Florida Senate - 2011                          SENATOR AMENDMENT
       Bill No. CS/HB 7107, 2nd Eng.
       
       
       
       
       
       
                                Barcode 491664                          
       
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
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                Floor: 1/AD/2R         .            Floor: C            
             05/05/2011 04:51 PM       .      05/06/2011 07:15 PM       
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       Senator Negron moved the following:
       
    1         Senate Amendment (with title amendment)
    2  
    3         Delete everything after the enacting clause
    4  and insert:
    5         Section 1. Sections 409.961 through 409.985, Florida
    6  Statutes, are designated as part IV of chapter 409, Florida
    7  Statutes, entitled “Medicaid Managed Care.”
    8         Section 2. Section 409.961, Florida Statutes, is created to
    9  read:
   10         409.961 Statutory construction; applicability; rules.—It is
   11  the intent of the Legislature that if any conflict exists
   12  between the provisions contained in this part and in other parts
   13  of this chapter, the provisions in this part control. Sections
   14  409.961–409.985 apply only to the Medicaid managed medical
   15  assistance program and long-term care managed care program, as
   16  provided in this part. The agency shall adopt any rules
   17  necessary to comply with or administer this part and all rules
   18  necessary to comply with federal requirements. In addition, the
   19  department shall adopt and accept the transfer of any rules
   20  necessary to carry out the department’s responsibilities for
   21  receiving and processing Medicaid applications and determining
   22  Medicaid eligibility and for ensuring compliance with and
   23  administering this part, as those rules relate to the
   24  department’s responsibilities, and any other provisions related
   25  to the department’s responsibility for the determination of
   26  Medicaid eligibility.
   27         Section 3. Section 409.962, Florida Statutes, is created to
   28  read:
   29         409.962 Definitions.—As used in this part, except as
   30  otherwise specifically provided, the term:
   31         (1) “Accountable care organization” means an entity
   32  qualified as an accountable care organization in accordance with
   33  federal regulations, and which meets the requirements of a
   34  provider service network as described in s. 409.912(4)(d).
   35         (2) “Agency” means the Agency for Health Care
   36  Administration.
   37         (3) “Aging network service provider” means a provider that
   38  participated in a home and community-based waiver administered
   39  by the Department of Elderly Affairs or the community care
   40  service system pursuant to s. 430.205 as of October 1, 2013.
   41         (4) “Comprehensive long-term care plan” means a managed
   42  care plan that provides services described in s. 409.973 and
   43  also provides the services described in s. 409.98.
   44         (5) “Department” means the Department of Children and
   45  Family Services.
   46         (6) “Eligible plan” means a health insurer authorized under
   47  chapter 624, an exclusive provider organization authorized under
   48  chapter 627, a health maintenance organization authorized under
   49  chapter 641, or a provider service network authorized under s.
   50  409.912(4)(d) or an accountable care organization authorized
   51  under federal law. For purposes of the managed medical
   52  assistance program, the term also includes the Children’s
   53  Medical Services Network authorized under chapter 391. For
   54  purposes of the long-term care managed care program, the term
   55  also includes entities qualified under 42 C.F.R. part 422 as
   56  Medicare Advantage Preferred Provider Organizations, Medicare
   57  Advantage Provider-sponsored Organizations, and Medicare
   58  Advantage Special Needs Plans, and the Program of All-Inclusive
   59  Care for the Elderly.
   60         (7) “Long-term care plan” means a managed care plan that
   61  provides the services described in s. 409.98 for the long-term
   62  care managed care program.
   63         (8) “Long-term care provider service network” means a
   64  provider service network a controlling interest of which is
   65  owned by one or more licensed nursing homes, assisted living
   66  facilities with 17 or more beds, home health agencies, community
   67  care for the elderly lead agencies, or hospices.
   68         (9) “Managed care plan” means an eligible plan under
   69  contract with the agency to provide services in the Medicaid
   70  program.
   71         (10) “Medicaid” means the medical assistance program
   72  authorized by Title XIX of the Social Security Act, 42 U.S.C.
   73  ss. 1396 et seq., and regulations thereunder, as administered in
   74  this state by the agency.
   75         (11) “Medicaid recipient” or “recipient” means an
   76  individual who the department or, for Supplemental Security
   77  Income, the Social Security Administration determines is
   78  eligible pursuant to federal and state law to receive medical
   79  assistance and related services for which the agency may make
   80  payments under the Medicaid program. For the purposes of
   81  determining third-party liability, the term includes an
   82  individual formerly determined to be eligible for Medicaid, an
   83  individual who has received medical assistance under the
   84  Medicaid program, or an individual on whose behalf Medicaid has
   85  become obligated.
   86         (12) “Prepaid plan” means a managed care plan that is
   87  licensed or certified as a risk-bearing entity, or qualified
   88  pursuant to s. 409.912(4)(d), in the state and is paid a
   89  prospective per-member, per-month payment by the agency.
   90         (13) “Provider service network” means an entity qualified
   91  pursuant to s. 409.912(4)(d) of which a controlling interest is
   92  owned by a health care provider, or group of affiliated
   93  providers, or a public agency or entity that delivers health
   94  services. Health care providers include Florida-licensed health
   95  care professionals or licensed health care facilities, federally
   96  qualified health care centers, and home health care agencies.
   97         (15) “Specialty plan” means a managed care plan that serves
   98  Medicaid recipients who meet specified criteria based on age,
   99  medical condition, or diagnosis.
  100         Section 4. Section 409.963, Florida Statutes, is created to
  101  read:
  102         409.963 Single state agency.—The agency is designated as
  103  the single state agency authorized to manage, operate, and make
  104  payments for medical assistance and related services under Title
  105  XIX of the Social Security Act. Subject to any limitations or
  106  directions provided in the General Appropriations Act, these
  107  payments may be made only for services included in the program,
  108  only on behalf of eligible individuals, and only to qualified
  109  providers in accordance with federal requirements for Title XIX
  110  of the Social Security Act and state law. This program of
  111  medical assistance is designated as the “Medicaid program.” The
  112  department is responsible for Medicaid eligibility
  113  determinations, including, but not limited to, policy, rules,
  114  and the agreement with the Social Security Administration for
  115  Medicaid eligibility determinations for Supplemental Security
  116  Income recipients, as well as the actual determination of
  117  eligibility. As a condition of Medicaid eligibility, subject to
  118  federal approval, the agency and the department shall ensure
  119  that each Medicaid recipient consents to the release of her or
  120  his medical records to the agency and the Medicaid Fraud Control
  121  Unit of the Department of Legal Affairs.
  122         Section 5. Section 409.964, Florida Statutes is created to
  123  read:
  124         409.964 Managed care program; state plan; waivers.—The
  125  Medicaid program is established as a statewide, integrated
  126  managed care program for all covered services, including long
  127  term care services. The agency shall apply for and implement
  128  state plan amendments or waivers of applicable federal laws and
  129  regulations necessary to implement the program. Before seeking a
  130  waiver, the agency shall provide public notice and the
  131  opportunity for public comment and include public feedback in
  132  the waiver application. The agency shall hold one public meeting
  133  in each of the regions described in s. 409.966(2) and the time
  134  period for public comment for each region shall end no sooner
  135  than 30 days after the completion of the public meeting in that
  136  region. The agency shall submit any state plan amendments, new
  137  waiver requests, or requests for extensions or expansions for
  138  existing waivers, needed to implement the managed care program
  139  by August 1, 2011.
  140         Section 6. Section 409.965, Florida Statutes, is created to
  141  read:
  142         409.965 Mandatory enrollment.—All Medicaid recipients shall
  143  receive covered services through the statewide managed care
  144  program, except as provided by this part pursuant to an approved
  145  federal waiver. The following Medicaid recipients are exempt
  146  from participation in the statewide managed care program:
  147         (1) Women who are eligible only for family planning
  148  services.
  149         (2) Women who are eligible only for breast and cervical
  150  cancer services.
  151         (3) Persons who are eligible for emergency Medicaid for
  152  aliens.
  153         (4) Children receiving services in a prescribed pediatric
  154  extended care center.
  155         Section 7. Section 409.966, Florida Statutes, is created to
  156  read:
  157         409.966 Eligible plans; selection.—
  158         (1) ELIGIBLE PLANS.—Services in the Medicaid managed care
  159  program shall be provided by eligible plans. A provider service
  160  network must be capable of providing all covered services to a
  161  mandatory Medicaid managed care enrollee or may limit the
  162  provision of services to a specific target population based on
  163  the age, chronic disease state, or medical condition of the
  164  enrollee to whom the network will provide services. A specialty
  165  provider service network must be capable of coordinating care
  166  and delivering or arranging for the delivery of all covered
  167  services to the target population. A provider service network
  168  may partner with an insurer licensed under chapter 627 or a
  169  health maintenance organization licensed under chapter 641 to
  170  meet the requirements of a Medicaid contract.
  171         (2) ELIGIBLE PLAN SELECTION.—The agency shall select a
  172  limited number of eligible plans to participate in the Medicaid
  173  program using invitations to negotiate in accordance with s.
  174  287.057(3)(a). At least 90 days before issuing an invitation to
  175  negotiate, the agency shall compile and publish a databook
  176  consisting of a comprehensive set of utilization and spending
  177  data for the 3 most recent contract years consistent with the
  178  rate-setting periods for all Medicaid recipients by region or
  179  county. The source of the data in the report must include both
  180  historic fee-for-service claims and validated data from the
  181  Medicaid Encounter Data System. The report must be available in
  182  electronic form and delineate utilization use by age, gender,
  183  eligibility group, geographic area, and aggregate clinical risk
  184  score. Separate and simultaneous procurements shall be conducted
  185  in each of the following regions:
  186         (a) Region 1, which consists of Escambia, Okaloosa, Santa
  187  Rosa and Walton Counties.
  188         (b) Region 2, which consists of Bay, Calhoun, Franklin,
  189  Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty,
  190  Madison, Taylor, Wakulla, and Washington Counties.
  191         (c) Region 3, which consists of Alachua, Bradford, Citrus,
  192  Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake,
  193  Levy, Marion, Putnam, Sumter, Suwannee, and Union Counties.
  194         (d) Region 4, which consists of Baker, Clay, Duval,
  195  Flagler, Nassau, St. Johns, and Volusia Counties.
  196         (e) Region 5, which consists of Pasco and Pinellas
  197  Counties.
  198         (f) Region 6, which consists of Hardee, Highlands,
  199  Hillsborough, Manatee and Polk Counties.
  200         (g) Region 7, which consists of Brevard, Orange, Osceola
  201  and Seminole Counties.
  202         (h) Region 8, which consists of Charlotte, Collier, DeSoto,
  203  Glades, Hendry, Lee, and Sarasota Counties.
  204         (i) Region 9, which consists of Indian River, Martin,
  205  Okeechobee, Palm Beach and St. Lucie Counties.
  206         (j) Region 10, which consists of Broward County.
  207         (k) Region 11, which consists of Miami-Dade and Monroe
  208  Counties.
  209         (3) QUALITY SELECTION CRITERIA.—
  210         (a) The invitation to negotiate must specify the criteria
  211  and the relative weight of the criteria that will be used for
  212  determining the acceptability of the reply and guiding the
  213  selection of the organizations with which the agency negotiates.
  214  In addition to criteria established by the agency, the agency
  215  shall consider the following factors in the selection of
  216  eligible plans:
  217         1. Accreditation by the National Committee for Quality
  218  Assurance, the Joint Commission, or another nationally
  219  recognized accrediting body.
  220         2. Experience serving similar populations, including the
  221  organization’s record in achieving specific quality standards
  222  with similar populations.
  223         3. Availability and accessibility of primary care and
  224  specialty physicians in the provider network.
  225         4. Establishment of community partnerships with providers
  226  that create opportunities for reinvestment in community-based
  227  services.
  228         5. Organization commitment to quality improvement and
  229  documentation of achievements in specific quality improvement
  230  projects, including active involvement by organization
  231  leadership.
  232         6. Provision of additional benefits, particularly dental
  233  care and disease management, and other initiatives that improve
  234  health outcomes.
  235         7. Evidence that a eligible plan has written agreements or
  236  signed contracts or has made substantial progress in
  237  establishing relationships with providers before the plan
  238  submitting a response.
  239         8. Comments submitted in writing by any enrolled Medicaid
  240  provider relating to a specifically identified plan
  241  participating in the procurement in the same region as the
  242  submitting provider.
  243         9. Documentation of policies and procedures for preventing
  244  fraud and abuse.
  245         10. The business relationship an eligible plan has with any
  246  other eligible plan that responds to the invitation to
  247  negotiate.
