CS/HB 7107

1
A bill to be entitled
2An act relating to Medicaid managed care; creating part 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 exemptions; creating s.
19409.966, F.S.; providing requirements for eligible plans
20that 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 regions for separate
26procurement of plans; providing quality criteria for plan
27selection; providing limitations on serving recipients
28during the pendency of procurement litigation; creating s.
29409.967, F.S.; providing for managed care plan
30accountability; establishing contract terms; providing for
31physician compensation; providing for emergency services;
32establishing requirements for access; requiring a drug
33formulary or preferred drug list; requiring plans to
34accept requests for service electronically; requiring the
35agency to maintain an encounter data system; requiring
36plans to provide encounter data; requiring the agency to
37establish performance standards for plans; providing
38program integrity requirements; establishing requirements
39for the database; establishing a grievance resolution
40process; providing penalties for early termination of
41contracts or reduction in enrollment levels; establishing
42prompt payment requirements; requiring fair payment to
43providers with a controlling interest in a provider
44service network by other plans; requiring itemized
45payment; providing for dispute resolutions between plans
46and providers; providing for achieved savings rebates to
47plans; creating s. 409.968, F.S.; establishing managed
48care plan payments; providing payment requirements for
49provider service networks; requiring the agency to conduct
50annual cost reconciliations to determine certain cost
51savings and report the results of the reconciliations to
52the fee-for-service provider; prohibiting rate increases
53that are not authorized in the appropriations act;
54creating s. 409.969, F.S.; requiring enrollment in managed
55care plans by all nonexempt Medicaid recipients; creating
56requirements for plan selection by recipients; authorizing
57disenrollment under certain circumstances; defining the
58term "good cause" for purposes of disenrollment; providing
59time limits on an internal grievance process; providing
60requirements for agency determination regarding
61disenrollment; requiring recipients to stay in plans for a
62specified time; creating s. 409.97, F.S.; authorizing the
63agency to accept the transfer of certain revenues from
64local governments; requiring the agency to contract with a
65representative of certain entities participating in the
66low-income pool for the provision of enhanced access to
67care; providing for support of these activities by the
68low-income pool as authorized in the General
69Appropriations Act; establishing the Access to Care
70Partnership; requiring the agency to seek necessary
71waivers and plan amendments; providing requirements for
72prepaid plans to submit data; authorizing the agency to
73implement a tiered hospital rate system; creating s.
74409.971, F.S.; creating the managed medical assistance
75program; providing deadlines to begin and finalize
76implementation of the program; creating s. 409.972, F.S.;
77providing eligibility requirements for mandatory and
78voluntary enrollment; creating s. 409.973, F.S.;
79establishing minimum benefits for managed care plans to
80cover; authorizing plans to customize benefit packages;
81requiring plans to establish programs to encourage healthy
82behaviors and establish written agreements with certain
83enrollees to participate in such programs; requiring plans
84to establish a primary care initiative; providing
85requirements for primary care initiatives; requiring plans
86to report certain primary care data to the agency;
87creating s. 409.974, F.S.; establishing a deadline for
88issuing invitations to negotiate; establishing a specified
89number or range of eligible plans to be selected in each
90region; establishing quality selection criteria;
91establishing requirements for participation by specialty
92plans; establishing the Children's Medical Service Network
93as an eligible plan; creating s. 409.975, F.S.; providing
94for managed care plan accountability; authorizing plans to
95limit providers in networks; requiring plans to include
96essential Medicaid providers in their networks unless an
97alternative arrangement is approved by the agency;
98identifying statewide essential providers; specifying
99provider payments under certain circumstances; requiring
100plans to include certain statewide essential providers in
101their networks; requiring good faith negotiations;
102specifying provider payments under certain circumstances;
103allowing plans to exclude essential providers under
104certain circumstances; requiring plans to offer a contract
105to home medical equipment and supply providers under
106certain circumstances; establishing the Florida medical
107school quality network; requiring the agency to contract
108with a representative of certain entities to establish a
109clinical outcome improvement program in all plans;
110providing for support of these activities by certain
111expenditures and federal matching funds; requiring the
112agency to seek necessary waivers and plan amendments;
113providing for eligibility for the quality network;
114requiring plans to monitor the quality and performance
115history of providers; establishing the MomCare network;
116requiring the agency to contract with a representative of
117all Healthy Start Coalitions to provide certain services
118to recipients; providing for support of these activities
119by certain expenditures and federal matching funds;
120requiring plans to enter into agreements with local
121Healthy Start Coalitions for certain purposes; requiring
122specified programs and procedures be established by plans;
123establishing a screening standard for the Early and
124Periodic Screening, Diagnosis, and Treatment Service;
125requiring managed care plans and hospitals to negotiate
126rates, methods, and terms of payment; providing a limit on
127payments to hospitals; establishing plan requirements for
128medically needy recipients; creating s. 409.976, F.S.;
129providing for managed care plan payment; requiring the
130agency to establish payment rates for statewide inpatient
131psychiatric programs; requiring payments to managed care
132plans to be reconciled to reimburse actual payments to
133statewide inpatient psychiatric programs; creating s.
134409.977, F.S.; providing for automatic enrollment in a
135managed care plan for certain recipients; establishing
136opt-out opportunities for recipients; creating s. 409.978,
137F.S.; requiring the agency to be responsible for
138administering the long-term care managed care program;
139providing implementation dates for the long-term care
140managed care program; providing duties of the Department
141of Elderly Affairs relating to assisting the agency in
142implementing the program; creating s. 409.979, F.S.;
143providing eligibility requirements for the long-term care
144managed care program; creating s. 409.98, F.S.;
145establishing the benefits covered under a managed care
146plan participating in the long-term care managed care
147program; creating s. 409.981, F.S.; providing criteria for
148eligible plans; designating regions for plan
149implementation throughout the state; providing criteria
150for the selection of plans to participate in the long-term
151care managed care program; providing that participation by
152the Program of All-Inclusive Care for the Elderly and
153certain Medicare plans is pursuant to an agency contract
154and not subject to procurement; creating s. 409.982, F.S.;
155requiring the agency to establish uniform accounting and
156reporting methods for plans; providing for mandatory
157participation in plans by certain service providers;
158authorizing the exclusion of certain providers from plans
159for failure to meet quality or performance criteria;
160requiring plans to monitor participating providers using
161specified criteria; requiring certain providers to be
162included in plan networks; providing provider payment
163specifications for nursing homes and hospices; creating s.
164409.983, F.S.; providing for negotiation of rates between
165the agency and the plans participating in the long-term
166care managed care program; providing specific criteria for
167calculating and adjusting plan payments; allowing the
168CARES program to assign plan enrollees to a level of care;
169providing incentives for adjustments of payment rates;
170requiring the agency to establish nursing facility-
171specific and hospice services payment rates; creating s.
172409.984, F.S.; providing criteria for automatic
173assignments of plan enrollees who fail to choose a plan;
174providing for hospice selection within a specified
175timeframe; providing for a choice of residential setting
176under certain circumstances; creating s. 409.9841, F.S.;
177creating the long-term care managed care technical
178advisory workgroup; providing duties; providing
179membership; providing for reimbursement for per diem and
180travel expenses; providing for repeal by a specified date;
181creating s. 409.985, F.S.; providing that the agency shall
182operate the Comprehensive Assessment and Review for Long-
183Term Care Services program through an interagency
184agreement with the Department of Elderly Affairs;
185providing duties of the program; defining the term
186"nursing facility care"; providing for severability;
187providing an effective date.
188
189Be It Enacted by the Legislature of the State of Florida:
190
191     Section 1.  Sections 409.961 through 409.985, Florida
192Statutes, are designated as part IV of chapter 409, Florida
193Statutes, entitled "Medicaid Managed Care."
194     Section 2.  Section 409.961, Florida Statutes, is created
195to read:
196     409.961  Statutory construction; applicability; rules.-It
197is the intent of the Legislature that if any conflict exists
198between the provisions contained in this part and in other parts
199of this chapter, the provisions in this part control. Sections
200409.961-409.985 apply only to the Medicaid managed medical
201assistance program and long-term care managed care program, as
202provided in this part. The agency shall adopt any rules
203necessary to comply with or administer this part and all rules
204necessary to comply with federal requirements. In addition, the
205department shall adopt and accept the transfer of any rules
206necessary to carry out the department's responsibilities for
207receiving and processing Medicaid applications and determining
208Medicaid eligibility and for ensuring compliance with and
209administering this part, as those rules relate to the
210department's responsibilities, and any other provisions related
211to the department's responsibility for the determination of
212Medicaid eligibility.
213     Section 3.  Section 409.962, Florida Statutes, is created
214to read:
215     409.962  Definitions.-As used in this part, except as
216otherwise specifically provided, the term:
217     (1)  "Accountable care organization" means an entity
218qualified as an accountable care organization in accordance with
219federal regulations, and which meets the requirements of a
220provider service network as described in s. 409.912(4)(d).
221     (2)  "Agency" means the Agency for Health Care
222Administration.
223     (3)  "Aging network service provider" means a provider that
224participated in a home and community-based waiver administered
225by the Department of Elderly Affairs or the community care
226service system pursuant to s. 430.205 as of October 1, 2013.
227     (4)  "Comprehensive long-term care plan" means a managed
228care plan that provides services described in s. 409.973 and
229also provides the services described in s. 409.98.
230     (5)  "Department" means the Department of Children and
231Family Services.
232     (6)  "Eligible plan" means a health insurer authorized
233under chapter 624, an exclusive provider organization authorized
234under chapter 627, a health maintenance organization authorized
235under chapter 641, or a provider service network authorized
236under s. 409.912(4)(d) or an accountable care organization
237authorized under federal law. For purposes of the managed
238medical assistance program, the term also includes the
239Children's Medical Services Network authorized under chapter
240391. For purposes of the long-term care managed care program,
241the term also includes entities qualified under 42 C.F.R. part
242422 as Medicare Advantage Preferred Provider Organizations,
243Medicare Advantage Provider-sponsored Organizations, and
244Medicare Advantage Special Needs Plans, and the Program of All-
245Inclusive Care for the Elderly.
246     (7)  "Long-term care plan" means a managed care plan that
247provides the services described in s. 409.98 for the long-term
248care managed care program.
249     (8)  "Long-term care provider service network" means a
250provider service network a controlling interest of which is
251owned by one or more licensed nursing homes, assisted living
252facilities with 17 or more beds, home health agencies, community
253care for the elderly lead agencies, or hospices.
254     (9)  "Managed care plan" means an eligible plan under
255contract with the agency to provide services in the Medicaid
256program.
257     (10)  "Medicaid" means the medical assistance program
258authorized by Title XIX of the Social Security Act, 42 U.S.C.
259ss. 1396 et seq., and regulations thereunder, as administered in
260this state by the agency.
261     (11)  "Medicaid recipient" or "recipient" means an
262individual who the department or, for Supplemental Security
263Income, the Social Security Administration determines is
264eligible pursuant to federal and state law to receive medical
265assistance and related services for which the agency may make
266payments under the Medicaid program. For the purposes of
267determining third-party liability, the term includes an
268individual formerly determined to be eligible for Medicaid, an
269individual who has received medical assistance under the
270Medicaid program, or an individual on whose behalf Medicaid has
271become obligated.
272     (12)  "Prepaid plan" means a managed care plan that is
273licensed or certified as a risk-bearing entity, or qualified
274pursuant to s. 409.912(4)(d), in the state and is paid a
275prospective per-member, per-month payment by the agency.
