Florida Senate - 2012 SENATOR AMENDMENT
Bill No. HB 5301
Barcode 872092
LEGISLATIVE ACTION
Senate . House
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Floor: 1/R/2R .
03/09/2012 10:20 PM .
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Senator Negron moved the following:
1 Senate Amendment (with title amendment)
2
3 Delete everything after the enacting clause
4 and insert:
5 Section 1. Subsection (3) of section 381.79, Florida
6 Statutes, is amended to read:
7 381.79 Brain and Spinal Cord Injury Program Trust Fund.—
8 (3) Annually, 5 percent of the revenues deposited monthly
9 into in the fund pursuant to s. 318.21(2)(d) shall be
10 appropriated to the University of Florida and 5 percent to the
11 University of Miami for spinal cord injury and brain injury
12 research. The amount to be distributed to the universities shall
13 be calculated based on the deposits into the fund for each
14 quarter in the fiscal year, but may not exceed $750,000 $500,000
15 per university per year. Funds distributed under this subsection
16 shall be made in quarterly payments at the end of each quarter
17 during the fiscal year.
18 Section 2. Section 383.15, Florida Statutes, is amended to
19 read:
20 383.15 Legislative intent; perinatal intensive care
21 services.—The Legislature finds and declares that many perinatal
22 diseases and disabilities have debilitating, costly, and often
23 fatal consequences if left untreated. Many of these debilitating
24 conditions could be prevented or ameliorated if services were
25 available to the public through a regional perinatal intensive
26 care centers program. Perinatal intensive care services are
27 critical to the well-being and development of a healthy society
28 and represent a constructive, cost-beneficial, and essential
29 investment in the future of our state. Therefore, it is the
30 intent of the Legislature to develop a regional perinatal
31 intensive care centers program. The Legislature further intends
32 that development of such a regional perinatal intensive care
33 centers program shall not reduce or dilute the current financial
34 commitment of the state, as indicated through appropriation, to
35 the existing regional perinatal intensive care centers. It is
36 also the intent of the Legislature that any additional centers
37 regional perinatal intensive care center authorized under s.
38 383.19 after July 1, 1993, shall not receive payments under a
39 disproportionate share program for regional perinatal intensive
40 care centers authorized under chapter 409 s. 409.9112 unless
41 specific appropriations are provided to expand such payments to
42 additional hospitals.
43 Section 3. Paragraph (b) of subsection (6) of section
44 409.8132, Florida Statutes, is amended to read:
45 409.8132 Medikids program component.—
46 (6) ELIGIBILITY.—
47 (b) The provisions of s. 409.814 apply 409.814(3), (4),
48 (5), and (6) shall be applicable to the Medikids program.
49 Section 4. Section 409.814, Florida Statutes, is amended to
50 read:
51 409.814 Eligibility.—A child who has not reached 19 years
52 of age whose family income is equal to or below 200 percent of
53 the federal poverty level is eligible for the Florida Kidcare
54 program as provided in this section. For enrollment in the
55 Children’s Medical Services Network, a complete application
56 includes the medical or behavioral health screening. If,
57 subsequently, an enrolled individual is determined to be
58 ineligible for coverage, he or she must be immediately be
59 disenrolled from the respective Florida Kidcare program
60 component.
61 (1) A child who is eligible for Medicaid coverage under s.
62 409.903 or s. 409.904 must be enrolled in Medicaid and is not
63 eligible to receive health benefits under any other health
64 benefits coverage authorized under the Florida Kidcare program.
65 (2) A child who is not eligible for Medicaid, but who is
66 eligible for the Florida Kidcare program, may obtain health
67 benefits coverage under any of the other components listed in s.
68 409.813 if such coverage is approved and available in the county
69 in which the child resides.
70 (3) A Title XXI-funded child who is eligible for the
71 Florida Kidcare program who is a child with special health care
72 needs, as determined through a medical or behavioral screening
73 instrument, is eligible for health benefits coverage from and
74 shall be assigned to and may opt out of the Children’s Medical
75 Services Network.
76 (4) The following children are not eligible to receive
77 Title XXI-funded premium assistance for health benefits coverage
78 under the Florida Kidcare program, except under Medicaid if the
79 child would have been eligible for Medicaid under s. 409.903 or
80 s. 409.904 as of June 1, 1997:
81 (a) A child who is eligible for coverage under a state
82 health benefit plan on the basis of a family member’s employment
83 with a public agency in the state.
84 (a)(b) A child who is covered under a family member’s group
85 health benefit plan or under other private or employer health
86 insurance coverage, if the cost of the child’s participation is
87 not greater than 5 percent of the family’s income. If a child is
88 otherwise eligible for a subsidy under the Florida Kidcare
89 program and the cost of the child’s participation in the family
90 member’s health insurance benefit plan is greater than 5 percent
91 of the family’s income, the child may enroll in the appropriate
92 subsidized Kidcare program.
93 (b)(c) A child who is seeking premium assistance for the
94 Florida Kidcare program through employer-sponsored group
95 coverage, if the child has been covered by the same employer’s
96 group coverage during the 60 days before the family submitted
97 prior to the family’s submitting an application for
98 determination of eligibility under the program.
99 (c)(d) A child who is an alien, but who does not meet the
100 definition of qualified alien, in the United States.
101 (d)(e) A child who is an inmate of a public institution or
102 a patient in an institution for mental diseases.
103 (e)(f) A child who is otherwise eligible for premium
104 assistance for the Florida Kidcare program and has had his or
105 her coverage in an employer-sponsored or private health benefit
106 plan voluntarily canceled in the last 60 days, except those
107 children whose coverage was voluntarily canceled for good cause,
108 including, but not limited to, the following circumstances:
109 1. The cost of participation in an employer-sponsored
110 health benefit plan is greater than 5 percent of the family’s
111 income;
112 2. The parent lost a job that provided an employer
113 sponsored health benefit plan for children;
114 3. The parent who had health benefits coverage for the
115 child is deceased;
116 4. The child has a medical condition that, without medical
117 care, would cause serious disability, loss of function, or
118 death;
119 5. The employer of the parent canceled health benefits
120 coverage for children;
121 6. The child’s health benefits coverage ended because the
122 child reached the maximum lifetime coverage amount;
123 7. The child has exhausted coverage under a COBRA
124 continuation provision;
125 8. The health benefits coverage does not cover the child’s
126 health care needs; or
127 9. Domestic violence led to loss of coverage.
128 (5) A child who is otherwise eligible for the Florida
129 Kidcare program and who has a preexisting condition that
130 prevents coverage under another insurance plan as described in
131 paragraph (4)(a) (4)(b) which would have disqualified the child
132 for the Florida Kidcare program if the child were able to enroll
133 in the plan is shall be eligible for Florida Kidcare coverage
134 when enrollment is possible.
135 (6) A child whose family income is above 200 percent of the
136 federal poverty level or a child who is excluded under the
137 provisions of subsection (4) may participate in the Florida
138 Kidcare program as provided in s. 409.8132 or, if the child is
139 ineligible for Medikids by reason of age, in the Florida Healthy
140 Kids program, subject to the following provisions:
141 (a) The family is not eligible for premium assistance
142 payments and must pay the full cost of the premium, including
143 any administrative costs.
144 (b) The board of directors of the Florida Healthy Kids
145 Corporation may offer a reduced benefit package to these
146 children in order to limit program costs for such families.
147 (7) Once a child is enrolled in the Florida Kidcare
148 program, the child is eligible for coverage under the program
149 for 12 months without a redetermination or reverification of
150 eligibility, if the family continues to pay the applicable
151 premium. Eligibility for program components funded through Title
152 XXI of the Social Security Act terminates shall terminate when a
153 child attains the age of 19. A child who has not attained the
154 age of 5 and who has been determined eligible for the Medicaid
155 program is eligible for coverage for 12 months without a
156 redetermination or reverification of eligibility.
157 (8) When determining or reviewing a child’s eligibility
158 under the Florida Kidcare program, the applicant shall be
159 provided with reasonable notice of changes in eligibility which
160 may affect enrollment in one or more of the program components.
161 If When a transition from one program component to another is
162 authorized, there shall be cooperation between the program
163 components and the affected family which promotes continuity of
164 health care coverage. Any authorized transfers must be managed
165 within the program’s overall appropriated or authorized levels
166 of funding. Each component of the program shall establish a
167 reserve to ensure that transfers between components will be
168 accomplished within current year appropriations. These reserves
169 shall be reviewed by each convening of the Social Services
170 Estimating Conference to determine the adequacy of such reserves
171 to meet actual experience.
172 (9) In determining the eligibility of a child, an assets
173 test is not required. Each applicant shall provide documentation
174 during the application process and the redetermination process,
175 including, but not limited to, the following:
176 (a) Each applicant’s Proof of family income, which must
177 shall be verified electronically to determine financial
178 eligibility for the Florida Kidcare program. Written
179 documentation, which may include wages and earnings statements
180 or pay stubs, W-2 forms, or a copy of the applicant’s most
181 recent federal income tax return, is shall be required only if
182 the electronic verification is not available or does not
183 substantiate the applicant’s income.
184 (b) Each applicant shall provide A statement from all
185 applicable, employed family members that:
186 1. Their employers do not sponsor health benefit plans for
187 employees;
188 2. The potential enrollee is not covered by an employer
189 sponsored health benefit plan; or
190 3. The potential enrollee is covered by an employer
191 sponsored health benefit plan and the cost of the employer
192 sponsored health benefit plan is more than 5 percent of the
193 family’s income.
194 (c) To enroll in the Children’s Medical Services Network, a
195 completed application, including a clinical screening.
196 (10) Subject to paragraph (4)(a) (4)(b), the Florida
197 Kidcare program shall withhold benefits from an enrollee if the
198 program obtains evidence that the enrollee is no longer
199 eligible, submitted incorrect or fraudulent information in order
200 to establish eligibility, or failed to provide verification of
201 eligibility. The applicant or enrollee shall be notified that
202 because of such evidence program benefits will be withheld
203 unless the applicant or enrollee contacts a designated
204 representative of the program by a specified date, which must be
205 within 10 working days after the date of notice, to discuss and
206 resolve the matter. The program shall make every effort to
207 resolve the matter within a timeframe that will not cause
208 benefits to be withheld from an eligible enrollee.
209 (11) The following individuals may be subject to
210 prosecution in accordance with s. 414.39:
211 (a) An applicant obtaining or attempting to obtain benefits
212 for a potential enrollee under the Florida Kidcare program if
213 when the applicant knows or should have known that the potential
214 enrollee does not qualify for the Florida Kidcare program.
215 (b) An individual who assists an applicant in obtaining or
216 attempting to obtain benefits for a potential enrollee under the
217 Florida Kidcare program if when the individual knows or should
218 have known that the potential enrollee does not qualify for the
219 Florida Kidcare program.
220 Section 5. Section 409.902, Florida Statutes, is amended to
221 read:
222 409.902 Designated single state agency; eligibility
223 determinations payment requirements; program title; release of
224 medical records.—
225 (1) The Agency for Health Care Administration is designated
226 as the single state agency authorized to make payments for
227 medical assistance and related services under Title XIX of the
228 Social Security Act. These payments shall be made, subject to
229 any limitations or directions provided for in the General
230 Appropriations Act, only for services included in the program,
231 shall be made only on behalf of eligible individuals, and shall
232 be made only to qualified providers in accordance with federal
233 requirements for Title XIX of the Social Security Act and the
234 provisions of state law. This program of medical assistance is
235 designated the “Medicaid program.”
236 (2) The Department of Children and Family Services is
237 responsible for determining Medicaid eligibility determinations,
238 including, but not limited to, policy, rules, and the agreement
239 with the Social Security Administration for Medicaid eligibility
240 determinations for Supplemental Security Income recipients, as
241 well as the actual determination of eligibility. As a condition
242 of Medicaid eligibility, subject to federal approval, the agency
243 for Health Care Administration and the department must of
244 Children and Family Services shall ensure that each recipient of
245 Medicaid consents to the release of her or his medical records
246 to the agency for Health Care Administration and the Medicaid
247 Fraud Control Unit of the Department of Legal Affairs.
248 (3)(2) Eligibility is restricted to United States citizens
249 and to lawfully admitted noncitizens who meet the criteria
250 provided in s. 414.095(3).