  248         (b) An eligible plan must disclose any business
  249  relationship it has with any other elgible plan that responds to
  250  the invitation to negotiate. The agency may not select plans in
  251  the same region for the same managed care program that have a
  252  business relationship with each other. Failure to disclose any
  253  business relationship shall result in disqualification from
  254  participation in any region for the first full contract period
  255  after the discovery of the business relationship by the agency.
  256  For the purpose of this section, “business relationship” means
  257  an ownership or controlling interest, an affiliate or subsidiary
  258  relationship, a common parent, or any mutual interest in any
  259  limited partnership, limited liability partnership, limited
  260  liability company, or other entity or business association,
  261  including all wholly or partially owned subsidiaries, majority
  262  owned subsidiaries, parent companies, or affiliates of such
  263  entities, business associations, or other enterprises, that
  264  exists for the purpose of making a profit.
  265         (c) After negotiations are conducted, the agency shall
  266  select the eligible plans that are determined to be responsive
  267  and provide the best value to the state. Preference shall be
  268  given to plans that:
  269         1. Have signed contracts with primary and specialty
  270  physicians in sufficient numbers to meet the specific standards
  271  established pursuant to s. 409.967(2)(b).
  272         2. Have well-defined programs for recognizing patient
  273  centered medical homes and providing for increased compensation
  274  for recognized medical homes, as defined by the plan.
  275         3. Are organizations that are based in and perform
  276  operational functions in this state, in-house or through
  277  contractual arrangements, by staff located in this state. Using
  278  a tiered approach, the highest number of points shall be awarded
  279  to a plan that has all or substantially all of its operational
  280  functions performed in the state. The second highest number of
  281  points shall be awarded to a plan that has a majority of its
  282  operational functions performed in the state. The agency may
  283  establish a third tier; however, preference points may not be
  284  awarded to plans that perform only community outreach, medical
  285  director functions, and state administrative functions in the
  286  state. For purposes of this subparagraph, operational functions
  287  include claims processing, member services, provider relations,
  288  utilization and prior authorization, case management, disease
  289  and quality functions, and finance and administration. For
  290  purposes of this subparagraph, the term “based in this state”
  291  means that the entity’s principal office is in this state and
  292  the plan is not a subsidiary, directly or indirectly through one
  293  or more subsidiaries of, or a joint venture with, any other
  294  entity whose principal office is not located in the state.
  295         4. Have contracts or other arrangements for cancer disease
  296  management programs that have a proven record of clinical
  297  efficiencies and cost savings.
  298         5. Have contracts or other arrangements for diabetes
  299  disease management programs that have a proven record of
  300  clinical efficiencies and cost savings.
  301         6. Have a claims payment process that ensures that claims
  302  that are not contested or denied will be promptly paid pursuant
  303  to s. 641.3155.
  304         (d) For the first year of the first contract term, the
  305  agency shall negotiate capitation rates or fee for service
  306  payments with each plan in order to guarantee aggregate savings
  307  of at least 5 percent.
  308         1. For prepaid plans, determination of the amount of
  309  savings shall be calculated by comparison to the Medicaid rates
  310  that the agency paid managed care plans for similar populations
  311  in the same areas in the prior year. In regions containing no
  312  prepaid plans in the prior year, determination of the amount of
  313  savings shall be calculated by comparison to the Medicaid rates
  314  established and certified for those regions in the prior year.
  315         2. For provider service networks operating on a fee-for
  316  service basis, determination of the amount of savings shall be
  317  calculated by comparison to the Medicaid rates that the agency
  318  paid on a fee-for-service basis for the same services in the
  319  prior year.
  320         (e) To ensure managed care plan participation in Regions 1
  321  and 2, the agency shall award an additional contract to each
  322  plan with a contract award in Region 1 or Region 2. Such
  323  contract shall be in any other region in which the plan
  324  submitted a responsive bid and negotiates a rate acceptable to
  325  the agency. If a plan that is awarded an additional contract
  326  pursuant to this paragraph is subject to penalties pursuant to
  327  s. 409.967(2)(g) for activities in Region 1 or Region 2, the
  328  additional contract is automatically terminated 180 days after
  329  the imposition of the penalties. The plan must reimburse the
  330  agency for the cost of enrollment changes and other transition
  331  activities.
  332         (f) The agency may not execute contracts with managed care
  333  plans at payment rates not supported by the General
  334  Appropriations Act.
  335         (4) ADMINISTRATIVE CHALLENGE.—Any eligible plan that
  336  participates in an invitation to negotiate in more than one
  337  region and is selected in at least one region may not begin
  338  serving Medicaid recipients in any region for which it was
  339  selected until all administrative challenges to procurements
  340  required by this section to which the eligible plan is a party
  341  have been finalized. If the number of plans selected is less
  342  than the maximum amount of plans permitted in the region, the
  343  agency may contract with other selected plans in the region not
  344  participating in the administrative challenge before resolution
  345  of the administrative challenge. For purposes of this
  346  subsection, an administrative challenge is finalized if an order
  347  granting voluntary dismissal with prejudice has been entered by
  348  any court established under Article V of the State Constitution
  349  or by the Division of Administrative Hearings, a final order has
  350  been entered into by the agency and the deadline for appeal has
  351  expired, a final order has been entered by the First District
  352  Court of Appeal and the time to seek any available review by the
  353  Florida Supreme Court has expired, or a final order has been
  354  entered by the Florida Supreme Court and a warrant has been
  355  issued.
  356         Section 8. Section 409.967, Florida Statutes, is created to
  357  read:
  358         409.967 Managed care plan accountability.—
  359         (1) The agency shall establish a 5-year contract with each
  360  managed care plan selected through the procurement process
  361  described in s. 409.966. A plan contract may not be renewed;
  362  however, the agency may extend the term of a plan contract to
  363  cover any delays during the transition to a new plan.
  364         (2) The agency shall establish such contract requirements
  365  as are necessary for the operation of the statewide managed care
  366  program. In addition to any other provisions the agency may deem
  367  necessary, the contract must require:
  368         (a) Physician compensation.—Managed care plans are expected
  369  to coordinate care, manage chronic disease, and prevent the need
  370  for more costly services. Effective care management should
  371  enable plans to redirect available resources and increase
  372  compensation for physicians. Plans achieve this performance
  373  standard when physician payment rates equal or exceed Medicare
  374  rates for similar services. The agency may impose fines or other
  375  sanctions on a plan that fails to meet this performance standard
  376  after 2 years of continuous operation.
  377         (b) Emergency services.—Managed care plans shall pay for
  378  services required by ss. 395.1041 and 401.45 and rendered by a
  379  noncontracted provider. The plans must comply with s. 641.3155.
  380  Reimbursement for services under this paragraph is the lesser
  381  of:
  382         1. The provider’s charges;
  383         2. The usual and customary provider charges for similar
  384  services in the community where the services were provided;
  385         3. The charge mutually agreed to by the entity and the
  386  provider within 60 days after submittal of the claim; or
  387         4. The rate the agency would have paid on the most recent
  388  October 1st.
  389         (c) Access.—
  390         1. The agency shall establish specific standards for the
  391  number, type, and regional distribution of providers in managed
  392  care plan networks to ensure access to care for both adults and
  393  children. Each plan must maintain a region-wide network of
  394  providers in sufficient numbers to meet the access standards for
  395  specific medical services for all recipients enrolled in the
  396  plan. The exclusive use of mail-order pharmacies may not be
  397  sufficient to meet network access standards. Consistent with the
  398  standards established by the agency, provider networks may
  399  include providers located outside the region. A plan may
  400  contract with a new hospital facility before the date the
  401  hospital becomes operational if the hospital has commenced
  402  construction, will be licensed and operational by January 1,
  403  2013, and a final order has issued in any civil or
  404  administrative challenge. Each plan shall establish and maintain
  405  an accurate and complete electronic database of contracted
  406  providers, including information about licensure or
  407  registration, locations and hours of operation, specialty
  408  credentials and other certifications, specific performance
  409  indicators, and such other information as the agency deems
  410  necessary. The database must be available online to both the
  411  agency and the public and have the capability to compare the
  412  availability of providers to network adequacy standards and to
  413  accept and display feedback from each provider’s patients. Each
  414  plan shall submit quarterly reports to the agency identifying
  415  the number of enrollees assigned to each primary care provider.
  416         2. Each managed care plan must publish any prescribed drug
  417  formulary or preferred drug list on the plan’s website in a
  418  manner that is accessible to and searchable by enrollees and
  419  providers. The plan must update the list within 24 hours after
  420  making a change. Each plan must ensure that the prior
  421  authorization process for prescribed drugs is readily accessible
  422  to health care providers, including posting appropriate contact
  423  information on its website and providing timely responses to
  424  providers. For Medicaid recipients diagnosed with hemophilia who
  425  have been prescribed anti-hemophilic-factor replacement
  426  products, the agency shall provide for those products and
  427  hemophilia overlay services through the agency’s hemophilia
  428  disease management program.
  429         3. Managed care plans, and their fiscal agents or
  430  intermediaries, must accept prior authorization requests for any
  431  service electronically.
  432         (d) Encounter data.—The agency shall maintain and operate a
  433  Medicaid Encounter Data System to collect, process, store, and
  434  report on covered services provided to all Medicaid recipients
  435  enrolled in prepaid plans.
  436         1. Each prepaid plan must comply with the agency’s
  437  reporting requirements for the Medicaid Encounter Data System.
  438  Prepaid plans must submit encounter data electronically in a
  439  format that complies with the Health Insurance Portability and
  440  Accountability Act provisions for electronic claims and in
  441  accordance with deadlines established by the agency. Prepaid
  442  plans must certify that the data reported is accurate and
  443  complete.
  444         2. The agency is responsible for validating the data
  445  submitted by the plans. The agency shall develop methods and
  446  protocols for ongoing analysis of the encounter data that
  447  adjusts for differences in characteristics of prepaid plan
  448  enrollees to allow comparison of service utilization among plans
  449  and against expected levels of use. The analysis shall be used
  450  to identify possible cases of systemic underutilization or
  451  denials of claims and inappropriate service utilization such as
  452  higher-than-expected emergency department encounters. The
  453  analysis shall provide periodic feedback to the plans and enable
  454  the agency to establish corrective action plans when necessary.
  455  One of the focus areas for the analysis shall be the use of
  456  prescription drugs.
  457         3. The agency shall make encounter data available to those
  458  plans accepting enrollees who are assigned to them from other
  459  plans leaving a region.
  460         (e) Continuous improvement.—The agency shall establish
  461  specific performance standards and expected milestones or
  462  timelines for improving performance over the term of the
  463  contract.
  464         1. Each managed care plan shall establish an internal
  465  health care quality improvement system, including enrollee
  466  satisfaction and disenrollment surveys. The quality improvement
  467  system must include incentives and disincentives for network
  468  providers.
  469         2. Each plan must collect and report the Health Plan
  470  Employer Data and Information Set (HEDIS) measures, as specified
  471  by the agency. These measures must be published on the plan’s
  472  website in a manner that allows recipients to reliably compare
  473  the performance of plans. The agency shall use the HEDIS
  474  measures as a tool to monitor plan performance.
  475         3. Each managed care plan must be accredited by the
  476  National Committee for Quality Assurance, the Joint Commission,
  477  or another nationally recognized accrediting body, or have
  478  initiated the accreditation process, within 1 year after the
  479  contract is executed. For any plan not accredited within 18
  480  months after executing the contract, the agency shall suspend
  481  automatic assignment under s. 409.977 and 409.984.
  482         4. By the end of the fourth year of the first contract
  483  term, the agency shall issue a request for information to
  484  determine whether cost savings could be achieved by contracting
  485  for plan oversight and monitoring, including analysis of
  486  encounter data, assessment of performance measures, and
  487  compliance with other contractual requirements.
  488         (f) Program integrity.—Each managed care plan shall
  489  establish program integrity functions and activities to reduce
  490  the incidence of fraud and abuse, including, at a minimum:
  491         1. A provider credentialing system and ongoing provider
  492  monitoring, including maintenance of written provider
  493  credentialing policies and procedures which comply with federal
  494  and agency guidelines;
  495         2. An effective prepayment and postpayment review process
  496  including, but not limited to, data analysis, system editing,
  497  and auditing of network providers;
  498         3. Procedures for reporting instances of fraud and abuse
  499  pursuant to chapter 641;
  500         4. Administrative and management arrangements or
  501  procedures, including a mandatory compliance plan, designed to
  502  prevent fraud and abuse; and
  503         5. Designation of a program integrity compliance officer.
  504         (g) Grievance resolution.—Consistent with federal law, each
  505  managed care plan shall establish and the agency shall approve
  506  an internal process for reviewing and responding to grievances
  507  from enrollees. Each plan shall submit quarterly reports on the
  508  number, description, and outcome of grievances filed by
  509  enrollees.