276     (13)  "Provider service network" means an entity qualified
277pursuant to s. 409.912(4)(d) of which a controlling interest is
278owned by a health care provider, or group of affiliated
279providers, or a public agency or entity that delivers health
280services. Health care providers include Florida-licensed health
281care professionals or licensed health care facilities, federally
282qualified health care centers, and home health care agencies.
283     (15)  "Specialty plan" means a managed care plan that
284serves Medicaid recipients who meet specified criteria based on
285age, medical condition, or diagnosis.
286     Section 4.  Section 409.963, Florida Statutes, is created
287to read:
288     409.963  Single state agency.-The agency is designated as
289the single state agency authorized to manage, operate, and make
290payments for medical assistance and related services under Title
291XIX of the Social Security Act. Subject to any limitations or
292directions provided in the General Appropriations Act, these
293payments may be made only for services included in the program,
294only on behalf of eligible individuals, and only to qualified
295providers in accordance with federal requirements for Title XIX
296of the Social Security Act and state law. This program of
297medical assistance is designated as the "Medicaid program." The
298department is responsible for Medicaid eligibility
299determinations, including, but not limited to, policy, rules,
300and the agreement with the Social Security Administration for
301Medicaid eligibility determinations for Supplemental Security
302Income recipients, as well as the actual determination of
303eligibility. As a condition of Medicaid eligibility, subject to
304federal approval, the agency and the department shall ensure
305that each Medicaid recipient consents to the release of her or
306his medical records to the agency and the Medicaid Fraud Control
307Unit of the Department of Legal Affairs.
308     Section 5.  Section 409.964, Florida Statutes is created to
309read:
310     409.964  Managed care program; state plan; waivers.-The
311Medicaid program is established as a statewide, integrated
312managed care program for all covered services, including long-
313term care services. The agency shall apply for and implement
314state plan amendments or waivers of applicable federal laws and
315regulations necessary to implement the program. Before seeking a
316waiver, the agency shall provide public notice and the
317opportunity for public comment and include public feedback in
318the waiver application. The agency shall hold one public meeting
319in each of the regions described in s. 409.966(2) and the time
320period for public comment for each region shall end no sooner
321than 30 days after the completion of the public meeting in that
322region. The agency shall submit any state plan amendments, new
323waiver requests, or requests for extensions or expansions for
324existing waivers, needed to implement the managed care program
325by August 1, 2011.
326     Section 6.  Section 409.965, Florida Statutes, is created
327to read:
328     409.965  Mandatory enrollment.-All Medicaid recipients
329shall receive covered services through the statewide managed
330care program, except as provided by this part pursuant to an
331approved federal waiver. The following Medicaid recipients are
332exempt from participation in the statewide managed care program:
333     (1)  Women who are eligible only for family planning
334services.
335     (2)  Women who are eligible only for breast and cervical
336cancer services.
337     (3)  Persons who are eligible for emergency Medicaid for
338aliens.
339     (4)  Children receiving services in a prescribed pediatric
340extended care center.
341     Section 7.  Section 409.966, Florida Statutes, is created
342to read:
343     409.966  Eligible plans; selection.-
344     (1)  ELIGIBLE PLANS.-Services in the Medicaid managed care
345program shall be provided by eligible plans. A provider service
346network must be capable of providing all covered services to a
347mandatory Medicaid managed care enrollee or may limit the
348provision of services to a specific target population based on
349the age, chronic disease state, or medical condition of the
350enrollee to whom the network will provide services. A specialty
351provider service network must be capable of coordinating care
352and delivering or arranging for the delivery of all covered
353services to the target population. A provider service network
354may partner with an insurer licensed under chapter 627 or a
355health maintenance organization licensed under chapter 641 to
356meet the requirements of a Medicaid contract.
357     (2)  ELIGIBLE PLAN SELECTION.-The agency shall select a
358limited number of eligible plans to participate in the Medicaid
359program using invitations to negotiate in accordance with s.
360287.057(3)(a). At least 90 days before issuing an invitation to
361negotiate, the agency shall compile and publish a databook
362consisting of a comprehensive set of utilization and spending
363data for the 3 most recent contract years consistent with the
364rate-setting periods for all Medicaid recipients by region or
365county. The source of the data in the report must include both
366historic fee-for-service claims and validated data from the
367Medicaid Encounter Data System. The report must be available in
368electronic form and delineate utilization use by age, gender,
369eligibility group, geographic area, and aggregate clinical risk
370score. Separate and simultaneous procurements shall be conducted
371in each of the following regions:
372     (a)  Region 1, which consists of Escambia, Okaloosa, Santa
373Rosa and Walton Counties.
374     (b)  Region 2, which consists of Bay, Calhoun, Franklin,
375Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty,
376Madison, Taylor, Wakulla, and Washington Counties.
377     (c)  Region 3, which consists of Alachua, Bradford, Citrus,
378Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake,
379Levy, Marion, Putnam, Sumter, Suwannee, and Union Counties.
380     (d)  Region 4, which consists of Baker, Clay, Duval,
381Flagler, Nassau, St. Johns, and Volusia Counties.
382     (e)  Region 5, which consists of Pasco and Pinellas
383Counties.
384     (f)  Region 6, which consists of Hardee, Highlands,
385Hillsborough, Manatee and Polk Counties.
386     (g)  Region 7, which consists of Brevard, Orange, Osceola
387and Seminole Counties.
388     (h)  Region 8, which consists of Charlotte, Collier,
389DeSoto, Glades, Hendry, Lee, and Sarasota Counties.
390     (i)  Region 9, which consists of Indian River, Martin,
391Okeechobee, Palm Beach and St. Lucie Counties.
392     (j)  Region 10, which consists of Broward County.
393     (k)  Region 11, which consists of Miami-Dade and Monroe
394Counties.
395     (3)  QUALITY SELECTION CRITERIA.-
396     (a)  The invitation to negotiate must specify the criteria
397and the relative weight of the criteria that will be used for
398determining the acceptability of the reply and guiding the
399selection of the organizations with which the agency negotiates.
400In addition to criteria established by the agency, the agency
401shall consider the following factors in the selection of
402eligible plans:
403     1.  Accreditation by the National Committee for Quality
404Assurance, the Joint Commission, or another nationally
405recognized accrediting body.
406     2.  Experience serving similar populations, including the
407organization's record in achieving specific quality standards
408with similar populations.
409     3.  Availability and accessibility of primary care and
410specialty physicians in the provider network.
411     4.  Establishment of community partnerships with providers
412that create opportunities for reinvestment in community-based
413services.
414     5.  Organization commitment to quality improvement and
415documentation of achievements in specific quality improvement
416projects, including active involvement by organization
417leadership.
418     6.  Provision of additional benefits, particularly dental
419care and disease management, and other initiatives that improve
420health outcomes.
421     7.  Evidence that a eligible plan has written agreements or
422signed contracts or has made substantial progress in
423establishing relationships with providers before the plan
424submitting a response.
425     8.  Comments submitted in writing by any enrolled Medicaid
426provider relating to a specifically identified plan
427participating in the procurement in the same region as the
428submitting provider.
429     9.  Documentation of policies and procedures for preventing
430fraud and abuse.
431     10.  The business relationship an eligible plan has with
432any other eligible plan that responds to the invitation to
433negotiate.
434     (b)  An eligible plan must disclose any business
435relationship it has with any other elgible plan that responds to
436the invitation to negotiate. The agency may not select plans in
437the same region for the same managed care program that have a
438business relationship with each other. Failure to disclose any
439business relationship shall result in disqualification from
440participation in any region for the first full contract period
441after the discovery of the business relationship by the agency.
442For the purpose of this section, "business relationship" means
443an ownership or controlling interest, an affiliate or subsidiary
444relationship, a common parent, or any mutual interest in any
445limited partnership, limited liability partnership, limited
446liability company, or other entity or business association,
447including all wholly or partially owned subsidiaries, majority-
448owned subsidiaries, parent companies, or affiliates of such
449entities, business associations, or other enterprises, that
450exists for the purpose of making a profit.
451     (c)  After negotiations are conducted, the agency shall
452select the eligible plans that are determined to be responsive
453and provide the best value to the state. Preference shall be
454given to plans that:
455     1.  Have signed contracts with primary and specialty
456physicians in sufficient numbers to meet the specific standards
457established pursuant to s. 409.967(2)(b).
458     2.  Have well-defined programs for recognizing patient-
459centered medical homes and providing for increased compensation
460for recognized medical homes, as defined by the plan.
461     3.  Are organizations that are based in and perform
462operational functions in this state, in-house or through
463contractual arrangements, by staff located in this state. Using
464a tiered approach, the highest number of points shall be awarded
465to a plan that has all or substantially all of its operational
466functions performed in the state. The second highest number of
467points shall be awarded to a plan that has a majority of its
468operational functions performed in the state. The agency may
469establish a third tier; however, preference points may not be
470awarded to plans that perform only community outreach, medical
471director functions, and state administrative functions in the
472state. For purposes of this subparagraph, operational functions
473include claims processing, member services, provider relations,
474utilization and prior authorization, case management, disease
475and quality functions, and finance and administration. For
476purposes of this subparagraph, the term "based in this state"
477means that the entity's principal office is in this state and
478the plan is not a subsidiary, directly or indirectly through one
479or more subsidiaries of, or a joint venture with, any other
480entity whose principal office is not located in the state.
481     4.  Have contracts or other arrangements for cancer disease
482management programs that have a proven record of clinical
483efficiencies and cost savings.
484     5.  Have contracts or other arrangements for diabetes
485disease management programs that have a proven record of
486clinical efficiencies and cost savings.
487     6.  Have a claims payment process that ensures that claims
488that are not contested or denied will be promptly paid pursuant
489to s. 641.3155.
490     (d)  For the first year of the first contract term, the
491agency shall negotiate capitation rates or fee for service
492payments with each plan in order to guarantee aggregate savings
493of at least 5 percent.
494     1.  For prepaid plans, determination of the amount of
495savings shall be calculated by comparison to the Medicaid rates
496that the agency paid managed care plans for similar populations
497in the same areas in the prior year. In regions containing no
498prepaid plans in the prior year, determination of the amount of
499savings shall be calculated by comparison to the Medicaid rates
500established and certified for those regions in the prior year.
501     2.  For provider service networks operating on a fee-for-
502service basis, determination of the amount of savings shall be
503calculated by comparison to the Medicaid rates that the agency
504paid on a fee-for-service basis for the same services in the
505prior year.
506     (e)  To ensure managed care plan participation in Regions 1
507and 2, the agency shall award an additional contract to each
508plan with a contract award in Region 1 or Region 2. Such
509contract shall be in any other region in which the plan
510submitted a responsive bid and negotiates a rate acceptable to
511the agency. If a plan that is awarded an additional contract
512pursuant to this paragraph is subject to penalties pursuant to
513s. 409.967(2)(g) for activities in Region 1 or Region 2, the
514additional contract is automatically terminated 180 days after
515the imposition of the penalties. The plan must reimburse the
516agency for the cost of enrollment changes and other transition
517activities.
518     (f)  The agency may not execute contracts with managed care
519plans at payment rates not supported by the General
520Appropriations Act.