251 (a) Citizenship or immigration status must be verified. For
252 noncitizens, this includes verification of the validity of
253 documents with the United States Citizenship and Immigration
254 Services using the federal SAVE verification process.
255 (b) State funds may not be used to provide medical services
256 to individuals who do not meet the requirements of this
257 subsection unless the services are necessary to treat an
258 emergency medical condition or are for pregnant women. Such
259 services are authorized only to the extent provided under
260 federal law and in accordance with federal regulations as
261 provided in 42 C.F.R. s. 440.255.
262 (4) To the extent funds are appropriated, the department
263 shall collaborate with the agency to develop an Internet-based
264 system for determining eligibility for the Medicaid and Kidcare
265 programs which complies with all applicable federal and state
266 laws and requirements.
267 (a) The system must accomplish the following primary
268 business objectives:
269 1. Provide individuals and families with a single access
270 point to information that explains benefits, premiums, and cost
271 sharing available through Medicaid, Kidcare, or any other state
272 or federal health insurance exchange.
273 2. Enable timely, accurate, and efficient enrollment of
274 eligible persons into available assistance programs.
275 3. Prevent eligibility fraud.
276 4. Allow for detailed financial analysis of eligibility
277 based cost drivers.
278 (b) The system must include, but need not be limited to,
279 the following business and functional requirements:
280 1. Allowing for the completion and submission of an online
281 application for determining eligibility which accepts the use of
282 electronic signatures.
283 2. Including a process that enables automatic enrollment of
284 qualified individuals into Medicaid, Kidcare, or any other state
285 or federal exchange that offers cost-sharing benefits for the
286 purchase of health insurance.
287 3. Allowing for the determination of Medicaid eligibility
288 based on modified adjusted gross income by using information
289 submitted in the application and information accessed and
290 verified through automated and secure interfaces with authorized
291 databases.
292 4. Including the ability to determine specific categories
293 of Medicaid eligibility and interface with the Florida Medicaid
294 Management Information System to support such determination,
295 using federally approved assessment methodologies, of state and
296 federal financial participation rates for persons in each
297 eligibility category.
298 5. Allowing for the accurate and timely processing of
299 eligibility claims and adjudications.
300 6. Aligning with and incorporating all applicable state and
301 federal laws, requirements, and standards, including the
302 information technology security requirements established under
303 s. 282.318 and the accessibility standards established under
304 part II of chapter 282.
305 7. Producing transaction data, reports, and performance
306 information that contributes to an evaluation of the program,
307 continuous improvement in business operations, and increased
308 transparency and accountability.
309 (c) The department shall develop the system subject to
310 approval by the Legislative Budget Commission and as required by
311 the General Appropriations Act for the 2012-2013 fiscal year.
312 (d) The system must be completed by October 1, 2013, and
313 ready for implementation by January 1, 2014.
314 (e) The department shall implement the following project
315 governance structure until the system is implemented:
316 1. The director of the department’s Economic Self
317 Sufficiency Services Program Office shall have overall
318 responsibility for the project.
319 2. The project shall be governed by an executive steering
320 committee composed of three department staff members appointed
321 by the Secretary of Children and Family Services; three agency
322 staff members, including at least two state Medicaid program
323 staff members, appointed by the Secretary of Health Care
324 Administration; and one staff member from Children’s Medical
325 Services within the Department of Health appointed by the
326 Surgeon General.
327 3. The executive steering committee shall have overall
328 responsibility for ensuring that the project meets its primary
329 business objectives and shall:
330 a. Provide management direction and support to the project
331 management team.
332 b. Review and approve any changes to the project’s scope,
333 schedule, and budget.
334 c. Review, approve, and determine whether to proceed with
335 any major deliverable project.
336 d. Recommend suspension or termination of the project to
337 the Governor, the President of the Senate, and the Speaker of
338 the House of Representatives if the committee determines that
339 the primary business objectives cannot be achieved.
340 4. A project management team shall be appointed by and work
341 under the direction of the executive steering committee. The
342 project management team shall:
343 a. Provide planning, management, and oversight of the
344 project.
345 b. Submit an operational work plan and provide quarterly
346 updates to the plan to the executive steering committee. The
347 plan must specify project milestones, deliverables, and
348 expenditures.
349 c. Submit written monthly project status reports to the
350 executive steering committee.
351 Section 6. Subsection (5) of section 409.905, Florida
352 Statutes, is amended to read:
353 409.905 Mandatory Medicaid services.—The agency may make
354 payments for the following services, which are required of the
355 state by Title XIX of the Social Security Act, furnished by
356 Medicaid providers to recipients who are determined to be
357 eligible on the dates on which the services were provided. Any
358 service under this section shall be provided only when medically
359 necessary and in accordance with state and federal law.
360 Mandatory services rendered by providers in mobile units to
361 Medicaid recipients may be restricted by the agency. Nothing in
362 this section shall be construed to prevent or limit the agency
363 from adjusting fees, reimbursement rates, lengths of stay,
364 number of visits, number of services, or any other adjustments
365 necessary to comply with the availability of moneys and any
366 limitations or directions provided for in the General
367 Appropriations Act or chapter 216.
368 (5) HOSPITAL INPATIENT SERVICES.—The agency shall pay for
369 all covered services provided for the medical care and treatment
370 of a Medicaid recipient who is admitted as an inpatient by a
371 licensed physician or dentist to a hospital licensed under part
372 I of chapter 395. However, the agency shall limit the payment
373 for inpatient hospital services for a nonpregnant Medicaid
374 recipient 21 years of age or older to 45 days per fiscal year or
375 the number of days necessary to comply with the General
376 Appropriations Act. Effective August 1, 2012, the agency shall
377 limit payment for hospital emergency department visits for a
378 nonpregnant recipient 21 years of age or older to six visits per
379 fiscal year.
380 (a) The agency may is authorized to implement reimbursement
381 and utilization management reforms in order to comply with any
382 limitations or directions in the General Appropriations Act,
383 which may include, but are not limited to: prior authorization
384 for inpatient psychiatric days; prior authorization for
385 nonemergency hospital inpatient admissions for individuals 21
386 years of age and older; authorization of emergency and urgent
387 care admissions within 24 hours after admission; enhanced
388 utilization and concurrent review programs for highly utilized
389 services; reduction or elimination of covered days of service;
390 adjusting reimbursement ceilings for variable costs; adjusting
391 reimbursement ceilings for fixed and property costs; and
392 implementing target rates of increase. The agency may limit
393 prior authorization for hospital inpatient services to selected
394 diagnosis-related groups, based on an analysis of the cost and
395 potential for unnecessary hospitalizations represented by
396 certain diagnoses. Admissions for normal delivery and newborns
397 are exempt from requirements for prior authorization
398 requirements. In implementing the provisions of this section
399 related to prior authorization, the agency must shall ensure
400 that the process for authorization is accessible 24 hours per
401 day, 7 days per week and authorization is automatically granted
402 if when not denied within 4 hours after the request.
403 Authorization procedures must include steps for the review of
404 denials. Upon implementing the prior authorization program for
405 hospital inpatient services, the agency shall discontinue its
406 hospital retrospective review program.
407 (b) A licensed hospital maintained primarily for the care
408 and treatment of patients having mental disorders or mental
409 diseases is not eligible to participate in the hospital
410 inpatient portion of the Medicaid program except as provided
411 under in federal law. However, the department shall apply for a
412 waiver, within 9 months after June 5, 1991, designed to provide
413 hospitalization services for mental health reasons to children
414 and adults in the most cost-effective and lowest cost setting
415 possible. Such waiver must shall include a request for the
416 opportunity to pay for care in hospitals known under federal law
417 as “institutions for mental disease” or “IMD’s.” The waiver
418 proposal may not shall propose no additional aggregate cost to
419 the state or Federal Government, and shall be conducted in
420 Hillsborough County, Highlands County, Hardee County, Manatee
421 County, and Polk County. The waiver proposal may incorporate
422 competitive bidding for hospital services, comprehensive
423 brokering, prepaid capitated arrangements, or other mechanisms
424 deemed by the department to show promise in reducing the cost of
425 acute care and increasing the effectiveness of preventive care.
426 When developing the waiver proposal, the department shall take
427 into account price, quality, accessibility, linkages of the
428 hospital to community services and family support programs,
429 plans of the hospital to ensure the earliest discharge possible,
430 and the comprehensiveness of the mental health and other health
431 care services offered by participating providers.
432 (c) The agency shall implement a methodology for
433 establishing base reimbursement rates for each hospital based on
434 allowable costs, as defined by the agency. Rates shall be
435 calculated annually and take effect July 1 of each year based on
436 the most recent complete and accurate cost report submitted by
437 each hospital. Adjustments may not be made to the rates after
438 September 30 of the state fiscal year in which the rate takes
439 effect, except that the agency may request that adjustments be
440 approved by the Legislative Budget Commission when needed due to
441 insufficient commitments or collections of intergovernmental
442 transfers under s. 409.908(1) or s. 409.908(4). Errors in cost
443 reporting or calculation of rates discovered after September 30
444 must be reconciled in a subsequent rate period. The agency may
445 not make any adjustment to a hospital’s reimbursement rate more
446 than 5 years after a hospital is notified of an audited rate
447 established by the agency. The prohibition against requirement
448 that the agency making may not make any adjustment to a
449 hospital’s reimbursement rate more than 5 years after a hospital
450 is notified of an audited rate established by the agency is
451 remedial and applies shall apply to actions by providers
452 involving Medicaid claims for hospital services. Hospital rates
453 shall be subject to such limits or ceilings as may be
454 established in law or described in the agency’s hospital
455 reimbursement plan. Specific exemptions to the limits or
456 ceilings may be provided in the General Appropriations Act.
457 (d) The agency shall implement a comprehensive utilization
458 management program for hospital neonatal intensive care stays in
459 certain high-volume participating hospitals, select counties, or
460 statewide, and replace existing hospital inpatient utilization
461 management programs for neonatal intensive care admissions. The
462 program shall be designed to manage the lengths of stay for
463 children being treated in neonatal intensive care units and must
464 seek the earliest medically appropriate discharge to the child’s
465 home or other less costly treatment setting. The agency may
466 competitively bid a contract for the selection of a qualified
467 organization to provide neonatal intensive care utilization
468 management services. The agency may seek federal waivers to
469 implement this initiative.
470 (e) The agency may develop and implement a program to
471 reduce the number of hospital readmissions among the non
472 Medicare population eligible in areas 9, 10, and 11.
473 (f) The agency shall develop a plan to convert Medicaid
474 inpatient hospital rates to a prospective payment system that
475 categorizes each case into diagnosis-related groups (DRG) and
476 assigns a payment weight based on the average resources used to
477 treat Medicaid patients in that DRG. To the extent possible, the
478 agency shall propose an adaptation of an existing prospective
479 payment system, such as the one used by Medicare, and shall
480 propose such adjustments as are necessary for the Medicaid
481 population and to maintain budget neutrality for inpatient
482 hospital expenditures.
483 1. The plan must:
484 a. Define and describe DRGs for inpatient hospital care
485 specific to Medicaid in this state;
486 b. Develop the use of resources needed for each DRG;
487 c. Apply current statewide levels of funding to DRGs based
488 on the associated resource value of DRGs. Current statewide
489 funding levels shall be calculated both with and without the use
490 of intergovernmental transfers;
491 d. Calculate the current number of services provided in the
492 Medicaid program based on DRGs defined under this subparagraph;
493 e. Estimate the number of cases in each DRG for future
494 years based on agency data and the official workload estimates
495 of the Social Services Estimating Conference;
496 f. Estimate potential funding for each hospital with a
497 Medicaid provider agreement, based on the DRGs and estimated
498 workload;
499 g. Propose supplemental DRG payments to augment hospital
500 reimbursements based on patient acuity and individual hospital
501 characteristics, including classification as a children’s
502 hospital, rural hospital, trauma center, burn unit, and other
503 characteristics that could warrant higher reimbursements; and
504 h. Estimate potential funding for each hospital with a
505 Medicaid provider agreement for DRGs defined pursuant to this
506 subparagraph and supplemental DRG payments using current funding
507 levels, calculated both with and without the use of
508 intergovernmental transfers.
509 2. The agency, through a competitive procurement pursuant
510 to chapter 287, shall engage a consultant with expertise and
511 experience in the implementation of DRG systems for hospital
512 reimbursement to develop the DRG plan under subparagraph 1.
