Amendment
Bill No. 0003B

Amendment No. 415475

CHAMBER ACTION
Senate		House
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1	Representative(s) Cusack, Bendross-Mindingall, A. Gibson, and
2	Roberson offered the following:
3
4	Amendment (with title amendment)
5	Remove line(s) 459-1526 and insert:
6	operational. The agency shall implement expansion of the program
7	to include the remaining counties of the state and remaining
8	eligibility groups in accordance with the process specified in
9	the federally approved special terms and conditions numbered 11-
10	W-00206/4 and approved by the Legislature, with a goal of full
11	statewide implementation by June 30, 2011. This waiver authority
12	is contingent upon federal approval to preserve the upper-
13	payment-limit funding mechanism for hospitals, including a
14	guarantee of a reasonable growth factor, a methodology to allow
15	the use of a portion of these funds to serve as a risk pool for
16	demonstration sites, provisions to preserve the state's ability
17	to use intergovernmental transfers, and provisions to protect
18	the disproportionate share program authorized pursuant to this
19	chapter. Under the upper payment limit program, the hospital
20	disproportionate share program, or the low income pool as
21	implemented by the agency pursuant to federal waiver, the state
22	matching funds required for the program shall be provided by the
23	state and by local governmental entities through
24	intergovernmental transfers in accordance with published federal
25	statutes and regulations. The agency shall distribute funds from
26	the upper payment limit program, the hospital disproportionate
27	share program, and the low income pool in accordance with
28	published federal statutes, regulations, and waivers and the low
29	income pool methodology approved by the Centers for Medicare and
30	Medicaid Services. Upon completion of the evaluation conducted
31	under s. 3, ch. 2005-133, Laws of Florida, the agency may
32	request statewide expansion of the demonstration projects.
33	Statewide phase-in to additional counties shall be contingent
34	upon review and approval by the Legislature.
35	(b)  It is the intent of the Legislature that the low
36	income pool plan required by the terms and conditions of the
37	Medicaid reform waiver and submitted to the Centers for Medicare
38	and Medicaid Services propose the distribution of the program
39	funds in paragraph (a) based on the following objectives:
40	1.  Ensure a broad and fair distribution of available funds
41	based on the access provided by Medicaid participating
42	hospitals, regardless of their ownership status, through their
43	delivery of inpatient or outpatient care for Medicaid
44	beneficiaries and uninsured and underinsured individuals.
45	2.  Ensure accessible emergency inpatient and outpatient
46	care for Medicaid beneficiaries and uninsured and underinsured
47	individuals.
48	3.  Enhance primary, preventive, and other ambulatory care
49	coverages for uninsured individuals.
50	4.  Promote teaching and specialty hospital programs.
51	5.  Promote the stability and viability of statutorily
52	defined rural hospitals and hospitals that serve as sole
53	community hospitals.
54	6.  Recognize the extent of hospital uncompensated care
55	costs.
56	7.  Maintain and enhance essential community hospital care.
57	8.  Maintain incentives for local governmental entities to
58	contribute to the cost of uncompensated care.
59	9.  Promote measures to avoid preventable hospitalizations.
60	10.  Account for hospital efficiency.
61	11.  Contribute to a community's overall health system.
62	(2)  The Legislature intends for the capitated managed care
63	pilot program to:
64	(a)  Provide recipients in Medicaid fee-for-service or the
65	MediPass program a comprehensive and coordinated capitated
66	managed care system for all health care services specified in
67	ss. 409.905 and 409.906.
68	(b)  Stabilize Medicaid expenditures under the pilot
69	program compared to Medicaid expenditures in the pilot area for
70	the 3 years before implementation of the pilot program, while
71	ensuring:
72	1.  Consumer education and choice.
73	2.  Access to medically necessary services.
74	3.  Coordination of preventative, acute, and long-term
75	care.
76	4.  Reductions in unnecessary service utilization.
77	(c)  Provide an opportunity to evaluate the feasibility of
78	statewide implementation of capitated managed care networks as a
79	replacement for the current Medicaid fee-for-service and
80	MediPass systems.
81	(3)  The agency shall have the following powers, duties,
82	and responsibilities with respect to the development of a pilot
83	program:
84	(a)  To implement develop and recommend a system to deliver
85	all mandatory services specified in s. 409.905 and optional
86	services specified in s. 409.906, as approved by the Centers for
87	Medicare and Medicaid Services and the Legislature in the waiver
88	pursuant to this section. Services to recipients under plan
89	benefits shall include emergency services provided under s.
90	409.9128.
91	(b)  To implement a pilot program that includes recommend
92	Medicaid eligibility categories, from those specified in ss.
93	409.903 and 409.904 as authorized in an approved federal waiver,
94	which shall be included in the pilot program.
95	(c)  To implement determine and recommend how to design the
96	managed care pilot program that maximizes in order to take
97	maximum advantage of all available state and federal funds,
98	including those obtained through intergovernmental transfers,
99	the low income pool, supplemental Medicaid payments upper-
100	payment-level funding systems, and the disproportionate share
101	program. Within the parameters allowed by federal statute and
102	rule, the agency is authorized to seek options for making direct
103	payments to hospitals and physicians employed by or under
104	contract with the state's medical schools for the costs
105	associated with graduate medical education under Medicaid
106	reform.
107	(d)  To implement determine and recommend actuarially
108	sound, risk-adjusted capitation rates for Medicaid recipients in
109	the pilot program which can be separated to cover comprehensive
110	care, enhanced services, and catastrophic care.
111	(e)  To implement determine and recommend policies and
112	guidelines for phasing in financial risk for approved provider
113	service networks over a 3-year period. These policies and
114	guidelines shall include an option for a provider service
115	network to be paid to pay fee-for-service rates. For any
116	provider service network established in a managed care pilot
117	area, the option to be paid fee-for-service rates shall include
118	a savings-settlement mechanism that is consistent with s.
119	409.912(44) that may include a savings-settlement option for at
120	least 2 years. This model shall may be converted to a risk-
121	adjusted capitated rate no later than the beginning of the
122	fourth in the third year of operation and may be converted
123	earlier at the option of the provider service network. Federally
124	qualified health centers may be offered an opportunity to accept
125	or decline a contract to participate in any provider network for
126	prepaid primary care services.
