Florida Senate - 2022                          SENATOR AMENDMENT
       Bill No. CS/CS/SB 1950, 1st Eng.
       
       
       
       
       
       
                                Ì114014hÎ114014                         
       
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
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                  Floor: WD            .                                
             03/11/2022 02:16 PM       .                                
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       Senator Bean moved the following:
       
    1         Senate Amendment to House Amendment (739505) (with title
    2  amendment)
    3  
    4         Delete lines 5 - 986
    5  and insert:
    6         Section 1. Subsection (1) of section 409.912, Florida
    7  Statutes, is amended to read:
    8         409.912 Cost-effective purchasing of health care.—The
    9  agency shall purchase goods and services for Medicaid recipients
   10  in the most cost-effective manner consistent with the delivery
   11  of quality medical care. To ensure that medical services are
   12  effectively utilized, the agency may, in any case, require a
   13  confirmation or second physician’s opinion of the correct
   14  diagnosis for purposes of authorizing future services under the
   15  Medicaid program. This section does not restrict access to
   16  emergency services or poststabilization care services as defined
   17  in 42 C.F.R. s. 438.114. Such confirmation or second opinion
   18  shall be rendered in a manner approved by the agency. The agency
   19  shall maximize the use of prepaid per capita and prepaid
   20  aggregate fixed-sum basis services when appropriate and other
   21  alternative service delivery and reimbursement methodologies,
   22  including competitive bidding pursuant to s. 287.057, designed
   23  to facilitate the cost-effective purchase of a case-managed
   24  continuum of care. The agency shall also require providers to
   25  minimize the exposure of recipients to the need for acute
   26  inpatient, custodial, and other institutional care and the
   27  inappropriate or unnecessary use of high-cost services. The
   28  agency shall contract with a vendor to monitor and evaluate the
   29  clinical practice patterns of providers in order to identify
   30  trends that are outside the normal practice patterns of a
   31  provider’s professional peers or the national guidelines of a
   32  provider’s professional association. The vendor must be able to
   33  provide information and counseling to a provider whose practice
   34  patterns are outside the norms, in consultation with the agency,
   35  to improve patient care and reduce inappropriate utilization.
   36  The agency may mandate prior authorization, drug therapy
   37  management, or disease management participation for certain
   38  populations of Medicaid beneficiaries, certain drug classes, or
   39  particular drugs to prevent fraud, abuse, overuse, and possible
   40  dangerous drug interactions. The Pharmaceutical and Therapeutics
   41  Committee shall make recommendations to the agency on drugs for
   42  which prior authorization is required. The agency shall inform
   43  the Pharmaceutical and Therapeutics Committee of its decisions
   44  regarding drugs subject to prior authorization. The agency is
   45  authorized to limit the entities it contracts with or enrolls as
   46  Medicaid providers by developing a provider network through
   47  provider credentialing. The agency may competitively bid single
   48  source-provider contracts if procurement of goods or services
   49  results in demonstrated cost savings to the state without
   50  limiting access to care. The agency may limit its network based
   51  on the assessment of beneficiary access to care, provider
   52  availability, provider quality standards, time and distance
   53  standards for access to care, the cultural competence of the
   54  provider network, demographic characteristics of Medicaid
   55  beneficiaries, practice and provider-to-beneficiary standards,
   56  appointment wait times, beneficiary use of services, provider
   57  turnover, provider profiling, provider licensure history,
   58  previous program integrity investigations and findings, peer
   59  review, provider Medicaid policy and billing compliance records,
   60  clinical and medical record audits, and other factors. Providers
   61  are not entitled to enrollment in the Medicaid provider network.
   62  The agency shall determine instances in which allowing Medicaid
   63  beneficiaries to purchase durable medical equipment and other
   64  goods is less expensive to the Medicaid program than long-term
   65  rental of the equipment or goods. The agency may establish rules
   66  to facilitate purchases in lieu of long-term rentals in order to
   67  protect against fraud and abuse in the Medicaid program as
   68  defined in s. 409.913. The agency may seek federal waivers
   69  necessary to administer these policies.
   70         (1) The agency may contract with a provider service
   71  network, which must may be reimbursed on a fee-for-service or
   72  prepaid basis. Prepaid Provider service networks shall receive
   73  per-member, per-month payments. A provider service network that
   74  does not choose to be a prepaid plan shall receive fee-for
   75  service rates with a shared savings settlement. The fee-for
   76  service option shall be available to a provider service network
   77  only for the first 2 years of the plan’s operation or until the
   78  contract year beginning September 1, 2014, whichever is later.
   79  The agency shall annually conduct cost reconciliations to
   80  determine the amount of cost savings achieved by fee-for-service
   81  provider service networks for the dates of service in the period
   82  being reconciled. Only payments for covered services for dates
   83  of service within the reconciliation period and paid within 6
   84  months after the last date of service in the reconciliation
   85  period shall be included. The agency shall perform the necessary
   86  adjustments for the inclusion of claims incurred but not
   87  reported within the reconciliation for claims that could be
   88  received and paid by the agency after the 6-month claims
   89  processing time lag. The agency shall provide the results of the
   90  reconciliations to the fee-for-service provider service networks
   91  within 45 days after the end of the reconciliation period. The
   92  fee-for-service provider service networks shall review and
   93  provide written comments or a letter of concurrence to the
   94  agency within 45 days after receipt of the reconciliation
   95  results. This reconciliation shall be considered final.
   96         (a) A provider service network which is reimbursed by the
   97  agency on a prepaid basis shall be exempt from parts I and III
   98  of chapter 641 but must comply with the solvency requirements in
   99  s. 641.2261(2) and meet appropriate financial reserve, quality
  100  assurance, and patient rights requirements as established by the
  101  agency.
