HB 267

1
A bill to be entitled
2An act relating to the nursing home diversion program;
3amending s. 409.912, F.S.; directing the Agency for Health
4Care Administration to expand the nursing home diversion
5program to include Medicaid recipients who meet certain
6criteria; specifying locations for phased-in
7implementation of the program; revising conditions for
8enrollment in the program; providing for Medicaid
9recipient choice with regard to contractors; requiring the
10nursing home diversion contractor to provide an enrollee
11with information regarding alternative service providers;
12requiring certain enrollees to participate in the program;
13requiring the program to combine funding for Medicaid
14services provided to specified individuals; removing an
15exception; excluding specified individuals from
16participation in the program; revising provisions relating
17to entities eligible to participate in the program;
18requiring the Department of Elderly Affairs and the agency
19to seek federal waivers to limit the number of nursing
20home diversion contractors in additional locations;
21directing the agency to impose certain requirements on
22contractors in the program; requiring the Office of
23Program Policy Analysis and Government Accountability, in
24consultation with the Auditor General, to evaluate the
25nursing home diversion contractors in the program;
26removing an obsolete provision relating to an
27appropriation for implementation of a pilot program;
28amending s. 408.040, F.S.; removing a reporting
29requirement, to conform; providing an effective date.
30
31Be It Enacted by the Legislature of the State of Florida:
32
33     Section 1.  Subsection (5) of section 409.912, Florida
34Statutes, is amended to read:
35     409.912  Cost-effective purchasing of health care.-The
36agency shall purchase goods and services for Medicaid recipients
37in the most cost-effective manner consistent with the delivery
38of quality medical care. To ensure that medical services are
39effectively utilized, the agency may, in any case, require a
40confirmation or second physician's opinion of the correct
41diagnosis for purposes of authorizing future services under the
42Medicaid program. This section does not restrict access to
43emergency services or poststabilization care services as defined
44in 42 C.F.R. part 438.114. Such confirmation or second opinion
45shall be rendered in a manner approved by the agency. The agency
46shall maximize the use of prepaid per capita and prepaid
47aggregate fixed-sum basis services when appropriate and other
48alternative service delivery and reimbursement methodologies,
49including competitive bidding pursuant to s. 287.057, designed
50to facilitate the cost-effective purchase of a case-managed
51continuum of care. The agency shall also require providers to
52minimize the exposure of recipients to the need for acute
53inpatient, custodial, and other institutional care and the
54inappropriate or unnecessary use of high-cost services. The
55agency shall contract with a vendor to monitor and evaluate the
56clinical practice patterns of providers in order to identify
57trends that are outside the normal practice patterns of a
58provider's professional peers or the national guidelines of a
59provider's professional association. The vendor must be able to
60provide information and counseling to a provider whose practice
61patterns are outside the norms, in consultation with the agency,
62to improve patient care and reduce inappropriate utilization.
63The agency may mandate prior authorization, drug therapy
64management, or disease management participation for certain
65populations of Medicaid beneficiaries, certain drug classes, or
66particular drugs to prevent fraud, abuse, overuse, and possible
67dangerous drug interactions. The Pharmaceutical and Therapeutics
68Committee shall make recommendations to the agency on drugs for
69which prior authorization is required. The agency shall inform
70the Pharmaceutical and Therapeutics Committee of its decisions
71regarding drugs subject to prior authorization. The agency is
72authorized to limit the entities it contracts with or enrolls as
73Medicaid providers by developing a provider network through
74provider credentialing. The agency may competitively bid single-
75source-provider contracts if procurement of goods or services
76results in demonstrated cost savings to the state without
77limiting access to care. The agency may limit its network based
78on the assessment of beneficiary access to care, provider
79availability, provider quality standards, time and distance
80standards for access to care, the cultural competence of the
81provider network, demographic characteristics of Medicaid
82beneficiaries, practice and provider-to-beneficiary standards,
83appointment wait times, beneficiary use of services, provider
84turnover, provider profiling, provider licensure history,
85previous program integrity investigations and findings, peer
86review, provider Medicaid policy and billing compliance records,
87clinical and medical record audits, and other factors. Providers
88shall not be entitled to enrollment in the Medicaid provider
89network. The agency shall determine instances in which allowing
90Medicaid beneficiaries to purchase durable medical equipment and
91other goods is less expensive to the Medicaid program than long-
92term rental of the equipment or goods. The agency may establish
93rules to facilitate purchases in lieu of long-term rentals in
94order to protect against fraud and abuse in the Medicaid program
95as defined in s. 409.913. The agency may seek federal waivers
96necessary to administer these policies.
