HB 7223

1	A bill to be entitled
2	An act relating to Medicaid managed care; creating pt. IV
3	of ch. 409, F.S.; creating s. 409.961, F.S.; providing for
4	statutory construction; providing applicability of
5	specified provisions throughout the part; providing
6	rulemaking authority for specified agencies; creating s.
7	409.962, F.S.; providing definitions; creating s. 409.963,
8	F.S.; designating the Agency for Health Care
9	Administration as the single state agency to administer
10	the Medicaid program; providing for specified agency
11	responsibilities; requiring client consent for release of
12	medical records; creating s. 409.964, F.S.; establishing
13	the Medicaid program as the statewide, integrated managed
14	care program for all covered services; authorizing the
15	agency to apply for and implement waivers; providing for
16	public notice and comment; creating s. 409.965, F.S.;
17	providing for mandatory enrollment; providing for
18	exemptions; creating s. 409.966, F.S.; providing
19	requirements for qualified plans that provide services in
20	the Medicaid managed care program; providing for a medical
21	home network to be designated as a qualified plan;
22	establishing provider service network requirements for
23	qualified plans; providing for qualified plan selection;
24	requiring the agency to use an invitation to negotiate;
25	requiring the agency to compile and publish certain
26	information; establishing regions for separate procurement
27	of plans; providing quality selection criteria for plan
28	selection; establishing quality selection criteria;
29	providing limitations on serving recipients during the
30	pendency of litigation; providing that a qualified plan
31	that participates in an invitation to negotiate in more
32	than one region may not serve Medicaid recipients until
33	all administrative challenges are finalized; creating s.
34	409.967, F.S.; providing for managed care plan
35	accountability; establishing contract terms; providing for
36	contract extension under certain circumstances;
37	establishing payments to noncontract providers;
38	establishing requirements for access; requiring plans to
39	establish and maintain an electronic database;
40	establishing requirements for the database; requiring
41	plans to provide encounter data; requiring the agency to
42	establish performance standards for plans; providing
43	program integrity requirements; establishing a grievance
44	resolution process; providing for penalties for early
45	termination of contracts or reduction in enrollment
46	levels; creating s. 409.968, F.S.; establishing managed
47	care plan payments; providing payment requirements for
48	provider service networks; creating s. 409.969, F.S.;
49	requiring enrollment in managed care plans by specified
50	Medicaid recipients; creating requirements for plan
51	selection by recipients; providing for choice counseling;
52	establishing choice counseling requirements; authorizing
53	disenrollment under certain circumstances; defining the
54	term "good cause" for purposes of disenrollment; providing
55	time limits on an internal grievance process; providing
56	requirements for agency determination regarding
57	disenrollment; requiring recipients to stay in plans for a
58	specified time; creating s. 409.970, F.S.; requiring the
59	agency to maintain an encounter data system; providing
60	requirements for prepaid plans to submit data; creating s.
61	409.971, F.S.; creating the managed medical assistance
62	program; providing deadlines to begin and finalize
63	implementation of the program; creating s. 409.972, F.S.;
64	providing for mandatory and voluntary enrollment; creating
65	s. 409.973, F.S.; establishing minimum benefits for
66	managed care plans to cover; authorizing plans to
67	customize benefit packages; requiring plans to establish
68	enhanced benefits programs; providing terms for enhanced
69	benefits package; establishing reserve requirements for
70	plans to fund enhanced benefits programs; creating s.
71	409.974, F.S.; establishing a specified number of
72	qualified plans to be selected in each region;
73	establishing a deadline for issuing invitations to
74	negotiate; establishing quality selection criteria;
75	establishing the Children's Medical Service Network as a
76	qualified plan; creating s. 409.975; establishing managed
77	care plan accountability; creating a medical loss ratio
78	requirement; authorizing plans to limit providers in
79	networks; mandating certain providers be offered contracts
80	in the first year; requiring certain provider types to
81	participate in plans; requiring plans to monitor the
82	quality and performance history of providers; requiring
83	specified programs and procedures be established by plans;
84	establishing provider payments for hospitals; establishing
85	conflict resolution procedures; establishing plan
86	requirements for medically needy recipients; creating s.
87	409.976, F.S.; providing for managed care plan payment;
88	requiring the agency to establish a methodology to ensure
89	certain types of payments to specified providers;
90	establishing eligibility for payments; creating s.
91	409.977, F.S.; providing for enrollment; establishing
92	choice counseling requirements; providing for automatic
93	enrollment of certain recipients; establishing opt-out
94	opportunities for recipients; creating s. 409.978, F.S.;
95	requiring the Agency for Health Care Administration be
96	responsible for administering the long-term care managed
97	care program; providing implementation dates for the long-
98	term care managed care program; providing duties for the
99	Department of Elderly Affairs relating to assisting the
100	agency in implementing the program; creating s. 409.979,
101	F.S.; providing eligibility requirements for the long-term
102	care managed care program; creating s. 409.980, F.S.;
103	providing the benefits that a managed care plan shall
104	provide when participating in the long-term care managed
105	care program; creating s. 409.981, F.S.; providing
106	criteria for qualified plans; designating regions for plan
107	implementation throughout the state; providing criteria
108	for the selection of plans to participate in the long-term
109	care managed care program; creating s. 409.982, F.S.;
110	providing the agency shall establish a uniform accounting
111	and reporting methods for plans; providing spending
112	thresholds and consequences relating to spending
113	thresholds; providing for mandatory participation in plans
114	of certain service providers; providing providers can be
115	excluded from plans for failure to meet quality or
116	performance criteria; providing the plans must monitor
117	participating providers using specified criteria;
118	providing certain providers that must be included in plan
119	networks; providing provider payment specifications for
120	nursing homes and hospices; creating s. 409.983, F.S.;
121	providing for negotiation of rates between the agency and
122	the plans participating in the long-term care managed care
123	program; providing specific criteria for calculating and
124	adjusting plan payments; allowing the CARES program to
125	assign plan enrollees to a level of care ; providing
126	incentives for adjustments of payment rates; providing the
127	agency shall establish nursing facility-specific and
128	hospice services payment rates; creating s. 409.984, F.S.;
129	providing that prior to contracting with another vender,
130	the agency shall offer to contract with the aging resource
131	centers to provide choice counseling for the long-term
132	care managed care program; providing criteria for
133	automatic assignments of plan enrollees who fail to chose
134	a plan; creating s. 409.985, F.S.; providing that the
135	agency shall operate the Comprehensive Assessment and
136	Review for Long-Term Care Services program through an
137	interagency agreement with the Department of Elderly
138	Affairs; providing duties of the program; defining  the
139	term "nursing facility care"; creating s. 409.986, F.S.;
140	providing authority and agency duties related to long-term
141	care plans; creating s. 409.987, F.S.; providing
142	eligibility requirements for long-term care plans;
143	creating s. 409.988, F.S.; providing benefits for long-
144	term care plans; creating s. 409.989, F.S.; establishing
145	criteria for qualified plans; specifying minimum and
146	maximum number of plans and selection criteria; creating
147	s. 409.990, F.S.; providing requirements for managed care
148	plan accountability; specifying limitations on providers
149	in plan networks; providing for evaluation and payment of
150	network providers; creating s. 409.991, F.S.; providing
151	for payment of managed care plans; providing duties for
152	the Agency for Persons with Disabilities to assign plan
153	enrollees into a payment rate level of care; establishing
154	level of care criteria; providing payment requirements for
155	intermediate care facilities for the developmentally
156	disabled; creating s. 409.992, F.S.; providing
157	requirements for enrollment and choice counseling;
158	specifying enrollment exceptions for certain Medicaid
159	recipients; providing an effective date.
160
161	Be It Enacted by the Legislature of the State of Florida:
162
163	Section 1.  Sections 409.961 through 409.992, Florida
164	Statutes, are designated as part IV of chapter 409, Florida
165	Statutes, entitled "Medicaid Managed Care."
166	Section 2.  Section 409.961, Florida Statutes, is created
167	to read:
168	409.961  Statutory construction; applicability; rules.-It
169	is the intent of the Legislature that if any conflict exists
170	between the provisions contained in this part and provisions
171	contained in other parts of this chapter, the provisions
172	contained in this part shall control. The provisions of ss.
173	409.961-409.970 apply only to the Medicaid managed medical
174	assistance program, long-term care managed care program, and
175	managed long-term care for persons with developmental
176	disabilities program, as provided in this part. The agency shall
177	adopt any rules necessary to comply with or administer this part
178	and all rules necessary to comply with federal requirements. In
179	addition, the department shall adopt and accept the transfer of
180	any rules necessary to carry out the department's
181	responsibilities for receiving and processing Medicaid
182	applications and determining Medicaid eligibility and for
183	ensuring compliance with and administering this part, as those
184	rules relate to the department's responsibilities, and any other
185	provisions related to the department's responsibility for the
186	determination of Medicaid eligibility.
