CS for CS for SB 1484 First Engrossed
20101484e1
1 A bill to be entitled
2 An act relating to Medicaid; amending s. 409.912,
3 F.S.; authorizing the Agency for Health Care
4 Administration to contract with an entity for the
5 provision of comprehensive behavioral health care
6 services to certain Medicaid recipients who are not
7 enrolled in a Medicaid managed care plan or a Medicaid
8 provider service network under certain circumstances;
9 requiring the agency to impose a fine against a person
10 under contract with the agency who violates certain
11 provisions; requiring an entity that contracts with
12 the agency as a managed care plan to post a surety
13 bond with the agency or maintain an account of a
14 specified sum; requiring the agency to pursue the
15 entity if the entity terminates the contract with the
16 agency before the end date of the contract; amending
17 s. 409.91211, F.S.; extending by 3 years the statewide
18 implementation of an enhanced service delivery system
19 for the Florida Medicaid program; providing for the
20 expansion of the pilot project into counties that have
21 two or more plans and the capacity to serve the
22 designated population; requiring that the agency
23 provide certain specified data to the recipient when
24 selecting a capitated managed care plan; revising
25 certain requirements for entities performing choice
26 counseling for recipients; requiring the agency to
27 provide behavioral health care services to Medicaid
28 eligible children; extending a date by which the
29 behavioral health care services will be delivered to
30 children; deleting a provision under which certain
31 Medicaid recipients who are not currently enrolled in
32 a capitated managed care plan upon implementation are
33 not eligible for specified services for the amount of
34 time that the recipients do not enroll in a capitated
35 managed care network; authorizing the agency to extend
36 the time to continue operation of the pilot program;
37 requiring that the agency seek public input on
38 extending and expanding the managed care pilot program
39 and post certain information on its website; amending
40 s. 409.9122, F.S.; providing that time allotted to any
41 Medicaid recipient for the selection of, enrollment
42 in, or disenrollment from a managed care plan or
43 MediPass is tolled throughout any month in which the
44 enrollment broker or choice counseling provider
45 adversely affects a beneficiary’s ability to access
46 choice counseling or enrollment broker services by its
47 failure to comply with the terms and conditions of its
48 contract with the agency or has otherwise acted or
49 failed to act in a manner that the agency deems likely
50 to jeopardize its ability to perform certain assigned
51 responsibilities; requiring the agency to incorporate
52 certain provisions after a specified date in its
53 contracts related to sanctions or fines for any action
54 or the failure to act on the part of an enrollment
55 broker or choice counselor provider; creating s.
56 624.35, F.S.; providing a short title; creating s.
57 624.351, F.S.; providing legislative intent;
58 establishing the Medicaid and Public Assistance Fraud
59 Strike Force within the Department of Financial
60 Services to coordinate efforts to eliminate Medicaid
61 and public assistance fraud; providing for membership;
62 providing for meetings; specifying duties; requiring
63 an annual report to the Legislature and Governor;
64 creating s. 624.352, F.S.; directing the Chief
65 Financial Officer to prepare model interagency
66 agreements that address Medicaid and public assistance
67 fraud; specifying which agencies can be a party to
68 such agreements; amending s. 16.59, F.S.; conforming
69 provisions to changes made by the act; requiring the
70 Divisions of Insurance Fraud and Public Assistance
71 Fraud in the Department of Financial Services to be
72 collocated with the Medicaid Fraud Control Unit if
73 possible; requiring positions dedicated to Medicaid
74 managed care fraud to be collocated with the Division
75 of Insurance Fraud; amending s. 20.121, F.S.;
76 establishing the Division of Public Assistance Fraud
77 within the Department of Financial Services; amending
78 ss. 411.01, 414.33, and 414.39, F.S.; conforming
79 provisions to changes made by the act; transferring,
80 renumbering, and amending s. 943.401, F.S.; directing
81 the Department of Financial Services rather than the
82 Department of Law Enforcement to investigate public
83 assistance fraud; directing the Auditor General and
84 the Office of Program Policy Analysis and Government
85 Accountability to review the Medicaid fraud and abuse
86 processes in the Agency for Health Care
87 Administration; requiring a report to the Legislature
88 and Governor by a certain date; establishing the
89 Medicaid claims adjudication project in the Agency for
90 Health Care Administration to decrease the incidence
91 of inaccurate payments and to improve the efficiency
92 of the Medicaid claims processing system; transferring
93 activities relating to public assistance fraud from
94 the Department of Law Enforcement to the Division of
95 Public Assistance Fraud in the Department of Financial
96 Services by a type two transfer; providing effective
97 dates.
98
99 WHEREAS, Florida’s Medicaid program is one of the largest
100 in the country, serving approximately 2.7 million persons each
101 month. The program provides health care benefits to families and
102 individuals below certain income and resource levels. For the
103 2008-2009 fiscal year, the Legislature appropriated $18.81
104 billion to operate the Medicaid program which is funded from
105 general revenue, trust funds that include federal matching
106 funds, and other state funds, and
107 WHEREAS, Medicaid fraud in Florida is epidemic, far
108 reaching, and costs the state and the Federal Government
109 billions of dollars annually. Medicaid fraud not only drives up
110 the cost of health care and reduces the availability of funds to
111 support needed services, but undermines the long-term solvency
112 of both health care providers and the state’s Medicaid program,
113 and
114 WHEREAS, the state’s public assistance programs serve
115 approximately 1.8 million Floridians each month by providing
116 benefits for food, cash assistance for needy families, home
117 health care for disabled adults, and grants to individuals and
118 communities affected by natural disasters. For the 2008-2009
119 fiscal year, the Legislature appropriated $626 million to
120 operate public assistance programs, and
121 WHEREAS, public assistance fraud costs taxpayers millions
122 of dollars annually, which significantly and negatively impacts
123 the various assistance programs by taking dollars that could be
124 used to provide services for those people who have a legitimate
125 need for assistance, and
126 WHEREAS, both Medicaid and public assistance programs are
127 vulnerable to fraudulent practices that can take many forms. For
128 Medicaid, these practices range from providers who bill for
129 services never rendered and who pay kickbacks to other providers
130 for client referrals, to fraud occurring at the corporate level
131 of a managed care organization. Fraudulent practices involving
132 public assistance involve persons not disclosing material facts
133 when obtaining assistance or not disclosing changes in
134 circumstances while on public assistance, and
135 WHEREAS, ridding the system of perpetrators who prey on the
136 state’s Medicaid and public assistance programs helps reduce the
137 state’s skyrocketing costs, makes more funds available for
138 essential services, and improves the quality of care and the
139 health status of our residents, and
140 WHEREAS, aggressive and comprehensive measures are needed
141 at the state level to investigate and prosecute Medicaid and
142 public assistance fraud and to recover dollars stolen from these
143 programs, and
144 WHEREAS, new statewide initiatives and coordinated efforts
145 are necessary to focus resources in order to aid law enforcement
146 and investigative agencies in detecting and deterring this type
147 of fraudulent activity, NOW, THEREFORE,
148
149 Be It Enacted by the Legislature of the State of Florida:
150
151 Section 1. Paragraph (b) of subsection (4) of section
152 409.912, Florida Statutes, is amended, paragraph (d) of
153 subsection (4) of that section is reenacted, present subsections
154 (23) through (53) of that section are renumbered as subsections
155 (24) through (54), respectively, a new subsection (23) is added
156 to that section, and present subsections (21) and (22) of that
157 section are amended, to read:
158 409.912 Cost-effective purchasing of health care.—The
159 agency shall purchase goods and services for Medicaid recipients
160 in the most cost-effective manner consistent with the delivery
161 of quality medical care. To ensure that medical services are
162 effectively utilized, the agency may, in any case, require a
163 confirmation or second physician’s opinion of the correct
164 diagnosis for purposes of authorizing future services under the
165 Medicaid program. This section does not restrict access to
166 emergency services or poststabilization care services as defined
167 in 42 C.F.R. part 438.114. Such confirmation or second opinion
168 shall be rendered in a manner approved by the agency. The agency
169 shall maximize the use of prepaid per capita and prepaid
170 aggregate fixed-sum basis services when appropriate and other
171 alternative service delivery and reimbursement methodologies,
172 including competitive bidding pursuant to s. 287.057, designed
173 to facilitate the cost-effective purchase of a case-managed
174 continuum of care. The agency shall also require providers to
175 minimize the exposure of recipients to the need for acute
176 inpatient, custodial, and other institutional care and the
177 inappropriate or unnecessary use of high-cost services. The
178 agency shall contract with a vendor to monitor and evaluate the
179 clinical practice patterns of providers in order to identify
180 trends that are outside the normal practice patterns of a
181 provider’s professional peers or the national guidelines of a
182 provider’s professional association. The vendor must be able to
183 provide information and counseling to a provider whose practice
184 patterns are outside the norms, in consultation with the agency,
185 to improve patient care and reduce inappropriate utilization.
