Florida Senate - 2017              PROPOSED COMMITTEE SUBSTITUTE
       Bill No. SB 916
       
       
       
       
       
                               Ì188616?Î188616                          
       
       576-03815-17                                                    
       Proposed Committee Substitute by the Committee on Appropriations
       (Appropriations Subcommittee on Health and Human Services)
    1                        A bill to be entitled                      
    2         An act relating to the statewide Medicaid managed care
    3         program; amending s. 409.912, F.S.; deleting the fee
    4         for-service option as a basis for the reimbursement of
    5         Medicaid provider service networks; amending s.
    6         409.964, F.S.; deleting an obsolete provision;
    7         amending s. 409.966, F.S.; requiring that a required
    8         databook consist of data that is consistent with
    9         actuarial rate-setting practices and standards;
   10         requiring that the source of such data include the 24
   11         most recent months of validated data from the Medicaid
   12         Encounter Data System; deleting provisions relating to
   13         a report and report requirements; revising the
   14         designation and county makeup of regions of the state
   15         for purposes of procuring health plans that may
   16         participate in the Medicaid program; adding a factor
   17         that the Agency for Health Care Administration must
   18         consider in the selection of eligible plans; deleting
   19         a requirement related to fee-for-service provider
   20         service networks; amending s. 409.968, F.S.; requiring
   21         provider service networks to be prepaid plans;
   22         deleting a fee-for-service option for Medicaid
   23         reimbursement for provider service networks; amending
   24         s. 409.971, F.S.; deleting an obsolete provision;
   25         amending s. 409.974, F.S.; revising the number of
   26         eligible Medicaid health care plans the agency must
   27         procure for certain regions in the state; deleting an
   28         obsolete provision; amending s. 409.978, F.S.;
   29         deleting an obsolete provision; amending s. 409.981,
   30         F.S.; revising the number of eligible Medicaid health
   31         care plans the agency must procure for certain regions
   32         in the state; deleting a requirement that the agency
   33         consider a specific factor relating to the selection
   34         of managed medical assistance plans; providing an
   35         effective date.
   36          
   37  Be It Enacted by the Legislature of the State of Florida:
   38  
   39         Section 1. Subsection (2) of section 409.912, Florida
   40  Statutes, is amended to read:
   41         409.912 Cost-effective purchasing of health care.—The
   42  agency shall purchase goods and services for Medicaid recipients
   43  in the most cost-effective manner consistent with the delivery
   44  of quality medical care. To ensure that medical services are
   45  effectively utilized, the agency may, in any case, require a
   46  confirmation or second physician’s opinion of the correct
   47  diagnosis for purposes of authorizing future services under the
   48  Medicaid program. This section does not restrict access to
   49  emergency services or poststabilization care services as defined
   50  in 42 C.F.R. s. 438.114. Such confirmation or second opinion
   51  shall be rendered in a manner approved by the agency. The agency
   52  shall maximize the use of prepaid per capita and prepaid
   53  aggregate fixed-sum basis services when appropriate and other
   54  alternative service delivery and reimbursement methodologies,
   55  including competitive bidding pursuant to s. 287.057, designed
   56  to facilitate the cost-effective purchase of a case-managed
   57  continuum of care. The agency shall also require providers to
   58  minimize the exposure of recipients to the need for acute
   59  inpatient, custodial, and other institutional care and the
   60  inappropriate or unnecessary use of high-cost services. The
   61  agency shall contract with a vendor to monitor and evaluate the
   62  clinical practice patterns of providers in order to identify
   63  trends that are outside the normal practice patterns of a
   64  provider’s professional peers or the national guidelines of a
   65  provider’s professional association. The vendor must be able to
   66  provide information and counseling to a provider whose practice
   67  patterns are outside the norms, in consultation with the agency,
   68  to improve patient care and reduce inappropriate utilization.
