Florida Senate - 2011 SENATOR AMENDMENT Bill No. CS/HB 7107, 2nd Eng. Barcode 491664 LEGISLATIVE ACTION Senate . House . . . Floor: 1/AD/2R . Floor: C 05/05/2011 04:51 PM . 05/06/2011 07:15 PM ————————————————————————————————————————————————————————————————— ————————————————————————————————————————————————————————————————— Senator Negron moved the following: 1 Senate Amendment (with title amendment) 2 3 Delete everything after the enacting clause 4 and insert: 5 Section 1. Sections 409.961 through 409.985, Florida 6 Statutes, are designated as part IV of chapter 409, Florida 7 Statutes, entitled “Medicaid Managed Care.” 8 Section 2. Section 409.961, Florida Statutes, is created to 9 read: 10 409.961 Statutory construction; applicability; rules.—It is 11 the intent of the Legislature that if any conflict exists 12 between the provisions contained in this part and in other parts 13 of this chapter, the provisions in this part control. Sections 14 409.961–409.985 apply only to the Medicaid managed medical 15 assistance program and long-term care managed care program, as 16 provided in this part. The agency shall adopt any rules 17 necessary to comply with or administer this part and all rules 18 necessary to comply with federal requirements. In addition, the 19 department shall adopt and accept the transfer of any rules 20 necessary to carry out the department’s responsibilities for 21 receiving and processing Medicaid applications and determining 22 Medicaid eligibility and for ensuring compliance with and 23 administering this part, as those rules relate to the 24 department’s responsibilities, and any other provisions related 25 to the department’s responsibility for the determination of 26 Medicaid eligibility. 27 Section 3. Section 409.962, Florida Statutes, is created to 28 read: 29 409.962 Definitions.—As used in this part, except as 30 otherwise specifically provided, the term: 31 (1) “Accountable care organization” means an entity 32 qualified as an accountable care organization in accordance with 33 federal regulations, and which meets the requirements of a 34 provider service network as described in s. 409.912(4)(d). 35 (2) “Agency” means the Agency for Health Care 36 Administration. 37 (3) “Aging network service provider” means a provider that 38 participated in a home and community-based waiver administered 39 by the Department of Elderly Affairs or the community care 40 service system pursuant to s. 430.205 as of October 1, 2013. 41 (4) “Comprehensive long-term care plan” means a managed 42 care plan that provides services described in s. 409.973 and 43 also provides the services described in s. 409.98. 44 (5) “Department” means the Department of Children and 45 Family Services. 46 (6) “Eligible plan” means a health insurer authorized under 47 chapter 624, an exclusive provider organization authorized under 48 chapter 627, a health maintenance organization authorized under 49 chapter 641, or a provider service network authorized under s. 50 409.912(4)(d) or an accountable care organization authorized 51 under federal law. For purposes of the managed medical 52 assistance program, the term also includes the Children’s 53 Medical Services Network authorized under chapter 391. For 54 purposes of the long-term care managed care program, the term 55 also includes entities qualified under 42 C.F.R. part 422 as 56 Medicare Advantage Preferred Provider Organizations, Medicare 57 Advantage Provider-sponsored Organizations, and Medicare 58 Advantage Special Needs Plans, and the Program of All-Inclusive 59 Care for the Elderly. 60 (7) “Long-term care plan” means a managed care plan that 61 provides the services described in s. 409.98 for the long-term 62 care managed care program. 63 (8) “Long-term care provider service network” means a 64 provider service network a controlling interest of which is 65 owned by one or more licensed nursing homes, assisted living 66 facilities with 17 or more beds, home health agencies, community 67 care for the elderly lead agencies, or hospices. 68 (9) “Managed care plan” means an eligible plan under 69 contract with the agency to provide services in the Medicaid 70 program. 71 (10) “Medicaid” means the medical assistance program 72 authorized by Title XIX of the Social Security Act, 42 U.S.C. 73 ss. 1396 et seq., and regulations thereunder, as administered in 74 this state by the agency. 75 (11) “Medicaid recipient” or “recipient” means an 76 individual who the department or, for Supplemental Security 77 Income, the Social Security Administration determines is 78 eligible pursuant to federal and state law to receive medical 79 assistance and related services for which the agency may make 80 payments under the Medicaid program. For the purposes of 81 determining third-party liability, the term includes an 82 individual formerly determined to be eligible for Medicaid, an 83 individual who has received medical assistance under the 84 Medicaid program, or an individual on whose behalf Medicaid has 85 become obligated. 86 (12) “Prepaid plan” means a managed care plan that is 87 licensed or certified as a risk-bearing entity, or qualified 88 pursuant to s. 409.912(4)(d), in the state and is paid a 89 prospective per-member, per-month payment by the agency. 90 (13) “Provider service network” means an entity qualified 91 pursuant to s. 409.912(4)(d) of which a controlling interest is 92 owned by a health care provider, or group of affiliated 93 providers, or a public agency or entity that delivers health 94 services. Health care providers include Florida-licensed health 95 care professionals or licensed health care facilities, federally 96 qualified health care centers, and home health care agencies. 97 (15) “Specialty plan” means a managed care plan that serves 98 Medicaid recipients who meet specified criteria based on age, 99 medical condition, or diagnosis. 100 Section 4. Section 409.963, Florida Statutes, is created to 101 read: 102 409.963 Single state agency.—The agency is designated as 103 the single state agency authorized to manage, operate, and make 104 payments for medical assistance and related services under Title 105 XIX of the Social Security Act. Subject to any limitations or 106 directions provided in the General Appropriations Act, these 107 payments may be made only for services included in the program, 108 only on behalf of eligible individuals, and only to qualified 109 providers in accordance with federal requirements for Title XIX 110 of the Social Security Act and state law. This program of 111 medical assistance is designated as the “Medicaid program.” The 112 department is responsible for Medicaid eligibility 113 determinations, including, but not limited to, policy, rules, 114 and the agreement with the Social Security Administration for 115 Medicaid eligibility determinations for Supplemental Security 116 Income recipients, as well as the actual determination of 117 eligibility. As a condition of Medicaid eligibility, subject to 118 federal approval, the agency and the department shall ensure 119 that each Medicaid recipient consents to the release of her or 120 his medical records to the agency and the Medicaid Fraud Control 121 Unit of the Department of Legal Affairs. 122 Section 5. Section 409.964, Florida Statutes is created to 123 read: 124 409.964 Managed care program; state plan; waivers.—The 125 Medicaid program is established as a statewide, integrated 126 managed care program for all covered services, including long 127 term care services. The agency shall apply for and implement 128 state plan amendments or waivers of applicable federal laws and 129 regulations necessary to implement the program. Before seeking a 130 waiver, the agency shall provide public notice and the 131 opportunity for public comment and include public feedback in 132 the waiver application. The agency shall hold one public meeting 133 in each of the regions described in s. 409.966(2) and the time 134 period for public comment for each region shall end no sooner 135 than 30 days after the completion of the public meeting in that 136 region. The agency shall submit any state plan amendments, new 137 waiver requests, or requests for extensions or expansions for 138 existing waivers, needed to implement the managed care program 139 by August 1, 2011. 140 Section 6. Section 409.965, Florida Statutes, is created to 141 read: 142 409.965 Mandatory enrollment.—All Medicaid recipients shall 143 receive covered services through the statewide managed care 144 program, except as provided by this part pursuant to an approved 145 federal waiver. The following Medicaid recipients are exempt 146 from participation in the statewide managed care program: 147 (1) Women who are eligible only for family planning 148 services. 149 (2) Women who are eligible only for breast and cervical 150 cancer services. 151 (3) Persons who are eligible for emergency Medicaid for 152 aliens. 153 (4) Children receiving services in a prescribed pediatric 154 extended care center. 155 Section 7. Section 409.966, Florida Statutes, is created to 156 read: 157 409.966 Eligible plans; selection.— 158 (1) ELIGIBLE PLANS.—Services in the Medicaid managed care 159 program shall be provided by eligible plans. A provider service 160 network must be capable of providing all covered services to a 161 mandatory Medicaid managed care enrollee or may limit the 162 provision of services to a specific target population based on 163 the age, chronic disease state, or medical condition of the 164 enrollee to whom the network will provide services. A specialty 165 provider service network must be capable of coordinating care 166 and delivering or arranging for the delivery of all covered 167 services to the target population. A provider service network 168 may partner with an insurer licensed under chapter 627 or a 169 health maintenance organization licensed under chapter 641 to 170 meet the requirements of a Medicaid contract. 171 (2) ELIGIBLE PLAN SELECTION.—The agency shall select a 172 limited number of eligible plans to participate in the Medicaid 173 program using invitations to negotiate in accordance with s. 174 287.057(3)(a). At least 90 days before issuing an invitation to 175 negotiate, the agency shall compile and publish a databook 176 consisting of a comprehensive set of utilization and spending 177 data for the 3 most recent contract years consistent with the 178 rate-setting periods for all Medicaid recipients by region or 179 county. The source of the data in the report must include both 180 historic fee-for-service claims and validated data from the 181 Medicaid Encounter Data System. The report must be available in 182 electronic form and delineate utilization use by age, gender, 183 eligibility group, geographic area, and aggregate clinical risk 184 score. Separate and simultaneous procurements shall be conducted 185 in each of the following regions: 186 (a) Region 1, which consists of Escambia, Okaloosa, Santa 187 Rosa and Walton Counties. 188 (b) Region 2, which consists of Bay, Calhoun, Franklin, 189 Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, 190 Madison, Taylor, Wakulla, and Washington Counties. 191 (c) Region 3, which consists of Alachua, Bradford, Citrus, 192 Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, 193 Levy, Marion, Putnam, Sumter, Suwannee, and Union Counties. 194 (d) Region 4, which consists of Baker, Clay, Duval, 195 Flagler, Nassau, St. Johns, and Volusia Counties. 196 (e) Region 5, which consists of Pasco and Pinellas 197 Counties. 198 (f) Region 6, which consists of Hardee, Highlands, 199 Hillsborough, Manatee and Polk Counties. 200 (g) Region 7, which consists of Brevard, Orange, Osceola 201 and Seminole Counties. 202 (h) Region 8, which consists of Charlotte, Collier, DeSoto, 203 Glades, Hendry, Lee, and Sarasota Counties. 204 (i) Region 9, which consists of Indian River, Martin, 205 Okeechobee, Palm Beach and St. Lucie Counties. 206 (j) Region 10, which consists of Broward County. 207 (k) Region 11, which consists of Miami-Dade and Monroe 208 Counties. 209 (3) QUALITY SELECTION CRITERIA.— 210 (a) The invitation to negotiate must specify the criteria 211 and the relative weight of the criteria that will be used for 212 determining the acceptability of the reply and guiding the 213 selection of the organizations with which the agency negotiates. 214 In addition to criteria established by the agency, the agency 215 shall consider the following factors in the selection of 216 eligible plans: 217 1. Accreditation by the National Committee for Quality 218 Assurance, the Joint Commission, or another nationally 219 recognized accrediting body. 220 2. Experience serving similar populations, including the 221 organization’s record in achieving specific quality standards 222 with similar populations. 223 3. Availability and accessibility of primary care and 224 specialty physicians in the provider network. 225 4. Establishment of community partnerships with providers 226 that create opportunities for reinvestment in community-based 227 services. 228 5. Organization commitment to quality improvement and 229 documentation of achievements in specific quality improvement 230 projects, including active involvement by organization 231 leadership. 232 6. Provision of additional benefits, particularly dental 233 care and disease management, and other initiatives that improve 234 health outcomes. 235 7. Evidence that a eligible plan has written agreements or 236 signed contracts or has made substantial progress in 237 establishing relationships with providers before the plan 238 submitting a response. 239 8. Comments submitted in writing by any enrolled Medicaid 240 provider relating to a specifically identified plan 241 participating in the procurement in the same region as the 242 submitting provider. 243 9. Documentation of policies and procedures for preventing 244 fraud and abuse. 245 10. The business relationship an eligible plan has with any 246 other eligible plan that responds to the invitation to 247 negotiate. 