187	Section 3.  Section 409.962, Florida Statutes, is created
188	to read:
189	409.962  Definitions.-As used in this part, except as
190	otherwise specifically provided, the term:
191	(1)  "Agency" means the Agency for Health Care
192	Administration. The agency is the Medicaid agency for the state,
193	as provided under federal law.
194	(2)  "Benefit" means any benefit, assistance, aid,
195	obligation, promise, debt, liability, or the like, related to
196	any covered injury, illness, or necessary medical care, goods,
197	or services.
198	(3)  "Direct care management" means care management
199	activities that involve direct interaction between providers and
200	patients.
201	(4)  "Long-term care comprehensive plan" means a long-term
202	care plan that also provides the services described in s.
203	409.973.
204	(5)  "Long-term care plan" means a specialty plan that
205	provides institutional and home and community-based services.
206	(6)  "Long term care provider service network" means an
207	entity certified pursuant to s. 409.912(4)(d), of which a
208	controlling interest is owned by one or more licensed nursing
209	homes, assisted living facilities with 17 or more beds, home
210	health agencies, community care for the elderly lead agencies,
211	or hospices.
212	(7)  "Managed care plan" means a qualified plan under
213	contract with the agency to provide services in the Medicaid
214	program.
215	(8)  "Medicaid" means the medical assistance program
216	authorized by Title XIX of the Social Security Act, 42 U.S.C. s.
217	1396 et seq., and regulations thereunder, as administered in
218	this state by the agency.
219	(9)  "Medicaid recipient" or "recipient" means an
220	individual who the department or, for Supplemental Security
221	Income, the Social Security Administration determines is
222	eligible pursuant to federal and state law to receive medical
223	assistance and related services for which the agency may make
224	payments under the Medicaid program. For the purposes of
225	determining third-party liability, the term includes an
226	individual formerly determined to be eligible for Medicaid, an
227	individual who has received medical assistance under the
228	Medicaid program, or an individual on whose behalf Medicaid has
229	become obligated.
230	(10)  "Medical home network" means a qualified plan
231	designated by the agency as a medical home network in accordance
232	with the criteria established in s. 409.91207.
233	(11)  "Prepaid plan" means a qualified plan that is
234	licensed or certified as a risk-bearing entity in the state and
235	is paid a prospective per-member, per-month payment by the
236	agency.
237	(12)  "Provider service network" means an entity certified
238	pursuant to s. 409.912(4)(d) of which a controlling interest is
239	owned by a health care provider, or group of affiliated
240	providers, or a public agency or entity that delivers health
241	services. Health care providers include Florida-licensed health
242	care professionals or licensed health care facilities and
243	federally qualified health care centers.
244	(13)  "Qualified plan" means a health insurer authorized
245	under chapter 624, an exclusive provider organization authorized
246	under chapter 627, a health maintenance organization authorized
247	under chapter 641, or a provider service network authorized
248	under s. 409.912(4)(d) that is eligible to participate in the
249	statewide managed care program.
250	(14)  "Specialty plan" means a qualified plan that serves
251	Medicaid recipients who meet specified criteria based on age,
252	medical condition, or diagnosis.
253	Section 4.  Section 409.963, Florida Statutes, is created
254	to read:
255	409.963  Single state agency.-The Agency for Health Care
256	Administration is designated as the single state agency
257	authorized to manage, operate, and make payments for medical
258	assistance and related services under Title XIX of the Social
259	Security Act. Subject to any limitations or directions provided
260	for in the General Appropriations Act, these payments shall be
261	made only for services included in the program, only on behalf
262	of eligible individuals, and only to qualified providers in
263	accordance with federal requirements for Title XIX of the Social
264	Security Act and the provisions of state law. This program of
265	medical assistance is designated as the "Medicaid program." The
266	department is responsible for Medicaid eligibility
267	determinations, including, but not limited to, policy, rules,
268	and the agreement with the Social Security Administration for
269	Medicaid eligibility determinations for Supplemental Security
270	Income recipients, as well as the actual determination of
271	eligibility. As a condition of Medicaid eligibility, subject to
272	federal approval, the agency and the department shall ensure
273	that each Medicaid recipient consents to the release of her or
274	his medical records to the agency and the Medicaid Fraud Control
275	Unit of the Department of Legal Affairs.
276	Section 5.  Section 409.964, Florida Statutes is created to
277	read:
278	409.964  Managed care program; state plan; waivers.-The
279	Medicaid program is established as a statewide, integrated
280	managed care program for all covered services, including long-
281	term care services. The agency shall apply for and implement
282	state plan amendments or waivers of applicable federal laws and
283	regulations necessary to implement the program. Prior to seeking
284	a waiver, the agency shall provide public notice and the
285	opportunity for public comment.
286	Section 6.  Section 409.965, Florida Statutes, is created
287	to read:
288	409.965  Mandatory enrollment.-All Medicaid recipients
289	shall receive covered services through the statewide managed
290	care program, except as provided by this part pursuant to an
291	approved federal waiver. The following Medicaid recipients are
292	exempt from participation in the statewide managed care program:
293	(1)  Women who are only eligible for family planning
294	services.
295	(2)  Women who are only eligible for breast and cervical
296	cancer services.
297	(3)  Persons who are eligible for emergency Medicaid for
298	aliens.
299	Section 7.  Section 409.966, Florida Statutes, is created
300	to read:
301	409.966  Qualified plans; selection.-
302	(1)  QUALIFIED PLANS.-Services in the Medicaid managed care
303	program shall be provided by qualified plans.
304	(a)  A qualified plan may request the agency to designate
305	the plan as a medical home network if it meets the criteria
306	established in s. 409.91207.
307	(b)  A provider service network must be capable of
308	providing all covered services to a mandatory Medicaid managed
309	care enrollee or may limit the provision of services to a
310	specific target population based on the age, chronic disease
311	state, or the medical condition of the enrollee to whom the
312	network will provide services. A specialty provider service
313	network must be capable of coordinating care and delivering or
314	arranging for the delivery of all covered services to the target
315	population. A provider service network may partner with an
316	insurer licensed under chapter 627 or a health maintenance
317	organization licensed under chapter 641 to meet the requirements
318	of a Medicaid contract.
319	(2)  QUALIFIED PLAN SELECTION.-The agency shall select a
320	limited number of qualified plans to participate in the Medicaid
321	program using invitations to negotiate in accordance with s.
322	287.057(3)(a). At least 30 days prior to issuing an invitation
323	to negotiate, the agency shall compile and publish a databook
324	consisting of a comprehensive set of utilization and spending
325	data for the 3 most recent contract years consistent with the
326	rate-setting periods for all Medicaid recipients by region or
327	county. The source of the data in the report shall include both
328	historic fee-for-service claims and validated data from the
329	Medicaid Encounter Data System. The report shall be made
330	available in electronic form and shall delineate utilization use
331	by age, gender, eligibility group, geographic area, and
332	aggregate clinical risk score. Separate and simultaneous
333	procurements shall be conducted in each of the following
334	regions:
335	(a)  Region I, which shall consist of Bay, Calhoun,
336	Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson,
337	Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla,
338	Walton, and Washington Counties.
339	(b)  Region II, which shall consist of Alachua, Baker,
340	Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler,
341	Gilchrist, Hamilton, Lafayette, Levy, Marion, Nassau, Putnam,
342	St. Johns, Suwannee, Union, and Volusia Counties.
343	(c)  Region III, which shall consist of Charlotte, DeSoto,
344	Hardee, Hernando, Highlands, Hillsborough, Lee, Manatee, Pasco,
345	Pinellas, Polk, and Sarasota Counties.
346	(d)  Region IV, which shall consist of Brevard, Indian
347	River, Lake, Orange, Osceola, Seminole, and Sumter Counties.
348	(e)  Region V, which shall consist of Broward, Glades,
349	Hendry, Martin, Okeechobee, Palm Beach, and St. Lucie Counties.
350	(f)  Region VI, which shall consist of Collier, Dade, and
351	Monroe Counties.
352	(3)  QUALITY SELECTION CRITERIA.-The invitation to
353	negotiate must specify the criteria and the relative weight of
354	the criteria that will be used for determining the acceptability
355	of the reply and guiding the selection of the organizations with
356	which the agency negotiates. In addition to criteria established
357	by the agency, the agency shall consider the following factors
358	in the selection of qualified plans:
359	(a)  Accreditation by the National Committee for Quality
360	Assurance or another nationally recognized accrediting body.
361	(b)  Experience serving similar populations, including the
362	organization's record in achieving specific quality standards
363	with similar populations.
364	(c)  Availability and accessibility of primary care and
365	specialty physicians in the provider network.
366	(d)  Establishment of community partnerships with providers
367	that create opportunities for reinvestment in community-based
368	services.
369	(e)  Organization commitment to quality improvement and
370	documentation of achievements in specific quality improvement
371	projects, including active involvement by organization
372	leadership.
373	(f)  Provision of additional benefits, particularly dental
374	care and disease management, and other enhanced-benefit
375	programs.
376	(g)  History of voluntary or involuntary withdrawal from
377	any state Medicaid program or program area.
