Florida Senate - 2012 COMMITTEE AMENDMENT
Bill No. SPB 7094
Barcode 385834
LEGISLATIVE ACTION
Senate . House
Comm: UNFAV .
02/18/2012 .
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The Committee on Budget (Rich) recommended the following:
1 Senate Amendment
2
3 Delete lines 1066 - 1431
4 and insert:
5 (2)(a) The agency shall enroll all Medicaid recipients in a
6 managed care plan or MediPass all Medicaid recipients, except
7 those Medicaid recipients who are: in an institution; are
8 enrolled in the Medicaid medically needy program; are or
9 eligible for both Medicaid and Medicare; are children under 19
10 years of age and eligible for SSI; are children determined to be
11 dependent pursuant to s. 39.01(15); are children enrolled in the
12 Children’s Medical Services Network; are pregnant women eligible
13 for Medicaid pursuant to s. 409.903(5); have other creditable
14 health care coverage; are eligible for refugee assistance; are
15 residents of a developmental disability center, including
16 Sunland Center in Marianna and Tacachale in Gainesville; are
17 enrolled in the home and community-based services waiver
18 pursuant to chapter 393 and waiting for waiver services; or have
19 been determined by the agency to be exempt from mandatory
20 enrollment pursuant to subsection (18). Upon enrollment,
21 recipients may individuals will be able to change their managed
22 care option during the 90-day opt out period required by federal
23 Medicaid regulations. The agency may is authorized to seek the
24 necessary Medicaid state plan amendment to implement this
25 policy. Persons eligible for Medicaid but exempt from mandatory
26 participation who do not choose to enroll in managed care shall
27 be served through the Medicaid fee-for-service program. However,
28 (a) To the extent permitted by federal law, the agency may
29 enroll a recipient in a managed care plan or MediPass a Medicaid
30 recipient who is exempt from mandatory managed care enrollment
31 if, provided that:
32 1. The recipient’s decision to enroll in a managed care
33 plan or MediPass is voluntary;
34 2. If The recipient chooses to enroll in a managed care
35 plan and, the agency has determined that the managed care plan
36 provides specific programs and services that which address the
37 special health needs of the recipient; and
38 3. The agency receives any necessary waivers from the
39 federal Centers for Medicare and Medicaid Services.
40
41 School districts participating in the certified school match
42 program pursuant to ss. 409.908(21) and 1011.70 shall be
43 reimbursed by Medicaid, subject to the limitations of s.
44 1011.70(1), for a Medicaid-eligible child participating in the
45 services as authorized in s. 1011.70, as provided for in s.
46 409.9071, regardless of whether the child is enrolled in
47 MediPass or a managed care plan. Managed care plans shall make a
48 good faith effort to execute agreements with school districts
49 regarding the coordinated provision of services authorized under
50 s. 1011.70. County health departments delivering school-based
51 services pursuant to ss. 381.0056 and 381.0057 shall be
52 reimbursed by Medicaid for the federal share for a Medicaid
53 eligible child who receives Medicaid-covered services in a
54 school setting, regardless of whether the child is enrolled in
55 MediPass or a managed care plan. Managed care plans shall make a
56 good faith effort to execute agreements with county health
57 departments regarding the coordinated provision of services to a
58 Medicaid-eligible child. To ensure continuity of care for
59 Medicaid patients, the agency, the Department of Health, and the
60 Department of Education shall develop procedures for ensuring
61 that a student’s managed care plan or MediPass provider receives
62 information relating to services provided in accordance with ss.
63 381.0056, 381.0057, 409.9071, and 1011.70.
64 (b) A Medicaid recipient may shall not be enrolled in or
65 assigned to a managed care plan or MediPass unless the managed
66 care plan or MediPass has complied with the quality-of-care
67 standards specified in paragraphs (3)(a) and (b), respectively.
68 (c) A Medicaid recipient eligible for managed care
69 enrollment recipients shall have a choice of managed care
70 options plans or MediPass. The Agency for Health Care
71 Administration, the Department of Health, the Department of
72 Children and Family Services, and the Department of Elderly
73 Affairs shall cooperate to ensure that each Medicaid recipient
74 receives clear and easily understandable information that meets
75 the following requirements:
76 1. Explains the concept of managed care, including
77 MediPass.
78 2. Provides information on the comparative performance of
79 managed care options available to the recipient plans and
80 MediPass in the areas of quality, credentialing, preventive
81 health programs, network size and availability, and patient
82 satisfaction.