97     (5)  The Agency for Health Care Administration, in
98partnership with the Department of Elderly Affairs, shall expand
99the nursing home diversion program into create an integrated,
100fixed-payment delivery program for all Medicaid recipients who
101meet nursing home admission criteria and are 60 years of age or
102older and or dually eligible for Medicare and Medicaid. The
103Agency for Health Care Administration shall implement the
104integrated program initially in on a pilot basis in two Areas 5,
1056, and 7 of the state. The program shall be implemented in Areas
1068, 9, 10, and 11 in 2013 and in Areas 1, 2, 3, and 4 in 2014.
107All Medicaid recipients shall be given a choice of nursing home
108diversion contractors in each area. In order to ensure enrollee
109choice, when an enrollee is determined to be likely to require
110the level of care provided in a hospital or nursing home, the
111enrollee shall be informed by the nursing home diversion
112contractor of any feasible alternatives available and given the
113choice of either institutional or home and community-based
114services pilot areas shall be Area 7 and Area 11 of the Agency
115for Health Care Administration. Enrollment in the pilot areas
116shall be on a voluntary basis and in accordance with approved
117federal waivers and this section. The agency and its program
118contractors and providers shall not enroll any individual in the
119integrated program because the individual or the person legally
120responsible for the individual fails to choose to enroll in the
121integrated program. Enrollment in the integrated program shall
122be exclusively by affirmative choice of the eligible individual
123or by the person legally responsible for the individual. The
124integrated program must transfer all Medicaid services for
125eligible elderly individuals who choose to participate into an
126integrated-care management model designed to serve Medicaid
127recipients in the community. The integrated program must combine
128all funding for Medicaid services provided to individuals who
129are 60 years of age or older and or dually eligible for Medicare
130and Medicaid into the integrated program, including funds for
131Medicaid home and community-based waiver services; all Medicaid
132services authorized in ss. 409.905 and 409.906, including
133excluding funds for Medicaid nursing home services unless the
134agency is able to demonstrate how the integration of the funds
135will improve coordinated care for these services in a less
136costly manner; and Medicare coinsurance and deductibles for
137persons dually eligible for Medicaid and Medicare as prescribed
138in s. 409.908(13).
139     (a)  Individuals who are 60 years of age or older, or
140dually eligible for Medicare and Medicaid, and enrolled in
141developmental disabilities waiver program, the family and
142supported-living waiver program, the project AIDS care waiver
143program, the traumatic brain injury and spinal cord injury
144waiver program, the consumer-directed care waiver program, and
145the program of all-inclusive care for the elderly program, and
146residents of institutional care facilities for the
147developmentally disabled, must be excluded from the integrated
148program.
149     (b)  Managed care entities who meet or exceed the agency's
150minimum standards are eligible to operate the integrated
151program. Entities eligible to participate include managed care
152organizations licensed under chapter 641, including entities
153eligible to participate in the nursing home diversion program
154contractors, other qualified providers as defined in s.
155430.703(6) and (7). The Department of Elderly Affairs and the
156agency shall comply with s. 430.705(3) prior to approval of any
157additional contractors, community care for the elderly lead
158agencies, and other state-certified community service networks
159that meet comparable standards as defined by the agency, in
160consultation with the Department of Elderly Affairs and the
161Office of Insurance Regulation, to be financially solvent and
162able to take on financial risk for managed care. Community
163service networks that are certified pursuant to the comparable
164standards defined by the agency are not required to be licensed
165under chapter 641. Managed care entities who operate the
166integrated program shall be subject to s. 408.7056. Eligible
167entities shall choose to serve enrollees who are dually eligible
168for Medicare and Medicaid, enrollees who are 60 years of age or
169older, or both.
