Florida Senate - 2012 SENATOR AMENDMENT
Bill No. CS for SB 730
Barcode 875574
LEGISLATIVE ACTION
Senate . House
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Floor: 2/F/RM .
03/08/2012 06:36 PM .
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Senator Garcia moved the following:
1 Senate Amendment to House Amendment (504515) (with title
2 amendment)
3
4 Between lines 470 and 471
5 insert:
6 Section 9. Subsection (1) of section 409.975, Florida
7 Statutes, is amended to read:
8 409.975 Managed care plan accountability.—In addition to
9 the requirements of s. 409.967, plans and providers
10 participating in the managed medical assistance program shall
11 comply with the requirements of this section.
12 (1) PROVIDER NETWORKS.—Managed care plans must develop and
13 maintain provider networks that meet the medical needs of their
14 enrollees in accordance with standards established pursuant to
15 s. 409.967(2)(b). Except as provided in this section, managed
16 care plans may limit the providers in their networks based on
17 credentials, quality indicators, and price.
18 (a) Plans must include all providers in the region that are
19 classified by the agency as essential Medicaid providers for the
20 essential services they provide, unless the agency approves, in
21 writing, an alternative arrangement for securing the types of
22 services offered by the essential providers. Providers are
23 essential for serving Medicaid enrollees if they offer services
24 that are not available from any other provider within a
25 reasonable access standard, or if they provided a substantial
26 share of the total units of a particular service used by
27 Medicaid patients within the region during the last 3 years and
28 the combined capacity of other service providers in the region
29 is insufficient to meet the total needs of the Medicaid
30 patients. The agency may not classify physicians and other
31 practitioners as essential providers.
32 1. The agency, at a minimum, shall determine which
33 providers in the following categories are essential Medicaid
34 providers:
35 a.1. Federally qualified health centers.
36 b.2. Statutory teaching hospitals as defined in s.
37 408.07(45).
38 c.3. Hospitals that are trauma centers as defined in s.
39 395.4001(14).
40 d.4. Hospitals located at least 25 miles from any other
41 hospital with similar services.
42 2. Before the selection of managed care plans as specified
43 in s. 409.966, each essential Medicaid provider and each
44 hospital that is necessary in order for a managed care plan to
45 demonstrate an adequate network, as determined by the agency,
46 are deemed a part of that managed care plan’s network for
47 purposes of the plan’s enrollment or expansion in the Medicaid
48 program. A hospital that is necessary for a managed care plan to
49 demonstrate an adequate network is an essential hospital. An
50 essential Medicaid provider is deemed a part of a managed care
51 plan’s network for the essential services it provides for
52 purposes of the plan’s enrollment or expansion in the Medicaid
53 program. The managed care plan, each essential Medicaid
54 provider, and each essential hospital shall negotiate in good
55 faith to enter into a provider network contract. During the plan
56 selection process, the managed care plan is not required to have
57 written agreements or contracts with essential Medicaid
58 providers or essential hospitals.
59 3. Managed care plans that have not contracted with all
60 essential Medicaid providers or essential hospitals in the
61 region as of the first date of recipient enrollment, or with
62 whom an essential Medicaid provider or essential hospital has
63 terminated its contract, must continue to negotiate in good
64 faith with such essential Medicaid providers or essential
65 hospitals for 1 year, or until an agreement is reached, or a
66 complaint is resolved as provided in paragraph (e), whichever is
67 first. Each essential Medicaid provider must continue to
68 negotiate in good faith during that year to enter into a
69 provider network contract for at least the essential services it
70 provides. Each essential hospital must continue to negotiate in
71 good faith during that year to enter into a provider network
72 contract. Payments for services rendered by a nonparticipating
73 essential Medicaid provider or essential hospital shall be made
74 at the applicable Medicaid rate as of the first day of the
75 contract between the agency and the plan. A rate schedule for
76 all essential Medicaid providers and essential hospitals must
77 shall be attached to the contract between the agency and the
78 plan.
79 4. After 1 year, managed care plans that are unable to
80 contract with essential Medicaid providers and essential
81 hospitals shall notify the agency and propose an alternative
82 arrangement for securing the essential services for Medicaid
83 enrollees. The arrangement must rely on contracts with other
84 participating providers, regardless of whether those providers
85 are located within the same region as the nonparticipating
86 essential service provider. If the alternative arrangement is
87 approved by the agency, payments to nonparticipating essential
88 Medicaid providers and essential hospitals after the date of the
89 agency’s approval must shall equal 90 percent of the applicable
90 Medicaid rate. If the alternative arrangement is not approved by
91 the agency, payment to nonparticipating essential Medicaid
92 providers and essential hospitals must shall equal 110 percent
93 of the applicable Medicaid rate.
