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	for the same managed care program that have a business
477	relationship with each other. Failure to disclose any business
478	relationship shall result in disqualification from participation
479	in any region for the first full contract period after the
480	discovery of the business relationship by the agency. For the
481	purpose of this section, "business relationship" means an
482	ownership or controlling interest, an affiliate or subsidiary
483	relationship, a common parent, or any mutual interest in any
484	limited partnership, limited liability partnership, limited
485	liability company, or other entity or business association,
486	including all wholly or partially owned subsidiaries, majority-
487	owned subsidiaries, parent companies, or affiliates of such
488	entities, business associations, or other enterprises, that
489	exists for the purpose 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. If a plan that is
513	awarded an additional contract pursuant to this paragraph is
514	subject to penalties pursuant to s. 409.967(2)(g) for activities
515	in Region I, the additional contract is automatically terminated
516	180 days after the imposition of the penalties. The plan shall
517	reimburse the agency for the cost of enrollment changes and
518	other transition activities, including the cost of additional
519	choice counseling services.
520	(4)  ADMINISTRATIVE CHALLENGE.-Any eligible plan that
521	participates in an invitation to negotiate in more than one
522	region and is selected in at least one region may not begin
523	serving Medicaid recipients in any region for which it was
524	selected until all administrative challenges to procurements
525	required by this section to which the eligible plan is a party
526	have been finalized. If the number of plans selected is less
527	than the maximum amount of plans permitted in the region, the
528	agency may contract with other selected plans in the region not
529	participating in the administrative challenge before resolution
530	of the administrative challenge. For purposes of this
531	subsection, an administrative challenge is finalized if an order
532	granting voluntary dismissal with prejudice has been entered by
533	any court established under Article V of the State Constitution
534	or by the Division of Administrative Hearings, a final order has
535	been entered into by the agency and the deadline for appeal has
536	expired, a final order has been entered by the First District
537	Court of Appeal and the time to seek any available review by the
538	Florida Supreme Court has expired, or a final order has been
539	entered by the Florida Supreme Court and a warrant has been
540	issued.
541	Section 8.  Section 409.967, Florida Statutes, is created
542	to read:
543	409.967  Managed care plan accountability.-
544	(1)  The agency shall establish a 5-year contract with each
545	managed care plan selected through the procurement process
546	described in s. 409.966. A plan contract may not be renewed;
547	however, the agency may extend the terms of a plan contract to
548	cover any delays in transition to a new plan.
549	(2)  The agency shall establish such contract requirements
550	as are necessary for the operation of the statewide managed care
551	program. In addition to any other provisions the agency may deem
552	necessary, the contract shall require:
553	(a)  Emergency services.-Managed care plans shall pay for
554	services required by ss. 395.1041 and 401.45 and rendered by a
555	noncontracted provider. The plans must comply with s. 641.3155.
556	Reimbursement for services under this paragraph shall be the
557	lesser of:
558	1.  The provider's charges;
559	2.  The usual and customary provider charges for similar
560	services in the community where the services were provided;
561	3.  The charge mutually agreed to by the entity and the
562	provider within 60 days after submittal of the claim; or
563	4.  The rate the agency would have paid on the most recent
564	October 1st.
565	(b)  Access.-The agency shall establish specific standards
566	for the number, type, and regional distribution of providers in
567	managed care plan networks to ensure access to care for both
568	adults and children. Each plan must maintain a region-wide
569	network of providers in sufficient numbers to meet the access
570	standards for specific medical services for all recipients
571	enrolled in the plan. The exclusive use of mail-order pharmacies
572	shall not be sufficient to meet network access standards.
573	Consistent with the standards established by the agency,
574	provider networks may include providers located outside the
575	region. A plan may contract with a new hospital facility before
576	the date the hospital becomes operational if the hospital has
577	commenced construction, will be licensed and operational by
578	January 1, 2013, and a final order has issued in any civil or
579	administrative challenge. Each plan shall establish and maintain
580	an accurate and complete electronic database of contracted
581	providers, including information about licensure or
582	registration, locations and hours of operation, specialty
583	credentials and other certifications, specific performance
584	indicators, and such other information as the agency deems
585	necessary. The database shall be available online to both the
586	agency and the public and shall have the capability to compare
587	the availability of providers to network adequacy standards and
588	to accept and display feedback from each provider's patients.
589	Each plan shall submit quarterly reports to the agency
590	identifying the number of enrollees assigned to each primary
591	care provider.
592	(c)  Encounter data.-The agency shall maintain and operate
593	a Medicaid Encounter Data System to collect, process, store, and
594	report on covered services provided to all Medicaid recipients
595	enrolled in prepaid plans.
596	1.  Each prepaid plan must comply with the agency's
597	reporting requirements for the Medicaid Encounter Data System.
598	Prepaid plans must submit encounter data electronically in a
599	format that complies with the Health Insurance Portability and
600	Accountability Act provisions for electronic claims and in
601	accordance with deadlines established by the agency. Prepaid
602	plans must certify that the data reported is accurate and
603	complete.
604	2.  The agency is responsible for validating the data
605	submitted by the plans. The agency shall develop methods and
606	protocols for ongoing analysis of the encounter data that
607	adjusts for differences in characteristics of prepaid plan
608	enrollees to allow comparison of service utilization among plans
609	and against expected levels of use. The analysis shall be used
610	to identify possible cases of systemic underutilization or
611	denials of claims and inappropriate service utilization such as
612	higher-than-expected emergency department encounters. The
613	analysis shall provide periodic feedback to the plans and enable
614	the agency to establish corrective action plans when necessary.
615	One of the focus areas for the analysis shall be the use of
616	prescription drugs.
617	3.  The agency shall make encounter data available to those
618	plans accepting enrollees who are assigned to them from other
619	plans leaving a region.
620	(d)  Continuous improvement.-The agency shall establish
621	specific performance standards and expected milestones or
622	timelines for improving performance over the term of the
623	contract. By the end of the fourth year of the first contract
624	term, the agency shall issue a request for information to
625	determine whether cost savings could be achieved by contracting
626	for plan oversight and monitoring, including analysis of
627	encounter data, assessment of performance measures, and
628	compliance with other contractual requirements. Each managed
629	care plan shall establish an internal health care quality
630	improvement system, including enrollee satisfaction and
631	disenrollment surveys. The quality improvement system shall
632	include incentives and disincentives for network providers.
633	(e)  Program integrity.-Each managed care plan shall
634	establish program integrity functions and activities to reduce
635	the incidence of fraud and abuse, including, at a minimum:
636	1.  A provider credentialing system and ongoing provider
637	monitoring;
638	2.  An effective prepayment and postpayment review process
639	including, but not limited to, data analysis, system editing,
640	and auditing of network providers;
641	3.  Procedures for reporting instances of fraud and abuse
642	pursuant to chapter 641;
643	4.  Administrative and management arrangements or
644	procedures, including a mandatory compliance plan, designed to
645	prevent fraud and abuse; and
646	5.  Designation of a program integrity compliance officer.
647	(f)  Grievance resolution.-Consistent with federal law,
648	each managed care plan shall establish and the agency shall
649	approve an internal process for reviewing and responding to
650	grievances from enrollees. Each plan shall submit quarterly
651	reports on the number, description, and outcome of grievances
652	filed by enrollees.
653	(g)  Penalties.-Managed care plans that reduce enrollment
654	levels or leave a region before the end of the contract term
655	shall reimburse the agency for the cost of enrollment changes
656	and other transition activities, including the cost of
657	additional choice counseling services. If more than one plan
658	leaves a region at the same time, costs shall be shared by the
659	departing plans proportionate to their enrollments. In addition
660	to the payment of costs, departing provider services networks
661	shall pay a per enrollee penalty not to exceed 3 month's payment
662	and shall continue to provide services to the enrollee for 90
663	days or until the enrollee is enrolled in another plan,
664	whichever is sooner. In addition to payment of costs, all other
665	plans shall pay a penalty equal to 25 percent of the minimum
666	surplus requirement pursuant to s. 641.225(1). Plans shall
667	provide the agency notice no less than 180 days before
668	withdrawing from a region.
669	(h)  Prompt payment.-Managed care plans shall comply with
670	ss. 641.315, 641.3155, and 641.513.
671	(i)  Electronic claims.-Managed care plans shall accept
672	electronic claims in compliance with federal standards.
673	(j)  Fair payment.-Provider service networks must ensure
674	that no network provider with a controlling interest in the
675	network charges any Medicaid managed care plan more than the
676	amount paid to that provider by the provider service network for
677	the same service.
678	(3)  ACHIEVED SAVINGS REBATE.-
679	(a)  The agency shall establish and the prepaid plans shall
680	use a uniform method for annually reporting premium revenue,
681	medical and administrative costs, and income or losses, across
682	all Florida Medicaid prepaid plan lines of business in all
683	regions. The reports shall be due to the agency within 270 days
684	after the conclusion of the reporting period and the agency may
685	audit the reports. Achieved savings rebates shall be due within
686	30 days after the report is submitted. Except as provided in
687	paragraph (b), the achieved savings rebate will be established
688	by determining pretax income as a percentage of revenues and
689	applying the following income sharing ratios:
690	1.  One hundred percent of income up to and including 5
691	percent of revenue shall be retained by the plan.
692	2.  Fifty percent of income above 5 percent and up to 10
693	percent shall be retained by the plan, with the other 50 percent
694	refunded to the state.
695	3.  One hundred percent of income above 10 percent of
696	revenue shall be refunded to the state.
697	(b)  A plan that meets or exceeds agency-defined quality
698	measures in the reporting period may retain an additional 1
699	percent of revenue.
700	(c)  The following expenses may not be included in
701	calculating income to the plan:
702	1.  Payment of achieved savings rebates.
703	2.  Any financial incentive payments made to the plan
704	outside of the capitation rate.
705	3.  Any financial disincentive payments levied by the state
706	or federal governments.
707	4.  Expenses associated with lobbying activities.
708	5.  Administrative, reinsurance, and outstanding claims
709	expenses in excess of actuarially sound maximum amounts set by
710	the agency.
711	6.  Any payment made pursuant to paragraph (f).
712	(d)  Prepaid plans that incur a loss in the first contract
713	year may apply the full amount of the loss as an offset to
714	income in the second contract year.
