Florida Senate - 2017 SENATOR AMENDMENT
Bill No. HB 7117, 1st Eng.
Ì280566=Î280566
LEGISLATIVE ACTION
Senate . House
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Floor: 1/AD/RM .
05/05/2017 06:02 PM .
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Senator Grimsley moved the following:
1 Senate Amendment to House Amendment (081821) to Senate
2 Amendment (with title amendment)
3
4 Delete lines 6 - 395
5 and insert:
6 Section 1. Section 409.964, Florida Statutes, is amended to
7 read:
8 409.964 Managed care program; state plan; waivers.—The
9 Medicaid program is established as a statewide, integrated
10 managed care program for all covered services, including long
11 term care services. The agency shall apply for and implement
12 state plan amendments or waivers of applicable federal laws and
13 regulations necessary to implement the program, including state
14 plan amendments or waivers required to implement chapter 2016
15 109, Laws of Florida. Before seeking a waiver, the agency shall
16 provide public notice and the opportunity for public comment and
17 include public feedback in the waiver application. The agency
18 shall hold one public meeting in each of the regions described
19 in s. 409.966(2), and the time period for public comment for
20 each region shall end no sooner than 30 days after the
21 completion of the public meeting in that region. The agency
22 shall submit any state plan amendments, new waiver requests, or
23 requests for extensions or expansions for existing waivers,
24 needed to implement the managed care program by August 1, 2011.
25 Section 2. Subsection (2) and paragraphs (a), (d), (e), and
26 (f) of subsection (3) of section 409.966, Florida Statutes, are
27 amended to read:
28 409.966 Eligible plans; selection.—
29 (2) ELIGIBLE PLAN SELECTION.—The agency shall select a
30 limited number of eligible plans to participate in the Medicaid
31 program using invitations to negotiate in accordance with s.
32 287.057(1)(c). At least 90 days before issuing an invitation to
33 negotiate, the agency shall compile and publish a databook
34 consisting of a comprehensive set of utilization and spending
35 data consistent with actuarial rate-setting practices and
36 standards for the 3 most recent contract years consistent with
37 the rate-setting periods for all Medicaid recipients by region
38 or county. The source of the data in the databook report must
39 include the 24 most recent months of both historic fee-for
40 service claims and validated data from the Medicaid Encounter
41 Data System. The report must be available in electronic form and
42 delineate utilization use by age, gender, eligibility group,
43 geographic area, and aggregate clinical risk score. Separate and
44 simultaneous procurements shall be conducted in each of the
45 following regions:
46 (a) Region A Region 1, which consists of Bay, Calhoun,
47 Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson,
48 Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla,
49 and Walton, and Washington Counties.
50 (b) Region B Region 2, which consists of Alachua, Baker,
51 Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler,
52 Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion,
53 Nassau, Putnam, St. Johns, Sumter, Suwannee, Union, and Volusia
54 Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson,
55 Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and
56 Washington Counties.
57 (c) Region C Region 3, which consists of Hardee, Highlands,
58 Hillsborough, Manatee, Pasco, Pinellas, and Polk Alachua,
59 Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton,
60 Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter,
61 Suwannee, and Union Counties.
62 (d) Region D Region 4, which consists of Brevard, Orange,
63 Osceola, and Seminole Baker, Clay, Duval, Flagler, Nassau, St.
64 Johns, and Volusia Counties.
65 (e) Region E Region 5, which consists of Charlotte,
66 Collier, DeSoto, Glades, Hendry, Lee, and Sarasota Pasco and
67 Pinellas Counties.
68 (f) Region F Region 6, which consists of Indian River,
69 Martin, Okeechobee, Palm Beach, and St. Lucie Hardee, Highlands,
70 Hillsborough, Manatee, and Polk Counties.
71 (g) Region G Region 7, which consists of Broward County
72 Brevard, Orange, Osceola, and Seminole Counties.
73 (h) Region H Region 8, which consists of Miami-Dade and
74 Monroe Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and
75 Sarasota Counties.
76 (i) Region 9, which consists of Indian River, Martin,
77 Okeechobee, Palm Beach, and St. Lucie Counties.
78 (j) Region 10, which consists of Broward County.
