Florida Senate - 2008 SB 1570
By Senator Lynn
7-02894-08 20081570__
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A bill to be entitled
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An act relating to the Medicaid managed care pilot
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program; amending s. 409.1211, F.S.; providing exceptions
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to mandatory enrollment in the pilot program; providing
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for the expiration of such exceptions; requiring that the
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Agency for Health Care Administration provide Medicaid
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recipients with certain information; requiring that the
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agency's encounter database collect certain information
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relating to prescription drugs; requiring that the
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encounter database collect certain information related to
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health care costs and utilization from managed care plans
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participating in demonstration sites; imposing upon the
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agency certain powers, duties, and responsibilities with
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respect to the pilot program; requiring that the agency
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adopt certain rules; requiring that the managed care plan
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allow an SSI-related Medicaid recipient to select a
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specialist within the provider network who is willing to
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serve as the recipient's primary care physician upon the
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request of the recipient; providing an effective date.
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Be It Enacted by the Legislature of the State of Florida:
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Section 1. Subsection (1), paragraphs (i) and (p) of
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subsection (3), and paragraph (f) of subsection (4) of section
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409.91211, Florida Statutes, are amended, and paragraphs (ee),
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(ff), (gg), (hh), (ii), (jj), and (kk) are added to subsection
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(3) of that section, to read:
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409.91211 Medicaid managed care pilot program.--
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(1)(a) The agency is authorized to seek and implement
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experimental, pilot, or demonstration project waivers, pursuant
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to s. 1115 of the Social Security Act, to create a statewide
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initiative to provide for a more efficient and effective service
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delivery system that enhances quality of care and client outcomes
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in the Florida Medicaid program pursuant to this section. Phase
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one of the demonstration shall be implemented in two geographic
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areas. One demonstration site shall include only Broward County.
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A second demonstration site shall initially include Duval County
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and shall be expanded to include Baker, Clay, and Nassau Counties
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within 1 year after the Duval County program becomes operational.
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Persons with developmental disabilities as defined by s.
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393.063(9), children found to be dependent pursuant to s.
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39.01(14), persons with severe and persistent mental illness, and
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recipients who meet the institutional or "ICP" level of care
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required for Medicaid nursing home care or enrollment in a
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Medicaid home-based or community-based waiver are excluded from
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mandatory enrollment in the pilot program until the service
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delivery systems described in paragraphs (3)(cc) and (dd) have
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been developed and evaluated for a period of at least 1 year and
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until the Legislature expressly authorizes their mandatory
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enrollment. The agency shall implement expansion of the program
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to include the remaining counties of the state and remaining
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eligibility groups in accordance with the process specified in
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the federally approved special terms and conditions numbered 11-
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W-00206/4, as approved by the federal Centers for Medicare and
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Medicaid Services on October 19, 2005, with a goal of full
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statewide implementation by June 30, 2011.
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(b) This waiver authority is contingent upon federal
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approval to preserve the upper-payment-limit funding mechanism
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for hospitals, including a guarantee of a reasonable growth
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factor, a methodology to allow the use of a portion of these
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funds to serve as a risk pool for demonstration sites, provisions
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to preserve the state's ability to use intergovernmental
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transfers, and provisions to protect the disproportionate share
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program authorized pursuant to this chapter. Upon completion of
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the evaluation conducted under s. 3, ch. 2005-133, Laws of
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Florida, the agency may request statewide expansion of the
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demonstration projects. Statewide phase-in to additional counties
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shall be contingent upon review and approval by the Legislature.
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Under the upper-payment-limit program, or the low-income pool as
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implemented by the Agency for Health Care Administration pursuant
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to federal waiver, the state matching funds required for the
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program shall be provided by local governmental entities through
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intergovernmental transfers in accordance with published federal
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statutes and regulations. The Agency for Health Care
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Administration shall distribute upper-payment-limit,
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disproportionate share hospital, and low-income pool funds
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according to published federal statutes, regulations, and waivers
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and the low-income pool methodology approved by the federal
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Centers for Medicare and Medicaid Services.