127	(f)  To implement determine and recommend provisions
128	related to stop-loss requirements and the transfer of excess
129	cost to catastrophic coverage that accommodates the risks
130	associated with the development of the pilot program.
131	(g)  To determine and recommend a process to be used by the
132	Social Services Estimating Conference to determine and validate
133	the rate of growth of the per-member costs of providing Medicaid
134	services under the managed care pilot program.
135	(h)  To implement determine and recommend program standards
136	and credentialing requirements for capitated managed care
137	networks to participate in the pilot program, including those
138	related to fiscal solvency, quality of care, and adequacy of
139	access to health care providers. It is the intent of the
140	Legislature that, to the extent possible, any pilot program
141	authorized by the state under this section include any federally
142	qualified health center, any federally qualified rural health
143	clinic, county health department, the Division of Children's
144	Medical Services Network within the Department of Health, or any
145	other federally, state, or locally funded entity that serves the
146	geographic areas within the boundaries of the pilot program that
147	requests to participate. This paragraph does not relieve an
148	entity that qualifies as a capitated managed care network under
149	this section from any other licensure or regulatory requirements
150	contained in state or federal law which would otherwise apply to
151	the entity. The standards and credentialing requirements shall
152	be based upon, but are not limited to:
153	1.  Compliance with the accreditation requirements as
154	provided in s. 641.512.
155	2.  Compliance with early and periodic screening,
156	diagnosis, and treatment screening requirements under federal
157	law.
158	3.  The percentage of voluntary disenrollments.
159	4.  Immunization rates.
160	5.  Standards of the National Committee for Quality
161	Assurance and other approved accrediting bodies.
162	6.  Recommendations of other authoritative bodies.
163	7.  Specific requirements of the Medicaid program, or
164	standards designed to specifically meet the unique needs of
165	Medicaid recipients.
166	8.  Compliance with the health quality improvement system
167	as established by the agency, which incorporates standards and
168	guidelines developed by the Centers for Medicare and Medicaid
169	Services as part of the quality assurance reform initiative.
170	9.  The network's infrastructure capacity to manage
171	financial transactions, recordkeeping, data collection, and
172	other administrative functions.
173	10.  The network's ability to submit any financial,
174	programmatic, or patient-encounter data or other information
175	required by the agency to determine the actual services provided
176	and the cost of administering the plan.
177	(i)  To implement develop and recommend a mechanism for
178	providing information to Medicaid recipients for the purpose of
179	selecting a capitated managed care plan. For each plan available
180	to a recipient, the agency, at a minimum, shall ensure that the
181	recipient is provided with:
182	1.  A list and description of the benefits provided.
183	2.  Information about cost sharing.
184	3.  Plan performance data, if available.
185	4.  An explanation of benefit limitations.
186	5.  Contact information, including identification of
187	providers participating in the network, geographic locations,
188	and transportation limitations.
189	6.  Any other information the agency determines would
190	facilitate a recipient's understanding of the plan or insurance
191	that would best meet his or her needs.
192	(j)  To implement develop and recommend a system to ensure
193	that there is a record of recipient acknowledgment that choice
194	counseling has been provided.
195	(k)  To implement develop and recommend a choice counseling
196	system to ensure that the choice counseling process and related
197	material are designed to provide counseling through face-to-face
198	interaction, by telephone, and in writing and through other
199	forms of relevant media. Materials shall be written at the
200	fourth-grade reading level and available in a language other
201	than English when 5 percent of the county speaks a language
202	other than English. Choice counseling shall also use language
203	lines and other services for impaired recipients, such as
204	TTD/TTY.
205	(l)  To implement develop and recommend a system that
206	prohibits capitated managed care plans, their representatives,
207	and providers employed by or contracted with the capitated
208	managed care plans from recruiting persons eligible for or
209	enrolled in Medicaid, from providing inducements to Medicaid
210	recipients to select a particular capitated managed care plan,
211	and from prejudicing Medicaid recipients against other capitated
212	managed care plans. The system shall require the entity
213	performing choice counseling to determine if the recipient has
214	made a choice of a plan or has opted out because of duress,
215	threats, payment to the recipient, or incentives promised to the
216	recipient by a third party. If the choice counseling entity
217	determines that the decision to choose a plan was unlawfully
218	influenced or a plan violated any of the provisions of s.
219	409.912(21), the choice counseling entity shall immediately
220	report the violation to the agency's program integrity section
221	for investigation. Verification of choice counseling by the
222	recipient shall include a stipulation that the recipient
223	acknowledges the provisions of this subsection.
224	(m)  To implement develop and recommend a choice counseling
225	system that promotes health literacy and provides information
226	aimed to reduce minority health disparities through outreach
227	activities for Medicaid recipients.
228	(n)  To develop and recommend a system for the agency to
229	contract with entities to perform choice counseling. The agency
230	may establish standards and performance contracts, including
231	standards requiring the contractor to hire choice counselors who
232	are representative of the state's diverse population and to
233	train choice counselors in working with culturally diverse
234	populations.
235	(o)  To implement determine and recommend descriptions of
236	the eligibility assignment processes which will be used to
237	facilitate client choice while ensuring pilot programs of
238	adequate enrollment levels. These processes shall ensure that
239	pilot sites have sufficient levels of enrollment to conduct a
240	valid test of the managed care pilot program within a 2-year
241	timeframe.
242	(p)  To implement standards for plan compliance, including,
243	but not limited to, quality assurance and performance
244	improvement standards, peer or professional review standards,
245	grievance policies, and program integrity policies.
246	(q)  To develop a data reporting system, seek input from
247	managed care plans to establish patient-encounter reporting
248	requirements, and ensure that the data reported is accurate and
249	complete.
250	(r)  To work with managed care plans to establish a uniform
251	system to measure and monitor outcomes of a recipient of
252	Medicaid services which shall use financial, clinical, and other
253	criteria based on pharmacy services, medical services, and other
254	data related to the provision of Medicaid services, including,
255	but not limited to:
256	1.  Health Plan Employer Data and Information Set (HEDIS)
257	or HEDIS measures specific to Medicaid.
258	2.  Member satisfaction.
