CS/HB 7107

1
A bill to be entitled
2An act relating to Medicaid managed care; creating pt. IV
3of ch. 409, F.S., entitled "Medicaid Managed Care";
4creating s. 409.961, F.S.; providing for statutory
5construction; providing applicability of specified
6provisions throughout the part; providing rulemaking
7authority for specified agencies; creating s. 409.962,
8F.S.; providing definitions; creating s. 409.963, F.S.;
9designating the Agency for Health Care Administration as
10the single state agency to administer the Medicaid
11program; providing for specified agency responsibilities;
12requiring client consent for release of medical records;
13creating s. 409.964, F.S.; establishing the Medicaid
14program as the statewide, integrated managed care program
15for all covered services; authorizing the agency to apply
16for and implement waivers; providing for public notice and
17comment; creating s. 409.965, F.S.; providing for
18mandatory enrollment; providing for exemptions; creating
19s. 409.966, F.S.; providing requirements for eligible
20plans that provide services in the Medicaid managed care
21program; establishing provider service network
22requirements for eligible plans; providing for eligible
23plan selection; requiring the agency to use an invitation
24to negotiate; requiring the agency to compile and publish
25certain information; establishing eight regions for
26separate procurement of plans; providing quality criteria
27for plan selection; providing limitations on serving
28recipients during the pendency of procurement litigation;
29creating s. 409.967, F.S.; providing for managed care plan
30accountability; establishing contract terms; providing for
31contract extension under certain circumstances;
32establishing payments to noncontract providers;
33establishing requirements for access; requiring plans to
34establish and maintain an electronic database;
35establishing requirements for the database; requiring
36plans to provide encounter data; requiring the agency to
37maintain an encounter data system; requiring the agency to
38establish performance standards for plans; providing
39program integrity requirements; establishing a grievance
40resolution process; providing penalties for early
41termination of contracts or reduction in enrollment
42levels; establishing prompt payment requirements;
43requiring plans to accept electronic claims; requiring
44fair payment to providers with a controlling interest in a
45provider service network by other plans; requiring the
46agency and prepaid plans to use a uniform method for
47certain financial reports; providing income-sharing
48ratios; providing a timeframe for a plan to pay an
49additional rebate under certain circumstances; requiring
50the agency to return prepaid plan overpayments; creating
51s. 409.968, F.S.; establishing managed care plan payments;
52providing payment requirements for provider service
53networks; requiring the agency to conduct annual cost
54reconciliations to determine certain cost savings and
55report the results of the reconciliations to the fee-for-
56service provider; providing a timeframe for the provider
57service to respond to the report; creating s. 409.969,
58F.S.; requiring enrollment in managed care plans by all
59nonexempt Medicaid recipients; creating requirements for
60plan selection by recipients; providing for choice
61counseling; establishing choice counseling vendor
62requirements; authorizing disenrollment under certain
63circumstances; defining the term "good cause" for purposes
64of disenrollment; providing time limits on an internal
65grievance process; providing requirements for agency
66determination regarding disenrollment; requiring
67recipients to stay in plans for a specified time; creating
68s. 409.97, F.S.; authorizing the agency to accept the
69transfer of certain revenues from local governments;
70requiring the agency to contract with a representative of
71certain entities participating in the low-income pool for
72the provision of enhanced access to care; providing for
73support of these activities by the low-income pool as
74authorized in the General Appropriations Act; establishing
75the Access to Care Partnership; requiring the agency to
76seek necessary waivers and plan amendments; providing
77requirements for prepaid plans to submit data; authorizing
78the agency to implement a tiered hospital rate system;
79creating s. 409.971, F.S.; creating the managed medical
80assistance program; providing deadlines to begin and
81finalize implementation of the program; creating s.
82409.972, F.S.; providing eligibility requirements for
83mandatory and voluntary enrollment; creating s. 409.973,
84F.S.; establishing minimum benefits for managed care plans
85to cover; authorizing plans to customize benefit packages;
86requiring plans to establish a program to encourage
87healthy behaviors; requiring plans to establish a primary
88care initiative; providing requirements for primary care
89initiatives; requiring plans to report certain primary
90care data to the agency; creating s. 409.974, F.S.;
91establishing a deadline for issuing invitations to
92negotiate; establishing a specified number or range of
93eligible plans to be selected in each region; establishing
94quality selection criteria; establishing requirements for
95participation by specialty plans; establishing the
96Children's Medical Service Network as an eligible plan;
97creating s. 409.975, F.S.; providing for managed care plan
98accountability; authorizing plans to limit providers in
99networks; requiring plans to include essential Medicaid
100providers in their networks unless an alternative
101arrangement is approved by the agency; identifying
102statewide essential providers; specifying provider
103payments under certain circumstances; requiring plans to
104include certain statewide essential providers in their
105networks; requiring good faith negotiations; specifying
106provider payments under certain circumstances; allowing
107plans to exclude essential providers under certain
108circumstances; requiring plans to offer a contract to home
109medical equipment and supply providers under certain
110circumstances; establishing the Florida medical school
111quality network; requiring the agency to contract with a
112representative of certain entities to establish a clinical
113outcome improvement program in all plans; providing for
114support of these activities by certain expenditures and
115federal matching funds; requiring the agency to seek
116necessary waivers and plan amendments; providing for
117eligibility for the quality network; requiring plans to
118monitor the quality and performance history of providers;
119establishing the MomCare network; requiring the agency to
120contract with a representative of all Healthy Start
121Coalitions to provide certain services to recipients;
122providing for support of these activities by certain
123expenditures and federal matching funds; requiring plans
124to enter into agreements with local Healthy Start
125Coalitions for certain purposes; requiring specified
126programs and procedures be established by plans;
127establishing a screening standard for the Early and
128Periodic Screening, Diagnosis, and Treatment Service;
129requiring managed care plans and hospitals to negotiate
130rates, methods, and terms of payment; providing a limit on
131payments to hospitals; establishing plan requirements for
132medically needy recipients; creating s. 409.976, F.S.;
133providing for managed care plan payment; requiring the
134agency to establish payment rates for statewide inpatient
135psychiatric programs; requiring payments to managed care
136plans to be reconciled to reimburse actual payments to
137statewide inpatient psychiatric programs; creating s.
138409.977, F.S.; establishing choice counseling
139requirements; providing for automatic enrollment in a
140managed care plan for certain recipients; establishing
141opt-out opportunities for recipients; creating s. 409.978,
142F.S.; requiring the agency to be responsible for
143administering the long-term care managed care program;
144providing implementation dates for the long-term care
145managed care program; providing duties of the Department
146of Elderly Affairs relating to assisting the agency in
147implementing the program; creating s. 409.979, F.S.;
148providing eligibility requirements for the long-term care
149managed care program; creating s. 409.98, F.S.;
150establishing the benefits covered under a managed care
151plan participating in the long-term care managed care
152program; creating s. 409.981, F.S.; providing criteria for
153eligible plans; designating regions for plan
154implementation throughout the state; providing criteria
155for the selection of plans to participate in the long-term
156care managed care program; providing that participation by
157the Program of All-Inclusive Care for the Elderly is
158pursuant to an agency contract; creating s. 409.982, F.S.;
159requiring the agency to establish uniform accounting and
160reporting methods for plans; providing for mandatory
161participation in plans by certain service providers;
162authorizing the exclusion of certain providers from plans
163for failure to meet quality or performance criteria;
164requiring plans to monitor participating providers using
165specified criteria; requiring certain providers to be
166included in plan networks; providing provider payment
167specifications for nursing homes and hospices; creating s.
168409.983, F.S.; providing for negotiation of rates between
169the agency and the plans participating in the long-term
170care managed care program; providing specific criteria for
171calculating and adjusting plan payments; allowing the
172CARES program to assign plan enrollees to a level of care;
173providing incentives for adjustments of payment rates;
174requiring the agency to establish nursing facility-
175specific and hospice services payment rates; creating s.
176409.984, F.S.; providing that before contracting with
177another vendor, the agency shall offer to contract with
178the aging resource centers to provide choice counseling
179for the long-term care managed care program; providing
180criteria for automatic assignments of plan enrollees who
181fail to choose a plan; providing for hospice selection
182within a specified timeframe; providing for a choice of
183residential setting under certain circumstances; creating
184s. 409.9841, F.S.; creating the long-term care managed
185care technical advisory workgroup; providing duties;
186providing membership; providing for reimbursement for per
187diem and travel expenses; providing for repeal by a
188specified date; creating s. 409.985, F.S.; providing that
189the agency shall operate the Comprehensive Assessment and
190Review for Long-Term Care Services program through an
191interagency agreement with the Department of Elderly
192Affairs; providing duties of the program; defining the
193term "nursing facility care"; creating s. 409.986, F.S.;
194providing authority and agency duties regarding long-term
195care programs for persons with developmental disabilities;
196authorizing the agency to delegate specific duties to and
197collaborate with the Agency for Persons with Disabilities;
198requiring the agency to make payments for long-term care
199for persons with developmental disabilities under certain
200conditions; creating s. 409.987, F.S.; providing
201eligibility requirements for long-term care plans;
202creating s. 409.988, F.S.; specifying covered benefits for
203long-term care plans; creating s. 409.989, F.S.;
204establishing criteria for eligible plans; specifying
205minimum and maximum number of plans and selection
206criteria; authorizing participation by the Children's
207Medical Services Network in long-term care plans under
208certain conditions; creating s. 409.99, F.S.; providing
209requirements for managed care plan accountability;
210specifying limitations on providers in plan networks;
211providing for evaluation and payment of network providers;
212requiring managed care plans to establish family advisory
213committees and offer consumer-directed care services;
214creating s. 409.991, F.S.; providing for payment of
215managed care plans; providing duties for the Agency for
216Persons with Disabilities to assign plan enrollees into a
217payment-rate level of care; establishing level-of-care
218criteria; providing payment requirements for intensive
219behavior residential habilitation providers and
220intermediate care facilities for the developmentally
221disabled; creating s. 409.992, F.S.; providing
222requirements for enrollment and choice counseling;
223specifying enrollment exceptions for certain Medicaid
224recipients; providing an effective date.
225
226Be It Enacted by the Legislature of the State of Florida:
227
228     Section 1.  Sections 409.961 through 409.992, Florida
229Statutes, are designated as part IV of chapter 409, Florida
230Statutes, entitled "Medicaid Managed Care."
231     Section 2.  Section 409.961, Florida Statutes, is created
232to read:
233     409.961  Statutory construction; applicability; rules.-It
234is the intent of the Legislature that if any conflict exists
235between the provisions contained in this part and provisions
236contained in other parts of this chapter, the provisions
237contained in this part shall control. The provisions of ss.
238409.961-409.97 apply only to the Medicaid managed medical
239assistance program, long-term care managed care program, and
240managed long-term care for persons with developmental
241disabilities program, as provided in this part. The agency shall
242adopt any rules necessary to comply with or administer this part
243and all rules necessary to comply with federal requirements. In
244addition, the department shall adopt and accept the transfer of
245any rules necessary to carry out the department's
246responsibilities for receiving and processing Medicaid
247applications and determining Medicaid eligibility and for
248ensuring compliance with and administering this part, as those
249rules relate to the department's responsibilities, and any other
250provisions related to the department's responsibility for the
251determination of Medicaid eligibility.
252     Section 3.  Section 409.962, Florida Statutes, is created
253to read:
254     409.962  Definitions.-As used in this part, except as
255otherwise specifically provided, the term:
256     (1)  "Agency" means the Agency for Health Care
257Administration.
258     (2)  "Aging network service provider" means a provider that
259participated in a home and community-based waiver administered
260by the Department of Elderly Affairs or the community care
261service system pursuant to s. 430.205, as of October 1, 2013.
262     (3)  "Comprehensive long-term care plan" means a managed
263care plan that provides services described in s. 409.973 and
264also provides the services described in s. 409.98 or s. 409.988.
265     (4)  "Department" means the Department of Children and
266Family Services.
267     (5)  "Developmental disability provider service network"
268means a provider service network, a controlling interest of
269which includes one or more entities licensed pursuant to s.
270393.067 or s. 400.962 with 18 or more licensed beds and the
271owner or owners of which have at least 10 years' experience
272serving persons with developmental disabilities.
273     (6)  "Direct care management" means care management
274activities that involve direct interaction with Medicaid
275recipients.