715	(e)  If, after an audit or other reconciliation, the agency
716	determines that a prepaid plan owes an additional rebate, the
717	plan shall have 30 days after notification to make the payment.
718	Upon failure to timely pay the rebate, the agency shall withhold
719	future payments to the plan until the entire amount is recouped.
720	If the agency determines that a prepaid plan has made an
721	overpayment, the agency shall return the overpayment within 30
722	days.
723	(f)  In addition to the reporting required by paragraph
724	(a), prepaid plans shall annually submit a report, consistent
725	with paragraph (a), which is specific to enrollees with
726	developmental disabilities. The agency shall compare each plan's
727	expenditures to the plan's aggregate premiums for this
728	population. The difference between aggregate premiums and
729	expenditures shall be shared equally between the plan and the
730	state. The state share shall be returned to the Medicaid
731	appropriation to serve people on the wait list for home and
732	community-based services provided through individual budgets.
733	Section 9.  Section 409.968, Florida Statutes, is created
734	to read:
735	409.968  Managed care plan payments.-
736	(1)  Prepaid plans shall receive per-member, per-month
737	payments negotiated pursuant to the procurements described in s.
738	409.966. Payments shall be risk-adjusted rates based on
739	historical utilization and spending data, projected forward, and
740	adjusted to reflect the eligibility category, geographic area,
741	and clinical risk profile of the recipients. In negotiating
742	rates with the plans, the agency shall consider any adjustments
743	necessary to encourage plans to use the most cost effective
744	modalities for treatment of chronic disease such as peritoneal
745	dialysis.
746	(2)  Provider service networks may be prepaid plans and
747	receive per-member, per-month payments negotiated pursuant to
748	the procurement process described in s. 409.966. Provider
749	service networks that choose not to be prepaid plans shall
750	receive fee-for-service rates with a shared savings settlement.
751	The fee-for-service option shall be available to a provider
752	service network only for the first 3 years of its operation. The
753	agency shall annually conduct cost reconciliations to determine
754	the amount of cost savings achieved by fee-for-service provider
755	service networks for the dates of service within the period
756	being reconciled. Only payments for covered services for dates
757	of service within the reconciliation period and paid within 6
758	months after the last date of service in the reconciliation
759	period shall be included. The agency shall perform the necessary
760	adjustments for the inclusion of claims incurred but not
761	reported within the reconciliation period for claims that could
762	be received and paid by the agency after the 6-month claims
763	processing time lag. The agency shall provide the results of the
764	reconciliations to the fee-for-service provider service networks
765	within 45 days after the end of the reconciliation period. The
766	fee-for-service provider service networks shall review and
767	provide written comments or a letter of concurrence to the
768	agency within 45 days after receipt of the reconciliation
769	results. This reconciliation shall be considered final.
770	Section 10.  Section 409.969, Florida Statutes, is created
771	to read:
772	409.969  Enrollment; choice counseling; automatic
773	assignment; disenrollment.-
774	(1)  ENROLLMENT.-All Medicaid recipients shall be enrolled
775	in a managed care plan unless specifically exempted under this
776	part. Each recipient shall have a choice of plans and may select
777	any available plan unless that plan is restricted by contract to
778	a specific population that does not include the recipient.
779	Medicaid recipients shall have 30 days in which to make a choice
780	of plans. All recipients shall be offered choice counseling
781	services in accordance with this section.
782	(2)  CHOICE COUNSELING.-The agency shall provide choice
783	counseling for Medicaid recipients. The agency may contract for
784	the provision for choice counseling. Except as provided in s.
785	409.984, any such contract shall be procured competitively. The
786	contract shall be with a vendor that employs Floridians to
787	accomplish the contract requirements, shall be for a period of 5
788	years, and shall comply with the provisions of 42 C.F.R. part
789	483, relating to enrollment brokers as defined in that part. The
790	agency may renew a contract for an additional 5-year period;
791	however, before renewal of the contract the agency shall hold at
792	least one public meeting in each of the regions covered by the
793	choice counseling vendor. The agency may extend the term of the
794	contract to cover any delays in transition to a new contractor.
795	Printed choice information and choice counseling shall be
796	offered in the native or preferred language of the recipient,
797	consistent with federal requirements. The manner and method of
798	choice counseling shall be modified as necessary to ensure
799	culturally competent, effective communication with people from
800	diverse cultural backgrounds. The agency shall maintain a record
801	of the recipients who receive such services, identifying the
802	scope and method of the services provided. The agency shall make
803	available clear and easily understandable choice information to
804	Medicaid recipients that includes:
805	(a)  An explanation that each recipient has the right to
806	choose a managed care plan at the time of enrollment in Medicaid
807	and again at regular intervals set by the agency, and that if a
808	recipient does not choose a plan, the agency will assign the
809	recipient to a plan according to the criteria specified in this
810	section.
811	(b)  A list and description of the benefits provided in
812	each managed care plan.
813	(c)  An explanation of benefit limits.
814	(d)  A current list of providers participating in the
815	network, including location and contact information.
816	(e)  Managed care plan performance data.
817	(3)  DISENROLLMENT; GRIEVANCES.-After a recipient has
818	enrolled in a managed care plan, the recipient shall have 90
819	days to voluntarily disenroll and select another plan. After 90
820	days, no further changes may be made except for good cause. For
821	purposes of this section, the term "good cause" includes, but is
822	not limited to, poor quality of care, lack of access to
823	necessary specialty services, an unreasonable delay or denial of
824	service, or fraudulent enrollment. The agency must make a
825	determination as to whether good cause exists. The agency may
826	require a recipient to use the plan's grievance process before
827	the agency's determination of good cause, except in cases in
828	which immediate risk of permanent damage to the recipient's
829	health is alleged.
830	(a)  The managed care plan internal grievance process, when
831	used, must be completed in time to permit the recipient to
832	disenroll by the first day of the second month after the month
833	the disenrollment request was made. If the result of the
834	grievance process is approval of an enrollee's request to
835	disenroll, the agency is not required to make a determination in
836	the case.
837	(b)  The agency must make a determination and take final
838	action on a recipient's request so that disenrollment occurs no
839	later than the first day of the second month after the month the
840	request was made. If the agency fails to act within the
841	specified timeframe, the recipient's request to disenroll is
842	deemed to be approved as of the date agency action was required.
843	Recipients who disagree with the agency's finding that good
844	cause does not exist for disenrollment shall be advised of their
845	right to pursue a Medicaid fair hearing to dispute the agency's
846	finding.
847	(c)  Medicaid recipients enrolled in a managed care plan
848	after the 90-day period shall remain in the plan for the
849	remainder of the 12-month period. After 12 months, the recipient
850	may select another plan. However, nothing shall prevent a
851	Medicaid recipient from changing providers within the plan
852	during that period.
853	(d)  On the first day of the month after receiving notice
854	from a recipient that the recipient has moved to another region,
855	the agency shall automatically disenroll the recipient from the
856	managed care plan the recipient is currently enrolled in and
857	treat the recipient as if the recipient is a new Medicaid
858	enrollee. At that time, the recipient may choose another plan
859	pursuant to the enrollment process established in this section.
860	(e)  The agency must monitor plan disenrollment throughout
861	the contract term to identify any discriminatory practices.
862	Section 11.  Section 409.97, Florida Statutes, is created
863	to read:
864	409.97  State and local Medicaid partnerships.-
865	(1)  INTERGOVERNMENTAL TRANSFERS.-In addition to the
866	contributions required pursuant to s. 409.915, beginning in the
867	2014-2015 fiscal year, the agency may accept voluntary transfers
868	of local taxes and other qualified revenue from counties,
869	municipalities, and special taxing districts. Such transfers
870	must be contributed to advance the general goals of the Florida
871	Medicaid program without restriction and must be executed
872	pursuant to a contract between the agency and the local funding
873	source. Contracts executed before October 31 shall result in
874	contributions to Medicaid for that same state fiscal year.
875	Contracts executed between November 1 and June 30 shall result
876	in contributions for the following state fiscal year. Based on
877	the date of the signed contracts, the agency shall allocate to
878	the low-income pool the first contributions received up to the
879	limit established by subsection (2). No more than 40 percent of
880	the low-income pool funding shall come from any single funding
881	source. Contributions in excess of the low-income pool shall be
882	allocated to the disproportionate share programs defined in ss.
883	409.911(3) and 409.9113 and to hospital rates pursuant to
884	subsection (4). The local funding source shall designate in the
885	contract which Medicaid providers ensure access to care for low-
886	income and uninsured people within the applicable jurisdiction
887	and are eligible for low-income pool funding. Eligible providers
888	may include hospitals, primary care providers, and primary care
889	access systems.
890	(2)  LOW-INCOME POOL.-The agency shall establish and
891	maintain a low-income pool in a manner authorized by federal
892	waiver. The low-income pool is created to compensate a network
893	of providers designated pursuant to subsection (1). Funding of
894	the low-income pool shall be limited to the maximum amount
895	permitted by federal waiver minus a percentage specified in the
896	General Appropriations Act. The low-income pool must be used to
897	support enhanced access to services by offsetting shortfalls in
898	Medicaid reimbursement, paying for otherwise uncompensated care,
899	and financing coverage for the uninsured. The low-income pool
900	shall be distributed in periodic payments to the Access to Care
901	Partnership throughout the fiscal year. Distribution of low-
902	income pool funds by the Access to Care Partnership to
903	participating providers may be made through capitated payments,
904	fees for services, or contracts for specific deliverables. The
905	agency shall include the distribution amount for each provider
906	in the contract with the Access to Care Partnership pursuant to
907	subsection (3). Regardless of the method of distribution,
908	providers participating in the Access to Care Partnership shall
909	receive payments such that the aggregate benefit in the
910	jurisdiction of each local funding source, as defined in
911	subsection (1), equals the amount of the contribution plus a
912	factor specified in the General Appropriations Act.
