The Florida Senate

430.205  Community care service system.--

(1)(a)  The department, through the area agency on aging, shall fund in each planning and service area at least one community care service system that provides case management and other in-home and community services as needed to help the older person maintain independence and prevent or delay more costly institutional care.

¹(b)  For fiscal year 2003-2004 only, the department shall fund, through the area agency on aging in each county as defined in s. 125.011(1), more than one community care service system that provides case management and other in-home and community services as needed to help elderly persons maintain independence and prevent or delay more costly institutional care. This paragraph expires July 1, 2004.

(2)  Core services and other support services may be furnished by public or private agencies or organizations. Each community care service system must be under the direction of a lead agency that coordinates the activities of individual contracting agencies providing community-care-for-the-elderly services. When practicable, the activities of a community care service area must be directed from a multiservice senior center and coordinated with other services offered therein. This subsection does not require programs in existence prior to the effective date of this act to be relocated.

(3)  The department shall define each core service that is to be provided or coordinated within a community care service area and establish rules and minimum standards for the delivery of core services. The department may conduct or contract for demonstration projects to determine the desirability of new concepts of organization, administration, or service delivery designed to prevent the institutionalization of functionally impaired elderly persons. Evaluations shall be made of the cost-avoidance of such demonstration projects, the ability of the projects to reduce the rate of placement of functionally impaired elderly persons in institutions, and the impact of projects on the use of institutional services and facilities.

(4)  A preservice and inservice training program for community-care-for-the-elderly service providers and staff may be designed and implemented to help assure the delivery of quality services. The department shall specify in rules the training standards and requirements for the community-care-for-the-elderly service providers and staff. Training must be sufficient to ensure that quality services are provided to clients and that appropriate skills are developed to conduct the program.

(5)  Any person who has been classified as a functionally impaired elderly person is eligible to receive community-care-for-the-elderly core services.

(a)  Those elderly persons who are determined by protective investigations to be vulnerable adults in need of services, pursuant to s. 415.104(3)(b), or to be victims of abuse, neglect, or exploitation who are in need of immediate services to prevent further harm and are referred by the adult protective services program, shall be given primary consideration for receiving community-care-for-the-elderly services. As used in this paragraph, "primary consideration" means that an assessment and services must commence within 72 hours after referral to the department or as established in accordance with department contracts by local protocols developed between department service providers and the adult protective services program.

(b)  The department shall determine an order of prioritization for all other functionally impaired elderly persons seeking community-care-for-the-elderly services which is based upon the potential recipient's frailty level and likelihood of institutional placement without such services. After determining such frailty level and likelihood of institutional placement, should the list of potential recipients require further prioritization, another factor that must be considered is the potential recipient's ability to pay for such services. Those who are less able to pay for such services must receive higher priority than those who are better able to pay for such services. A potential recipient's ability to pay may be determined by the department based on the potential recipient's self-declared statement of income and expenses.

(6)  Notwithstanding other requirements of this chapter, the Department of Elderly Affairs and the Agency for Health Care Administration shall develop a model system to transition all state-funded services for elderly individuals in one of the department's planning and service areas to a managed, integrated long-term-care delivery system under the direction of a single entity.

(a)  The duties of the model system shall include organizing and administering service delivery for the elderly, obtaining contracts for services with providers in the area, monitoring the quality of services provided, determining levels of need and disability for payment purposes, and other activities determined by the department and the agency in order to operate the model system.

(b)  The agency and the department shall integrate all funding for services to individuals over the age of 65 in the model planning and service areas into a single per-person per-month payment rate, except that funds for Medicaid behavioral health care services are exempt from this section. The funds to be integrated shall include:

1.  Community-care-for-the-elderly funds;

2.  Home-care-for-the-elderly funds;

3.  Local services program funds;

4.  Contracted services funds;

5.  Alzheimer's disease initiative funds;

6.  Medicaid home and community-based waiver services funds;

7.  Funds for all Medicaid services authorized in ss. 409.905 and 409.906, including Medicaid nursing home services; and

8.  Funds paid for Medicare premiums, coinsurance and deductibles for persons dually eligible for Medicaid and Medicare as prescribed in s. 409.908(13).

The department and the agency shall not make payments for services for people age 65 and older except through the model delivery system.

(c)  The entity selected to administer the model system shall develop a comprehensive health and long-term-care service delivery system through contracts with providers of medical, social, and long-term-care services sufficient to meet the needs of the population age 65 and older. The entity selected to administer the model system shall not directly provide services other than intake, assessment, and referral services.