248 (b) An eligible plan must disclose any business 249 relationship it has with any other elgible plan that responds to 250 the invitation to negotiate. The agency may not select plans in 251 the same region for the same managed care program that have a 252 business relationship with each other. Failure to disclose any 253 business relationship shall result in disqualification from 254 participation in any region for the first full contract period 255 after the discovery of the business relationship by the agency. 256 For the purpose of this section, “business relationship” means 257 an ownership or controlling interest, an affiliate or subsidiary 258 relationship, a common parent, or any mutual interest in any 259 limited partnership, limited liability partnership, limited 260 liability company, or other entity or business association, 261 including all wholly or partially owned subsidiaries, majority 262 owned subsidiaries, parent companies, or affiliates of such 263 entities, business associations, or other enterprises, that 264 exists for the purpose of making a profit. 265 (c) After negotiations are conducted, the agency shall 266 select the eligible plans that are determined to be responsive 267 and provide the best value to the state. Preference shall be 268 given to plans that: 269 1. Have signed contracts with primary and specialty 270 physicians in sufficient numbers to meet the specific standards 271 established pursuant to s. 409.967(2)(b). 272 2. Have well-defined programs for recognizing patient 273 centered medical homes and providing for increased compensation 274 for recognized medical homes, as defined by the plan. 275 3. Are organizations that are based in and perform 276 operational functions in this state, in-house or through 277 contractual arrangements, by staff located in this state. Using 278 a tiered approach, the highest number of points shall be awarded 279 to a plan that has all or substantially all of its operational 280 functions performed in the state. The second highest number of 281 points shall be awarded to a plan that has a majority of its 282 operational functions performed in the state. The agency may 283 establish a third tier; however, preference points may not be 284 awarded to plans that perform only community outreach, medical 285 director functions, and state administrative functions in the 286 state. For purposes of this subparagraph, operational functions 287 include claims processing, member services, provider relations, 288 utilization and prior authorization, case management, disease 289 and quality functions, and finance and administration. For 290 purposes of this subparagraph, the term “based in this state” 291 means that the entity’s principal office is in this state and 292 the plan is not a subsidiary, directly or indirectly through one 293 or more subsidiaries of, or a joint venture with, any other 294 entity whose principal office is not located in the state. 295 4. Have contracts or other arrangements for cancer disease 296 management programs that have a proven record of clinical 297 efficiencies and cost savings. 298 5. Have contracts or other arrangements for diabetes 299 disease management programs that have a proven record of 300 clinical efficiencies and cost savings. 301 6. Have a claims payment process that ensures that claims 302 that are not contested or denied will be promptly paid pursuant 303 to s. 641.3155. 304 (d) For the first year of the first contract term, the 305 agency shall negotiate capitation rates or fee for service 306 payments with each plan in order to guarantee aggregate savings 307 of at least 5 percent. 308 1. For prepaid plans, determination of the amount of 309 savings shall be calculated by comparison to the Medicaid rates 310 that the agency paid managed care plans for similar populations 311 in the same areas in the prior year. In regions containing no 312 prepaid plans in the prior year, determination of the amount of 313 savings shall be calculated by comparison to the Medicaid rates 314 established and certified for those regions in the prior year. 315 2. For provider service networks operating on a fee-for 316 service basis, determination of the amount of savings shall be 317 calculated by comparison to the Medicaid rates that the agency 318 paid on a fee-for-service basis for the same services in the 319 prior year. 320 (e) To ensure managed care plan participation in Regions 1 321 and 2, the agency shall award an additional contract to each 322 plan with a contract award in Region 1 or Region 2. Such 323 contract shall be in any other region in which the plan 324 submitted a responsive bid and negotiates a rate acceptable to 325 the agency. If a plan that is awarded an additional contract 326 pursuant to this paragraph is subject to penalties pursuant to 327 s. 409.967(2)(g) for activities in Region 1 or Region 2, the 328 additional contract is automatically terminated 180 days after 329 the imposition of the penalties. The plan must reimburse the 330 agency for the cost of enrollment changes and other transition 331 activities. 332 (f) The agency may not execute contracts with managed care 333 plans at payment rates not supported by the General 334 Appropriations Act. 335 (4) ADMINISTRATIVE CHALLENGE.—Any eligible plan that 336 participates in an invitation to negotiate in more than one 337 region and is selected in at least one region may not begin 338 serving Medicaid recipients in any region for which it was 339 selected until all administrative challenges to procurements 340 required by this section to which the eligible plan is a party 341 have been finalized. If the number of plans selected is less 342 than the maximum amount of plans permitted in the region, the 343 agency may contract with other selected plans in the region not 344 participating in the administrative challenge before resolution 345 of the administrative challenge. For purposes of this 346 subsection, an administrative challenge is finalized if an order 347 granting voluntary dismissal with prejudice has been entered by 348 any court established under Article V of the State Constitution 349 or by the Division of Administrative Hearings, a final order has 350 been entered into by the agency and the deadline for appeal has 351 expired, a final order has been entered by the First District 352 Court of Appeal and the time to seek any available review by the 353 Florida Supreme Court has expired, or a final order has been 354 entered by the Florida Supreme Court and a warrant has been 355 issued. 356 Section 8. Section 409.967, Florida Statutes, is created to 357 read: 358 409.967 Managed care plan accountability.— 359 (1) The agency shall establish a 5-year contract with each 360 managed care plan selected through the procurement process 361 described in s. 409.966. A plan contract may not be renewed; 362 however, the agency may extend the term of a plan contract to 363 cover any delays during the transition to a new plan. 364 (2) The agency shall establish such contract requirements 365 as are necessary for the operation of the statewide managed care 366 program. In addition to any other provisions the agency may deem 367 necessary, the contract must require: 368 (a) Physician compensation.—Managed care plans are expected 369 to coordinate care, manage chronic disease, and prevent the need 370 for more costly services. Effective care management should 371 enable plans to redirect available resources and increase 372 compensation for physicians. Plans achieve this performance 373 standard when physician payment rates equal or exceed Medicare 374 rates for similar services. The agency may impose fines or other 375 sanctions on a plan that fails to meet this performance standard 376 after 2 years of continuous operation. 377 (b) Emergency services.—Managed care plans shall pay for 378 services required by ss. 395.1041 and 401.45 and rendered by a 379 noncontracted provider. The plans must comply with s. 641.3155. 380 Reimbursement for services under this paragraph is the lesser 381 of: 382 1. The provider’s charges; 383 2. The usual and customary provider charges for similar 384 services in the community where the services were provided; 385 3. The charge mutually agreed to by the entity and the 386 provider within 60 days after submittal of the claim; or 387 4. The rate the agency would have paid on the most recent 388 October 1st. 389 (c) Access.— 390 1. The agency shall establish specific standards for the 391 number, type, and regional distribution of providers in managed 392 care plan networks to ensure access to care for both adults and 393 children. Each plan must maintain a region-wide network of 394 providers in sufficient numbers to meet the access standards for 395 specific medical services for all recipients enrolled in the 396 plan. The exclusive use of mail-order pharmacies may not be 397 sufficient to meet network access standards. Consistent with the 398 standards established by the agency, provider networks may 399 include providers located outside the region. A plan may 400 contract with a new hospital facility before the date the 401 hospital becomes operational if the hospital has commenced 402 construction, will be licensed and operational by January 1, 403 2013, and a final order has issued in any civil or 404 administrative challenge. Each plan shall establish and maintain 405 an accurate and complete electronic database of contracted 406 providers, including information about licensure or 407 registration, locations and hours of operation, specialty 408 credentials and other certifications, specific performance 409 indicators, and such other information as the agency deems 410 necessary. The database must be available online to both the 411 agency and the public and have the capability to compare the 412 availability of providers to network adequacy standards and to 413 accept and display feedback from each provider’s patients. Each 414 plan shall submit quarterly reports to the agency identifying 415 the number of enrollees assigned to each primary care provider. 416 2. Each managed care plan must publish any prescribed drug 417 formulary or preferred drug list on the plan’s website in a 418 manner that is accessible to and searchable by enrollees and 419 providers. The plan must update the list within 24 hours after 420 making a change. Each plan must ensure that the prior 421 authorization process for prescribed drugs is readily accessible 422 to health care providers, including posting appropriate contact 423 information on its website and providing timely responses to 424 providers. For Medicaid recipients diagnosed with hemophilia who 425 have been prescribed anti-hemophilic-factor replacement 426 products, the agency shall provide for those products and 427 hemophilia overlay services through the agency’s hemophilia 428 disease management program. 429 3. Managed care plans, and their fiscal agents or 430 intermediaries, must accept prior authorization requests for any 431 service electronically. 432 (d) Encounter data.—The agency shall maintain and operate a 433 Medicaid Encounter Data System to collect, process, store, and 434 report on covered services provided to all Medicaid recipients 435 enrolled in prepaid plans. 436 1. Each prepaid plan must comply with the agency’s 437 reporting requirements for the Medicaid Encounter Data System. 438 Prepaid plans must submit encounter data electronically in a 439 format that complies with the Health Insurance Portability and 440 Accountability Act provisions for electronic claims and in 441 accordance with deadlines established by the agency. Prepaid 442 plans must certify that the data reported is accurate and 443 complete. 444 2. The agency is responsible for validating the data 445 submitted by the plans. The agency shall develop methods and 446 protocols for ongoing analysis of the encounter data that 447 adjusts for differences in characteristics of prepaid plan 448 enrollees to allow comparison of service utilization among plans 449 and against expected levels of use. The analysis shall be used 450 to identify possible cases of systemic underutilization or 451 denials of claims and inappropriate service utilization such as 452 higher-than-expected emergency department encounters. The 453 analysis shall provide periodic feedback to the plans and enable 454 the agency to establish corrective action plans when necessary. 455 One of the focus areas for the analysis shall be the use of 456 prescription drugs. 457 3. The agency shall make encounter data available to those 458 plans accepting enrollees who are assigned to them from other 459 plans leaving a region. 460 (e) Continuous improvement.—The agency shall establish 461 specific performance standards and expected milestones or 462 timelines for improving performance over the term of the 463 contract. 464 1. Each managed care plan shall establish an internal 465 health care quality improvement system, including enrollee 466 satisfaction and disenrollment surveys. The quality improvement 467 system must include incentives and disincentives for network 468 providers. 469 2. Each plan must collect and report the Health Plan 470 Employer Data and Information Set (HEDIS) measures, as specified 471 by the agency. These measures must be published on the plan’s 472 website in a manner that allows recipients to reliably compare 473 the performance of plans. The agency shall use the HEDIS 474 measures as a tool to monitor plan performance. 475 3. Each managed care plan must be accredited by the 476 National Committee for Quality Assurance, the Joint Commission, 477 or another nationally recognized accrediting body, or have 478 initiated the accreditation process, within 1 year after the 479 contract is executed. For any plan not accredited within 18 480 months after executing the contract, the agency shall suspend 481 automatic assignment under s. 409.977 and 409.984. 482 4. By the end of the fourth year of the first contract 483 term, the agency shall issue a request for information to 484 determine whether cost savings could be achieved by contracting 485 for plan oversight and monitoring, including analysis of 486 encounter data, assessment of performance measures, and 487 compliance with other contractual requirements. 488 (f) Program integrity.