HB 7223

1	A bill to be entitled
2	An act relating to Medicaid managed care; creating pt. IV
3	of ch. 409, F.S.; creating s. 409.961, F.S.; providing for
4	statutory construction; providing applicability of
5	specified provisions throughout the part; providing
6	rulemaking authority for specified agencies; creating s.
7	409.962, F.S.; providing definitions; creating s. 409.963,
8	F.S.; designating the Agency for Health Care
9	Administration as the single state agency to administer
10	the Medicaid program; providing for specified agency
11	responsibilities; requiring client consent for release of
12	medical records; creating s. 409.964, F.S.; establishing
13	the Medicaid program as the statewide, integrated managed
14	care program for all covered services; authorizing the
15	agency to apply for and implement waivers; providing for
16	public notice and comment; creating s. 409.965, F.S.;
17	providing for mandatory enrollment; providing for
18	exemptions; creating s. 409.966, F.S.; providing
19	requirements for qualified plans that provide services in
20	the Medicaid managed care program; providing for a medical
21	home network to be designated as a qualified plan;
22	establishing provider service network requirements for
23	qualified plans; providing for qualified plan selection;
24	requiring the agency to use an invitation to negotiate;
25	requiring the agency to compile and publish certain
26	information; establishing regions for separate procurement
27	of plans; providing quality selection criteria for plan
28	selection; establishing quality selection criteria;
29	providing limitations on serving recipients during the
30	pendency of litigation; providing that a qualified plan
31	that participates in an invitation to negotiate in more
32	than one region may not serve Medicaid recipients until
33	all administrative challenges are finalized; creating s.
34	409.967, F.S.; providing for managed care plan
35	accountability; establishing contract terms; providing for
36	contract extension under certain circumstances;
37	establishing payments to noncontract providers;
38	establishing requirements for access; requiring plans to
39	establish and maintain an electronic database;
40	establishing requirements for the database; requiring
41	plans to provide encounter data; requiring the agency to
42	establish performance standards for plans; providing
43	program integrity requirements; establishing a grievance
44	resolution process; providing for penalties for early
45	termination of contracts or reduction in enrollment
46	levels; creating s. 409.968, F.S.; establishing managed
47	care plan payments; providing payment requirements for
48	provider service networks; creating s. 409.969, F.S.;
49	requiring enrollment in managed care plans by specified
50	Medicaid recipients; creating requirements for plan
51	selection by recipients; providing for choice counseling;
52	establishing choice counseling requirements; authorizing
53	disenrollment under certain circumstances; defining the
54	term "good cause" for purposes of disenrollment; providing
55	time limits on an internal grievance process; providing
56	requirements for agency determination regarding
57	disenrollment; requiring recipients to stay in plans for a
58	specified time; creating s. 409.970, F.S.; requiring the
59	agency to maintain an encounter data system; providing
60	requirements for prepaid plans to submit data; creating s.
61	409.971, F.S.; creating the managed medical assistance
62	program; providing deadlines to begin and finalize
63	implementation of the program; creating s. 409.972, F.S.;
64	providing for mandatory and voluntary enrollment; creating
65	s. 409.973, F.S.; establishing minimum benefits for
66	managed care plans to cover; authorizing plans to
67	customize benefit packages; requiring plans to establish
68	enhanced benefits programs; providing terms for enhanced
69	benefits package; establishing reserve requirements for
70	plans to fund enhanced benefits programs; creating s.
71	409.974, F.S.; establishing a specified number of
72	qualified plans to be selected in each region;
73	establishing a deadline for issuing invitations to
74	negotiate; establishing quality selection criteria;
75	establishing the Children's Medical Service Network as a
76	qualified plan; creating s. 409.975; establishing managed
77	care plan accountability; creating a medical loss ratio
78	requirement; authorizing plans to limit providers in
79	networks; mandating certain providers be offered contracts
80	in the first year; requiring certain provider types to
81	participate in plans; requiring plans to monitor the
82	quality and performance history of providers; requiring
83	specified programs and procedures be established by plans;
84	establishing provider payments for hospitals; establishing
85	conflict resolution procedures; establishing the Medicaid
86	Resolution Board for specified purposes; establishing plan
87	requirements for medically needy recipients; creating s.
88	409.976, F.S.; providing for managed care plan payment;
89	requiring the agency to establish a methodology to ensure
90	certain types of payments to specified providers;
91	establishing eligibility for payments; creating s.
92	409.977, F.S.; providing for enrollment; establishing
93	choice counseling requirements; providing for automatic
94	enrollment of certain recipients; establishing opt-out
95	opportunities for recipients; creating s. 409.978, F.S.;
96	requiring the Agency for Health Care Administration be
97	responsible for administering the long-term care managed
98	care program; providing implementation dates for the long-
99	term care managed care program; providing duties for the
100	Department of Elderly Affairs relating to assisting the
101	agency in implementing the program; creating s. 409.979,
102	F.S.; providing eligibility requirements for the long-term
103	care managed care program; creating s. 409.980, F.S.;
104	providing the benefits that a managed care plan shall
105	provide when participating in the long-term care managed
106	care program; creating s. 409.981, F.S.; providing
107	criteria for qualified plans; designating regions for plan
108	implementation throughout the state; providing criteria
109	for the selection of plans to participate in the long-term
110	care managed care program; creating s. 409.982, F.S.;
111	providing the agency shall establish a uniform accounting
112	and reporting methods for plans; providing spending
113	thresholds and consequences relating to spending
114	thresholds; providing for mandatory participation in plans
115	of certain service providers; providing providers can be
116	excluded from plans for failure to meet quality or
117	performance criteria; providing the plans must monitor
118	participating providers using specified criteria;
119	providing certain providers that must be included in plan
120	networks; providing provider payment specifications for
121	nursing homes and hospices; creating s. 409.983, F.S.;
122	providing for negotiation of rates between the agency and
123	the plans participating in the long-term care managed care
124	program; providing specific criteria for calculating and
125	adjusting plan payments; allowing the CARES program to
126	assign plan enrollees to a level of care ; providing
127	incentives for adjustments of payment rates; providing the
128	agency shall establish nursing facility-specific and
129	hospice services payment rates; creating s. 409.984, F.S.;
130	providing that prior to contracting with another vender,
131	the agency shall offer to contract with the aging resource
132	centers to provide choice counseling for the long-term
133	care managed care program; providing criteria for
134	automatic assignments of plan enrollees who fail to chose
135	a plan; creating s. 409.985, F.S.; providing that the
136	agency shall operate the Comprehensive Assessment and
137	Review for Long-Term Care Services program through an
138	interagency agreement with the Department of Elderly
139	Affairs; providing duties of the program; defining  the
140	term "nursing facility care"; creating s. 409.986, F.S.;
141	providing authority and agency duties related to long-term
142	care plans; creating s. 409.987, F.S.; providing
143	eligibility requirements for long-term care plans;
144	creating s. 409.988, F.S.; providing benefits for long-
145	term care plans; creating s. 409.989, F.S.; establishing
146	criteria for qualified plans; specifying minimum and
147	maximum number of plans and selection criteria; creating
148	s. 409.990, F.S.; providing requirements for managed care
149	plan accountability; specifying limitations on providers
150	in plan networks; providing for evaluation and payment of
151	network providers; creating s. 409.991, F.S.; providing
152	for payment of managed care plans; providing duties for
153	the Agency for Persons with Disabilities to assign plan
154	enrollees into a payment rate level of care; establishing
155	level of care criteria; providing payment requirements for
156	intensive behavior residential habilitation providers and
157	intermediate care facilities for the developmentally
158	disabled; creating s. 409.992, F.S.; providing
159	requirements for enrollment and choice counseling;
160	specifying enrollment exceptions for certain Medicaid
161	recipients; providing an effective date.
162
163	Be It Enacted by the Legislature of the State of Florida:
164
165	Section 1.  Sections 409.961 through 409.992, Florida
166	Statutes, are designated as part IV of chapter 409, Florida
167	Statutes, entitled "Medicaid Managed Care."
168	Section 2.  Section 409.961, Florida Statutes, is created
169	to read:
170	409.961  Statutory construction; applicability; rules.-It
171	is the intent of the Legislature that if any conflict exists
172	between the provisions contained in this part and provisions
173	contained in other parts of this chapter, the provisions
174	contained in this part shall control. The provisions of ss.
175	409.961-409.970 apply only to the Medicaid managed medical
176	assistance program, long-term care managed care program, and
177	managed long-term care for persons with developmental
178	disabilities program, as provided in this part. The agency shall
179	adopt any rules necessary to comply with or administer this part
180	and all rules necessary to comply with federal requirements. In
181	addition, the department shall adopt and accept the transfer of
182	any rules necessary to carry out the department's
183	responsibilities for receiving and processing Medicaid
184	applications and determining Medicaid eligibility and for
185	ensuring compliance with and administering this part, as those
186	rules relate to the department's responsibilities, and any other
187	provisions related to the department's responsibility for the
188	determination of Medicaid eligibility.
189	Section 3.  Section 409.962, Florida Statutes, is created
190	to read:
191	409.962  Definitions.-As used in this part, except as
192	otherwise specifically provided, the term:
193	(1)  "Agency" means the Agency for Health Care
194	Administration. The agency is the Medicaid agency for the state,
195	as provided under federal law.
196	(2)  "Benefit" means any benefit, assistance, aid,
197	obligation, promise, debt, liability, or the like, related to
198	any covered injury, illness, or necessary medical care, goods,
199	or services.
200	(3)  "Direct care management" means care management
201	activities that involve direct interaction between providers and
202	patients.
203	(4)  "Long-term care comprehensive plan" means a long-term
204	care plan that also provides the services described in s.
205	409.973.
206	(5)  "Long-term care plan" means a specialty plan that
207	provides institutional and home and community-based services.
208	(6)  "Long term care provider service network" means an
209	entity certified pursuant to s. 409.912(4)(d), of which a
210	controlling interest is owned by one or more licensed nursing
211	homes, assisted living facilities with 17 or more beds, home
212	health agencies, community care for the elderly lead agencies,
213	or hospices.
214	(7)  "Managed care plan" means a qualified plan under
215	contract with the agency to provide services in the Medicaid
216	program.
217	(8)  "Medicaid" means the medical assistance program
218	authorized by Title XIX of the Social Security Act, 42 U.S.C. s.
219	1396 et seq., and regulations thereunder, as administered in
220	this state by the agency.
221	(9)  "Medicaid recipient" or "recipient" means an
222	individual who the department or, for Supplemental Security
223	Income, the Social Security Administration determines is
224	eligible pursuant to federal and state law to receive medical
225	assistance and related services for which the agency may make
226	payments under the Medicaid program. For the purposes of
227	determining third-party liability, the term includes an
228	individual formerly determined to be eligible for Medicaid, an
229	individual who has received medical assistance under the
230	Medicaid program, or an individual on whose behalf Medicaid has
231	become obligated.
232	(10)  "Medical home network" means a qualified plan
233	designated by the agency as a medical home network in accordance
234	with the criteria established in s. 409.91207.
