Florida Senate - 2011 SB 2034
By Senator Braynon
33-02446-11 20112034__
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
5 for Health Care Administration to establish an
6 Independence at Home Chronic Care Coordination Pilot
7 Project; providing for Independence at Home programs
8 within the pilot project; specifying objectives of the
9 programs; providing for implementation and independent
10 evaluation of the pilot project; providing eligibility
11 criteria for participation; providing rulemaking
12 authority to the agency; providing for best-practices
13 teleconferences; providing definitions; providing for
14 enrollment of program participants; providing program
15 requirements; providing requirements for plan
16 development; providing terms and conditions of
17 agreements between the agency and Independence at Home
18 organizations; requiring a report to the Legislature;
19 establishing quality, performance, and participation
20 standards; providing for terms, modification,
21 termination, and nonrenewal of agreements; requiring
22 mandatory minimum savings and for computation thereof;
23 providing a waiver of coinsurance for house calls;
24 providing an effective date.
25
26 Be It Enacted by the Legislature of the State of Florida:
27
28 Section 1. Short title.—This act may be cited as the
29 “Independence at Home Act.”
30 Section 2. Legislative findings.—The Legislature finds,
31 pursuant to the November 2007 Congressional Budget Office’s
32 Long-Term Outlook for Health Care Spending, that:
33 (1) Unless changes are made to the way health care is
34 delivered, the growing demand for resources caused by rising
35 health care costs and, to a lesser extent, the nation’s
36 expanding elderly and chronically ill population will confront
37 Floridians with increasingly difficult choices between health
38 care and other priorities. However, opportunities exist to
39 constrain health care costs without adverse health care
40 consequences.
41 (2) Medicaid beneficiaries with multiple chronic conditions
42 account for a disproportionate share of Medicaid spending
43 compared to their representation in the overall Medicaid
44 population, and evidence suggests that such patients often
45 receive poorly coordinated care, including conflicting
46 information from health providers and different diagnoses of the
47 same symptoms.
48 (3) People with chronic conditions account for 76 percent
49 of all hospital admissions, 88 percent of all prescriptions
50 filled, and 72 percent of physician visits.
51 (4) Hospital utilization and emergency room visits for
52 patients with multiple chronic conditions can be reduced and
53 significant savings can be achieved through the use of
54 interdisciplinary teams of health care professionals caring for
55 patients in their places of residence.
56 Section 3. Independence at Home Act; purpose.—The purpose
57 of the Independence at Home Act is to:
58 (1) Create a chronic care coordination pilot project to
59 bring primary care medical services to the highest cost Medicaid
60 beneficiaries with multiple chronic conditions in their home or
61 place of residence so that they may be as independent as
62 possible for as long as possible in a comfortable setting.
63 (2) Generate savings by providing better, more coordinated
64 care across all treatment settings to the highest cost Medicaid
65 beneficiaries with multiple chronic conditions, reducing
66 duplicative and unnecessary services, and avoiding unnecessary
67 hospitalizations, nursing home admissions, and emergency room
68 visits.
69 (3) Hold providers accountable for improving beneficiary
70 outcomes, ensuring patient and caregiver satisfaction, and
71 achieving cost savings to Medicaid on an annual basis.
72 (4) Create incentives for practitioners and providers to
73 develop methods and technologies for providing better and lower
74 cost health care to the highest cost Medicaid beneficiaries with
75 the greatest incentives provided in the case of highest cost
76 Medicaid beneficiaries.
77 (5) Contain the central elements of proven home-based
78 primary care delivery models that have been utilized for years
79 by the United States Department of Veterans Affairs and its
80 house calls program to deliver coordinated care for chronic
81 conditions in the comfort of the patient’s home or place of
82 residence.
83 Section 4. Independence at Home Chronic Care Coordination
84 Pilot Project.—
85 (1) IMPLEMENTATION BY THE AGENCY FOR HEALTH CARE
86 ADMINISTRATION.—The Secretary of Health Care Administration
87 shall provide for the phased-in development, implementation, and
88 evaluation of the Independence at Home Chronic Care Coordination
89 Pilot Project described in this section to meet the following
90 objectives:
91 (a) To improve patient outcomes, compared to outcomes
92 achieved by comparable beneficiaries who do not participate in
93 such a program, through reduced hospitalizations, nursing home
94 admissions, and emergency room visits and increased symptom
95 self-management and other similar results.
96 (b) To improve patient and caregiver satisfaction, as
97 demonstrated through a quantitative pretest and posttest survey
98 developed by the agency that measures patient and caregiver
99 satisfaction relating to coordination of care, provision of
100 educational information, timeliness of response, and similar
101 care features.