276     (7)  "Eligible plan" means a health insurer authorized
277under chapter 624, an exclusive provider organization authorized
278under chapter 627, a health maintenance organization authorized
279under chapter 641, or a provider service network authorized
280under s. 409.912(4)(d). For purposes of the managed medical
281assistance program, the term also includes the Children's
282Medical Services Network authorized under chapter 391. For
283purposes of the long-term care managed care program, the term
284also includes entities qualified under 42 C.F.R. part 422 as
285Medicare Advantage Preferred Provider Organizations, Medicare
286Advantage Provider-sponsored Organizations, and Medicare
287Advantage Special Needs Plans, and the Program of All-Inclusive
288Care for the Elderly.
289     (8)  "Long-term care plan" means a managed care plan that
290provides the services described in s. 409.98 for the long-term
291care managed care program or the services described in s.
292409.988 for the long-term care managed care program for persons
293with developmental disabilities.
294     (9)  "Long-term care provider service network" means a
295provider service network a controlling interest of which is
296owned by one or more licensed nursing homes, assisted living
297facilities with 17 or more beds, home health agencies, community
298care for the elderly lead agencies, or hospices.
299     (10)  "Managed care plan" means an eligible plan under
300contract with the agency to provide services in the Medicaid
301program.
302     (11)  "Medicaid" means the medical assistance program
303authorized by Title XIX of the Social Security Act, 42 U.S.C.
304ss. 1396 et seq., and regulations thereunder, as administered in
305this state by the agency.
306     (12)  "Medicaid recipient" or "recipient" means an
307individual who the department or, for Supplemental Security
308Income, the Social Security Administration determines is
309eligible pursuant to federal and state law to receive medical
310assistance and related services for which the agency may make
311payments under the Medicaid program. For the purposes of
312determining third-party liability, the term includes an
313individual formerly determined to be eligible for Medicaid, an
314individual who has received medical assistance under the
315Medicaid program, or an individual on whose behalf Medicaid has
316become obligated.
317     (13)  "Prepaid plan" means a managed care plan that is
318licensed or certified as a risk-bearing entity, or qualified
319pursuant to s. 409.912(4)(d), in the state and is paid a
320prospective per-member, per-month payment by the agency.
321     (14)  "Provider service network" means an entity qualified
322pursuant to s. 409.912(4)(d) of which a controlling interest is
323owned by a health care provider, or group of affiliated
324providers, or a public agency or entity that delivers health
325services. Health care providers include Florida-licensed health
326care professionals or licensed health care facilities, federally
327qualified health care centers, and home health care agencies.
328     (15)  "Specialty plan" means a managed care plan that
329serves Medicaid recipients who meet specified criteria based on
330age, medical condition, or diagnosis.
331     Section 4.  Section 409.963, Florida Statutes, is created
332to read:
333     409.963  Single state agency.-The Agency for Health Care
334Administration is designated as the single state agency
335authorized to manage, operate, and make payments for medical
336assistance and related services under Title XIX of the Social
337Security Act. Subject to any limitations or directions provided
338for in the General Appropriations Act, these payments may be
339made only for services included in the program, only on behalf
340of eligible individuals, and only to qualified providers in
341accordance with federal requirements for Title XIX of the Social
342Security Act and the provisions of state law. This program of
343medical assistance is designated as the "Medicaid program." The
344department is responsible for Medicaid eligibility
345determinations, including, but not limited to, policy, rules,
346and the agreement with the Social Security Administration for
347Medicaid eligibility determinations for Supplemental Security
348Income recipients, as well as the actual determination of
349eligibility. As a condition of Medicaid eligibility, subject to
350federal approval, the agency and the department shall ensure
351that each Medicaid recipient consents to the release of her or
352his medical records to the agency and the Medicaid Fraud Control
353Unit of the Department of Legal Affairs.
354     Section 5.  Section 409.964, Florida Statutes is created to
355read:
356     409.964  Managed care program; state plan; waivers.-The
357Medicaid program is established as a statewide, integrated
358managed care program for all covered services, including long-
359term care services. The agency shall apply for and implement
360state plan amendments or waivers of applicable federal laws and
361regulations necessary to implement the program. Before seeking a
362waiver, the agency shall provide public notice and the
363opportunity for public comment and shall include public feedback
364in the waiver application. The agency shall hold one public
365meeting in each of the regions described in s. 409.966(2) and
366the time period for public comment for each region shall end no
367sooner than 30 days after the completion of the public meeting
368in that region.
369     Section 6.  Section 409.965, Florida Statutes, is created
370to read:
371     409.965  Mandatory enrollment.-All Medicaid recipients
372shall receive covered services through the statewide managed
373care program, except as provided by this part pursuant to an
374approved federal waiver. The following Medicaid recipients are
375exempt from participation in the statewide managed care program:
376     (1)  Women who are only eligible for family planning
377services.
378     (2)  Women who are only eligible for breast and cervical
379cancer services.
380     (3)  Persons who are eligible for emergency Medicaid for
381aliens.
382     Section 7.  Section 409.966, Florida Statutes, is created
383to read:
384     409.966  Eligible plans; selection.-
385     (1)  ELIGIBLE PLANS.-Services in the Medicaid managed care
386program shall be provided by eligible plans. A provider service
387network must be capable of providing all covered services to a
388mandatory Medicaid managed care enrollee or may limit the
389provision of services to a specific target population based on
390the age, chronic disease state, or medical condition of the
391enrollee to whom the network will provide services. A specialty
392provider service network must be capable of coordinating care
393and delivering or arranging for the delivery of all covered
394services to the target population. A provider service network
395may partner with an insurer licensed under chapter 627 or a
396health maintenance organization licensed under chapter 641 to
397meet the requirements of a Medicaid contract.
398     (2)  ELIGIBLE PLAN SELECTION.-The agency shall select a
399limited number of eligible plans to participate in the Medicaid
400program using invitations to negotiate in accordance with s.
401287.057(3)(a). At least 90 days before issuing an invitation to
402negotiate, the agency shall compile and publish a databook
403consisting of a comprehensive set of utilization and spending
404data for the 3 most recent contract years consistent with the
405rate-setting periods for all Medicaid recipients by region or
406county. The source of the data in the report shall include both
407historic fee-for-service claims and validated data from the
408Medicaid Encounter Data System. The report shall be made
409available in electronic form and shall delineate utilization use
410by age, gender, eligibility group, geographic area, and
411aggregate clinical risk score. Separate and simultaneous
412procurements shall be conducted in each of the following
413regions:
414     (a)  Region I, which shall consist of Bay, Calhoun,
415Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson,
416Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla,
417Walton, and Washington Counties.
418     (b)  Region II, which shall consist of Alachua, Baker,
419Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton,
420Lafayette, Lake, Levy, Marion, Sumter, Suwannee, and Union
421Counties.
422     (c)  Region III, which shall consist of Clay, Duval,
423Flagler, Nassau, Putman, St. Johns, and Volusia Counties.
424     (d)  Region IV, which shall consist of Brevard, Indian
425River, Okeechobee, Orange, Osceola, Seminole, and St. Lucie
426Counties.
427     (e)  Region V, which shall consist of Hernando,
428Hillsborough, Pasco, Pinellas, and Polk Counties.
429     (f)  Region VI, which shall consist of Charlotte, Collier,
430DeSoto, Hardee, Highlands, Lee, Manatee, and Sarasota Counties.
431     (g)  Region VII, which shall consist of Broward, Glades,
432Hendry, Martin, and Palm Beach Counties.
433     (h)  Region VIII, which shall consist of Miami-Dade and
434Monroe Counties.
435     (3)  QUALITY SELECTION CRITERIA.-
436     (a)  The invitation to negotiate must specify the criteria
437and the relative weight of the criteria that will be used for
438determining the acceptability of the reply and guiding the
439selection of the organizations with which the agency negotiates.
440In addition to criteria established by the agency, the agency
441shall consider the following factors in the selection of
442eligible plans:
443     1.  Accreditation by the National Committee for Quality
444Assurance, the Joint Commission, or another nationally
445recognized accrediting body.
446     2.  Experience serving similar populations, including the
447organization's record in achieving specific quality standards
448with similar populations.
449     3.  Availability and accessibility of primary care and
450specialty physicians in the provider network.
451     4.  Establishment of community partnerships with providers
452that create opportunities for reinvestment in community-based
453services.
454     5.  Organization commitment to quality improvement and
455documentation of achievements in specific quality improvement
456projects, including active involvement by organization
457leadership.
458     6.  Provision of additional benefits, particularly dental
459care and disease management, and other initiatives that improve
460health outcomes.
461     7.  Evidence that a qualified plan has written agreements
462or signed contracts or has made substantial progress in
463establishing relationships with providers before the plan
464submitting a response.
465     8.  Comments submitted in writing by any enrolled Medicaid
466provider relating to a specifically identified plan
467participating in the procurement in the same region as the
468submitting provider.
469     9.  The business relationship a qualified plan has with any
470other qualified plan that responds to the invitation to
471negotiate.
472
473A qualified plan must disclose any business relationship it has
474with any other qualified plan that responds to the invitation to
475negotiate. The agency may not select plans in the same region
476for the same managed care program that have a business
477relationship with each other. Failure to disclose any business
478relationship shall result in disqualification from participation
479in any region for the first full contract period after the
480discovery of the business relationship by the agency. For the
481purpose of this section, "business relationship" means an
482ownership or controlling interest, an affiliate or subsidiary
483relationship, a common parent, or any mutual interest in any
484limited partnership, limited liability partnership, limited
485liability company, or other entity or business association,
486including all wholly or partially owned subsidiaries, majority-
487owned subsidiaries, parent companies, or affiliates of such
488entities, business associations, or other enterprises, that
489exists for the purpose of making a profit.
490     (b)  After negotiations are conducted, the agency shall
491select the eligible plans that are determined to be responsive
492and provide the best value to the state. Preference shall be
493given to plans that demonstrate the following:
494     1.  Signed contracts with primary and specialty physicians
495in sufficient numbers to meet the specific standards established
496pursuant to s. 409.967(2)(b).
497     2.  Well-defined programs for recognizing patient-centered
498medical homes or accountable care organizations, and providing
499for increased compensation for recognized medical homes or
500accountable care organizations, as defined by the plan.
501     3.  Greater net economic benefit to Florida compared to
502other bidders through employment of, or subcontracting with
503firms that employ, Floridians in order to accomplish the
504contract requirements. Contracts with such bidders shall specify
505performance measures to evaluate the plan's employment-based
506economic impact. Valuation of the net economic benefit may not
507include employment of or subcontracts with providers.
508     (c)  To ensure managed care plan participation in Region I,
509the agency shall award an additional contract to each plan with
510a contract award in Region I. Such contract shall be in any
511other region in which the plan submitted a responsive bid and
512negotiates a rate acceptable to the agency. If a plan that is
513awarded an additional contract pursuant to this paragraph is
514subject to penalties pursuant to s. 409.967(2)(g) for activities
515in Region I, the additional contract is automatically terminated
516180 days after the imposition of the penalties. The plan shall
517reimburse the agency for the cost of enrollment changes and
518other transition activities, including the cost of additional
519choice counseling services.
520     (4)  ADMINISTRATIVE CHALLENGE.-Any eligible plan that
521participates in an invitation to negotiate in more than one
522region and is selected in at least one region may not begin
523serving Medicaid recipients in any region for which it was
524selected until all administrative challenges to procurements
525required by this section to which the eligible plan is a party
526have been finalized. If the number of plans selected is less
527than the maximum amount of plans permitted in the region, the
528agency may contract with other selected plans in the region not
529participating in the administrative challenge before resolution
530of the administrative challenge. For purposes of this
531subsection, an administrative challenge is finalized if an order
532granting voluntary dismissal with prejudice has been entered by
533any court established under Article V of the State Constitution
534or by the Division of Administrative Hearings, a final order has
535been entered into by the agency and the deadline for appeal has
536expired, a final order has been entered by the First District
537Court of Appeal and the time to seek any available review by the
538Florida Supreme Court has expired, or a final order has been
539entered by the Florida Supreme Court and a warrant has been
540issued.
541     Section 8.  Section 409.967, Florida Statutes, is created
542to read:
543     409.967  Managed care plan accountability.-
544     (1)  The agency shall establish a 5-year contract with each
545managed care plan selected through the procurement process
546described in s. 409.966. A plan contract may not be renewed;
547however, the agency may extend the terms of a plan contract to
548cover any delays in transition to a new plan.
549     (2)  The agency shall establish such contract requirements
550as are necessary for the operation of the statewide managed care
551program. In addition to any other provisions the agency may deem
552necessary, the contract shall require:
553     (a)  Emergency services.-Managed care plans shall pay for
554services required by ss. 395.1041 and 401.45 and rendered by a
555noncontracted provider. The plans must comply with s. 641.3155.  