513 3. The agency shall submit the Medicaid DRG plan,
514 identifying all steps necessary for the transition and any costs
515 associated with plan implementation, to the Governor, the
516 President of the Senate, and the Speaker of the House of
517 Representatives no later than December 1, 2012 January 1, 2013.
518 Upon receiving legislative authorization, the agency shall begin
519 making the necessary changes to fiscal agent coding by June 1,
520 2013, with a target date of November 1, 2013, for full
521 implementation of the DRG system of hospital reimbursement. If,
522 during implementation of this paragraph, the agency determines
523 that these timeframes might not be achievable, the agency shall
524 report to the Legislative Budget Commission the status of its
525 implementation efforts, the reasons the timeframes might not be
526 achievable, and proposals for new timeframes.
527 Section 7. Paragraph (c) of subsection (1) of section
528 409.908, Florida Statutes, is amended, paragraph (e) is added to
529 that subsection, and subsections (4) and (21) of that section
530 are amended, to read:
531 409.908 Reimbursement of Medicaid providers.—Subject to
532 specific appropriations, the agency shall reimburse Medicaid
533 providers, in accordance with state and federal law, according
534 to methodologies set forth in the rules of the agency and in
535 policy manuals and handbooks incorporated by reference therein.
536 These methodologies may include fee schedules, reimbursement
537 methods based on cost reporting, negotiated fees, competitive
538 bidding pursuant to s. 287.057, and other mechanisms the agency
539 considers efficient and effective for purchasing services or
540 goods on behalf of recipients. If a provider is reimbursed based
541 on cost reporting and submits a cost report late and that cost
542 report would have been used to set a lower reimbursement rate
543 for a rate semester, then the provider’s rate for that semester
544 shall be retroactively calculated using the new cost report, and
545 full payment at the recalculated rate shall be effected
546 retroactively. Medicare-granted extensions for filing cost
547 reports, if applicable, shall also apply to Medicaid cost
548 reports. Payment for Medicaid compensable services made on
549 behalf of Medicaid eligible persons is subject to the
550 availability of moneys and any limitations or directions
551 provided for in the General Appropriations Act or chapter 216.
552 Further, nothing in this section shall be construed to prevent
553 or limit the agency from adjusting fees, reimbursement rates,
554 lengths of stay, number of visits, or number of services, or
555 making any other adjustments necessary to comply with the
556 availability of moneys and any limitations or directions
557 provided for in the General Appropriations Act, provided the
558 adjustment is consistent with legislative intent.
559 (1) Reimbursement to hospitals licensed under part I of
560 chapter 395 must be made prospectively or on the basis of
561 negotiation.
562 (c) Hospitals that provide services to a disproportionate
563 share of low-income Medicaid recipients, or that participate in
564 the regional perinatal intensive care center program under
565 chapter 383, or that participate in the statutory teaching
566 hospital disproportionate share program may receive additional
567 reimbursement. The total amount of payment for disproportionate
568 share hospitals shall be fixed by the General Appropriations
569 Act. The computation of these payments must be made in
570 compliance with all federal regulations and the methodologies
571 described in ss. 409.911, 409.9112, and 409.9113.
572 (e) The agency may accept voluntary intergovernmental
573 transfers of local taxes and other qualified revenue from
574 counties, municipalities, or special taxing districts under
575 paragraphs (a) and (b) or the General Appropriations Act for the
576 purpose of funding the costs of special Medicaid payments to
577 hospitals, the costs of exempting hospitals from reimbursement
578 ceilings, or the costs of buying back hospital Medicaid trend
579 adjustments authorized under the General Appropriations Act,
580 except that the use of these intergovernmental transfers for
581 fee-for-service payments to hospitals is limited to the
582 proportionate use of such funds accepted by the agency under
583 subsection (4). As used in this paragraph, the term
584 “proportionate use” means that the use of intergovernmental
585 transfer funds under this subsection must be in the same
586 proportion to the use of such funds under subsection (4)
587 relative to the need for funding hospital costs under each
588 subsection.
589 (4) Subject to any limitations or directions provided for
590 in the General Appropriations Act, alternative health plans,
591 health maintenance organizations, and prepaid health plans,
592 including health maintenance organizations, prepaid provider
593 service networks, and other capitated managed care plans, shall
594 be reimbursed a fixed, prepaid amount negotiated, or
595 competitively bid pursuant to s. 287.057, by the agency and
596 prospectively paid to the provider monthly for each Medicaid
597 recipient enrolled. The amount may not exceed the average amount
598 the agency determines it would have paid, based on claims
599 experience, for recipients in the same or similar category of
600 eligibility. The agency shall calculate capitation rates on a
601 regional basis and, beginning September 1, 1995, shall include
602 age-band differentials in such calculations.
603 (a) Effective September 1, 2012:
604 1. The costs of special Medicaid payments to hospitals, the
605 costs of exempting hospitals from reimbursement ceilings, and
606 the costs of buying back hospital Medicaid trend adjustments
607 authorized under the General Appropriations Act, which are
608 funded through intergovernmental transfers, may not be included
609 as inpatient or outpatient costs in the calculation of prepaid
610 health plan capitations under this part. This provision must be
611 construed so that inpatient hospital costs included in the
612 calculation of prepaid health plan capitations are identical to
613 those represented by county billing rates under s. 409.915.
614 2. Prepaid health plans may not reimburse hospitals for the
615 costs described in subparagraph 1., except that plans may
616 contract with hospitals to pay inpatient per diems that are
617 between 95 percent and 105 percent of the county billing rate.
618 Hospitals and prepaid health plans may negotiate mutually
619 acceptable higher rates for medically complex care.
620 (b) Notwithstanding paragraph (a):
621 1. In order to fund the inclusion of costs described in
622 paragraph (a) in the calculation of capitations paid to prepaid
623 health plans, the agency may accept voluntary intergovernmental
624 transfers of local taxes and other qualified revenue from
625 counties, municipalities, or special taxing districts. After
626 securing commitments from counties, municipalities, or special
627 taxing districts to contribute intergovernmental transfers for
628 that purpose, the agency shall develop capitation payments for
629 prepaid health plans which include the costs described in
630 paragraph (a) if those components of the capitation are funded
631 through intergovernmental transfers and not with general
632 revenue. The rate-setting methodology must preserve federal
633 matching funds for the intergovernmental transfers collected
634 under this paragraph and result in actuarially sound rates. The
635 agency has the discretion to perform this function using
636 supplemental capitation payments.
637 2. The amounts included in a prepaid health plan’s
638 capitations or supplemental capitations under this paragraph for
639 funding the costs described in paragraph (a) must be used
640 exclusively by the prepaid health plan to enhance hospital
641 payments and be calculated by the agency as accurately as
642 possible to equal the costs described in paragraph (a) which the
643 prepaid health plan actually incurs and for which
644 intergovernmental transfers have been secured.
645 (21) The agency shall reimburse school districts that which
646 certify the state match pursuant to ss. 409.9071 and 1011.70 for
647 the federal portion of the school district’s allowable costs to
648 deliver the services, based on the reimbursement schedule. The
649 school district shall determine the costs for delivering
650 services as authorized in ss. 409.9071 and 1011.70 for which the
651 state match will be certified.
652 (a) School districts participating in the certified school
653 match program pursuant to this subsection and s. 1011.70 shall
654 be reimbursed by Medicaid, subject to the limitations of s.
655 1011.70(1), for a Medicaid-eligible child participating in the
656 services, as authorized under s. 1011.70 and as provided in s.
657 409.9071, regardless of whether the child is enrolled in
658 MediPass or a managed care plan. Managed care plans and school
659 districts shall make good faith efforts to execute agreements
660 regarding the coordinated provision of services authorized under
661 s. 1011.70. County health departments delivering school-based
662 services pursuant to ss. 381.0056 and 381.0057 shall be
663 reimbursed by Medicaid for the federal share for a Medicaid
664 eligible child who receives Medicaid-covered services in a
665 school setting, regardless of whether the child is enrolled in
666 MediPass or a managed care plan. Managed care plans and county
667 health departments shall make good faith efforts to execute
668 agreements regarding the coordinated provision of services to a
669 Medicaid-eligible child. To ensure continuity of care for
670 Medicaid patients, the agency, the Department of Health, and the
671 Department of Education shall develop procedures for ensuring
672 that a student’s managed care plan or MediPass primary care
673 provider receives information relating to services provided in
674 accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
675 (b) Reimbursement of school-based providers is contingent
676 on such providers being enrolled as Medicaid providers and
677 meeting the qualifications contained in 42 C.F.R. s. 440.110,
678 unless otherwise waived by the federal Centers for Medicare and
679 Medicaid Services Health Care Financing Administration. Speech
680 therapy providers who are certified through the Department of
681 Education pursuant to rule 6A-4.0176, Florida Administrative
682 Code, are eligible for reimbursement for services that are
683 provided on school premises. An Any employee of the school
684 district who has been fingerprinted and has received a criminal
685 background check in accordance with Department of Education
686 rules and guidelines is shall be exempt from any agency
687 requirements relating to criminal background checks.
688 Section 8. Subsection (1), paragraphs (a) and (b) of
689 subsection (2), and paragraph (d) of subsection (4) of section
690 409.911, Florida Statutes, are amended to read:
691 409.911 Disproportionate share program.—Subject to specific
692 allocations established within the General Appropriations Act
693 and any limitations established pursuant to chapter 216, the
694 agency shall distribute, pursuant to this section, moneys to
695 hospitals providing a disproportionate share of Medicaid or
696 charity care services by making quarterly Medicaid payments as
697 required. Notwithstanding the provisions of s. 409.915, counties
698 are exempt from contributing toward the cost of this special
699 reimbursement for hospitals serving a disproportionate share of
700 low-income patients.
701 (1) DEFINITIONS.—As used in this section, s. 409.9112, and
702 the Florida Hospital Uniform Reporting System manual:
703 (a) “Adjusted patient days” means the sum of acute care
704 patient days and intensive care patient days as reported to the
705 agency for Health Care Administration, divided by the ratio of
706 inpatient revenues generated from acute, intensive, ambulatory,
707 and ancillary patient services to gross revenues.
708 (b) “Actual audited data” or “actual audited experience”
709 means data reported to the agency for Health Care Administration
710 which has been audited in accordance with generally accepted
711 auditing standards by the agency or representatives under
712 contract with the agency.
713 (c) “Charity care” or “uncompensated charity care” means
714 that portion of hospital charges reported to the agency for
715 Health Care Administration for which there is no compensation,
716 other than restricted or unrestricted revenues provided to a
717 hospital by local governments or tax districts, regardless of
718 the method of payment, for care provided to a patient whose
719 family income for the 12 months preceding the determination is
720 less than or equal to 200 percent of the federal poverty level,
721 unless the amount of hospital charges due from the patient
722 exceeds 25 percent of the annual family income. However, in no
723 case shall the hospital charges for a patient whose family
724 income exceeds four times the federal poverty level for a family
725 of four may not be considered charity.
726 (d) “Charity care days” means the sum of the deductions
727 from revenues for charity care minus 50 percent of restricted
728 and unrestricted revenues provided to a hospital by local
729 governments or tax districts, divided by gross revenues per
730 adjusted patient day.
731 (e) “Hospital” means a health care institution licensed as
732 a hospital pursuant to chapter 395, but does not include
733 ambulatory surgical centers.
734 (f) “Medicaid days” means the number of actual days
735 attributable to Medicaid recipients patients as determined by
736 the agency for Health Care Administration.
737 (2) The agency for Health Care Administration shall use the
738 following actual audited data to determine the Medicaid days and
739 charity care to be used in calculating the disproportionate
740 share payment:
741 (a) The average of the 2004, 2005, and 2006 audited
742 disproportionate share data to determine each hospital’s
743 Medicaid days and charity care for the 2012-2013 2011-2012 state
744 fiscal year.
745 (b) If the agency for Health Care Administration does not
746 have the prescribed 3 years of audited disproportionate share
747 data as noted in paragraph (a) for a hospital, the agency shall
748 use the average of the years of the audited disproportionate
749 share data as noted in paragraph (a) which is available.
750 (4) The following formulas shall be used to pay
751 disproportionate share dollars to public hospitals:
752 (d) Any nonstate government owned or operated hospital
753 eligible for payments under this section on July 1, 2011,
754 remains eligible for payments during the 2012-2013 2011-2012
755 state fiscal year.