  102         (b) A provider service network is a network established or
  103  organized and operated by a health care provider, or group of
  104  affiliated health care providers, which provides a substantial
  105  proportion of the health care items and services under a
  106  contract directly through the provider or affiliated group of
  107  providers and may make arrangements with physicians or other
  108  health care professionals, health care institutions, or any
  109  combination of such individuals or institutions to assume all or
  110  part of the financial risk on a prospective basis for the
  111  provision of basic health services by the physicians, by other
  112  health professionals, or through the institutions. The health
  113  care providers must have a controlling interest in the governing
  114  body of the provider service network organization.
  115         (a)A provider service network is exempt from parts I and
  116  III of chapter 641 but must comply with the solvency
  117  requirements in s. 641.2261(2) and meet appropriate financial
  118  reserve, quality assurance, and patient rights requirements as
  119  established by the agency.
  120         (b)This subsection does not authorize the agency to
  121  contract with a provider service network outside of the
  122  procurement process described in s. 409.966.
  123         Section 2. Section 409.9124, Florida Statutes, is repealed.
  124         Section 3. Section 409.964, Florida Statutes, is amended to
  125  read:
  126         409.964 Managed care program; state plan; waivers.—The
  127  Medicaid program is established as a statewide, integrated
  128  managed care program for all covered services, including long
  129  term care services. The agency shall apply for and implement
  130  state plan amendments or waivers of applicable federal laws and
  131  regulations necessary to implement the program. Before seeking a
  132  waiver, the agency shall provide public notice and the
  133  opportunity for public comment and include public feedback in
  134  the waiver application. The agency shall hold one public meeting
  135  in each of the regions described in s. 409.966(2), and the time
  136  period for public comment for each region shall end no sooner
  137  than 30 days after the completion of the public meeting in that
  138  region.
  139         Section 4. Subsections (2), (3), and (4) of section
  140  409.966, Florida Statutes, are amended to read:
  141         409.966 Eligible plans; selection.—
  142         (2) ELIGIBLE PLAN SELECTION.—The agency shall select a
  143  limited number of eligible plans to participate in the Medicaid
  144  program using invitations to negotiate in accordance with s.
  145  287.057(1)(c). At least 90 days before issuing an invitation to
  146  negotiate, the agency shall compile and publish a databook
  147  consisting of a comprehensive set of utilization and spending
  148  data consistent with actuarial rate-setting practices and
  149  standards for the 3 most recent contract years consistent with
  150  the rate-setting periods for all Medicaid recipients by region
  151  or county. The source of the data in the databook report must
  152  include, at a minimum, the 24 most recent months of both
  153  historic fee-for-service claims and validated data from the
  154  Medicaid Encounter Data System, and the databook must. The
  155  report must be available in electronic form and delineate
  156  utilization use by age, gender, eligibility group, geographic
  157  area, and aggregate clinical risk score. The statewide managed
  158  care program includes Separate and simultaneous procurements
  159  shall be conducted in each of the following regions:
  160         (a) Region A 1, which consists of Bay, Calhoun, Escambia,
  161  Okaloosa, Santa Rosa, and Walton Counties.
  162         (b) Region 2, which consists of Bay, Calhoun, Franklin,
  163  Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty,
  164  Madison, Okaloosa, Santa Rosa, Taylor, Wakulla, Walton, and
  165  Washington Counties.
  166         (b)(c) Region B 3, which consists of Alachua, Baker,
  167  Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler,
  168  Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion,
  169  Nassau, Putnam, St. Johns, Sumter, Suwannee, and Union Counties.
  170         (d) Region 4, which consists of Baker, Clay, Duval,
  171  Flagler, Nassau, St. Johns, and Volusia Counties.
  172         (c)(e) Region C 5, which consists of Pasco and Pinellas
  173  Counties.
  174         (d)(f) Region D 6, which consists of Hardee, Highlands,
  175  Hillsborough, Manatee, and Polk Counties.
  176         (e)(g) Region E 7, which consists of Brevard, Orange,
  177  Osceola, and Seminole Counties.
  178         (f)(h) Region F 8, which consists of Charlotte, Collier,
  179  DeSoto, Glades, Hendry, Lee, and Sarasota Counties.
  180         (g)(i) Region G 9, which consists of Indian River, Martin,
  181  Okeechobee, Palm Beach, and St. Lucie Counties.
  182         (h)(j) Region H 10, which consists of Broward County.
  183         (i)(k) Region I 11, which consists of Miami-Dade and Monroe
  184  Counties.
  185         (3) QUALITY SELECTION CRITERIA.—
  186         (a) The invitation to negotiate must specify the criteria
  187  and the relative weight of the criteria that will be used for
  188  determining the acceptability of the reply and guiding the
  189  selection of the organizations with which the agency negotiates.
  190  In addition to criteria established by the agency, the agency
  191  shall consider the following factors in the selection of
  192  eligible plans:
  193         1. Accreditation by the National Committee for Quality
  194  Assurance, the Joint Commission, or another nationally
  195  recognized accrediting body.
  196         2. Experience serving similar populations, including the
  197  organization’s record in achieving specific quality standards
  198  with similar populations.
  199         3. Availability and accessibility of primary care and
  200  specialty physicians in the provider network.
  201         4. Establishment of community partnerships with providers
  202  that create opportunities for reinvestment in community-based
  203  services.
  204         5. Organization commitment to quality improvement and
  205  documentation of achievements in specific quality improvement
  206  projects, including active involvement by organization
  207  leadership.
  208         6. Provision of additional benefits, particularly dental
  209  care and disease management, and other initiatives that improve
  210  health outcomes.
  211         7. Evidence that an eligible plan has obtained signed
  212  contracts or written agreements or signed contracts or has made
  213  substantial progress in establishing relationships with
  214  providers before the plan submits submitting a response.
  215         8. Comments submitted in writing by any enrolled Medicaid
  216  provider relating to a specifically identified plan
  217  participating in the procurement in the same region as the
  218  submitting provider.
  219         9. Documentation of policies and procedures for preventing
  220  fraud and abuse.
  221         10. The business relationship an eligible plan has with any
  222  other eligible plan that responds to the invitation to
  223  negotiate.
