Florida Senate - 2017                                     SB 916
       
       
        
       By Senator Grimsley
       
       
       
       
       
       26-00434A-17                                           2017916__
    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         revising the designation and county makeup of regions
   11         of the state for purposes of procuring health plans
   12         that may participate in the Medicaid program; adding a
   13         factor that the Agency for Health Care Administration
   14         must consider in the selection of eligible plans;
   15         deleting a requirement related to fee-for-service
   16         provider service networks; amending s. 409.968, F.S.;
   17         requiring provider service networks to be prepaid
   18         plans; deleting a fee-for-service option for Medicaid
   19         reimbursement for provider service networks; amending
   20         s. 409.971, F.S.; deleting an obsolete provision;
   21         amending s. 409.974, F.S.; revising the number of
   22         eligible Medicaid health care plans the agency must
   23         procure for certain regions in the state; deleting an
   24         obsolete provision; amending s. 409.978, F.S.;
   25         deleting an obsolete provision; amending s. 409.981,
   26         F.S.; revising the number of eligible Medicaid health
   27         care plans the agency must procure for certain regions
   28         in the state; deleting a requirement that the agency
   29         consider a specific factor relating to the selection
   30         of managed medical assistance plans; providing an
   31         effective date.
   32          
   33  Be It Enacted by the Legislature of the State of Florida:
   34  
   35         Section 1. Subsection (2) of section 409.912, Florida
   36  Statutes, is amended to read:
   37         409.912 Cost-effective purchasing of health care.—The
   38  agency shall purchase goods and services for Medicaid recipients
   39  in the most cost-effective manner consistent with the delivery
   40  of quality medical care. To ensure that medical services are
   41  effectively utilized, the agency may, in any case, require a
   42  confirmation or second physician’s opinion of the correct
   43  diagnosis for purposes of authorizing future services under the
   44  Medicaid program. This section does not restrict access to
   45  emergency services or poststabilization care services as defined
   46  in 42 C.F.R. s. 438.114. Such confirmation or second opinion
   47  shall be rendered in a manner approved by the agency. The agency
   48  shall maximize the use of prepaid per capita and prepaid
   49  aggregate fixed-sum basis services when appropriate and other
   50  alternative service delivery and reimbursement methodologies,
   51  including competitive bidding pursuant to s. 287.057, designed
   52  to facilitate the cost-effective purchase of a case-managed
   53  continuum of care. The agency shall also require providers to
   54  minimize the exposure of recipients to the need for acute
   55  inpatient, custodial, and other institutional care and the
   56  inappropriate or unnecessary use of high-cost services. The
   57  agency shall contract with a vendor to monitor and evaluate the
   58  clinical practice patterns of providers in order to identify
   59  trends that are outside the normal practice patterns of a
   60  provider’s professional peers or the national guidelines of a
   61  provider’s professional association. The vendor must be able to
   62  provide information and counseling to a provider whose practice
   63  patterns are outside the norms, in consultation with the agency,
   64  to improve patient care and reduce inappropriate utilization.
   65  The agency may mandate prior authorization, drug therapy
   66  management, or disease management participation for certain
   67  populations of Medicaid beneficiaries, certain drug classes, or
   68  particular drugs to prevent fraud, abuse, overuse, and possible
   69  dangerous drug interactions. The Pharmaceutical and Therapeutics
   70  Committee shall make recommendations to the agency on drugs for
   71  which prior authorization is required. The agency shall inform
   72  the Pharmaceutical and Therapeutics Committee of its decisions
   73  regarding drugs subject to prior authorization. The agency is
   74  authorized to limit the entities it contracts with or enrolls as
   75  Medicaid providers by developing a provider network through
   76  provider credentialing. The agency may competitively bid single
   77  source-provider contracts if procurement of goods or services
   78  results in demonstrated cost savings to the state without
   79  limiting access to care. The agency may limit its network based
   80  on the assessment of beneficiary access to care, provider
   81  availability, provider quality standards, time and distance
   82  standards for access to care, the cultural competence of the
   83  provider network, demographic characteristics of Medicaid
   84  beneficiaries, practice and provider-to-beneficiary standards,
   85  appointment wait times, beneficiary use of services, provider
   86  turnover, provider profiling, provider licensure history,
   87  previous program integrity investigations and findings, peer
   88  review, provider Medicaid policy and billing compliance records,
   89  clinical and medical record audits, and other factors. Providers
   90  are not entitled to enrollment in the Medicaid provider network.