83 3. Explains where additional information on each managed
84 care option plan and MediPass in the recipient’s area can be
85 obtained.
86 4. Explains that recipients have the right to choose their
87 managed care coverage at the time they first enroll in Medicaid
88 and again at regular intervals set by the agency. However, if a
89 recipient does not choose a managed care option plan or
90 MediPass, the agency shall will assign the recipient to a
91 managed care plan or MediPass according to the criteria
92 specified in this section.
93 5. Explains the recipient’s right to complain, file a
94 grievance, or change his or her managed care option as specified
95 in this section plans or MediPass providers if the recipient is
96 not satisfied with the managed care plan or MediPass.
97 6. Explains the recipient’s right to request an exemption
98 from mandatory managed care enrollment if the recipient meets
99 the criteria in subsection (18).
100 (d) The agency shall develop a mechanism for providing
101 information to Medicaid recipients for the purpose of choosing
102 making a managed care option plan or MediPass selection.
103 Examples of such mechanisms may include, but are not be limited
104 to, interactive information systems, mailings, and mass
105 marketing materials. The agency must also have mechanisms that
106 ensure that persons required to disenroll from the MediPass
107 program and enroll into a managed care plan can timely access
108 information through the state or its contracted vendor to
109 determine whether their current medications are included on a
110 plan’s preferred drug list and whether their current physicians
111 are included in the plan’s network. Managed care plans and
112 MediPass providers may not provide are prohibited from providing
113 inducements to Medicaid recipients to select their plans or
114 prejudice from prejudicing Medicaid recipients against other
115 managed care plans or MediPass providers.
116 (e) Medicaid recipients who are already enrolled in a
117 managed care plan or MediPass shall be offered the opportunity
118 to change managed care plans or MediPass providers, as
119 applicable, on a staggered basis, as defined by the agency. All
120 Medicaid recipients shall have 30 days in which to choose a
121 managed care option make a choice of managed care plans or
122 MediPass providers. Those Medicaid recipients who do not make a
123 choice shall be assigned in accordance with paragraph (f). To
124 facilitate continuity of care, for a Medicaid recipient who is
125 also a recipient of Supplemental Security Income (SSI), prior to
126 assigning the SSI recipient to a managed care plan or MediPass,
127 the agency shall determine whether the SSI recipient has an
128 ongoing relationship with a MediPass provider or managed care
129 plan, and if so, the agency shall assign the SSI recipient to
130 that MediPass provider or managed care plan. Those SSI
131 recipients who do not have such a provider relationship shall be
132 assigned to a managed care plan or MediPass provider in
133 accordance with paragraph (f).
134 1. During the 30-day choice period:
135 a. A recipient residing in a county in which two or more
136 managed care plans are eligible to accept Medicaid enrollees,
137 including a recipient who was enrolled in MediPass at the
138 commencement of his or her 30-day choice period, shall choose
139 from those managed care plans. A recipient may opt out of his or
140 her choice and choose a different managed care plan during the
141 90-day opt out period.
142 b. A recipient residing in a county in which only one
143 managed care plan is eligible to accept Medicaid enrollees shall
144 choose the managed care plan or a MediPass provider. A recipient
145 who chooses the managed care plan may opt out of the plan and
146 choose a MediPass provider during the 90-day opt out period.
147 c. A recipient residing in a county in which no managed
148 care plan is accepting Medicaid enrollees shall choose a
149 MediPass provider.
150 2. For the purposes of recipient choice, if a managed care
151 plan reaches its enrollment capacity, as determined by the
152 agency, the plan may not accept additional Medicaid enrollees
153 until the agency determines that the plan’s enrollment is
154 sufficiently less than its enrollment capacity, due to a decline
155 in enrollment or by an increase in enrollment capacity. If a
156 managed care plan notifies the agency of its intent to exit a
157 county, the plan may not accept additional Medicaid enrollees in
158 that county before the exit date.