  510         (h) Penalties.—
  511         1. Withdrawal and enrollment reduction.—Managed care plans
  512  that reduce enrollment levels or leave a region before the end
  513  of the contract term must reimburse the agency for the cost of
  514  enrollment changes and other transition activities. If more than
  515  one plan leaves a region at the same time, costs must be shared
  516  by the departing plans proportionate to their enrollments. In
  517  addition to the payment of costs, departing provider services
  518  networks must pay a per enrollee penalty of up to 3 month’s
  519  payment and continue to provide services to the enrollee for 90
  520  days or until the enrollee is enrolled in another plan,
  521  whichever occurs first. In addition to payment of costs, all
  522  other plans must pay a penalty of 25 percent of the minimum
  523  surplus requirement pursuant to s. 641.225(1). Plans shall
  524  provide at least 180 days notice to the agency before
  525  withdrawing from a region. If a managed care plan leaves a
  526  region before the end of the contract term, the agency shall
  527  terminate all contracts with that plan in other regions,
  528  pursuant to the termination procedures in subparagraph 3.
  529         2. Encounter data.—If a plan fails to comply with the
  530  encounter data reporting requirements of this section for 30
  531  days, the agency must assess a fine of $5,000 per day for each
  532  day of noncompliance beginning on the 31st day. On the 31st day,
  533  the agency must notify the plan that the agency will initiate
  534  contract termination procedures on the 90th day unless the plan
  535  comes into compliance before that date.
  536         3. Termination.—If the agency terminates more than one
  537  regional contract with the same managed care plan due to
  538  noncompliance with the requirements of this section, the agency
  539  shall terminate all the regional contracts held by that plan.
  540  When terminating multiple contracts, the agency must develop a
  541  plan to transition enrollees to other plans, and phase-in the
  542  terminations over a time period sufficient to ensure a smooth
  543  transition.
  544         (i) Prompt payment.—Managed care plans shall comply with
  545  ss. 641.315, 641.3155, and 641.513.
  546         (j) Electronic claims.—Managed care plans, and their fiscal
  547  agents or intermediaries, shall accept electronic claims in
  548  compliance with federal standards.
  549         (k) Fair payment.—Provider service networks must ensure
  550  that no entity licensed under chapter 395 with a controlling
  551  interest in the network charges a Medicaid managed care plan
  552  more than the amount paid to that provider by the provider
  553  service network for the same service.
  554         (l) Itemized payment.—Any claims payment to a provider by a
  555  managed care plan, or by a fiscal agent or intermediary of the
  556  plan, must be accompanied by an itemized accounting of the
  557  individual claims included in the payment including, but not
  558  limited to, the enrollee’s name, the date of service, the
  559  procedure code, the amount of reimbursement, and the
  560  identification of the plan on whose behalf the payment is made.
  561         (m) Provider dispute resolution.—Disputes between a plan
  562  and a provider may be resolved as described in s. 408.7057.
  563         (3) ACHIEVED SAVINGS REBATE.—
  564         (a) The agency is responsible for verifying the achieved
  565  savings rebate for all Medicaid prepaid plans. To assist the
  566  agency, a prepaid plan shall:
  567         1. Submit an annual financial audit conducted by an
  568  independent certified public accountant in accordance with
  569  generally accepted auditing standards to the agency on or before
  570  June 1 for the preceding year; and
  571         2. Submit an annual statement prepared in accordance with
  572  statutory accounting principles on or before March 1 pursuant to
  573  s. 624.424 if the plan is regulated by the Office of Insurance
  574  Regulation.
  575         (b) The agency shall contract with independent certified
  576  public accountants to conduct compliance audits for the purpose
  577  of auditing financial information, including but not limited to:
  578  annual premium revenue, medical and administrative costs, and
  579  income or losses reported by each prepaid plan, in order to
  580  determine and validate the achieved savings rebate.
  581         (c) Any audit required under this subsection must be
  582  conducted by an independent certified public accountant who
  583  meets criteria specified by rule. The rules must also provide
  584  that:
  585         1. The entity selected by the agency to conduct the audit
  586  may not have a conflict of interest that might affect its
  587  ability to perform its responsibilities with respect to an
  588  examination.
  589         2. The rates charged to the prepaid plan being audited are
  590  consistent with rates charged by other certified public
  591  accountants and are comparable with the rates charged for
  592  comparable examinations.
  593         3. Each prepaid plan audited shall pay to the agency the
  594  expenses of the audit at the rates established by the agency by
  595  rule. Such expenses include actual travel expenses, reasonable
  596  living expense allowances, compensation of the certified public
  597  accountant, and necessary attendant administrative costs of the
  598  agency directly related to the examination. Travel expense and
  599  living expense allowances are limited to those expenses incurred
  600  on account of the audit and must be paid by the examined prepaid
  601  plan together with compensation upon presentation by the agency
  602  to the prepaid plan of a detailed account of the charges and
  603  expenses after a detailed statement has been filed by the
  604  auditor and approved by the agency.
  605         4. All moneys collected from prepaid plans for such audits
  606  shall be deposited into the Grants and Donations Trust Fund and
  607  the agency may make deposits into such fund from moneys
  608  appropriated for the operation of the agency.
  609         (d) At a location in this state, the prepaid plan shall
  610  make available to the agency and the agency’s contracted
  611  certified public accountant all books, accounts, documents,
  612  files, information, that relate to the prepaid plan’s Medicaid
  613  transactions. Records not in the prepaid plan’s immediate
  614  possession must be made available to the agency or the certified
  615  public accountant in this state within 3 days after a request is
  616  made by the agency or certified public accountant engaged by the
  617  agency. A prepaid plan has an obligation to cooperate in good
  618  faith with the agency and the certified public accountant.
  619  Failure to comply to such record requests shall be deemed a
  620  breach of contract.
  621         (e) Once the certified public accountant completes the
  622  audit, the certified public accountant shall submit an audit
  623  report to the agency attesting to the achieved savings of the
  624  plan. The results of the audit report are dispositive.
  625         (f) Achieved savings rebates validated by the certified
  626  public accountant are due within 30 days after the report is
  627  submitted. Except as provided in paragraph (h), the achieved
  628  savings rebate is established by determining pretax income as a
  629  percentage of revenues and applying the following income sharing
  630  ratios:
  631         1. One hundred percent of income up to and including 5
  632  percent of revenue shall be retained by the plan.
  633         2. Fifty percent of income above 5 percent and up to 10
  634  percent shall be retained by the plan, and the other 50 percent
  635  refunded to the state.
  636         3. One hundred percent of income above 10 percent of
  637  revenue shall be refunded to the state.
  638         (g) A plan that exceeds agency-defined quality measures in
  639  the reporting period may retain an additional 1 percent of
  640  revenue. For the purpose of this paragraph, the quality measures
  641  must include plan performance for preventing or managing
  642  complex, chronic conditions that are associated with an elevated
  643  likelihood of requiring high-cost medical treatments.
  644         (h) The following may not be included as allowable expenses
  645  in calculating income for determining the achieved savings
  646  rebate:
  647         1. Payment of achieved savings rebates.
  648         2. Any financial incentive payments made to the plan
  649  outside of the capitation rate.
  650         3. Any financial disincentive payments levied by the state
  651  or federal governments.
  652         4. Expenses associated with any lobbying or political
  653  activities.
  654         5. The cash value or equivalent cash value of bonuses of
  655  any type paid or awarded to the plan’s executive staff, other
  656  than base salary.
  657         6. Reserves and reserve accounts.
  658         7. Administrative costs, including, but not limited to,
  659  reinsurance expenses, interest payments, depreciation expenses,
  660  bad debt expenses, and outstanding claims expenses in excess of
  661  actuarially sound maximum amounts set by the agency.
  662  
  663  The agency shall consider these and other factors in developing
  664  contracts that establish shared savings arrangements.
  665         (i) Prepaid plans that incur a loss in the first contract
  666  year may apply the full amount of the loss as an offset to
  667  income in the second contract year.
  668         (j) If, after an audit, the agency determines that a
  669  prepaid plan owes an additional rebate, the plan has 30 days
  670  after notification to make the payment. Upon failure to timely
  671  pay the rebate, the agency shall withhold future payments to the
  672  plan until the entire amount is recouped. If the agency
  673  determines that a prepaid plan has made an overpayment, the
  674  agency shall return the overpayment within 30 days.
  675         Section 9. Section 409.968, Florida Statutes, is created to
  676  read:
  677         409.968 Managed care plan payments.—
  678         (1) Prepaid plans shall receive per-member, per-month
  679  payments negotiated pursuant to the procurements described in s.
  680  409.966. Payments shall be risk-adjusted rates based on
  681  historical utilization and spending data, projected forward, and
  682  adjusted to reflect the eligibility category, geographic area,
  683  and clinical risk profile of the recipients. In negotiating
  684  rates with the plans, the agency shall consider any adjustments
  685  necessary to encourage plans to use the most cost effective
  686  modalities for treatment of chronic disease such as peritoneal
  687  dialysis.
  688         (2) Provider service networks may be prepaid plans and
  689  receive per-member, per-month payments negotiated pursuant to
  690  the procurement process described in s. 409.966. Provider
  691  service networks that choose not to be prepaid plans shall
  692  receive fee-for-service rates with a shared savings settlement.
  693  The fee-for-service option shall be available to a provider
  694  service network only for the first 2 years of its operation. The
  695  agency shall annually conduct cost reconciliations to determine
  696  the amount of cost savings achieved by fee-for-service provider
  697  service networks for the dates of service within the period
  698  being reconciled. Only payments for covered services for dates
  699  of service within the reconciliation period and paid within 6
  700  months after the last date of service in the reconciliation
  701  period must be included. The agency shall perform the necessary
  702  adjustments for the inclusion of claims incurred but not
  703  reported within the reconciliation period for claims that could
  704  be received and paid by the agency after the 6-month claims
  705  processing time lag. The agency shall provide the results of the
  706  reconciliations to the fee-for-service provider service networks
  707  within 45 days after the end of the reconciliation period. The
  708  fee-for-service provider service networks shall review and
  709  provide written comments or a letter of concurrence to the
  710  agency within 45 days after receipt of the reconciliation
  711  results. This reconciliation is considered final.
  712         (3) The agency may not approve any plan request for a rate
  713  increase unless sufficient funds to support the increase have
  714  been authorized in the General Appropriations Act.
  715         Section 10. Section 409.969, Florida Statutes, is created
  716  to read:
  717         409.969 Enrollment; disenrollment.—
  718         (1) ENROLLMENT.—All Medicaid recipients shall be enrolled
  719  in a managed care plan unless specifically exempted under this
  720  part. Each recipient shall have a choice of plans and may select
  721  any available plan unless that plan is restricted by contract to
  722  a specific population that does not include the recipient.
  723  Medicaid recipients shall have 30 days in which to make a choice
  724  of plans.
  725         (2) DISENROLLMENT; GRIEVANCES.—After a recipient has
  726  enrolled in a managed care plan, the recipient shall have 90
  727  days to voluntarily disenroll and select another plan. After 90
  728  days, no further changes may be made except for good cause. For
  729  purposes of this section, the term “good cause” includes, but is
  730  not limited to, poor quality of care, lack of access to
  731  necessary specialty services, an unreasonable delay or denial of
  732  service, or fraudulent enrollment. The agency must make a
  733  determination as to whether good cause exists. The agency may
  734  require a recipient to use the plan’s grievance process before
  735  the agency’s determination of good cause, except in cases in
  736  which immediate risk of permanent damage to the recipient’s
  737  health is alleged.
  738         (a) The managed care plan internal grievance process, when
  739  used, must be completed in time to permit the recipient to
  740  disenroll by the first day of the second month after the month
  741  the disenrollment request was made. If the result of the
  742  grievance process is approval of an enrollee’s request to
  743  disenroll, the agency is not required to make a determination in
  744  the case.
  745         (b) The agency must make a determination and take final
  746  action on a recipient’s request so that disenrollment occurs no
  747  later than the first day of the second month after the month the
  748  request was made. If the agency fails to act within the
  749  specified timeframe, the recipient’s request to disenroll is
  750  deemed to be approved as of the date agency action was required.
  751  Recipients who disagree with the agency’s finding that good
  752  cause does not exist for disenrollment shall be advised of their
  753  right to pursue a Medicaid fair hearing to dispute the agency’s
  754  finding.
  755         (c) Medicaid recipients enrolled in a managed care plan
  756  after the 90-day period shall remain in the plan for the
  757  remainder of the 12-month period. After 12 months, the recipient
  758  may select another plan. However, nothing shall prevent a
  759  Medicaid recipient from changing providers within the plan
  760  during that period.