186 The agency may mandate prior authorization, drug therapy
187 management, or disease management participation for certain
188 populations of Medicaid beneficiaries, certain drug classes, or
189 particular drugs to prevent fraud, abuse, overuse, and possible
190 dangerous drug interactions. The Pharmaceutical and Therapeutics
191 Committee shall make recommendations to the agency on drugs for
192 which prior authorization is required. The agency shall inform
193 the Pharmaceutical and Therapeutics Committee of its decisions
194 regarding drugs subject to prior authorization. The agency is
195 authorized to limit the entities it contracts with or enrolls as
196 Medicaid providers by developing a provider network through
197 provider credentialing. The agency may competitively bid single
198 source-provider contracts if procurement of goods or services
199 results in demonstrated cost savings to the state without
200 limiting access to care. The agency may limit its network based
201 on the assessment of beneficiary access to care, provider
202 availability, provider quality standards, time and distance
203 standards for access to care, the cultural competence of the
204 provider network, demographic characteristics of Medicaid
205 beneficiaries, practice and provider-to-beneficiary standards,
206 appointment wait times, beneficiary use of services, provider
207 turnover, provider profiling, provider licensure history,
208 previous program integrity investigations and findings, peer
209 review, provider Medicaid policy and billing compliance records,
210 clinical and medical record audits, and other factors. Providers
211 shall not be entitled to enrollment in the Medicaid provider
212 network. The agency shall determine instances in which allowing
213 Medicaid beneficiaries to purchase durable medical equipment and
214 other goods is less expensive to the Medicaid program than long
215 term rental of the equipment or goods. The agency may establish
216 rules to facilitate purchases in lieu of long-term rentals in
217 order to protect against fraud and abuse in the Medicaid program
218 as defined in s. 409.913. The agency may seek federal waivers
219 necessary to administer these policies.
220 (4) The agency may contract with:
221 (b) An entity that is providing comprehensive behavioral
222 health care services to certain Medicaid recipients through a
223 capitated, prepaid arrangement pursuant to the federal waiver
224 provided for by s. 409.905(5). Such entity must be licensed
225 under chapter 624, chapter 636, or chapter 641, or authorized
226 under paragraph (c) or paragraph (d), and must possess the
227 clinical systems and operational competence to manage risk and
228 provide comprehensive behavioral health care to Medicaid
229 recipients. As used in this paragraph, the term “comprehensive
230 behavioral health care services” means covered mental health and
231 substance abuse treatment services that are available to
232 Medicaid recipients. The secretary of the Department of Children
233 and Family Services shall approve provisions of procurements
234 related to children in the department’s care or custody before
235 enrolling such children in a prepaid behavioral health plan. Any
236 contract awarded under this paragraph must be competitively
237 procured. In developing the behavioral health care prepaid plan
238 procurement document, the agency shall ensure that the
239 procurement document requires the contractor to develop and
240 implement a plan to ensure compliance with s. 394.4574 related
241 to services provided to residents of licensed assisted living
242 facilities that hold a limited mental health license. Except as
243 provided in subparagraph 8., and except in counties where the
244 Medicaid managed care pilot program is authorized pursuant to s.
245 409.91211, the agency shall seek federal approval to contract
246 with a single entity meeting these requirements to provide
247 comprehensive behavioral health care services to all Medicaid
248 recipients not enrolled in a Medicaid managed care plan
249 authorized under s. 409.91211, a provider service network
250 authorized under paragraph (d), or a Medicaid health maintenance
251 organization in an AHCA area. In an AHCA area where the Medicaid
252 managed care pilot program is authorized pursuant to s.
253 409.91211 in one or more counties, the agency may procure a
254 contract with a single entity to serve the remaining counties as
255 an AHCA area or the remaining counties may be included with an
256 adjacent AHCA area and are subject to this paragraph. Each
257 entity must offer a sufficient choice of providers in its
258 network to ensure recipient access to care and the opportunity
259 to select a provider with whom they are satisfied. The network
260 shall include all public mental health hospitals. To ensure
261 unimpaired access to behavioral health care services by Medicaid
262 recipients, all contracts issued pursuant to this paragraph must
263 require 80 percent of the capitation paid to the managed care
264 plan, including health maintenance organizations and capitated
265 provider service networks, to be expended for the provision of
266 behavioral health care services. If the managed care plan
267 expends less than 80 percent of the capitation paid for the
268 provision of behavioral health care services, the difference
269 shall be returned to the agency. The agency shall provide the
270 plan with a certification letter indicating the amount of
271 capitation paid during each calendar year for behavioral health
272 care services pursuant to this section. The agency may reimburse
273 for substance abuse treatment services on a fee-for-service
274 basis until the agency finds that adequate funds are available
275 for capitated, prepaid arrangements.
276 1. By January 1, 2001, the agency shall modify the
277 contracts with the entities providing comprehensive inpatient
278 and outpatient mental health care services to Medicaid
279 recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
280 Counties, to include substance abuse treatment services.
281 2. By July 1, 2003, the agency and the Department of
282 Children and Family Services shall execute a written agreement
283 that requires collaboration and joint development of all policy,
284 budgets, procurement documents, contracts, and monitoring plans
285 that have an impact on the state and Medicaid community mental
286 health and targeted case management programs.
287 3. Except as provided in subparagraph 8., by July 1, 2006,
288 the agency and the Department of Children and Family Services
289 shall contract with managed care entities in each AHCA area
290 except area 6 or arrange to provide comprehensive inpatient and
291 outpatient mental health and substance abuse services through
292 capitated prepaid arrangements to all Medicaid recipients who
293 are eligible to participate in such plans under federal law and
294 regulation. In AHCA areas where eligible individuals number less
295 than 150,000, the agency shall contract with a single managed
296 care plan to provide comprehensive behavioral health services to
297 all recipients who are not enrolled in a Medicaid health
298 maintenance organization, a provider service network authorized
299 under paragraph (d), or a Medicaid capitated managed care plan
300 authorized under s. 409.91211. The agency may contract with more
301 than one comprehensive behavioral health provider to provide
302 care to recipients who are not enrolled in a Medicaid capitated
303 managed care plan authorized under s. 409.91211, a provider
304 service network authorized under paragraph (d), or a Medicaid
305 health maintenance organization in AHCA areas where the eligible
306 population exceeds 150,000. In an AHCA area where the Medicaid
307 managed care pilot program is authorized pursuant to s.
308 409.91211 in one or more counties, the agency may procure a
309 contract with a single entity to serve the remaining counties as
310 an AHCA area or the remaining counties may be included with an
311 adjacent AHCA area and shall be subject to this paragraph.
312 Contracts for comprehensive behavioral health providers awarded
313 pursuant to this section shall be competitively procured. Both
314 for-profit and not-for-profit corporations are eligible to
315 compete. Managed care plans contracting with the agency under
316 subsection (3) or paragraph (d), shall provide and receive
317 payment for the same comprehensive behavioral health benefits as
318 provided in AHCA rules, including handbooks incorporated by
319 reference. In AHCA area 11, the agency shall contract with at
320 least two comprehensive behavioral health care providers to
321 provide behavioral health care to recipients in that area who
322 are enrolled in, or assigned to, the MediPass program. One of
323 the behavioral health care contracts must be with the existing
324 provider service network pilot project, as described in
325 paragraph (d), for the purpose of demonstrating the cost
326 effectiveness of the provision of quality mental health services
327 through a public hospital-operated managed care model. Payment
328 shall be at an agreed-upon capitated rate to ensure cost
329 savings. Of the recipients in area 11 who are assigned to
330 MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
331 MediPass-enrolled recipients shall be assigned to the existing
332 provider service network in area 11 for their behavioral care.
333 4. By October 1, 2003, the agency and the department shall
334 submit a plan to the Governor, the President of the Senate, and
335 the Speaker of the House of Representatives which provides for
336 the full implementation of capitated prepaid behavioral health
337 care in all areas of the state.
338 a. Implementation shall begin in 2003 in those AHCA areas
339 of the state where the agency is able to establish sufficient
340 capitation rates.
341 b. If the agency determines that the proposed capitation
342 rate in any area is insufficient to provide appropriate
343 services, the agency may adjust the capitation rate to ensure
344 that care will be available. The agency and the department may
345 use existing general revenue to address any additional required
346 match but may not over-obligate existing funds on an annualized
347 basis.
348 c. Subject to any limitations provided in the General
349 Appropriations Act, the agency, in compliance with appropriate
350 federal authorization, shall develop policies and procedures
351 that allow for certification of local and state funds.
352 5. Children residing in a statewide inpatient psychiatric
353 program, or in a Department of Juvenile Justice or a Department
354 of Children and Family Services residential program approved as
355 a Medicaid behavioral health overlay services provider may not
356 be included in a behavioral health care prepaid health plan or
357 any other Medicaid managed care plan pursuant to this paragraph.
358 6. In converting to a prepaid system of delivery, the
359 agency shall in its procurement document require an entity
360 providing only comprehensive behavioral health care services to
361 prevent the displacement of indigent care patients by enrollees
362 in the Medicaid prepaid health plan providing behavioral health
363 care services from facilities receiving state funding to provide
364 indigent behavioral health care, to facilities licensed under
365 chapter 395 which do not receive state funding for indigent
366 behavioral health care, or reimburse the unsubsidized facility
367 for the cost of behavioral health care provided to the displaced
368 indigent care patient.