79 (k) Region 11, which consists of Miami-Dade and Monroe
80 Counties.
81 (3) QUALITY SELECTION CRITERIA.—
82 (a) The invitation to negotiate must specify the criteria
83 and the relative weight of the criteria that will be used for
84 determining the acceptability of the reply and guiding the
85 selection of the organizations with which the agency negotiates.
86 The agency shall give preference to plans that propose
87 establishing a comprehensive long-term care plan. In addition to
88 criteria established by the agency, the agency shall consider
89 the following factors in the selection of eligible plans:
90 1. Accreditation by the National Committee for Quality
91 Assurance, the Joint Commission, or another nationally
92 recognized accrediting body.
93 2. Experience serving similar populations, including the
94 organization’s record in achieving specific quality standards
95 with similar populations.
96 3. Availability and accessibility of primary care and
97 specialty physicians in the provider network.
98 4. Establishment of community partnerships with providers
99 that create opportunities for reinvestment in community-based
100 services.
101 5. Organization commitment to quality improvement and
102 documentation of achievements in specific quality improvement
103 projects, including active involvement by organization
104 leadership.
105 6. Provision of additional benefits, particularly dental
106 care and disease management, and other initiatives that improve
107 health outcomes.
108 7. Evidence that an eligible plan has obtained signed
109 contracts or written agreements or signed contracts or has made
110 substantial progress in establishing relationships with
111 providers before the plan submits submitting a response.
112 8. Comments submitted in writing by any enrolled Medicaid
113 provider relating to a specifically identified plan
114 participating in the procurement in the same region as the
115 submitting provider.
116 9. Documentation of policies and procedures for preventing
117 fraud and abuse.
118 10. The business relationship an eligible plan has with any
119 other eligible plan that responds to the invitation to
120 negotiate.
121 (d) For the first year of the first contract term, the
122 agency shall negotiate capitation rates or fee for service
123 payments with each plan in order to guarantee aggregate savings
124 of at least 5 percent.
125 1. For prepaid plans, determination of the amount of
126 savings shall be calculated by comparison to the Medicaid rates
127 that the agency paid managed care plans for similar populations
128 in the same areas in the prior year. In regions containing no
129 prepaid plans in the prior year, determination of the amount of
130 savings shall be calculated by comparison to the Medicaid rates
131 established and certified for those regions in the prior year.
132 2. For provider service networks operating on a fee-for
133 service basis, determination of the amount of savings shall be
134 calculated by comparison to the Medicaid rates that the agency
135 paid on a fee-for-service basis for the same services in the
136 prior year.
137 (d)(e) To ensure managed care plan participation in Regions
138 A and E Regions 1 and 2, the agency shall award an additional
139 contract to each plan with a contract award in Region A Region 1
140 or Region E Region 2. Such contract shall be in any other region
141 in which the plan submitted a responsive bid and negotiates a
142 rate acceptable to the agency. If a plan that is awarded an
143 additional contract pursuant to this paragraph is subject to
144 penalties pursuant to s. 409.967(2)(i) for activities in Region
145 A Region 1 or Region E Region 2, the additional contract is
146 automatically terminated 180 days after the imposition of the
147 penalties. The plan must reimburse the agency for the cost of
148 enrollment changes and other transition activities.