521     (4)  ADMINISTRATIVE CHALLENGE.-Any eligible plan that
522participates in an invitation to negotiate in more than one
523region and is selected in at least one region may not begin
524serving Medicaid recipients in any region for which it was
525selected until all administrative challenges to procurements
526required by this section to which the eligible plan is a party
527have been finalized. If the number of plans selected is less
528than the maximum amount of plans permitted in the region, the
529agency may contract with other selected plans in the region not
530participating in the administrative challenge before resolution
531of the administrative challenge. For purposes of this
532subsection, an administrative challenge is finalized if an order
533granting voluntary dismissal with prejudice has been entered by
534any court established under Article V of the State Constitution
535or by the Division of Administrative Hearings, a final order has
536been entered into by the agency and the deadline for appeal has
537expired, a final order has been entered by the First District
538Court of Appeal and the time to seek any available review by the
539Florida Supreme Court has expired, or a final order has been
540entered by the Florida Supreme Court and a warrant has been
541issued.
542     Section 8.  Section 409.967, Florida Statutes, is created
543to read:
544     409.967  Managed care plan accountability.-
545     (1)  The agency shall establish a 5-year contract with each
546managed care plan selected through the procurement process
547described in s. 409.966. A plan contract may not be renewed;
548however, the agency may extend the term of a plan contract to
549cover any delays during the transition to a new plan.
550     (2)  The agency shall establish such contract requirements
551as are necessary for the operation of the statewide managed care
552program. In addition to any other provisions the agency may deem
553necessary, the contract must require:
554     (a)  Physician compensation.-Managed care plans are
555expected to coordinate care, manage chronic disease, and prevent
556the need for more costly services.  Effective care management
557should enable plans to redirect available resources and increase
558compensation for physicians.  Plans achieve this performance
559standard when physician payment rates equal or exceed Medicare
560rates for similar services.  The agency may impose fines or
561other sanctions on a plan that fails to meet this performance
562standard after 2 years of continuous operation.
563     (b)  Emergency services.-Managed care plans shall pay for
564services required by ss. 395.1041 and 401.45 and rendered by a
565noncontracted provider. The plans must comply with s. 641.3155.  
566Reimbursement for services under this paragraph is the lesser
567of:
568     1.  The provider's charges;
569     2.  The usual and customary provider charges for similar
570services in the community where the services were provided;
571     3.  The charge mutually agreed to by the entity and the
572provider within 60 days after submittal of the claim; or
573     4.  The rate the agency would have paid on the most recent
574October 1st.
575     (c)  Access.-
576     1.  The agency shall establish specific standards for the
577number, type, and regional distribution of providers in managed
578care plan networks to ensure access to care for both adults and
579children. Each plan must maintain a region-wide network of
580providers in sufficient numbers to meet the access standards for
581specific medical services for all recipients enrolled in the
582plan. The exclusive use of mail-order pharmacies may not be
583sufficient to meet network access standards. Consistent with the
584standards established by the agency, provider networks may
585include providers located outside the region. A plan may
586contract with a new hospital facility before the date the
587hospital becomes operational if the hospital has commenced
588construction, will be licensed and operational by January 1,
5892013, and a final order has issued in any civil or
590administrative challenge. Each plan shall establish and maintain
591an accurate and complete electronic database of contracted
592providers, including information about licensure or
593registration, locations and hours of operation, specialty
594credentials and other certifications, specific performance
595indicators, and such other information as the agency deems
596necessary. The database must be available online to both the
597agency and the public and have the capability to compare the
598availability of providers to network adequacy standards and to
599accept and display feedback from each provider's patients. Each
600plan shall submit quarterly reports to the agency identifying
601the number of enrollees assigned to each primary care provider.
602     2.  Each managed care plan must publish any prescribed drug
603formulary or preferred drug list on the plan's website in a
604manner that is accessible to and searchable by enrollees and
605providers. The plan must update the list within 24 hours after
606making a change. Each plan must ensure that the prior
607authorization process for prescribed drugs is readily accessible
608to health care providers, including posting appropriate contact
609information on its website and providing timely responses to
610providers. For Medicaid recipients diagnosed with hemophilia who
611have been prescribed anti-hemophilic-factor replacement
612products, the agency shall provide for those products and
613hemophilia overlay services through the agency's hemophilia
614disease management program.
615     3.  Managed care plans, and their fiscal agents or
616intermediaries, must accept prior authorization requests for any
617service electronically.
618     (d)  Encounter data.-The agency shall maintain and operate
619a Medicaid Encounter Data System to collect, process, store, and
620report on covered services provided to all Medicaid recipients
621enrolled in prepaid plans.
622     1.  Each prepaid plan must comply with the agency's
623reporting requirements for the Medicaid Encounter Data System.
624Prepaid plans must submit encounter data electronically in a
625format that complies with the Health Insurance Portability and
626Accountability Act provisions for electronic claims and in
627accordance with deadlines established by the agency. Prepaid
628plans must certify that the data reported is accurate and
629complete.
630     2.  The agency is responsible for validating the data
631submitted by the plans. The agency shall develop methods and
632protocols for ongoing analysis of the encounter data that
633adjusts for differences in characteristics of prepaid plan
634enrollees to allow comparison of service utilization among plans
635and against expected levels of use. The analysis shall be used
636to identify possible cases of systemic underutilization or
637denials of claims and inappropriate service utilization such as
638higher-than-expected emergency department encounters. The
639analysis shall provide periodic feedback to the plans and enable
640the agency to establish corrective action plans when necessary.
641One of the focus areas for the analysis shall be the use of
642prescription drugs.
643     3.  The agency shall make encounter data available to those
644plans accepting enrollees who are assigned to them from other
645plans leaving a region.
646     (e)  Continuous improvement.-The agency shall establish
647specific performance standards and expected milestones or
648timelines for improving performance over the term of the
649contract.
650     1.  Each managed care plan shall establish an internal
651health care quality improvement system, including enrollee
652satisfaction and disenrollment surveys. The quality improvement
653system must include incentives and disincentives for network
654providers.
655     2.  Each plan must collect and report the Health Plan
656Employer Data and Information Set (HEDIS) measures, as specified
657by the agency. These measures must be published on the plan's
658website in a manner that allows recipients to reliably compare
659the performance of plans. The agency shall use the HEDIS
660measures as a tool to monitor plan performance.
661     3.  Each managed care plan must be accredited by the
662National Committee for Quality Assurance, the Joint Commission,
663or another nationally recognized accrediting body, or have
664initiated the accreditation process, within 1 year after the
665contract is executed. For any plan not accredited within 18
666months after executing the contract, the agency shall suspend
667automatic assignment under s. 409.977 and 409.984.
668     4.  By the end of the fourth year of the first contract
669term, the agency shall issue a request for information to
670determine whether cost savings could be achieved by contracting
671for plan oversight and monitoring, including analysis of
672encounter data, assessment of performance measures, and
673compliance with other contractual requirements.
674     (f)  Program integrity.-Each managed care plan shall
675establish program integrity functions and activities to reduce
676the incidence of fraud and abuse, including, at a minimum:
677     1.  A provider credentialing system and ongoing provider
678monitoring, including maintenance of written provider
679credentialing policies and procedures which comply with federal
680and agency guidelines;
681     2.  An effective prepayment and postpayment review process
682including, but not limited to, data analysis, system editing,
683and auditing of network providers;
684     3.  Procedures for reporting instances of fraud and abuse
685pursuant to chapter 641;
686     4.  Administrative and management arrangements or
687procedures, including a mandatory compliance plan, designed to
688prevent fraud and abuse; and
689     5.  Designation of a program integrity compliance officer.
690     (g)  Grievance resolution.-Consistent with federal law,
691each managed care plan shall establish and the agency shall
692approve an internal process for reviewing and responding to
693grievances from enrollees. Each plan shall submit quarterly
694reports on the number, description, and outcome of grievances
695filed by enrollees.
696     (h)  Penalties.-
697     1.  Withdrawal and enrollment reduction.-Managed care plans
698that reduce enrollment levels or leave a region before the end
699of the contract term must reimburse the agency for the cost of
700enrollment changes and other transition activities. If more than
701one plan leaves a region at the same time, costs must be shared
702by the departing plans proportionate to their enrollments. In
703addition to the payment of costs, departing provider services
704networks must pay a per enrollee penalty of up to 3 month's
705payment and continue to provide services to the enrollee for 90
706days or until the enrollee is enrolled in another plan,
707whichever occurs first. In addition to payment of costs, all
708other plans must pay a penalty of 25 percent of the minimum
709surplus requirement pursuant to s. 641.225(1). Plans shall
710provide at least 180 days notice to the agency before
711withdrawing from a region. If a managed care plan leaves a
712region before the end of the contract term, the agency shall
713terminate all contracts with that plan in other regions,
714pursuant to the termination procedures in subparagraph 3.
715     2.  Encounter data.-If a plan fails to comply with the
716encounter data reporting requirements of this section for 30
717days, the agency must assess a fine of $5,000 per day for each
718day of noncompliance beginning on the 31st day. On the 31st day,
719the agency must notify the plan that the agency will initiate
720contract termination procedures on the 90th day unless the plan
721comes into compliance before that date.
722     3.  Termination.-If the agency terminates more than one
723regional contract with the same managed care plan due to
724noncompliance with the requirements of this section, the agency
725shall terminate all the regional contracts held by that plan.
726When terminating multiple contracts, the agency must develop a
727plan to transition enrollees to other plans, and phase-in the
728terminations over a time period sufficient to ensure a smooth
729transition.
730     (i)  Prompt payment.-Managed care plans shall comply with
731ss. 641.315, 641.3155, and 641.513.
732     (j)  Electronic claims.-Managed care plans, and their
733fiscal agents or intermediaries, shall accept electronic claims
734in compliance with federal standards.
735     (k)  Fair payment.-Provider service networks must ensure
736that no entity licensed under chapter 395 with a controlling
737interest in the network charges a Medicaid managed care plan
738more than the amount paid to that provider by the provider
739service network for the same service.
740     (l)  Itemized payment.-Any claims payment to a provider by
741a managed care plan, or by a fiscal agent or intermediary of the
742plan, must be accompanied by an itemized accounting of the
743individual claims included in the payment including, but not
744limited to, the enrollee's name, the date of service, the
745procedure code, the amount of reimbursement, and the
746identification of the plan on whose behalf the payment is made.
747     (m)  Provider dispute resolution.-Disputes between a plan
748and a provider may be resolved as described in s. 408.7057.
749     (3)  ACHIEVED SAVINGS REBATE.-
750     (a)  The agency is responsible for verifying the achieved
751savings rebate for all Medicaid prepaid plans. To assist the
752agency, a prepaid plan shall:
753     1.  Submit an annual financial audit conducted by an
754independent certified public accountant in accordance with
755generally accepted auditing standards to the agency on or before
756June 1 for the preceding year; and
757     2.  Submit an annual statement prepared in accordance with
758statutory accounting principles on or before March 1 pursuant to
759s. 624.424 if the plan is regulated by the Office of Insurance
760Regulation.
761     (b)  The agency shall contract with independent certified
762public accountants to conduct compliance audits for the purpose
763of auditing financial information, including but not limited to:
764annual premium revenue, medical and administrative costs, and
765income or losses reported by each prepaid plan, in order to
766determine and validate the achieved savings rebate.
767     (c)  Any audit required under this subsection must be
768conducted by an independent certified public accountant who
769meets criteria specified by rule. The rules must also provide
770that:
771     1.  The entity selected by the agency to conduct the audit
772may not have a conflict of interest that might affect its
773ability to perform its responsibilities with respect to an
774examination.
775     2.  The rates charged to the prepaid plan being audited are
776consistent with rates charged by other certified public
777accountants and are comparable with the rates charged for
778comparable examinations.