235	(11)  "Prepaid plan" means a qualified plan that is
236	licensed or certified as a risk-bearing entity in the state and
237	is paid a prospective per-member, per-month payment by the
238	agency.
239	(12)  "Provider service network" means an entity certified
240	pursuant to s. 409.912(4)(d) of which a controlling interest is
241	owned by a health care provider, or group of affiliated
242	providers, or a public agency or entity that delivers health
243	services. Health care providers include Florida-licensed health
244	care professionals or licensed health care facilities and
245	federally qualified health care centers.
246	(13)  "Qualified plan" means a health insurer authorized
247	under chapter 624, an exclusive provider organization authorized
248	under chapter 627, a health maintenance organization authorized
249	under chapter 641, or a provider service network authorized
250	under s. 409.912(4)(d) that is eligible to participate in the
251	statewide managed care program.
252	(14)  "Specialty plan" means a qualified plan that serves
253	Medicaid recipients who meet specified criteria based on age,
254	medical condition, or diagnosis.
255	Section 4.  Section 409.963, Florida Statutes, is created
256	to read:
257	409.963  Single state agency.-The Agency for Health Care
258	Administration is designated as the single state agency
259	authorized to manage, operate, and make payments for medical
260	assistance and related services under Title XIX of the Social
261	Security Act. Subject to any limitations or directions provided
262	for in the General Appropriations Act, these payments shall be
263	made only for services included in the program, only on behalf
264	of eligible individuals, and only to qualified providers in
265	accordance with federal requirements for Title XIX of the Social
266	Security Act and the provisions of state law. This program of
267	medical assistance is designated as the "Medicaid program." The
268	department is responsible for Medicaid eligibility
269	determinations, including, but not limited to, policy, rules,
270	and the agreement with the Social Security Administration for
271	Medicaid eligibility determinations for Supplemental Security
272	Income recipients, as well as the actual determination of
273	eligibility. As a condition of Medicaid eligibility, subject to
274	federal approval, the agency and the department shall ensure
275	that each Medicaid recipient consents to the release of her or
276	his medical records to the agency and the Medicaid Fraud Control
277	Unit of the Department of Legal Affairs.
278	Section 5.  Section 409.964, Florida Statutes is created to
279	read:
280	409.964  Managed care program; state plan; waivers.-The
281	Medicaid program is established as a statewide, integrated
282	managed care program for all covered services, including long-
283	term care services. The agency shall apply for and implement
284	state plan amendments or waivers of applicable federal laws and
285	regulations necessary to implement the program. Prior to seeking
286	a waiver, the agency shall provide public notice and the
287	opportunity for public comment and shall include public feedback
288	in the waiver application. The agency shall include the public
289	feedback in the application. The agency shall hold one public
290	meeting in each of the regions described in s. 409.966(2) and
291	the time period for public comment for each region shall end no
292	sooner than 30 days after the completion of the public meeting
293	in that region.
294	Section 6.  Section 409.965, Florida Statutes, is created
295	to read:
296	409.965  Mandatory enrollment.-All Medicaid recipients
297	shall receive covered services through the statewide managed
298	care program, except as provided by this part pursuant to an
299	approved federal waiver. The following Medicaid recipients are
300	exempt from participation in the statewide managed care program:
301	(1)  Women who are only eligible for family planning
302	services.
303	(2)  Women who are only eligible for breast and cervical
304	cancer services.
305	(3)  Persons who are eligible for emergency Medicaid for
306	aliens.
307	Section 7.  Section 409.966, Florida Statutes, is created
308	to read:
309	409.966  Qualified plans; selection.-
310	(1)  QUALIFIED PLANS.-Services in the Medicaid managed care
311	program shall be provided by qualified plans.
312	(a)  A qualified plan may request the agency to designate
313	the plan as a medical home network if it meets the criteria
314	established in s. 409.91207.
315	(b)  A provider service network must be capable of
316	providing all covered services to a mandatory Medicaid managed
317	care enrollee or may limit the provision of services to a
318	specific target population based on the age, chronic disease
319	state, or the medical condition of the enrollee to whom the
320	network will provide services. A specialty provider service
321	network must be capable of coordinating care and delivering or
322	arranging for the delivery of all covered services to the target
323	population. A provider service network may partner with an
324	insurer licensed under chapter 627 or a health maintenance
325	organization licensed under chapter 641 to meet the requirements
326	of a Medicaid contract.
327	(2)  QUALIFIED PLAN SELECTION.-The agency shall select a
328	limited number of qualified plans to participate in the Medicaid
329	program using invitations to negotiate in accordance with s.
330	287.057(3)(a). At least 30 days prior to issuing an invitation
331	to negotiate, the agency shall compile and publish a databook
332	consisting of a comprehensive set of utilization and spending
333	data for the 3 most recent contract years consistent with the
334	rate-setting periods for all Medicaid recipients by region or
335	county. The source of the data in the report shall include both
336	historic fee-for-service claims and validated data from the
337	Medicaid Encounter Data System. The report shall be made
338	available in electronic form and shall delineate utilization use
339	by age, gender, eligibility group, geographic area, and
340	aggregate clinical risk score. Separate and simultaneous
341	procurements shall be conducted in each of the following
342	regions:
343	(a)  Region I, which shall consist of Bay, Calhoun,
344	Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson,
345	Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla,
346	Walton, and Washington Counties.
347	(b)  Region II, which shall consist of Alachua, Baker,
348	Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler,
349	Gilchrist, Hamilton, Lafayette, Levy, Marion, Nassau, Putnam,
350	St. Johns, Suwannee, Union, and Volusia Counties.
351	(c)  Region III, which shall consist of Charlotte, DeSoto,
352	Hardee, Hernando, Highlands, Hillsborough, Lee, Manatee, Pasco,
353	Pinellas, Polk, and Sarasota Counties.
354	(d)  Region IV, which shall consist of Brevard, Indian
355	River, Lake, Orange, Osceola, Seminole, and Sumter Counties.
356	(e)  Region V, which shall consist of Broward, Glades,
357	Hendry, Martin, Okeechobee, Palm Beach, and St. Lucie Counties.
358	(f)  Region VI, which shall consist of Collier, Dade, and
359	Monroe Counties.
360	(3)  QUALITY SELECTION CRITERIA.-The invitation to
361	negotiate must specify the criteria and the relative weight of
362	the criteria that will be used for determining the acceptability
363	of the reply and guiding the selection of the organizations with
364	which the agency negotiates. In addition to criteria established
365	by the agency, the agency shall consider the following factors
366	in the selection of qualified plans:
367	(a)  Accreditation by the National Committee for Quality
368	Assurance or another nationally recognized accrediting body.
369	(b)  Experience serving similar populations, including the
370	organization's record in achieving specific quality standards
371	with similar populations.
372	(c)  Availability and accessibility of primary care and
373	specialty physicians in the provider network.
374	(d)  Establishment of community partnerships with providers
375	that create opportunities for reinvestment in community-based
376	services.
377	(e)  Organization commitment to quality improvement and
378	documentation of achievements in specific quality improvement
379	projects, including active involvement by organization
380	leadership.
381	(f)  Provision of additional benefits, particularly dental
382	care and disease management, and other enhanced-benefit
383	programs.
384	(g)  History of voluntary or involuntary withdrawal from
385	any state Medicaid program or program area.
386	(h)  Evidence that a qualified plan has written agreements
387	or signed contracts or has made substantial progress in
388	establishing relationships with providers prior to the plan
389	submitting a response. The agency shall evaluate and give
390	special weight to such evidence, and the evaluation shall be
391	based on the following factors:
392	1.  Contracts with primary and specialty physicians in
393	sufficient numbers to meet the specific standards established
394	pursuant to s. 409.967(2)(b).
395	2.  Specific arrangements that provide evidence that the
396	compensation offered is sufficient to retain primary and
397	specialty physicians in sufficient numbers to continue to comply
398	with the standards established pursuant to s. 409.967(2)
399	throughout the 5-year contract term.
400
401	After negotiations are conducted, the agency shall select the
402	qualified plans that are determined to be responsive and provide
403	the best value to the state. Preference shall be given to
404	organizations designated as medical home networks pursuant to s.
405	409.91207 or organizations with the greatest number of primary
406	care providers that are recognized as patient-centered medical
407	homes by the National Committee for Quality Assurance or
408	organizations with networks that reflect recruitment of minority
409	physicians and other minority providers.
410	(4)  ADMINISTRATIVE CHALLENGE.-Any qualified plan that
411	participates in an invitation to negotiate in more than one
412	region and is selected in at least one region may not begin
413	serving Medicaid recipients in any region for which it was
414	selected until all administrative challenges to procurements
415	required by this section to which the qualified plan is a party
416	have been finalized. For purposes of this subsection, an
417	administrative challenge is finalized if an order granting
418	voluntary dismissal with prejudice has been entered by any court
419	established under Article V of the State Constitution or by the
420	Division of Administrative Hearings, a final order has been
421	entered into by the agency and the deadline for appeal has
422	expired, a final order has been entered by the First District
423	Court of Appeal and the time to seek any available review by the
424	Florida Supreme Court has expired, or a final order has been
425	entered by the Florida Supreme Court and a warrant has been
426	issued.
427	Section 8.  Section 409.967, Florida Statutes, is created
428	to read:
429	409.967  Managed care plan accountability.-
430	(1)  The agency shall establish a 5-year contract with each
431	of the qualified plans selected through the procurement process
432	described in s. 409.966. A plan contract may not be renewed;
433	however, the agency may extend the terms of a plan contract to
434	cover any delays in transition to a new plan.
435	(2)  The agency shall establish such contract requirements
436	as are necessary for the operation of the statewide managed care
437	program. In addition to any other provisions the agency may deem
438	necessary, the contract shall require:
439	(a)  Emergency services.-Plans shall pay for services
440	required by ss. 395.1041 and 401.45 and rendered by a
441	noncontracted provider within 30 days after receipt of a
442	complete and correct claim. Plans must give providers of these
443	services a specific explanation for each claim denied for being
444	incomplete or incorrect. Payment shall be made at the rate the
445	agency would pay for such services from the same provider.
446	Claims from noncontracted providers shall be accepted by the
447	qualified plan for at least 1 year after the date the services
448	are provided.
449	(b)  Access.-The agency shall establish specific standards
450	for the number, type, and regional distribution of providers in
451	plan networks to ensure access to care. Each plan must maintain
452	a region-wide network of providers in sufficient numbers to meet
453	the access standards for specific medical services for all
454	recipients enrolled in the plan. Each plan shall establish and
455	maintain an accurate and complete electronic database of
456	contracted providers, including information about licensure or
457	registration, locations and hours of operation, specialty
458	credentials and other certifications, specific performance
459	indicators, and such other information as the agency deems
460	necessary. The database shall be available online to both the
461	agency and the public and shall have the capability to compare
462	the availability of providers to network adequacy standards and
463	to accept and display feedback from each provider's patients.
