Florida Senate - 2017 SENATOR AMENDMENT
Bill No. HB 7117, 1st Eng.
Ì449058EÎ449058
LEGISLATIVE ACTION
Senate . House
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Floor: 1/RE/2R .
05/03/2017 07:06 PM .
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Senator Grimsley moved the following:
1 Senate Amendment (with title amendment)
2
3 Delete everything after the enacting clause
4 and insert:
5 Section 1. Effective October 1, 2018, paragraph (v) is
6 added to subsection (1) of section 400.141, Florida Statutes, to
7 read:
8 400.141 Administration and management of nursing home
9 facilities.—
10 (1) Every licensed facility shall comply with all
11 applicable standards and rules of the agency and shall:
12 (v) Be prepared to confirm for the agency whether a nursing
13 home facility resident who is a Medicaid recipient, or whose
14 Medicaid eligibility is pending, is a candidate for home and
15 community-based services under s. 409.965(3)(c), no later than
16 the resident’s 50th consecutive day of residency in the nursing
17 home facility.
18 Section 2. Subsection (2) of section 409.912, Florida
19 Statutes, is amended to read:
20 409.912 Cost-effective purchasing of health care.—The
21 agency shall purchase goods and services for Medicaid recipients
22 in the most cost-effective manner consistent with the delivery
23 of quality medical care. To ensure that medical services are
24 effectively utilized, the agency may, in any case, require a
25 confirmation or second physician’s opinion of the correct
26 diagnosis for purposes of authorizing future services under the
27 Medicaid program. This section does not restrict access to
28 emergency services or poststabilization care services as defined
29 in 42 C.F.R. s. 438.114. Such confirmation or second opinion
30 shall be rendered in a manner approved by the agency. The agency
31 shall maximize the use of prepaid per capita and prepaid
32 aggregate fixed-sum basis services when appropriate and other
33 alternative service delivery and reimbursement methodologies,
34 including competitive bidding pursuant to s. 287.057, designed
35 to facilitate the cost-effective purchase of a case-managed
36 continuum of care. The agency shall also require providers to
37 minimize the exposure of recipients to the need for acute
38 inpatient, custodial, and other institutional care and the
39 inappropriate or unnecessary use of high-cost services. The
40 agency shall contract with a vendor to monitor and evaluate the
41 clinical practice patterns of providers in order to identify
42 trends that are outside the normal practice patterns of a
43 provider’s professional peers or the national guidelines of a
44 provider’s professional association. The vendor must be able to
45 provide information and counseling to a provider whose practice
46 patterns are outside the norms, in consultation with the agency,
47 to improve patient care and reduce inappropriate utilization.
48 The agency may mandate prior authorization, drug therapy
49 management, or disease management participation for certain
50 populations of Medicaid beneficiaries, certain drug classes, or
51 particular drugs to prevent fraud, abuse, overuse, and possible
52 dangerous drug interactions. The Pharmaceutical and Therapeutics
53 Committee shall make recommendations to the agency on drugs for
54 which prior authorization is required. The agency shall inform
55 the Pharmaceutical and Therapeutics Committee of its decisions
56 regarding drugs subject to prior authorization. The agency is
57 authorized to limit the entities it contracts with or enrolls as
58 Medicaid providers by developing a provider network through
59 provider credentialing. The agency may competitively bid single
60 source-provider contracts if procurement of goods or services
61 results in demonstrated cost savings to the state without
62 limiting access to care. The agency may limit its network based
63 on the assessment of beneficiary access to care, provider
64 availability, provider quality standards, time and distance
65 standards for access to care, the cultural competence of the
66 provider network, demographic characteristics of Medicaid
67 beneficiaries, practice and provider-to-beneficiary standards,
68 appointment wait times, beneficiary use of services, provider
69 turnover, provider profiling, provider licensure history,
70 previous program integrity investigations and findings, peer
71 review, provider Medicaid policy and billing compliance records,
72 clinical and medical record audits, and other factors. Providers
73 are not entitled to enrollment in the Medicaid provider network.
74 The agency shall determine instances in which allowing Medicaid
75 beneficiaries to purchase durable medical equipment and other
76 goods is less expensive to the Medicaid program than long-term
77 rental of the equipment or goods. The agency may establish rules
78 to facilitate purchases in lieu of long-term rentals in order to
79 protect against fraud and abuse in the Medicaid program as
80 defined in s. 409.913. The agency may seek federal waivers
81 necessary to administer these policies.
