Senate Bill sb0002B
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Florida Senate - 2005 SB 2-B
By Senators Peaden, Carlton and Atwater
2-832B-06
1 A bill to be entitled
2 An act relating to Medicaid; amending s.
3 409.911, F.S.; creating the Medicaid Low-Income
4 Pool Council; providing for membership and
5 duties; abolishing the Medicaid
6 Disproportionate Share Council; amending s.
7 409.912, F.S.; authorizing the Agency for
8 Health Care Administration to contract with
9 comprehensive behavioral health plans in
10 separate counties within or adjacent to an AHCA
11 area; conforming provisions to the solvency
12 requirements in s. 641.2261, F.S.; deleting the
13 competitive-procurement requirement for
14 provider service networks; updating a reference
15 to the provider service network; amending s.
16 409.91211, F.S.; specifying the process for
17 statewide expansion of the Medicaid managed
18 care demonstration program; requiring that
19 matching funds for the Medicaid managed care
20 pilot program be provided by local governmental
21 entities; providing for distribution of funds
22 by the agency; providing legislative intent
23 with respect to the low-income pool plan
24 required under the Medicaid reform waiver;
25 specifying the agency's powers, duties, and
26 responsibilities with respect to implementing
27 the Medicaid managed care pilot program;
28 revising the guidelines for allowing a provider
29 service network to receive fee-for-service
30 payments in the demonstration areas;
31 authorizing the agency to make direct payments
1
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1 to hospitals and physicians for the costs
2 associated with graduate medical education
3 under Medicaid reform; including the Children's
4 Medical Services Network in the Department of
5 Health within those programs intended by the
6 Legislature to participate in the pilot program
7 to the extent possible; requiring that the
8 agency implement standards of quality assurance
9 and performance improvement in the
10 demonstration areas of the pilot program;
11 requiring the agency to establish an encounter
12 database to compile data from managed care
13 plans; requiring the agency to implement
14 procedures to minimize the risk of Medicaid
15 fraud and abuse in all managed care plans in
16 the demonstration areas; clarifying that the
17 assignment process for the pilot program is
18 exempt from certain mandatory procedures for
19 Medicaid managed care enrollment specified in
20 s. 409.9122, F.S.; revising the automatic
21 assignment process in the demonstration areas;
22 requiring that the agency report any
23 modifications to the approved waiver and
24 special terms and conditions to the Legislature
25 within specified time periods; authorizing the
26 agency to implement the provisions of the
27 waiver approved by federal Centers for Medicare
28 and Medicaid Services; providing that, if any
29 conflict exists between the provisions
30 contained in s. 409.91211, F.S., and ch. 409,
31 F.S., concerning the implementation of the
2
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1 pilot program, the provisions contained in s.
2 409.91211, F.S., control; creating s.
3 409.91213, F.S.; requiring the agency to submit
4 quarterly and annual progress reports to the
5 Legislature; providing requirements for the
6 reports; amending s. 641.2261, F.S.; revising
7 the application of solvency requirements to
8 include Medicaid provider service networks;
9 updating a reference; requiring that the agency
10 report to the Legislature the
11 pre-implementation milestones concerning the
12 low-income pool which have been approved by the
13 Federal Government and the status of those
14 remaining to be approved; providing an
15 effective date.
16
17 Be It Enacted by the Legislature of the State of Florida:
18
19 Section 1. Subsection (9) of section 409.911, Florida
20 Statutes, is amended to read:
21 409.911 Disproportionate share program.--Subject to
22 specific allocations established within the General
23 Appropriations Act and any limitations established pursuant to
24 chapter 216, the agency shall distribute, pursuant to this
25 section, moneys to hospitals providing a disproportionate
26 share of Medicaid or charity care services by making quarterly
27 Medicaid payments as required. Notwithstanding the provisions
28 of s. 409.915, counties are exempt from contributing toward
29 the cost of this special reimbursement for hospitals serving a
30 disproportionate share of low-income patients.
31
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1 (9) The Agency for Health Care Administration shall
2 create a Medicaid Low-Income Pool Council. The Low-Income Pool
3 Council shall consist of 17 members, including three
4 representatives of statutory teaching hospitals, three
5 representatives of public hospitals, three representatives of
6 nonprofit hospitals, three representatives of for-profit
7 hospitals, two representatives of rural hospitals, two
8 representatives of units of local government which contribute
9 funding, and one representative of the Department of Health.
10 The council shall:
11 (a) Make recommendations on the financing of the
12 low-income pool and the disproportionate share hospital
13 program and the distribution of their funds.
14 (b) Advise the Agency for Health Care Administration
15 on the development of the low-income pool plan required by the
16 federal Centers for Medicare and Medicaid Services pursuant to
17 the Medicaid reform waiver.
18 (c) Advise the Agency for Health Care Administration
19 on the distribution of hospital funds used to adjust inpatient
20 hospital rates, rebase rates, or otherwise exempt hospitals
21 from reimbursement limits as financed by intergovernmental
22 transfers.
23 (d) Submit its findings and recommendations to the
24 Governor and the Legislature no later than February 1 of each
25 year. The Agency for Health Care Administration shall create a
26 Medicaid Disproportionate Share Council.
27 (a) The purpose of the council is to study and make
28 recommendations regarding:
29 1. The formula for the regular disproportionate share
30 program and alternative financing options.
31
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1 2. Enhanced Medicaid funding through the Special
2 Medicaid Payment program.
3 3. The federal status of the upper-payment-limit
4 funding option and how this option may be used to promote
5 health care initiatives determined by the council to be state
6 health care priorities.
7 (b) The council shall include representatives of the
8 Executive Office of the Governor and of the agency;
9 representatives from teaching, public, private nonprofit,
10 private for-profit, and family practice teaching hospitals;
11 and representatives from other groups as needed.
12 (c) The council shall submit its findings and
13 recommendations to the Governor and the Legislature no later
14 than February 1 of each year.
15 Section 2. Paragraphs (b) and (d) of subsection (4) of
16 section 409.912, Florida Statutes, are amended to read:
17 409.912 Cost-effective purchasing of health care.--The
18 agency shall purchase goods and services for Medicaid
19 recipients in the most cost-effective manner consistent with
20 the delivery of quality medical care. To ensure that medical
21 services are effectively utilized, the agency may, in any
22 case, require a confirmation or second physician's opinion of
23 the correct diagnosis for purposes of authorizing future
24 services under the Medicaid program. This section does not
25 restrict access to emergency services or poststabilization
26 care services as defined in 42 C.F.R. part 438.114. Such
27 confirmation or second opinion shall be rendered in a manner
28 approved by the agency. The agency shall maximize the use of
29 prepaid per capita and prepaid aggregate fixed-sum basis
30 services when appropriate and other alternative service
31 delivery and reimbursement methodologies, including
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1 competitive bidding pursuant to s. 287.057, designed to
2 facilitate the cost-effective purchase of a case-managed
3 continuum of care. The agency shall also require providers to
4 minimize the exposure of recipients to the need for acute
5 inpatient, custodial, and other institutional care and the
6 inappropriate or unnecessary use of high-cost services. The
7 agency shall contract with a vendor to monitor and evaluate
8 the clinical practice patterns of providers in order to
9 identify trends that are outside the normal practice patterns
10 of a provider's professional peers or the national guidelines
11 of a provider's professional association. The vendor must be
12 able to provide information and counseling to a provider whose
13 practice patterns are outside the norms, in consultation with
14 the agency, to improve patient care and reduce inappropriate
15 utilization. The agency may mandate prior authorization, drug
16 therapy management, or disease management participation for
17 certain populations of Medicaid beneficiaries, certain drug
18 classes, or particular drugs to prevent fraud, abuse, overuse,
19 and possible dangerous drug interactions. The Pharmaceutical
20 and Therapeutics Committee shall make recommendations to the
21 agency on drugs for which prior authorization is required. The
22 agency shall inform the Pharmaceutical and Therapeutics
23 Committee of its decisions regarding drugs subject to prior
24 authorization. The agency is authorized to limit the entities
25 it contracts with or enrolls as Medicaid providers by
26 developing a provider network through provider credentialing.
