Florida Senate - 2012 SB 1988
By the Committee on Budget
576-03468-12 20121988__
1 A bill to be entitled
2 An act relating to Medicaid; amending s. 383.15, F.S.;
3 revising legislative intent relating to funding for
4 regional perinatal intensive care centers; amending s.
5 409.8132, F.S.; revising a cross-reference; amending
6 s. 409.814, F.S.; deleting a prohibition preventing
7 children who are eligible for coverage under a state
8 health benefit plan from being eligible for services
9 provided through the subsidized program; revising
10 cross-references; requiring a completed application,
11 including a clinical screening, for enrollment in the
12 Children’s Medical Services Network; amending s.
13 409.902, F.S.; providing for the creation an Internet
14 based system for determining eligibility for the
15 Medicaid and Kidcare programs, contingent on the
16 appropriation; providing system business objectives
17 and requirements; requiring the Department of Children
18 and Family Services to develop the system; requiring
19 the system to be completed and implemented by
20 specified dates; providing a governance structure
21 pending implementation of the program, including an
22 executive steering committee and a project management
23 team; amending s. 409.905, F.S.; limiting the number
24 of paid hospital emergency department visits for
25 nonpregnant adults; authorizing the Agency for Health
26 Care Administration to request approval by the
27 Legislative Budget Commission of hospital rate
28 adjustments; providing components for the agency’s
29 plan to convert inpatient hospital rates to a
30 prospective payment system; revising dates for
31 submitting the plan and implementing the system;
32 amending 409.908, F.S.; conforming a cross-reference;
33 authorizing the Agency for Health Care Administration
34 to accept voluntary intergovernmental transfers of
35 local taxes and other qualified revenue from counties,
36 municipalities, or special taxing districts in order
37 to fund certain costs; limiting the use of
38 intergovernmental transfer funds for hospital
39 reimbursements; prohibiting the inclusion of certain
40 hospital costs in the capitation rates for prepaid
41 health plans; providing for the inclusion of certain
42 hospital costs in capitation rates for prepaid health
43 plans if funded by intergovernmental transfers;
44 incorporating a transferred provision; amending s.
45 409.911, F.S.; updating references to data used for
46 calculations in the disproportionate share program;
47 repealing s. 409.9112, F.S., relating to the
48 disproportionate share program for regional perinatal
49 intensive care centers; amending s. 409.9113, F.S.;
50 conforming a cross-reference; authorizing the agency
51 to distribute moneys in the disproportionate share
52 program for teaching hospitals; repealing s. 409.9117,
53 F.S., relating to the primary care disproportionate
54 share program; amending s. 409.912, F.S.; revising the
55 conditions for contracting with certain managed care
56 plans for behavioral health care services; deleting
57 requirements for assigning certain MediPass recipients
58 to managed care plans for behavioral health care
59 services; requiring the assignment of recipients to
60 provider service networks; amending s. 409.9121, F.S.;
61 revising legislative findings relating to the Medicaid
62 program; amending s. 409.9122, F.S.; providing
63 criteria and procedures relating to recipient
64 enrollment choice and assignment among Medicaid
65 managed care plans and MediPass; deleting transferred
66 provisions relating to school districts; amending s.
67 409.9123, F.S.; revising provisions relating to the
68 publication of quality measures for managed care
69 plans; reenacting s. 409.9126, F.S., relating to
70 children with special health care needs; amending s.
71 409.915, F.S.; specifying criteria for determining a
72 county’s eligible recipients; providing for payment of
73 billings that have been denied by the county from the
74 county’s tax revenues; providing for refunds;
75 providing for the transfer of certain refunds to the
76 Lawton Chiles Endowment Fund; amending ss. 409.979 and
77 430.04, F.S.; deleting references to the Adult Day
78 Health Care Waiver in provisions relating to Medicaid
79 eligibility and duties and responsibilities of the
80 Department of Elderly Affairs; amending s. 31, chapter
81 2009-223, Laws of Florida, as amended, and
82 redesignating that section as s. 409.9132, F.S.;
83 expanding the home health agency monitoring pilot
84 project statewide; amending s. 32, chapter 2009-223,
85 Laws of Florida, and redesignating that section as s.
86 409.9133, F.S.; expanding the comprehensive care
87 management pilot project for home health services
88 statewide and including private-duty nursing and
89 personal care services; providing an additional site
90 in Broward County for the Program of All-Inclusive
91 Care for the Elderly; providing that a public hospital
92 located in trauma service area 2 which has local funds
93 available for intergovernmental transfers may have its
94 reimbursement rates adjusted after a certain date;
95 providing effective dates.
96
97 Be It Enacted by the Legislature of the State of Florida:
98
99 Section 1. Section 383.15, Florida Statutes, is amended to
100 read:
101 383.15 Legislative intent; perinatal intensive care
102 services.—The Legislature finds and declares that many perinatal
103 diseases and disabilities have debilitating, costly, and often
104 fatal consequences if left untreated. Many of these debilitating
105 conditions could be prevented or ameliorated if services were
106 available to the public through a regional perinatal intensive
107 care centers program. Perinatal intensive care services are
108 critical to the well-being and development of a healthy society
109 and represent a constructive, cost-beneficial, and essential
110 investment in the future of our state. Therefore, it is the
111 intent of the Legislature to develop a regional perinatal
112 intensive care centers program. The Legislature further intends
113 that development of such a regional perinatal intensive care
114 centers program shall not reduce or dilute the current financial
115 commitment of the state, as indicated through appropriation, to
116 the existing regional perinatal intensive care centers. It is
117 also the intent of the Legislature that any additional centers
118 regional perinatal intensive care center authorized under s.
119 383.19 after July 1, 1993, shall not receive payments under a
120 disproportionate share program for regional perinatal intensive
121 care centers authorized under chapter 409 s. 409.9112 unless
122 specific appropriations are provided to expand such payments to
123 additional hospitals.
124 Section 2. Paragraph (b) of subsection (6) of section
125 409.8132, Florida Statutes, is amended to read:
126 409.8132 Medikids program component.—
127 (6) ELIGIBILITY.—
128 (b) The provisions of s. 409.814 apply 409.814(3), (4),
129 (5), and (6) shall be applicable to the Medikids program.
130 Section 3. Section 409.814, Florida Statutes, is amended to
131 read:
132 409.814 Eligibility.—A child who has not reached 19 years
133 of age whose family income is equal to or below 200 percent of
134 the federal poverty level is eligible for the Florida Kidcare
135 program as provided in this section. For enrollment in the
136 Children’s Medical Services Network, a complete application
137 includes the medical or behavioral health screening. If,
138 subsequently, an enrolled individual is determined to be
139 ineligible for coverage, he or she must be immediately be
140 disenrolled from the respective Florida Kidcare program
141 component.
142 (1) A child who is eligible for Medicaid coverage under s.
143 409.903 or s. 409.904 must be enrolled in Medicaid and is not
144 eligible to receive health benefits under any other health
145 benefits coverage authorized under the Florida Kidcare program.
146 (2) A child who is not eligible for Medicaid, but who is
147 eligible for the Florida Kidcare program, may obtain health
148 benefits coverage under any of the other components listed in s.
149 409.813 if such coverage is approved and available in the county
150 in which the child resides.
151 (3) A Title XXI-funded child who is eligible for the
152 Florida Kidcare program who is a child with special health care
153 needs, as determined through a medical or behavioral screening
154 instrument, is eligible for health benefits coverage from and
155 shall be assigned to and may opt out of the Children’s Medical
156 Services Network.
157 (4) The following children are not eligible to receive
158 Title XXI-funded premium assistance for health benefits coverage
159 under the Florida Kidcare program, except under Medicaid if the
160 child would have been eligible for Medicaid under s. 409.903 or
161 s. 409.904 as of June 1, 1997:
162 (a) A child who is eligible for coverage under a state
163 health benefit plan on the basis of a family member’s employment
164 with a public agency in the state.
165 (a)(b) A child who is covered under a family member’s group
166 health benefit plan or under other private or employer health
167 insurance coverage, if the cost of the child’s participation is
168 not greater than 5 percent of the family’s income. If a child is
169 otherwise eligible for a subsidy under the Florida Kidcare
170 program and the cost of the child’s participation in the family
171 member’s health insurance benefit plan is greater than 5 percent
172 of the family’s income, the child may enroll in the appropriate
173 subsidized Kidcare program.
174 (b)(c) A child who is seeking premium assistance for the
175 Florida Kidcare program through employer-sponsored group
176 coverage, if the child has been covered by the same employer’s
177 group coverage during the 60 days before the family submitted
178 prior to the family’s submitting an application for
179 determination of eligibility under the program.
180 (c)(d) A child who is an alien, but who does not meet the
181 definition of qualified alien, in the United States.
182 (d)(e) A child who is an inmate of a public institution or
183 a patient in an institution for mental diseases.
184 (e)(f) A child who is otherwise eligible for premium
185 assistance for the Florida Kidcare program and has had his or
186 her coverage in an employer-sponsored or private health benefit
187 plan voluntarily canceled in the last 60 days, except those
188 children whose coverage was voluntarily canceled for good cause,
189 including, but not limited to, the following circumstances:
190 1. The cost of participation in an employer-sponsored
191 health benefit plan is greater than 5 percent of the family’s
192 income;
193 2. The parent lost a job that provided an employer
194 sponsored health benefit plan for children;
195 3. The parent who had health benefits coverage for the
196 child is deceased;
197 4. The child has a medical condition that, without medical
198 care, would cause serious disability, loss of function, or
199 death;
200 5. The employer of the parent canceled health benefits
201 coverage for children;
202 6. The child’s health benefits coverage ended because the
203 child reached the maximum lifetime coverage amount;
204 7. The child has exhausted coverage under a COBRA
205 continuation provision;
206 8. The health benefits coverage does not cover the child’s
207 health care needs; or
208 9. Domestic violence led to loss of coverage.
209 (5) A child who is otherwise eligible for the Florida
210 Kidcare program and who has a preexisting condition that
211 prevents coverage under another insurance plan as described in
212 paragraph (4)(a) (4)(b) which would have disqualified the child
213 for the Florida Kidcare program if the child were able to enroll
214 in the plan is shall be eligible for Florida Kidcare coverage
215 when enrollment is possible.
216 (6) A child whose family income is above 200 percent of the
217 federal poverty level or a child who is excluded under the
218 provisions of subsection (4) may participate in the Florida
219 Kidcare program as provided in s. 409.8132 or, if the child is
220 ineligible for Medikids by reason of age, in the Florida Healthy
221 Kids program, subject to the following provisions:
222 (a) The family is not eligible for premium assistance
223 payments and must pay the full cost of the premium, including
224 any administrative costs.
225 (b) The board of directors of the Florida Healthy Kids
226 Corporation may offer a reduced benefit package to these
227 children in order to limit program costs for such families.
228 (7) Once a child is enrolled in the Florida Kidcare
229 program, the child is eligible for coverage under the program
230 for 12 months without a redetermination or reverification of
231 eligibility, if the family continues to pay the applicable
232 premium. Eligibility for program components funded through Title
233 XXI of the Social Security Act terminates shall terminate when a
234 child attains the age of 19. A child who has not attained the
235 age of 5 and who has been determined eligible for the Medicaid
236 program is eligible for coverage for 12 months without a
237 redetermination or reverification of eligibility.
238 (8) When determining or reviewing a child’s eligibility
239 under the Florida Kidcare program, the applicant shall be
240 provided with reasonable notice of changes in eligibility which
241 may affect enrollment in one or more of the program components.
242 If When a transition from one program component to another is
243 authorized, there shall be cooperation between the program
244 components and the affected family which promotes continuity of
245 health care coverage. Any authorized transfers must be managed
246 within the program’s overall appropriated or authorized levels
247 of funding. Each component of the program shall establish a
248 reserve to ensure that transfers between components will be
249 accomplished within current year appropriations. These reserves
250 shall be reviewed by each convening of the Social Services
251 Estimating Conference to determine the adequacy of such reserves
252 to meet actual experience.