913	(3)  ACCESS TO CARE PARTNERSHIP.-The agency shall contract
914	with an administrative services organization that has operating
915	agreements with all health care facilities, programs, and
916	providers supported with local taxes or certified public
917	expenditures and designated pursuant to subsection (1). The
918	contract shall provide for enhanced access to care for Medicaid,
919	low-income, and uninsured Floridians. The partnership shall be
920	responsible for an ongoing program of activities that provides
921	needed, but uncovered or undercompensated, health services to
922	Medicaid enrollees and persons receiving charity care, as
923	defined in s. 409.911. Accountability for services rendered
924	under this contract must be based on the number of services
925	provided to unduplicated qualified beneficiaries, the total
926	units of service provided to these persons, and the
927	effectiveness of services provided as measured by specific
928	standards of care. The agency shall seek such plan amendments or
929	waivers as may be necessary to authorize the implementation of
930	the low-income pool as the Access to Care Partnership pursuant
931	to this section.
932	(4)  HOSPITAL RATE DISTRIBUTION.-
933	(a)  The agency is authorized to implement a tiered
934	hospital rate system to enhance Medicaid payments to all
935	hospitals when resources for the tiered rates are available from
936	general revenue and such contributions pursuant to subsection
937	(1) as are authorized under the General Appropriations Act.
938	1.  Tier 1 hospitals are statutory rural hospitals as
939	defined in s. 395.602, statutory teaching hospitals as defined
940	in s. 408.07(45), and specialty children's hospitals as defined
941	in s. 395.002(28).
942	2.  Tier 2 hospitals are community hospitals not included
943	in Tier 1 that provided more than 9 percent of the hospital's
944	total inpatient days to Medicaid patients and charity patients,
945	as defined in s. 409.911, and are located in the jurisdiction of
946	a local funding source pursuant to subsection (1).
947	3.  Tier 3 hospitals include all community hospitals.
948	(b)  When rates are increased pursuant to this section, the
949	Total Tier Allocation (TTA) shall be distributed as follows:
950	1.  Tier 1 (T1A) = 0.35 x TTA.
951	2.  Tier 2 (T2A) = 0.35 x TTA.
952	3.  Tier 3 (T3A) = 0.30 x TTA.
953	(c)  The tier allocation shall be distributed as a
954	percentage increase to the hospital specific base rate (HSBR)
955	established pursuant to s. 409.905(5)(c). The increase in each
956	tier shall be calculated according to the proportion of tier-
957	specific allocation to the total estimated inpatient spending
958	(TEIS) for all hospitals in each tier:
959	1.  Tier 1 percent increase (T1PI) = T1A/Tier 1 total
960	estimated inpatient spending (T1TEIS).
961	2.  Tier 2 percent increase (T2PI) = T2A /Tier 2 total
962	estimated inpatient spending (T2TEIS).
963	3.  Tier 3 percent increase (T3PI) = T3A/ Tier 3 total
964	estimated inpatient spending (T3TEIS).
965	(d)  The hospital-specific tiered rate (HSTR) shall be
966	calculated as follows:
967	1.  For hospitals in Tier 3: HSTR = (1 + T3PI) x HSBR.
968	2.  For hospitals in Tier 2: HSTR = (1 + T2PI) x HSBR.
969	3.  For hospitals in Tier 1: HSTR = (1 + T1PI) x HSBR.
970	Section 12.  Section 409.971, Florida Statutes, is created
971	to read:
972	409.971  Managed medical assistance program.-The agency
973	shall make payments for primary and acute medical assistance and
974	related services using a managed care model. By January 1, 2013,
975	the agency shall begin implementation of the statewide managed
976	medical assistance program, with full implementation in all
977	regions by October 1, 2014.
978	Section 13.  Section 409.972, Florida Statutes, is created
979	to read:
980	409.972  Mandatory and voluntary enrollment.-
981	(1)  Persons eligible for the program known as "medically
982	needy" pursuant to s. 409.904(2)(a) shall enroll in managed care
983	plans. Medically needy recipients shall meet the share of the
984	cost by paying the plan premium, up to the share of the cost
985	amount, contingent upon federal approval.
986	(2)  The following Medicaid-eligible persons are exempt
987	from mandatory managed care enrollment required by s. 409.965,
988	and may voluntarily choose to participate in the managed medical
989	assistance program:
990	(a)  Medicaid recipients who have other creditable health
991	care coverage, excluding Medicare.
992	(b)  Medicaid recipients residing in residential commitment
993	facilities operated through the Department of Juvenile Justice
994	or mental health treatment facilities as defined by s.
995	394.455(32).
996	(c)  Persons eligible for refugee assistance.
997	(d)  Medicaid recipients who are residents of a
998	developmental disability center, including Sunland Center in
999	Marianna and Tacachale in Gainesville.
1000	(3)  Persons eligible for Medicaid but exempt from
1001	mandatory participation who do not choose to enroll in managed
1002	care shall be served in the Medicaid fee-for-service program as
1003	provided in part III of this chapter.
1004	Section 14.  Section 409.973, Florida Statutes, is created
1005	to read:
1006	409.973  Benefits.-
1007	(1)  MINIMUM BENEFITS.-Managed care plans shall cover, at a
1008	minimum, the following services:
1009	(a)  Advanced registered nurse practitioner services.
1010	(b)  Ambulatory surgical treatment center services.
1011	(c)  Birthing center services.
1012	(d)  Chiropractic services.
1013	(e)  Dental services.
1014	(f)  Early periodic screening diagnosis and treatment
1015	services for recipients under age 21.
1016	(g)  Emergency services.
1017	(h)  Family planning services and supplies.
1018	(i)  Healthy start services, except as provided in s.
1019	409.975(4).
1020	(j)  Hearing services.
1021	(k)  Home health agency services.
1022	(l)  Hospice services.
1023	(m)  Hospital inpatient services.
1024	(n)  Hospital outpatient services.
1025	(o)  Laboratory and imaging services.
1026	(p)  Medical supplies, equipment, prostheses, and orthoses.
1027	(q)  Mental health services.
1028	(r)  Nursing care.
1029	(s)  Optical services and supplies.
1030	(t)  Optometrist services.
1031	(u)  Physical, occupational, respiratory, and speech
1032	therapy services.
1033	(v)  Physician services, including physician assistant
1034	services.
1035	(w)  Podiatric services.
1036	(x)  Prescription drugs.
1037	(y)  Renal dialysis services.
1038	(z)  Respiratory equipment and supplies.
1039	(aa)  Rural health clinic services.
1040	(bb)  Substance abuse treatment services.
1041	(cc)  Transportation to access covered services, except as
1042	provided in s. 409.975(5).
1043	(2)  CUSTOMIZED BENEFITS.-Managed care plans may customize
1044	benefit packages for nonpregnant adults, vary cost-sharing
1045	provisions, and provide coverage for additional services. The
1046	agency shall evaluate the proposed benefit packages to ensure
1047	services are sufficient to meet the needs of the plan's
1048	enrollees and to verify actuarial equivalence.
1049	(3)  HEALTHY BEHAVIORS.-Each plan operating in the managed
1050	medical assistance program shall establish a program to
1051	encourage and reward healthy behaviors.
1052	(4)  PRIMARY CARE INITIATIVE.-Each plan operating in the
1053	managed medical assistance program shall establish a program to
1054	encourage enrollees to establish a relationship with their
1055	primary care provider. Each plan shall:
1056	(a)  Within 30 days after enrollment, provide information
1057	to each enrollee on the importance of and procedure for
1058	selecting a primary care physician, and thereafter automatically
1059	assign to a primary care provider any enrollee who fails to
1060	choose a primary care provider.
1061	(b)  Within 90 days after selection of or assignment to a
1062	primary care provider, provide information to each enrollee on
1063	the importance of scheduling a wellness screening with the
1064	enrollee's primary care physician.
1065	(c)  Report to the agency the number of enrollees assigned
1066	to each primary care provider within the plan's network.
1067	(d)  Report to the agency the number of enrollees who have
1068	not had an appointment with their primary care provider within
1069	their first year of enrollment.
1070	(e)  Report to the agency the number of emergency room
1071	visits by enrollees who have not had a least one appointment
1072	with their primary care provider.
1073	Section 15.  Section 409.974, Florida Statutes, is created
1074	to read:
1075	409.974  Eligible plans.-
1076	(1)  ELIGIBLE PLAN SELECTION.-The agency shall select
1077	eligible plans through the procurement process described in s.
1078	409.966. The agency shall notice invitations to negotiate no
1079	later than January 1, 2013.
1080	(a)  The agency shall procure three plans for Region I. At
1081	least one plan shall be a provider service network, if any
1082	provider service network submits a responsive bid.
1083	(b)  The agency shall procure three plans for Region II. At
1084	least one plan shall be a provider service network, if any
1085	provider service network submits a responsive bid.
1086	(c)  The agency shall procure at least three plans and no
1087	more than four plans for Region III. At least two plans shall be
1088	provider service networks, if any two provider service networks
1089	submit responsive bids.
1090	(d)  The agency shall procure at least four plans and no
1091	more than seven plans for Region IV. At least two plans shall be
1092	provider service networks if any two provider service networks
1093	submit responsive bids.
1094	(e)  The agency shall procure at least five plans and no
1095	more than eight plans for Region V. At least two plans shall be
1096	provider service networks, if any two provider service networks
1097	submit responsive bids.
1098	(f)  The agency shall procure at least three plans and no
1099	more than four plans for Region VI. At least one plan shall be a
1100	provider service network, if any provider service network
1101	submits a responsive bid.
1102	(g)  The agency shall procure at least four plans and no
1103	more than seven plans for Region VII. At least two plans shall
1104	be provider service networks, if any two provider service
1105	networks submit a responsive bid.
1106	(h)  The agency shall procure at least six plans and no
1107	more than ten plans for Region VIII. At least two plans shall be
1108	provider service networks, if any two provider service networks
1109	submit a responsive bid.
1110
1111	If no provider service network submits a responsive bid, the
1112	agency shall procure no more than one less than the maximum
1113	number of eligible plans permitted in that region. Within 12
1114	months after the initial invitation to negotiate, the agency
1115	shall attempt to procure a provider service network. The agency
1116	shall notice another invitation to negotiate only with provider
1117	service networks in such region where no provider service
1118	network has been selected.