259	3.  Provider satisfaction.
260	4.  Report cards on plan performance and best practices.
261	5.  Compliance with the prompt payment of claims
262	requirements provided in ss. 627.613, 641.3155, and 641.513.
263	6.  Utilization and quality data for the purpose of
264	ensuring access to medically necessary services, including
265	underutilization or inappropriate denial of services.
266	(s)  To require managed care plans that have contracted
267	with the agency to establish a quality assurance system that
268	incorporates the provisions of s. 409.912(27) and any standards,
269	rules, and guidelines developed by the agency.
270	(t)  To establish a patient-encounter database to compile
271	data on health care services rendered by health care
272	practitioners that provide services to patients enrolled in
273	managed care plans in the demonstration sites. Health care
274	practitioners and facilities in the demonstration sites shall
275	submit, and managed care plans participating in the
276	demonstration sites shall receive, claims payment and any other
277	information reasonably related to the patient-encounter database
278	electronically in a standard format as required by the agency.
279	The agency shall establish reasonable deadlines for phasing in
280	the electronic transmittal of full-encounter data. The patient-
281	encounter database shall:
282	1.  Collect the following information, if applicable, for
283	each type of patient encounter with a health care practitioner
284	or facility, including:
285	a.  The demographic characteristics of the patient.
286	b.  The principal, secondary, and tertiary diagnosis.
287	c.  The procedure performed.
288	d.  The date when and the location where the procedure was
289	performed.
290	e.  The amount of the payment for the procedure.
291	f.  The health care practitioner's universal identification
292	number.
293	g.  If the health care practitioner rendering the service
294	is a dependent practitioner, the modifiers appropriate to
295	indicate that the service was delivered by the dependent
296	practitioner.
297	2.  Collect appropriate information relating to
298	prescription drugs for each type of patient encounter.
299	3.  Collect appropriate information related to health care
300	costs and utilization from managed care plans participating in
301	the demonstration sites. To the extent practicable, the agency
302	shall utilize a standardized claim form or electronic transfer
303	system that is used by health care practitioners, facilities,
304	and payors. To develop and recommend a system to monitor the
305	provision of health care services in the pilot program,
306	including utilization and quality of health care services for
307	the purpose of ensuring access to medically necessary services.
308	This system shall include an encounter data-information system
309	that collects and reports utilization information. The system
310	shall include a method for verifying data integrity within the
311	database and within the provider's medical records.
312	(u)(q)  To implement recommend a grievance resolution
313	process for Medicaid recipients enrolled in a capitated managed
314	care network under the pilot program modeled after the
315	subscriber assistance panel, as created in s. 408.7056. This
316	process shall include a mechanism for an expedited review of no
317	greater than 24 hours after notification of a grievance if the
318	life of a Medicaid recipient is in imminent and emergent
319	jeopardy.
320	(v)(r)  To implement recommend a grievance resolution
321	process for health care providers employed by or contracted with
322	a capitated managed care network under the pilot program in
323	order to settle disputes among the provider and the managed care
324	network or the provider and the agency.
325	(w)(s)  To implement develop and recommend criteria in an
326	approved federal waiver to designate health care providers as
327	eligible to participate in the pilot program. The agency and
328	capitated managed care networks must follow national guidelines
329	for selecting health care providers, whenever available. These
330	criteria must include at a minimum those criteria specified in
331	s. 409.907.
332	(x)(t)  To use develop and recommend health care provider
333	agreements for participation in the pilot program.
334	(y)(u)  To require that all health care providers under
335	contract with the pilot program be duly licensed in the state,
336	if such licensure is available, and meet other criteria as may
337	be established by the agency. These criteria shall include at a
338	minimum those criteria specified in s. 409.907.
339	(z)(v)  To ensure that managed care organizations work
340	collaboratively develop and recommend agreements with other
341	state or local governmental programs or institutions for the
342	coordination of health care to eligible individuals receiving
343	services from such programs or institutions.
344	(aa)(w)  To implement procedures to minimize the risk of
345	Medicaid fraud and abuse in all plans operating in the Medicaid
346	managed care pilot program authorized in this section:
347	1.  The agency shall ensure that applicable provisions of
348	chapters 409, 414, 626, 641, and 932, relating to Medicaid fraud
349	and abuse, are applied and enforced at the demonstration sites.
350	2.  Providers shall have the necessary certification,
351	license, and credentials required by law and federal waiver.
352	3.  The agency shall ensure that the plan is in compliance
353	with the provisions of s. 409.912(21) and (22).
354	4.  The agency shall require each plan to establish program
355	integrity functions and activities to reduce the incidence of
356	fraud and abuse. Plans must report instances of fraud and abuse
357	pursuant to chapter 641.
358	5.  The plan shall have written administrative and
359	management procedures, including a mandatory compliance plan,
360	that are designed to guard against fraud and abuse. The plan
361	shall designate a compliance officer with sufficient experience
362	in health care.
363	6.a.  The agency shall require all managed care plan
364	contractors in the pilot program to report all instances of
365	suspected fraud and abuse. A failure to report instances of
366	suspected fraud and abuse is a violation of law and subject to
367	the penalties provided by law.
368	b.  An instance of fraud and abuse in the managed care
369	plan, including, but not limited to, defrauding the state health
370	care benefit program by misrepresentation of fact in reports,
371	claims, certifications, enrollment claims, demographic
372	statistics, and patient-encounter data; misrepresentation of the
373	qualifications of persons rendering health care and ancillary
374	services; bribery and false statements relating to the delivery
375	of health care; unfair and deceptive marketing practices; and
376	managed care false claims actions, is a violation of law and
377	subject to the penalties provided by law.
378	c.  The agency shall require all contractors to make all
379	files and relevant billing and claims data accessible to state
380	regulators and investigators and all such data shall be linked
381	into a unified system for seamless reviews and investigations.
382	To develop and recommend a system to oversee the activities of
383	pilot program participants, health care providers, capitated
384	managed care networks, and their representatives in order to
385	prevent fraud or abuse, overutilization or duplicative
386	utilization, underutilization or inappropriate denial of
387	services, and neglect of participants and to recover
388	overpayments as appropriate. For the purposes of this paragraph,
389	the terms "abuse" and "fraud" have the meanings as provided in
390	s. 409.913. The agency must refer incidents of suspected fraud,
391	abuse, overutilization and duplicative utilization, and
392	underutilization or inappropriate denial of services to the
393	appropriate regulatory agency.