253 (9) In determining the eligibility of a child, an assets
254 test is not required. Each applicant shall provide documentation
255 during the application process and the redetermination process,
256 including, but not limited to, the following:
257 (a) Each applicant’s Proof of family income, which must
258 shall be verified electronically to determine financial
259 eligibility for the Florida Kidcare program. Written
260 documentation, which may include wages and earnings statements
261 or pay stubs, W-2 forms, or a copy of the applicant’s most
262 recent federal income tax return, is shall be required only if
263 the electronic verification is not available or does not
264 substantiate the applicant’s income.
265 (b) Each applicant shall provide A statement from all
266 applicable, employed family members that:
267 1. Their employers do not sponsor health benefit plans for
268 employees;
269 2. The potential enrollee is not covered by an employer
270 sponsored health benefit plan; or
271 3. The potential enrollee is covered by an employer
272 sponsored health benefit plan and the cost of the employer
273 sponsored health benefit plan is more than 5 percent of the
274 family’s income.
275 (c) To enroll in the Children’s Medical Services Network, a
276 completed application, including a clinical screening.
277 (10) Subject to paragraph (4)(a) (4)(b), the Florida
278 Kidcare program shall withhold benefits from an enrollee if the
279 program obtains evidence that the enrollee is no longer
280 eligible, submitted incorrect or fraudulent information in order
281 to establish eligibility, or failed to provide verification of
282 eligibility. The applicant or enrollee shall be notified that
283 because of such evidence program benefits will be withheld
284 unless the applicant or enrollee contacts a designated
285 representative of the program by a specified date, which must be
286 within 10 working days after the date of notice, to discuss and
287 resolve the matter. The program shall make every effort to
288 resolve the matter within a timeframe that will not cause
289 benefits to be withheld from an eligible enrollee.
290 (11) The following individuals may be subject to
291 prosecution in accordance with s. 414.39:
292 (a) An applicant obtaining or attempting to obtain benefits
293 for a potential enrollee under the Florida Kidcare program if
294 when the applicant knows or should have known that the potential
295 enrollee does not qualify for the Florida Kidcare program.
296 (b) An individual who assists an applicant in obtaining or
297 attempting to obtain benefits for a potential enrollee under the
298 Florida Kidcare program if when the individual knows or should
299 have known that the potential enrollee does not qualify for the
300 Florida Kidcare program.
301 Section 4. Section 409.902, Florida Statutes, is amended to
302 read:
303 409.902 Designated single state agency; eligibility
304 determinations payment requirements; program title; release of
305 medical records.—
306 (1) The Agency for Health Care Administration is designated
307 as the single state agency authorized to make payments for
308 medical assistance and related services under Title XIX of the
309 Social Security Act. These payments shall be made, subject to
310 any limitations or directions provided for in the General
311 Appropriations Act, only for services included in the program,
312 shall be made only on behalf of eligible individuals, and shall
313 be made only to qualified providers in accordance with federal
314 requirements for Title XIX of the Social Security Act and the
315 provisions of state law. This program of medical assistance is
316 designated the “Medicaid program.”
317 (2) The Department of Children and Family Services is
318 responsible for determining Medicaid eligibility determinations,
319 including, but not limited to, policy, rules, and the agreement
320 with the Social Security Administration for Medicaid eligibility
321 determinations for Supplemental Security Income recipients, as
322 well as the actual determination of eligibility. As a condition
323 of Medicaid eligibility, subject to federal approval, the agency
324 for Health Care Administration and the department must of
325 Children and Family Services shall ensure that each recipient of
326 Medicaid consents to the release of her or his medical records
327 to the agency for Health Care Administration and the Medicaid
328 Fraud Control Unit of the Department of Legal Affairs.
329 (3)(2) Eligibility is restricted to United States citizens
330 and to lawfully admitted noncitizens who meet the criteria
331 provided in s. 414.095(3).
332 (a) Citizenship or immigration status must be verified. For
333 noncitizens, this includes verification of the validity of
334 documents with the United States Citizenship and Immigration
335 Services using the federal SAVE verification process.
336 (b) State funds may not be used to provide medical services
337 to individuals who do not meet the requirements of this
338 subsection unless the services are necessary to treat an
339 emergency medical condition or are for pregnant women. Such
340 services are authorized only to the extent provided under
341 federal law and in accordance with federal regulations as
342 provided in 42 C.F.R. s. 440.255.
343 (4) To the extent funds are appropriated, the department
344 shall collaborate with the agency to develop an Internet-based
345 system for determining eligibility for the Medicaid and Kidcare
346 programs which complies with all applicable federal and state
347 laws and requirements.
348 (a) The system must accomplish the following primary
349 business objectives:
350 1. Provide individuals and families with a single access
351 point to information that explains benefits, premiums, and cost
352 sharing available through Medicaid, Kidcare, or any other state
353 or federal health insurance exchange.
354 2. Enable timely, accurate, and efficient enrollment of
355 eligible persons into available assistance programs.
356 3. Prevent eligibility fraud.
357 4. Allow for detailed financial analysis of eligibility
358 based cost drivers.
359 (b) The system must include, but need not be limited to,
360 the following business and functional requirements:
361 1. Allowing for the completion and submission of an online
362 application for determining eligibility which accepts the use of
363 electronic signatures.
364 2. Including a process that enables automatic enrollment of
365 qualified individuals into Medicaid, Kidcare, or any other state
366 or federal exchange that offers cost-sharing benefits for the
367 purchase of health insurance.
368 3. Allowing for the determination of Medicaid eligibility
369 based on modified adjusted gross income by using information
370 submitted in the application and information accessed and
371 verified through automated and secure interfaces with authorized
372 databases.
373 4. Including the ability to determine specific categories
374 of Medicaid eligibility and interface with the Florida Medicaid
375 Management Information System to support such determination,
376 using federally approved assessment methodologies, of state and
377 federal financial participation rates for persons in each
378 eligibility category.
379 5. Allowing for the accurate and timely processing of
380 eligibility claims and adjudications.
381 6. Aligning with and incorporating all applicable state and
382 federal laws, requirements, and standards, including the
383 information technology security requirements established under
384 s. 282.318 and the accessibility standards established under
385 part II of chapter 282.
386 7. Producing transaction data, reports, and performance
387 information that contributes to an evaluation of the program,
388 continuous improvement in business operations, and increased
389 transparency and accountability.
390 (c) The department shall develop the system subject to
391 approval by the Legislative Budget Commission and as required by
392 the General Appropriations Act for the 2012-2013 fiscal year.
393 (d) The system must be completed by October 1, 2013, and
394 ready for implementation by January 1, 2014.
395 (e) The department shall implement the following project
396 governance structure until the system is implemented:
397 1. The director of the department’s Economic Self
398 Sufficiency Services Program Office shall have overall
399 responsibility for the project.
400 2. The project shall be governed by an executive steering
401 committee composed of three department staff members appointed
402 by the Secretary of Children and Family Services; three agency
403 staff members, including at least two state Medicaid program
404 staff members, appointed by the Secretary of Health Care
405 Administration; and one staff member from Children’s Medical
406 Services within the Department of Health appointed by the
407 Surgeon General.
408 3. The executive steering committee shall have overall
409 responsibility for ensuring that the project meets its primary
410 business objectives and shall:
411 a. Provide management direction and support to the project
412 management team.
413 b. Review and approve any changes to the project’s scope,
414 schedule, and budget.
415 c. Review, approve, and determine whether to proceed with
416 any major deliverable project.
417 d. Recommend suspension or termination of the project to
418 the Governor, the President of the Senate, and the Speaker of
419 the House of Representatives if the committee determines that
420 the primary business objectives cannot be achieved.
421 4. A project management team shall be appointed by and work
422 under the direction of the executive steering committee. The
423 project management team shall:
424 a. Provide planning, management, and oversight of the
425 project.
426 b. Submit an operational work plan and provide quarterly
427 updates to the plan to the executive steering committee. The
428 plan must specify project milestones, deliverables, and
429 expenditures.
430 c. Submit written monthly project status reports to the
431 executive steering committee.
432 Section 5. Subsections (5) of section 409.905, Florida
433 Statutes, is amended to read:
434 409.905 Mandatory Medicaid services.—The agency may make
435 payments for the following services, which are required of the
436 state by Title XIX of the Social Security Act, furnished by
437 Medicaid providers to recipients who are determined to be
438 eligible on the dates on which the services were provided. Any
439 service under this section shall be provided only when medically
440 necessary and in accordance with state and federal law.
441 Mandatory services rendered by providers in mobile units to
442 Medicaid recipients may be restricted by the agency. Nothing in
443 this section shall be construed to prevent or limit the agency
444 from adjusting fees, reimbursement rates, lengths of stay,
445 number of visits, number of services, or any other adjustments
446 necessary to comply with the availability of moneys and any
447 limitations or directions provided for in the General
448 Appropriations Act or chapter 216.
449 (5) HOSPITAL INPATIENT SERVICES.—The agency shall pay for
450 all covered services provided for the medical care and treatment
451 of a Medicaid recipient who is admitted as an inpatient by a
452 licensed physician or dentist to a hospital licensed under part
453 I of chapter 395. However, the agency shall limit the payment
454 for inpatient hospital services for a nonpregnant Medicaid
455 recipient 21 years of age or older to 45 days per fiscal year or
456 the number of days necessary to comply with the General
457 Appropriations Act. Effective August 1, 2012, the agency shall
458 limit payment for hospital emergency department visits for a
459 nonpregnant recipient 21 years of age or older to six visits per
460 fiscal year.
461 (a) The agency may is authorized to implement reimbursement
462 and utilization management reforms in order to comply with any
463 limitations or directions in the General Appropriations Act,
464 which may include, but are not limited to: prior authorization
465 for inpatient psychiatric days; prior authorization for
466 nonemergency hospital inpatient admissions for individuals 21
467 years of age and older; authorization of emergency and urgent
468 care admissions within 24 hours after admission; enhanced
469 utilization and concurrent review programs for highly utilized
470 services; reduction or elimination of covered days of service;
471 adjusting reimbursement ceilings for variable costs; adjusting
472 reimbursement ceilings for fixed and property costs; and
473 implementing target rates of increase. The agency may limit
474 prior authorization for hospital inpatient services to selected
475 diagnosis-related groups, based on an analysis of the cost and
476 potential for unnecessary hospitalizations represented by
477 certain diagnoses. Admissions for normal delivery and newborns
478 are exempt from requirements for prior authorization
479 requirements. In implementing the provisions of this section
480 related to prior authorization, the agency must shall ensure
481 that the process for authorization is accessible 24 hours per
482 day, 7 days per week and authorization is automatically granted
483 if when not denied within 4 hours after the request.
484 Authorization procedures must include steps for the review of
485 denials. Upon implementing the prior authorization program for
486 hospital inpatient services, the agency shall discontinue its
487 hospital retrospective review program.
488 (b) A licensed hospital maintained primarily for the care
489 and treatment of patients having mental disorders or mental
490 diseases is not eligible to participate in the hospital
491 inpatient portion of the Medicaid program except as provided
492 under in federal law. However, the department shall apply for a
493 waiver, within 9 months after June 5, 1991, designed to provide
494 hospitalization services for mental health reasons to children
495 and adults in the most cost-effective and lowest cost setting
496 possible. Such waiver must shall include a request for the
497 opportunity to pay for care in hospitals known under federal law
498 as “institutions for mental disease” or “IMD’s.” The waiver
499 proposal may not shall propose no additional aggregate cost to
500 the state or Federal Government, and shall be conducted in
501 Hillsborough County, Highlands County, Hardee County, Manatee
502 County, and Polk County. The waiver proposal may incorporate
503 competitive bidding for hospital services, comprehensive
504 brokering, prepaid capitated arrangements, or other mechanisms
505 deemed by the department to show promise in reducing the cost of
506 acute care and increasing the effectiveness of preventive care.
507 When developing the waiver proposal, the department shall take
508 into account price, quality, accessibility, linkages of the
509 hospital to community services and family support programs,
510 plans of the hospital to ensure the earliest discharge possible,
511 and the comprehensiveness of the mental health and other health
512 care services offered by participating providers.
