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