27 The agency may competitively bid single-source-provider
28 contracts if procurement of goods or services results in
29 demonstrated cost savings to the state without limiting access
30 to care. The agency may limit its network based on the
31 assessment of beneficiary access to care, provider
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1 availability, provider quality standards, time and distance
2 standards for access to care, the cultural competence of the
3 provider network, demographic characteristics of Medicaid
4 beneficiaries, practice and provider-to-beneficiary standards,
5 appointment wait times, beneficiary use of services, provider
6 turnover, provider profiling, provider licensure history,
7 previous program integrity investigations and findings, peer
8 review, provider Medicaid policy and billing compliance
9 records, clinical and medical record audits, and other
10 factors. Providers shall not be entitled to enrollment in the
11 Medicaid provider network. The agency shall determine
12 instances in which allowing Medicaid beneficiaries to purchase
13 durable medical equipment and other goods is less expensive to
14 the Medicaid program than long-term rental of the equipment or
15 goods. The agency may establish rules to facilitate purchases
16 in lieu of long-term rentals in order to protect against fraud
17 and abuse in the Medicaid program as defined in s. 409.913.
18 The agency may seek federal waivers necessary to administer
19 these policies.
20 (4) The agency may contract with:
21 (b) An entity that is providing comprehensive
22 behavioral health care services to certain Medicaid recipients
23 through a capitated, prepaid arrangement pursuant to the
24 federal waiver provided for by s. 409.905(5). Such an entity
25 must be licensed under chapter 624, chapter 636, or chapter
26 641 and must possess the clinical systems and operational
27 competence to manage risk and provide comprehensive behavioral
28 health care to Medicaid recipients. As used in this paragraph,
29 the term "comprehensive behavioral health care services" means
30 covered mental health and substance abuse treatment services
31 that are available to Medicaid recipients. The secretary of
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1 the Department of Children and Family Services shall approve
2 provisions of procurements related to children in the
3 department's care or custody prior to enrolling such children
4 in a prepaid behavioral health plan. Any contract awarded
5 under this paragraph must be competitively procured. In
6 developing the behavioral health care prepaid plan procurement
7 document, the agency shall ensure that the procurement
8 document requires the contractor to develop and implement a
9 plan to ensure compliance with s. 394.4574 related to services
10 provided to residents of licensed assisted living facilities
11 that hold a limited mental health license. Except as provided
12 in subparagraph 8., and except in counties where the Medicaid
13 managed care pilot program is authorized pursuant s.
14 409.91211, the agency shall seek federal approval to contract
15 with a single entity meeting these requirements to provide
16 comprehensive behavioral health care services to all Medicaid
17 recipients not enrolled in a Medicaid managed care plan
18 authorized under s. 409.91211 or a Medicaid health maintenance
19 organization in an AHCA area. In an AHCA area where the
20 Medicaid managed care pilot program is authorized pursuant to
21 s. 409.91211 in one or more counties, the agency may procure a
22 contract with a single entity to serve the remaining counties
23 as an AHCA area or the remaining counties may be included with
24 an adjacent AHCA area and shall be subject to this paragraph.
25 Each entity must offer sufficient choice of providers in its
26 network to ensure recipient access to care and the opportunity
27 to select a provider with whom they are satisfied. The network
28 shall include all public mental health hospitals. To ensure
29 unimpaired access to behavioral health care services by
30 Medicaid recipients, all contracts issued pursuant to this
31 paragraph shall require 80 percent of the capitation paid to
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1 the managed care plan, including health maintenance
2 organizations, to be expended for the provision of behavioral
3 health care services. In the event the managed care plan
4 expends less than 80 percent of the capitation paid pursuant
5 to this paragraph for the provision of behavioral health care
6 services, the difference shall be returned to the agency. The
7 agency shall provide the managed care plan with a
8 certification letter indicating the amount of capitation paid
9 during each calendar year for the provision of behavioral
10 health care services pursuant to this section. The agency may
11 reimburse for substance abuse treatment services on a
12 fee-for-service basis until the agency finds that adequate
13 funds are available for capitated, prepaid arrangements.
14 1. By January 1, 2001, the agency shall modify the
15 contracts with the entities providing comprehensive inpatient
16 and outpatient mental health care services to Medicaid
17 recipients in Hillsborough, Highlands, Hardee, Manatee, and
18 Polk Counties, to include substance abuse treatment services.
19 2. By July 1, 2003, the agency and the Department of
20 Children and Family Services shall execute a written agreement
21 that requires collaboration and joint development of all
22 policy, budgets, procurement documents, contracts, and
23 monitoring plans that have an impact on the state and Medicaid
24 community mental health and targeted case management programs.
25 3. Except as provided in subparagraph 8., by July 1,
26 2006, the agency and the Department of Children and Family
27 Services shall contract with managed care entities in each
28 AHCA area except area 6 or arrange to provide comprehensive
29 inpatient and outpatient mental health and substance abuse
30 services through capitated prepaid arrangements to all
31 Medicaid recipients who are eligible to participate in such
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1 plans under federal law and regulation. In AHCA areas where
2 eligible individuals number less than 150,000, the agency
3 shall contract with a single managed care plan to provide
4 comprehensive behavioral health services to all recipients who
5 are not enrolled in a Medicaid health maintenance organization
6 or a Medicaid capitated managed care plan authorized under s.
7 409.91211. The agency may contract with more than one
8 comprehensive behavioral health provider to provide care to
9 recipients who are not enrolled in a Medicaid capitated
10 managed care plan authorized under s. 409.91211 or a Medicaid
11 health maintenance organization in AHCA areas where the
12 eligible population exceeds 150,000. In an AHCA area where the
13 Medicaid managed care pilot program is authorized pursuant to
14 s. 409.91211 in one or more counties, the agency may procure a
15 contract with a single entity to serve the remaining counties
16 as an AHCA area or the remaining counties may be included with
17 an adjacent AHCA area and shall be subject to this paragraph.
18 Contracts for comprehensive behavioral health providers
19 awarded pursuant to this section shall be competitively
20 procured. Both for-profit and not-for-profit corporations
21 shall be eligible to compete. Managed care plans contracting
22 with the agency under subsection (3) shall provide and receive
23 payment for the same comprehensive behavioral health benefits
24 as provided in AHCA rules, including handbooks incorporated by
25 reference. In AHCA area 11, the agency shall contract with at
26 least two comprehensive behavioral health care providers to
27 provide behavioral health care to recipients in that area who
28 are enrolled in, or assigned to, the MediPass program. One of
29 the behavioral health care contracts shall be with the
30 existing provider service network pilot project, as described
31 in paragraph (d), for the purpose of demonstrating the
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1 cost-effectiveness of the provision of quality mental health
2 services through a public hospital-operated managed care
3 model. Payment shall be at an agreed-upon capitated rate to
4 ensure cost savings. Of the recipients in area 11 who are
5 assigned to MediPass under the provisions of s.