394	(bb)(x)  To develop and provide actuarial and benefit
395	design analyses that indicate the effect on capitation rates and
396	benefits offered in the pilot program over a prospective 5-year
397	period based on the following assumptions:
398	1.  Growth in capitation rates which is limited to the
399	estimated growth rate in general revenue.
400	2.  Growth in capitation rates which is limited to the
401	average growth rate over the last 3 years in per-recipient
402	Medicaid expenditures.
403	3.  Growth in capitation rates which is limited to the
404	growth rate of aggregate Medicaid expenditures between the 2003-
405	2004 fiscal year and the 2004-2005 fiscal year.
406	(cc)(y)  To develop a mechanism to require capitated
407	managed care plans to reimburse qualified emergency service
408	providers, including, but not limited to, ambulance services, in
409	accordance with ss. 409.908 and 409.9128. The pilot program must
410	include a provision for continuing fee-for-service payments for
411	emergency services, including, but not limited to, individuals
412	who access ambulance services or emergency departments and who
413	are subsequently determined to be eligible for Medicaid
414	services.
415	(dd)(z)  To ensure develop a system whereby school
416	districts participating in the certified school match program
417	pursuant to ss. 409.908(21) and 1011.70 shall be reimbursed by
418	Medicaid, subject to the limitations of s. 1011.70(1), for a
419	Medicaid-eligible child participating in the services as
420	authorized in s. 1011.70, as provided for in s. 409.9071,
421	regardless of whether the child is enrolled in a capitated
422	managed care network. Capitated managed care networks must make
423	a good faith effort to execute agreements with school districts
424	regarding the coordinated provision of services authorized under
425	s. 1011.70. County health departments and federally qualified
426	health centers delivering school-based services pursuant to ss.
427	381.0056 and 381.0057 must be reimbursed by Medicaid for the
428	federal share for a Medicaid-eligible child who receives
429	Medicaid-covered services in a school setting, regardless of
430	whether the child is enrolled in a capitated managed care
431	network. Capitated managed care networks must make a good faith
432	effort to execute agreements with county health departments
433	regarding the coordinated provision of services to a Medicaid-
434	eligible child. To ensure continuity of care for Medicaid
435	patients, the agency, the Department of Health, and the
436	Department of Education shall develop procedures for ensuring
437	that a student's capitated managed care network provider
438	receives information relating to services provided in accordance
439	with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
440	(ee)(aa)  To implement develop and recommend a mechanism
441	whereby Medicaid recipients who are already enrolled in a
442	managed care plan or the MediPass program in the pilot areas
443	shall be offered the opportunity to change to capitated managed
444	care plans on a staggered basis, as defined by the agency. All
445	Medicaid recipients shall have 30 days in which to make a choice
446	of capitated managed care plans. Those Medicaid recipients who
447	do not make a choice shall be assigned to a capitated managed
448	care plan in accordance with paragraph (4)(a) and shall be
449	exempt from s. 409.9122. To facilitate continuity of care for a
450	Medicaid recipient who is also a recipient of Supplemental
451	Security Income (SSI), prior to assigning the SSI recipient to a
452	capitated managed care plan, the agency shall determine whether
453	the SSI recipient has an ongoing relationship with a provider or
454	capitated managed care plan, and, if so, the agency shall assign
455	the SSI recipient to that provider or capitated managed care
456	plan where feasible. Those SSI recipients who do not have such a
457	provider relationship shall be assigned to a capitated managed
458	care plan provider in accordance with paragraph (4)(a) and shall
459	be exempt from s. 409.9122.
460	(ff)(bb)  To develop and recommend a service delivery
461	alternative for children having chronic medical conditions which
462	establishes a medical home project to provide primary care
463	services to this population. The project shall provide
464	community-based primary care services that are integrated with
465	other subspecialties to meet the medical, developmental, and
466	emotional needs for children and their families. This project
467	shall include an evaluation component to determine impacts on
468	hospitalizations, length of stays, emergency room visits, costs,
469	and access to care, including specialty care and patient and
470	family satisfaction.
471	(gg)(cc)  To develop and recommend service delivery
472	mechanisms within capitated managed care plans to provide
473	Medicaid services as specified in ss. 409.905 and 409.906 to
474	persons with developmental disabilities sufficient to meet the
475	medical, developmental, and emotional needs of these persons.
476	(hh)(dd)  To develop and recommend service delivery
477	mechanisms within capitated managed care plans to provide
478	Medicaid services as specified in ss. 409.905 and 409.906 to
479	Medicaid-eligible children in foster care. These services must
480	be coordinated with community-based care providers as specified
481	in s. 409.1675, where available, and be sufficient to meet the
482	medical, developmental, and emotional needs of these children.
483	(4)(a)  A Medicaid recipient in the pilot area who is not
484	currently enrolled in a capitated managed care plan upon
485	implementation is not eligible for services as specified in ss.
486	409.905 and 409.906, for the amount of time that the recipient
487	does not enroll in a capitated managed care network. If a
488	Medicaid recipient has not enrolled in a capitated managed care
489	plan within 30 days after eligibility, the agency shall assign
490	the Medicaid recipient to a capitated managed care plan based on
491	the assessed needs of the recipient as determined by the agency
492	and shall be exempt from s. 409.9122. When making assignments,
493	the agency shall take into account the following criteria:
494	1.  A capitated managed care network has sufficient network
495	capacity to meet the needs of members.
496	2.  The capitated managed care network has previously
497	enrolled the recipient as a member, or one of the capitated
498	managed care network's primary care providers has previously
499	provided health care to the recipient.
500	3.  The agency has knowledge that the member has previously
501	expressed a preference for a particular capitated managed care
502	network as indicated by Medicaid fee-for-service claims data,
503	but has failed to make a choice.
504	4.  The capitated managed care network's primary care
505	providers are geographically accessible to the recipient's
506	residence.
507	(b)  When more than one capitated managed care network
508	provider meets the criteria specified in paragraph (3)(h), the
509	agency shall make recipient assignments consecutively by family
510	unit.