779     3.  Each prepaid plan audited shall pay to the agency the
780expenses of the audit at the rates established by the agency by
781rule. Such expenses include actual travel expenses, reasonable
782living expense allowances, compensation of the certified public
783accountant, and necessary attendant administrative costs of the
784agency directly related to the examination. Travel expense and
785living expense allowances are limited to those expenses incurred
786on account of the audit and must be paid by the examined prepaid
787plan together with compensation upon presentation by the agency
788to the prepaid plan of a detailed account of the charges and
789expenses after a detailed statement has been filed by the
790auditor and approved by the agency.
791     4.  All moneys collected from prepaid plans for such audits
792shall be deposited into the Grants and Donations Trust Fund and
793the agency may make deposits into such fund from moneys
794appropriated for the operation of the agency.
795     (d)  At a location in this state, the prepaid plan shall
796make available to the agency and the agency's contracted
797certified public accountant all books, accounts, documents,
798files, information, that relate to the prepaid plan's Medicaid
799transactions. Records not in the prepaid plan's immediate
800possession must be made available to the agency or the certified
801public accountant in this state within 3 days after a request is
802made by the agency or certified public accountant engaged by the
803agency. A prepaid plan has an obligation to cooperate in good
804faith with the agency and the certified public accountant.
805Failure to comply to such record requests shall be deemed a
806breach of contract.
807     (e)  Once the certified public accountant completes the
808audit, the certified public accountant shall submit an audit
809report to the agency attesting to the achieved savings of the
810plan. The results of the audit report are dispositive.
811     (f)  Achieved savings rebates validated by the certified
812public accountant are due within 30 days after the report is
813submitted. Except as provided in paragraph (h), the achieved
814savings rebate is established by determining pretax income as a
815percentage of revenues and applying the following income sharing
816ratios:
817     1.  One hundred percent of income up to and including 5
818percent of revenue shall be retained by the plan.
819     2.  Fifty percent of income above 5 percent and up to 10
820percent shall be retained by the plan, and the other 50 percent
821refunded to the state.
822     3.  One hundred percent of income above 10 percent of
823revenue shall be refunded to the state.
824     (g)  A plan that exceeds agency-defined quality measures in
825the reporting period may retain an additional 1 percent of
826revenue. For the purpose of this paragraph, the quality measures
827must include plan performance for preventing or managing
828complex, chronic conditions that are associated with an elevated
829likelihood of requiring high-cost medical treatments.
830     (h)  The following may not be included as allowable
831expenses in calculating income for determining the achieved
832savings rebate:
833     1.  Payment of achieved savings rebates.
834     2.  Any financial incentive payments made to the plan
835outside of the capitation rate.
836     3.  Any financial disincentive payments levied by the state
837or federal governments.
838     4.  Expenses associated with any lobbying or political
839activities.
840     5.  The cash value or equivalent cash value of bonuses of
841any type paid or awarded to the plan's executive staff, other
842than base salary.
843     6.  Reserves and reserve accounts.
844     7.  Administrative costs, including, but not limited to,
845reinsurance expenses, interest payments, depreciation expenses,
846bad debt expenses, and outstanding claims expenses in excess of
847actuarially sound maximum amounts set by the agency.
848
849The agency shall consider these and other factors in developing
850contracts that establish shared savings arrangements.
851     (i)  Prepaid plans that incur a loss in the first contract
852year may apply the full amount of the loss as an offset to
853income in the second contract year.
854     (j)  If, after an audit, the agency determines that a
855prepaid plan owes an additional rebate, the plan has 30 days
856after notification to make the payment. Upon failure to timely
857pay the rebate, the agency shall withhold future payments to the
858plan until the entire amount is recouped. If the agency
859determines that a prepaid plan has made an overpayment, the
860agency shall return the overpayment within 30 days.
861     Section 9.  Section 409.968, Florida Statutes, is created
862to read:
863     409.968  Managed care plan payments.-
864     (1)  Prepaid plans shall receive per-member, per-month
865payments negotiated pursuant to the procurements described in s.
866409.966. Payments shall be risk-adjusted rates based on
867historical utilization and spending data, projected forward, and
868adjusted to reflect the eligibility category, geographic area,
869and clinical risk profile of the recipients. In negotiating
870rates with the plans, the agency shall consider any adjustments
871necessary to encourage plans to use the most cost effective
872modalities for treatment of chronic disease such as peritoneal
873dialysis.
874     (2)  Provider service networks may be prepaid plans and
875receive per-member, per-month payments negotiated pursuant to
876the procurement process described in s. 409.966. Provider
877service networks that choose not to be prepaid plans shall
878receive fee-for-service rates with a shared savings settlement.
879The fee-for-service option shall be available to a provider
880service network only for the first 2 years of its operation. The
881agency shall annually conduct cost reconciliations to determine
882the amount of cost savings achieved by fee-for-service provider
883service networks for the dates of service within the period
884being reconciled. Only payments for covered services for dates
885of service within the reconciliation period and paid within 6
886months after the last date of service in the reconciliation
887period must be included. The agency shall perform the necessary
888adjustments for the inclusion of claims incurred but not
889reported within the reconciliation period for claims that could
890be received and paid by the agency after the 6-month claims
891processing time lag. The agency shall provide the results of the
892reconciliations to the fee-for-service provider service networks
893within 45 days after the end of the reconciliation period. The
894fee-for-service provider service networks shall review and
895provide written comments or a letter of concurrence to the
896agency within 45 days after receipt of the reconciliation
897results. This reconciliation is considered final.
898     (3)  The agency may not approve any plan request for a rate
899increase unless sufficient funds to support the increase have
900been authorized in the General Appropriations Act.
901     Section 10.  Section 409.969, Florida Statutes, is created
902to read:
903     409.969  Enrollment; disenrollment.-
904     (1)  ENROLLMENT.-All Medicaid recipients shall be enrolled
905in a managed care plan unless specifically exempted under this
906part. Each recipient shall have a choice of plans and may select
907any available plan unless that plan is restricted by contract to
908a specific population that does not include the recipient.
909Medicaid recipients shall have 30 days in which to make a choice
910of plans.
911     (2)  DISENROLLMENT; GRIEVANCES.-After a recipient has
912enrolled in a managed care plan, the recipient shall have 90
913days to voluntarily disenroll and select another plan. After 90
914days, no further changes may be made except for good cause. For
915purposes of this section, the term "good cause" includes, but is
916not limited to, poor quality of care, lack of access to
917necessary specialty services, an unreasonable delay or denial of
918service, or fraudulent enrollment. The agency must make a
919determination as to whether good cause exists. The agency may
920require a recipient to use the plan's grievance process before
921the agency's determination of good cause, except in cases in
922which immediate risk of permanent damage to the recipient's
923health is alleged.
924     (a)  The managed care plan internal grievance process, when
925used, must be completed in time to permit the recipient to
926disenroll by the first day of the second month after the month
927the disenrollment request was made. If the result of the
928grievance process is approval of an enrollee's request to
929disenroll, the agency is not required to make a determination in
930the case.
931     (b)  The agency must make a determination and take final
932action on a recipient's request so that disenrollment occurs no
933later than the first day of the second month after the month the
934request was made. If the agency fails to act within the
935specified timeframe, the recipient's request to disenroll is
936deemed to be approved as of the date agency action was required.
937Recipients who disagree with the agency's finding that good
938cause does not exist for disenrollment shall be advised of their
939right to pursue a Medicaid fair hearing to dispute the agency's
940finding.
941     (c)  Medicaid recipients enrolled in a managed care plan
942after the 90-day period shall remain in the plan for the
943remainder of the 12-month period. After 12 months, the recipient
944may select another plan. However, nothing shall prevent a
945Medicaid recipient from changing providers within the plan
946during that period.
947     (d)  On the first day of the month after receiving notice
948from a recipient that the recipient has moved to another region,
949the agency shall automatically disenroll the recipient from the
950managed care plan the recipient is currently enrolled in and
951treat the recipient as if the recipient is a new Medicaid
952enrollee. At that time, the recipient may choose another plan
953pursuant to the enrollment process established in this section.
954     (e)  The agency must monitor plan disenrollment throughout
955the contract term to identify any discriminatory practices.
956     Section 11.  Section 409.97, Florida Statutes, is created
957to read:
958     409.97  State and local Medicaid partnerships.-
959     (1)  INTERGOVERNMENTAL TRANSFERS.-In addition to the
960contributions required pursuant to s. 409.915, beginning in the
9612014-2015 fiscal year, the agency may accept voluntary transfers
962of local taxes and other qualified revenue from counties,
963municipalities, and special taxing districts. Such transfers
964must be contributed to advance the general goals of the Florida
965Medicaid program without restriction and must be executed
966pursuant to a contract between the agency and the local funding
967source. Contracts executed before October 31 shall result in
968contributions to Medicaid for that same state fiscal year.
969Contracts executed between November 1 and June 30 shall result
970in contributions for the following state fiscal year. Based on
971the date of the signed contracts, the agency shall allocate to
972the low-income pool the first contributions received up to the
973limit established by subsection (2). No more than 40 percent of
974the low-income pool funding shall come from any single funding
975source. Contributions in excess of the low-income pool shall be
976allocated to the disproportionate share programs defined in ss.
977409.911(3) and 409.9113 and to hospital rates pursuant to
978subsection (4). The local funding source shall designate in the
979contract which Medicaid providers ensure access to care for low-
980income and uninsured people within the applicable jurisdiction
981and are eligible for low-income pool funding. Eligible providers
982may include hospitals, primary care providers, and primary care
983access systems.
984     (2)  LOW-INCOME POOL.-The agency shall establish and
985maintain a low-income pool in a manner authorized by federal
986waiver. The low-income pool is created to compensate a network
987of providers designated pursuant to subsection (1). Funding of
988the low-income pool shall be limited to the maximum amount
989permitted by federal waiver minus a percentage specified in the
990General Appropriations Act. The low-income pool must be used to
991support enhanced access to services by offsetting shortfalls in
992Medicaid reimbursement, paying for otherwise uncompensated care,
993and financing coverage for the uninsured. The low-income pool
994shall be distributed in periodic payments to the Access to Care
995Partnership throughout the fiscal year. Distribution of low-
996income pool funds by the Access to Care Partnership to
997participating providers may be made through capitated payments,
998fees for services, or contracts for specific deliverables. The
999agency shall include the distribution amount for each provider
1000in the contract with the Access to Care Partnership pursuant to
1001subsection (3). Regardless of the method of distribution,
1002providers participating in the Access to Care Partnership shall
1003receive payments such that the aggregate benefit in the
1004jurisdiction of each local funding source, as defined in
1005subsection (1), equals the amount of the contribution plus a
1006factor specified in the General Appropriations Act.
1007     (3)  ACCESS TO CARE PARTNERSHIP.-The agency shall contract
1008with an administrative services organization that has operating
1009agreements with all health care facilities, programs, and
1010providers supported with local taxes or certified public
1011expenditures and designated pursuant to subsection (1). The
1012contract shall provide for enhanced access to care for Medicaid,
1013low-income, and uninsured Floridians. The partnership shall be
1014responsible for an ongoing program of activities that provides
1015needed, but uncovered or undercompensated, health services to
1016Medicaid enrollees and persons receiving charity care, as
1017defined in s. 409.911. Accountability for services rendered
1018under this contract must be based on the number of services
1019provided to unduplicated qualified beneficiaries, the total
1020units of service provided to these persons, and the
1021effectiveness of services provided as measured by specific
1022standards of care. The agency shall seek such plan amendments or
1023waivers as may be necessary to authorize the implementation of
1024the low-income pool as the Access to Care Partnership pursuant
1025to this section.