464	Each plan shall submit quarterly reports to the agency
465	identifying the number of enrollees assigned to each primary
466	care provider.
467	(c)  Encounter data.-Each prepaid plan must comply with the
468	agency's reporting requirements for the Medicaid Encounter Data
469	System. The agency shall develop methods and protocols for
470	ongoing analysis of the encounter data that adjusts for
471	differences in characteristics of plans' enrollees to allow
472	comparison of service utilization among plans and against
473	expected levels of use. The analysis shall be used to identify
474	possible cases of systemic under-utilization or denials of
475	claims and inappropriate service utilization such as higher than
476	expected emergency department encounters. The analysis shall
477	provide periodic feedback to the plans and enable the agency to
478	establish corrective action plans when necessary. One of the
479	primary focus areas for the analysis shall be the use of
480	prescription drugs.
481	(d)  Continuous improvement.-The agency shall establish
482	specific performance standards and expected milestones or
483	timelines for improving performance over the term of the
484	contract. Each plan shall establish an internal health care
485	quality improvement system, including enrollee satisfaction and
486	disenrollment surveys. The quality improvement system shall
487	include incentives and disincentives for network providers.
488	(e)  Program integrity.-Each plan shall establish program
489	integrity functions and activities to reduce the incidence of
490	fraud and abuse, including, at a minimum:
491	1.  A provider credentialing system and ongoing provider
492	monitoring;
493	2.  An effective prepayment and postpayment review process
494	including, but not limited to, data analysis, system editing,
495	and auditing of network providers;
496	3.  Procedures for reporting instances of fraud and abuse
497	pursuant to chapter 641;
498	4.  Administrative and management arrangements or
499	procedures, including a mandatory compliance plan, designed to
500	prevent fraud and abuse; and
501	5.  Designation of a program integrity compliance officer.
502	(f)  Grievance resolution.-Each plan shall establish and
503	the agency shall approve an internal process for reviewing and
504	responding to grievances from enrollees consistent with the
505	requirements of s. 641.511. Each plan shall submit quarterly
506	reports on the number, description, and outcome of grievances
507	filed by enrollees. The agency shall maintain a process for
508	provider service networks consistent with s. 408.7056.
509	(g)  Penalties.-Plans that reduce enrollment levels or
510	leave a region prior to the end of the contract term shall
511	reimburse the agency for the cost of enrollment changes and
512	other transition activities, including the cost of additional
513	choice counseling services. If more than one plan leaves a
514	region at the same time, costs shall be shared by the departing
515	plans proportionate to their enrollments. In addition to the
516	payment of costs, departing plans shall pay a per enrollee
517	penalty not to exceed 5 percent of 1 month's payment. Plans
518	shall provide the agency notice no less than 180 days prior to
519	withdrawing from a region.
520	(h)  Prompt payment.-For all electronically submitted
521	claims, a managed care plan shall:
522	1.  Within 24 hours after the beginning of the next
523	business day after receipt of the claim, provide electronic
524	acknowledgment of the receipt of the claim to the electronic
525	source submitting the claim;
526	2.  Within 20 days after receipt of the claim, pay the
527	claim or notify the provider or designee if a claim is denied or
528	contested. Notice of the organization's action on the claim and
529	payment of the claim is considered to be made on the date the
530	notice or payment was mailed or electronically transferred; and
531	3.  Within 90 days after receipt of the claim, pay or deny
532	the claim. Failure to pay or deny a claim within 120 days after
533	receipt of the claim creates an uncontestable obligation to pay
534	the claim.
535	(i)  Electronic claims.-Plans shall accept electronic
536	claims in compliance with federal standards.
537	(j)  Medical home development.-The managed care plan, if
538	not designated as a medical home network pursuant to s.
539	409.91207, must develop a plan to assist and to provide
540	incentives for its primary care providers to become recognized
541	as patient-centered medical homes by the National Committee for
542	Quality Assurance.
543	Section 9.  Section 409.968, Florida Statutes, is created
544	to read:
545	409.968  Managed care plan payment.-
546	(1)  Prepaid plans shall receive per-member, per-month
547	payments negotiated pursuant to the procurements described in s.
548	409.966. Payments shall be risk-adjusted rates based on
549	historical utilization and spending data, projected forward, and
550	adjusted to reflect the eligibility category, geographic area,
551	and the clinical risk profile of the recipients.
552	(2)  Beginning September 1, 2010, the agency shall update
553	the rate-setting methodology by initiating a transition to rates
554	based on statewide encounter data submitted by Medicaid managed
555	care plans pursuant to s. 409.970. Prior to this transition, the
556	agency shall conduct appropriate tests and establish specific
557	milestones in order to determine that the Medicaid Encounter
558	Data system consists of valid, complete, and sound data for a
559	sufficient period of time to provide a reliable basis for
560	establishing actuarially sound payment rates. The transition
561	shall be implemented within 3 years or less, and shall utilize
562	such other data sources as necessary and reliable to make
563	appropriate adjustments during the transition. The agency shall
564	establish a technical advisory panel to obtain input from the
565	prepaid plans regarding the incorporation of encounter data in
566	the rate setting process.
567	(3)  Provider service networks may be prepaid plans and
568	receive per-member, per-month payments negotiated pursuant to
569	the procurement process described in s. 409.966. Provider
570	service networks that choose not to be prepaid plans shall
571	receive fee-for-service rates with a shared savings settlement.
572	The fee-for-service option shall be available to a provider
573	service network only for the first 5 years of the plan's
574	operation in a given region or until the contract year that
575	begins on October 1, 2015, whichever is later. The agency shall
576	annually conduct cost reconciliations to determine the amount of
577	cost savings achieved by fee-for-service provider service
578	networks for the dates of service within the period being
579	reconciled. Only payments for covered services for dates of
580	service within the reconciliation period and paid within 6
581	months after the last date of service in the reconciliation
582	period shall be included. The agency shall perform the necessary
583	adjustments for the inclusion of incurred but not reported
584	claims within the reconciliation period for claims that could be
585	received and paid by the agency after the 6-month claims
586	processing time lag. The agency shall provide the results of the
587	reconciliations to the fee-for-service provider service networks
588	within 45 days after the end of the reconciliation period. The
589	fee-for-service provider service networks shall review and
590	provide written comments or a letter of concurrence to the
591	agency within 45 days after receipt of the reconciliation
592	results. This reconciliation shall be considered final.
593	Section 10.  Section 409.969, Florida Statutes, is created
594	to read:
595	409.969  Enrollment; choice counseling; automatic
596	assignment; disenrollment.-
597	(1)  ENROLLMENT.-All Medicaid recipients shall be enrolled
598	in a managed care plan unless specifically exempted in this
599	part. Each recipient shall have a choice of plans and may select
600	any available plan unless that plan is restricted by contract to
601	a specific population that does not include the recipient.
602	Medicaid recipients shall have 30 days in which to make a choice
603	of plans. All recipients shall be offered choice counseling
604	services in accordance with this section.
605	(2)  CHOICE COUNSELING.-The agency shall provide choice
606	counseling for Medicaid recipients. The agency may contract for
607	the provision of choice counseling. Any such contract shall be
608	for a period of 5 years. The agency may renew a contract for an
609	additional 5-year period; however, prior to renewal of the
610	contract the agency shall hold at least one public meeting in
611	each of the regions covered by the choice counseling vendor. The
612	agency may extend the term of the contract to cover any delays
613	in transition to a new contractor. Printed choice information
614	and choice counseling shall be offered in the native or
615	preferred language of the recipient, consistent with federal
616	requirements. The manner and method of choice counseling shall
617	be modified as necessary to assure culturally competent,
618	effective communication with people from diverse cultural
619	backgrounds. The agency shall maintain a record of the
620	recipients who receive such services, identifying the scope and
621	method of the services provided. The agency shall make available
622	clear and easily understandable choice information to Medicaid
623	recipients that includes:
624	(a)  An explanation that each recipient has the right to
625	choose a managed care plan at the time of enrollment in Medicaid
626	and again at regular intervals set by the agency, and that if a
627	recipient does not choose a plan, the agency will assign the
628	recipient to a plan according to the criteria specified in this
629	section.
630	(b)  A list and description of the benefits provided in
631	each plan.
632	(c)  An explanation of benefit limits.
633	(d)  A current list of providers participating in the
634	network, including location and contact information.
635	(e)  Plan performance data.
636	(3)  DISENROLLMENT; GRIEVANCES.-After a recipient has
637	enrolled in a managed care plan, the recipient shall have 90
638	days to voluntarily disenroll and select another plan. After 90
639	days, no further changes may be made except for good cause. Good
640	cause includes, but is not limited to, poor quality of care,
641	lack of access to necessary specialty services, an unreasonable
642	delay or denial of service, or fraudulent enrollment. The agency
643	must make a determination as to whether good cause exists. The
644	agency may require a recipient to use the plan's grievance
645	process prior to the agency's determination of good cause,
646	except in cases in which immediate risk of permanent damage to
647	the recipient's health is alleged.
648	(a)  The managed care plan internal grievance process, when
649	utilized, must be completed in time to permit the recipient to
650	disenroll by the first day of the second month after the month
651	the disenrollment request was made. If the result of the
652	grievance process is approval of an enrollee's request to
653	disenroll, the agency is not required to make a determination in
654	the case.
655	(b)  The agency must make a determination and take final
656	action on a recipient's request so that disenrollment occurs no
657	later than the first day of the second month after the month the
658	request was made. If the agency fails to act within the
659	specified timeframe, the recipient's request to disenroll is
660	deemed to be approved as of the date agency action was required.
661	Recipients who disagree with the agency's finding that good
662	cause does not exist for disenrollment shall be advised of their
663	right to pursue a Medicaid fair hearing to dispute the agency's
664	finding.
665	(c)  Medicaid recipients enrolled in a managed care plan
666	after the 90-day period shall remain in the plan for the
667	remainder of the 12-month period. After 12 months, the recipient
668	may select another plan. However, nothing shall prevent a
669	Medicaid recipient from changing primary care providers within
670	the plan during that period.
671	(d)  On the first day of the next month after receiving
672	notice from a recipient that the recipient has moved to another
673	region, the agency shall automatically disenroll the recipient
674	from the plan the recipient is currently enrolled in and treat
675	the recipient as if the recipient is a new Medicaid enrollee. At
676	that time, the recipient may choose another plan pursuant to the
677	enrollment process established in this section.
678	Section 11.  Section 409.970, Florida Statutes, is created
679	to read:
680	409.970  Encounter data.-The agency shall maintain and
681	operate the Medicaid Encounter Data System to collect, process,
682	store, and report on covered services provided to all Medicaid
683	recipients enrolled in prepaid plans. Prepaid plans shall submit
684	encounter data electronically in a format that complies with the
685	Health Insurance Portability and Accountability Act provisions
686	for electronic claims and in accordance with deadlines
687	established by the agency. Prepaid plans must certify that the
688	data reported is accurate and complete. The agency is
689	responsible for validating the data submitted by the plans. The
690	agency shall make encounter data available to those plans
691	accepting enrollees who are assigned to them from other plans
692	leaving a region.