   91  The agency shall determine instances in which allowing Medicaid
   92  beneficiaries to purchase durable medical equipment and other
   93  goods is less expensive to the Medicaid program than long-term
   94  rental of the equipment or goods. The agency may establish rules
   95  to facilitate purchases in lieu of long-term rentals in order to
   96  protect against fraud and abuse in the Medicaid program as
   97  defined in s. 409.913. The agency may seek federal waivers
   98  necessary to administer these policies.
   99         (2) The agency may contract with a provider service
  100  network, which may be reimbursed on a fee-for-service or prepaid
  101  basis. Prepaid provider service networks shall receive per
  102  member, per-month payments. A provider service network that does
  103  not choose to be a prepaid plan shall receive fee-for-service
  104  rates with a shared savings settlement. The fee-for-service
  105  option shall be available to a provider service network only for
  106  the first 2 years of the plan’s operation or until the contract
  107  year beginning September 1, 2014, whichever is later. The agency
  108  shall annually conduct cost reconciliations to determine the
  109  amount of cost savings achieved by fee-for-service provider
  110  service networks for the dates of service in the period being
  111  reconciled. Only payments for covered services for dates of
  112  service within the reconciliation period and paid within 6
  113  months after the last date of service in the reconciliation
  114  period shall be included. The agency shall perform the necessary
  115  adjustments for the inclusion of claims incurred but not
  116  reported within the reconciliation for claims that could be
  117  received and paid by the agency after the 6-month claims
  118  processing time lag. The agency shall provide the results of the
  119  reconciliations to the fee-for-service provider service networks
  120  within 45 days after the end of the reconciliation period. The
  121  fee-for-service provider service networks shall review and
  122  provide written comments or a letter of concurrence to the
  123  agency within 45 days after receipt of the reconciliation
  124  results. This reconciliation shall be considered final.
  125         (a) A provider service network that which is reimbursed by
  126  the agency on a prepaid basis shall be exempt from parts I and
  127  III of chapter 641, but must comply with the solvency
  128  requirements in s. 641.2261(2) and meet appropriate financial
  129  reserve, quality assurance, and patient rights requirements as
  130  established by the agency.
  131         (b) A provider service network is a network established or
  132  organized and operated by a health care provider, or group of
  133  affiliated health care providers, which provides a substantial
  134  proportion of the health care items and services under a
  135  contract directly through the provider or affiliated group of
  136  providers and may make arrangements with physicians or other
  137  health care professionals, health care institutions, or any
  138  combination of such individuals or institutions to assume all or
  139  part of the financial risk on a prospective basis for the
  140  provision of basic health services by the physicians, by other
  141  health professionals, or through the institutions. The health
  142  care providers must have a controlling interest in the governing
  143  body of the provider service network organization.
  144         Section 2. Section 409.964, Florida Statutes, is amended to
  145  read:
  146         409.964 Managed care program; state plan; waivers.—The
  147  Medicaid program is established as a statewide, integrated
  148  managed care program for all covered services, including long
  149  term care services. The agency shall apply for and implement
  150  state plan amendments or waivers of applicable federal laws and
  151  regulations necessary to implement the program. Before seeking a
  152  waiver, the agency shall provide public notice and the
  153  opportunity for public comment and include public feedback in
  154  the waiver application. The agency shall hold one public meeting
  155  in each of the regions described in s. 409.966(2), and the time
  156  period for public comment for each region shall end no sooner
  157  than 30 days after the completion of the public meeting in that
  158  region. The agency shall submit any state plan amendments, new
  159  waiver requests, or requests for extensions or expansions for
  160  existing waivers, needed to implement the managed care program
  161  by August 1, 2011.