1026     (4)  HOSPITAL RATE DISTRIBUTION.-
1027     (a)  The agency is authorized to implement a tiered
1028hospital rate system to enhance Medicaid payments to all
1029hospitals when resources for the tiered rates are available from
1030general revenue and such contributions pursuant to subsection
1031(1) as are authorized under the General Appropriations Act.
1032     1.  Tier 1 hospitals are statutory rural hospitals as
1033defined in s. 395.602, statutory teaching hospitals as defined
1034in s. 408.07(45), and specialty children's hospitals as defined
1035in s. 395.002(28).
1036     2.  Tier 2 hospitals are community hospitals not included
1037in Tier 1 that provided more than 9 percent of the hospital's
1038total inpatient days to Medicaid patients and charity patients,
1039as defined in s. 409.911, and are located in the jurisdiction of
1040a local funding source pursuant to subsection (1).
1041     3.  Tier 3 hospitals include all community hospitals.
1042     (b)  When rates are increased pursuant to this section, the
1043Total Tier Allocation (TTA) shall be distributed as follows:
1044     1.  Tier 1 (T1A) = 0.35 x TTA.
1045     2.  Tier 2 (T2A) = 0.35 x TTA.
1046     3.  Tier 3 (T3A) = 0.30 x TTA.
1047     (c)  The tier allocation shall be distributed as a
1048percentage increase to the hospital specific base rate (HSBR)
1049established pursuant to s. 409.905(5)(c). The increase in each
1050tier shall be calculated according to the proportion of tier-
1051specific allocation to the total estimated inpatient spending
1052(TEIS) for all hospitals in each tier:
1053     1.  Tier 1 percent increase (T1PI) = T1A/Tier 1 total
1054estimated inpatient spending (T1TEIS).
1055     2.  Tier 2 percent increase (T2PI) = T2A /Tier 2 total
1056estimated inpatient spending (T2TEIS).
1057     3.  Tier 3 percent increase (T3PI) = T3A/ Tier 3 total
1058estimated inpatient spending (T3TEIS).
1059     (d)  The hospital-specific tiered rate (HSTR) shall be
1060calculated as follows:
1061     1.  For hospitals in Tier 3: HSTR = (1 + T3PI) x HSBR.
1062     2.  For hospitals in Tier 2: HSTR = (1 + T2PI) x HSBR.
1063     3.  For hospitals in Tier 1: HSTR = (1 + T1PI) x HSBR.
1064     Section 12.  Section 409.971, Florida Statutes, is created
1065to read:
1066     409.971  Managed medical assistance program.-The agency
1067shall make payments for primary and acute medical assistance and
1068related services using a managed care model. By January 1, 2013,
1069the agency shall begin implementation of the statewide managed
1070medical assistance program, with full implementation in all
1071regions by October 1, 2014.
1072     Section 13.  Section 409.972, Florida Statutes, is created
1073to read:
1074     409.972  Mandatory and voluntary enrollment.-
1075     (1)  Persons eligible for the program known as "medically
1076needy" pursuant to s. 409.904(2)(a) shall enroll in managed care
1077plans. Medically needy recipients shall meet the share of the
1078cost by paying the plan premium, up to the share of the cost
1079amount, contingent upon federal approval.
1080     (2)  The following Medicaid-eligible persons are exempt
1081from mandatory managed care enrollment required by s. 409.965,
1082and may voluntarily choose to participate in the managed medical
1083assistance program:
1084     (a)  Medicaid recipients who have other creditable health
1085care coverage, excluding Medicare.
1086     (b)  Medicaid recipients residing in residential commitment
1087facilities operated through the Department of Juvenile Justice
1088or mental health treatment facilities as defined by s.
1089394.455(32).
1090     (c)  Persons eligible for refugee assistance.
1091     (d)  Medicaid recipients who are residents of a
1092developmental disability center, including Sunland Center in
1093Marianna and Tacachale in Gainesville.
1094     (e)  Medicaid recipients enrolled in the home and community
1095based services waiver pursuant to chapter 393, and Medicaid
1096recipients waiting for waiver services.
1097     (3)  Persons eligible for Medicaid but exempt from
1098mandatory participation who do not choose to enroll in managed
1099care shall be served in the Medicaid fee-for-service program as
1100provided in part III of this chapter.
1101     (4)  The agency shall seek federal approval to require
1102Medicaid recipients enrolled in managed care plans, as a
1103condition of Medicaid eligibility, to pay the Medicaid program a
1104share of the premium of $10 per month.
1105     Section 14.  Section 409.973, Florida Statutes, is created
1106to read:
1107     409.973  Benefits.-
1108     (1)  MINIMUM BENEFITS.-Managed care plans shall cover, at a
1109minimum, the following services:
1110     (a)  Advanced registered nurse practitioner services.
1111     (b)  Ambulatory surgical treatment center services.
1112     (c)  Birthing center services.
1113     (d)  Chiropractic services.
1114     (e)  Dental services.
1115     (f)  Early periodic screening diagnosis and treatment
1116services for recipients under age 21.
1117     (g)  Emergency services.
1118     (h)  Family planning services and supplies. Pursuant to 42
1119C.F.R. s. 438.102, plans may elect to not provide these services
1120due to an objection on moral or religious grounds, and must
1121notify the agency of that election when submitting a reply to an
1122invitation to negotiate.
1123     (i)  Healthy start services, except as provided in s.
1124409.975(4).
1125     (j)  Hearing services.
1126     (k)  Home health agency services.
1127     (l)  Hospice services.
1128     (m)  Hospital inpatient services.
1129     (n)  Hospital outpatient services.
1130     (o)  Laboratory and imaging services.
1131     (p)  Medical supplies, equipment, prostheses, and orthoses.
1132     (q)  Mental health services.
1133     (r)  Nursing care.
1134     (s)  Optical services and supplies.
1135     (t)  Optometrist services.
1136     (u)  Physical, occupational, respiratory, and speech
1137therapy services.
1138     (v)  Physician services, including physician assistant
1139services.
1140     (w)  Podiatric services.
1141     (x)  Prescription drugs.
1142     (y)  Renal dialysis services.
1143     (z)  Respiratory equipment and supplies.
1144     (aa)  Rural health clinic services.
1145     (bb)  Substance abuse treatment services.
1146     (cc)  Transportation to access covered services.
1147     (2)  CUSTOMIZED BENEFITS.-Managed care plans may customize
1148benefit packages for nonpregnant adults, vary cost-sharing
1149provisions, and provide coverage for additional services. The
1150agency shall evaluate the proposed benefit packages to ensure
1151services are sufficient to meet the needs of the plan's
1152enrollees and to verify actuarial equivalence.
1153     (3)  HEALTHY BEHAVIORS.-Each plan operating in the managed
1154medical assistance program shall establish a program to
1155encourage and reward healthy behaviors. At a minimum, each plan
1156must establish a medically approved smoking cessation program, a
1157medically directed weight loss program, and a medically approved
1158alcohol or substance abuse recovery program. Each plan must
1159identify enrollees who smoke, are morbidly obese, or are
1160diagnosed with alcohol or substance abuse in order to establish
1161written agreements to secure the enrollees' commitment to
1162participation in these programs.
1163     (4)  PRIMARY CARE INITIATIVE.-Each plan operating in the
1164managed medical assistance program shall establish a program to
1165encourage enrollees to establish a relationship with their
1166primary care provider. Each plan shall:
1167     (a)  Provide information to each enrollee on the importance
1168of and procedure for selecting a primary care physician, and
1169thereafter automatically assign to a primary care provider any
1170enrollee who fails to choose a primary care provider.
1171     (b)  If the enrollee was not a Medicaid recipient before
1172enrollment in the plan, assist the enrollee in scheduling an
1173appointment with the primary care provider. If possible the
1174appointment should be made within 30 days after enrollment in
1175the plan. For enrollees who become eligible for Medicaid between
1176January 1, 2014, and December 31, 2015, the appointment should
1177be be scheduled within 6 months after enrollment in the plan.
1178     (c)  Report to the agency the number of enrollees assigned
1179to each primary care provider within the plan's network.
1180     (d)  Report to the agency the number of enrollees who have
1181not had an appointment with their primary care provider within
1182their first year of enrollment.
1183     (e)  Report to the agency the number of emergency room
1184visits by enrollees who have not had a least one appointment
1185with their primary care provider.
1186     Section 15.  Section 409.974, Florida Statutes, is created
1187to read:
1188     409.974  Eligible plans.-
1189     (1)  ELIGIBLE PLAN SELECTION.-The agency shall select
1190eligible plans through the procurement process described in s.
1191409.966. The agency shall notice invitations to negotiate no
1192later than January 1, 2013.
1193     (a)  The agency shall procure two plans for Region 1. At
1194least one plan shall be a provider service network if any
1195provider service networks submit a responsive bid.
1196     (b)  The agency shall procure two plans for Region 2. At
1197least one plan shall be a provider service network if any
1198provider service networks submit a responsive bid.
1199     (c)  The agency shall procure at least three plans and up
1200to five plans for Region 3. At least one plan must be a provider
1201service network if any provider service networks submit a
1202responsive bids.
1203     (d)  The agency shall procure at least three plans and up
1204to five plans for Region 4. At least one plan must be a provider
1205service network if any provider service networks submit a
1206responsive bid.
1207     (e)  The agency shall procure at least two plans and up to
12084 plans for Region 5. At least one plan must be a provider
1209service network if any provider service networks submit a
1210responsive bid.
1211     (f)  The agency shall procure at least four plans and up to
1212seven plans for Region 6. At least one plan must be a provider
1213service network if any provider service networks submit a
1214responsive bid.
1215     (g)  The agency shall procure at least three plans and up
1216to six plans for Region 7. At least one plan must be a provider
1217service network if any provider service networks submit a
1218responsive bid.
1219     (h)  The agency shall procure at least two plans and up to
1220four plans for Region 8. At least one plan must be a provider
1221service network if any provider service networks submit a
1222responsive bid.
1223     (i)  The agency shall procure at least two plans and up to
1224four plans for Region 9. At least one plan must be a provider
1225service network if any provider service networks submit a
1226responsive bid.
1227     (j)  The agency shall procure at least two plans and up to
1228four plans for Region 10. At least one plan must be a provider
1229service network if any provider service networks submit a
1230responsive bid.
1231     (k)  The agency shall procure at least five plans and up to
1232ten plans for Region 11. At least one plan must be a provider
1233service network if any provider service networks submit a
1234responsive bid.
1235
1236If no provider service network submits a responsive bid, the
1237agency shall procure no more than one less than the maximum
1238number of eligible plans permitted in that region. Within 12
1239months after the initial invitation to negotiate, the agency
1240shall attempt to procure a provider service network. The agency
1241shall notice another invitation to negotiate only with provider
1242service networks in those regions where no provider service
1243network has been selected.
1244     (2)  QUALITY SELECTION CRITERIA.-In addition to the
1245criteria established in s. 409.966, the agency shall consider
1246evidence that an eligible plan has written agreements or signed
1247contracts or has made substantial progress in establishing
1248relationships with providers before the plan submitting a
1249response. The agency shall evaluate and give special weight to
1250evidence of signed contracts with essential providers as defined
1251by the agency pursuant to s. 409.975(2). The agency shall
1252exercise a preference for plans with a provider network in which
1253over 10 percent of the providers use electronic health records,
1254as defined in s. 408.051. When all other factors are equal, the
1255agency shall consider whether the organization has a contract to
1256provide managed long-term care services in the same region and
1257shall exercise a preference for such plans.
