Florida Senate - 2011                                     SB 542
       By Senator Bennett
       21-00695-11                                            2011542__
    1                        A bill to be entitled                      
    2         An act relating to the nursing home diversion program;
    3         amending s. 409.912, F.S.; directing the Agency for
    4         Health Care Administration to expand the nursing home
    5         diversion program to include Medicaid recipients who
    6         meet certain criteria; specifying locations for
    7         phased-in implementation of the program; revising
    8         conditions for enrollment in the program; providing
    9         for Medicaid recipient choice with regard to
   10         contractors; requiring the nursing home diversion
   11         contractor to provide an enrollee with information
   12         regarding alternative service providers; requiring
   13         certain enrollees to participate in the program;
   14         requiring the program to combine funding for Medicaid
   15         services provided to specified individuals; removing
   16         an exception; excluding specified individuals from
   17         participation in the program; revising provisions
   18         relating to entities eligible to participate in the
   19         program; requiring the Department of Elderly Affairs
   20         and the agency to seek federal waivers to limit the
   21         number of nursing home diversion contractors in
   22         additional locations; directing the agency to impose
   23         certain requirements on contractors in the program;
   24         requiring the Office of Program Policy Analysis and
   25         Government Accountability, in consultation with the
   26         Auditor General, to evaluate the nursing home
   27         diversion contractors in the program; removing an
   28         obsolete provision relating to an appropriation for
   29         implementation of a pilot program; amending s.
   30         408.040, F.S.; removing a reporting requirement, to
   31         conform; providing an effective date.
   33  Be It Enacted by the Legislature of the State of Florida:
   35         Section 1. Subsection (5) of section 409.912, Florida
   36  Statutes, is amended to read:
   37         409.912 Cost-effective purchasing of health care.—The
   38  agency shall purchase goods and services for Medicaid recipients
   39  in the most cost-effective manner consistent with the delivery
   40  of quality medical care. To ensure that medical services are
   41  effectively utilized, the agency may, in any case, require a
   42  confirmation or second physician’s opinion of the correct
   43  diagnosis for purposes of authorizing future services under the
   44  Medicaid program. This section does not restrict access to
   45  emergency services or poststabilization care services as defined
   46  in 42 C.F.R. part 438.114. Such confirmation or second opinion
   47  shall be rendered in a manner approved by the agency. The agency
   48  shall maximize the use of prepaid per capita and prepaid
   49  aggregate fixed-sum basis services when appropriate and other
   50  alternative service delivery and reimbursement methodologies,
   51  including competitive bidding pursuant to s. 287.057, designed
   52  to facilitate the cost-effective purchase of a case-managed
   53  continuum of care. The agency shall also require providers to
   54  minimize the exposure of recipients to the need for acute
   55  inpatient, custodial, and other institutional care and the
   56  inappropriate or unnecessary use of high-cost services. The
   57  agency shall contract with a vendor to monitor and evaluate the
   58  clinical practice patterns of providers in order to identify
   59  trends that are outside the normal practice patterns of a
   60  provider’s professional peers or the national guidelines of a
   61  provider’s professional association. The vendor must be able to
   62  provide information and counseling to a provider whose practice
   63  patterns are outside the norms, in consultation with the agency,
   64  to improve patient care and reduce inappropriate utilization.
   65  The agency may mandate prior authorization, drug therapy
   66  management, or disease management participation for certain
   67  populations of Medicaid beneficiaries, certain drug classes, or
   68  particular drugs to prevent fraud, abuse, overuse, and possible
   69  dangerous drug interactions. The Pharmaceutical and Therapeutics
   70  Committee shall make recommendations to the agency on drugs for
   71  which prior authorization is required. The agency shall inform
   72  the Pharmaceutical and Therapeutics Committee of its decisions
   73  regarding drugs subject to prior authorization. The agency is
   74  authorized to limit the entities it contracts with or enrolls as
   75  Medicaid providers by developing a provider network through
   76  provider credentialing. The agency may competitively bid single
   77  source-provider contracts if procurement of goods or services
   78  results in demonstrated cost savings to the state without
   79  limiting access to care. The agency may limit its network based
   80  on the assessment of beneficiary access to care, provider
   81  availability, provider quality standards, time and distance
   82  standards for access to care, the cultural competence of the
   83  provider network, demographic characteristics of Medicaid
   84  beneficiaries, practice and provider-to-beneficiary standards,
   85  appointment wait times, beneficiary use of services, provider
   86  turnover, provider profiling, provider licensure history,
   87  previous program integrity investigations and findings, peer
   88  review, provider Medicaid policy and billing compliance records,
   89  clinical and medical record audits, and other factors. Providers
   90  shall not be entitled to enrollment in the Medicaid provider
   91  network. The agency shall determine instances in which allowing
   92  Medicaid beneficiaries to purchase durable medical equipment and
   93  other goods is less expensive to the Medicaid program than long
   94  term rental of the equipment or goods. The agency may establish
   95  rules to facilitate purchases in lieu of long-term rentals in
   96  order to protect against fraud and abuse in the Medicaid program
   97  as defined in s. 409.913. The agency may seek federal waivers
   98  necessary to administer these policies.