1119	(2)  QUALITY SELECTION CRITERIA.-In addition to the
1120	criteria established in s. 409.966, the agency shall consider
1121	evidence that an eligible plan has written agreements or signed
1122	contracts or has made substantial progress in establishing
1123	relationships with providers before the plan submitting a
1124	response. The agency shall evaluate and give special weight to
1125	evidence of signed contracts with essential providers as defined
1126	by the agency pursuant to s. 409.975(2). The agency shall
1127	exercise a preference for plans with a provider network in which
1128	over 10 percent of the providers use electronic health records,
1129	as defined in s. 408.051. When all other factors are equal, the
1130	agency shall consider whether the organization has a contract to
1131	provide managed long-term care services in the same region and
1132	shall exercise a preference for such plans.
1133	(3)  SPECIALTY PLANS.-Participation by specialty plans
1134	shall be subject to the procurement requirements and regional
1135	plan number limits of this section. However, a specialty plan
1136	whose target population includes no more than 10 percent of the
1137	enrollees of that region is not subject to the regional plan
1138	number limits of this section.
1139	(4)  CHILDREN'S MEDICAL SERVICES NETWORK.-Participation by
1140	the Children's Medical Services Network shall be pursuant to a
1141	single, statewide contract with the agency that is not subject
1142	to the procurement requirements or regional plan number limits
1143	of this section. The Children's Medical Services Network must
1144	meet all other plan requirements for the managed medical
1145	assistance program.
1146	Section 16.  Section 409.975, Florida Statutes, is created
1147	to read:
1148	409.975  Managed care plan accountability.-In addition to
1149	the requirements of s. 409.967, plans and providers
1150	participating in the managed medical assistance program shall
1151	comply with the requirements of this section.
1152	(1)  PROVIDER NETWORKS.-Managed care plans must develop and
1153	maintain provider networks that meet the medical needs of their
1154	enrollees in accordance with standards established pursuant to
1155	409.967(2)(b). Except as provided in this section, managed care
1156	plans may limit the providers in their networks based on
1157	credentials, quality indicators, and price.
1158	(a)  Plans must include all providers in the region that
1159	are classified by the agency as essential Medicaid providers,
1160	unless the agency approves, in writing, an alternative
1161	arrangement for securing the types of services offered by the
1162	essential providers. Providers are essential for serving
1163	Medicaid enrollees if they offer services that are not available
1164	from any other provider within a reasonable access standard, or
1165	if they provided a substantial share of the total units of a
1166	particular service used by Medicaid patients within the region
1167	during the last 3 years and the combined capacity of other
1168	service providers in the region is insufficient to meet the
1169	total needs of the Medicaid patients. The agency may not
1170	classify physicians and other practitioners as essential
1171	providers. The agency, at a minimum, shall determine which
1172	providers in the following categories are essential Medicaid
1173	providers:
1174	1.  Federally qualified health centers.
1175	2.  Statutory teaching hospitals as defined in s.
1176	408.07(45).
1177	3.  Hospitals that are trauma centers as defined in s.
1178	395.4001(14).
1179	4.  Hospitals located at least 25 miles from any other
1180	hospital with similar services.
1181
1182	Managed care plans that have not contracted with all essential
1183	providers in the region as of the first date of recipient
1184	enrollment, or with whom an essential provider has terminated
1185	its contract, must negotiate in good faith with such essential
1186	providers for 1 year or until an agreement is reached, whichever
1187	is first. Payments for services rendered by a nonparticipating
1188	essential provider shall be made at the applicable Medicaid rate
1189	as of the first day of the contract between the agency and the
1190	plan. A rate schedule for all essential providers shall be
1191	attached to the contract between the agency and the plan. After
1192	1 year, managed care plans that are unable to contract with
1193	essential providers shall notify the agency and propose an
1194	alternative arrangement for securing the essential services for
1195	Medicaid enrollees. The arrangement must rely on contracts with
1196	other participating providers, regardless of whether those
1197	providers are located within the same region as the
1198	nonparticipating essential service provider. If the alternative
1199	arrangement is approved by the agency, payments to
1200	nonparticipating essential providers after the date of the
1201	agency's approval shall equal 90 percent of the applicable
1202	Medicaid rate. If the alternative arrangement is not approved by
1203	the agency, payment to nonparticipating essential providers
1204	shall equal 110 percent of the applicable Medicaid rate.
1205	(b)  Certain providers are statewide resources and
1206	essential providers for all managed care plans in all regions.
1207	All managed care plans must include these essential providers in
1208	their networks. Statewide essential providers include:
1209	1.  Faculty plans of Florida medical schools.
1210	2.  Regional perinatal intensive care centers as defined in
1211	s. 383.16(2).
1212	3.  Hospitals licensed as specialty children's hospitals as
1213	defined in s. 395.002(28).
1214	4.  Accredited and integrated systems serving medically
1215	complex children that are comprised of separately licensed, but
1216	commonly owned, health care providers delivering at least the
1217	following services: medical group home, in-home and outpatient
1218	nursing care and therapies, pharmacy services, durable medical
1219	equipment, and Prescribed Pediatric Extended Care.
1220
1221	Managed care plans that have not contracted with all statewide
1222	essential providers in all regions as of the first date of
1223	recipient enrollment must continue to negotiate in good faith.
1224	Payments to physicians on the faculty of nonparticipating
1225	Florida medical schools shall be made at the applicable Medicaid
1226	rate. Payments for services rendered by a regional perinatal
1227	intensive care centers shall be made at the applicable Medicaid
1228	rate as of the first day of the contract between the agency and
1229	the plan. Payments to nonparticipating specialty children's
1230	hospitals shall equal the highest rate established by contract
1231	between that provider and any other Medicaid managed care plan.
1232	(c)  After 12 months of active participation in a plan's
1233	network, the plan may exclude any essential provider from the
1234	network for failure to meet quality or performance criteria. If
1235	the plan excludes an essential provider from the plan, the plan
1236	must provide written notice to all recipients who have chosen
1237	that provider for care. The notice shall be provided at least 30
1238	days before the effective date of the exclusion.
1239	(d)  Each managed care plan must offer a network contract
1240	to each home medical equipment and supplies provider in the
1241	region which meets quality and fraud prevention and detection
1242	standards established by the plan and which agrees to accept the
1243	lowest price previously negotiated between the plan and another
1244	such provider.
1245	(2)  FLORIDA MEDICAL SCHOOLS QUALITY NETWORK.-The agency
1246	shall contract with a single organization representing medical
1247	schools and graduate medical education programs in the state for
1248	the purpose of establishing an active and ongoing program to
1249	improve clinical outcomes in all managed care plans. Contracted
1250	activities must support greater clinical integration for
1251	Medicaid enrollees through interdependent and cooperative
1252	efforts of all providers participating in managed care plans.
1253	The agency shall support these activities with certified public
1254	expenditures and any earned federal matching funds and shall
1255	seek any plan amendments or waivers necessary to comply with
1256	this subsection. To be eligible to participate in the quality
1257	network, a medical school must contract with each managed care
1258	plan in its region.
1259	(3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
1260	monitor the quality and performance of each participating
1261	provider. At the beginning of the contract period, each plan
1262	shall notify all its network providers of the metrics used by
1263	the plan for evaluating the provider's performance and
1264	determining continued participation in the network.
1265	(4)  MOMCARE NETWORK.-
1266	(a)  The agency shall contract with an administrative
1267	services organization representing all Healthy Start Coalitions
1268	providing risk appropriate care coordination and other services
1269	in accordance with a federal waiver and pursuant to s. 409.906.
1270	The contract shall require the network of coalitions to provide
1271	choice counseling, education, risk-reduction and case management
1272	services, and quality assurance for all enrollees of the waiver.
1273	The agency shall evaluate the impact of the MomCare network by
1274	monitoring each plan's performance on specific measures to
1275	determine the adequacy, timeliness, and quality of services for
1276	pregnant women and infants. The agency shall support this
1277	contract with certified public expenditures of general revenue
1278	appropriated for Healthy Start services and any earned federal
1279	matching funds.
1280	(b)  Each managed care plan shall establish specific
1281	programs and procedures to improve pregnancy outcomes and infant
1282	health, including, but not limited to, coordination with the
1283	Healthy Start program, immunization programs, and referral to
1284	the Special Supplemental Nutrition Program for Women, Infants,
1285	and Children, and the Children's Medical Services program for
1286	children with special health care needs. Each plan's programs
1287	and procedures shall include agreements with each local Healthy
1288	Start Coalition in the region to provide risk-appropriate care
1289	coordination for pregnant women and infants, consistent with
1290	agency policies and the MomCare network.
1291	(5)  TRANSPORTATION.-Nonemergency transportation services
1292	shall be provided pursuant to a single, statewide contract
1293	between the agency and the Commission for the Transportation
1294	Disadvantaged. The agency shall establish performance standards
1295	in the contract and shall evaluate the performance of the
1296	Commission for the Transportation Disadvantaged. For the
1297	purposes of this subsection, the term "nonemergency
1298	transportation" does not include transportation by ambulance and
1299	any medical services received during transport.
1300	(6)  SCREENING RATE.-After the end of the second contract
1301	year, each managed care plan shall achieve an annual Early and
1302	Periodic Screening, Diagnosis, and Treatment Service screening
1303	rate of at least 80 percent of those recipients continuously
1304	enrolled for at least 8 months.
1305	(7)  PROVIDER PAYMENT.-Managed care plan and hospitals
1306	shall negotiate mutually acceptable rates, methods, and terms of
1307	payment. For rates, methods, and terms of payment negotiated
1308	after the contract between the agency and the plan is executed,
1309	plans shall pay hospitals, at a minimum, the rate the agency
1310	would have paid on the first day of the contract between the
1311	provider and the plan. Such payments to hospitals may not exceed
1312	120 percent of the rate the agency would have paid on the first
1313	day of the contract between the provider and the plan, unless
1314	specifically approved by the agency. Payment rates may be
1315	updated periodically.
1316	(8)  MEDICALLY NEEDY ENROLLEES.-Each managed care plan
1317	shall accept any medically needy recipient who selects or is
1318	assigned to the plan and provide that recipient with continuous
1319	enrollment for 12 months. After the first month of qualifying as
1320	a medically needy recipient and enrolling in a plan, and
1321	contingent upon federal approval, the enrollee shall pay the
1322	plan a portion of the monthly premium equal to the enrollee's
1323	share of the cost as determined by the department. The agency
1324	shall pay any remaining portion of the monthly premium. Plans
1325	are not obligated to pay claims for medically needy patients for
1326	services provided before enrollment in the plan. Medically needy
1327	patients are responsible for payment of incurred claims that are
1328	used to determine eligibility. Plans must provide a grace period
1329	of at least 90 days before disenrolling recipients who fail to
1330	pay their shares of the premium.