369 7. Traditional community mental health providers under
370 contract with the Department of Children and Family Services
371 pursuant to part IV of chapter 394, child welfare providers
372 under contract with the Department of Children and Family
373 Services in areas 1 and 6, and inpatient mental health providers
374 licensed pursuant to chapter 395 must be offered an opportunity
375 to accept or decline a contract to participate in any provider
376 network for prepaid behavioral health services.
377 8. All Medicaid-eligible children, except children in area
378 1 and children in Highlands County, Hardee County, Polk County,
379 or Manatee County of area 6, that are open for child welfare
380 services in the HomeSafeNet system, shall receive their
381 behavioral health care services through a specialty prepaid plan
382 operated by community-based lead agencies through a single
383 agency or formal agreements among several agencies. The
384 specialty prepaid plan must result in savings to the state
385 comparable to savings achieved in other Medicaid managed care
386 and prepaid programs. Such plan must provide mechanisms to
387 maximize state and local revenues. The specialty prepaid plan
388 shall be developed by the agency and the Department of Children
389 and Family Services. The agency may seek federal waivers to
390 implement this initiative. Medicaid-eligible children whose
391 cases are open for child welfare services in the HomeSafeNet
392 system and who reside in AHCA area 10 are exempt from the
393 specialty prepaid plan upon the development of a service
394 delivery mechanism for children who reside in area 10 as
395 specified in s. 409.91211(3)(dd).
396 (d) A provider service network may be reimbursed on a fee
397 for-service or prepaid basis. A provider service network which
398 is reimbursed by the agency on a prepaid basis shall be exempt
399 from parts I and III of chapter 641, but must comply with the
400 solvency requirements in s. 641.2261(2) and meet appropriate
401 financial reserve, quality assurance, and patient rights
402 requirements as established by the agency. Medicaid recipients
403 assigned to a provider service network shall be chosen equally
404 from those who would otherwise have been assigned to prepaid
405 plans and MediPass. The agency is authorized to seek federal
406 Medicaid waivers as necessary to implement the provisions of
407 this section. Any contract previously awarded to a provider
408 service network operated by a hospital pursuant to this
409 subsection shall remain in effect for a period of 3 years
410 following the current contract expiration date, regardless of
411 any contractual provisions to the contrary. A provider service
412 network is a network established or organized and operated by a
413 health care provider, or group of affiliated health care
414 providers, including minority physician networks and emergency
415 room diversion programs that meet the requirements of s.
416 409.91211, which provides a substantial proportion of the health
417 care items and services under a contract directly through the
418 provider or affiliated group of providers and may make
419 arrangements with physicians or other health care professionals,
420 health care institutions, or any combination of such individuals
421 or institutions to assume all or part of the financial risk on a
422 prospective basis for the provision of basic health services by
423 the physicians, by other health professionals, or through the
424 institutions. The health care providers must have a controlling
425 interest in the governing body of the provider service network
426 organization.
427 (21) Any entity contracting with the agency pursuant to
428 this section to provide health care services to Medicaid
429 recipients is prohibited from engaging in any of the following
430 practices or activities:
431 (a) Practices that are discriminatory, including, but not
432 limited to, attempts to discourage participation on the basis of
433 actual or perceived health status.
434 (b) Activities that could mislead or confuse recipients, or
435 misrepresent the organization, its marketing representatives, or
436 the agency. Violations of this paragraph include, but are not
437 limited to:
438 1. False or misleading claims that marketing
439 representatives are employees or representatives of the state or
440 county, or of anyone other than the entity or the organization
441 by whom they are reimbursed.
442 2. False or misleading claims that the entity is
443 recommended or endorsed by any state or county agency, or by any
444 other organization which has not certified its endorsement in
445 writing to the entity.
446 3. False or misleading claims that the state or county
447 recommends that a Medicaid recipient enroll with an entity.
448 4. Claims that a Medicaid recipient will lose benefits
449 under the Medicaid program, or any other health or welfare
450 benefits to which the recipient is legally entitled, if the
451 recipient does not enroll with the entity.
452 (c) Granting or offering of any monetary or other valuable
453 consideration for enrollment, except as authorized by subsection
454 (25) (24).
455 (d) Door-to-door solicitation of recipients who have not
456 contacted the entity or who have not invited the entity to make
457 a presentation.
458 (e) Solicitation of Medicaid recipients by marketing
459 representatives stationed in state offices unless approved and
460 supervised by the agency or its agent and approved by the
461 affected state agency when solicitation occurs in an office of
462 the state agency. The agency shall ensure that marketing
463 representatives stationed in state offices shall market their
464 managed care plans to Medicaid recipients only in designated
465 areas and in such a way as to not interfere with the recipients’
466 activities in the state office.
467 (f) Enrollment of Medicaid recipients.
468 (22) The agency shall may impose a fine for a violation of
469 this section or the contract with the agency by a person or
470 entity that is under contract with the agency. With respect to
471 any nonwillful violation, such fine shall not exceed $2,500 per
472 violation. In no event shall such fine exceed an aggregate
473 amount of $10,000 for all nonwillful violations arising out of
474 the same action. With respect to any knowing and willful
475 violation of this section or the contract with the agency, the
476 agency may impose a fine upon the entity in an amount not to
477 exceed $20,000 for each such violation. In no event shall such
478 fine exceed an aggregate amount of $100,000 for all knowing and
479 willful violations arising out of the same action.
480 (23) Any entity that contracts with the agency on a prepaid
481 or fixed-sum basis as a managed care plan as defined in s.
482 409.9122(2)(f) or s. 409.91211 shall post a surety bond with the
483 agency in an amount that is equivalent to a 1-year guaranteed
484 savings amount as specified in the contract. In lieu of a surety
485 bond, the agency may establish an irrevocable account in which
486 the vendor funds an equivalent amount over a 6-month period. The
487 purpose of the surety bond or account is to protect the agency
488 if the entity terminates its contract with the agency before the
489 scheduled end date for the contract. If the contract is
490 terminated by the vendor for any reason, the agency shall pursue
491 a claim against the surety bond or account for an early
492 termination fee. The early termination fee must be equal to
493 administrative costs incurred by the state due to the early
494 termination and the differential of the guaranteed savings based
495 on the original contract term and the corresponding termination
496 date. The agency shall terminate a vendor who does not reimburse
497 the state within 30 days after any early termination involving
498 administrative costs and requiring reimbursement of lost savings
499 from the Medicaid program.
500 Section 2. Subsections (1) through (6) of section
501 409.91211, Florida Statutes, are amended to read:
502 409.91211 Medicaid managed care pilot program.—
503 (1)(a) The agency is authorized to seek and implement
504 experimental, pilot, or demonstration project waivers, pursuant
505 to s. 1115 of the Social Security Act, to create a statewide
506 initiative to provide for a more efficient and effective service
507 delivery system that enhances quality of care and client
508 outcomes in the Florida Medicaid program pursuant to this
509 section. Phase one of the demonstration shall be implemented in
510 two geographic areas. One demonstration site shall include only
511 Broward County. A second demonstration site shall initially
512 include Duval County and shall be expanded to include Baker,
513 Clay, and Nassau Counties within 1 year after the Duval County
514 program becomes operational. The agency shall implement
515 expansion of the program to include the remaining counties of
516 the state and remaining eligibility groups in accordance with
517 the process specified in the federally approved special terms
518 and conditions numbered 11-W-00206/4, as approved by the federal
519 Centers for Medicare and Medicaid Services on October 19, 2005,
520 with a goal of full statewide implementation by June 30, 2014
521 2011.
522 (b) This waiver extension shall authority is contingent
523 upon federal approval to preserve the low-income pool upper
524 payment-limit funding mechanism for providers and hospitals,
525 including a guarantee of a reasonable growth factor, a
526 methodology to allow the use of a portion of these funds to
527 serve as a risk pool for demonstration sites, provisions to
528 preserve the state’s ability to use intergovernmental transfers,
529 and provisions to protect the disproportionate share program
530 authorized pursuant to this chapter. Upon completion of the
531 evaluation conducted under s. 3, ch. 2005-133, Laws of Florida,
532 The agency shall expand may request statewide expansion of the
533 demonstration to counties that have two or more plans and that
534 have capacity to serve the designated population projects. The
535 agency may expand to additional counties as plan capacity is
536 developed. Statewide phase-in to additional counties shall be
537 contingent upon review and approval by the Legislature. Under
538 the upper-payment-limit program, or the low-income pool as
539 implemented by the Agency for Health Care Administration
540 pursuant to federal waiver, the state matching funds required
541 for the program shall be provided by local governmental entities
542 through intergovernmental transfers in accordance with published
543 federal statutes and regulations. The Agency for Health Care
544 Administration shall distribute upper-payment-limit,
545 disproportionate share hospital, and low-income pool funds
546 according to published federal statutes, regulations, and
547 waivers and the low-income pool methodology approved by the
548 federal Centers for Medicare and Medicaid Services.