  761         (d) On the first day of the month after receiving notice
  762  from a recipient that the recipient has moved to another region,
  763  the agency shall automatically disenroll the recipient from the
  764  managed care plan the recipient is currently enrolled in and
  765  treat the recipient as if the recipient is a new Medicaid
  766  enrollee. At that time, the recipient may choose another plan
  767  pursuant to the enrollment process established in this section.
  768         (e) The agency must monitor plan disenrollment throughout
  769  the contract term to identify any discriminatory practices.
  770         Section 11. Section 409.97, Florida Statutes, is created to
  771  read:
  772         409.97 State and local Medicaid partnerships.—
  773         (1) INTERGOVERNMENTAL TRANSFERS.—In addition to the
  774  contributions required pursuant to s. 409.915, beginning in the
  775  2014-2015 fiscal year, the agency may accept voluntary transfers
  776  of local taxes and other qualified revenue from counties,
  777  municipalities, and special taxing districts. Such transfers
  778  must be contributed to advance the general goals of the Florida
  779  Medicaid program without restriction and must be executed
  780  pursuant to a contract between the agency and the local funding
  781  source. Contracts executed before October 31 shall result in
  782  contributions to Medicaid for that same state fiscal year.
  783  Contracts executed between November 1 and June 30 shall result
  784  in contributions for the following state fiscal year. Based on
  785  the date of the signed contracts, the agency shall allocate to
  786  the low-income pool the first contributions received up to the
  787  limit established by subsection (2). No more than 40 percent of
  788  the low-income pool funding shall come from any single funding
  789  source. Contributions in excess of the low-income pool shall be
  790  allocated to the disproportionate share programs defined in ss.
  791  409.911(3) and 409.9113 and to hospital rates pursuant to
  792  subsection (4). The local funding source shall designate in the
  793  contract which Medicaid providers ensure access to care for low
  794  income and uninsured people within the applicable jurisdiction
  795  and are eligible for low-income pool funding. Eligible providers
  796  may include hospitals, primary care providers, and primary care
  797  access systems.
  798         (2) LOW-INCOME POOL.—The agency shall establish and
  799  maintain a low-income pool in a manner authorized by federal
  800  waiver. The low-income pool is created to compensate a network
  801  of providers designated pursuant to subsection (1). Funding of
  802  the low-income pool shall be limited to the maximum amount
  803  permitted by federal waiver minus a percentage specified in the
  804  General Appropriations Act. The low-income pool must be used to
  805  support enhanced access to services by offsetting shortfalls in
  806  Medicaid reimbursement, paying for otherwise uncompensated care,
  807  and financing coverage for the uninsured. The low-income pool
  808  shall be distributed in periodic payments to the Access to Care
  809  Partnership throughout the fiscal year. Distribution of low
  810  income pool funds by the Access to Care Partnership to
  811  participating providers may be made through capitated payments,
  812  fees for services, or contracts for specific deliverables. The
  813  agency shall include the distribution amount for each provider
  814  in the contract with the Access to Care Partnership pursuant to
  815  subsection (3). Regardless of the method of distribution,
  816  providers participating in the Access to Care Partnership shall
  817  receive payments such that the aggregate benefit in the
  818  jurisdiction of each local funding source, as defined in
  819  subsection (1), equals the amount of the contribution plus a
  820  factor specified in the General Appropriations Act.
  821         (3) ACCESS TO CARE PARTNERSHIP.—The agency shall contract
  822  with an administrative services organization that has operating
  823  agreements with all health care facilities, programs, and
  824  providers supported with local taxes or certified public
  825  expenditures and designated pursuant to subsection (1). The
  826  contract shall provide for enhanced access to care for Medicaid,
  827  low-income, and uninsured Floridians. The partnership shall be
  828  responsible for an ongoing program of activities that provides
  829  needed, but uncovered or undercompensated, health services to
  830  Medicaid enrollees and persons receiving charity care, as
  831  defined in s. 409.911. Accountability for services rendered
  832  under this contract must be based on the number of services
  833  provided to unduplicated qualified beneficiaries, the total
  834  units of service provided to these persons, and the
  835  effectiveness of services provided as measured by specific
  836  standards of care. The agency shall seek such plan amendments or
  837  waivers as may be necessary to authorize the implementation of
  838  the low-income pool as the Access to Care Partnership pursuant
  839  to this section.
  840         (4) HOSPITAL RATE DISTRIBUTION.—
  841         (a) The agency is authorized to implement a tiered hospital
  842  rate system to enhance Medicaid payments to all hospitals when
  843  resources for the tiered rates are available from general
  844  revenue and such contributions pursuant to subsection (1) as are
  845  authorized under the General Appropriations Act.
  846         1. Tier 1 hospitals are statutory rural hospitals as
  847  defined in s. 395.602, statutory teaching hospitals as defined
  848  in s. 408.07(45), and specialty children’s hospitals as defined
  849  in s. 395.002(28).
  850         2. Tier 2 hospitals are community hospitals not included in
  851  Tier 1 that provided more than 9 percent of the hospital’s total
  852  inpatient days to Medicaid patients and charity patients, as
  853  defined in s. 409.911, and are located in the jurisdiction of a
  854  local funding source pursuant to subsection (1).
  855         3. Tier 3 hospitals include all community hospitals.
  856         (b) When rates are increased pursuant to this section, the
  857  Total Tier Allocation (TTA) shall be distributed as follows:
  858         1. Tier 1 (T1A) = 0.35 x TTA.
  859         2. Tier 2 (T2A) = 0.35 x TTA.
  860         3. Tier 3 (T3A) = 0.30 x TTA.
  861         (c) The tier allocation shall be distributed as a
  862  percentage increase to the hospital specific base rate (HSBR)
  863  established pursuant to s. 409.905(5)(c). The increase in each
  864  tier shall be calculated according to the proportion of tier
  865  specific allocation to the total estimated inpatient spending
  866  (TEIS) for all hospitals in each tier:
  867         1. Tier 1 percent increase (T1PI) = T1A/Tier 1 total
  868  estimated inpatient spending (T1TEIS).
  869         2. Tier 2 percent increase (T2PI) = T2A /Tier 2 total
  870  estimated inpatient spending (T2TEIS).
  871         3. Tier 3 percent increase (T3PI) = T3A/ Tier 3 total
  872  estimated inpatient spending (T3TEIS).
  873         (d) The hospital-specific tiered rate (HSTR) shall be
  874  calculated as follows:
  875         1. For hospitals in Tier 3: HSTR = (1 + T3PI) x HSBR.
  876         2. For hospitals in Tier 2: HSTR = (1 + T2PI) x HSBR.
  877         3. For hospitals in Tier 1: HSTR = (1 + T1PI) x HSBR.
  878         Section 12. Section 409.971, Florida Statutes, is created
  879  to read:
  880         409.971 Managed medical assistance program.—The agency
  881  shall make payments for primary and acute medical assistance and
  882  related services using a managed care model. By January 1, 2013,
  883  the agency shall begin implementation of the statewide managed
  884  medical assistance program, with full implementation in all
  885  regions by October 1, 2014.
  886         Section 13. Section 409.972, Florida Statutes, is created
  887  to read:
  888         409.972 Mandatory and voluntary enrollment.—
  889         (1) Persons eligible for the program known as “medically
  890  needy” pursuant to s. 409.904(2)(a) shall enroll in managed care
  891  plans. Medically needy recipients shall meet the share of the
  892  cost by paying the plan premium, up to the share of the cost
  893  amount, contingent upon federal approval.
  894         (2) The following Medicaid-eligible persons are exempt from
  895  mandatory managed care enrollment required by s. 409.965, and
  896  may voluntarily choose to participate in the managed medical
  897  assistance program:
  898         (a) Medicaid recipients who have other creditable health
  899  care coverage, excluding Medicare.
  900         (b) Medicaid recipients residing in residential commitment
  901  facilities operated through the Department of Juvenile Justice
  902  or mental health treatment facilities as defined by s.
  903  394.455(32).
  904         (c) Persons eligible for refugee assistance.
  905         (d) Medicaid recipients who are residents of a
  906  developmental disability center, including Sunland Center in
  907  Marianna and Tacachale in Gainesville.
  908         (e) Medicaid recipients enrolled in the home and community
  909  based services waiver pursuant to chapter 393, and Medicaid
  910  recipients waiting for waiver services.
  911         (3) Persons eligible for Medicaid but exempt from mandatory
  912  participation who do not choose to enroll in managed care shall
  913  be served in the Medicaid fee-for-service program as provided in
  914  part III of this chapter.
  915         (4) The agency shall seek federal approval to require
  916  Medicaid recipients enrolled in managed care plans, as a
  917  condition of Medicaid eligibility, to pay the Medicaid program a
  918  share of the premium of $10 per month.
  919         Section 14. Section 409.973, Florida Statutes, is created
  920  to read:
  921         409.973 Benefits.—
  922         (1) MINIMUM BENEFITS.—Managed care plans shall cover, at a
  923  minimum, the following services:
  924         (a) Advanced registered nurse practitioner services.
  925         (b) Ambulatory surgical treatment center services.
  926         (c) Birthing center services.
  927         (d) Chiropractic services.
  928         (e) Dental services.
  929         (f) Early periodic screening diagnosis and treatment
  930  services for recipients under age 21.
  931         (g) Emergency services.
  932         (h) Family planning services and supplies. Pursuant to 42
  933  C.F.R. s. 438.102, plans may elect to not provide these services
  934  due to an objection on moral or religious grounds, and must
  935  notify the agency of that election when submitting a reply to an
  936  invitation to negotiate.
  937         (i) Healthy start services, except as provided in s.
  938  409.975(4).
  939         (j) Hearing services.
  940         (k) Home health agency services.
  941         (l) Hospice services.
  942         (m) Hospital inpatient services.
  943         (n) Hospital outpatient services.
  944         (o) Laboratory and imaging services.
  945         (p) Medical supplies, equipment, prostheses, and orthoses.
  946         (q) Mental health services.
  947         (r) Nursing care.
  948         (s) Optical services and supplies.
  949         (t) Optometrist services.
  950         (u) Physical, occupational, respiratory, and speech therapy
  951  services.
  952         (v) Physician services, including physician assistant
  953  services.
  954         (w) Podiatric services.
  955         (x) Prescription drugs.
  956         (y) Renal dialysis services.
  957         (z) Respiratory equipment and supplies.
  958         (aa) Rural health clinic services.
  959         (bb) Substance abuse treatment services.
  960         (cc) Transportation to access covered services.
  961         (2) CUSTOMIZED BENEFITS.—Managed care plans may customize
  962  benefit packages for nonpregnant adults, vary cost-sharing
  963  provisions, and provide coverage for additional services. The
  964  agency shall evaluate the proposed benefit packages to ensure
  965  services are sufficient to meet the needs of the plan’s
  966  enrollees and to verify actuarial equivalence.
  967         (3) HEALTHY BEHAVIORS.—Each plan operating in the managed
  968  medical assistance program shall establish a program to
  969  encourage and reward healthy behaviors. At a minimum, each plan
  970  must establish a medically approved smoking cessation program, a
  971  medically directed weight loss program, and a medically approved
  972  alcohol or substance abuse recovery program. Each plan must
  973  identify enrollees who smoke, are morbidly obese, or are
  974  diagnosed with alcohol or substance abuse in order to establish
  975  written agreements to secure the enrollees’ commitment to
  976  participation in these programs.
  977         (4) PRIMARY CARE INITIATIVE.—Each plan operating in the
  978  managed medical assistance program shall establish a program to
  979  encourage enrollees to establish a relationship with their
  980  primary care provider. Each plan shall:
  981         (a) Provide information to each enrollee on the importance
  982  of and procedure for selecting a primary care physician, and
  983  thereafter automatically assign to a primary care provider any
  984  enrollee who fails to choose a primary care provider.
  985         (b) If the enrollee was not a Medicaid recipient before
  986  enrollment in the plan, assist the enrollee in scheduling an
  987  appointment with the primary care provider. If possible the
  988  appointment should be made within 30 days after enrollment in
  989  the plan. For enrollees who become eligible for Medicaid between
  990  January 1, 2014, and December 31, 2015, the appointment should
  991  be be scheduled within 6 months after enrollment in the plan.
  992         (c) Report to the agency the number of enrollees assigned
  993  to each primary care provider within the plan’s network.
  994         (d) Report to the agency the number of enrollees who have
  995  not had an appointment with their primary care provider within
  996  their first year of enrollment.
  997         (e) Report to the agency the number of emergency room
  998  visits by enrollees who have not had a least one appointment
  999  with their primary care provider.