102 (c) To achieve a minimum of 5 percent cost savings
103 associated with the care of Medicaid beneficiaries served under
104 this program who suffer from multiple high-cost chronic
105 diseases.
106 (2) INITIAL IMPLEMENTATION; PHASE I.—
107 (a) For the purpose of carrying out this section and to the
108 extent possible, the Agency for Health Care Administration shall
109 enter into agreements with at least two unaffiliated
110 Independence at Home organizations in each county in the state
111 to provide chronic care coordination services for a period of 3
112 years or until those agreements are terminated by the agency.
113 Agreements under this paragraph shall continue in effect until
114 the agency makes a determination pursuant to subsection (3) or
115 until those agreements are supplanted by new agreements entered
116 into under subsection (3).
117 (b) In selecting an Independence at Home organization under
118 this subsection, the agency shall give a preference to the
119 extent practicable to an organization that:
120 1. Has documented experience in furnishing the types of
121 services covered under this subsection to eligible beneficiaries
122 in their home or place of residence using qualified teams of
123 health care professionals who are under the direction of a
124 qualified Independence at Home physician or, in a case when such
125 direction is provided by an Independence at Home physician to a
126 physician assistant who has at least 1 year of experience
127 providing medical and related services for chronically ill
128 individuals in their homes, or other similar qualifications as
129 determined by the agency to be appropriate for the Independence
130 at Home program, by the physician assistant acting under the
131 supervision of an Independence at Home physician and as
132 permitted under state law, or by an Independence at Home nurse
133 practitioner;
134 2. Has the capacity to provide services covered by this
135 section to at least 150 eligible Medicaid beneficiaries; and
136 3. Uses electronic medical records, health information
137 technology, and individualized plans of care.
138 (3) EXPANDED IMPLEMENTATION; PHASE II.—
139 (a) For periods beginning after the end of the 3-year
140 initial implementation period under subsection (2), and subject
141 to paragraph (b), the agency shall renew agreements described in
142 subsection (2) with an Independence at Home organization that
143 has met all the objectives specified in subsection (1) and enter
144 into agreements described in subsection (2) with any other
145 organization located in the state that was not an Independence
146 at Home organization during the initial implementation period
147 and meets the qualifications for an Independence at Home
148 organization under this section. The agency may terminate and
149 decline to renew an agreement with an organization that has not
150 met those objectives during the initial implementation period.
151 (b) The expanded implementation under paragraph (a) may not
152 occur if the agency finds, not later than 60 days after the date
153 of issuance of the independent evaluation under subsection (5),
154 that continuation of the Independence at Home Chronic Care
155 Coordination Pilot Project is not in the best interest of
156 Medicaid beneficiaries participating under this section.
157 (4) ELIGIBILITY.—An organization is not prohibited from
158 participating under this section during the expanded
159 implementation phase under subsection (3) and, to the extent
160 practicable, during the initial implementation phase under
161 subsection (2) because of its small size as long as it meets the
162 eligibility requirements of this section.
163 (5) INDEPENDENT EVALUATIONS.—
164 (a) The agency shall contract for an independent evaluation
165 of the initial implementation phase under subsection (2) and
166 provide an interim report to the Legislature regarding the
167 evaluation as soon as practicable after the first year of phase
168 I and provide a final report to the Legislature as soon as
169 practicable following the conclusion of the phase I, but not
170 later than 6 months following the end of phase I. The evaluation
171 shall be conducted by individuals with knowledge of chronic care
172 coordination programs for the targeted patient population and
173 prior experience in the evaluation of such programs.
174 (b) Each report shall include an assessment of the
175 following factors and shall identify the characteristics of
176 individual Independence at Home programs that are the most
177 effective in producing improvements in:
178 1. Beneficiary, caregiver, and provider satisfaction.
179 2. Health outcomes appropriate for patients with multiple
180 chronic diseases.
181 3. Cost savings to the program under this section, such as
182 reductions in:
183 a. Hospital and skilled nursing facility admission rates
184 and lengths of stay.
185 b. Hospital readmission rates.
186 c. Emergency department visits.
187 (c) Each report shall include data on the performance of
188 Independence at Home organizations in responding to the needs of
189 eligible Medicaid beneficiaries with specific chronic conditions
190 and combinations of conditions and responding to the needs of
191 the overall eligible beneficiary population.