—Each managed care plan shall 489 establish program integrity functions and activities to reduce 490 the incidence of fraud and abuse, including, at a minimum: 491 1. A provider credentialing system and ongoing provider 492 monitoring, including maintenance of written provider 493 credentialing policies and procedures which comply with federal 494 and agency guidelines; 495 2. An effective prepayment and postpayment review process 496 including, but not limited to, data analysis, system editing, 497 and auditing of network providers; 498 3. Procedures for reporting instances of fraud and abuse 499 pursuant to chapter 641; 500 4. Administrative and management arrangements or 501 procedures, including a mandatory compliance plan, designed to 502 prevent fraud and abuse; and 503 5. Designation of a program integrity compliance officer. 504 (g) Grievance resolution.—Consistent with federal law, each 505 managed care plan shall establish and the agency shall approve 506 an internal process for reviewing and responding to grievances 507 from enrollees. Each plan shall submit quarterly reports on the 508 number, description, and outcome of grievances filed by 509 enrollees. 510 (h) Penalties.— 511 1. Withdrawal and enrollment reduction.—Managed care plans 512 that reduce enrollment levels or leave a region before the end 513 of the contract term must reimburse the agency for the cost of 514 enrollment changes and other transition activities. If more than 515 one plan leaves a region at the same time, costs must be shared 516 by the departing plans proportionate to their enrollments. In 517 addition to the payment of costs, departing provider services 518 networks must pay a per enrollee penalty of up to 3 month’s 519 payment and continue to provide services to the enrollee for 90 520 days or until the enrollee is enrolled in another plan, 521 whichever occurs first. In addition to payment of costs, all 522 other plans must pay a penalty of 25 percent of the minimum 523 surplus requirement pursuant to s. 641.225(1). Plans shall 524 provide at least 180 days notice to the agency before 525 withdrawing from a region. If a managed care plan leaves a 526 region before the end of the contract term, the agency shall 527 terminate all contracts with that plan in other regions, 528 pursuant to the termination procedures in subparagraph 3. 529 2. Encounter data.—If a plan fails to comply with the 530 encounter data reporting requirements of this section for 30 531 days, the agency must assess a fine of $5,000 per day for each 532 day of noncompliance beginning on the 31st day. On the 31st day, 533 the agency must notify the plan that the agency will initiate 534 contract termination procedures on the 90th day unless the plan 535 comes into compliance before that date. 536 3. Termination.—If the agency terminates more than one 537 regional contract with the same managed care plan due to 538 noncompliance with the requirements of this section, the agency 539 shall terminate all the regional contracts held by that plan. 540 When terminating multiple contracts, the agency must develop a 541 plan to transition enrollees to other plans, and phase-in the 542 terminations over a time period sufficient to ensure a smooth 543 transition. 544 (i) Prompt payment.—Managed care plans shall comply with 545 ss. 641.315, 641.3155, and 641.513. 546 (j) Electronic claims.—Managed care plans, and their fiscal 547 agents or intermediaries, shall accept electronic claims in 548 compliance with federal standards. 549 (k) Fair payment.—Provider service networks must ensure 550 that no entity licensed under chapter 395 with a controlling 551 interest in the network charges a Medicaid managed care plan 552 more than the amount paid to that provider by the provider 553 service network for the same service. 554 (l) Itemized payment.—Any claims payment to a provider by a 555 managed care plan, or by a fiscal agent or intermediary of the 556 plan, must be accompanied by an itemized accounting of the 557 individual claims included in the payment including, but not 558 limited to, the enrollee’s name, the date of service, the 559 procedure code, the amount of reimbursement, and the 560 identification of the plan on whose behalf the payment is made. 561 (m) Provider dispute resolution.—Disputes between a plan 562 and a provider may be resolved as described in s. 408.7057. 563 (3) ACHIEVED SAVINGS REBATE.— 564 (a) The agency is responsible for verifying the achieved 565 savings rebate for all Medicaid prepaid plans. To assist the 566 agency, a prepaid plan shall: 567 1. Submit an annual financial audit conducted by an 568 independent certified public accountant in accordance with 569 generally accepted auditing standards to the agency on or before 570 June 1 for the preceding year; and 571 2. Submit an annual statement prepared in accordance with 572 statutory accounting principles on or before March 1 pursuant to 573 s. 624.424 if the plan is regulated by the Office of Insurance 574 Regulation. 575 (b) The agency shall contract with independent certified 576 public accountants to conduct compliance audits for the purpose 577 of auditing financial information, including but not limited to: 578 annual premium revenue, medical and administrative costs, and 579 income or losses reported by each prepaid plan, in order to 580 determine and validate the achieved savings rebate. 581 (c) Any audit required under this subsection must be 582 conducted by an independent certified public accountant who 583 meets criteria specified by rule. The rules must also provide 584 that: 585 1. The entity selected by the agency to conduct the audit 586 may not have a conflict of interest that might affect its 587 ability to perform its responsibilities with respect to an 588 examination. 589 2. The rates charged to the prepaid plan being audited are 590 consistent with rates charged by other certified public 591 accountants and are comparable with the rates charged for 592 comparable examinations. 593 3. Each prepaid plan audited shall pay to the agency the 594 expenses of the audit at the rates established by the agency by 595 rule. Such expenses include actual travel expenses, reasonable 596 living expense allowances, compensation of the certified public 597 accountant, and necessary attendant administrative costs of the 598 agency directly related to the examination. Travel expense and 599 living expense allowances are limited to those expenses incurred 600 on account of the audit and must be paid by the examined prepaid 601 plan together with compensation upon presentation by the agency 602 to the prepaid plan of a detailed account of the charges and 603 expenses after a detailed statement has been filed by the 604 auditor and approved by the agency. 605 4. All moneys collected from prepaid plans for such audits 606 shall be deposited into the Grants and Donations Trust Fund and 607 the agency may make deposits into such fund from moneys 608 appropriated for the operation of the agency. 609 (d) At a location in this state, the prepaid plan shall 610 make available to the agency and the agency’s contracted 611 certified public accountant all books, accounts, documents, 612 files, information, that relate to the prepaid plan’s Medicaid 613 transactions. Records not in the prepaid plan’s immediate 614 possession must be made available to the agency or the certified 615 public accountant in this state within 3 days after a request is 616 made by the agency or certified public accountant engaged by the 617 agency. A prepaid plan has an obligation to cooperate in good 618 faith with the agency and the certified public accountant. 619 Failure to comply to such record requests shall be deemed a 620 breach of contract. 621 (e) Once the certified public accountant completes the 622 audit, the certified public accountant shall submit an audit 623 report to the agency attesting to the achieved savings of the 624 plan. The results of the audit report are dispositive. 625 (f) Achieved savings rebates validated by the certified 626 public accountant are due within 30 days after the report is 627 submitted. Except as provided in paragraph (h), the achieved 628 savings rebate is established by determining pretax income as a 629 percentage of revenues and applying the following income sharing 630 ratios: 631 1. One hundred percent of income up to and including 5 632 percent of revenue shall be retained by the plan. 633 2. Fifty percent of income above 5 percent and up to 10 634 percent shall be retained by the plan, and the other 50 percent 635 refunded to the state. 636 3. One hundred percent of income above 10 percent of 637 revenue shall be refunded to the state. 638 (g) A plan that exceeds agency-defined quality measures in 639 the reporting period may retain an additional 1 percent of 640 revenue. For the purpose of this paragraph, the quality measures 641 must include plan performance for preventing or managing 642 complex, chronic conditions that are associated with an elevated 643 likelihood of requiring high-cost medical treatments. 644 (h) The following may not be included as allowable expenses 645 in calculating income for determining the achieved savings 646 rebate: 647 1. Payment of achieved savings rebates. 648 2. Any financial incentive payments made to the plan 649 outside of the capitation rate. 650 3. Any financial disincentive payments levied by the state 651 or federal governments. 652 4. Expenses associated with any lobbying or political 653 activities. 654 5. The cash value or equivalent cash value of bonuses of 655 any type paid or awarded to the plan’s executive staff, other 656 than base salary. 657 6. Reserves and reserve accounts. 658 7. Administrative costs, including, but not limited to, 659 reinsurance expenses, interest payments, depreciation expenses, 660 bad debt expenses, and outstanding claims expenses in excess of 661 actuarially sound maximum amounts set by the agency. 662 663 The agency shall consider these and other factors in developing 664 contracts that establish shared savings arrangements. 665 (i) Prepaid plans that incur a loss in the first contract 666 year may apply the full amount of the loss as an offset to 667 income in the second contract year. 668 (j) If, after an audit, the agency determines that a 669 prepaid plan owes an additional rebate, the plan has 30 days 670 after notification to make the payment. Upon failure to timely 671 pay the rebate, the agency shall withhold future payments to the 672 plan until the entire amount is recouped. If the agency 673 determines that a prepaid plan has made an overpayment, the 674 agency shall return the overpayment within 30 days. 675 Section 9. Section 409.968, Florida Statutes, is created to 676 read: 677 409.968 Managed care plan payments.— 678 (1) Prepaid plans shall receive per-member, per-month 679 payments negotiated pursuant to the procurements described in s. 680 409.966. Payments shall be risk-adjusted rates based on 681 historical utilization and spending data, projected forward, and 682 adjusted to reflect the eligibility category, geographic area, 683 and clinical risk profile of the recipients. In negotiating 684 rates with the plans, the agency shall consider any adjustments 685 necessary to encourage plans to use the most cost effective 686 modalities for treatment of chronic disease such as peritoneal 687 dialysis. 688 (2) Provider service networks may be prepaid plans and 689 receive per-member, per-month payments negotiated pursuant to 690 the procurement process described in s. 409.966. Provider 691 service networks that choose not to be prepaid plans shall 692 receive fee-for-service rates with a shared savings settlement. 693 The fee-for-service option shall be available to a provider 694 service network only for the first 2 years of its operation. The 695 agency shall annually conduct cost reconciliations to determine 696 the amount of cost savings achieved by fee-for-service provider 697 service networks for the dates of service within the period 698 being reconciled. Only payments for covered services for dates 699 of service within the reconciliation period and paid within 6 700 months after the last date of service in the reconciliation 701 period must be included. The agency shall perform the necessary 702 adjustments for the inclusion of claims incurred but not 703 reported within the reconciliation period for claims that could 704 be received and paid by the agency after the 6-month claims 705 processing time lag. The agency shall provide the results of the 706 reconciliations to the fee-for-service provider service networks 707 within 45 days after the end of the reconciliation period. The 708 fee-for-service provider service networks shall review and 709 provide written comments or a letter of concurrence to the 710 agency within 45 days after receipt of the reconciliation 711 results. This reconciliation is considered final. 712 (3) The agency may not approve any plan request for a rate 713 increase unless sufficient funds to support the increase have 714 been authorized in the General Appropriations Act. 715 Section 10. Section 409.969, Florida Statutes, is created 716 to read: 717 409.969 Enrollment; disenrollment.— 718 (1) ENROLLMENT.—All Medicaid recipients shall be enrolled 719 in a managed care plan unless specifically exempted under this 720 part. Each recipient shall have a choice of plans and may select 721 any available plan unless that plan is restricted by contract to 722 a specific population that does not include the recipient. 723 Medicaid recipients shall have 30 days in which to make a choice 724 of plans. 725 (2) DISENROLLMENT; GRIEVANCES.—After a recipient has 726 enrolled in a managed care plan, the recipient shall have 90 727 days to voluntarily disenroll and select another plan. After 90 728 days, no further changes may be made except for good cause. For 729 purposes of this section, the term “good cause” includes, but is 730 not limited to, poor quality of care, lack of access to 731 necessary specialty services, an unreasonable delay or denial of 732 service, or fraudulent enrollment. The agency must make a 733 determination as to whether good cause exists. The agency may 734 require a recipient to use the plan’s grievance process before 735 the agency’s determination of good cause, except in cases in 736 which immediate risk of permanent damage to the recipient’s 737 health is alleged. 