82 (2) The agency may contract with a provider service
83 network, which may be reimbursed on a fee-for-service or prepaid
84 basis. Prepaid provider service networks shall receive per
85 member, per-month payments. A provider service network that does
86 not choose to be a prepaid plan shall receive fee-for-service
87 rates with a shared savings settlement. The fee-for-service
88 option shall be available to a provider service network only for
89 the first 2 years of the plan’s operation or until the contract
90 year beginning September 1, 2014, whichever is later. The agency
91 shall annually conduct cost reconciliations to determine the
92 amount of cost savings achieved by fee-for-service provider
93 service networks for the dates of service in the period being
94 reconciled. Only payments for covered services for dates of
95 service within the reconciliation period and paid within 6
96 months after the last date of service in the reconciliation
97 period shall be included. The agency shall perform the necessary
98 adjustments for the inclusion of claims incurred but not
99 reported within the reconciliation for claims that could be
100 received and paid by the agency after the 6-month claims
101 processing time lag. The agency shall provide the results of the
102 reconciliations to the fee-for-service provider service networks
103 within 45 days after the end of the reconciliation period. The
104 fee-for-service provider service networks shall review and
105 provide written comments or a letter of concurrence to the
106 agency within 45 days after receipt of the reconciliation
107 results. This reconciliation shall be considered final.
108 (a) A provider service network that which is reimbursed by
109 the agency on a prepaid basis shall be exempt from parts I and
110 III of chapter 641, but must comply with the solvency
111 requirements in s. 641.2261(2) and meet appropriate financial
112 reserve, quality assurance, and patient rights requirements as
113 established by the agency.
114 (b) A provider service network is a network established or
115 organized and operated by a health care provider, or group of
116 affiliated health care providers, which provides a substantial
117 proportion of the health care items and services under a
118 contract directly through the provider or affiliated group of
119 providers and may make arrangements with physicians or other
120 health care professionals, health care institutions, or any
121 combination of such individuals or institutions to assume all or
122 part of the financial risk on a prospective basis for the
123 provision of basic health services by the physicians, by other
124 health professionals, or through the institutions. The health
125 care providers must have a controlling interest in the governing
126 body of the provider service network organization.
127 Section 3. Section 409.964, Florida Statutes, is amended to
128 read:
129 409.964 Managed care program; state plan; waivers.—The
130 Medicaid program is established as a statewide, integrated
131 managed care program for all covered services, including long
132 term care services as specified under this part. The agency
133 shall apply for and implement state plan amendments or waivers
134 of applicable federal laws and regulations necessary to
135 implement the program, including state plan amendments or
136 waivers required to implement chapter 2016-109, Laws of Florida.
137 Before seeking a waiver, the agency shall provide public notice
138 and the opportunity for public comment and include public
139 feedback in the waiver application. The agency shall hold one
140 public meeting in each of the regions described in s.
141 409.966(2), and the time period for public comment for each
142 region shall end no sooner than 30 days after the completion of
143 the public meeting in that region. The agency shall submit any
144 state plan amendments, new waiver requests, or requests for
145 extensions or expansions for existing waivers, needed to
146 implement the managed care program by August 1, 2011.
147 Section 4. Effective October 1, 2018, section 409.965,
148 Florida Statutes, is amended to read:
149 409.965 Mandatory enrollment.—All Medicaid recipients shall
150 receive covered services through the statewide managed care
151 program, except as provided by this part pursuant to an approved
152 federal waiver.
153 (1) The following Medicaid recipients are exempt from
154 participation in the statewide managed care program:
155 (a)(1) Women who are eligible only for family planning
156 services.
157 (b)(2) Women who are eligible only for breast and cervical
158 cancer services.
159 (c)(3) Persons who are eligible for emergency Medicaid for
160 aliens.
161 (2)(a) Persons who are assigned into level of care 1 under
162 s. 409.983(4) and have resided in a nursing facility for 60 or
163 more consecutive days are exempt from participation in the long
164 term care managed care program. For a person who becomes exempt
165 under this paragraph while enrolled in the long-term care
166 managed care program, the exemption shall take effect on the
167 first day of the first month after the person meets the criteria
168 for the exemption. This paragraph does not affect a person’s
169 eligibility for the Medicaid managed medical assistance program.
170 (b) Persons receiving hospice care while residing in a
171 nursing facility are exempt from participation in the long-term
172 care managed care program. For a person who becomes exempt under
173 this paragraph while enrolled in the long-term care managed care
174 program, the exemption takes effect on the first day of the
175 first month after the person meets the criteria for the
176 exemption. This paragraph does not affect a person’s eligibility
177 for the Medicaid managed medical assistance program.
178 (3) Notwithstanding subsection (2):
179 (a) A Medicaid recipient who is otherwise eligible for the
180 long-term care managed care program, who is 18 years of age or
181 older, and who is eligible for Medicaid by reason of a
182 disability is not exempt from the long-term care managed care
183 program under subsection (2).
184 (b) A person who is afforded priority enrollment for home
185 and community-based services under s. 409.979(3)(f) is not
186 exempt from the long-term care managed care program under
187 subsection (2).
188 (c) A nursing facility resident is not exempt from the
189 long-term care managed care program under paragraph (2)(a) if
190 the resident has been identified as a candidate for home and
191 community-based services by the nursing facility administrator
192 and any long-term care plan case manager assigned to the
193 resident. Such identification must be made in consultation with
194 the following persons:
195 1. The resident or the resident’s legal representative or
196 designee;
197 2. The resident’s personal physician or, if the resident
198 does not have a personal physician, the facility’s medical
199 director; and
200 3. A registered nurse who has participated in developing,
201 maintaining, or reviewing the individual’s resident care plan as
202 defined in s. 400.021.