 1000         Section 15. Section 409.974, Florida Statutes, is created
 1001  to read:
 1002         409.974 Eligible plans.—
 1003         (1) ELIGIBLE PLAN SELECTION.—The agency shall select
 1004  eligible plans through the procurement process described in s.
 1005  409.966. The agency shall notice invitations to negotiate no
 1006  later than January 1, 2013.
 1007         (a) The agency shall procure two plans for Region 1. At
 1008  least one plan shall be a provider service network if any
 1009  provider service networks submit a responsive bid.
 1010         (b) The agency shall procure two plans for Region 2. At
 1011  least one plan shall be a provider service network if any
 1012  provider service networks submit a responsive bid.
 1013         (c) The agency shall procure at least three plans and up to
 1014  five plans for Region 3. At least one plan must be a provider
 1015  service network if any provider service networks submit a
 1016  responsive bids.
 1017         (d) The agency shall procure at least three plans and up to
 1018  five plans for Region 4. At least one plan must be a provider
 1019  service network if any provider service networks submit a
 1020  responsive bid.
 1021         (e) The agency shall procure at least two plans and up to 4
 1022  plans for Region 5. At least one plan must be a provider service
 1023  network if any provider service networks submit a responsive
 1024  bid.
 1025         (f) The agency shall procure at least four plans and up to
 1026  seven plans for Region 6. At least one plan must be a provider
 1027  service network if any provider service networks submit a
 1028  responsive bid.
 1029         (g) The agency shall procure at least three plans and up to
 1030  six plans for Region 7. At least one plan must be a provider
 1031  service network if any provider service networks submit a
 1032  responsive bid.
 1033         (h) The agency shall procure at least two plans and up to
 1034  four plans for Region 8. At least one plan must be a provider
 1035  service network if any provider service networks submit a
 1036  responsive bid.
 1037         (i) The agency shall procure at least two plans and up to
 1038  four plans for Region 9. At least one plan must be a provider
 1039  service network if any provider service networks submit a
 1040  responsive bid.
 1041         (j) The agency shall procure at least two plans and up to
 1042  four plans for Region 10. At least one plan must be a provider
 1043  service network if any provider service networks submit a
 1044  responsive bid.
 1045         (k) The agency shall procure at least five plans and up to
 1046  ten plans for Region 11. At least one plan must be a provider
 1047  service network if any provider service networks submit a
 1048  responsive bid.
 1049  
 1050  If no provider service network submits a responsive bid, the
 1051  agency shall procure no more than one less than the maximum
 1052  number of eligible plans permitted in that region. Within 12
 1053  months after the initial invitation to negotiate, the agency
 1054  shall attempt to procure a provider service network. The agency
 1055  shall notice another invitation to negotiate only with provider
 1056  service networks in those regions where no provider service
 1057  network has been selected.
 1058         (2) QUALITY SELECTION CRITERIA.—In addition to the criteria
 1059  established in s. 409.966, the agency shall consider evidence
 1060  that an eligible plan has written agreements or signed contracts
 1061  or has made substantial progress in establishing relationships
 1062  with providers before the plan submitting a response. The agency
 1063  shall evaluate and give special weight to evidence of signed
 1064  contracts with essential providers as defined by the agency
 1065  pursuant to s. 409.975(2). The agency shall exercise a
 1066  preference for plans with a provider network in which over 10
 1067  percent of the providers use electronic health records, as
 1068  defined in s. 408.051. When all other factors are equal, the
 1069  agency shall consider whether the organization has a contract to
 1070  provide managed long-term care services in the same region and
 1071  shall exercise a preference for such plans.
 1072         (3) SPECIALTY PLANS.—Participation by specialty plans shall
 1073  be subject to the procurement requirements and regional plan
 1074  number limits of this section. However, a specialty plan whose
 1075  target population includes no more than 10 percent of the
 1076  enrollees of that region is not subject to the regional plan
 1077  number limits of this section.
 1078         (4) CHILDREN’S MEDICAL SERVICES NETWORK.—Participation by
 1079  the Children’s Medical Services Network shall be pursuant to a
 1080  single, statewide contract with the agency that is not subject
 1081  to the procurement requirements or regional plan number limits
 1082  of this section. The Children’s Medical Services Network must
 1083  meet all other plan requirements for the managed medical
 1084  assistance program.
 1085         Section 16. Section 409.975, Florida Statutes, is created
 1086  to read:
 1087         409.975 Managed care plan accountability.—In addition to
 1088  the requirements of s. 409.967, plans and providers
 1089  participating in the managed medical assistance program shall
 1090  comply with the requirements of this section.
 1091         (1) PROVIDER NETWORKS.—Managed care plans must develop and
 1092  maintain provider networks that meet the medical needs of their
 1093  enrollees in accordance with standards established pursuant to
 1094  409.967(2)(b). Except as provided in this section, managed care
 1095  plans may limit the providers in their networks based on
 1096  credentials, quality indicators, and price.
 1097         (a) Plans must include all providers in the region that are
 1098  classified by the agency as essential Medicaid providers, unless
 1099  the agency approves, in writing, an alternative arrangement for
 1100  securing the types of services offered by the essential
 1101  providers. Providers are essential for serving Medicaid
 1102  enrollees if they offer services that are not available from any
 1103  other provider within a reasonable access standard, or if they
 1104  provided a substantial share of the total units of a particular
 1105  service used by Medicaid patients within the region during the
 1106  last 3 years and the combined capacity of other service
 1107  providers in the region is insufficient to meet the total needs
 1108  of the Medicaid patients. The agency may not classify physicians
 1109  and other practitioners as essential providers. The agency, at a
 1110  minimum, shall determine which providers in the following
 1111  categories are essential Medicaid providers:
 1112         1. Federally qualified health centers.
 1113         2. Statutory teaching hospitals as defined in s.
 1114  408.07(45).
 1115         3. Hospitals that are trauma centers as defined in s.
 1116  395.4001(14).
 1117         4. Hospitals located at least 25 miles from any other
 1118  hospital with similar services.
 1119  
 1120  Managed care plans that have not contracted with all essential
 1121  providers in the region as of the first date of recipient
 1122  enrollment, or with whom an essential provider has terminated
 1123  its contract, must negotiate in good faith with such essential
 1124  providers for 1 year or until an agreement is reached, whichever
 1125  is first. Payments for services rendered by a nonparticipating
 1126  essential provider shall be made at the applicable Medicaid rate
 1127  as of the first day of the contract between the agency and the
 1128  plan. A rate schedule for all essential providers shall be
 1129  attached to the contract between the agency and the plan. After
 1130  1 year, managed care plans that are unable to contract with
 1131  essential providers shall notify the agency and propose an
 1132  alternative arrangement for securing the essential services for
 1133  Medicaid enrollees. The arrangement must rely on contracts with
 1134  other participating providers, regardless of whether those
 1135  providers are located within the same region as the
 1136  nonparticipating essential service provider. If the alternative
 1137  arrangement is approved by the agency, payments to
 1138  nonparticipating essential providers after the date of the
 1139  agency’s approval shall equal 90 percent of the applicable
 1140  Medicaid rate. If the alternative arrangement is not approved by
 1141  the agency, payment to nonparticipating essential providers
 1142  shall equal 110 percent of the applicable Medicaid rate.
 1143         (b) Certain providers are statewide resources and essential
 1144  providers for all managed care plans in all regions. All managed
 1145  care plans must include these essential providers in their
 1146  networks. Statewide essential providers include:
 1147         1. Faculty plans of Florida medical schools.
 1148         2. Regional perinatal intensive care centers as defined in
 1149  s. 383.16(2).
 1150         3. Hospitals licensed as specialty children’s hospitals as
 1151  defined in s. 395.002(28).
 1152         4. Accredited and integrated systems serving medically
 1153  complex children that are comprised of separately licensed, but
 1154  commonly owned, health care providers delivering at least the
 1155  following services: medical group home, in-home and outpatient
 1156  nursing care and therapies, pharmacy services, durable medical
 1157  equipment, and Prescribed Pediatric Extended Care.
 1158  
 1159  Managed care plans that have not contracted with all statewide
 1160  essential providers in all regions as of the first date of
 1161  recipient enrollment must continue to negotiate in good faith.
 1162  Payments to physicians on the faculty of nonparticipating
 1163  Florida medical schools shall be made at the applicable Medicaid
 1164  rate. Payments for services rendered by a regional perinatal
 1165  intensive care centers shall be made at the applicable Medicaid
 1166  rate as of the first day of the contract between the agency and
 1167  the plan. Payments to nonparticipating specialty children’s
 1168  hospitals shall equal the highest rate established by contract
 1169  between that provider and any other Medicaid managed care plan.
 1170         (c) After 12 months of active participation in a plan’s
 1171  network, the plan may exclude any essential provider from the
 1172  network for failure to meet quality or performance criteria. If
 1173  the plan excludes an essential provider from the plan, the plan
 1174  must provide written notice to all recipients who have chosen
 1175  that provider for care. The notice shall be provided at least 30
 1176  days before the effective date of the exclusion.
 1177         (d) Each managed care plan must offer a network contract to
 1178  each home medical equipment and supplies provider in the region
 1179  which meets quality and fraud prevention and detection standards
 1180  established by the plan and which agrees to accept the lowest
 1181  price previously negotiated between the plan and another such
 1182  provider.
 1183         (2) FLORIDA MEDICAL SCHOOLS QUALITY NETWORK.—The agency
 1184  shall contract with a single organization representing medical
 1185  schools and graduate medical education programs in the state for
 1186  the purpose of establishing an active and ongoing program to
 1187  improve clinical outcomes in all managed care plans. Contracted
 1188  activities must support greater clinical integration for
 1189  Medicaid enrollees through interdependent and cooperative
 1190  efforts of all providers participating in managed care plans.
 1191  The agency shall support these activities with certified public
 1192  expenditures and any earned federal matching funds and shall
 1193  seek any plan amendments or waivers necessary to comply with
 1194  this subsection. To be eligible to participate in the quality
 1195  network, a medical school must contract with each managed care
 1196  plan in its region.
 1197         (3) PERFORMANCE MEASUREMENT.—Each managed care plan shall
 1198  monitor the quality and performance of each participating
 1199  provider. At the beginning of the contract period, each plan
 1200  shall notify all its network providers of the metrics used by
 1201  the plan for evaluating the provider’s performance and
 1202  determining continued participation in the network.
 1203         (4) MOMCARE NETWORK.—
 1204         (a) The agency shall contract with an administrative
 1205  services organization representing all Healthy Start Coalitions
 1206  providing risk appropriate care coordination and other services
 1207  in accordance with a federal waiver and pursuant to s. 409.906.
 1208  The contract shall require the network of coalitions to provide
 1209  counseling, education, risk-reduction and case management
 1210  services, and quality assurance for all enrollees of the waiver.
 1211  The agency shall evaluate the impact of the MomCare network by
 1212  monitoring each plan’s performance on specific measures to
 1213  determine the adequacy, timeliness, and quality of services for
 1214  pregnant women and infants. The agency shall support this
 1215  contract with certified public expenditures of general revenue
 1216  appropriated for Healthy Start services and any earned federal
 1217  matching funds.
 1218         (b) Each managed care plan shall establish specific
 1219  programs and procedures to improve pregnancy outcomes and infant
 1220  health, including, but not limited to, coordination with the
 1221  Healthy Start program, immunization programs, and referral to
 1222  the Special Supplemental Nutrition Program for Women, Infants,
 1223  and Children, and the Children’s Medical Services program for
 1224  children with special health care needs. Each plan’s programs
 1225  and procedures shall include agreements with each local Healthy
 1226  Start Coalition in the region to provide risk-appropriate care
 1227  coordination for pregnant women and infants, consistent with
 1228  agency policies and the MomCare network. Each managed care plan
 1229  must notify the agency of the impending birth of a child to an
 1230  enrollee, or notify the agency as soon as practicable after the
 1231  child’s birth.
 1232         (5) SCREENING RATE.—After the end of the second contract
 1233  year, each managed care plan shall achieve an annual Early and
 1234  Periodic Screening, Diagnosis, and Treatment Service screening
 1235  rate of at least 80 percent of those recipients continuously
 1236  enrolled for at least 8 months.
 1237         (6) PROVIDER PAYMENT.—Managed care plans and hospitals
 1238  shall negotiate mutually acceptable rates, methods, and terms of
 1239  payment. For rates, methods, and terms of payment negotiated
 1240  after the contract between the agency and the plan is executed,
 1241  plans shall pay hospitals, at a minimum, the rate the agency
 1242  would have paid on the first day of the contract between the
 1243  provider and the plan. Such payments to hospitals may not exceed
 1244  120 percent of the rate the agency would have paid on the first
 1245  day of the contract between the provider and the plan, unless
 1246  specifically approved by the agency. Payment rates may be
 1247  updated periodically.