378	(h)  Evidence that a qualified plan has written agreements
379	or signed contracts or has made substantial progress in
380	establishing relationships with providers prior to the plan
381	submitting a response. The agency shall evaluate and give
382	special weight to such evidence, and the evaluation shall be
383	based on the following factors:
384	1.  Contracts with primary and specialty physicians in
385	sufficient numbers to meet the specific standards established
386	pursuant to s. 409.967(2)(b).
387	2.  Specific arrangements that provide evidence that the
388	compensation offered is sufficient to retain primary and
389	specialty physicians in sufficient numbers to continue to comply
390	with the standards established pursuant to s. 409.967(2)
391	throughout the 5-year contract term.
392
393	After negotiations are conducted, the agency shall select the
394	qualified plans that are determined to be responsive and provide
395	the best value to the state. If all other factors are equal
396	among competing organizations, preference shall be given to
397	organizations designated as medical home networks pursuant to s.
398	409.91207 or organizations with the greatest number of primary
399	care providers that are recognized as patient-centered medical
400	homes by the National Committee for Quality Assurance or
401	organizations with networks that reflect recruitment of minority
402	physicians and other minority providers.
403	(4)  ADMINISTRATIVE CHALLENGE.-Any qualified plan that
404	participates in an invitation to negotiate in more than one
405	region and is selected in at least one region may not begin
406	serving Medicaid recipients in any region for which it was
407	selected until all administrative challenges to procurements
408	required by this section to which the qualified plan is a party
409	have been finalized. For purposes of this subsection, an
410	administrative challenge is finalized if an order granting
411	voluntary dismissal with prejudice has been entered by any court
412	established under Article V of the State Constitution or by the
413	Division of Administrative Hearings, a final order has been
414	entered into by the agency and the deadline for appeal has
415	expired, a final order has been entered by the First District
416	Court of Appeal and the time to seek any available review by the
417	Florida Supreme Court has expired, or a final order has been
418	entered by the Florida Supreme Court and a warrant has been
419	issued.
420	Section 8.  Section 409.967, Florida Statutes, is created
421	to read:
422	409.967  Managed care plan accountability.-
423	(1)  The agency shall establish a 5-year contract with each
424	of the qualified plans selected through the procurement process
425	described in s. 409.966. A plan contract may not be renewed;
426	however, the agency may extend the terms of a plan contract to
427	cover any delays in transition to a new plan.
428	(2)  The agency shall establish such contract requirements
429	as are necessary for the operation of the statewide managed care
430	program. In addition to any other provisions the agency may deem
431	necessary, the contract shall require:
432	(a)  Emergency services.-Plans shall pay for services
433	required by ss. 395.1041 and 401.45 and rendered by a
434	noncontracted provider within 30 days after receipt of a
435	complete and correct claim. Plans must give providers of these
436	services a specific explanation for each claim denied for being
437	incomplete or incorrect. Payment shall be made at the rate the
438	agency would pay for such services from the same provider.
439	Claims from noncontracted providers shall be accepted by the
440	qualified plan for at least 1 year after the date the services
441	are provided.
442	(b)  Access.-The agency shall establish specific standards
443	for the number, type, and regional distribution of providers in
444	plan networks to ensure access to care. Each plan must maintain
445	a region-wide network of providers in sufficient numbers to meet
446	the access standards for specific medical services for all
447	recipients enrolled in the plan. Each plan shall establish and
448	maintain an accurate and complete electronic database of
449	contracted providers, including information about licensure or
450	registration, locations and hours of operation, specialty
451	credentials and other certifications, specific performance
452	indicators, and such other information as the agency deems
453	necessary. The database shall be available online to both the
454	agency and the public and shall have the capability to compare
455	the availability of providers to network adequacy standards and
456	to accept and display feedback from each provider's patients.
457	Each plan shall submit quarterly reports to the agency
458	identifying the number of enrollees assigned to each primary
459	care provider.
460	(c)  Encounter data.-Each prepaid plan must comply with the
461	agency's reporting requirements for the Medicaid Encounter Data
462	System.
463	(d)  Continuous improvement.-The agency shall establish
464	specific performance standards and expected milestones or
465	timelines for improving performance over the term of the
466	contract. Each plan shall establish an internal health care
467	quality improvement system, including enrollee satisfaction and
468	disenrollment surveys. The quality improvement system shall
469	include incentives and disincentives for network providers.
470	(e)  Program integrity.-Each plan shall establish program
471	integrity functions and activities to reduce the incidence of
472	fraud and abuse, including, at a minimum:
473	1.  A provider credentialing system and ongoing provider
474	monitoring;
475	2.  An effective prepayment and postpayment review process
476	including, but not limited to, data analysis, system editing,
477	and auditing of network providers;
478	3.  Procedures for reporting instances of fraud and abuse
479	pursuant to chapter 641;
480	4.  Administrative and management arrangements or
481	procedures, including a mandatory compliance plan, designed to
482	prevent fraud and abuse; and
483	5.  Designation of a program integrity compliance officer.
484	(f)  Grievance resolution.-Each plan shall establish an
485	internal process for reviewing and responding to grievances from
486	enrollees. The contract shall specify timeframes for submission,
487	plan response, and resolution. Grievances not resolved by a
488	plan's internal process shall be submitted to the subscriber
489	assistance panel pursuant to s. 408.7056. Each plan shall submit
490	quarterly reports on the number, description, and outcome of
491	grievances filed by enrollees. The agency shall maintain a
492	similar process for provider service networks.
493	(g)  Penalties.-Plans that reduce enrollment levels or
494	leave a region prior to the end of the contract term shall
495	reimburse the agency for the cost of enrollment changes and
496	other transition activities, including the cost of additional
497	choice counseling services. If more than one plan leaves a
498	region at the same time, costs shall be shared by the departing
499	plans proportionate to their enrollments. In addition to the
500	payment of costs, departing plans shall pay a per enrollee
501	penalty not to exceed 5 percent of 1 month's payment. Plans
502	shall provide the agency notice no less than 180 days prior to
503	withdrawing from a region.
504	Section 9.  Section 409.968, Florida Statutes, is created
505	to read:
506	409.968  Managed care plan payment.-
507	(1)  Prepaid plans shall receive per-member, per-month
508	payments negotiated pursuant to the procurements described in s.
509	409.966. Payments shall be risk-adjusted rates based on
510	historical utilization and spending data, projected forward, and
511	adjusted to reflect the eligibility category, geographic area,
512	and the clinical risk profile of the recipients.
513	(2)  Beginning September 1, 2010, the agency shall update
514	the rate-setting methodology by initiating a transition to rates
515	based on statewide encounter data submitted by Medicaid managed
516	care plans pursuant to s. 409.970. Prior to this transition, the
517	agency shall conduct appropriate tests and establish specific
518	milestones in order to determine that the Medicaid Encounter
519	Data system consists of valid, complete, and sound data for a
520	sufficient period of time to provide a reliable basis for
521	establishing actuarially sound payment rates. The transition
522	shall be implemented within 3 years or less, and shall utilize
523	such other data sources as necessary and reliable to make
524	appropriate adjustments during the transition. The agency shall
525	establish a technical advisory panel to obtain input from the
526	prepaid plans regarding the incorporation of encounter data in
527	the rate setting process.
528	(3)  Provider service networks may be prepaid plans and
529	receive per-member, per-month payments negotiated pursuant to
530	the procurement process described in s. 409.966. Provider
531	service networks that choose not to be prepaid plans shall
532	receive fee-for-service rates with a shared savings settlement.
533	The fee-for-service option shall be available to a provider
534	service network only for the first 5 years of the plan's
535	operation in a given region or until the contract year that
536	begins on October 1, 2015, whichever is later. The agency shall
537	annually conduct cost reconciliations to determine the amount of
538	cost savings achieved by fee-for-service provider service
539	networks for the dates of service within the period being
540	reconciled. Only payments for covered services for dates of
541	service within the reconciliation period and paid within 6
542	months after the last date of service in the reconciliation
543	period shall be included. The agency shall perform the necessary
544	adjustments for the inclusion of incurred but not reported
545	claims within the reconciliation period for claims that could be
546	received and paid by the agency after the 6-month claims
547	processing time lag. The agency shall provide the results of the
548	reconciliations to the fee-for-service provider service networks
549	within 45 days after the end of the reconciliation period. The
550	fee-for-service provider service networks shall review and
551	provide written comments or a letter of concurrence to the
552	agency within 45 days after receipt of the reconciliation
553	results. This reconciliation shall be considered final.
554	Section 10.  Section 409.969, Florida Statutes, is created
555	to read:
556	409.969  Enrollment; choice counseling; automatic
557	assignment; disenrollment.-
558	(1)  ENROLLMENT.-All Medicaid recipients shall be enrolled
559	in a managed care plan unless specifically exempted in this
560	part. Each recipient shall have a choice of plans and may select
561	any available plan unless that plan is restricted by contract to
562	a specific population that does not include the recipient.