192 (6) AGREEMENTS.—
193 (a) Beginning not later than July 1, 2012, the agency shall
194 enter into agreements with Independence at Home organizations
195 that meet the participation requirements of this section,
196 including minimum performance standards developed under
197 subsection (17), in order to provide access by eligible Medicaid
198 beneficiaries to Independence at Home programs under this
199 section.
200 (b) If the agency deems it necessary to serve the best
201 interest of the Medicaid beneficiaries under this section, the
202 agency may:
203 1. Require screening of all potential Independence at Home
204 organizations, including owners, using fingerprinting, licensure
205 checks, site visits, or other database checks before entering
206 into an agreement.
207 2. Require a provisional period during which a new
208 Independence at Home organization is subject to enhanced
209 oversight that may include prepayment review, unannounced site
210 visits, and payment caps.
211 3. Require applicants to disclose any previous affiliation
212 with entities that have uncollected Medicaid debt and authorize
213 the denial of enrollment if the agency determines that these
214 affiliations pose undue risk to the program.
215 (7) RULEMAKING.—At least 3 months before entering into the
216 first agreement under this section, the agency shall publish in
217 the Florida Administrative Weekly the specifications for
218 implementing this section. Such specifications shall describe
219 the implementation process from the initial through the final
220 implementation phases, including how the agency will identify
221 and notify potential enrollees and how and when a Medicaid
222 beneficiary may enroll, disenroll, or change enrollment in an
223 Independence at Home program.
224 (8) PERIODIC PROGRESS REPORTS.—Semiannually during the
225 first year, and annually thereafter, during the period of
226 implementation of this section, the agency shall submit to the
227 appropriate committees of the House of Representatives and the
228 Senate a report that describes the progress of the
229 implementation of the pilot project and explains any variation
230 from the Independence at Home program model as described in this
231 section.
232 (9) ANNUAL BEST PRACTICES TELECONFERENCE.—During the
233 initial implementation phase and to the extent practicable at
234 intervals thereafter, the agency shall provide for an annual
235 Independence at Home teleconference for Independence at Home
236 organizations to share best practices and review treatment
237 interventions and protocols that were successful in meeting the
238 objectives specified in subsection (1).
239 (10) DEFINITIONS.—As used in this section, the term:
240 (a) “Activities of daily living” means bathing, dressing,
241 grooming, transferring, feeding, or toileting.
242 (b) “Caregiver” means, with respect to an individual with a
243 qualifying functional impairment, a family member, friend, or
244 neighbor who provides assistance to the individual.
245 (c) “Chronic conditions” includes the following:
246 1. Congestive heart failure.
247 2. Diabetes.
248 3. Chronic obstructive pulmonary disease.
249 4. Ischemic heart disease.
250 5. Peripheral arterial disease.
251 6. Stroke.
252 7. Alzheimer’s disease and other forms of dementia
253 designated by the agency.
254 8. Pressure ulcers.
255 9. Hypertension.
256 10. Myasthenia gravis.
257 11. Neurodegenerative diseases designated by the agency
258 that result in high costs to the program, including amyotrophic
259 lateral sclerosis (ALS), multiple sclerosis, and Parkinson’s
260 disease.
261 12. Any other chronic condition that the agency identifies
262 as likely to result in high costs when such condition is present
263 in combination with one or more of the chronic conditions
264 specified in this paragraph.
265 (d) “Disqualification” does not include an individual:
266 1. Who resides in a setting that presents a danger to the
267 safety of in-home health care providers and primary caregivers;
268 or
269 2. Whose enrollment in an Independence at Home program is
270 determined by the agency to be inappropriate.
271 (e) “Eligible beneficiary” means, with respect to an
272 Independence at Home program, an individual who:
273 1. Is entitled to benefits under the Florida Medicaid
274 program;
275 2. Has a qualifying functional impairment and has been
276 diagnosed with two or more of the chronic conditions described
277 in paragraph (c); and
278 3. Within the 12 months prior to the individual first
279 enrolling with an Independence at Home program under this
280 section, has received benefits under Medicare Part A for the
281 following services:
282 a. Nonelective inpatient hospital services;
283 b. Services in the emergency department of a hospital;
284 c. Skilled nursing or subacute rehabilitation services in a
285 Medicaid-certified nursing facility;
286 d. Comprehensive acute rehabilitation facility or
287 comprehensive outpatient rehabilitation facility services; or
288 e. Skilled nursing or rehabilitation services through a
289 Medicaid-certified home health agency.
290 (f) “Independence at Home assessment” means a determination
291 of eligibility of an individual for an Independence at Home
292 program as an eligible beneficiary and includes a comprehensive
293 medical history, physical examination, and assessment of the
294 beneficiary’s clinical and functional status that is conducted
295 in person by an Independence at Home physician or an
296 Independence at Home nurse practitioner or by a physician
297 assistant, nurse practitioner, or clinical nurse specialist who
298 is employed by an Independence at Home organization and is
299 supervised by an Independence at Home physician or Independence
300 at Home nurse practitioner. The individual conducting the
301 assessment may not have an ownership interest in the
302 Independence at Home organization unless the agency determines
303 that it is impracticable to preclude such individual’s
304 involvement. The assessment shall include an evaluation of:
305 1. Activities of daily living and other comorbidities.