149 (e)(f) The agency may not execute contracts with managed
150 care plans at payment rates not supported by the General
151 Appropriations Act.
152 Section 3. Paragraphs (c) and (j) of subsection (2) of
153 section 409.967, Florida Statutes, are amended to read:
154 409.967 Managed care plan accountability.—
155 (2) The agency shall establish such contract requirements
156 as are necessary for the operation of the statewide managed care
157 program. In addition to any other provisions the agency may deem
158 necessary, the contract must require:
159 (c) Access.—
160 1. The agency shall establish specific standards for the
161 number, type, and regional distribution of providers in managed
162 care plan networks to ensure access to care for both adults and
163 children. Each plan must maintain a regionwide network of
164 providers in sufficient numbers to meet the access standards for
165 specific medical services for all recipients enrolled in the
166 plan. The exclusive use of mail-order pharmacies may not be
167 sufficient to meet network access standards. Consistent with the
168 standards established by the agency, provider networks may
169 include providers located outside the region. A plan may
170 contract with a new hospital facility before the date the
171 hospital becomes operational if the hospital has commenced
172 construction, will be licensed and operational by January 1,
173 2013, and a final order has issued in any civil or
174 administrative challenge. Each plan shall establish and maintain
175 an accurate and complete electronic database of contracted
176 providers, including information about licensure or
177 registration, locations and hours of operation, specialty
178 credentials and other certifications, specific performance
179 indicators, and such other information as the agency deems
180 necessary. The database must be available online to both the
181 agency and the public and have the capability to compare the
182 availability of providers to network adequacy standards and to
183 accept and display feedback from each provider’s patients. Each
184 plan shall submit quarterly reports to the agency identifying
185 the number of enrollees assigned to each primary care provider.
186 The agency shall conduct, or contract with a third party to
187 conduct, systematic and ongoing testing of the provider network
188 databases maintained by each plan to confirm database accuracy,
189 to confirm that network providers are accepting enrollees, and
190 to confirm that such enrollees have access to care.
191 2. Each managed care plan must publish any prescribed drug
192 formulary or preferred drug list on the plan’s website in a
193 manner that is accessible to and searchable by enrollees and
194 providers. The plan must update the list within 24 hours after
195 making a change. Each plan must ensure that the prior
196 authorization process for prescribed drugs is readily accessible
197 to health care providers, including posting appropriate contact
198 information on its website and providing timely responses to
199 providers. For Medicaid recipients diagnosed with hemophilia who
200 have been prescribed anti-hemophilic-factor replacement
201 products, the agency shall provide for those products and
202 hemophilia overlay services through the agency’s hemophilia
203 disease management program.
204 3. Managed care plans, and their fiscal agents or
205 intermediaries, must accept prior authorization requests for any
206 service electronically.
207 4. Managed care plans serving children in the care and
208 custody of the Department of Children and Families must maintain
209 complete medical, dental, and behavioral health encounter
210 information and participate in making such information available
211 to the department or the applicable contracted community-based
212 care lead agency for use in providing comprehensive and
213 coordinated case management. The agency and the department shall
214 establish an interagency agreement to provide guidance for the
215 format, confidentiality, recipient, scope, and method of
216 information to be made available and the deadlines for
217 submission of the data. The scope of information available to
218 the department shall be the data that managed care plans are
219 required to submit to the agency. The agency shall determine the
220 plan’s compliance with standards for access to medical, dental,
221 and behavioral health services; the use of medications; and
222 followup on all medically necessary services recommended as a
223 result of early and periodic screening, diagnosis, and
224 treatment.
225 (j) Prompt payment.—Managed care plans shall comply with
226 ss. 641.315, 641.3155, and 641.513, and the agency shall impose
227 fines, and may impose other sanctions, on a plan that willfully
228 fails to comply with ss. 641.315, 641.3155, and 641.513 or s.
229 409.982(5).
230 Section 4. Section 409.971, Florida Statutes, is amended to
231 read:
232 409.971 Managed medical assistance program.—The agency
233 shall make payments for primary and acute medical assistance and
234 related services using a managed care model. By January 1, 2013,
235 the agency shall begin implementation of the statewide managed
236 medical assistance program, with full implementation in all
237 regions by October 1, 2014.
238 Section 5. Subsections (1) and (2) of section 409.974,
239 Florida Statutes, are amended to read:
240 409.974 Eligible plans.—
241 (1) ELIGIBLE PLAN SELECTION.—The agency shall select
242 eligible plans for the managed medical assistance program
243 through the procurement process described in s. 409.966. The
244 agency shall notice invitations to negotiate no later than
245 January 1, 2013.
246 (a) The agency shall procure at least three two plans and
247 up to four plans for Region A Region 1. At least one plan shall
248 be a provider service network if any provider service networks
249 submit a responsive bid.
250 (b) The agency shall procure at least four plans and up to
251 eight two plans for Region B Region 2. At least one plan shall
252 be a provider service network if any provider service networks
253 submit a responsive bid.
254 (c) The agency shall procure at least five three plans and
255 up to 10 five plans for Region C Region 3. At least one plan
256 must be a provider service network if any provider service
257 networks submit a responsive bid.