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(c) It is the intent of the Legislature that the low-income
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pool plan required by the terms and conditions of the Medicaid
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reform waiver and submitted to the federal Centers for Medicare
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and Medicaid Services propose the distribution of the above-
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mentioned program funds based on the following objectives:
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1. Assure a broad and fair distribution of available funds
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based on the access provided by Medicaid participating hospitals,
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regardless of their ownership status, through their delivery of
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inpatient or outpatient care for Medicaid beneficiaries and
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uninsured and underinsured individuals;
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2. Assure accessible emergency inpatient and outpatient
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care for Medicaid beneficiaries and uninsured and underinsured
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individuals;
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3. Enhance primary, preventive, and other ambulatory care
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coverages for uninsured individuals;
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4. Promote teaching and specialty hospital programs;
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5. Promote the stability and viability of statutorily
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defined rural hospitals and hospitals that serve as sole
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community hospitals;
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6. Recognize the extent of hospital uncompensated care
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costs;
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7. Maintain and enhance essential community hospital care;
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8. Maintain incentives for local governmental entities to
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contribute to the cost of uncompensated care;
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9. Promote measures to avoid preventable hospitalizations;
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10. Account for hospital efficiency; and
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11. Contribute to a community's overall health system.
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(3) The agency shall have the following powers, duties, and
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responsibilities with respect to the pilot program:
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(i) To implement a mechanism for providing information to
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Medicaid recipients for the purpose of selecting a capitated
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managed care plan. For each plan available to a recipient, the
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agency, at a minimum, shall ensure that the recipient is provided
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with:
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1. A list and description of the benefits provided.
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2. Information about cost sharing.
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3. Plan performance data, if available.
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4. An explanation of benefit limitations.
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5. Contact information, including identification of
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providers participating in the network, geographic locations, and
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transportation limitations.
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6. Plan standards for granting services in excess of the
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plan's service caps.
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7. Plan preferred drug lists, including listings of covered
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drugs according to the same therapeutic classification used in
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the agency's preferred drug list, and utilization review criteria
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for granting coverage of drugs not on the preferred drug list.
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8. Information on the right to transitional coverage of
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services the recipient is receiving prior to enrollment in the
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plan.
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9.6. Any other information the agency determines would
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facilitate a recipient's understanding of the plan or insurance
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that would best meet his or her needs.
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(p) To implement standards for plan compliance, including,
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but not limited to, standards for quality assurance and
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performance improvement, standards for peer or professional
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reviews, grievance policies, and policies for maintaining program
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integrity. The agency shall develop a data-reporting system, seek
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input from managed care plans in order to establish requirements
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for patient-encounter reporting, and ensure that the data
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reported is accurate and complete.
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1. In performing the duties required under this section,
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the agency shall work with managed care plans to establish a
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uniform system to measure and monitor outcomes for a recipient of
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Medicaid services.
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2. The system shall use financial, clinical, and other
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criteria based on pharmacy, medical services, and other data that
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is related to the provision of Medicaid services, including, but
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not limited to:
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a. The Health Plan Employer Data and Information Set
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(HEDIS) or measures that are similar to HEDIS.
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b. Member satisfaction.
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c. Provider satisfaction.
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d. Report cards on plan performance and best practices.
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e. Compliance with the requirements for prompt payment of
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f. Utilization and quality data for the purpose of ensuring
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access to medically necessary services, including
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underutilization or inappropriate denial of services.
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3. The agency shall require the managed care plans that
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have contracted with the agency to establish a quality assurance
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system that incorporates the provisions of s. 409.912(27) and any
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standards, rules, and guidelines developed by the agency.
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4. The agency shall establish an encounter database in
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order to compile data on health services rendered by health care
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practitioners who provide services to patients enrolled in
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managed care plans in the demonstration sites. The encounter
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database shall:
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a. Collect the following for each type of patient encounter
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with a health care practitioner or facility, including:
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(I) The demographic characteristics of the patient.
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(II) The principal, secondary, and tertiary diagnosis.
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(III) The procedure performed.
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(IV) The date and location where the procedure was
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performed.
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(V) The payment for the procedure, if any.
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(VI) If applicable, the health care practitioner's
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universal identification number.
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(VII) If the health care practitioner rendering the service
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is a dependent practitioner, the modifiers appropriate to
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indicate that the service was delivered by the dependent
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practitioner.
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b. Collect appropriate information relating to prescription
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drugs for each type of patient encounter including, but not
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limited to:
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(I) Data showing the unduplicated number of recipients
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whose prescription coverage, by therapeutic class, was rejected
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each month at the point of service because the drug was not on
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the plan's preferred drug list, and, of those rejections:
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(A) The number of recipients receiving the original
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prescription;
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(B) The number of recipients receiving a therapeutic brand
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alternative;
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(C) The number of recipients receiving a therapeutic
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generic alternative; and
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(D) The number of recipients who did not receive a
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medication in this therapeutic class.