306 2. Medications and the client’s adherence to medication
307 plans.
308 3. Affect, cognition, executive function, and presence of
309 mental disorders.
310 4. Functional status, including mobility, balance, gait,
311 risk of falling, and sensory function.
312 5. Social functioning and social integration.
313 6. Environmental needs and a safety assessment.
314 7. The ability of the beneficiary’s primary caregiver to
315 assist with the beneficiary’s care as well as the caregiver’s
316 own physical and emotional capacity, education, and training.
317 8. Whether, in the professional judgment of the individual
318 conducting the assessment, the beneficiary is likely to benefit
319 from an Independence at Home program.
320 9. Whether the conditions in the beneficiary’s home or
321 place of residence would permit the safe provision of services
322 in the home or residence, respectively, under an Independence at
323 Home program.
324 10. Whether the beneficiary has a designated primary care
325 physician whom the beneficiary has seen in an office-based
326 setting within the previous 12 months.
327 11. Other factors determined appropriate for consideration
328 by the agency.
329 (g) “Independence at Home care team” means a team of
330 qualified individuals that provides services to the participant
331 as part of an Independence at Home program. The term includes a
332 team consisting of an Independence at Home physician or an
333 Independence at Home nurse practitioner, working with an
334 Independence at Home coordinator, who may also be an
335 Independence at Home physician or an Independence at Home nurse
336 practitioner.
337 (h) “Independence at Home coordinator” means an individual
338 who:
339 1. Is employed by an Independence at Home organization and
340 is responsible for coordinating all of the services of the
341 participant’s Independence at Home plan;
342 2. Is a licensed health professional, such as a physician,
343 registered nurse, nurse practitioner, clinical nurse specialist,
344 physician assistant, or other health care professional as the
345 agency determines appropriate, who has at least 1 year of
346 experience providing and coordinating medical and related
347 services for individuals in their homes; and
348 3. Serves as the primary point of contact responsible for
349 communications with the participant and for facilitating
350 communications with other health care providers under the plan.
351 (k) “Independence at Home nurse practitioner” means a nurse
352 practitioner who:
353 1. Is employed by or affiliated with an Independence at
354 Home organization or has another contractual relationship with
355 the Independence at Home organization that requires the nurse
356 practitioner to make in-home visits and to be responsible for
357 the plans of care for the nurse practitioner’s patients;
358 2. Practices in accordance with state law regarding scope
359 of practice for nurse practitioners;
360 3. Is certified as:
361 a. A gerontological nurse practitioner by the American
362 Academy of Nurse Practitioners Certification Program or the
363 American Nurses Credentialing Center; or
364 b. A family nurse practitioner or adult nurse practitioner
365 by the American Academy of Nurse Practitioners Certification
366 Program or the American Nurses Credentialing Center and holds a
367 Certificate of Added Qualification in gerontology, elder care,
368 or care of the older adult provided by the American Academy of
369 Nurse Practitioners Certification Program, the American Nurses
370 Credentialing Center, or a national nurse practitioner
371 certification board deemed by the agency to be appropriate for
372 an Independence at Home program; and
373 4. Has furnished services during the previous 12 months for
374 which payment is made under this section.
375 (i) “Independence at Home organization” means a provider of
376 services, a physician or physician group practice which receives
377 payment for services furnished under Title XVIII of the Social
378 Security Act, rather than only under this section, and 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 who:
398 1. Is employed by or affiliated with an Independence at
399 Home organization or has another contractual relationship with
400 the Independence at Home organization that requires the
401 physician to make in-home visits and be responsible for the
402 plans of care for the physician’s patients;
403 2. Is certified by:
404 a. The American Board of Family Physicians, the American
405 Board of Internal Medicine, the American Osteopathic Board of
406 Family Physicians, the American Osteopathic Board of Internal
407 Medicine, the American Board of Emergency Medicine, or the
408 American Board of Physical Medicine and Rehabilitation; or
409 b. A board recognized by the American Board of Medical
410 Specialties and determined by the agency to be appropriate for
411 the Independence at Home program;
412 3. Has a certification in geriatric medicine as provided by
413 the American Board of Medical Specialties or has passed the
414 clinical competency examination of the American Academy of Home
415 Care Physicians and has substantial experience in the delivery
416 of medical care in the home, including at least 2 years of
417 experience in the management of Medicare or Medicaid patients
418 and 1 year of experience in home-based medical care, including
419 at least 200 house calls; and
420 4. Has furnished services during the previous 12 months for
421 which payment is made under this section.