1331	Section 17.  Section 409.976, Florida Statutes, is created
1332	to read:
1333	409.976  Managed care plan payment.-In addition to the
1334	payment provisions of s. 409.968, the agency shall provide
1335	payment to plans in the managed medical assistance program
1336	pursuant to this section.
1337	(1)  Prepaid payment rates shall be negotiated between the
1338	agency and the eligible plans as part of the procurement process
1339	described in s. 409.966.
1340	(2)  The agency shall establish payment rates for statewide
1341	inpatient psychiatric programs. Payments to managed care plans
1342	shall be reconciled to reimburse actual payments to statewide
1343	inpatient psychiatric programs.
1344	Section 18.  Section 409.977, Florida Statutes, is created
1345	to read:
1346	409.977  Choice counseling and enrollment.-
1347	(1)  CHOICE COUNSELING.-In addition to the choice
1348	counseling information required by s. 409.969, the agency shall
1349	make available clear and easily understandable choice
1350	information to Medicaid recipients that includes information
1351	about the cost-sharing requirements of each managed care plan.
1352	(2)  AUTOMATIC ENROLLMENT.-The agency shall automatically
1353	enroll into a managed care plan those Medicaid recipients who do
1354	not voluntarily choose a plan pursuant to s. 409.969. The agency
1355	shall automatically enroll recipients in plans that meet or
1356	exceed the performance or quality standards established pursuant
1357	to s. 409.967 and may not automatically enroll recipients in a
1358	plan that is deficient in those performance or quality
1359	standards. When a specialty plan is available to accommodate a
1360	specific condition or diagnosis of a recipient, the agency shall
1361	assign the recipient to that plan. In the first year of the
1362	first contract term only, if a recipient was previously enrolled
1363	in a plan that is still available in the region, the agency
1364	shall automatically enroll the recipient in that plan unless an
1365	applicable specialty plan is available. Except as otherwise
1366	provided in this part, the agency may not engage in practices
1367	that are designed to favor one managed care plan over another.
1368	When automatically enrolling recipients in managed care plans,
1369	the agency shall automatically enroll based on the following
1370	criteria:
1371	(a)  Whether the plan has sufficient network capacity to
1372	meet the needs of the recipients.
1373	(b)  Whether the recipient has previously received services
1374	from one of the plan's primary care providers.
1375	(c)  Whether primary care providers in one plan are more
1376	geographically accessible to the recipient's residence than
1377	those in other plans.
1378	(3)  OPT-OUT OPTION.-The agency shall develop a process to
1379	enable any recipient with access to employer-sponsored health
1380	care coverage to opt out of all managed care plans and to use
1381	Medicaid financial assistance to pay for the recipient's share
1382	of the cost in such employer-sponsored coverage. Contingent upon
1383	federal approval, the agency shall also enable recipients with
1384	access to other insurance or related products providing access
1385	to health care services created pursuant to state law, including
1386	any product available under the Florida Health Choices Program,
1387	or any health exchange, to opt out. The amount of financial
1388	assistance provided for each recipient may not exceed the amount
1389	of the Medicaid premium that would have been paid to a managed
1390	care plan for that recipient.
1391	Section 19.  Section 409.978, Florida Statutes, is created
1392	to read:
1393	409.978  Long-term care managed care program.-
1394	(1)  Pursuant to s. 409.963, the agency shall administer
1395	the long-term care managed care program described in ss.
1396	409.978-409.985, but may delegate specific duties and
1397	responsibilities for the program to the Department of Elderly
1398	Affairs and other state agencies. By July 1, 2012, the agency
1399	shall begin implementation of the statewide long-term care
1400	managed care program, with full implementation in all regions by
1401	October 1, 2013.
1402	(2)  The agency shall make payments for long-term care,
1403	including home and community-based services, using a managed
1404	care model. Unless otherwise specified, the provisions of ss.
1405	409.961-409.97 apply to the long-term care managed care program.
1406	(3)  The Department of Elderly Affairs shall assist the
1407	agency to develop specifications for use in the invitation to
1408	negotiate and the model contract, determine clinical eligibility
1409	for enrollment in managed long-term care plans, monitor plan
1410	performance and measure quality of service delivery, assist
1411	clients and families to address complaints with the plans,
1412	facilitate working relationships between plans and providers
1413	serving elders and disabled adults, and perform other functions
1414	specified in a memorandum of agreement.
1415	Section 20.  Section 409.979, Florida Statutes, is created
1416	to read:
1417	409.979  Eligibility.-
1418	(1)  Medicaid recipients who meet all of the following
1419	criteria are eligible to receive long-term care services and
1420	must receive long-term care services by participating in the
1421	long-term care managed care program. The recipient must be:
1422	(a)  Sixty-five years of age or older, or age 18 or older
1423	and eligible for Medicaid by reason of a disability.
1424	(b)  Determined by the Comprehensive Assessment Review and
1425	Evaluation for Long-Term Care Services (CARES) Program to
1426	require nursing facility care as defined in s. 409.985(3).
1427	(2)  Medicaid recipients who, on the date long-term care
1428	managed care plans become available in their region, reside in a
1429	nursing home facility or are enrolled in one of the following
1430	long-term care Medicaid waiver programs are eligible to
1431	participate in the long-term care managed care program for up to
1432	12 months without being reevaluated for their need for nursing
1433	facility care as defined in s. 409.985(3):
1434	(a)  The Assisted Living for the Frail Elderly Waiver.
1435	(b)  The Aged and Disabled Adult Waiver.
1436	(c)  The Adult Day Health Care Waiver.
1437	(d)  The Consumer-Directed Care Plus Program as described
1438	in s. 409.221.
1439	(e)  The Program of All-inclusive Care for the Elderly.
1440	(f)  The long-term care community-based diversion pilot
1441	project as described in s. 430.705.
1442	(g)  The Channeling Services Waiver for Frail Elders.
1443	(3)  The Department of Elderly Affairs shall make offers
1444	for enrollment to eligible individuals based on a wait-list
1445	prioritization and subject to availability of funds. Before
1446	enrollment offers, the department shall determine that
1447	sufficient funds exist to support additional enrollment into
1448	plans.
1449	Section 21.  Section 409.98, Florida Statutes, is created
1450	to read:
1451	409.98  Benefits.-Long-term care plans shall cover, at a
1452	minimum, the following:
1453	(1)  Nursing facility care.
1454	(2)  Services provided in assisted living facilities.
1455	(3)  Hospice.
1456	(4)  Adult day care.
1457	(5)  Medical equipment and supplies, including incontinence
1458	supplies.
1459	(6)  Personal care.
1460	(7)  Home accessibility adaptation.
1461	(8)  Behavior management.
1462	(9)  Home-delivered meals.
1463	(10)  Case management.
1464	(11)  Therapies:
1465	(a)  Occupational therapy.
1466	(b)  Speech therapy.
1467	(c)  Respiratory therapy.
1468	(d)  Physical therapy.
1469	(12)  Intermittent and skilled nursing.
1470	(13)  Medication administration.
1471	(14)  Medication management.
1472	(15)  Nutritional assessment and risk reduction.
1473	(16)  Caregiver training.
1474	(17)  Respite care.
1475	(18)  Transportation.
1476	(19)  Personal emergency response system.
1477	Section 22.  Section 409.981, Florida Statutes, is created
1478	to read:
1479	409.981  Eligible plans.-
1480	(1)  ELIGIBLE PLANS.-Provider service networks must be
1481	long-term care provider service networks. Other eligible plans
1482	may either be long-term care plans or comprehensive long-term
1483	care plans.
1484	(2)  ELIGIBLE PLAN SELECTION.-The agency shall select
1485	eligible plans through the procurement process described in s.
1486	409.966. The agency shall provide notice of invitations to
1487	negotiate no later than July 1, 2012.
1488	(a)  The agency shall procure three plans for Region I. At
1489	least one plan shall be a provider service network, if any
1490	submit a responsive bid.
1491	(b)  The agency shall procure three plans for Region II. At
1492	least one plan shall be a provider service network, if any
1493	provider service network submits a responsive bid.
1494	(c)  The agency shall procure at least three plans and no
1495	more than four plans for Region III. At least two plans shall be
1496	provider service networks, if any two provider service networks
1497	submit responsive bids.
1498	(d)  The agency shall procure at least four plans and no
1499	more than seven plans for Region IV. At least two plans shall be
1500	provider service networks if any two provider service networks
1501	submit responsive bids.
1502	(e)  The agency shall procure at least five plans and no
1503	more than eight plans for Region V. At least two plans shall be
1504	provider service networks, if any two provider service networks
1505	submit responsive bids.
1506	(f)  The agency shall procure at least three plans and no
1507	more than four plans for Region VI. At least one plan shall be a
1508	provider service network, if any provider service network
1509	submits a responsive bid.
1510	(g)  The agency shall procure at least four plans and no
1511	more than seven plans for Region VII. At least two plans shall
1512	be provider service networks, if any two provider service
1513	networks submit responsive bids.
1514	(h)  The agency shall procure at least five plans and no
1515	more than nine plans for Region VIII. At least two plans shall
1516	be provider service networks, if any two provider service
1517	networks submit a responsive bid.
1518
1519	If no provider service network submits a responsive bid, the
1520	agency shall procure one fewer eligible plan in each of the
1521	regions. Within 12 months after the initial invitation to
1522	negotiate, the agency shall attempt to procure an eligible plan
1523	that is a provider service network. The agency shall notice
1524	another invitation to negotiate only with provider service
1525	networks in a region where no provider service network has been
1526	selected.
1527	(3)  QUALITY SELECTION CRITERIA.-In addition to the
1528	criteria established in s. 409.966, the agency shall consider
1529	the following factors in the selection of eligible plans:
1530	(a)  Evidence of the employment of executive managers with
1531	expertise and experience in serving aged and disabled persons
1532	who require long-term care.
1533	(b)  Whether a plan has established a network of service
1534	providers dispersed throughout the region and in sufficient
1535	numbers to meet specific service standards established by the
1536	agency for specialty services for persons receiving home and
1537	community-based care.