563	Medicaid recipients shall have 30 days in which to make a choice
564	of plans. All recipients shall be offered choice counseling
565	services in accordance with this section.
566	(2)  CHOICE COUNSELING.-The agency shall provide choice
567	counseling for Medicaid recipients. The agency may contract for
568	the provision of choice counseling. Any such contract shall be
569	for a period of 5 years and may be renewed for an additional 5-
570	year period. The agency may extend the term of the contract to
571	cover any delays in transition to a new contractor. Choice
572	counseling shall be offered in the native or preferred language
573	of the recipient, consistent with federal requirements. The
574	agency shall maintain a record of the recipients who receive
575	such services, identifying the scope and method of the services
576	provided. The agency shall make available clear and easily
577	understandable choice information to Medicaid recipients that
578	includes:
579	(a)  An explanation that each recipient has the right to
580	choose a managed care plan at the time of enrollment in Medicaid
581	and again at regular intervals set by the agency, and that if a
582	recipient does not choose a plan, the agency will assign the
583	recipient to a plan according to the criteria specified in this
584	section.
585	(b)  A list and description of the benefits provided in
586	each plan.
587	(c)  An explanation of benefit limits.
588	(d)  A current list of providers participating in the
589	network, including location and contact information.
590	(e)  Plan performance data.
591	(3)  DISENROLLMENT; GRIEVANCES.-After a recipient has
592	enrolled in a managed care plan, the recipient shall have 90
593	days to voluntarily disenroll and select another plan. After 90
594	days, no further changes may be made except for good cause. Good
595	cause includes, but is not limited to, poor quality of care,
596	lack of access to necessary specialty services, an unreasonable
597	delay or denial of service, or fraudulent enrollment. The agency
598	must make a determination as to whether good cause exists. The
599	agency may require a recipient to use the plan's grievance
600	process prior to the agency's determination of good cause,
601	except in cases in which immediate risk of permanent damage to
602	the recipient's health is alleged.
603	(a)  The managed care plan internal grievance process, when
604	utilized, must be completed in time to permit the recipient to
605	disenroll by the first day of the second month after the month
606	the disenrollment request was made. If the result of the
607	grievance process is approval of an enrollee's request to
608	disenroll, the agency is not required to make a determination in
609	the case.
610	(b)  The agency must make a determination and take final
611	action on a recipient's request so that disenrollment occurs no
612	later than the first day of the second month after the month the
613	request was made. If the agency fails to act within the
614	specified timeframe, the recipient's request to disenroll is
615	deemed to be approved as of the date agency action was required.
616	Recipients who disagree with the agency's finding that good
617	cause does not exist for disenrollment shall be advised of their
618	right to pursue a Medicaid fair hearing to dispute the agency's
619	finding.
620	(c)  Medicaid recipients enrolled in a managed care plan
621	after the 90-day period shall remain in the plan for the
622	remainder of the 12-month period. After 12 months, the recipient
623	may select another plan. However, nothing shall prevent a
624	Medicaid recipient from changing primary care providers within
625	the plan during that period.
626	Section 11.  Section 409.970, Florida Statutes, is created
627	to read:
628	409.970  Encounter data.-The agency shall maintain and
629	operate the Medicaid Encounter Data System to collect, process,
630	store, and report on covered services provided to all Medicaid
631	recipients enrolled in prepaid plans. Prepaid plans shall submit
632	encounter data electronically in a format that complies with the
633	Health Insurance Portability and Accountability Act provisions
634	for electronic claims and in accordance with deadlines
635	established by the agency. Prepaid plans must certify that the
636	data reported is accurate and complete. The agency is
637	responsible for validating the data submitted by the plans. The
638	agency shall make encounter data available to those plans
639	accepting enrollees who are assigned to them from other plans
640	leaving a region.
641	Section 12.  Section 409.971, Florida Statutes, is created
642	to read:
643	409.971  Managed medical assistance program.-The agency
644	shall make payments for primary and acute medical assistance and
645	related services using a managed care model. By January 1, 2012,
646	the agency shall begin implementation of the statewide managed
647	medical assistance program, with full implementation in all
648	regions by October 1, 2013.
649	Section 13.  Section 409.972, Florida Statutes, is created
650	to read:
651	409.972  Mandatory and voluntary enrollment.-
652	(1)  Persons eligible for the program known as "medically
653	needy" pursuant to s. 409.904(2)(a) shall enroll in managed care
654	plans. Medically needy recipients shall meet the share of cost
655	by paying the plan premium, up to the share of cost amount,
656	contingent upon federal approval.
657	(2)  The following Medicaid-eligible persons are exempt
658	from mandatory managed care enrollment required by s. 409.965,
659	and may voluntarily choose to participate in the managed medical
660	assistance program:
661	(a)  Medicaid recipients who have other creditable health
662	care coverage, excluding Medicare.
663	(b)  Medicaid recipients residing in residential commitment
664	facilities operated through the Department of Juvenile Justice,
665	group care facilities operated by the Department of Children and
666	Families, and treatment facilities funded through the Substance
667	Abuse and Mental Health program of the Department of Children
668	and Families.
669	(c)  Persons eligible for refugee assistance.
670	(d)  Medicaid recipients who are residents of a
671	developmental disability center including Sunland Center in
672	Marianna and Tacachale in Gainesville.
673	(3)  Persons eligible for Medicaid but exempt from
674	mandatory participation who do not choose to enroll in managed
675	care shall be served in the Medicaid fee-for-service program as
676	provided in part III of this chapter.
677	Section 14.  Section 409.973, Florida Statutes, is created
678	to read:
679	409.973  Benefits.-
680	(1)  MINIMUM BENEFITS.-Managed care plans shall cover, at a
681	minimum, the following services:
682	(a)  Advanced registered nurse practitioner services.
683	(b)  Ambulatory surgical treatment center services.
684	(c)  Birthing center services.
685	(d)  Chiropractic services.
686	(e)  Dental services.
687	(f)  Early periodic screening diagnosis and treatment
688	services for recipients under age 21.
689	(g)  Emergency services.
690	(h)  Family planning services and supplies.
691	(i)  Healthy start services.
692	(j)  Hearing services.
693	(k)  Home health agency services.
694	(l)  Hospice services.
695	(m)  Hospital inpatient services.
696	(n)  Hospital outpatient services.
697	(o)  Laboratory and X-ray services.
698	(p)  Medical supplies, equipment, prostheses, and orthoses.
699	(q)  Mental health services.
700	(r)  Nursing care.
701	(s)  Optical services and supplies.
702	(t)  Optometrist services.
703	(u)  Physical, occupational, respiratory, and speech
704	therapy services.
705	(v)  Physician services.
706	(w)  Podiatric services.
707	(x)  Prescription drugs.
708	(y)  Renal dialysis services.
709	(z)  Respiratory equipment and supplies.
710	(aa)  Rural health clinic services.
711	(bb)  Substance abuse treatment services.
712	(cc)  Transportation to access covered services.
713	(2)  CUSTOMIZED BENEFITS.-Managed care plans may customize
714	benefit packages for nonpregnant adults, vary cost-sharing
715	provisions, and provide coverage for additional services. The
716	agency shall evaluate the proposed benefit packages to ensure
717	services are sufficient to meet the needs of the plans'
718	enrollees and to verify actuarial equivalence.
719	(3)  ENHANCED BENEFITS.-Each plan operating in the managed
720	medical assistance program shall establish an incentive program
721	that rewards specific healthy behaviors with credits in a
722	flexible spending account.
723	(a)  At the discretion of the recipient, credits shall be
724	used to purchase otherwise uncovered health and related services
725	during the entire period of, and for a maximum of 3 years after,
726	the recipient's Medicaid eligibility, whether or not the
727	recipient remains continuously enrolled in the plan in which the
728	credits were earned.
729	(b)  Enhanced benefits shall be structured to provide
730	greater incentives for those diseases linked with lifestyle and
731	conditions or behaviors associated with avoidable utilization of
732	high-cost services.
733	(c)  To fund these credits, each plan must maintain a
734	reserve account in an amount of up to 2 percent of the plan's
735	Medicaid premium revenue, or benchmark premium revenue in the
736	case of provider service networks, based on an actuarial
737	assessment of the value of the enhanced benefits program.
738	Section 15.  Section 409.974, Florida Statutes, is created
739	to read:
740	409.974  Qualified plans.-
741	(1)  QUALIFIED PLAN SELECTION.-The agency shall select
742	qualified plans through the procurement described in s. 409.966.
743	The agency shall notice invitations to negotiate no later than
744	January 1, 2012.
745	(a)  The agency shall procure three plans for Region I. At
746	least one plan shall be a provider service network, if any
747	provider service network submits a responsive bid.
748	(b)  The agency shall procure at least four and no more
749	than seven plans for Region II. At least one plan shall be a
750	provider service network, if any provider service network
751	submits a responsive bid.
752	(c)  The agency shall procure at least five plans and no
753	more than ten plans for Region III. At least two plans shall be
754	provider service networks, if any two provider service networks
755	submit a responsive bid.