258 (d) The agency shall procure at least three plans and up to
259 six five plans for Region D Region 4. At least one plan must be
260 a provider service network if any provider service networks
261 submit a responsive bid.
262 (e) The agency shall procure at least three two plans and
263 up to four plans for Region E Region 5. At least one plan must
264 be a provider service network if any provider service networks
265 submit a responsive bid.
266 (f) The agency shall procure at least three four plans and
267 up to five seven plans for Region F Region 6. At least one plan
268 must be a provider service network if any provider service
269 networks submit a responsive bid.
270 (g) The agency shall procure at least three plans and up to
271 five six plans for Region G Region 7. At least one plan must be
272 a provider service network if any provider service networks
273 submit a responsive bid.
274 (h) The agency shall procure at least five two plans and up
275 to 10 four plans for Region H Region 8. At least one plan must
276 be a provider service network if any provider service networks
277 submit a responsive bid.
278 (i) The agency shall procure at least two plans and up to
279 four plans for Region 9. At least one plan must be a provider
280 service network if any provider service networks submit a
281 responsive bid.
282 (j) The agency shall procure at least two plans and up to
283 four plans for Region 10. At least one plan must be a provider
284 service network if any provider service networks submit a
285 responsive bid.
286 (k) The agency shall procure at least five plans and up to
287 10 plans for Region 11. At least one plan must be a provider
288 service network if any provider service networks submit a
289 responsive bid.
290
291 If no provider service network submits a responsive bid, the
292 agency shall procure no more than one less than the maximum
293 number of eligible plans permitted in that region. Within 12
294 months after the initial invitation to negotiate, the agency
295 shall attempt to procure a provider service network. The agency
296 shall notice another invitation to negotiate only with provider
297 service networks in those regions where no provider service
298 network has been selected.
299 (2) QUALITY SELECTION CRITERIA.—In addition to the criteria
300 established in s. 409.966, the agency shall consider evidence
301 that an eligible plan has obtained signed contracts or written
302 agreements or signed contracts or has made substantial progress
303 in establishing relationships with providers before the plan
304 submits submitting a response. The agency shall evaluate and
305 give special weight to evidence of signed contracts with
306 essential providers as defined by the agency pursuant to s.
307 409.975(1). The agency shall exercise a preference for plans
308 with a provider network in which more than over 10 percent of
309 the providers use electronic health records, as defined in s.
310 408.051. When all other factors are equal, the agency shall
311 consider whether the organization has a contract to provide
312 managed long-term care services in the same region and shall
313 exercise a preference for such plans.
314 Section 6. Subsection (1) of section 409.978, Florida
315 Statutes, is amended to read:
316 409.978 Long-term care managed care program.—
317 (1) Pursuant to s. 409.963, the agency shall administer the
318 long-term care managed care program described in ss. 409.978
319 409.985, but may delegate specific duties and responsibilities
320 for the program to the Department of Elderly Affairs and other
321 state agencies. By July 1, 2012, the agency shall begin
322 implementation of the statewide long-term care managed care
323 program, with full implementation in all regions by October 1,
324 2013.
325 Section 7. Subsection (2) and paragraphs (c), (d), and (e)
326 of subsection (3) of section 409.981, Florida Statutes, are
327 amended to read:
328 409.981 Eligible long-term care plans.—
329 (2) ELIGIBLE PLAN SELECTION.—The agency shall select
330 eligible plans for the long-term care managed care program
331 through the procurement process described in s. 409.966. The
332 agency shall procure:
333 (a) At least three two plans and up to four plans for
334 Region A Region 1. At least one plan must be a provider service
335 network if any provider service networks submit a responsive
336 bid.
337 (b) At least three Two plans and up to six plans for Region
338 B Region 2. At least one plan must be a provider service network
339 if any provider service networks submit a responsive bid.
340 (c) At least five three plans and up to eight five plans
341 for Region C Region 3. At least one plan must be a provider
342 service network if any provider service networks submit a
343 responsive bid.
344 (d) At least three plans and up to six five plans for
345 Region D Region 4. At least one plan must be a provider service
346 network if any provider service network submits a responsive
347 bid.