693	Section 12.  Section 409.971, Florida Statutes, is created
694	to read:
695	409.971  Managed medical assistance program.-The agency
696	shall make payments for primary and acute medical assistance and
697	related services using a managed care model. By January 1, 2012,
698	the agency shall begin implementation of the statewide managed
699	medical assistance program, with full implementation in all
700	regions by October 1, 2013.
701	Section 13.  Section 409.972, Florida Statutes, is created
702	to read:
703	409.972  Mandatory and voluntary enrollment.-
704	(1)  Persons eligible for the program known as "medically
705	needy" pursuant to s. 409.904(2)(a) shall enroll in managed care
706	plans. Medically needy recipients shall meet the share of cost
707	by paying the plan premium, up to the share of cost amount,
708	contingent upon federal approval.
709	(2)  The following Medicaid-eligible persons are exempt
710	from mandatory managed care enrollment required by s. 409.965,
711	and may voluntarily choose to participate in the managed medical
712	assistance program:
713	(a)  Medicaid recipients who have other creditable health
714	care coverage, excluding Medicare.
715	(b)  Medicaid recipients residing in residential commitment
716	facilities operated through the Department of Juvenile Justice,
717	group care facilities operated by the Department of Children and
718	Families, and treatment facilities funded through the Substance
719	Abuse and Mental Health program of the Department of Children
720	and Families.
721	(c)  Persons eligible for refugee assistance.
722	(d)  Medicaid recipients who are residents of a
723	developmental disability center including Sunland Center in
724	Marianna and Tacachale in Gainesville.
725	(3)  Persons eligible for Medicaid but exempt from
726	mandatory participation who do not choose to enroll in managed
727	care shall be served in the Medicaid fee-for-service program as
728	provided in part III of this chapter.
729	Section 14.  Section 409.973, Florida Statutes, is created
730	to read:
731	409.973  Benefits.-
732	(1)  MINIMUM BENEFITS.-Managed care plans shall cover, at a
733	minimum, the following services:
734	(a)  Advanced registered nurse practitioner services.
735	(b)  Ambulatory surgical treatment center services.
736	(c)  Birthing center services.
737	(d)  Chiropractic services.
738	(e)  Dental services.
739	(f)  Early periodic screening diagnosis and treatment
740	services for recipients under age 21.
741	(g)  Emergency services.
742	(h)  Family planning services and supplies.
743	(i)  Healthy start services.
744	(j)  Hearing services.
745	(k)  Home health agency services.
746	(l)  Hospice services.
747	(m)  Hospital inpatient services.
748	(n)  Hospital outpatient services.
749	(o)  Laboratory and X-ray services.
750	(p)  Medical supplies, equipment, prostheses, and orthoses.
751	(q)  Mental health services.
752	(r)  Nursing care.
753	(s)  Optical services and supplies.
754	(t)  Optometrist services.
755	(u)  Physical, occupational, respiratory, and speech
756	therapy services.
757	(v)  Physician services.
758	(w)  Podiatric services.
759	(x)  Prescription drugs.
760	(y)  Renal dialysis services.
761	(z)  Respiratory equipment and supplies.
762	(aa)  Rural health clinic services.
763	(bb)  Substance abuse treatment services.
764	(cc)  Transportation to access covered services.
765	(2)  CUSTOMIZED BENEFITS.-Managed care plans may customize
766	benefit packages for nonpregnant adults, vary cost-sharing
767	provisions, and provide coverage for additional services. The
768	agency shall evaluate the proposed benefit packages to ensure
769	services are sufficient to meet the needs of the plans'
770	enrollees and to verify actuarial equivalence.
771	(3)  ENHANCED BENEFITS.-Each plan operating in the managed
772	medical assistance program shall establish an incentive program
773	that rewards specific healthy behaviors with credits in a
774	flexible spending account.
775	(a)  At the discretion of the recipient, credits shall be
776	used to purchase otherwise uncovered health and related services
777	during the entire period of, and for a maximum of 3 years after,
778	the recipient's Medicaid eligibility, whether or not the
779	recipient remains continuously enrolled in the plan in which the
780	credits were earned.
781	(b)  Enhanced benefits shall be structured to provide
782	greater incentives for those diseases linked with lifestyle and
783	conditions or behaviors associated with avoidable utilization of
784	high-cost services.
785	(c)  To fund these credits, each plan must maintain a
786	reserve account in an amount of up to 2 percent of the plan's
787	Medicaid premium revenue, or benchmark premium revenue in the
788	case of provider service networks, based on an actuarial
789	assessment of the value of the enhanced benefits program.
790	Section 15.  Section 409.974, Florida Statutes, is created
791	to read:
792	409.974  Qualified plans.-
793	(1)  QUALIFIED PLAN SELECTION.-The agency shall select
794	qualified plans through the procurement described in s. 409.966.
795	The agency shall notice invitations to negotiate no later than
796	January 1, 2012.
797	(a)  The agency shall procure three plans for Region I. At
798	least one plan shall be a provider service network, if any
799	provider service network submits a responsive bid.
800	(b)  The agency shall procure at least four and no more
801	than seven plans for Region II. At least one plan shall be a
802	provider service network, if any provider service network
803	submits a responsive bid.
804	(c)  The agency shall procure at least five plans and no
805	more than ten plans for Region III. At least two plans shall be
806	provider service networks, if any two provider service networks
807	submit a responsive bid.
808	(d)  The agency shall procure at least four plans and no
809	more than eight plans for Region IV. At least one plan shall be
810	a provider service network if any provider service network
811	submits a responsive bid.
812	(e)  The agency shall procure at least four plans and no
813	more than seven plans for Region V. At least one plan shall be a
814	provider service network, if any provider service network
815	submits a responsive bid.
816	(f)  The agency shall procure at least five plans and no
817	more than ten plans for Region VI. At least two plans shall be
818	provider service networks, if any two provider service networks
819	submit a responsive bid.
820	If no provider service network submits a responsive bid, the
821	agency shall procure no more than one less than the maximum
822	number of qualified plans permitted in that region. Within 12
823	months after the initial invitation to negotiate, the agency
824	shall attempt to procure a qualified plan that is a provider
825	service network. The agency shall notice another invitation to
826	negotiate only with provider service networks in such region
827	where no provider service network has been selected.
828	(2)  QUALITY SELECTION CRITERIA.-In addition to the
829	criteria established in s. 409.966, the agency shall consider
830	evidence that a qualified plan has written agreements or signed
831	contracts or has made substantial progress in establishing
832	relationships with providers prior to the plan submitting a
833	response. The agency shall evaluate and give special weight to
834	evidence of signed contracts with providers of critical services
835	pursuant to s. 409.975(3)(a)-(d). The agency shall also consider
836	whether the organization is a specialty plan. When all other
837	factors are equal, the agency shall consider whether the
838	organization has a contract to provide managed long-term care
839	services in the same region and shall exercise a preference for
840	such plans.
841	(3)  CHILDREN'S MEDICAL SERVICES NETWORK.-The Children's
842	Medical Services Network authorized under chapter 391 is a
843	qualified plan for purposes of the managed medical assistance
844	program. Participation by the Children's Medical Services
845	Network shall be pursuant to a single, statewide contract with
846	the agency that is not subject to the procurement requirements
847	or regional plan number limits of this section. The Children's
848	Medical Services Network must meet all other plan requirements
849	for the managed medical assistance program.
850	Section 16.  Section 409.975, Florida Statutes, is created
851	to read:
852	409.975  Managed care plan accountability.-In addition to
853	the requirements of s. 409.967, plans and providers
854	participating in the managed medical assistance program shall
855	comply with the requirements of this section.
856	(1)  MEDICAL LOSS RATIO.-The agency shall establish and
857	implement managed care plans that shall use a uniform method of
858	accounting for and reporting medical, direct care management,
859	and nonmedical costs. The agency shall evaluate plan spending
860	patterns beginning after the plan completes 2 full years of
861	operation and at least annually thereafter. The agency shall
862	implement the following thresholds and consequences of various
863	spending patterns:
864	(a)  Plans that spend less than 75 percent of Medicaid
865	premium revenue on medical services and direct care management
866	as determined by the agency shall be excluded from automatic
867	enrollments and shall be required to pay back the amount between
868	actual spending and 85 percent of the Medicaid premium revenue.
869	(b)  Plans that spend less than 85 percent of Medicaid
870	premium revenue on medical services and direct care management
871	as determined by the agency shall be required to pay back the
872	amount between actual spending and 85 percent of the Medicaid
873	premium revenue.
874	(c)  Plans that spend more than 92 percent of Medicaid
875	premium revenue shall be evaluated by the agency to determine
876	whether higher expenditures are the result of failures in care
877	management.
878	(d)  Plans that spend 95 percent or more of Medicaid
879	premium revenue and are determined to be failing to
880	appropriately manage care shall be excluded from automatic
881	enrollments.
882	(2)  PROVIDER NETWORKS.-Plans may limit the providers in
883	their networks based on credentials, quality indicators, and
884	price. However, in the first contract period after a qualified
885	plan is selected in a region by the agency, the plan must offer
886	a network contract to the following providers in the region:
887	(a)  Federally qualified health centers.
888	(b)  Primary care providers certified as medical homes.
889	(c)  Providers listed in paragraphs (3)(a)-(d).
890
891	After 12 months of active participation in a plan's network, the
892	plan may exclude any of the above-named providers from the
893	network for failure to meet quality or performance criteria. If
894	the plan excludes a provider from the plan, the plan must
895	provide written notice to all recipients who have chosen that
896	provider for care. The notice shall be provided at least 30 days
897	prior to the effective date of the exclusion.
898	(3)  SELECT PROVIDER PARTICIPATION.-Providers may not be
899	required to participate in any qualified plan selected by the
900	agency except as provided in this subsection. The following
901	providers must agree to participate with each qualified plan
902	selected by the agency in the regions where they are located:
903	(a)  Statutory teaching hospitals as defined in s.
904	408.07(45).
905	(b)  Hospitals that are trauma centers as defined in s.
906	395.4001(14).
907	(c)  Hospitals that are regional perinatal intensive care
908	centers as defined in s. 383.16(2).
909	(d)  Hospitals licensed as specialty children's hospitals
910	as defined in s. 395.002(28).
911	(e)  Hospitals with both an active Medicaid provider
912	agreement under s. 409.907 and a certificate of need.
913
914	The hospitals described in paragraphs (a)-(d) shall make
915	adequate arrangements for medical staff sufficient to fulfill
916	their contractual obligations with the plans.
917	(4)  PERFORMANCE MEASUREMENT.-Each plan shall monitor the
918	quality and performance of each participating provider. At the
919	beginning of the contract period, each plan shall notify all its
920	network providers of the metrics used by the plan for evaluating
921	the provider's performance and determining continued
922	participation in the network.