6 409.9122(2)(k), a minimum of 50,000 of those MediPass-enrolled
7 recipients shall be assigned to the existing provider service
8 network in area 11 for their behavioral care.
9 4. By October 1, 2003, the agency and the department
10 shall submit a plan to the Governor, the President of the
11 Senate, and the Speaker of the House of Representatives which
12 provides for the full implementation of capitated prepaid
13 behavioral health care in all areas of the state.
14 a. Implementation shall begin in 2003 in those AHCA
15 areas of the state where the agency is able to establish
16 sufficient capitation rates.
17 b. If the agency determines that the proposed
18 capitation rate in any area is insufficient to provide
19 appropriate services, the agency may adjust the capitation
20 rate to ensure that care will be available. The agency and the
21 department may use existing general revenue to address any
22 additional required match but may not over-obligate existing
23 funds on an annualized basis.
24 c. Subject to any limitations provided for in the
25 General Appropriations Act, the agency, in compliance with
26 appropriate federal authorization, shall develop policies and
27 procedures that allow for certification of local and state
28 funds.
29 5. Children residing in a statewide inpatient
30 psychiatric program, or in a Department of Juvenile Justice or
31 a Department of Children and Family Services residential
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1 program approved as a Medicaid behavioral health overlay
2 services provider shall not be included in a behavioral health
3 care prepaid health plan or any other Medicaid managed care
4 plan pursuant to this paragraph.
5 6. In converting to a prepaid system of delivery, the
6 agency shall in its procurement document require an entity
7 providing only comprehensive behavioral health care services
8 to prevent the displacement of indigent care patients by
9 enrollees in the Medicaid prepaid health plan providing
10 behavioral health care services from facilities receiving
11 state funding to provide indigent behavioral health care, to
12 facilities licensed under chapter 395 which do not receive
13 state funding for indigent behavioral health care, or
14 reimburse the unsubsidized facility for the cost of behavioral
15 health care provided to the displaced indigent care patient.
16 7. Traditional community mental health providers under
17 contract with the Department of Children and Family Services
18 pursuant to part IV of chapter 394, child welfare providers
19 under contract with the Department of Children and Family
20 Services in areas 1 and 6, and inpatient mental health
21 providers licensed pursuant to chapter 395 must be offered an
22 opportunity to accept or decline a contract to participate in
23 any provider network for prepaid behavioral health services.
24 8. For fiscal year 2004-2005, all Medicaid eligible
25 children, except children in areas 1 and 6, whose cases are
26 open for child welfare services in the HomeSafeNet system,
27 shall be enrolled in MediPass or in Medicaid fee-for-service
28 and all their behavioral health care services including
29 inpatient, outpatient psychiatric, community mental health,
30 and case management shall be reimbursed on a fee-for-service
31 basis. Beginning July 1, 2005, such children, who are open for
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1 child welfare services in the HomeSafeNet system, shall
2 receive their behavioral health care services through a
3 specialty prepaid plan operated by community-based lead
4 agencies either through a single agency or formal agreements
5 among several agencies. The specialty prepaid plan must result
6 in savings to the state comparable to savings achieved in
7 other Medicaid managed care and prepaid programs. Such plan
8 must provide mechanisms to maximize state and local revenues.
9 The specialty prepaid plan shall be developed by the agency
10 and the Department of Children and Family Services. The agency
11 is authorized to seek any federal waivers to implement this
12 initiative.
13 (d) A provider service network may be reimbursed on a
14 fee-for-service or prepaid basis. A provider service network
15 which is reimbursed by the agency on a prepaid basis shall be
16 exempt from parts I and III of chapter 641, but must comply
17 with the solvency requirements in s. 641.2261(2) and meet
18 appropriate financial reserve, quality assurance, and patient
19 rights requirements as established by the agency. The agency
20 shall award contracts on a competitive bid basis and shall
21 select bidders based upon price and quality of care. Medicaid
22 recipients assigned to a provider service network
23 demonstration project shall be chosen equally from those who
24 would otherwise have been assigned to prepaid plans and
25 MediPass. The agency is authorized to seek federal Medicaid
26 waivers as necessary to implement the provisions of this
27 section. Any contract previously awarded to a provider service
28 network operated by a hospital pursuant to this subsection
29 shall remain in effect for a period of 3 years following the
30 current contract expiration date, regardless of any
31 contractual provisions to the contrary. A provider service
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1 network is a network established or organized and operated by
2 a health care provider, or group of affiliated health care
3 providers, which provides a substantial proportion of the
4 health care items and services under a contract directly
5 through the provider or affiliated group of providers and may
6 make arrangements with physicians or other health care
7 professionals, health care institutions, or any combination of
8 such individuals or institutions to assume all or part of the
9 financial risk on a prospective basis for the provision of
10 basic health services by the physicians, by other health
11 professionals, or through the institutions. The health care
12 providers must have a controlling interest in the governing
13 body of the provider service network organization.
14 Section 3. Section 409.91211, Florida Statutes, is
15 amended to read:
16 409.91211 Medicaid managed care pilot program.--
17 (1)(a) The agency is authorized to seek and implement
18 experimental, pilot, or demonstration project waivers,
19 pursuant to s. 1115 of the Social Security Act, to create a
20 statewide initiative to provide for a more efficient and
21 effective service delivery system that enhances quality of
22 care and client outcomes in the Florida Medicaid program
23 pursuant to this section. Phase one of the demonstration shall
24 be implemented in two geographic areas. One demonstration site
25 shall include only Broward County. A second demonstration site
26 shall initially include Duval County and shall be expanded to
27 include Baker, Clay, and Nassau Counties within 1 year after
28 the Duval County program becomes operational. The agency shall
29 implement expansion of the program to include the remaining
30 counties of the state and remaining eligibility groups in
31 accordance with the process specified in the
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1 federally-approved special terms and conditions numbered
2 11-W-00206/4, with a goal of full statewide implementation by
3 June 30, 2011.
4 (b) This waiver authority is contingent upon federal
5 approval to preserve the upper-payment-limit funding mechanism
6 for hospitals, including a guarantee of a reasonable growth
7 factor, a methodology to allow the use of a portion of these
8 funds to serve as a risk pool for demonstration sites,
9 provisions to preserve the state's ability to use
10 intergovernmental transfers, and provisions to protect the
11 disproportionate share program authorized pursuant to this
12 chapter. Upon completion of the evaluation conducted under s.
13 3, ch. 2005-133, Laws of Florida, the agency may request
14 statewide expansion of the demonstration projects. Statewide
15 phase-in to additional counties shall be contingent upon
16 review and approval by the Legislature. Under the
17 upper-payment-limit program, or the low-income pool as
18 implemented by the Agency for Health Care Administration
19 pursuant to federal waiver, the state matching funds required
20 for the program shall be provided by local governmental
21 entities through intergovernmental transfers. The Agency for
22 Health Care Administration shall distribute
23 upper-payment-limit, disproportionate share hospital, and
24 low-income pool funds according to federal regulations and
25 waivers and the low-income pool methodology approved by the
26 federal Centers for Medicare and Medicaid Services.