  162         Section 3. Subsection (2) and paragraphs (a), (d), and (e)
  163  of subsection (3) of section 409.966, Florida Statutes, are
  164  amended to read:
  165         409.966 Eligible plans; selection.—
  166         (2) ELIGIBLE PLAN SELECTION.—The agency shall select a
  167  limited number of eligible plans to participate in the Medicaid
  168  program using invitations to negotiate in accordance with s.
  169  287.057(1)(c). At least 90 days before issuing an invitation to
  170  negotiate, the agency shall compile and publish a databook
  171  consisting of a comprehensive set of utilization and spending
  172  data consistent with actuarial rate-setting practices and
  173  standards for the 3 most recent contract years consistent with
  174  the rate-setting periods for all Medicaid recipients by region
  175  or county. The source of the data in the report must include
  176  both historic fee-for-service claims and validated data from the
  177  Medicaid Encounter Data System. The report must be available in
  178  electronic form and delineate utilization use by age, gender,
  179  eligibility group, geographic area, and aggregate clinical risk
  180  score. Separate and simultaneous procurements shall be conducted
  181  in each of the following regions:
  182         (a) Region A Region 1, which consists of Bay, Calhoun,
  183  Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson,
  184  Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla,
  185  and Walton, and Washington Counties.
  186         (b) Region B Region 2, which consists of Alachua, Baker,
  187  Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler,
  188  Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion,
  189  Nassau, Putnam, St. Johns, Sumter, Suwannee, Union, and Volusia
  190  Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson,
  191  Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and
  192  Washington Counties.
  193         (c) Region C Region 3, which consists of Hardee, Highlands,
  194  Hillsborough, Manatee, Pasco, Pinellas, and Polk Alachua,
  195  Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton,
  196  Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter,
  197  Suwannee, and Union Counties.
  198         (d) Region D Region 4, which consists of Brevard, Orange,
  199  Osceola, and Seminole Baker, Clay, Duval, Flagler, Nassau, St.
  200  Johns, and Volusia Counties.
  201         (e) Region E Region 5, which consists of Charlotte,
  202  Collier, DeSoto, Glades, Hendry, Lee, and Sarasota Pasco and
  203  Pinellas Counties.
  204         (f) Region F Region 6, which consists of Indian River,
  205  Martin, Okeechobee, Palm Beach, and St. Lucie Hardee, Highlands,
  206  Hillsborough, Manatee, and Polk Counties.
  207         (g) Region G Region 7, which consists of Broward County
  208  Brevard, Orange, Osceola, and Seminole Counties.
  209         (h) Region H Region 8, which consists of Miami-Dade and
  210  Monroe Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and
  211  Sarasota Counties.
  212         (i) Region 9, which consists of Indian River, Martin,
  213  Okeechobee, Palm Beach, and St. Lucie Counties.
  214         (j) Region 10, which consists of Broward County.
  215         (k) Region 11, which consists of Miami-Dade and Monroe
  216  Counties.
  217         (3) QUALITY SELECTION CRITERIA.—
  218         (a) The invitation to negotiate must specify the criteria
  219  and the relative weight of the criteria that will be used for
  220  determining the acceptability of the reply and guiding the
  221  selection of the organizations with which the agency negotiates.
  222  In addition to criteria established by the agency, the agency
  223  shall consider the following factors in the selection of
  224  eligible plans:
  225         1. Accreditation by the National Committee for Quality
  226  Assurance, the Joint Commission, or another nationally
  227  recognized accrediting body.
  228         2. Experience serving similar populations, including the
  229  organization’s record in achieving specific quality standards
  230  with similar populations.
  231         3. Availability and accessibility of primary care and
  232  specialty physicians in the provider network.