549 (c) It is the intent of the Legislature that the low-income
550 pool plan required by the terms and conditions of the Medicaid
551 reform waiver and submitted to the federal Centers for Medicare
552 and Medicaid Services propose the distribution of the above
553 mentioned program funds based on the following objectives:
554 1. Assure a broad and fair distribution of available funds
555 based on the access provided by Medicaid participating
556 hospitals, regardless of their ownership status, through their
557 delivery of inpatient or outpatient care for Medicaid
558 beneficiaries and uninsured and underinsured individuals;
559 2. Assure accessible emergency inpatient and outpatient
560 care for Medicaid beneficiaries and uninsured and underinsured
561 individuals;
562 3. Enhance primary, preventive, and other ambulatory care
563 coverages for uninsured individuals;
564 4. Promote teaching and specialty hospital programs;
565 5. Promote the stability and viability of statutorily
566 defined rural hospitals and hospitals that serve as sole
567 community hospitals;
568 6. Recognize the extent of hospital uncompensated care
569 costs;
570 7. Maintain and enhance essential community hospital care;
571 8. Maintain incentives for local governmental entities to
572 contribute to the cost of uncompensated care;
573 9. Promote measures to avoid preventable hospitalizations;
574 10. Account for hospital efficiency; and
575 11. Contribute to a community’s overall health system.
576 (2) The Legislature intends for the capitated managed care
577 pilot program to:
578 (a) Provide recipients in Medicaid fee-for-service or the
579 MediPass program a comprehensive and coordinated capitated
580 managed care system for all health care services specified in
581 ss. 409.905 and 409.906.
582 (b) Stabilize Medicaid expenditures under the pilot program
583 compared to Medicaid expenditures in the pilot area for the 3
584 years before implementation of the pilot program, while
585 ensuring:
586 1. Consumer education and choice.
587 2. Access to medically necessary services.
588 3. Coordination of preventative, acute, and long-term care.
589 4. Reductions in unnecessary service utilization.
590 (c) Provide an opportunity to evaluate the feasibility of
591 statewide implementation of capitated managed care networks as a
592 replacement for the current Medicaid fee-for-service and
593 MediPass systems.
594 (3) The agency shall have the following powers, duties, and
595 responsibilities with respect to the pilot program:
596 (a) To implement a system to deliver all mandatory services
597 specified in s. 409.905 and optional services specified in s.
598 409.906, as approved by the Centers for Medicare and Medicaid
599 Services and the Legislature in the waiver pursuant to this
600 section. Services to recipients under plan benefits shall
601 include emergency services provided under s. 409.9128.
602 (b) To implement a pilot program, including Medicaid
603 eligibility categories specified in ss. 409.903 and 409.904, as
604 authorized in an approved federal waiver.
605 (c) To implement the managed care pilot program that
606 maximizes all available state and federal funds, including those
607 obtained through intergovernmental transfers, the low-income
608 pool, supplemental Medicaid payments, and the disproportionate
609 share program. Within the parameters allowed by federal statute
610 and rule, the agency may seek options for making direct payments
611 to hospitals and physicians employed by or under contract with
612 the state’s medical schools for the costs associated with
613 graduate medical education under Medicaid reform.
614 (d) To implement actuarially sound, risk-adjusted
615 capitation rates for Medicaid recipients in the pilot program
616 which cover comprehensive care, enhanced services, and
617 catastrophic care.
618 (e) To implement policies and guidelines for phasing in
619 financial risk for approved provider service networks that, for
620 purposes of this paragraph, include the Children’s Medical
621 Services Network, over a 5-year period. These policies and
622 guidelines must include an option for a provider service network
623 to be paid fee-for-service rates. For any provider service
624 network established in a managed care pilot area, the option to
625 be paid fee-for-service rates must include a savings-settlement
626 mechanism that is consistent with s. 409.912(44). This model
627 must be converted to a risk-adjusted capitated rate by the
628 beginning of the sixth year of operation, and may be converted
629 earlier at the option of the provider service network. Federally
630 qualified health centers may be offered an opportunity to accept
631 or decline a contract to participate in any provider network for
632 prepaid primary care services.
633 (f) To implement stop-loss requirements and the transfer of
634 excess cost to catastrophic coverage that accommodates the risks
635 associated with the development of the pilot program.
636 (g) To recommend a process to be used by the Social
637 Services Estimating Conference to determine and validate the
638 rate of growth of the per-member costs of providing Medicaid
639 services under the managed care pilot program.
640 (h) To implement program standards and credentialing
641 requirements for capitated managed care networks to participate
642 in the pilot program, including those related to fiscal
643 solvency, quality of care, and adequacy of access to health care
644 providers. It is the intent of the Legislature that, to the
645 extent possible, any pilot program authorized by the state under
646 this section include any federally qualified health center,
647 federally qualified rural health clinic, county health
648 department, the Children’s Medical Services Network within the
649 Department of Health, or other federally, state, or locally
650 funded entity that serves the geographic areas within the
651 boundaries of the pilot program that requests to participate.
652 This paragraph does not relieve an entity that qualifies as a
653 capitated managed care network under this section from any other
654 licensure or regulatory requirements contained in state or
655 federal law which would otherwise apply to the entity. The
656 standards and credentialing requirements shall be based upon,
657 but are not limited to:
658 1. Compliance with the accreditation requirements as
659 provided in s. 641.512.
660 2. Compliance with early and periodic screening, diagnosis,
661 and treatment screening requirements under federal law.
662 3. The percentage of voluntary disenrollments.
663 4. Immunization rates.
664 5. Standards of the National Committee for Quality
665 Assurance and other approved accrediting bodies.
666 6. Recommendations of other authoritative bodies.
667 7. Specific requirements of the Medicaid program, or
668 standards designed to specifically meet the unique needs of
669 Medicaid recipients.
670 8. Compliance with the health quality improvement system as
671 established by the agency, which incorporates standards and
672 guidelines developed by the Centers for Medicare and Medicaid
673 Services as part of the quality assurance reform initiative.
674 9. The network’s infrastructure capacity to manage
675 financial transactions, recordkeeping, data collection, and
676 other administrative functions.
677 10. The network’s ability to submit any financial,
678 programmatic, or patient-encounter data or other information
679 required by the agency to determine the actual services provided
680 and the cost of administering the plan.
681 (i) To implement a mechanism for providing information to
682 Medicaid recipients for the purpose of selecting a capitated
683 managed care plan. For each plan available to a recipient, the
684 agency, at a minimum, shall ensure that the recipient is
685 provided with:
686 1. A list and description of the benefits provided.
687 2. Information about cost sharing.
688 3. A list of providers participating in the plan networks.
689 4.3. Plan performance data, if available.
690 4. An explanation of benefit limitations.
691 5. Contact information, including identification of
692 providers participating in the network, geographic locations,
693 and transportation limitations.
694 6. Any other information the agency determines would
695 facilitate a recipient’s understanding of the plan or insurance
696 that would best meet his or her needs.
697 (j) To implement a system to ensure that there is a record
698 of recipient acknowledgment that plan choice counseling has been
699 provided.
700 (k) To implement a choice counseling system to ensure that
701 the choice counseling process and related material are designed
702 to provide counseling through face-to-face interaction, by
703 telephone or, and in writing and through other forms of relevant
704 media. Materials shall be written at the fourth-grade reading
705 level and available in a language other than English when 5
706 percent of the county speaks a language other than English.
707 Choice counseling shall also use language lines and other
708 services for impaired recipients, such as TTD/TTY.
709 (l) To implement a system that prohibits capitated managed
710 care plans, their representatives, and providers employed by or
711 contracted with the capitated managed care plans from recruiting
712 persons eligible for or enrolled in Medicaid, from providing
713 inducements to Medicaid recipients to select a particular
714 capitated managed care plan, and from prejudicing Medicaid
715 recipients against other capitated managed care plans. The
716 system shall require the entity performing choice counseling to
717 determine if the recipient has made a choice of a plan or has
718 opted out because of duress, threats, payment to the recipient,
719 or incentives promised to the recipient by a third party. If the
720 choice counseling entity determines that the decision to choose
721 a plan was unlawfully influenced or a plan violated any of the
722 provisions of s. 409.912(21), the choice counseling entity shall
723 immediately report the violation to the agency’s program
724 integrity section for investigation. Verification of choice
725 counseling by the recipient shall include a stipulation that the
726 recipient acknowledges the provisions of this subsection.
727 (m) To implement a choice counseling system that promotes
728 health literacy, uses technology effectively, and provides
729 information intended aimed to reduce minority health disparities
730 through outreach activities for Medicaid recipients.
731 (n) To contract with entities to perform choice counseling.
732 The agency may establish standards and performance contracts,
733 including standards requiring the contractor to hire choice
734 counselors who are representative of the state’s diverse
735 population and to train choice counselors in working with
736 culturally diverse populations.
737 (o) To implement eligibility assignment processes to
738 facilitate client choice while ensuring pilot programs of
739 adequate enrollment levels. These processes shall ensure that
740 pilot sites have sufficient levels of enrollment to conduct a
741 valid test of the managed care pilot program within a 2-year
742 timeframe.
743 (p) To implement standards for plan compliance, including,
744 but not limited to, standards for quality assurance and
745 performance improvement, standards for peer or professional
746 reviews, grievance policies, and policies for maintaining
747 program integrity. The agency shall develop a data-reporting
748 system, seek input from managed care plans in order to establish
749 requirements for patient-encounter reporting, and ensure that
750 the data reported is accurate and complete.
751 1. In performing the duties required under this section,
752 the agency shall work with managed care plans to establish a
753 uniform system to measure and monitor outcomes for a recipient
754 of Medicaid services.