756 Section 9. Section 409.9112, Florida Statutes, is repealed.
757 Section 10. Section 409.9113, Florida Statutes, is amended
758 to read:
759 409.9113 Disproportionate share program for teaching
760 hospitals.—In addition to the payments made under s. ss. 409.911
761 and 409.9112, the agency shall make disproportionate share
762 payments to teaching hospitals, as defined in s. 408.07, for
763 their increased costs associated with medical education programs
764 and for tertiary health care services provided to the indigent.
765 This system of payments must conform to federal requirements and
766 distribute funds in each fiscal year for which an appropriation
767 is made by making quarterly Medicaid payments. Notwithstanding
768 s. 409.915, counties are exempt from contributing toward the
769 cost of this special reimbursement for hospitals serving a
770 disproportionate share of low-income patients. For the 2011-2012
771 state fiscal year, The agency shall distribute the moneys
772 provided in the General Appropriations Act to statutorily
773 defined teaching hospitals and family practice teaching
774 hospitals, as defined in s. 395.805, pursuant to this section.
775 The funds provided for statutorily defined teaching hospitals
776 shall be distributed as provided in the General Appropriations
777 Act. The funds provided for family practice teaching hospitals
778 shall be distributed equally among family practice teaching
779 hospitals.
780 (1) On or before September 15 of each year, the agency
781 shall calculate an allocation fraction to be used for
782 distributing funds to statutory teaching hospitals. Subsequent
783 to the end of each quarter of the state fiscal year, the agency
784 shall distribute to each statutory teaching hospital an amount
785 determined by multiplying one-fourth of the funds appropriated
786 for this purpose by the Legislature times such hospital’s
787 allocation fraction. The allocation fraction for each such
788 hospital shall be determined by the sum of the following three
789 primary factors, divided by three:
790 (a) The number of nationally accredited graduate medical
791 education programs offered by the hospital, including programs
792 accredited by the Accreditation Council for Graduate Medical
793 Education and the combined Internal Medicine and Pediatrics
794 programs acceptable to both the American Board of Internal
795 Medicine and the American Board of Pediatrics at the beginning
796 of the state fiscal year preceding the date on which the
797 allocation fraction is calculated. The numerical value of this
798 factor is the fraction that the hospital represents of the total
799 number of programs, where the total is computed for all
800 statutory teaching hospitals.
801 (b) The number of full-time equivalent trainees in the
802 hospital, which comprises two components:
803 1. The number of trainees enrolled in nationally accredited
804 graduate medical education programs, as defined in paragraph
805 (a). Full-time equivalents are computed using the fraction of
806 the year during which each trainee is primarily assigned to the
807 given institution, over the state fiscal year preceding the date
808 on which the allocation fraction is calculated. The numerical
809 value of this factor is the fraction that the hospital
810 represents of the total number of full-time equivalent trainees
811 enrolled in accredited graduate programs, where the total is
812 computed for all statutory teaching hospitals.
813 2. The number of medical students enrolled in accredited
814 colleges of medicine and engaged in clinical activities,
815 including required clinical clerkships and clinical electives.
816 Full-time equivalents are computed using the fraction of the
817 year during which each trainee is primarily assigned to the
818 given institution, over the course of the state fiscal year
819 preceding the date on which the allocation fraction is
820 calculated. The numerical value of this factor is the fraction
821 that the given hospital represents of the total number of full
822 time equivalent students enrolled in accredited colleges of
823 medicine, where the total is computed for all statutory teaching
824 hospitals.
825
826 The primary factor for full-time equivalent trainees is computed
827 as the sum of these two components, divided by two.
828 (c) A service index that comprises three components:
829 1. The Agency for Health Care Administration Service Index,
830 computed by applying the standard Service Inventory Scores
831 established by the agency to services offered by the given
832 hospital, as reported on Worksheet A-2 for the last fiscal year
833 reported to the agency before the date on which the allocation
834 fraction is calculated. The numerical value of this factor is
835 the fraction that the given hospital represents of the total
836 index values, where the total is computed for all statutory
837 teaching hospitals.
838 2. A volume-weighted service index, computed by applying
839 the standard Service Inventory Scores established by the agency
840 to the volume of each service, expressed in terms of the
841 standard units of measure reported on Worksheet A-2 for the last
842 fiscal year reported to the agency before the date on which the
843 allocation factor is calculated. The numerical value of this
844 factor is the fraction that the given hospital represents of the
845 total volume-weighted service index values, where the total is
846 computed for all statutory teaching hospitals.
847 3. Total Medicaid payments to each hospital for direct
848 inpatient and outpatient services during the fiscal year
849 preceding the date on which the allocation factor is calculated.
850 This includes payments made to each hospital for such services
851 by Medicaid prepaid health plans, whether the plan was
852 administered by the hospital or not. The numerical value of this
853 factor is the fraction that each hospital represents of the
854 total of such Medicaid payments, where the total is computed for
855 all statutory teaching hospitals.
856
857 The primary factor for the service index is computed as the sum
858 of these three components, divided by three.
859 (2) By October 1 of each year, the agency shall use the
860 following formula to calculate the maximum additional
861 disproportionate share payment for statutory teaching hospitals:
862
863 TAP = THAF x A
864
865 Where:
866 TAP = total additional payment.
867 THAF = teaching hospital allocation factor.
868 A = amount appropriated for a teaching hospital
869 disproportionate share program.
870 Section 11. Section 409.9117, Florida Statutes, is
871 repealed.
872 Section 12. Paragraphs (b) and (d) of subsection (4) of
873 section 409.912, Florida Statutes, are amended to read:
874 409.912 Cost-effective purchasing of health care.—The
875 agency shall purchase goods and services for Medicaid recipients
876 in the most cost-effective manner consistent with the delivery
877 of quality medical care. To ensure that medical services are
878 effectively utilized, the agency may, in any case, require a
879 confirmation or second physician’s opinion of the correct
880 diagnosis for purposes of authorizing future services under the
881 Medicaid program. This section does not restrict access to
882 emergency services or poststabilization care services as defined
883 in 42 C.F.R. part 438.114. Such confirmation or second opinion
884 shall be rendered in a manner approved by the agency. The agency
885 shall maximize the use of prepaid per capita and prepaid
886 aggregate fixed-sum basis services when appropriate and other
887 alternative service delivery and reimbursement methodologies,
888 including competitive bidding pursuant to s. 287.057, designed
889 to facilitate the cost-effective purchase of a case-managed
890 continuum of care. The agency shall also require providers to
891 minimize the exposure of recipients to the need for acute
892 inpatient, custodial, and other institutional care and the
893 inappropriate or unnecessary use of high-cost services. The
894 agency shall contract with a vendor to monitor and evaluate the
895 clinical practice patterns of providers in order to identify
896 trends that are outside the normal practice patterns of a
897 provider’s professional peers or the national guidelines of a
898 provider’s professional association. The vendor must be able to
899 provide information and counseling to a provider whose practice
900 patterns are outside the norms, in consultation with the agency,
901 to improve patient care and reduce inappropriate utilization.
902 The agency may mandate prior authorization, drug therapy
903 management, or disease management participation for certain
904 populations of Medicaid beneficiaries, certain drug classes, or
905 particular drugs to prevent fraud, abuse, overuse, and possible
906 dangerous drug interactions. The Pharmaceutical and Therapeutics
907 Committee shall make recommendations to the agency on drugs for
908 which prior authorization is required. The agency shall inform
909 the Pharmaceutical and Therapeutics Committee of its decisions
910 regarding drugs subject to prior authorization. The agency is
911 authorized to limit the entities it contracts with or enrolls as
912 Medicaid providers by developing a provider network through
913 provider credentialing. The agency may competitively bid single
914 source-provider contracts if procurement of goods or services
915 results in demonstrated cost savings to the state without
916 limiting access to care. The agency may limit its network based
917 on the assessment of beneficiary access to care, provider
918 availability, provider quality standards, time and distance
919 standards for access to care, the cultural competence of the
920 provider network, demographic characteristics of Medicaid
921 beneficiaries, practice and provider-to-beneficiary standards,
922 appointment wait times, beneficiary use of services, provider
923 turnover, provider profiling, provider licensure history,
924 previous program integrity investigations and findings, peer
925 review, provider Medicaid policy and billing compliance records,
926 clinical and medical record audits, and other factors. Providers
927 are not entitled to enrollment in the Medicaid provider network.
928 The agency shall determine instances in which allowing Medicaid
929 beneficiaries to purchase durable medical equipment and other
930 goods is less expensive to the Medicaid program than long-term
931 rental of the equipment or goods. The agency may establish rules
932 to facilitate purchases in lieu of long-term rentals in order to
933 protect against fraud and abuse in the Medicaid program as
934 defined in s. 409.913. The agency may seek federal waivers
935 necessary to administer these policies.
936 (4) The agency may contract with:
937 (b) An entity that is providing comprehensive behavioral
938 health care services to certain Medicaid recipients through a
939 capitated, prepaid arrangement pursuant to the federal waiver
940 provided for by s. 409.905(5). Such entity must be licensed
941 under chapter 624, chapter 636, or chapter 641, or authorized
942 under paragraph (c) or paragraph (d), and must possess the
943 clinical systems and operational competence to manage risk and
944 provide comprehensive behavioral health care to Medicaid
945 recipients. As used in this paragraph, the term “comprehensive
946 behavioral health care services” means covered mental health and
947 substance abuse treatment services that are available to
948 Medicaid recipients. The secretary of the Department of Children
949 and Family Services shall approve provisions of procurements
950 related to children in the department’s care or custody before
951 enrolling such children in a prepaid behavioral health plan. Any
952 contract awarded under this paragraph must be competitively
953 procured. In developing the behavioral health care prepaid plan
954 procurement document, the agency must shall ensure that the
955 procurement document requires the contractor to develop and
956 implement a plan that ensures to ensure compliance with s.
957 394.4574 related to services provided to residents of licensed
958 assisted living facilities that hold a limited mental health
959 license. Except as provided in subparagraph 5., and except in
960 counties where the Medicaid managed care pilot program is
961 authorized pursuant to s. 409.91211, the agency shall seek
962 federal approval to contract with a single entity meeting these
963 requirements to provide comprehensive behavioral health care
964 services to all Medicaid recipients not enrolled in a Medicaid
965 managed care plan authorized under s. 409.91211, a provider
966 service network authorized under paragraph (d), or a Medicaid
967 health maintenance organization in an AHCA area. In an AHCA area
968 where the Medicaid managed care pilot program is authorized
969 pursuant to s. 409.91211 in one or more counties, the agency may
970 procure a contract with a single entity to serve the remaining
971 counties as an AHCA area or the remaining counties may be
972 included with an adjacent AHCA area and are subject to this
973 paragraph. Each entity must offer a sufficient choice of
974 providers in its network to ensure recipient access to care and
975 the opportunity to select a provider with whom they are
976 satisfied. The network must shall include all public mental
977 health hospitals. To ensure unimpaired access to behavioral
978 health care services by Medicaid recipients, all contracts
979 issued pursuant to this paragraph must require 80 percent of the
980 capitation paid to the managed care plan, including health
981 maintenance organizations and capitated provider service
982 networks, to be expended for the provision of behavioral health
983 care services. If the managed care plan expends less than 80
984 percent of the capitation paid for the provision of behavioral
985 health care services, the difference shall be returned to the
986 agency. The agency shall provide the plan with a certification
987 letter indicating the amount of capitation paid during each
988 calendar year for behavioral health care services pursuant to
989 this section. The agency may reimburse for substance abuse
990 treatment services on a fee-for-service basis until the agency
991 finds that adequate funds are available for capitated, prepaid
992 arrangements.
993 1. The agency shall modify the contracts with the entities
994 providing comprehensive inpatient and outpatient mental health
995 care services to Medicaid recipients in Hillsborough, Highlands,
996 Hardee, Manatee, and Polk Counties, to include substance abuse
997 treatment services.