556Reimbursement for services under this paragraph shall be the
557lesser of:
558     1.  The provider's charges;
559     2.  The usual and customary provider charges for similar
560services in the community where the services were provided;
561     3.  The charge mutually agreed to by the entity and the
562provider within 60 days after submittal of the claim; or
563     4.  The rate the agency would have paid on the most recent
564October 1st.
565     (b)  Access.-The agency shall establish specific standards
566for the number, type, and regional distribution of providers in
567managed care plan networks to ensure access to care for both
568adults and children. Each plan must maintain a region-wide
569network of providers in sufficient numbers to meet the access
570standards for specific medical services for all recipients
571enrolled in the plan. The exclusive use of mail-order pharmacies
572shall not be sufficient to meet network access standards.
573Consistent with the standards established by the agency,
574provider networks may include providers located outside the
575region. A plan may contract with a new hospital facility before
576the date the hospital becomes operational if the hospital has
577commenced construction, will be licensed and operational by
578January 1, 2013, and a final order has issued in any civil or
579administrative challenge. Each plan shall establish and maintain
580an accurate and complete electronic database of contracted
581providers, including information about licensure or
582registration, locations and hours of operation, specialty
583credentials and other certifications, specific performance
584indicators, and such other information as the agency deems
585necessary. The database shall be available online to both the
586agency and the public and shall have the capability to compare
587the availability of providers to network adequacy standards and
588to accept and display feedback from each provider's patients.
589Each plan shall submit quarterly reports to the agency
590identifying the number of enrollees assigned to each primary
591care provider.
592     (c)  Encounter data.-The agency shall maintain and operate
593a Medicaid Encounter Data System to collect, process, store, and
594report on covered services provided to all Medicaid recipients
595enrolled in prepaid plans.
596     1.  Each prepaid plan must comply with the agency's
597reporting requirements for the Medicaid Encounter Data System.
598Prepaid plans must submit encounter data electronically in a
599format that complies with the Health Insurance Portability and
600Accountability Act provisions for electronic claims and in
601accordance with deadlines established by the agency. Prepaid
602plans must certify that the data reported is accurate and
603complete.
604     2.  The agency is responsible for validating the data
605submitted by the plans. The agency shall develop methods and
606protocols for ongoing analysis of the encounter data that
607adjusts for differences in characteristics of prepaid plan
608enrollees to allow comparison of service utilization among plans
609and against expected levels of use. The analysis shall be used
610to identify possible cases of systemic underutilization or
611denials of claims and inappropriate service utilization such as
612higher-than-expected emergency department encounters. The
613analysis shall provide periodic feedback to the plans and enable
614the agency to establish corrective action plans when necessary.
615One of the focus areas for the analysis shall be the use of
616prescription drugs.
617     3.  The agency shall make encounter data available to those
618plans accepting enrollees who are assigned to them from other
619plans leaving a region.
620     (d)  Continuous improvement.-The agency shall establish
621specific performance standards and expected milestones or
622timelines for improving performance over the term of the
623contract. By the end of the fourth year of the first contract
624term, the agency shall issue a request for information to
625determine whether cost savings could be achieved by contracting
626for plan oversight and monitoring, including analysis of
627encounter data, assessment of performance measures, and
628compliance with other contractual requirements. Each managed
629care plan shall establish an internal health care quality
630improvement system, including enrollee satisfaction and
631disenrollment surveys. The quality improvement system shall
632include incentives and disincentives for network providers.
633     (e)  Program integrity.-Each managed care plan shall
634establish program integrity functions and activities to reduce
635the incidence of fraud and abuse, including, at a minimum:
636     1.  A provider credentialing system and ongoing provider
637monitoring;
638     2.  An effective prepayment and postpayment review process
639including, but not limited to, data analysis, system editing,
640and auditing of network providers;
641     3.  Procedures for reporting instances of fraud and abuse
642pursuant to chapter 641;
643     4.  Administrative and management arrangements or
644procedures, including a mandatory compliance plan, designed to
645prevent fraud and abuse; and
646     5.  Designation of a program integrity compliance officer.
647     (f)  Grievance resolution.-Consistent with federal law,
648each managed care plan shall establish and the agency shall
649approve an internal process for reviewing and responding to
650grievances from enrollees. Each plan shall submit quarterly
651reports on the number, description, and outcome of grievances
652filed by enrollees.
653     (g)  Penalties.-Managed care plans that reduce enrollment
654levels or leave a region before the end of the contract term
655shall reimburse the agency for the cost of enrollment changes
656and other transition activities, including the cost of
657additional choice counseling services. If more than one plan
658leaves a region at the same time, costs shall be shared by the
659departing plans proportionate to their enrollments. In addition
660to the payment of costs, departing provider services networks
661shall pay a per enrollee penalty not to exceed 3 month's payment
662and shall continue to provide services to the enrollee for 90
663days or until the enrollee is enrolled in another plan,
664whichever is sooner. In addition to payment of costs, all other
665plans shall pay a penalty equal to 25 percent of the minimum
666surplus requirement pursuant to s. 641.225(1). Plans shall
667provide the agency notice no less than 180 days before
668withdrawing from a region.
669     (h)  Prompt payment.-Managed care plans shall comply with
670ss. 641.315, 641.3155, and 641.513.
671     (i)  Electronic claims.-Managed care plans shall accept
672electronic claims in compliance with federal standards.
673     (j)  Fair payment.-Provider service networks must ensure
674that no network provider with a controlling interest in the
675network charges any Medicaid managed care plan more than the
676amount paid to that provider by the provider service network for
677the same service.
678     (3)  ACHIEVED SAVINGS REBATE.-
679     (a)  The agency shall establish and the prepaid plans shall
680use a uniform method for annually reporting premium revenue,
681medical and administrative costs, and income or losses, across
682all Florida Medicaid prepaid plan lines of business in all
683regions. The reports shall be due to the agency within 270 days
684after the conclusion of the reporting period and the agency may
685audit the reports. Achieved savings rebates shall be due within
68630 days after the report is submitted. Except as provided in
687paragraph (b), the achieved savings rebate will be established
688by determining pretax income as a percentage of revenues and
689applying the following income sharing ratios:
690     1.  One hundred percent of income up to and including 5
691percent of revenue shall be retained by the plan.
692     2.  Fifty percent of income above 5 percent and up to 10
693percent shall be retained by the plan, with the other 50 percent
694refunded to the state.
695     3.  One hundred percent of income above 10 percent of
696revenue shall be refunded to the state.
697     (b)  A plan that meets or exceeds agency-defined quality
698measures in the reporting period may retain an additional 1
699percent of revenue.
700     (c)  The following expenses may not be included in
701calculating income to the plan:
702     1.  Payment of achieved savings rebates.
703     2.  Any financial incentive payments made to the plan
704outside of the capitation rate.
705     3.  Any financial disincentive payments levied by the state
706or federal governments.
707     4.  Expenses associated with lobbying activities.
708     5.  Administrative, reinsurance, and outstanding claims
709expenses in excess of actuarially sound maximum amounts set by
710the agency.
711     6.  Any payment made pursuant to paragraph (f).
712     (d)  Prepaid plans that incur a loss in the first contract
713year may apply the full amount of the loss as an offset to
714income in the second contract year.
715     (e)  If, after an audit or other reconciliation, the agency
716determines that a prepaid plan owes an additional rebate, the
717plan shall have 30 days after notification to make the payment.
718Upon failure to timely pay the rebate, the agency shall withhold
719future payments to the plan until the entire amount is recouped.
720If the agency determines that a prepaid plan has made an
721overpayment, the agency shall return the overpayment within 30
722days.
723     (f)  In addition to the reporting required by paragraph
724(a), prepaid plans shall annually submit a report, consistent
725with paragraph (a), which is specific to enrollees with
726developmental disabilities. The agency shall compare each plan's
727expenditures to the plan's aggregate premiums for this
728population. The difference between aggregate premiums and
729expenditures shall be shared equally between the plan and the
730state. The state share shall be returned to the Medicaid
731appropriation to serve people on the wait list for home and
732community-based services provided through individual budgets.
733     Section 9.  Section 409.968, Florida Statutes, is created
734to read:
735     409.968  Managed care plan payments.-
736     (1)  Prepaid plans shall receive per-member, per-month
737payments negotiated pursuant to the procurements described in s.
738409.966. Payments shall be risk-adjusted rates based on
739historical utilization and spending data, projected forward, and
740adjusted to reflect the eligibility category, geographic area,
741and clinical risk profile of the recipients. In negotiating
742rates with the plans, the agency shall consider any adjustments
743necessary to encourage plans to use the most cost effective
744modalities for treatment of chronic disease such as peritoneal
745dialysis.
746     (2)  Provider service networks may be prepaid plans and
747receive per-member, per-month payments negotiated pursuant to
748the procurement process described in s. 409.966. Provider
749service networks that choose not to be prepaid plans shall
750receive fee-for-service rates with a shared savings settlement.
751The fee-for-service option shall be available to a provider
752service network only for the first 3 years of its operation. The
753agency shall annually conduct cost reconciliations to determine
754the amount of cost savings achieved by fee-for-service provider
755service networks for the dates of service within the period
756being reconciled. Only payments for covered services for dates
757of service within the reconciliation period and paid within 6
758months after the last date of service in the reconciliation
759period shall be included. The agency shall perform the necessary
760adjustments for the inclusion of claims incurred but not
761reported within the reconciliation period for claims that could
762be received and paid by the agency after the 6-month claims
763processing time lag. The agency shall provide the results of the
764reconciliations to the fee-for-service provider service networks
765within 45 days after the end of the reconciliation period. The
766fee-for-service provider service networks shall review and
767provide written comments or a letter of concurrence to the
768agency within 45 days after receipt of the reconciliation
769results. This reconciliation shall be considered final.
770     Section 10.  Section 409.969, Florida Statutes, is created
771to read:
772     409.969  Enrollment; choice counseling; automatic
773assignment; disenrollment.-
774     (1)  ENROLLMENT.-All Medicaid recipients shall be enrolled
775in a managed care plan unless specifically exempted under this
776part. Each recipient shall have a choice of plans and may select
777any available plan unless that plan is restricted by contract to
778a specific population that does not include the recipient.
779Medicaid recipients shall have 30 days in which to make a choice
780of plans. All recipients shall be offered choice counseling
781services in accordance with this section.
782     (2)  CHOICE COUNSELING.-The agency shall provide choice
783counseling for Medicaid recipients. The agency may contract for
784the provision for choice counseling. Except as provided in s.
785409.984, any such contract shall be procured competitively. The
786contract shall be with a vendor that employs Floridians to
787accomplish the contract requirements, shall be for a period of 5
788years, and shall comply with the provisions of 42 C.F.R. part
789483, relating to enrollment brokers as defined in that part. The
790agency may renew a contract for an additional 5-year period;
791however, before renewal of the contract the agency shall hold at
792least one public meeting in each of the regions covered by the
793choice counseling vendor. The agency may extend the term of the
794contract to cover any delays in transition to a new contractor.
795Printed choice information and choice counseling shall be
796offered in the native or preferred language of the recipient,
797consistent with federal requirements. The manner and method of
798choice counseling shall be modified as necessary to ensure
799culturally competent, effective communication with people from
800diverse cultural backgrounds. The agency shall maintain a record
801of the recipients who receive such services, identifying the
802scope and method of the services provided. The agency shall make
803available clear and easily understandable choice information to
804Medicaid recipients that includes:
805     (a)  An explanation that each recipient has the right to
806choose a managed care plan at the time of enrollment in Medicaid
807and again at regular intervals set by the agency, and that if a
808recipient does not choose a plan, the agency will assign the
809recipient to a plan according to the criteria specified in this
810section.
811     (b)  A list and description of the benefits provided in
812each managed care plan.
813     (c)  An explanation of benefit limits.
814     (d)  A current list of providers participating in the
815network, including location and contact information.
816     (e)  Managed care plan performance data.
817     (3)  DISENROLLMENT; GRIEVANCES.-After a recipient has
818enrolled in a managed care plan, the recipient shall have 90
819days to voluntarily disenroll and select another plan. After 90
820days, no further changes may be made except for good cause. For
821purposes of this section, the term "good cause" includes, but is
822not limited to, poor quality of care, lack of access to
823necessary specialty services, an unreasonable delay or denial of
824service, or fraudulent enrollment. The agency must make a
825determination as to whether good cause exists. The agency may
826require a recipient to use the plan's grievance process before
827the agency's determination of good cause, except in cases in
828which immediate risk of permanent damage to the recipient's
829health is alleged.
830     (a)  The managed care plan internal grievance process, when
831used, must be completed in time to permit the recipient to
832disenroll by the first day of the second month after the month
833the disenrollment request was made. If the result of the
834grievance process is approval of an enrollee's request to
835disenroll, the agency is not required to make a determination in
836the case.