755 2. The system shall use financial, clinical, and other
756 criteria based on pharmacy, medical services, and other data
757 that is related to the provision of Medicaid services,
758 including, but not limited to:
759 a. The Health Plan Employer Data and Information Set
760 (HEDIS) or measures that are similar to HEDIS.
761 b. Member satisfaction.
762 c. Provider satisfaction.
763 d. Report cards on plan performance and best practices.
764 e. Compliance with the requirements for prompt payment of
765 claims under ss. 627.613, 641.3155, and 641.513.
766 f. Utilization and quality data for the purpose of ensuring
767 access to medically necessary services, including
768 underutilization or inappropriate denial of services.
769 3. The agency shall require the managed care plans that
770 have contracted with the agency to establish a quality assurance
771 system that incorporates the provisions of s. 409.912(27) and
772 any standards, rules, and guidelines developed by the agency.
773 4. The agency shall establish an encounter database in
774 order to compile data on health services rendered by health care
775 practitioners who provide services to patients enrolled in
776 managed care plans in the demonstration sites. The encounter
777 database shall:
778 a. Collect the following for each type of patient encounter
779 with a health care practitioner or facility, including:
780 (I) The demographic characteristics of the patient.
781 (II) The principal, secondary, and tertiary diagnosis.
782 (III) The procedure performed.
783 (IV) The date and location where the procedure was
784 performed.
785 (V) The payment for the procedure, if any.
786 (VI) If applicable, the health care practitioner’s
787 universal identification number.
788 (VII) If the health care practitioner rendering the service
789 is a dependent practitioner, the modifiers appropriate to
790 indicate that the service was delivered by the dependent
791 practitioner.
792 b. Collect appropriate information relating to prescription
793 drugs for each type of patient encounter.
794 c. Collect appropriate information related to health care
795 costs and utilization from managed care plans participating in
796 the demonstration sites.
797 5. To the extent practicable, when collecting the data the
798 agency shall use a standardized claim form or electronic
799 transfer system that is used by health care practitioners,
800 facilities, and payors.
801 6. Health care practitioners and facilities in the
802 demonstration sites shall electronically submit, and managed
803 care plans participating in the demonstration sites shall
804 electronically receive, information concerning claims payments
805 and any other information reasonably related to the encounter
806 database using a standard format as required by the agency.
807 7. The agency shall establish reasonable deadlines for
808 phasing in the electronic transmittal of full encounter data.
809 8. The system must ensure that the data reported is
810 accurate and complete.
811 (q) To implement a grievance resolution process for
812 Medicaid recipients enrolled in a capitated managed care network
813 under the pilot program modeled after the subscriber assistance
814 panel, as created in s. 408.7056. This process shall include a
815 mechanism for an expedited review of no greater than 24 hours
816 after notification of a grievance if the life of a Medicaid
817 recipient is in imminent and emergent jeopardy.
818 (r) To implement a grievance resolution process for health
819 care providers employed by or contracted with a capitated
820 managed care network under the pilot program in order to settle
821 disputes among the provider and the managed care network or the
822 provider and the agency.
823 (s) To implement criteria in an approved federal waiver to
824 designate health care providers as eligible to participate in
825 the pilot program. These criteria must include at a minimum
826 those criteria specified in s. 409.907.
827 (t) To use health care provider agreements for
828 participation in the pilot program.
829 (u) To require that all health care providers under
830 contract with the pilot program be duly licensed in the state,
831 if such licensure is available, and meet other criteria as may
832 be established by the agency. These criteria shall include at a
833 minimum those criteria specified in s. 409.907.
834 (v) To ensure that managed care organizations work
835 collaboratively with other state or local governmental programs
836 or institutions for the coordination of health care to eligible
837 individuals receiving services from such programs or
838 institutions.
839 (w) To implement procedures to minimize the risk of
840 Medicaid fraud and abuse in all plans operating in the Medicaid
841 managed care pilot program authorized in this section.
842 1. The agency shall ensure that applicable provisions of
843 this chapter and chapters 414, 626, 641, and 932 which relate to
844 Medicaid fraud and abuse are applied and enforced at the
845 demonstration project sites.
846 2. Providers must have the certification, license, and
847 credentials that are required by law and waiver requirements.
848 3. The agency shall ensure that the plan is in compliance
849 with s. 409.912(21) and (22).
850 4. The agency shall require that each plan establish
851 functions and activities governing program integrity in order to
852 reduce the incidence of fraud and abuse. Plans must report
853 instances of fraud and abuse pursuant to chapter 641.
854 5. The plan shall have written administrative and
855 management arrangements or procedures, including a mandatory
856 compliance plan, which are designed to guard against fraud and
857 abuse. The plan shall designate a compliance officer who has
858 sufficient experience in health care.
859 6.a. The agency shall require all managed care plan
860 contractors in the pilot program to report all instances of
861 suspected fraud and abuse. A failure to report instances of
862 suspected fraud and abuse is a violation of law and subject to
863 the penalties provided by law.
864 b. An instance of fraud and abuse in the managed care plan,
865 including, but not limited to, defrauding the state health care
866 benefit program by misrepresentation of fact in reports, claims,
867 certifications, enrollment claims, demographic statistics, or
868 patient-encounter data; misrepresentation of the qualifications
869 of persons rendering health care and ancillary services; bribery
870 and false statements relating to the delivery of health care;
871 unfair and deceptive marketing practices; and false claims
872 actions in the provision of managed care, is a violation of law
873 and subject to the penalties provided by law.
874 c. The agency shall require that all contractors make all
875 files and relevant billing and claims data accessible to state
876 regulators and investigators and that all such data is linked
877 into a unified system to ensure consistent reviews and
878 investigations.
879 (x) To develop and provide actuarial and benefit design
880 analyses that indicate the effect on capitation rates and
881 benefits offered in the pilot program over a prospective 5-year
882 period based on the following assumptions:
883 1. Growth in capitation rates which is limited to the
884 estimated growth rate in general revenue.
885 2. Growth in capitation rates which is limited to the
886 average growth rate over the last 3 years in per-recipient
887 Medicaid expenditures.
888 3. Growth in capitation rates which is limited to the
889 growth rate of aggregate Medicaid expenditures between the 2003
890 2004 fiscal year and the 2004-2005 fiscal year.
891 (y) To develop a mechanism to require capitated managed
892 care plans to reimburse qualified emergency service providers,
893 including, but not limited to, ambulance services, in accordance
894 with ss. 409.908 and 409.9128. The pilot program must include a
895 provision for continuing fee-for-service payments for emergency
896 services, including, but not limited to, individuals who access
897 ambulance services or emergency departments and who are
898 subsequently determined to be eligible for Medicaid services.
899 (z) To ensure that school districts participating in the
900 certified school match program pursuant to ss. 409.908(21) and
901 1011.70 shall be reimbursed by Medicaid, subject to the
902 limitations of s. 1011.70(1), for a Medicaid-eligible child
903 participating in the services as authorized in s. 1011.70, as
904 provided for in s. 409.9071, regardless of whether the child is
905 enrolled in a capitated managed care network. Capitated managed
906 care networks must make a good faith effort to execute
907 agreements with school districts regarding the coordinated
908 provision of services authorized under s. 1011.70. County health
909 departments and federally qualified health centers delivering
910 school-based services pursuant to ss. 381.0056 and 381.0057 must
911 be reimbursed by Medicaid for the federal share for a Medicaid
912 eligible child who receives Medicaid-covered services in a
913 school setting, regardless of whether the child is enrolled in a
914 capitated managed care network. Capitated managed care networks
915 must make a good faith effort to execute agreements with county
916 health departments and federally qualified health centers
917 regarding the coordinated provision of services to a Medicaid
918 eligible child. To ensure continuity of care for Medicaid
919 patients, the agency, the Department of Health, and the
920 Department of Education shall develop procedures for ensuring
921 that a student’s capitated managed care network provider
922 receives information relating to services provided in accordance
923 with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
924 (aa) To implement a mechanism whereby Medicaid recipients
925 who are already enrolled in a managed care plan or the MediPass
926 program in the pilot areas shall be offered the opportunity to
927 change to capitated managed care plans on a staggered basis, as
928 defined by the agency. All Medicaid recipients shall have 30
929 days in which to make a choice of capitated managed care plans.
930 Those Medicaid recipients who do not make a choice shall be
931 assigned to a capitated managed care plan in accordance with
932 paragraph (4)(a) and shall be exempt from s. 409.9122. To
933 facilitate continuity of care for a Medicaid recipient who is
934 also a recipient of Supplemental Security Income (SSI), prior to
935 assigning the SSI recipient to a capitated managed care plan,
936 the agency shall determine whether the SSI recipient has an
937 ongoing relationship with a provider or capitated managed care
938 plan, and, if so, the agency shall assign the SSI recipient to
939 that provider or capitated managed care plan where feasible.
940 Those SSI recipients who do not have such a provider
941 relationship shall be assigned to a capitated managed care plan
942 provider in accordance with paragraph (4)(a) and shall be exempt
943 from s. 409.9122.