(d)  The department shall determine which of the department's planning and services areas is to be designated as a model area by means of a request for proposals. The department shall select an area to be designated as a model area and the entity to administer the model system based on demonstration of capacity of the entity to:

1.  Develop contracts with providers currently under contract with the department, area agencies on aging, or community-care-for-the-elderly lead agencies;

2.  Provide a comprehensive system of appropriate medical and long-term-care services that provides high-quality medical and social services to assist older individuals in remaining in the least restrictive setting;

3.  Demonstrate a quality assurance and quality improvement system satisfactory to the department and the agency;

4.  Develop a system to identify participants who have special health care needs such as polypharmacy, mental health and substance abuse problems, falls, chronic pain, nutritional deficits, and cognitive deficits, in order to respond to and meet these needs;

5.  Use a multidisciplinary team approach to participant management which ensures that information is shared among providers responsible for delivering care to a participant;

6.  Ensure medical oversight of care plans and service delivery, regular medical evaluation of care plans, and the availability of medical consultation for case managers and service coordinators;

7.  Develop, monitor, and enforce quality-of-care requirements;

8.  Secure subcontracts with providers of medical, nursing home, and community-based long-term-care services sufficient to assure access to and choice of providers;

9.  Ensure a system of case management and service coordination which includes educational and training standards for case managers and service coordinators;

10.  Develop a business plan that considers the ability of the applicant to organize and operate a risk-bearing entity;

11.  Furnish evidence of adequate liability insurance coverage or an adequate plan of self-insurance to respond to claims for injuries arising out of the furnishing of health care; and

12.  Provide, through contract or otherwise, for periodic review of its medical facilities as required by the department and the agency.

The department shall give preference in selecting an area to be designated as a model area to that in which the administering entity is an existing area agency on aging or community-care-for-the-elderly lead agency demonstrating the ability to perform the functions described in this paragraph.

(e)  The department in consultation with the selected entity shall develop a statewide proposal regarding the long-term use and structure of a program that addresses a risk pool to reduce financial risk.

(f)  The department and the agency shall develop capitation rates based on the historical cost experience of the state in providing acute and long-term-care services to the population over 65 years of age in the area served.

1.  Payment rates in the first 2 years of operation shall be set at no more than 100 percent of the costs to the state of providing equivalent services to the population of the model area for the year prior to the year in which the model system is implemented, adjusted forward to account for inflation and population growth. In subsequent years, the rate shall be negotiated based on the cost experience of the model system in providing contracted services, but may not exceed 95 percent of the amount that would have been paid by the state in the model planning and service area absent the model integrated service delivery system.

2.  The agency and the department may develop innovative risk-sharing agreements that limit the level of custodial nursing home risk that the administering entity assumes, consistent with the intent of the Legislature to reduce the use and cost of nursing home care. Under risk-sharing arrangements, the agency and the department may reimburse the administering entity for the cost of providing nursing home care for Medicaid-eligible participants who have been permanently placed and remain in nursing home care for more than 1 year.

(g)  The department and the Agency for Health Care Administration shall seek federal waivers necessary to implement the requirements of this section.

(h)  The Department of Children and Family Services shall develop a streamlined and simplified eligibility system and shall outstation a sufficient number and quality of eligibility-determination staff with the administering entity to assure determination of Medicaid eligibility for the integrated service delivery system in the model planning and service area within 10 days after receipt of a complete application.

(i)  The Department of Elderly Affairs shall make arrangements to outstation a sufficient number of nursing home preadmission screening staff with the administering entity to assure timely assessment of level of need for long-term-care services in the model area.

(j)  The Department of Elderly Affairs shall conduct or contract for an evaluation of the pilot project. The department shall submit the evaluation to the Governor and the Legislature by January 1, 2005. The evaluation must address the effects of the pilot project on the effectiveness of the entity providing a comprehensive system of appropriate and high-quality medical and long-term-care services to elders in the least restrictive setting and make recommendations on a phased-in implementation expansion for the rest of the state.

History.--s. 5, ch. 80-181; s. 272, ch. 81-259; s. 9, ch. 90-319; s. 33, ch. 95-418; s. 7, ch. 98-182; s. 99, ch. 2000-349; s. 18, ch. 2001-254; s. 9, ch. 2002-223; ss. 11, 79, ch. 2002-402; s. 3, ch. 2003-67; s. 21, ch. 2003-399.

¹Note.--Section 21, ch. 2003-399, amended paragraph (1)(b) "[i]n order to implement Specific Appropriations 426-441 of the 2003-2004 General Appropriations Act."

Note.--Former s. 410.0241.