   69  The agency may mandate prior authorization, drug therapy
   70  management, or disease management participation for certain
   71  populations of Medicaid beneficiaries, certain drug classes, or
   72  particular drugs to prevent fraud, abuse, overuse, and possible
   73  dangerous drug interactions. The Pharmaceutical and Therapeutics
   74  Committee shall make recommendations to the agency on drugs for
   75  which prior authorization is required. The agency shall inform
   76  the Pharmaceutical and Therapeutics Committee of its decisions
   77  regarding drugs subject to prior authorization. The agency is
   78  authorized to limit the entities it contracts with or enrolls as
   79  Medicaid providers by developing a provider network through
   80  provider credentialing. The agency may competitively bid single
   81  source-provider contracts if procurement of goods or services
   82  results in demonstrated cost savings to the state without
   83  limiting access to care. The agency may limit its network based
   84  on the assessment of beneficiary access to care, provider
   85  availability, provider quality standards, time and distance
   86  standards for access to care, the cultural competence of the
   87  provider network, demographic characteristics of Medicaid
   88  beneficiaries, practice and provider-to-beneficiary standards,
   89  appointment wait times, beneficiary use of services, provider
   90  turnover, provider profiling, provider licensure history,
   91  previous program integrity investigations and findings, peer
   92  review, provider Medicaid policy and billing compliance records,
   93  clinical and medical record audits, and other factors. Providers
   94  are not entitled to enrollment in the Medicaid provider network.
   95  The agency shall determine instances in which allowing Medicaid
   96  beneficiaries to purchase durable medical equipment and other
   97  goods is less expensive to the Medicaid program than long-term
   98  rental of the equipment or goods. The agency may establish rules
   99  to facilitate purchases in lieu of long-term rentals in order to
  100  protect against fraud and abuse in the Medicaid program as
  101  defined in s. 409.913. The agency may seek federal waivers
  102  necessary to administer these policies.
  103         (2) The agency may contract with a provider service
  104  network, which may be reimbursed on a fee-for-service or prepaid
  105  basis. Prepaid provider service networks shall receive per
  106  member, per-month payments. A provider service network that does
  107  not choose to be a prepaid plan shall receive fee-for-service
  108  rates with a shared savings settlement. The fee-for-service
  109  option shall be available to a provider service network only for
  110  the first 2 years of the plan’s operation or until the contract
  111  year beginning September 1, 2014, whichever is later. The agency
  112  shall annually conduct cost reconciliations to determine the
  113  amount of cost savings achieved by fee-for-service provider
  114  service networks for the dates of service in the period being
  115  reconciled. Only payments for covered services for dates of
  116  service within the reconciliation period and paid within 6
  117  months after the last date of service in the reconciliation
  118  period shall be included. The agency shall perform the necessary
  119  adjustments for the inclusion of claims incurred but not
  120  reported within the reconciliation for claims that could be
  121  received and paid by the agency after the 6-month claims
  122  processing time lag. The agency shall provide the results of the
  123  reconciliations to the fee-for-service provider service networks
  124  within 45 days after the end of the reconciliation period. The
  125  fee-for-service provider service networks shall review and
  126  provide written comments or a letter of concurrence to the
  127  agency within 45 days after receipt of the reconciliation
  128  results. This reconciliation shall be considered final.
  129         (a) A provider service network that which is reimbursed by
  130  the agency on a prepaid basis shall be exempt from parts I and
  131  III of chapter 641, but must comply with the solvency
  132  requirements in s. 641.2261(2) and meet appropriate financial
  133  reserve, quality assurance, and patient rights requirements as
  134  established by the agency.
  135         (b) A provider service network is a network established or
  136  organized and operated by a health care provider, or group of
  137  affiliated health care providers, which provides a substantial
  138  proportion of the health care items and services under a
  139  contract directly through the provider or affiliated group of
  140  providers and may make arrangements with physicians or other
  141  health care professionals, health care institutions, or any
  142  combination of such individuals or institutions to assume all or
  143  part of the financial risk on a prospective basis for the
  144  provision of basic health services by the physicians, by other
  145  health professionals, or through the institutions. The health
  146  care providers must have a controlling interest in the governing
  147  body of the provider service network organization.