944 (bb) To develop and recommend a service delivery
945 alternative for children having chronic medical conditions which
946 establishes a medical home project to provide primary care
947 services to this population. The project shall provide
948 community-based primary care services that are integrated with
949 other subspecialties to meet the medical, developmental, and
950 emotional needs for children and their families. This project
951 shall include an evaluation component to determine impacts on
952 hospitalizations, length of stays, emergency room visits, costs,
953 and access to care, including specialty care and patient and
954 family satisfaction.
955 (cc) To develop and recommend service delivery mechanisms
956 within capitated managed care plans to provide Medicaid services
957 as specified in ss. 409.905 and 409.906 to persons with
958 developmental disabilities sufficient to meet the medical,
959 developmental, and emotional needs of these persons.
960 (dd) To implement service delivery mechanisms within a
961 specialty plan in area 10 capitated managed care plans to
962 provide behavioral health care services Medicaid services as
963 specified in ss. 409.905 and 409.906 to Medicaid-eligible
964 children whose cases are open for child welfare services in the
965 HomeSafeNet system. These services must be coordinated with
966 community-based care providers as specified in s. 409.1671,
967 where available, and be sufficient to meet the medical,
968 developmental, behavioral, and emotional needs of these
969 children. Children in area 10 who have an open case in the
970 HomeSafeNet system shall be enrolled into the specialty plan.
971 These service delivery mechanisms must be implemented no later
972 than July 1, 2011 2008, in AHCA area 10 in order for the
973 children in AHCA area 10 to remain exempt from the statewide
974 plan under s. 409.912(4)(b)8. An administrative fee may be paid
975 to the specialty plan for the coordination of services based on
976 the receipt of the state share of that fee being provided
977 through intergovernmental transfers.
978 (4)(a) A Medicaid recipient in the pilot area who is not
979 currently enrolled in a capitated managed care plan upon
980 implementation is not eligible for services as specified in ss.
981 409.905 and 409.906, for the amount of time that the recipient
982 does not enroll in a capitated managed care network. If a
983 Medicaid recipient has not enrolled in a capitated managed care
984 plan within 30 days after eligibility, the agency shall assign
985 the Medicaid recipient to a capitated managed care plan based on
986 the assessed needs of the recipient as determined by the agency
987 and the recipient shall be exempt from s. 409.9122. When making
988 assignments, the agency shall take into account the following
989 criteria:
990 1. A capitated managed care network has sufficient network
991 capacity to meet the needs of members.
992 2. The capitated managed care network has previously
993 enrolled the recipient as a member, or one of the capitated
994 managed care network’s primary care providers has previously
995 provided health care to the recipient.
996 3. The agency has knowledge that the member has previously
997 expressed a preference for a particular capitated managed care
998 network as indicated by Medicaid fee-for-service claims data,
999 but has failed to make a choice.
1000 4. The capitated managed care network’s primary care
1001 providers are geographically accessible to the recipient’s
1002 residence.
1003 5. Plan performance as designed by the agency.
1004 (b) When more than one capitated managed care network
1005 provider meets the criteria specified in paragraph (3)(h), the
1006 agency shall make recipient assignments consecutively by family
1007 unit.
1008 (c) If a recipient is currently enrolled with a Medicaid
1009 managed care organization that also operates an approved reform
1010 plan within a demonstration area and the recipient fails to
1011 choose a plan during the reform enrollment process or during
1012 redetermination of eligibility, the recipient shall be
1013 automatically assigned by the agency into the most appropriate
1014 reform plan operated by the recipient’s current Medicaid managed
1015 care plan. If the recipient’s current managed care plan does not
1016 operate a reform plan in the demonstration area which adequately
1017 meets the needs of the Medicaid recipient, the agency shall use
1018 the automatic assignment process as prescribed in the special
1019 terms and conditions numbered 11-W-00206/4. All enrollment and
1020 choice counseling materials provided by the agency must contain
1021 an explanation of the provisions of this paragraph for current
1022 managed care recipients.
1023 (d) Except for plan performance as provided for in
1024 paragraph (a), the agency may not engage in practices that are
1025 designed to favor one capitated managed care plan over another
1026 or that are designed to influence Medicaid recipients to enroll
1027 in a particular capitated managed care network in order to
1028 strengthen its particular fiscal viability.
1029 (e) After a recipient has made a selection or has been
1030 enrolled in a capitated managed care network, the recipient
1031 shall have 90 days in which to voluntarily disenroll and select
1032 another capitated managed care network. After 90 days, no
1033 further changes may be made except for cause. Cause shall
1034 include, but not be limited to, poor quality of care, lack of
1035 access to necessary specialty services, an unreasonable delay or
1036 denial of service, inordinate or inappropriate changes of
1037 primary care providers, service access impairments due to
1038 significant changes in the geographic location of services, or
1039 fraudulent enrollment. The agency may require a recipient to use
1040 the capitated managed care network’s grievance process as
1041 specified in paragraph (3)(q) prior to the agency’s
1042 determination of cause, except in cases in which immediate risk
1043 of permanent damage to the recipient’s health is alleged. The
1044 grievance process, when used, must be completed in time to
1045 permit the recipient to disenroll no later than the first day of
1046 the second month after the month the disenrollment request was
1047 made. If the capitated managed care network, as a result of the
1048 grievance process, approves an enrollee’s request to disenroll,
1049 the agency is not required to make a determination in the case.
1050 The agency must make a determination and take final action on a
1051 recipient’s request so that disenrollment occurs no later than
1052 the first day of the second month after the month the request
1053 was made. If the agency fails to act within the specified
1054 timeframe, the recipient’s request to disenroll is deemed to be
1055 approved as of the date agency action was required. Recipients
1056 who disagree with the agency’s finding that cause does not exist
1057 for disenrollment shall be advised of their right to pursue a
1058 Medicaid fair hearing to dispute the agency’s finding.
1059 (f) The agency shall apply for federal waivers from the
1060 Centers for Medicare and Medicaid Services to lock eligible
1061 Medicaid recipients into a capitated managed care network for 12
1062 months after an open enrollment period. After 12 months of
1063 enrollment, a recipient may select another capitated managed
1064 care network. However, nothing shall prevent a Medicaid
1065 recipient from changing primary care providers within the
1066 capitated managed care network during the 12-month period.
1067 (g) The agency shall apply for federal waivers from the
1068 Centers for Medicare and Medicaid Services to allow recipients
1069 to purchase health care coverage through an employer-sponsored
1070 health insurance plan instead of through a Medicaid-certified
1071 plan. This provision shall be known as the opt-out option.
1072 1. A recipient who chooses the Medicaid opt-out option
1073 shall have an opportunity for a specified period of time, as
1074 authorized under a waiver granted by the Centers for Medicare
1075 and Medicaid Services, to select and enroll in a Medicaid
1076 certified plan. If the recipient remains in the employer
1077 sponsored plan after the specified period, the recipient shall
1078 remain in the opt-out program for at least 1 year or until the
1079 recipient no longer has access to employer-sponsored coverage,
1080 until the employer’s open enrollment period for a person who
1081 opts out in order to participate in employer-sponsored coverage,
1082 or until the person is no longer eligible for Medicaid,
1083 whichever time period is shorter.
1084 2. Notwithstanding any other provision of this section,
1085 coverage, cost sharing, and any other component of employer
1086 sponsored health insurance shall be governed by applicable state
1087 and federal laws.
1088 (5) This section authorizes does not authorize the agency
1089 to seek an extension amendment and to continue operation
1090 implement any provision of the s. 1115 of the Social Security
1091 Act experimental, pilot, or demonstration project waiver to
1092 reform the state Medicaid program in any part of the state other
1093 than the two geographic areas specified in this section unless
1094 approved by the Legislature.
1095 (6) The agency shall develop and submit for approval
1096 applications for waivers of applicable federal laws and
1097 regulations as necessary to extend and expand implement the
1098 managed care pilot project as defined in this section. The
1099 agency shall seek public input on the waiver and post all waiver
1100 applications under this section on its Internet website for 30
1101 days before submitting the applications to the United States
1102 Centers for Medicare and Medicaid Services. The 30 days shall
1103 commence with the initial posting and must conclude 30 days
1104 prior to approval by the United States Centers for Medicare and
1105 Medicaid Services. All waiver applications shall be provided for
1106 review and comment to the appropriate committees of the Senate
1107 and House of Representatives for at least 10 working days prior
1108 to submission. All waivers submitted to and approved by the
1109 United States Centers for Medicare and Medicaid Services under
1110 this section must be approved by the Legislature. Federally
1111 approved waivers must be submitted to the President of the
1112 Senate and the Speaker of the House of Representatives for
1113 referral to the appropriate legislative committees. The
1114 appropriate committees shall recommend whether to approve the
1115 implementation of any waivers to the Legislature as a whole. The
1116 agency shall submit a plan containing a recommended timeline for
1117 implementation of any waivers and budgetary projections of the
1118 effect of the pilot program under this section on the total
1119 Medicaid budget for the 2006-2007 through 2009-2010 state fiscal
1120 years. This implementation plan shall be submitted to the
1121 President of the Senate and the Speaker of the House of
1122 Representatives at the same time any waivers are submitted for
1123 consideration by the Legislature. The agency may implement the
1124 waiver and special terms and conditions numbered 11-W-00206/4,
1125 as approved by the federal Centers for Medicare and Medicaid
1126 Services. If the agency seeks approval by the Federal Government
1127 of any modifications to these special terms and conditions, the
1128 agency must provide written notification of its intent to modify
1129 these terms and conditions to the President of the Senate and
1130 the Speaker of the House of Representatives at least 15 days
1131 before submitting the modifications to the Federal Government
1132 for consideration. The notification must identify all
1133 modifications being pursued and the reason the modifications are
1134 needed. Upon receiving federal approval of any modifications to
1135 the special terms and conditions, the agency shall provide a
1136 report to the Legislature describing the federally approved
1137 modifications to the special terms and conditions within 7 days
1138 after approval by the Federal Government.