513 (c) The agency shall implement a methodology for
514 establishing base reimbursement rates for each hospital based on
515 allowable costs, as defined by the agency. Rates shall be
516 calculated annually and take effect July 1 of each year based on
517 the most recent complete and accurate cost report submitted by
518 each hospital. Adjustments may not be made to the rates after
519 September 30 of the state fiscal year in which the rate takes
520 effect, except that the agency may request that adjustments be
521 approved by the Legislative Budget Commission when needed due to
522 insufficient commitments or collections of intergovernmental
523 transfers under s. 409.908(1) or s. 409.908(4). Errors in cost
524 reporting or calculation of rates discovered after September 30
525 must be reconciled in a subsequent rate period. The agency may
526 not make any adjustment to a hospital’s reimbursement rate more
527 than 5 years after a hospital is notified of an audited rate
528 established by the agency. The prohibition against requirement
529 that the agency making may not make any adjustment to a
530 hospital’s reimbursement rate more than 5 years after a hospital
531 is notified of an audited rate established by the agency is
532 remedial and applies shall apply to actions by providers
533 involving Medicaid claims for hospital services. Hospital rates
534 shall be subject to such limits or ceilings as may be
535 established in law or described in the agency’s hospital
536 reimbursement plan. Specific exemptions to the limits or
537 ceilings may be provided in the General Appropriations Act.
538 (d) The agency shall implement a comprehensive utilization
539 management program for hospital neonatal intensive care stays in
540 certain high-volume participating hospitals, select counties, or
541 statewide, and replace existing hospital inpatient utilization
542 management programs for neonatal intensive care admissions. The
543 program shall be designed to manage the lengths of stay for
544 children being treated in neonatal intensive care units and must
545 seek the earliest medically appropriate discharge to the child’s
546 home or other less costly treatment setting. The agency may
547 competitively bid a contract for the selection of a qualified
548 organization to provide neonatal intensive care utilization
549 management services. The agency may seek federal waivers to
550 implement this initiative.
551 (e) The agency may develop and implement a program to
552 reduce the number of hospital readmissions among the non
553 Medicare population eligible in areas 9, 10, and 11.
554 (f) The agency shall develop a plan to convert Medicaid
555 inpatient hospital rates to a prospective payment system that
556 categorizes each case into diagnosis-related groups (DRG) and
557 assigns a payment weight based on the average resources used to
558 treat Medicaid patients in that DRG. To the extent possible, the
559 agency shall propose an adaptation of an existing prospective
560 payment system, such as the one used by Medicare, and shall
561 propose such adjustments as are necessary for the Medicaid
562 population and to maintain budget neutrality for inpatient
563 hospital expenditures.
564 1. The plan must:
565 a. Define and describe DRGs for inpatient hospital care
566 specific to Medicaid in this state;
567 b. Develop the use of resources needed for each DRG;
568 c. Apply current statewide levels of funding to DRGs based
569 on the associated resource value of DRGs. Current statewide
570 funding levels shall be calculated both with and without the use
571 of intergovernmental transfers;
572 d. Calculate the current number of services provided in the
573 Medicaid program based on DRGs defined under this subparagraph;
574 e. Estimate the number of cases in each DRG for future
575 years based on agency data and the official workload estimates
576 of the Social Services Estimating Conference;
577 f. Estimate potential funding for each hospital with a
578 Medicaid provider agreement, based on the DRGs and estimated
579 workload;
580 g. Propose supplemental DRG payments to augment hospital
581 reimbursements based on patient acuity and individual hospital
582 characteristics, including classification as a children’s
583 hospital, rural hospital, trauma center, burn unit, and other
584 characteristics that could warrant higher reimbursements; and
585 h. Estimate potential funding for each hospital with a
586 Medicaid provider agreement for DRGs defined pursuant to this
587 subparagraph and supplemental DRG payments using current funding
588 levels, calculated both with and without the use of
589 intergovernmental transfers.
590 2. The agency, through a competitive procurement pursuant
591 to chapter 287, shall engage a consultant with expertise and
592 experience in the implementation of DRG systems for hospital
593 reimbursement to develop the DRG plan under subparagraph 1.
594 3. The agency shall submit the Medicaid DRG plan,
595 identifying all steps necessary for the transition and any costs
596 associated with plan implementation, to the Governor, the
597 President of the Senate, and the Speaker of the House of
598 Representatives no later than December 1, 2012 January 1, 2013.
599 Upon receiving legislative authorization, the agency shall begin
600 making the necessary changes to fiscal agent coding by June 1,
601 2013, with a target date of November 1, 2013, for full
602 implementation of the DRG system of hospital reimbursement. If,
603 during implementation of this paragraph, the agency determines
604 that these timeframes might not be achievable, the agency shall
605 report to the Legislative Budget Commission the status of its
606 implementation efforts, the reasons the timeframes might not be
607 achievable, and proposals for new timeframes.
608 Section 6. Paragraph (c) of subsection (1) of section
609 409.908, Florida Statutes, is amended, paragraph (e) is added to
610 that subsection, and subsections (4) and (21) of that section
611 are amended, to read:
612 409.908 Reimbursement of Medicaid providers.—Subject to
613 specific appropriations, the agency shall reimburse Medicaid
614 providers, in accordance with state and federal law, according
615 to methodologies set forth in the rules of the agency and in
616 policy manuals and handbooks incorporated by reference therein.
617 These methodologies may include fee schedules, reimbursement
618 methods based on cost reporting, negotiated fees, competitive
619 bidding pursuant to s. 287.057, and other mechanisms the agency
620 considers efficient and effective for purchasing services or
621 goods on behalf of recipients. If a provider is reimbursed based
622 on cost reporting and submits a cost report late and that cost
623 report would have been used to set a lower reimbursement rate
624 for a rate semester, then the provider’s rate for that semester
625 shall be retroactively calculated using the new cost report, and
626 full payment at the recalculated rate shall be effected
627 retroactively. Medicare-granted extensions for filing cost
628 reports, if applicable, shall also apply to Medicaid cost
629 reports. Payment for Medicaid compensable services made on
630 behalf of Medicaid eligible persons is subject to the
631 availability of moneys and any limitations or directions
632 provided for in the General Appropriations Act or chapter 216.
633 Further, nothing in this section shall be construed to prevent
634 or limit the agency from adjusting fees, reimbursement rates,
635 lengths of stay, number of visits, or number of services, or
636 making any other adjustments necessary to comply with the
637 availability of moneys and any limitations or directions
638 provided for in the General Appropriations Act, provided the
639 adjustment is consistent with legislative intent.
640 (1) Reimbursement to hospitals licensed under part I of
641 chapter 395 must be made prospectively or on the basis of
642 negotiation.
643 (c) Hospitals that provide services to a disproportionate
644 share of low-income Medicaid recipients, or that participate in
645 the regional perinatal intensive care center program under
646 chapter 383, or that participate in the statutory teaching
647 hospital disproportionate share program may receive additional
648 reimbursement. The total amount of payment for disproportionate
649 share hospitals shall be fixed by the General Appropriations
650 Act. The computation of these payments must be made in
651 compliance with all federal regulations and the methodologies
652 described in ss. 409.911, 409.9112, and 409.9113.
653 (e) The agency may accept voluntary intergovernmental
654 transfers of local taxes and other qualified revenue from
655 counties, municipalities, or special taxing districts under
656 paragraphs (a) and (b) or the General Appropriations Act for the
657 purpose of funding the costs of special Medicaid payments to
658 hospitals, the costs of exempting hospitals from reimbursement
659 ceilings, or the costs of buying back hospital Medicaid trend
660 adjustments authorized under the General Appropriations Act,
661 except that the use of these intergovernmental transfers for
662 fee-for-service payments to hospitals is limited to the
663 proportionate use of such funds accepted by the agency under
664 subsection (4). As used in this paragraph, the term
665 “proportionate use” means that the use of intergovernmental
666 transfer funds under this subsection must be in the same
667 proportion to the use of such funds under subsection (4)
668 relative to the need for funding hospital costs under each
669 subsection.
670 (4) Subject to any limitations or directions provided for
671 in the General Appropriations Act, alternative health plans,
672 health maintenance organizations, and prepaid health plans,
673 including health maintenance organizations, prepaid provider
674 service networks, and other capitated managed care plans, shall
675 be reimbursed a fixed, prepaid amount negotiated, or
676 competitively bid pursuant to s. 287.057, by the agency and
677 prospectively paid to the provider monthly for each Medicaid
678 recipient enrolled. The amount may not exceed the average amount
679 the agency determines it would have paid, based on claims
680 experience, for recipients in the same or similar category of
681 eligibility. The agency shall calculate capitation rates on a
682 regional basis and, beginning September 1, 1995, shall include
683 age-band differentials in such calculations.
684 (a) Effective September 1, 2012:
685 1. The costs of special Medicaid payments to hospitals, the
686 costs of exempting hospitals from reimbursement ceilings, and
687 the costs of buying back hospital Medicaid trend adjustments
688 authorized under the General Appropriations Act, which are
689 funded through intergovernmental transfers, may not be included
690 as inpatient or outpatient costs in the calculation of prepaid
691 health plan capitations under this part. This provision must be
692 construed so that inpatient hospital costs included in the
693 calculation of prepaid health plan capitations are identical to
694 those represented by county billing rates under s. 409.915.
695 2. Prepaid health plans may not reimburse hospitals for the
696 costs described in subparagraph 1., except that plans may
697 contract with hospitals to pay inpatient per diems that are
698 between 95 percent and 105 percent of the county billing rate.
699 Hospitals and prepaid health plans may negotiate mutually
700 acceptable higher rates for medically complex care.
701 (b) Notwithstanding paragraph (a):
702 1. In order to fund the inclusion of costs described in
703 paragraph (a) in the calculation of capitations paid to prepaid
704 health plans, the agency may accept voluntary intergovernmental
705 transfers of local taxes and other qualified revenue from
706 counties, municipalities, or special taxing districts. After
707 securing commitments from counties, municipalities, or special
708 taxing districts to contribute intergovernmental transfers for
709 that purpose, the agency shall develop capitation payments for
710 prepaid health plans which include the costs described in
711 paragraph (a) if those components of the capitation are funded
712 through intergovernmental transfers and not with general
713 revenue. The rate-setting methodology must preserve federal
714 matching funds for the intergovernmental transfers collected
715 under this paragraph and result in actuarially sound rates. The
716 agency has the discretion to perform this function using
717 supplemental capitation payments.
718 2. The amounts included in a prepaid health plan’s
719 capitations or supplemental capitations under this paragraph for
720 funding the costs described in paragraph (a) must be used
721 exclusively by the prepaid health plan to enhance hospital
722 payments and be calculated by the agency as accurately as
723 possible to equal the costs described in paragraph (a) which the
724 prepaid health plan actually incurs and for which
725 intergovernmental transfers have been secured.
726 (21) The agency shall reimburse school districts that which
727 certify the state match pursuant to ss. 409.9071 and 1011.70 for
728 the federal portion of the school district’s allowable costs to
729 deliver the services, based on the reimbursement schedule. The
730 school district shall determine the costs for delivering
731 services as authorized in ss. 409.9071 and 1011.70 for which the
732 state match will be certified.
733 (a) School districts participating in the certified school
734 match program pursuant to this subsection and s. 1011.70 shall
735 be reimbursed by Medicaid, subject to the limitations of s.
736 1011.70(1), for a Medicaid-eligible child participating in the
737 services, as authorized under s. 1011.70 and as provided in s.
738 409.9071, regardless of whether the child is enrolled in
739 MediPass or a managed care plan. Managed care plans and school
740 districts shall make good faith efforts to execute agreements
741 regarding the coordinated provision of services authorized under
742 s. 1011.70. County health departments delivering school-based
743 services pursuant to ss. 381.0056 and 381.0057 shall be
744 reimbursed by Medicaid for the federal share for a Medicaid
745 eligible child who receives Medicaid-covered services in a
746 school setting, regardless of whether the child is enrolled in
747 MediPass or a managed care plan. Managed care plans and county
748 health departments shall make good faith efforts to execute
749 agreements regarding the coordinated provision of services to a
750 Medicaid-eligible child. To ensure continuity of care for
751 Medicaid patients, the agency, the Department of Health, and the
752 Department of Education shall develop procedures for ensuring
753 that a student’s managed care plan or MediPass primary care
754 provider receives information relating to services provided in
755 accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
756 (b) Reimbursement of school-based providers is contingent
757 on such providers being enrolled as Medicaid providers and
758 meeting the qualifications contained in 42 C.F.R. s. 440.110,
759 unless otherwise waived by the federal Centers for Medicare and
760 Medicaid Services Health Care Financing Administration. Speech
761 therapy providers who are certified through the Department of
762 Education pursuant to rule 6A-4.0176, Florida Administrative
763 Code, are eligible for reimbursement for services that are
764 provided on school premises. An Any employee of the school
765 district who has been fingerprinted and has received a criminal
766 background check in accordance with Department of Education
767 rules and guidelines is shall be exempt from any agency
768 requirements relating to criminal background checks.