170     (c)  The agency must ensure that the capitation-rate-
171setting methodology for the integrated program is actuarially
172sound and reflects the intent to provide quality care in the
173least restrictive setting. The agency must also require nursing
174home diversion contractors integrated-program providers to
175develop a credentialing system for service providers and to
176contract with all Gold Seal nursing homes, where feasible, and
177exclude, where feasible, chronically poor-performing facilities
178and providers as defined by the agency. The integrated program
179must develop and maintain an informal provider grievance system
180that addresses provider payment and contract problems. The
181agency shall also establish a formal grievance system to address
182those issues that were not resolved through the informal
183grievance system. The integrated program must provide that if
184the recipient resides in a noncontracted residential facility
185licensed under chapter 400 or chapter 429 at the time of
186enrollment in the integrated program and the recipient's needs
187cannot be met in a less restrictive environment, the recipient
188must be permitted to continue to reside in the noncontracted
189facility as long as the recipient desires. The integrated
190program must also provide that, in the absence of a contract
191between the nursing home diversion contractor integrated-program
192provider and the residential facility licensed under chapter 400
193or chapter 429, current Medicaid rates must prevail. The nursing
194home diversion contractor integrated-program provider must
195ensure that electronic nursing home claims that contain
196sufficient information for processing are paid within 10
197business days after receipt. Alternately, the nursing home
198diversion contractor integrated-program provider may establish a
199capitated payment mechanism to prospectively pay nursing homes
200at the beginning of each month. The agency and the Department of
201Elderly Affairs must jointly develop procedures to manage the
202services provided through the integrated program in order to
203ensure quality and recipient choice.
204     (d)  The Office of Program Policy Analysis and Government
205Accountability, in consultation with the Auditor General, shall
206comprehensively evaluate the pilot project for the integrated,
207fixed-payment delivery program for Medicaid recipients created
208under this subsection. The evaluation shall begin as soon as
209Medicaid recipients are enrolled in the managed care pilot
210program plans and shall continue for 24 months thereafter. The
211evaluation must include assessments of each nursing home
212diversion contractor managed care plan in the integrated program
213with regard to cost savings; consumer education, choice, and
214access to services; coordination of care; and quality of care.
215The evaluation must describe administrative or legal barriers to
216the implementation and operation of the pilot program and
217include recommendations regarding statewide expansion of the
218pilot program. The office shall submit its evaluation report to
219the Governor, the President of the Senate, and the Speaker of
220the House of Representatives no later than December 31, 2014
2212009.
222     (e)  The agency may seek federal waivers or Medicaid state
223plan amendments and adopt rules as necessary to administer the
224integrated program. The agency may implement the approved
225federal waivers and other provisions as specified in this
226subsection.
227     (f)  The implementation of the integrated, fixed-payment
228delivery program created under this subsection is subject to an
229appropriation in the General Appropriations Act.
230     Section 2.  Paragraph (e) of subsection (1) of section
231408.040, Florida Statutes, is redesignated as paragraph (d), and
232present paragraph (d) of that subsection is amended to read:
233     408.040  Conditions and monitoring.-
234     (1)
235     (d)  If a nursing home is located in a county in which a
236long-term care community diversion pilot project has been
237implemented under s. 430.705 or in a county in which an
238integrated, fixed-payment delivery program for Medicaid
239recipients who are 60 years of age or older or dually eligible
240for Medicare and Medicaid has been implemented under s.
241409.912(5), the nursing home may request a reduction in the
242percentage of annual patient days used by residents who are
243eligible for care under Title XIX of the Social Security Act,
244which is a condition of the nursing home's certificate of need.
245The agency shall automatically grant the nursing home's request
246if the reduction is not more than 15 percent of the nursing
247home's annual Medicaid-patient-days condition. A nursing home
248may submit only one request every 2 years for an automatic
249reduction. A requesting nursing home must notify the agency in
250writing at least 60 days in advance of its intent to reduce its
251annual Medicaid-patient-days condition by not more than 15
252percent. The agency must acknowledge the request in writing and
253must change its records to reflect the revised certificate-of-
254need condition. This paragraph expires June 30, 2011.
255     Section 3.  This act shall take effect July 1, 2011.


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