422 (l) “Independence at Home plan” means a plan established
423 under subsection (13) for a specific participant in an
424 Independence at Home program.
425 (m) “Independence at Home program” means a program
426 described in subsection (12) that is operated by an Independence
427 at Home organization.
428 (n) “Participant” means an eligible beneficiary who has
429 voluntarily enrolled in an Independence at Home program.
430 (o) “Qualified entity” means a person or organization that
431 is licensed or otherwise legally permitted to provide the
432 specific service provided under an Independence at Home plan
433 that the entity has agreed to provide.
434 (p) “Qualified individual” means an individual who is
435 licensed or otherwise legally permitted to provide the specific
436 service under an Independence at Home plan that the individual
437 has agreed to provide.
438 (q) “Qualifying functional impairment” means an inability
439 to perform, without the assistance of another person, three or
440 more activities of daily living.
441 (11) IDENTIFICATION AND ENROLLMENT OF PROSPECTIVE PROGRAM
442 PARTICIPANTS.—
443 (a) The agency shall develop a model notice to be made
444 available by participating providers and Independence at Home
445 programs to Medicaid beneficiaries, and their caregivers, who
446 are potentially eligible for an Independence at Home program.
447 The notice shall include the following information:
448 1. A description of the potential advantages to the
449 beneficiary participating in an Independence at Home program.
450 2. A description of the eligibility requirements to
451 participate.
452 3. Notice that participation is voluntary.
453 4. A statement that all other Medicaid benefits remain
454 available to Medicaid beneficiaries who enroll in an
455 Independence at Home program.
456 5. Notice that those who enroll in an Independence at Home
457 program are responsible for copayments for house calls made by
458 Independence at Home physicians, physician assistants, or
459 Independence at Home nurse practitioners, except that such
460 copayments may be reduced or eliminated at the discretion of the
461 Independence at Home physician, physician assistant, or
462 Independence at Home nurse practitioner.
463 6. A description of the services that may be provided.
464 7. A description of the method for participating or
465 withdrawing from participation in an Independence at Home
466 program or becoming ineligible to participate.
467 (b) An eligible beneficiary may participate in an
468 Independence at Home program through enrollment in the program
469 on a voluntary basis and may terminate participation at any
470 time. The beneficiary may also receive Independence at Home
471 services from the Independence at Home organization of the
472 beneficiary’s choice but may not receive Independence at Home
473 services from more than one Independence at Home organization at
474 a time.
475 (12) INDEPENDENCE AT HOME PROGRAM REQUIREMENTS.—Each
476 Independence at Home program shall, for each participant
477 enrolled in the program:
478 (a) Designate an Independence at Home coordinator and
479 either an Independence at Home physician or an Independence at
480 Home nurse practitioner.
481 (b) Have a process to ensure that the participant receives
482 an Independence at Home assessment before enrollment in the
483 program.
484 (c) With the participation of the participant, or the
485 participant’s representative or caregiver, an Independence at
486 Home physician, a physician assistant under the supervision of
487 an Independence at Home physician, and, as permitted under state
488 law, an Independence at Home nurse practitioner, or the
489 Independence at Home coordinator, develop an Independence at
490 Home plan for the participant in accordance with subsection
491 (13).
492 (d) Ensure that the participant receives an Independence at
493 Home assessment at least every 6 months after the original
494 assessment to ensure that the Independence at Home plan for the
495 participant remains current and appropriate.
496 (e) Implement all of the services under the participant’s
497 Independence at Home plan and, in instances in which the
498 Independence at Home organization does not provide specific
499 services within the Independence at Home plan, ensure that
500 qualified entities successfully provide those specific services.
501 (f) Provide for an electronic medical record and electronic
502 health information technology to coordinate the participant’s
503 care and to exchange information with the Medicaid program and
504 electronic monitoring and communication technologies and mobile
505 diagnostic and therapeutic technologies as appropriate and
506 accepted by the participant.