  224         (b) An eligible plan must disclose any business
  225  relationship it has with any other eligible plan that responds
  226  to the invitation to negotiate. The agency may not select plans
  227  in the same region for the same managed care program that have a
  228  business relationship with each other. Failure to disclose any
  229  business relationship shall result in disqualification from
  230  participation in any region for the first full contract period
  231  after the discovery of the business relationship by the agency.
  232  For the purpose of this section, “business relationship” means
  233  an ownership or controlling interest, an affiliate or subsidiary
  234  relationship, a common parent, or any mutual interest in any
  235  limited partnership, limited liability partnership, limited
  236  liability company, or other entity or business association,
  237  including all wholly or partially owned subsidiaries, majority
  238  owned subsidiaries, parent companies, or affiliates of such
  239  entities, business associations, or other enterprises, that
  240  exists for the purpose of making a profit.
  241         (c) After negotiations are conducted, the agency shall
  242  select the eligible plans that are determined to be responsive
  243  and provide the best value to the state. Preference shall be
  244  given to plans that:
  245         1. Have signed contracts with primary and specialty
  246  physicians in sufficient numbers to meet the specific standards
  247  established pursuant to s. 409.967(2)(c).
  248         2. Have well-defined programs for recognizing patient
  249  centered medical homes and providing for increased compensation
  250  for recognized medical homes, as defined by the plan.
  251         3. Are organizations that are based in and perform
  252  operational functions in this state, in-house or through
  253  contractual arrangements, by staff located in this state. Using
  254  a tiered approach, the highest number of points shall be awarded
  255  to a plan that has all or substantially all of its operational
  256  functions performed in the state. The second highest number of
  257  points shall be awarded to a plan that has a majority of its
  258  operational functions performed in the state. The agency may
  259  establish a third tier; however, preference points may not be
  260  awarded to plans that perform only community outreach, medical
  261  director functions, and state administrative functions in the
  262  state. For purposes of this subparagraph, operational functions
  263  include corporate headquarters, claims processing, member
  264  services, provider relations, utilization and prior
  265  authorization, case management, disease and quality functions,
  266  and finance and administration. For purposes of this
  267  subparagraph, the term “corporate headquarters” means the
  268  principal office of the organization, which may not be a
  269  subsidiary, directly or indirectly through one or more
  270  subsidiaries of, or a joint venture with, any other entity whose
  271  principal office is not located in the state.
  272         4. Have contracts or other arrangements for cancer disease
  273  management programs that have a proven record of clinical
  274  efficiencies and cost savings.
  275         5. Have contracts or other arrangements for diabetes
  276  disease management programs that have a proven record of
  277  clinical efficiencies and cost savings.
  278         6. Have a claims payment process that ensures that claims
  279  that are not contested or denied will be promptly paid pursuant
  280  to s. 641.3155.
  281         (d) For the first year of the first contract term, the
  282  agency shall negotiate capitation rates or fee for service
  283  payments with each plan in order to guarantee aggregate savings
  284  of at least 5 percent.
  285         1. For prepaid plans, determination of the amount of
  286  savings shall be calculated by comparison to the Medicaid rates
  287  that the agency paid managed care plans for similar populations
  288  in the same areas in the prior year. In regions containing no
  289  prepaid plans in the prior year, determination of the amount of
  290  savings shall be calculated by comparison to the Medicaid rates
  291  established and certified for those regions in the prior year.
  292         2. For provider service networks operating on a fee-for
  293  service basis, determination of the amount of savings shall be
  294  calculated by comparison to the Medicaid rates that the agency
  295  paid on a fee-for-service basis for the same services in the
  296  prior year.
  297         (e) To ensure managed care plan participation in Regions 1
  298  and 2, the agency shall award an additional contract to each
  299  plan with a contract award in Region 1 or Region 2. Such
  300  contract shall be in any other region in which the plan
  301  submitted a responsive bid and negotiates a rate acceptable to
  302  the agency. If a plan that is awarded an additional contract
  303  pursuant to this paragraph is subject to penalties pursuant to
  304  s. 409.967(2)(i) for activities in Region 1 or Region 2, the
  305  additional contract is automatically terminated 180 days after
  306  the imposition of the penalties. The plan must reimburse the
  307  agency for the cost of enrollment changes and other transition
  308  activities.
  309         (d)(f) The agency may not execute contracts with managed
  310  care plans at payment rates not supported by the General
  311  Appropriations Act.
  312         (4) ADMINISTRATIVE CHALLENGE.—Any eligible plan that
  313  participates in an invitation to negotiate in more than one
  314  region and is selected in at least one region may not begin
  315  serving Medicaid recipients in any region for which it was
  316  selected until all administrative challenges to procurements
  317  required by this section to which the eligible plan is a party
  318  have been finalized. If the number of plans selected is less
  319  than the maximum amount of plans permitted in the region, the
  320  agency may contract with other selected plans in the region not
  321  participating in the administrative challenge before resolution
  322  of the administrative challenge. For purposes of this
  323  subsection, an administrative challenge is finalized if an order
  324  granting voluntary dismissal with prejudice has been entered by
  325  any court established under Article V of the State Constitution
  326  or by the Division of Administrative Hearings, a final order has
  327  been entered into by the agency and the deadline for appeal has
  328  expired, a final order has been entered by the First District
  329  Court of Appeal and the time to seek any available review by the
  330  Florida Supreme Court has expired, or a final order has been
  331  entered by the Florida Supreme Court and a warrant has been
  332  issued.