1258     (3)  SPECIALTY PLANS.-Participation by specialty plans
1259shall be subject to the procurement requirements and regional
1260plan number limits of this section. However, a specialty plan
1261whose target population includes no more than 10 percent of the
1262enrollees of that region is not subject to the regional plan
1263number limits of this section.
1264     (4)  CHILDREN'S MEDICAL SERVICES NETWORK.-Participation by
1265the Children's Medical Services Network shall be pursuant to a
1266single, statewide contract with the agency that is not subject
1267to the procurement requirements or regional plan number limits
1268of this section. The Children's Medical Services Network must
1269meet all other plan requirements for the managed medical
1270assistance program.
1271     Section 16.  Section 409.975, Florida Statutes, is created
1272to read:
1273     409.975  Managed care plan accountability.-In addition to
1274the requirements of s. 409.967, plans and providers
1275participating in the managed medical assistance program shall
1276comply with the requirements of this section.
1277     (1)  PROVIDER NETWORKS.-Managed care plans must develop and
1278maintain provider networks that meet the medical needs of their
1279enrollees in accordance with standards established pursuant to
1280409.967(2)(b). Except as provided in this section, managed care
1281plans may limit the providers in their networks based on
1282credentials, quality indicators, and price.
1283     (a)  Plans must include all providers in the region that
1284are classified by the agency as essential Medicaid providers,
1285unless the agency approves, in writing, an alternative
1286arrangement for securing the types of services offered by the
1287essential providers. Providers are essential for serving
1288Medicaid enrollees if they offer services that are not available
1289from any other provider within a reasonable access standard, or
1290if they provided a substantial share of the total units of a
1291particular service used by Medicaid patients within the region
1292during the last 3 years and the combined capacity of other
1293service providers in the region is insufficient to meet the
1294total needs of the Medicaid patients. The agency may not
1295classify physicians and other practitioners as essential
1296providers. The agency, at a minimum, shall determine which
1297providers in the following categories are essential Medicaid
1298providers:
1299     1.  Federally qualified health centers.
1300     2.  Statutory teaching hospitals as defined in s.
1301408.07(45).
1302     3.  Hospitals that are trauma centers as defined in s.
1303395.4001(14).
1304     4.  Hospitals located at least 25 miles from any other
1305hospital with similar services.
1306
1307Managed care plans that have not contracted with all essential
1308providers in the region as of the first date of recipient
1309enrollment, or with whom an essential provider has terminated
1310its contract, must negotiate in good faith with such essential
1311providers for 1 year or until an agreement is reached, whichever
1312is first. Payments for services rendered by a nonparticipating
1313essential provider shall be made at the applicable Medicaid rate
1314as of the first day of the contract between the agency and the
1315plan. A rate schedule for all essential providers shall be
1316attached to the contract between the agency and the plan. After
13171 year, managed care plans that are unable to contract with
1318essential providers shall notify the agency and propose an
1319alternative arrangement for securing the essential services for
1320Medicaid enrollees. The arrangement must rely on contracts with
1321other participating providers, regardless of whether those
1322providers are located within the same region as the
1323nonparticipating essential service provider. If the alternative
1324arrangement is approved by the agency, payments to
1325nonparticipating essential providers after the date of the
1326agency's approval shall equal 90 percent of the applicable
1327Medicaid rate. If the alternative arrangement is not approved by
1328the agency, payment to nonparticipating essential providers
1329shall equal 110 percent of the applicable Medicaid rate.
1330     (b)  Certain providers are statewide resources and
1331essential providers for all managed care plans in all regions.
1332All managed care plans must include these essential providers in
1333their networks. Statewide essential providers include:
1334     1.  Faculty plans of Florida medical schools.
1335     2.  Regional perinatal intensive care centers as defined in
1336s. 383.16(2).
1337     3.  Hospitals licensed as specialty children's hospitals as
1338defined in s. 395.002(28).
1339     4.  Accredited and integrated systems serving medically
1340complex children that are comprised of separately licensed, but
1341commonly owned, health care providers delivering at least the
1342following services: medical group home, in-home and outpatient
1343nursing care and therapies, pharmacy services, durable medical
1344equipment, and Prescribed Pediatric Extended Care.
1345
1346Managed care plans that have not contracted with all statewide
1347essential providers in all regions as of the first date of
1348recipient enrollment must continue to negotiate in good faith.
1349Payments to physicians on the faculty of nonparticipating
1350Florida medical schools shall be made at the applicable Medicaid
1351rate. Payments for services rendered by a regional perinatal
1352intensive care centers shall be made at the applicable Medicaid
1353rate as of the first day of the contract between the agency and
1354the plan. Payments to nonparticipating specialty children's
1355hospitals shall equal the highest rate established by contract
1356between that provider and any other Medicaid managed care plan.
1357     (c)  After 12 months of active participation in a plan's
1358network, the plan may exclude any essential provider from the
1359network for failure to meet quality or performance criteria. If
1360the plan excludes an essential provider from the plan, the plan
1361must provide written notice to all recipients who have chosen
1362that provider for care. The notice shall be provided at least 30
1363days before the effective date of the exclusion.
1364     (d)  Each managed care plan must offer a network contract
1365to each home medical equipment and supplies provider in the
1366region which meets quality and fraud prevention and detection
1367standards established by the plan and which agrees to accept the
1368lowest price previously negotiated between the plan and another
1369such provider.
1370     (2)  FLORIDA MEDICAL SCHOOLS QUALITY NETWORK.-The agency
1371shall contract with a single organization representing medical
1372schools and graduate medical education programs in the state for
1373the purpose of establishing an active and ongoing program to
1374improve clinical outcomes in all managed care plans. Contracted
1375activities must support greater clinical integration for
1376Medicaid enrollees through interdependent and cooperative
1377efforts of all providers participating in managed care plans.
1378The agency shall support these activities with certified public
1379expenditures and any earned federal matching funds and shall
1380seek any plan amendments or waivers necessary to comply with
1381this subsection. To be eligible to participate in the quality
1382network, a medical school must contract with each managed care
1383plan in its region.
1384     (3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
1385monitor the quality and performance of each participating
1386provider. At the beginning of the contract period, each plan
1387shall notify all its network providers of the metrics used by
1388the plan for evaluating the provider's performance and
1389determining continued participation in the network.
1390     (4)  MOMCARE NETWORK.-
1391     (a)  The agency shall contract with an administrative
1392services organization representing all Healthy Start Coalitions
1393providing risk appropriate care coordination and other services
1394in accordance with a federal waiver and pursuant to s. 409.906.
1395The contract shall require the network of coalitions to provide
1396counseling, education, risk-reduction and case management
1397services, and quality assurance for all enrollees of the waiver.
1398The agency shall evaluate the impact of the MomCare network by
1399monitoring each plan's performance on specific measures to
1400determine the adequacy, timeliness, and quality of services for
1401pregnant women and infants. The agency shall support this
1402contract with certified public expenditures of general revenue
1403appropriated for Healthy Start services and any earned federal
1404matching funds.
1405     (b)  Each managed care plan shall establish specific
1406programs and procedures to improve pregnancy outcomes and infant
1407health, including, but not limited to, coordination with the
1408Healthy Start program, immunization programs, and referral to
1409the Special Supplemental Nutrition Program for Women, Infants,
1410and Children, and the Children's Medical Services program for
1411children with special health care needs. Each plan's programs
1412and procedures shall include agreements with each local Healthy
1413Start Coalition in the region to provide risk-appropriate care
1414coordination for pregnant women and infants, consistent with
1415agency policies and the MomCare network. Each managed care plan
1416must notify the agency of the impending birth of a child to an
1417enrollee, or notify the agency as soon as practicable after the
1418child's birth.
1419     (5)  SCREENING RATE.-After the end of the second contract
1420year, each managed care plan shall achieve an annual Early and
1421Periodic Screening, Diagnosis, and Treatment Service screening
1422rate of at least 80 percent of those recipients continuously
1423enrolled for at least 8 months.
1424     (6)  PROVIDER PAYMENT.-Managed care plans and hospitals
1425shall negotiate mutually acceptable rates, methods, and terms of
1426payment. For rates, methods, and terms of payment negotiated
1427after the contract between the agency and the plan is executed,
1428plans shall pay hospitals, at a minimum, the rate the agency
1429would have paid on the first day of the contract between the
1430provider and the plan. Such payments to hospitals may not exceed
1431120 percent of the rate the agency would have paid on the first
1432day of the contract between the provider and the plan, unless
1433specifically approved by the agency. Payment rates may be
1434updated periodically.
1435     (7)  MEDICALLY NEEDY ENROLLEES.-Each managed care plan must
1436accept any medically needy recipient who selects or is assigned
1437to the plan and provide that recipient with continuous
1438enrollment for 12 months. After the first month of qualifying as
1439a medically needy recipient and enrolling in a plan, and
1440contingent upon federal approval, the enrollee shall pay the
1441plan a portion of the monthly premium equal to the enrollee's
1442share of the cost as determined by the department. The agency
1443shall pay any remaining portion of the monthly premium. Plans
1444are not obligated to pay claims for medically needy patients for
1445services provided before enrollment in the plan. Medically needy
1446patients are responsible for payment of incurred claims that are
1447used to determine eligibility. Plans must provide a grace period
1448of at least 90 days before disenrolling recipients who fail to
1449pay their shares of the premium.
1450     Section 17.  Section 409.976, Florida Statutes, is created
1451to read:
1452     409.976  Managed care plan payment.-In addition to the
1453payment provisions of s. 409.968, the agency shall provide
1454payment to plans in the managed medical assistance program
1455pursuant to this section.
1456     (1)  Prepaid payment rates shall be negotiated between the
1457agency and the eligible plans as part of the procurement process
1458described in s. 409.966.
1459     (2)  The agency shall establish payment rates for statewide
1460inpatient psychiatric programs. Payments to managed care plans
1461shall be reconciled to reimburse actual payments to statewide
1462inpatient psychiatric programs.
1463     Section 18.  Section 409.977, Florida Statutes, is created
1464to read:
1465     409.977  Enrollment.-
1466     (1)  The agency shall automatically enroll into a managed
1467care plan those Medicaid recipients who do not voluntarily
1468choose a plan pursuant to s. 409.969. The agency shall
1469automatically enroll recipients in plans that meet or exceed the
1470performance or quality standards established pursuant to s.
1471409.967 and may not automatically enroll recipients in a plan
1472that is deficient in those performance or quality standards.
1473When a specialty plan is available to accommodate a specific
1474condition or diagnosis of a recipient, the agency shall assign
1475the recipient to that plan. In the first year of the first
1476contract term only, if a recipient was previously enrolled in a
1477plan that is still available in the region, the agency shall
1478automatically enroll the recipient in that plan unless an
1479applicable specialty plan is available. Except as otherwise
1480provided in this part, the agency may not engage in practices
1481that are designed to favor one managed care plan over another.
1482     (2)  When automatically enrolling recipients in managed
1483care plans, the agency shall automatically enroll based on the
1484following criteria:
1485     (a)  Whether the plan has sufficient network capacity to
1486meet the needs of the recipients.
1487     (b)  Whether the recipient has previously received services
1488from one of the plan's primary care providers.
1489     (c)  Whether primary care providers in one plan are more
1490geographically accessible to the recipient's residence than
1491those in other plans.