159 3. As used in this paragraph, when referring to recipient
160 choice, the term “managed care plans” includes health
161 maintenance organizations, exclusive provider organizations,
162 provider service networks, minority physician networks,
163 Children’s Medical Services Networks, and pediatric emergency
164 department diversion programs authorized by this chapter or the
165 General Appropriations Act.
166 4. The agency shall seek federal waiver authority or a
167 state plan amendment consistent with 42 U.S.C. 1396u-2(a)(1), as
168 needed, to implement this paragraph.
169 (f) If a Medicaid recipient does not choose a managed care
170 option:
171 1. If the recipient resides in a county in which two or
172 more managed care plans are accepting Medicaid enrollees, the
173 agency shall assign the recipient, including a recipient who was
174 enrolled in MediPass at the commencement of his or her 30-day
175 choice period, to one of those managed care plans. A recipient
176 assigned to a managed care plan under this subparagraph may opt
177 out of the managed care plan and enroll in a different managed
178 care plan during the 90-day opt out period. The agency shall
179 seek to make assignments among the managed care plans on an even
180 basis under the criteria in subparagraph 6.
181 2. If the recipient resides in a county in which only one
182 managed care plan is accepting Medicaid enrollees, the agency
183 shall assign the recipient, including a recipient who was
184 enrolled in MediPass at the commencement of his or her 30-day
185 choice period, to the managed care plan. A recipient assigned to
186 a managed care plan under this subparagraph may opt out of the
187 managed care plan and choose a MediPass provider during the 90
188 day opt out period.
189 3. If the recipient resides in a county in which no managed
190 care plan is accepting Medicaid enrollees, the agency shall
191 assign the recipient to a MediPass provider.
192 4. For the purpose of assignment, if a managed care plan
193 reaches its enrollment capacity, as determined by the agency,
194 the plan may not accept additional Medicaid enrollees until the
195 agency determines that the plan’s enrollment is sufficiently
196 less than its enrollment capacity, due to a decline in
197 enrollment or by an increase in enrollment capacity. If a
198 managed care plan notifies the agency of its intent to exit a
199 county, the agency may not assign additional Medicaid enrollees
200 to the plan in that county before the exit date. plan or
201 MediPass provider, the agency shall assign the Medicaid
202 recipient to a managed care plan or MediPass provider. Medicaid
203 recipients eligible for managed care plan enrollment who are
204 subject to mandatory assignment but who fail to make a choice
205 shall be assigned to managed care plans until an enrollment of
206 35 percent in MediPass and 65 percent in managed care plans, of
207 all those eligible to choose managed care, is achieved. Once
208 this enrollment is achieved, the assignments shall be divided in
209 order to maintain an enrollment in MediPass and managed care
210 plans which is in a 35 percent and 65 percent proportion,
211 respectively. Thereafter, assignment of Medicaid recipients who
212 fail to make a choice shall be based proportionally on the
213 preferences of recipients who have made a choice in the previous
214 period. Such proportions shall be revised at least quarterly to
215 reflect an update of the preferences of Medicaid recipients. The
216 agency shall disproportionately assign Medicaid-eligible
217 recipients who are required to but have failed to make a choice
218 of managed care plan or MediPass to the Children’s Medical
219 Services Network as defined in s. 391.021, exclusive provider
220 organizations, provider service networks, minority physician
221 networks, and pediatric emergency department diversion programs
222 authorized by this chapter or the General Appropriations Act, in
223 such manner as the agency deems appropriate, until the agency
224 has determined that the networks and programs have sufficient
225 numbers to be operated economically.
226 5. As used in For purposes of this paragraph, when
227 referring to assignment, the term “managed care plans” includes
228 health maintenance organizations, exclusive provider
229 organizations, provider service networks, minority physician
230 networks, Children’s Medical Services Network, and pediatric
231 emergency department diversion programs authorized by this
232 chapter or the General Appropriations Act.
233 6. When making assignments, the agency shall consider take
234 into account the following criteria, as applicable:
235 a.1. Whether a managed care plan has sufficient network
236 capacity to meet the need of members.
237 b.2. Whether the managed care plan or MediPass has
238 previously enrolled the recipient as a member, or one of the
239 managed care plan’s primary care providers or a MediPass primary
240 care provider providers has previously provided health care to
241 the recipient.