738 (a) The managed care plan internal grievance process, when 739 used, must be completed in time to permit the recipient to 740 disenroll by the first day of the second month after the month 741 the disenrollment request was made. If the result of the 742 grievance process is approval of an enrollee’s request to 743 disenroll, the agency is not required to make a determination in 744 the case. 745 (b) The agency must make a determination and take final 746 action on a recipient’s request so that disenrollment occurs no 747 later than the first day of the second month after the month the 748 request was made. If the agency fails to act within the 749 specified timeframe, the recipient’s request to disenroll is 750 deemed to be approved as of the date agency action was required. 751 Recipients who disagree with the agency’s finding that good 752 cause does not exist for disenrollment shall be advised of their 753 right to pursue a Medicaid fair hearing to dispute the agency’s 754 finding. 755 (c) Medicaid recipients enrolled in a managed care plan 756 after the 90-day period shall remain in the plan for the 757 remainder of the 12-month period. After 12 months, the recipient 758 may select another plan. However, nothing shall prevent a 759 Medicaid recipient from changing providers within the plan 760 during that period. 761 (d) On the first day of the month after receiving notice 762 from a recipient that the recipient has moved to another region, 763 the agency shall automatically disenroll the recipient from the 764 managed care plan the recipient is currently enrolled in and 765 treat the recipient as if the recipient is a new Medicaid 766 enrollee. At that time, the recipient may choose another plan 767 pursuant to the enrollment process established in this section. 768 (e) The agency must monitor plan disenrollment throughout 769 the contract term to identify any discriminatory practices. 770 Section 11. Section 409.97, Florida Statutes, is created to 771 read: 772 409.97 State and local Medicaid partnerships.— 773 (1) INTERGOVERNMENTAL TRANSFERS.—In addition to the 774 contributions required pursuant to s. 409.915, beginning in the 775 2014-2015 fiscal year, the agency may accept voluntary transfers 776 of local taxes and other qualified revenue from counties, 777 municipalities, and special taxing districts. Such transfers 778 must be contributed to advance the general goals of the Florida 779 Medicaid program without restriction and must be executed 780 pursuant to a contract between the agency and the local funding 781 source. Contracts executed before October 31 shall result in 782 contributions to Medicaid for that same state fiscal year. 783 Contracts executed between November 1 and June 30 shall result 784 in contributions for the following state fiscal year. Based on 785 the date of the signed contracts, the agency shall allocate to 786 the low-income pool the first contributions received up to the 787 limit established by subsection (2). No more than 40 percent of 788 the low-income pool funding shall come from any single funding 789 source. Contributions in excess of the low-income pool shall be 790 allocated to the disproportionate share programs defined in ss. 791 409.911(3) and 409.9113 and to hospital rates pursuant to 792 subsection (4). The local funding source shall designate in the 793 contract which Medicaid providers ensure access to care for low 794 income and uninsured people within the applicable jurisdiction 795 and are eligible for low-income pool funding. Eligible providers 796 may include hospitals, primary care providers, and primary care 797 access systems. 798 (2) LOW-INCOME POOL.—The agency shall establish and 799 maintain a low-income pool in a manner authorized by federal 800 waiver. The low-income pool is created to compensate a network 801 of providers designated pursuant to subsection (1). Funding of 802 the low-income pool shall be limited to the maximum amount 803 permitted by federal waiver minus a percentage specified in the 804 General Appropriations Act. The low-income pool must be used to 805 support enhanced access to services by offsetting shortfalls in 806 Medicaid reimbursement, paying for otherwise uncompensated care, 807 and financing coverage for the uninsured. The low-income pool 808 shall be distributed in periodic payments to the Access to Care 809 Partnership throughout the fiscal year. Distribution of low 810 income pool funds by the Access to Care Partnership to 811 participating providers may be made through capitated payments, 812 fees for services, or contracts for specific deliverables. The 813 agency shall include the distribution amount for each provider 814 in the contract with the Access to Care Partnership pursuant to 815 subsection (3). Regardless of the method of distribution, 816 providers participating in the Access to Care Partnership shall 817 receive payments such that the aggregate benefit in the 818 jurisdiction of each local funding source, as defined in 819 subsection (1), equals the amount of the contribution plus a 820 factor specified in the General Appropriations Act. 821 (3) ACCESS TO CARE PARTNERSHIP.—The agency shall contract 822 with an administrative services organization that has operating 823 agreements with all health care facilities, programs, and 824 providers supported with local taxes or certified public 825 expenditures and designated pursuant to subsection (1). The 826 contract shall provide for enhanced access to care for Medicaid, 827 low-income, and uninsured Floridians. The partnership shall be 828 responsible for an ongoing program of activities that provides 829 needed, but uncovered or undercompensated, health services to 830 Medicaid enrollees and persons receiving charity care, as 831 defined in s. 409.911. Accountability for services rendered 832 under this contract must be based on the number of services 833 provided to unduplicated qualified beneficiaries, the total 834 units of service provided to these persons, and the 835 effectiveness of services provided as measured by specific 836 standards of care. The agency shall seek such plan amendments or 837 waivers as may be necessary to authorize the implementation of 838 the low-income pool as the Access to Care Partnership pursuant 839 to this section. 840 (4) HOSPITAL RATE DISTRIBUTION.— 841 (a) The agency is authorized to implement a tiered hospital 842 rate system to enhance Medicaid payments to all hospitals when 843 resources for the tiered rates are available from general 844 revenue and such contributions pursuant to subsection (1) as are 845 authorized under the General Appropriations Act. 846 1. Tier 1 hospitals are statutory rural hospitals as 847 defined in s. 395.602, statutory teaching hospitals as defined 848 in s. 408.07(45), and specialty children’s hospitals as defined 849 in s. 395.002(28). 850 2. Tier 2 hospitals are community hospitals not included in 851 Tier 1 that provided more than 9 percent of the hospital’s total 852 inpatient days to Medicaid patients and charity patients, as 853 defined in s. 409.911, and are located in the jurisdiction of a 854 local funding source pursuant to subsection (1). 855 3. Tier 3 hospitals include all community hospitals. 856 (b) When rates are increased pursuant to this section, the 857 Total Tier Allocation (TTA) shall be distributed as follows: 858 1. Tier 1 (T1A) = 0.35 x TTA. 859 2. Tier 2 (T2A) = 0.35 x TTA. 860 3. Tier 3 (T3A) = 0.30 x TTA. 861 (c) The tier allocation shall be distributed as a 862 percentage increase to the hospital specific base rate (HSBR) 863 established pursuant to s. 409.905(5)(c). The increase in each 864 tier shall be calculated according to the proportion of tier 865 specific allocation to the total estimated inpatient spending 866 (TEIS) for all hospitals in each tier: 867 1. Tier 1 percent increase (T1PI) = T1A/Tier 1 total 868 estimated inpatient spending (T1TEIS). 869 2. Tier 2 percent increase (T2PI) = T2A /Tier 2 total 870 estimated inpatient spending (T2TEIS). 871 3. Tier 3 percent increase (T3PI) = T3A/ Tier 3 total 872 estimated inpatient spending (T3TEIS). 873 (d) The hospital-specific tiered rate (HSTR) shall be 874 calculated as follows: 875 1. For hospitals in Tier 3: HSTR = (1 + T3PI) x HSBR. 876 2. For hospitals in Tier 2: HSTR = (1 + T2PI) x HSBR. 877 3. For hospitals in Tier 1: HSTR = (1 + T1PI) x HSBR. 878 Section 12. Section 409.971, Florida Statutes, is created 879 to read: 880 409.971 Managed medical assistance program.—The agency 881 shall make payments for primary and acute medical assistance and 882 related services using a managed care model. By January 1, 2013, 883 the agency shall begin implementation of the statewide managed 884 medical assistance program, with full implementation in all 885 regions by October 1, 2014. 886 Section 13. Section 409.972, Florida Statutes, is created 887 to read: 888 409.972 Mandatory and voluntary enrollment.— 889 (1) Persons eligible for the program known as “medically 890 needy” pursuant to s. 409.904(2)(a) shall enroll in managed care 891 plans. Medically needy recipients shall meet the share of the 892 cost by paying the plan premium, up to the share of the cost 893 amount, contingent upon federal approval. 894 (2) The following Medicaid-eligible persons are exempt from 895 mandatory managed care enrollment required by s. 409.965, and 896 may voluntarily choose to participate in the managed medical 897 assistance program: 898 (a) Medicaid recipients who have other creditable health 899 care coverage, excluding Medicare. 900 (b) Medicaid recipients residing in residential commitment 901 facilities operated through the Department of Juvenile Justice 902 or mental health treatment facilities as defined by s. 903 394.455(32). 904 (c) Persons eligible for refugee assistance. 905 (d) Medicaid recipients who are residents of a 906 developmental disability center, including Sunland Center in 907 Marianna and Tacachale in Gainesville. 908 (e) Medicaid recipients enrolled in the home and community 909 based services waiver pursuant to chapter 393, and Medicaid 910 recipients waiting for waiver services. 911 (3) Persons eligible for Medicaid but exempt from mandatory 912 participation who do not choose to enroll in managed care shall 913 be served in the Medicaid fee-for-service program as provided in 914 part III of this chapter. 915 (4) The agency shall seek federal approval to require 916 Medicaid recipients enrolled in managed care plans, as a 917 condition of Medicaid eligibility, to pay the Medicaid program a 918 share of the premium of $10 per month. 919 Section 14. Section 409.973, Florida Statutes, is created 920 to read: 921 409.973 Benefits.— 922 (1) MINIMUM BENEFITS.—Managed care plans shall cover, at a 923 minimum, the following services: 924 (a) Advanced registered nurse practitioner services. 925 (b) Ambulatory surgical treatment center services. 926 (c) Birthing center services. 927 (d) Chiropractic services. 928 (e) Dental services. 929 (f) Early periodic screening diagnosis and treatment 930 services for recipients under age 21. 931 (g) Emergency services. 932 (h) Family planning services and supplies. Pursuant to 42 933 C.F.R. s. 438.102, plans may elect to not provide these services 934 due to an objection on moral or religious grounds, and must 935 notify the agency of that election when submitting a reply to an 936 invitation to negotiate. 937 (i) Healthy start services, except as provided in s. 938 409.975(4). 939 (j) Hearing services. 940 (k) Home health agency services. 941 (l) Hospice services. 942 (m) Hospital inpatient services. 943 (n) Hospital outpatient services. 944 (o) Laboratory and imaging services. 945 (p) Medical supplies, equipment, prostheses, and orthoses. 946 (q) Mental health services. 947 (r) Nursing care. 948 (s) Optical services and supplies. 949 (t) Optometrist services. 950 (u) Physical, occupational, respiratory, and speech therapy 951 services. 952 (v) Physician services, including physician assistant 953 services. 954 (w) Podiatric services. 955 (x) Prescription drugs. 956 (y) Renal dialysis services. 957 (z) Respiratory equipment and supplies. 958 (aa) Rural health clinic services. 959 (bb) Substance abuse treatment services. 960 (cc) Transportation to access covered services. 961 (2) CUSTOMIZED BENEFITS.—Managed care plans may customize 962 benefit packages for nonpregnant adults, vary cost-sharing 963 provisions, and provide coverage for additional services. The 964 agency shall evaluate the proposed benefit packages to ensure 965 services are sufficient to meet the needs of the plan’s 966 enrollees and to verify actuarial equivalence. 967 (3) HEALTHY BEHAVIORS.—Each plan operating in the managed 968 medical assistance program shall establish a program to 969 encourage and reward healthy behaviors. At a minimum, each plan 970 must establish a medically approved smoking cessation program, a 971 medically directed weight loss program, and a medically approved 972 alcohol or substance abuse recovery program. Each plan must 973 identify enrollees who smoke, are morbidly obese, or are 974 diagnosed with alcohol or substance abuse in order to establish 975 written agreements to secure the enrollees’ commitment to 976 participation in these programs. 977 (4) PRIMARY CARE INITIATIVE.—Each plan operating in the 978 managed medical assistance program shall establish a program to 979 encourage enrollees to establish a relationship with their 980 primary care provider. Each plan shall: 981 (a) Provide information to each enrollee on the importance 982 of and procedure for selecting a primary care physician, and 983 thereafter automatically assign to a primary care provider any 984 enrollee who fails to choose a primary care provider. 985 (b) If the enrollee was not a Medicaid recipient before 986 enrollment in the plan, assist the enrollee in scheduling an 987 appointment with the primary care provider. If possible the 988 appointment should be made within 30 days after enrollment in 989 the plan. For enrollees who become eligible for Medicaid between 990 January 1, 2014, and December 31, 2015, the appointment should 991 be be scheduled within 6 months after enrollment in the plan. 992 (c) Report to the agency the number of enrollees assigned 993 to each primary care provider within the plan’s network. 