1492     (3)  A newborn of a mother enrolled in a plan at the time
1493of the child's birth shall be enrolled in the mother's plan.
1494Upon birth, such a newborn is deemed enrolled in the managed
1495care plan, regardless of the administrative enrollment
1496procedures, and the managed care plan is responsible for
1497providing Medicaid services to the newborn. The mother may
1498choose another plan for the newborn within 90 days after the
1499child's birth.
1500     (4)  The agency shall develop a process to enable a
1501recipient with access to employer-sponsored health care coverage
1502to opt out of all managed care plans and to use Medicaid
1503financial assistance to pay for the recipient's share of the
1504cost in such employer-sponsored coverage. Contingent upon
1505federal approval, the agency shall also enable recipients with
1506access to other insurance or related products providing access
1507to health care services created pursuant to state law, including
1508any product available under the Florida Health Choices Program,
1509or any health exchange, to opt out. The amount of financial
1510assistance provided for each recipient may not exceed the amount
1511of the Medicaid premium that would have been paid to a managed
1512care plan for that recipient. The agency shall seek federal
1513approval to require Medicaid recipients with access to employer-
1514sponsored health care coverage to enroll in that coverage and
1515use Medicaid financial assistance to pay for the recipient's
1516share of the cost for such coverage. The amount of financial
1517assistance provided for each recipient may not exceed the amount
1518of the Medicaid premium that would have been paid to a managed
1519care plan for that recipient.
1520     Section 19.  Section 409.978, Florida Statutes, is created
1521to read:
1522     409.978  Long-term care managed care program.-
1523     (1)  Pursuant to s. 409.963, the agency shall administer
1524the long-term care managed care program described in ss.
1525409.978-409.985, but may delegate specific duties and
1526responsibilities for the program to the Department of Elderly
1527Affairs and other state agencies. By July 1, 2012, the agency
1528shall begin implementation of the statewide long-term care
1529managed care program, with full implementation in all regions by
1530October 1, 2013.
1531     (2)  The agency shall make payments for long-term care,
1532including home and community-based services, using a managed
1533care model. Unless otherwise specified, ss. 409.961-409.97 apply
1534to the long-term care managed care program.
1535     (3)  The Department of Elderly Affairs shall assist the
1536agency to develop specifications for use in the invitation to
1537negotiate and the model contract, determine clinical eligibility
1538for enrollment in managed long-term care plans, monitor plan
1539performance and measure quality of service delivery, assist
1540clients and families to address complaints with the plans,
1541facilitate working relationships between plans and providers
1542serving elders and disabled adults, and perform other functions
1543specified in a memorandum of agreement.
1544     Section 20.  Section 409.979, Florida Statutes, is created
1545to read:
1546     409.979  Eligibility.-
1547     (1)  Medicaid recipients who meet all of the following
1548criteria are eligible to receive long-term care services and
1549must receive long-term care services by participating in the
1550long-term care managed care program. The recipient must be:
1551     (a)  Sixty-five years of age or older, or age 18 or older
1552and eligible for Medicaid by reason of a disability.
1553     (b)  Determined by the Comprehensive Assessment Review and
1554Evaluation for Long-Term Care Services (CARES) Program to
1555require nursing facility care as defined in s. 409.985(3).
1556     (2)  Medicaid recipients who, on the date long-term care
1557managed care plans become available in their region, reside in a
1558nursing home facility or are enrolled in one of the following
1559long-term care Medicaid waiver programs are eligible to
1560participate in the long-term care managed care program for up to
156112 months without being reevaluated for their need for nursing
1562facility care as defined in s. 409.985(3):
1563     (a)  The Assisted Living for the Frail Elderly Waiver.
1564     (b)  The Aged and Disabled Adult Waiver.
1565     (c)  The Adult Day Health Care Waiver.
1566     (d)  The Consumer-Directed Care Plus Program as described
1567in s. 409.221.
1568     (e)  The Program of All-inclusive Care for the Elderly.
1569     (f)  The long-term care community-based diversion pilot
1570project as described in s. 430.705.
1571     (g)  The Channeling Services Waiver for Frail Elders.
1572     (3)  The Department of Elderly Affairs shall make offers
1573for enrollment to eligible individuals based on a wait-list
1574prioritization and subject to availability of funds. Before
1575enrollment offers, the department shall determine that
1576sufficient funds exist to support additional enrollment into
1577plans.
1578     Section 21.  Section 409.98, Florida Statutes, is created
1579to read:
1580     409.98  Long-term care plan benefits.-Long-term care plans
1581shall, at a minimum, cover the following:
1582     (1)  Nursing facility care.
1583     (2)  Services provided in assisted living facilities.
1584     (3)  Hospice.
1585     (4)  Adult day care.
1586     (5)  Medical equipment and supplies, including incontinence
1587supplies.
1588     (6)  Personal care.
1589     (7)  Home accessibility adaptation.
1590     (8)  Behavior management.
1591     (9)  Home-delivered meals.
1592     (10)  Case management.
1593     (11)  Therapies:
1594     (a)  Occupational therapy.
1595     (b)  Speech therapy.
1596     (c)  Respiratory therapy.
1597     (d)  Physical therapy.
1598     (12)  Intermittent and skilled nursing.
1599     (13)  Medication administration.
1600     (14)  Medication management.
1601     (15)  Nutritional assessment and risk reduction.
1602     (16)  Caregiver training.
1603     (17)  Respite care.
1604     (18)  Transportation.
1605     (19)  Personal emergency response system.
1606     Section 22.  Section 409.981, Florida Statutes, is created
1607to read:
1608     409.981  Eligible long-term care plans.-
1609     (1)  ELIGIBLE PLANS.-Provider service networks must be
1610long-term care provider service networks. Other eligible plans
1611may be long-term care plans or comprehensive long-term care
1612plans.
1613     (2)  ELIGIBLE PLAN SELECTION.-The agency shall select
1614eligible plans through the procurement process described in s.
1615409.966. The agency shall provide notice of invitations to
1616negotiate by July 1, 2012. The agency shall procure:
1617     (a)  Two plans for Region 1. At least one plan must be a
1618provider service network if any provider service networks submit
1619a responsive bid.
1620     (b)  Two plans for Region 2. At least one plan must be a
1621provider service network if any provider service networks submit
1622a responsive bid.
1623     (c)  At least three plans and up to five plans for Region
16243. At least one plan must be a provider service network if any
1625provider service networks submit a responsive bid.
1626     (d)  At least three plans and up to five plans for Region
16274. At least one plan must be a provider service network if any
1628provider service network submits a responsive bid.
1629     (e)  At least two plans and up to 4 plans for Region 5. At
1630least one plan must be a provider service network if any
1631provider service networks submit a responsive bid.
1632     (f)  At least four plans and up to seven plans for Region
16336. At least one plan must be a provider service network if any
1634provider service networks submit a responsive bid.
1635     (g)  At least three plans and up to 6 plans for Region 7.
1636At least one plan must be a provider service networks if any
1637provider service networks submit a responsive bid.
1638     (h)  At least two plans and up to four plans for Region 8.
1639At least one plan must be a provider service network if any
1640provider service networks submit a responsive bid.
1641     (i)  At least two plans and up to four plans for Region 9.
1642At least one plan must be a provider service network if any
1643provider service networks submit a responsive bid.
1644     (j)  At least two plans and up to four plans for Region 10.
1645At least one plan must be a provider service network if any
1646provider service networks submit a responsive bid.
1647     (k)  At least five plans and up to ten plans for Region 11.
1648At least one plan must be a provider service network if any
1649provider service networks submit a responsive bid.
1650
1651If no provider service network submits a responsive bid in a
1652region other than Region 1 or Region 2, the agency shall procure
1653no more than one less than the maximum number of eligible plans
1654permitted in that region. Within 12 months after the initial
1655invitation to negotiate, the agency shall attempt to procure a
1656provider service network. The agency shall notice another
1657invitation to negotiate only with provider service networks in
1658regions where no provider service network has been selected.
1659     (3)  QUALITY SELECTION CRITERIA.-In addition to the
1660criteria established in s. 409.966, the agency shall consider
1661the following factors in the selection of eligible plans:
1662     (a)  Evidence of the employment of executive managers with
1663expertise and experience in serving aged and disabled persons
1664who require long-term care.
1665     (b)  Whether a plan has established a network of service
1666providers dispersed throughout the region and in sufficient
1667numbers to meet specific service standards established by the
1668agency for specialty services for persons receiving home and
1669community-based care.
1670     (c)  Whether a plan is proposing to establish a
1671comprehensive long-term care plan and whether the eligible plan
1672has a contract to provide managed medical assistance services in
1673the same region.
1674     (d)  Whether a plan offers consumer-directed care services
1675to enrollees pursuant to s. 409.221.
1676     (e)  Whether a plan is proposing to provide home and
1677community-based services in addition to the minimum benefits
1678required by s. 409.98.
1679     (4)  PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY.-
1680Participation by the Program of All-Inclusive Care for the
1681Elderly (PACE) shall be pursuant to a contract with the agency
1682and not subject to the procurement requirements or regional plan
1683number limits of this section. PACE plans may continue to
1684provide services to individuals at such levels and enrollment
1685caps as authorized by the General Appropriations Act.
1686     (5)  MEDICARE PLANS.-Participation by a Medicare Advantage
1687Preferred Provider Organization, Medicare Advantage Provider-
1688sponsored Organization, or Medicare Advantage Special Needs Plan
1689shall be pursuant to a contract with the agency and not subject
1690to the procurement requirements if the plan's Medicaid enrollees
1691consist exclusively of recipients who are deemed dually eligible
1692for Medicaid and Medicare services. Otherwise, Medicare
1693Advantage Preferred Provider Organizations, Medicare Advantage
1694Provider-Sponsored Organizations, and Medicare Advantage Special
1695Needs Plans are subject to all procurement requirements.
1696     Section 23.  Section 409.982, Florida Statutes, is created
1697to read:
1698     409.982  Long-term care managed care plan accountability.-
1699In addition to the requirements of s. 409.967, plans and
1700providers participating in the long-term care managed care
1701program must comply with the requirements of this section.
1702     (1)  PROVIDER NETWORKS.-Managed care plans may limit the
1703providers in their networks based on credentials, quality
1704indicators, and price. For the period between October 1, 2013,
1705and September 30, 2014, each selected plan must offer a network
1706contract to all the following providers in the region:
1707     (a)  Nursing homes.
1708     (b)  Hospices.
1709     (c)  Aging network service providers that have previously
1710participated in home and community-based waivers serving elders
1711or community-service programs administered by the Department of
1712Elderly Affairs.
1713
1714After 12 months of active participation in a managed care plan's
1715network, the plan may exclude any of the providers named in this
1716subsection from the network for failure to meet quality or
1717performance criteria. If the plan excludes a provider from the
1718plan, the plan must provide written notice to all recipients who
1719have chosen that provider for care. The notice must be provided
1720at least 30 days before the effective date of the exclusion. The
1721agency shall establish contract provisions governing the
1722transfer of recipients from excluded residential providers.
1723     (2)  SELECT PROVIDER PARTICIPATION.-Except as provided in
1724this subsection, providers may limit the managed care plans they
1725join. Nursing homes and hospices that are enrolled Medicaid
1726providers must participate in all eligible plans selected by the
1727agency in the region in which the provider is located.