756	(d)  The agency shall procure at least four plans and no
757	more than eight plans for Region IV. At least one plan shall be
758	a provider service network if any provider service network
759	submits a responsive bid.
760	(e)  The agency shall procure at least four plans and no
761	more than seven plans for Region V. At least one plan shall be a
762	provider service network, if any provider service network
763	submits a responsive bid.
764	(f)  The agency shall procure at least five plans and no
765	more than ten plans for Region VI. At least two plans shall be
766	provider service networks, if any two provider service networks
767	submit a responsive bid.
768	(2)  QUALITY SELECTION CRITERIA.-In addition to the
769	criteria established in s. 409.966, the agency shall consider
770	evidence that a qualified plan has written agreements or signed
771	contracts or has made substantial progress in establishing
772	relationships with providers prior to the plan submitting a
773	response. The agency shall evaluate and give special weight to
774	evidence of signed contracts with providers of critical services
775	pursuant to s. 409.975(3)(a)-(d). The agency shall also consider
776	whether the organization is a specialty plan. When all other
777	factors are equal, the agency shall consider whether the
778	organization has a contract to provide managed long-term care
779	services in the same region and shall exercise a preference for
780	such plans.
781	(3)  CHILDREN'S MEDICAL SERVICES NETWORK.-The Children's
782	Medical Services Network authorized under chapter 391 is a
783	qualified plan for purposes of the managed medical assistance
784	program. Participation by the Children's Medical Services
785	Network shall be pursuant to a single, statewide contract with
786	the agency that is not subject to the procurement requirements
787	or regional plan number limits of this section. The Children's
788	Medical Services Network must meet all other plan requirements
789	for the managed medical assistance program.
790	Section 16.  Section 409.975, Florida Statutes, is created
791	to read:
792	409.975  Managed care plan accountability.-In addition to
793	the requirements of s. 409.967, plans and providers
794	participating in the managed medical assistance program shall
795	comply with the requirements of this section.
796	(1)  MEDICAL LOSS RATIO.-The agency shall establish and
797	implement managed care plans that shall use a uniform method of
798	accounting for and reporting medical, direct care management,
799	and nonmedical costs. The agency shall evaluate plan spending
800	patterns beginning after the plan completes 2 full years of
801	operation and at least annually thereafter. The agency shall
802	implement the following thresholds and consequences of various
803	spending patterns:
804	(a)  Plans that spend less than 75 percent of Medicaid
805	premium revenue on medical services and direct care management
806	as determined by the agency shall be excluded from automatic
807	enrollments and shall be required to pay back the amount between
808	actual spending and 85 percent of the Medicaid premium revenue.
809	(b)  Plans that spend less than 85 percent of Medicaid
810	premium revenue on medical services and direct care management
811	as determined by the agency shall be required to pay back the
812	amount between actual spending and 85 percent of the Medicaid
813	premium revenue.
814	(c)  Plans that spend more than 92 percent of Medicaid
815	premium revenue shall be evaluated by the agency to determine
816	whether higher expenditures are the result of failures in care
817	management. Such a determination may result in the plan being
818	excluded from automatic enrollments.
819	(2)  PROVIDER NETWORKS.-Plans may limit the providers in
820	their networks based on credentials, quality indicators, and
821	price. However, in the first contract period after a qualified
822	plan is selected in a region by the agency, the plan must offer
823	a network contract to the following providers in the region:
824	(a)  Federally qualified health centers.
825	(b)  Primary care providers certified as medical homes.
826	(c)  Providers listed in paragraphs (3)(a)-(d).
827
828	After 12 months of active participation in a plan's network, the
829	plan may exclude any of the above-named providers from the
830	network for failure to meet quality or performance criteria.
831	(3)  SELECT PROVIDER PARTICIPATION.-Providers may not be
832	required to participate in any qualified plan selected by the
833	agency except as provided in this subsection. The following
834	providers must agree to participate with each qualified plan
835	selected by the agency in the regions where they are located:
836	(a)  Statutory teaching hospitals as defined in s.
837	408.07(45).
838	(b)  Hospitals that are trauma centers as defined in s.
839	395.4001(14).
840	(c)  Hospitals that are regional perinatal intensive care
841	centers as defined in s. 383.16(2).
842	(d)  Hospitals licensed as specialty children's hospitals
843	as defined in s. 395.002(28).
844	(e)  Hospitals with both an active Medicaid provider
845	agreement under s. 409.907 and a certificate of need.
846
847	To the extent that the contracts between the hospitals described
848	in paragraphs (a)-(d) and the qualified plans require the
849	services of the hospital's medical staff who are employees or
850	under contract with the hospital to meet the hospital's
851	contractual obligations, such staff is also required to contract
852	with the plans selected by the agency. Any services provided by
853	the medical staff independent of their employment or contractual
854	obligations to the hospital are not covered by this subsection.
855	(4)  PERFORMANCE MEASUREMENT.-Each plan shall monitor the
856	quality and performance of each participating provider. At the
857	beginning of the contract period, each plan shall notify all its
858	network providers of the metrics used by the plan for evaluating
859	the provider's performance and determining continued
860	participation in the network.
861	(5)  PREGNANCY AND INFANT HEALTH.-Each plan shall establish
862	specific programs and procedures to improve pregnancy outcomes
863	and infant health, including, but not limited to, coordination
864	with the Healthy Start program, immunization programs, and
865	referral to the Special Supplemental Nutrition Program for
866	Women, Infants, and Children, and the Children's Medical
867	Services program for children with special health care needs.
868	(6)  SCREENING RATE.-Each plan shall achieve an annual
869	Early and Periodic Screening, Diagnosis, and Treatment Service
870	screening rate of at least 60 percent for those recipients
871	continuously enrolled for at least 8 months.
872	(7)  PROVIDER PAYMENT.-Plans and hospitals shall negotiate
873	mutually acceptable rates, methods, and terms of payment. At a
874	minimum, plans shall pay hospitals the Medicaid rate. Payments
875	to hospitals shall not exceed 150 percent of the Medicaid rate,
876	unless specifically approved by the agency. For purposes of this
877	subsection, the Medicaid rate is the rate the agency would have
878	paid on the first day of the contract between the provider and
879	the plan. Payment rates may be updated periodically.
880	(8)  CONFLICT RESOLUTION.-The agency shall establish a
881	process for resolving disputes between qualified plans Medicaid
882	inpatient hospital providers or the medical staff of the
883	providers listed in s. 409.975(3)(a)-(d) when the agency is
884	notified by either party of irreconcilable differences and the
885	agency determines that the dispute jeopardizes access to or
886	quality of services for Medicaid recipients. The agency may
887	contract with an outside entity for any portion of this process.
888	When this process is invoked by one or both of the parties, the
889	agency is authorized to establish payment rates, contract terms,
890	and other conditions on either or both parties. This process may
891	not be used to review and reverse any plan decision to exclude
892	any provider that fails to meet quality standards.
893	Administration costs of each instance of conflict resolution
894	shall be paid by the entities which invoke it, in equal parts.
895	(9)  MEDICALLY NEEDY ENROLLEES.-Each selected plan shall
896	accept any medically needy recipient who selects or is assigned
897	to the plan and provide that recipient with continuous
898	enrollment for 12 months. After the first month of qualifying as
899	a medically needy recipient and enrolling in a plan, and
900	contingent upon federal approval, the enrollee shall pay the
901	plan a portion of the monthly premium equal to the enrollee's
902	share of the cost as determined by the department. The agency
903	shall pay the remainder of the monthly premium. Plans must
904	provide a grace period of at least 60 days before disenrolling
905	recipients who fail to pay their shares of the premium.
906	Section 17.  Section 409.976, Florida Statutes, is created
907	to read:
908	409.976  Managed care plan payment.-In addition to the
909	payment provisions of s. 409.968, the agency shall provide
910	payment to plans in the managed medical assistance program
911	pursuant to this section.
912	(1)  Prepaid payment rates shall be negotiated between the
913	agency and the qualified plans as part of the procurement
914	described in s. 409.966.
915	(2)  The agency shall develop a methodology to ensure the
916	availability of intergovernmental transfers in the statewide
917	integrated managed care program to support providers that have
918	historically served Medicaid recipients. Such providers include,
919	but are not limited to, safety net providers, trauma hospitals,
920	children's hospitals, statutory teaching hospitals, and medical
921	and osteopathic physicians employed by or under contract with a
922	medical school in this state. The agency may develop a
923	supplemental capitation rate, risk pool, or incentive payment to
924	plans that contract with these providers. A plan is eligible for
925	a supplemental payment only if there are sufficient
926	intergovernmental transfers available from allowable sources and
927	the plan can demonstrate that it pays a reimbursement rate not
928	less than the equivalent fee-for-service rate. The agency may
929	develop the supplemental capitation rate to consider rates
930	higher than the fee-for-service Medicaid rate when needed to
931	ensure access and supported by funds provided by a locality. The
932	agency shall evaluate the development of the rate cell to
933	accurately reflect the underlying utilization to the maximum
934	extent possible. This methodology may include interim rate
935	adjustments as permitted under federal regulations. Any such
936	methodology shall preserve federal funding to these entities and
937	must be actuarially sound. In the absence of federal approval
938	for the above methodology, the agency is authorized to set an
939	enhanced rate and require that plans pay the enhanced rate, if
940	the agency determines the enhanced rate is necessary to ensure
941	access to care by the providers described in this subsection.