994 (d) Report to the agency the number of enrollees who have 995 not had an appointment with their primary care provider within 996 their first year of enrollment. 997 (e) Report to the agency the number of emergency room 998 visits by enrollees who have not had a least one appointment 999 with their primary care provider. 1000 Section 15. Section 409.974, Florida Statutes, is created 1001 to read: 1002 409.974 Eligible plans.— 1003 (1) ELIGIBLE PLAN SELECTION.—The agency shall select 1004 eligible plans through the procurement process described in s. 1005 409.966. The agency shall notice invitations to negotiate no 1006 later than January 1, 2013. 1007 (a) The agency shall procure two plans for Region 1. At 1008 least one plan shall be a provider service network if any 1009 provider service networks submit a responsive bid. 1010 (b) The agency shall procure two plans for Region 2. At 1011 least one plan shall be a provider service network if any 1012 provider service networks submit a responsive bid. 1013 (c) The agency shall procure at least three plans and up to 1014 five plans for Region 3. At least one plan must be a provider 1015 service network if any provider service networks submit a 1016 responsive bids. 1017 (d) The agency shall procure at least three plans and up to 1018 five plans for Region 4. At least one plan must be a provider 1019 service network if any provider service networks submit a 1020 responsive bid. 1021 (e) The agency shall procure at least two plans and up to 4 1022 plans for Region 5. At least one plan must be a provider service 1023 network if any provider service networks submit a responsive 1024 bid. 1025 (f) The agency shall procure at least four plans and up to 1026 seven plans for Region 6. At least one plan must be a provider 1027 service network if any provider service networks submit a 1028 responsive bid. 1029 (g) The agency shall procure at least three plans and up to 1030 six plans for Region 7. At least one plan must be a provider 1031 service network if any provider service networks submit a 1032 responsive bid. 1033 (h) The agency shall procure at least two plans and up to 1034 four plans for Region 8. At least one plan must be a provider 1035 service network if any provider service networks submit a 1036 responsive bid. 1037 (i) The agency shall procure at least two plans and up to 1038 four plans for Region 9. At least one plan must be a provider 1039 service network if any provider service networks submit a 1040 responsive bid. 1041 (j) The agency shall procure at least two plans and up to 1042 four plans for Region 10. At least one plan must be a provider 1043 service network if any provider service networks submit a 1044 responsive bid. 1045 (k) The agency shall procure at least five plans and up to 1046 ten plans for Region 11. At least one plan must be a provider 1047 service network if any provider service networks submit a 1048 responsive bid. 1049 1050 If no provider service network submits a responsive bid, the 1051 agency shall procure no more than one less than the maximum 1052 number of eligible plans permitted in that region. Within 12 1053 months after the initial invitation to negotiate, the agency 1054 shall attempt to procure a provider service network. The agency 1055 shall notice another invitation to negotiate only with provider 1056 service networks in those regions where no provider service 1057 network has been selected. 1058 (2) QUALITY SELECTION CRITERIA.—In addition to the criteria 1059 established in s. 409.966, the agency shall consider evidence 1060 that an eligible plan has written agreements or signed contracts 1061 or has made substantial progress in establishing relationships 1062 with providers before the plan submitting a response. The agency 1063 shall evaluate and give special weight to evidence of signed 1064 contracts with essential providers as defined by the agency 1065 pursuant to s. 409.975(2). The agency shall exercise a 1066 preference for plans with a provider network in which over 10 1067 percent of the providers use electronic health records, as 1068 defined in s. 408.051. When all other factors are equal, the 1069 agency shall consider whether the organization has a contract to 1070 provide managed long-term care services in the same region and 1071 shall exercise a preference for such plans. 1072 (3) SPECIALTY PLANS.—Participation by specialty plans shall 1073 be subject to the procurement requirements and regional plan 1074 number limits of this section. However, a specialty plan whose 1075 target population includes no more than 10 percent of the 1076 enrollees of that region is not subject to the regional plan 1077 number limits of this section. 1078 (4) CHILDREN’S MEDICAL SERVICES NETWORK.—Participation by 1079 the Children’s Medical Services Network shall be pursuant to a 1080 single, statewide contract with the agency that is not subject 1081 to the procurement requirements or regional plan number limits 1082 of this section. The Children’s Medical Services Network must 1083 meet all other plan requirements for the managed medical 1084 assistance program. 1085 Section 16. Section 409.975, Florida Statutes, is created 1086 to read: 1087 409.975 Managed care plan accountability.—In addition to 1088 the requirements of s. 409.967, plans and providers 1089 participating in the managed medical assistance program shall 1090 comply with the requirements of this section. 1091 (1) PROVIDER NETWORKS.—Managed care plans must develop and 1092 maintain provider networks that meet the medical needs of their 1093 enrollees in accordance with standards established pursuant to 1094 409.967(2)(b). Except as provided in this section, managed care 1095 plans may limit the providers in their networks based on 1096 credentials, quality indicators, and price. 1097 (a) Plans must include all providers in the region that are 1098 classified by the agency as essential Medicaid providers, unless 1099 the agency approves, in writing, an alternative arrangement for 1100 securing the types of services offered by the essential 1101 providers. Providers are essential for serving Medicaid 1102 enrollees if they offer services that are not available from any 1103 other provider within a reasonable access standard, or if they 1104 provided a substantial share of the total units of a particular 1105 service used by Medicaid patients within the region during the 1106 last 3 years and the combined capacity of other service 1107 providers in the region is insufficient to meet the total needs 1108 of the Medicaid patients. The agency may not classify physicians 1109 and other practitioners as essential providers. The agency, at a 1110 minimum, shall determine which providers in the following 1111 categories are essential Medicaid providers: 1112 1. Federally qualified health centers. 1113 2. Statutory teaching hospitals as defined in s. 1114 408.07(45). 1115 3. Hospitals that are trauma centers as defined in s. 1116 395.4001(14). 1117 4. Hospitals located at least 25 miles from any other 1118 hospital with similar services. 1119 1120 Managed care plans that have not contracted with all essential 1121 providers in the region as of the first date of recipient 1122 enrollment, or with whom an essential provider has terminated 1123 its contract, must negotiate in good faith with such essential 1124 providers for 1 year or until an agreement is reached, whichever 1125 is first. Payments for services rendered by a nonparticipating 1126 essential provider shall be made at the applicable Medicaid rate 1127 as of the first day of the contract between the agency and the 1128 plan. A rate schedule for all essential providers shall be 1129 attached to the contract between the agency and the plan. After 1130 1 year, managed care plans that are unable to contract with 1131 essential providers shall notify the agency and propose an 1132 alternative arrangement for securing the essential services for 1133 Medicaid enrollees. The arrangement must rely on contracts with 1134 other participating providers, regardless of whether those 1135 providers are located within the same region as the 1136 nonparticipating essential service provider. If the alternative 1137 arrangement is approved by the agency, payments to 1138 nonparticipating essential providers after the date of the 1139 agency’s approval shall equal 90 percent of the applicable 1140 Medicaid rate. If the alternative arrangement is not approved by 1141 the agency, payment to nonparticipating essential providers 1142 shall equal 110 percent of the applicable Medicaid rate. 1143 (b) Certain providers are statewide resources and essential 1144 providers for all managed care plans in all regions. All managed 1145 care plans must include these essential providers in their 1146 networks. Statewide essential providers include: 1147 1. Faculty plans of Florida medical schools. 1148 2. Regional perinatal intensive care centers as defined in 1149 s. 383.16(2). 1150 3. Hospitals licensed as specialty children’s hospitals as 1151 defined in s. 395.002(28). 1152 4. Accredited and integrated systems serving medically 1153 complex children that are comprised of separately licensed, but 1154 commonly owned, health care providers delivering at least the 1155 following services: medical group home, in-home and outpatient 1156 nursing care and therapies, pharmacy services, durable medical 1157 equipment, and Prescribed Pediatric Extended Care. 1158 1159 Managed care plans that have not contracted with all statewide 1160 essential providers in all regions as of the first date of 1161 recipient enrollment must continue to negotiate in good faith. 1162 Payments to physicians on the faculty of nonparticipating 1163 Florida medical schools shall be made at the applicable Medicaid 1164 rate. Payments for services rendered by a regional perinatal 1165 intensive care centers shall be made at the applicable Medicaid 1166 rate as of the first day of the contract between the agency and 1167 the plan. Payments to nonparticipating specialty children’s 1168 hospitals shall equal the highest rate established by contract 1169 between that provider and any other Medicaid managed care plan. 1170 (c) After 12 months of active participation in a plan’s 1171 network, the plan may exclude any essential provider from the 1172 network for failure to meet quality or performance criteria. If 1173 the plan excludes an essential provider from the plan, the plan 1174 must provide written notice to all recipients who have chosen 1175 that provider for care. The notice shall be provided at least 30 1176 days before the effective date of the exclusion. 1177 (d) Each managed care plan must offer a network contract to 1178 each home medical equipment and supplies provider in the region 1179 which meets quality and fraud prevention and detection standards 1180 established by the plan and which agrees to accept the lowest 1181 price previously negotiated between the plan and another such 1182 provider. 1183 (2) FLORIDA MEDICAL SCHOOLS QUALITY NETWORK.—The agency 1184 shall contract with a single organization representing medical 1185 schools and graduate medical education programs in the state for 1186 the purpose of establishing an active and ongoing program to 1187 improve clinical outcomes in all managed care plans. Contracted 1188 activities must support greater clinical integration for 1189 Medicaid enrollees through interdependent and cooperative 1190 efforts of all providers participating in managed care plans. 1191 The agency shall support these activities with certified public 1192 expenditures and any earned federal matching funds and shall 1193 seek any plan amendments or waivers necessary to comply with 1194 this subsection. To be eligible to participate in the quality 1195 network, a medical school must contract with each managed care 1196 plan in its region. 1197 (3) PERFORMANCE MEASUREMENT.—Each managed care plan shall 1198 monitor the quality and performance of each participating 1199 provider. At the beginning of the contract period, each plan 1200 shall notify all its network providers of the metrics used by 1201 the plan for evaluating the provider’s performance and 1202 determining continued participation in the network. 1203 (4) MOMCARE NETWORK.— 1204 (a) The agency shall contract with an administrative 1205 services organization representing all Healthy Start Coalitions 1206 providing risk appropriate care coordination and other services 1207 in accordance with a federal waiver and pursuant to s. 409.906. 1208 The contract shall require the network of coalitions to provide 1209 counseling, education, risk-reduction and case management 1210 services, and quality assurance for all enrollees of the waiver. 1211 The agency shall evaluate the impact of the MomCare network by 1212 monitoring each plan’s performance on specific measures to 1213 determine the adequacy, timeliness, and quality of services for 1214 pregnant women and infants. The agency shall support this 1215 contract with certified public expenditures of general revenue 1216 appropriated for Healthy Start services and any earned federal 1217 matching funds. 1218 (b) Each managed care plan shall establish specific 1219 programs and procedures to improve pregnancy outcomes and infant 1220 health, including, but not limited to, coordination with the 1221 Healthy Start program, immunization programs, and referral to 1222 the Special Supplemental Nutrition Program for Women, Infants, 1223 and Children, and the Children’s Medical Services program for 1224 children with special health care needs. Each plan’s programs 1225 and procedures shall include agreements with each local Healthy 1226 Start Coalition in the region to provide risk-appropriate care 1227 coordination for pregnant women and infants, consistent with 1228 agency policies and the MomCare network. Each managed care plan 1229 must notify the agency of the impending birth of a child to an 1230 enrollee, or notify the agency as soon as practicable after the 1231 child’s birth. 1232 (5) SCREENING RATE.