CS/HB 7107

1	A bill to be entitled
2	An act relating to Medicaid managed care; creating pt. IV
3	of ch. 409, F.S., entitled "Medicaid Managed Care";
4	creating s. 409.961, F.S.; providing for statutory
5	construction; providing applicability of specified
6	provisions throughout the part; providing rulemaking
7	authority for specified agencies; creating s. 409.962,
8	F.S.; providing definitions; creating s. 409.963, F.S.;
9	designating the Agency for Health Care Administration as
10	the single state agency to administer the Medicaid
11	program; providing for specified agency responsibilities;
12	requiring client consent for release of medical records;
13	creating s. 409.964, F.S.; establishing the Medicaid
14	program as the statewide, integrated managed care program
15	for all covered services; authorizing the agency to apply
16	for and implement waivers; providing for public notice and
17	comment; creating s. 409.965, F.S.; providing for
18	mandatory enrollment; providing for exemptions; creating
19	s. 409.966, F.S.; providing requirements for eligible
20	plans that provide services in the Medicaid managed care
21	program; establishing provider service network
22	requirements for eligible plans; providing for eligible
23	plan selection; requiring the agency to use an invitation
24	to negotiate; requiring the agency to compile and publish
25	certain information; establishing eight regions for
26	separate procurement of plans; providing quality criteria
27	for plan selection; providing limitations on serving
28	recipients during the pendency of procurement litigation;
29	creating s. 409.967, F.S.; providing for managed care plan
30	accountability; establishing contract terms; providing for
31	contract extension under certain circumstances;
32	establishing payments to noncontract providers;
33	establishing requirements for access; requiring plans to
34	establish and maintain an electronic database;
35	establishing requirements for the database; requiring
36	plans to provide encounter data; requiring the agency to
37	maintain an encounter data system; requiring the agency to
38	establish performance standards for plans; providing
39	program integrity requirements; establishing a grievance
40	resolution process; providing penalties for early
41	termination of contracts or reduction in enrollment
42	levels; establishing prompt payment requirements;
43	requiring plans to accept electronic claims; requiring
44	fair payment to providers with a controlling interest in a
45	provider service network by other plans; requiring the
46	agency and prepaid plans to use a uniform method for
47	certain financial reports; providing income-sharing
48	ratios; providing a timeframe for a plan to pay an
49	additional rebate under certain circumstances; requiring
50	the agency to return prepaid plan overpayments; creating
51	s. 409.968, F.S.; establishing managed care plan payments;
52	providing payment requirements for provider service
53	networks; requiring the agency to conduct annual cost
54	reconciliations to determine certain cost savings and
55	report the results of the reconciliations to the fee-for-
56	service provider; providing a timeframe for the provider
57	service to respond to the report; creating s. 409.969,
58	F.S.; requiring enrollment in managed care plans by all
59	nonexempt Medicaid recipients; creating requirements for
60	plan selection by recipients; providing for choice
61	counseling; establishing choice counseling vendor
62	requirements; authorizing disenrollment under certain
63	circumstances; defining the term "good cause" for purposes
64	of disenrollment; providing time limits on an internal
65	grievance process; providing requirements for agency
66	determination regarding disenrollment; requiring
67	recipients to stay in plans for a specified time; creating
68	s. 409.97, F.S.; authorizing the agency to accept the
69	transfer of certain revenues from local governments;
70	requiring the agency to contract with a representative of
71	certain entities participating in the low-income pool for
72	the provision of enhanced access to care; providing for
73	support of these activities by the low-income pool as
74	authorized in the General Appropriations Act; establishing
75	the Access to Care Partnership; requiring the agency to
76	seek necessary waivers and plan amendments; providing
77	requirements for prepaid plans to submit data; authorizing
78	the agency to implement a tiered hospital rate system;
79	creating s. 409.971, F.S.; creating the managed medical
80	assistance program; providing deadlines to begin and
81	finalize implementation of the program; creating s.
82	409.972, F.S.; providing eligibility requirements for
83	mandatory and voluntary enrollment; creating s. 409.973,
84	F.S.; establishing minimum benefits for managed care plans
85	to cover; authorizing plans to customize benefit packages;
86	requiring plans to establish a program to encourage
87	healthy behaviors; requiring plans to establish a primary
88	care initiative; providing requirements for primary care
89	initiatives; requiring plans to report certain primary
90	care data to the agency; creating s. 409.974, F.S.;
91	establishing a deadline for issuing invitations to
92	negotiate; establishing a specified number or range of
93	eligible plans to be selected in each region; establishing
94	quality selection criteria; establishing requirements for
95	participation by specialty plans; establishing the
96	Children's Medical Service Network as an eligible plan;
97	creating s. 409.975, F.S.; providing for managed care plan
98	accountability; authorizing plans to limit providers in
99	networks; requiring plans to include essential Medicaid
100	providers in their networks unless an alternative
101	arrangement is approved by the agency; identifying
102	statewide essential providers; specifying provider
103	payments under certain circumstances; requiring plans to
104	include certain statewide essential providers in their
105	networks; requiring good faith negotiations; specifying
106	provider payments under certain circumstances; allowing
107	plans to exclude essential providers under certain
108	circumstances; requiring plans to offer a contract to home
109	medical equipment and supply providers under certain
110	circumstances; establishing the Florida medical school
111	quality network; requiring the agency to contract with a
112	representative of certain entities to establish a clinical
113	outcome improvement program in all plans; providing for
114	support of these activities by certain expenditures and
115	federal matching funds; requiring the agency to seek
116	necessary waivers and plan amendments; providing for
117	eligibility for the quality network; requiring plans to
118	monitor the quality and performance history of providers;
119	establishing the MomCare network; requiring the agency to
120	contract with a representative of all Healthy Start
121	Coalitions to provide certain services to recipients;
122	providing for support of these activities by certain
123	expenditures and federal matching funds; requiring plans
124	to enter into agreements with local Healthy Start
125	Coalitions for certain purposes; requiring specified
126	programs and procedures be established by plans;
127	establishing a screening standard for the Early and
128	Periodic Screening, Diagnosis, and Treatment Service;
129	requiring managed care plans and hospitals to negotiate
130	rates, methods, and terms of payment; providing a limit on
131	payments to hospitals; establishing plan requirements for
132	medically needy recipients; creating s. 409.976, F.S.;
133	providing for managed care plan payment; requiring the
134	agency to establish payment rates for statewide inpatient
135	psychiatric programs; requiring payments to managed care
136	plans to be reconciled to reimburse actual payments to
137	statewide inpatient psychiatric programs; creating s.
138	409.977, F.S.; establishing choice counseling
139	requirements; providing for automatic enrollment in a
140	managed care plan for certain recipients; establishing
141	opt-out opportunities for recipients; creating s. 409.978,
142	F.S.; requiring the agency to be responsible for
143	administering the long-term care managed care program;
144	providing implementation dates for the long-term care
145	managed care program; providing duties of the Department
146	of Elderly Affairs relating to assisting the agency in
147	implementing the program; creating s. 409.979, F.S.;
148	providing eligibility requirements for the long-term care
149	managed care program; creating s. 409.98, F.S.;
150	establishing the benefits covered under a managed care
151	plan participating in the long-term care managed care
152	program; creating s. 409.981, F.S.; providing criteria for
153	eligible plans; designating regions for plan
154	implementation throughout the state; providing criteria
155	for the selection of plans to participate in the long-term
156	care managed care program; providing that participation by
157	the Program of All-Inclusive Care for the Elderly is
158	pursuant to an agency contract; creating s. 409.982, F.S.;
159	requiring the agency to establish uniform accounting and
160	reporting methods for plans; providing for mandatory
161	participation in plans by certain service providers;
162	authorizing the exclusion of certain providers from plans
163	for failure to meet quality or performance criteria;
164	requiring plans to monitor participating providers using
165	specified criteria; requiring certain providers to be
166	included in plan networks; providing provider payment
167	specifications for nursing homes and hospices; creating s.
168	409.983, F.S.; providing for negotiation of rates between
169	the agency and the plans participating in the long-term
170	care managed care program; providing specific criteria for
171	calculating and adjusting plan payments; allowing the
172	CARES program to assign plan enrollees to a level of care;
173	providing incentives for adjustments of payment rates;
174	requiring the agency to establish nursing facility-
175	specific and hospice services payment rates; creating s.
176	409.984, F.S.; providing that before contracting with
177	another vendor, the agency shall offer to contract with
178	the aging resource centers to provide choice counseling
179	for the long-term care managed care program; providing
180	criteria for automatic assignments of plan enrollees who
181	fail to choose a plan; providing for hospice selection
182	within a specified timeframe; providing for a choice of
183	residential setting under certain circumstances; creating
184	s. 409.9841, F.S.; creating the long-term care managed
185	care technical advisory workgroup; providing duties;
186	providing membership; providing for reimbursement for per
187	diem and travel expenses; providing for repeal by a
188	specified date; creating s. 409.985, F.S.; providing that
189	the agency shall operate the Comprehensive Assessment and
190	Review for Long-Term Care Services program through an
191	interagency agreement with the Department of Elderly
192	Affairs; providing duties of the program; defining the
193	term "nursing facility care"; creating s. 409.986, F.S.;
194	providing authority and agency duties regarding long-term
195	care programs for persons with developmental disabilities;
196	authorizing the agency to delegate specific duties to and
197	collaborate with the Agency for Persons with Disabilities;
198	requiring the agency to make payments for long-term care
199	for persons with developmental disabilities under certain
200	conditions; creating s. 409.987, F.S.; providing
201	eligibility requirements for long-term care plans;
202	creating s. 409.988, F.S.; specifying covered benefits for
203	long-term care plans; creating s. 409.989, F.S.;
204	establishing criteria for eligible plans; specifying
205	minimum and maximum number of plans and selection
206	criteria; authorizing participation by the Children's
207	Medical Services Network in long-term care plans under
208	certain conditions; creating s. 409.99, F.S.; providing
209	requirements for managed care plan accountability;
210	specifying limitations on providers in plan networks;
211	providing for evaluation and payment of network providers;
212	requiring managed care plans to establish family advisory
213	committees and offer consumer-directed care services;
214	creating s. 409.991, F.S.; providing for payment of
215	managed care plans; providing duties for the Agency for
216	Persons with Disabilities to assign plan enrollees into a
217	payment-rate level of care; establishing level-of-care
218	criteria; providing payment requirements for intensive
219	behavior residential habilitation providers and
220	intermediate care facilities for the developmentally
221	disabled; creating s. 409.992, F.S.; providing
222	requirements for enrollment and choice counseling;
223	specifying enrollment exceptions for certain Medicaid
224	recipients; providing an effective date.
225
226	Be It Enacted by the Legislature of the State of Florida:
227
228	Section 1.  Sections 409.961 through 409.992, Florida
229	Statutes, are designated as part IV of chapter 409, Florida
230	Statutes, entitled "Medicaid Managed Care."
231	Section 2.  Section 409.961, Florida Statutes, is created
232	to read:
233	409.961  Statutory construction; applicability; rules.-It
234	is the intent of the Legislature that if any conflict exists
235	between the provisions contained in this part and provisions
236	contained in other parts of this chapter, the provisions
237	contained in this part shall control. The provisions of ss.
238	409.961-409.97 apply only to the Medicaid managed medical
239	assistance program, long-term care managed care program, and
240	managed long-term care for persons with developmental
241	disabilities program, as provided in this part. The agency shall
242	adopt any rules necessary to comply with or administer this part
243	and all rules necessary to comply with federal requirements. In
244	addition, the department shall adopt and accept the transfer of
245	any rules necessary to carry out the department's
246	responsibilities for receiving and processing Medicaid
247	applications and determining Medicaid eligibility and for
248	ensuring compliance with and administering this part, as those
249	rules relate to the department's responsibilities, and any other
250	provisions related to the department's responsibility for the
251	determination of Medicaid eligibility.
252	Section 3.  Section 409.962, Florida Statutes, is created
253	to read:
254	409.962  Definitions.-As used in this part, except as
255	otherwise specifically provided, the term:
256	(1)  "Agency" means the Agency for Health Care
257	Administration.
258	(2)  "Aging network service provider" means a provider that
259	participated in a home and community-based waiver administered
260	by the Department of Elderly Affairs or the community care
261	service system pursuant to s. 430.205, as of October 1, 2013.
262	(3)  "Comprehensive long-term care plan" means a managed
263	care plan that provides services described in s. 409.973 and
264	also provides the services described in s. 409.98 or s. 409.988.
265	(4)  "Department" means the Department of Children and
266	Family Services.
267	(5)  "Developmental disability provider service network"
268	means a provider service network, a controlling interest of
269	which includes one or more entities licensed pursuant to s.
270	393.067 or s. 400.962 with 18 or more licensed beds and the
271	owner or owners of which have at least 10 years' experience
272	serving persons with developmental disabilities.
273	(6)  "Direct care management" means care management
274	activities that involve direct interaction with Medicaid
275	recipients.