27 (c) It is the intent of the Legislature that the
28 low-income pool plan required by the terms and conditions of
29 the Medicaid reform waiver and submitted to the federal
30 Centers for Medicare and Medicaid Services propose the
31
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1 distribution of the abovementioned program funds based on the
2 following objectives:
3 1. Assure a broad and fair distribution of available
4 funds based on the access provided by Medicaid participating
5 hospitals, regardless of their ownership status, through their
6 delivery of inpatient or outpatient care for Medicaid
7 beneficiaries and uninsured and underinsured individuals;
8 2. Assure accessible emergency inpatient and
9 outpatient care for Medicaid beneficiaries and uninsured and
10 underinsured individuals;
11 3. Enhance primary, preventive, and other ambulatory
12 care coverages for uninsured individuals;
13 4. Promote teaching and specialty hospital programs;
14 5. Promote the stability and viability of statutorily
15 defined rural hospitals and hospitals that serve as sole
16 community hospitals;
17 6. Recognize the extent of hospital uncompensated care
18 costs;
19 7. Maintain and enhance essential community hospital
20 care;
21 8. Maintain incentives for local governmental entities
22 to contribute to the cost of uncompensated care;
23 9. Promote measures to avoid preventable
24 hospitalizations;
25 10. Account for hospital efficiency; and
26 11. Contribute to a community's overall health system.
27 (2) The Legislature intends for the capitated managed
28 care pilot program to:
29 (a) Provide recipients in Medicaid fee-for-service or
30 the MediPass program a comprehensive and coordinated capitated
31 managed care system for all health care services specified in
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1 ss. 409.905 and 409.906. For purposes of this section, the
2 term "capitated managed care plan" includes health maintenance
3 organizations authorized under chapter 641, exclusive provider
4 organizations authorized under chapter 627, health insurers
5 authorized under chapter 624, and provider service networks
6 that elect to be paid fee-for-service for up to 3 years as
7 authorized under this section.
8 (b) Stabilize Medicaid expenditures under the pilot
9 program compared to Medicaid expenditures in the pilot area
10 for the 3 years before implementation of the pilot program,
11 while ensuring:
12 1. Consumer education and choice.
13 2. Access to medically necessary services.
14 3. Coordination of preventative, acute, and long-term
15 care.
16 4. Reductions in unnecessary service utilization.
17 (c) Provide an opportunity to evaluate the feasibility
18 of statewide implementation of capitated managed care networks
19 as a replacement for the current Medicaid fee-for-service and
20 MediPass systems.
21 (3) The agency shall have the following powers,
22 duties, and responsibilities with respect to the development
23 of a pilot program:
24 (a) To implement develop and recommend a system to
25 deliver all mandatory services specified in s. 409.905 and
26 optional services specified in s. 409.906, as approved by the
27 Centers for Medicare and Medicaid Services and the Legislature
28 in the waiver pursuant to this section. Services to recipients
29 under plan benefits shall include emergency services provided
30 under s. 409.9128.
31
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1 (b) To implement a pilot program, including recommend
2 Medicaid eligibility categories, from those specified in ss.
3 409.903 and 409.904, as authorized in an approved federal
4 waiver which shall be included in the pilot program.
5 (c) To implement determine and recommend how to design
6 the managed care pilot program that maximizes in order to take
7 maximum advantage of all available state and federal funds,
8 including those obtained through intergovernmental transfers,
9 the low-income pool, supplemental Medicaid payments the
10 upper-payment-level funding systems, and the disproportionate
11 share program. Within the parameters allowed by federal
12 statute and rule, the agency may seek options for making
13 direct payments to hospitals and physicians employed by or
14 under contract with the state's medical schools for the costs
15 associated with graduate medical education under Medicaid
16 reform.
17 (d) To implement determine and recommend actuarially
18 sound, risk-adjusted capitation rates for Medicaid recipients
19 in the pilot program which can be separated to cover
20 comprehensive care, enhanced services, and catastrophic care.
21 (e) To implement determine and recommend policies and
22 guidelines for phasing in financial risk for approved provider
23 service networks over a 3-year period. These policies and
24 guidelines must shall include an option for a provider service
25 network to be paid to pay fee-for-service rates that may
26 include a savings-settlement option for at least 2 years. For
27 any provider service network established in a managed care
28 pilot area, the option to be paid fee-for-service rates shall
29 include a savings-settlement mechanism that is consistent with
30 s. 409.912(44). This model shall may be converted to a
31 risk-adjusted capitated rate no later than the beginning of
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1 the fourth in the third year of operation, and may be
2 converted earlier at the option of the provider service
3 network. Federally qualified health centers may be offered an
4 opportunity to accept or decline a contract to participate in
5 any provider network for prepaid primary care services.
6 (f) To implement determine and recommend provisions
7 related to stop-loss requirements and the transfer of excess
8 cost to catastrophic coverage that accommodates the risks
9 associated with the development of the pilot program.
10 (g) To determine and recommend a process to be used by
11 the Social Services Estimating Conference to determine and
12 validate the rate of growth of the per-member costs of
13 providing Medicaid services under the managed care pilot
14 program.
15 (h) To implement determine and recommend program
16 standards and credentialing requirements for capitated managed
17 care networks to participate in the pilot program, including
18 those related to fiscal solvency, quality of care, and
19 adequacy of access to health care providers. It is the intent
20 of the Legislature that, to the extent possible, any pilot
21 program authorized by the state under this section include any
22 federally qualified health center, federally qualified rural
23 health clinic, county health department, the Children's
24 Medical Services Network within the Department of Health, or
25 other federally, state, or locally funded entity that serves
26 the geographic areas within the boundaries of the pilot
27 program that requests to participate. This paragraph does not
28 relieve an entity that qualifies as a capitated managed care
29 network under this section from any other licensure or
30 regulatory requirements contained in state or federal law
31 which would otherwise apply to the entity. The standards and
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1 credentialing requirements shall be based upon, but are not
2 limited to:
3 1. Compliance with the accreditation requirements as
4 provided in s. 641.512.
5 2. Compliance with early and periodic screening,
6 diagnosis, and treatment screening requirements under federal
7 law.
8 3. The percentage of voluntary disenrollments.
9 4. Immunization rates.
10 5. Standards of the National Committee for Quality
11 Assurance and other approved accrediting bodies.
12 6. Recommendations of other authoritative bodies.
13 7. Specific requirements of the Medicaid program, or
14 standards designed to specifically meet the unique needs of
15 Medicaid recipients.
16 8. Compliance with the health quality improvement
17 system as established by the agency, which incorporates
18 standards and guidelines developed by the Centers for Medicare
19 and Medicaid Services as part of the quality assurance reform
20 initiative.
21 9. The network's infrastructure capacity to manage
22 financial transactions, recordkeeping, data collection, and
23 other administrative functions.
24 10. The network's ability to submit any financial,
25 programmatic, or patient-encounter data or other information
26 required by the agency to determine the actual services
27 provided and the cost of administering the plan.
28 (i) To implement develop and recommend a mechanism for
29 providing information to Medicaid recipients for the purpose
30 of selecting a capitated managed care plan. For each plan
31
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1 available to a recipient, the agency, at a minimum, shall
2 ensure that the recipient is provided with:
3 1. A list and description of the benefits provided.
4 2. Information about cost sharing.