507 (13) INDEPENDENCE AT HOME PLAN.—
508 (a) An Independence at Home plan for a participant shall be
509 developed with the participant, an Independence at Home
510 physician, a physician assistant under the supervision of an
511 Independence at Home physician and, as permitted under state
512 law, an Independence at Home nurse practitioner or an
513 Independence at Home coordinator, and, if appropriate, one or
514 more of the participant’s caregivers and shall:
515 1. Document the chronic conditions, comorbidities, and
516 other health needs identified in the participant’s Independence
517 at Home assessment.
518 2. Determine which services under an Independence at Home
519 plan described in paragraph (c) are appropriate for the
520 participant.
521 3. Identify the qualified entity responsible for providing
522 each service under such plan.
523 (b) If the individual responsible for conducting the
524 participant’s Independence at Home assessment and developing the
525 Independence at Home plan is not the participant’s Independence
526 at Home coordinator, the Independence at Home physician or
527 Independence at Home nurse practitioner is responsible for
528 ensuring that the participant’s Independence at Home coordinator
529 has that plan, is familiar with the requirements of the plan,
530 and has the appropriate contact information for all of the
531 members of the Independence at Home care team.
532 (c) An Independence at Home organization shall coordinate
533 and make available through referral to a qualified entity the
534 services described in subparagraphs 1.-3. to the extent they are
535 needed and covered under this section and shall provide the care
536 coordination services described in subparagraph 4. to the extent
537 they are appropriate and accepted by a participant. The services
538 provided are:
539 1. Primary care services, such as physician visits and
540 diagnosis, treatment, and preventive services.
541 2. Home health services, such as skilled nursing care and
542 physical and occupational therapy.
543 3. Phlebotomy and ancillary laboratory and imaging
544 services, including point-of-care laboratory and imaging
545 diagnostics.
546 4. Coordination of care services, consisting of:
547 a. Monitoring and management of medications by a pharmacist
548 who is certified in geriatric pharmacy by the Commission for
549 Certification in Geriatric Pharmacy or possesses other
550 comparable certification demonstrating knowledge and expertise
551 in geriatric or chronic disease pharmacotherapy and providing
552 assistance to participants and their caregivers with respect to
553 selection of a prescription drug plan that best meets the needs
554 of the participant’s chronic conditions.
555 b. Coordination of all medical treatment furnished to the
556 participant, regardless of whether that treatment is covered and
557 available to the participant under this section.
558 c. Self-care education and preventive care consistent with
559 the participant’s condition.
560 d. Education for primary caregivers and family members.
561 e. Caregiver counseling services and information about and
562 referral to other caregiver support and health care services in
563 the community.
564 f. Referral to social services that provide personal care,
565 meals, volunteers, and individual and family therapy.
566 g. Information about and access to hospice care.
567 h. Pain and palliative care and end-of-life care, including
568 information about developing advance directives and physicians
569 orders for life-sustaining treatment.
570 (14) PRIMARY TREATMENT ROLE WITHIN AN INDEPENDENCE AT HOME
571 CARE TEAM.—An Independence at Home physician, a physician
572 assistant under the supervision of an Independence at Home
573 physician, and, as permitted under state law, an Independence at
574 Home nurse practitioner may assume the primary treatment role as
575 permitted under state law.
576 (15) ADDITIONAL RESPONSIBILITIES.—
577 (a) Each Independence at Home organization offering an
578 Independence at Home program shall monitor and report to the
579 agency, in a manner specified by the agency, on:
580 1. Patient outcomes.
581 2. Beneficiary, caregiver, and provider satisfaction with
582 respect to coordination of the participant’s care.
583 3. The achievement of mandatory minimum savings described
584 in subsection (21).
585 (b) Each Independence at Home organization shall provide
586 the agency with listings of individuals employed by the
587 organization, including contract employees and individuals with
588 an ownership interest in the organization, and comply with such
589 additional requirements as the agency may specify.
590 (16) TERMS AND CONDITIONS.—
591 (a) An agreement under this section with an Independence at
592 Home organization shall contain such terms and conditions as the
593 agency may specify consistent with this section.
594 (b) The agency may not enter into an agreement with an
595 Independence at Home organization under this section for the
596 operation of an Independence at Home program unless:
597 1. The program and organization meet the requirements of
598 subsection (12), minimum quality and performance standards
599 developed under subsection (17), and such clinical, quality
600 improvement, financial, program integrity, and other
601 requirements as the agency deems to be appropriate for
602 participants to be served.
603 2. The organization demonstrates to the satisfaction of the
604 agency that the organization is able to assume financial risk
605 for performance under the agreement with respect to payments
606 made to the organization under the agreement through available
607 reserves, reinsurance, or withholding of funding provided under
608 this section or through such other means as the agency deems
609 appropriate.