  233         4. Establishment of community partnerships with providers
  234  that create opportunities for reinvestment in community-based
  235  services.
  236         5. Organization commitment to quality improvement and
  237  documentation of achievements in specific quality improvement
  238  projects, including active involvement by organization
  239  leadership.
  240         6. Provision of additional benefits, particularly dental
  241  care and disease management, and other initiatives that improve
  242  health outcomes.
  243         7. Evidence that an eligible plan has written agreements or
  244  signed contracts or has made substantial progress in
  245  establishing relationships with providers before the plan
  246  submitting a response.
  247         8. Comments submitted in writing by any enrolled Medicaid
  248  provider relating to a specifically identified plan
  249  participating in the procurement in the same region as the
  250  submitting provider.
  251         9. Documentation of policies and procedures for preventing
  252  fraud and abuse.
  253         10. The business relationship an eligible plan has with any
  254  other eligible plan that responds to the invitation to
  255  negotiate.
  256         11. Whether a plan is proposing to establish a
  257  comprehensive long-term care plan.
  258         (d) For the first year of the first contract term, the
  259  agency shall negotiate capitation rates or fee for service
  260  payments with each plan in order to guarantee aggregate savings
  261  of at least 5 percent.
  262         1. For prepaid plans, determination of the amount of
  263  savings shall be calculated by comparison to the Medicaid rates
  264  that the agency paid managed care plans for similar populations
  265  in the same areas in the prior year. In regions containing no
  266  prepaid plans in the prior year, determination of the amount of
  267  savings shall be calculated by comparison to the Medicaid rates
  268  established and certified for those regions in the prior year.
  269         2. For provider service networks operating on a fee-for
  270  service basis, determination of the amount of savings shall be
  271  calculated by comparison to the Medicaid rates that the agency
  272  paid on a fee-for-service basis for the same services in the
  273  prior year.
  274         (e) To ensure managed care plan participation in Regions A
  275  and E Regions 1 and 2, the agency shall award an additional
  276  contract to each plan with a contract award in Region A Region 1
  277  or Region E Region 2. Such contract shall be in any other region
  278  in which the plan submitted a responsive bid and negotiates a
  279  rate acceptable to the agency. If a plan that is awarded an
  280  additional contract pursuant to this paragraph is subject to
  281  penalties pursuant to s. 409.967(2)(i) for activities in Region
  282  A Region 1 or Region E Region 2, the additional contract is
  283  automatically terminated 180 days after the imposition of the
  284  penalties. The plan must reimburse the agency for the cost of
  285  enrollment changes and other transition activities.
  286         Section 4. Subsection (2) of section 409.968, Florida
  287  Statutes, is amended to read:
  288         409.968 Managed care plan payments.—
  289         (2) Provider service networks shall may be prepaid plans
  290  and receive per-member, per-month payments negotiated pursuant
  291  to the procurement process described in s. 409.966. Provider
  292  service networks that choose not to be prepaid plans shall
  293  receive fee-for-service rates with a shared savings settlement.
  294  The fee-for-service option shall be available to a provider
  295  service network only for the first 2 years of its operation. The
  296  agency shall annually conduct cost reconciliations to determine
  297  the amount of cost savings achieved by fee-for-service provider
  298  service networks for the dates of service within the period
  299  being reconciled. Only payments for covered services for dates
  300  of service within the reconciliation period and paid within 6
  301  months after the last date of service in the reconciliation
  302  period must be included. The agency shall perform the necessary
  303  adjustments for the inclusion of claims incurred but not
  304  reported within the reconciliation period for claims that could
  305  be received and paid by the agency after the 6-month claims
  306  processing time lag. The agency shall provide the results of the
  307  reconciliations to the fee-for-service provider service networks
  308  within 45 days after the end of the reconciliation period. The
  309  fee-for-service provider service networks shall review and
  310  provide written comments or a letter of concurrence to the
  311  agency within 45 days after receipt of the reconciliation
  312  results. This reconciliation is considered final.