511	(c)  If a recipient is currently enrolled with a Medicaid
512	managed care organization that also operates an approved reform
513	plan within a pilot area and the recipient fails to choose a
514	plan during the reform enrollment process or during
515	redetermination of eligibility, the recipient shall be
516	automatically assigned by the agency into the most appropriate
517	reform plan operated by the recipient's current Medicaid managed
518	care organization. If the recipient's current managed care
519	organization does not operate a reform plan in the pilot area
520	that adequately meets the needs of the Medicaid recipient, the
521	agency shall use the auto assignment process as prescribed in
522	the Centers for Medicare and Medicaid Services Special Terms and
523	Conditions number 11-W-00206/4. All agency enrollment and choice
524	counseling materials shall communicate the provisions of this
525	paragraph to current managed care recipients.
526	(d)(c)  The agency may not engage in practices that are
527	designed to favor one capitated managed care plan over another
528	or that are designed to influence Medicaid recipients to enroll
529	in a particular capitated managed care network in order to
530	strengthen its particular fiscal viability.
531	(e)(d)  After a recipient has made a selection or has been
532	enrolled in a capitated managed care network, the recipient
533	shall have 90 days in which to voluntarily disenroll and select
534	another capitated managed care network. After 90 days, no
535	further changes may be made except for cause. Cause shall
536	include, but not be limited to, poor quality of care, lack of
537	access to necessary specialty services, an unreasonable delay or
538	denial of service, inordinate or inappropriate changes of
539	primary care providers, service access impairments due to
540	significant changes in the geographic location of services, or
541	fraudulent enrollment. The agency may require a recipient to use
542	the capitated managed care network's grievance process as
543	specified in paragraph (3)(g) prior to the agency's
544	determination of cause, except in cases in which immediate risk
545	of permanent damage to the recipient's health is alleged. The
546	grievance process, when used, must be completed in time to
547	permit the recipient to disenroll no later than the first day of
548	the second month after the month the disenrollment request was
549	made. If the capitated managed care network, as a result of the
550	grievance process, approves an enrollee's request to disenroll,
551	the agency is not required to make a determination in the case.
552	The agency must make a determination and take final action on a
553	recipient's request so that disenrollment occurs no later than
554	the first day of the second month after the month the request
555	was made. If the agency fails to act within the specified
556	timeframe, the recipient's request to disenroll is deemed to be
557	approved as of the date agency action was required. Recipients
558	who disagree with the agency's finding that cause does not exist
559	for disenrollment shall be advised of their right to pursue a
560	Medicaid fair hearing to dispute the agency's finding.
561	(f)(e)  The agency shall apply for federal waivers from the
562	Centers for Medicare and Medicaid Services to lock eligible
563	Medicaid recipients into a capitated managed care network for 12
564	months after an open enrollment period. After 12 months of
565	enrollment, a recipient may select another capitated managed
566	care network. However, nothing shall prevent a Medicaid
567	recipient from changing primary care providers within the
568	capitated managed care network during the 12-month period.
569	(g)(f)  The agency shall apply for federal waivers from the
570	Centers for Medicare and Medicaid Services to allow recipients
571	to purchase health care coverage through an employer-sponsored
572	health insurance plan instead of through a Medicaid-certified
573	plan. This provision shall be known as the opt-out option.
574	1.  A recipient who chooses the Medicaid opt-out option
575	shall have an opportunity for a specified period of time, as
576	authorized under a waiver granted by the Centers for Medicare
577	and Medicaid Services, to select and enroll in a Medicaid-
578	certified plan. If the recipient remains in the employer-
579	sponsored plan after the specified period, the recipient shall
580	remain in the opt-out program for at least 1 year or until the
581	recipient no longer has access to employer-sponsored coverage,
582	until the employer's open enrollment period for a person who
583	opts out in order to participate in employer-sponsored coverage,
584	or until the person is no longer eligible for Medicaid,
585	whichever time period is shorter.
586	2.  Notwithstanding any other provision of this section,
587	coverage, cost sharing, and any other component of employer-
588	sponsored health insurance shall be governed by applicable state
589	and federal laws.
590	(5)  This section does not authorize the agency to
591	implement any provision of s. 1115 of the Social Security Act
592	experimental, pilot, or demonstration project waiver to reform
593	the state Medicaid program in any part of the state other than
594	the two geographic areas specified in this section unless
595	approved by the Legislature.
596	(6)  The agency shall develop and submit for approval
597	applications for waivers of applicable federal laws and
598	regulations as necessary to implement the managed care pilot
599	project as defined in this section. The agency shall post all
600	waiver applications under this section on its Internet website
601	30 days before submitting the applications to the United States
602	Centers for Medicare and Medicaid Services. All waiver
603	applications shall be provided for review and comment to the
604	appropriate committees of the Senate and House of
605	Representatives for at least 10 working days prior to
606	submission. All waivers submitted to and approved by the United
607	States Centers for Medicare and Medicaid Services under this
608	section must be approved by the Legislature. Federally approved
609	waivers must be submitted to the President of the Senate and the
610	Speaker of the House of Representatives for referral to the
611	appropriate legislative committees. The appropriate committees
612	shall recommend whether to approve the implementation of any
613	waivers to the Legislature as a whole. The agency shall submit a
614	plan containing a recommended timeline for implementation of any
615	waivers and budgetary projections of the effect of the pilot
616	program under this section on the total Medicaid budget for the
617	2006-2007 through 2009-2010 state fiscal years. This
618	implementation plan shall be submitted to the President of the
619	Senate and the Speaker of the House of Representatives at the
620	same time any waivers are submitted for consideration by the
621	Legislature. The agency is authorized to implement the waiver
622	and Centers for Medicare and Medicaid Services Special Terms and
623	Conditions number 11-W-00206/4. If the agency seeks approval by
624	the Federal Government of any modifications to these special
625	terms and conditions, the agency shall provide written
626	notification of its intent to modify these terms and conditions
627	to the President of the Senate and Speaker of the House of
628	Representatives at least 15 days prior to submitting the
629	modifications to the Federal Government for consideration. The
630	notification shall identify all modifications being pursued and
631	the reason they are needed. Upon receiving federal approval of
632	any modifications to the special terms and conditions, the
633	agency shall report to the Legislature describing the federally
634	approved modifications to the special terms and conditions
635	within 7 days after their approval by the Federal Government.