610 (17) MINIMUM QUALITY AND PERFORMANCE STANDARDS.—The agency
611 shall develop mandatory minimum quality and performance
612 standards for Independence at Home organizations and programs
613 that are no more stringent that those established by the Centers
614 for Medicare and Medicaid Services. The standards shall require:
615 (a) Improvement in participant outcomes and beneficiary,
616 caregiver, and provider satisfaction.
617 (b) Cost savings consistent with the requirements of
618 subsection (20).
619 (c) For any year after the first year, and except for a
620 program provided by the agency to serve a rural area, an average
621 of at least 150 participants during the previous year.
622 (18) TERM OF AGREEMENT AND MODIFICATION.—The agreement
623 under this section shall be, subject to paragraph (17)(c) and
624 subsection (19), for a period of 3 years and the terms and
625 conditions may be modified during the contract period by the
626 agency as necessary to serve the best interest of the Medicaid
627 beneficiaries under this section or the best interest of federal
628 health care programs or upon the request of the Independence at
629 Home organization.
630 (19) TERMINATION AND NONRENEWAL OF AGREEMENT.—
631 (a) If the agency determines that an Independence at Home
632 organization has failed to meet the minimum performance
633 standards under paragraph (17)(c) or other requirements under
634 this section, or if the agency determines it necessary to serve
635 the best interest of the Medicaid beneficiaries under this
636 section or the best interest of federal health care programs,
637 the agency may terminate the agreement of the organization at
638 the end of the contract year.
639 (b) The agency shall terminate an agreement with an
640 Independence at Home organization if the agency determines that
641 the care being provided by that organization poses a threat to
642 the health and safety of a participant.
643 (c) Notwithstanding any other provision of this section, an
644 Independence at Home organization may terminate an agreement
645 with the agency to provide an Independence at Home program at
646 the end of a contract year if the organization provides
647 notification of the termination to the agency and the Medicaid
648 beneficiaries participating in the program at least 90 days
649 before the end of that contract year. Subsections (20) and (23)
650 and paragraphs (24)(b) and (c) shall apply to the organization
651 until the date of termination.
652 (d) The agency shall notify the participants in an
653 Independence at Home program as soon as practicable if a
654 determination is made to terminate an agreement with the
655 Independence at Home organization involuntarily as provided in
656 paragraphs (a) and (b). The notice shall inform the beneficiary
657 of any other Independence at Home organizations that might be
658 available to the beneficiary.
659 (20) MANDATORY MINIMUM SAVINGS.—
660 (a) Pursuant to an agreement under this subsection, each
661 Independence at Home organization shall ensure that during any
662 year of the agreement for its Independence at Home program,
663 there is an aggregate savings in the cost to the program under
664 this section for participating Medicaid beneficiaries, as
665 calculated under paragraphs (c)-(e), that is not less than 5
666 percent of the product described in paragraph (b) for such
667 participating Medicaid beneficiaries and for that program year.
668 (b) The product described in this subsection for
669 participating Medicaid beneficiaries in an Independence at Home
670 program for a year is the product of:
671 1. The estimated average monthly costs that would have been
672 incurred under Florida Medicaid, other than those in the
673 Medicaid reform pilot program counties if those Medicaid
674 beneficiaries had not participated in the Independence at Home
675 program; and
676 2. The number of participant-months for that year. For
677 purposes of this paragraph, the term “participant-month” means
678 each month or part of a month in a program year that a
679 beneficiary participates in an Independence at Home program.
680 (c) The agency shall contract with a nongovernmental
681 organization or academic institution to independently develop an
682 analytical model for determining whether an Independence at Home
683 program achieves at least the savings required under paragraphs
684 (a) and (b) relative to costs that would have been incurred by
685 Medicaid in the absence of Independence at Home programs. The
686 analytical model developed by the independent research
687 organization for making these determinations shall utilize
688 state-of-the-art econometric techniques, such as Heckman’s
689 selection correction methodologies, to account for sample
690 selection bias, omitted variable bias, or problems with
691 endogeneity.
692 (d) Using the model developed under paragraph (c), the
693 agency shall compare the actual costs to Medicaid of
694 beneficiaries participating in an Independence at Home program
695 to the predicted costs to Medicaid for such beneficiaries to
696 determine whether an Independence at Home program achieves the
697 savings required under this subsection.