942	Section 18.  Section 409.977, Florida Statutes, is created
943	to read:
944	409.977  Choice counseling and enrollment.-
945	(1)  CHOICE COUNSELING.-In addition to the choice
946	counseling information required by s. 409.969, the agency shall
947	make available clear and easily understandable choice
948	information to Medicaid recipients that includes:
949	(a)  Information about earning credits in the plan's
950	enhanced benefit program.
951	(b)  Information about cost sharing requirements of each
952	plan.
953	(2)  AUTOMATIC ENROLLMENT.-The agency shall automatically
954	enroll into a managed care plan those Medicaid recipients who do
955	not voluntarily choose a plan pursuant to s. 409.969. The agency
956	shall automatically enroll recipients in plans that meet or
957	exceed the performance or quality standards established pursuant
958	to s. 409.967, and shall not automatically enroll recipients in
959	a plan that is deficient in those performance or quality
960	standards. The agency may not engage in practices that are
961	designed to favor one managed care plan over another. When
962	automatically enrolling recipients in plans, the agency shall
963	take into account the following criteria:
964	(a)  Whether the plan has sufficient network capacity to
965	meet the needs of the recipients.
966	(b)  Whether the recipient has previously received services
967	from one of the plan's primary care providers.
968	(c)  Whether primary care providers in one plan are more
969	geographically accessible to the recipient's residence than
970	those in other plans.
971	(d)  The recipient's medical condition or diagnosis, and
972	the availability of a plan to accommodate the condition or
973	diagnosis.
974	(3)  OPT-OUT OPTION.-The agency shall develop a process to
975	enable any recipient with access to employer-sponsored insurance
976	to opt out of all qualified plans in the Medicaid program and to
977	use Medicaid financial assistance to pay for the recipient's
978	share of the cost in any such plan. Contingent upon federal
979	approval, the agency shall also enable recipients with access to
980	other insurance or related products providing access to health
981	care services created pursuant to state law, including any
982	product available under the Cover Florida Health Access Program,
983	the Florida Health Choices Program, or any health exchange, to
984	opt out. The amount of financial assistance provided for each
985	recipient may not exceed the amount of the Medicaid premium that
986	would have been paid to a plan for that recipient.
987	Section 19.  Section 409.978, Florida Statutes, is created
988	to read:
989	409.978  Long-term care managed care program.-
990	(1)  Pursuant to s. 409.963, the agency shall administer
991	the long-term care managed care program described in ss.
992	409.978-409.985, but may delegate specific duties and
993	responsibilities for the program to the Department of Elderly
994	Affairs and other state agencies. By July 1, 2011, the agency
995	shall begin implementation of the statewide long-term care
996	managed care program, with full implementation in all regions by
997	October 1, 2012.
998	(2)  The agency shall make payments for long-term care,
999	including home and community-based services, using a managed
1000	care model. Unless otherwise specified, the provisions of ss.
1001	409.961-409.970 apply to the long-term care managed care
1002	program.
1003	(3)  The Department of Elderly Affairs shall assist the
1004	agency to develop specifications for use in the invitation to
1005	negotiate and the model contract; determine clinical eligibility
1006	for enrollment in managed long-term care plans; monitor plan
1007	performance and measure quality of service delivery; assist
1008	clients and families to address complaints with the plans;
1009	facilitate working relationships between plans and providers
1010	serving elders and disabled adults; and perform other functions
1011	specified in a memorandum of agreement.
1012	Section 20.  Section 409.979, Florida Statutes, is created
1013	to read:
1014	409.979  Eligibility.-
1015	(1)  Medicaid recipients who meet all of the following
1016	criteria are eligible to participate in the long-term care
1017	managed care program. The recipient must be:
1018	(a)  Sixty-five years of age or older or eligible for
1019	Medicaid by reason of a disability.
1020	(b)  Determined by the Comprehensive Assessment Review and
1021	Evaluation for Long-Term Care Services (CARES) Program to
1022	require nursing facility care.
1023	(2)  Medicaid recipients who on the date long-term care
1024	managed care plans becomes available in the recipient's region,
1025	are residing in a nursing home facility or enrolled in one of
1026	the following long-term care Medicaid waiver programs are
1027	eligible to participate in the long-term care managed care
1028	program:
1029	(a)  The Assisted Living for the Frail Elderly Waiver.
1030	(b)  The Aged and Disabled Adult Waiver.
1031	(c)  The Adult Day Health Care Waiver.
1032	(d)  The Consumer-Directed Care Plus Program as described
1033	in s. 409.221.
1034	(e)  The Program of All-inclusive Care for the Elderly.
1035	(f)  The Long-Term Care Community-Based Diversion Pilot
1036	Project as described in s. 430.705.
1037	(g)  The Channeling Services Waiver for Frail Elders.
1038	Section 21.  Section 409.980, Florida Statutes, is created
1039	to read:
1040	409.980  Benefits.-Managed care plans shall cover, at a
1041	minimum, the following services:
1042	(1)  Nursing facility.
1043	(2)  Assisted living facility.
1044	(3)  Hospice.
1045	(4)  Adult day care.
1046	(5)  Medical equipment and supplies, including incontinence
1047	supplies.
1048	(5)  Personal care.
1049	(7)  Home accessibility adaptation.
1050	(9)  Behavior management.
1051	(9)  Home delivered meals.
1052	(10)  Case management.
1053	(11)  Therapies:
1054	(a)  Occupational therapy
1055	(b)  Speech therapy
1056	(c)  Respiratory therapy
1057	(d)  Physical therapy.
1058	(12)  Intermittent and skilled nursing.
1059	(13)  Medication administration.
1060	(14)  Medication management.
1061	(15)  Nutritional assessment and risk reduction.
1062	(16)  Caregiver training.
1063	(17)  Respite care.
1064	(18)  Transportation.
1065	(19)  Personal emergency response system.
1066	Section 22.  Section 409.981, Florida Statutes, is created
1067	to read:
1068	409.981  Qualified plans.-
1069	(1)  QUALIFIED PLANS.-For purposes of the long-term care
1070	managed care program, qualified plans also include entities who
1071	are qualified under 42 C.F.R. part 422 as Medicare Advantage
1072	Preferred Provider Organizations, Medicare Advantage Provider-
1073	sponsored Organizations, and Medicare Advantage Special Needs
1074	Plans. Such plans are eligible to participate in the statewide
1075	long-term care managed care program. Qualified plans that are
1076	provider service networks must be long-term care provider
1077	service networks. Qualified plans may either be long-term care
1078	plans that cover benefits pursuant to s. 409.980, or
1079	comprehensive long-term care plans that cover benefits pursuant
1080	to ss. 409.973 and 409.980.
1081	(2) QUALIFIED PLAN SELECTION.-The agency shall select
1082	qualified plans through the procurement described in s. 409.966.
1083	The agency shall notice invitations to negotiate no later than
1084	July 1, 2011.
1085	(a)  The agency shall procure three plans for Region I. At
1086	least one plan shall be a provider service network, if any
1087	submit a responsive bid.
1088	(b)  The agency shall procure at least four and no more
1089	than seven plans for Region II. At least one plan shall be a
1090	provider service network, if any submit a responsive bid.
1091	(c)  The agency shall procure at least five plans and no
1092	more than ten plans for Region III. At least two plans shall be
1093	provider service networks, if any two submit a responsive bid.
1094	(d)  The agency shall procure at least four plans and no
1095	more than eight plans for Region IV. At least one plan shall be
1096	a provider service network if any submit a responsive bid.
1097	(e)  The agency shall procure at least four plans and no
1098	more than seven plans for Region V. At least one plan shall be a
1099	provider service network, if any submit a responsive bid.
1100	(f)  The agency shall procure at least five plans and no
1101	more than ten plans for Region VI. At least two plans shall be
1102	provider service networks, if any two submit a responsive bid.
1103	(3) QUALITY SELECTION CRITERIA.-In addition to the criteria
1104	established in s. 409.966, the agency shall consider the
1105	following factors in the selection of qualified plans:
1106	(a)  Specialized staffing. Plan employment of executive
1107	managers with expertise and experience in serving aged and
1108	disabled persons who require long-term care.
1109	(b)  Network qualifications. Plan establishment of a
1110	network of service providers dispersed throughout the region and
1111	in sufficient numbers to meet specific service standards
1112	established by the agency for specialty services for persons
1113	receiving home and community-based care.
1114	(c)  Whether a plan is proposing to establish a
1115	comprehensive long-term care plan and whether the qualified plan
1116	has a contract to provide managed medical assistance services in
1117	the same region. The agency shall exercise a preference for such
1118	plans.