923	(5)  PREGNANCY AND INFANT HEALTH.-Each plan shall establish
924	specific programs and procedures to improve pregnancy outcomes
925	and infant health, including, but not limited to, coordination
926	with the Healthy Start program, immunization programs, and
927	referral to the Special Supplemental Nutrition Program for
928	Women, Infants, and Children, and the Children's Medical
929	Services program for children with special health care needs.
930	(6)  SCREENING RATE.-Each plan shall achieve an annual
931	Early and Periodic Screening, Diagnosis, and Treatment Service
932	screening rate of at least 80 percent of those recipients
933	continuously enrolled for at least 8 months.
934	(7)  PROVIDER PAYMENT.-Plans and hospitals shall negotiate
935	mutually acceptable rates, methods, and terms of payment. At a
936	minimum, plans shall pay hospitals the Medicaid rate. Payments
937	to hospitals shall not exceed 150 percent of the rate the agency
938	would have paid on the first day of the contract between the
939	provider and the plan, unless specifically approved by the
940	agency. Payment rates may be updated periodically.
941	(8)  CONFLICT RESOLUTION.-In order to protect the continued
942	statewide operation of the Medicaid managed care program, the
943	Medicaid Resolution Board is established to resolve disputes
944	between managed care plans and hospitals and between managed
945	care plans and the medical staff of the providers listed in s.
946	409.975(3)(a)-(d). The board shall consist of two members
947	appointed by the Speaker of the House of Representatives, two
948	members appointed by the President of the Senate, and three
949	members appointed by the Governor. The costs of the board's
950	activities to review and resolve disputes shall be shared
951	equally by the parties to the dispute. Any managed care plan or
952	above-named provider may initiate a review by the board for any
953	conflict related to payment rates, contract terms, or other
954	conditions. The board shall make recommendations to the agency
955	regarding payment rates, procedures, or other contract terms to
956	resolve such conflicts. The agency may amend the terms of the
957	contracts with the parties to ensure compliance with these
958	recommendations. This process shall not be used to review and
959	reverse any managed care plan decision to exclude any provider
960	that fails to meet quality standards.
961	(9)  MEDICALLY NEEDY ENROLLEES.-Each selected plan shall
962	accept any medically needy recipient who selects or is assigned
963	to the plan and provide that recipient with continuous
964	enrollment for 12 months. After the first month of qualifying as
965	a medically needy recipient and enrolling in a plan, and
966	contingent upon federal approval, the enrollee shall pay the
967	plan a portion of the monthly premium equal to the enrollee's
968	share of the cost as determined by the department. The agency
969	shall pay the remainder of the monthly premium. Plans must
970	provide a grace period of at least 120 days before disenrolling
971	recipients who fail to pay their shares of the premium.
972	Section 17.  Section 409.976, Florida Statutes, is created
973	to read:
974	409.976  Managed care plan payment.-In addition to the
975	payment provisions of s. 409.968, the agency shall provide
976	payment to plans in the managed medical assistance program
977	pursuant to this section.
978	(1)  Prepaid payment rates shall be negotiated between the
979	agency and the qualified plans as part of the procurement
980	described in s. 409.966.
981	(2)  The agency shall develop a methodology to ensure the
982	availability of intergovernmental transfers in the statewide
983	integrated managed care program to support providers that have
984	historically served Medicaid recipients. Such providers include,
985	but are not limited to, safety net providers, trauma hospitals,
986	children's hospitals, statutory teaching hospitals, and medical
987	and osteopathic physicians employed by or under contract with a
988	medical school in this state. The agency may develop a
989	supplemental capitation rate, risk pool, or incentive payment to
990	plans that contract with these providers. A plan is eligible for
991	a supplemental payment only if there are sufficient
992	intergovernmental transfers available from allowable sources and
993	the plan can demonstrate that it pays a reimbursement rate not
994	less than the equivalent fee-for-service rate. The agency may
995	develop the supplemental capitation rate to consider rates
996	higher than the fee-for-service Medicaid rate when needed to
997	ensure access and supported by funds provided by a locality. The
998	agency shall evaluate the development of the rate cell to
999	accurately reflect the underlying utilization to the maximum
1000	extent possible. This methodology may include interim rate
1001	adjustments as permitted under federal regulations. Any such
1002	methodology shall preserve federal funding to these entities and
1003	must be actuarially sound. In the absence of federal approval
1004	for the above methodology, the agency is authorized to set an
1005	enhanced rate and require that plans pay the enhanced rate, if
1006	the agency determines the enhanced rate is necessary to ensure
1007	access to care by the providers described in this subsection.
1008	The amount paid to the plans to make supplemental payments or to
1009	enhance provider rates pursuant to this subsection shall be
1010	reconciled to the exact amounts the plans are required to pay to
1011	providers. The plans shall make the designated payments to
1012	providers within 15 business days of notification by the agency
1013	regarding provider-specific distributions.
1014	Section 18.  Section 409.977, Florida Statutes, is created
1015	to read:
1016	409.977  Choice counseling and enrollment.-
1017	(1)  CHOICE COUNSELING.-In addition to the choice
1018	counseling information required by s. 409.969, the agency shall
1019	make available clear and easily understandable choice
1020	information to Medicaid recipients that includes:
1021	(a)  Information about earning credits in the plan's
1022	enhanced benefit program.
1023	(b)  Information about cost sharing requirements of each
1024	plan.
1025	(2)  AUTOMATIC ENROLLMENT.-The agency shall automatically
1026	enroll into a managed care plan those Medicaid recipients who do
1027	not voluntarily choose a plan pursuant to s. 409.969. The agency
1028	shall automatically enroll recipients in plans that meet or
1029	exceed the performance or quality standards established pursuant
1030	to s. 409.967, and shall not automatically enroll recipients in
1031	a plan that is deficient in those performance or quality
1032	standards. When a specialty plan is available to accommodate a
1033	specific condition or diagnosis of a recipient, the agency shall
1034	assign the recipient to that plan. The agency may not engage in
1035	practices that are designed to favor one managed care plan over
1036	another. When automatically enrolling recipients in plans, the
1037	agency shall automatically enroll based on the following
1038	criteria:
1039	(a)  Whether the plan has sufficient network capacity to
1040	meet the needs of the recipients.
1041	(b)  Whether the recipient has previously received services
1042	from one of the plan's primary care providers.
1043	(c)  Whether primary care providers in one plan are more
1044	geographically accessible to the recipient's residence than
1045	those in other plans.
1046	(3)  OPT-OUT OPTION.-The agency shall develop a process to
1047	enable any recipient with access to employer-sponsored insurance
1048	to opt out of all qualified plans in the Medicaid program and to
1049	use Medicaid financial assistance to pay for the recipient's
1050	share of the cost in any such plan. Contingent upon federal
1051	approval, the agency shall also enable recipients with access to
1052	other insurance or related products providing access to health
1053	care services created pursuant to state law, including any
1054	product available under the Cover Florida Health Access Program,
1055	the Florida Health Choices Program, or any health exchange, to
1056	opt out. The amount of financial assistance provided for each
1057	recipient may not exceed the amount of the Medicaid premium that
1058	would have been paid to a plan for that recipient.
1059	Section 19.  Section 409.978, Florida Statutes, is created
1060	to read:
1061	409.978  Long-term care managed care program.-
1062	(1)  Pursuant to s. 409.963, the agency shall administer
1063	the long-term care managed care program described in ss.
1064	409.978-409.985, but may delegate specific duties and
1065	responsibilities for the program to the Department of Elderly
1066	Affairs and other state agencies. By July 1, 2011, the agency
1067	shall begin implementation of the statewide long-term care
1068	managed care program, with full implementation in all regions by
1069	October 1, 2012.
1070	(2)  The agency shall make payments for long-term care,
1071	including home and community-based services, using a managed
1072	care model. Unless otherwise specified, the provisions of ss.
1073	409.961-409.970 apply to the long-term care managed care
1074	program.
1075	(3)  The Department of Elderly Affairs shall assist the
1076	agency to develop specifications for use in the invitation to
1077	negotiate and the model contract; determine clinical eligibility
1078	for enrollment in managed long-term care plans; monitor plan
1079	performance and measure quality of service delivery; assist
1080	clients and families to address complaints with the plans;
1081	facilitate working relationships between plans and providers
1082	serving elders and disabled adults; and perform other functions
1083	specified in a memorandum of agreement.
1084	Section 20.  Section 409.979, Florida Statutes, is created
1085	to read:
1086	409.979  Eligibility.-
1087	(1)  Medicaid recipients who meet all of the following
1088	criteria are eligible to participate in the long-term care
1089	managed care program. The recipient must be:
1090	(a)  Sixty-five years of age or older or eligible for
1091	Medicaid by reason of a disability.
1092	(b)  Determined by the Comprehensive Assessment Review and
1093	Evaluation for Long-Term Care Services (CARES) Program to
1094	require nursing facility care.
1095	(2)  Medicaid recipients who on the date long-term care
1096	managed care plans becomes available in the recipient's region,
1097	are residing in a nursing home facility or enrolled in one of
1098	the following long-term care Medicaid waiver programs are
1099	eligible to participate in the long-term care managed care
1100	program:
1101	(a)  The Assisted Living for the Frail Elderly Waiver.
1102	(b)  The Aged and Disabled Adult Waiver.
1103	(c)  The Adult Day Health Care Waiver.
1104	(d)  The Consumer-Directed Care Plus Program as described
1105	in s. 409.221.
1106	(e)  The Program of All-inclusive Care for the Elderly.
1107	(f)  The Long-Term Care Community-Based Diversion Pilot
1108	Project as described in s. 430.705.
1109	(g)  The Channeling Services Waiver for Frail Elders.
1110	Section 21.  Section 409.980, Florida Statutes, is created
1111	to read:
1112	409.980  Benefits.-Managed care plans shall cover, at a
1113	minimum, the following services:
1114	(1)  Nursing facility.
1115	(2)  Assisted living facility.
1116	(3)  Hospice.
1117	(4)  Adult day care.
1118	(5)  Medical equipment and supplies, including incontinence
1119	supplies.
1120	(5)  Personal care.
1121	(7)  Home accessibility adaptation.
1122	(9)  Behavior management.
1123	(9)  Home delivered meals.
1124	(10)  Case management.
1125	(11)  Therapies:
1126	(a)  Occupational therapy
1127	(b)  Speech therapy
1128	(c)  Respiratory therapy
1129	(d)  Physical therapy.
1130	(12)  Intermittent and skilled nursing.
1131	(13)  Medication administration.
1132	(14)  Medication management.
1133	(15)  Nutritional assessment and risk reduction.
1134	(16)  Caregiver training.
1135	(17)  Respite care.
1136	(18)  Transportation.
1137	(19)  Personal emergency response system.
