	Independence at Home programs and funds paid to Independence at
741	Home organizations under this section does not exceed the
742	Medicaid program benefit expenditures under such parts that the
743	agency estimates would have been made for such participants in
744	the absence of such programs.
745	(b)  If an Independence at Home organization achieves
746	aggregate savings in a year in the initial implementation phase
747	in excess of the product described in paragraph (20)(b), 80
748	percent of such aggregate savings shall be paid to the
749	organization and the remainder shall be retained by the programs
750	during the initial implementation phase.
751	(c)  If an Independence at Home organization achieves
752	aggregate savings in a year in the expanded implementation phase
753	in excess of 5 percent of the product described in paragraph
754	(20)(b):
755	1.  Insofar as the savings do not exceed 25 percent of the
756	product, 80 percent of such aggregate savings shall be paid to
757	the organization and the remainder shall be retained by the
758	programs established under this section.
759	2.  Insofar as the savings exceed 25 percent of the
760	product, at the agency's discretion, 50 percent of such excess
761	aggregate savings shall be paid to the organization and the
762	remainder shall be retained by the programs established under
763	this section.
764	(25)  WAIVER OF COINSURANCE FOR HOUSE CALLS.-A physician,
765	physician assistant, or nurse practitioner furnishing services
766	related to the Independence at Home program in the home or
767	residence of a participant in an Independence at Home program
768	may waive collection of any coinsurance that might otherwise be
769	payable under s. 1833, Title I, Subtitle A of the Healthcare
770	Equality and Accountability Act, with respect to such services,
771	but only if the conditions described in 42 U.S.C. s.
772	1128A(i)(6)(A) are met.
773	(26)  REPORT.-Not later than 3 months after the date of
774	receipt of the independent evaluation provided under subsection
775	(5) and each year thereafter during which this section is being
776	implemented, the agency shall submit to the President of the
777	Senate, the Speaker of the House of Representatives, and the
778	chairs of the appropriate legislative committees a report that
779	shall include:
780	(a)  Whether the Independence at Home programs under this
781	section are meeting the minimum quality and performance
782	standards described in subsection (17).
783	(b)  A comparative evaluation of Independence at Home
784	organizations in order to identify which programs, and
785	characteristics of those programs, were the most effective in
786	producing the best participant outcomes, patient and caregiver
787	satisfaction, and cost savings.
788	(c)  An evaluation of whether the participant eligibility
789	criteria identified Medicaid beneficiaries who were in the top
790	10 percent of the highest cost Medicaid beneficiaries.
791	Section 5.  This act shall take effect July 1, 2011.

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