1538	(c)  Whether a plan is proposing to establish a
1539	comprehensive long-term care plan and whether the eligible plan
1540	has a contract to provide managed medical assistance services in
1541	the same region.
1542	(d)  Whether a plan offers consumer-directed care services
1543	to enrollees pursuant to s. 409.221.
1544	(e)  Whether a plan is proposing to provide home and
1545	community-based services in addition to the minimum benefits
1546	required by s. 409.98.
1547	(4)  PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY.-
1548	Participation by the Program of All-Inclusive Care for the
1549	Elderly (PACE) shall be pursuant to a contract with the agency
1550	and not subject to the procurement requirements or regional plan
1551	number limits of this section. PACE plans may continue to
1552	provide services to individuals at such levels and enrollment
1553	caps as authorized by the General Appropriations Act.
1554	Section 23.  Section 409.982, Florida Statutes, is created
1555	to read:
1556	409.982  Managed care plan accountability.-In addition to
1557	the requirements of s. 409.967, plans and providers
1558	participating in the long-term care managed care program shall
1559	comply with the requirements of this section.
1560	(1)  PROVIDER NETWORKS.-Managed care plans may limit the
1561	providers in their networks based on credentials, quality
1562	indicators, and price. For the period between October 1, 2013,
1563	and September 30, 2014, each selected plan must offer a network
1564	contract to all the following providers in the region:
1565	(a)  Nursing homes.
1566	(b)  Hospices.
1567	(c)  Aging network service providers that have previously
1568	participated in home and community-based waivers serving elders
1569	or community-service programs administered by the Department of
1570	Elderly Affairs.
1571
1572	After 12 months of active participation in a managed care plan's
1573	network, the plan may exclude any of the providers named in this
1574	subsection from the network for failure to meet quality or
1575	performance criteria. If the plan excludes a provider from the
1576	plan, the plan must provide written notice to all recipients who
1577	have chosen that provider for care. The notice shall be provided
1578	at least 30 days before the effective date of the exclusion. The
1579	agency shall establish contract provisions governing the
1580	transfer of recipients from excluded residential providers.
1581	(2)  SELECT PROVIDER PARTICIPATION.-Except as provided in
1582	this subsection, providers may limit the managed care plans they
1583	join. Nursing homes and hospices that are enrolled Medicaid
1584	providers must participate in all eligible plans selected by the
1585	agency in the region in which the provider is located.
1586	(3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
1587	monitor the quality and performance of each participating
1588	provider using measures adopted by and collected by the agency
1589	and any additional measures mutually agreed upon by the provider
1590	and the plan
1591	(4)  PROVIDER NETWORK STANDARDS.-The agency shall establish
1592	and each managed care plan must comply with specific standards
1593	for the number, type, and regional distribution of providers in
1594	the plan's network, which must include:
1595	(a)  Adult day care centers.
1596	(b)  Adult family-care homes.
1597	(c)  Assisted living facilities.
1598	(d)  Health care services pools.
1599	(e)  Home health agencies.
1600	(f)  Homemaker and companion services.
1601	(g)  Hospices.
1602	(h)  Community care for the elderly lead agencies.
1603	(i)  Nurse registries.
1604	(j)  Nursing homes.
1605	(5)  PROVIDER PAYMENT.-Managed care plans and providers
1606	shall negotiate mutually acceptable rates, methods, and terms of
1607	payment. Plans shall pay nursing homes an amount equal to the
1608	nursing facility-specific payment rates set by the agency;
1609	however, mutually acceptable higher rates may be negotiated for
1610	medically complex care. Plans shall pay hospice providers
1611	through a prospective system for each enrollee an amount equal
1612	to the per diem rate set by the agency. For recipients residing
1613	in a nursing facility and receiving hospice services, the plan
1614	shall pay the hospice provider the per diem rate set by the
1615	agency minus the nursing facility component and shall pay the
1616	nursing facility the applicable state rate. Plans shall ensure
1617	that electronic nursing home and hospice claims that contain
1618	sufficient information for processing are paid within 10
1619	business days after receipt.
1620	Section 24.  Section 409.983, Florida Statutes, is created
1621	to read:
1622	409.983  Managed care plan payment.-In addition to the
1623	payment provisions of s. 409.968, the agency shall provide
1624	payment to plans in the long-term care managed care program
1625	pursuant to this section.
1626	(1)  Prepaid payment rates for long-term care managed care
1627	plans shall be negotiated between the agency and the eligible
1628	plans as part of the procurement process described in s.
1629	409.966.
1630	(2)  Payment rates for comprehensive long-term care plans
1631	covering services described in s. 409.973 shall be blended with
1632	rates for long-term care plans for services specified in s.
1633	409.98.
1634	(3)  Payment rates for plans shall reflect historic
1635	utilization and spending for covered services projected forward
1636	and adjusted to reflect the level of care profile for enrollees
1637	in each plan. The payment shall be adjusted to provide an
1638	incentive for reducing institutional placements and increasing
1639	the utilization of home and community-based services.
1640	(4)  The initial assessment of an enrollee's level of care
1641	shall be made by the Comprehensive Assessment and Review for
1642	Long-Term-Care Services (CARES) program, which shall assign the
1643	recipient into one of the following levels of care:
1644	(a)  Level of care 1 consists of recipients residing in or
1645	who must be placed in a nursing home.
1646	(b)  Level of care 2 consists of recipients at imminent
1647	risk of nursing home placement, as evidenced by the need for the
1648	constant availability of routine medical and nursing treatment
1649	and care, and require extensive health-related care and services
1650	because of mental or physical incapacitation.
1651	(c)  Level of care 3 consists of recipients at imminent
1652	risk of nursing home placement, as evidenced by the need for the
1653	constant availability of routine medical and nursing treatment
1654	and care, who have a limited need for health-related care and
1655	services and are mildly medically or physically incapacitated.
1656
1657	The agency shall periodically adjust payment rates to account
1658	for changes in the level of care profile for each managed care
1659	plan based on encounter data.
1660	(5)  The agency shall make an incentive adjustment in
1661	payment rates to encourage the increased utilization of home and
1662	community-based services and a commensurate reduction of
1663	institutional placement. The incentive adjustment shall be
1664	modified in each successive rate period during the first
1665	contract period, as follows:
1666	(a)  A 2 percentage point shift in the first rate-setting
1667	period;
1668	(b)  A 2 percentage point shift in the second rate-setting
1669	period, as compared to the utilization mix at the end of the
1670	first rate-setting period;
1671	(c)  A 3 percentage point shift in the third rate-setting
1672	period, and in each subsequent rate-setting period during the
1673	first contract period, as compared to the utilization mix at the
1674	end of the immediately preceding rate-setting period.
1675
1676	The incentive adjustment shall continue in subsequent contract
1677	periods, at a rate of 3 percentage points per year as compared
1678	to the utilization mix at the end of the immediately preceding
1679	rate-setting period, until no more than 35 percent of the plan's
1680	enrollees are placed in institutional settings. The agency shall
1681	annually report to the Legislature the actual change in the
1682	utilization mix of home and community-based services compared to
1683	institutional placements and provide a recommendation for
1684	utilization mix requirements for future contracts.
1685	(6)  The agency shall establish nursing-facility-specific
1686	payment rates for each licensed nursing home based on facility
1687	costs adjusted for inflation and other factors as authorized in
1688	the General Appropriations Act. Payments to long-term care
1689	managed care plans shall be reconciled to reimburse actual
1690	payments to nursing facilities.
1691	(7)  The agency shall establish hospice payment rates
1692	pursuant to Title XVIII of the Social Security Act. Payments to
1693	long-term care managed care plans shall be reconciled to
1694	reimburse actual payments to hospices.
1695	Section 25.  Section 409.984, Florida Statutes, is created
1696	to read:
1697	409.984  Choice counseling; enrollment.-
1698	(1)  CHOICE COUNSELING.-Before contracting with a vendor to
1699	provide choice counseling as authorized under s. 409.969, the
1700	agency shall offer to contract with aging resource centers
1701	established under s. 430.2053 for choice counseling services. If
1702	the aging resource center is determined not to be the vendor
1703	that provides choice counseling, the agency shall establish a
1704	memorandum of understanding with the aging resource center to
1705	coordinate staffing and collaborate with the choice counseling
1706	vendor. In addition to the requirements of s. 409.969, any
1707	contract to provide choice counseling for the long-term care
1708	managed care program shall provide that each recipient be given
1709	the option of having in-person choice counseling.
1710	(2)  AUTOMATIC ENROLLMENT.-The agency shall automatically
1711	enroll into a long-term care managed care plan those Medicaid
1712	recipients who do not voluntarily choose a plan pursuant to s.
1713	409.969. The agency shall automatically enroll recipients in
1714	plans that meet or exceed the performance or quality standards
1715	established pursuant to s. 409.967 and may not automatically
1716	enroll recipients in a plan that is deficient in those
1717	performance or quality standards. If a recipient is deemed
1718	dually eligible for Medicaid and Medicare services and is
1719	currently receiving Medicare services from an entity qualified
1720	under 42 C.F.R. part 422 as a Medicare Advantage Preferred
1721	Provider Organization, Medicare Advantage Provider-sponsored
1722	Organization, or Medicare Advantage Special Needs Plan, the
1723	agency shall automatically enroll the recipient in such plan for
1724	Medicaid services if the plan is currently participating in the
1725	long-term care managed care program. Except as otherwise
1726	provided in this part, the agency may not engage in practices
1727	that are designed to favor one managed care plan over another.
1728	When automatically enrolling recipients in plans, the agency
1729	shall take into account the following criteria:
1730	(a)  Whether the plan has sufficient network capacity to
1731	meet the needs of the recipients.
1732	(b)  Whether the recipient has previously received services
1733	from one of the plan's home and community-based service
1734	providers.
1735	(c)  Whether the home and community-based providers in one
1736	plan are more geographically accessible to the recipient's
1737	residence than those in other plans.
1738	(3)  HOSPICE SELECTION.-Notwithstanding the provisions of
1739	s. 409.969(3)(c), when a recipient is referred for hospice
1740	services, the recipient shall have a 30-day period during which
1741	the recipient may select to enroll in another managed care plan
1742	to access the hospice provider of the recipient's choice.