 1248         (7) MEDICALLY NEEDY ENROLLEES.—Each managed care plan must
 1249  accept any medically needy recipient who selects or is assigned
 1250  to the plan and provide that recipient with continuous
 1251  enrollment for 12 months. After the first month of qualifying as
 1252  a medically needy recipient and enrolling in a plan, and
 1253  contingent upon federal approval, the enrollee shall pay the
 1254  plan a portion of the monthly premium equal to the enrollee’s
 1255  share of the cost as determined by the department. The agency
 1256  shall pay any remaining portion of the monthly premium. Plans
 1257  are not obligated to pay claims for medically needy patients for
 1258  services provided before enrollment in the plan. Medically needy
 1259  patients are responsible for payment of incurred claims that are
 1260  used to determine eligibility. Plans must provide a grace period
 1261  of at least 90 days before disenrolling recipients who fail to
 1262  pay their shares of the premium.
 1263         Section 17. Section 409.976, Florida Statutes, is created
 1264  to read:
 1265         409.976 Managed care plan payment.—In addition to the
 1266  payment provisions of s. 409.968, the agency shall provide
 1267  payment to plans in the managed medical assistance program
 1268  pursuant to this section.
 1269         (1) Prepaid payment rates shall be negotiated between the
 1270  agency and the eligible plans as part of the procurement process
 1271  described in s. 409.966.
 1272         (2) The agency shall establish payment rates for statewide
 1273  inpatient psychiatric programs. Payments to managed care plans
 1274  shall be reconciled to reimburse actual payments to statewide
 1275  inpatient psychiatric programs.
 1276         Section 18. Section 409.977, Florida Statutes, is created
 1277  to read:
 1278         409.977 Enrollment.—
 1279         (1) The agency shall automatically enroll into a managed
 1280  care plan those Medicaid recipients who do not voluntarily
 1281  choose a plan pursuant to s. 409.969. The agency shall
 1282  automatically enroll recipients in plans that meet or exceed the
 1283  performance or quality standards established pursuant to s.
 1284  409.967 and may not automatically enroll recipients in a plan
 1285  that is deficient in those performance or quality standards.
 1286  When a specialty plan is available to accommodate a specific
 1287  condition or diagnosis of a recipient, the agency shall assign
 1288  the recipient to that plan. In the first year of the first
 1289  contract term only, if a recipient was previously enrolled in a
 1290  plan that is still available in the region, the agency shall
 1291  automatically enroll the recipient in that plan unless an
 1292  applicable specialty plan is available. Except as otherwise
 1293  provided in this part, the agency may not engage in practices
 1294  that are designed to favor one managed care plan over another.
 1295         (2) When automatically enrolling recipients in managed care
 1296  plans, the agency shall automatically enroll based on the
 1297  following criteria:
 1298         (a) Whether the plan has sufficient network capacity to
 1299  meet the needs of the recipients.
 1300         (b) Whether the recipient has previously received services
 1301  from one of the plan’s primary care providers.
 1302         (c) Whether primary care providers in one plan are more
 1303  geographically accessible to the recipient’s residence than
 1304  those in other plans.
 1305         (3) A newborn of a mother enrolled in a plan at the time of
 1306  the child’s birth shall be enrolled in the mother’s plan. Upon
 1307  birth, such a newborn is deemed enrolled in the managed care
 1308  plan, regardless of the administrative enrollment procedures,
 1309  and the managed care plan is responsible for providing Medicaid
 1310  services to the newborn. The mother may choose another plan for
 1311  the newborn within 90 days after the child’s birth.
 1312         (4) The agency shall develop a process to enable a
 1313  recipient with access to employer-sponsored health care coverage
 1314  to opt out of all managed care plans and to use Medicaid
 1315  financial assistance to pay for the recipient’s share of the
 1316  cost in such employer-sponsored coverage. Contingent upon
 1317  federal approval, the agency shall also enable recipients with
 1318  access to other insurance or related products providing access
 1319  to health care services created pursuant to state law, including
 1320  any product available under the Florida Health Choices Program,
 1321  or any health exchange, to opt out. The amount of financial
 1322  assistance provided for each recipient may not exceed the amount
 1323  of the Medicaid premium that would have been paid to a managed
 1324  care plan for that recipient. The agency shall seek federal
 1325  approval to require Medicaid recipients with access to employer
 1326  sponsored health care coverage to enroll in that coverage and
 1327  use Medicaid financial assistance to pay for the recipient’s
 1328  share of the cost for such coverage. The amount of financial
 1329  assistance provided for each recipient may not exceed the amount
 1330  of the Medicaid premium that would have been paid to a managed
 1331  care plan for that recipient.
 1332         Section 19. Section 409.978, Florida Statutes, is created
 1333  to read:
 1334         409.978 Long-term care managed care program.—
 1335         (1) Pursuant to s. 409.963, the agency shall administer the
 1336  long-term care managed care program described in ss. 409.978
 1337  409.985, but may delegate specific duties and responsibilities
 1338  for the program to the Department of Elderly Affairs and other
 1339  state agencies. By July 1, 2012, the agency shall begin
 1340  implementation of the statewide long-term care managed care
 1341  program, with full implementation in all regions by October 1,
 1342  2013.
 1343         (2) The agency shall make payments for long-term care,
 1344  including home and community-based services, using a managed
 1345  care model. Unless otherwise specified, ss. 409.961-409.97 apply
 1346  to the long-term care managed care program.
 1347         (3) The Department of Elderly Affairs shall assist the
 1348  agency to develop specifications for use in the invitation to
 1349  negotiate and the model contract, determine clinical eligibility
 1350  for enrollment in managed long-term care plans, monitor plan
 1351  performance and measure quality of service delivery, assist
 1352  clients and families to address complaints with the plans,
 1353  facilitate working relationships between plans and providers
 1354  serving elders and disabled adults, and perform other functions
 1355  specified in a memorandum of agreement.
 1356         Section 20. Section 409.979, Florida Statutes, is created
 1357  to read:
 1358         409.979 Eligibility.—
 1359         (1) Medicaid recipients who meet all of the following
 1360  criteria are eligible to receive long-term care services and
 1361  must receive long-term care services by participating in the
 1362  long-term care managed care program. The recipient must be:
 1363         (a) Sixty-five years of age or older, or age 18 or older
 1364  and eligible for Medicaid by reason of a disability.
 1365         (b) Determined by the Comprehensive Assessment Review and
 1366  Evaluation for Long-Term Care Services (CARES) Program to
 1367  require nursing facility care as defined in s. 409.985(3).
 1368         (2) Medicaid recipients who, on the date long-term care
 1369  managed care plans become available in their region, reside in a
 1370  nursing home facility or are enrolled in one of the following
 1371  long-term care Medicaid waiver programs are eligible to
 1372  participate in the long-term care managed care program for up to
 1373  12 months without being reevaluated for their need for nursing
 1374  facility care as defined in s. 409.985(3):
 1375         (a) The Assisted Living for the Frail Elderly Waiver.
 1376         (b) The Aged and Disabled Adult Waiver.
 1377         (c) The Adult Day Health Care Waiver.
 1378         (d) The Consumer-Directed Care Plus Program as described in
 1379  s. 409.221.
 1380         (e) The Program of All-inclusive Care for the Elderly.
 1381         (f) The long-term care community-based diversion pilot
 1382  project as described in s. 430.705.
 1383         (g) The Channeling Services Waiver for Frail Elders.
 1384         (3) The Department of Elderly Affairs shall make offers for
 1385  enrollment to eligible individuals based on a wait-list
 1386  prioritization and subject to availability of funds. Before
 1387  enrollment offers, the department shall determine that
 1388  sufficient funds exist to support additional enrollment into
 1389  plans.
 1390         Section 21. Section 409.98, Florida Statutes, is created to
 1391  read:
 1392         409.98 Long-term care plan benefits.—Long-term care plans
 1393  shall, at a minimum, cover the following:
 1394         (1) Nursing facility care.
 1395         (2) Services provided in assisted living facilities.
 1396         (3) Hospice.
 1397         (4) Adult day care.
 1398         (5) Medical equipment and supplies, including incontinence
 1399  supplies.
 1400         (6) Personal care.
 1401         (7) Home accessibility adaptation.
 1402         (8) Behavior management.
 1403         (9) Home-delivered meals.
 1404         (10) Case management.
 1405         (11) Therapies:
 1406         (a) Occupational therapy.
 1407         (b) Speech therapy.
 1408         (c) Respiratory therapy.
 1409         (d) Physical therapy.
 1410         (12) Intermittent and skilled nursing.
 1411         (13) Medication administration.
 1412         (14) Medication management.
 1413         (15) Nutritional assessment and risk reduction.
 1414         (16) Caregiver training.
 1415         (17) Respite care.
 1416         (18) Transportation.
 1417         (19) Personal emergency response system.
 1418         Section 22. Section 409.981, Florida Statutes, is created
 1419  to read:
 1420         409.981 Eligible long-term care plans.—
 1421         (1) ELIGIBLE PLANS.—Provider service networks must be long
 1422  term care provider service networks. Other eligible plans may be
 1423  long-term care plans or comprehensive long-term care plans.
 1424         (2) ELIGIBLE PLAN SELECTION.—The agency shall select
 1425  eligible plans through the procurement process described in s.
 1426  409.966. The agency shall provide notice of invitations to
 1427  negotiate by July 1, 2012. The agency shall procure:
 1428         (a) Two plans for Region 1. At least one plan must be a
 1429  provider service network if any provider service networks submit
 1430  a responsive bid.
 1431         (b) Two plans for Region 2. At least one plan must be a
 1432  provider service network if any provider service networks submit
 1433  a responsive bid.
 1434         (c) At least three plans and up to five plans for Region 3.
 1435  At least one plan must be a provider service network if any
 1436  provider service networks submit a responsive bid.
 1437         (d) At least three plans and up to five plans for Region 4.
 1438  At least one plan must be a provider service network if any
 1439  provider service network submits a responsive bid.
 1440         (e) At least two plans and up to 4 plans for Region 5. At
 1441  least one plan must be a provider service network if any
 1442  provider service networks submit a responsive bid.
 1443         (f) At least four plans and up to seven plans for Region 6.
 1444  At least one plan must be a provider service network if any
 1445  provider service networks submit a responsive bid.
 1446         (g) At least three plans and up to 6 plans for Region 7. At
 1447  least one plan must be a provider service networks if any
 1448  provider service networks submit a responsive bid.
 1449         (h) At least two plans and up to four plans for Region 8.
 1450  At least one plan must be a provider service network if any
 1451  provider service networks submit a responsive bid.
 1452         (i) At least two plans and up to four plans for Region 9.
 1453  At least one plan must be a provider service network if any
 1454  provider service networks submit a responsive bid.
 1455         (j) At least two plans and up to four plans for Region 10.
 1456  At least one plan must be a provider service network if any
 1457  provider service networks submit a responsive bid.
 1458         (k) At least five plans and up to ten plans for Region 11.
 1459  At least one plan must be a provider service network if any
 1460  provider service networks submit a responsive bid.
 1461  
 1462  If no provider service network submits a responsive bid in a
 1463  region other than Region 1 or Region 2, the agency shall procure
 1464  no more than one less than the maximum number of eligible plans
 1465  permitted in that region. Within 12 months after the initial
 1466  invitation to negotiate, the agency shall attempt to procure a
 1467  provider service network. The agency shall notice another
 1468  invitation to negotiate only with provider service networks in
 1469  regions where no provider service network has been selected.
 1470         (3) QUALITY SELECTION CRITERIA.—In addition to the criteria
 1471  established in s. 409.966, the agency shall consider the
 1472  following factors in the selection of eligible plans:
 1473         (a) Evidence of the employment of executive managers with
 1474  expertise and experience in serving aged and disabled persons
 1475  who require long-term care.
 1476         (b) Whether a plan has established a network of service
 1477  providers dispersed throughout the region and in sufficient
 1478  numbers to meet specific service standards established by the
 1479  agency for specialty services for persons receiving home and
 1480  community-based care.
 1481         (c) Whether a plan is proposing to establish a
 1482  comprehensive long-term care plan and whether the eligible plan
 1483  has a contract to provide managed medical assistance services in
 1484  the same region.
 1485         (d) Whether a plan offers consumer-directed care services
 1486  to enrollees pursuant to s. 409.221.
 1487         (e) Whether a plan is proposing to provide home and
 1488  community-based services in addition to the minimum benefits
 1489  required by s. 409.98.
 1490         (4) PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY.