  333         Section 5. Paragraphs (c) and (f) of subsection (2) of
  334  section 409.967, Florida Statutes, are amended to read:
  335         409.967 Managed care plan accountability.—
  336         (2) The agency shall establish such contract requirements
  337  as are necessary for the operation of the statewide managed care
  338  program. In addition to any other provisions the agency may deem
  339  necessary, the contract must require:
  340         (c) Access.—
  341         1. The agency shall establish specific standards for the
  342  number, type, and regional distribution of providers in managed
  343  care plan networks to ensure access to care for both adults and
  344  children. Each plan must maintain a regionwide network of
  345  providers in sufficient numbers to meet the access standards for
  346  specific medical services for all recipients enrolled in the
  347  plan. The exclusive use of mail-order pharmacies may not be
  348  sufficient to meet network access standards. Consistent with the
  349  standards established by the agency, provider networks may
  350  include providers located outside the region. A plan may
  351  contract with a new hospital facility before the date the
  352  hospital becomes operational if the hospital has commenced
  353  construction, will be licensed and operational by January 1,
  354  2013, and a final order has issued in any civil or
  355  administrative challenge. Each plan shall establish and maintain
  356  an accurate and complete electronic database of contracted
  357  providers, including information about licensure or
  358  registration, locations and hours of operation, specialty
  359  credentials and other certifications, specific performance
  360  indicators, and such other information as the agency deems
  361  necessary. The database must be available online to both the
  362  agency and the public and have the capability to compare the
  363  availability of providers to network adequacy standards and to
  364  accept and display feedback from each provider’s patients. Each
  365  plan shall submit quarterly reports to the agency identifying
  366  the number of enrollees assigned to each primary care provider.
  367  The agency shall conduct, or contract for, systematic and
  368  continuous testing of the provider network databases maintained
  369  by each plan to confirm accuracy, confirm that behavioral health
  370  providers are accepting enrollees, and confirm that enrollees
  371  have access to behavioral health services.
  372         2. Each managed care plan must publish any prescribed drug
  373  formulary or preferred drug list on the plan’s website in a
  374  manner that is accessible to and searchable by enrollees and
  375  providers. The plan must update the list within 24 hours after
  376  making a change. Each plan must ensure that the prior
  377  authorization process for prescribed drugs is readily accessible
  378  to health care providers, including posting appropriate contact
  379  information on its website and providing timely responses to
  380  providers. For Medicaid recipients diagnosed with hemophilia who
  381  have been prescribed anti-hemophilic-factor replacement
  382  products, the agency shall provide for those products and
  383  hemophilia overlay services through the agency’s hemophilia
  384  disease management program.
  385         3. Managed care plans, and their fiscal agents or
  386  intermediaries, must accept prior authorization requests for any
  387  service electronically.
  388         4. Managed care plans serving children in the care and
  389  custody of the Department of Children and Families must maintain
  390  complete medical, dental, and behavioral health encounter
  391  information and participate in making such information available
  392  to the department or the applicable contracted community-based
  393  care lead agency for use in providing comprehensive and
  394  coordinated case management. The agency and the department shall
  395  establish an interagency agreement to provide guidance for the
  396  format, confidentiality, recipient, scope, and method of
  397  information to be made available and the deadlines for
  398  submission of the data. The scope of information available to
  399  the department shall be the data that managed care plans are
  400  required to submit to the agency. The agency shall determine the
  401  plan’s compliance with standards for access to medical, dental,
  402  and behavioral health services; the use of medications; and
  403  followup on all medically necessary services recommended as a
  404  result of early and periodic screening, diagnosis, and
  405  treatment.
  406         (f) Continuous improvement.—The agency shall establish
  407  specific performance standards and expected milestones or
  408  timelines for improving performance over the term of the
  409  contract.
  410         1. Each managed care plan shall establish an internal
  411  health care quality improvement system, including enrollee
  412  satisfaction and disenrollment surveys. The quality improvement
  413  system must include incentives and disincentives for network
  414  providers.
  415         2. Each plan must collect and report the Health Plan
  416  Employer Data and Information Set (HEDIS) measures, as specified
  417  by the agency. These measures must be published on the plan’s
  418  website in a manner that allows recipients to reliably compare
  419  the performance of plans. The agency shall use the HEDIS
  420  measures as a tool to monitor plan performance.
  421         3. Each managed care plan must be accredited by the
  422  National Committee for Quality Assurance, the Joint Commission,
  423  or another nationally recognized accrediting body, or have
  424  initiated the accreditation process, within 1 year after the
  425  contract is executed. For any plan not accredited within 18
  426  months after executing the contract, the agency shall suspend
  427  automatic assignment under s. 409.977 and 409.984.
  428         4. By the end of the fourth year of the first contract
  429  term, the agency shall issue a request for information to
  430  determine whether cost savings could be achieved by contracting
  431  for plan oversight and monitoring, including analysis of
  432  encounter data, assessment of performance measures, and
  433  compliance with other contractual requirements.
  434         Section 6. Subsection (2) of section 409.968, Florida
  435  Statutes, is amended to read:
  436         409.968 Managed care plan payments.—
  437         (2) Provider service networks must may be prepaid plans and
  438  receive per-member, per-month payments negotiated pursuant to
  439  the procurement process described in s. 409.966. Provider
  440  service networks that choose not to be prepaid plans shall
  441  receive fee-for-service rates with a shared savings settlement.
  442  The fee-for-service option shall be available to a provider
  443  service network only for the first 2 years of its operation. The
  444  agency shall annually conduct cost reconciliations to determine
  445  the amount of cost savings achieved by fee-for-service provider
  446  service networks for the dates of service within the period
  447  being reconciled. Only payments for covered services for dates
  448  of service within the reconciliation period and paid within 6
  449  months after the last date of service in the reconciliation
  450  period must be included. The agency shall perform the necessary
  451  adjustments for the inclusion of claims incurred but not
  452  reported within the reconciliation period for claims that could
  453  be received and paid by the agency after the 6-month claims
  454  processing time lag. The agency shall provide the results of the
  455  reconciliations to the fee-for-service provider service networks
  456  within 45 days after the end of the reconciliation period. The
  457  fee-for-service provider service networks shall review and
  458  provide written comments or a letter of concurrence to the
  459  agency within 45 days after receipt of the reconciliation
  460  results. This reconciliation is considered final.