276	(7)  "Eligible plan" means a health insurer authorized
277	under chapter 624, an exclusive provider organization authorized
278	under chapter 627, a health maintenance organization authorized
279	under chapter 641, or a provider service network authorized
280	under s. 409.912(4)(d). For purposes of the managed medical
281	assistance program, the term also includes the Children's
282	Medical Services Network authorized under chapter 391. For
283	purposes of the long-term care managed care program, the term
284	also includes entities qualified under 42 C.F.R. part 422 as
285	Medicare Advantage Preferred Provider Organizations, Medicare
286	Advantage Provider-sponsored Organizations, and Medicare
287	Advantage Special Needs Plans, and the Program of All-Inclusive
288	Care for the Elderly.
289	(8)  "Long-term care plan" means a managed care plan that
290	provides the services described in s. 409.98 for the long-term
291	care managed care program or the services described in s.
292	409.988 for the long-term care managed care program for persons
293	with developmental disabilities.
294	(9)  "Long-term care provider service network" means a
295	provider service network a controlling interest of which is
296	owned by one or more licensed nursing homes, assisted living
297	facilities with 17 or more beds, home health agencies, community
298	care for the elderly lead agencies, or hospices.
299	(10)  "Managed care plan" means an eligible plan under
300	contract with the agency to provide services in the Medicaid
301	program.
302	(11)  "Medicaid" means the medical assistance program
303	authorized by Title XIX of the Social Security Act, 42 U.S.C.
304	ss. 1396 et seq., and regulations thereunder, as administered in
305	this state by the agency.
306	(12)  "Medicaid recipient" or "recipient" means an
307	individual who the department or, for Supplemental Security
308	Income, the Social Security Administration determines is
309	eligible pursuant to federal and state law to receive medical
310	assistance and related services for which the agency may make
311	payments under the Medicaid program. For the purposes of
312	determining third-party liability, the term includes an
313	individual formerly determined to be eligible for Medicaid, an
314	individual who has received medical assistance under the
315	Medicaid program, or an individual on whose behalf Medicaid has
316	become obligated.
317	(13)  "Prepaid plan" means a managed care plan that is
318	licensed or certified as a risk-bearing entity, or qualified
319	pursuant to s. 409.912(4)(d), in the state and is paid a
320	prospective per-member, per-month payment by the agency.
321	(14)  "Provider service network" means an entity qualified
322	pursuant to s. 409.912(4)(d) of which a controlling interest is
323	owned by a health care provider, or group of affiliated
324	providers, or a public agency or entity that delivers health
325	services. Health care providers include Florida-licensed health
326	care professionals or licensed health care facilities, federally
327	qualified health care centers, and home health care agencies.
328	(15)  "Specialty plan" means a managed care plan that
329	serves Medicaid recipients who meet specified criteria based on
330	age, medical condition, or diagnosis.
331	Section 4.  Section 409.963, Florida Statutes, is created
332	to read:
333	409.963  Single state agency.-The Agency for Health Care
334	Administration is designated as the single state agency
335	authorized to manage, operate, and make payments for medical
336	assistance and related services under Title XIX of the Social
337	Security Act. Subject to any limitations or directions provided
338	for in the General Appropriations Act, these payments may be
339	made only for services included in the program, only on behalf
340	of eligible individuals, and only to qualified providers in
341	accordance with federal requirements for Title XIX of the Social
342	Security Act and the provisions of state law. This program of
343	medical assistance is designated as the "Medicaid program." The
344	department is responsible for Medicaid eligibility
345	determinations, including, but not limited to, policy, rules,
346	and the agreement with the Social Security Administration for
347	Medicaid eligibility determinations for Supplemental Security
348	Income recipients, as well as the actual determination of
349	eligibility. As a condition of Medicaid eligibility, subject to
350	federal approval, the agency and the department shall ensure
351	that each Medicaid recipient consents to the release of her or
352	his medical records to the agency and the Medicaid Fraud Control
353	Unit of the Department of Legal Affairs.
354	Section 5.  Section 409.964, Florida Statutes is created to
355	read:
356	409.964  Managed care program; state plan; waivers.-The
357	Medicaid program is established as a statewide, integrated
358	managed care program for all covered services, including long-
359	term care services. The agency shall apply for and implement
360	state plan amendments or waivers of applicable federal laws and
361	regulations necessary to implement the program. Before seeking a
362	waiver, the agency shall provide public notice and the
363	opportunity for public comment and shall include public feedback
364	in the waiver application. The agency shall hold one public
365	meeting in each of the regions described in s. 409.966(2) and
366	the time period for public comment for each region shall end no
367	sooner than 30 days after the completion of the public meeting
368	in that region.
369	Section 6.  Section 409.965, Florida Statutes, is created
370	to read:
371	409.965  Mandatory enrollment.-All Medicaid recipients
372	shall receive covered services through the statewide managed
373	care program, except as provided by this part pursuant to an
374	approved federal waiver. The following Medicaid recipients are
375	exempt from participation in the statewide managed care program:
376	(1)  Women who are only eligible for family planning
377	services.
378	(2)  Women who are only eligible for breast and cervical
379	cancer services.
380	(3)  Persons who are eligible for emergency Medicaid for
381	aliens.
382	Section 7.  Section 409.966, Florida Statutes, is created
383	to read:
384	409.966  Eligible plans; selection.-
385	(1)  ELIGIBLE PLANS.-Services in the Medicaid managed care
386	program shall be provided by eligible plans. A provider service
387	network must be capable of providing all covered services to a
388	mandatory Medicaid managed care enrollee or may limit the
389	provision of services to a specific target population based on
390	the age, chronic disease state, or medical condition of the
391	enrollee to whom the network will provide services. A specialty
392	provider service network must be capable of coordinating care
393	and delivering or arranging for the delivery of all covered
394	services to the target population. A provider service network
395	may partner with an insurer licensed under chapter 627 or a
396	health maintenance organization licensed under chapter 641 to
397	meet the requirements of a Medicaid contract.
398	(2)  ELIGIBLE PLAN SELECTION.-The agency shall select a
399	limited number of eligible plans to participate in the Medicaid
400	program using invitations to negotiate in accordance with s.
401	287.057(3)(a). At least 90 days before issuing an invitation to
402	negotiate, the agency shall compile and publish a databook
403	consisting of a comprehensive set of utilization and spending
404	data for the 3 most recent contract years consistent with the
405	rate-setting periods for all Medicaid recipients by region or
406	county. The source of the data in the report shall include both
407	historic fee-for-service claims and validated data from the
408	Medicaid Encounter Data System. The report shall be made
409	available in electronic form and shall delineate utilization use
410	by age, gender, eligibility group, geographic area, and
411	aggregate clinical risk score. Separate and simultaneous
412	procurements shall be conducted in each of the following
413	regions:
414	(a)  Region I, which shall consist of Bay, Calhoun,
415	Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson,
416	Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla,
417	Walton, and Washington Counties.
418	(b)  Region II, which shall consist of Alachua, Baker,
419	Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton,
420	Lafayette, Lake, Levy, Marion, Sumter, Suwannee, and Union
421	Counties.
422	(c)  Region III, which shall consist of Clay, Duval,
423	Flagler, Nassau, Putman, St. Johns, and Volusia Counties.
424	(d)  Region IV, which shall consist of Brevard, Indian
425	River, Okeechobee, Orange, Osceola, Seminole, and St. Lucie
426	Counties.
427	(e)  Region V, which shall consist of Hernando,
428	Hillsborough, Pasco, Pinellas, and Polk Counties.
429	(f)  Region VI, which shall consist of Charlotte, Collier,
430	DeSoto, Hardee, Highlands, Lee, Manatee, and Sarasota Counties.
431	(g)  Region VII, which shall consist of Broward, Glades,
432	Hendry, Martin, and Palm Beach Counties.
433	(h)  Region VIII, which shall consist of Miami-Dade and
434	Monroe Counties.
435	(3)  QUALITY SELECTION CRITERIA.-
436	(a)  The invitation to negotiate must specify the criteria
437	and the relative weight of the criteria that will be used for
438	determining the acceptability of the reply and guiding the
439	selection of the organizations with which the agency negotiates.
440	In addition to criteria established by the agency, the agency
441	shall consider the following factors in the selection of
442	eligible plans:
443	1.  Accreditation by the National Committee for Quality
444	Assurance, the Joint Commission, or another nationally
445	recognized accrediting body.
446	2.  Experience serving similar populations, including the
447	organization's record in achieving specific quality standards
448	with similar populations.
449	3.  Availability and accessibility of primary care and
450	specialty physicians in the provider network.
451	4.  Establishment of community partnerships with providers
452	that create opportunities for reinvestment in community-based
453	services.
454	5.  Organization commitment to quality improvement and
455	documentation of achievements in specific quality improvement
456	projects, including active involvement by organization
457	leadership.
458	6.  Provision of additional benefits, particularly dental
459	care and disease management, and other initiatives that improve
460	health outcomes.
461	7.  Evidence that a qualified plan has written agreements
462	or signed contracts or has made substantial progress in
463	establishing relationships with providers before the plan
464	submitting a response.
465	8.  Comments submitted in writing by any enrolled Medicaid
466	provider relating to a specifically identified plan
467	participating in the procurement in the same region as the
468	submitting provider.
469	9.  The business relationship a qualified plan has with any
470	other qualified plan that responds to the invitation to
471	negotiate.
472
473	A qualified plan must disclose any business relationship it has
474	with any other qualified plan that responds to the invitation to
475	negotiate. The agency may not select plans in the same region
476	that have a business relationship with each other. Failure to
477	disclose any business relationship shall result in
478	disqualification from participation in any region for the first
479	full contract period after the discovery of the business
480	relationship by the agency. For the purpose of this section,
481	"business relationship" means an ownership or controlling
482	interest, an affiliate or subsidiary relationship, a common
483	parent, or any mutual interest in any limited partnership,
484	limited liability partnership, limited liability company, or
485	other entity or business association, including all wholly or
486	partially owned subsidiaries, majority-owned subsidiaries,
487	parent companies, or affiliates of such entities, business
488	associations, or other enterprises, that exists for the purpose
489	of making a profit.
490	(b)  After negotiations are conducted, the agency shall
491	select the eligible plans that are determined to be responsive
492	and provide the best value to the state. Preference shall be
493	given to plans that demonstrate the following:
494	1.  Signed contracts with primary and specialty physicians
495	in sufficient numbers to meet the specific standards established
496	pursuant to s. 409.967(2)(b).
497	2.  Well-defined programs for recognizing patient-centered
498	medical homes or accountable care organizations, and providing
499	for increased compensation for recognized medical homes or
500	accountable care organizations, as defined by the plan.
501	3.  Greater net economic benefit to Florida compared to
502	other bidders through employment of, or subcontracting with
503	firms that employ, Floridians in order to accomplish the
504	contract requirements. Contracts with such bidders shall specify
505	performance measures to evaluate the plan's employment-based
506	economic impact. Valuation of the net economic benefit may not
507	include employment of or subcontracts with providers.
508	(c)  To ensure managed care plan participation in Region I,
509	the agency shall award an additional contract to each plan with
510	a contract award in Region I. Such contract shall be in any
511	other region in which the plan submitted a responsive bid and
512	negotiates a rate acceptable to the agency.
513	(4)  ADMINISTRATIVE CHALLENGE.-Any eligible plan that
514	participates in an invitation to negotiate in more than one
515	region and is selected in at least one region may not begin
516	serving Medicaid recipients in any region for which it was
517	selected until all administrative challenges to procurements
518	required by this section to which the eligible plan is a party
519	have been finalized. If the number of plans selected is less
520	than the maximum amount of plans permitted in the region, the
521	agency may contract with other selected plans in the region not
522	participating in the administrative challenge before resolution
523	of the administrative challenge. For purposes of this
524	subsection, an administrative challenge is finalized if an order
525	granting voluntary dismissal with prejudice has been entered by
526	any court established under Article V of the State Constitution
527	or by the Division of Administrative Hearings, a final order has
528	been entered into by the agency and the deadline for appeal has
529	expired, a final order has been entered by the First District
530	Court of Appeal and the time to seek any available review by the
531	Florida Supreme Court has expired, or a final order has been
532	entered by the Florida Supreme Court and a warrant has been
533	issued.
534	Section 8.  Section 409.967, Florida Statutes, is created
535	to read:
536	409.967  Managed care plan accountability.-
537	(1)  The agency shall establish a 5-year contract with each
538	managed care plan selected through the procurement process
539	described in s. 409.966. A plan contract may not be renewed;
540	however, the agency may extend the terms of a plan contract to
541	cover any delays in transition to a new plan.
542	(2)  The agency shall establish such contract requirements
543	as are necessary for the operation of the statewide managed care
544	program. In addition to any other provisions the agency may deem
545	necessary, the contract shall require:
546	(a)  Emergency services.-Managed care plans shall pay for
547	services required by ss. 395.1041 and 401.45 and rendered by a
548	noncontracted provider pursuant to s. 641.3155. Reimbursement
549	for services under this paragraph shall be the lesser of:
550	1.  The provider's charges;
551	2.  The usual and customary provider charges for similar
552	services in the community where the services were provided;
553	3.  The charge mutually agreed to by the entity and the
554	provider within 60 days after submittal of the claim; or
555	4.  The rate the agency would have paid on the first day of
556	the contract between the provider and the plan.