94 (b) Certain providers are statewide resources and essential
95 providers for all managed care plans in all regions. All managed
96 care plans must include these essential providers in their
97 networks for the essential services they provide.
98 1. Statewide essential providers include:
99 a.1. Faculty plans of Florida medical schools.
100 b.2. Regional perinatal intensive care centers as defined
101 in s. 383.16(2).
102 c.3. Hospitals licensed as a specialty hospital for
103 children children’s hospitals as defined in s. 395.002(28).
104 d.4. Accredited and integrated systems serving medically
105 complex children that are comprised of separately licensed, but
106 commonly owned, health care providers delivering at least the
107 following services: medical group home, in-home and outpatient
108 nursing care and therapies, pharmacy services, durable medical
109 equipment, and Prescribed Pediatric Extended Care.
110 2. Before the selection of managed care plans as specified
111 in s. 409.966, each statewide essential provider is deemed a
112 part of that managed care plan’s network for the essential
113 services they provide and for purposes of the plan’s enrollment
114 or expansion in the Medicaid program. The managed care plan and
115 each statewide essential provider shall negotiate in good faith
116 to enter into a provider network contract. During the plan
117 selection process, the managed care plan is not required to have
118 written agreements or contracts with statewide essential
119 providers or essential hospitals.
120 3. Managed care plans that have not contracted with all
121 statewide essential providers in all regions as of the first
122 date of recipient enrollment and all statewide essential
123 providers that have not entered into a contract with each
124 managed care plan must continue to negotiate in good faith. to
125 enter into a provider network contract for at least the
126 essential services. As of the first day of the contract between
127 the agency and the plan, and until a provider network contract
128 is signed, payments:
129 a. To physicians on the faculty of nonparticipating Florida
130 medical schools shall be made at the applicable Medicaid rate.
131 Payments
132 b. For services rendered by regional perinatal intensive
133 care centers shall be made at the applicable Medicaid rate as of
134 the first day of the contract between the agency and the plan.
135 Payments
136 c. To nonparticipating specialty children’s hospitals shall
137 equal the highest rate established by contract between that
138 provider and any other Medicaid managed care plan.
139 (c) After 12 months of active participation in a plan’s
140 network, the plan may exclude any essential provider from the
141 network for failure to meet quality or performance criteria. If
142 the plan excludes an essential provider from the plan, the plan
143 must provide written notice to all recipients who have chosen
144 that provider for care. The notice shall be provided at least 30
145 days before the effective date of the exclusion.
146 (d) Each managed care plan must offer a network contract to
147 each home medical equipment and supplies provider in the region
148 which meets quality and fraud prevention and detection standards
149 established by the plan and which agrees to accept the lowest
150 price previously negotiated between the plan and another such
151 provider.
152 (e) At any time during negotiations a managed care plan, an
153 essential Medicaid provider, an essential hospital, or a
154 statewide essential provider may file a complaint with the
155 agency alleging that, in provider network negotiations, the
156 other party is not negotiating in good faith. The agency shall
157 review each complaint and make a determination whether or not
158 one or both parties have failed to negotiate in good faith.
159 1. If the agency determines that:
160 a. The managed care plan was not negotiating in good faith,
161 payment to the nonparticipating essential Medicaid provider,
162 essential hospital, or statewide essential provider shall equal
163 110 percent of the applicable Medicaid rate or the highest
164 contracted rate the provider has with a plan, whichever is
165 higher.
166 b. The essential Medicaid provider, essential hospital, or
167 statewide essential provider was not negotiating in good faith,
168 payment to the nonparticipating provider shall equal 90 percent
169 of the applicable Medicaid rate or the lowest contracted rate
170 the provider has with a plan, whichever is lower.
171 c. Both parties were not negotiating in good faith, payment
172 to the nonparticipating provider shall be made at the applicable
173 Medicaid rate.
174 2. In making a determination under this paragraph regarding
175 a managed care plan’s good faith efforts to negotiate, the
176 agency, at a minimum, shall consider whether the managed care
177 plan has:
178 a. Offered payment rates that are comparable to other
179 managed care plan rates to the provider or that are comparable
180 to fee-for-service rates for the provider.