769 Section 7. Subsection (1), paragraphs (a) and (b) of
770 subsection (2), and paragraph (d) of subsection (4) of section
771 409.911, Florida Statutes, are amended to read:
772 409.911 Disproportionate share program.—Subject to specific
773 allocations established within the General Appropriations Act
774 and any limitations established pursuant to chapter 216, the
775 agency shall distribute, pursuant to this section, moneys to
776 hospitals providing a disproportionate share of Medicaid or
777 charity care services by making quarterly Medicaid payments as
778 required. Notwithstanding the provisions of s. 409.915, counties
779 are exempt from contributing toward the cost of this special
780 reimbursement for hospitals serving a disproportionate share of
781 low-income patients.
782 (1) DEFINITIONS.—As used in this section, s. 409.9112, and
783 the Florida Hospital Uniform Reporting System manual:
784 (a) “Adjusted patient days” means the sum of acute care
785 patient days and intensive care patient days as reported to the
786 agency for Health Care Administration, divided by the ratio of
787 inpatient revenues generated from acute, intensive, ambulatory,
788 and ancillary patient services to gross revenues.
789 (b) “Actual audited data” or “actual audited experience”
790 means data reported to the agency for Health Care Administration
791 which has been audited in accordance with generally accepted
792 auditing standards by the agency or representatives under
793 contract with the agency.
794 (c) “Charity care” or “uncompensated charity care” means
795 that portion of hospital charges reported to the agency for
796 Health Care Administration for which there is no compensation,
797 other than restricted or unrestricted revenues provided to a
798 hospital by local governments or tax districts, regardless of
799 the method of payment, for care provided to a patient whose
800 family income for the 12 months preceding the determination is
801 less than or equal to 200 percent of the federal poverty level,
802 unless the amount of hospital charges due from the patient
803 exceeds 25 percent of the annual family income. However, in no
804 case shall the hospital charges for a patient whose family
805 income exceeds four times the federal poverty level for a family
806 of four may not be considered charity.
807 (d) “Charity care days” means the sum of the deductions
808 from revenues for charity care minus 50 percent of restricted
809 and unrestricted revenues provided to a hospital by local
810 governments or tax districts, divided by gross revenues per
811 adjusted patient day.
812 (e) “Hospital” means a health care institution licensed as
813 a hospital pursuant to chapter 395, but does not include
814 ambulatory surgical centers.
815 (f) “Medicaid days” means the number of actual days
816 attributable to Medicaid recipients patients as determined by
817 the agency for Health Care Administration.
818 (2) The agency for Health Care Administration shall use the
819 following actual audited data to determine the Medicaid days and
820 charity care to be used in calculating the disproportionate
821 share payment:
822 (a) The average of the 2004, 2005, and 2006 audited
823 disproportionate share data to determine each hospital’s
824 Medicaid days and charity care for the 2012-2013 2011-2012 state
825 fiscal year.
826 (b) If the agency for Health Care Administration does not
827 have the prescribed 3 years of audited disproportionate share
828 data as noted in paragraph (a) for a hospital, the agency shall
829 use the average of the years of the audited disproportionate
830 share data as noted in paragraph (a) which is available.
831 (4) The following formulas shall be used to pay
832 disproportionate share dollars to public hospitals:
833 (d) Any nonstate government owned or operated hospital
834 eligible for payments under this section on July 1, 2011,
835 remains eligible for payments during the 2012-2013 2011-2012
836 state fiscal year.
837 Section 8. Section 409.9112, Florida Statutes, is repealed.
838 Section 9. Section 409.9113, Florida Statutes, is amended
839 to read:
840 409.9113 Disproportionate share program for teaching
841 hospitals.—In addition to the payments made under s. ss. 409.911
842 and 409.9112, the agency shall make disproportionate share
843 payments to teaching hospitals, as defined in s. 408.07, for
844 their increased costs associated with medical education programs
845 and for tertiary health care services provided to the indigent.
846 This system of payments must conform to federal requirements and
847 distribute funds in each fiscal year for which an appropriation
848 is made by making quarterly Medicaid payments. Notwithstanding
849 s. 409.915, counties are exempt from contributing toward the
850 cost of this special reimbursement for hospitals serving a
851 disproportionate share of low-income patients. For the 2011-2012
852 state fiscal year, The agency shall distribute the moneys
853 provided in the General Appropriations Act to statutorily
854 defined teaching hospitals and family practice teaching
855 hospitals, as defined in s. 395.805, pursuant to this section.
856 The funds provided for statutorily defined teaching hospitals
857 shall be distributed as provided in the General Appropriations
858 Act. The funds provided for family practice teaching hospitals
859 shall be distributed equally among family practice teaching
860 hospitals.
861 (1) On or before September 15 of each year, the agency
862 shall calculate an allocation fraction to be used for
863 distributing funds to statutory teaching hospitals. Subsequent
864 to the end of each quarter of the state fiscal year, the agency
865 shall distribute to each statutory teaching hospital an amount
866 determined by multiplying one-fourth of the funds appropriated
867 for this purpose by the Legislature times such hospital’s
868 allocation fraction. The allocation fraction for each such
869 hospital shall be determined by the sum of the following three
870 primary factors, divided by three:
871 (a) The number of nationally accredited graduate medical
872 education programs offered by the hospital, including programs
873 accredited by the Accreditation Council for Graduate Medical
874 Education and the combined Internal Medicine and Pediatrics
875 programs acceptable to both the American Board of Internal
876 Medicine and the American Board of Pediatrics at the beginning
877 of the state fiscal year preceding the date on which the
878 allocation fraction is calculated. The numerical value of this
879 factor is the fraction that the hospital represents of the total
880 number of programs, where the total is computed for all
881 statutory teaching hospitals.
882 (b) The number of full-time equivalent trainees in the
883 hospital, which comprises two components:
884 1. The number of trainees enrolled in nationally accredited
885 graduate medical education programs, as defined in paragraph
886 (a). Full-time equivalents are computed using the fraction of
887 the year during which each trainee is primarily assigned to the
888 given institution, over the state fiscal year preceding the date
889 on which the allocation fraction is calculated. The numerical
890 value of this factor is the fraction that the hospital
891 represents of the total number of full-time equivalent trainees
892 enrolled in accredited graduate programs, where the total is
893 computed for all statutory teaching hospitals.
894 2. The number of medical students enrolled in accredited
895 colleges of medicine and engaged in clinical activities,
896 including required clinical clerkships and clinical electives.
897 Full-time equivalents are computed using the fraction of the
898 year during which each trainee is primarily assigned to the
899 given institution, over the course of the state fiscal year
900 preceding the date on which the allocation fraction is
901 calculated. The numerical value of this factor is the fraction
902 that the given hospital represents of the total number of full
903 time equivalent students enrolled in accredited colleges of
904 medicine, where the total is computed for all statutory teaching
905 hospitals.
906
907 The primary factor for full-time equivalent trainees is computed
908 as the sum of these two components, divided by two.
909 (c) A service index that comprises three components:
910 1. The Agency for Health Care Administration Service Index,
911 computed by applying the standard Service Inventory Scores
912 established by the agency to services offered by the given
913 hospital, as reported on Worksheet A-2 for the last fiscal year
914 reported to the agency before the date on which the allocation
915 fraction is calculated. The numerical value of this factor is
916 the fraction that the given hospital represents of the total
917 index values, where the total is computed for all statutory
918 teaching hospitals.
919 2. A volume-weighted service index, computed by applying
920 the standard Service Inventory Scores established by the agency
921 to the volume of each service, expressed in terms of the
922 standard units of measure reported on Worksheet A-2 for the last
923 fiscal year reported to the agency before the date on which the
924 allocation factor is calculated. The numerical value of this
925 factor is the fraction that the given hospital represents of the
926 total volume-weighted service index values, where the total is
927 computed for all statutory teaching hospitals.
928 3. Total Medicaid payments to each hospital for direct
929 inpatient and outpatient services during the fiscal year
930 preceding the date on which the allocation factor is calculated.
931 This includes payments made to each hospital for such services
932 by Medicaid prepaid health plans, whether the plan was
933 administered by the hospital or not. The numerical value of this
934 factor is the fraction that each hospital represents of the
935 total of such Medicaid payments, where the total is computed for
936 all statutory teaching hospitals.
937
938 The primary factor for the service index is computed as the sum
939 of these three components, divided by three.
940 (2) By October 1 of each year, the agency shall use the
941 following formula to calculate the maximum additional
942 disproportionate share payment for statutory teaching hospitals:
943
944 TAP = THAF x A
945
946 Where:
947 TAP = total additional payment.
948 THAF = teaching hospital allocation factor.
949 A = amount appropriated for a teaching hospital
950 disproportionate share program.
951 Section 10. Section 409.9117, Florida Statutes, is
952 repealed.
953 Section 11. Paragraphs (b) and (d) of subsection (4) of
954 section 409.912, Florida Statutes, are amended to read:
955 409.912 Cost-effective purchasing of health care.—The
956 agency shall purchase goods and services for Medicaid recipients
957 in the most cost-effective manner consistent with the delivery
958 of quality medical care. To ensure that medical services are
959 effectively utilized, the agency may, in any case, require a
960 confirmation or second physician’s opinion of the correct
961 diagnosis for purposes of authorizing future services under the
962 Medicaid program. This section does not restrict access to
963 emergency services or poststabilization care services as defined
964 in 42 C.F.R. part 438.114. Such confirmation or second opinion
965 shall be rendered in a manner approved by the agency. The agency
966 shall maximize the use of prepaid per capita and prepaid
967 aggregate fixed-sum basis services when appropriate and other
968 alternative service delivery and reimbursement methodologies,
969 including competitive bidding pursuant to s. 287.057, designed
970 to facilitate the cost-effective purchase of a case-managed
971 continuum of care. The agency shall also require providers to
972 minimize the exposure of recipients to the need for acute
973 inpatient, custodial, and other institutional care and the
974 inappropriate or unnecessary use of high-cost services. The
975 agency shall contract with a vendor to monitor and evaluate the
976 clinical practice patterns of providers in order to identify
977 trends that are outside the normal practice patterns of a
978 provider’s professional peers or the national guidelines of a
979 provider’s professional association. The vendor must be able to
980 provide information and counseling to a provider whose practice
981 patterns are outside the norms, in consultation with the agency,
982 to improve patient care and reduce inappropriate utilization.
983 The agency may mandate prior authorization, drug therapy
984 management, or disease management participation for certain
985 populations of Medicaid beneficiaries, certain drug classes, or
986 particular drugs to prevent fraud, abuse, overuse, and possible
987 dangerous drug interactions. The Pharmaceutical and Therapeutics
988 Committee shall make recommendations to the agency on drugs for
989 which prior authorization is required. The agency shall inform
990 the Pharmaceutical and Therapeutics Committee of its decisions
991 regarding drugs subject to prior authorization. The agency is
992 authorized to limit the entities it contracts with or enrolls as
993 Medicaid providers by developing a provider network through
994 provider credentialing. The agency may competitively bid single
995 source-provider contracts if procurement of goods or services
996 results in demonstrated cost savings to the state without
997 limiting access to care. The agency may limit its network based
998 on the assessment of beneficiary access to care, provider
999 availability, provider quality standards, time and distance
1000 standards for access to care, the cultural competence of the
1001 provider network, demographic characteristics of Medicaid
1002 beneficiaries, practice and provider-to-beneficiary standards,
1003 appointment wait times, beneficiary use of services, provider
1004 turnover, provider profiling, provider licensure history,
1005 previous program integrity investigations and findings, peer
1006 review, provider Medicaid policy and billing compliance records,
1007 clinical and medical record audits, and other factors. Providers
1008 are not entitled to enrollment in the Medicaid provider network.