5 3. Plan performance data, if available.
6 4. An explanation of benefit limitations.
7 5. Contact information, including identification of
8 providers participating in the network, geographic locations,
9 and transportation limitations.
10 6. Any other information the agency determines would
11 facilitate a recipient's understanding of the plan or
12 insurance that would best meet his or her needs.
13 (j) To implement develop and recommend a system to
14 ensure that there is a record of recipient acknowledgment that
15 choice counseling has been provided.
16 (k) To implement develop and recommend a choice
17 counseling system to ensure that the choice counseling process
18 and related material are designed to provide counseling
19 through face-to-face interaction, by telephone, and in writing
20 and through other forms of relevant media. Materials shall be
21 written at the fourth-grade reading level and available in a
22 language other than English when 5 percent of the county
23 speaks a language other than English. Choice counseling shall
24 also use language lines and other services for impaired
25 recipients, such as TTD/TTY.
26 (l) To implement develop and recommend a system that
27 prohibits capitated managed care plans, their representatives,
28 and providers employed by or contracted with the capitated
29 managed care plans from recruiting persons eligible for or
30 enrolled in Medicaid, from providing inducements to Medicaid
31 recipients to select a particular capitated managed care plan,
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1 and from prejudicing Medicaid recipients against other
2 capitated managed care plans. The system shall require the
3 entity performing choice counseling to determine if the
4 recipient has made a choice of a plan or has opted out because
5 of duress, threats, payment to the recipient, or incentives
6 promised to the recipient by a third party. If the choice
7 counseling entity determines that the decision to choose a
8 plan was unlawfully influenced or a plan violated any of the
9 provisions of s. 409.912(21), the choice counseling entity
10 shall immediately report the violation to the agency's program
11 integrity section for investigation. Verification of choice
12 counseling by the recipient shall include a stipulation that
13 the recipient acknowledges the provisions of this subsection.
14 (m) To implement develop and recommend a choice
15 counseling system that promotes health literacy and provides
16 information aimed to reduce minority health disparities
17 through outreach activities for Medicaid recipients.
18 (n) To develop and recommend a system for the agency
19 to contract with entities to perform choice counseling. The
20 agency may establish standards and performance contracts,
21 including standards requiring the contractor to hire choice
22 counselors who are representative of the state's diverse
23 population and to train choice counselors in working with
24 culturally diverse populations.
25 (o) To implement determine and recommend descriptions
26 of the eligibility assignment processes which will be used to
27 facilitate client choice while ensuring pilot programs of
28 adequate enrollment levels. These processes shall ensure that
29 pilot sites have sufficient levels of enrollment to conduct a
30 valid test of the managed care pilot program within a 2-year
31 timeframe.
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1 (p) To implement standards for plan compliance,
2 including, but not limited to, standards for quality assurance
3 and performance improvement, standards for peer or
4 professional reviews, grievance policies, and policies for
5 maintaining program integrity. The agency shall develop a
6 data-reporting system, seek input from managed care plans in
7 order to establish requirements for patient-encounter
8 reporting, and ensure that the data reported is accurate and
9 complete.
10 1. In performing the duties required under this
11 section, the agency shall work with managed care plans to
12 establish a uniform system to measure and monitor outcomes for
13 a recipient of Medicaid services.
14 2. The system shall use financial, clinical, and other
15 criteria based on pharmacy, medical services, and other data
16 that is related to the provision of Medicaid services,
17 including, but not limited to:
18 a. The Health Plan Employer Data and Information Set
19 (HEDIS) or measures that are similar to HEDIS.
20 b. Member satisfaction.
21 c. Provider satisfaction.
22 d. Report cards on plan performance and best
23 practices.
24 e. Compliance with the requirements for prompt payment
25 of claims under ss. 627.613, 641.3155, and 641.513.
26 3. The agency shall require the managed care plans
27 that have contracted with the agency to establish a quality
28 assurance system that incorporates the provisions of s.
29 409.912(27) and any standards, rules, and guidelines developed
30 by the agency.
31
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1 4. The agency shall establish an encounter database in
2 order to compile data on health services rendered by health
3 care practitioners who provide services to patients enrolled
4 in managed care plans in the demonstration sites. The
5 encounter database shall:
6 a. Collect the following for each type of patient
7 encounter with a health care practitioner or facility,
8 including:
9 (I) The demographic characteristics of the patient.
10 (II) The principal, secondary, and tertiary diagnosis.
11 (III) The procedure performed.
12 (IV) The date and location where the procedure was
13 performed.
14 (V) The payment for the procedure, if any.
15 (VI) If applicable, the health care practitioner's
16 universal identification number.
17 (VII) If the health care practitioner rendering the
18 service is a dependent practitioner, the modifiers appropriate
19 to indicate that the service was delivered by the dependent
20 practitioner.
21 b. Collect appropriate information relating to
22 prescription drugs for each type of patient encounter.
23 c. Collect appropriate information related to health
24 care costs and utilization from managed care plans
25 participating in the demonstration sites.
26 5. To the extent practicable, when collecting the data
27 the agency shall use a standardized claim form or electronic
28 transfer system that is used by health care practitioners,
29 facilities, and payors.
30 6. Health care practitioners and facilities in the
31 demonstration sites shall electronically submit, and managed
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1 care plans participating in the demonstration sites shall
2 electronically receive, information concerning claims payments
3 and any other information reasonably related to the encounter
4 database using a standard format as required by the agency.
5 7. The agency shall establish reasonable deadlines for
6 phasing in the electronic transmittal of full encounter data.
7 8. The system must ensure that the data reported is
8 accurate and complete.
9 (p) To develop and recommend a system to monitor the
10 provision of health care services in the pilot program,
11 including utilization and quality of health care services for
12 the purpose of ensuring access to medically necessary
13 services. This system shall include an encounter
14 data-information system that collects and reports utilization
15 information. The system shall include a method for verifying
16 data integrity within the database and within the provider's
17 medical records.
18 (q) To implement recommend a grievance resolution
19 process for Medicaid recipients enrolled in a capitated
20 managed care network under the pilot program modeled after the
21 subscriber assistance panel, as created in s. 408.7056. This
22 process shall include a mechanism for an expedited review of
23 no greater than 24 hours after notification of a grievance if
24 the life of a Medicaid recipient is in imminent and emergent
25 jeopardy.
26 (r) To implement recommend a grievance resolution
27 process for health care providers employed by or contracted
28 with a capitated managed care network under the pilot program
29 in order to settle disputes among the provider and the managed
30 care network or the provider and the agency.
31
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1 (s) To implement develop and recommend criteria in an
2 approved federal waiver to designate health care providers as
3 eligible to participate in the pilot program. The agency and
4 capitated managed care networks must follow national
5 guidelines for selecting health care providers, whenever
6 available. These criteria must include at a minimum those
7 criteria specified in s. 409.907.
8 (t) To use develop and recommend health care provider
9 agreements for participation in the pilot program.
10 (u) To require that all health care providers under
11 contract with the pilot program be duly licensed in the state,
12 if such licensure is available, and meet other criteria as may
13 be established by the agency. These criteria shall include at
14 a minimum those criteria specified in s. 409.907.
15 (v) To ensure that managed care organizations work
16 collaboratively develop and recommend agreements with other
17 state or local governmental programs or institutions for the
18 coordination of health care to eligible individuals receiving
19 services from such programs or institutions.