636	(7)  Upon review and approval of the applications for
637	waivers of applicable federal laws and regulations to implement
638	the managed care pilot program by the Legislature, the agency
639	may initiate adoption of rules pursuant to ss. 120.536(1) and
640	120.54 to implement and administer the managed care pilot
641	program as provided in this section.
642	(8)(a)  The Secretary of Health Care Administration shall
643	convene a technical advisory panel to advise the agency in the
644	following areas:  risk-adjusted rate setting, benefit design,
645	and choice counseling. The panel shall include representatives
646	from the Florida Association of Health Plans, representatives
647	from provider-sponsored networks, and a representative from the
648	Office of Insurance Regulation.
649	(b)  The technical advisory panel shall advise the agency
650	on the following:
651	1.  The risk-adjusted rate methodology to be used by the
652	agency including recommendations on mechanisms to recognize the
653	risk of all Medicaid enrollees and transitioning to a risk-
654	adjustment system, including recommendations for phasing in risk
655	adjustment and the uses of risk corridors.
656	2.  Implementation of an encounter data system to be used
657	for risk-adjusted rates.
658	3.  Administrative and implementation issues regarding the
659	use of risk-adjusted rates, including, but not limited to, cost,
660	simplicity, client privacy, data accuracy, and data exchange.
661	4.  Benefit design issues, including the actuarial
662	equivalence and sufficiency standards to be used.
663	5.  The implementation plan for the proposed choice
664	counseling system, including the information and materials to be
665	provided to recipients, the methodologies by which recipients
666	will be counseled regarding choices, criteria to be used to
667	assess plan quality, the methodology to be used to assign
668	recipients to plans if they fail to choose a managed care plan,
669	and the standards to be used for responsiveness to recipient
670	inquiries.
671	(c)  The technical advisory panel shall continue in
672	existence and advise the secretary on matters outlined in this
673	subsection.
674	(9)  The agency must ensure in the first 2 state fiscal
675	years in which a risk-adjusted methodology is a component of
676	rate setting that no managed care plan providing comprehensive
677	benefits to TANF and SSI recipients has an aggregate risk score
678	that varies by more than 10 percent from the aggregate weighted
679	mean of all managed care plans providing comprehensive benefits
680	to TANF and SSI recipients in a reform area. The agency's
681	payment to a managed care plan shall be based on such revised
682	aggregate risk score.
683	(10)  After any calculations of aggregate risk scores or
684	revised aggregate risk scores pursuant to subsection (9), the
685	capitation rates for plans participating under 409.91211 shall
686	be phased in as follows:
687	(a)  In the first fiscal year, the capitation rates shall
688	be weighted so that 75 percent of each capitation rate is based
689	on the current methodology and 25 percent is based upon a new
690	risk-adjusted capitation rate methodology.
691	(b)  In the second fiscal year, the capitation rates shall
692	be weighted so that 50 percent of each capitation rate is based
693	on the current methodology and 50 percent is based on a new
694	risk-adjusted rate methodology.
695	(c)  In the following fiscal year, the risk-adjusted
696	capitation methodology may be fully implemented.
697	(11)  Subsections (9) and (10) shall not apply to managed
698	care plans offering benefits exclusively to high-risk, specialty
699	populations. The agency shall have the discretion to set risk-
700	adjusted rates immediately for said plans.
701	(12)  Prior to the implementation of risk-adjusted rates,
702	rates shall be certified by an actuary and approved by the
703	federal Centers for Medicare and Medicaid Services.
704	(13)  For purposes of this section, the term "capitated
705	managed care plan" includes health insurers authorized under
706	chapter 624, exclusive provider organizations authorized under
707	chapter 627, health maintenance organizations authorized under
708	chapter 641, the Children's Medical Services Network authorized
709	under chapter 391, and provider service networks that elect to
710	be paid fee-for-service for up to 3 years as authorized under
711	this section.
712	(14)  It is the intent of the Legislature that if any
713	conflict exists between the provisions contained in this section
714	and other provisions of chapter 409, as they relate to
715	implementation of the Medicaid managed care pilot program, the
716	provisions contained in this section shall control. The agency
717	shall provide a written report to the President of the Senate
718	and the Speaker of the House of Representatives by April 1,
719	2006, identifying any provisions of chapter 409 that conflict
720	with the implementation of the Medicaid managed care pilot
721	program as created in this section. After April 1, 2006, the
722	agency shall provide a written report to the President of the
723	Senate and the Speaker of the House of Representatives
724	immediately upon identifying any provisions of chapter 409 that
725	conflict with the implementation of the Medicaid managed care
726	pilot program as created in this section.
727	Section 5.  Subsections (8) through (14) of section
728	409.9122, Florida Statutes, are renumbered as subsections (7)
729	through (13), respectively, and paragraphs (e), (f), (g), (h),
730	(k), and (l) of subsection (2) and present subsection (7) of
731	that section are amended to read:
732	409.9122  Mandatory Medicaid managed care enrollment;
733	programs and procedures.--
734	(2)
735	(e)  Medicaid recipients who are already enrolled in a
736	managed care plan or MediPass shall be offered the opportunity
737	to change managed care plans or MediPass providers on a
738	staggered basis, as defined by the agency. All Medicaid
739	recipients shall have 30 days in which to make a choice of
740	managed care plans or MediPass providers. Those Medicaid
741	recipients who do not make a choice shall be assigned to a
742	managed care plan or MediPass in accordance with paragraph (f).
743	To facilitate continuity of care, for a Medicaid recipient who
744	is also a recipient of Supplemental Security Income (SSI), prior
745	to assigning the SSI recipient to a managed care plan or
746	MediPass, the agency shall determine whether the SSI recipient
747	has an ongoing relationship with a MediPass provider or managed
748	care plan, and if so, the agency shall assign the SSI recipient
749	to that MediPass provider or managed care plan. Those SSI
750	recipients who do not have such a provider relationship shall be
751	assigned to a managed care plan or MediPass provider in
752	accordance with paragraph (f).