1009 The agency shall determine instances in which allowing Medicaid
1010 beneficiaries to purchase durable medical equipment and other
1011 goods is less expensive to the Medicaid program than long-term
1012 rental of the equipment or goods. The agency may establish rules
1013 to facilitate purchases in lieu of long-term rentals in order to
1014 protect against fraud and abuse in the Medicaid program as
1015 defined in s. 409.913. The agency may seek federal waivers
1016 necessary to administer these policies.
1017 (4) The agency may contract with:
1018 (b) An entity that is providing comprehensive behavioral
1019 health care services to certain Medicaid recipients through a
1020 capitated, prepaid arrangement pursuant to the federal waiver
1021 provided for by s. 409.905(5). Such entity must be licensed
1022 under chapter 624, chapter 636, or chapter 641, or authorized
1023 under paragraph (c) or paragraph (d), and must possess the
1024 clinical systems and operational competence to manage risk and
1025 provide comprehensive behavioral health care to Medicaid
1026 recipients. As used in this paragraph, the term “comprehensive
1027 behavioral health care services” means covered mental health and
1028 substance abuse treatment services that are available to
1029 Medicaid recipients. The secretary of the Department of Children
1030 and Family Services shall approve provisions of procurements
1031 related to children in the department’s care or custody before
1032 enrolling such children in a prepaid behavioral health plan. Any
1033 contract awarded under this paragraph must be competitively
1034 procured. In developing the behavioral health care prepaid plan
1035 procurement document, the agency must shall ensure that the
1036 procurement document requires the contractor to develop and
1037 implement a plan that ensures to ensure compliance with s.
1038 394.4574 related to services provided to residents of licensed
1039 assisted living facilities that hold a limited mental health
1040 license. Except as provided in subparagraph 5., and except in
1041 counties where the Medicaid managed care pilot program is
1042 authorized pursuant to s. 409.91211, the agency shall seek
1043 federal approval to contract with a single entity meeting these
1044 requirements to provide comprehensive behavioral health care
1045 services to all Medicaid recipients not enrolled in a Medicaid
1046 managed care plan authorized under s. 409.91211, a provider
1047 service network authorized under paragraph (d), or a Medicaid
1048 health maintenance organization in an AHCA area. In an AHCA area
1049 where the Medicaid managed care pilot program is authorized
1050 pursuant to s. 409.91211 in one or more counties, the agency may
1051 procure a contract with a single entity to serve the remaining
1052 counties as an AHCA area or the remaining counties may be
1053 included with an adjacent AHCA area and are subject to this
1054 paragraph. Each entity must offer a sufficient choice of
1055 providers in its network to ensure recipient access to care and
1056 the opportunity to select a provider with whom they are
1057 satisfied. The network must shall include all public mental
1058 health hospitals. To ensure unimpaired access to behavioral
1059 health care services by Medicaid recipients, all contracts
1060 issued pursuant to this paragraph must require 80 percent of the
1061 capitation paid to the managed care plan, including health
1062 maintenance organizations and capitated provider service
1063 networks, to be expended for the provision of behavioral health
1064 care services. If the managed care plan expends less than 80
1065 percent of the capitation paid for the provision of behavioral
1066 health care services, the difference shall be returned to the
1067 agency. The agency shall provide the plan with a certification
1068 letter indicating the amount of capitation paid during each
1069 calendar year for behavioral health care services pursuant to
1070 this section. The agency may reimburse for substance abuse
1071 treatment services on a fee-for-service basis until the agency
1072 finds that adequate funds are available for capitated, prepaid
1073 arrangements.
1074 1. The agency shall modify the contracts with the entities
1075 providing comprehensive inpatient and outpatient mental health
1076 care services to Medicaid recipients in Hillsborough, Highlands,
1077 Hardee, Manatee, and Polk Counties, to include substance abuse
1078 treatment services.
1079 2. Except as provided in subparagraph 5., the agency and
1080 the Department of Children and Family Services shall contract
1081 with managed care entities in each AHCA area except area 6 or
1082 arrange to provide comprehensive inpatient and outpatient mental
1083 health and substance abuse services through capitated prepaid
1084 arrangements to all Medicaid recipients who are eligible to
1085 participate in such plans under federal law and regulation. In
1086 AHCA areas where eligible individuals number less than 150,000,
1087 the agency shall contract with a single managed care plan to
1088 provide comprehensive behavioral health services to all
1089 recipients who are not enrolled in a Medicaid health maintenance
1090 organization, a provider service network authorized under
1091 paragraph (d), or a Medicaid capitated managed care plan
1092 authorized under s. 409.91211. The agency may contract with more
1093 than one comprehensive behavioral health provider to provide
1094 care to recipients who are not enrolled in a Medicaid capitated
1095 managed care plan authorized under s. 409.91211, a provider
1096 service network authorized under paragraph (d), or a Medicaid
1097 health maintenance organization in AHCA areas where the eligible
1098 population exceeds 150,000. In an AHCA area where the Medicaid
1099 managed care pilot program is authorized pursuant to s.
1100 409.91211 in one or more counties, the agency may procure a
1101 contract with a single entity to serve the remaining counties as
1102 an AHCA area or the remaining counties may be included with an
1103 adjacent AHCA area and shall be subject to this paragraph.
1104 Contracts for comprehensive behavioral health providers awarded
1105 pursuant to this section shall be competitively procured. Both
1106 for-profit and not-for-profit corporations are eligible to
1107 compete. Managed care plans contracting with the agency under
1108 subsection (3) or paragraph (d) shall provide and receive
1109 payment for the same comprehensive behavioral health benefits as
1110 provided in AHCA rules, including handbooks incorporated by
1111 reference. In AHCA area 11, prior to any fiscal year for which
1112 the agency expects the number of MediPass enrollees in that area
1113 to exceed 150,000, the agency shall seek to contract with at
1114 least two comprehensive behavioral health care providers to
1115 provide behavioral health care to recipients in that area who
1116 are enrolled in, or assigned to, the MediPass program, and the
1117 agency must offer one. One of the behavioral health care
1118 contracts to must be with the existing public hospital-operated
1119 provider service network pilot project, as described in
1120 paragraph (d), for the purpose of demonstrating the cost
1121 effectiveness of the provision of quality mental health services
1122 through a public hospital-operated managed care model. Payment
1123 shall be at an agreed-upon capitated rate to ensure cost
1124 savings. Of the recipients in area 11 who are assigned to
1125 MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
1126 MediPass-enrolled recipients shall be assigned to the existing
1127 provider service network in area 11 for their behavioral care.
1128 3. Children residing in a statewide inpatient psychiatric
1129 program, or in a Department of Juvenile Justice or a Department
1130 of Children and Family Services residential program approved as
1131 a Medicaid behavioral health overlay services provider may not
1132 be included in a behavioral health care prepaid health plan or
1133 any other Medicaid managed care plan pursuant to this paragraph.
1134 4. Traditional community mental health providers under
1135 contract with the Department of Children and Family Services
1136 pursuant to part IV of chapter 394, child welfare providers
1137 under contract with the Department of Children and Family
1138 Services in areas 1 and 6, and inpatient mental health providers
1139 licensed pursuant to chapter 395 must be offered an opportunity
1140 to accept or decline a contract to participate in a any provider
1141 network for prepaid behavioral health services.
1142 5. All Medicaid-eligible children, except children in area
1143 1 and children in Highlands County, Hardee County, Polk County,
1144 or Manatee County of area 6, which that are open for child
1145 welfare services in the statewide automated child welfare
1146 information system, shall receive their behavioral health care
1147 services through a specialty prepaid plan operated by community
1148 based lead agencies through a single agency or formal agreements
1149 among several agencies. The agency shall work with the specialty
1150 plan to develop clinically effective, evidence-based
1151 alternatives as a downward substitution for the statewide
1152 inpatient psychiatric program and similar residential care and
1153 institutional services. The specialty prepaid plan must result
1154 in savings to the state comparable to savings achieved in other
1155 Medicaid managed care and prepaid programs. Such plan must
1156 provide mechanisms to maximize state and local revenues. The
1157 specialty prepaid plan shall be developed by the agency and the
1158 Department of Children and Family Services. The agency may seek
1159 federal waivers to implement this initiative. Medicaid-eligible
1160 children whose cases are open for child welfare services in the
1161 statewide automated child welfare information system and who
1162 reside in AHCA area 10 shall be enrolled in a capitated provider
1163 service network or other capitated managed care plan, which, in
1164 coordination with available community-based care providers
1165 specified in s. 409.1671, must shall provide sufficient medical,
1166 developmental, and behavioral health services to meet the needs
1167 of these children.
1168
1169 This paragraph expires October 1, 2014.
1170 (d)1. A provider service network, which may be reimbursed
1171 on a fee-for-service or prepaid basis. Prepaid provider service
1172 networks shall receive per-member, per-month payments. A
1173 provider service network that does not choose to be a prepaid
1174 plan shall receive fee-for-service rates with a shared savings
1175 settlement. The fee-for-service option shall be available to a
1176 provider service network only for the first 2 years of the
1177 plan’s operation or until the contract year beginning September
1178 1, 2014, whichever is later. The agency shall annually conduct
1179 cost reconciliations to determine the amount of cost savings
1180 achieved by fee-for-service provider service networks for the
1181 dates of service in the period being reconciled. Only payments
1182 for covered services for dates of service within the
1183 reconciliation period and paid within 6 months after the last
1184 date of service in the reconciliation period shall be included.
1185 The agency shall perform the necessary adjustments for the
1186 inclusion of claims incurred but not reported within the
1187 reconciliation for claims that could be received and paid by the
1188 agency after the 6-month claims processing time lag. The agency
1189 shall provide the results of the reconciliations to the fee-for
1190 service provider service networks within 45 days after the end
1191 of the reconciliation period. The fee-for-service provider
1192 service networks shall review and provide written comments or a
1193 letter of concurrence to the agency within 45 days after receipt
1194 of the reconciliation results. This reconciliation shall be
1195 considered final.
1196 2. A provider service network that which is reimbursed by
1197 the agency on a prepaid basis is shall be exempt from parts I
1198 and III of chapter 641, but must comply with the solvency
1199 requirements in s. 641.2261(2) and meet appropriate financial
1200 reserve, quality assurance, and patient rights requirements as
1201 established by the agency.
1202 3. The agency shall assign Medicaid recipients assigned to
1203 a provider service network in accordance with s. 409.9122 or s.
1204 409.91211, as applicable shall be chosen equally from those who
1205 would otherwise have been assigned to prepaid plans and
1206 MediPass. The agency may is authorized to seek federal Medicaid
1207 waivers as necessary to implement the provisions of this
1208 section. This subparagraph expires October 1, 2014.
1209 4. A provider service network is a network established or
1210 organized and operated by a health care provider, or group of
1211 affiliated health care providers, including minority physician
1212 networks and emergency room diversion programs that meet the
1213 requirements of s. 409.91211, which provides a substantial
1214 proportion of the health care items and services under a
1215 contract directly through the provider or affiliated group of
1216 providers and may make arrangements with physicians or other
1217 health care professionals, health care institutions, or any
1218 combination of such individuals or institutions to assume all or
1219 part of the financial risk on a prospective basis for the
1220 provision of basic health services by the physicians, by other
1221 health professionals, or through the institutions. The health
1222 care providers must have a controlling interest in the governing
1223 body of the provider service network organization.
1224 Section 12. Section 409.9121, Florida Statutes, is amended
1225 to read:
1226 409.9121 Legislative findings and intent.—The Legislature
1227 hereby finds that the Medicaid program has experienced an annual
1228 growth rate of approximately 28 percent per year for the past 5
1229 years, and is consuming more than half of all new general
1230 revenue growth. The present Medicaid system must be reoriented
1231 to emphasize, to the maximum extent possible, the delivery of
1232 health care through entities and mechanisms that which are
1233 designed to contain costs, to emphasize preventive and primary
1234 care, and to promote access and continuity of care. The
1235 Legislature further finds that the concept of “managed care”
1236 best encompasses these multiple goals. The Legislature also
1237 finds that, with the cooperation of the physician community,
1238 MediPass, the Medicaid primary care case management program, is
1239 responsible for ensuring that there is a sufficient supply of
1240 primary care to provide access to preventive and primary care
1241 services to Medicaid recipients. Therefore, the Legislature
1242 declares its intent that the Medicaid program require, to the
1243 maximum extent practicable and permitted by federal law, that
1244 all Medicaid recipients be enrolled in a managed care program.