1728     (3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
1729monitor the quality and performance of each participating
1730provider using measures adopted by and collected by the agency
1731and any additional measures mutually agreed upon by the provider
1732and the plan
1733     (4)  PROVIDER NETWORK STANDARDS.-The agency shall establish
1734and each managed care plan must comply with specific standards
1735for the number, type, and regional distribution of providers in
1736the plan's network, which must include:
1737     (a)  Adult day care centers.
1738     (b)  Adult family-care homes.
1739     (c)  Assisted living facilities.
1740     (d)  Health care services pools.
1741     (e)  Home health agencies.
1742     (f)  Homemaker and companion services.
1743     (g)  Hospices.
1744     (h)  Community care for the elderly lead agencies.
1745     (i)  Nurse registries.
1746     (j)  Nursing homes.
1747     (5)  PROVIDER PAYMENT.-Managed care plans and providers
1748shall negotiate mutually acceptable rates, methods, and terms of
1749payment. Plans shall pay nursing homes an amount equal to the
1750nursing facility-specific payment rates set by the agency;
1751however, mutually acceptable higher rates may be negotiated for
1752medically complex care. Plans shall pay hospice providers
1753through a prospective system for each enrollee an amount equal
1754to the per diem rate set by the agency. For recipients residing
1755in a nursing facility and receiving hospice services, the plan
1756shall pay the hospice provider the per diem rate set by the
1757agency minus the nursing facility component and shall pay the
1758nursing facility the applicable state rate. Plans must ensure
1759that electronic nursing home and hospice claims that contain
1760sufficient information for processing are paid within 10
1761business days after receipt.
1762     Section 24.  Section 409.983, Florida Statutes, is created
1763to read:
1764     409.983  Long-term care managed care plan payment.-In
1765addition to the payment provisions of s. 409.968, the agency
1766shall provide payment to plans in the long-term care managed
1767care program pursuant to this section.
1768     (1)  Prepaid payment rates for long-term care managed care
1769plans shall be negotiated between the agency and the eligible
1770plans as part of the procurement process described in s.
1771409.966.
1772     (2)  Payment rates for comprehensive long-term care plans
1773covering services described in s. 409.973 shall be blended with
1774rates for long-term care plans for services specified in s.
1775409.98.
1776     (3)  Payment rates for plans must reflect historic
1777utilization and spending for covered services projected forward
1778and adjusted to reflect the level of care profile for enrollees
1779in each plan. The payment shall be adjusted to provide an
1780incentive for reducing institutional placements and increasing
1781the utilization of home and community-based services.
1782     (4)  The initial assessment of an enrollee's level of care
1783shall be made by the Comprehensive Assessment and Review for
1784Long-Term-Care Services (CARES) program, which shall assign the
1785recipient into one of the following levels of care:
1786     (a)  Level of care 1 consists of recipients residing in or
1787who must be placed in a nursing home.
1788     (b)  Level of care 2 consists of recipients at imminent
1789risk of nursing home placement, as evidenced by the need for the
1790constant availability of routine medical and nursing treatment
1791and care, and require extensive health-related care and services
1792because of mental or physical incapacitation.
1793     (c)  Level of care 3 consists of recipients at imminent
1794risk of nursing home placement, as evidenced by the need for the
1795constant availability of routine medical and nursing treatment
1796and care, who have a limited need for health-related care and
1797services and are mildly medically or physically incapacitated.
1798
1799The agency shall periodically adjust payment rates to account
1800for changes in the level of care profile for each managed care
1801plan based on encounter data.
1802     (5)  The agency shall make an incentive adjustment in
1803payment rates to encourage the increased utilization of home and
1804community-based services and a commensurate reduction of
1805institutional placement. The incentive adjustment shall be
1806modified in each successive rate period during the first
1807contract period, as follows:
1808     (a)  A 2 percentage point shift in the first rate-setting
1809period;
1810     (b)  A 2 percentage point shift in the second rate-setting
1811period, as compared to the utilization mix at the end of the
1812first rate-setting period; or
1813     (c)  A 3 percentage point shift in the third rate-setting
1814period, and in each subsequent rate-setting period during the
1815first contract period, as compared to the utilization mix at the
1816end of the immediately preceding rate-setting period.
1817
1818The incentive adjustment shall continue in subsequent contract
1819periods, at a rate of 3 percentage points per year as compared
1820to the utilization mix at the end of the immediately preceding
1821rate-setting period, until no more than 35 percent of the plan's
1822enrollees are placed in institutional settings. The agency shall
1823annually report to the Legislature the actual change in the
1824utilization mix of home and community-based services compared to
1825institutional placements and provide a recommendation for
1826utilization mix requirements for future contracts.
1827     (6)  The agency shall establish nursing-facility-specific
1828payment rates for each licensed nursing home based on facility
1829costs adjusted for inflation and other factors as authorized in
1830the General Appropriations Act. Payments to long-term care
1831managed care plans shall be reconciled to reimburse actual
1832payments to nursing facilities.
1833     (7)  The agency shall establish hospice payment rates
1834pursuant to Title XVIII of the Social Security Act. Payments to
1835long-term care managed care plans shall be reconciled to
1836reimburse actual payments to hospices.
1837     Section 25.  Section 409.984, Florida Statutes, is created
1838to read:
1839     409.984  Enrollment in a long-term care managed care plan.-
1840     (1)  The agency shall automatically enroll into a long-term
1841care managed care plan those Medicaid recipients who do not
1842voluntarily choose a plan pursuant to s. 409.969. The agency
1843shall automatically enroll recipients in plans that meet or
1844exceed the performance or quality standards established pursuant
1845to s. 409.967 and may not automatically enroll recipients in a
1846plan that is deficient in those performance or quality
1847standards. If a recipient is deemed dually eligible for Medicaid
1848and Medicare services and is currently receiving Medicare
1849services from an entity qualified under 42 C.F.R. part 422 as a
1850Medicare Advantage Preferred Provider Organization, Medicare
1851Advantage Provider-sponsored Organization, or Medicare Advantage
1852Special Needs Plan, the agency shall automatically enroll the
1853recipient in such plan for Medicaid services if the plan is
1854currently participating in the long-term care managed care
1855program. Except as otherwise provided in this part, the agency
1856may not engage in practices that are designed to favor one
1857managed care plan over another.
1858     (1)  When automatically enrolling recipients in plans, the
1859agency shall take into account the following criteria:
1860     (a)  Whether the plan has sufficient network capacity to
1861meet the needs of the recipients.
1862     (b)  Whether the recipient has previously received services
1863from one of the plan's home and community-based service
1864providers.
1865     (c)  Whether the home and community-based providers in one
1866plan are more geographically accessible to the recipient's
1867residence than those in other plans.
1868     (3)  Notwithstanding s. 409.969(3)(c), if a recipient is
1869referred for hospice services, the recipient has 30 days during
1870which the recipient may select to enroll in another managed care
1871plan to access the hospice provider of the recipient's choice.
1872     (4)  If a recipient is referred for placement in a nursing
1873home or assisted living facility, the plan must inform the
1874recipient of any facilities within the plan that have specific
1875cultural or religious affiliations and, if requested by the
1876recipient, make a reasonable effort to place the recipient in
1877the facility of the recipient's choice.
1878     Section 26.  Section 409.9841, Florida Statutes, is created
1879to read:
1880     409.9841  Long-term care managed care technical advisory
1881workgroup.-
1882     (1)  Before August 1, 2011, the agency shall establish a
1883technical advisory workgroup to assist in developing:
1884     (a)  The method of determining Medicaid eligibility
1885pursuant to s. 409.985(3).
1886     (b)  The requirements for provider payments to nursing
1887homes under s. 409.983(6).
1888     (c)  The method for managing Medicare coinsurance crossover
1889claims.
1890     (d)  Uniform requirements for claims submissions and
1891payments, including electronic funds transfers and claims
1892processing.
1893     (e)  The process for enrollment of and payment for
1894individuals pending determination of Medicaid eligibility.
1895     (2)  The advisory workgroup must include, but is not
1896limited to, representatives of providers and plans who could
1897potentially participate in long-term care managed care. Members
1898of the workgroup shall serve without compensation but may be
1899reimbursed for per diem and travel expenses as provided in s.
1900112.061.
1901     (3)  This section is repealed on June 30, 2013.
1902     Section 27.  Section 409.985, Florida Statutes, is created
1903to read:
1904     409.985  Comprehensive Assessment and Review for Long-Term
1905Care Services (CARES) Program.-
1906     (1)  The agency shall operate the Comprehensive Assessment
1907and Review for Long-Term Care Services (CARES) preadmission
1908screening program to ensure that only individuals whose
1909conditions require long-term care services are enrolled in the
1910long-term care managed care program.
1911     (2)  The agency shall operate the CARES program through an
1912interagency agreement with the Department of Elderly Affairs.
1913The agency, in consultation with the Department of Elderly
1914Affairs, may contract for any function or activity of the CARES
1915program, including any function or activity required by 42
1916C.F.R. part 483.20, relating to preadmission screening and
1917review.
1918     (3)  The CARES program shall determine if an individual
1919requires nursing facility care and, if the individual requires
1920such care, assign the individual to a level of care as described
1921in s. 409.983(4). When determining the need for nursing facility
1922care, consideration shall be given to the nature of the services
1923prescribed and which level of nursing or other health care
1924personnel meets the qualifications necessary to provide such
1925services and the availability to and access by the individual of
1926community or alternative resources. For the purposes of the
1927long-term care managed care program, the term "nursing facility
1928care" means the individual:
1929     (a)  Requires nursing home placement as evidenced by the
1930need for medical observation throughout a 24-hour period and
1931care required to be performed on a daily basis by, or under the
1932direct supervision of, a registered nurse or other health care
1933professional and requires services that are sufficiently
1934medically complex to require supervision, assessment, planning,
1935or intervention by a registered nurse because of a mental or
1936physical incapacitation by the individual;
1937     (b)  Requires or is at imminent risk of nursing home
1938placement as evidenced by the need for observation throughout a
193924-hour period and care and the constant availability of medical
1940and nursing treatment and requires services on a daily or
1941intermittent basis that are to be performed under the
1942supervision of licensed nursing or other health professionals
1943because the individual who is incapacitated mentally or
1944physically; or
1945     (c)  Requires or is at imminent risk of nursing home
1946placement as evidenced by the need for observation throughout a
194724-hour period and care and the constant availability of medical
1948and nursing treatment and requires limited services that are to
1949be performed under the supervision of licensed nursing or other
1950health professionals because the individual is mildly
1951incapacitated mentally or physically.
1952     (4)  For individuals whose nursing home stay is initially
1953funded by Medicare and Medicare coverage and is being terminated
1954for lack of progress towards rehabilitation, CARES staff shall
1955consult with the person making the determination of progress
1956toward rehabilitation to ensure that the recipient is not being
1957inappropriately disqualified from Medicare coverage. If, in
1958their professional judgment, CARES staff believe that a Medicare
1959beneficiary is still making progress toward rehabilitation, they
1960may assist the Medicare beneficiary with an appeal of the
1961disqualification from Medicare coverage. The use of CARES teams
1962to review Medicare denials for coverage under this section is
1963authorized only if it is determined that such reviews qualify
1964for federal matching funds through Medicaid. The agency shall
1965seek or amend federal waivers as necessary to implement this
1966section.
1967     Section 28.  If any provision of this act or its
1968application to any person or circumstance is held invalid, the
1969invalidity does not affect other provisions or applications of
1970the act which can be given effect without the invalid provision
1971or application, and to this end the provisions of this act are
1972severable.
1973     Section 29.  This act shall take effect July 1, 2011.


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