—After the end of the second contract 1233 year, each managed care plan shall achieve an annual Early and 1234 Periodic Screening, Diagnosis, and Treatment Service screening 1235 rate of at least 80 percent of those recipients continuously 1236 enrolled for at least 8 months. 1237 (6) PROVIDER PAYMENT.—Managed care plans and hospitals 1238 shall negotiate mutually acceptable rates, methods, and terms of 1239 payment. For rates, methods, and terms of payment negotiated 1240 after the contract between the agency and the plan is executed, 1241 plans shall pay hospitals, at a minimum, the rate the agency 1242 would have paid on the first day of the contract between the 1243 provider and the plan. Such payments to hospitals may not exceed 1244 120 percent of the rate the agency would have paid on the first 1245 day of the contract between the provider and the plan, unless 1246 specifically approved by the agency. Payment rates may be 1247 updated periodically. 1248 (7) MEDICALLY NEEDY ENROLLEES.—Each managed care plan must 1249 accept any medically needy recipient who selects or is assigned 1250 to the plan and provide that recipient with continuous 1251 enrollment for 12 months. After the first month of qualifying as 1252 a medically needy recipient and enrolling in a plan, and 1253 contingent upon federal approval, the enrollee shall pay the 1254 plan a portion of the monthly premium equal to the enrollee’s 1255 share of the cost as determined by the department. The agency 1256 shall pay any remaining portion of the monthly premium. Plans 1257 are not obligated to pay claims for medically needy patients for 1258 services provided before enrollment in the plan. Medically needy 1259 patients are responsible for payment of incurred claims that are 1260 used to determine eligibility. Plans must provide a grace period 1261 of at least 90 days before disenrolling recipients who fail to 1262 pay their shares of the premium. 1263 Section 17. Section 409.976, Florida Statutes, is created 1264 to read: 1265 409.976 Managed care plan payment.—In addition to the 1266 payment provisions of s. 409.968, the agency shall provide 1267 payment to plans in the managed medical assistance program 1268 pursuant to this section. 1269 (1) Prepaid payment rates shall be negotiated between the 1270 agency and the eligible plans as part of the procurement process 1271 described in s. 409.966. 1272 (2) The agency shall establish payment rates for statewide 1273 inpatient psychiatric programs. Payments to managed care plans 1274 shall be reconciled to reimburse actual payments to statewide 1275 inpatient psychiatric programs. 1276 Section 18. Section 409.977, Florida Statutes, is created 1277 to read: 1278 409.977 Enrollment.— 1279 (1) The agency shall automatically enroll into a managed 1280 care plan those Medicaid recipients who do not voluntarily 1281 choose a plan pursuant to s. 409.969. The agency shall 1282 automatically enroll recipients in plans that meet or exceed the 1283 performance or quality standards established pursuant to s. 1284 409.967 and may not automatically enroll recipients in a plan 1285 that is deficient in those performance or quality standards. 1286 When a specialty plan is available to accommodate a specific 1287 condition or diagnosis of a recipient, the agency shall assign 1288 the recipient to that plan. In the first year of the first 1289 contract term only, if a recipient was previously enrolled in a 1290 plan that is still available in the region, the agency shall 1291 automatically enroll the recipient in that plan unless an 1292 applicable specialty plan is available. Except as otherwise 1293 provided in this part, the agency may not engage in practices 1294 that are designed to favor one managed care plan over another. 1295 (2) When automatically enrolling recipients in managed care 1296 plans, the agency shall automatically enroll based on the 1297 following criteria: 1298 (a) Whether the plan has sufficient network capacity to 1299 meet the needs of the recipients. 1300 (b) Whether the recipient has previously received services 1301 from one of the plan’s primary care providers. 1302 (c) Whether primary care providers in one plan are more 1303 geographically accessible to the recipient’s residence than 1304 those in other plans. 1305 (3) A newborn of a mother enrolled in a plan at the time of 1306 the child’s birth shall be enrolled in the mother’s plan. Upon 1307 birth, such a newborn is deemed enrolled in the managed care 1308 plan, regardless of the administrative enrollment procedures, 1309 and the managed care plan is responsible for providing Medicaid 1310 services to the newborn. The mother may choose another plan for 1311 the newborn within 90 days after the child’s birth. 1312 (4) The agency shall develop a process to enable a 1313 recipient with access to employer-sponsored health care coverage 1314 to opt out of all managed care plans and to use Medicaid 1315 financial assistance to pay for the recipient’s share of the 1316 cost in such employer-sponsored coverage. Contingent upon 1317 federal approval, the agency shall also enable recipients with 1318 access to other insurance or related products providing access 1319 to health care services created pursuant to state law, including 1320 any product available under the Florida Health Choices Program, 1321 or any health exchange, to opt out. The amount of financial 1322 assistance provided for each recipient may not exceed the amount 1323 of the Medicaid premium that would have been paid to a managed 1324 care plan for that recipient. The agency shall seek federal 1325 approval to require Medicaid recipients with access to employer 1326 sponsored health care coverage to enroll in that coverage and 1327 use Medicaid financial assistance to pay for the recipient’s 1328 share of the cost for such coverage. The amount of financial 1329 assistance provided for each recipient may not exceed the amount 1330 of the Medicaid premium that would have been paid to a managed 1331 care plan for that recipient. 1332 Section 19. Section 409.978, Florida Statutes, is created 1333 to read: 1334 409.978 Long-term care managed care program.— 1335 (1) Pursuant to s. 409.963, the agency shall administer the 1336 long-term care managed care program described in ss. 409.978 1337 409.985, but may delegate specific duties and responsibilities 1338 for the program to the Department of Elderly Affairs and other 1339 state agencies. By July 1, 2012, the agency shall begin 1340 implementation of the statewide long-term care managed care 1341 program, with full implementation in all regions by October 1, 1342 2013. 1343 (2) The agency shall make payments for long-term care, 1344 including home and community-based services, using a managed 1345 care model. Unless otherwise specified, ss. 409.961-409.97 apply 1346 to the long-term care managed care program. 1347 (3) The Department of Elderly Affairs shall assist the 1348 agency to develop specifications for use in the invitation to 1349 negotiate and the model contract, determine clinical eligibility 1350 for enrollment in managed long-term care plans, monitor plan 1351 performance and measure quality of service delivery, assist 1352 clients and families to address complaints with the plans, 1353 facilitate working relationships between plans and providers 1354 serving elders and disabled adults, and perform other functions 1355 specified in a memorandum of agreement. 1356 Section 20. Section 409.979, Florida Statutes, is created 1357 to read: 1358 409.979 Eligibility.— 1359 (1) Medicaid recipients who meet all of the following 1360 criteria are eligible to receive long-term care services and 1361 must receive long-term care services by participating in the 1362 long-term care managed care program. The recipient must be: 1363 (a) Sixty-five years of age or older, or age 18 or older 1364 and eligible for Medicaid by reason of a disability. 1365 (b) Determined by the Comprehensive Assessment Review and 1366 Evaluation for Long-Term Care Services (CARES) Program to 1367 require nursing facility care as defined in s. 409.985(3). 1368 (2) Medicaid recipients who, on the date long-term care 1369 managed care plans become available in their region, reside in a 1370 nursing home facility or are enrolled in one of the following 1371 long-term care Medicaid waiver programs are eligible to 1372 participate in the long-term care managed care program for up to 1373 12 months without being reevaluated for their need for nursing 1374 facility care as defined in s. 409.985(3): 1375 (a) The Assisted Living for the Frail Elderly Waiver. 1376 (b) The Aged and Disabled Adult Waiver. 1377 (c) The Adult Day Health Care Waiver. 1378 (d) The Consumer-Directed Care Plus Program as described in 1379 s. 409.221. 1380 (e) The Program of All-inclusive Care for the Elderly. 1381 (f) The long-term care community-based diversion pilot 1382 project as described in s. 430.705. 1383 (g) The Channeling Services Waiver for Frail Elders. 1384 (3) The Department of Elderly Affairs shall make offers for 1385 enrollment to eligible individuals based on a wait-list 1386 prioritization and subject to availability of funds. Before 1387 enrollment offers, the department shall determine that 1388 sufficient funds exist to support additional enrollment into 1389 plans. 1390 Section 21. Section 409.98, Florida Statutes, is created to 1391 read: 1392 409.98 Long-term care plan benefits.—Long-term care plans 1393 shall, at a minimum, cover the following: 1394 (1) Nursing facility care. 1395 (2) Services provided in assisted living facilities. 1396 (3) Hospice. 1397 (4) Adult day care. 1398 (5) Medical equipment and supplies, including incontinence 1399 supplies. 1400 (6) Personal care. 1401 (7) Home accessibility adaptation. 1402 (8) Behavior management. 1403 (9) Home-delivered meals. 1404 (10) Case management. 1405 (11) Therapies: 1406 (a) Occupational therapy. 1407 (b) Speech therapy. 1408 (c) Respiratory therapy. 1409 (d) Physical therapy. 1410 (12) Intermittent and skilled nursing. 1411 (13) Medication administration. 1412 (14) Medication management. 1413 (15) Nutritional assessment and risk reduction. 1414 (16) Caregiver training. 1415 (17) Respite care. 1416 (18) Transportation. 1417 (19) Personal emergency response system. 1418 Section 22. Section 409.981, Florida Statutes, is created 1419 to read: 1420 409.981 Eligible long-term care plans.— 1421 (1) ELIGIBLE PLANS.—Provider service networks must be long 1422 term care provider service networks. Other eligible plans may be 1423 long-term care plans or comprehensive long-term care plans. 1424 (2) ELIGIBLE PLAN SELECTION.—The agency shall select 1425 eligible plans through the procurement process described in s. 1426 409.966. The agency shall provide notice of invitations to 1427 negotiate by July 1, 2012. The agency shall procure: 1428 (a) Two plans for Region 1. At least one plan must be a 1429 provider service network if any provider service networks submit 1430 a responsive bid. 1431 (b) Two plans for Region 2. At least one plan must be a 1432 provider service network if any provider service networks submit 1433 a responsive bid. 1434 (c) At least three plans and up to five plans for Region 3. 1435 At least one plan must be a provider service network if any 1436 provider service networks submit a responsive bid. 1437 (d) At least three plans and up to five plans for Region 4. 1438 At least one plan must be a provider service network if any 1439 provider service network submits a responsive bid. 1440 (e) At least two plans and up to 4 plans for Region 5. At 1441 least one plan must be a provider service network if any 1442 provider service networks submit a responsive bid. 1443 (f) At least four plans and up to seven plans for Region 6. 1444 At least one plan must be a provider service network if any 1445 provider service networks submit a responsive bid. 1446 (g) At least three plans and up to 6 plans for Region 7. At 1447 least one plan must be a provider service networks if any 1448 provider service networks submit a responsive bid. 1449 (h) At least two plans and up to four plans for Region 8. 1450 At least one plan must be a provider service network if any 1451 provider service networks submit a responsive bid. 1452 (i) At least two plans and up to four plans for Region 9. 1453 At least one plan must be a provider service network if any 1454 provider service networks submit a responsive bid. 1455 (j) At least two plans and up to four plans for Region 10. 1456 At least one plan must be a provider service network if any 1457 provider service networks submit a responsive bid. 1458 (k) At least five plans and up to ten plans for Region 11. 1459 At least one plan must be a provider service network if any 1460 provider service networks submit a responsive bid. 1461 1462 If no provider service network submits a responsive bid in a 1463 region other than Region 1 or Region 2, the agency shall procure 1464 no more than one less than the maximum number of eligible plans 1465 permitted in that region. Within 12 months after the initial 1466 invitation to negotiate, the agency shall attempt to procure a 1467 provider service network. The agency shall notice another 1468 invitation to negotiate only with provider service networks in 1469 regions where no provider service network has been selected. 1470 (3) QUALITY SELECTION CRITERIA.—In addition to the criteria 1471 established in s. 409.966, the agency shall consider the 1472 following factors in the selection of eligible plans: 1473 (a) Evidence of the employment of executive managers with 1474 expertise and experience in serving aged and disabled persons 1475 who require long-term care. 1476 (b) Whether a plan has established a network of service 1477 providers dispersed throughout the region and in sufficient 1478 numbers to meet specific service standards established by the 1479 agency for specialty services for persons receiving home and 1480 community-based care. 1481 (c) Whether a plan is proposing to establish a 1482 comprehensive long-term care plan and whether the eligible plan 1483 has a contract to provide managed medical assistance services in 1484 the same region. 1485 (d) Whether a plan offers consumer-directed care services 1486 to enrollees pursuant to s. 409.221. 