1119	(d)  Whether a plan is designated as a medical home network
1120	pursuant to s. 409.91207 or offers consumer-directed care
1121	services to enrollees pursuant to s. 409.221. Consumer-directed
1122	care services provide a flexible budget which is managed by
1123	enrolled individuals and their families or representatives and
1124	allows them to choose providers of services, determine provider
1125	rates of payment and direct the delivery of services to best
1126	meet their special long-term care needs. When all other factors
1127	are equal among competing qualified plans, the agency shall
1128	exercise a preference for such plans.
1129	(e)  Evidence that a qualified plan has written agreements
1130	or signed contracts or has made substantial progress in
1131	establishing relationships with providers prior to the plan
1132	submitting a response. The agency shall evaluate and give
1133	special weight to evidence of signed contracts with providers of
1134	critical services pursuant to s. 409.982(2)(a)-(c).
1135	(4)  PROGRAM FOR ALL-INCLUSIVE CARE FOR THE ELDERLY.-The
1136	Program for All-Inclusive Care for the Elderly (PACE) is a
1137	qualified plan for purposes of the long-term care managed care
1138	program. Participation by PACE shall be pursuant to a contract
1139	with the agency and not subject to the procurement requirements
1140	or regional plan number limits of this section. PACE plans may
1141	continue to provide services to individuals at such levels and
1142	enrollment caps as authorized by the General Appropriations Act.
1143	Section 23.  Section 409.982, Florida Statutes, is created
1144	to read:
1145	409.982  Managed care plan accountability.-In addition to
1146	the requirements of s. 409.967, plans and providers
1147	participating in the long-term care managed care program shall
1148	comply with the requirements of this section.
1149	(1)  MEDICAL LOSS RATIO.-The agency shall establish and
1150	plans shall use a uniform method of accounting and reporting
1151	long-term care service costs, direct care management costs, and
1152	administrative costs. The agency shall evaluate plan spending
1153	patterns beginning after the plan completes 2 full years of
1154	operation and at least annually thereafter. The agency shall
1155	implement the following thresholds and consequences of various
1156	spending patterns:
1157	(a)  Plans that spend less than 75 percent of Medicaid
1158	premium revenue on long-term care services, including direct
1159	care management as determined by the agency shall be excluded
1160	from automatic enrollments and shall be required to pay back the
1161	amount between actual spending and 85 percent of the Medicaid
1162	premium revenue.
1163	(b)  Plans that spend less than 85 percent of Medicaid
1164	premium revenue on long-term care services, including direct
1165	care management as determined by the agency shall be required to
1166	pay back the amount of the difference between actual spending
1167	and 85 percent of Medicaid premium revenue.
1168	(c)  Plans that spend more than 92 percent of Medicaid
1169	premium revenue on long-term care services, including direct
1170	care management as determined by the agency shall be evaluated
1171	by the agency to determine whether higher expenditures are the
1172	result of failures in care management. Such a determination may
1173	result in the plan being excluded from automatic enrollments.
1174	(2)  PROVIDER NETWORKS.-Plans may limit the providers in
1175	their networks based on credentials, quality indicators, and
1176	price. However, in the first contract period after a qualified
1177	plan is selected in a region by the agency, the plan must offer
1178	a network contract to the following providers in the region:
1179	(a)  Nursing homes.
1180	(b)  Hospices.
1181	(c)  Aging network service providers that have previously
1182	participated in home and community-based waivers serving elders
1183	or community-service programs administered by the Department of
1184	Elderly Affairs.
1185
1186	After 12 months of active participation in a plan's network, the
1187	plan may exclude any of the providers named in this subsection
1188	from the network for failure to meet quality or performance
1189	criteria.
1190	(3)  SELECT PROVIDER PARTICIPATION.-Except as provided in
1191	this subsection, providers may limit the plans they join.
1192	Nursing homes and hospices must participate in all qualified
1193	plans selected by the agency in the region in which the provider
1194	is located.
1195	(4) PERFORMANCE MEASUREMENT.-Each plan shall monitor the
1196	quality and performance of each participating provider. At the
1197	beginning of the contract period, each plan shall notify all its
1198	network providers of the metrics used by the plan for evaluating
1199	the provider's performance and determining continued
1200	participation in the network.
1201	(5)  PROVIDER NETWORK STANDARDS.-The agency shall establish
1202	and each plan must comply with specific standards for the
1203	number, type, and regional distribution of providers in the
1204	plan's network, which must include:
1205	(a)  Adult day centers.
1206	(b)  Adult family care homes.
1207	(c)  Assisted living facilities.
1208	(d)  Health care services pools.
1209	(e)  Home health agencies.
1210	(f)  Homemaker and companion services.
1211	(g)  Hospices.
1212	(h)  Community Care for the Elderly Lead Agencies.
1213	(i)  Nurse registries.
1214	(j)  Nursing homes.
1215	(6) PROVIDER PAYMENT.-Plans and providers shall negotiate
1216	mutually acceptable rates, methods, and terms of payment. Plans
1217	shall pay nursing homes an amount equal to the nursing facility-
1218	specific payment rates set by the agency. Plans shall pay
1219	hospice providers an amount equal to the per diem rate set by
1220	the agency. For recipients residing in a nursing facility and
1221	receiving hospice services, the plan shall pay the hospice
1222	provider the per diem rate set by the agency minus the nursing
1223	facility component and shall pay the nursing facility the
1224	appropriate state rate.
1225	Section 24.  Section 409.983, Florida Statutes, is created
1226	to read:
1227	409.983  Managed care plan payment.-In addition to the
1228	payment provisions of s. 409.968, the agency shall provide
1229	payment to plans in the long-term care managed care program
1230	pursuant to this section.
1231	(1)  Prepaid payment rates for long-term care managed care
1232	plans shall be negotiated between the agency and the qualified
1233	plans as part of the procurement described in s. 409.966.
1234	(2)  Payment rates for comprehensive long-term care plans
1235	covering services described in s. 409.973 shall be combined with
1236	rates for long-term care plans for services specified in s.
1237	409.980.
1238	(3)  Payment rates for plans shall reflect historic
1239	utilization and spending for covered services projected forward
1240	and adjusted to reflect the level of care profile for enrollees
1241	of each plan. The payment shall be adjusted to provide an
1242	incentive for reducing institutional placements and increasing
1243	the utilization of home and community-based services.
1244	(4)  The initial assessment of an enrollee's level of care
1245	shall be made by the Comprehensive Assessment and Review for
1246	Long-Term-Care Services (CARES) program, which shall assign the
1247	recipient into one of the following levels of care:
1248	(a)  Level of care 1 consists of recipients residing in
1249	nursing homes or needing immediate placement in a nursing home.
1250	(b)  Level of care 2 consists of recipients who require the
1251	constant availability of routine medical and nursing treatment
1252	and care, and require extensive health-related care and services
1253	because of mental or physical incapacitation.
1254	(c)  Level of care 3 consists of recipients who require the
1255	constant availability of routine medical and nursing treatment
1256	and care, have a limited need for health-related care and
1257	services, are mildly medically or physically incapacitated, and
1258	have a priority score of 5 or above.
1259
1260	The agency shall periodically adjust payment rates to account
1261	for changes in the level of care profile for each plan based on
1262	encounter data.
1263	(5)  The incentive adjustment for reducing institutional
1264	placements shall be modified in each successive rate period
1265	during the contract in order to encourage a progressive
1266	rebalancing of the spending distribution for institutional and
1267	community services. The expected change toward more home and
1268	community-based services shall be a 5 percent or greater annual
1269	increase in the ratio of home and community-based service
1270	expenditures compared to nursing facility expenditures.
1271	(6)  The agency shall establish nursing facility-specific
1272	payment rates for each licensed nursing home based on facility
1273	costs adjusted for inflation and other factors. Payments to
1274	long-term care managed care plans shall be reconciled to
1275	reimburse actual payments to nursing facilities.
1276	(7)  The agency shall establish hospice payment rates.
1277	Payments to long-term care managed care plans shall be
1278	reconciled to reimburse actual payments to hospices.
1279	Section 25.  Section 409.984, Florida Statutes, is created
1280	to read:
1281	409.984  Choice counseling; enrollment.-
1282	(1) CHOICE COUNSELING.-Before contracting with a vendor to
1283	provide choice counseling as authorized under s. 409.969, the
1284	agency shall offer to contract with aging resource centers
1285	established under s. 430.2053 for choice counseling services. If
1286	the aging resource center is determined not to be the vendor
1287	that provides choice counseling, the agency shall establish a
1288	memorandum of understanding with the aging resource center to
1289	coordinate staffing and collaborate with the choice counseling
1290	vendor.
1291	(2)  AUTOMATIC ENROLLMENT.-The agency shall automatically
1292	enroll into a long-term care managed care plan those Medicaid
1293	recipients who do not voluntarily choose a plan pursuant to s.