1743	(4)  CHOICE OF RESIDENTIAL SETTING.-When a recipient is
1744	referred for placement in a nursing home or assisted living
1745	facility, the plan shall inform the recipient of any facilities
1746	within the plan that have specific cultural or religious
1747	affiliations and, if requested by the recipient, make a
1748	reasonable effort to place the recipient in the facility of the
1749	recipient's choice.
1750	Section 26.  Section 409.9841, Florida Statutes, is created
1751	to read:
1752	409.9841  Long-term care managed care technical advisory
1753	workgroup.-
1754	(1)  Before August 1, 2011, the agency shall establish a
1755	technical advisory workgroup to assist in developing:
1756	(a)  The method of determining Medicaid eligibility
1757	pursuant to s. 409.985(3).
1758	(b)  The requirements for provider payments to nursing
1759	homes under s. 409.983(6).
1760	(c)  The method for managing Medicare coinsurance crossover
1761	claims.
1762	(d)  Uniform requirements for claims submissions and
1763	payments, including electronic funds transfers and claims
1764	processing.
1765	(e)  The process for enrollment of and payment for
1766	individuals pending determination of Medicaid eligibility.
1767	(2)  The advisory workgroup shall include, but is not
1768	limited to, representatives of providers and plans who could
1769	potentially participate in long-term care managed care. Members
1770	of the workgroup shall serve without compensation but may be
1771	reimbursed for per diem and travel expenses as provided in s.
1772	112.061.
1773	(3)  This section is repealed on June 30, 2013.
1774	Section 27.  Section 409.985, Florida Statutes, is created
1775	to read:
1776	409.985  Comprehensive Assessment and Review for Long-Term
1777	Care Services (CARES) Program.-
1778	(1)  The agency shall operate the Comprehensive Assessment
1779	and Review for Long-Term Care Services (CARES) preadmission
1780	screening program to ensure that only individuals whose
1781	conditions require long-term care services are enrolled in the
1782	long-term care managed care program.
1783	(2)  The agency shall operate the CARES program through an
1784	interagency agreement with the Department of Elderly Affairs.
1785	The agency, in consultation with the Department of Elderly
1786	Affairs, may contract for any function or activity of the CARES
1787	program, including any function or activity required by 42
1788	C.F.R. part 483.20, relating to preadmission screening and
1789	review.
1790	(3)  The CARES program shall determine if an individual
1791	requires nursing facility care and, if the individual requires
1792	such care, assign the individual to a level of care as described
1793	in s. 409.983(4). When determining the need for nursing facility
1794	care, consideration shall be given to the nature of the services
1795	prescribed and which level of nursing or other health care
1796	personnel meets the qualifications necessary to provide such
1797	services and the availability to and access by the individual of
1798	community or alternative resources. For the purposes of the
1799	long-term care managed care program, the term "nursing facility
1800	care" means the individual:
1801	(a)  Requires nursing home placement as evidenced by the
1802	need for medical observation throughout a 24-hour period and
1803	care required to be performed on a daily basis by, or under the
1804	direct supervision of, a registered nurse or other health care
1805	professional and requires services that are sufficiently
1806	medically complex to require supervision, assessment, planning,
1807	or intervention by a registered nurse because of a mental or
1808	physical incapacitation by the individual;
1809	(b)  Requires or is at imminent risk of nursing home
1810	placement as evidenced by the need for observation throughout a
1811	24-hour period and care and the constant availability of medical
1812	and nursing treatment and requires services on a daily or
1813	intermittent basis that are to be performed under the
1814	supervision of licensed nursing or other health professionals
1815	because the individual who is incapacitated mentally or
1816	physically; or
1817	(c)  Requires or is at imminent risk of nursing home
1818	placement as evidenced by the need for observation throughout a
1819	24-hour period and care and the constant availability of medical
1820	and nursing treatment and requires limited services that are to
1821	be performed under the supervision of licensed nursing or other
1822	health professionals because the individual is mildly
1823	incapacitated mentally or physically.
1824	(4)  For individuals whose nursing home stay is initially
1825	funded by Medicare and Medicare coverage and is being terminated
1826	for lack of progress towards rehabilitation, CARES staff shall
1827	consult with the person making the determination of progress
1828	toward rehabilitation to ensure that the recipient is not being
1829	inappropriately disqualified from Medicare coverage. If, in
1830	their professional judgment, CARES staff believe that a Medicare
1831	beneficiary is still making progress toward rehabilitation, they
1832	may assist the Medicare beneficiary with an appeal of the
1833	disqualification from Medicare coverage. The use of CARES teams
1834	to review Medicare denials for coverage under this section is
1835	authorized only if it is determined that such reviews qualify
1836	for federal matching funds through Medicaid. The agency shall
1837	seek or amend federal waivers as necessary to implement this
1838	section.
1839	Section 28.  Section 409.986, Florida Statutes, is created
1840	to read:
1841	409.986  Managed long-term care for persons with
1842	developmental disabilities.-
1843	(1)  Pursuant to s. 409.963, the agency is responsible for
1844	administering the long-term care managed care program for
1845	persons with developmental disabilities described in ss.
1846	409.986-409.992, but may delegate specific duties and
1847	responsibilities for the program to the Agency for Persons with
1848	Disabilities and other state agencies. By January 1, 2015, the
1849	agency shall begin implementation of statewide long-term care
1850	managed care for persons with developmental disabilities, with
1851	full implementation in all regions by October 1, 2016.
1852	(2)  The agency shall make payments for long-term care for
1853	persons with developmental disabilities, including home and
1854	community-based services, using a managed care model. Unless
1855	otherwise specified, the provisions of ss. 409.961-409.97 apply
1856	to the long-term care managed care program for persons with
1857	developmental disabilities.
1858	(3)  The Agency for Persons with Disabilities shall assist
1859	the agency to develop the specifications for use in the
1860	invitations to negotiate and the model contract, determine
1861	clinical eligibility for enrollment in long-term care plans for
1862	persons with developmental disabilities, assist the agency to
1863	monitor plan performance and measure quality, assist clients and
1864	families to address complaints with the plans, facilitate
1865	working relationships between plans and providers serving
1866	persons with developmental disabilities, and perform other
1867	functions specified in a memorandum of agreement.
1868	Section 29.  Section 409.987, Florida Statutes, is created
1869	to read:
1870	409.987  Eligibility.-
1871	(1)  Medicaid recipients who meet all of the following
1872	criteria are eligible and shall be enrolled in a comprehensive
1873	long-term care plan or long-term care plan:
1874	(a)  Is Medicaid eligible pursuant to s. 409.904.
1875	(b)  Is a Florida resident who has a developmental
1876	disability as defined in s. 393.063.
1877	(c)  Meets the level of care need, including:
1878	1.  The recipient's intelligence quotient is 59 or less;
1879	2.  The recipient's intelligence quotient is 60-69,
1880	inclusive, and the recipient has a secondary condition that
1881	includes cerebral palsy, spina bifida, Prader-Willi syndrome,
1882	epilepsy, or autistic disorder or has ambulation, sensory,
1883	chronic health, and behavioral problems;
1884	3.  The recipient's intelligence quotient is 60-69,
1885	inclusive, and the recipient has severe functional limitations
1886	in at least three major life activities, including self-care,
1887	learning, mobility, self-direction, understanding and use of
1888	language, and capacity for independent living; or
1889	4.  The recipient is eligible under a primary disability of
1890	autistic disorder, cerebral palsy, spina bifida, or Prader-Willi
1891	syndrome. In addition, the condition must result in substantial
1892	functional limitations in three or more major life activities,
1893	including self-care, learning, mobility, self-direction,
1894	understanding and use of language, and capacity for independent
1895	living.
1896	(d)  Meets the level of care need to receive services in an
1897	intermediate care facility for the developmentally disabled.
1898	(e)  Is enrolled in a home and community-based Medicaid
1899	waiver established in chapter 393 or the Consumer Directed Care
1900	Plus program for persons with developmental disabilities under
1901	the Medicaid state plan, is a Medicaid-funded resident of a
1902	private intermediate care facility for the developmentally
1903	disabled on the date the managed long-term care plans for
1904	persons with disabilities becomes available in the recipient's
1905	region, or has been offered enrollment in a comprehensive long-
1906	term care plan or a long-term care plan.
1907	(2)  The Agency for Persons with Disabilities shall make
1908	offers for enrollment to eligible individuals based on the wait-
1909	list prioritization in s. 393.065(5) and subject to availability
1910	of funds. Before enrollment offers, the agency shall determine
1911	that sufficient funds exist to support additional enrollment
1912	into plans.
1913	(3)  Unless specifically exempted, all eligible persons
1914	must be enrolled in a comprehensive long-term care plan or a
1915	long-term care plan. Medicaid recipients who are residents of a
1916	developmental disability center, including Sunland Center in
1917	Marianna and Tacachale Center in Gainesville, are exempt from
1918	mandatory enrollment but may voluntarily enroll in a long-term
1919	care plan.
1920	Section 30.  Section 409.988, Florida Statutes, is created
1921	to read:
1922	409.988  Benefits.-Managed care plans shall cover, at a
1923	minimum, the services in this section. Plans may customize
1924	benefit packages or offer additional benefits to meet the needs
1925	of enrollees in the plan.
1926	(1)  Intermediate care for the developmentally disabled.
1927	(2)  Services in alternative residential settings,
1928	including, but not limited to:
1929	(a)  Group homes licensed under chapter 393 and foster care
1930	homes licensed under chapter 409.
1931	(b)  Comprehensive transitional education programs licensed
1932	under chapter 393.
1933	(c)  Residential habilitation centers licensed under
1934	chapter 393.
1935	(d)  Assisted living facilities licensed under chapter 429
1936	and transitional living facilities licensed under part V of
1937	chapter 400.
1938	(3)  Adult day training.
1939	(4)  Behavior analysis services.
1940	(5)  Companion services.
1941	(6)  Consumable medical supplies.
1942	(7)  Durable medical equipment and supplies.
1943	(8)  Environmental accessibility adaptations.
1944	(9)  In-home support services.
1945	(10)  Therapies, including occupational, speech,
1946	respiratory, and physical therapy.
1947	(11)  Personal care assistance.
1948	(12)  Residential habilitation services.