837     (b)  The agency must make a determination and take final
838action on a recipient's request so that disenrollment occurs no
839later than the first day of the second month after the month the
840request was made. If the agency fails to act within the
841specified timeframe, the recipient's request to disenroll is
842deemed to be approved as of the date agency action was required.
843Recipients who disagree with the agency's finding that good
844cause does not exist for disenrollment shall be advised of their
845right to pursue a Medicaid fair hearing to dispute the agency's
846finding.
847     (c)  Medicaid recipients enrolled in a managed care plan
848after the 90-day period shall remain in the plan for the
849remainder of the 12-month period. After 12 months, the recipient
850may select another plan. However, nothing shall prevent a
851Medicaid recipient from changing providers within the plan
852during that period.
853     (d)  On the first day of the month after receiving notice
854from a recipient that the recipient has moved to another region,
855the agency shall automatically disenroll the recipient from the
856managed care plan the recipient is currently enrolled in and
857treat the recipient as if the recipient is a new Medicaid
858enrollee. At that time, the recipient may choose another plan
859pursuant to the enrollment process established in this section.
860     (e)  The agency must monitor plan disenrollment throughout
861the contract term to identify any discriminatory practices.
862     Section 11.  Section 409.97, Florida Statutes, is created
863to read:
864     409.97  State and local Medicaid partnerships.-
865     (1)  INTERGOVERNMENTAL TRANSFERS.-In addition to the
866contributions required pursuant to s. 409.915, beginning in the
8672014-2015 fiscal year, the agency may accept voluntary transfers
868of local taxes and other qualified revenue from counties,
869municipalities, and special taxing districts. Such transfers
870must be contributed to advance the general goals of the Florida
871Medicaid program without restriction and must be executed
872pursuant to a contract between the agency and the local funding
873source. Contracts executed before October 31 shall result in
874contributions to Medicaid for that same state fiscal year.
875Contracts executed between November 1 and June 30 shall result
876in contributions for the following state fiscal year. Based on
877the date of the signed contracts, the agency shall allocate to
878the low-income pool the first contributions received up to the
879limit established by subsection (2). No more than 40 percent of
880the low-income pool funding shall come from any single funding
881source. Contributions in excess of the low-income pool shall be
882allocated to the disproportionate share programs defined in ss.
883409.911(3) and 409.9113 and to hospital rates pursuant to
884subsection (4). The local funding source shall designate in the
885contract which Medicaid providers ensure access to care for low-
886income and uninsured people within the applicable jurisdiction
887and are eligible for low-income pool funding. Eligible providers
888may include hospitals, primary care providers, and primary care
889access systems.
890     (2)  LOW-INCOME POOL.-The agency shall establish and
891maintain a low-income pool in a manner authorized by federal
892waiver. The low-income pool is created to compensate a network
893of providers designated pursuant to subsection (1). Funding of
894the low-income pool shall be limited to the maximum amount
895permitted by federal waiver minus a percentage specified in the
896General Appropriations Act. The low-income pool must be used to
897support enhanced access to services by offsetting shortfalls in
898Medicaid reimbursement, paying for otherwise uncompensated care,
899and financing coverage for the uninsured. The low-income pool
900shall be distributed in periodic payments to the Access to Care
901Partnership throughout the fiscal year. Distribution of low-
902income pool funds by the Access to Care Partnership to
903participating providers may be made through capitated payments,
904fees for services, or contracts for specific deliverables. The
905agency shall include the distribution amount for each provider
906in the contract with the Access to Care Partnership pursuant to
907subsection (3). Regardless of the method of distribution,
908providers participating in the Access to Care Partnership shall
909receive payments such that the aggregate benefit in the
910jurisdiction of each local funding source, as defined in
911subsection (1), equals the amount of the contribution plus a
912factor specified in the General Appropriations Act.
913     (3)  ACCESS TO CARE PARTNERSHIP.-The agency shall contract
914with an administrative services organization that has operating
915agreements with all health care facilities, programs, and
916providers supported with local taxes or certified public
917expenditures and designated pursuant to subsection (1). The
918contract shall provide for enhanced access to care for Medicaid,
919low-income, and uninsured Floridians. The partnership shall be
920responsible for an ongoing program of activities that provides
921needed, but uncovered or undercompensated, health services to
922Medicaid enrollees and persons receiving charity care, as
923defined in s. 409.911. Accountability for services rendered
924under this contract must be based on the number of services
925provided to unduplicated qualified beneficiaries, the total
926units of service provided to these persons, and the
927effectiveness of services provided as measured by specific
928standards of care. The agency shall seek such plan amendments or
929waivers as may be necessary to authorize the implementation of
930the low-income pool as the Access to Care Partnership pursuant
931to this section.
932     (4)  HOSPITAL RATE DISTRIBUTION.-
933     (a)  The agency is authorized to implement a tiered
934hospital rate system to enhance Medicaid payments to all
935hospitals when resources for the tiered rates are available from
936general revenue and such contributions pursuant to subsection
937(1) as are authorized under the General Appropriations Act.
938     1.  Tier 1 hospitals are statutory rural hospitals as
939defined in s. 395.602, statutory teaching hospitals as defined
940in s. 408.07(45), and specialty children's hospitals as defined
941in s. 395.002(28).
942     2.  Tier 2 hospitals are community hospitals not included
943in Tier 1 that provided more than 9 percent of the hospital's
944total inpatient days to Medicaid patients and charity patients,
945as defined in s. 409.911, and are located in the jurisdiction of
946a local funding source pursuant to subsection (1).
947     3.  Tier 3 hospitals include all community hospitals.
948     (b)  When rates are increased pursuant to this section, the
949Total Tier Allocation (TTA) shall be distributed as follows:
950     1.  Tier 1 (T1A) = 0.35 x TTA.
951     2.  Tier 2 (T2A) = 0.35 x TTA.
952     3.  Tier 3 (T3A) = 0.30 x TTA.
953     (c)  The tier allocation shall be distributed as a
954percentage increase to the hospital specific base rate (HSBR)
955established pursuant to s. 409.905(5)(c). The increase in each
956tier shall be calculated according to the proportion of tier-
957specific allocation to the total estimated inpatient spending
958(TEIS) for all hospitals in each tier:
959     1.  Tier 1 percent increase (T1PI) = T1A/Tier 1 total
960estimated inpatient spending (T1TEIS).
961     2.  Tier 2 percent increase (T2PI) = T2A /Tier 2 total
962estimated inpatient spending (T2TEIS).
963     3.  Tier 3 percent increase (T3PI) = T3A/ Tier 3 total
964estimated inpatient spending (T3TEIS).
965     (d)  The hospital-specific tiered rate (HSTR) shall be
966calculated as follows:
967     1.  For hospitals in Tier 3: HSTR = (1 + T3PI) x HSBR.
968     2.  For hospitals in Tier 2: HSTR = (1 + T2PI) x HSBR.
969     3.  For hospitals in Tier 1: HSTR = (1 + T1PI) x HSBR.
970     Section 12.  Section 409.971, Florida Statutes, is created
971to read:
972     409.971  Managed medical assistance program.-The agency
973shall make payments for primary and acute medical assistance and
974related services using a managed care model. By January 1, 2013,
975the agency shall begin implementation of the statewide managed
976medical assistance program, with full implementation in all
977regions by October 1, 2014.
978     Section 13.  Section 409.972, Florida Statutes, is created
979to read:
980     409.972  Mandatory and voluntary enrollment.-
981     (1)  Persons eligible for the program known as "medically
982needy" pursuant to s. 409.904(2)(a) shall enroll in managed care
983plans. Medically needy recipients shall meet the share of the
984cost by paying the plan premium, up to the share of the cost
985amount, contingent upon federal approval.
986     (2)  The following Medicaid-eligible persons are exempt
987from mandatory managed care enrollment required by s. 409.965,
988and may voluntarily choose to participate in the managed medical
989assistance program:
990     (a)  Medicaid recipients who have other creditable health
991care coverage, excluding Medicare.
992     (b)  Medicaid recipients residing in residential commitment
993facilities operated through the Department of Juvenile Justice
994or mental health treatment facilities as defined by s.
995394.455(32).
996     (c)  Persons eligible for refugee assistance.
997     (d)  Medicaid recipients who are residents of a
998developmental disability center, including Sunland Center in
999Marianna and Tacachale in Gainesville.
1000     (3)  Persons eligible for Medicaid but exempt from
1001mandatory participation who do not choose to enroll in managed
1002care shall be served in the Medicaid fee-for-service program as
1003provided in part III of this chapter.
1004     Section 14.  Section 409.973, Florida Statutes, is created
1005to read:
1006     409.973  Benefits.-
1007     (1)  MINIMUM BENEFITS.-Managed care plans shall cover, at a
1008minimum, the following services:
1009     (a)  Advanced registered nurse practitioner services.
1010     (b)  Ambulatory surgical treatment center services.
1011     (c)  Birthing center services.
1012     (d)  Chiropractic services.
1013     (e)  Dental services.
1014     (f)  Early periodic screening diagnosis and treatment
1015services for recipients under age 21.
1016     (g)  Emergency services.
1017     (h)  Family planning services and supplies.
1018(i)  Healthy start services, except as provided in s.
1019409.975(4).
1020     (j)  Hearing services.
1021     (k)  Home health agency services.
1022     (l)  Hospice services.
1023     (m)  Hospital inpatient services.
1024     (n)  Hospital outpatient services.
1025     (o)  Laboratory and imaging services.
1026     (p)  Medical supplies, equipment, prostheses, and orthoses.
1027     (q)  Mental health services.
1028     (r)  Nursing care.
1029     (s)  Optical services and supplies.
1030     (t)  Optometrist services.
1031     (u)  Physical, occupational, respiratory, and speech
1032therapy services.
1033     (v)  Physician services, including physician assistant
1034services.
1035     (w)  Podiatric services.
1036     (x)  Prescription drugs.
1037     (y)  Renal dialysis services.
1038     (z)  Respiratory equipment and supplies.
1039     (aa)  Rural health clinic services.
1040     (bb)  Substance abuse treatment services.
1041     (cc)  Transportation to access covered services, except as
1042provided in s. 409.975(5).
1043     (2)  CUSTOMIZED BENEFITS.-Managed care plans may customize
1044benefit packages for nonpregnant adults, vary cost-sharing
1045provisions, and provide coverage for additional services. The
1046agency shall evaluate the proposed benefit packages to ensure
1047services are sufficient to meet the needs of the plan's
1048enrollees and to verify actuarial equivalence.
1049     (3)  HEALTHY BEHAVIORS.-Each plan operating in the managed
1050medical assistance program shall establish a program to
1051encourage and reward healthy behaviors.
1052     (4)  PRIMARY CARE INITIATIVE.-Each plan operating in the
1053managed medical assistance program shall establish a program to
1054encourage enrollees to establish a relationship with their
1055primary care provider. Each plan shall:
1056     (a)  Within 30 days after enrollment, provide information
1057to each enrollee on the importance of and procedure for
1058selecting a primary care physician, and thereafter automatically
1059assign to a primary care provider any enrollee who fails to
1060choose a primary care provider.
1061     (b)  Within 90 days after selection of or assignment to a
1062primary care provider, provide information to each enrollee on
1063the importance of scheduling a wellness screening with the
1064enrollee's primary care physician.
1065     (c)  Report to the agency the number of enrollees assigned
1066to each primary care provider within the plan's network.
1067     (d)  Report to the agency the number of enrollees who have
1068not had an appointment with their primary care provider within
1069their first year of enrollment.
1070     (e)  Report to the agency the number of emergency room
1071visits by enrollees who have not had a least one appointment
1072with their primary care provider.
1073     Section 15.  Section 409.974, Florida Statutes, is created
1074to read:
1075     409.974  Eligible plans.-
1076     (1)  ELIGIBLE PLAN SELECTION.-The agency shall select
1077eligible plans through the procurement process described in s.
1078409.966. The agency shall notice invitations to negotiate no
1079later than January 1, 2013.
1080     (a)  The agency shall procure three plans for Region I. At
1081least one plan shall be a provider service network, if any
1082provider service network submits a responsive bid.
1083     (b)  The agency shall procure three plans for Region II. At
1084least one plan shall be a provider service network, if any
1085provider service network submits a responsive bid.
1086     (c)  The agency shall procure at least three plans and no
1087more than four plans for Region III. At least two plans shall be
1088provider service networks, if any two provider service networks
1089submit responsive bids.
1090     (d)  The agency shall procure at least four plans and no
1091more than seven plans for Region IV. At least two plans shall be
1092provider service networks if any two provider service networks
1093submit responsive bids.