1138	Section 22.  Section 409.981, Florida Statutes, is created
1139	to read:
1140	409.981  Qualified plans.-
1141	(1)  QUALIFIED PLANS.-For purposes of the long-term care
1142	managed care program, qualified plans also include entities who
1143	are qualified under 42 C.F.R. part 422 as Medicare Advantage
1144	Preferred Provider Organizations, Medicare Advantage Provider-
1145	sponsored Organizations, and Medicare Advantage Special Needs
1146	Plans. Such plans are eligible to participate in the statewide
1147	long-term care managed care program. Qualified plans that are
1148	provider service networks must be long-term care provider
1149	service networks. Qualified plans may either be long-term care
1150	plans that cover benefits pursuant to s. 409.980, or
1151	comprehensive long-term care plans that cover benefits pursuant
1152	to ss. 409.973 and 409.980.
1153	(2) QUALIFIED PLAN SELECTION.-The agency shall select
1154	qualified plans through the procurement described in s. 409.966.
1155	The agency shall notice invitations to negotiate no later than
1156	July 1, 2011.
1157	(a)  The agency shall procure three plans for Region I. At
1158	least one plan shall be a provider service network, if any
1159	submit a responsive bid.
1160	(b)  The agency shall procure at least four and no more
1161	than seven plans for Region II. At least one plan shall be a
1162	provider service network, if any submit a responsive bid.
1163	(c)  The agency shall procure at least five plans and no
1164	more than ten plans for Region III. At least two plans shall be
1165	provider service networks, if any two submit a responsive bid.
1166	(d)  The agency shall procure at least four plans and no
1167	more than eight plans for Region IV. At least one plan shall be
1168	a provider service network if any submit a responsive bid.
1169	(e)  The agency shall procure at least four plans and no
1170	more than seven plans for Region V. At least one plan shall be a
1171	provider service network, if any submit a responsive bid.
1172	(f)  The agency shall procure at least five plans and no
1173	more than ten plans for Region VI. At least two plans shall be
1174	provider service networks, if any two submit a responsive bid.
1175	If no provider service network submits a responsive bid, the
1176	agency shall procure one less qualified plan in each of the
1177	regions. Within 12 months after the initial invitation to
1178	negotiate, the agency shall attempt to procure a qualified plan
1179	that is a provider service network. The agency shall notice
1180	another invitation to negotiate only with provider service
1181	networks in such region where no provider service network has
1182	been selected.
1183	(3) QUALITY SELECTION CRITERIA.-In addition to the criteria
1184	established in s. 409.966, the agency shall consider the
1185	following factors in the selection of qualified plans:
1186	(a)  Specialized staffing. Plan employment of executive
1187	managers with expertise and experience in serving aged and
1188	disabled persons who require long-term care.
1189	(b)  Network qualifications. Plan establishment of a
1190	network of service providers dispersed throughout the region and
1191	in sufficient numbers to meet specific service standards
1192	established by the agency for specialty services for persons
1193	receiving home and community-based care.
1194	(c)  Whether a plan is proposing to establish a
1195	comprehensive long-term care plan and whether the qualified plan
1196	has a contract to provide managed medical assistance services in
1197	the same region. The agency shall exercise a preference for such
1198	plans.
1199	(d)  Whether a plan is designated as a medical home network
1200	pursuant to s. 409.91207 or offers consumer-directed care
1201	services to enrollees pursuant to s. 409.221. Consumer-directed
1202	care services provide a flexible budget which is managed by
1203	enrolled individuals and their families or representatives and
1204	allows them to choose providers of services, determine provider
1205	rates of payment and direct the delivery of services to best
1206	meet their special long-term care needs. When all other factors
1207	are equal among competing qualified plans, the agency shall
1208	exercise a preference for such plans.
1209	(e)  Evidence that a qualified plan has written agreements
1210	or signed contracts or has made substantial progress in
1211	establishing relationships with providers prior to the plan
1212	submitting a response. The agency shall evaluate and give
1213	special weight to evidence of signed contracts with providers of
1214	critical services pursuant to s. 409.982(2)(a)-(c).
1215	(4)  PROGRAM FOR ALL-INCLUSIVE CARE FOR THE ELDERLY.-The
1216	Program for All-Inclusive Care for the Elderly (PACE) is a
1217	qualified plan for purposes of the long-term care managed care
1218	program. Participation by PACE shall be pursuant to a contract
1219	with the agency and not subject to the procurement requirements
1220	or regional plan number limits of this section. PACE plans may
1221	continue to provide services to individuals at such levels and
1222	enrollment caps as authorized by the General Appropriations Act.
1223	Section 23.  Section 409.982, Florida Statutes, is created
1224	to read:
1225	409.982  Managed care plan accountability.-In addition to
1226	the requirements of s. 409.967, plans and providers
1227	participating in the long-term care managed care program shall
1228	comply with the requirements of this section.
1229	(1)  MEDICAL LOSS RATIO.-The agency shall establish and
1230	plans shall use a uniform method of accounting and reporting
1231	long-term care service costs, direct care management costs, and
1232	administrative costs. The agency shall evaluate plan spending
1233	patterns beginning after the plan completes 2 full years of
1234	operation and at least annually thereafter. The agency shall
1235	implement the following thresholds and consequences of various
1236	spending patterns:
1237	(a)  Plans that spend less than 75 percent of Medicaid
1238	premium revenue on long-term care services, including direct
1239	care management as determined by the agency shall be excluded
1240	from automatic enrollments and shall be required to pay back the
1241	amount between actual spending and 85 percent of the Medicaid
1242	premium revenue.
1243	(b)  Plans that spend less than 85 percent of Medicaid
1244	premium revenue on long-term care services, including direct
1245	care management as determined by the agency shall be required to
1246	pay back the amount of the difference between actual spending
1247	and 85 percent of Medicaid premium revenue.
1248	(c)  Plans that spend more than 92 percent of Medicaid
1249	premium revenue on long-term care services, including direct
1250	care management as determined by the agency, shall be evaluated
1251	by the agency to determine whether higher expenditures are the
1252	result of failures in care management.
1253	(d)  Plans that spend 95 percent or more of Medicaid
1254	premium revenue on long-term care services, including direct
1255	care management as determined by the agency, and are determined
1256	to be failing to appropriately manage care shall be excluded
1257	from automatic enrollments.
1258	(2)  PROVIDER NETWORKS.-Plans may limit the providers in
1259	their networks based on credentials, quality indicators, and
1260	price. However, in the first contract period after a qualified
1261	plan is selected in a region by the agency, the plan must offer
1262	a network contract to the following providers in the region:
1263	(a)  Nursing homes.
1264	(b)  Hospices.
1265	(c)  Aging network service providers that have previously
1266	participated in home and community-based waivers serving elders
1267	or community-service programs administered by the Department of
1268	Elderly Affairs.
1269
1270	After 12 months of active participation in a plan's network, the
1271	plan may exclude any of the providers named in this subsection
1272	from the network for failure to meet quality or performance
1273	criteria.
1274	(3)  SELECT PROVIDER PARTICIPATION.-Except as provided in
1275	this subsection, providers may limit the plans they join.
1276	Nursing homes and hospices must participate in all qualified
1277	plans selected by the agency in the region in which the provider
1278	is located.
1279	(4) PERFORMANCE MEASUREMENT.-Each plan shall monitor the
1280	quality and performance of each participating provider. At the
1281	beginning of the contract period, each plan shall notify all its
1282	network providers of the metrics used by the plan for evaluating
1283	the provider's performance and determining continued
1284	participation in the network.
1285	(5)  PROVIDER NETWORK STANDARDS.-The agency shall establish
1286	and each plan must comply with specific standards for the
1287	number, type, and regional distribution of providers in the
1288	plan's network, which must include:
1289	(a)  Adult day centers.
1290	(b)  Adult family care homes.
1291	(c)  Assisted living facilities.
1292	(d)  Health care services pools.
1293	(e)  Home health agencies.
1294	(f)  Homemaker and companion services.
1295	(g)  Hospices.
1296	(h)  Community Care for the Elderly Lead Agencies.
1297	(i)  Nurse registries.
1298	(j)  Nursing homes.
1299	(6) PROVIDER PAYMENT.-Plans and providers shall negotiate
1300	mutually acceptable rates, methods, and terms of payment. Plans
1301	shall pay nursing homes an amount equal to the nursing facility-
1302	specific payment rates set by the agency. Plans shall pay
1303	hospice providers an amount equal to the per diem rate set by
1304	the agency. For recipients residing in a nursing facility and
1305	receiving hospice services, the plan shall pay the hospice
1306	provider the per diem rate set by the agency minus the nursing
1307	facility component and shall pay the nursing facility the
1308	appropriate state rate.
1309	Section 24.  Section 409.983, Florida Statutes, is created
1310	to read:
1311	409.983  Managed care plan payment.-In addition to the
1312	payment provisions of s. 409.968, the agency shall provide
1313	payment to plans in the long-term care managed care program
1314	pursuant to this section.
1315	(1)  Prepaid payment rates for long-term care managed care
1316	plans shall be negotiated between the agency and the qualified
1317	plans as part of the procurement described in s. 409.966.
1318	(2)  Payment rates for comprehensive long-term care plans
1319	covering services described in s. 409.973 shall be combined with
1320	rates for long-term care plans for services specified in s.
1321	409.980.
1322	(3)  Payment rates for plans shall reflect historic
1323	utilization and spending for covered services projected forward
1324	and adjusted to reflect the level of care profile for enrollees
1325	of each plan. The payment shall be adjusted to provide an
1326	incentive for reducing institutional placements and increasing
1327	the utilization of home and community-based services.
1328	(4)  The initial assessment of an enrollee's level of care
1329	shall be made by the Comprehensive Assessment and Review for
1330	Long-Term-Care Services (CARES) program, which shall assign the
1331	recipient into one of the following levels of care:
1332	(a)  Level of care 1 consists of recipients residing in
1333	nursing homes or needing immediate placement in a nursing home.
1334	(b)  Level of care 2 consists of recipients who require the
1335	constant availability of routine medical and nursing treatment
1336	and care, and require extensive health-related care and services
1337	because of mental or physical incapacitation.
1338	(c)  Level of care 3 consists of recipients who require the
1339	constant availability of routine medical and nursing treatment
1340	and care, have a limited need for health-related care and
1341	services, are mildly medically or physically incapacitated, and
1342	have a priority score of 5 or above.
1343
1344	The agency shall periodically adjust payment rates to account
1345	for changes in the level of care profile for each plan based on
1346	encounter data.
1347	(5)  The incentive adjustment for reducing institutional
1348	placements shall be modified in each successive rate period
1349	during the contract in order to encourage a progressive
1350	rebalancing of the spending distribution for institutional and
1351	community services. The expected change toward more home and
1352	community-based services shall be at least a 3 percent, up to a
1353	5 percent, annual increase in the ratio of home and community-
1354	based service expenditures compared to nursing facility
1355	expenditures.
1356	(6)  The agency shall establish nursing facility-specific
1357	payment rates for each licensed nursing home based on facility
1358	costs adjusted for inflation and other factors. Payments to
1359	long-term care managed care plans shall be reconciled to
1360	reimburse actual payments to nursing facilities.
1361	(7)  The agency shall establish hospice payment rates.