1487 (e) Whether a plan is proposing to provide home and 1488 community-based services in addition to the minimum benefits 1489 required by s. 409.98. 1490 (4) PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY. 1491 Participation by the Program of All-Inclusive Care for the 1492 Elderly (PACE) shall be pursuant to a contract with the agency 1493 and not subject to the procurement requirements or regional plan 1494 number limits of this section. PACE plans may continue to 1495 provide services to individuals at such levels and enrollment 1496 caps as authorized by the General Appropriations Act. 1497 (5) MEDICARE PLANS.—Participation by a Medicare Advantage 1498 Preferred Provider Organization, Medicare Advantage Provider 1499 sponsored Organization, or Medicare Advantage Special Needs Plan 1500 shall be pursuant to a contract with the agency and not subject 1501 to the procurement requirements if the plan’s Medicaid enrollees 1502 consist exclusively of recipients who are deemed dually eligible 1503 for Medicaid and Medicare services. Otherwise, Medicare 1504 Advantage Preferred Provider Organizations, Medicare Advantage 1505 Provider-Sponsored Organizations, and Medicare Advantage Special 1506 Needs Plans are subject to all procurement requirements. 1507 Section 23. Section 409.982, Florida Statutes, is created 1508 to read: 1509 409.982 Long-term care managed care plan accountability.—In 1510 addition to the requirements of s. 409.967, plans and providers 1511 participating in the long-term care managed care program must 1512 comply with the requirements of this section. 1513 (1) PROVIDER NETWORKS.—Managed care plans may limit the 1514 providers in their networks based on credentials, quality 1515 indicators, and price. For the period between October 1, 2013, 1516 and September 30, 2014, each selected plan must offer a network 1517 contract to all the following providers in the region: 1518 (a) Nursing homes. 1519 (b) Hospices. 1520 (c) Aging network service providers that have previously 1521 participated in home and community-based waivers serving elders 1522 or community-service programs administered by the Department of 1523 Elderly Affairs. 1524 1525 After 12 months of active participation in a managed care plan’s 1526 network, the plan may exclude any of the providers named in this 1527 subsection from the network for failure to meet quality or 1528 performance criteria. If the plan excludes a provider from the 1529 plan, the plan must provide written notice to all recipients who 1530 have chosen that provider for care. The notice must be provided 1531 at least 30 days before the effective date of the exclusion. The 1532 agency shall establish contract provisions governing the 1533 transfer of recipients from excluded residential providers. 1534 (2) SELECT PROVIDER PARTICIPATION.—Except as provided in 1535 this subsection, providers may limit the managed care plans they 1536 join. Nursing homes and hospices that are enrolled Medicaid 1537 providers must participate in all eligible plans selected by the 1538 agency in the region in which the provider is located. 1539 (3) PERFORMANCE MEASUREMENT.—Each managed care plan shall 1540 monitor the quality and performance of each participating 1541 provider using measures adopted by and collected by the agency 1542 and any additional measures mutually agreed upon by the provider 1543 and the plan 1544 (4) PROVIDER NETWORK STANDARDS.—The agency shall establish 1545 and each managed care plan must comply with specific standards 1546 for the number, type, and regional distribution of providers in 1547 the plan’s network, which must include: 1548 (a) Adult day care centers. 1549 (b) Adult family-care homes. 1550 (c) Assisted living facilities. 1551 (d) Health care services pools. 1552 (e) Home health agencies. 1553 (f) Homemaker and companion services. 1554 (g) Hospices. 1555 (h) Community care for the elderly lead agencies. 1556 (i) Nurse registries. 1557 (j) Nursing homes. 1558 (5) PROVIDER PAYMENT.—Managed care plans and providers 1559 shall negotiate mutually acceptable rates, methods, and terms of 1560 payment. Plans shall pay nursing homes an amount equal to the 1561 nursing facility-specific payment rates set by the agency; 1562 however, mutually acceptable higher rates may be negotiated for 1563 medically complex care. Plans shall pay hospice providers 1564 through a prospective system for each enrollee an amount equal 1565 to the per diem rate set by the agency. For recipients residing 1566 in a nursing facility and receiving hospice services, the plan 1567 shall pay the hospice provider the per diem rate set by the 1568 agency minus the nursing facility component and shall pay the 1569 nursing facility the applicable state rate. Plans must ensure 1570 that electronic nursing home and hospice claims that contain 1571 sufficient information for processing are paid within 10 1572 business days after receipt. 1573 Section 24. Section 409.983, Florida Statutes, is created 1574 to read: 1575 409.983 Long-term care managed care plan payment.—In 1576 addition to the payment provisions of s. 409.968, the agency 1577 shall provide payment to plans in the long-term care managed 1578 care program pursuant to this section. 1579 (1) Prepaid payment rates for long-term care managed care 1580 plans shall be negotiated between the agency and the eligible 1581 plans as part of the procurement process described in s. 1582 409.966. 1583 (2) Payment rates for comprehensive long-term care plans 1584 covering services described in s. 409.973 shall be blended with 1585 rates for long-term care plans for services specified in s. 1586 409.98. 1587 (3) Payment rates for plans must reflect historic 1588 utilization and spending for covered services projected forward 1589 and adjusted to reflect the level of care profile for enrollees 1590 in each plan. The payment shall be adjusted to provide an 1591 incentive for reducing institutional placements and increasing 1592 the utilization of home and community-based services. 1593 (4) The initial assessment of an enrollee’s level of care 1594 shall be made by the Comprehensive Assessment and Review for 1595 Long-Term-Care Services (CARES) program, which shall assign the 1596 recipient into one of the following levels of care: 1597 (a) Level of care 1 consists of recipients residing in or 1598 who must be placed in a nursing home. 1599 (b) Level of care 2 consists of recipients at imminent risk 1600 of nursing home placement, as evidenced by the need for the 1601 constant availability of routine medical and nursing treatment 1602 and care, and require extensive health-related care and services 1603 because of mental or physical incapacitation. 1604 (c) Level of care 3 consists of recipients at imminent risk 1605 of nursing home placement, as evidenced by the need for the 1606 constant availability of routine medical and nursing treatment 1607 and care, who have a limited need for health-related care and 1608 services and are mildly medically or physically incapacitated. 1609 1610 The agency shall periodically adjust payment rates to account 1611 for changes in the level of care profile for each managed care 1612 plan based on encounter data. 1613 (5) The agency shall make an incentive adjustment in 1614 payment rates to encourage the increased utilization of home and 1615 community-based services and a commensurate reduction of 1616 institutional placement. The incentive adjustment shall be 1617 modified in each successive rate period during the first 1618 contract period, as follows: 1619 (a) A 2 percentage point shift in the first rate-setting 1620 period; 1621 (b) A 2 percentage point shift in the second rate-setting 1622 period, as compared to the utilization mix at the end of the 1623 first rate-setting period; or 1624 (c) A 3 percentage point shift in the third rate-setting 1625 period, and in each subsequent rate-setting period during the 1626 first contract period, as compared to the utilization mix at the 1627 end of the immediately preceding rate-setting period. 1628 1629 The incentive adjustment shall continue in subsequent contract 1630 periods, at a rate of 3 percentage points per year as compared 1631 to the utilization mix at the end of the immediately preceding 1632 rate-setting period, until no more than 35 percent of the plan’s 1633 enrollees are placed in institutional settings. The agency shall 1634 annually report to the Legislature the actual change in the 1635 utilization mix of home and community-based services compared to 1636 institutional placements and provide a recommendation for 1637 utilization mix requirements for future contracts. 1638 (6) The agency shall establish nursing-facility-specific 1639 payment rates for each licensed nursing home based on facility 1640 costs adjusted for inflation and other factors as authorized in 1641 the General Appropriations Act. Payments to long-term care 1642 managed care plans shall be reconciled to reimburse actual 1643 payments to nursing facilities. 1644 (7) The agency shall establish hospice payment rates 1645 pursuant to Title XVIII of the Social Security Act. Payments to 1646 long-term care managed care plans shall be reconciled to 1647 reimburse actual payments to hospices. 1648 Section 25. Section 409.984, Florida Statutes, is created 1649 to read: 1650 409.984 Enrollment in a long-term care managed care plan.— 1651 (1) The agency shall automatically enroll into a long-term 1652 care managed care plan those Medicaid recipients who do not 1653 voluntarily choose a plan pursuant to s. 409.969. The agency 1654 shall automatically enroll recipients in plans that meet or 1655 exceed the performance or quality standards established pursuant 1656 to s. 409.967 and may not automatically enroll recipients in a 1657 plan that is deficient in those performance or quality 1658 standards. If a recipient is deemed dually eligible for Medicaid 1659 and Medicare services and is currently receiving Medicare 1660 services from an entity qualified under 42 C.F.R. part 422 as a 1661 Medicare Advantage Preferred Provider Organization, Medicare 1662 Advantage Provider-sponsored Organization, or Medicare Advantage 1663 Special Needs Plan, the agency shall automatically enroll the 1664 recipient in such plan for Medicaid services if the plan is 1665 currently participating in the long-term care managed care 1666 program. Except as otherwise provided in this part, the agency 1667 may not engage in practices that are designed to favor one 1668 managed care plan over another. 1669 (1) When automatically enrolling recipients in plans, the 1670 agency shall take into account the following criteria: 1671 (a) Whether the plan has sufficient network capacity to 1672 meet the needs of the recipients. 1673 (b) Whether the recipient has previously received services 1674 from one of the plan’s home and community-based service 1675 providers. 1676 (c) Whether the home and community-based providers in one 1677 plan are more geographically accessible to the recipient’s 1678 residence than those in other plans. 1679 (3) Notwithstanding s. 409.969(3)(c), if a recipient is 1680 referred for hospice services, the recipient has 30 days during 1681 which the recipient may select to enroll in another managed care 1682 plan to access the hospice provider of the recipient’s choice. 1683 (4) If a recipient is referred for placement in a nursing 1684 home or assisted living facility, the plan must inform the 1685 recipient of any facilities within the plan that have specific 1686 cultural or religious affiliations and, if requested by the 1687 recipient, make a reasonable effort to place the recipient in 1688 the facility of the recipient’s choice. 1689 Section 26. Section 409.9841, Florida Statutes, is created 1690 to read: 1691 409.9841 Long-term care managed care technical advisory 1692 workgroup.— 1693 (1) Before August 1, 2011, the agency shall establish a 1694 technical advisory workgroup to assist in developing: 1695 (a) The method of determining Medicaid eligibility pursuant 1696 to s. 409.985(3). 1697 (b) The requirements for provider payments to nursing homes 1698 under s. 409.983(6). 1699 (c) The method for managing Medicare coinsurance crossover 1700 claims. 1701 (d) Uniform requirements for claims submissions and 1702 payments, including electronic funds transfers and claims 1703 processing. 1704 (e) The process for enrollment of and payment for 1705 individuals pending determination of Medicaid eligibility. 1706 (2) The advisory workgroup must include, but is not limited 1707 to, representatives of providers and plans who could potentially 1708 participate in long-term care managed care. Members of the 1709 workgroup shall serve without compensation but may be reimbursed 1710 for per diem and travel expenses as provided in s. 112.061. 1711 (3) This section is repealed on June 30, 2013. 1712 Section 27. Section 409.985, Florida Statutes, is created 1713 to read: 1714 409.985 Comprehensive Assessment and Review for Long-Term 1715 Care Services (CARES) Program.— 1716 (1) The agency shall operate the Comprehensive Assessment 1717 and Review for Long-Term Care Services (CARES) preadmission 1718 screening program to ensure that only individuals whose 1719 conditions require long-term care services are enrolled in the 1720 long-term care managed care program. 1721 (2) The agency shall operate the CARES program through an 1722 interagency agreement with the Department of Elderly Affairs. 1723 The agency, in consultation with the Department of Elderly 1724 Affairs, may contract for any function or activity of the CARES 1725 program, including any function or activity required by 42 1726 C.F.R. part 483.20, relating to preadmission screening and 1727 review. 