998 2. Except as provided in subparagraph 5., the agency and
999 the Department of Children and Family Services shall contract
1000 with managed care entities in each AHCA area except area 6 or
1001 arrange to provide comprehensive inpatient and outpatient mental
1002 health and substance abuse services through capitated prepaid
1003 arrangements to all Medicaid recipients who are eligible to
1004 participate in such plans under federal law and regulation. In
1005 AHCA areas where eligible individuals number less than 150,000,
1006 the agency shall contract with a single managed care plan to
1007 provide comprehensive behavioral health services to all
1008 recipients who are not enrolled in a Medicaid health maintenance
1009 organization, a provider service network authorized under
1010 paragraph (d), or a Medicaid capitated managed care plan
1011 authorized under s. 409.91211. The agency may contract with more
1012 than one comprehensive behavioral health provider to provide
1013 care to recipients who are not enrolled in a Medicaid capitated
1014 managed care plan authorized under s. 409.91211, a provider
1015 service network authorized under paragraph (d), or a Medicaid
1016 health maintenance organization in AHCA areas where the eligible
1017 population exceeds 150,000. In an AHCA area where the Medicaid
1018 managed care pilot program is authorized pursuant to s.
1019 409.91211 in one or more counties, the agency may procure a
1020 contract with a single entity to serve the remaining counties as
1021 an AHCA area or the remaining counties may be included with an
1022 adjacent AHCA area and shall be subject to this paragraph.
1023 Contracts for comprehensive behavioral health providers awarded
1024 pursuant to this section shall be competitively procured. Both
1025 for-profit and not-for-profit corporations are eligible to
1026 compete. Managed care plans contracting with the agency under
1027 subsection (3) or paragraph (d) shall provide and receive
1028 payment for the same comprehensive behavioral health benefits as
1029 provided in AHCA rules, including handbooks incorporated by
1030 reference. In AHCA area 11, prior to any fiscal year for which
1031 the agency expects the number of MediPass enrollees in that area
1032 to exceed 150,000, the agency shall seek to contract with at
1033 least two comprehensive behavioral health care providers to
1034 provide behavioral health care to recipients in that area who
1035 are enrolled in, or assigned to, the MediPass program, and the
1036 agency must offer one. One of the behavioral health care
1037 contracts to must be with the existing public hospital-operated
1038 provider service network pilot project, as described in
1039 paragraph (d), for the purpose of demonstrating the cost
1040 effectiveness of the provision of quality mental health services
1041 through a public hospital-operated managed care model. Payment
1042 shall be at an agreed-upon capitated rate to ensure cost
1043 savings. Of the recipients in area 11 who are assigned to
1044 MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
1045 MediPass-enrolled recipients shall be assigned to the existing
1046 provider service network in area 11 for their behavioral care.
1047 3. Children residing in a statewide inpatient psychiatric
1048 program, or in a Department of Juvenile Justice or a Department
1049 of Children and Family Services residential program approved as
1050 a Medicaid behavioral health overlay services provider may not
1051 be included in a behavioral health care prepaid health plan or
1052 any other Medicaid managed care plan pursuant to this paragraph.
1053 4. Traditional community mental health providers under
1054 contract with the Department of Children and Family Services
1055 pursuant to part IV of chapter 394, child welfare providers
1056 under contract with the Department of Children and Family
1057 Services in areas 1 and 6, and inpatient mental health providers
1058 licensed pursuant to chapter 395 must be offered an opportunity
1059 to accept or decline a contract to participate in a any provider
1060 network for prepaid behavioral health services.
1061 5. All Medicaid-eligible children, except children in area
1062 1 and children in Highlands County, Hardee County, Polk County,
1063 or Manatee County of area 6, which that are open for child
1064 welfare services in the statewide automated child welfare
1065 information system, shall receive their behavioral health care
1066 services through a specialty prepaid plan operated by community
1067 based lead agencies through a single agency or formal agreements
1068 among several agencies. The agency shall work with the specialty
1069 plan to develop clinically effective, evidence-based
1070 alternatives as a downward substitution for the statewide
1071 inpatient psychiatric program and similar residential care and
1072 institutional services. The specialty prepaid plan must result
1073 in savings to the state comparable to savings achieved in other
1074 Medicaid managed care and prepaid programs. Such plan must
1075 provide mechanisms to maximize state and local revenues. The
1076 specialty prepaid plan shall be developed by the agency and the
1077 Department of Children and Family Services. The agency may seek
1078 federal waivers to implement this initiative. Medicaid-eligible
1079 children whose cases are open for child welfare services in the
1080 statewide automated child welfare information system and who
1081 reside in AHCA area 10 shall be enrolled in a capitated provider
1082 service network or other capitated managed care plan, which, in
1083 coordination with available community-based care providers
1084 specified in s. 409.1671, must shall provide sufficient medical,
1085 developmental, and behavioral health services to meet the needs
1086 of these children.
1087
1088 This paragraph expires October 1, 2014.
1089 (d)1. A provider service network, which may be reimbursed
1090 on a fee-for-service or prepaid basis. Prepaid provider service
1091 networks shall receive per-member, per-month payments. A
1092 provider service network that does not choose to be a prepaid
1093 plan shall receive fee-for-service rates with a shared savings
1094 settlement. The fee-for-service option shall be available to a
1095 provider service network only for the first 2 years of the
1096 plan’s operation or until the contract year beginning September
1097 1, 2014, whichever is later. The agency shall annually conduct
1098 cost reconciliations to determine the amount of cost savings
1099 achieved by fee-for-service provider service networks for the
1100 dates of service in the period being reconciled. Only payments
1101 for covered services for dates of service within the
1102 reconciliation period and paid within 6 months after the last
1103 date of service in the reconciliation period shall be included.
1104 The agency shall perform the necessary adjustments for the
1105 inclusion of claims incurred but not reported within the
1106 reconciliation for claims that could be received and paid by the
1107 agency after the 6-month claims processing time lag. The agency
1108 shall provide the results of the reconciliations to the fee-for
1109 service provider service networks within 45 days after the end
1110 of the reconciliation period. The fee-for-service provider
1111 service networks shall review and provide written comments or a
1112 letter of concurrence to the agency within 45 days after receipt
1113 of the reconciliation results. This reconciliation shall be
1114 considered final.
1115 2. A provider service network that which is reimbursed by
1116 the agency on a prepaid basis is shall be exempt from parts I
1117 and III of chapter 641, but must comply with the solvency
1118 requirements in s. 641.2261(2) and meet appropriate financial
1119 reserve, quality assurance, and patient rights requirements as
1120 established by the agency.
1121 3. The agency shall assign Medicaid recipients assigned to
1122 a provider service network in accordance with s. 409.9122 or s.
1123 409.91211, as applicable shall be chosen equally from those who
1124 would otherwise have been assigned to prepaid plans and
1125 MediPass. The agency may is authorized to seek federal Medicaid
1126 waivers as necessary to implement the provisions of this
1127 section. This subparagraph expires October 1, 2014.
1128 4. A provider service network is a network established or
1129 organized and operated by a health care provider, or group of
1130 affiliated health care providers, including minority physician
1131 networks and emergency room diversion programs that meet the
1132 requirements of s. 409.91211, which provides a substantial
1133 proportion of the health care items and services under a
1134 contract directly through the provider or affiliated group of
1135 providers and may make arrangements with physicians or other
1136 health care professionals, health care institutions, or any
1137 combination of such individuals or institutions to assume all or
1138 part of the financial risk on a prospective basis for the
1139 provision of basic health services by the physicians, by other
1140 health professionals, or through the institutions. The health
1141 care providers must have a controlling interest in the governing
1142 body of the provider service network organization.
1143 Section 13. Section 409.9121, Florida Statutes, is amended
1144 to read:
1145 409.9121 Legislative findings and intent.—The Legislature
1146 hereby finds that the Medicaid program has experienced an annual
1147 growth rate of approximately 28 percent per year for the past 5
1148 years, and is consuming more than half of all new general
1149 revenue growth. The present Medicaid system must be reoriented
1150 to emphasize, to the maximum extent possible, the delivery of
1151 health care through entities and mechanisms that which are
1152 designed to contain costs, to emphasize preventive and primary
1153 care, and to promote access and continuity of care. The
1154 Legislature further finds that the concept of “managed care”
1155 best encompasses these multiple goals. The Legislature also
1156 finds that, with the cooperation of the physician community,
1157 MediPass, the Medicaid primary care case management program, is
1158 responsible for ensuring that there is a sufficient supply of
1159 primary care to provide access to preventive and primary care
1160 services to Medicaid recipients. Therefore, the Legislature
1161 declares its intent that the Medicaid program require, to the
1162 maximum extent practicable and permitted by federal law, that
1163 all Medicaid recipients be enrolled in a managed care program.
1164 Section 14. Subsections (1), (2), (4), (5), and (12) of
1165 section 409.9122, Florida Statutes, are amended to read:
1166 409.9122 Mandatory Medicaid managed care enrollment;
1167 programs and procedures.—
1168 (1) It is the intent of the Legislature that Medicaid
1169 managed care the MediPass program be cost-effective, provide
1170 quality health care, and improve access to health services, and
1171 that the program be implemented statewide. Medicaid managed care
1172 shall consist of the enrollment of Medicaid recipients in the
1173 MediPass program or managed care plans for comprehensive medical
1174 services. This subsection expires October 1, 2014.
1175 (2)(a) The agency shall enroll all Medicaid recipients in a
1176 managed care plan or MediPass all Medicaid recipients, except
1177 those Medicaid recipients who are: in an institution,; enrolled
1178 in the Medicaid medically needy program,; or eligible for both
1179 Medicaid and Medicare. Upon enrollment, recipients may
1180 individuals will be able to change their managed care option
1181 during the 90-day opt out period required by federal Medicaid
1182 regulations. The agency may is authorized to seek the necessary
1183 Medicaid state plan amendment to implement this policy. However,
1184 (a) To the extent permitted by federal law, the agency may
1185 enroll a recipient in a managed care plan or MediPass a Medicaid
1186 recipient who is exempt from mandatory managed care enrollment
1187 if, provided that:
1188 1. The recipient’s decision to enroll in a managed care
1189 plan or MediPass is voluntary;
1190 2. If The recipient chooses to enroll in a managed care
1191 plan and, the agency has determined that the managed care plan
1192 provides specific programs and services that which address the
1193 special health needs of the recipient; and
1194 3. The agency receives any necessary waivers from the
1195 federal Centers for Medicare and Medicaid Services.
1196
1197 School districts participating in the certified school match
1198 program pursuant to ss. 409.908(21) and 1011.70 shall be
1199 reimbursed by Medicaid, subject to the limitations of s.
1200 1011.70(1), for a Medicaid-eligible child participating in the
1201 services as authorized in s. 1011.70, as provided for in s.
1202 409.9071, regardless of whether the child is enrolled in
1203 MediPass or a managed care plan. Managed care plans shall make a
1204 good faith effort to execute agreements with school districts
1205 regarding the coordinated provision of services authorized under
1206 s. 1011.70. County health departments delivering school-based
1207 services pursuant to ss. 381.0056 and 381.0057 shall be
1208 reimbursed by Medicaid for the federal share for a Medicaid
1209 eligible child who receives Medicaid-covered services in a
1210 school setting, regardless of whether the child is enrolled in
1211 MediPass or a managed care plan. Managed care plans shall make a
1212 good faith effort to execute agreements with county health
1213 departments regarding the coordinated provision of services to a
1214 Medicaid-eligible child. To ensure continuity of care for
1215 Medicaid patients, the agency, the Department of Health, and the
1216 Department of Education shall develop procedures for ensuring
1217 that a student’s managed care plan or MediPass provider receives
1218 information relating to services provided in accordance with ss.
1219 381.0056, 381.0057, 409.9071, and 1011.70.
1220 (b) A Medicaid recipient may shall not be enrolled in or
1221 assigned to a managed care plan or MediPass unless the managed
1222 care plan or MediPass has complied with the quality-of-care
1223 standards specified in paragraphs (3)(a) and (b), respectively.
1224 (c) A Medicaid recipient eligible for managed care
1225 enrollment recipients shall have a choice of managed care
1226 options plans or MediPass. The Agency for Health Care
1227 Administration, the Department of Health, the Department of
1228 Children and Family Services, and the Department of Elderly
1229 Affairs shall cooperate to ensure that each Medicaid recipient
1230 receives clear and easily understandable information that meets
1231 the following requirements:
1232 1. Explains the concept of managed care, including
1233 MediPass.
1234 2. Provides information on the comparative performance of
1235 managed care options available to the recipient plans and
1236 MediPass in the areas of quality, credentialing, preventive
1237 health programs, network size and availability, and patient
1238 satisfaction.