557	(b)  Access.-The agency shall establish specific standards
558	for the number, type, and regional distribution of providers in
559	managed care plan networks to ensure access to care for both
560	adults and children. Each plan must maintain a region-wide
561	network of providers in sufficient numbers to meet the access
562	standards for specific medical services for all recipients
563	enrolled in the plan. Consistent with the standards established
564	by the agency, provider networks may include providers located
565	outside the region. A plan may contract with a new hospital
566	facility before the date the hospital becomes operational if the
567	hospital has commenced construction, will be licensed and
568	operational by January 1, 2013, and a final order has issued in
569	any civil or administrative challenge. Each plan shall establish
570	and maintain an accurate and complete electronic database of
571	contracted providers, including information about licensure or
572	registration, locations and hours of operation, specialty
573	credentials and other certifications, specific performance
574	indicators, and such other information as the agency deems
575	necessary. The database shall be available online to both the
576	agency and the public and shall have the capability to compare
577	the availability of providers to network adequacy standards and
578	to accept and display feedback from each provider's patients.
579	Each plan shall submit quarterly reports to the agency
580	identifying the number of enrollees assigned to each primary
581	care provider.
582	(c)  Encounter data.-The agency shall maintain and operate
583	a Medicaid Encounter Data System to collect, process, store, and
584	report on covered services provided to all Medicaid recipients
585	enrolled in prepaid plans.
586	1.  Each prepaid plan must comply with the agency's
587	reporting requirements for the Medicaid Encounter Data System.
588	Prepaid plans must submit encounter data electronically in a
589	format that complies with the Health Insurance Portability and
590	Accountability Act provisions for electronic claims and in
591	accordance with deadlines established by the agency. Prepaid
592	plans must certify that the data reported is accurate and
593	complete.
594	2.  The agency is responsible for validating the data
595	submitted by the plans. The agency shall develop methods and
596	protocols for ongoing analysis of the encounter data that
597	adjusts for differences in characteristics of prepaid plan
598	enrollees to allow comparison of service utilization among plans
599	and against expected levels of use. The analysis shall be used
600	to identify possible cases of systemic underutilization or
601	denials of claims and inappropriate service utilization such as
602	higher-than-expected emergency department encounters. The
603	analysis shall provide periodic feedback to the plans and enable
604	the agency to establish corrective action plans when necessary.
605	One of the focus areas for the analysis shall be the use of
606	prescription drugs.
607	3.  The agency shall make encounter data available to those
608	plans accepting enrollees who are assigned to them from other
609	plans leaving a region.
610	(d)  Continuous improvement.-The agency shall establish
611	specific performance standards and expected milestones or
612	timelines for improving performance over the term of the
613	contract. By the end of the fourth year of the first contract
614	term, the agency shall issue a request for information to
615	determine whether cost savings could be achieved by contracting
616	for plan oversight and monitoring, including analysis of
617	encounter data, assessment of performance measures, and
618	compliance with other contractual requirements. Each managed
619	care plan shall establish an internal health care quality
620	improvement system, including enrollee satisfaction and
621	disenrollment surveys. The quality improvement system shall
622	include incentives and disincentives for network providers.
623	(e)  Program integrity.-Each managed care plan shall
624	establish program integrity functions and activities to reduce
625	the incidence of fraud and abuse, including, at a minimum:
626	1.  A provider credentialing system and ongoing provider
627	monitoring;
628	2.  An effective prepayment and postpayment review process
629	including, but not limited to, data analysis, system editing,
630	and auditing of network providers;
631	3.  Procedures for reporting instances of fraud and abuse
632	pursuant to chapter 641;
633	4.  Administrative and management arrangements or
634	procedures, including a mandatory compliance plan, designed to
635	prevent fraud and abuse; and
636	5.  Designation of a program integrity compliance officer.
637	(f)  Grievance resolution.-Each managed care plan shall
638	establish and the agency shall approve an internal process for
639	reviewing and responding to grievances from enrollees consistent
640	with the requirements of s. 641.511. Each plan shall submit
641	quarterly reports on the number, description, and outcome of
642	grievances filed by enrollees. The agency shall maintain a
643	process for provider service networks consistent with s.
644	408.7056.
645	(g)  Penalties.-Managed care plans that reduce enrollment
646	levels or leave a region before the end of the contract term
647	shall reimburse the agency for the cost of enrollment changes
648	and other transition activities, including the cost of
649	additional choice counseling services. If more than one plan
650	leaves a region at the same time, costs shall be shared by the
651	departing plans proportionate to their enrollments. In addition
652	to the payment of costs, departing provider services networks
653	shall pay a per enrollee penalty not to exceed 3 month's payment
654	and shall continue to provide services to the enrollee for 90
655	days or until the enrollee is enrolled in another plan,
656	whichever is sooner. In addition to payment of costs, all other
657	plans shall pay a penalty equal to 25 percent of the minimum
658	surplus requirement pursuant to s. 641.225(1). Plans shall
659	provide the agency notice no less than 180 days before
660	withdrawing from a region.
661	(h)  Prompt payment.-Managed care plans shall comply with
662	ss. 641.315, 641.3155, and 641.513.
663	(i)  Electronic claims.-Managed care plans shall accept
664	electronic claims in compliance with federal standards.
665	(j)  Fair payment.-Provider service networks must ensure
666	that no network provider with a controlling interest in the
667	network charges any Medicaid managed care plan more than the
668	amount paid to that provider by the provider service network for
669	the same service.
670	(3)  ACHIEVED SAVINGS REBATE.-
671	(a)  The agency shall establish and the prepaid plans shall
672	use a uniform method for annually reporting premium revenue,
673	medical and administrative costs, and income or losses, across
674	all Florida Medicaid prepaid plan lines of business in all
675	regions. The reports shall be due to the agency within 270 days
676	after the conclusion of the reporting period and the agency may
677	audit the reports. Achieved savings rebates shall be due within
678	30 days after the report is submitted. Except as provided in
679	paragraph (b), the achieved savings rebate will be established
680	by determining pretax income as a percentage of revenues and
681	applying the following income sharing ratios:
682	1.  One hundred percent of income up to and including 5
683	percent of revenue shall be retained by the plan.
684	2.  Fifty percent of income above 5 percent and up to 10
685	percent shall be retained by the plan, with the other 50 percent
686	refunded to the state.
687	3.  One hundred percent of income above 10 percent of
688	revenue shall be refunded to the state.
689	(b)  A plan that meets or exceeds agency-defined quality
690	measures in the reporting period may retain an additional 1
691	percent of revenue.
692	(c)  The following expenses may not be included in
693	calculating income to the plan:
694	1.  Payment of achieved savings rebates.
695	2.  Any financial incentive payments made to the plan
696	outside of the capitation rate.
697	3.  Any financial disincentive payments levied by the state
698	or federal governments.
699	4.  Expenses associated with lobbying activities.
700	5.  Administrative, reinsurance, and outstanding claims
701	expenses in excess of actuarially sound maximum amounts set by
702	the agency.
703	6.  Any payment made pursuant to paragraph (f).
704	(d)  Prepaid plans that incur a loss in the first contract
705	year may apply the full amount of the loss as an offset to
706	income in the second contract year.
707	(e)  If, after an audit or other reconciliation, the agency
708	determines that a prepaid plan owes an additional rebate, the
709	plan shall have 30 days after notification to make the payment.
710	Upon failure to timely pay the rebate, the agency shall withhold
711	future payments to the plan until the entire amount is recouped.
712	If the agency determines that a prepaid plan has made an
713	overpayment, the agency shall return the overpayment within 30
714	days.
715	(f)  In addition to the reporting required by paragraph
716	(a), prepaid plans shall annually submit a report, consistent
717	with paragraph (a), which is specific to enrollees with
718	developmental disabilities. The agency shall compare each plan's
719	expenditures to the plan's aggregate premiums for this
720	population. The difference between aggregate premiums and
721	expenditures shall be shared equally between the plan and the
722	state. The state share shall be returned to the Medicaid
723	appropriation to serve people on the wait list for home and
724	community-based services provided through individual budgets.
725	Section 9.  Section 409.968, Florida Statutes, is created
726	to read:
727	409.968  Managed care plan payments.-
728	(1)  Prepaid plans shall receive per-member, per-month
729	payments negotiated pursuant to the procurements described in s.
730	409.966. Payments shall be risk-adjusted rates based on
731	historical utilization and spending data, projected forward, and
732	adjusted to reflect the eligibility category, geographic area,
733	and clinical risk profile of the recipients.
734	(2)  Provider service networks may be prepaid plans and
735	receive per-member, per-month payments negotiated pursuant to
736	the procurement process described in s. 409.966. Provider
737	service networks that choose not to be prepaid plans shall
738	receive fee-for-service rates with a shared savings settlement.
739	The fee-for-service option shall be available to a provider
740	service network only for the first 5 years of its operation in a
741	given region. The agency shall annually conduct cost
742	reconciliations to determine the amount of cost savings achieved
743	by fee-for-service provider service networks for the dates of
744	service within the period being reconciled. Only payments for
745	covered services for dates of service within the reconciliation
746	period and paid within 6 months after the last date of service
747	in the reconciliation period shall be included. The agency shall
748	perform the necessary adjustments for the inclusion of claims
749	incurred but not reported within the reconciliation period for
750	claims that could be received and paid by the agency after the
751	6-month claims processing time lag. The agency shall provide the
752	results of the reconciliations to the fee-for-service provider
753	service networks within 45 days after the end of the
754	reconciliation period. The fee-for-service provider service
755	networks shall review and provide written comments or a letter
756	of concurrence to the agency within 45 days after receipt of the
757	reconciliation results. This reconciliation shall be considered
758	final.
759	Section 10.  Section 409.969, Florida Statutes, is created
760	to read:
761	409.969  Enrollment; choice counseling; automatic
762	assignment; disenrollment.-
763	(1)  ENROLLMENT.-All Medicaid recipients shall be enrolled
764	in a managed care plan unless specifically exempted under this
765	part. Each recipient shall have a choice of plans and may select
766	any available plan unless that plan is restricted by contract to
767	a specific population that does not include the recipient.
768	Medicaid recipients shall have 30 days in which to make a choice
769	of plans. All recipients shall be offered choice counseling
770	services in accordance with this section.
771	(2)  CHOICE COUNSELING.-The agency shall provide choice
772	counseling for Medicaid recipients. The agency may contract for
773	the provision of choice counseling. Any such contract shall be
774	with a vendor that employs Floridians to accomplish the contract
775	requirements and shall be for a period of 5 years. The agency
776	may renew a contract for an additional 5-year period; however,
777	before renewal of the contract the agency shall hold at least
778	one public meeting in each of the regions covered by the choice
779	counseling vendor. The agency may extend the term of the
780	contract to cover any delays in transition to a new contractor.
781	Printed choice information and choice counseling shall be
782	offered in the native or preferred language of the recipient,
783	consistent with federal requirements. The manner and method of
784	choice counseling shall be modified as necessary to ensure
785	culturally competent, effective communication with people from
786	diverse cultural backgrounds. The agency shall maintain a record
787	of the recipients who receive such services, identifying the
788	scope and method of the services provided. The agency shall make
789	available clear and easily understandable choice information to
790	Medicaid recipients that includes:
791	(a)  An explanation that each recipient has the right to
792	choose a managed care plan at the time of enrollment in Medicaid
793	and again at regular intervals set by the agency, and that if a
794	recipient does not choose a plan, the agency will assign the
795	recipient to a plan according to the criteria specified in this
796	section.
797	(b)  A list and description of the benefits provided in
798	each managed care plan.
799	(c)  An explanation of benefit limits.
800	(d)  A current list of providers participating in the
801	network, including location and contact information.
802	(e)  Managed care plan performance data.
803	(3)  DISENROLLMENT; GRIEVANCES.-After a recipient has
804	enrolled in a managed care plan, the recipient shall have 90
805	days to voluntarily disenroll and select another plan. After 90
806	days, no further changes may be made except for good cause. For
807	purposes of this section, the term "good cause" includes, but is
808	not limited to, poor quality of care, lack of access to
809	necessary specialty services, an unreasonable delay or denial of
810	service, or fraudulent enrollment. The agency must make a
811	determination as to whether good cause exists. The agency may
812	require a recipient to use the plan's grievance process before
813	the agency's determination of good cause, except in cases in
814	which immediate risk of permanent damage to the recipient's
815	health is alleged.
816	(a)  The managed care plan internal grievance process, when
817	used, must be completed in time to permit the recipient to
818	disenroll by the first day of the second month after the month
819	the disenrollment request was made. If the result of the
820	grievance process is approval of an enrollee's request to
821	disenroll, the agency is not required to make a determination in
822	the case.