 1491  Participation by the Program of All-Inclusive Care for the
 1492  Elderly (PACE) shall be pursuant to a contract with the agency
 1493  and not subject to the procurement requirements or regional plan
 1494  number limits of this section. PACE plans may continue to
 1495  provide services to individuals at such levels and enrollment
 1496  caps as authorized by the General Appropriations Act.
 1497         (5) MEDICARE PLANS.—Participation by a Medicare Advantage
 1498  Preferred Provider Organization, Medicare Advantage Provider
 1499  sponsored Organization, or Medicare Advantage Special Needs Plan
 1500  shall be pursuant to a contract with the agency and not subject
 1501  to the procurement requirements if the plan’s Medicaid enrollees
 1502  consist exclusively of recipients who are deemed dually eligible
 1503  for Medicaid and Medicare services. Otherwise, Medicare
 1504  Advantage Preferred Provider Organizations, Medicare Advantage
 1505  Provider-Sponsored Organizations, and Medicare Advantage Special
 1506  Needs Plans are subject to all procurement requirements.
 1507         Section 23. Section 409.982, Florida Statutes, is created
 1508  to read:
 1509         409.982 Long-term care managed care plan accountability.—In
 1510  addition to the requirements of s. 409.967, plans and providers
 1511  participating in the long-term care managed care program must
 1512  comply with the requirements of this section.
 1513         (1) PROVIDER NETWORKS.—Managed care plans may limit the
 1514  providers in their networks based on credentials, quality
 1515  indicators, and price. For the period between October 1, 2013,
 1516  and September 30, 2014, each selected plan must offer a network
 1517  contract to all the following providers in the region:
 1518         (a) Nursing homes.
 1519         (b) Hospices.
 1520         (c) Aging network service providers that have previously
 1521  participated in home and community-based waivers serving elders
 1522  or community-service programs administered by the Department of
 1523  Elderly Affairs.
 1524  
 1525  After 12 months of active participation in a managed care plan’s
 1526  network, the plan may exclude any of the providers named in this
 1527  subsection from the network for failure to meet quality or
 1528  performance criteria. If the plan excludes a provider from the
 1529  plan, the plan must provide written notice to all recipients who
 1530  have chosen that provider for care. The notice must be provided
 1531  at least 30 days before the effective date of the exclusion. The
 1532  agency shall establish contract provisions governing the
 1533  transfer of recipients from excluded residential providers.
 1534         (2) SELECT PROVIDER PARTICIPATION.—Except as provided in
 1535  this subsection, providers may limit the managed care plans they
 1536  join. Nursing homes and hospices that are enrolled Medicaid
 1537  providers must participate in all eligible plans selected by the
 1538  agency in the region in which the provider is located.
 1539         (3) PERFORMANCE MEASUREMENT.—Each managed care plan shall
 1540  monitor the quality and performance of each participating
 1541  provider using measures adopted by and collected by the agency
 1542  and any additional measures mutually agreed upon by the provider
 1543  and the plan
 1544         (4) PROVIDER NETWORK STANDARDS.—The agency shall establish
 1545  and each managed care plan must comply with specific standards
 1546  for the number, type, and regional distribution of providers in
 1547  the plan’s network, which must include:
 1548         (a) Adult day care centers.
 1549         (b) Adult family-care homes.
 1550         (c) Assisted living facilities.
 1551         (d) Health care services pools.
 1552         (e) Home health agencies.
 1553         (f) Homemaker and companion services.
 1554         (g) Hospices.
 1555         (h) Community care for the elderly lead agencies.
 1556         (i) Nurse registries.
 1557         (j) Nursing homes.
 1558         (5) PROVIDER PAYMENT.—Managed care plans and providers
 1559  shall negotiate mutually acceptable rates, methods, and terms of
 1560  payment. Plans shall pay nursing homes an amount equal to the
 1561  nursing facility-specific payment rates set by the agency;
 1562  however, mutually acceptable higher rates may be negotiated for
 1563  medically complex care. Plans shall pay hospice providers
 1564  through a prospective system for each enrollee an amount equal
 1565  to the per diem rate set by the agency. For recipients residing
 1566  in a nursing facility and receiving hospice services, the plan
 1567  shall pay the hospice provider the per diem rate set by the
 1568  agency minus the nursing facility component and shall pay the
 1569  nursing facility the applicable state rate. Plans must ensure
 1570  that electronic nursing home and hospice claims that contain
 1571  sufficient information for processing are paid within 10
 1572  business days after receipt.
 1573         Section 24. Section 409.983, Florida Statutes, is created
 1574  to read:
 1575         409.983 Long-term care managed care plan payment.—In
 1576  addition to the payment provisions of s. 409.968, the agency
 1577  shall provide payment to plans in the long-term care managed
 1578  care program pursuant to this section.
 1579         (1) Prepaid payment rates for long-term care managed care
 1580  plans shall be negotiated between the agency and the eligible
 1581  plans as part of the procurement process described in s.
 1582  409.966.
 1583         (2) Payment rates for comprehensive long-term care plans
 1584  covering services described in s. 409.973 shall be blended with
 1585  rates for long-term care plans for services specified in s.
 1586  409.98.
 1587         (3) Payment rates for plans must reflect historic
 1588  utilization and spending for covered services projected forward
 1589  and adjusted to reflect the level of care profile for enrollees
 1590  in each plan. The payment shall be adjusted to provide an
 1591  incentive for reducing institutional placements and increasing
 1592  the utilization of home and community-based services.
 1593         (4) The initial assessment of an enrollee’s level of care
 1594  shall be made by the Comprehensive Assessment and Review for
 1595  Long-Term-Care Services (CARES) program, which shall assign the
 1596  recipient into one of the following levels of care:
 1597         (a) Level of care 1 consists of recipients residing in or
 1598  who must be placed in a nursing home.
 1599         (b) Level of care 2 consists of recipients at imminent risk
 1600  of nursing home placement, as evidenced by the need for the
 1601  constant availability of routine medical and nursing treatment
 1602  and care, and require extensive health-related care and services
 1603  because of mental or physical incapacitation.
 1604         (c) Level of care 3 consists of recipients at imminent risk
 1605  of nursing home placement, as evidenced by the need for the
 1606  constant availability of routine medical and nursing treatment
 1607  and care, who have a limited need for health-related care and
 1608  services and are mildly medically or physically incapacitated.
 1609  
 1610  The agency shall periodically adjust payment rates to account
 1611  for changes in the level of care profile for each managed care
 1612  plan based on encounter data.
 1613         (5) The agency shall make an incentive adjustment in
 1614  payment rates to encourage the increased utilization of home and
 1615  community-based services and a commensurate reduction of
 1616  institutional placement. The incentive adjustment shall be
 1617  modified in each successive rate period during the first
 1618  contract period, as follows:
 1619         (a) A 2 percentage point shift in the first rate-setting
 1620  period;
 1621         (b) A 2 percentage point shift in the second rate-setting
 1622  period, as compared to the utilization mix at the end of the
 1623  first rate-setting period; or
 1624         (c) A 3 percentage point shift in the third rate-setting
 1625  period, and in each subsequent rate-setting period during the
 1626  first contract period, as compared to the utilization mix at the
 1627  end of the immediately preceding rate-setting period.
 1628  
 1629  The incentive adjustment shall continue in subsequent contract
 1630  periods, at a rate of 3 percentage points per year as compared
 1631  to the utilization mix at the end of the immediately preceding
 1632  rate-setting period, until no more than 35 percent of the plan’s
 1633  enrollees are placed in institutional settings. The agency shall
 1634  annually report to the Legislature the actual change in the
 1635  utilization mix of home and community-based services compared to
 1636  institutional placements and provide a recommendation for
 1637  utilization mix requirements for future contracts.
 1638         (6) The agency shall establish nursing-facility-specific
 1639  payment rates for each licensed nursing home based on facility
 1640  costs adjusted for inflation and other factors as authorized in
 1641  the General Appropriations Act. Payments to long-term care
 1642  managed care plans shall be reconciled to reimburse actual
 1643  payments to nursing facilities.
 1644         (7) The agency shall establish hospice payment rates
 1645  pursuant to Title XVIII of the Social Security Act. Payments to
 1646  long-term care managed care plans shall be reconciled to
 1647  reimburse actual payments to hospices.
 1648         Section 25. Section 409.984, Florida Statutes, is created
 1649  to read:
 1650         409.984 Enrollment in a long-term care managed care plan.—
 1651         (1) The agency shall automatically enroll into a long-term
 1652  care managed care plan those Medicaid recipients who do not
 1653  voluntarily choose a plan pursuant to s. 409.969. The agency
 1654  shall automatically enroll recipients in plans that meet or
 1655  exceed the performance or quality standards established pursuant
 1656  to s. 409.967 and may not automatically enroll recipients in a
 1657  plan that is deficient in those performance or quality
 1658  standards. If a recipient is deemed dually eligible for Medicaid
 1659  and Medicare services and is currently receiving Medicare
 1660  services from an entity qualified under 42 C.F.R. part 422 as a
 1661  Medicare Advantage Preferred Provider Organization, Medicare
 1662  Advantage Provider-sponsored Organization, or Medicare Advantage
 1663  Special Needs Plan, the agency shall automatically enroll the
 1664  recipient in such plan for Medicaid services if the plan is
 1665  currently participating in the long-term care managed care
 1666  program. Except as otherwise provided in this part, the agency
 1667  may not engage in practices that are designed to favor one
 1668  managed care plan over another.
 1669         (1) When automatically enrolling recipients in plans, the
 1670  agency shall take into account the following criteria:
 1671         (a) Whether the plan has sufficient network capacity to
 1672  meet the needs of the recipients.
 1673         (b) Whether the recipient has previously received services
 1674  from one of the plan’s home and community-based service
 1675  providers.
 1676         (c) Whether the home and community-based providers in one
 1677  plan are more geographically accessible to the recipient’s
 1678  residence than those in other plans.
 1679         (3) Notwithstanding s. 409.969(3)(c), if a recipient is
 1680  referred for hospice services, the recipient has 30 days during
 1681  which the recipient may select to enroll in another managed care
 1682  plan to access the hospice provider of the recipient’s choice.
 1683         (4) If a recipient is referred for placement in a nursing
 1684  home or assisted living facility, the plan must inform the
 1685  recipient of any facilities within the plan that have specific
 1686  cultural or religious affiliations and, if requested by the
 1687  recipient, make a reasonable effort to place the recipient in
 1688  the facility of the recipient’s choice.
 1689         Section 26. Section 409.9841, Florida Statutes, is created
 1690  to read:
 1691         409.9841 Long-term care managed care technical advisory
 1692  workgroup.—
 1693         (1) Before August 1, 2011, the agency shall establish a
 1694  technical advisory workgroup to assist in developing:
 1695         (a) The method of determining Medicaid eligibility pursuant
 1696  to s. 409.985(3).
 1697         (b) The requirements for provider payments to nursing homes
 1698  under s. 409.983(6).
 1699         (c) The method for managing Medicare coinsurance crossover
 1700  claims.
 1701         (d) Uniform requirements for claims submissions and
 1702  payments, including electronic funds transfers and claims
 1703  processing.
 1704         (e) The process for enrollment of and payment for
 1705  individuals pending determination of Medicaid eligibility.
 1706         (2) The advisory workgroup must include, but is not limited
 1707  to, representatives of providers and plans who could potentially
 1708  participate in long-term care managed care. Members of the
 1709  workgroup shall serve without compensation but may be reimbursed
 1710  for per diem and travel expenses as provided in s. 112.061.
 1711         (3) This section is repealed on June 30, 2013.
 1712         Section 27. Section 409.985, Florida Statutes, is created
 1713  to read:
 1714         409.985 Comprehensive Assessment and Review for Long-Term
 1715  Care Services (CARES) Program.—
 1716         (1) The agency shall operate the Comprehensive Assessment
 1717  and Review for Long-Term Care Services (CARES) preadmission
 1718  screening program to ensure that only individuals whose
 1719  conditions require long-term care services are enrolled in the
 1720  long-term care managed care program.
 1721         (2) The agency shall operate the CARES program through an
 1722  interagency agreement with the Department of Elderly Affairs.
 1723  The agency, in consultation with the Department of Elderly
 1724  Affairs, may contract for any function or activity of the CARES
 1725  program, including any function or activity required by 42
 1726  C.F.R. part 483.20, relating to preadmission screening and
 1727  review.