1239 3. Explains where additional information on each managed
1240 care option plan and MediPass in the recipient’s area can be
1241 obtained.
1242 4. Explains that recipients have the right to choose their
1243 managed care coverage at the time they first enroll in Medicaid
1244 and again at regular intervals set by the agency. However, if a
1245 recipient does not choose a managed care option plan or
1246 MediPass, the agency shall will assign the recipient to a
1247 managed care plan or MediPass according to the criteria
1248 specified in this section.
1249 5. Explains the recipient’s right to complain, file a
1250 grievance, or change his or her managed care option as specified
1251 in this section plans or MediPass providers if the recipient is
1252 not satisfied with the managed care plan or MediPass.
1253 (d) The agency shall develop a mechanism for providing
1254 information to Medicaid recipients for the purpose of choosing
1255 making a managed care option plan or MediPass selection.
1256 Examples of such mechanisms may include, but are not be limited
1257 to, interactive information systems, mailings, and mass
1258 marketing materials. Managed care plans and MediPass providers
1259 may not provide are prohibited from providing inducements to
1260 Medicaid recipients to select their plans or prejudice from
1261 prejudicing Medicaid recipients against other managed care plans
1262 or MediPass providers.
1263 (e) Medicaid recipients who are already enrolled in a
1264 managed care plan or MediPass shall be offered the opportunity
1265 to change managed care plans or MediPass providers, as
1266 applicable, on a staggered basis, as defined by the agency. All
1267 Medicaid recipients shall have 30 days in which to choose a
1268 managed care option make a choice of managed care plans or
1269 MediPass providers. Those Medicaid recipients who do not make a
1270 choice shall be assigned in accordance with paragraph (f). To
1271 facilitate continuity of care, for a Medicaid recipient who is
1272 also a recipient of Supplemental Security Income (SSI), prior to
1273 assigning the SSI recipient to a managed care plan or MediPass,
1274 the agency shall determine whether the SSI recipient has an
1275 ongoing relationship with a MediPass provider or managed care
1276 plan, and if so, the agency shall assign the SSI recipient to
1277 that MediPass provider or managed care plan. Those SSI
1278 recipients who do not have such a provider relationship shall be
1279 assigned to a managed care plan or MediPass provider in
1280 accordance with paragraph (f).
1281 1. During the 30-day choice period:
1282 a. A recipient residing in a county in which two or more
1283 managed care plans are eligible to accept Medicaid enrollees,
1284 including a recipient who was enrolled in MediPass at the
1285 commencement of his or her 30-day choice period, shall choose
1286 from those managed care plans. A recipient may opt out of his or
1287 her choice and choose a different managed care plan during the
1288 90-day opt out period.
1289 b. A recipient residing in a county in which only one
1290 managed care plan is eligible to accept Medicaid enrollees shall
1291 choose the managed care plan or a MediPass provider. A recipient
1292 who chooses the managed care plan may opt out of the plan and
1293 choose a MediPass provider during the 90-day opt out period.
1294 c. A recipient residing in a county in which no managed
1295 care plan is accepting Medicaid enrollees shall choose a
1296 MediPass provider.
1297 2. For the purposes of recipient choice, if a managed care
1298 plan reaches its enrollment capacity, as determined by the
1299 agency, the plan may not accept additional Medicaid enrollees
1300 until the agency determines that the plan’s enrollment is
1301 sufficiently less than its enrollment capacity, due to a decline
1302 in enrollment or by an increase in enrollment capacity. If a
1303 managed care plan notifies the agency of its intent to exit a
1304 county, the plan may not accept additional Medicaid enrollees in
1305 that county before the exit date.
1306 3. As used in this paragraph, when referring to recipient
1307 choice, the term “managed care plans” includes health
1308 maintenance organizations, exclusive provider organizations,
1309 provider service networks, minority physician networks,
1310 Children’s Medical Services Networks, and pediatric emergency
1311 department diversion programs authorized by this chapter or the
1312 General Appropriations Act.
1313 4. The agency shall seek federal waiver authority or a
1314 state plan amendment consistent with 42 U.S.C. 1396u-2(a)(1), as
1315 needed, to implement this paragraph.
1316 (f) If a Medicaid recipient does not choose a managed care
1317 option:
1318 1. If the recipient resides in a county in which two or
1319 more managed care plans are accepting Medicaid enrollees, the
1320 agency shall assign the recipient, including a recipient who was
1321 enrolled in MediPass at the commencement of his or her 30-day
1322 choice period, to one of those managed care plans. A recipient
1323 assigned to a managed care plan under this subparagraph may opt
1324 out of the managed care plan and enroll in a different managed
1325 care plan during the 90-day opt out period. The agency shall
1326 seek to make assignments among the managed care plans on an even
1327 basis under the criteria in subparagraph 6.
1328 2. If the recipient resides in a county in which only one
1329 managed care plan is accepting Medicaid enrollees, the agency
1330 shall assign the recipient, including a recipient who was
1331 enrolled in MediPass at the commencement of his or her 30-day
1332 choice period, to the managed care plan. A recipient assigned to
1333 a managed care plan under this subparagraph may opt out of the
1334 managed care plan and choose a MediPass provider during the 90
1335 day opt out period.
1336 3. If the recipient resides in a county in which no managed
1337 care plan is accepting Medicaid enrollees, the agency shall
1338 assign the recipient to a MediPass provider.
1339 4. For the purpose of assignment, if a managed care plan
1340 reaches its enrollment capacity, as determined by the agency,
1341 the plan may not accept additional Medicaid enrollees until the
1342 agency determines that the plan’s enrollment is sufficiently
1343 less than its enrollment capacity, due to a decline in
1344 enrollment or by an increase in enrollment capacity. If a
1345 managed care plan notifies the agency of its intent to exit a
1346 county, the agency may not assign additional Medicaid enrollees
1347 to the plan in that county before the exit date. plan or
1348 MediPass provider, the agency shall assign the Medicaid
1349 recipient to a managed care plan or MediPass provider. Medicaid
1350 recipients eligible for managed care plan enrollment who are
1351 subject to mandatory assignment but who fail to make a choice
1352 shall be assigned to managed care plans until an enrollment of
1353 35 percent in MediPass and 65 percent in managed care plans, of
1354 all those eligible to choose managed care, is achieved. Once
1355 this enrollment is achieved, the assignments shall be divided in
1356 order to maintain an enrollment in MediPass and managed care
1357 plans which is in a 35 percent and 65 percent proportion,
1358 respectively. Thereafter, assignment of Medicaid recipients who
1359 fail to make a choice shall be based proportionally on the
1360 preferences of recipients who have made a choice in the previous
1361 period. Such proportions shall be revised at least quarterly to
1362 reflect an update of the preferences of Medicaid recipients. The
1363 agency shall disproportionately assign Medicaid-eligible
1364 recipients who are required to but have failed to make a choice
1365 of managed care plan or MediPass to the Children’s Medical
1366 Services Network as defined in s. 391.021, exclusive provider
1367 organizations, provider service networks, minority physician
1368 networks, and pediatric emergency department diversion programs
1369 authorized by this chapter or the General Appropriations Act, in
1370 such manner as the agency deems appropriate, until the agency
1371 has determined that the networks and programs have sufficient
1372 numbers to be operated economically.
1373 5. As used in For purposes of this paragraph, when
1374 referring to assignment, the term “managed care plans” includes
1375 health maintenance organizations, exclusive provider
1376 organizations, provider service networks, minority physician
1377 networks, Children’s Medical Services Network, and pediatric
1378 emergency department diversion programs authorized by this
1379 chapter or the General Appropriations Act.
1380 6. When making assignments, the agency shall consider take
1381 into account the following criteria, as applicable:
1382 a.1. Whether a managed care plan has sufficient network
1383 capacity to meet the need of members.
1384 b.2. Whether the managed care plan or MediPass has
1385 previously enrolled the recipient as a member, or one of the
1386 managed care plan’s primary care providers or a MediPass primary
1387 care provider providers has previously provided health care to
1388 the recipient.
1389 c.3. Whether the agency has knowledge that the recipient
1390 member has previously expressed a preference for a particular
1391 managed care plan or MediPass primary care provider as indicated
1392 by Medicaid fee-for-service claims data, but has failed to make
1393 a choice.
1394 d.4. Whether the managed care plan’s or MediPass primary
1395 care providers are geographically accessible to the recipient’s
1396 residence.
1397 e. If the recipient was already enrolled in a managed care
1398 plan at the commencement of his or her 30-day choice period and
1399 fails to choose a different option, the recipient must remain
1400 enrolled in that same managed care plan.
1401 f. To facilitate continuity of care for a Medicaid
1402 recipient who is also a recipient of Supplemental Security
1403 Income (SSI), before assigning the SSI recipient, the agency
1404 shall determine whether the SSI recipient has an ongoing
1405 relationship with a managed care plan or a MediPass primary care
1406 provider, and if so, the agency shall assign the SSI recipient
1407 to that managed care plan or MediPass provider, as applicable.
1408 However, if the recipient has an ongoing relationship with a
1409 MediPass primary care provider who is included in the provider
1410 network of one or more managed care plans, the agency shall
1411 assign the recipient to one of those managed care plans.
1412 g. If the recipient is diagnosed with HIV/AIDS and resides
1413 in Broward County, Miami-Dade County, or Palm Beach County, the
1414 agency shall assign the Medicaid recipient to a managed care
1415 plan that is a health maintenance organization authorized under
1416 chapter 641, that was under contract with the agency on July 1,
1417 2011, and that offers a delivery system in partnership with a
1418 university-based teaching and research-oriented organization
1419 specializing in providing health care services and treatment for
1420 individuals diagnosed with HIV/AIDS. Recipients not diagnosed
1421 with HIV/AIDS may not be assigned under this paragraph to a
1422 managed care plan that specializes in HIV/AIDS.
1423 7. The agency shall seek federal waiver authority or a
1424 state plan amendment consistent with 42 U.S.C. 1396u-2(a)(4)(D),
1425 as needed, to implement this paragraph.
1426 (g) When more than one managed care plan or MediPass
1427 provider meets the criteria specified in paragraph (f), the
1428 agency shall make recipient assignments consecutively by family
1429 unit.
1430 (h) The agency may not engage in practices that are
1431 designed to favor one managed care plan over another or that are
1432 designed to influence Medicaid recipients to enroll in MediPass
1433 rather than in a managed care plan or to enroll in a managed
1434 care plan rather than in MediPass, as applicable. This
1435 subsection does not prohibit the agency from reporting on the
1436 performance of MediPass or any managed care plan, as measured by
1437 performance criteria developed by the agency.
1438 (i) After a recipient has made his or her selection or has
1439 been enrolled in a managed care plan or MediPass, the recipient
1440 shall have 90 days to exercise the opportunity to voluntarily
1441 disenroll and select another managed care option plan or
1442 MediPass. After 90 days, no further changes may be made except
1443 for good cause. Good cause includes, but is not limited to, poor
1444 quality of care, lack of access to necessary specialty services,
1445 an unreasonable delay or denial of service, or fraudulent
1446 enrollment. The agency shall develop criteria for good cause
1447 disenrollment for chronically ill and disabled populations who
1448 are assigned to managed care plans if more appropriate care is
1449 available through the MediPass program. The agency must make a
1450 determination as to whether good cause exists. However, the
1451 agency may require a recipient to use the managed care plan’s or
1452 MediPass grievance process prior to the agency’s determination
1453 of good cause, except in cases in which immediate risk of
1454 permanent damage to the recipient’s health is alleged. The
1455 grievance process, if used when utilized, must be completed in
1456 time to permit the recipient to disenroll by the first day of
1457 the second month after the month the disenrollment request was
1458 made. If the managed care plan or MediPass, as a result of the
1459 grievance process, approves an enrollee’s request to disenroll,
1460 the agency is not required to make a determination in the case.
1461 The agency must make a determination and take final action on a
1462 recipient’s request so that disenrollment occurs by no later
1463 than the first day of the second month after the month the
1464 request was made. If the agency fails to act within the
1465 specified timeframe, the recipient’s request to disenroll is
1466 deemed to be approved as of the date agency action was required.
1467 Recipients who disagree with the agency’s finding that good
1468 cause does not exist for disenrollment shall be advised of their
1469 right to pursue a Medicaid fair hearing to dispute the agency’s
1470 finding.