1362	Payments to long-term care managed care plans shall be
1363	reconciled to reimburse actual payments to hospices.
1364	Section 25.  Section 409.984, Florida Statutes, is created
1365	to read:
1366	409.984  Choice counseling; enrollment.-
1367	(1) CHOICE COUNSELING.-Before contracting with a vendor to
1368	provide choice counseling as authorized under s. 409.969, the
1369	agency shall offer to contract with aging resource centers
1370	established under s. 430.2053 for choice counseling services. If
1371	the aging resource center is determined not to be the vendor
1372	that provides choice counseling, the agency shall establish a
1373	memorandum of understanding with the aging resource center to
1374	coordinate staffing and collaborate with the choice counseling
1375	vendor.
1376	(2)  AUTOMATIC ENROLLMENT.-The agency shall automatically
1377	enroll into a long-term care managed care plan those Medicaid
1378	recipients who do not voluntarily choose a plan pursuant to s.
1379	409.969. The agency shall automatically enroll recipients in
1380	plans that meet or exceed the performance or quality standards
1381	established pursuant to s. 409.967, and shall not automatically
1382	enroll recipients in a plan that is deficient in those
1383	performance or quality standards. The agency shall assign
1384	individuals who are deemed dually eligible for Medicaid and
1385	Medicare to a plan that provides both Medicaid and Medicare
1386	services. The agency may not engage in practices that are
1387	designed to favor one managed care plan over another. When
1388	automatically enrolling recipients in plans, the agency shall
1389	take into account the following criteria:
1390	(a)  Whether the plan has sufficient network capacity to
1391	meet the needs of the recipients.
1392	(b)  Whether the recipient has previously received services
1393	from one of the plan's home and community-based service
1394	providers.
1395	(c)  Whether the home and community-based providers in one
1396	plan are more geographically accessible to the recipient's
1397	residence than those in other plans.
1398	(3)  Notwithstanding the provisions of s. 409.969(3)(c),
1399	when a recipient is referred for hospice services, the recipient
1400	shall have a 30-day period during which the recipient may select
1401	to enroll in another plan to access the hospice provider of the
1402	recipient's choice.
1403	Section 26.  Section 409.985, Florida Statutes, is created
1404	to read:
1405	409.985  Comprehensive Assessment and Review for Long-Term
1406	Care Services (CARES) Program.-
1407	(1)  The agency shall operate the Comprehensive Assessment
1408	and Review for Long-Term Care Services (CARES) preadmission
1409	screening program to ensure that only individuals whose
1410	conditions require long-term care services are enrolled in the
1411	long-term care managed care program.
1412	(2)  The agency shall operate the CARES program through an
1413	interagency agreement with the Department of Elderly Affairs.
1414	The agency, in consultation with the Department of Elderly
1415	Affairs, may contract for any function or activity of the CARES
1416	program, including any function or activity required by 42
1417	C.F.R. part 483.20, relating to preadmission screening and
1418	review.
1419	(3)  The CARES program shall determine if an individual
1420	requires nursing facility care and, if the individual requires
1421	such care, assign the individual to a level of care as described
1422	in s. 409.983(4). For the purposes of the long-term care managed
1423	care program, "nursing facility care" means the individual:
1424	(a)  Requires the constant availability of routine medical
1425	and nursing treatment and care, and requires extensive health-
1426	related care and services because of mental or physical
1427	incapacitation; or
1428	(b)  Requires the constant availability of routine medical
1429	and nursing treatment and care, has a limited need for health-
1430	related care and services, is mildly medically or physically
1431	incapacitated, and has a priority score of 5 or above.
1432	(4)  For individuals whose nursing home stay is initially
1433	funded by Medicare and Medicare coverage is being terminated for
1434	lack of progress towards rehabilitation, CARES staff shall
1435	consult with the person making the determination of progress
1436	toward rehabilitation to ensure that the recipient is not being
1437	inappropriately disqualified from Medicare coverage. If, in
1438	their professional judgment, CARES staff believes that a
1439	Medicare beneficiary is still making progress toward
1440	rehabilitation, they may assist the Medicare beneficiary with an
1441	appeal of the disqualification from Medicare coverage. The use
1442	of CARES teams to review Medicare denials for coverage under
1443	this section is authorized only if it is determined that such
1444	reviews qualify for federal matching funds through Medicaid. The
1445	agency shall seek or amend federal waivers as necessary to
1446	implement this section.
1447	Section 27.  Section 409.986, Florida Statutes, is created
1448	to read:
1449	409.986  Managed long-term care for persons with
1450	developmental disabilities.-
1451	(1)  Pursuant to s. 409.963, the agency is responsible for
1452	administering the long-term care managed care program for
1453	persons with developmental disabilities described in ss.
1454	409.986-409.992, but may delegate specific duties and
1455	responsibilities for the program to the Agency for Persons with
1456	Disabilities and other state agencies. By January 1, 2014, the
1457	agency shall begin implementation of statewide long-term care
1458	managed care for persons with developmental disabilities, with
1459	full implementation in all regions by October 1, 2015.
1460	(2)  The agency shall make payments for long-term care for
1461	persons with developmental disabilities, including home and
1462	community-based services, using a managed care model. Unless
1463	otherwise specified, the provisions of ss. 409.961-409.970 apply
1464	to the long-term care managed care program for persons with
1465	developmental disabilities.
1466	(3)  The Agency for Persons with Disabilities shall assist
1467	the agency to develop the specifications for use in the
1468	invitations to negotiate and the model contract; determine
1469	clinical eligibility for enrollment in long-term care plans for
1470	persons with developmental disabilities; assist the agency to
1471	monitor plan performance and measure quality; assist clients and
1472	families to address complaints with the plans; facilitate
1473	working relationships between plans and providers serving
1474	persons with developmental disabilities; and perform other
1475	functions specified in a memorandum of agreement.
1476	Section 28.  Section 409.987, Florida Statutes, is created
1477	to read:
1478	409.987  Eligibility.-
1479	(1)  Medicaid recipients who meet all of the following
1480	criteria are eligible to be enrolled in a developmental
1481	disabilities comprehensive long-term care plan or developmental
1482	disabilities long-term care plan:
1483	(a)  Medicaid eligible pursuant to income and asset tests
1484	in state and federal law.
1485	(b)  A Florida resident who has a developmental disability
1486	as defined in s. 393.063.
1487	(c)  Meets the level of care need including:
1488	1.  The recipient's intelligence quotient is 59 or less;
1489	2.  The recipient's intelligence quotient is 60-69,
1490	inclusive, and the recipient has a secondary handicapping
1491	condition that includes cerebral palsy, spina bifida, Prader-
1492	Willi syndrome, epilepsy, or autism; or ambulation, sensory,
1493	chronic health, and behavioral problems;
1494	3.  The recipient's intelligence quotient is 60-69,
1495	inclusive, and the recipient has severe functional limitations
1496	in at least three major life activities including self-care,
1497	learning, mobility, self-direction, understanding and use of
1498	language, and capacity for independent living; or
1499	4.  The recipient is eligible under a primary disability of
1500	autism, cerebral palsy, spina bifida, or Prader-Willi syndrome.
1501	In addition, the condition must result in substantial functional
1502	limitations in three or more major life activities, including
1503	self-care, learning, mobility, self-direction, understanding and
1504	use of language, and capacity for independent living.
1505	(d)  Meets the level of care need for services in an
1506	intermediate care facility for the developmentally disabled.
1507	(e)  Is enrolled or has been offered enrollment in one of
1508	the four tier waivers established in s. 393.0661(3) or the
1509	recipient is a Medicaid-funded resident of a private
1510	intermediate care facility for the developmentally disabled on
1511	the date the managed long-term care plans for persons with
1512	disabilities become available in the recipient's region or the
1513	recipient has been offered enrollment in a developmental
1514	disabilities comprehensive long-term care plan or developmental
1515	disabilities long-term care plan.
1516	(2)  Unless specifically exempted, all eligible persons
1517	must be enrolled in a developmental disabilities comprehensive
1518	long-term care plan or a developmental disabilities long-term
1519	care plan. Medicaid recipients who are residents of a
1520	developmental disability center, including Sunland Center in
1521	Marianna and Tacachale Center in Gainesville, are exempt from
1522	mandatory enrollment but may voluntarily enroll in a long-term
1523	care plan.
1524	Section 29.  Section 409.988, Florida Statutes, is created
1525	to read:
1526	409.988  Benefits.-Managed care plans shall cover, at a
1527	minimum, the services in this section. Plans may customize
1528	benefit packages or offer additional benefits to meet the needs
1529	of enrollees in the plan.
1530	(1)  Intermediate care for the developmentally disabled.
1531	(2)  Alternative residential services, including, but not
1532	limited to:
1533	(a)  Group homes and foster care homes licensed pursuant to
1534	chapters 393 and 409.
1535	(b)  Comprehensive transitional education programs licensed
1536	pursuant to chapter 393.
1537	(c)  Residential habilitation centers licensed pursuant to
1538	chapter 393.
1539	(d)  Assisted living facilities, and transitional living
1540	facilities licensed pursuant to chapters 400 and 429.
1541	(3)  Adult day training.
1542	(4)  Behavior analysis services.
1543	(5)  Companion services.
1544	(6)  Consumable medical supplies.
1545	(7)  Durable medical equipment and supplies.
1546	(8)  Environmental accessibility adaptations.
1547	(9)  In-home support services.
1548	(10)  Therapies, including occupational, speech,
1549	respiratory, and physical therapy.
1550	(11)  Personal care assistance.
1551	(12)  Residential habilitation services.
1552	(13)  Intensive behavioral residential habilitation
1553	services.
1554	(14)  Behavior focus residential habilitation services.
1555	(15)  Residential nursing services.
1556	(16)  Respite care.
1557	(17)  Case management.
1558	(18)  Supported employment.
1559	(19)  Supported living coaching.
1560	(20)  Transportation.
1561	Section 30.  Section 409.989, Florida Statutes, is created
1562	to read:
1563	409.989  Qualified plans.-
1564	(1)  QUALIFIED PLANS.-Qualified plans that are a provider
1565	service network or the Children's Medical Services Network
1566	authorized under chapter 391 may be either developmental
1567	disabilities long-term care plans that cover benefits pursuant
1568	to s. 409.988, or developmental disabilities comprehensive long-
1569	term care plans that cover benefits pursuant to ss. 409.973 and
1570	409.988. Other qualified plans may only be developmental
1571	disabilities comprehensive long-term care plans that cover
1572	benefits pursuant to ss. 409.973 and 409.988.
1573	(2)  SPECIALTY PROVIDER SERVICE NETWORKS.-Provider service
1574	networks targeted to serve persons with disabilities must
1575	include one or more owners licensed pursuant to s. 393.067 or s.
1576	400.962 and with at least 10 years experience in serving this
1577	population.
1578	(3)  QUALIFIED PLAN SELECTION.-The agency shall select
1579	qualified plans through the procurement described in s. 409.966.