  461         Section 7. Subsections (3) and (4) of section 409.973,
  462  Florida Statutes, are amended to read:
  463         409.973 Benefits.—
  464         (3) HEALTHY BEHAVIORS.—Each plan operating in the managed
  465  medical assistance program shall establish a program to
  466  encourage and reward healthy behaviors. At a minimum, each plan
  467  must establish a medically approved tobacco smoking cessation
  468  program, a medically directed weight loss program, and a
  469  medically approved alcohol recovery program or substance abuse
  470  recovery program that must include, but may not be limited to,
  471  opioid abuse recovery. Each plan must identify enrollees who
  472  smoke, are morbidly obese, or are diagnosed with alcohol or
  473  substance abuse in order to establish written agreements to
  474  secure the enrollees’ commitment to participation in these
  475  programs.
  476         (4) PRIMARY CARE INITIATIVE.—Each plan operating in the
  477  managed medical assistance program shall establish a program to
  478  encourage enrollees to establish a relationship with their
  479  primary care provider. Each plan shall:
  480         (a) Provide information to each enrollee on the importance
  481  of and procedure for selecting a primary care provider, and
  482  thereafter automatically assign to a primary care provider any
  483  enrollee who fails to choose a primary care provider.
  484         (b) If the enrollee was not a Medicaid recipient before
  485  enrollment in the plan, assist the enrollee in scheduling an
  486  appointment with the primary care provider. If possible the
  487  appointment should be made within 30 days after enrollment in
  488  the plan. For enrollees who become eligible for Medicaid between
  489  January 1, 2014, and December 31, 2015, the appointment should
  490  be scheduled within 6 months after enrollment in the plan.
  491         (c) Report to the agency the number of enrollees assigned
  492  to each primary care provider within the plan’s network.
  493         (d) Report to the agency the number of enrollees who have
  494  not had an appointment with their primary care provider within
  495  their first year of enrollment.
  496         (e) Report to the agency the number of emergency room
  497  visits by enrollees who have not had at least one appointment
  498  with their primary care provider.
  499         Section 8. Subsections (1) and (2) of section 409.974,
  500  Florida Statutes, are amended to read:
  501         409.974 Eligible plans.—
  502         (1) ELIGIBLE PLAN SELECTION.—The agency shall select
  503  eligible plans for the managed medical assistance program
  504  through the procurement process described in s. 409.966 through
  505  a single statewide procurement. The agency may award contracts
  506  to plans selected through the procurement process either on a
  507  regional or statewide basis. The awards must include at least
  508  one provider service network in each of the nine regions
  509  outlined in this subsection. The agency shall procure:
  510         (a)At least 3 plans and up to 4 plans for Region A.
  511         (b)At least 3 plans and up to 6 plans for Region B.
  512         (c) At least 3 plans and up to 5 plans for Region C.
  513         (d) At least 4 plans and up to 7 plans for Region D.
  514         (e) At least 3 plans and up to 6 plans for Region E.
  515         (f) At least 3 plans and up to 4 plans for Region F.
  516         (g) At least 3 plans and up to 5 plans for Region G.
  517         (h) At least 3 plans and up to 5 plans for Region H.
  518         (i) At least 5 plans and up to 10 plans for Region I. The
  519  agency shall notice invitations to negotiate no later than
  520  January 1, 2013.
  521         (a) The agency shall procure two plans for Region 1. At
  522  least one plan shall be a provider service network if any
  523  provider service networks submit a responsive bid.
  524         (b) The agency shall procure two plans for Region 2. At
  525  least one plan shall be a provider service network if any
  526  provider service networks submit a responsive bid.
  527         (c) The agency shall procure at least three plans and up to
  528  five plans for Region 3. At least one plan must be a provider
  529  service network if any provider service networks submit a
  530  responsive bid.
  531         (d) The agency shall procure at least three plans and up to
  532  five plans for Region 4. At least one plan must be a provider
  533  service network if any provider service networks submit a
  534  responsive bid.
  535         (e) The agency shall procure at least two plans and up to
  536  four plans for Region 5. At least one plan must be a provider
  537  service network if any provider service networks submit a
  538  responsive bid.
  539         (f) The agency shall procure at least four plans and up to
  540  seven plans for Region 6. At least one plan must be a provider
  541  service network if any provider service networks submit a
  542  responsive bid.
  543         (g) The agency shall procure at least three plans and up to
  544  six plans for Region 7. At least one plan must be a provider
  545  service network if any provider service networks submit a
  546  responsive bid.
  547         (h) The agency shall procure at least two plans and up to
  548  four plans for Region 8. At least one plan must be a provider
  549  service network if any provider service networks submit a
  550  responsive bid.
  551         (i) The agency shall procure at least two plans and up to
  552  four plans for Region 9. At least one plan must be a provider
  553  service network if any provider service networks submit a
  554  responsive bid.
  555         (j) The agency shall procure at least two plans and up to
  556  four plans for Region 10. At least one plan must be a provider
  557  service network if any provider service networks submit a
  558  responsive bid.
  559         (k) The agency shall procure at least five plans and up to
  560  10 plans for Region 11. At least one plan must be a provider
  561  service network if any provider service networks submit a
  562  responsive bid.
  563  
  564  If no provider service network submits a responsive bid, the
  565  agency shall procure no more than one less than the maximum
  566  number of eligible plans permitted in that region. Within 12
  567  months after the initial invitation to negotiate, the agency
  568  shall attempt to procure a provider service network. The agency
  569  shall notice another invitation to negotiate only with provider
  570  service networks in those regions where no provider service
  571  network has been selected.
  572         (2) QUALITY SELECTION CRITERIA.—In addition to the criteria
  573  established in s. 409.966, the agency shall consider evidence
  574  that an eligible plan has obtained signed contracts or written
  575  agreements or signed contracts or has made substantial progress
  576  in establishing relationships with providers before the plan
  577  submits submitting a response. The agency shall evaluate and
  578  give special weight to evidence of signed contracts with
  579  essential providers as defined by the agency pursuant to s.
  580  409.975(1). The agency shall exercise a preference for plans
  581  with a provider network in which over 10 percent of the
  582  providers use electronic health records, as defined in s.