1139 Section 3. Paragraph (m) is added to subsection (2) of
1140 section 409.9122, Florida Statutes, to read:
1141 409.9122 Mandatory Medicaid managed care enrollment;
1142 programs and procedures.—
1143 (2)
1144 (m)1. Time allotted pursuant to this subsection to any
1145 Medicaid recipient for the selection of, enrollment in, or
1146 disenrollment from a managed care plan or MediPass is tolled
1147 throughout any month in which the enrollment broker or choice
1148 counseling provider, whichever is applicable, has adversely
1149 affected a beneficiary’s ability to access choice counseling or
1150 enrollment broker services by its failure to comply with the
1151 terms and conditions of its contract or has otherwise acted or
1152 failed to act in a manner that the agency deems likely to
1153 jeopardize its ability to perform its assigned responsibilities
1154 as set forth in paragraphs (c) and (d). During any month in
1155 which time is tolled for a recipient, he or she must be afforded
1156 uninterrupted access to benefits and services in the same
1157 delivery system available prior to such tolling.
1158 2. The agency shall incorporate into all pertinent
1159 contracts that are executed or renewed on or after July 1, 2010,
1160 provisions authorizing and requiring the agency to impose
1161 sanctions or fines against an enrollment broker or choice
1162 counselor if a recipient is adversely affected due to any action
1163 or failure to act on the part of the enrollment broker or choice
1164 counselor.
1165 Section 4. Section 624.35, Florida Statutes, is created to
1166 read:
1167 624.35 Short title.—Sections 624.35-624.352 may be cited as
1168 the “Medicaid and Public Assistance Fraud Strike Force Act.”
1169 Section 5. Section 624.351, Florida Statutes, is created to
1170 read:
1171 624.351 Medicaid and Public Assistance Fraud Strike Force.—
1172 (1) LEGISLATIVE FINDINGS.—The Legislature finds that there
1173 is a need to develop and implement a statewide strategy to
1174 coordinate state and local agencies, law enforcement entities,
1175 and investigative units in order to increase the effectiveness
1176 of programs and initiatives dealing with the prevention,
1177 detection, and prosecution of Medicaid and public assistance
1178 fraud.
1179 (2) ESTABLISHMENT.—The Medicaid and Public Assistance Fraud
1180 Strike Force is created within the department to oversee and
1181 coordinate state and local efforts to eliminate Medicaid and
1182 public assistance fraud and to recover state and federal funds.
1183 The strike force shall serve in an advisory capacity and provide
1184 recommendations and policy alternatives to the Chief Financial
1185 Officer.
1186 (3) MEMBERSHIP.—The strike force shall consist of the
1187 following 11 members who may not designate anyone to serve in
1188 their place:
1189 (a) The Chief Financial Officer, who shall serve as chair.
1190 (b) The Attorney General, who shall serve as vice chair.
1191 (c) The executive director of the Department of Law
1192 Enforcement.
1193 (d) The Secretary of Health Care Administration.
1194 (e) The Secretary of Children and Family Services.
1195 (f) The State Surgeon General.
1196 (g) Five members appointed by the Chief Financial Officer,
1197 consisting of two sheriffs, two chiefs of police, and one state
1198 attorney. When making these appointments, the Chief Financial
1199 Officer shall consider representation by geography, population,
1200 ethnicity, and other relevant factors in order to ensure that
1201 the membership of the strike force is representative of the
1202 state as a whole.
1203 (4) TERMS OF MEMBERSHIP; COMPENSATION; STAFF.—
1204 (a) The five members appointed by the Chief Financial
1205 Officer will serve 4-year terms; however, for the purpose of
1206 providing staggered terms, of the initial appointments, two
1207 members will be appointed to a 2-year term, two members will be
1208 appointed to a 3-year term, and one member will be appointed to
1209 a 4-year term. The remaining members are standing members of the
1210 strike force and may not serve beyond the time he or she holds
1211 the position that was the basis for strike force membership. A
1212 vacancy shall be filled in the same manner as the original
1213 appointment but only for the unexpired term.
1214 (b) The Legislature finds that the strike force serves a
1215 legitimate state, county, and municipal purpose and that service
1216 on the strike force is consistent with a member’s principal
1217 service in a public office or employment. Therefore membership
1218 on the strike force does not disqualify a member from holding
1219 any other public office or from being employed by a public
1220 entity, except that a member of the Legislature may not serve on
1221 the strike force.
1222 (c) Members of the strike force shall serve without
1223 compensation, but are entitled to reimbursement for per diem and
1224 travel expenses pursuant to s. 112.061. Reimbursements may be
1225 paid from appropriations provided to the department by the
1226 Legislature for the purposes of this section.
1227 (d) The Chief Financial Officer shall appoint a chief of
1228 staff for the strike force who must have experience, education,
1229 and expertise in the fields of law, prosecution, or fraud
1230 investigations and shall serve at the pleasure of the Chief
1231 Financial Officer. The department shall provide the strike force
1232 with staff necessary to assist the strike force in the
1233 performance of its duties.
1234 (5) MEETINGS.—The strike force shall hold its
1235 organizational session by March 1, 2011. Thereafter, the strike
1236 force shall meet at least four times per year. Additional
1237 meetings may be held if the chair determines that extraordinary
1238 circumstances require an additional meeting. Members may appear
1239 by electronic means. A majority of the members of the strike
1240 force constitutes a quorum.
1241 (6) STRIKE FORCE DUTIES.—The strike force shall provide
1242 advice and make recommendations, as necessary, to the Chief
1243 Financial Officer.
1244 (a) The strike force may advise the Chief Financial Officer
1245 on initiatives that include, but are not limited to:
1246 1. Conducting a census of local, state, and federal efforts
1247 to address Medicaid and public assistance fraud in this state,
1248 including fraud detection, prevention, and prosecution, in order
1249 to discern overlapping missions, maximize existing resources,
1250 and strengthen current programs.
1251 2. Developing a strategic plan for coordinating and
1252 targeting state and local resources for preventing and
1253 prosecuting Medicaid and public assistance fraud. The plan must
1254 identify methods to enhance multiagency efforts that contribute
1255 to achieving the state’s goal of eliminating Medicaid and public
1256 assistance fraud.
1257 3. Identifying methods to implement innovative technology
1258 and data sharing in order to detect and analyze Medicaid and
1259 public assistance fraud with speed and efficiency.
1260 4. Establishing a program to provide grants to state and
1261 local agencies that develop and implement effective Medicaid and
1262 public assistance fraud prevention, detection, and investigation
1263 programs, which are evaluated by the strike force and ranked by
1264 their potential to contribute to achieving the state’s goal of
1265 eliminating Medicaid and public assistance fraud. The grant
1266 program may also provide startup funding for new initiatives by
1267 local and state law enforcement or administrative agencies to
1268 combat Medicaid and public assistance fraud.
1269 5. Developing and promoting crime prevention services and
1270 educational programs that serve the public, including, but not
1271 limited to, a well-publicized rewards program for the
1272 apprehension and conviction of criminals who perpetrate Medicaid
1273 and public assistance fraud.
1274 6. Providing grants, contingent upon appropriation, for
1275 multiagency or state and local Medicaid and public assistance
1276 fraud efforts, which include, but are not limited to:
1277 a. Providing for a Medicaid and public assistance fraud
1278 prosecutor in the Office of the Statewide Prosecutor.
1279 b. Providing assistance to state attorneys for support
1280 services or equipment, or for the hiring of assistant state
1281 attorneys, as needed, to prosecute Medicaid and public
1282 assistance fraud cases.
1283 c. Providing assistance to judges for support services or
1284 for the hiring of senior judges, as needed, so that Medicaid and
1285 public assistance fraud cases can be heard expeditiously.
1286 (b) The strike force shall receive periodic reports from
1287 state agencies, law enforcement officers, investigators,
1288 prosecutors, and coordinating teams regarding Medicaid and
1289 public assistance criminal and civil investigations. Such
1290 reports may include discussions regarding significant factors
1291 and trends relevant to a statewide Medicaid and public
1292 assistance fraud strategy.
1293 (7) REPORTS.—The strike force shall annually prepare and
1294 submit a report on its activities and recommendations, by
1295 October 1, to the President of the Senate, the Speaker of the
1296 House of Representatives, the Governor, and the chairs of the
1297 House of Representatives and Senate committees that have
1298 substantive jurisdiction over Medicaid and public assistance
1299 fraud.