823	(b)  The agency must make a determination and take final
824	action on a recipient's request so that disenrollment occurs no
825	later than the first day of the second month after the month the
826	request was made. If the agency fails to act within the
827	specified timeframe, the recipient's request to disenroll is
828	deemed to be approved as of the date agency action was required.
829	Recipients who disagree with the agency's finding that good
830	cause does not exist for disenrollment shall be advised of their
831	right to pursue a Medicaid fair hearing to dispute the agency's
832	finding.
833	(c)  Medicaid recipients enrolled in a managed care plan
834	after the 90-day period shall remain in the plan for the
835	remainder of the 12-month period. After 12 months, the recipient
836	may select another plan. However, nothing shall prevent a
837	Medicaid recipient from changing providers within the plan
838	during that period.
839	(d)  On the first day of the month after receiving notice
840	from a recipient that the recipient has moved to another region,
841	the agency shall automatically disenroll the recipient from the
842	managed care plan the recipient is currently enrolled in and
843	treat the recipient as if the recipient is a new Medicaid
844	enrollee. At that time, the recipient may choose another plan
845	pursuant to the enrollment process established in this section.
846	(e)  The agency must monitor plan disenrollment throughout
847	the contract term to identify any discriminatory practices.
848	Section 11.  Section 409.97, Florida Statutes, is created
849	to read:
850	409.97  State and local Medicaid partnerships.-
851	(1)  INTERGOVERNMENTAL TRANSFERS.-In addition to the
852	contributions required pursuant to s. 409.915, beginning in the
853	2014-2015 fiscal year, the agency may accept voluntary transfers
854	of local taxes and other qualified revenue from counties,
855	municipalities, and special taxing districts. Such transfers
856	must be contributed to advance the general goals of the Florida
857	Medicaid program without restriction and must be executed
858	pursuant to a contract between the agency and the local funding
859	source. Contracts executed before October 31 shall result in
860	contributions to Medicaid for that same state fiscal year.
861	Contracts executed between November 1 and June 30 shall result
862	in contributions for the following state fiscal year. Based on
863	the date of the signed contracts, the agency shall allocate to
864	the low-income pool the first contributions received up to the
865	limit established by subsection (2). No more than 40 percent of
866	the low-income pool funding shall come from any single funding
867	source. Contributions in excess of the low-income pool shall be
868	allocated to the disproportionate share programs defined in ss.
869	409.911(3) and 409.9113 and to hospital rates pursuant to
870	subsection (4). The local funding source shall designate in the
871	contract which Medicaid providers ensure access to care for low-
872	income and uninsured people within the applicable jurisdiction
873	and are eligible for low-income pool funding. Eligible providers
874	may include both hospitals and primary care providers.
875	(2)  LOW-INCOME POOL.-The agency shall establish and
876	maintain a low-income pool in a manner authorized by federal
877	waiver. The low-income pool is created to compensate a network
878	of providers designated pursuant to subsection (1). Funding of
879	the low-income pool shall be limited to the maximum amount
880	permitted by federal waiver minus a percentage specified in the
881	General Appropriations Act. The low-income pool must be used to
882	support enhanced access to services by offsetting shortfalls in
883	Medicaid reimbursement, paying for otherwise uncompensated care,
884	and financing coverage for the uninsured. The low-income pool
885	shall be distributed in periodic payments to the Access to Care
886	Partnership throughout the fiscal year. Distribution of low-
887	income pool funds by the Access to Care Partnership to
888	participating providers may be made through capitated payments,
889	fees for services, or contracts for specific deliverables. The
890	agency shall include the distribution amount for each provider
891	in the contract with the Access to Care Partnership pursuant to
892	subsection (3). Regardless of the method of distribution,
893	providers participating in the Access to Care Partnership shall
894	receive payments such that the aggregate benefit in the
895	jurisdiction of each local funding source, as defined in
896	subsection (1), equals the amount of the contribution plus a
897	factor specified in the General Appropriations Act.
898	(3)  ACCESS TO CARE PARTNERSHIP.-The agency shall contract
899	with an administrative services organization that has operating
900	agreements with all health care facilities, programs, and
901	providers supported with local taxes or certified public
902	expenditures and designated pursuant to subsection (1). The
903	contract shall provide for enhanced access to care for Medicaid,
904	low-income, and uninsured Floridians. The partnership shall be
905	responsible for an ongoing program of activities that provides
906	needed, but uncovered or undercompensated, health services to
907	Medicaid enrollees and persons receiving charity care, as
908	defined in s. 409.911. Accountability for services rendered
909	under this contract must be based on the number of services
910	provided to unduplicated qualified beneficiaries, the total
911	units of service provided to these persons, and the
912	effectiveness of services provided as measured by specific
913	standards of care. The agency shall seek such plan amendments or
914	waivers as may be necessary to authorize the implementation of
915	the low-income pool as the Access to Care Partnership pursuant
916	to this section.
917	(4)  HOSPITAL RATE DISTRIBUTION.-
918	(a)  The agency is authorized to implement a tiered
919	hospital rate system to enhance Medicaid payments to all
920	hospitals when resources for the tiered rates are available from
921	general revenue and such contributions pursuant to subsection
922	(1) as are authorized under the General Appropriations Act.
923	1.  Tier 1 hospitals are statutory rural hospitals as
924	defined in s. 395.602, statutory teaching hospitals as defined
925	in s. 408.07(45), and specialty children's hospitals as defined
926	in s. 395.002(28).
927	2.  Tier 2 hospitals are community hospitals not included
928	in Tier 1 that provided more than 9 percent of the hospital's
929	total inpatient days to Medicaid patients and charity patients,
930	as defined in s. 409.911, and are located in the jurisdiction of
931	a local funding source pursuant to subsection (1).
932	3.  Tier 3 hospitals include all community hospitals.
933	(b)  When rates are increased pursuant to this section, the
934	Total Tier Allocation (TTA) shall be distributed as follows:
935	1.  Tier 1 (T1A) = 0.35 x TTA.
936	2.  Tier 2 (T2A) = 0.35 x TTA.
937	3.  Tier 3 (T3A) = 0.30 x TTA.
938	(c)  The tier allocation shall be distributed as a
939	percentage increase to the hospital specific base rate (HSBR)
940	established pursuant to s. 409.905(5)(c). The increase in each
941	tier shall be calculated according to the proportion of tier-
942	specific allocation to the total estimated inpatient spending
943	(TEIS) for all hospitals in each tier:
944	1.  Tier 1 percent increase (T1PI) = T1A/Tier 1 total
945	estimated inpatient spending (T1TEIS).
946	2.  Tier 2 percent increase (T2PI) = T2A /Tier 2 total
947	estimated inpatient spending (T2TEIS).
948	3.  Tier 3 percent increase (T3PI) = T3A/ Tier 3 total
949	estimated inpatient spending (T3TEIS).
950	(d)  The hospital-specific tiered rate (HSTR) shall be
951	calculated as follows:
952	1.  For hospitals in Tier 3: HSTR = (1 + T3PI) x HSBR.
953	2.  For hospitals in Tier 2: HSTR = (1 + T2PI) x HSBR.
954	3.  For hospitals in Tier 1: HSTR = (1 + T1PI) x HSBR.
955	Section 12.  Section 409.971, Florida Statutes, is created
956	to read:
957	409.971  Managed medical assistance program.-The agency
958	shall make payments for primary and acute medical assistance and
959	related services using a managed care model. By January 1, 2013,
960	the agency shall begin implementation of the statewide managed
961	medical assistance program, with full implementation in all
962	regions by October 1, 2014.
963	Section 13.  Section 409.972, Florida Statutes, is created
964	to read:
965	409.972  Mandatory and voluntary enrollment.-
966	(1)  Persons eligible for the program known as "medically
967	needy" pursuant to s. 409.904(2)(a) shall enroll in managed care
968	plans. Medically needy recipients shall meet the share of the
969	cost by paying the plan premium, up to the share of the cost
970	amount, contingent upon federal approval.
971	(2)  The following Medicaid-eligible persons are exempt
972	from mandatory managed care enrollment required by s. 409.965,
973	and may voluntarily choose to participate in the managed medical
974	assistance program:
975	(a)  Medicaid recipients who have other creditable health
976	care coverage, excluding Medicare.
977	(b)  Medicaid recipients residing in residential commitment
978	facilities operated through the Department of Juvenile Justice
979	or mental health treatment facilities as defined by s.
980	394.455(32).
981	(c)  Persons eligible for refugee assistance.
982	(d)  Medicaid recipients who are residents of a
983	developmental disability center, including Sunland Center in
984	Marianna and Tacachale in Gainesville.
985	(3)  Persons eligible for Medicaid but exempt from
986	mandatory participation who do not choose to enroll in managed
987	care shall be served in the Medicaid fee-for-service program as
988	provided in part III of this chapter.
989	Section 14.  Section 409.973, Florida Statutes, is created
990	to read:
991	409.973  Benefits.-
992	(1)  MINIMUM BENEFITS.-Managed care plans shall cover, at a
993	minimum, the following services:
994	(a)  Advanced registered nurse practitioner services.
995	(b)  Ambulatory surgical treatment center services.
996	(c)  Birthing center services.
997	(d)  Chiropractic services.
998	(e)  Dental services.
999	(f)  Early periodic screening diagnosis and treatment
1000	services for recipients under age 21.
1001	(g)  Emergency services.
1002	(h)  Family planning services and supplies.
1003	(i)  Healthy start services.
1004	(j)  Hearing services.
1005	(k)  Home health agency services.
1006	(l)  Hospice services.
1007	(m)  Hospital inpatient services.
1008	(n)  Hospital outpatient services.
1009	(o)  Laboratory and imaging services.
1010	(p)  Medical supplies, equipment, prostheses, and orthoses.
1011	(q)  Mental health services.
1012	(r)  Nursing care.
1013	(s)  Optical services and supplies.
1014	(t)  Optometrist services.
1015	(u)  Physical, occupational, respiratory, and speech
1016	therapy services.
1017	(v)  Physician services, including physician assistant
1018	services.
1019	(w)  Podiatric services.
1020	(x)  Prescription drugs.
1021	(y)  Renal dialysis services.
1022	(z)  Respiratory equipment and supplies.
1023	(aa)  Rural health clinic services.
1024	(bb)  Substance abuse treatment services.
1025	(cc)  Transportation to access covered services.
1026	(2)  CUSTOMIZED BENEFITS.-Managed care plans may customize
1027	benefit packages for nonpregnant adults, vary cost-sharing
1028	provisions, and provide coverage for additional services. The
1029	agency shall evaluate the proposed benefit packages to ensure
1030	services are sufficient to meet the needs of the plan's
1031	enrollees and to verify actuarial equivalence.
1032	(3)  HEALTHY BEHAVIORS.-Each plan operating in the managed
1033	medical assistance program shall establish a program to
1034	encourage and reward healthy behaviors.
1035	(4)  PRIMARY CARE INITIATIVE.-Each plan operating in the
1036	managed medical assistance program shall establish a program to
1037	encourage enrollees to establish a relationship with their
1038	primary care provider. Each plan shall:
1039	(a)  Within 30 days after enrollment, provide information
1040	to each enrollee on the importance of and procedure for
1041	selecting a primary care physician, and thereafter automatically
1042	assign to a primary care provider any enrollee who fails to
1043	choose a primary care provider.
1044	(b)  Within 90 days after selection of or assignment to a
1045	primary care provider, provide information to each enrollee on
1046	the importance of scheduling a wellness screening with the
1047	enrollee's primary care physician.
1048	(c)  Report to the agency the number of enrollees assigned
1049	to each primary care provider within the plan's network.
1050	(d)  Report to the agency the number of enrollees who have
1051	not had an appointment with their primary care provider within
1052	their first year of enrollment.
1053	(e)  Report to the agency the number of emergency room
1054	visits by enrollees who have not had a least one appointment
1055	with their primary care provider.
1056	Section 15.  Section 409.974, Florida Statutes, is created
1057	to read:
1058	409.974  Eligible plans.-
1059	(1)  ELIGIBLE PLAN SELECTION.-The agency shall select
1060	eligible plans through the procurement process described in s.
1061	409.966. The agency shall notice invitations to negotiate no
1062	later than January 1, 2013.
1063	(a)  The agency shall procure three plans for Region I. At
1064	least one plan shall be a provider service network, if any
1065	provider service network submits a responsive bid.
1066	(b)  The agency shall procure three plans for Region II. At
1067	least one plan shall be a provider service network, if any
1068	provider service network submits a responsive bid.
1069	(c)  The agency shall procure at least three plans and no
1070	more than four plans for Region III. At least two plans shall be
1071	provider service networks, if any two provider service networks
1072	submit responsive bids.
1073	(d)  The agency shall procure at least four plans and no
1074	more than seven plans for Region IV. At least two plans shall be
1075	provider service networks if any two provider service networks
1076	submit responsive bids.