203 (d) Before determining that a person is exempt from the
204 long-term care managed care program under paragraph (2)(a), the
205 agency shall confirm whether the person has been identified as a
206 candidate for home and community-based services under paragraph
207 (c). If a nursing facility resident who has been determined
208 exempt is later identified as a candidate for home and
209 community-based services, the nursing facility administrator
210 shall promptly notify the agency. If the agency receives such a
211 notification, the agency shall make a redetermination regarding
212 the resident’s exempt status pursuant to paragraph (c).
213 Section 5. Subsection (2) and paragraphs (a), (d), (e), and
214 (f) of subsection (3) of section 409.966, Florida Statutes, are
215 amended to read:
216 409.966 Eligible plans; selection.—
217 (2) ELIGIBLE PLAN SELECTION.—The agency shall select a
218 limited number of eligible plans to participate in the Medicaid
219 program using invitations to negotiate in accordance with s.
220 287.057(1)(c). At least 90 days before issuing an invitation to
221 negotiate, the agency shall compile and publish a databook
222 consisting of a comprehensive set of utilization and spending
223 data consistent with actuarial rate-setting practices and
224 standards for the 3 most recent contract years consistent with
225 the rate-setting periods for all Medicaid recipients by region
226 or county. The source of the data in the databook report must
227 include the 24 most recent months of both historic fee-for
228 service claims and validated data from the Medicaid Encounter
229 Data System. The report must be available in electronic form and
230 delineate utilization use by age, gender, eligibility group,
231 geographic area, and aggregate clinical risk score. Separate and
232 simultaneous procurements shall be conducted in each of the
233 following regions:
234 (a) Region A Region 1, which consists of Bay, Calhoun,
235 Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson,
236 Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla,
237 and Walton, and Washington Counties.
238 (b) Region B Region 2, which consists of Alachua, Baker,
239 Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler,
240 Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion,
241 Nassau, Putnam, St. Johns, Sumter, Suwannee, Union, and Volusia
242 Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson,
243 Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and
244 Washington Counties.
245 (c) Region C Region 3, which consists of Hardee, Highlands,
246 Hillsborough, Manatee, Pasco, Pinellas, and Polk Alachua,
247 Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton,
248 Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter,
249 Suwannee, and Union Counties.
250 (d) Region D Region 4, which consists of Brevard, Orange,
251 Osceola, and Seminole Baker, Clay, Duval, Flagler, Nassau, St.
252 Johns, and Volusia Counties.
253 (e) Region E Region 5, which consists of Charlotte,
254 Collier, DeSoto, Glades, Hendry, Lee, and Sarasota Pasco and
255 Pinellas Counties.
256 (f) Region F Region 6, which consists of Indian River,
257 Martin, Okeechobee, Palm Beach, and St. Lucie Hardee, Highlands,
258 Hillsborough, Manatee, and Polk Counties.
259 (g) Region G Region 7, which consists of Broward County
260 Brevard, Orange, Osceola, and Seminole Counties.
261 (h) Region H Region 8, which consists of Miami-Dade and
262 Monroe Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and
263 Sarasota Counties.
264 (i) Region 9, which consists of Indian River, Martin,
265 Okeechobee, Palm Beach, and St. Lucie Counties.
266 (j) Region 10, which consists of Broward County.
267 (k) Region 11, which consists of Miami-Dade and Monroe
268 Counties.
269 (3) QUALITY SELECTION CRITERIA.—
270 (a) The invitation to negotiate must specify the criteria
271 and the relative weight of the criteria that will be used for
272 determining the acceptability of the reply and guiding the
273 selection of the organizations with which the agency negotiates.
274 The agency shall give preference to plans that propose
275 establishing a comprehensive long-term care plan. In addition to
276 criteria established by the agency, the agency shall consider
277 the following factors in the selection of eligible plans:
278 1. Accreditation by the National Committee for Quality
279 Assurance, the Joint Commission, or another nationally
280 recognized accrediting body.
281 2. Experience serving similar populations, including the
282 organization’s record in achieving specific quality standards
283 with similar populations.
284 3. Availability and accessibility of primary care and
285 specialty physicians in the provider network.
286 4. Establishment of community partnerships with providers
287 that create opportunities for reinvestment in community-based
288 services.
289 5. Organization commitment to quality improvement and
290 documentation of achievements in specific quality improvement
291 projects, including active involvement by organization
292 leadership.
293 6. Provision of additional benefits, particularly dental
294 care and disease management, and other initiatives that improve
295 health outcomes.
296 7. Evidence that an eligible plan has obtained signed
297 contracts or written agreements or signed contracts or has made
298 substantial progress in establishing relationships with
299 providers before the plan submits submitting a response.
300 8. Comments submitted in writing by any enrolled Medicaid
301 provider relating to a specifically identified plan
302 participating in the procurement in the same region as the
303 submitting provider.
304 9. Documentation of policies and procedures for preventing
305 fraud and abuse.
306 10. The business relationship an eligible plan has with any
307 other eligible plan that responds to the invitation to
308 negotiate.