1094     (e)  The agency shall procure at least five plans and no
1095more than eight plans for Region V. At least two plans shall be
1096provider service networks, if any two provider service networks
1097submit responsive bids.
1098     (f)  The agency shall procure at least three plans and no
1099more than four plans for Region VI. At least one plan shall be a
1100provider service network, if any provider service network
1101submits a responsive bid.
1102     (g)  The agency shall procure at least four plans and no
1103more than seven plans for Region VII. At least two plans shall
1104be provider service networks, if any two provider service
1105networks submit a responsive bid.
1106     (h)  The agency shall procure at least six plans and no
1107more than ten plans for Region VIII. At least two plans shall be
1108provider service networks, if any two provider service networks
1109submit a responsive bid.
1110
1111If no provider service network submits a responsive bid, the
1112agency shall procure no more than one less than the maximum
1113number of eligible plans permitted in that region. Within 12
1114months after the initial invitation to negotiate, the agency
1115shall attempt to procure a provider service network. The agency
1116shall notice another invitation to negotiate only with provider
1117service networks in such region where no provider service
1118network has been selected.
1119     (2)  QUALITY SELECTION CRITERIA.-In addition to the
1120criteria established in s. 409.966, the agency shall consider
1121evidence that an eligible plan has written agreements or signed
1122contracts or has made substantial progress in establishing
1123relationships with providers before the plan submitting a
1124response. The agency shall evaluate and give special weight to
1125evidence of signed contracts with essential providers as defined
1126by the agency pursuant to s. 409.975(2). The agency shall
1127exercise a preference for plans with a provider network in which
1128over 10 percent of the providers use electronic health records,
1129as defined in s. 408.051. When all other factors are equal, the
1130agency shall consider whether the organization has a contract to
1131provide managed long-term care services in the same region and
1132shall exercise a preference for such plans.
1133     (3)  SPECIALTY PLANS.-Participation by specialty plans
1134shall be subject to the procurement requirements and regional
1135plan number limits of this section. However, a specialty plan
1136whose target population includes no more than 10 percent of the
1137enrollees of that region is not subject to the regional plan
1138number limits of this section.
1139     (4)  CHILDREN'S MEDICAL SERVICES NETWORK.-Participation by
1140the Children's Medical Services Network shall be pursuant to a
1141single, statewide contract with the agency that is not subject
1142to the procurement requirements or regional plan number limits
1143of this section. The Children's Medical Services Network must
1144meet all other plan requirements for the managed medical
1145assistance program.
1146     Section 16.  Section 409.975, Florida Statutes, is created
1147to read:
1148     409.975  Managed care plan accountability.-In addition to
1149the requirements of s. 409.967, plans and providers
1150participating in the managed medical assistance program shall
1151comply with the requirements of this section.
1152     (1)  PROVIDER NETWORKS.-Managed care plans must develop and
1153maintain provider networks that meet the medical needs of their
1154enrollees in accordance with standards established pursuant to
1155409.967(2)(b). Except as provided in this section, managed care
1156plans may limit the providers in their networks based on
1157credentials, quality indicators, and price.
1158     (a)  Plans must include all providers in the region that
1159are classified by the agency as essential Medicaid providers,
1160unless the agency approves, in writing, an alternative
1161arrangement for securing the types of services offered by the
1162essential providers. Providers are essential for serving
1163Medicaid enrollees if they offer services that are not available
1164from any other provider within a reasonable access standard, or
1165if they provided a substantial share of the total units of a
1166particular service used by Medicaid patients within the region
1167during the last 3 years and the combined capacity of other
1168service providers in the region is insufficient to meet the
1169total needs of the Medicaid patients. The agency may not
1170classify physicians and other practitioners as essential
1171providers. The agency, at a minimum, shall determine which
1172providers in the following categories are essential Medicaid
1173providers:
1174     1.  Federally qualified health centers.
1175     2.  Statutory teaching hospitals as defined in s.
1176408.07(45).
1177     3.  Hospitals that are trauma centers as defined in s.
1178395.4001(14).
1179     4.  Hospitals located at least 25 miles from any other
1180hospital with similar services.
1181
1182Managed care plans that have not contracted with all essential
1183providers in the region as of the first date of recipient
1184enrollment, or with whom an essential provider has terminated
1185its contract, must negotiate in good faith with such essential
1186providers for 1 year or until an agreement is reached, whichever
1187is first. Payments for services rendered by a nonparticipating
1188essential provider shall be made at the applicable Medicaid rate
1189as of the first day of the contract between the agency and the
1190plan. A rate schedule for all essential providers shall be
1191attached to the contract between the agency and the plan. After
11921 year, managed care plans that are unable to contract with
1193essential providers shall notify the agency and propose an
1194alternative arrangement for securing the essential services for
1195Medicaid enrollees. The arrangement must rely on contracts with
1196other participating providers, regardless of whether those
1197providers are located within the same region as the
1198nonparticipating essential service provider. If the alternative
1199arrangement is approved by the agency, payments to
1200nonparticipating essential providers after the date of the
1201agency's approval shall equal 90 percent of the applicable
1202Medicaid rate. If the alternative arrangement is not approved by
1203the agency, payment to nonparticipating essential providers
1204shall equal 110 percent of the applicable Medicaid rate.
1205     (b)  Certain providers are statewide resources and
1206essential providers for all managed care plans in all regions.
1207All managed care plans must include these essential providers in
1208their networks. Statewide essential providers include:
1209     1.  Faculty plans of Florida medical schools.
1210     2.  Regional perinatal intensive care centers as defined in
1211s. 383.16(2).
1212     3.  Hospitals licensed as specialty children's hospitals as
1213defined in s. 395.002(28).
1214     4.  Accredited and integrated systems serving medically
1215complex children that are comprised of separately licensed, but
1216commonly owned, health care providers delivering at least the
1217following services: medical group home, in-home and outpatient
1218nursing care and therapies, pharmacy services, durable medical
1219equipment, and Prescribed Pediatric Extended Care.
1220
1221Managed care plans that have not contracted with all statewide
1222essential providers in all regions as of the first date of
1223recipient enrollment must continue to negotiate in good faith.
1224Payments to physicians on the faculty of nonparticipating
1225Florida medical schools shall be made at the applicable Medicaid
1226rate. Payments for services rendered by a regional perinatal
1227intensive care centers shall be made at the applicable Medicaid
1228rate as of the first day of the contract between the agency and
1229the plan. Payments to nonparticipating specialty children's
1230hospitals shall equal the highest rate established by contract
1231between that provider and any other Medicaid managed care plan.
1232     (c)  After 12 months of active participation in a plan's
1233network, the plan may exclude any essential provider from the
1234network for failure to meet quality or performance criteria. If
1235the plan excludes an essential provider from the plan, the plan
1236must provide written notice to all recipients who have chosen
1237that provider for care. The notice shall be provided at least 30
1238days before the effective date of the exclusion.
1239     (d)  Each managed care plan must offer a network contract
1240to each home medical equipment and supplies provider in the
1241region which meets quality and fraud prevention and detection
1242standards established by the plan and which agrees to accept the
1243lowest price previously negotiated between the plan and another
1244such provider.
1245     (2)  FLORIDA MEDICAL SCHOOLS QUALITY NETWORK.-The agency
1246shall contract with a single organization representing medical
1247schools and graduate medical education programs in the state for
1248the purpose of establishing an active and ongoing program to
1249improve clinical outcomes in all managed care plans. Contracted
1250activities must support greater clinical integration for
1251Medicaid enrollees through interdependent and cooperative
1252efforts of all providers participating in managed care plans.
1253The agency shall support these activities with certified public
1254expenditures and any earned federal matching funds and shall
1255seek any plan amendments or waivers necessary to comply with
1256this subsection. To be eligible to participate in the quality
1257network, a medical school must contract with each managed care
1258plan in its region.
1259     (3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
1260monitor the quality and performance of each participating
1261provider. At the beginning of the contract period, each plan
1262shall notify all its network providers of the metrics used by
1263the plan for evaluating the provider's performance and
1264determining continued participation in the network.
1265     (4)  MOMCARE NETWORK.-
1266     (a)  The agency shall contract with an administrative
1267services organization representing all Healthy Start Coalitions
1268providing risk appropriate care coordination and other services
1269in accordance with a federal waiver and pursuant to s. 409.906.
1270The contract shall require the network of coalitions to provide
1271choice counseling, education, risk-reduction and case management
1272services, and quality assurance for all enrollees of the waiver.
1273The agency shall evaluate the impact of the MomCare network by
1274monitoring each plan's performance on specific measures to
1275determine the adequacy, timeliness, and quality of services for
1276pregnant women and infants. The agency shall support this
1277contract with certified public expenditures of general revenue
1278appropriated for Healthy Start services and any earned federal
1279matching funds.
1280     (b)  Each managed care plan shall establish specific
1281programs and procedures to improve pregnancy outcomes and infant
1282health, including, but not limited to, coordination with the
1283Healthy Start program, immunization programs, and referral to
1284the Special Supplemental Nutrition Program for Women, Infants,
1285and Children, and the Children's Medical Services program for
1286children with special health care needs. Each plan's programs
1287and procedures shall include agreements with each local Healthy
1288Start Coalition in the region to provide risk-appropriate care
1289coordination for pregnant women and infants, consistent with
1290agency policies and the MomCare network.
1291     (5)  TRANSPORTATION.-Nonemergency transportation services
1292shall be provided pursuant to a single, statewide contract
1293between the agency and the Commission for the Transportation
1294Disadvantaged. The agency shall establish performance standards
1295in the contract and shall evaluate the performance of the
1296Commission for the Transportation Disadvantaged. For the
1297purposes of this subsection, the term "nonemergency
1298transportation" does not include transportation by ambulance and
1299any medical services received during transport.
1300     (6)  SCREENING RATE.-After the end of the second contract
1301year, each managed care plan shall achieve an annual Early and
1302Periodic Screening, Diagnosis, and Treatment Service screening
1303rate of at least 80 percent of those recipients continuously
1304enrolled for at least 8 months.
1305     (7)  PROVIDER PAYMENT.-Managed care plan and hospitals
1306shall negotiate mutually acceptable rates, methods, and terms of
1307payment. For rates, methods, and terms of payment negotiated
1308after the contract between the agency and the plan is executed,
1309plans shall pay hospitals, at a minimum, the rate the agency
1310would have paid on the first day of the contract between the
1311provider and the plan. Such payments to hospitals may not exceed
1312120 percent of the rate the agency would have paid on the first
1313day of the contract between the provider and the plan, unless
1314specifically approved by the agency. Payment rates may be
1315updated periodically.
1316     (8)  MEDICALLY NEEDY ENROLLEES.-Each managed care plan
1317shall accept any medically needy recipient who selects or is
1318assigned to the plan and provide that recipient with continuous
1319enrollment for 12 months. After the first month of qualifying as
1320a medically needy recipient and enrolling in a plan, and
1321contingent upon federal approval, the enrollee shall pay the
1322plan a portion of the monthly premium equal to the enrollee's
1323share of the cost as determined by the department. The agency
1324shall pay any remaining portion of the monthly premium. Plans
1325are not obligated to pay claims for medically needy patients for
1326services provided before enrollment in the plan. Medically needy
1327patients are responsible for payment of incurred claims that are
1328used to determine eligibility. Plans must provide a grace period
1329of at least 90 days before disenrolling recipients who fail to
1330pay their shares of the premium.
1331     Section 17.  Section 409.976, Florida Statutes, is created
1332to read:
1333     409.976  Managed care plan payment.-In addition to the
1334payment provisions of s. 409.968, the agency shall provide
1335payment to plans in the managed medical assistance program
1336pursuant to this section.
1337     (1)  Prepaid payment rates shall be negotiated between the
1338agency and the eligible plans as part of the procurement process
1339described in s. 409.966.
1340     (2)  The agency shall establish payment rates for statewide
1341inpatient psychiatric programs. Payments to managed care plans
1342shall be reconciled to reimburse actual payments to statewide
1343inpatient psychiatric programs.
1344     Section 18.  Section 409.977, Florida Statutes, is created
1345to read:
1346     409.977  Choice counseling and enrollment.-
1347     (1)  CHOICE COUNSELING.-In addition to the choice
1348counseling information required by s. 409.969, the agency shall
1349make available clear and easily understandable choice
1350information to Medicaid recipients that includes information
1351about the cost-sharing requirements of each managed care plan.