1300 Section 6. Section 624.352, Florida Statutes, is created to
1301 read:
1302 624.352 Interagency agreements to detect and deter Medicaid
1303 and public assistance fraud.—
1304 (1) The Chief Financial Officer shall prepare model
1305 interagency agreements for the coordination of prevention,
1306 investigation, and prosecution of Medicaid and public assistance
1307 fraud to be known as “Strike Force” agreements. Parties to such
1308 agreements may include any agency that is headed by a Cabinet
1309 officer, the Governor, the Governor and Cabinet, a collegial
1310 body, or any federal, state, or local law enforcement agency.
1311 (2) The agreements must include, but are not limited to:
1312 (a) Establishing the agreement’s purpose, mission,
1313 authority, organizational structure, procedures, supervision,
1314 operations, deputations, funding, expenditures, property and
1315 equipment, reports and records, assets and forfeitures, media
1316 policy, liability, and duration.
1317 (b) Requiring that parties to an agreement have appropriate
1318 powers and authority relative to the purpose and mission of the
1319 agreement.
1320 Section 7. Section 16.59, Florida Statutes, is amended to
1321 read:
1322 16.59 Medicaid fraud control.—The Medicaid Fraud Control
1323 Unit There is created in the Department of Legal Affairs to the
1324 Medicaid Fraud Control Unit, which may investigate all
1325 violations of s. 409.920 and any criminal violations discovered
1326 during the course of those investigations. The Medicaid Fraud
1327 Control Unit may refer any criminal violation so uncovered to
1328 the appropriate prosecuting authority. The offices of the
1329 Medicaid Fraud Control Unit, and the offices of the Agency for
1330 Health Care Administration Medicaid program integrity program,
1331 and the Divisions of Insurance Fraud and Public Assistance Fraud
1332 within the Department of Financial Services shall, to the extent
1333 possible, be collocated; however, positions dedicated to
1334 Medicaid managed care fraud within the Medicaid Fraud Control
1335 Unit shall be collocated with the Division of Insurance Fraud.
1336 The Agency for Health Care Administration, and the Department of
1337 Legal Affairs, and the Divisions of Insurance Fraud and Public
1338 Assistance Fraud within the Department of Financial Services
1339 shall conduct joint training and other joint activities designed
1340 to increase communication and coordination in recovering
1341 overpayments.
1342 Section 8. Paragraph (o) is added to subsection (2) of
1343 section 20.121, Florida Statutes, to read:
1344 20.121 Department of Financial Services.—There is created a
1345 Department of Financial Services.
1346 (2) DIVISIONS.—The Department of Financial Services shall
1347 consist of the following divisions:
1348 (o) The Division of Public Assistance Fraud.
1349 Section 9. Paragraph (b) of subsection (7) of section
1350 411.01, Florida Statutes, is amended to read:
1351 411.01 School readiness programs; early learning
1352 coalitions.—
1353 (7) PARENTAL CHOICE.—
1354 (b) If it is determined that a provider has provided any
1355 cash to the beneficiary in return for receiving the purchase
1356 order, the early learning coalition or its fiscal agent shall
1357 refer the matter to the Department of Financial Services
1358 pursuant to s. 414.411 Division of Public Assistance Fraud for
1359 investigation.
1360 Section 10. Subsection (2) of section 414.33, Florida
1361 Statutes, is amended to read:
1362 414.33 Violations of food stamp program.—
1363 (2) In addition, the department shall establish procedures
1364 for referring to the Department of Law Enforcement any case that
1365 involves a suspected violation of federal or state law or rules
1366 governing the administration of the food stamp program to the
1367 Department of Financial Services pursuant to s. 414.411.
1368 Section 11. Subsection (9) of section 414.39, Florida
1369 Statutes, is amended to read:
1370 414.39 Fraud.—
1371 (9) All records relating to investigations of public
1372 assistance fraud in the custody of the department and the Agency
1373 for Health Care Administration are available for examination by
1374 the Department of Financial Services Law Enforcement pursuant to
1375 s. 414.411 943.401 and are admissible into evidence in
1376 proceedings brought under this section as business records
1377 within the meaning of s. 90.803(6).
1378 Section 12. Section 943.401, Florida Statutes, is
1379 transferred, renumbered as section 414.411, Florida Statutes,
1380 and amended to read:
1381 414.411 943.401 Public assistance fraud.—
1382 (1)(a) The Department of Financial Services Law Enforcement
1383 shall investigate all public assistance provided to residents of
1384 the state or provided to others by the state. In the course of
1385 such investigation the department of Law Enforcement shall
1386 examine all records, including electronic benefits transfer
1387 records and make inquiry of all persons who may have knowledge
1388 as to any irregularity incidental to the disbursement of public
1389 moneys, food stamps, or other items or benefits authorizations
1390 to recipients.
1391 (b) All public assistance recipients, as a condition
1392 precedent to qualification for public assistance received and as
1393 defined under the provisions of chapter 409, chapter 411, or
1394 this chapter 414, must shall first give in writing, to the
1395 Agency for Health Care Administration, the Department of Health,
1396 the Agency for Workforce Innovation, and the Department of
1397 Children and Family Services, as appropriate, and to the
1398 Department of Financial Services Law Enforcement, consent to
1399 make inquiry of past or present employers and records, financial
1400 or otherwise.
1401 (2) In the conduct of such investigation the Department of
1402 Financial Services Law Enforcement may employ persons having
1403 such qualifications as are useful in the performance of this
1404 duty.
1405 (3) The results of such investigation shall be reported by
1406 the Department of Financial Services Law Enforcement to the
1407 appropriate legislative committees, the Agency for Health Care
1408 Administration, the Department of Health, the Agency for
1409 Workforce Innovation, and the Department of Children and Family
1410 Services, and to such others as the department of Law
1411 Enforcement may determine.
1412 (4) The Department of Health and the Department of Children
1413 and Family Services shall report to the Department of Financial
1414 Services Law Enforcement the final disposition of all cases
1415 wherein action has been taken pursuant to s. 414.39, based upon
1416 information furnished by the Department of Financial Services
1417 Law Enforcement.
1418 (5) All lawful fees and expenses of officers and witnesses,
1419 expenses incident to taking testimony and transcripts of
1420 testimony and proceedings are a proper charge to the Department
1421 of Financial Services Law Enforcement.
1422 (6) The provisions of this section shall be liberally
1423 construed in order to carry out effectively the purposes of this
1424 section in the interest of protecting public moneys and other
1425 public property.
1426 Section 13. Review of the Medicaid fraud and abuse
1427 processes.—
1428 (1) The Auditor General and the Office of Program Policy
1429 Analysis and Government Accountability shall review and evaluate
1430 the Agency for Health Care Administration’s Medicaid fraud and
1431 abuse systems, including the Medicaid program integrity program.
1432 The reviewers may access Medicaid-related information and data
1433 from the Attorney General’s Medicaid Fraud Control Unit, the
1434 Department of Health, the Department of Elderly Affairs, the
1435 Agency for Persons with Disabilities, and the Department of
1436 Children and Family Services, as necessary, to conduct the
1437 review. The review must include, but is not limited to:
1438 (a) An evaluation of current Medicaid policies and the
1439 Medicaid fiscal agent;
1440 (b) An analysis of the Medicaid fraud and abuse prevention
1441 and detection processes, including agency contracts, Medicaid
1442 databases, and internal control risk assessments;
1443 (c) A comprehensive evaluation of the effectiveness of the
1444 current laws, rules, and contractual requirements that govern
1445 Medicaid managed care entities;
1446 (d) An evaluation of the agency’s Medicaid managed care
1447 oversight processes;
1448 (e) Recommendations to improve the Medicaid claims
1449 adjudication process, to increase the overall efficiency of the
1450 Medicaid program, and to reduce Medicaid overpayments; and
1451 (f) Operational and legislative recommendations to improve
1452 the prevention and detection of fraud and abuse in the Medicaid
1453 managed care program.
1454 (2) The Auditor General’s Office and the Office of Program
1455 Policy Analysis and Government Accountability may contract with
1456 technical consultants to assist in the performance of the
1457 review. The Auditor General and the Office of Program Policy
1458 Analysis and Government Accountability shall report to the
1459 President of the Senate, the Speaker of the House of
1460 Representatives, and the Governor by December 1, 2011.
1461 Section 14. Medicaid claims adjudication project.—The
1462 Agency for Health Care Administration shall issue a competitive
1463 procurement pursuant to chapter 287, Florida Statutes, with a
1464 third-party vendor, at no cost to the state, to provide a real
1465 time, front-end database to augment the Medicaid fiscal agent
1466 program edits and claims adjudication process. The vendor shall
1467 provide an interface with the Medicaid fiscal agent to decrease
1468 inaccurate payment to Medicaid providers and improve the overall
1469 efficiency of the Medicaid claims-processing system.
1470 Section 15. All powers, duties, functions, records,
1471 offices, personnel, property, pending issues and existing
1472 contracts, administrative authority, administrative rules, and
1473 unexpended balances of appropriations, allocations, and other
1474 funds relating to public assistance fraud in the Department of
1475 Law Enforcement are transferred by a type two transfer, as
1476 defined in s. 20.06(2), Florida Statutes, to the Division of
1477 Public Assistance Fraud in the Department of Financial Services.
1478 Section 16. Except for sections 1, 2, 3, and 13 of this act
1479 and this section, which shall take effect July 1, 2010, sections
1480 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, and 15 shall take effect
1481 January 1, 2011.