1077	(e)  The agency shall procure at least five plans and no
1078	more than eight plans for Region V. At least two plans shall be
1079	provider service networks, if any two provider service networks
1080	submit responsive bids.
1081	(f)  The agency shall procure at least three plans and no
1082	more than four plans for Region VI. At least one plan shall be a
1083	provider service network, if any provider service network
1084	submits a responsive bid.
1085	(g)  The agency shall procure at least four plans and no
1086	more than seven plans for Region VII. At least two plans shall
1087	be provider service networks, if any two provider service
1088	networks submit a responsive bid.
1089	(h)  The agency shall procure at least six plans and no
1090	more than ten plans for Region VIII. At least two plans shall be
1091	provider service networks, if any two provider service networks
1092	submit a responsive bid.
1093
1094	If no provider service network submits a responsive bid, the
1095	agency shall procure no more than one less than the maximum
1096	number of eligible plans permitted in that region. Within 12
1097	months after the initial invitation to negotiate, the agency
1098	shall attempt to procure a provider service network. The agency
1099	shall notice another invitation to negotiate only with provider
1100	service networks in such region where no provider service
1101	network has been selected.
1102	(2)  QUALITY SELECTION CRITERIA.-In addition to the
1103	criteria established in s. 409.966, the agency shall consider
1104	evidence that an eligible plan has written agreements or signed
1105	contracts or has made substantial progress in establishing
1106	relationships with providers before the plan submitting a
1107	response. The agency shall evaluate and give special weight to
1108	evidence of signed contracts with essential providers as defined
1109	by the agency pursuant to s. 409.975(2). The agency shall
1110	exercise a preference for plans with a provider network in which
1111	over 10 percent of the providers use electronic health records,
1112	as defined in s. 408.051. When all other factors are equal, the
1113	agency shall consider whether the organization has a contract to
1114	provide managed long-term care services in the same region and
1115	shall exercise a preference for such plans.
1116	(3)  SPECIALTY PLANS.-Participation by specialty plans
1117	shall be subject to the procurement requirements and regional
1118	plan number limits of this section. However, a specialty plan
1119	whose target population includes no more than 10 percent of the
1120	enrollees of that region is not subject to the regional plan
1121	number limits of this section.
1122	(4)  CHILDREN'S MEDICAL SERVICES NETWORK.-Participation by
1123	the Children's Medical Services Network shall be pursuant to a
1124	single, statewide contract with the agency that is not subject
1125	to the procurement requirements or regional plan number limits
1126	of this section. The Children's Medical Services Network must
1127	meet all other plan requirements for the managed medical
1128	assistance program.
1129	Section 16.  Section 409.975, Florida Statutes, is created
1130	to read:
1131	409.975  Managed care plan accountability.-In addition to
1132	the requirements of s. 409.967, plans and providers
1133	participating in the managed medical assistance program shall
1134	comply with the requirements of this section.
1135	(1)  PROVIDER NETWORKS.-Managed care plans must develop and
1136	maintain provider networks that meet the medical needs of their
1137	enrollees in accordance with standards established pursuant to
1138	409.967(2)(b). Except as provided in this section, managed care
1139	plans may limit the providers in their networks based on
1140	credentials, quality indicators, and price.
1141	(a)  Plans must include all providers in the region that
1142	are classified by the agency as essential Medicaid providers,
1143	unless the agency approves, in writing, an alternative
1144	arrangement for securing the types of services offered by the
1145	essential providers. Providers are essential for serving
1146	Medicaid enrollees if they offer services that are not available
1147	from any other provider within a reasonable access standard, or
1148	if they provided a substantial share of the total units of a
1149	particular service used by Medicaid patients within the region
1150	during the last 3 years and the combined capacity of other
1151	service providers in the region is insufficient to meet the
1152	total needs of the Medicaid patients. The agency may not
1153	classify physicians and other practitioners as essential
1154	providers. The agency, at a minimum, shall determine which
1155	providers in the following categories are essential Medicaid
1156	providers:
1157	1.  Federally qualified health centers.
1158	2.  Statutory teaching hospitals as defined in s.
1159	408.07(45).
1160	3.  Hospitals that are trauma centers as defined in s.
1161	395.4001(14).
1162	4.  Hospitals located at least 25 miles from any other
1163	hospital with similar services.
1164
1165	Managed care plans that have not contracted with all essential
1166	providers in the region as of the first date of recipient
1167	enrollment, or with whom an essential provider has terminated
1168	its contract, must negotiate in good faith with such essential
1169	providers for 1 year or until an agreement is reached, whichever
1170	is first. Payments for services rendered by a nonparticipating
1171	essential provider shall be made at the applicable Medicaid rate
1172	as of the first day of the contract between the agency and the
1173	plan. A rate schedule for all essential providers shall be
1174	attached to the contract between the agency and the plan. After
1175	1 year, managed care plans that are unable to contract with
1176	essential providers shall notify the agency and propose an
1177	alternative arrangement for securing the essential services for
1178	Medicaid enrollees. The arrangement must rely on contracts with
1179	other participating providers, regardless of whether those
1180	providers are located within the same region as the
1181	nonparticipating essential service provider. If the alternative
1182	arrangement is approved by the agency, payments to
1183	nonparticipating essential providers after the date of the
1184	agency's approval shall equal 90 percent of the applicable
1185	Medicaid rate. If the alternative arrangement is not approved by
1186	the agency, payment to nonparticipating essential providers
1187	shall equal 110 percent of the applicable Medicaid rate.
1188	(b)  Certain providers are statewide resources and
1189	essential providers for all managed care plans in all regions.
1190	All managed care plans must include these essential providers in
1191	their networks. Statewide essential providers include:
1192	1.  Faculty plans of Florida medical schools.
1193	2.  Regional perinatal intensive care centers as defined in
1194	s. 383.16(2).
1195	3.  Hospitals licensed as specialty children's hospitals as
1196	defined in s. 395.002(28).
1197
1198	Managed care plans that have not contracted with all statewide
1199	essential providers in all regions as of the first date of
1200	recipient enrollment must continue to negotiate in good faith.
1201	Payments to physicians on the faculty of nonparticipating
1202	Florida medical schools shall be made at the applicable Medicaid
1203	rate. Payments for services rendered by a regional perinatal
1204	intensive care centers shall be made at the applicable Medicaid
1205	rate as of the first day of the contract between the agency and
1206	the plan. Payments to nonparticipating specialty children's
1207	hospitals shall equal the highest rate established by contract
1208	between that provider and any other Medicaid managed care plan.
1209	(c)  After 12 months of active participation in a plan's
1210	network, the plan may exclude any essential provider from the
1211	network for failure to meet quality or performance criteria. If
1212	the plan excludes an essential provider from the plan, the plan
1213	must provide written notice to all recipients who have chosen
1214	that provider for care. The notice shall be provided at least 30
1215	days before the effective date of the exclusion.
1216	(d)  Each managed care plan must offer a network contract
1217	to each home medical equipment and supplies provider in the
1218	region which meets quality and fraud prevention and detection
1219	standards established by the plan and which agrees to accept the
1220	lowest price previously negotiated between the plan and another
1221	such provider.
1222	(2)  FLORIDA MEDICAL SCHOOLS QUALITY NETWORK.-The agency
1223	shall contract with a single organization representing medical
1224	schools and graduate medical education programs in the state for
1225	the purpose of establishing an active and ongoing program to
1226	improve clinical outcomes in all managed care plans. Contracted
1227	activities must support greater clinical integration for
1228	Medicaid enrollees through interdependent and cooperative
1229	efforts of all providers participating in managed care plans.
1230	The agency shall support these activities with certified public
1231	expenditures and any earned federal matching funds and shall
1232	seek any plan amendments or waivers necessary to comply with
1233	this subsection. To be eligible to participate in the quality
1234	network, a medical school must contract with each managed care
1235	plan in its region.
1236	(3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
1237	monitor the quality and performance of each participating
1238	provider. At the beginning of the contract period, each plan
1239	shall notify all its network providers of the metrics used by
1240	the plan for evaluating the provider's performance and
1241	determining continued participation in the network.
1242	(4)  MOMCARE NETWORK.-
1243	(a)  The agency shall contract with an administrative
1244	services organization representing all Healthy Start Coalitions
1245	providing risk appropriate care coordination and other services
1246	in accordance with a federal waiver and pursuant to s. 409.906.
1247	The contract shall require the network of coalitions to provide
1248	choice counseling, education, risk-reduction and case management
1249	services, and quality assurance for all enrollees of the waiver.
1250	The agency shall evaluate the impact of the MomCare network by
1251	monitoring each plan's performance on specific measures to
1252	determine the adequacy, timeliness, and quality of services for
1253	pregnant women and infants. The agency shall support this
1254	contract with certified public expenditures of general revenue
1255	appropriated for Healthy Start services and any earned federal
1256	matching funds.
1257	(b)  Each managed care plan shall establish specific
1258	programs and procedures to improve pregnancy outcomes and infant
1259	health, including, but not limited to, coordination with the
1260	Healthy Start program, immunization programs, and referral to
1261	the Special Supplemental Nutrition Program for Women, Infants,
1262	and Children, and the Children's Medical Services program for
1263	children with special health care needs. Each plan's programs
1264	and procedures shall include agreements with each local Healthy
1265	Start Coalition in the region to provide risk-appropriate care
1266	coordination for pregnant women and infants, consistent with
1267	agency policies and the MomCare network.
1268	(5)  TRANSPORTATION.-Nonemergency transportation services
1269	shall be provided pursuant to a single, statewide contract
1270	between the agency and the Commission for the Transportation
1271	Disadvantaged. The agency shall establish performance standards
1272	in the contract and shall evaluate the performance of the
1273	Commission for the Transportation Disadvantaged. For the
1274	purposes of this subsection, the term "nonemergency
1275	transportation" does not include transportation by ambulance and
1276	any medical services received during transport.
1277	(6)  SCREENING RATE.-After the end of the second contract
1278	year, each managed care plan shall achieve an annual Early and
1279	Periodic Screening, Diagnosis, and Treatment Service screening
1280	rate of at least 80 percent of those recipients continuously
1281	enrolled for at least 8 months.
1282	(7)  PROVIDER PAYMENT.-Managed care plan and hospitals
1283	shall negotiate mutually acceptable rates, methods, and terms of
1284	payment. For rates, methods, and terms of payment negotiated
1285	after the contract between the agency and the plan is executed,
1286	plans shall pay hospitals, at a minimum, the rate the agency
1287	would have paid on the first day of the contract between the
1288	provider and the plan. Such payments to hospitals may not exceed
1289	120 percent of the rate the agency would have paid on the first
1290	day of the contract between the provider and the plan, unless
1291	specifically approved by the agency. Payment rates may be
1292	updated periodically.
1293	(8)  MEDICALLY NEEDY ENROLLEES.-Each managed care plan
1294	shall accept any medically needy recipient who selects or is
1295	assigned to the plan and provide that recipient with continuous
1296	enrollment for 12 months. After the first month of qualifying as
1297	a medically needy recipient and enrolling in a plan, and
1298	contingent upon federal approval, the enrollee shall pay the
1299	plan a portion of the monthly premium equal to the enrollee's
1300	share of the cost as determined by the department. The agency
1301	shall pay any remaining portion of the monthly premium. Plans
1302	are not obligated to pay claims for medically needy patients for
1303	services provided before enrollment in the plan. Medically needy
1304	patients are responsible for payment of incurred claims that are
1305	used to determine eligibility. Plans must provide a grace period
1306	of at least 90 days before disenrolling recipients who fail to
1307	pay their shares of the premium.
1308	Section 17.  Section 409.976, Florida Statutes, is created
1309	to read:
1310	409.976  Managed care plan payment.-In addition to the
1311	payment provisions of s. 409.968, the agency shall provide
1312	payment to plans in the managed medical assistance program
1313	pursuant to this section.
1314	(1)  Prepaid payment rates shall be negotiated between the
1315	agency and the eligible plans as part of the procurement process
1316	described in s. 409.966.
1317	(2)  The agency shall establish payment rates for statewide
1318	inpatient psychiatric programs. Payments to managed care plans
1319	shall be reconciled to reimburse actual payments to statewide
1320	inpatient psychiatric programs.
1321	Section 18.  Section 409.977, Florida Statutes, is created
1322	to read:
1323	409.977  Choice counseling and enrollment.-
1324	(1)  CHOICE COUNSELING.-In addition to the choice
1325	counseling information required by s. 409.969, the agency shall
1326	make available clear and easily understandable choice
1327	information to Medicaid recipients that includes information
1328	about the cost-sharing requirements of each managed care plan.
1329	(2)  AUTOMATIC ENROLLMENT.-The agency shall automatically
1330	enroll into a managed care plan those Medicaid recipients who do
1331	not voluntarily choose a plan pursuant to s. 409.969. The agency
1332	shall automatically enroll recipients in plans that meet or
1333	exceed the performance or quality standards established pursuant
1334	to s. 409.967 and may not automatically enroll recipients in a
1335	plan that is deficient in those performance or quality
1336	standards. When a specialty plan is available to accommodate a
1337	specific condition or diagnosis of a recipient, the agency shall
1338	assign the recipient to that plan. In the first year of the
1339	first contract term only, if a recipient was previously enrolled
1340	in a plan that is still available in the region, the agency
1341	shall automatically enroll the recipient in that plan unless an
1342	applicable specialty plan is available. Except as otherwise
1343	provided in this part, the agency may not engage in practices
1344	that are designed to favor one managed care plan over another.