1471 (j) Consistent with 42 U.S.C. 1396u-2(a)(4)(A) or under
1472 federal waiver authority, as needed, the agency shall apply for
1473 a federal waiver from the Centers for Medicare and Medicaid
1474 Services to lock eligible Medicaid recipients into a managed
1475 care plan or MediPass for 12 months after an open enrollment
1476 period, except for the 90-day opt out period and good cause
1477 disenrollment. After 12 months’ enrollment, a recipient may
1478 select another managed care plan or MediPass provider. However,
1479 nothing shall prevent a Medicaid recipient may not be prevented
1480 from changing primary care providers within the managed care
1481 plan or MediPass program, as applicable, during the 12-month
1482 period.
1483 (k) The agency shall maintain MediPass provider networks in
1484 all counties, including those counties in which two or more
1485 managed care plans are accepting Medicaid enrollees. When a
1486 Medicaid recipient does not choose a managed care plan or
1487 MediPass provider, the agency shall assign the Medicaid
1488 recipient to a managed care plan, except in those counties in
1489 which there are fewer than two managed care plans accepting
1490 Medicaid enrollees, in which case assignment shall be to a
1491 managed care plan or a MediPass provider. Medicaid recipients in
1492 counties with fewer than two managed care plans accepting
1493 Medicaid enrollees who are subject to mandatory assignment but
1494 who fail to make a choice shall be assigned to managed care
1495 plans until an enrollment of 35 percent in MediPass and 65
1496 percent in managed care plans, of all those eligible to choose
1497 managed care, is achieved. Once that enrollment is achieved, the
1498 assignments shall be divided in order to maintain an enrollment
1499 in MediPass and managed care plans which is in a 35 percent and
1500 65 percent proportion, respectively. For purposes of this
1501 paragraph, when referring to assignment, the term “managed care
1502 plans” includes exclusive provider organizations, provider
1503 service networks, Children’s Medical Services Network, minority
1504 physician networks, and pediatric emergency department diversion
1505 programs authorized by this chapter or the General
1506 Appropriations Act. When making assignments, the agency shall
1507 take into account the following criteria:
1508 1. A managed care plan has sufficient network capacity to
1509 meet the need of members.
1510 2. The managed care plan or MediPass has previously
1511 enrolled the recipient as a member, or one of the managed care
1512 plan’s primary care providers or MediPass providers has
1513 previously provided health care to the recipient.
1514 3. The agency has knowledge that the member has previously
1515 expressed a preference for a particular managed care plan or
1516 MediPass provider as indicated by Medicaid fee-for-service
1517 claims data, but has failed to make a choice.
1518 4. The managed care plan’s or MediPass primary care
1519 providers are geographically accessible to the recipient’s
1520 residence.
1521 5. The agency has authority to make mandatory assignments
1522 based on quality of service and performance of managed care
1523 plans.
1524 (l) If the Medicaid recipient is diagnosed with HIV/AIDS
1525 and resides in Broward County, Miami-Dade County, or Palm Beach
1526 County, the agency shall assign the Medicaid recipient to a
1527 managed care plan that is a health maintenance organization
1528 authorized under chapter 641, is under contract with the agency
1529 on July 1, 2011, and which offers a delivery system through a
1530 university-based teaching and research-oriented organization
1531 that specializes in providing health care services and treatment
1532 for individuals diagnosed with HIV/AIDS.
1533 (l)(m) Notwithstanding the provisions of chapter 287, the
1534 agency may, at its discretion, renew cost-effective contracts
1535 for choice counseling services once or more for such periods as
1536 the agency may decide. However, all such renewals may not
1537 combine to exceed a total period longer than the term of the
1538 original contract.
1539
1540 This subsection expires October 1, 2014.
1541 (4)(a) Each female recipient may select as her primary care
1542 provider an obstetrician/gynecologist who has agreed to
1543 participate within a managed care plan’s provider network or as
1544 a MediPass primary care case manager, as applicable.
1545 (b) The agency shall establish a complaints and grievance
1546 process to assist Medicaid recipients enrolled in the MediPass
1547 program to resolve complaints and grievances. The agency shall
1548 investigate reports of quality-of-care grievances which remain
1549 unresolved to the satisfaction of the enrollee.
1550
1551 This subsection expires October 1, 2014.
1552 (5)(a) The agency shall work cooperatively with the Social
1553 Security Administration to identify recipients beneficiaries who
1554 are jointly eligible for Medicare and Medicaid and shall develop
1555 cooperative programs to encourage these recipients beneficiaries
1556 to enroll in a Medicare participating health maintenance
1557 organization or prepaid health plans.
1558 (b) The agency shall work cooperatively with the Department
1559 of Elderly Affairs to assess the potential cost-effectiveness of
1560 providing managed care enrollment MediPass to recipients
1561 beneficiaries who are jointly eligible for Medicare and Medicaid
1562 on a voluntary choice basis. If the agency determines that
1563 enrollment of these recipients beneficiaries in managed care
1564 MediPass has the potential for being cost-effective for the
1565 state, the agency shall offer managed care enrollment MediPass
1566 to these recipients beneficiaries on a voluntary choice basis in
1567 the counties where managed care is available MediPass operates.
1568
1569 This subsection expires October 1, 2014.
1570 (12) The agency shall include in its calculation of the
1571 hospital inpatient component of a Medicaid health maintenance
1572 organization’s capitation rate any special payments, including,
1573 but not limited to, upper payment limit or disproportionate
1574 share hospital payments, made to qualifying hospitals through
1575 the fee-for-service program. The agency may seek federal waiver
1576 approval or state plan amendment as needed to implement this
1577 adjustment. This subsection expires September 1, 2012.
1578 Section 15. Section 409.9123, Florida Statutes, is amended
1579 to read:
1580 409.9123 Quality-of-care reporting.—In order to promote
1581 competition between Medicaid managed care plans and MediPass
1582 based on quality-of-care indicators, The agency shall annually
1583 develop and publish a set of measures of managed care plan
1584 performance based on quality-of-care indicators. This
1585 information shall be made available to each Medicaid recipient
1586 who makes a choice of a managed care plan in her or his area.
1587 This information must shall be easily understandable to the
1588 Medicaid recipient and shall use nationally recognized standards
1589 wherever possible. In formulating this information, the agency
1590 shall, at a minimum, consider take into account at least the
1591 following:
1592 (1) The recommendations of the National Committee for
1593 Quality Assurance Medicaid HEDIS Task Force.
1594 (2) Requirements and recommendations of the Centers for
1595 Medicare and Medicaid Services Health Care Financing
1596 Administration.
1597 (3) Recommendations of the managed care industry.
1598 Section 16. For the purpose of incorporating the amendment
1599 made by this act to section 409.9122, Florida Statutes, in a
1600 reference thereto, subsection (1) of section 409.9126, Florida
1601 Statutes, is reenacted to read:
1602 409.9126 Children with special health care needs.—
1603 (1) Except as provided in subsection (4), children eligible
1604 for Children’s Medical Services who receive Medicaid benefits,
1605 and other Medicaid-eligible children with special health care
1606 needs, shall be exempt from the provisions of s. 409.9122 and
1607 shall be served through the Children’s Medical Services network
1608 established in chapter 391.
1609 Section 17. Effective upon this act becoming a law,
1610 subsections (4) through (6) of section 409.915, Florida
1611 Statutes, are amended, and subsections (7) through (11) are
1612 added to that section, to read:
1613 409.915 County contributions to Medicaid.—Although the
1614 state is responsible for the full portion of the state share of
1615 the matching funds required for the Medicaid program, in order
1616 to acquire a certain portion of these funds, the state shall
1617 charge the counties for certain items of care and service as
1618 provided in this section.
1619 (4) Each county shall contribute pay into the General
1620 Revenue Fund, unallocated, its pro rata share of the total
1621 county participation based upon statements rendered by the
1622 agency in consultation with the counties. The agency shall
1623 render such statements monthly based on each county’s eligible
1624 recipients. For purposes of this section, each county’s eligible
1625 recipients shall be determined by the recipients’ address
1626 information contained in the federally approved Medicaid
1627 eligibility system within the Department of Children and Family
1628 Services. The process developed under subsection (10) may be
1629 used for cases in which the Medicaid eligibility system’s
1630 address information may indicate a need for revision.
1631 (5) The Department of Financial Services shall withhold
1632 from the cigarette tax receipts or any other funds to be
1633 distributed to the counties the individual county share that has
1634 not been remitted within 60 days after billing.
1635 (5)(6) In any county in which a special taxing district or
1636 authority is located which will benefit from the medical
1637 assistance programs covered by this section, the board of county
1638 commissioners may divide the county’s financial responsibility
1639 for this purpose proportionately, and each such district or
1640 authority must furnish its share to the board of county
1641 commissioners in time for the board to comply with the
1642 provisions of subsection (3). Any appeal of the proration made
1643 by the board of county commissioners must be made to the
1644 Department of Financial Services, which shall then set the
1645 proportionate share of each party.
1646 (6)(7) Counties are exempt from contributing toward the
1647 cost of new exemptions on inpatient ceilings for statutory
1648 teaching hospitals, specialty hospitals, and community hospital
1649 education program hospitals that came into effect July 1, 2000,
1650 and for special Medicaid payments that came into effect on or
1651 after July 1, 2000.
1652 (7) By September 1, 2012, the agency shall certify to the
1653 Department of Revenue, for each county, an amount equal to 85
1654 percent of each county’s billings through April 30, 2012, which
1655 remain unpaid.
1656 (8)(a) Beginning with the October 2012 distribution, the
1657 Department of Revenue shall reduce each county’s distributions
1658 pursuant to s. 218.26 by one thirty-sixth of the amount
1659 certified by the agency under subsection (7) for that county.
1660 However, the amount of the reduction may not exceed 50 percent
1661 of each county’s distribution. If, after 36 months, the
1662 reductions for each county do not equal the total amount
1663 initially certified by the agency, the Department of Revenue
1664 shall continue to reduce each distribution by up to 50 percent
1665 until the total amount certified is reached. The amounts by
1666 which the distributions are reduced shall be transferred to the
1667 General Revenue Fund.
1668 (b) As an assurance to holders of bonds issued before the
1669 effective date of this act to which distributions made pursuant
1670 to s. 218.26 are pledged, or bonds issued to refund such bonds
1671 which mature no later than the bonds they refunded and which
1672 result in a reduction of debt service payable in each fiscal
1673 year, the amount available for distribution to a county shall
1674 remain as provided by law and continue to be subject to any lien
1675 or claim on behalf of the bondholders. The Department of Revenue
1676 must ensure that any reduction in amounts distributed pursuant
1677 to paragraph (a) does not reduce the amount of distribution to a
1678 county below the amount necessary for the payment of principal
1679 and interest on the bonds and the amount necessary to comply
1680 with any covenant under the bond resolution or other documents
1681 relating to the issuance of the bonds.
1682 (9)(a) Beginning May 1, 2012, and each month thereafter,
1683 the agency shall certify to the Department of Revenue the amount
1684 of the monthly statement rendered to each county pursuant to
1685 subsection (4). The department shall reduce each county’s
1686 monthly distribution pursuant to s. 218.61 by the amount
1687 certified. The amounts by which the distributions are reduced
1688 shall be transferred to the General Revenue Fund.
1689 (b) As an assurance to holders of bonds issued before the
1690 effective date of this act to which distributions made pursuant
1691 to s. 218.61 are pledged, or bonds issued to refund such bonds
1692 which mature no later than the bonds they refunded and which
1693 result in a reduction of debt service payable in each fiscal
1694 year, the amount available for distribution to a county shall
1695 remain as provided by law and continue to be subject to any lien
1696 or claim on behalf of the bondholders. The Department of Revenue
1697 must ensure that any reductions in amounts distributed pursuant
1698 to paragraph (a) does not reduce the amount of distribution to a
1699 county below the amount necessary for the payment of principal
1700 and interest on the bonds and the amount necessary to comply
1701 with any covenant under the bond resolution or other documents
1702 relating to the issuance of the bonds.
1703 (10) The Department of Revenue shall pay certified refund
1704 requests in accordance with a process developed by the agency
1705 and the department which:
1706 (a) Allows counties to submit to the agency written
1707 requests for refunds of any amounts by which the distributions
1708 were reduced as provided in subsection (9) and which set forth
1709 the reasons for the refund requests.