   99         (5) The Agency for Health Care Administration, in
  100  partnership with the Department of Elderly Affairs, shall expand
  101  the nursing home diversion program into create an integrated,
  102  fixed-payment delivery program for all Medicaid recipients who
  103  meet nursing home admission criteria and are 60 years of age or
  104  older and or dually eligible for Medicare and Medicaid. The
  105  Agency for Health Care Administration shall implement the
  106  integrated program initially in on a pilot basis in two Areas 5,
  107  6, and 7 of the state. The program shall be implemented in Areas
  108  8, 9, 10, and 11 in 2013 and in Areas 1, 2, 3, and 4 in 2014.
  109  All Medicaid recipients shall be given a choice of nursing home
  110  diversion contractors in each area. In order to ensure enrollee
  111  choice, when an enrollee is determined to be likely to require
  112  the level of care provided in a hospital or nursing home, the
  113  enrollee shall be informed by the nursing home diversion
  114  contractor of any feasible alternatives available and given the
  115  choice of either institutional or home and community-based
  116  services pilot areas shall be Area 7 and Area 11 of the Agency
  117  for Health Care Administration. Enrollment in the pilot areas
  118  shall be on a voluntary basis and in accordance with approved
  119  federal waivers and this section. The agency and its program
  120  contractors and providers shall not enroll any individual in the
  121  integrated program because the individual or the person legally
  122  responsible for the individual fails to choose to enroll in the
  123  integrated program. Enrollment in the integrated program shall
  124  be exclusively by affirmative choice of the eligible individual
  125  or by the person legally responsible for the individual. The
  126  integrated program must transfer all Medicaid services for
  127  eligible elderly individuals who choose to participate into an
  128  integrated-care management model designed to serve Medicaid
  129  recipients in the community. The integrated program must combine
  130  all funding for Medicaid services provided to individuals who
  131  are 60 years of age or older and or dually eligible for Medicare
  132  and Medicaid into the integrated program, including funds for
  133  Medicaid home and community-based waiver services; all Medicaid
  134  services authorized in ss. 409.905 and 409.906, including
  135  excluding funds for Medicaid nursing home services unless the
  136  agency is able to demonstrate how the integration of the funds
  137  will improve coordinated care for these services in a less
  138  costly manner; and Medicare coinsurance and deductibles for
  139  persons dually eligible for Medicaid and Medicare as prescribed
  140  in s. 409.908(13).
  141         (a) Individuals who are 60 years of age or older, or dually
  142  eligible for Medicare and Medicaid, and enrolled in the
  143  developmental disabilities waiver program, the family and
  144  supported-living waiver program, the project AIDS care waiver
  145  program, the traumatic brain injury and spinal cord injury
  146  waiver program, the consumer-directed care waiver program, and
  147  the program of all-inclusive care for the elderly program, and
  148  residents of institutional care facilities for the
  149  developmentally disabled, must be excluded from the integrated
  150  program.
  151         (b) Managed care entities who meet or exceed the agency’s
  152  minimum standards are eligible to operate the integrated
  153  program. Entities eligible to participate include managed care
  154  organizations licensed under chapter 641, including entities
  155  eligible to participate in the nursing home diversion program
  156  contractors, other qualified providers as defined in s.
  157  430.703(6) and (7). The Department of Elderly Affairs and the
  158  agency shall comply with s. 430.705(3) prior to approval of any
  159  additional contractors, community care for the elderly lead
  160  agencies, and other state-certified community service networks
  161  that meet comparable standards as defined by the agency, in
  162  consultation with the Department of Elderly Affairs and the
  163  Office of Insurance Regulation, to be financially solvent and
  164  able to take on financial risk for managed care. Community
  165  service networks that are certified pursuant to the comparable
  166  standards defined by the agency are not required to be licensed
  167  under chapter 641. Managed care entities who operate the
  168  integrated program shall be subject to s. 408.7056. Eligible
  169  entities shall choose to serve enrollees who are dually eligible
  170  for Medicare and Medicaid, enrollees who are 60 years of age or
  171  older, or both.