1345	When automatically enrolling recipients in managed care plans,
1346	the agency shall automatically enroll based on the following
1347	criteria:
1348	(a)  Whether the plan has sufficient network capacity to
1349	meet the needs of the recipients.
1350	(b)  Whether the recipient has previously received services
1351	from one of the plan's primary care providers.
1352	(c)  Whether primary care providers in one plan are more
1353	geographically accessible to the recipient's residence than
1354	those in other plans.
1355	(3)  OPT-OUT OPTION.-The agency shall develop a process to
1356	enable any recipient with access to employer-sponsored health
1357	care coverage to opt out of all managed care plans and to use
1358	Medicaid financial assistance to pay for the recipient's share
1359	of the cost in such employer-sponsored coverage. Contingent upon
1360	federal approval, the agency shall also enable recipients with
1361	access to other insurance or related products providing access
1362	to health care services created pursuant to state law, including
1363	any product available under the Florida Health Choices Program,
1364	or any health exchange, to opt out. The amount of financial
1365	assistance provided for each recipient may not exceed the amount
1366	of the Medicaid premium that would have been paid to a managed
1367	care plan for that recipient.
1368	Section 19.  Section 409.978, Florida Statutes, is created
1369	to read:
1370	409.978  Long-term care managed care program.-
1371	(1)  Pursuant to s. 409.963, the agency shall administer
1372	the long-term care managed care program described in ss.
1373	409.978-409.985, but may delegate specific duties and
1374	responsibilities for the program to the Department of Elderly
1375	Affairs and other state agencies. By July 1, 2012, the agency
1376	shall begin implementation of the statewide long-term care
1377	managed care program, with full implementation in all regions by
1378	October 1, 2013.
1379	(2)  The agency shall make payments for long-term care,
1380	including home and community-based services, using a managed
1381	care model. Unless otherwise specified, the provisions of ss.
1382	409.961-409.97 apply to the long-term care managed care program.
1383	(3)  The Department of Elderly Affairs shall assist the
1384	agency to develop specifications for use in the invitation to
1385	negotiate and the model contract, determine clinical eligibility
1386	for enrollment in managed long-term care plans, monitor plan
1387	performance and measure quality of service delivery, assist
1388	clients and families to address complaints with the plans,
1389	facilitate working relationships between plans and providers
1390	serving elders and disabled adults, and perform other functions
1391	specified in a memorandum of agreement.
1392	Section 20.  Section 409.979, Florida Statutes, is created
1393	to read:
1394	409.979  Eligibility.-
1395	(1)  Medicaid recipients who meet all of the following
1396	criteria are eligible to receive long-term care services and
1397	must receive long-term care services by participating in the
1398	long-term care managed care program. The recipient must be:
1399	(a)  Sixty-five years of age or older or eligible for
1400	Medicaid by reason of a disability.
1401	(b)  Determined by the Comprehensive Assessment Review and
1402	Evaluation for Long-Term Care Services (CARES) Program to
1403	require nursing facility care as defined in s. 409.985(3).
1404	(2)  Medicaid recipients who, on the date long-term care
1405	managed care plans become available in their region, reside in a
1406	nursing home facility or are enrolled in one of the following
1407	long-term care Medicaid waiver programs are eligible to
1408	participate in the long-term care managed care program for up to
1409	24 months without being reevaluated for their need of nursing
1410	facility care as defined in s. 409.985(3):
1411	(a)  The Assisted Living for the Frail Elderly Waiver.
1412	(b)  The Aged and Disabled Adult Waiver.
1413	(c)  The Adult Day Health Care Waiver.
1414	(d)  The Consumer-Directed Care Plus Program as described
1415	in s. 409.221.
1416	(e)  The Program of All-inclusive Care for the Elderly.
1417	(f)  The long-term care community-based diversion pilot
1418	project as described in s. 430.705.
1419	(g)  The Channeling Services Waiver for Frail Elders.
1420	(3)  The Department of Elderly Affairs shall make offers
1421	for enrollment to eligible individuals based on a wait-list
1422	prioritization and subject to availability of funds. Before
1423	enrollment offers, the department shall determine that
1424	sufficient funds exist to support additional enrollment into
1425	plans.
1426	Section 21.  Section 409.98, Florida Statutes, is created
1427	to read:
1428	409.98  Benefits.-Long-term care plans shall cover, at a
1429	minimum, the following:
1430	(1)  Nursing facility care.
1431	(2)  Services provided in assisted living facilities.
1432	(3)  Hospice.
1433	(4)  Adult day care.
1434	(5)  Medical equipment and supplies, including incontinence
1435	supplies.
1436	(6)  Personal care.
1437	(7)  Home accessibility adaptation.
1438	(8)  Behavior management.
1439	(9)  Home-delivered meals.
1440	(10)  Case management.
1441	(11)  Therapies:
1442	(a)  Occupational therapy.
1443	(b)  Speech therapy.
1444	(c)  Respiratory therapy.
1445	(d)  Physical therapy.
1446	(12)  Intermittent and skilled nursing.
1447	(13)  Medication administration.
1448	(14)  Medication management.
1449	(15)  Nutritional assessment and risk reduction.
1450	(16)  Caregiver training.
1451	(17)  Respite care.
1452	(18)  Transportation.
1453	(19)  Personal emergency response system.
1454	Section 22.  Section 409.981, Florida Statutes, is created
1455	to read:
1456	409.981  Eligible plans.-
1457	(1)  ELIGIBLE PLANS.-Provider service networks must be
1458	long-term care provider service networks. Other eligible plans
1459	may either be long-term care plans or comprehensive long-term
1460	care plans.
1461	(2)  ELIGIBLE PLAN SELECTION.-The agency shall select
1462	eligible plans through the procurement process described in s.
1463	409.966. The agency shall provide notice of invitations to
1464	negotiate no later than July 1, 2012.
1465	(a)  The agency shall procure three plans for Region I. At
1466	least one plan shall be a provider service network, if any
1467	submit a responsive bid.
1468	(b)  The agency shall procure three plans for Region II. At
1469	least one plan shall be a provider service network, if any
1470	provider service network submits a responsive bid.
1471	(c)  The agency shall procure at least three plans and no
1472	more than four plans for Region III. At least two plans shall be
1473	provider service networks, if any two provider service networks
1474	submit responsive bids.
1475	(d)  The agency shall procure at least four plans and no
1476	more than seven plans for Region IV. At least two plans shall be
1477	provider service networks if any two provider service networks
1478	submit responsive bids.
1479	(e)  The agency shall procure at least five plans and no
1480	more than eight plans for Region V. At least two plans shall be
1481	provider service networks, if any two provider service networks
1482	submit responsive bids.
1483	(f)  The agency shall procure at least three plans and no
1484	more than four plans for Region VI. At least one plan shall be a
1485	provider service network, if any provider service network
1486	submits a responsive bid.
1487	(g)  The agency shall procure at least four plans and no
1488	more than seven plans for Region VII. At least two plans shall
1489	be provider service networks, if any two provider service
1490	networks submit responsive bids.
1491	(h)  The agency shall procure at least five plans and no
1492	more than nine plans for Region VIII. At least two plans shall
1493	be provider service networks, if any two provider service
1494	networks submit a responsive bid.
1495
1496	If no provider service network submits a responsive bid, the
1497	agency shall procure one fewer eligible plan in each of the
1498	regions. Within 12 months after the initial invitation to
1499	negotiate, the agency shall attempt to procure an eligible plan
1500	that is a provider service network. The agency shall notice
1501	another invitation to negotiate only with provider service
1502	networks in a region where no provider service network has been
1503	selected.
1504	(3)  QUALITY SELECTION CRITERIA.-In addition to the
1505	criteria established in s. 409.966, the agency shall consider
1506	the following factors in the selection of eligible plans:
1507	(a)  Evidence of the employment of executive managers with
1508	expertise and experience in serving aged and disabled persons
1509	who require long-term care.
1510	(b)  Whether a plan has established a network of service
1511	providers dispersed throughout the region and in sufficient
1512	numbers to meet specific service standards established by the
1513	agency for specialty services for persons receiving home and
1514	community-based care.
1515	(c)  Whether a plan is proposing to establish a
1516	comprehensive long-term care plan and whether the eligible plan
1517	has a contract to provide managed medical assistance services in
1518	the same region.
1519	(d)  Whether a plan offers consumer-directed care services
1520	to enrollees pursuant to s. 409.221.
1521	(e)  Whether a plan is proposing to provide home and
1522	community-based services in addition to the minimum benefits
1523	required by s. 409.98.
1524	(4)  PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY.-
1525	Participation by the Program of All-Inclusive Care for the
1526	Elderly (PACE) shall be pursuant to a contract with the agency
1527	and not subject to the procurement requirements or regional plan
1528	number limits of this section. PACE plans may continue to
1529	provide services to individuals at such levels and enrollment
1530	caps as authorized by the General Appropriations Act.
1531	Section 23.  Section 409.982, Florida Statutes, is created
1532	to read:
1533	409.982  Managed care plan accountability.-In addition to
1534	the requirements of s. 409.967, plans and providers
1535	participating in the long-term care managed care program shall
1536	comply with the requirements of this section.
1537	(1)  PROVIDER NETWORKS.-Managed care plans may limit the
1538	providers in their networks based on credentials, quality
1539	indicators, and price. For the period between October 1, 2013,
1540	and September 30, 2014, each selected plan must offer a network
1541	contract to all the following providers in the region:
1542	(a)  Nursing homes.
1543	(b)  Hospices.
1544	(c)  Aging network service providers that have previously
1545	participated in home and community-based waivers serving elders
1546	or community-service programs administered by the Department of
1547	Elderly Affairs.
1548
1549	After 12 months of active participation in a managed care plan's
1550	network, the plan may exclude any of the providers named in this
1551	subsection from the network for failure to meet quality or
1552	performance criteria. If the plan excludes a provider from the
1553	plan, the plan must provide written notice to all recipients who
1554	have chosen that provider for care. The notice shall be provided
1555	at least 30 days before the effective date of the exclusion. The
1556	agency shall establish contract provisions governing the
1557	transfer of recipients from excluded residential providers.
1558	(2)  SELECT PROVIDER PARTICIPATION.-Except as provided in
1559	this subsection, providers may limit the managed care plans they
1560	join. Nursing homes and hospices that are enrolled Medicaid
1561	providers must participate in all eligible plans selected by the
1562	agency in the region in which the provider is located.
1563	(3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
1564	monitor the quality and performance of each participating
1565	provider using measures adopted by and collected by the agency
1566	and any additional measures mutually agreed upon by the provider
1567	and the plan
1568	(4)  PROVIDER NETWORK STANDARDS.-The agency shall establish
1569	and each managed care plan must comply with specific standards
1570	for the number, type, and regional distribution of providers in
1571	the plan's network, which must include:
1572	(a)  Adult day care centers.
1573	(b)  Adult family-care homes.
1574	(c)  Assisted living facilities.
1575	(d)  Health care services pools.
1576	(e)  Home health agencies.
1577	(f)  Homemaker and companion services.
1578	(g)  Hospices.
1579	(h)  Community care for the elderly lead agencies.
1580	(i)  Nurse registries.
1581	(j)  Nursing homes.
1582	(5)  PROVIDER PAYMENT.-Managed care plans and providers
1583	shall negotiate mutually acceptable rates, methods, and terms of
1584	payment. Plans shall pay nursing homes an amount equal to the
1585	nursing facility-specific payment rates set by the agency;
1586	however, mutually acceptable higher rates may be negotiated for
1587	medically complex care. Plans shall pay hospice providers an
1588	amount equal to the per diem rate set by the agency. For
1589	recipients residing in a nursing facility and receiving hospice
1590	services, the plan shall pay the hospice provider the per diem
1591	rate set by the agency minus the nursing facility component and
1592	shall pay the nursing facility the applicable state rate. Plans
1593	shall ensure that electronic nursing home and hospice claims
1594	that contain sufficient information for processing are paid
1595	within 10 business days after receipt.
1596	Section 24.  Section 409.983, Florida Statutes, is created
1597	to read:
1598	409.983  Managed care plan payment.-In addition to the
1599	payment provisions of s. 409.968, the agency shall provide
1600	payment to plans in the long-term care managed care program
1601	pursuant to this section.
1602	(1)  Prepaid payment rates for long-term care managed care
1603	plans shall be negotiated between the agency and the eligible
1604	plans as part of the procurement process described in s.
1605	409.966.
1606	(2)  Payment rates for comprehensive long-term care plans
1607	covering services described in s. 409.973 shall be blended with
1608	rates for long-term care plans for services specified in s.