1710 (b) Requires the agency to make a determination as to
1711 whether a refund request is appropriate and should be approved,
1712 in which case the agency shall certify the amount of the refund
1713 to the department.
1714 (c) Requires the department to issue the refund for the
1715 certified amount to the county from the General Revenue Fund.
1716 (11) Beginning in the 2013-2014 fiscal year and each year
1717 thereafter until the 2020-2021 fiscal year, the Chief Financial
1718 Officer shall transfer from the General Revenue Fund to the
1719 Lawton Chiles Endowment Fund an amount equal to the amounts
1720 transferred to the General Revenue Fund in the previous fiscal
1721 year pursuant to subsections (8) and (9), reduced by the amount
1722 of refunds paid pursuant to subsection (10), which are in excess
1723 of the official estimate for medical hospital fees for such
1724 previous fiscal year adopted by the Revenue Estimating
1725 Conference on January 12, 2012, as reflected in the conference’s
1726 workpapers. By July 20 of each year, the Office of Economic and
1727 Demographic Research shall certify the amount to be transferred
1728 to the Chief Financial Officer. Such transfers must be made
1729 before July 31 of each year until the total transfers for all
1730 years equal $265 million. The Office of Economic and Demographic
1731 Research shall publish the official estimates reflected in the
1732 conference’s workpapers on its website.
1733 Section 18. Subsection (2) of section 409.979, Florida
1734 Statutes, is amended to read:
1735 409.979 Eligibility.—
1736 (2) Medicaid recipients who, on the date long-term care
1737 managed care plans become available in their region, reside in a
1738 nursing home facility or are enrolled in one of the following
1739 long-term care Medicaid waiver programs are eligible to
1740 participate in the long-term care managed care program for up to
1741 12 months without being reevaluated for their need for nursing
1742 facility care as defined in s. 409.985(3):
1743 (a) The Assisted Living for the Frail Elderly Waiver.
1744 (b) The Aged and Disabled Adult Waiver.
1745 (c) The Adult Day Health Care Waiver.
1746 (c)(d) The Consumer-Directed Care Plus Program as described
1747 in s. 409.221.
1748 (d)(e) The Program of All-inclusive Care for the Elderly.
1749 (e)(f) The long-term care community-based diversion pilot
1750 project as described in s. 430.705.
1751 (f)(g) The Channeling Services Waiver for Frail Elders.
1752 Section 19. Subsection (15) of section 430.04, Florida
1753 Statutes, is amended to read:
1754 430.04 Duties and responsibilities of the Department of
1755 Elderly Affairs.—The Department of Elderly Affairs shall:
1756 (15) Administer all Medicaid waivers and programs relating
1757 to elders and their appropriations. The waivers include, but are
1758 not limited to:
1759 (a) The Assisted Living for the Frail Elderly Waiver.
1760 (b) The Aged and Disabled Adult Waiver.
1761 (c) The Adult Day Health Care Waiver.
1762 (c)(d) The Consumer-Directed Care Plus Program as defined
1763 in s. 409.221.
1764 (d)(e) The Program of All-inclusive Care for the Elderly.
1765 (e)(f) The Long-Term Care Community-Based Diversion Pilot
1766 Project as described in s. 430.705.
1767 (f)(g) The Channeling Services Waiver for Frail Elders.
1768
1769 The department shall develop a transition plan for recipients
1770 receiving services in long-term care Medicaid waivers for elders
1771 or disabled adults on the date eligible plans become available
1772 in each recipient’s region defined in s. 409.981(2) to enroll
1773 those recipients in eligible plans. This subsection expires
1774 October 1, 2014.
1775 Section 20. Section 31 of chapter 2009-223, Laws of
1776 Florida, as amended by section 44 of chapter 2010-151, Laws of
1777 Florida, is redesignated as section 409.9132, Florida Statutes,
1778 and amended to read:
1779 409.9132 Section 31. Pilot project to monitor home health
1780 services.—The agency for Health Care Administration shall expand
1781 the develop and implement a home health agency monitoring pilot
1782 project in Miami-Dade County on a statewide basis effective July
1783 1, 2012, except in counties in which the program will not be
1784 cost-effective, as determined by the agency by January 1, 2010.
1785 The agency shall contract with a vendor to verify the
1786 utilization and delivery of home health services and provide an
1787 electronic billing interface for home health services. The
1788 contract must require the creation of a program to submit claims
1789 electronically for the delivery of home health services. The
1790 program must verify telephonically visits for the delivery of
1791 home health services using voice biometrics. The agency may seek
1792 amendments to the Medicaid state plan and waivers of federal
1793 laws, as necessary, to implement or expand the pilot project.
1794 Notwithstanding s. 287.057(3)(f), Florida Statutes, the agency
1795 must award the contract through the competitive solicitation
1796 process and may use the current contract to expand the home
1797 health agency monitoring pilot project to include additional
1798 counties as authorized under this section. The agency shall
1799 submit a report to the Governor, the President of the Senate,
1800 and the Speaker of the House of Representatives evaluating the
1801 pilot project by February 1, 2011.
1802 Section 21. Section 32 of chapter 2009-223, Laws of
1803 Florida, is redesignated as section 409.9133, Florida Statutes,
1804 and amended to read:
1805 409.9133 Section 32. Pilot project for home health care
1806 management.—The agency for Health Care Administration shall
1807 expand the implement a comprehensive care management pilot
1808 project for home health services statewide and include private
1809 duty nursing and personal care services effective July 1, 2012,
1810 except in counties in which the program will not be cost
1811 effective, as determined by the agency by January 1, 2010. The
1812 program must include, which includes face-to-face assessments by
1813 a nurse licensed pursuant to chapter 464, Florida Statutes,
1814 consultation with physicians ordering services to substantiate
1815 the medical necessity for services, and on-site or desk reviews
1816 of recipients’ medical records in Miami-Dade County. The agency
1817 may enter into a contract with a qualified organization to
1818 implement or expand the pilot project. The agency may use the
1819 current contract to expand the comprehensive care management
1820 pilot project to include the additional services and counties
1821 authorized under this section. The agency may seek amendments to
1822 the Medicaid state plan and waivers of federal laws, as
1823 necessary, to implement or expand the pilot project.
1824 Section 22. Notwithstanding s. 430.707, Florida Statutes,
1825 and subject to federal approval of an additional site for the
1826 Program of All-Inclusive Care for the Elderly (PACE), the Agency
1827 for Health Care Administration shall contract with a current
1828 PACE organization authorized to provide PACE services in
1829 Southeast Florida to develop and operate a PACE program in
1830 Broward County to serve frail elders who reside in Broward
1831 County. The organization shall be exempt from chapter 641,
1832 Florida Statutes. The agency, in consultation with the
1833 Department of Elderly Affairs and subject to an appropriation,
1834 shall approve up to 150 initial enrollee slots in the Broward
1835 program established by the organization.
1836 Section 23. Effective upon this act becoming a law and for
1837 the 2011-2012 state fiscal year only, a public hospital located
1838 in trauma service area 2 which has local funds available for
1839 intergovernmental transfers that allow for exemptions from
1840 inpatient and outpatient reimbursement limitations may,
1841 notwithstanding s. 409.905(5)(c), Florida Statues, have its
1842 reimbursement rates adjusted after September 30 of the state
1843 fiscal year in which the rates take effect.
1844 Section 24. Except as otherwise expressly provided in this
1845 act and except for this section, which shall take effect upon
1846 this act becoming a law, this act shall take effect July 1,
1847 2012.
1848
1849 ================= T I T L E A M E N D M E N T ================
1850 And the title is amended as follows:
1851 Delete everything before the enacting clause
1852 and insert:
1853 A bill to be entitled
1854 An act relating to Medicaid; amending s. 381.79, F.S.;
1855 increasing the amount that may be available to the
1856 University of Florida and the University of Miami for
1857 brain and spinal cord injury research; amending s.
1858 383.15, F.S.; revising legislative intent relating to
1859 funding for regional perinatal intensive care centers;
1860 amending s. 409.8132, F.S.; revising a cross
1861 reference; amending s. 409.814, F.S.; deleting a
1862 prohibition preventing children who are eligible for
1863 coverage under a state health benefit plan from being
1864 eligible for services provided through the subsidized
1865 program; revising cross-references; requiring a
1866 completed application, including a clinical screening,
1867 for enrollment in the Children’s Medical Services
1868 Network; amending s. 409.902, F.S.; providing for the
1869 creation of an Internet-based system for determining
1870 eligibility for the Medicaid and Kidcare programs,
1871 contingent on the appropriation; providing system
1872 business objectives and requirements; requiring the
1873 Department of Children and Family Services to develop
1874 the system; requiring the system to be completed and
1875 implemented by specified dates; providing a governance
1876 structure pending implementation of the program,
1877 including an executive steering committee and a
1878 project management team; amending s. 409.905, F.S.;
1879 limiting the number of paid hospital emergency
1880 department visits for nonpregnant adults; authorizing
1881 the Agency for Health Care Administration to request
1882 approval by the Legislative Budget Commission of
1883 hospital rate adjustments; providing components for
1884 the agency’s plan to convert inpatient hospital rates
1885 to a prospective payment system; revising dates for
1886 submitting the plan and implementing the system;
1887 amending s. 409.908, F.S.; conforming a cross
1888 reference; authorizing the Agency for Health Care
1889 Administration to accept voluntary intergovernmental
1890 transfers of local taxes and other qualified revenue
1891 from counties, municipalities, or special taxing
1892 districts in order to fund certain costs; limiting the
1893 use of intergovernmental transfer funds for hospital
1894 reimbursements; prohibiting the inclusion of certain
1895 hospital costs in the capitation rates for prepaid
1896 health plans; providing for the inclusion of certain
1897 hospital costs in capitation rates for prepaid health
1898 plans if funded by intergovernmental transfers;
1899 incorporating a transferred provision; amending s.
1900 409.911, F.S.; updating references to data used for
1901 calculations in the disproportionate share program;
1902 repealing s. 409.9112, F.S., relating to the
1903 disproportionate share program for regional perinatal
1904 intensive care centers; amending s. 409.9113, F.S.;
1905 conforming a cross-reference; authorizing the agency
1906 to distribute moneys in the disproportionate share
1907 program for teaching hospitals; repealing s. 409.9117,
1908 F.S., relating to the primary care disproportionate
1909 share program; amending s. 409.912, F.S.; revising the
1910 conditions for contracting with certain managed care
1911 plans for behavioral health care services; deleting
1912 requirements for assigning certain MediPass recipients
1913 to managed care plans for behavioral health care
1914 services; requiring the assignment of recipients to
1915 provider service networks; amending s. 409.9121, F.S.;
1916 revising legislative findings relating to the Medicaid
1917 program; amending s. 409.9122, F.S.; providing
1918 criteria and procedures relating to recipient
1919 enrollment choice and assignment among Medicaid
1920 managed care plans and MediPass; deleting transferred
1921 provisions relating to school districts; amending s.
1922 409.9123, F.S.; revising provisions relating to the
1923 publication of quality measures for managed care
1924 plans; reenacting s. 409.9126, F.S., relating to
1925 children with special health care needs; amending s.
1926 409.915, F.S.; specifying criteria for determining a
1927 county’s eligible recipients; providing for payment of
1928 billings that have been denied by the county from the
1929 county’s tax revenues; providing for refunds;
1930 providing for the transfer of certain refunds to the
1931 Lawton Chiles Endowment Fund; amending ss. 409.979 and
1932 430.04, F.S.; deleting references to the Adult Day
1933 Health Care Waiver in provisions relating to Medicaid
1934 eligibility and duties and responsibilities of the
1935 Department of Elderly Affairs; amending s. 31, chapter
1936 2009-223, Laws of Florida, as amended, and
1937 redesignating that section as s. 409.9132, F.S.;
1938 expanding the home health agency monitoring pilot
1939 project statewide; amending s. 32, chapter 2009-223,
1940 Laws of Florida, and redesignating that section as s.
1941 409.9133, F.S.; expanding the comprehensive care
1942 management pilot project for home health services
1943 statewide and including private-duty nursing and
1944 personal care services; providing an additional site
1945 in Broward County for the Program of All-Inclusive
1946 Care for the Elderly; providing that a public hospital
1947 located in trauma service area 2 which has local funds
1948 available for intergovernmental transfers may have its
1949 reimbursement rates adjusted after a certain date;
1950 providing effective dates.