  172         (c) The agency must ensure that the capitation-rate-setting
  173  methodology for the integrated program is actuarially sound and
  174  reflects the intent to provide quality care in the least
  175  restrictive setting. The agency must also require nursing home
  176  diversion contractors integrated-program providers to develop a
  177  credentialing system for service providers and to contract with
  178  all Gold Seal nursing homes, where feasible, and exclude, where
  179  feasible, chronically poor-performing facilities and providers
  180  as defined by the agency. The integrated program must develop
  181  and maintain an informal provider grievance system that
  182  addresses provider payment and contract problems. The agency
  183  shall also establish a formal grievance system to address those
  184  issues that were not resolved through the informal grievance
  185  system. The integrated program must provide that if the
  186  recipient resides in a noncontracted residential facility
  187  licensed under chapter 400 or chapter 429 at the time of
  188  enrollment in the integrated program and the recipient’s needs
  189  cannot be met in a less restrictive environment, the recipient
  190  must be permitted to continue to reside in the noncontracted
  191  facility as long as the recipient desires. The integrated
  192  program must also provide that, in the absence of a contract
  193  between the nursing home diversion contractor integrated-program
  194  provider and the residential facility licensed under chapter 400
  195  or chapter 429, current Medicaid rates must prevail. The nursing
  196  home diversion contractor integrated-program provider must
  197  ensure that electronic nursing home claims that contain
  198  sufficient information for processing are paid within 10
  199  business days after receipt. Alternately, the nursing home
  200  diversion contractor integrated-program provider may establish a
  201  capitated payment mechanism to prospectively pay nursing homes
  202  at the beginning of each month. The agency and the Department of
  203  Elderly Affairs must jointly develop procedures to manage the
  204  services provided through the integrated program in order to
  205  ensure quality and recipient choice.
  206         (d) The Office of Program Policy Analysis and Government
  207  Accountability, in consultation with the Auditor General, shall
  208  comprehensively evaluate the pilot project for the integrated,
  209  fixed-payment delivery program for Medicaid recipients created
  210  under this subsection. The evaluation shall begin as soon as
  211  Medicaid recipients are enrolled in the managed care pilot
  212  program plans and shall continue for 24 months thereafter. The
  213  evaluation must include assessments of each nursing home
  214  diversion contractor managed care plan in the integrated program
  215  with regard to cost savings; consumer education, choice, and
  216  access to services; coordination of care; and quality of care.
  217  The evaluation must describe administrative or legal barriers to
  218  the implementation and operation of the pilot program and
  219  include recommendations regarding statewide expansion of the
  220  pilot program. The office shall submit its evaluation report to
  221  the Governor, the President of the Senate, and the Speaker of
  222  the House of Representatives no later than December 31, 2014
  223  2009.
  224         (e) The agency may seek federal waivers or Medicaid state
  225  plan amendments and adopt rules as necessary to administer the
  226  integrated program. The agency may implement the approved
  227  federal waivers and other provisions as specified in this
  228  subsection.
  229         (f) The implementation of the integrated, fixed-payment
  230  delivery program created under this subsection is subject to an
  231  appropriation in the General Appropriations Act.
  232         Section 2. Paragraph (e) of subsection (1) of section
  233  408.040, Florida Statutes, is redesignated as paragraph (d), and
  234  present paragraph (d) of that subsection is amended to read:
  235         408.040 Conditions and monitoring.—
  236         (1)
  237         (d) If a nursing home is located in a county in which a
  238  long-term care community diversion pilot project has been
  239  implemented under s. 430.705 or in a county in which an
  240  integrated, fixed-payment delivery program for Medicaid
  241  recipients who are 60 years of age or older or dually eligible
  242  for Medicare and Medicaid has been implemented under s.
  243  409.912(5), the nursing home may request a reduction in the
  244  percentage of annual patient days used by residents who are
  245  eligible for care under Title XIX of the Social Security Act,
  246  which is a condition of the nursing home’s certificate of need.
  247  The agency shall automatically grant the nursing home’s request
  248  if the reduction is not more than 15 percent of the nursing
  249  home’s annual Medicaid-patient-days condition. A nursing home
  250  may submit only one request every 2 years for an automatic
  251  reduction. A requesting nursing home must notify the agency in
  252  writing at least 60 days in advance of its intent to reduce its
  253  annual Medicaid-patient-days condition by not more than 15
  254  percent. The agency must acknowledge the request in writing and
  255  must change its records to reflect the revised certificate-of
  256  need condition. This paragraph expires June 30, 2011.
  257         Section 3. This act shall take effect July 1, 2011.