  313         Section 5. Section 409.971, Florida Statutes, is amended to
  314  read:
  315         409.971 Managed medical assistance program.—The agency
  316  shall make payments for primary and acute medical assistance and
  317  related services using a managed care model. By January 1, 2013,
  318  the agency shall begin implementation of the statewide managed
  319  medical assistance program, with full implementation in all
  320  regions by October 1, 2014.
  321         Section 6. Subsections (1) and (2) of section 409.974,
  322  Florida Statutes, are amended to read:
  323         409.974 Eligible plans.—
  324         (1) ELIGIBLE PLAN SELECTION.—The agency shall select
  325  eligible plans through the procurement process described in s.
  326  409.966. The agency shall notice invitations to negotiate no
  327  later than January 1, 2013.
  328         (a) The agency shall procure at least two plans and up to
  329  four plans for Region A Region 1. At least one plan shall be a
  330  provider service network if any provider service networks submit
  331  a responsive bid.
  332         (b) The agency shall procure at least three plans and up to
  333  five two plans for Region B Region 2. At least one plan shall be
  334  a provider service network if any provider service networks
  335  submit a responsive bid.
  336         (c) The agency shall procure at least four three plans and
  337  up to seven five plans for Region C Region 3. At least one plan
  338  must be a provider service network if any provider service
  339  networks submit a responsive bid.
  340         (d) The agency shall procure at least three plans and up to
  341  six five plans for Region D Region 4. At least one plan must be
  342  a provider service network if any provider service networks
  343  submit a responsive bid.
  344         (e) The agency shall procure at least two plans and up to
  345  four plans for Region E Region 5. At least one plan must be a
  346  provider service network if any provider service networks submit
  347  a responsive bid.
  348         (f) The agency shall procure at least two four plans and up
  349  to four seven plans for Region F Region 6. At least one plan
  350  must be a provider service network if any provider service
  351  networks submit a responsive bid.
  352         (g) The agency shall procure at least two three plans and
  353  up to four six plans for Region G Region 7. At least one plan
  354  must be a provider service network if any provider service
  355  networks submit a responsive bid.
  356         (h) The agency shall procure at least five two plans and up
  357  to 10 four plans for Region H Region 8. At least one plan must
  358  be a provider service network if any provider service networks
  359  submit a responsive bid.
  360         (i) The agency shall procure at least two plans and up to
  361  four plans for Region 9. At least one plan must be a provider
  362  service network if any provider service networks submit a
  363  responsive bid.
  364         (j) The agency shall procure at least two plans and up to
  365  four plans for Region 10. At least one plan must be a provider
  366  service network if any provider service networks submit a
  367  responsive bid.
  368         (k) The agency shall procure at least five plans and up to
  369  10 plans for Region 11. At least one plan must be a provider
  370  service network if any provider service networks submit a
  371  responsive bid.
  372  
  373  If no provider service network submits a responsive bid, the
  374  agency shall procure no more than one less than the maximum
  375  number of eligible plans permitted in that region. Within 12
  376  months after the initial invitation to negotiate, the agency
  377  shall attempt to procure a provider service network. The agency
  378  shall notice another invitation to negotiate only with provider
  379  service networks in those regions where no provider service
  380  network has been selected.
  381         (2) QUALITY SELECTION CRITERIA.—In addition to the criteria
  382  established in s. 409.966, the agency shall consider evidence
  383  that an eligible plan has written agreements or signed contracts
  384  or has made substantial progress in establishing relationships
  385  with providers before the plan submits submitting a response.
  386  The agency shall evaluate and give special weight to evidence of
  387  signed contracts with essential providers as defined by the
  388  agency pursuant to s. 409.975(1). The agency shall exercise a
  389  preference for plans with a provider network in which more than
  390  over 10 percent of the providers use electronic health records,
  391  as defined in s. 408.051. When all other factors are equal, the
  392  agency shall consider whether the organization has a contract to
  393  provide managed long-term care services in the same region and
  394  shall exercise a preference for such plans.