242 c.3. Whether the agency has knowledge that the recipient
243 member has previously expressed a preference for a particular
244 managed care plan or MediPass primary care provider as indicated
245 by Medicaid fee-for-service claims data, but has failed to make
246 a choice.
247 d.4. Whether the managed care plan’s or MediPass primary
248 care providers are geographically accessible to the recipient’s
249 residence.
250 e. If the recipient was already enrolled in a managed care
251 plan at the commencement of his or her 30-day choice period and
252 fails to choose a different option, the recipient must remain
253 enrolled in that same managed care plan.
254 f. To facilitate continuity of care for a Medicaid
255 recipient who is also a recipient of Supplemental Security
256 Income (SSI), before assigning the SSI recipient, the agency
257 shall determine whether the SSI recipient has an ongoing
258 relationship with a managed care plan or a MediPass primary care
259 provider, and if so, the agency shall assign the SSI recipient
260 to that managed care plan or MediPass provider, as applicable.
261 However, if the recipient has an ongoing relationship with a
262 MediPass primary care provider who is included in the provider
263 network of one or more managed care plans, the agency shall
264 assign the recipient to one of those managed care plans.
265 g. If the recipient is diagnosed with HIV/AIDS and resides
266 in Broward County, Miami-Dade County, or Palm Beach County, the
267 agency shall assign the Medicaid recipient to a managed care
268 plan that is a health maintenance organization authorized under
269 chapter 641, that was under contract with the agency on July 1,
270 2011, and that offers a delivery system in partnership with a
271 university-based teaching and research-oriented organization
272 specializing in providing health care services and treatment for
273 individuals diagnosed with HIV/AIDS. Recipients not diagnosed
274 with HIV/AIDS may not be assigned under this paragraph to a
275 managed care plan that specializes in HIV/AIDS.
276 7. The agency shall seek federal waiver authority or a
277 state plan amendment consistent with 42 U.S.C. 1396u-2(a)(4)(D),
278 as needed, to implement this paragraph.
279 (g) When more than one managed care plan or MediPass
280 provider meets the criteria specified in paragraph (f), the
281 agency shall make recipient assignments consecutively by family
282 unit.
283 (h) The agency may not engage in practices that are
284 designed to favor one managed care plan over another or that are
285 designed to influence Medicaid recipients to enroll in MediPass
286 rather than in a managed care plan or to enroll in a managed
287 care plan rather than in MediPass, as applicable. This
288 subsection does not prohibit the agency from reporting on the
289 performance of MediPass or any managed care plan, as measured by
290 performance criteria developed by the agency.
291 (i) After a recipient has made his or her selection or has
292 been enrolled in a managed care plan or MediPass, the recipient
293 shall have 90 days to exercise the opportunity to voluntarily
294 disenroll and select another managed care option plan or
295 MediPass. After 90 days, no further changes may be made except
296 for good cause. Good cause includes, but is not limited to, poor
297 quality of care, lack of access to necessary specialty services,
298 an unreasonable delay or denial of service, or fraudulent
299 enrollment. The agency shall develop criteria for good cause
300 disenrollment for chronically ill and disabled populations who
301 are assigned to managed care plans if more appropriate care is
302 available through the MediPass program. The agency must make a
303 determination as to whether good cause exists. However, the
304 agency may require a recipient to use the managed care plan’s or
305 MediPass grievance process prior to the agency’s determination
306 of good cause, except in cases in which immediate risk of
307 permanent damage to the recipient’s health is alleged. The
308 grievance process, if used when utilized, must be completed in
309 time to permit the recipient to disenroll by the first day of
310 the second month after the month the disenrollment request was
311 made. If the managed care plan or MediPass, as a result of the
312 grievance process, approves an enrollee’s request to disenroll,
313 the agency is not required to make a determination in the case.
314 The agency must make a determination and take final action on a
315 recipient’s request so that disenrollment occurs by no later
316 than the first day of the second month after the month the
317 request was made. If the agency fails to act within the
318 specified timeframe, the recipient’s request to disenroll is
319 deemed to be approved as of the date agency action was required.
320 Recipients who disagree with the agency’s finding that good
321 cause does not exist for disenrollment shall be advised of their
322 right to pursue a Medicaid fair hearing to dispute the agency’s
323 finding.