1352     (2)  AUTOMATIC ENROLLMENT.-The agency shall automatically
1353enroll into a managed care plan those Medicaid recipients who do
1354not voluntarily choose a plan pursuant to s. 409.969. The agency
1355shall automatically enroll recipients in plans that meet or
1356exceed the performance or quality standards established pursuant
1357to s. 409.967 and may not automatically enroll recipients in a
1358plan that is deficient in those performance or quality
1359standards. When a specialty plan is available to accommodate a
1360specific condition or diagnosis of a recipient, the agency shall
1361assign the recipient to that plan. In the first year of the
1362first contract term only, if a recipient was previously enrolled
1363in a plan that is still available in the region, the agency
1364shall automatically enroll the recipient in that plan unless an
1365applicable specialty plan is available. Except as otherwise
1366provided in this part, the agency may not engage in practices
1367that are designed to favor one managed care plan over another.
1368When automatically enrolling recipients in managed care plans,
1369the agency shall automatically enroll based on the following
1370criteria:
1371     (a)  Whether the plan has sufficient network capacity to
1372meet the needs of the recipients.
1373     (b)  Whether the recipient has previously received services
1374from one of the plan's primary care providers.
1375     (c)  Whether primary care providers in one plan are more
1376geographically accessible to the recipient's residence than
1377those in other plans.
1378     (3)  OPT-OUT OPTION.-The agency shall develop a process to
1379enable any recipient with access to employer-sponsored health
1380care coverage to opt out of all managed care plans and to use
1381Medicaid financial assistance to pay for the recipient's share
1382of the cost in such employer-sponsored coverage. Contingent upon
1383federal approval, the agency shall also enable recipients with
1384access to other insurance or related products providing access
1385to health care services created pursuant to state law, including
1386any product available under the Florida Health Choices Program,
1387or any health exchange, to opt out. The amount of financial
1388assistance provided for each recipient may not exceed the amount
1389of the Medicaid premium that would have been paid to a managed
1390care plan for that recipient.
1391     Section 19.  Section 409.978, Florida Statutes, is created
1392to read:
1393     409.978  Long-term care managed care program.-
1394     (1)  Pursuant to s. 409.963, the agency shall administer
1395the long-term care managed care program described in ss.
1396409.978-409.985, but may delegate specific duties and
1397responsibilities for the program to the Department of Elderly
1398Affairs and other state agencies. By July 1, 2012, the agency
1399shall begin implementation of the statewide long-term care
1400managed care program, with full implementation in all regions by
1401October 1, 2013.
1402     (2)  The agency shall make payments for long-term care,
1403including home and community-based services, using a managed
1404care model. Unless otherwise specified, the provisions of ss.
1405409.961-409.97 apply to the long-term care managed care program.
1406     (3)  The Department of Elderly Affairs shall assist the
1407agency to develop specifications for use in the invitation to
1408negotiate and the model contract, determine clinical eligibility
1409for enrollment in managed long-term care plans, monitor plan
1410performance and measure quality of service delivery, assist
1411clients and families to address complaints with the plans,
1412facilitate working relationships between plans and providers
1413serving elders and disabled adults, and perform other functions
1414specified in a memorandum of agreement.
1415     Section 20.  Section 409.979, Florida Statutes, is created
1416to read:
1417     409.979  Eligibility.-
1418     (1)  Medicaid recipients who meet all of the following
1419criteria are eligible to receive long-term care services and
1420must receive long-term care services by participating in the
1421long-term care managed care program. The recipient must be:
1422     (a)  Sixty-five years of age or older, or age 18 or older
1423and eligible for Medicaid by reason of a disability.
1424     (b)  Determined by the Comprehensive Assessment Review and
1425Evaluation for Long-Term Care Services (CARES) Program to
1426require nursing facility care as defined in s. 409.985(3).
1427     (2)  Medicaid recipients who, on the date long-term care
1428managed care plans become available in their region, reside in a
1429nursing home facility or are enrolled in one of the following
1430long-term care Medicaid waiver programs are eligible to
1431participate in the long-term care managed care program for up to
143212 months without being reevaluated for their need for nursing
1433facility care as defined in s. 409.985(3):
1434     (a)  The Assisted Living for the Frail Elderly Waiver.
1435     (b)  The Aged and Disabled Adult Waiver.
1436     (c)  The Adult Day Health Care Waiver.
1437     (d)  The Consumer-Directed Care Plus Program as described
1438in s. 409.221.
1439     (e)  The Program of All-inclusive Care for the Elderly.
1440     (f)  The long-term care community-based diversion pilot
1441project as described in s. 430.705.
1442     (g)  The Channeling Services Waiver for Frail Elders.
1443     (3)  The Department of Elderly Affairs shall make offers
1444for enrollment to eligible individuals based on a wait-list
1445prioritization and subject to availability of funds. Before
1446enrollment offers, the department shall determine that
1447sufficient funds exist to support additional enrollment into
1448plans.
1449     Section 21.  Section 409.98, Florida Statutes, is created
1450to read:
1451     409.98  Benefits.-Long-term care plans shall cover, at a
1452minimum, the following:
1453     (1)  Nursing facility care.
1454     (2)  Services provided in assisted living facilities.
1455     (3)  Hospice.
1456     (4)  Adult day care.
1457     (5)  Medical equipment and supplies, including incontinence
1458supplies.
1459     (6)  Personal care.
1460     (7)  Home accessibility adaptation.
1461     (8)  Behavior management.
1462     (9)  Home-delivered meals.
1463     (10)  Case management.
1464     (11)  Therapies:
1465     (a)  Occupational therapy.
1466     (b)  Speech therapy.
1467     (c)  Respiratory therapy.
1468     (d)  Physical therapy.
1469     (12)  Intermittent and skilled nursing.
1470     (13)  Medication administration.
1471     (14)  Medication management.
1472     (15)  Nutritional assessment and risk reduction.
1473     (16)  Caregiver training.
1474     (17)  Respite care.
1475     (18)  Transportation.
1476     (19)  Personal emergency response system.
1477     Section 22.  Section 409.981, Florida Statutes, is created
1478to read:
1479     409.981  Eligible plans.-
1480     (1)  ELIGIBLE PLANS.-Provider service networks must be
1481long-term care provider service networks. Other eligible plans
1482may either be long-term care plans or comprehensive long-term
1483care plans.
1484     (2)  ELIGIBLE PLAN SELECTION.-The agency shall select
1485eligible plans through the procurement process described in s.
1486409.966. The agency shall provide notice of invitations to
1487negotiate no later than July 1, 2012.
1488     (a)  The agency shall procure three plans for Region I. At
1489least one plan shall be a provider service network, if any
1490submit a responsive bid.
1491     (b)  The agency shall procure three plans for Region II. At
1492least one plan shall be a provider service network, if any
1493provider service network submits a responsive bid.
1494     (c)  The agency shall procure at least three plans and no
1495more than four plans for Region III. At least two plans shall be
1496provider service networks, if any two provider service networks
1497submit responsive bids.
1498     (d)  The agency shall procure at least four plans and no
1499more than seven plans for Region IV. At least two plans shall be
1500provider service networks if any two provider service networks
1501submit responsive bids.
1502     (e)  The agency shall procure at least five plans and no
1503more than eight plans for Region V. At least two plans shall be
1504provider service networks, if any two provider service networks
1505submit responsive bids.
1506     (f)  The agency shall procure at least three plans and no
1507more than four plans for Region VI. At least one plan shall be a
1508provider service network, if any provider service network
1509submits a responsive bid.
1510     (g)  The agency shall procure at least four plans and no
1511more than seven plans for Region VII. At least two plans shall
1512be provider service networks, if any two provider service
1513networks submit responsive bids.
1514     (h)  The agency shall procure at least five plans and no
1515more than nine plans for Region VIII. At least two plans shall
1516be provider service networks, if any two provider service
1517networks submit a responsive bid.
1518
1519If no provider service network submits a responsive bid, the
1520agency shall procure one fewer eligible plan in each of the
1521regions. Within 12 months after the initial invitation to
1522negotiate, the agency shall attempt to procure an eligible plan
1523that is a provider service network. The agency shall notice
1524another invitation to negotiate only with provider service
1525networks in a region where no provider service network has been
1526selected.
1527     (3)  QUALITY SELECTION CRITERIA.-In addition to the
1528criteria established in s. 409.966, the agency shall consider
1529the following factors in the selection of eligible plans:
1530     (a)  Evidence of the employment of executive managers with
1531expertise and experience in serving aged and disabled persons
1532who require long-term care.
1533     (b)  Whether a plan has established a network of service
1534providers dispersed throughout the region and in sufficient
1535numbers to meet specific service standards established by the
1536agency for specialty services for persons receiving home and
1537community-based care.
1538     (c)  Whether a plan is proposing to establish a
1539comprehensive long-term care plan and whether the eligible plan
1540has a contract to provide managed medical assistance services in
1541the same region.
1542     (d)  Whether a plan offers consumer-directed care services
1543to enrollees pursuant to s. 409.221.
1544     (e)  Whether a plan is proposing to provide home and
1545community-based services in addition to the minimum benefits
1546required by s. 409.98.
1547     (4)  PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY.-
1548Participation by the Program of All-Inclusive Care for the
1549Elderly (PACE) shall be pursuant to a contract with the agency
1550and not subject to the procurement requirements or regional plan
1551number limits of this section. PACE plans may continue to
1552provide services to individuals at such levels and enrollment
1553caps as authorized by the General Appropriations Act.
1554     Section 23.  Section 409.982, Florida Statutes, is created
1555to read:
1556     409.982  Managed care plan accountability.-In addition to
1557the requirements of s. 409.967, plans and providers
1558participating in the long-term care managed care program shall
1559comply with the requirements of this section.
1560     (1)  PROVIDER NETWORKS.-Managed care plans may limit the
1561providers in their networks based on credentials, quality
1562indicators, and price. For the period between October 1, 2013,
1563and September 30, 2014, each selected plan must offer a network
1564contract to all the following providers in the region:
1565     (a)  Nursing homes.
1566     (b)  Hospices.
1567     (c)  Aging network service providers that have previously
1568participated in home and community-based waivers serving elders
1569or community-service programs administered by the Department of
1570Elderly Affairs.
1571
1572After 12 months of active participation in a managed care plan's
1573network, the plan may exclude any of the providers named in this
1574subsection from the network for failure to meet quality or
1575performance criteria. If the plan excludes a provider from the
1576plan, the plan must provide written notice to all recipients who
1577have chosen that provider for care. The notice shall be provided
1578at least 30 days before the effective date of the exclusion. The
1579agency shall establish contract provisions governing the
1580transfer of recipients from excluded residential providers.
1581     (2)  SELECT PROVIDER PARTICIPATION.-Except as provided in
1582this subsection, providers may limit the managed care plans they
1583join. Nursing homes and hospices that are enrolled Medicaid
1584providers must participate in all eligible plans selected by the
1585agency in the region in which the provider is located.
1586     (3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
1587monitor the quality and performance of each participating
1588provider using measures adopted by and collected by the agency
1589and any additional measures mutually agreed upon by the provider
1590and the plan
1591     (4)  PROVIDER NETWORK STANDARDS.-The agency shall establish
1592and each managed care plan must comply with specific standards
1593for the number, type, and regional distribution of providers in
1594the plan's network, which must include:
1595     (a)  Adult day care centers.
1596     (b)  Adult family-care homes.
1597     (c)  Assisted living facilities.
1598     (d)  Health care services pools.
1599     (e)  Home health agencies.
1600     (f)  Homemaker and companion services.
1601     (g)  Hospices.
1602     (h)  Community care for the elderly lead agencies.
1603     (i)  Nurse registries.
1604     (j)  Nursing homes.
1605     (5)  PROVIDER PAYMENT.-Managed care plans and providers
1606shall negotiate mutually acceptable rates, methods, and terms of
1607payment. Plans shall pay nursing homes an amount equal to the
1608nursing facility-specific payment rates set by the agency;
1609however, mutually acceptable higher rates may be negotiated for
1610medically complex care. Plans shall pay hospice providers
1611through a prospective system for each enrollee an amount equal
1612to the per diem rate set by the agency. For recipients residing
1613in a nursing facility and receiving hospice services, the plan
1614shall pay the hospice provider the per diem rate set by the
1615agency minus the nursing facility component and shall pay the
1616nursing facility the applicable state rate. Plans shall ensure
1617that electronic nursing home and hospice claims that contain
1618sufficient information for processing are paid within 10
1619business days after receipt.
1620     Section 24.  Section 409.983, Florida Statutes, is created
1621to read:
1622     409.983  Managed care plan payment.-In addition to the
1623payment provisions of s. 409.968, the agency shall provide
1624payment to plans in the long-term care managed care program
1625pursuant to this section.
1626     (1)  Prepaid payment rates for long-term care managed care
1627plans shall be negotiated between the agency and the eligible
1628plans as part of the procurement process described in s.