753	(f)  When a Medicaid recipient does not choose a managed
754	care plan or MediPass provider, the agency shall assign the
755	Medicaid recipient to a managed care plan or MediPass provider.
756	Medicaid recipients who are subject to mandatory assignment but
757	who fail to make a choice shall be assigned to managed care
758	plans until an enrollment of 40 percent in MediPass and 60
759	percent in managed care plans is achieved. Once this enrollment
760	is achieved, the assignments shall be divided in order to
761	maintain an enrollment in MediPass and managed care plans which
762	is in a 40 percent and 60 percent proportion, respectively.
763	Thereafter, assignment of Medicaid recipients who fail to make a
764	choice shall be based proportionally on the preferences of
765	recipients who have made a choice in the previous period. Such
766	proportions shall be revised at least quarterly to reflect an
767	update of the preferences of Medicaid recipients. The agency
768	shall disproportionately assign Medicaid-eligible recipients who
769	are required to but have failed to make a choice of managed care
770	plan or MediPass, including children, and who are to be assigned
771	to the MediPass program to children's networks as described in
772	s. 409.912(4)(g), Children's Medical Services Network as defined
773	in s. 391.021, exclusive provider organizations, provider
774	service networks, minority physician networks, and pediatric
775	emergency department diversion programs authorized by this
776	chapter or the General Appropriations Act, in such manner as the
777	agency deems appropriate, until the agency has determined that
778	the networks and programs have sufficient numbers to be
779	economically operated. For purposes of this paragraph, when
780	referring to assignment, the term "managed care plans" includes
781	health maintenance organizations, exclusive provider
782	organizations, provider service networks, minority physician
783	networks, Children's Medical Services Network, and pediatric
784	emergency department diversion programs authorized by this
785	chapter or the General Appropriations Act. When making
786	assignments, the agency shall take into account the following
787	criteria:
788	1.  A managed care plan has sufficient network capacity to
789	meet the need of members.
790	2.  The managed care plan or MediPass has previously
791	enrolled the recipient as a member, or one of the managed care
792	plan's primary care providers or MediPass providers has
793	previously provided health care to the recipient.
794	3.  The agency has knowledge that the member has previously
795	expressed a preference for a particular managed care plan or
796	MediPass provider as indicated by Medicaid fee-for-service
797	claims data, but has failed to make a choice.
798	4.  The managed care plan is plan's or MediPass primary
799	care providers are geographically accessible to the recipient's
800	residence.
801	5.  The agency has authority to make mandatory assignments
802	based on quality of service and performance of managed care
803	plans.
804	(g)  When more than one managed care plan or MediPass
805	provider meets the criteria specified in paragraph (f), the
806	agency shall make recipient assignments consecutively by family
807	unit.
808	(h)  The agency may not engage in practices that are
809	designed to favor one managed care plan over another or that are
810	designed to influence Medicaid recipients to enroll in MediPass
811	rather than in a managed care plan or to enroll in a managed
812	care plan rather than in MediPass. This subsection does not
813	prohibit the agency from reporting on the performance of
814	MediPass or any managed care plan, as measured by performance
815	criteria developed by the agency.
816	(k)  When a Medicaid recipient does not choose a managed
817	care plan or MediPass provider, the agency shall assign the
818	Medicaid recipient to a managed care plan, except in those
819	counties in which there are fewer than two managed care plans
820	accepting Medicaid enrollees, in which case assignment shall be
821	to a managed care plan or a MediPass provider. Medicaid
822	recipients in counties with fewer than two managed care plans
823	accepting Medicaid enrollees who are subject to mandatory
824	assignment but who fail to make a choice shall be assigned to
825	managed care plans until an enrollment of 40 percent in MediPass
826	and 60 percent in managed care plans is achieved. Once that
827	enrollment is achieved, the assignments shall be divided in
828	order to maintain an enrollment in MediPass and managed care
829	plans which is in a 40 percent and 60 percent proportion,
830	respectively. In service areas 1 and 6 of the Agency for Health
831	Care Administration where the agency is contracting for the
832	provision of comprehensive behavioral health services through a
833	capitated prepaid arrangement, recipients who fail to make a
834	choice shall be assigned equally to MediPass or a managed care
835	plan. For purposes of this paragraph, when referring to
836	assignment, the term "managed care plans" includes exclusive
837	provider organizations, provider service networks, Children's
838	Medical Services Network, minority physician networks, and
839	pediatric emergency department diversion programs authorized by
840	this chapter or the General Appropriations Act. When making
841	assignments, the agency shall take into account the following
842	criteria:
843	1.  A managed care plan has sufficient network capacity to
844	meet the need of members.
845	2.  The managed care plan or MediPass has previously
846	enrolled the recipient as a member, or one of the managed care
847	plan's primary care providers or MediPass providers has
848	previously provided health care to the recipient.
849	3.  The agency has knowledge that the member has previously
850	expressed a preference for a particular managed care plan or
851	MediPass provider as indicated by Medicaid fee-for-service
852	claims data, but has failed to make a choice.
853	4.  The managed care plan's or MediPass primary care
854	providers are geographically accessible to the recipient's
855	residence.
856	5.  The agency has authority to make mandatory assignments
857	based on quality of service and performance of managed care
858	plans.
859	(k)(l)  Notwithstanding the provisions of chapter 287, the
860	agency may, at its discretion, renew cost-effective contracts
861	for choice counseling services once or more for such periods as
862	the agency may decide. However, all such renewals may not
863	combine to exceed a total period longer than the term of the
864	original contract.
865	(7)  The agency shall investigate the feasibility of
866	developing managed care plan and MediPass options for the
867	following groups of Medicaid recipients:
868	(a)  Pregnant women and infants.
869	(b)  Elderly and disabled recipients, especially those who
870	are at risk of nursing home placement.
871	(c)  Persons with developmental disabilities.
872	(d)  Qualified Medicare beneficiaries.
873	(e)  Adults who have chronic, high-cost medical conditions.
874	(f)  Adults and children who have mental health problems.
875	(g)  Other recipients for whom managed care plans and
876	MediPass offer the opportunity of more cost-effective care and
877	greater access to qualified providers.