  583  408.051. When all other factors are equal, the agency shall
  584  consider whether the organization has a contract to provide
  585  managed long-term care services in the same region and shall
  586  exercise a preference for such plans.
  587         Section 9. Paragraph (b) of subsection (1) of section
  588  409.975, Florida Statutes, is amended to read:
  589         409.975 Managed care plan accountability.—In addition to
  590  the requirements of s. 409.967, plans and providers
  591  participating in the managed medical assistance program shall
  592  comply with the requirements of this section.
  593         (1) PROVIDER NETWORKS.—Managed care plans must develop and
  594  maintain provider networks that meet the medical needs of their
  595  enrollees in accordance with standards established pursuant to
  596  s. 409.967(2)(c). Except as provided in this section, managed
  597  care plans may limit the providers in their networks based on
  598  credentials, quality indicators, and price.
  599         (b) Certain providers are statewide resources and essential
  600  providers for all managed care plans in all regions. All managed
  601  care plans must include these essential providers in their
  602  networks. Statewide essential providers include:
  603         1. Faculty plans of Florida medical schools.
  604         2. Regional perinatal intensive care centers as defined in
  605  s. 383.16(2).
  606         3. Hospitals licensed as specialty children’s hospitals as
  607  defined in s. 395.002(28).
  608         4. Accredited and integrated systems serving medically
  609  complex children which comprise separately licensed, but
  610  commonly owned, health care providers delivering at least the
  611  following services: medical group home, in-home and outpatient
  612  nursing care and therapies, pharmacy services, durable medical
  613  equipment, and Prescribed Pediatric Extended Care.
  614         5. Florida cancer hospitals that meet the criteria in 42
  615  U.S.C. s. 1395ww(d)(1)(B)(v).
  616  
  617  Managed care plans that have not contracted with all statewide
  618  essential providers in all regions as of the first date of
  619  recipient enrollment must continue to negotiate in good faith.
  620  Payments to physicians on the faculty of nonparticipating
  621  Florida medical schools shall be made at the applicable Medicaid
  622  rate. Payments for services rendered by regional perinatal
  623  intensive care centers shall be made at the applicable Medicaid
  624  rate as of the first day of the contract between the agency and
  625  the plan. Except for payments for emergency services, payments
  626  to nonparticipating specialty children’s hospitals, and payments
  627  to nonparticipating Florida cancer hospitals that meet the
  628  criteria in 42 U.S.C. s. 1395ww(d)(1)(B)(v), shall equal the
  629  highest rate established by contract between that provider and
  630  any other Medicaid managed care plan.
  631         Section 10. Subsections (1), (2), (4), and (5) of section
  632  409.977, Florida Statutes, are amended to read:
  633         409.977 Enrollment.—
  634         (1) The agency shall automatically enroll into a managed
  635  care plan those Medicaid recipients who do not voluntarily
  636  choose a plan pursuant to s. 409.969. The agency shall
  637  automatically enroll recipients in plans that meet or exceed the
  638  performance or quality standards established pursuant to s.
  639  409.967 and may not automatically enroll recipients in a plan
  640  that is deficient in those performance or quality standards.
  641  When a specialty plan is available to accommodate a specific
  642  condition or diagnosis of a recipient, the agency shall assign
  643  the recipient to that plan. In the first year of the first
  644  contract term only, if a recipient was previously enrolled in a
  645  plan that is still available in the region, the agency shall
  646  automatically enroll the recipient in that plan unless an
  647  applicable specialty plan is available. Except as otherwise
  648  provided in this part, the agency may not engage in practices
  649  that are designed to favor one managed care plan over another.
  650         (2) When automatically enrolling recipients in managed care
  651  plans, if a recipient was enrolled in a plan immediately before
  652  the recipient′s choice period and that plan is still available
  653  in the region, the agency must maintain the recipient′s
  654  enrollment in that plan unless an applicable specialty plan is
  655  available. Otherwise, the agency shall automatically enroll
  656  based on the following criteria:
  657         (a) Whether the plan has sufficient network capacity to
  658  meet the needs of the recipients.
  659         (b) Whether the recipient has previously received services
  660  from one of the plan’s primary care providers.
  661         (c) Whether primary care providers in one plan are more
  662  geographically accessible to the recipient’s residence than
  663  those in other plans.
  664         (4) The agency shall develop a process to enable a
  665  recipient with access to employer-sponsored health care coverage
  666  to opt out of all managed care plans and to use Medicaid
  667  financial assistance to pay for the recipient’s share of the
  668  cost in such employer-sponsored coverage. Contingent upon
  669  federal approval, The agency shall also enable recipients with
  670  access to other insurance or related products providing access
  671  to health care services created pursuant to state law, including
  672  any product available under the Florida Health Choices Program,
  673  or any health exchange, to opt out. The amount of financial
  674  assistance provided for each recipient may not exceed the amount
  675  of the Medicaid premium that would have been paid to a managed
  676  care plan for that recipient. The agency shall seek federal
  677  approval to require Medicaid recipients with access to employer
  678  sponsored health care coverage to enroll in that coverage and
  679  use Medicaid financial assistance to pay for the recipient’s
  680  share of the cost for such coverage. The amount of financial
  681  assistance provided for each recipient may not exceed the amount
  682  of the Medicaid premium that would have been paid to a managed
  683  care plan for that recipient.
  684         (5) Specialty plans serving children in the care and
  685  custody of the department may serve such children as long as
  686  they remain in care, including those remaining in extended
  687  foster care pursuant to s. 39.6251, or are in subsidized
  688  adoption and continue to be eligible for Medicaid pursuant to s.
  689  409.903, or are receiving guardianship assistance payments and
  690  continue to be eligible for Medicaid pursuant to s. 409.903.