1629409.966.
1630     (2)  Payment rates for comprehensive long-term care plans
1631covering services described in s. 409.973 shall be blended with
1632rates for long-term care plans for services specified in s.
1633409.98.
1634     (3)  Payment rates for plans shall reflect historic
1635utilization and spending for covered services projected forward
1636and adjusted to reflect the level of care profile for enrollees
1637in each plan. The payment shall be adjusted to provide an
1638incentive for reducing institutional placements and increasing
1639the utilization of home and community-based services.
1640     (4)  The initial assessment of an enrollee's level of care
1641shall be made by the Comprehensive Assessment and Review for
1642Long-Term-Care Services (CARES) program, which shall assign the
1643recipient into one of the following levels of care:
1644     (a)  Level of care 1 consists of recipients residing in or
1645who must be placed in a nursing home.
1646     (b)  Level of care 2 consists of recipients at imminent
1647risk of nursing home placement, as evidenced by the need for the
1648constant availability of routine medical and nursing treatment
1649and care, and require extensive health-related care and services
1650because of mental or physical incapacitation.
1651     (c)  Level of care 3 consists of recipients at imminent
1652risk of nursing home placement, as evidenced by the need for the
1653constant availability of routine medical and nursing treatment
1654and care, who have a limited need for health-related care and
1655services and are mildly medically or physically incapacitated.
1656
1657The agency shall periodically adjust payment rates to account
1658for changes in the level of care profile for each managed care
1659plan based on encounter data.
1660     (5)  The agency shall make an incentive adjustment in
1661payment rates to encourage the increased utilization of home and
1662community-based services and a commensurate reduction of
1663institutional placement. The incentive adjustment shall be
1664modified in each successive rate period during the first
1665contract period, as follows:
1666     (a)  A 2 percentage point shift in the first rate-setting
1667period;
1668     (b)  A 2 percentage point shift in the second rate-setting
1669period, as compared to the utilization mix at the end of the
1670first rate-setting period;
1671     (c)  A 3 percentage point shift in the third rate-setting
1672period, and in each subsequent rate-setting period during the
1673first contract period, as compared to the utilization mix at the
1674end of the immediately preceding rate-setting period.
1675
1676The incentive adjustment shall continue in subsequent contract
1677periods, at a rate of 3 percentage points per year as compared
1678to the utilization mix at the end of the immediately preceding
1679rate-setting period, until no more than 35 percent of the plan's
1680enrollees are placed in institutional settings. The agency shall
1681annually report to the Legislature the actual change in the
1682utilization mix of home and community-based services compared to
1683institutional placements and provide a recommendation for
1684utilization mix requirements for future contracts.
1685     (6)  The agency shall establish nursing-facility-specific
1686payment rates for each licensed nursing home based on facility
1687costs adjusted for inflation and other factors as authorized in
1688the General Appropriations Act. Payments to long-term care
1689managed care plans shall be reconciled to reimburse actual
1690payments to nursing facilities.
1691     (7)  The agency shall establish hospice payment rates
1692pursuant to Title XVIII of the Social Security Act. Payments to
1693long-term care managed care plans shall be reconciled to
1694reimburse actual payments to hospices.
1695     Section 25.  Section 409.984, Florida Statutes, is created
1696to read:
1697     409.984  Choice counseling; enrollment.-
1698     (1)  CHOICE COUNSELING.-Before contracting with a vendor to
1699provide choice counseling as authorized under s. 409.969, the
1700agency shall offer to contract with aging resource centers
1701established under s. 430.2053 for choice counseling services. If
1702the aging resource center is determined not to be the vendor
1703that provides choice counseling, the agency shall establish a
1704memorandum of understanding with the aging resource center to
1705coordinate staffing and collaborate with the choice counseling
1706vendor. In addition to the requirements of s. 409.969, any
1707contract to provide choice counseling for the long-term care
1708managed care program shall provide that each recipient be given
1709the option of having in-person choice counseling.
1710     (2)  AUTOMATIC ENROLLMENT.-The agency shall automatically
1711enroll into a long-term care managed care plan those Medicaid
1712recipients who do not voluntarily choose a plan pursuant to s.
1713409.969. The agency shall automatically enroll recipients in
1714plans that meet or exceed the performance or quality standards
1715established pursuant to s. 409.967 and may not automatically
1716enroll recipients in a plan that is deficient in those
1717performance or quality standards. If a recipient is deemed
1718dually eligible for Medicaid and Medicare services and is
1719currently receiving Medicare services from an entity qualified
1720under 42 C.F.R. part 422 as a Medicare Advantage Preferred
1721Provider Organization, Medicare Advantage Provider-sponsored
1722Organization, or Medicare Advantage Special Needs Plan, the
1723agency shall automatically enroll the recipient in such plan for
1724Medicaid services if the plan is currently participating in the
1725long-term care managed care program. Except as otherwise
1726provided in this part, the agency may not engage in practices
1727that are designed to favor one managed care plan over another.
1728When automatically enrolling recipients in plans, the agency
1729shall take into account the following criteria:
1730     (a)  Whether the plan has sufficient network capacity to
1731meet the needs of the recipients.
1732     (b)  Whether the recipient has previously received services
1733from one of the plan's home and community-based service
1734providers.
1735     (c)  Whether the home and community-based providers in one
1736plan are more geographically accessible to the recipient's
1737residence than those in other plans.
1738     (3)  HOSPICE SELECTION.-Notwithstanding the provisions of
1739s. 409.969(3)(c), when a recipient is referred for hospice
1740services, the recipient shall have a 30-day period during which
1741the recipient may select to enroll in another managed care plan
1742to access the hospice provider of the recipient's choice.
1743     (4)  CHOICE OF RESIDENTIAL SETTING.-When a recipient is
1744referred for placement in a nursing home or assisted living
1745facility, the plan shall inform the recipient of any facilities
1746within the plan that have specific cultural or religious
1747affiliations and, if requested by the recipient, make a
1748reasonable effort to place the recipient in the facility of the
1749recipient's choice.
1750     Section 26.  Section 409.9841, Florida Statutes, is created
1751to read:
1752     409.9841  Long-term care managed care technical advisory
1753workgroup.-
1754     (1)  Before August 1, 2011, the agency shall establish a
1755technical advisory workgroup to assist in developing:
1756     (a)  The method of determining Medicaid eligibility
1757pursuant to s. 409.985(3).
1758     (b)  The requirements for provider payments to nursing
1759homes under s. 409.983(6).
1760     (c)  The method for managing Medicare coinsurance crossover
1761claims.
1762     (d)  Uniform requirements for claims submissions and
1763payments, including electronic funds transfers and claims
1764processing.
1765     (e)  The process for enrollment of and payment for
1766individuals pending determination of Medicaid eligibility.
1767     (2)  The advisory workgroup shall include, but is not
1768limited to, representatives of providers and plans who could
1769potentially participate in long-term care managed care. Members
1770of the workgroup shall serve without compensation but may be
1771reimbursed for per diem and travel expenses as provided in s.
1772112.061.
1773     (3)  This section is repealed on June 30, 2013.
1774     Section 27.  Section 409.985, Florida Statutes, is created
1775to read:
1776     409.985  Comprehensive Assessment and Review for Long-Term
1777Care Services (CARES) Program.-
1778     (1)  The agency shall operate the Comprehensive Assessment
1779and Review for Long-Term Care Services (CARES) preadmission
1780screening program to ensure that only individuals whose
1781conditions require long-term care services are enrolled in the
1782long-term care managed care program.
1783     (2)  The agency shall operate the CARES program through an
1784interagency agreement with the Department of Elderly Affairs.
1785The agency, in consultation with the Department of Elderly
1786Affairs, may contract for any function or activity of the CARES
1787program, including any function or activity required by 42
1788C.F.R. part 483.20, relating to preadmission screening and
1789review.
1790     (3)  The CARES program shall determine if an individual
1791requires nursing facility care and, if the individual requires
1792such care, assign the individual to a level of care as described
1793in s. 409.983(4). When determining the need for nursing facility
1794care, consideration shall be given to the nature of the services
1795prescribed and which level of nursing or other health care
1796personnel meets the qualifications necessary to provide such
1797services and the availability to and access by the individual of
1798community or alternative resources. For the purposes of the
1799long-term care managed care program, the term "nursing facility
1800care" means the individual:
1801     (a)  Requires nursing home placement as evidenced by the
1802need for medical observation throughout a 24-hour period and
1803care required to be performed on a daily basis by, or under the
1804direct supervision of, a registered nurse or other health care
1805professional and requires services that are sufficiently
1806medically complex to require supervision, assessment, planning,
1807or intervention by a registered nurse because of a mental or
1808physical incapacitation by the individual;
1809     (b)  Requires or is at imminent risk of nursing home
1810placement as evidenced by the need for observation throughout a
181124-hour period and care and the constant availability of medical
1812and nursing treatment and requires services on a daily or
1813intermittent basis that are to be performed under the
1814supervision of licensed nursing or other health professionals
1815because the individual who is incapacitated mentally or
1816physically; or
1817     (c)  Requires or is at imminent risk of nursing home
1818placement as evidenced by the need for observation throughout a
181924-hour period and care and the constant availability of medical
1820and nursing treatment and requires limited services that are to
1821be performed under the supervision of licensed nursing or other
1822health professionals because the individual is mildly
1823incapacitated mentally or physically.
1824     (4)  For individuals whose nursing home stay is initially
1825funded by Medicare and Medicare coverage and is being terminated
1826for lack of progress towards rehabilitation, CARES staff shall
1827consult with the person making the determination of progress
1828toward rehabilitation to ensure that the recipient is not being
1829inappropriately disqualified from Medicare coverage. If, in
1830their professional judgment, CARES staff believe that a Medicare
1831beneficiary is still making progress toward rehabilitation, they
1832may assist the Medicare beneficiary with an appeal of the
1833disqualification from Medicare coverage. The use of CARES teams
1834to review Medicare denials for coverage under this section is
1835authorized only if it is determined that such reviews qualify
1836for federal matching funds through Medicaid. The agency shall
1837seek or amend federal waivers as necessary to implement this
1838section.
1839     Section 28.  Section 409.986, Florida Statutes, is created
1840to read:
1841     409.986  Managed long-term care for persons with
1842developmental disabilities.-
1843     (1)  Pursuant to s. 409.963, the agency is responsible for
1844administering the long-term care managed care program for
1845persons with developmental disabilities described in ss.
1846409.986-409.992, but may delegate specific duties and
1847responsibilities for the program to the Agency for Persons with
1848Disabilities and other state agencies. By January 1, 2015, the
1849agency shall begin implementation of statewide long-term care
1850managed care for persons with developmental disabilities, with
1851full implementation in all regions by October 1, 2016.
1852     (2)  The agency shall make payments for long-term care for
1853persons with developmental disabilities, including home and
1854community-based services, using a managed care model. Unless
1855otherwise specified, the provisions of ss. 409.961-409.97 apply
1856to the long-term care managed care program for persons with
1857developmental disabilities.
1858     (3)  The Agency for Persons with Disabilities shall assist
1859the agency to develop the specifications for use in the
1860invitations to negotiate and the model contract, determine
1861clinical eligibility for enrollment in long-term care plans for
1862persons with developmental disabilities, assist the agency to
1863monitor plan performance and measure quality, assist clients and
1864families to address complaints with the plans, facilitate
1865working relationships between plans and providers serving
1866persons with developmental disabilities, and perform other
1867functions specified in a memorandum of agreement.
1868     Section 29.  Section 409.987, Florida Statutes, is created
1869to read:
1870     409.987  Eligibility.-
1871     (1)  Medicaid recipients who meet all of the following
1872criteria are eligible and shall be enrolled in a comprehensive
1873long-term care plan or long-term care plan:
1874     (a)  Is Medicaid eligible pursuant to s. 409.904.
1875     (b)  Is a Florida resident who has a developmental
1876disability as defined in s. 393.063.
1877     (c)  Meets the level of care need, including:
1878     1.  The recipient's intelligence quotient is 59 or less;
1879     2.  The recipient's intelligence quotient is 60-69,
1880inclusive, and the recipient has a secondary condition that
1881includes cerebral palsy, spina bifida, Prader-Willi syndrome,
1882epilepsy, or autistic disorder or has ambulation, sensory,
1883chronic health, and behavioral problems;
1884     3.  The recipient's intelligence quotient is 60-69,
1885inclusive, and the recipient has severe functional limitations
1886in at least three major life activities, including self-care,
1887learning, mobility, self-direction, understanding and use of
1888language, and capacity for independent living; or
1889     4.  The recipient is eligible under a primary disability of
1890autistic disorder, cerebral palsy, spina bifida, or Prader-Willi
1891syndrome. In addition, the condition must result in substantial
1892functional limitations in three or more major life activities,
1893including self-care, learning, mobility, self-direction,
1894understanding and use of language, and capacity for independent
1895living.