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(II) The number of recipients whose prescription coverage
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was rejected each month due to:
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(A) The recipient reaching the plan cap on the number of
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covered prescriptions; or
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(B) The recipient reaching the dollar cap on the cost of
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covered prescriptions.
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c. Collect appropriate information related to health care
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costs and utilization from managed care plans participating in
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the demonstration sites including, but not limited to:
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(I) The number of recipients reaching the annual benefit
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maximum cost cap;
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(II) The number of recipients receiving the maximum number
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of services for each service category;
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(III) The number of notices sent to recipients meeting the
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plan cap for a specific service advising them that services have
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been terminated due to reaching the cap;
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(IV) The number of notices sent to recipients meeting the
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plan cap for a specific service and advising them of the
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opportunity to request prior authorization for additional
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services in excess of the plan cap;
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(V) The number of recipients requesting additional
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services; and
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(VI) The number of recipients granted services in excess of
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the plan cap.
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5. To the extent practicable, when collecting the data the
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agency shall use a standardized claim form or electronic transfer
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system that is used by health care practitioners, facilities, and
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payors.
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6. Health care practitioners and facilities in the
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demonstration sites shall electronically submit, and managed care
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plans participating in the demonstration sites shall
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electronically receive, information concerning claims payments
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and any other information reasonably related to the encounter
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database using a standard format as required by the agency.
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7. The agency shall establish reasonable deadlines for
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phasing in the electronic transmittal of full encounter data.
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8. The system must ensure that the data reported is
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accurate and complete.
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(ee) To develop and recommend service delivery mechanisms
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within capitated managed care plans to provide Medicaid services
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Medicaid nursing home level-of-care requirements sufficient to
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meet the medical, developmental, and emotional needs of these
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persons.
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(ff) To develop and recommend service delivery mechanisms
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within capitated managed care plans to provide Medicaid services
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and persistent mental illness sufficient to meet the medical,
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developmental, and emotional needs of these persons.
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(gg) To implement contractual requirements and adopt rules
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that will require capitated managed care plans and provider
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services networks to continue providing any current service,
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including those services subject to prior authorization, during
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the period of time in which prior authorization is being
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requested, processed, or appealed. Services must be continued at
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the current level until a notice conforming with 42 C.F.R. s.
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431.200 is sent and at least 10 days after the date of the notice
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has passed and a hearing is not requested, or, if a hearing is
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requested, the hearing decision affirms the adverse action.
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(hh) To ensure that policies and procedures are in place to
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identify individuals excluded from mandatory enrollment pursuant
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to paragraph (1)(a), including written materials provided to all
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prospective enrollees, current reform enrollees, and choice
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counselors.
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(ii) To adopt rules to establish policies by which
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exceptions to mandatory Medicaid reform enrollment may be made on
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a case-by-case basis, in addition to those groups specified in
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paragraph (1)(a). The rules shall include the specific criteria
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to be applied when making a determination regarding whether to
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exempt a recipient from mandatory enrollment.
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(jj) To develop improvement benchmarks in the areas of
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health plan and system readiness, timely claims processing,
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implementation of a consolidated complaint-tracking system that
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has analytical capabilities for producing trending reports, and
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receipt and validations of encounter data, including paid and
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denied claims. Before the program may be expanded beyond the
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pilot project counties, the improvement benchmarks must be met
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and encounter data sufficient to conduct assessments of cost-
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effectiveness and quality, and access to care must be available.
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Future audits or evaluations of cost-effectiveness must examine
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indicators of cost-shifting, including, but not limited to,
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increases in emergency room admissions, incarceration rates, use
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of indigent drug program funds, outsourcing, and administrative
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costs.
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(kk) To perform monthly audits of reports of health plan
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provider networks by comparing them with enrollee handbooks for
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discrepancies and contacting a statistically significant sample
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of providers to ensure accuracy.
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(4)
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(f) The agency shall apply for federal waivers from the
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Centers for Medicare and Medicaid Services to lock eligible
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Medicaid recipients into a capitated managed care network for 12
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months after an open enrollment period. After 12 months of
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enrollment, a recipient may select another capitated managed care
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network. However, nothing shall prevent a Medicaid recipient from
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changing primary care providers within the capitated managed care
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network during the 12-month period. When there is a request by an
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SSI-related recipient for a specialist to serve as his or her
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primary physician due to a recipient's particular health
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condition, the managed care plan shall allow the recipient to
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select a specialist within the provider network who is willing to
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serve as the recipient's primary care physician.
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Section 2. This act shall take effect July 1, 2008.
CODING: Words stricken are deletions; words underlined are additions.