1609	409.98.
1610	(3)  Payment rates for plans shall reflect historic
1611	utilization and spending for covered services projected forward
1612	and adjusted to reflect the level of care profile for enrollees
1613	in each plan. The payment shall be adjusted to provide an
1614	incentive for reducing institutional placements and increasing
1615	the utilization of home and community-based services.
1616	(4)  The initial assessment of an enrollee's level of care
1617	shall be made by the Comprehensive Assessment and Review for
1618	Long-Term-Care Services (CARES) program, which shall assign the
1619	recipient into one of the following levels of care:
1620	(a)  Level of care 1 consists of recipients residing in or
1621	who must be placed in a nursing home.
1622	(b)  Level of care 2 consists of recipients at imminent
1623	risk of nursing home placement, as evidenced by the need for the
1624	constant availability of routine medical and nursing treatment
1625	and care, and require extensive health-related care and services
1626	because of mental or physical incapacitation.
1627	(c)  Level of care 3 consists of recipients at imminent
1628	risk of nursing home placement, as evidenced by the need for the
1629	constant availability of routine medical and nursing treatment
1630	and care, who have a limited need for health-related care and
1631	services and are mildly medically or physically incapacitated.
1632
1633	The agency shall periodically adjust payment rates to account
1634	for changes in the level of care profile for each managed care
1635	plan based on encounter data.
1636	(5)  The agency shall make an incentive adjustment in
1637	payment rates to encourage the increased utilization of home and
1638	community-based services and a commensurate reduction of
1639	institutional placement. The incentive adjustment shall be
1640	modified in each successive rate period during the first
1641	contract period, as follows:
1642	(a)  A 2 percentage point shift in the first rate-setting
1643	period;
1644	(b)  A 2 percentage point shift in the second rate-setting
1645	period, as compared to the utilization mix at the end of the
1646	first rate-setting period;
1647	(c)  A 3 percentage point shift in the third rate-setting
1648	period, and in each subsequent rate-setting period during the
1649	first contract period, as compared to the utilization mix at the
1650	end of the immediately preceding rate-setting period.
1651
1652	The incentive adjustment shall continue in subsequent contract
1653	periods, at a rate of 3 percentage points per year as compared
1654	to the utilization mix at the end of the immediately preceding
1655	rate-setting period, until no more than 35 percent of the plan's
1656	enrollees are placed in institutional settings. The agency shall
1657	annually report to the Legislature the actual change in the
1658	utilization mix of home and community-based services compared to
1659	institutional placements and provide a recommendation for
1660	utilization mix requirements for future contracts.
1661	(6)  The agency shall establish nursing-facility-specific
1662	payment rates for each licensed nursing home based on facility
1663	costs adjusted for inflation and other factors as authorized in
1664	the General Appropriations Act. Payments to long-term care
1665	managed care plans shall be reconciled to reimburse actual
1666	payments to nursing facilities.
1667	(7)  The agency shall establish hospice payment rates.
1668	Payments to long-term care managed care plans shall be
1669	reconciled to reimburse actual payments to hospices.
1670	Section 25.  Section 409.984, Florida Statutes, is created
1671	to read:
1672	409.984  Choice counseling; enrollment.-
1673	(1)  CHOICE COUNSELING.-Before contracting with a vendor to
1674	provide choice counseling as authorized under s. 409.969, the
1675	agency shall offer to contract with aging resource centers
1676	established under s. 430.2053 for choice counseling services. If
1677	the aging resource center is determined not to be the vendor
1678	that provides choice counseling, the agency shall establish a
1679	memorandum of understanding with the aging resource center to
1680	coordinate staffing and collaborate with the choice counseling
1681	vendor. In addition to the requirements of s. 409.969, any
1682	contract to provide choice counseling for the long-term care
1683	managed care program shall provide that each recipient be given
1684	the option of having in-person choice counseling.
1685	(2)  AUTOMATIC ENROLLMENT.-The agency shall automatically
1686	enroll into a long-term care managed care plan those Medicaid
1687	recipients who do not voluntarily choose a plan pursuant to s.
1688	409.969. The agency shall automatically enroll recipients in
1689	plans that meet or exceed the performance or quality standards
1690	established pursuant to s. 409.967 and may not automatically
1691	enroll recipients in a plan that is deficient in those
1692	performance or quality standards. If a recipient is deemed
1693	dually eligible for Medicaid and Medicare services and is
1694	currently receiving Medicare services from an entity qualified
1695	under 42 C.F.R. part 422 as a Medicare Advantage Preferred
1696	Provider Organization, Medicare Advantage Provider-sponsored
1697	Organization, or Medicare Advantage Special Needs Plan, the
1698	agency shall automatically enroll the recipient in such plan for
1699	Medicaid services if the plan is currently participating in the
1700	long-term care managed care program. Except as otherwise
1701	provided in this part, the agency may not engage in practices
1702	that are designed to favor one managed care plan over another.
1703	When automatically enrolling recipients in plans, the agency
1704	shall take into account the following criteria:
1705	(a)  Whether the plan has sufficient network capacity to
1706	meet the needs of the recipients.
1707	(b)  Whether the recipient has previously received services
1708	from one of the plan's home and community-based service
1709	providers.
1710	(c)  Whether the home and community-based providers in one
1711	plan are more geographically accessible to the recipient's
1712	residence than those in other plans.
1713	(3)  HOSPICE SELECTION.-Notwithstanding the provisions of
1714	s. 409.969(3)(c), when a recipient is referred for hospice
1715	services, the recipient shall have a 30-day period during which
1716	the recipient may select to enroll in another managed care plan
1717	to access the hospice provider of the recipient's choice.
1718	(4)  CHOICE OF RESIDENTIAL SETTING.-When a recipient is
1719	referred for placement in a nursing home or assisted living
1720	facility, the plan shall inform the recipient of any facilities
1721	within the plan that have specific cultural or religious
1722	affiliations and, if requested by the recipient, make a
1723	reasonable effort to place the recipient in the facility of the
1724	recipient's choice.
1725	Section 26.  Section 409.9841, Florida Statutes, is created
1726	to read:
1727	409.9841  Long-term care managed care technical advisory
1728	workgroup.-
1729	(1)  Before August 1, 2011, the agency shall establish a
1730	technical advisory workgroup to assist in developing:
1731	(a)  The method of determining Medicaid eligibility
1732	pursuant to s. 409.985(3).
1733	(b)  The requirements for provider payments to nursing
1734	homes under s. 409.983(6).
1735	(c)  The method for managing Medicare coinsurance crossover
1736	claims.
1737	(d)  Uniform requirements for claims submissions and
1738	payments, including electronic funds transfers and claims
1739	processing.
1740	(e)  The process for enrollment of and payment for
1741	individuals pending determination of Medicaid eligibility.
1742	(2)  The advisory workgroup shall include, but is not
1743	limited to, representatives of providers and plans who could
1744	potentially participate in long-term care managed care. Members
1745	of the workgroup shall serve without compensation but may be
1746	reimbursed for per diem and travel expenses as provided in s.
1747	112.061.
1748	(3)  This section is repealed on June 30, 2013.
1749	Section 27.  Section 409.985, Florida Statutes, is created
1750	to read:
1751	409.985  Comprehensive Assessment and Review for Long-Term
1752	Care Services (CARES) Program.-
1753	(1)  The agency shall operate the Comprehensive Assessment
1754	and Review for Long-Term Care Services (CARES) preadmission
1755	screening program to ensure that only individuals whose
1756	conditions require long-term care services are enrolled in the
1757	long-term care managed care program.
1758	(2)  The agency shall operate the CARES program through an
1759	interagency agreement with the Department of Elderly Affairs.
1760	The agency, in consultation with the Department of Elderly
1761	Affairs, may contract for any function or activity of the CARES
1762	program, including any function or activity required by 42
1763	C.F.R. part 483.20, relating to preadmission screening and
1764	review.
1765	(3)  The CARES program shall determine if an individual
1766	requires nursing facility care and, if the individual requires
1767	such care, assign the individual to a level of care as described
1768	in s. 409.983(4). When determining the need for nursing facility
1769	care, consideration shall be given to the nature of the services
1770	prescribed and which level of nursing or other health care
1771	personnel meets the qualifications necessary to provide such
1772	services and the availability to and access by the individual of
1773	community or alternative resources. For the purposes of the
1774	long-term care managed care program, the term "nursing facility
1775	care" means the individual:
1776	(a)  Requires nursing home placement as evidenced by the
1777	need for medical observation throughout a 24-hour period and
1778	care required to be performed on a daily basis by, or under the
1779	direct supervision of, a registered nurse or other health care
1780	professional and requires services that are sufficiently
1781	medically complex to require supervision, assessment, planning,
1782	or intervention by a registered nurse because of a mental or
1783	physical incapacitation by the individual;
1784	(b)  Requires or is at imminent risk of nursing home
1785	placement as evidenced by the need for observation throughout a
1786	24-hour period and care and the constant availability of medical
1787	and nursing treatment and requires services on a daily or
1788	intermittent basis that are to be performed under the
1789	supervision of licensed nursing or other health professionals
1790	because the individual who is incapacitated mentally or
1791	physically; or
1792	(c)  Requires or is at imminent risk of nursing home
1793	placement as evidenced by the need for observation throughout a
1794	24-hour period and care and the constant availability of medical
1795	and nursing treatment and requires limited services that are to
1796	be performed under the supervision of licensed nursing or other
1797	health professionals because the individual is mildly
1798	incapacitated mentally or physically.
1799	(4)  For individuals whose nursing home stay is initially
1800	funded by Medicare and Medicare coverage and is being terminated
1801	for lack of progress towards rehabilitation, CARES staff shall
1802	consult with the person making the determination of progress
1803	toward rehabilitation to ensure that the recipient is not being
1804	inappropriately disqualified from Medicare coverage. If, in
1805	their professional judgment, CARES staff believe that a Medicare
1806	beneficiary is still making progress toward rehabilitation, they
1807	may assist the Medicare beneficiary with an appeal of the
1808	disqualification from Medicare coverage. The use of CARES teams
1809	to review Medicare denials for coverage under this section is
1810	authorized only if it is determined that such reviews qualify
1811	for federal matching funds through Medicaid. The agency shall
1812	seek or amend federal waivers as necessary to implement this
1813	section.
1814	Section 28.  Section 409.986, Florida Statutes, is created
1815	to read:
1816	409.986  Managed long-term care for persons with
1817	developmental disabilities.-
1818	(1)  Pursuant to s. 409.963, the agency is responsible for
1819	administering the long-term care managed care program for
1820	persons with developmental disabilities described in ss.
1821	409.986-409.992, but may delegate specific duties and
1822	responsibilities for the program to the Agency for Persons with
1823	Disabilities and other state agencies. By January 1, 2015, the
1824	agency shall begin implementation of statewide long-term care
1825	managed care for persons with developmental disabilities, with
1826	full implementation in all regions by October 1, 2016.
1827	(2)  The agency shall make payments for long-term care for
1828	persons with developmental disabilities, including home and
1829	community-based services, using a managed care model. Unless
1830	otherwise specified, the provisions of ss. 409.961-409.97 apply
1831	to the long-term care managed care program for persons with
1832	developmental disabilities.
1833	(3)  The Agency for Persons with Disabilities shall assist
1834	the agency to develop the specifications for use in the
1835	invitations to negotiate and the model contract, determine
1836	clinical eligibility for enrollment in long-term care plans for
1837	persons with developmental disabilities, assist the agency to
1838	monitor plan performance and measure quality, assist clients and
1839	families to address complaints with the plans, facilitate
1840	working relationships between plans and providers serving
1841	persons with developmental disabilities, and perform other
1842	functions specified in a memorandum of agreement.
1843	Section 29.  Section 409.987, Florida Statutes, is created
1844	to read:
1845	409.987  Eligibility.-
1846	(1)  Medicaid recipients who meet all of the following
1847	criteria are eligible and shall be enrolled in a comprehensive
1848	long-term care plan or long-term care plan:
1849	(a)  Is Medicaid eligible pursuant to s. 409.904.
1850	(b)  Is a Florida resident who has a developmental
1851	disability as defined in s. 393.063.
1852	(c)  Meets the level of care need, including:
1853	1.  The recipient's intelligence quotient is 59 or less;
1854	2.  The recipient's intelligence quotient is 60-69,
1855	inclusive, and the recipient has a secondary condition that
1856	includes cerebral palsy, spina bifida, Prader-Willi syndrome,
1857	epilepsy, or autistic disorder or has ambulation, sensory,
1858	chronic health, and behavioral problems;
1859	3.  The recipient's intelligence quotient is 60-69,
1860	inclusive, and the recipient has severe functional limitations
1861	in at least three major life activities, including self-care,
1862	learning, mobility, self-direction, understanding and use of
1863	language, and capacity for independent living; or
1864	4.  The recipient is eligible under a primary disability of
1865	autistic disorder, cerebral palsy, spina bifida, or Prader-Willi
1866	syndrome. In addition, the condition must result in substantial
1867	functional limitations in three or more major life activities,
1868	including self-care, learning, mobility, self-direction,
1869	understanding and use of language, and capacity for independent
1870	living.