  148         Section 2. Section 409.964, Florida Statutes, is amended to
  149  read:
  150         409.964 Managed care program; state plan; waivers.—The
  151  Medicaid program is established as a statewide, integrated
  152  managed care program for all covered services, including long
  153  term care services. The agency shall apply for and implement
  154  state plan amendments or waivers of applicable federal laws and
  155  regulations necessary to implement the program. Before seeking a
  156  waiver, the agency shall provide public notice and the
  157  opportunity for public comment and include public feedback in
  158  the waiver application. The agency shall hold one public meeting
  159  in each of the regions described in s. 409.966(2), and the time
  160  period for public comment for each region shall end no sooner
  161  than 30 days after the completion of the public meeting in that
  162  region. The agency shall submit any state plan amendments, new
  163  waiver requests, or requests for extensions or expansions for
  164  existing waivers, needed to implement the managed care program
  165  by August 1, 2011.
  166         Section 3. Subsection (2) and paragraphs (a), (d), and (e)
  167  of subsection (3) of section 409.966, Florida Statutes, are
  168  amended to read:
  169         409.966 Eligible plans; selection.—
  170         (2) ELIGIBLE PLAN SELECTION.—The agency shall select a
  171  limited number of eligible plans to participate in the Medicaid
  172  program using invitations to negotiate in accordance with s.
  173  287.057(1)(c). At least 90 days before issuing an invitation to
  174  negotiate, the agency shall compile and publish a databook
  175  consisting of a comprehensive set of utilization and spending
  176  data consistent with actuarial rate-setting practices and
  177  standards for the 3 most recent contract years consistent with
  178  the rate-setting periods for all Medicaid recipients by region
  179  or county. The source of the data in the databook report must
  180  include the 24 most recent months of both historic fee-for
  181  service claims and validated data from the Medicaid Encounter
  182  Data System. The report must be available in electronic form and
  183  delineate utilization use by age, gender, eligibility group,
  184  geographic area, and aggregate clinical risk score. Separate and
  185  simultaneous procurements shall be conducted in each of the
  186  following regions:
  187         (a) Region A Region 1, which consists of Bay, Calhoun,
  188  Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson,
  189  Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla,
  190  and Walton, and Washington Counties.
  191         (b) Region B Region 2, which consists of Alachua, Baker,
  192  Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler,
  193  Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion,
  194  Nassau, Putnam, St. Johns, Sumter, Suwannee, Union, and Volusia
  195  Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson,
  196  Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and
  197  Washington Counties.
  198         (c) Region C Region 3, which consists of Hardee, Highlands,
  199  Hillsborough, Manatee, Pasco, Pinellas, and Polk Alachua,
  200  Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton,
  201  Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter,
  202  Suwannee, and Union Counties.
  203         (d) Region D Region 4, which consists of Brevard, Orange,
  204  Osceola, and Seminole Baker, Clay, Duval, Flagler, Nassau, St.
  205  Johns, and Volusia Counties.
  206         (e) Region E Region 5, which consists of Charlotte,
  207  Collier, DeSoto, Glades, Hendry, Lee, and Sarasota Pasco and
  208  Pinellas Counties.
  209         (f) Region F Region 6, which consists of Indian River,
  210  Martin, Okeechobee, Palm Beach, and St. Lucie Hardee, Highlands,
  211  Hillsborough, Manatee, and Polk Counties.
  212         (g) Region G Region 7, which consists of Broward County
  213  Brevard, Orange, Osceola, and Seminole Counties.
  214         (h) Region H Region 8, which consists of Miami-Dade and
  215  Monroe Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and
  216  Sarasota Counties.
  217         (i) Region 9, which consists of Indian River, Martin,
  218  Okeechobee, Palm Beach, and St. Lucie Counties.
  219         (j) Region 10, which consists of Broward County.
  220         (k) Region 11, which consists of Miami-Dade and Monroe
  221  Counties.
  222         (3) QUALITY SELECTION CRITERIA.—
  223         (a) The invitation to negotiate must specify the criteria
  224  and the relative weight of the criteria that will be used for
  225  determining the acceptability of the reply and guiding the
  226  selection of the organizations with which the agency negotiates.