20 (w) To implement procedures to minimize the risk of
21 Medicaid fraud and abuse in all plans operating in the
22 Medicaid managed care pilot program authorized in this
23 section.
24 1. The agency shall ensure that applicable provisions
25 of this chapter and chapters 414, 626, 641, and 932 which
26 relate to Medicaid fraud and abuse are applied and enforced at
27 the demonstration project sites.
28 2. Providers must have the certification, license, and
29 credentials that are required by law and waiver requirements.
30 3. The agency shall ensure that the plan is in
31 compliance with s. 409.912(21) and (22).
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1 4. The agency shall require that each plan establish
2 functions and activities governing program integrity in order
3 to reduce the incidence of fraud and abuse. Plans must report
4 instances of fraud and abuse pursuant to chapter 641.
5 5. The plan shall have written administrative and
6 management arrangements or procedures, including a mandatory
7 compliance plan, which are designed to guard against fraud and
8 abuse. The plan shall designate a compliance officer who has
9 sufficient experience in health care.
10 6.a. The agency shall require all managed care plan
11 contractors in the pilot program to report all instances of
12 suspected fraud and abuse. A failure to report instances of
13 suspected fraud and abuse is a violation of law and subject to
14 the penalties provided by law.
15 b. An instance of fraud and abuse in the managed care
16 plan, including, but not limited to, defrauding the state
17 health care benefit program by misrepresentation of fact in
18 reports, claims, certifications, enrollment claims,
19 demographic statistics, or patient-encounter data;
20 misrepresentation of the qualifications of persons rendering
21 health care and ancillary services; bribery and false
22 statements relating to the delivery of health care; unfair and
23 deceptive marketing practices; and false claims actions in the
24 provision of managed care, is a violation of law and subject
25 to the penalties provided by law.
26 c. The agency shall require that all contractors make
27 all files and relevant billing and claims data accessible to
28 state regulators and investigators and that all such data is
29 linked into a unified system to ensure consistent reviews and
30 investigations.
31
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1 (w) To develop and recommend a system to oversee the
2 activities of pilot program participants, health care
3 providers, capitated managed care networks, and their
4 representatives in order to prevent fraud or abuse,
5 overutilization or duplicative utilization, underutilization
6 or inappropriate denial of services, and neglect of
7 participants and to recover overpayments as appropriate. For
8 the purposes of this paragraph, the terms "abuse" and "fraud"
9 have the meanings as provided in s. 409.913. The agency must
10 refer incidents of suspected fraud, abuse, overutilization and
11 duplicative utilization, and underutilization or inappropriate
12 denial of services to the appropriate regulatory agency.
13 (x) To develop and provide actuarial and benefit
14 design analyses that indicate the effect on capitation rates
15 and benefits offered in the pilot program over a prospective
16 5-year period based on the following assumptions:
17 1. Growth in capitation rates which is limited to the
18 estimated growth rate in general revenue.
19 2. Growth in capitation rates which is limited to the
20 average growth rate over the last 3 years in per-recipient
21 Medicaid expenditures.
22 3. Growth in capitation rates which is limited to the
23 growth rate of aggregate Medicaid expenditures between the
24 2003-2004 fiscal year and the 2004-2005 fiscal year.
25 (y) To develop a mechanism to require capitated
26 managed care plans to reimburse qualified emergency service
27 providers, including, but not limited to, ambulance services,
28 in accordance with ss. 409.908 and 409.9128. The pilot program
29 must include a provision for continuing fee-for-service
30 payments for emergency services, including, but not limited
31 to, individuals who access ambulance services or emergency
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1 departments and who are subsequently determined to be eligible
2 for Medicaid services.
3 (z) To ensure that develop a system whereby school
4 districts participating in the certified school match program
5 pursuant to ss. 409.908(21) and 1011.70 shall be reimbursed by
6 Medicaid, subject to the limitations of s. 1011.70(1), for a
7 Medicaid-eligible child participating in the services as
8 authorized in s. 1011.70, as provided for in s. 409.9071,
9 regardless of whether the child is enrolled in a capitated
10 managed care network. Capitated managed care networks must
11 make a good faith effort to execute agreements with school
12 districts regarding the coordinated provision of services
13 authorized under s. 1011.70. County health departments
14 delivering school-based services pursuant to ss. 381.0056 and
15 381.0057 must be reimbursed by Medicaid for the federal share
16 for a Medicaid-eligible child who receives Medicaid-covered
17 services in a school setting, regardless of whether the child
18 is enrolled in a capitated managed care network. Capitated
19 managed care networks must make a good faith effort to execute
20 agreements with county health departments regarding the
21 coordinated provision of services to a Medicaid-eligible
22 child. To ensure continuity of care for Medicaid patients, the
23 agency, the Department of Health, and the Department of
24 Education shall develop procedures for ensuring that a
25 student's capitated managed care network provider receives
26 information relating to services provided in accordance with
27 ss. 381.0056, 381.0057, 409.9071, and 1011.70.
28 (aa) To implement develop and recommend a mechanism
29 whereby Medicaid recipients who are already enrolled in a
30 managed care plan or the MediPass program in the pilot areas
31 shall be offered the opportunity to change to capitated
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1 managed care plans on a staggered basis, as defined by the
2 agency. All Medicaid recipients shall have 30 days in which to
3 make a choice of capitated managed care plans. Those Medicaid
4 recipients who do not make a choice shall be assigned to a
5 capitated managed care plan in accordance with paragraph
6 (4)(a) and shall be exempt from s. 409.9122. To facilitate
7 continuity of care for a Medicaid recipient who is also a
8 recipient of Supplemental Security Income (SSI), prior to
9 assigning the SSI recipient to a capitated managed care plan,
10 the agency shall determine whether the SSI recipient has an
11 ongoing relationship with a provider or capitated managed care
12 plan, and, if so, the agency shall assign the SSI recipient to
13 that provider or capitated managed care plan where feasible.
14 Those SSI recipients who do not have such a provider
15 relationship shall be assigned to a capitated managed care
16 plan provider in accordance with paragraph (4)(a) and shall be
17 exempt from s. 409.9122.
18 (bb) To develop and recommend a service delivery
19 alternative for children having chronic medical conditions
20 which establishes a medical home project to provide primary
21 care services to this population. The project shall provide
22 community-based primary care services that are integrated with
23 other subspecialties to meet the medical, developmental, and
24 emotional needs for children and their families. This project
25 shall include an evaluation component to determine impacts on
26 hospitalizations, length of stays, emergency room visits,
27 costs, and access to care, including specialty care and
28 patient and family satisfaction.
29 (cc) To develop and recommend service delivery
30 mechanisms within capitated managed care plans to provide
31 Medicaid services as specified in ss. 409.905 and 409.906 to
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1 persons with developmental disabilities sufficient to meet the
2 medical, developmental, and emotional needs of these persons.
3 (dd) To develop and recommend service delivery
4 mechanisms within capitated managed care plans to provide
5 Medicaid services as specified in ss. 409.905 and 409.906 to
6 Medicaid-eligible children in foster care. These services must
7 be coordinated with community-based care providers as
8 specified in s. 409.1675, where available, and be sufficient
9 to meet the medical, developmental, and emotional needs of
10 these children.