1245 Section 13. Subsections (1), (2), (4), (5), and (12) of
1246 section 409.9122, Florida Statutes, are amended to read:
1247 409.9122 Mandatory Medicaid managed care enrollment;
1248 programs and procedures.—
1249 (1) It is the intent of the Legislature that Medicaid
1250 managed care the MediPass program be cost-effective, provide
1251 quality health care, and improve access to health services, and
1252 that the program be implemented statewide. Medicaid managed care
1253 shall consist of the enrollment of Medicaid recipients in the
1254 MediPass program or managed care plans for comprehensive medical
1255 services. This subsection expires October 1, 2014.
1256 (2)(a) The agency shall enroll all Medicaid recipients in a
1257 managed care plan or MediPass all Medicaid recipients, except
1258 those Medicaid recipients who are: in an institution,; enrolled
1259 in the Medicaid medically needy program,; or eligible for both
1260 Medicaid and Medicare. Upon enrollment, recipients may
1261 individuals will be able to change their managed care option
1262 during the 90-day opt out period required by federal Medicaid
1263 regulations. The agency may is authorized to seek the necessary
1264 Medicaid state plan amendment to implement this policy. However,
1265 (a) To the extent permitted by federal law, the agency may
1266 enroll a recipient in a managed care plan or MediPass a Medicaid
1267 recipient who is exempt from mandatory managed care enrollment
1268 if, provided that:
1269 1. The recipient’s decision to enroll in a managed care
1270 plan or MediPass is voluntary;
1271 2. If The recipient chooses to enroll in a managed care
1272 plan and, the agency has determined that the managed care plan
1273 provides specific programs and services that which address the
1274 special health needs of the recipient; and
1275 3. The agency receives any necessary waivers from the
1276 federal Centers for Medicare and Medicaid Services.
1277
1278 School districts participating in the certified school match
1279 program pursuant to ss. 409.908(21) and 1011.70 shall be
1280 reimbursed by Medicaid, subject to the limitations of s.
1281 1011.70(1), for a Medicaid-eligible child participating in the
1282 services as authorized in s. 1011.70, as provided for in s.
1283 409.9071, regardless of whether the child is enrolled in
1284 MediPass or a managed care plan. Managed care plans shall make a
1285 good faith effort to execute agreements with school districts
1286 regarding the coordinated provision of services authorized under
1287 s. 1011.70. County health departments delivering school-based
1288 services pursuant to ss. 381.0056 and 381.0057 shall be
1289 reimbursed by Medicaid for the federal share for a Medicaid
1290 eligible child who receives Medicaid-covered services in a
1291 school setting, regardless of whether the child is enrolled in
1292 MediPass or a managed care plan. Managed care plans shall make a
1293 good faith effort to execute agreements with county health
1294 departments regarding the coordinated provision of services to a
1295 Medicaid-eligible child. To ensure continuity of care for
1296 Medicaid patients, the agency, the Department of Health, and the
1297 Department of Education shall develop procedures for ensuring
1298 that a student’s managed care plan or MediPass provider receives
1299 information relating to services provided in accordance with ss.
1300 381.0056, 381.0057, 409.9071, and 1011.70.
1301 (b) A Medicaid recipient may shall not be enrolled in or
1302 assigned to a managed care plan or MediPass unless the managed
1303 care plan or MediPass has complied with the quality-of-care
1304 standards specified in paragraphs (3)(a) and (b), respectively.
1305 (c) A Medicaid recipient eligible for managed care
1306 enrollment recipients shall have a choice of managed care
1307 options plans or MediPass. The Agency for Health Care
1308 Administration, the Department of Health, the Department of
1309 Children and Family Services, and the Department of Elderly
1310 Affairs shall cooperate to ensure that each Medicaid recipient
1311 receives clear and easily understandable information that meets
1312 the following requirements:
1313 1. Explains the concept of managed care, including
1314 MediPass.
1315 2. Provides information on the comparative performance of
1316 managed care options available to the recipient plans and
1317 MediPass in the areas of quality, credentialing, preventive
1318 health programs, network size and availability, and patient
1319 satisfaction.
1320 3. Explains where additional information on each managed
1321 care option plan and MediPass in the recipient’s area can be
1322 obtained.
1323 4. Explains that recipients have the right to choose their
1324 managed care coverage at the time they first enroll in Medicaid
1325 and again at regular intervals set by the agency. However, if a
1326 recipient does not choose a managed care option plan or
1327 MediPass, the agency shall will assign the recipient to a
1328 managed care plan or MediPass according to the criteria
1329 specified in this section.
1330 5. Explains the recipient’s right to complain, file a
1331 grievance, or change his or her managed care option as specified
1332 in this section plans or MediPass providers if the recipient is
1333 not satisfied with the managed care plan or MediPass.
1334 (d) The agency shall develop a mechanism for providing
1335 information to Medicaid recipients for the purpose of choosing
1336 making a managed care option plan or MediPass selection.
1337 Examples of such mechanisms may include, but are not be limited
1338 to, interactive information systems, mailings, and mass
1339 marketing materials. Managed care plans and MediPass providers
1340 may not provide are prohibited from providing inducements to
1341 Medicaid recipients to select their plans or prejudice from
1342 prejudicing Medicaid recipients against other managed care plans
1343 or MediPass providers.
1344 (e) Medicaid recipients who are already enrolled in a
1345 managed care plan or MediPass shall be offered the opportunity
1346 to change managed care plans or MediPass providers, as
1347 applicable, on a staggered basis, as defined by the agency. All
1348 Medicaid recipients shall have 30 days in which to choose a
1349 managed care option make a choice of managed care plans or
1350 MediPass providers. Those Medicaid recipients who do not make a
1351 choice shall be assigned in accordance with paragraph (f). To
1352 facilitate continuity of care, for a Medicaid recipient who is
1353 also a recipient of Supplemental Security Income (SSI), prior to
1354 assigning the SSI recipient to a managed care plan or MediPass,
1355 the agency shall determine whether the SSI recipient has an
1356 ongoing relationship with a MediPass provider or managed care
1357 plan, and if so, the agency shall assign the SSI recipient to
1358 that MediPass provider or managed care plan. Those SSI
1359 recipients who do not have such a provider relationship shall be
1360 assigned to a managed care plan or MediPass provider in
1361 accordance with paragraph (f).
1362 1. During the 30-day choice period:
1363 a. A recipient residing in a county in which two or more
1364 managed care plans are eligible to accept Medicaid enrollees,
1365 including a recipient who was enrolled in MediPass at the
1366 commencement of his or her 30-day choice period, shall choose
1367 from those managed care plans. A recipient may opt out of his or
1368 her choice and choose a different managed care plan during the
1369 90-day opt out period.
1370 b. A recipient residing in a county in which only one
1371 managed care plan is eligible to accept Medicaid enrollees shall
1372 choose the managed care plan or a MediPass provider. A recipient
1373 who chooses the managed care plan may opt out of the plan and
1374 choose a MediPass provider during the 90-day opt out period.
1375 c. A recipient residing in a county in which no managed
1376 care plan is accepting Medicaid enrollees shall choose a
1377 MediPass provider.
1378 2. For the purposes of recipient choice, if a managed care
1379 plan reaches its enrollment capacity, as determined by the
1380 agency, the plan may not accept additional Medicaid enrollees
1381 until the agency determines that the plan’s enrollment is
1382 sufficiently less than its enrollment capacity, due to a decline
1383 in enrollment or by an increase in enrollment capacity. If a
1384 managed care plan notifies the agency of its intent to exit a
1385 county, the plan may not accept additional Medicaid enrollees in
1386 that county before the exit date.
1387 3. As used in this paragraph, when referring to recipient
1388 choice, the term “managed care plans” includes health
1389 maintenance organizations, exclusive provider organizations,
1390 provider service networks, minority physician networks,
1391 Children’s Medical Services Networks, and pediatric emergency
1392 department diversion programs authorized by this chapter or the
1393 General Appropriations Act.
1394 4. The agency shall seek federal waiver authority or a
1395 state plan amendment consistent with 42 U.S.C. 1396u-2(a)(1), as
1396 needed, to implement this paragraph.
1397 (f) If a Medicaid recipient does not choose a managed care
1398 option:
1399 1. If the recipient resides in a county in which two or
1400 more managed care plans are accepting Medicaid enrollees, the
1401 agency shall assign the recipient, including a recipient who was
1402 enrolled in MediPass at the commencement of his or her 30-day
1403 choice period, to one of those managed care plans. A recipient
1404 assigned to a managed care plan under this subparagraph may opt
1405 out of the managed care plan and enroll in a different managed
1406 care plan during the 90-day opt out period. The agency shall
1407 seek to make assignments among the managed care plans on an even
1408 basis under the criteria in subparagraph 6.
1409 2. If the recipient resides in a county in which only one
1410 managed care plan is accepting Medicaid enrollees, the agency
1411 shall assign the recipient, including a recipient who was
1412 enrolled in MediPass at the commencement of his or her 30-day
1413 choice period, to the managed care plan. A recipient assigned to
1414 a managed care plan under this subparagraph may opt out of the
1415 managed care plan and choose a MediPass provider during the 90
1416 day opt out period.
1417 3. If the recipient resides in a county in which no managed
1418 care plan is accepting Medicaid enrollees, the agency shall
1419 assign the recipient to a MediPass provider.
1420 4. For the purpose of assignment, if a managed care plan
1421 reaches its enrollment capacity, as determined by the agency,
1422 the plan may not accept additional Medicaid enrollees until the
1423 agency determines that the plan’s enrollment is sufficiently
1424 less than its enrollment capacity, due to a decline in
1425 enrollment or by an increase in enrollment capacity. If a
1426 managed care plan notifies the agency of its intent to exit a
1427 county, the agency may not assign additional Medicaid enrollees
1428 to the plan in that county before the exit date. plan or
1429 MediPass provider, the agency shall assign the Medicaid
1430 recipient to a managed care plan or MediPass provider. Medicaid
1431 recipients eligible for managed care plan enrollment who are
1432 subject to mandatory assignment but who fail to make a choice
1433 shall be assigned to managed care plans until an enrollment of
1434 35 percent in MediPass and 65 percent in managed care plans, of
1435 all those eligible to choose managed care, is achieved. Once
1436 this enrollment is achieved, the assignments shall be divided in
1437 order to maintain an enrollment in MediPass and managed care
1438 plans which is in a 35 percent and 65 percent proportion,
1439 respectively. Thereafter, assignment of Medicaid recipients who
1440 fail to make a choice shall be based proportionally on the
1441 preferences of recipients who have made a choice in the previous
1442 period. Such proportions shall be revised at least quarterly to
1443 reflect an update of the preferences of Medicaid recipients. The
1444 agency shall disproportionately assign Medicaid-eligible
1445 recipients who are required to but have failed to make a choice
1446 of managed care plan or MediPass to the Children’s Medical
1447 Services Network as defined in s. 391.021, exclusive provider
1448 organizations, provider service networks, minority physician
1449 networks, and pediatric emergency department diversion programs
1450 authorized by this chapter or the General Appropriations Act, in
1451 such manner as the agency deems appropriate, until the agency
1452 has determined that the networks and programs have sufficient
1453 numbers to be operated economically.
1454 5. As used in For purposes of this paragraph, when
1455 referring to assignment, the term “managed care plans” includes
1456 health maintenance organizations, exclusive provider
1457 organizations, provider service networks, minority physician
1458 networks, Children’s Medical Services Network, and pediatric
1459 emergency department diversion programs authorized by this
1460 chapter or the General Appropriations Act.
1461 6. When making assignments, the agency shall consider take
1462 into account the following criteria, as applicable:
1463 a.1. Whether a managed care plan has sufficient network
1464 capacity to meet the need of members.