1896     (d)  Meets the level of care need to receive services in an
1897intermediate care facility for the developmentally disabled.
1898     (e)  Is enrolled in a home and community-based Medicaid
1899waiver established in chapter 393 or the Consumer Directed Care
1900Plus program for persons with developmental disabilities under
1901the Medicaid state plan, is a Medicaid-funded resident of a
1902private intermediate care facility for the developmentally
1903disabled on the date the managed long-term care plans for
1904persons with disabilities becomes available in the recipient's
1905region, or has been offered enrollment in a comprehensive long-
1906term care plan or a long-term care plan.
1907     (2)  The Agency for Persons with Disabilities shall make
1908offers for enrollment to eligible individuals based on the wait-
1909list prioritization in s. 393.065(5) and subject to availability
1910of funds. Before enrollment offers, the agency shall determine
1911that sufficient funds exist to support additional enrollment
1912into plans.
1913     (3)  Unless specifically exempted, all eligible persons
1914must be enrolled in a comprehensive long-term care plan or a
1915long-term care plan. Medicaid recipients who are residents of a
1916developmental disability center, including Sunland Center in
1917Marianna and Tacachale Center in Gainesville, are exempt from
1918mandatory enrollment but may voluntarily enroll in a long-term
1919care plan.
1920     Section 30.  Section 409.988, Florida Statutes, is created
1921to read:
1922     409.988  Benefits.-Managed care plans shall cover, at a
1923minimum, the services in this section. Plans may customize
1924benefit packages or offer additional benefits to meet the needs
1925of enrollees in the plan.
1926     (1)  Intermediate care for the developmentally disabled.
1927     (2)  Services in alternative residential settings,
1928including, but not limited to:
1929     (a)  Group homes licensed under chapter 393 and foster care
1930homes licensed under chapter 409.
1931     (b)  Comprehensive transitional education programs licensed
1932under chapter 393.
1933     (c)  Residential habilitation centers licensed under
1934chapter 393.
1935     (d)  Assisted living facilities licensed under chapter 429
1936and transitional living facilities licensed under part V of
1937chapter 400.
1938     (3)  Adult day training.
1939     (4)  Behavior analysis services.
1940     (5)  Companion services.
1941     (6)  Consumable medical supplies.
1942     (7)  Durable medical equipment and supplies.
1943     (8)  Environmental accessibility adaptations.
1944     (9)  In-home support services.
1945     (10)  Therapies, including occupational, speech,
1946respiratory, and physical therapy.
1947     (11)  Personal care assistance.
1948     (12)  Residential habilitation services.
1949     (13)  Intensive behavioral residential habilitation
1950services.
1951     (14)  Behavior focus residential habilitation services.
1952     (15)  Residential nursing services.
1953     (16)  Respite care.
1954     (17)  Support coordination.
1955     (18)  Supported employment.
1956     (19)  Supported living coaching.
1957     (20)  Transportation.
1958     Section 31.  Section 409.989, Florida Statutes, is created
1959to read:
1960     409.989  Eligible plans.-
1961     (1)  ELIGIBLE PLANS.-Provider service networks may be
1962either long-term care plans or comprehensive long-term care
1963plans. Other plans must be comprehensive long-term care plans
1964and under contract to provide services pursuant to s. 409.973 or
1965s. 409.98 in any of the regions that form the combined region as
1966defined in this section.
1967     (2)  PROVIDER SERVICE NETWORKS.-Provider service networks
1968targeted to serve persons with disabilities must include one or
1969more owners licensed pursuant to s. 393.067 or s. 400.962 and
1970with at least 10 years' experience in serving this population.
1971     (3)  ELIGIBLE PLAN SELECTION.-The agency shall select
1972eligible plans through the procurement process described in s.
1973409.966. The agency shall notice invitations to negotiate no
1974later than January 1, 2015.
1975     (a)  The agency shall procure at least two plans and no
1976more than three plans for services in combined Regions I, II,
1977and III. At least one plan shall be a provider service network,
1978if any submit a responsive bid.
1979     (b)  The agency shall procure at least two plans and no
1980more than three plans for services in combined Regions IV and V.
1981At least one plan shall be a provider service network, if any
1982submit a responsive bid.
1983     (c)  The agency shall procure at least two plans and no
1984more than four plans for services in combined Regions VI, VII,
1985and VIII. At least one plan shall be a provider service network,
1986if any submit a responsive bid.
1987
1988If no provider service network submits a responsive bid, the
1989agency shall procure no more than one less than the maximum
1990number of eligible plans permitted in the combined region.
1991Within 12 months after the initial invitation to negotiate, the
1992agency shall attempt to procure an eligible plan that is a
1993provider service network. The agency shall notice another
1994invitation to negotiate only with provider service networks in
1995such combined region where no provider service network has been
1996selected.
1997     (4)  QUALITY SELECTION CRITERIA.-In addition to the
1998criteria established in s. 409.966, the agency shall consider
1999the following factors in the selection of eligible plans:
2000     (a)  Whether the plan has sufficient specialized staffing,
2001including employment of executive managers with expertise and
2002experience in serving persons with developmental disabilities.
2003     (b)  Whether the plan has sufficient network
2004qualifications, including establishment of a network of service
2005providers dispersed throughout the combined region and in
2006sufficient numbers to meet specific accessibility standards
2007established by the agency for specialty services for persons
2008with developmental disabilities.
2009     (c)  Whether the plan has written agreements or signed
2010contracts or has made substantial progress in establishing
2011relationships with providers before the plan submitting a
2012response. The agency shall give preference to plans with
2013evidence of signed contracts with providers listed in s.
2014409.99(1).
2015     (5)  CHILDREN'S MEDICAL SERVICES NETWORK.-The Children's
2016Medical Services Network may provide either long-term care plans
2017or comprehensive long-term care plans. Participation by the
2018Children's Medical Services Network shall be pursuant to a
2019single, statewide contract with the agency not subject to the
2020procurement requirements or regional plan number limits of this
2021section. The Children's Medical Services Network must meet all
2022other plan requirements.
2023     Section 32.  Section 409.99, Florida Statutes, is created
2024to read:
2025     409.99  Managed care plan accountability.-In addition to
2026the requirements of s. 409.967, managed care plans and providers
2027shall comply with the requirements of this section.
2028     (1)  PROVIDER NETWORKS.-Managed care plans may limit the
2029providers in their networks based on credentials, quality
2030indicators, and price. However, in the first contract period
2031after an eligible plan is selected in a region by the agency,
2032the plan must offer a network contract to the following
2033providers in the region:
2034     (a)  Providers with licensed institutional care facilities
2035for the developmentally disabled.
2036     (b)  Providers of alternative residential facilities
2037specified in s. 409.988.
2038
2039After 12 months of active participation in a managed care plan
2040network, the plan may exclude any of the above-named providers
2041from the network for failure to meet quality or performance
2042criteria. If the plan excludes a provider from the plan, the
2043plan must provide written notice to all recipients who have
2044chosen that provider for care. The notice shall be issued at
2045least 90 days before the effective date of the exclusion.
2046     (2)  SELECT PROVIDER PARTICIPATION.-Except as provided in
2047this subsection, providers may limit the managed care plans they
2048join. Licensed institutional care facilities for the
2049developmentally disabled and licensed residential settings
2050providing Intensive Behavioral Residential Habilitation services
2051with an active Medicaid provider agreement must agree to
2052participate in any eligible plan selected by the agency.
2053     (3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
2054monitor the quality and performance of each participating
2055provider. At the beginning of the contract period, each plan
2056shall notify all its network providers of the metrics used by
2057the plan for evaluating the provider's performance and
2058determining continued participation in the network.
2059     (4)  PROVIDER PAYMENT.-Managed care plans and providers
2060shall negotiate mutually acceptable rates, methods, and terms of
2061payment. Plans shall pay intermediate care facilities for the
2062developmentally disabled and intensive behavior residential
2063habilitation providers an amount equal to the facility-specific
2064payment rate set by the agency.
2065     (5)  CONSUMER AND FAMILY INVOLVEMENT.-Each managed care
2066plan must establish a family advisory committee to participate
2067in program design and oversight.
2068     (6)  CONSUMER-DIRECTED CARE.-Each managed care plan must
2069offer consumer-directed care services to enrollees pursuant to
2070s. 409.221.
2071     Section 33.  Section 409.991, Florida Statutes, is created
2072to read:
2073     409.991  Managed care plan payment.-In addition to the
2074payment provisions of s. 409.968, the agency shall provide
2075payment to comprehensive long-term care plans and long-term care
2076plans pursuant to this section.
2077     (1)  Prepaid payment rates shall be negotiated between the
2078agency and the eligible plans as part of the procurement process
2079described in s. 409.966.
2080     (2)  Payment for comprehensive long-term care plans
2081covering services pursuant to s. 409.973 shall be blended with
2082payments for long-term care plans for services specified in s.
2083409.988.
2084     (3)  Payment rates for plans covering services specified in
2085s. 409.988 shall be based on historical utilization and spending
2086for covered services projected forward and adjusted to reflect
2087the level-of-care profile of each plan's enrollees.
2088     (4)  The Agency for Persons with Disabilities shall conduct
2089the initial assessment of an enrollee's level of care. The
2090evaluation of level of care shall be based on assessment and
2091service utilization information from the most recent version of
2092the Questionnaire for Situational Information and encounter
2093data.
2094     (5)  The agency shall assign enrollees of developmental
2095disabilities long-term care plans into one of five levels of
2096care to account for variations in risk status and service needs
2097among enrollees.
2098     (a)  Level of care 1 consists of individuals receiving
2099services in an intermediate care facility for the
2100developmentally disabled.
2101     (b)  Level of care 2 consists of individuals with intensive
2102medical or adaptive needs and who require essential services to
2103avoid institutionalization or who possess behavioral problems
2104that are exceptional in intensity, duration, or frequency and
2105present a substantial risk of harm to themselves or others.
2106     (c)  Level of care 3 consists of individuals with service
2107needs, including a licensed residential facility and a moderate
2108level of support for standard residential habilitation services
2109or a minimal level of support for behavior focus residential
2110habilitation services, or individuals in supported living who
2111require more than 6 hours a day of in-home support services.
2112     (d)  Level of care 4 consists of individuals requiring less
2113than a moderate level of residential habilitation support in a
2114residential placement or individuals in supported living who
2115require 6 hours a day or less of in-home support services.
2116     (e)  Level of care 5 consists of individuals who do not
2117receive in-home support services and need minimal support
2118services while living in independent or supported living
2119situations or in their family home.
2120
2121The agency shall periodically adjust aggregate payments to plans
2122based on encounter data to account for variations in risk levels
2123among plans' enrollees.
2124     (6)  The agency shall establish intensive behavior
2125residential habilitation rates for providers approved by the
2126agency to provide this service. The agency shall also establish
2127intermediate care facility for the developmentally disabled-
2128specific payment rates for each licensed intermediate care
2129facility. Payments to intermediate care facilities for the
2130developmentally disabled and providers of intensive behavior
2131residential habilitation services shall be reconciled to
2132reimburse the plan's actual payments to the facilities.
2133     Section 34.  Section 409.992, Florida Statutes, is created
2134to read:
2135     409.992  Automatic enrollment.-The agency shall
2136automatically enroll into a comprehensive long-term care plan or
2137a long-term care plan those Medicaid recipients who do not
2138voluntarily choose a plan pursuant to s. 409.969. The agency
2139shall automatically enroll recipients in plans that meet or
2140exceed the performance or quality standards established pursuant
2141to s. 409.967 and shall not automatically enroll recipients in a
2142plan that is deficient in those performance or quality
2143standards. Except as otherwise provided in this part, the agency
2144shall assign individuals who are deemed dually eligible for
2145Medicaid and Medicare to a plan that provides both Medicaid and
2146Medicare services. The agency may not engage in practices that
2147are designed to favor one managed care plan over another. When
2148automatically enrolling recipients in plans, the agency shall
2149take into account the following criteria:
2150     (1)  Whether the plan has sufficient network capacity to
2151meet the needs of the recipients.
2152     (2)  Whether the recipient has previously received services
2153from one of the plan's home and community-based service
2154providers.
2155     (3)  Whether home and community-based providers in one plan
2156are more geographically accessible to the recipient's residence
2157than those in other plans.
2158     Section 35.  This act shall take effect July 1, 2011.


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