11 (4)(a) A Medicaid recipient in the pilot area who is
12 not currently enrolled in a capitated managed care plan upon
13 implementation is not eligible for services as specified in
14 ss. 409.905 and 409.906, for the amount of time that the
15 recipient does not enroll in a capitated managed care network.
16 If a Medicaid recipient has not enrolled in a capitated
17 managed care plan within 30 days after eligibility, the agency
18 shall assign the Medicaid recipient to a capitated managed
19 care plan based on the assessed needs of the recipient as
20 determined by the agency and the recipient shall be exempt
21 from s. 409.9122. When making assignments, the agency shall
22 take into account the following criteria:
23 1. A capitated managed care network has sufficient
24 network capacity to meet the needs of members.
25 2. The capitated managed care network has previously
26 enrolled the recipient as a member, or one of the capitated
27 managed care network's primary care providers has previously
28 provided health care to the recipient.
29 3. The agency has knowledge that the member has
30 previously expressed a preference for a particular capitated
31
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1 managed care network as indicated by Medicaid fee-for-service
2 claims data, but has failed to make a choice.
3 4. The capitated managed care network's primary care
4 providers are geographically accessible to the recipient's
5 residence.
6 (b) When more than one capitated managed care network
7 provider meets the criteria specified in paragraph (3)(h), the
8 agency shall make recipient assignments consecutively by
9 family unit.
10 (c) If a recipient is currently enrolled with a
11 Medicaid managed care organization that also operates an
12 approved reform plan within a demonstration area and the
13 recipient fails to choose a plan during the reform enrollment
14 process or during redetermination of eligibility, the
15 recipient shall be automatically assigned by the agency into
16 the most appropriate reform plan operated by the recipient's
17 current Medicaid managed care plan. If the recipient's current
18 managed care plan does not operate a reform plan in the
19 demonstration area which adequately meets the needs of the
20 Medicaid recipient, the agency shall use the automatic
21 assignment process as prescribed in the special terms and
22 conditions numbered 11-W-00206/4. All enrollment and choice
23 counseling materials provided by the agency must contain an
24 explanation of the provisions of this paragraph for current
25 managed care recipients.
26 (d)(c) The agency may not engage in practices that are
27 designed to favor one capitated managed care plan over another
28 or that are designed to influence Medicaid recipients to
29 enroll in a particular capitated managed care network in order
30 to strengthen its particular fiscal viability.
31
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1 (e)(d) After a recipient has made a selection or has
2 been enrolled in a capitated managed care network, the
3 recipient shall have 90 days in which to voluntarily disenroll
4 and select another capitated managed care network. After 90
5 days, no further changes may be made except for cause. Cause
6 shall include, but not be limited to, poor quality of care,
7 lack of access to necessary specialty services, an
8 unreasonable delay or denial of service, inordinate or
9 inappropriate changes of primary care providers, service
10 access impairments due to significant changes in the
11 geographic location of services, or fraudulent enrollment. The
12 agency may require a recipient to use the capitated managed
13 care network's grievance process as specified in paragraph
14 (3)(g) prior to the agency's determination of cause, except in
15 cases in which immediate risk of permanent damage to the
16 recipient's health is alleged. The grievance process, when
17 used, must be completed in time to permit the recipient to
18 disenroll no later than the first day of the second month
19 after the month the disenrollment request was made. If the
20 capitated managed care network, as a result of the grievance
21 process, approves an enrollee's request to disenroll, the
22 agency is not required to make a determination in the case.
23 The agency must make a determination and take final action on
24 a recipient's request so that disenrollment occurs no later
25 than the first day of the second month after the month the
26 request was made. If the agency fails to act within the
27 specified timeframe, the recipient's request to disenroll is
28 deemed to be approved as of the date agency action was
29 required. Recipients who disagree with the agency's finding
30 that cause does not exist for disenrollment shall be advised
31
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1 of their right to pursue a Medicaid fair hearing to dispute
2 the agency's finding.
3 (f)(e) The agency shall apply for federal waivers from
4 the Centers for Medicare and Medicaid Services to lock
5 eligible Medicaid recipients into a capitated managed care
6 network for 12 months after an open enrollment period. After
7 12 months of enrollment, a recipient may select another
8 capitated managed care network. However, nothing shall prevent
9 a Medicaid recipient from changing primary care providers
10 within the capitated managed care network during the 12-month
11 period.
12 (g)(f) The agency shall apply for federal waivers from
13 the Centers for Medicare and Medicaid Services to allow
14 recipients to purchase health care coverage through an
15 employer-sponsored health insurance plan instead of through a
16 Medicaid-certified plan. This provision shall be known as the
17 opt-out option.
18 1. A recipient who chooses the Medicaid opt-out option
19 shall have an opportunity for a specified period of time, as
20 authorized under a waiver granted by the Centers for Medicare
21 and Medicaid Services, to select and enroll in a
22 Medicaid-certified plan. If the recipient remains in the
23 employer-sponsored plan after the specified period, the
24 recipient shall remain in the opt-out program for at least 1
25 year or until the recipient no longer has access to
26 employer-sponsored coverage, until the employer's open
27 enrollment period for a person who opts out in order to
28 participate in employer-sponsored coverage, or until the
29 person is no longer eligible for Medicaid, whichever time
30 period is shorter.
31
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1 2. Notwithstanding any other provision of this
2 section, coverage, cost sharing, and any other component of
3 employer-sponsored health insurance shall be governed by
4 applicable state and federal laws.
5 (5) This section does not authorize the agency to
6 implement any provision of s. 1115 of the Social Security Act
7 experimental, pilot, or demonstration project waiver to reform
8 the state Medicaid program in any part of the state other than
9 the two geographic areas specified in this section unless
10 approved by the Legislature.
11 (6) The agency shall develop and submit for approval
12 applications for waivers of applicable federal laws and
13 regulations as necessary to implement the managed care pilot
14 project as defined in this section. The agency shall post all
15 waiver applications under this section on its Internet website
16 30 days before submitting the applications to the United
17 States Centers for Medicare and Medicaid Services. All waiver
18 applications shall be provided for review and comment to the
19 appropriate committees of the Senate and House of
20 Representatives for at least 10 working days prior to
21 submission. All waivers submitted to and approved by the
22 United States Centers for Medicare and Medicaid Services under
23 this section must be approved by the Legislature. Federally
24 approved waivers must be submitted to the President of the
25 Senate and the Speaker of the House of Representatives for
26 referral to the appropriate legislative committees. The
27 appropriate committees shall recommend whether to approve the
28 implementation of any waivers to the Legislature as a whole.
29 The agency shall submit a plan containing a recommended
30 timeline for implementation of any waivers and budgetary
31 projections of the effect of the pilot program under this
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1 section on the total Medicaid budget for the 2006-2007 through
2 2009-2010 state fiscal years. This implementation plan shall
3 be submitted to the President of the Senate and the Speaker of
4 the House of Representatives at the same time any waivers are
5 submitted for consideration by the Legislature. The agency may
6 implement the waiver and special terms and conditions numbered
7 11-W-00206/4, as approved by the federal Centers for Medicare
8 and Medicaid Services. If the agency seeks approval by the
9 Federal Government of any modifications to these special terms
10 and conditions, the agency must provide written notification
11 of its intent to modify these terms and conditions to the
12 President of the Senate and the Speaker of the House of
13 Representatives at least 15 days before submitting the
14 modifications to the Federal Government for consideration. The
15 notification must identify all modifications being pursued and
16 the reason the modifications are needed. Upon receiving
17 federal approval of any modifications to the special terms and
18 conditions, the agency shall provide a report to the
19 Legislature describing the federally approved modifications to
20 the special terms and conditions within 7 days after approval
21 by the Federal Government.