309 (d) For the first year of the first contract term, the
310 agency shall negotiate capitation rates or fee for service
311 payments with each plan in order to guarantee aggregate savings
312 of at least 5 percent.
313 1. For prepaid plans, determination of the amount of
314 savings shall be calculated by comparison to the Medicaid rates
315 that the agency paid managed care plans for similar populations
316 in the same areas in the prior year. In regions containing no
317 prepaid plans in the prior year, determination of the amount of
318 savings shall be calculated by comparison to the Medicaid rates
319 established and certified for those regions in the prior year.
320 2. For provider service networks operating on a fee-for
321 service basis, determination of the amount of savings shall be
322 calculated by comparison to the Medicaid rates that the agency
323 paid on a fee-for-service basis for the same services in the
324 prior year.
325 (d)(e) To ensure managed care plan participation in Regions
326 A and E Regions 1 and 2, the agency shall award an additional
327 contract to each plan with a contract award in Region A Region 1
328 or Region E Region 2. Such contract shall be in any other region
329 in which the plan submitted a responsive bid and negotiates a
330 rate acceptable to the agency. If a plan that is awarded an
331 additional contract pursuant to this paragraph is subject to
332 penalties pursuant to s. 409.967(2)(i) for activities in Region
333 A Region 1 or Region E Region 2, the additional contract is
334 automatically terminated 180 days after the imposition of the
335 penalties. The plan must reimburse the agency for the cost of
336 enrollment changes and other transition activities.
337 (e)(f) The agency may not execute contracts with managed
338 care plans at payment rates not supported by the General
339 Appropriations Act.
340 Section 6. Paragraphs (c) and (j) of subsection (2) of
341 section 409.967, Florida Statutes, are amended to read:
342 409.967 Managed care plan accountability.—
343 (2) The agency shall establish such contract requirements
344 as are necessary for the operation of the statewide managed care
345 program. In addition to any other provisions the agency may deem
346 necessary, the contract must require:
347 (c) Access.—
348 1. The agency shall establish specific standards for the
349 number, type, and regional distribution of providers in managed
350 care plan networks to ensure access to care for both adults and
351 children. Each plan must maintain a regionwide network of
352 providers in sufficient numbers to meet the access standards for
353 specific medical services for all recipients enrolled in the
354 plan. The exclusive use of mail-order pharmacies may not be
355 sufficient to meet network access standards. Consistent with the
356 standards established by the agency, provider networks may
357 include providers located outside the region. A plan may
358 contract with a new hospital facility before the date the
359 hospital becomes operational if the hospital has commenced
360 construction, will be licensed and operational by January 1,
361 2013, and a final order has issued in any civil or
362 administrative challenge. Each plan shall establish and maintain
363 an accurate and complete electronic database of contracted
364 providers, including information about licensure or
365 registration, locations and hours of operation, specialty
366 credentials and other certifications, specific performance
367 indicators, and such other information as the agency deems
368 necessary. The database must be available online to both the
369 agency and the public and have the capability to compare the
370 availability of providers to network adequacy standards and to
371 accept and display feedback from each provider’s patients. Each
372 plan shall submit quarterly reports to the agency identifying
373 the number of enrollees assigned to each primary care provider.
374 The agency shall conduct, or contract with a third party to
375 conduct, systematic and ongoing testing of the provider network
376 databases maintained by each plan to confirm database accuracy,
377 to confirm that network providers are accepting enrollees, and
378 to confirm that such enrollees have access to care.
379 2. Each managed care plan must publish any prescribed drug
380 formulary or preferred drug list on the plan’s website in a
381 manner that is accessible to and searchable by enrollees and
382 providers. The plan must update the list within 24 hours after
383 making a change. Each plan must ensure that the prior
384 authorization process for prescribed drugs is readily accessible
385 to health care providers, including posting appropriate contact
386 information on its website and providing timely responses to
387 providers. For Medicaid recipients diagnosed with hemophilia who
388 have been prescribed anti-hemophilic-factor replacement
389 products, the agency shall provide for those products and
390 hemophilia overlay services through the agency’s hemophilia
391 disease management program.
392 3. Managed care plans, and their fiscal agents or
393 intermediaries, must accept prior authorization requests for any
394 service electronically.
395 4. Managed care plans serving children in the care and
396 custody of the Department of Children and Families must maintain
397 complete medical, dental, and behavioral health encounter
398 information and participate in making such information available
399 to the department or the applicable contracted community-based
400 care lead agency for use in providing comprehensive and
401 coordinated case management. The agency and the department shall
402 establish an interagency agreement to provide guidance for the
403 format, confidentiality, recipient, scope, and method of
404 information to be made available and the deadlines for
405 submission of the data. The scope of information available to
406 the department shall be the data that managed care plans are
407 required to submit to the agency. The agency shall determine the
408 plan’s compliance with standards for access to medical, dental,
409 and behavioral health services; the use of medications; and
410 followup on all medically necessary services recommended as a
411 result of early and periodic screening, diagnosis, and
412 treatment.