1871	(d)  Meets the level of care need to receive services in an
1872	intermediate care facility for the developmentally disabled.
1873	(e)  Is enrolled in a home and community-based Medicaid
1874	waiver established in chapter 393 or the Consumer Directed Care
1875	Plus program for persons with developmental disabilities under
1876	the Medicaid state plan, is a Medicaid-funded resident of a
1877	private intermediate care facility for the developmentally
1878	disabled on the date the managed long-term care plans for
1879	persons with disabilities becomes available in the recipient's
1880	region, or has been offered enrollment in a comprehensive long-
1881	term care plan or a long-term care plan.
1882	(2)  The Agency for Persons with Disabilities shall make
1883	offers for enrollment to eligible individuals based on the wait-
1884	list prioritization in s. 393.065(5) and subject to availability
1885	of funds. Before enrollment offers, the agency shall determine
1886	that sufficient funds exist to support additional enrollment
1887	into plans.
1888	(3)  Unless specifically exempted, all eligible persons
1889	must be enrolled in a comprehensive long-term care plan or a
1890	long-term care plan. Medicaid recipients who are residents of a
1891	developmental disability center, including Sunland Center in
1892	Marianna and Tacachale Center in Gainesville, are exempt from
1893	mandatory enrollment but may voluntarily enroll in a long-term
1894	care plan.
1895	Section 30.  Section 409.988, Florida Statutes, is created
1896	to read:
1897	409.988  Benefits.-Managed care plans shall cover, at a
1898	minimum, the services in this section. Plans may customize
1899	benefit packages or offer additional benefits to meet the needs
1900	of enrollees in the plan.
1901	(1)  Intermediate care for the developmentally disabled.
1902	(2)  Services in alternative residential settings,
1903	including, but not limited to:
1904	(a)  Group homes licensed under chapter 393 and foster care
1905	homes licensed under chapter 409.
1906	(b)  Comprehensive transitional education programs licensed
1907	under chapter 393.
1908	(c)  Residential habilitation centers licensed under
1909	chapter 393.
1910	(d)  Assisted living facilities licensed under chapter 429
1911	and transitional living facilities licensed under part V of
1912	chapter 400.
1913	(3)  Adult day training.
1914	(4)  Behavior analysis services.
1915	(5)  Companion services.
1916	(6)  Consumable medical supplies.
1917	(7)  Durable medical equipment and supplies.
1918	(8)  Environmental accessibility adaptations.
1919	(9)  In-home support services.
1920	(10)  Therapies, including occupational, speech,
1921	respiratory, and physical therapy.
1922	(11)  Personal care assistance.
1923	(12)  Residential habilitation services.
1924	(13)  Intensive behavioral residential habilitation
1925	services.
1926	(14)  Behavior focus residential habilitation services.
1927	(15)  Residential nursing services.
1928	(16)  Respite care.
1929	(17)  Support coordination.
1930	(18)  Supported employment.
1931	(19)  Supported living coaching.
1932	(20)  Transportation.
1933	Section 31.  Section 409.989, Florida Statutes, is created
1934	to read:
1935	409.989  Eligible plans.-
1936	(1)  ELIGIBLE PLANS.-Provider service networks may be
1937	either long-term care plans or comprehensive long-term care
1938	plans. Other plans must be comprehensive long-term care plans
1939	and under contract to provide services pursuant to s. 409.973 or
1940	s. 409.98 in any of the regions that form the combined region as
1941	defined in this section.
1942	(2)  PROVIDER SERVICE NETWORKS.-Provider service networks
1943	targeted to serve persons with disabilities must include one or
1944	more owners licensed pursuant to s. 393.067 or s. 400.962 and
1945	with at least 10 years' experience in serving this population.
1946	(3)  ELIGIBLE PLAN SELECTION.-The agency shall select
1947	eligible plans through the procurement process described in s.
1948	409.966. The agency shall notice invitations to negotiate no
1949	later than January 1, 2015.
1950	(a)  The agency shall procure at least two plans and no
1951	more than three plans for services in combined Regions I, II,
1952	and III. At least one plan shall be a provider service network,
1953	if any submit a responsive bid.
1954	(b)  The agency shall procure at least two plans and no
1955	more than three plans for services in combined Regions IV and V.
1956	At least one plan shall be a provider service network, if any
1957	submit a responsive bid.
1958	(c)  The agency shall procure at least two plans and no
1959	more than four plans for services in combined Regions VI, VII,
1960	and VIII. At least one plan shall be a provider service network,
1961	if any submit a responsive bid.
1962
1963	If no provider service network submits a responsive bid, the
1964	agency shall procure no more than one less than the maximum
1965	number of eligible plans permitted in the combined region.
1966	Within 12 months after the initial invitation to negotiate, the
1967	agency shall attempt to procure an eligible plan that is a
1968	provider service network. The agency shall notice another
1969	invitation to negotiate only with provider service networks in
1970	such combined region where no provider service network has been
1971	selected.
1972	(4)  QUALITY SELECTION CRITERIA.-In addition to the
1973	criteria established in s. 409.966, the agency shall consider
1974	the following factors in the selection of eligible plans:
1975	(a)  Whether the plan has sufficient specialized staffing,
1976	including employment of executive managers with expertise and
1977	experience in serving persons with developmental disabilities.
1978	(b)  Whether the plan has sufficient network
1979	qualifications, including establishment of a network of service
1980	providers dispersed throughout the combined region and in
1981	sufficient numbers to meet specific accessibility standards
1982	established by the agency for specialty services for persons
1983	with developmental disabilities.
1984	(c)  Whether the plan has written agreements or signed
1985	contracts or has made substantial progress in establishing
1986	relationships with providers before the plan submitting a
1987	response. The agency shall give preference to plans with
1988	evidence of signed contracts with providers listed in s.
1989	409.99(1).
1990	(5)  CHILDREN'S MEDICAL SERVICES NETWORK.-The Children's
1991	Medical Services Network may provide either long-term care plans
1992	or comprehensive long-term care plans. Participation by the
1993	Children's Medical Services Network shall be pursuant to a
1994	single, statewide contract with the agency not subject to the
1995	procurement requirements or regional plan number limits of this
1996	section. The Children's Medical Services Network must meet all
1997	other plan requirements.
1998	Section 32.  Section 409.99, Florida Statutes, is created
1999	to read:
2000	409.99  Managed care plan accountability.-In addition to
2001	the requirements of s. 409.967, managed care plans and providers
2002	shall comply with the requirements of this section.
2003	(1)  PROVIDER NETWORKS.-Managed care plans may limit the
2004	providers in their networks based on credentials, quality
2005	indicators, and price. However, in the first contract period
2006	after an eligible plan is selected in a region by the agency,
2007	the plan must offer a network contract to the following
2008	providers in the region:
2009	(a)  Providers with licensed institutional care facilities
2010	for the developmentally disabled.
2011	(b)  Providers of alternative residential facilities
2012	specified in s. 409.988.
2013
2014	After 12 months of active participation in a managed care plan
2015	network, the plan may exclude any of the above-named providers
2016	from the network for failure to meet quality or performance
2017	criteria. If the plan excludes a provider from the plan, the
2018	plan must provide written notice to all recipients who have
2019	chosen that provider for care. The notice shall be issued at
2020	least 90 days before the effective date of the exclusion.
2021	(2)  SELECT PROVIDER PARTICIPATION.-Except as provided in
2022	this subsection, providers may limit the managed care plans they
2023	join. Licensed institutional care facilities for the
2024	developmentally disabled and licensed residential settings
2025	providing Intensive Behavioral Residential Habilitation services
2026	with an active Medicaid provider agreement must agree to
2027	participate in any eligible plan selected by the agency.
2028	(3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
2029	monitor the quality and performance of each participating
2030	provider. At the beginning of the contract period, each plan
2031	shall notify all its network providers of the metrics used by
2032	the plan for evaluating the provider's performance and
2033	determining continued participation in the network.
2034	(4)  PROVIDER PAYMENT.-Managed care plans and providers
2035	shall negotiate mutually acceptable rates, methods, and terms of
2036	payment. Plans shall pay intermediate care facilities for the
2037	developmentally disabled and intensive behavior residential
2038	habilitation providers an amount equal to the facility-specific
2039	payment rate set by the agency.
2040	(5)  CONSUMER AND FAMILY INVOLVEMENT.-Each managed care
2041	plan must establish a family advisory committee to participate
2042	in program design and oversight.
2043	(6)  CONSUMER-DIRECTED CARE.-Each managed care plan must
2044	offer consumer-directed care services to enrollees pursuant to
2045	s. 409.221.
2046	Section 33.  Section 409.991, Florida Statutes, is created
2047	to read:
2048	409.991  Managed care plan payment.-In addition to the
2049	payment provisions of s. 409.968, the agency shall provide
2050	payment to comprehensive long-term care plans and long-term care
2051	plans pursuant to this section.
2052	(1)  Prepaid payment rates shall be negotiated between the
2053	agency and the eligible plans as part of the procurement process
2054	described in s. 409.966.
2055	(2)  Payment for comprehensive long-term care plans
2056	covering services pursuant to s. 409.973 shall be blended with
2057	payments for long-term care plans for services specified in s.
2058	409.988.
2059	(3)  Payment rates for plans covering services specified in
2060	s. 409.988 shall be based on historical utilization and spending
2061	for covered services projected forward and adjusted to reflect
2062	the level-of-care profile of each plan's enrollees.
2063	(4)  The Agency for Persons with Disabilities shall conduct
2064	the initial assessment of an enrollee's level of care. The
2065	evaluation of level of care shall be based on assessment and
2066	service utilization information from the most recent version of
2067	the Questionnaire for Situational Information and encounter
2068	data.
2069	(5)  The agency shall assign enrollees of developmental
2070	disabilities long-term care plans into one of five levels of
2071	care to account for variations in risk status and service needs
2072	among enrollees.
2073	(a)  Level of care 1 consists of individuals receiving
2074	services in an intermediate care facility for the
2075	developmentally disabled.
2076	(b)  Level of care 2 consists of individuals with intensive
2077	medical or adaptive needs and who require essential services to
2078	avoid institutionalization or who possess behavioral problems
2079	that are exceptional in intensity, duration, or frequency and
2080	present a substantial risk of harm to themselves or others.
2081	(c)  Level of care 3 consists of individuals with service
2082	needs, including a licensed residential facility and a moderate
2083	level of support for standard residential habilitation services
2084	or a minimal level of support for behavior focus residential
2085	habilitation services, or individuals in supported living who
2086	require more than 6 hours a day of in-home support services.
2087	(d)  Level of care 4 consists of individuals requiring less
2088	than a moderate level of residential habilitation support in a
2089	residential placement or individuals in supported living who
2090	require 6 hours a day or less of in-home support services.
2091	(e)  Level of care 5 consists of individuals who do not
2092	receive in-home support services and need minimal support
2093	services while living in independent or supported living
2094	situations or in their family home.
2095
2096	The agency shall periodically adjust aggregate payments to plans
2097	based on encounter data to account for variations in risk levels
2098	among plans' enrollees.
2099	(6)  The agency shall establish intensive behavior
2100	residential habilitation rates for providers approved by the
2101	agency to provide this service. The agency shall also establish
2102	intermediate care facility for the developmentally disabled-
2103	specific payment rates for each licensed intermediate care
2104	facility. Payments to intermediate care facilities for the
2105	developmentally disabled and providers of intensive behavior
2106	residential habilitation services shall be reconciled to
2107	reimburse the plan's actual payments to the facilities.
2108	Section 34.  Section 409.992, Florida Statutes, is created
2109	to read:
2110	409.992  Automatic enrollment.-The agency shall
2111	automatically enroll into a comprehensive long-term care plan or
2112	a long-term care plan those Medicaid recipients who do not
2113	voluntarily choose a plan pursuant to s. 409.969. The agency
2114	shall automatically enroll recipients in plans that meet or
2115	exceed the performance or quality standards established pursuant
2116	to s. 409.967 and shall not automatically enroll recipients in a
2117	plan that is deficient in those performance or quality
2118	standards. Except as otherwise provided in this part, the agency
2119	shall assign individuals who are deemed dually eligible for
2120	Medicaid and Medicare to a plan that provides both Medicaid and
2121	Medicare services. The agency may not engage in practices that
2122	are designed to favor one managed care plan over another. When
2123	automatically enrolling recipients in plans, the agency shall
2124	take into account the following criteria:
2125	(1)  Whether the plan has sufficient network capacity to
2126	meet the needs of the recipients.
2127	(2)  Whether the recipient has previously received services
2128	from one of the plan's home and community-based service
2129	providers.
2130	(3)  Whether home and community-based providers in one plan
2131	are more geographically accessible to the recipient's residence
2132	than those in other plans.
2133	Section 35.  This act shall take effect July 1, 2011.

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