  691         Section 11. Subsection (2) of section 409.981, Florida
  692  Statutes, is amended to read:
  693         409.981 Eligible long-term care plans.—
  694         (2) ELIGIBLE PLAN SELECTION.—The agency shall select
  695  eligible plans for the long-term care managed care program
  696  through the procurement process described in s. 409.966 through
  697  a single statewide procurement. The agency may award contracts
  698  to plans selected through the procurement process on a regional
  699  or statewide basis. The awards must include at least one
  700  provider service network in each of the nine regions outlined in
  701  this subsection. The agency shall procure:
  702         (a) At least 3 plans and up to 4 plans for Region A.
  703         (b) At least 3 plans and up to 6 plans for Region B.
  704         (c) At least 3 plans and up to 5 plans for Region C.
  705         (d) At least 4 plans and up to 7 plans for Region D.
  706         (e) At least 3 plans and up to 6 plans for Region E.
  707         (f) At least 3 plans and up to 4 plans for Region F.
  708         (g) At least 3 plans and up to 5 plans for Region G.
  709         (h) At least 3 plans and up to 4 plans for Region H.
  710         (i) At least 5 plans and up to 10 plans for Region I Two
  711  plans for Region 1. At least one plan must be a provider service
  712  network if any provider service networks submit a responsive
  713  bid.
  714         (b) Two plans for Region 2. At least one plan must be a
  715  provider service network if any provider service networks submit
  716  a responsive bid.
  717         (c) At least three plans and up to five plans for Region 3.
  718  At least one plan must be a provider service network if any
  719  provider service networks submit a responsive bid.
  720         (d) At least three plans and up to five plans for Region 4.
  721  At least one plan must be a provider service network if any
  722  provider service network submits a responsive bid.
  723         (e) At least two plans and up to four plans for Region 5.
  724  At least one plan must be a provider service network if any
  725  provider service networks submit a responsive bid.
  726         (f) At least four plans and up to seven plans for Region 6.
  727  At least one plan must be a provider service network if any
  728  provider service networks submit a responsive bid.
  729         (g) At least three plans and up to six plans for Region 7.
  730  At least one plan must be a provider service network if any
  731  provider service networks submit a responsive bid.
  732         (h) At least two plans and up to four plans for Region 8.
  733  At least one plan must be a provider service network if any
  734  provider service networks submit a responsive bid.
  735         (i) At least two plans and up to four plans for Region 9.
  736  At least one plan must be a provider service network if any
  737  provider service networks submit a responsive bid.
  738         (j) At least two plans and up to four plans for Region 10.
  739  At least one plan must be a provider service network if any
  740  provider service networks submit a responsive bid.
  741         (k) At least five plans and up to 10 plans for Region 11.
  742  At least one plan must be a provider service network if any
  743  provider service networks submit a responsive bid.
  744  
  745  If no provider service network submits a responsive bid in a
  746  region other than Region 1 or Region 2, the agency shall procure
  747  no more than one less than the maximum number of eligible plans
  748  permitted in that region. Within 12 months after the initial
  749  invitation to negotiate, the agency shall attempt to procure a
  750  provider service network. The agency shall notice another
  751  invitation to negotiate only with provider service networks in
  752  regions where no provider service network has been selected.
  753         Section 12. Subsection (4) of section 409.8132, Florida
  754  Statutes, is amended to read:
  755         409.8132 Medikids program component.—
  756         (4) APPLICABILITY OF LAWS RELATING TO MEDICAID.—The
  757  provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
  758  409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
  759  409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205 apply
  760  to the administration of the Medikids program component of the
  761  Florida Kidcare program, except that s. 409.9122 applies to
  762  Medikids as modified by the provisions of subsection (7).
  763         Section 13. For the purpose of incorporating the amendment
  764  made by this act to section 409.912, Florida Statutes, in
  765  references thereto, subsections (1), (7), (13), and (14) of
  766  section 409.962, Florida Statutes, are reenacted to read:
  767         409.962 Definitions.—As used in this part, except as
  768  otherwise specifically provided, the term:
  769         (1) “Accountable care organization” means an entity
  770  qualified as an accountable care organization in accordance with
  771  federal regulations, and which meets the requirements of a
  772  provider service network as described in s. 409.912(1).
  773         (7) “Eligible plan” means a health insurer authorized under
  774  chapter 624, an exclusive provider organization authorized under
  775  chapter 627, a health maintenance organization authorized under
  776  chapter 641, or a provider service network authorized under s.
  777  409.912(1) or an accountable care organization authorized under
  778  federal law. For purposes of the managed medical assistance
  779  program, the term also includes the Children’s Medical Services
  780  Network authorized under chapter 391 and entities qualified
  781  under 42 C.F.R. part 422 as Medicare Advantage Preferred
  782  Provider Organizations, Medicare Advantage Provider-sponsored
  783  Organizations, Medicare Advantage Health Maintenance
  784  Organizations, Medicare Advantage Coordinated Care Plans, and
  785  Medicare Advantage Special Needs Plans, and the Program of All
  786  inclusive Care for the Elderly.
  787         (13) “Prepaid plan” means a managed care plan that is
  788  licensed or certified as a risk-bearing entity, or qualified
  789  pursuant to s. 409.912(1), in the state and is paid a
  790  prospective per-member, per-month payment by the agency.
  791         (14) “Provider service network” means an entity qualified
  792  pursuant to s. 409.912(1) of which a controlling interest is
  793  owned by a health care provider, or group of affiliated
  794  providers, or a public agency or entity that delivers health
  795  services. Health care providers include Florida-licensed health
  796  care professionals or licensed health care facilities, federally
  797  qualified health care centers, and home health care agencies.
  798         Section 14. For the purpose of incorporating the amendment
  799  made by this act to section 409.912, Florida Statutes, in a
  800  reference thereto, subsection (22) of section 641.19, Florida
  801  Statutes, is reenacted to read:
  802         641.19 Definitions.—As used in this part, the term:
  803         (22) “Provider service network” means a network authorized
  804  under s. 409.912(1), reimbursed on a prepaid basis, operated by
  805  a health care provider or group of affiliated health care
  806  providers, and which directly provides health care services
  807  under a Medicare, Medicaid, or Healthy Kids contract.