413 (j) Prompt payment.—Managed care plans shall comply with
414 ss. 641.315, 641.3155, and 641.513, and the agency shall impose
415 fines, and may impose other sanctions, on a plan that willfully
416 fails to comply with ss. 641.315, 641.3155, and 641.513 or s.
417 409.982(5).
418 Section 7. Effective January 1, 2018, paragraph (p) is
419 added to subsection (2) of section 409.967, Florida Statutes, to
420 read:
421 409.967 Managed care plan accountability.—
422 (2) The agency shall establish such contract requirements
423 as are necessary for the operation of the statewide managed care
424 program. In addition to any other provisions the agency may deem
425 necessary, the contract must require:
426 (p) Robust primary care networks.—A health insurer or
427 health maintenance organization selected as a managed care plan
428 under this part may not, directly or indirectly, purchase, own,
429 or otherwise have a controlling interest in any primary care
430 group or practice in this state.
431 Section 8. Subsection (2) of section 409.968, Florida
432 Statutes, is amended to read:
433 409.968 Managed care plan payments.—
434 (2) Provider service networks shall may be prepaid plans
435 and receive per-member, per-month payments negotiated pursuant
436 to the procurement process described in s. 409.966. Provider
437 service networks that choose not to be prepaid plans shall
438 receive fee-for-service rates with a shared savings settlement.
439 The fee-for-service option shall be available to a provider
440 service network only for the first 2 years of its operation. The
441 agency shall annually conduct cost reconciliations to determine
442 the amount of cost savings achieved by fee-for-service provider
443 service networks for the dates of service within the period
444 being reconciled. Only payments for covered services for dates
445 of service within the reconciliation period and paid within 6
446 months after the last date of service in the reconciliation
447 period must be included. The agency shall perform the necessary
448 adjustments for the inclusion of claims incurred but not
449 reported within the reconciliation period for claims that could
450 be received and paid by the agency after the 6-month claims
451 processing time lag. The agency shall provide the results of the
452 reconciliations to the fee-for-service provider service networks
453 within 45 days after the end of the reconciliation period. The
454 fee-for-service provider service networks shall review and
455 provide written comments or a letter of concurrence to the
456 agency within 45 days after receipt of the reconciliation
457 results. This reconciliation is considered final.
458 Section 9. Section 409.971, Florida Statutes, is amended to
459 read:
460 409.971 Managed medical assistance program.—The agency
461 shall make payments for primary and acute medical assistance and
462 related services using a managed care model. By January 1, 2013,
463 the agency shall begin implementation of the statewide managed
464 medical assistance program, with full implementation in all
465 regions by October 1, 2014.
466 Section 10. Subsections (1) and (2) of section 409.974,
467 Florida Statutes, are amended to read:
468 409.974 Eligible plans.—
469 (1) ELIGIBLE PLAN SELECTION.—The agency shall select
470 eligible plans for the managed medical assistance program
471 through the procurement process described in s. 409.966. The
472 agency shall notice invitations to negotiate no later than
473 January 1, 2013.
474 (a) The agency shall procure at least three two plans and
475 up to four plans for Region A Region 1. At least one plan shall
476 be a provider service network if any provider service networks
477 submit a responsive bid.
478 (b) The agency shall procure at least four plans and up to
479 eight two plans for Region B Region 2. At least one plan shall
480 be a provider service network if any provider service networks
481 submit a responsive bid.
482 (c) The agency shall procure at least five three plans and
483 up to 10 five plans for Region C Region 3. At least one plan
484 must be a provider service network if any provider service
485 networks submit a responsive bid.
486 (d) The agency shall procure at least three plans and up to
487 six five plans for Region D Region 4. At least one plan must be
488 a provider service network if any provider service networks
489 submit a responsive bid.
490 (e) The agency shall procure at least three two plans and
491 up to four plans for Region E Region 5. At least one plan must
492 be a provider service network if any provider service networks
493 submit a responsive bid.
494 (f) The agency shall procure at least three four plans and
495 up to five seven plans for Region F Region 6. At least one plan
496 must be a provider service network if any provider service
497 networks submit a responsive bid.
498 (g) The agency shall procure at least three plans and up to
499 five six plans for Region G Region 7. At least one plan must be
500 a provider service network if any provider service networks
501 submit a responsive bid.
502 (h) The agency shall procure at least five two plans and up
503 to 10 four plans for Region H Region 8. At least one plan must
504 be a provider service network if any provider service networks
505 submit a responsive bid.
506 (i) The agency shall procure at least two plans and up to
507 four plans for Region 9. At least one plan must be a provider
508 service network if any provider service networks submit a
509 responsive bid.
510 (j) The agency shall procure at least two plans and up to
511 four plans for Region 10. At least one plan must be a provider
512 service network if any provider service networks submit a
513 responsive bid.
514 (k) The agency shall procure at least five plans and up to
515 10 plans for Region 11. At least one plan must be a provider
516 service network if any provider service networks submit a
517 responsive bid.
518
519 If no provider service network submits a responsive bid, the
520 agency shall procure no more than one less than the maximum
521 number of eligible plans permitted in that region. Within 12
522 months after the initial invitation to negotiate, the agency
523 shall attempt to procure a provider service network. The agency
524 shall notice another invitation to negotiate only with provider
525 service networks in those regions where no provider service
526 network has been selected.