348 (e) At least three two plans and up to four plans for
349 Region E Region 5. At least one plan must be a provider service
350 network if any provider service networks submit a responsive
351 bid.
352 (f) At least three four plans and up to five seven plans
353 for Region F Region 6. At least one plan must be a provider
354 service network if any provider service networks submit a
355 responsive bid.
356 (g) At least three plans and up to four six plans for
357 Region G Region 7. At least one plan must be a provider service
358 network if any provider service networks submit a responsive
359 bid.
360 (h) At least five two plans and up to 10 four plans for
361 Region H Region 8. At least one plan must be a provider service
362 network if any provider service networks submit a responsive
363 bid.
364 (i) At least two plans and up to four plans for Region 9.
365 At least one plan must be a provider service network if any
366 provider service networks submit a responsive bid.
367 (j) At least two plans and up to four plans for Region 10.
368 At least one plan must be a provider service network if any
369 provider service networks submit a responsive bid.
370 (k) At least five plans and up to 10 plans for Region 11.
371 At least one plan must be a provider service network if any
372 provider service networks submit a responsive bid.
373
374 If no provider service network submits a responsive bid in a
375 region other than Region 1 or Region 2, the agency shall procure
376 no more than one less than the maximum number of eligible plans
377 permitted in that region. Within 12 months after the initial
378 invitation to negotiate, the agency shall attempt to procure a
379 provider service network. The agency shall notice another
380 invitation to negotiate only with provider service networks in
381 regions where no provider service network has been selected.
382 (3) QUALITY SELECTION CRITERIA.—In addition to the criteria
383 established in s. 409.966, the agency shall consider the
384 following factors in the selection of eligible plans:
385 (c) Whether a plan is proposing to establish a
386 comprehensive long-term care plan and whether the eligible plan
387 has a contract to provide managed medical assistance services in
388 the same region.
389 (c)(d) Whether a plan offers consumer-directed care
390 services to enrollees pursuant to s. 409.221.
391 (d)(e) Whether a plan is proposing to provide home and
392 community-based services in addition to the minimum benefits
393 required by s. 409.98.
394 Section 8. This act shall take effect July 1, 2017.
395
396 ================= T I T L E A M E N D M E N T ================
397 And the title is amended as follows:
398 Delete lines 403 - 436
399 and insert:
400 An act relating to the statewide Medicaid managed care
401 program; amending s. 409.964, F.S.; requiring the
402 agency to apply for and implement state plan
403 amendments or waivers of applicable federal laws in
404 order to implement specified Florida law; deleting an
405 obsolete provision; amending s. 409.966, F.S.;
406 revising requirements relating to the compilation and
407 publication of certain Medicaid data by the Agency for
408 Health Care Administration; revising the designation
409 and county makeup of regions for procurement of health
410 plans eligible to participate in the program;
411 requiring the agency to give preference to plans that
412 propose establishing a comprehensive long-term care
413 plan; deleting a provision for certain additional
414 benefits to receive particular consideration; deleting
415 provisions relating to capitation rate and fee-for
416 service payment calculations; amending s. 409.967,
417 F.S.; requiring the agency to test provider network
418 databases maintained by Medicaid managed care plans;
419 requiring the agency to impose fines, and authorizing
420 the agency to impose other sanctions, on plans that
421 fail to comply with certain claim payment
422 requirements; amending s. 409.971, F.S.; deleting an
423 obsolete provision; amending s. 409.974, F.S.;
424 deleting an obsolete provision; revising the number of
425 eligible plans the agency must procure for certain
426 regions; deleting provisions that require the agency
427 to issue an invitation to negotiate and to give
428 preference to certain plans; amending s. 409.978,
429 F.S.; deleting an obsolete provision; amending s.
430 409.981, F.S.; revising the number of eligible plans
431 that the agency must procure for certain regions;
432 deleting provisions that require the agency to issue
433 an invitation to negotiate and to consider a specific
434 factor relating to the selection of eligible plans;
435 amending s. 409.982, F.S.; deleting a provision that
436 requires long-term care managed care plans to pay
437 nursing homes at the payment rate set by the agency;
438 providing an effective date.