  227  In addition to criteria established by the agency, the agency
  228  shall consider the following factors in the selection of
  229  eligible plans:
  230         1. Accreditation by the National Committee for Quality
  231  Assurance, the Joint Commission, or another nationally
  232  recognized accrediting body.
  233         2. Experience serving similar populations, including the
  234  organization’s record in achieving specific quality standards
  235  with similar populations.
  236         3. Availability and accessibility of primary care and
  237  specialty physicians in the provider network.
  238         4. Establishment of community partnerships with providers
  239  that create opportunities for reinvestment in community-based
  240  services.
  241         5. Organization commitment to quality improvement and
  242  documentation of achievements in specific quality improvement
  243  projects, including active involvement by organization
  244  leadership.
  245         6. Provision of additional benefits, particularly dental
  246  care and disease management, and other initiatives that improve
  247  health outcomes.
  248         7. Evidence that an eligible plan has written agreements or
  249  signed contracts or has made substantial progress in
  250  establishing relationships with providers before the plan
  251  submitting a response.
  252         8. Comments submitted in writing by any enrolled Medicaid
  253  provider relating to a specifically identified plan
  254  participating in the procurement in the same region as the
  255  submitting provider.
  256         9. Documentation of policies and procedures for preventing
  257  fraud and abuse.
  258         10. The business relationship an eligible plan has with any
  259  other eligible plan that responds to the invitation to
  260  negotiate.
  261         11. Whether a plan is proposing to establish a
  262  comprehensive long-term care plan.
  263         (d) For the first year of the first contract term, the
  264  agency shall negotiate capitation rates or fee for service
  265  payments with each plan in order to guarantee aggregate savings
  266  of at least 5 percent.
  267         1. For prepaid plans, determination of the amount of
  268  savings shall be calculated by comparison to the Medicaid rates
  269  that the agency paid managed care plans for similar populations
  270  in the same areas in the prior year. In regions containing no
  271  prepaid plans in the prior year, determination of the amount of
  272  savings shall be calculated by comparison to the Medicaid rates
  273  established and certified for those regions in the prior year.
  274         2. For provider service networks operating on a fee-for
  275  service basis, determination of the amount of savings shall be
  276  calculated by comparison to the Medicaid rates that the agency
  277  paid on a fee-for-service basis for the same services in the
  278  prior year.
  279         (e) To ensure managed care plan participation in Regions A
  280  and E Regions 1 and 2, the agency shall award an additional
  281  contract to each plan with a contract award in Region A Region 1
  282  or Region E Region 2. Such contract shall be in any other region
  283  in which the plan submitted a responsive bid and negotiates a
  284  rate acceptable to the agency. If a plan that is awarded an
  285  additional contract pursuant to this paragraph is subject to
  286  penalties pursuant to s. 409.967(2)(i) for activities in Region
  287  A Region 1 or Region E Region 2, the additional contract is
  288  automatically terminated 180 days after the imposition of the
  289  penalties. The plan must reimburse the agency for the cost of
  290  enrollment changes and other transition activities.
  291         Section 4. Subsection (2) of section 409.968, Florida
  292  Statutes, is amended to read:
  293         409.968 Managed care plan payments.—
  294         (2) Provider service networks shall may be prepaid plans
  295  and receive per-member, per-month payments negotiated pursuant
  296  to the procurement process described in s. 409.966. Provider
  297  service networks that choose not to be prepaid plans shall
  298  receive fee-for-service rates with a shared savings settlement.
  299  The fee-for-service option shall be available to a provider
  300  service network only for the first 2 years of its operation. The
  301  agency shall annually conduct cost reconciliations to determine
  302  the amount of cost savings achieved by fee-for-service provider
  303  service networks for the dates of service within the period
  304  being reconciled. Only payments for covered services for dates
  305  of service within the reconciliation period and paid within 6
  306  months after the last date of service in the reconciliation
  307  period must be included. The agency shall perform the necessary
  308  adjustments for the inclusion of claims incurred but not
  309  reported within the reconciliation period for claims that could
  310  be received and paid by the agency after the 6-month claims
  311  processing time lag. The agency shall provide the results of the
  312  reconciliations to the fee-for-service provider service networks
  313  within 45 days after the end of the reconciliation period. The
  314  fee-for-service provider service networks shall review and
  315  provide written comments or a letter of concurrence to the
  316  agency within 45 days after receipt of the reconciliation
  317  results. This reconciliation is considered final.