324 (j) Consistent with 42 U.S.C. 1396u-2(a)(4)(A) or under
325 federal waiver authority, as needed, the agency shall apply for
326 a federal waiver from the Centers for Medicare and Medicaid
327 Services to lock eligible Medicaid recipients into a managed
328 care plan or MediPass for 12 months after an open enrollment
329 period, except for the 90-day opt out period and good cause
330 disenrollment. After 12 months’ enrollment, a recipient may
331 select another managed care plan or MediPass provider. However,
332 nothing shall prevent a Medicaid recipient may not be prevented
333 from changing primary care providers within the managed care
334 plan or MediPass program, as applicable, during the 12-month
335 period.
336 (k) The agency shall maintain MediPass provider networks in
337 all counties, including those counties in which two or more
338 managed care plans are accepting Medicaid enrollees. When a
339 Medicaid recipient does not choose a managed care plan or
340 MediPass provider, the agency shall assign the Medicaid
341 recipient to a managed care plan, except in those counties in
342 which there are fewer than two managed care plans accepting
343 Medicaid enrollees, in which case assignment shall be to a
344 managed care plan or a MediPass provider. Medicaid recipients in
345 counties with fewer than two managed care plans accepting
346 Medicaid enrollees who are subject to mandatory assignment but
347 who fail to make a choice shall be assigned to managed care
348 plans until an enrollment of 35 percent in MediPass and 65
349 percent in managed care plans, of all those eligible to choose
350 managed care, is achieved. Once that enrollment is achieved, the
351 assignments shall be divided in order to maintain an enrollment
352 in MediPass and managed care plans which is in a 35 percent and
353 65 percent proportion, respectively. For purposes of this
354 paragraph, when referring to assignment, the term “managed care
355 plans” includes exclusive provider organizations, provider
356 service networks, Children’s Medical Services Network, minority
357 physician networks, and pediatric emergency department diversion
358 programs authorized by this chapter or the General
359 Appropriations Act. When making assignments, the agency shall
360 take into account the following criteria:
361 1. A managed care plan has sufficient network capacity to
362 meet the need of members.
363 2. The managed care plan or MediPass has previously
364 enrolled the recipient as a member, or one of the managed care
365 plan’s primary care providers or MediPass providers has
366 previously provided health care to the recipient.
367 3. The agency has knowledge that the member has previously
368 expressed a preference for a particular managed care plan or
369 MediPass provider as indicated by Medicaid fee-for-service
370 claims data, but has failed to make a choice.
371 4. The managed care plan’s or MediPass primary care
372 providers are geographically accessible to the recipient’s
373 residence.
374 5. The agency has authority to make mandatory assignments
375 based on quality of service and performance of managed care
376 plans.
377 (l) If the Medicaid recipient is diagnosed with HIV/AIDS
378 and resides in Broward County, Miami-Dade County, or Palm Beach
379 County, the agency shall assign the Medicaid recipient to a
380 managed care plan that is a health maintenance organization
381 authorized under chapter 641, is under contract with the agency
382 on July 1, 2011, and which offers a delivery system through a
383 university-based teaching and research-oriented organization
384 that specializes in providing health care services and treatment
385 for individuals diagnosed with HIV/AIDS.
386 (l)(m) Notwithstanding the provisions of chapter 287, the
387 agency may, at its discretion, renew cost-effective contracts
388 for choice counseling services once or more for such periods as
389 the agency may decide. However, all such renewals may not
390 combine to exceed a total period longer than the term of the
391 original contract.
392 (m) To ensure continuity of care, Medicaid recipients
393 enrolled in MediPass who have not completed a course of
394 treatment with their current provider at the time they are
395 required to enroll in a managed care plan shall be permitted to
396 maintain their provider and Medicaid coverage for up to 6 months
397 in order to complete their treatment, if otherwise eligible.
398 Recipients who are receiving treatment covered by Medicaid from
399 a specialty provider at the time they are required to enroll in
400 a managed care plan shall also be permitted to continue
401 receiving treatment from the specialty provider until their
402 initial appointment with a similar specialty provider under
403 their managed plan. The agency shall develop notice procedures
404 and other mechanisms to ensure that recipients are aware of
405 these transition benefits and how to access them.
406
407 This subsection expires October 1, 2014.