1949	(13)  Intensive behavioral residential habilitation
1950	services.
1951	(14)  Behavior focus residential habilitation services.
1952	(15)  Residential nursing services.
1953	(16)  Respite care.
1954	(17)  Support coordination.
1955	(18)  Supported employment.
1956	(19)  Supported living coaching.
1957	(20)  Transportation.
1958	Section 31.  Section 409.989, Florida Statutes, is created
1959	to read:
1960	409.989  Eligible plans.-
1961	(1)  ELIGIBLE PLANS.-Provider service networks may be
1962	either long-term care plans or comprehensive long-term care
1963	plans. Other plans must be comprehensive long-term care plans
1964	and under contract to provide services pursuant to s. 409.973 or
1965	s. 409.98 in any of the regions that form the combined region as
1966	defined in this section.
1967	(2)  PROVIDER SERVICE NETWORKS.-Provider service networks
1968	targeted to serve persons with disabilities must include one or
1969	more owners licensed pursuant to s. 393.067 or s. 400.962 and
1970	with at least 10 years' experience in serving this population.
1971	(3)  ELIGIBLE PLAN SELECTION.-The agency shall select
1972	eligible plans through the procurement process described in s.
1973	409.966. The agency shall notice invitations to negotiate no
1974	later than January 1, 2015.
1975	(a)  The agency shall procure at least two plans and no
1976	more than three plans for services in combined Regions I, II,
1977	and III. At least one plan shall be a provider service network,
1978	if any submit a responsive bid.
1979	(b)  The agency shall procure at least two plans and no
1980	more than three plans for services in combined Regions IV and V.
1981	At least one plan shall be a provider service network, if any
1982	submit a responsive bid.
1983	(c)  The agency shall procure at least two plans and no
1984	more than four plans for services in combined Regions VI, VII,
1985	and VIII. At least one plan shall be a provider service network,
1986	if any submit a responsive bid.
1987
1988	If no provider service network submits a responsive bid, the
1989	agency shall procure no more than one less than the maximum
1990	number of eligible plans permitted in the combined region.
1991	Within 12 months after the initial invitation to negotiate, the
1992	agency shall attempt to procure an eligible plan that is a
1993	provider service network. The agency shall notice another
1994	invitation to negotiate only with provider service networks in
1995	such combined region where no provider service network has been
1996	selected.
1997	(4)  QUALITY SELECTION CRITERIA.-In addition to the
1998	criteria established in s. 409.966, the agency shall consider
1999	the following factors in the selection of eligible plans:
2000	(a)  Whether the plan has sufficient specialized staffing,
2001	including employment of executive managers with expertise and
2002	experience in serving persons with developmental disabilities.
2003	(b)  Whether the plan has sufficient network
2004	qualifications, including establishment of a network of service
2005	providers dispersed throughout the combined region and in
2006	sufficient numbers to meet specific accessibility standards
2007	established by the agency for specialty services for persons
2008	with developmental disabilities.
2009	(c)  Whether the plan has written agreements or signed
2010	contracts or has made substantial progress in establishing
2011	relationships with providers before the plan submitting a
2012	response. The agency shall give preference to plans with
2013	evidence of signed contracts with providers listed in s.
2014	409.99(1).
2015	(5)  CHILDREN'S MEDICAL SERVICES NETWORK.-The Children's
2016	Medical Services Network may provide either long-term care plans
2017	or comprehensive long-term care plans. Participation by the
2018	Children's Medical Services Network shall be pursuant to a
2019	single, statewide contract with the agency not subject to the
2020	procurement requirements or regional plan number limits of this
2021	section. The Children's Medical Services Network must meet all
2022	other plan requirements.
2023	Section 32.  Section 409.99, Florida Statutes, is created
2024	to read:
2025	409.99  Managed care plan accountability.-In addition to
2026	the requirements of s. 409.967, managed care plans and providers
2027	shall comply with the requirements of this section.
2028	(1)  PROVIDER NETWORKS.-Managed care plans may limit the
2029	providers in their networks based on credentials, quality
2030	indicators, and price. However, in the first contract period
2031	after an eligible plan is selected in a region by the agency,
2032	the plan must offer a network contract to the following
2033	providers in the region:
2034	(a)  Providers with licensed institutional care facilities
2035	for the developmentally disabled.
2036	(b)  Providers of alternative residential facilities
2037	specified in s. 409.988.
2038
2039	After 12 months of active participation in a managed care plan
2040	network, the plan may exclude any of the above-named providers
2041	from the network for failure to meet quality or performance
2042	criteria. If the plan excludes a provider from the plan, the
2043	plan must provide written notice to all recipients who have
2044	chosen that provider for care. The notice shall be issued at
2045	least 90 days before the effective date of the exclusion.
2046	(2)  SELECT PROVIDER PARTICIPATION.-Except as provided in
2047	this subsection, providers may limit the managed care plans they
2048	join. Licensed institutional care facilities for the
2049	developmentally disabled and licensed residential settings
2050	providing Intensive Behavioral Residential Habilitation services
2051	with an active Medicaid provider agreement must agree to
2052	participate in any eligible plan selected by the agency.
2053	(3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
2054	monitor the quality and performance of each participating
2055	provider. At the beginning of the contract period, each plan
2056	shall notify all its network providers of the metrics used by
2057	the plan for evaluating the provider's performance and
2058	determining continued participation in the network.
2059	(4)  PROVIDER PAYMENT.-Managed care plans and providers
2060	shall negotiate mutually acceptable rates, methods, and terms of
2061	payment. Plans shall pay intermediate care facilities for the
2062	developmentally disabled and intensive behavior residential
2063	habilitation providers an amount equal to the facility-specific
2064	payment rate set by the agency.
2065	(5)  CONSUMER AND FAMILY INVOLVEMENT.-Each managed care
2066	plan must establish a family advisory committee to participate
2067	in program design and oversight.
2068	(6)  CONSUMER-DIRECTED CARE.-Each managed care plan must
2069	offer consumer-directed care services to enrollees pursuant to
2070	s. 409.221.
2071	Section 33.  Section 409.991, Florida Statutes, is created
2072	to read:
2073	409.991  Managed care plan payment.-In addition to the
2074	payment provisions of s. 409.968, the agency shall provide
2075	payment to comprehensive long-term care plans and long-term care
2076	plans pursuant to this section.
2077	(1)  Prepaid payment rates shall be negotiated between the
2078	agency and the eligible plans as part of the procurement process
2079	described in s. 409.966.
2080	(2)  Payment for comprehensive long-term care plans
2081	covering services pursuant to s. 409.973 shall be blended with
2082	payments for long-term care plans for services specified in s.
2083	409.988.
2084	(3)  Payment rates for plans covering services specified in
2085	s. 409.988 shall be based on historical utilization and spending
2086	for covered services projected forward and adjusted to reflect
2087	the level-of-care profile of each plan's enrollees.
2088	(4)  The Agency for Persons with Disabilities shall conduct
2089	the initial assessment of an enrollee's level of care. The
2090	evaluation of level of care shall be based on assessment and
2091	service utilization information from the most recent version of
2092	the Questionnaire for Situational Information and encounter
2093	data.
2094	(5)  The agency shall assign enrollees of developmental
2095	disabilities long-term care plans into one of five levels of
2096	care to account for variations in risk status and service needs
2097	among enrollees.
2098	(a)  Level of care 1 consists of individuals receiving
2099	services in an intermediate care facility for the
2100	developmentally disabled.
2101	(b)  Level of care 2 consists of individuals with intensive
2102	medical or adaptive needs and who require essential services to
2103	avoid institutionalization or who possess behavioral problems
2104	that are exceptional in intensity, duration, or frequency and
2105	present a substantial risk of harm to themselves or others.
2106	(c)  Level of care 3 consists of individuals with service
2107	needs, including a licensed residential facility and a moderate
2108	level of support for standard residential habilitation services
2109	or a minimal level of support for behavior focus residential
2110	habilitation services, or individuals in supported living who
2111	require more than 6 hours a day of in-home support services.
2112	(d)  Level of care 4 consists of individuals requiring less
2113	than a moderate level of residential habilitation support in a
2114	residential placement or individuals in supported living who
2115	require 6 hours a day or less of in-home support services.
2116	(e)  Level of care 5 consists of individuals who do not
2117	receive in-home support services and need minimal support
2118	services while living in independent or supported living
2119	situations or in their family home.
2120
2121	The agency shall periodically adjust aggregate payments to plans
2122	based on encounter data to account for variations in risk levels
2123	among plans' enrollees.
2124	(6)  The agency shall establish intensive behavior
2125	residential habilitation rates for providers approved by the
2126	agency to provide this service. The agency shall also establish
2127	intermediate care facility for the developmentally disabled-
2128	specific payment rates for each licensed intermediate care
2129	facility. Payments to intermediate care facilities for the
2130	developmentally disabled and providers of intensive behavior
2131	residential habilitation services shall be reconciled to
2132	reimburse the plan's actual payments to the facilities.
2133	Section 34.  Section 409.992, Florida Statutes, is created
2134	to read:
2135	409.992  Automatic enrollment.-The agency shall
2136	automatically enroll into a comprehensive long-term care plan or
2137	a long-term care plan those Medicaid recipients who do not
2138	voluntarily choose a plan pursuant to s. 409.969. The agency
2139	shall automatically enroll recipients in plans that meet or
2140	exceed the performance or quality standards established pursuant
2141	to s. 409.967 and shall not automatically enroll recipients in a
2142	plan that is deficient in those performance or quality
2143	standards. Except as otherwise provided in this part, the agency
2144	shall assign individuals who are deemed dually eligible for
2145	Medicaid and Medicare to a plan that provides both Medicaid and
2146	Medicare services. The agency may not engage in practices that
2147	are designed to favor one managed care plan over another. When
2148	automatically enrolling recipients in plans, the agency shall
2149	take into account the following criteria:
2150	(1)  Whether the plan has sufficient network capacity to
2151	meet the needs of the recipients.
2152	(2)  Whether the recipient has previously received services
2153	from one of the plan's home and community-based service
2154	providers.
2155	(3)  Whether home and community-based providers in one plan
2156	are more geographically accessible to the recipient's residence
2157	than those in other plans.
2158	Section 35.  This act shall take effect July 1, 2011.

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