  318         Section 5. Section 409.971, Florida Statutes, is amended to
  319  read:
  320         409.971 Managed medical assistance program.—The agency
  321  shall make payments for primary and acute medical assistance and
  322  related services using a managed care model. By January 1, 2013,
  323  the agency shall begin implementation of the statewide managed
  324  medical assistance program, with full implementation in all
  325  regions by October 1, 2014.
  326         Section 6. Subsections (1) and (2) of section 409.974,
  327  Florida Statutes, are amended to read:
  328         409.974 Eligible plans.—
  329         (1) ELIGIBLE PLAN SELECTION.—The agency shall select
  330  eligible plans for the managed medical assistance program
  331  through the procurement process described in s. 409.966. The
  332  agency shall notice invitations to negotiate no later than
  333  January 1, 2013.
  334         (a) The agency shall procure at least three two plans and
  335  up to four plans for Region A Region 1. At least one plan shall
  336  be a provider service network if any provider service networks
  337  submit a responsive bid.
  338         (b) The agency shall procure at least three plans and up to
  339  six two plans for Region B Region 2. At least one plan shall be
  340  a provider service network if any provider service networks
  341  submit a responsive bid.
  342         (c) The agency shall procure at least five three plans and
  343  up to 10 five plans for Region C Region 3. At least one plan
  344  must be a provider service network if any provider service
  345  networks submit a responsive bid.
  346         (d) The agency shall procure at least three plans and up to
  347  six five plans for Region D Region 4. At least one plan must be
  348  a provider service network if any provider service networks
  349  submit a responsive bid.
  350         (e) The agency shall procure at least three two plans and
  351  up to four plans for Region E Region 5. At least one plan must
  352  be a provider service network if any provider service networks
  353  submit a responsive bid.
  354         (f) The agency shall procure at least three four plans and
  355  up to five seven plans for Region F Region 6. At least one plan
  356  must be a provider service network if any provider service
  357  networks submit a responsive bid.
  358         (g) The agency shall procure at least three plans and up to
  359  five six plans for Region G Region 7. At least one plan must be
  360  a provider service network if any provider service networks
  361  submit a responsive bid.
  362         (h) The agency shall procure at least five two plans and up
  363  to 10 four plans for Region H Region 8. At least one plan must
  364  be a provider service network if any provider service networks
  365  submit a responsive bid.
  366         (i) The agency shall procure at least two plans and up to
  367  four plans for Region 9. At least one plan must be a provider
  368  service network if any provider service networks submit a
  369  responsive bid.
  370         (j) The agency shall procure at least two plans and up to
  371  four plans for Region 10. At least one plan must be a provider
  372  service network if any provider service networks submit a
  373  responsive bid.
  374         (k) The agency shall procure at least five plans and up to
  375  10 plans for Region 11. At least one plan must be a provider
  376  service network if any provider service networks submit a
  377  responsive bid.
  378  
  379  If no provider service network submits a responsive bid, the
  380  agency shall procure no more than one less than the maximum
  381  number of eligible plans permitted in that region. Within 12
  382  months after the initial invitation to negotiate, the agency
  383  shall attempt to procure a provider service network. The agency
  384  shall notice another invitation to negotiate only with provider
  385  service networks in those regions where no provider service
  386  network has been selected.
  387         (2) QUALITY SELECTION CRITERIA.—In addition to the criteria
  388  established in s. 409.966, the agency shall consider evidence
  389  that an eligible plan has written agreements or signed contracts
  390  or has made substantial progress in establishing relationships
  391  with providers before the plan submits submitting a response.
  392  The agency shall evaluate and give special weight to evidence of
  393  signed contracts with essential providers as defined by the
  394  agency pursuant to s. 409.975(1). The agency shall exercise a
  395  preference for plans with a provider network in which more than
  396  over 10 percent of the providers use electronic health records,
  397  as defined in s. 408.051. When all other factors are equal, the
  398  agency shall consider whether the organization has a contract to
  399  provide managed long-term care services in the same region and
  400  shall exercise a preference for such plans.