1580	The agency shall notice invitations to negotiate no later than
1581	January 1, 2014.
1582	(a)  The agency shall procure two plans for Region I. At
1583	least one plan shall be a provider service network, if any
1584	submit a responsive bid.
1585	(b)  The agency shall procure at least two and no more than
1586	five plans for Region II. At least one plan shall be a provider
1587	service network, if any submit a responsive bid.
1588	(c)  The agency shall procure at least three plans and no
1589	more than six plans for Region III. At least one plan shall be a
1590	provider service network, if any submit a responsive bid.
1591	(d)  The agency shall procure at least three plans and no
1592	more than six plans for Region IV. At least one plan shall be a
1593	provider service network if any submit a responsive bid.
1594	(e)  The agency shall procure at least three plans and no
1595	more than six plans for Region V. At least one plan shall be a
1596	provider service network, if any submit a responsive bid.
1597	(f)  The agency shall procure at least three plans and no
1598	more than six plans for Region VI. At least one plan shall be a
1599	provider service network, if any submit a responsive bid.
1600	If no provider service network submits a responsive bid, the
1601	agency shall procure no more than one less than the maximum
1602	number of qualified plans permitted in that region. Within 12
1603	months after the initial invitation to negotiate, the agency
1604	shall attempt to procure a qualified plan that is a provider
1605	service network. The agency shall notice another invitation to
1606	negotiate only with provider service networks in such region
1607	where no provider service network has been selected.
1608	(4)  QUALITY SELECTION CRITERIA.-In addition to the
1609	criteria established in s. 409.966, the agency shall consider
1610	the following factors in the selection of qualified plans:
1611	(a)  Specialized staffing. Plan employment of executive
1612	managers with expertise and experience in serving persons with
1613	developmental disabilities.
1614	(b)  Network qualifications. Plan establishment of a
1615	network of service providers dispersed throughout the region and
1616	in sufficient numbers to meet specific accessibility standards
1617	established by the agency for specialty services for persons
1618	with developmental disabilities.
1619	(c)  Whether the plan has proposed to be a developmental
1620	disabilities comprehensive long-term care plan and has a
1621	contract to provide managed medical assistance services in the
1622	same region. The agency shall exercise a preference for such
1623	plans.
1624	(d)  Whether the plan offers consumer-directed care
1625	services to enrollees pursuant to s. 409.221. Consumer-directed
1626	care services provide a flexible budget which is managed by
1627	enrolled individuals and their families or representatives and
1628	allows them to choose providers of services, determine provider
1629	rates of payment and direct the delivery of services to best
1630	meet their special long-term care needs. When all other factors
1631	are equal among competing qualified plans, the agency shall
1632	exercise a preference for such plans.
1633	(e)  Evidence that a qualified plan has written agreements
1634	or signed contracts or has made substantial progress in
1635	establishing relationships with providers prior to the plan
1636	submitting a response. The agency shall evaluate and give
1637	special weight to evidence of signed contracts with providers of
1638	critical services pursuant to s. 409.990(2)a)-(b).
1639	(5)  CHILDREN'S MEDICAL SERVICES NETWORK.-The Children's
1640	Medical Services Network authorized under chapter 391 is a
1641	qualified plan for purposes of the developmental disabilities
1642	long-term care plans and developmental disabilities
1643	comprehensive long-term care plans. Participation by the
1644	Children's Medical Services Network shall be pursuant to a
1645	single, statewide contract with the agency not subject to the
1646	procurement requirements or regional plan number limits of this
1647	section. The Children's Medical Services Network must meet all
1648	other plan requirements.
1649	Section 31.  Section 409.990, Florida Statutes, is created
1650	to read:
1651	409.990  Managed care plan accountability.-In addition to
1652	the requirements of s. 409.967, qualified plans and providers
1653	shall comply with the requirements of this section.
1654	(1)  MEDICAL LOSS RATIO.-The agency shall establish and
1655	plans shall use a uniform method of accounting and reporting
1656	long-term care service costs, direct care management costs, and
1657	administrative costs. The agency shall evaluate plan spending
1658	patterns beginning after the plan completes 2 full years of
1659	operation and at least annually thereafter. The agency shall
1660	implement the following thresholds and consequences of various
1661	spending patterns:
1662	(a)  Plans that spend less than 75 percent of Medicaid
1663	premium revenue on long-term care services, including direct
1664	care management as determined by the agency shall be excluded
1665	from automatic enrollments and shall be required to pay back the
1666	amount between actual spending and 92 percent of the Medicaid
1667	premium revenue.
1668	(b)  Plans that spend less than 92 percent of Medicaid
1669	premium revenue on long-term care services, including direct
1670	care management as determined by the agency shall be required to
1671	pay back the amount between actual spending and 92 percent of
1672	the Medicaid premium revenue.
1673	(2)  PROVIDER NETWORKS.-Plans may limit the providers in
1674	their networks based on credentials, quality indicators, and
1675	price. However, in the first contract period after a qualified
1676	plan is selected in a region by the agency, the plan must offer
1677	a network contract to the following providers in the region:
1678	(a)  Providers with licensed institutional care facilities
1679	for the developmentally disabled.
1680	(b)  Providers of alternative residential facilities
1681	specified in s.409.988.
1682
1683	After 12 months of active participation in a plan's network, the
1684	plan may exclude any of the above-named providers from the
1685	network for failure to meet quality or performance criteria. If
1686	the plan excludes a provider from the plan, the plan must
1687	provide written notice to all recipients who have chosen that
1688	provider for care. The notice shall be issued at least 90 days
1689	before the effective date of the exclusion.
1690	(3)  SELECT PROVIDER PARTICIPATION.-Except as provided in
1691	this subsection, providers may limit the plans they join.
1692	Licensed institutional care facilities for the developmentally
1693	disabled with an active Medicaid provider agreement must agree
1694	to participate in any qualified plan selected by the agency in
1695	the region in which the provider is located.
1696	(4)  PERFORMANCE MEASUREMENT.-Each plan shall monitor the
1697	quality and performance of each participating provider. At the
1698	beginning of the contract period, each plan shall notify all its
1699	network providers of the metrics used by the plan for evaluating
1700	the provider's performance and determining continued
1701	participation in the network.
1702	(5)  PROVIDER PAYMENT.-Plans and providers shall negotiate
1703	mutually acceptable rates, methods, and terms of payment. Plans
1704	shall pay intermediate care facilities for the developmentally
1705	disabled an amount equal to the facility-specific payment rate
1706	set by the agency.
1707	(6)  CONSUMER AND FAMILY INVOLVEMENT.-Plans must establish
1708	a family advisory committee to participate in program design and
1709	oversight.
1710	Section 32.  Section 409.991, Florida Statutes, is created
1711	to read:
1712	409.991  Managed care plan payment.-In addition to the
1713	payment provisions of s. 409.968, the agency shall provide
1714	payment to developmental disabilities comprehensive long-term
1715	care plans and developmental disabilities long-term care plans
1716	pursuant to this section.
1717	(1)  Prepaid payment rates shall be negotiated between the
1718	agency and the qualified plans as part of the procurement
1719	described in s. 409.966.
1720	(2)  Payment for developmental disabilities comprehensive
1721	long-term care plans covering services pursuant to s. 409.973
1722	shall be combined with payments for developmental disabilities
1723	long-term care plans for services specified in s. 409.988.
1724	(3)  Payment rates for plans covering service specified in
1725	s. 409.988 shall be based on historical utilization and spending
1726	for covered services projected forward and adjusted to reflect
1727	the level of care profile of each plan's enrollees.
1728	(4)  The Agency for Persons with Disabilities shall conduct
1729	the initial assessment of an enrollee's level of care. The
1730	evaluation of level of care shall be based on assessment and
1731	service utilization information from the most recent version of
1732	the Questionnaire for Situational Information and encounter
1733	data.
1734	(5)  Payment rates for developmental disabilities long-term
1735	care plans shall be classified into five levels of care to
1736	account for variations in risk status and service needs among
1737	enrollees.
1738	(a)  Level of care 1 consists of individuals receiving
1739	services in an intermediate care facility for the
1740	developmentally disabled.
1741	(b)  Level of care 2 consists of individuals with intensive
1742	medical or adaptive needs and that are essential for avoiding
1743	institutionalization, or who possess behavioral problems that
1744	are exceptional in intensity, duration, or frequency and present
1745	a substantial risk of harm to themselves or others.
1746	(c)  Level of care 3 consists of individuals with service
1747	needs, including a licensed residential facility and a moderate
1748	level of support for standard residential habilitation services
1749	or a minimal level of support for behavior focus residential
1750	habilitation services, or individuals in supported living who
1751	require more than 6 hours a day of in-home support services.
1752	(d)  Level of care 4 consists of individuals requiring less
1753	than moderate level of residential habilitation support in a
1754	residential placement, or individuals in independent or
1755	supported living situations, or who live in their family home.
1756	(e)  Level of care 5 consists of individuals requiring
1757	minimal support services while living in independent or
1758	supported living situations and individuals who live in their
1759	family home.
1760
1761	The agency shall periodically adjust payment rates to account
1762	for changes in the level of care profile of each plan's
1763	enrollees based on encounter data.
1764	(6)  The agency shall establish intensive behavior
1765	residential habilitation rates for providers approved by the
1766	agency to provide this service. The agency shall also establish
1767	intermediate care facility for the developmentally disabled-
1768	specific payment rates for each licensed intermediate care
1769	facility based on facility costs adjusted for inflation and
1770	other factors. Payments to intermediate care facilities for the
1771	developmentally disabled and providers of intensive behavior
1772	residential habilitation service shall be reconciled to
1773	reimburse the plan's actual payments to the facilities.
1774	Section 33.  Section 409.992, Florida Statutes, is created
1775	to read:
1776	409.992  Automatic enrollment.-
1777	(1)  The agency shall automatically enroll into a
1778	developmental disabilities comprehensive long-term care plan or
1779	a developmental disabilities long-term care plan those Medicaid
1780	recipients who do not voluntarily choose a plan pursuant to s.
1781	409.969. The agency shall automatically enroll recipients in
1782	plans that meet or exceed the performance or quality standards
1783	established pursuant to s. 409.967, and shall not automatically
1784	enroll recipients in a plan that is deficient in those
1785	performance or quality standards. The agency shall assign
1786	individuals who are deemed dually eligible for Medicaid and
1787	Medicare, to a plan that provides both Medicaid and Medicare
1788	services. The agency may not engage in practices that are
1789	designed to favor one managed care plan over another. When
1790	automatically enrolling recipients in plans, the agency shall
1791	take into account the following criteria:
1792	(a)  Whether the plan has sufficient network capacity to
1793	meet the needs of the recipients.
1794	(b)  Whether the recipient has previously received services
1795	from one of the plan's home and community-based service
1796	providers.
1797	(c)  Whether home and community-based providers in one plan
1798	are more geographically accessible to the recipient's residence
1799	than those in other plans.
1800	Section 34.  This act shall take effect July 1, 2010.

CODING: Words stricken are deletions; words underlined are additions.