22 (7) Upon review and approval of the applications for
23 waivers of applicable federal laws and regulations to
24 implement the managed care pilot program by the Legislature,
25 the agency may initiate adoption of rules pursuant to ss.
26 120.536(1) and 120.54 to implement and administer the managed
27 care pilot program as provided in this section.
28 (8) It is the intent of the Legislature that if any
29 conflict exists between the provisions contained in this
30 section and other provisions of this chapter which relate to
31 the implementation of the Medicaid managed care pilot program,
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1 the provisions contained in this section shall control. The
2 agency shall provide a written report to the Legislature by
3 April 1, 2006, identifying any provisions of this chapter
4 which conflict with the implementation of the Medicaid managed
5 care pilot program created in this section. After April 1,
6 2006, the agency shall provide a written report to the
7 Legislature immediately upon identifying any provisions of
8 this chapter which conflict with the implementation of the
9 Medicaid managed care pilot program created in this section.
10 Section 4. Section 409.91213, Florida Statutes, is
11 created to read:
12 409.91213 Quarterly progress reports and annual
13 reports.--
14 (1) The agency shall submit to the Governor, the
15 President of the Senate, the Speaker of the House of
16 Representatives, the Minority Leader of the Senate, the
17 Minority Leader of the House of Representatives, and the
18 Office of Program Policy Analysis and Government
19 Accountability the following reports:
20 (a) The quarterly progress report submitted to the
21 United States Centers for Medicare and Medicaid Services no
22 later than 60 days following the end of each quarter. The
23 intent of this report is to present the agency's analysis and
24 the status of various operational areas. The quarterly
25 progress report must include, but need not be limited to:
26 1. Events occurring during the quarter or anticipated
27 to occur in the near future which affect health care delivery,
28 including, but not limited to, the approval of and contracts
29 for new plans, which report must specify the coverage area,
30 phase-in period, populations served, and benefits; the
31 enrollment; grievances; and other operational issues.
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1 2. Action plans for addressing any policy and
2 administrative issues.
3 3. Agency efforts related to collecting and verifying
4 encounter data and utilization data.
5 4. Enrollment data disaggregated by plan and by
6 eligibility category, such as Temporary Assistance for Needy
7 Families or Supplemental Security Income; the total number of
8 enrollees; market share; and the percentage change in
9 enrollment by plan. In addition, the agency shall provide a
10 summary of voluntary and mandatory selection rates and
11 disenrollment data.
12 5. For purposes of monitoring budget neutrality,
13 enrollment data, member-month data, and expenditures in the
14 format for monitoring budget neutrality which is provided by
15 the federal Centers for Medicare and Medicaid Services.
16 6. Activities and associated expenditures of the
17 low-income pool.
18 7. Activities related to the implementation of choice
19 counseling, including efforts to improve health literacy and
20 the methods used to obtain public input, such as recipient
21 focus groups.
22 8. Participation rates in the enhanced benefit
23 accounts program, including participation levels; a summary of
24 activities and associated expenditures; the number of accounts
25 established, including active participants and individuals who
26 continue to retain access to funds in an account but who no
27 longer actively participate; an estimate of quarterly deposits
28 in the accounts; and expenditures from the accounts.
29 9. Enrollment data concerning employer-sponsored
30 insurance which document the number of individuals selecting
31 to opt out when employer-sponsored insurance is available. The
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1 agency shall include data that identify enrollee
2 characteristics, including the eligibility category, type of
3 employer-sponsored insurance, and type of coverage, such as
4 individual or family coverage. The agency shall develop and
5 maintain disenrollment reports specifying the reason for
6 disenrollment in an employer-sponsored insurance program. The
7 agency shall also track and report on those enrollees who
8 elect the option to reenroll in the Medicaid reform
9 demonstration.
10 10. Progress toward meeting the demonstration goals.
11 11. Evaluation activities.
12 (b) An annual report documenting accomplishments,
13 project status, quantitative and case-study findings,
14 utilization data, and policy and administrative difficulties
15 in the operation of the Medicaid waiver demonstration program.
16 The agency shall submit the draft annual report no later than
17 October 1 after the end of each fiscal year.
18 (2) Beginning with the annual report for demonstration
19 year two, the agency shall include a section concerning the
20 administration of enhanced benefit accounts, the participation
21 rates, an assessment of expenditures, and an assessment of
22 potential cost savings.
23 (3) Beginning with the annual report for demonstration
24 year four, the agency shall include a section that provides
25 qualitative and quantitative data describing the impact the
26 low-income pool has had on the rate of uninsured people in
27 this state, beginning with the implementation of the
28 demonstration program.
29 Section 5. Section 641.2261, Florida Statutes, is
30 amended to read:
31
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1 641.2261 Application of federal solvency requirements
2 to provider-sponsored organizations and Medicaid provider
3 service networks.--
4 (1) The solvency requirements of ss. 1855 and 1856 of
5 the Balanced Budget Act of 1997 and 42 C.F.R. 422.350, subpart
6 H, rules adopted by the Secretary of the United States
7 Department of Health and Human Services apply to a health
8 maintenance organization that is a provider-sponsored
9 organization rather than the solvency requirements of this
10 part. However, if the provider-sponsored organization does not
11 meet the solvency requirements of this part, the organization
12 is limited to the issuance of Medicare+Choice plans to
13 eligible individuals. For the purposes of this section, the
14 terms "Medicare+Choice plans," "provider-sponsored
15 organizations," and "solvency requirements" have the same
16 meaning as defined in the federal act and federal rules and
17 regulations.
18 (2) The solvency requirements in 42 C.F.R. 422.350,
19 subpart H, and the solvency requirements established in
20 approved federal waivers pursuant to chapter 409, apply to a
21 Medicaid provider service network rather than the solvency
22 requirements of this part.
23 Section 6. The Agency for Health Care Administration
24 shall report to the Legislature by April 1, 2006, on the
25 specific pre-implementation milestones required by the special
26 terms and conditions related to the low-income pool which have
27 been approved by the Federal Government and the status of any
28 remaining pre-implementation milestones that have not been
29 approved by the Federal Government.
30 Section 7. This act shall take effect upon becoming a
31 law.
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1 *****************************************
2 SENATE SUMMARY
3 Revises various provisions of the Medicaid program to
implement a Medicaid managed care pilot program. Creates
4 the Medicaid Low-Income Pool Council. Authorizes the
Agency for Health Care Administration to contract with
5 comprehensive behavioral health plans in separate
counties within or adjacent to an AHCA area. Deletes
6 certain competitive-procurement requirements for provider
service networks. Provides the agency's powers, duties,
7 and responsibilities with respect to implementing the
Medicaid managed care pilot program. Provides for
8 standards of quality assurance and performance
improvement in the demonstration areas of the pilot
9 program. Requires that the agency establish an encounter
database to compile data from managed care plans.
10 Requires procedures to minimize the risk of Medicaid
fraud and abuse in all managed care plans in the
11 demonstration areas. Revises the automatic assignment
process to managed care plans. Requires the agency to
12 submit quarterly and annual progress reports to the
Legislature. (See bill for details.)
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