  395         Section 7. Subsection (1) of section 409.978, Florida
  396  Statutes, is amended to read:
  397         409.978 Long-term care managed care program.—
  398         (1) Pursuant to s. 409.963, the agency shall administer the
  399  long-term care managed care program described in ss. 409.978
  400  409.985, but may delegate specific duties and responsibilities
  401  for the program to the Department of Elderly Affairs and other
  402  state agencies. By July 1, 2012, the agency shall begin
  403  implementation of the statewide long-term care managed care
  404  program, with full implementation in all regions by October 1,
  405  2013.
  406         Section 8. Subsection (2) and paragraphs (c), (d), and (e)
  407  of subsection (3) of section 409.981, Florida Statutes, are
  408  amended to read:
  409         409.981 Eligible long-term care plans.—
  410         (2) ELIGIBLE PLAN SELECTION.—The agency shall select
  411  eligible plans through the procurement process described in s.
  412  409.966. The agency shall procure:
  413         (a) At least two plans and up to four plans for Region A
  414  Region 1. At least one plan must be a provider service network
  415  if any provider service networks submit a responsive bid.
  416         (b) At least three Two plans and up to five plans for
  417  Region B Region 2. At least one plan must be a provider service
  418  network if any provider service networks submit a responsive
  419  bid.
  420         (c) At least four three plans and up to seven five plans
  421  for Region C Region 3. At least one plan must be a provider
  422  service network if any provider service networks submit a
  423  responsive bid.
  424         (d) At least three plans and up to six five plans for
  425  Region D Region 4. At least one plan must be a provider service
  426  network if any provider service network submits a responsive
  427  bid.
  428         (e) At least two plans and up to four plans for Region E
  429  Region 5. At least one plan must be a provider service network
  430  if any provider service networks submit a responsive bid.
  431         (f) At least two four plans and up to four seven plans for
  432  Region F Region 6. At least one plan must be a provider service
  433  network if any provider service networks submit a responsive
  434  bid.
  435         (g) At least two three plans and up to four six plans for
  436  Region G Region 7. At least one plan must be a provider service
  437  network if any provider service networks submit a responsive
  438  bid.
  439         (h) At least five two plans and up to 10 four plans for
  440  Region H Region 8. At least one plan must be a provider service
  441  network if any provider service networks submit a responsive
  442  bid.
  443         (i) At least two plans and up to four plans for Region 9.
  444  At least one plan must be a provider service network if any
  445  provider service networks submit a responsive bid.
  446         (j) At least two plans and up to four plans for Region 10.
  447  At least one plan must be a provider service network if any
  448  provider service networks submit a responsive bid.
  449         (k) At least five plans and up to 10 plans for Region 11.
  450  At least one plan must be a provider service network if any
  451  provider service networks submit a responsive bid.
  452  
  453  If no provider service network submits a responsive bid in a
  454  region other than Region 1 or Region 2, the agency shall procure
  455  no more than one less than the maximum number of eligible plans
  456  permitted in that region. Within 12 months after the initial
  457  invitation to negotiate, the agency shall attempt to procure a
  458  provider service network. The agency shall notice another
  459  invitation to negotiate only with provider service networks in
  460  regions where no provider service network has been selected.
  461         (3) QUALITY SELECTION CRITERIA.—In addition to the criteria
  462  established in s. 409.966, the agency shall consider the
  463  following factors in the selection of eligible plans:
  464         (c) Whether a plan is proposing to establish a
  465  comprehensive long-term care plan and whether the eligible plan
  466  has a contract to provide managed medical assistance services in
  467  the same region.
  468         (c)(d) Whether a plan offers consumer-directed care
  469  services to enrollees pursuant to s. 409.221.
  470         (d)(e) Whether a plan is proposing to provide home and
  471  community-based services in addition to the minimum benefits
  472  required by s. 409.98.
  473         Section 9. This act shall take effect July 1, 2017.