527 (2) QUALITY SELECTION CRITERIA.—In addition to the criteria
528 established in s. 409.966, the agency shall consider evidence
529 that an eligible plan has obtained signed contracts or written
530 agreements or signed contracts or has made substantial progress
531 in establishing relationships with providers before the plan
532 submits submitting a response. The agency shall evaluate and
533 give special weight to evidence of signed contracts with
534 essential providers as defined by the agency pursuant to s.
535 409.975(1). The agency shall exercise a preference for plans
536 with a provider network in which more than over 10 percent of
537 the providers use electronic health records, as defined in s.
538 408.051. When all other factors are equal, the agency shall
539 consider whether the organization has a contract to provide
540 managed long-term care services in the same region and shall
541 exercise a preference for such plans.
542 Section 11. Subsection (1) of section 409.978, Florida
543 Statutes, is amended to read:
544 409.978 Long-term care managed care program.—
545 (1) Pursuant to s. 409.963, the agency shall administer the
546 long-term care managed care program described in ss. 409.978
547 409.985, but may delegate specific duties and responsibilities
548 for the program to the Department of Elderly Affairs and other
549 state agencies. By July 1, 2012, the agency shall begin
550 implementation of the statewide long-term care managed care
551 program, with full implementation in all regions by October 1,
552 2013.
553 Section 12. Subsection (1) of section 409.979, Florida
554 Statutes, is amended to read:
555 409.979 Eligibility.—
556 (1) PREREQUISITE CRITERIA FOR ELIGIBILITY.—Medicaid
557 recipients who meet all of the following criteria are eligible
558 to receive long-term care services and, unless exempt under s.
559 409.965, must receive long-term care services by participating
560 in the long-term care managed care program. The recipient must
561 be:
562 (a) Sixty-five years of age or older, or age 18 or older
563 and eligible for Medicaid by reason of a disability.
564 (b) Determined by the Comprehensive Assessment Review and
565 Evaluation for Long-Term Care Services (CARES) preadmission
566 screening program to require nursing facility care as defined in
567 s. 409.985(3).
568 Section 13. Subsection (2) and paragraphs (c), (d), and (e)
569 of subsection (3) of section 409.981, Florida Statutes, are
570 amended to read:
571 409.981 Eligible long-term care plans.—
572 (2) ELIGIBLE PLAN SELECTION.—The agency shall select
573 eligible plans for the long-term care managed care program
574 through the procurement process described in s. 409.966. The
575 agency shall procure:
576 (a) At least three two plans and up to four plans for
577 Region A Region 1. At least one plan must be a provider service
578 network if any provider service networks submit a responsive
579 bid.
580 (b) At least three Two plans and up to six plans for Region
581 B Region 2. At least one plan must be a provider service network
582 if any provider service networks submit a responsive bid.
583 (c) At least five three plans and up to eight five plans
584 for Region C Region 3. At least one plan must be a provider
585 service network if any provider service networks submit a
586 responsive bid.
587 (d) At least three plans and up to six five plans for
588 Region D Region 4. At least one plan must be a provider service
589 network if any provider service network submits a responsive
590 bid.
591 (e) At least three two plans and up to four plans for
592 Region E Region 5. At least one plan must be a provider service
593 network if any provider service networks submit a responsive
594 bid.
595 (f) At least three four plans and up to five seven plans
596 for Region F Region 6. At least one plan must be a provider
597 service network if any provider service networks submit a
598 responsive bid.
599 (g) At least three plans and up to four six plans for
600 Region G Region 7. At least one plan must be a provider service
601 network if any provider service networks submit a responsive
602 bid.
603 (h) At least five two plans and up to 10 four plans for
604 Region H Region 8. At least one plan must be a provider service
605 network if any provider service networks submit a responsive
606 bid.
607 (i) At least two plans and up to four plans for Region 9.
608 At least one plan must be a provider service network if any
609 provider service networks submit a responsive bid.
610 (j) At least two plans and up to four plans for Region 10.
611 At least one plan must be a provider service network if any
612 provider service networks submit a responsive bid.
613 (k) At least five plans and up to 10 plans for Region 11.
614 At least one plan must be a provider service network if any
615 provider service networks submit a responsive bid.
616
617 If no provider service network submits a responsive bid in a
618 region other than Region 1 or Region 2, the agency shall procure
619 no more than one less than the maximum number of eligible plans
620 permitted in that region. Within 12 months after the initial
621 invitation to negotiate, the agency shall attempt to procure a
622 provider service network. The agency shall notice another
623 invitation to negotiate only with provider service networks in
624 regions where no provider service network has been selected.
625 (3) QUALITY SELECTION CRITERIA.—In addition to the criteria
626 established in s. 409.966, the agency shall consider the
627 following factors in the selection of eligible plans:
628 (c) Whether a plan is proposing to establish a
629 comprehensive long-term care plan and whether the eligible plan
630 has a contract to provide managed medical assistance services in
631 the same region.