1465 b.2. Whether the managed care plan or MediPass has
1466 previously enrolled the recipient as a member, or one of the
1467 managed care plan’s primary care providers or a MediPass primary
1468 care provider providers has previously provided health care to
1469 the recipient.
1470 c.3. Whether the agency has knowledge that the recipient
1471 member has previously expressed a preference for a particular
1472 managed care plan or MediPass primary care provider as indicated
1473 by Medicaid fee-for-service claims data, but has failed to make
1474 a choice.
1475 d.4. Whether the managed care plan’s or MediPass primary
1476 care providers are geographically accessible to the recipient’s
1477 residence.
1478 e. If the recipient was already enrolled in a managed care
1479 plan at the commencement of his or her 30-day choice period and
1480 fails to choose a different option, the recipient must remain
1481 enrolled in that same managed care plan.
1482 f. To facilitate continuity of care for a Medicaid
1483 recipient who is also a recipient of Supplemental Security
1484 Income (SSI), before assigning the SSI recipient, the agency
1485 shall determine whether the SSI recipient has an ongoing
1486 relationship with a managed care plan or a MediPass primary care
1487 provider, and if so, the agency shall assign the SSI recipient
1488 to that managed care plan or MediPass provider, as applicable.
1489 However, if the recipient has an ongoing relationship with a
1490 MediPass primary care provider who is included in the provider
1491 network of one or more managed care plans, the agency shall
1492 assign the recipient to one of those managed care plans.
1493 g. If the recipient is diagnosed with HIV/AIDS and resides
1494 in Broward County, Miami-Dade County, or Palm Beach County, the
1495 agency shall assign the Medicaid recipient to a managed care
1496 plan that is a health maintenance organization authorized under
1497 chapter 641, that was under contract with the agency on July 1,
1498 2011, and that offers a delivery system in partnership with a
1499 university-based teaching and research-oriented organization
1500 specializing in providing health care services and treatment for
1501 individuals diagnosed with HIV/AIDS. Recipients not diagnosed
1502 with HIV/AIDS may not be assigned under this paragraph to a
1503 managed care plan that specializes in HIV/AIDS.
1504 7. The agency shall seek federal waiver authority or a
1505 state plan amendment consistent with 42 U.S.C. 1396u-2(a)(4)(D),
1506 as needed, to implement this paragraph.
1507 (g) When more than one managed care plan or MediPass
1508 provider meets the criteria specified in paragraph (f), the
1509 agency shall make recipient assignments consecutively by family
1510 unit.
1511 (h) The agency may not engage in practices that are
1512 designed to favor one managed care plan over another or that are
1513 designed to influence Medicaid recipients to enroll in MediPass
1514 rather than in a managed care plan or to enroll in a managed
1515 care plan rather than in MediPass, as applicable. This
1516 subsection does not prohibit the agency from reporting on the
1517 performance of MediPass or any managed care plan, as measured by
1518 performance criteria developed by the agency.
1519 (i) After a recipient has made his or her selection or has
1520 been enrolled in a managed care plan or MediPass, the recipient
1521 shall have 90 days to exercise the opportunity to voluntarily
1522 disenroll and select another managed care option plan or
1523 MediPass. After 90 days, no further changes may be made except
1524 for good cause. Good cause includes, but is not limited to, poor
1525 quality of care, lack of access to necessary specialty services,
1526 an unreasonable delay or denial of service, or fraudulent
1527 enrollment. The agency shall develop criteria for good cause
1528 disenrollment for chronically ill and disabled populations who
1529 are assigned to managed care plans if more appropriate care is
1530 available through the MediPass program. The agency must make a
1531 determination as to whether good cause exists. However, the
1532 agency may require a recipient to use the managed care plan’s or
1533 MediPass grievance process prior to the agency’s determination
1534 of good cause, except in cases in which immediate risk of
1535 permanent damage to the recipient’s health is alleged. The
1536 grievance process, if used when utilized, must be completed in
1537 time to permit the recipient to disenroll by the first day of
1538 the second month after the month the disenrollment request was
1539 made. If the managed care plan or MediPass, as a result of the
1540 grievance process, approves an enrollee’s request to disenroll,
1541 the agency is not required to make a determination in the case.
1542 The agency must make a determination and take final action on a
1543 recipient’s request so that disenrollment occurs by no later
1544 than the first day of the second month after the month the
1545 request was made. If the agency fails to act within the
1546 specified timeframe, the recipient’s request to disenroll is
1547 deemed to be approved as of the date agency action was required.
1548 Recipients who disagree with the agency’s finding that good
1549 cause does not exist for disenrollment shall be advised of their
1550 right to pursue a Medicaid fair hearing to dispute the agency’s
1551 finding.
1552 (j) Consistent with 42 U.S.C. 1396u-2(a)(4)(A) or under
1553 federal waiver authority, as needed, the agency shall apply for
1554 a federal waiver from the Centers for Medicare and Medicaid
1555 Services to lock eligible Medicaid recipients into a managed
1556 care plan or MediPass for 12 months after an open enrollment
1557 period, except for the 90-day opt out period and good cause
1558 disenrollment. After 12 months’ enrollment, a recipient may
1559 select another managed care plan or MediPass provider. However,
1560 nothing shall prevent a Medicaid recipient may not be prevented
1561 from changing primary care providers within the managed care
1562 plan or MediPass program, as applicable, during the 12-month
1563 period.
1564 (k) The agency shall maintain MediPass provider networks in
1565 all counties, including those counties in which two or more
1566 managed care plans are accepting Medicaid enrollees. When a
1567 Medicaid recipient does not choose a managed care plan or
1568 MediPass provider, the agency shall assign the Medicaid
1569 recipient to a managed care plan, except in those counties in
1570 which there are fewer than two managed care plans accepting
1571 Medicaid enrollees, in which case assignment shall be to a
1572 managed care plan or a MediPass provider. Medicaid recipients in
1573 counties with fewer than two managed care plans accepting
1574 Medicaid enrollees who are subject to mandatory assignment but
1575 who fail to make a choice shall be assigned to managed care
1576 plans until an enrollment of 35 percent in MediPass and 65
1577 percent in managed care plans, of all those eligible to choose
1578 managed care, is achieved. Once that enrollment is achieved, the
1579 assignments shall be divided in order to maintain an enrollment
1580 in MediPass and managed care plans which is in a 35 percent and
1581 65 percent proportion, respectively. For purposes of this
1582 paragraph, when referring to assignment, the term “managed care
1583 plans” includes exclusive provider organizations, provider
1584 service networks, Children’s Medical Services Network, minority
1585 physician networks, and pediatric emergency department diversion
1586 programs authorized by this chapter or the General
1587 Appropriations Act. When making assignments, the agency shall
1588 take into account the following criteria:
1589 1. A managed care plan has sufficient network capacity to
1590 meet the need of members.
1591 2. The managed care plan or MediPass has previously
1592 enrolled the recipient as a member, or one of the managed care
1593 plan’s primary care providers or MediPass providers has
1594 previously provided health care to the recipient.
1595 3. The agency has knowledge that the member has previously
1596 expressed a preference for a particular managed care plan or
1597 MediPass provider as indicated by Medicaid fee-for-service
1598 claims data, but has failed to make a choice.
1599 4. The managed care plan’s or MediPass primary care
1600 providers are geographically accessible to the recipient’s
1601 residence.
1602 5. The agency has authority to make mandatory assignments
1603 based on quality of service and performance of managed care
1604 plans.
1605 (l) If the Medicaid recipient is diagnosed with HIV/AIDS
1606 and resides in Broward County, Miami-Dade County, or Palm Beach
1607 County, the agency shall assign the Medicaid recipient to a
1608 managed care plan that is a health maintenance organization
1609 authorized under chapter 641, is under contract with the agency
1610 on July 1, 2011, and which offers a delivery system through a
1611 university-based teaching and research-oriented organization
1612 that specializes in providing health care services and treatment
1613 for individuals diagnosed with HIV/AIDS.
1614 (l)(m) Notwithstanding the provisions of chapter 287, the
1615 agency may, at its discretion, renew cost-effective contracts
1616 for choice counseling services once or more for such periods as
1617 the agency may decide. However, all such renewals may not
1618 combine to exceed a total period longer than the term of the
1619 original contract.
1620
1621 This subsection expires October 1, 2014.
1622 (4)(a) Each female recipient may select as her primary care
1623 provider an obstetrician/gynecologist who has agreed to
1624 participate within a managed care plan’s provider network or as
1625 a MediPass primary care case manager, as applicable.
1626 (b) The agency shall establish a complaints and grievance
1627 process to assist Medicaid recipients enrolled in the MediPass
1628 program to resolve complaints and grievances. The agency shall
1629 investigate reports of quality-of-care grievances which remain
1630 unresolved to the satisfaction of the enrollee.
1631
1632 This subsection expires October 1, 2014.
1633 (5)(a) The agency shall work cooperatively with the Social
1634 Security Administration to identify recipients beneficiaries who
1635 are jointly eligible for Medicare and Medicaid and shall develop
1636 cooperative programs to encourage these recipients beneficiaries
1637 to enroll in a Medicare participating health maintenance
1638 organization or prepaid health plans.
1639 (b) The agency shall work cooperatively with the Department
1640 of Elderly Affairs to assess the potential cost-effectiveness of
1641 providing managed care enrollment MediPass to recipients
1642 beneficiaries who are jointly eligible for Medicare and Medicaid
1643 on a voluntary choice basis. If the agency determines that
1644 enrollment of these recipients beneficiaries in managed care
1645 MediPass has the potential for being cost-effective for the
1646 state, the agency shall offer managed care enrollment MediPass
1647 to these recipients beneficiaries on a voluntary choice basis in
1648 the counties where managed care is available MediPass operates.
1649
1650 This subsection expires October 1, 2014.
1651 (12) The agency shall include in its calculation of the
1652 hospital inpatient component of a Medicaid health maintenance
1653 organization’s capitation rate any special payments, including,
1654 but not limited to, upper payment limit or disproportionate
1655 share hospital payments, made to qualifying hospitals through
1656 the fee-for-service program. The agency may seek federal waiver
1657 approval or state plan amendment as needed to implement this
1658 adjustment. This subsection expires September 1, 2012.
1659 Section 14. Section 409.9123, Florida Statutes, is amended
1660 to read:
1661 409.9123 Quality-of-care reporting.—In order to promote
1662 competition between Medicaid managed care plans and MediPass
1663 based on quality-of-care indicators, The agency shall annually
1664 develop and publish a set of measures of managed care plan
1665 performance based on quality-of-care indicators. This
1666 information shall be made available to each Medicaid recipient
1667 who makes a choice of a managed care plan in her or his area.
1668 This information must shall be easily understandable to the
1669 Medicaid recipient and shall use nationally recognized standards
1670 wherever possible. In formulating this information, the agency
1671 shall, at a minimum, consider take into account at least the
1672 following:
1673 (1) The recommendations of the National Committee for
1674 Quality Assurance Medicaid HEDIS Task Force.
1675 (2) Requirements and recommendations of the Centers for
1676 Medicare and Medicaid Services Health Care Financing
1677 Administration.
1678 (3) Recommendations of the managed care industry.
1679 Section 15. For the purpose of incorporating the amendment
1680 made by this act to section 409.9122, Florida Statutes, in a
1681 reference thereto, subsection (1) of section 409.9126, Florida
1682 Statutes, is reenacted to read:
1683 409.9126 Children with special health care needs.—
1684 (1) Except as provided in subsection (4), children eligible
1685 for Children’s Medical Services who receive Medicaid benefits,
1686 and other Medicaid-eligible children with special health care
1687 needs, shall be exempt from the provisions of s. 409.9122 and
1688 shall be served through the Children’s Medical Services network
1689 established in chapter 391.
1690 Section 16. Effective upon this act becoming a law,
1691 subsections (4) through (6) of section 409.915, Florida
1692 Statutes, are amended, and subsections (7) through (11) are
1693 added to that section, to read:
1694 409.915 County contributions to Medicaid.—Although the
1695 state is responsible for the full portion of the state share of
1696 the matching funds required for the Medicaid program, in order
1697 to acquire a certain portion of these funds, the state shall
1698 charge the counties for certain items of care and service as
1699 provided in this section.