 1728         (3) The CARES program shall determine if an individual
 1729  requires nursing facility care and, if the individual requires
 1730  such care, assign the individual to a level of care as described
 1731  in s. 409.983(4). When determining the need for nursing facility
 1732  care, consideration shall be given to the nature of the services
 1733  prescribed and which level of nursing or other health care
 1734  personnel meets the qualifications necessary to provide such
 1735  services and the availability to and access by the individual of
 1736  community or alternative resources. For the purposes of the
 1737  long-term care managed care program, the term “nursing facility
 1738  care” means the individual:
 1739         (a) Requires nursing home placement as evidenced by the
 1740  need for medical observation throughout a 24-hour period and
 1741  care required to be performed on a daily basis by, or under the
 1742  direct supervision of, a registered nurse or other health care
 1743  professional and requires services that are sufficiently
 1744  medically complex to require supervision, assessment, planning,
 1745  or intervention by a registered nurse because of a mental or
 1746  physical incapacitation by the individual;
 1747         (b) Requires or is at imminent risk of nursing home
 1748  placement as evidenced by the need for observation throughout a
 1749  24-hour period and care and the constant availability of medical
 1750  and nursing treatment and requires services on a daily or
 1751  intermittent basis that are to be performed under the
 1752  supervision of licensed nursing or other health professionals
 1753  because the individual who is incapacitated mentally or
 1754  physically; or
 1755         (c) Requires or is at imminent risk of nursing home
 1756  placement as evidenced by the need for observation throughout a
 1757  24-hour period and care and the constant availability of medical
 1758  and nursing treatment and requires limited services that are to
 1759  be performed under the supervision of licensed nursing or other
 1760  health professionals because the individual is mildly
 1761  incapacitated mentally or physically.
 1762         (4) For individuals whose nursing home stay is initially
 1763  funded by Medicare and Medicare coverage and is being terminated
 1764  for lack of progress towards rehabilitation, CARES staff shall
 1765  consult with the person making the determination of progress
 1766  toward rehabilitation to ensure that the recipient is not being
 1767  inappropriately disqualified from Medicare coverage. If, in
 1768  their professional judgment, CARES staff believe that a Medicare
 1769  beneficiary is still making progress toward rehabilitation, they
 1770  may assist the Medicare beneficiary with an appeal of the
 1771  disqualification from Medicare coverage. The use of CARES teams
 1772  to review Medicare denials for coverage under this section is
 1773  authorized only if it is determined that such reviews qualify
 1774  for federal matching funds through Medicaid. The agency shall
 1775  seek or amend federal waivers as necessary to implement this
 1776  section.
 1777         Section 28. If any provision of this act or its application
 1778  to any person or circumstance is held invalid, the invalidity
 1779  does not affect other provisions or applications of the act
 1780  which can be given effect without the invalid provision or
 1781  application, and to this end the provisions of this act are
 1782  severable.
 1783         Section 29. This act shall take effect July 1, 2011.
 1784  
 1785  ================= T I T L E  A M E N D M E N T ================
 1786         And the title is amended as follows:
 1787         Delete everything before the enacting clause
 1788  and insert:
 1789                        A bill to be entitled                      
 1790         An act relating to Medicaid managed care; creating
 1791         part IV of ch. 409, F.S., entitled “Medicaid Managed
 1792         Care”; creating s. 409.961, F.S.; providing for
 1793         statutory construction; providing applicability of
 1794         specified provisions throughout the part; providing
 1795         rulemaking authority for specified agencies; creating
 1796         s. 409.962, F.S.; providing definitions; creating s.
 1797         409.963, F.S.; designating the Agency for Health Care
 1798         Administration as the single state agency to
 1799         administer the Medicaid program; providing for
 1800         specified agency responsibilities; requiring client
 1801         consent for release of medical records; creating s.
 1802         409.964, F.S.; establishing the Medicaid program as
 1803         the statewide, integrated managed care program for all
 1804         covered services; authorizing the agency to apply for
 1805         and implement waivers; providing for public notice and
 1806         comment; creating s. 409.965, F.S.; providing for
 1807         mandatory enrollment; providing exemptions; creating
 1808         s. 409.966, F.S.; providing requirements for eligible
 1809         plans that provide services in the Medicaid managed
 1810         care program; establishing provider service network
 1811         requirements for eligible plans; providing for
 1812         eligible plan selection; requiring the agency to use
 1813         an invitation to negotiate; requiring the agency to
 1814         compile and publish certain information; establishing
 1815         regions for separate procurement of plans; providing
 1816         quality criteria for plan selection; providing
 1817         limitations on serving recipients during the pendency
 1818         of procurement litigation; creating s. 409.967, F.S.;
 1819         providing for managed care plan accountability;
 1820         establishing contract terms; providing for physician
 1821         compensation; providing for emergency services;
 1822         establishing requirements for access; requiring a drug
 1823         formulary or preferred drug list; requiring plans to
 1824         accept requests for service electronically; requiring
 1825         the agency to maintain an encounter data system;
 1826         requiring plans to provide encounter data; requiring
 1827         the agency to establish performance standards for
 1828         plans; providing program integrity requirements;
 1829         establishing requirements for the database;
 1830         establishing a grievance resolution process; providing
 1831         penalties for early termination of contracts or
 1832         reduction in enrollment levels; establishing prompt
 1833         payment requirements; requiring fair payment to
 1834         providers with a controlling interest in a provider
 1835         service network by other plans; requiring itemized
 1836         payment; providing for dispute resolutions between
 1837         plans and providers; providing for achieved savings
 1838         rebates to plans; creating s. 409.968, F.S.;
 1839         establishing managed care plan payments; providing
 1840         payment requirements for provider service networks;
 1841         requiring the agency to conduct annual cost
 1842         reconciliations to determine certain cost savings and
 1843         report the results of the reconciliations to the fee
 1844         for-service provider; prohibiting rate increases that
 1845         are not authorized in the appropriations act; creating
 1846         s. 409.969, F.S.; requiring enrollment in managed care
 1847         plans by all nonexempt Medicaid recipients; creating
 1848         requirements for plan selection by recipients;
 1849         authorizing disenrollment under certain circumstances;
 1850         defining the term “good cause” for purposes of
 1851         disenrollment; providing time limits on an internal
 1852         grievance process; providing requirements for agency
 1853         determination regarding disenrollment; requiring
 1854         recipients to stay in plans for a specified time;
 1855         creating s. 409.97, F.S.; authorizing the agency to
 1856         accept the transfer of certain revenues from local
 1857         governments; requiring the agency to contract with a
 1858         representative of certain entities participating in
 1859         the low-income pool for the provision of enhanced
 1860         access to care; providing for support of these
 1861         activities by the low-income pool as authorized in the
 1862         General Appropriations Act; establishing the Access to
 1863         Care Partnership; requiring the agency to seek
 1864         necessary waivers and plan amendments; providing
 1865         requirements for prepaid plans to submit data;
 1866         authorizing the agency to implement a tiered hospital
 1867         rate system; creating s. 409.971, F.S.; creating the
 1868         managed medical assistance program; providing
 1869         deadlines to begin and finalize implementation of the
 1870         program; creating s. 409.972, F.S.; providing
 1871         eligibility requirements for mandatory and voluntary
 1872         enrollment; creating s. 409.973, F.S.; establishing
 1873         minimum benefits for managed care plans to cover;
 1874         authorizing plans to customize benefit packages;
 1875         requiring plans to establish programs to encourage
 1876         healthy behaviors and establish written agreements
 1877         with certain enrollees to participate in such
 1878         programs; requiring plans to establish a primary care
 1879         initiative; providing requirements for primary care
 1880         initiatives; requiring plans to report certain primary
 1881         care data to the agency; creating s. 409.974, F.S.;
 1882         establishing a deadline for issuing invitations to
 1883         negotiate; establishing a specified number or range of
 1884         eligible plans to be selected in each region;
 1885         establishing quality selection criteria; establishing
 1886         requirements for participation by specialty plans;
 1887         establishing the Children’s Medical Service Network as
 1888         an eligible plan; creating s. 409.975, F.S.; providing
 1889         for managed care plan accountability; authorizing
 1890         plans to limit providers in networks; requiring plans
 1891         to include essential Medicaid providers in their
 1892         networks unless an alternative arrangement is approved
 1893         by the agency; identifying statewide essential
 1894         providers; specifying provider payments under certain
 1895         circumstances; requiring plans to include certain
 1896         statewide essential providers in their networks;
 1897         requiring good faith negotiations; specifying provider
 1898         payments under certain circumstances; allowing plans
 1899         to exclude essential providers under certain
 1900         circumstances; requiring plans to offer a contract to
 1901         home medical equipment and supply providers under
 1902         certain circumstances; establishing the Florida
 1903         medical school quality network; requiring the agency
 1904         to contract with a representative of certain entities
 1905         to establish a clinical outcome improvement program in
 1906         all plans; providing for support of these activities
 1907         by certain expenditures and federal matching funds;
 1908         requiring the agency to seek necessary waivers and
 1909         plan amendments; providing for eligibility for the
 1910         quality network; requiring plans to monitor the
 1911         quality and performance history of providers;
 1912         establishing the MomCare network; requiring the agency
 1913         to contract with a representative of all Healthy Start
 1914         Coalitions to provide certain services to recipients;
 1915         providing for support of these activities by certain
 1916         expenditures and federal matching funds; requiring
 1917         plans to enter into agreements with local Healthy
 1918         Start Coalitions for certain purposes; requiring
 1919         specified programs and procedures be established by
 1920         plans; establishing a screening standard for the Early
 1921         and Periodic Screening, Diagnosis, and Treatment
 1922         Service; requiring managed care plans and hospitals to
 1923         negotiate rates, methods, and terms of payment;
 1924         providing a limit on payments to hospitals;
 1925         establishing plan requirements for medically needy
 1926         recipients; creating s. 409.976, F.S.; providing for
 1927         managed care plan payment; requiring the agency to
 1928         establish payment rates for statewide inpatient
 1929         psychiatric programs; requiring payments to managed
 1930         care plans to be reconciled to reimburse actual
 1931         payments to statewide inpatient psychiatric programs;
 1932         creating s. 409.977, F.S.; providing for automatic
 1933         enrollment in a managed care plan for certain
 1934         recipients; establishing opt-out opportunities for
 1935         recipients; creating s. 409.978, F.S.; requiring the
 1936         agency to be responsible for administering the long
 1937         term care managed care program; providing
 1938         implementation dates for the long-term care managed
 1939         care program; providing duties of the Department of
 1940         Elderly Affairs relating to assisting the agency in
 1941         implementing the program; creating s. 409.979, F.S.;
 1942         providing eligibility requirements for the long-term
 1943         care managed care program; creating s. 409.98, F.S.;
 1944         establishing the benefits covered under a managed care
 1945         plan participating in the long-term care managed care
 1946         program; creating s. 409.981, F.S.; providing criteria
 1947         for eligible plans; designating regions for plan
 1948         implementation throughout the state; providing
 1949         criteria for the selection of plans to participate in
 1950         the long-term care managed care program; providing
 1951         that participation by the Program of All-Inclusive
 1952         Care for the Elderly and certain Medicare plans is
 1953         pursuant to an agency contract and not subject to
 1954         procurement; creating s. 409.982, F.S.; requiring the
 1955         agency to establish uniform accounting and reporting
 1956         methods for plans; providing for mandatory
 1957         participation in plans by certain service providers;
 1958         authorizing the exclusion of certain providers from
 1959         plans for failure to meet quality or performance
 1960         criteria; requiring plans to monitor participating
 1961         providers using specified criteria; requiring certain
 1962         providers to be included in plan networks; providing
 1963         provider payment specifications for nursing homes and
 1964         hospices; creating s. 409.983, F.S.; providing for
 1965         negotiation of rates between the agency and the plans
 1966         participating in the long-term care managed care
 1967         program; providing specific criteria for calculating
 1968         and adjusting plan payments; allowing the CARES
 1969         program to assign plan enrollees to a level of care;
 1970         providing incentives for adjustments of payment rates;
 1971         requiring the agency to establish nursing facility
 1972         specific and hospice services payment rates; creating
 1973         s. 409.984, F.S.; providing criteria for automatic
 1974         assignments of plan enrollees who fail to choose a
 1975         plan; providing for hospice selection within a
 1976         specified timeframe; providing for a choice of
 1977         residential setting under certain circumstances;
 1978         creating s. 409.9841, F.S.; creating the long-term
 1979         care managed care technical advisory workgroup;
 1980         providing duties; providing membership; providing for
 1981         reimbursement for per diem and travel expenses;
 1982         providing for repeal by a specified date; creating s.
 1983         409.985, F.S.; providing that the agency shall operate
 1984         the Comprehensive Assessment and Review for Long-Term
 1985         Care Services program through an interagency agreement
 1986         with the Department of Elderly Affairs; providing
 1987         duties of the program; defining the term “nursing
 1988         facility care”; providing for severability; providing
 1989         an effective date.