181 b. Proposed its prepayment edits and audits and prior
182 authorizations in a manner comparable to other managed care
183 plans or comparable to current fee for service utilization
184 management and prior authorization procedures for non-emergent
185 services.
186 c. Offered to pay the provider’s undisputed claims faster
187 or equal to existing Medicaid managed care plan contract
188 standards and, if the managed care plan’s claims payment system
189 has been used in other markets, has it failed to meet these
190 standards.
191 d. Offered a provider dispute resolution system that meets
192 or exceeds existing Medicaid managed care plan contract
193 requirements.
194 e. If the provider is a hospital essential provider,
195 offered a reasonable payment amount for use of the hospital
196 emergency room for non-emergent care, developed referral
197 arrangements with the hospital for non-emergent care, and
198 offered reasonable prior or post authorization requirements for
199 non-emergent care in the emergency room.
200 f. Attempted to work with the provider to assist the
201 provider with any patient volume arrangements and whether
202 patient volume arrangements benefit the provider.
203 g. Demonstrated its financial viability and commitment to
204 meeting its financial obligations.
205 h. Demonstrated its ability to support HIPAA-compliant
206 electronic data interchange transactions.
207 3. In making a determination under this paragraph regarding
208 a provider’s good faith efforts to negotiate, the agency shall,
209 at a minimum, consider whether the provider has:
210 a. Met with the managed care plan at a reasonable frequency
211 and involved empowered decision makers in the meetings.
212 b. Offered reasonable rates that are comparable to other
213 managed care plan rates to the provider or comparable to fee
214 for-service rates to the provider.
215 c. Negotiated managed care plan prepayment edits and audits
216 and prior authorizations in a manner comparable to other managed
217 care plans or comparable to fee for service utilization
218 management and prior authorization procedures for non-emergent
219 services.
220 d. Negotiated reasonable payment timeframes for payment of
221 undisputed claims that are comparable to existing Medicaid
222 managed care plan standards or comparable to fee-for-service
223 experience.
224 e. Researched other providers’ experience with the managed
225 care plan’s claims payment system for timeliness of payment.
226 f. Negotiated with the managed care plan regarding a
227 provider dispute resolution system that meets or exceeds the
228 managed care plan’s Medicaid contract requirements.
229 g. If the provider is an essential hospital, negotiated
230 with the managed care plan regarding primary care alternatives
231 to non-emergent use of the emergency room.
232 h. Negotiated patient volume arrangements with the managed
233 care plan.
234 i. Developed, or is developing, a hospital-based provider
235 service network.
236 j. Already contracted with other Medicaid managed care
237 plans.
238 4. Either party may appeal a determination by the agency
239 under this paragraph pursuant to chapter 120. The party
240 appealing the agency’s determination shall pay the appellee’s
241 attorney’s fees and costs, in an amount up to $1 million, from
242 the beginning of the agency’s review of the complaint if the
243 appealing party loses the appeal.
244
245 ================= T I T L E A M E N D M E N T ================
246 And the title is amended as follows:
247 Delete line 529
248 and insert:
249 standards; setting enrollment requirements; amending
250 s. 409.975, F.S.; providing that an essential provider
251 and a hospital that is necessary for a managed care
252 plan to demonstrate an adequate network as determined
253 by the Agency for Health Care Administration are
254 deemed part of that managed care plan’s network for
255 purposes of the provider’s or hospital’s application
256 for enrollment or expansion in Medicaid; requiring
257 good faith negotiations between Medicaid managed care
258 plans and essential Medicaid providers; providing that
259 a statewide essential provider is part of a Medicaid
260 managed care plan’s network for purposes of the
261 managed care plan’s application for enrollment or
262 expansion in the Medicaid program; requiring good
263 faith negotiations between Medicaid managed care plans
264 and statewide essential providers; authorizing
265 Medicaid managed care plans and certain Medicaid
266 providers to file a complaint alleging that, in
267 provider network negotiations, the other party is not
268 negotiating in good faith; requiring the agency to
269 review such complaints and make a determination
270 whether or not one or both parties have failed to
271 negotiate in good faith; providing criteria for the
272 agency to consider in making a determination about
273 good faith negotiations; providing financial penalties
274 for parties that do not negotiate in good faith;
275 providing for appeal of the agency’s determination
276 pursuant to ch. 120, F.S.; providing for payment of
277 attorney fees and costs; amending