878	Section 6.  The Agency for Health Care Administration shall
879	report to the Legislature by April 1, 2006, the specific
880	preimplementation milestones required by the Centers for
881	Medicare and Medicaid Services Special Terms and Conditions
882	related to the low income pool that have been approved by the
883	Federal Government and the status of any remaining
884	preimplementation milestones that have not been approved by the
885	Federal Government.
886	Section 7.  Quarterly progress and annual reports.--The
887	Agency for Health Care Administration shall submit to the
888	Governor, the President of the Senate, the Speaker of the House
889	of Representatives, the Minority Leader of the Senate, the
890	Minority Leader of the House of Representatives, and the Office
891	of Program Policy Analysis and Government Accountability the
892	following reports:
893	(1)  Quarterly progress reports submitted to Centers for
894	Medicare and Medicaid Services no later than 60 days following
895	the end of each quarter. These reports shall present the
896	agency's analysis and the status of various operational areas.
897	The quarterly progress reports shall include, but are not
898	limited to, the following:
899	(a)  Documentation of events that occurred during the
900	quarter or that are anticipated to occur in the near future that
901	affect health care delivery, including, but not limited to, the
902	approval of contracts with new managed care plans, the
903	procedures for designating coverage areas, the process of
904	phasing in managed care, a description of the populations served
905	and the benefits provided, the number of recipients enrolled, a
906	list of grievances submitted by enrollees, and other operational
907	issues.
908	(b)  Action plans for addressing policy and administrative
909	issues.
910	(c)  Documentation of agency efforts related to the
911	collection and verification of encounter and utilization data.
912	(d)  Enrollment data for each managed care plan according
913	to the following specifications: total number of enrollees,
914	eligibility category, number of enrollees receiving Temporary
915	Assistance for Needy Families or Supplemental Security Income,
916	market share, and percentage change in enrollment. In addition,
917	the agency shall provide a summary of voluntary and mandatory
918	selection rates and disenrollment data. Enrollment data, number
919	of members by month, and expenditures shall be submitted in the
920	format for monitoring budget neutrality provided by the Centers
921	for Medicare and Medicaid Services.
922	(e)  Documentation of low income pool activities and
923	associated expenditures.
924	(f)  Documentation of activities related to the
925	implementation of choice counseling including efforts to improve
926	health literacy and the methods used to obtain public input
927	including recipient focus groups.
928	(g)  Participation rates in the Enhanced Benefit Accounts
929	Program, as established in the Centers for Medicare and Medicaid
930	Services Special Terms and Conditions number 11-W-00206/4, which
931	shall include: participation levels, summary of activities and
932	associated expenditures, number of accounts established
933	including active participants and individuals who continue to
934	retain access to funds in an account but no longer actively
935	participate, estimated quarterly deposits in accounts, and
936	expenditures from the accounts.
937	(h)  Enrollment data on employer-sponsored insurance that
938	documents the number of individuals selecting to opt out when
939	employer-sponsored insurance is available. The agency shall
940	include data that identifies enrollee characteristics to include
941	eligibility category, type of employer-sponsored insurance, and
942	type of coverage based on whether the coverage is for the
943	individual or the family. The agency shall develop and maintain
944	disenrollment reports specifying the reason for disenrolling in
945	an employer-sponsored insurance program. The agency shall also
946	track and report on those enrollees who elect to reenroll in the
947	Medicaid reform waiver demonstration program.
948	(i)  Documentation of progress toward the demonstration
949	program goals.
950	(j)  Documentation of evaluation activities.
951	(2)  The annual report shall document accomplishments,
952	program status, quantitative and case study findings,
953	utilization data, and policy and administrative difficulties in
954	the operation of the Medicaid reform waiver demonstration
955	program. The agency shall submit the draft annual report no
956	later than October 1 after the end of each fiscal year.
957	(a)  Beginning with the annual report for demonstration
958	program year two, the agency shall include a section on the
959	administration of enhanced benefit accounts, participation
960	rates, an assessment of expenditures, and potential cost
961	savings.
962	(b)  Beginning with the annual report for demonstration
963	program year four, the agency shall include a section that
964	provides qualitative and quantitative data that describes the
965	impact of the low income pool on the number of uninsured persons
966	in the state from the start of the implementation of the
967	demonstration program.
968
969	======= T I T L E  A M E N D M E N T =======
970	Remove line(s) 26-72 and insert:
971	of provider service networks; amending s. 409.91211, F.S.;
972	providing for implementation of expansion of the Medicaid
973	managed care pilot program upon approval by the Legislature;
974	providing for distribution of upper payment limit, hospital
975	disproportionate share program, and low income pool funds;
976	providing legislative intent with respect to distribution of
977	said funds; providing for implementation of the powers, duties,
978	and responsibilities of the Agency for Health Care
979	Administration with respect to the pilot program; including the
980	Division of Children's Medical Services Network within the
981	Department of Health in a list of state-authorized pilot
982	programs; requiring the agency to develop a data reporting
983	system; requiring the agency to implement procedures to minimize
984	fraud and abuse; providing that certain Medicaid and
985	Supplemental Security Income recipients are exempt from s.
986	409.9122, F.S.; providing for Medicaid reimbursement of
987	federally qualified health centers that deliver certain school-
988	based services; authorizing the agency to assign certain
989	Medicaid recipients to reform plans; authorizing the agency to
990	implement the provisions of the waiver approved by the Centers
991	for Medicare and Medicaid Services and requiring the agency to
992	notify the Legislature prior to seeking federal approval of
993	modifications to said terms and conditions; requiring the
994	Secretary of Health Care Administration to convene a technical
995	advisory panel; providing for membership and duties; limiting
996	aggregate risk score of certain managed care plans for payment
997	purposes for a specified period of time; providing for phase in
998	of capitation rates; providing applicability; requiring rates to
999	be certified and approved; defining the term "capitated managed
1000	care plan"; providing for conflict between specified provisions
1001	of ch. 409, F.S., and requiring a report by the agency
1002	pertaining thereto; amending s. 409.9122, F.S.; revising
1003	provisions relating to assignment of certain Medicaid recipients
1004	to managed care plans; requiring the agency to submit reports to
1005	the Legislature; specifying content of reports; amending s.
1006	216.346, F.S.; revising provisions

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