698 (e) The agency shall require that the model developed under
699 paragraph (c) for determining savings shall be designed
700 according to instructions that control or adjust for inflation
701 and risk factors, including age; race; gender; disability
702 status; socioeconomic status; region of the state, such as
703 county, municipality, or zip code; and such other factors as the
704 agency determines to be appropriate, including adjustment for
705 prior health care utilization. The agency may add to, modify, or
706 substitute for those adjustment factors if the changes will
707 improve the sensitivity or specificity of the calculation of
708 cost savings.
709 (21) NOTICE OF SAVINGS CALCULATION.—No later than 30 days
710 before the beginning of the first year of the pilot project and
711 120 days before the beginning of any Independence at Home
712 program year after the first year of implementation, the agency
713 shall publish in the Florida Administrative Weekly a description
714 of the model developed under subparagraph (20)(c) and
715 information for calculating savings required under paragraph
716 (20)(a), including any revisions, sufficient to permit
717 Independence at Home organizations to determine the savings they
718 will be required to achieve during the program year to meet the
719 savings requirement under paragraph (20)(a). In order to
720 facilitate this notice, the agency may designate a single annual
721 date for the beginning of all Independence at Home program years
722 that shall not be later than July 1, 2012.
723 (22) MANNER OF PAYMENT.—Subject to subsection (23),
724 payments shall be made by the agency to an Independence at Home
725 organization at a rate negotiated between the agency and the
726 organization under the agreement for:
727 (a) Independence at Home assessments.
728 (b) On a per-participant, per-month basis, the items and
729 services required to be provided or made available under
730 subparagraph (13)(c)4.
731 (23) ENSURING MANDATORY MINIMUM SAVINGS.—The agency shall
732 require any Independence at Home organization that fails in any
733 year to achieve the mandatory minimum savings described in
734 subsection (20) to provide those savings by refunding payments
735 made to the organization under subsection (22) during that year.
736 (24) BUDGET-NEUTRAL PAYMENT CONDITION.—
737 (a) The agency shall ensure that the cumulative, aggregate
738 sum of Medicaid program benefit expenditures for participants in
739 Independence at Home programs and funds paid to Independence at
740 Home organizations under this section does not exceed the
741 Medicaid program benefit expenditures under such parts that the
742 agency estimates would have been made for such participants in
743 the absence of such programs.
744 (b) If an Independence at Home organization achieves
745 aggregate savings in a year in the initial implementation phase
746 in excess of the product described in paragraph (20)(b), 80
747 percent of such aggregate savings shall be paid to the
748 organization and the remainder shall be retained by the programs
749 during the initial implementation phase.
750 (c) If an Independence at Home organization achieves
751 aggregate savings in a year in the expanded implementation phase
752 in excess of 5 percent of the product described in paragraph
753 (20)(b):
754 1. Insofar as the savings do not exceed 25 percent of the
755 product, 80 percent of such aggregate savings shall be paid to
756 the organization and the remainder shall be retained by the
757 programs established under this section.
758 2. Insofar as the savings exceed 25 percent of the product,
759 at the agency’s discretion, 50 percent of such excess aggregate
760 savings shall be paid to the organization and the remainder
761 shall be retained by the programs established under this
762 section.
763 (25) WAIVER OF COINSURANCE FOR HOUSE CALLS.—A physician,
764 physician assistant, or nurse practitioner furnishing services
765 related to the Independence at Home program in the home or
766 residence of a participant in an Independence at Home program
767 may waive collection of any coinsurance that might otherwise be
768 payable under s. 1833, Title I, Subtitle A of the Healthcare
769 Equality and Accountability Act, with respect to such services,
770 but only if the conditions described in 42 U.S.C. s.
771 1128A(i)(6)(A) are met.
772 (26) REPORT.—Not later than 3 months after the date of
773 receipt of the independent evaluation provided under subsection
774 (5) and each year thereafter during which this section is being
775 implemented, the agency shall submit to the President of the
776 Senate, the Speaker of the House of Representatives, and the
777 chairs of the appropriate legislative committees a report that
778 shall include:
779 (a) Whether the Independence at Home programs under this
780 section are meeting the minimum quality and performance
781 standards described in subsection (17).
782 (b) A comparative evaluation of Independence at Home
783 organizations in order to identify which programs, and
784 characteristics of those programs, were the most effective in
785 producing the best participant outcomes, patient and caregiver
786 satisfaction, and cost savings.
787 (c) An evaluation of whether the participant eligibility
788 criteria identified Medicaid beneficiaries who were in the top
789 10 percent of the highest cost Medicaid beneficiaries.
790 Section 5. This act shall take effect July 1, 2011.