  401         Section 7. Subsection (1) of section 409.978, Florida
  402  Statutes, is amended to read:
  403         409.978 Long-term care managed care program.—
  404         (1) Pursuant to s. 409.963, the agency shall administer the
  405  long-term care managed care program described in ss. 409.978
  406  409.985, but may delegate specific duties and responsibilities
  407  for the program to the Department of Elderly Affairs and other
  408  state agencies. By July 1, 2012, the agency shall begin
  409  implementation of the statewide long-term care managed care
  410  program, with full implementation in all regions by October 1,
  411  2013.
  412         Section 8. Subsection (2) and paragraphs (c), (d), and (e)
  413  of subsection (3) of section 409.981, Florida Statutes, are
  414  amended to read:
  415         409.981 Eligible long-term care plans.—
  416         (2) ELIGIBLE PLAN SELECTION.—The agency shall select
  417  eligible plans for the long-term care managed care program
  418  through the procurement process described in s. 409.966. The
  419  agency shall procure:
  420         (a) At least three two plans and up to four plans for
  421  Region A Region 1. At least one plan must be a provider service
  422  network if any provider service networks submit a responsive
  423  bid.
  424         (b) At least three Two plans and up to six plans for Region
  425  B Region 2. At least one plan must be a provider service network
  426  if any provider service networks submit a responsive bid.
  427         (c) At least five three plans and up to eight five plans
  428  for Region C Region 3. At least one plan must be a provider
  429  service network if any provider service networks submit a
  430  responsive bid.
  431         (d) At least three plans and up to six five plans for
  432  Region D Region 4. At least one plan must be a provider service
  433  network if any provider service network submits a responsive
  434  bid.
  435         (e) At least three two plans and up to four plans for
  436  Region E Region 5. At least one plan must be a provider service
  437  network if any provider service networks submit a responsive
  438  bid.
  439         (f) At least three four plans and up to five seven plans
  440  for Region F Region 6. At least one plan must be a provider
  441  service network if any provider service networks submit a
  442  responsive bid.
  443         (g) At least three plans and up to four six plans for
  444  Region G Region 7. At least one plan must be a provider service
  445  network if any provider service networks submit a responsive
  446  bid.
  447         (h) At least five two plans and up to 10 four plans for
  448  Region H Region 8. At least one plan must be a provider service
  449  network if any provider service networks submit a responsive
  450  bid.
  451         (i) At least two plans and up to four plans for Region 9.
  452  At least one plan must be a provider service network if any
  453  provider service networks submit a responsive bid.
  454         (j) At least two plans and up to four plans for Region 10.
  455  At least one plan must be a provider service network if any
  456  provider service networks submit a responsive bid.
  457         (k) At least five plans and up to 10 plans for Region 11.
  458  At least one plan must be a provider service network if any
  459  provider service networks submit a responsive bid.
  460  
  461  If no provider service network submits a responsive bid in a
  462  region other than Region 1 or Region 2, the agency shall procure
  463  no more than one less than the maximum number of eligible plans
  464  permitted in that region. Within 12 months after the initial
  465  invitation to negotiate, the agency shall attempt to procure a
  466  provider service network. The agency shall notice another
  467  invitation to negotiate only with provider service networks in
  468  regions where no provider service network has been selected.
  469         (3) QUALITY SELECTION CRITERIA.—In addition to the criteria
  470  established in s. 409.966, the agency shall consider the
  471  following factors in the selection of eligible plans:
  472         (c) Whether a plan is proposing to establish a
  473  comprehensive long-term care plan and whether the eligible plan
  474  has a contract to provide managed medical assistance services in
  475  the same region.
  476         (c)(d) Whether a plan offers consumer-directed care
  477  services to enrollees pursuant to s. 409.221.
  478         (d)(e) Whether a plan is proposing to provide home and
  479  community-based services in addition to the minimum benefits
  480  required by s. 409.98.
  481         Section 9. This act shall take effect July 1, 2017.