  808         Section 15. For the purpose of incorporating the amendments
  809  made by this act to section 409.981, Florida Statutes, in
  810  references thereto, paragraphs (h), (i), and (j) of subsection
  811  (3) and subsection (11) of section 430.2053, Florida Statutes,
  812  are reenacted to read:
  813         430.2053 Aging resource centers.—
  814         (3) The duties of an aging resource center are to:
  815         (h) Assist clients who request long-term care services in
  816  being evaluated for eligibility for enrollment in the Medicaid
  817  long-term care managed care program as eligible plans become
  818  available in each of the regions pursuant to s. 409.981(2).
  819         (i) Provide enrollment and coverage information to Medicaid
  820  managed long-term care enrollees as qualified plans become
  821  available in each of the regions pursuant to s. 409.981(2).
  822         (j) Assist Medicaid recipients enrolled in the Medicaid
  823  long-term care managed care program with informally resolving
  824  grievances with a managed care network and assist Medicaid
  825  recipients in accessing the managed care network’s formal
  826  grievance process as eligible plans become available in each of
  827  the regions defined in s. 409.981(2).
  828         (11) In an area in which the department has designated an
  829  area agency on aging as an aging resource center, the department
  830  and the agency shall not make payments for the services listed
  831  in subsection (9) and the Long-Term Care Community Diversion
  832  Project for such persons who were not screened and enrolled
  833  through the aging resource center. The department shall cease
  834  making payments for recipients in eligible plans as eligible
  835  plans become available in each of the regions defined in s.
  836  409.981(2).
  837         Section 16. The Agency for Health Care Administration shall
  838  amend existing Statewide Medicaid Managed Care contracts to
  839  implement the changes made by this act to sections 409.973,
  840  409.975, and 409.977, Florida Statutes. The agency shall
  841  implement the changes made by this act to sections 409.966,
  842  409.974, and 409.981, Florida Statutes, for the 2025 plan year.
  843         Section 17. This act shall take effect July 1, 2022.
  844  
  845  ================= T I T L E  A M E N D M E N T ================
  846  And the title is amended as follows:
  847         Delete lines 992 - 1091
  848  and insert:
  849         An act relating to the statewide Medicaid managed care
  850         program; amending s. 409.912, F.S.; requiring, rather
  851         than authorizing, that the reimbursement method for
  852         provider service networks be on a prepaid basis;
  853         deleting the authority to reimburse provider service
  854         networks on a fee-for-service basis; conforming
  855         provisions to changes made by the act; providing that
  856         provider service networks are subject to and exempt
  857         from certain requirements; providing construction;
  858         repealing s. 409.9124, F.S., relating to managed care
  859         reimbursement; amending s. 409.964, F.S.; deleting a
  860         requirement that the Agency for Health Care
  861         Administration provide the opportunity for public
  862         feedback on a certain waiver application; amending s.
  863         409.966, F.S.; revising requirements relating to the
  864         databook published by the agency consisting of
  865         Medicaid utilization and spending data; reallocating
  866         regions within the statewide managed care program;
  867         deleting a requirement that the agency negotiate plan
  868         rates or payments to guarantee a certain savings
  869         amount; deleting a requirement for the agency to award
  870         additional contracts to plans in specified regions for
  871         certain purposes; revising a limitation on when plans
  872         may begin serving Medicaid recipients to apply to any
  873         eligible plan that participates in an invitation to
  874         negotiate, rather than plans participating in certain
  875         regions; making technical changes; amending s.
  876         409.967, F.S.; deleting obsolete provisions; amending
  877         s. 409.968, F.S.; conforming provisions to changes
  878         made by the act; amending s. 409.973, F.S.; revising
  879         requirements for healthy behaviors programs
  880         established by plans; deleting an obsolete provision;
  881         amending s. 409.974, F.S.; requiring the agency to
  882         select plans for the managed medical assistance
  883         program through a single statewide procurement;
  884         authorizing the agency to award contracts to plans on
  885         a regional or statewide basis; specifying requirements
  886         for minimum numbers of plans which the agency must
  887         procure for each specified region; conforming
  888         provisions to changes made by the act; deleting
  889         procedures for plan procurements when no provider
  890         service networks submit bids; making technical
  891         changes; deleting a requirement for the agency to
  892         exercise a preference for certain plans; amending s.
  893         409.975, F.S.; providing that cancer hospitals meeting
  894         certain criteria are statewide essential providers;
  895         requiring payments to such hospitals to equal a
  896         certain rate; amending s. 409.977, F.S.; revising the
  897         circumstances for maintaining a recipient’s enrollment
  898         in a plan; deleting obsolete language; authorizing
  899         specialty plans to serve certain children who receive
  900         guardianship assistance payments under the
  901         Guardianship Assistance Program; amending s. 409.981,
  902         F.S.; requiring the agency to select plans for the
  903         long-term care managed medical assistance program
  904         through a single statewide procurement; authorizing
  905         the agency to award contracts to plans on a regional
  906         or statewide basis; specifying requirements for
  907         minimum numbers of plans which the agency must procure
  908         for each specified region; conforming provisions to
  909         changes made by the act; deleting procedures for plan
  910         procurements when no provider service networks submit
  911         bids; amending s. 409.8132, F.S.; conforming a cross
  912         reference; reenacting ss. 409.962(1), (7), (13), and
  913         (14) and 641.19(22) relating to definitions, to
  914         incorporate the amendments made by this act to s.
  915         409.912, F.S., in references thereto; reenacting s.
  916         430.2053(3)(h), (i), and (j) and (11), relating to
  917         aging resource centers, to incorporate the amendments
  918         made by this act to s. 409.981, F.S., in references
  919         thereto; requiring the agency to amend existing
  920         Statewide Medicaid Managed Care contracts to implement
  921         changes made by the act; requiring the agency to
  922         implement changes made by the act for a specified plan
  923         year; providing an effective date.