1728 (3) The CARES program shall determine if an individual 1729 requires nursing facility care and, if the individual requires 1730 such care, assign the individual to a level of care as described 1731 in s. 409.983(4). When determining the need for nursing facility 1732 care, consideration shall be given to the nature of the services 1733 prescribed and which level of nursing or other health care 1734 personnel meets the qualifications necessary to provide such 1735 services and the availability to and access by the individual of 1736 community or alternative resources. For the purposes of the 1737 long-term care managed care program, the term “nursing facility 1738 care” means the individual: 1739 (a) Requires nursing home placement as evidenced by the 1740 need for medical observation throughout a 24-hour period and 1741 care required to be performed on a daily basis by, or under the 1742 direct supervision of, a registered nurse or other health care 1743 professional and requires services that are sufficiently 1744 medically complex to require supervision, assessment, planning, 1745 or intervention by a registered nurse because of a mental or 1746 physical incapacitation by the individual; 1747 (b) Requires or is at imminent risk of nursing home 1748 placement as evidenced by the need for observation throughout a 1749 24-hour period and care and the constant availability of medical 1750 and nursing treatment and requires services on a daily or 1751 intermittent basis that are to be performed under the 1752 supervision of licensed nursing or other health professionals 1753 because the individual who is incapacitated mentally or 1754 physically; or 1755 (c) Requires or is at imminent risk of nursing home 1756 placement as evidenced by the need for observation throughout a 1757 24-hour period and care and the constant availability of medical 1758 and nursing treatment and requires limited services that are to 1759 be performed under the supervision of licensed nursing or other 1760 health professionals because the individual is mildly 1761 incapacitated mentally or physically. 1762 (4) For individuals whose nursing home stay is initially 1763 funded by Medicare and Medicare coverage and is being terminated 1764 for lack of progress towards rehabilitation, CARES staff shall 1765 consult with the person making the determination of progress 1766 toward rehabilitation to ensure that the recipient is not being 1767 inappropriately disqualified from Medicare coverage. If, in 1768 their professional judgment, CARES staff believe that a Medicare 1769 beneficiary is still making progress toward rehabilitation, they 1770 may assist the Medicare beneficiary with an appeal of the 1771 disqualification from Medicare coverage. The use of CARES teams 1772 to review Medicare denials for coverage under this section is 1773 authorized only if it is determined that such reviews qualify 1774 for federal matching funds through Medicaid. The agency shall 1775 seek or amend federal waivers as necessary to implement this 1776 section. 1777 Section 28. If any provision of this act or its application 1778 to any person or circumstance is held invalid, the invalidity 1779 does not affect other provisions or applications of the act 1780 which can be given effect without the invalid provision or 1781 application, and to this end the provisions of this act are 1782 severable. 1783 Section 29. This act shall take effect July 1, 2011. 1784 1785 ================= T I T L E A M E N D M E N T ================ 1786 And the title is amended as follows: 1787 Delete everything before the enacting clause 1788 and insert: 1789 A bill to be entitled 1790 An act relating to Medicaid managed care; creating 1791 part IV of ch. 409, F.S., entitled “Medicaid Managed 1792 Care”; creating s. 409.961, F.S.; providing for 1793 statutory construction; providing applicability of 1794 specified provisions throughout the part; providing 1795 rulemaking authority for specified agencies; creating 1796 s. 409.962, F.S.; providing definitions; creating s. 1797 409.963, F.S.; designating the Agency for Health Care 1798 Administration as the single state agency to 1799 administer the Medicaid program; providing for 1800 specified agency responsibilities; requiring client 1801 consent for release of medical records; creating s. 1802 409.964, F.S.; establishing the Medicaid program as 1803 the statewide, integrated managed care program for all 1804 covered services; authorizing the agency to apply for 1805 and implement waivers; providing for public notice and 1806 comment; creating s. 409.965, F.S.; providing for 1807 mandatory enrollment; providing exemptions; creating 1808 s. 409.966, F.S.; providing requirements for eligible 1809 plans that provide services in the Medicaid managed 1810 care program; establishing provider service network 1811 requirements for eligible plans; providing for 1812 eligible plan selection; requiring the agency to use 1813 an invitation to negotiate; requiring the agency to 1814 compile and publish certain information; establishing 1815 regions for separate procurement of plans; providing 1816 quality criteria for plan selection; providing 1817 limitations on serving recipients during the pendency 1818 of procurement litigation; creating s. 409.967, F.S.; 1819 providing for managed care plan accountability; 1820 establishing contract terms; providing for physician 1821 compensation; providing for emergency services; 1822 establishing requirements for access; requiring a drug 1823 formulary or preferred drug list; requiring plans to 1824 accept requests for service electronically; requiring 1825 the agency to maintain an encounter data system; 1826 requiring plans to provide encounter data; requiring 1827 the agency to establish performance standards for 1828 plans; providing program integrity requirements; 1829 establishing requirements for the database; 1830 establishing a grievance resolution process; providing 1831 penalties for early termination of contracts or 1832 reduction in enrollment levels; establishing prompt 1833 payment requirements; requiring fair payment to 1834 providers with a controlling interest in a provider 1835 service network by other plans; requiring itemized 1836 payment; providing for dispute resolutions between 1837 plans and providers; providing for achieved savings 1838 rebates to plans; creating s. 409.968, F.S.; 1839 establishing managed care plan payments; providing 1840 payment requirements for provider service networks; 1841 requiring the agency to conduct annual cost 1842 reconciliations to determine certain cost savings and 1843 report the results of the reconciliations to the fee 1844 for-service provider; prohibiting rate increases that 1845 are not authorized in the appropriations act; creating 1846 s. 409.969, F.S.; requiring enrollment in managed care 1847 plans by all nonexempt Medicaid recipients; creating 1848 requirements for plan selection by recipients; 1849 authorizing disenrollment under certain circumstances; 1850 defining the term “good cause” for purposes of 1851 disenrollment; providing time limits on an internal 1852 grievance process; providing requirements for agency 1853 determination regarding disenrollment; requiring 1854 recipients to stay in plans for a specified time; 1855 creating s. 409.97, F.S.; authorizing the agency to 1856 accept the transfer of certain revenues from local 1857 governments; requiring the agency to contract with a 1858 representative of certain entities participating in 1859 the low-income pool for the provision of enhanced 1860 access to care; providing for support of these 1861 activities by the low-income pool as authorized in the 1862 General Appropriations Act; establishing the Access to 1863 Care Partnership; requiring the agency to seek 1864 necessary waivers and plan amendments; providing 1865 requirements for prepaid plans to submit data; 1866 authorizing the agency to implement a tiered hospital 1867 rate system; creating s. 409.971, F.S.; creating the 1868 managed medical assistance program; providing 1869 deadlines to begin and finalize implementation of the 1870 program; creating s. 409.972, F.S.; providing 1871 eligibility requirements for mandatory and voluntary 1872 enrollment; creating s. 409.973, F.S.; establishing 1873 minimum benefits for managed care plans to cover; 1874 authorizing plans to customize benefit packages; 1875 requiring plans to establish programs to encourage 1876 healthy behaviors and establish written agreements 1877 with certain enrollees to participate in such 1878 programs; requiring plans to establish a primary care 1879 initiative; providing requirements for primary care 1880 initiatives; requiring plans to report certain primary 1881 care data to the agency; creating s. 409.974, F.S.; 1882 establishing a deadline for issuing invitations to 1883 negotiate; establishing a specified number or range of 1884 eligible plans to be selected in each region; 1885 establishing quality selection criteria; establishing 1886 requirements for participation by specialty plans; 1887 establishing the Children’s Medical Service Network as 1888 an eligible plan; creating s. 409.975, F.S.; providing 1889 for managed care plan accountability; authorizing 1890 plans to limit providers in networks; requiring plans 1891 to include essential Medicaid providers in their 1892 networks unless an alternative arrangement is approved 1893 by the agency; identifying statewide essential 1894 providers; specifying provider payments under certain 1895 circumstances; requiring plans to include certain 1896 statewide essential providers in their networks; 1897 requiring good faith negotiations; specifying provider 1898 payments under certain circumstances; allowing plans 1899 to exclude essential providers under certain 1900 circumstances; requiring plans to offer a contract to 1901 home medical equipment and supply providers under 1902 certain circumstances; establishing the Florida 1903 medical school quality network; requiring the agency 1904 to contract with a representative of certain entities 1905 to establish a clinical outcome improvement program in 1906 all plans; providing for support of these activities 1907 by certain expenditures and federal matching funds; 1908 requiring the agency to seek necessary waivers and 1909 plan amendments; providing for eligibility for the 1910 quality network; requiring plans to monitor the 1911 quality and performance history of providers; 1912 establishing the MomCare network; requiring the agency 1913 to contract with a representative of all Healthy Start 1914 Coalitions to provide certain services to recipients; 1915 providing for support of these activities by certain 1916 expenditures and federal matching funds; requiring 1917 plans to enter into agreements with local Healthy 1918 Start Coalitions for certain purposes; requiring 1919 specified programs and procedures be established by 1920 plans; establishing a screening standard for the Early 1921 and Periodic Screening, Diagnosis, and Treatment 1922 Service; requiring managed care plans and hospitals to 1923 negotiate rates, methods, and terms of payment; 1924 providing a limit on payments to hospitals; 1925 establishing plan requirements for medically needy 1926 recipients; creating s. 409.976, F.S.; providing for 1927 managed care plan payment; requiring the agency to 1928 establish payment rates for statewide inpatient 1929 psychiatric programs; requiring payments to managed 1930 care plans to be reconciled to reimburse actual 1931 payments to statewide inpatient psychiatric programs; 1932 creating s. 409.977, F.S.; providing for automatic 1933 enrollment in a managed care plan for certain 1934 recipients; establishing opt-out opportunities for 1935 recipients; creating s. 409.978, F.S.; requiring the 1936 agency to be responsible for administering the long 1937 term care managed care program; providing 1938 implementation dates for the long-term care managed 1939 care program; providing duties of the Department of 1940 Elderly Affairs relating to assisting the agency in 1941 implementing the program; creating s. 409.979, F.S.; 1942 providing eligibility requirements for the long-term 1943 care managed care program; creating s. 409.98, F.S.; 1944 establishing the benefits covered under a managed care 1945 plan participating in the long-term care managed care 1946 program; creating s. 409.981, F.S.; providing criteria 1947 for eligible plans; designating regions for plan 1948 implementation throughout the state; providing 1949 criteria for the selection of plans to participate in 1950 the long-term care managed care program; providing 1951 that participation by the Program of All-Inclusive 1952 Care for the Elderly and certain Medicare plans is 1953 pursuant to an agency contract and not subject to 1954 procurement; creating s. 409.982, F.S.; requiring the 1955 agency to establish uniform accounting and reporting 1956 methods for plans; providing for mandatory 1957 participation in plans by certain service providers; 1958 authorizing the exclusion of certain providers from 1959 plans for failure to meet quality or performance 1960 criteria; requiring plans to monitor participating 1961 providers using specified criteria; requiring certain 1962 providers to be included in plan networks; providing 1963 provider payment specifications for nursing homes and 1964 hospices; creating s. 409.983, F.S.; providing for 1965 negotiation of rates between the agency and the plans 1966 participating in the long-term care managed care 1967 program; providing specific criteria for calculating 1968 and adjusting plan payments; allowing the CARES 1969 program to assign plan enrollees to a level of care; 1970 providing incentives for adjustments of payment rates; 1971 requiring the agency to establish nursing facility 1972 specific and hospice services payment rates; creating 1973 s. 409.984, F.S.; providing criteria for automatic 1974 assignments of plan enrollees who fail to choose a 1975 plan; providing for hospice selection within a 1976 specified timeframe; providing for a choice of 1977 residential setting under certain circumstances; 1978 creating s. 409.9841, F.S.; creating the long-term 1979 care managed care technical advisory workgroup; 1980 providing duties; providing membership; providing for 1981 reimbursement for per diem and travel expenses; 1982 providing for repeal by a specified date; creating s. 1983 409.985, F.S.; providing that the agency shall operate 1984 the Comprehensive Assessment and Review for Long-Term 1985 Care Services program through an interagency agreement 1986 with the Department of Elderly Affairs; providing 1987 duties of the program; defining the term “nursing 1988 facility care”; providing for severability; providing 1989 an effective date.