632 (c)(d) Whether a plan offers consumer-directed care
633 services to enrollees pursuant to s. 409.221.
634 (d)(e) Whether a plan is proposing to provide home and
635 community-based services in addition to the minimum benefits
636 required by s. 409.98.
637 Section 14. Subsections (1) and (2) of section 409.982,
638 Florida Statutes, are amended to read:
639 409.982 Long-term care managed care plan accountability.—In
640 addition to the requirements of s. 409.967, plans and providers
641 participating in the long-term care managed care program must
642 comply with the requirements of this section.
643 (1) PROVIDER NETWORKS.—Managed care plans may limit the
644 providers in their networks based on credentials, quality
645 indicators, and price. For the first 12 months of a contract
646 period following a procurement for the long-term care managed
647 care program under s. 409.981, if a plan has been period between
648 October 1, 2013, and September 30, 2014, each selected for a
649 region encompassing a county that the plan was not serving
650 immediately prior to the procurement, the plan must offer a
651 network contract to all nursing homes in that county which meet
652 the recredentialing requirements and to all hospices in that
653 county which meet the credentialing requirements specified in
654 the plan’s contract with the agency the following providers in
655 the region:
656 (a) Nursing homes.
657 (b) Hospices.
658 (c) Aging network service providers that have previously
659 participated in home and community-based waivers serving elders
660 or community-service programs administered by the Department of
661 Elderly Affairs. After a provider specified in this subsection
662 has actively participated in a managed care plan’s network for
663 12 months of active participation in a managed care plan’s
664 network, the plan may exclude the provider any of the providers
665 named in this subsection from the plan’s network for failure to
666 meet quality or performance criteria. If a the plan excludes a
667 provider from its network under this subsection the plan, the
668 plan must provide written notice to all recipients who have
669 chosen that provider for care. The notice must be provided at
670 least 30 days before the effective date of the exclusion. The
671 agency shall establish contract provisions governing the
672 transfer of recipients from excluded residential providers. The
673 agency shall require a plan that excludes a provider from its
674 network or that fails to renew the plan’s contract with a
675 provider under this subsection to report to the agency the
676 quality or performance criteria the plan used in deciding to
677 exclude the provider and to demonstrate how the provider failed
678 to meet those criteria.
679 (2) SELECT PROVIDER PARTICIPATION.—Except as provided in
680 this subsection, providers may limit the managed care plans they
681 join. Nursing homes and hospices that are enrolled Medicaid
682 providers must participate in all eligible plans selected by the
683 agency in the region in which the provider is located, with the
684 exception of plans from which the provider has been excluded
685 under subsection (1).
686 Section 15. Section 456.0625, Florida Statutes, is created
687 to read:
688 456.0625 Direct primary care agreements.—
689 (1) As used in this section, the term:
690 (a) “Direct primary care agreement” means a contract
691 between a primary care provider and a patient, the patient’s
692 legal representative, or an employer which meets the
693 requirements specified under subsection (3) and which does not
694 indemnify for services provided by a third party.
695 (b) “Primary care provider” means a health care
696 practitioner licensed under chapter 458, chapter 459, chapter
697 460, or chapter 464 or a primary care group practice that
698 provides medical services to patients which are commonly
699 provided without referral from another health care provider.
700 (c) “Primary care service” means the screening, assessment,
701 diagnosis, and treatment of a patient for the purpose of
702 promoting health or detecting and managing disease or injury
703 within the competency and training of the primary care provider.
704 (2) A primary care provider or an agent of the primary care
705 provider may enter into a direct primary care agreement for
706 providing primary care services. Section 624.27 applies to a
707 direct primary care agreement.
708 (3) A direct primary care agreement must:
709 (a) Be in writing.
710 (b) Be signed by the primary care provider or an agent of
711 the primary care provider and the patient, the patient’s legal
712 representative, or an employer.
713 (c) Allow a party to terminate the agreement by giving the
714 other party at least 30 days’ advance written notice. The
715 agreement may provide for immediate termination due to a
716 violation of the physician-patient relationship or a breach of
717 the terms of the agreement.
718 (d) Describe the scope of primary care services that are
719 covered by the monthly fee.
720 (e) Specify the monthly fee and any fees for primary care
721 services not covered by the monthly fee.
722 (f) Specify the duration of the agreement and any automatic
723 renewal provisions.
724 (g) Offer a refund to the patient of monthly fees paid in
725 advance if the primary care provider ceases to offer primary
726 care services for any reason.
727 (h) Contain, in contrasting color and in not less than 12
728 point type, the following statements on the same page as the
729 applicant’s signature:
730 1. This agreement is not health insurance, and the primary
731 care provider will not file any claims against the patient’s
732 health insurance policy or plan for reimbursement of any primary
733 care services covered by this agreement.
734 2. This agreement does not qualify as minimum essential
735 coverage to satisfy the individual shared responsibility
736 provision of the federal Patient Protection and Affordable Care
737 Act, Pub. L. No. 111-148.
738 3. This agreement is not workers’ compensation insurance
739 and may not replace the employer’s obligations under chapter
740 440, Florida Statutes.