1700 (4) Each county shall contribute pay into the General
1701 Revenue Fund, unallocated, its pro rata share of the total
1702 county participation based upon statements rendered by the
1703 agency in consultation with the counties. The agency shall
1704 render such statements monthly based on each county’s eligible
1705 recipients. For purposes of this section, each county’s eligible
1706 recipients shall be determined by the recipients’ address
1707 information contained in the federally approved Medicaid
1708 eligibility system within the Department of Children and Family
1709 Services. The process developed under subsection (10) may be
1710 used for cases in which the Medicaid eligibility system’s
1711 address information may indicate a need for revision.
1712 (5) The Department of Financial Services shall withhold
1713 from the cigarette tax receipts or any other funds to be
1714 distributed to the counties the individual county share that has
1715 not been remitted within 60 days after billing.
1716 (5)(6) In any county in which a special taxing district or
1717 authority is located which will benefit from the medical
1718 assistance programs covered by this section, the board of county
1719 commissioners may divide the county’s financial responsibility
1720 for this purpose proportionately, and each such district or
1721 authority must furnish its share to the board of county
1722 commissioners in time for the board to comply with the
1723 provisions of subsection (3). Any appeal of the proration made
1724 by the board of county commissioners must be made to the
1725 Department of Financial Services, which shall then set the
1726 proportionate share of each party.
1727 (6)(7) Counties are exempt from contributing toward the
1728 cost of new exemptions on inpatient ceilings for statutory
1729 teaching hospitals, specialty hospitals, and community hospital
1730 education program hospitals that came into effect July 1, 2000,
1731 and for special Medicaid payments that came into effect on or
1732 after July 1, 2000.
1733 (7) By September 1, 2012, the agency shall certify to the
1734 Department of Revenue, for each county, an amount equal to 85
1735 percent of each county’s billings through April 30, 2012, which
1736 remain unpaid.
1737 (8)(a) Beginning with the October 2012 distribution, the
1738 Department of Revenue shall reduce each county’s distributions
1739 pursuant to s. 218.26 by one thirty-sixth of the amount
1740 certified by the agency under subsection (7) for that county.
1741 However, the amount of the reduction may not exceed 50 percent
1742 of each county’s distribution. If, after 36 months, the
1743 reductions for each county do not equal the total amount
1744 initially certified by the agency, the Department of Revenue
1745 shall continue to reduce each distribution by up to 50 percent
1746 until the total amount certified is reached. The amounts by
1747 which the distributions are reduced shall be transferred to the
1748 General Revenue Fund.
1749 (b) As an assurance to holders of bonds issued before the
1750 effective date of this act to which distributions made pursuant
1751 to s. 218.26 are pledged, or bonds issued to refund such bonds
1752 which mature no later than the bonds they refunded and which
1753 result in a reduction of debt service payable in each fiscal
1754 year, the amount available for distribution to a county shall
1755 remain as provided by law and continue to be subject to any lien
1756 or claim on behalf of the bondholders. The Department of Revenue
1757 must ensure that any reduction in amounts distributed pursuant
1758 to paragraph (a) does not reduce the amount of distribution to a
1759 county below the amount necessary for the payment of principal
1760 and interest on the bonds and the amount necessary to comply
1761 with any covenant under the bond resolution or other documents
1762 relating to the issuance of the bonds.
1763 (9)(a) Beginning May 1, 2012, and each month thereafter,
1764 the agency shall certify to the Department of Revenue the amount
1765 of the monthly statement rendered to each county pursuant to
1766 subsection (4). The department shall reduce each county’s
1767 monthly distribution pursuant to s. 218.61 by the amount
1768 certified. The amounts by which the distributions are reduced
1769 shall be transferred to the General Revenue Fund.
1770 (b) As an assurance to holders of bonds issued before the
1771 effective date of this act to which distributions made pursuant
1772 to s. 218.61 are pledged, or bonds issued to refund such bonds
1773 which mature no later than the bonds they refunded and which
1774 result in a reduction of debt service payable in each fiscal
1775 year, the amount available for distribution to a county shall
1776 remain as provided by law and continue to be subject to any lien
1777 or claim on behalf of the bondholders. The Department of Revenue
1778 must ensure that any reductions in amounts distributed pursuant
1779 to paragraph (a) does not reduce the amount of distribution to a
1780 county below the amount necessary for the payment of principal
1781 and interest on the bonds and the amount necessary to comply
1782 with any covenant under the bond resolution or other documents
1783 relating to the issuance of the bonds.
1784 (10) The Department of Revenue shall pay certified refund
1785 requests in accordance with a process developed by the agency
1786 and the department which:
1787 (a) Allows counties to submit to the agency written
1788 requests for refunds of any amounts by which the distributions
1789 were reduced as provided in subsection (9) and which set forth
1790 the reasons for the refund requests.
1791 (b) Requires the agency to make a determination as to
1792 whether a refund request is appropriate and should be approved,
1793 in which case the agency shall certify the amount of the refund
1794 to the department.
1795 (c) Requires the department to issue the refund for the
1796 certified amount to the county from the General Revenue Fund.
1797 (11) Beginning in the 2013-2014 fiscal year and each year
1798 thereafter until the 2020-2021 fiscal year, the Chief Financial
1799 Officer shall transfer from the General Revenue Fund to the
1800 Lawton Chiles Endowment Fund an amount equal to the amounts
1801 transferred to the General Revenue Fund in the previous fiscal
1802 year pursuant to subsections (8) and (9), reduced by the amount
1803 of refunds paid pursuant to subsection (10), which are in excess
1804 of the official estimate for medical hospital fees for such
1805 previous fiscal year adopted by the Revenue Estimating
1806 Conference on January 12, 2012, as reflected in the conference’s
1807 workpapers. By July 20 of each year, the Office of Economic and
1808 Demographic Research shall certify the amount to be transferred
1809 to the Chief Financial Officer. Such transfers must be made
1810 before July 31 of each year until the total transfers for all
1811 years equal $265 million. The Office of Economic and Demographic
1812 Research shall publish the official estimates reflected in the
1813 conference’s workpapers on its website.
1814 Section 17. Subsection (2) of section 409.979, Florida
1815 Statutes, is amended to read:
1816 409.979 Eligibility.—
1817 (2) Medicaid recipients who, on the date long-term care
1818 managed care plans become available in their region, reside in a
1819 nursing home facility or are enrolled in one of the following
1820 long-term care Medicaid waiver programs are eligible to
1821 participate in the long-term care managed care program for up to
1822 12 months without being reevaluated for their need for nursing
1823 facility care as defined in s. 409.985(3):
1824 (a) The Assisted Living for the Frail Elderly Waiver.
1825 (b) The Aged and Disabled Adult Waiver.
1826 (c) The Adult Day Health Care Waiver.
1827 (c)(d) The Consumer-Directed Care Plus Program as described
1828 in s. 409.221.
1829 (d)(e) The Program of All-inclusive Care for the Elderly.
1830 (e)(f) The long-term care community-based diversion pilot
1831 project as described in s. 430.705.
1832 (f)(g) The Channeling Services Waiver for Frail Elders.
1833 Section 18. Subsection (15) of section 430.04, Florida
1834 Statutes, is amended to read:
1835 430.04 Duties and responsibilities of the Department of
1836 Elderly Affairs.—The Department of Elderly Affairs shall:
1837 (15) Administer all Medicaid waivers and programs relating
1838 to elders and their appropriations. The waivers include, but are
1839 not limited to:
1840 (a) The Assisted Living for the Frail Elderly Waiver.
1841 (b) The Aged and Disabled Adult Waiver.
1842 (c) The Adult Day Health Care Waiver.
1843 (c)(d) The Consumer-Directed Care Plus Program as defined
1844 in s. 409.221.
1845 (d)(e) The Program of All-inclusive Care for the Elderly.
1846 (e)(f) The Long-Term Care Community-Based Diversion Pilot
1847 Project as described in s. 430.705.
1848 (f)(g) The Channeling Services Waiver for Frail Elders.
1849
1850 The department shall develop a transition plan for recipients
1851 receiving services in long-term care Medicaid waivers for elders
1852 or disabled adults on the date eligible plans become available
1853 in each recipient’s region defined in s. 409.981(2) to enroll
1854 those recipients in eligible plans. This subsection expires
1855 October 1, 2014.
1856 Section 19. Section 31 of chapter 2009-223, Laws of
1857 Florida, as amended by section 44 of chapter 2010-151, Laws of
1858 Florida, is redesignated as section 409.9132, Florida Statutes,
1859 and amended to read:
1860 409.9132 Section 31. Pilot project to monitor home health
1861 services.—The agency for Health Care Administration shall expand
1862 the develop and implement a home health agency monitoring pilot
1863 project in Miami-Dade County on a statewide basis effective July
1864 1, 2012, except in counties in which the program will not be
1865 cost-effective, as determined by the agency by January 1, 2010.
1866 The agency shall contract with a vendor to verify the
1867 utilization and delivery of home health services and provide an
1868 electronic billing interface for home health services. The
1869 contract must require the creation of a program to submit claims
1870 electronically for the delivery of home health services. The
1871 program must verify telephonically visits for the delivery of
1872 home health services using voice biometrics. The agency may seek
1873 amendments to the Medicaid state plan and waivers of federal
1874 laws, as necessary, to implement or expand the pilot project.
1875 Notwithstanding s. 287.057(3)(f), Florida Statutes, the agency
1876 must award the contract through the competitive solicitation
1877 process and may use the current contract to expand the home
1878 health agency monitoring pilot project to include additional
1879 counties as authorized under this section. The agency shall
1880 submit a report to the Governor, the President of the Senate,
1881 and the Speaker of the House of Representatives evaluating the
1882 pilot project by February 1, 2011.
1883 Section 20. Section 32 of chapter 2009-223, Laws of
1884 Florida, is redesignated as section 409.9133, Florida Statutes,
1885 and amended to read:
1886 409.9133 Section 32. Pilot project for home health care
1887 management.—The agency for Health Care Administration shall
1888 expand the implement a comprehensive care management pilot
1889 project for home health services statewide and include private
1890 duty nursing and personal care services effective July 1, 2012,
1891 except in counties in which the program will not be cost
1892 effective, as determined by the agency by January 1, 2010. The
1893 program must include, which includes face-to-face assessments by
1894 a nurse licensed pursuant to chapter 464, Florida Statutes,
1895 consultation with physicians ordering services to substantiate
1896 the medical necessity for services, and on-site or desk reviews
1897 of recipients’ medical records in Miami-Dade County. The agency
1898 may enter into a contract with a qualified organization to
1899 implement or expand the pilot project. The agency may use the
1900 current contract to expand the comprehensive care management
1901 pilot project to include the additional services and counties
1902 authorized under this section. The agency may seek amendments to
1903 the Medicaid state plan and waivers of federal laws, as
1904 necessary, to implement or expand the pilot project.
1905 Section 21. Notwithstanding s. 430.707, Florida Statutes,
1906 and subject to federal approval of an additional site for the
1907 Program of All-Inclusive Care for the Elderly (PACE), the Agency
1908 for Health Care Administration shall contract with a current
1909 PACE organization authorized to provide PACE services in
1910 Southeast Florida to develop and operate a PACE program in
1911 Broward County to serve frail elders who reside in Broward
1912 County. The organization shall be exempt from chapter 641,
1913 Florida Statutes. The agency, in consultation with the
1914 Department of Elderly Affairs and subject to an appropriation,
1915 shall approve up to 150 initial enrollee slots in the Broward
1916 program established by the organization.
1917 Section 22. Effective upon this act becoming a law and for
1918 the 2011-2012 state fiscal year only, a public hospital located
1919 in trauma service area 2 which has local funds available for
1920 intergovernmental transfers that allow for exemptions from
1921 inpatient and outpatient reimbursement limitations may,
1922 notwithstanding s. 409.905(5)(c), Florida Statues, have its
1923 reimbursement rates adjusted after September 30 of the state
1924 fiscal year in which the rates take effect.
1925 Section 23. Except as otherwise expressly provided in this
1926 act and except for this section, which shall take effect upon
1927 this act becoming a law, this act shall take effect July 1.
1928 2012.