741 Section 16. Section 624.27, Florida Statutes, is created to
742 read:
743 624.27 Application of code as to direct primary care
744 agreements.—
745 (1) A direct primary care agreement, as defined in s.
746 456.0625, does not constitute insurance and is not subject to
747 any chapter of the Florida Insurance Code. The act of entering
748 into a direct primary care agreement does not constitute the
749 business of insurance and is not subject to any chapter of the
750 Florida Insurance Code.
751 (2) A primary care provider or an agent of a primary care
752 provider is not required to obtain a certificate of authority or
753 license under any chapter of the Florida Insurance Code to
754 market, sell, or offer to sell a direct primary care agreement
755 pursuant to s. 456.0625.
756 Section 17. Except as otherwise provided in this act, this
757 act shall take effect July 1, 2017.
758
759 ================= T I T L E A M E N D M E N T ================
760 And the title is amended as follows:
761 Delete everything before the enacting clause
762 and insert:
763 A bill to be entitled
764 An act relating to health care services; amending s.
765 400.141, F.S.; requiring that nursing home facilities
766 be prepared to provide confirmation within a specified
767 timeframe to the Agency for Health Care Administration
768 as to whether certain nursing home facility residents
769 are candidates for certain services; amending s.
770 409.912, F.S.; deleting the fee-for-service option as
771 a basis for the reimbursement of Medicaid provider
772 service networks; amending s. 409.964, F.S.; providing
773 that covered services for long-term care under the
774 Medicaid managed care program are those specified in
775 part IV of ch. 409, F.S.; requiring the agency to
776 apply for and implement state plan amendments or
777 waivers of applicable federal laws in order to
778 implement specified Florida law; deleting an obsolete
779 provision; amending s. 409.965, F.S.; providing that
780 certain residents of nursing facilities are exempt
781 from participation in the long-term care managed care
782 program; providing for application of the exemption;
783 providing that eligibility for the Medicaid managed
784 medical assistance program is not affected by such
785 provisions; providing conditions under which the
786 exemption does not apply; requiring the agency to
787 confirm whether certain persons have been identified
788 as candidates for home and community-based services;
789 requiring a certain notice to the agency by nursing
790 facility administrators; amending s. 409.966, F.S.;
791 requiring that a required databook consist of data
792 that is consistent with actuarial rate-setting
793 practices and standards; requiring that the source of
794 such data include the 24 most recent months of
795 validated data from the Medicaid Encounter Data
796 System; deleting provisions relating to a report and
797 report requirements; revising the designation and
798 county makeup of regions of the state for purposes of
799 procuring health plans that may participate in the
800 Medicaid program; adding a factor that the agency must
801 consider in the selection of eligible plans; deleting
802 a provision for certain additional benefits to receive
803 particular consideration; deleting an obsolete
804 provision; amending s. 409.967, F.S.; requiring the
805 agency to test provider network databases maintained
806 by Medicaid managed care plans; requiring the agency
807 to impose fines, and authorizing the agency to impose
808 other sanctions, on plans that fail to comply with
809 certain claim payment requirements; prohibiting
810 certain health insurers or health maintenance
811 organizations from owning or having a controlling
812 interest in any primary care group or practice in the
813 state; amending s. 409.968, F.S.; requiring provider
814 service networks to be prepaid plans; deleting a fee
815 for-service option for Medicaid reimbursement for
816 provider service networks; amending s. 409.971, F.S.;
817 deleting an obsolete provision; amending s. 409.974,
818 F.S.; revising the number of eligible Medicaid health
819 care plans the agency must procure for certain regions
820 in the state; deleting provisions that require the
821 agency to issue an invitation to negotiate under
822 certain circumstances; deleting preference for certain
823 plans; deleting an obsolete provision; amending s.
824 409.978, F.S.; deleting an obsolete provision;
825 amending s. 409.979, F.S.; providing that certain
826 exempt Medicaid recipients are not required to receive
827 long-term care services through the long-term care
828 managed care program; amending s. 409.981, F.S.;
829 revising the number of eligible Medicaid health care
830 plans the agency must procure for certain regions in
831 the state; deleting provisions that require the agency
832 to issue an invitation to negotiate under certain
833 circumstances; deleting a requirement that the agency
834 consider a specific factor relating to the selection
835 of managed medical assistance plans; amending s.
836 409.982, F.S.; revising parameters under which a long
837 term care managed care plan must contract with nursing
838 homes and hospices; specifying that the agency must
839 require certain plans to report information on the
840 quality or performance criteria used in making a
841 certain determination; creating s. 456.0625, F.S.;
842 defining terms; authorizing primary care providers or
843 their agents to enter into direct primary care
844 agreements for providing primary care services;
845 providing applicability; specifying requirements for
846 direct primary care agreements; creating s. 624.27,
847 F.S.; providing construction and applicability of the
848 Florida Insurance Code as to direct primary care
849 agreements; providing an exception for primary care
850 providers or their agents from certain requirements
851 under the code under certain circumstances; providing
852 effective dates.