1294	409.969. The agency shall automatically enroll recipients in
1295	plans that meet or exceed the performance or quality standards
1296	established pursuant to s. 409.967, and shall not automatically
1297	enroll recipients in a plan that is deficient in those
1298	performance or quality standards. The agency shall assign
1299	individuals who are deemed dually eligible for Medicaid and
1300	Medicare to a plan that provides both Medicaid and Medicare
1301	services. The agency may not engage in practices that are
1302	designed to favor one managed care plan over another. When
1303	automatically enrolling recipients in plans, the agency shall
1304	take into account the following criteria:
1305	(a)  Whether the plan has sufficient network capacity to
1306	meet the needs of the recipients.
1307	(b)  Whether the recipient has previously received services
1308	from one of the plan's home and community-based service
1309	providers.
1310	(c)  Whether the home and community-based providers in one
1311	plan are more geographically accessible to the recipient's
1312	residence than those in other plans.
1313	(3)  Notwithstanding the provisions of s. 409.969(3)(c),
1314	when a recipient is referred for hospice services, the recipient
1315	shall have a 30-day period during which the recipient may select
1316	to enroll in another plan to access the hospice provider of the
1317	recipient's choice.
1318	Section 26.  Section 409.985, Florida Statutes, is created
1319	to read:
1320	409.985  Comprehensive Assessment and Review for Long-Term
1321	Care Services (CARES) Program.-
1322	(1)  The agency shall operate the Comprehensive Assessment
1323	and Review for Long-Term Care Services (CARES) preadmission
1324	screening program to ensure that only individuals whose
1325	conditions require long-term care services are enrolled in the
1326	long-term care managed care program.
1327	(2)  The agency shall operate the CARES program through an
1328	interagency agreement with the Department of Elderly Affairs.
1329	The agency, in consultation with the Department of Elderly
1330	Affairs, may contract for any function or activity of the CARES
1331	program, including any function or activity required by 42
1332	C.F.R. part 483.20, relating to preadmission screening and
1333	review.
1334	(3)  The CARES program shall determine if an individual
1335	requires nursing facility care and, if the individual requires
1336	such care, assign the individual to a level of care as described
1337	in s. 409.983(4). For the purposes of the long-term care managed
1338	care program, "nursing facility care" means the individual:
1339	(a)  Requires the constant availability of routine medical
1340	and nursing treatment and care, and requires extensive health-
1341	related care and services because of mental or physical
1342	incapacitation; or
1343	(b)  Requires the constant availability of routine medical
1344	and nursing treatment and care, has a limited need for health-
1345	related care and services, is mildly medically or physically
1346	incapacitated, and has a priority score of 5 or above.
1347	(4)  For individuals whose nursing home stay is initially
1348	funded by Medicare and Medicare coverage is being terminated for
1349	lack of progress towards rehabilitation, CARES staff shall
1350	consult with the person making the determination of progress
1351	toward rehabilitation to ensure that the recipient is not being
1352	inappropriately disqualified from Medicare coverage. If, in
1353	their professional judgment, CARES staff believes that a
1354	Medicare beneficiary is still making progress toward
1355	rehabilitation, they may assist the Medicare beneficiary with an
1356	appeal of the disqualification from Medicare coverage. The use
1357	of CARES teams to review Medicare denials for coverage under
1358	this section is authorized only if it is determined that such
1359	reviews qualify for federal matching funds through Medicaid. The
1360	agency shall seek or amend federal waivers as necessary to
1361	implement this section.
1362	Section 27.  Section 409.986, Florida Statutes, is created
1363	to read:
1364	409.986  Managed long-term care for persons with
1365	developmental disabilities.-
1366	(1)  Pursuant to s. 409.963, the agency is responsible for
1367	administering the long-term care managed care program for
1368	persons with developmental disabilities described in ss.
1369	409.986-409.992, but may delegate specific duties and
1370	responsibilities for the program to the Agency for Persons with
1371	Disabilities and other state agencies. By January 1, 2014, the
1372	agency shall begin implementation of statewide long-term care
1373	managed care for persons with developmental disabilities, with
1374	full implementation in all regions by October 1, 2015.
1375	(2)  The agency shall make payments for long-term care for
1376	persons with developmental disabilities, including home and
1377	community-based services, using a managed care model. Unless
1378	otherwise specified, the provisions of ss. 409.961-409.970 apply
1379	to the long-term care managed care program for persons with
1380	developmental disabilities.
1381	(3)  The Agency for Persons with Disabilities shall assist
1382	the agency to develop the specifications for use in the
1383	invitations to negotiate and the model contract; determine
1384	clinical eligibility for enrollment in long-term care plans for
1385	persons with developmental disabilities; assist the agency to
1386	monitor plan performance and measure quality; assist clients and
1387	families to address complaints with the plans; facilitate
1388	working relationships between plans and providers serving
1389	persons with developmental disabilities; and perform other
1390	functions specified in a memorandum of agreement.
1391	Section 28.  Section 409.987, Florida Statutes, is created
1392	to read:
1393	409.987  Eligibility.-
1394	(1)  Medicaid recipients who meet all of the following
1395	criteria are eligible to be enrolled in a developmental
1396	disabilities comprehensive long-term care plan or developmental
1397	disabilities long-term care plan:
1398	(a)  Medicaid eligible pursuant to income and asset tests
1399	in state and federal law.
1400	(b)  A Florida resident who has a developmental disability
1401	as defined in s. 393.063.
1402	(c)  Meets the level of care need including:
1403	1.  The recipient's intelligence quotient is 59 or less;
1404	2.  The recipient's intelligence quotient is 60-69,
1405	inclusive, and the recipient has a secondary handicapping
1406	condition that includes cerebral palsy, spina bifida, Prader-
1407	Willi syndrome, epilepsy, or autism; or ambulation, sensory,
1408	chronic health, and behavioral problems;
1409	3.  The recipient's intelligence quotient is 60-69,
1410	inclusive, and the recipient has severe functional limitations
1411	in at least three major life activities including self-care,
1412	learning, mobility, self-direction, understanding and use of
1413	language, and capacity for independent living; or
1414	4.  The recipient is eligible under a primary disability of
1415	autism, cerebral palsy, spina bifida, or Prader-Willi syndrome.
1416	In addition, the condition must result in substantial functional
1417	limitations in three or more major life activities, including
1418	self-care, learning, mobility, self-direction, understanding and
1419	use of language, and capacity for independent living.
1420	(d)  Meets the level of care need for services in an
1421	intermediate care facility for the developmentally disabled.
1422	(e)  Is enrolled or has been offered enrollment in one of
1423	the four tier waivers established in s. 393.0661(3) or the
1424	recipient is a Medicaid-funded resident of a private
1425	intermediate care facility for the developmentally disabled on
1426	the date the managed long-term care plans for persons with
1427	disabilities become available in the recipient's region.
1428	(2) Unless specifically exempted, all eligible persons must
1429	be enrolled in a developmental disabilities comprehensive long-
1430	term care plan or a developmental disabilities long-term care
1431	plan. Medicaid recipients who are residents of a developmental
1432	disability center, including Sunland Center in Marianna and
1433	Tacachale Center in Gainesville, are exempt from mandatory
1434	enrollment but may voluntarily enroll in a long-term care plan.
1435	Section 29.  Section 409.988, Florida Statutes, is created
1436	to read:
1437	409.988  Benefits.-Managed care plans shall cover, at a
1438	minimum, the services in this section. Plans may customize
1439	benefit packages or offer additional benefits to meet the needs
1440	of enrollees in the plan.
1441	(1)  Intermediate care for developmentally disabled.
1442	(2)  Alternative residential services, including, but not
1443	limited to:
1444	(a)  Group homes and foster care homes licensed pursuant to
1445	chapters 393 and 409.
1446	(b)  Comprehensive transitional education programs licensed
1447	pursuant to chapter 393.
1448	(c)  Residential habilitation centers licensed pursuant to
1449	chapter 393.
1450	(d)  Assisted living facilities, and transitional living
1451	facilities licensed pursuant to chapters 400 and 429.
1452	(3)  Adult day training.
1453	(4)  Behavior analysis services.
1454	(5)  Companion services.
1455	(6)  Consumable medical supplies.
1456	(7)  Durable medical equipment and supplies.
1457	(8)  Environmental accessibility adaptations.
1458	(9)  In-home support services.
1459	(10)  Therapies, including occupational, speech,
1460	respiratory, and physical therapy.
1461	(11)  Personal care assistance.
1462	(12)  Residential habilitation services.
1463	(13)  Intensive behavior residential habilitation services.
1464	(14)  Behavior focus residential habilitation services.
1465	(15)  Residential nursing services.
1466	(16)  Respite care.
1467	(17)  Case management.
1468	(18)  Supported employment.
1469	(19)  Supported living coaching.
1470	(20)  Transportation.
1471	Section 30.  Section 409.989, Florida Statutes, is created
1472	to read:
1473	409.989  Qualified plans.-
1474	(1)  QUALIFIED PLANS.-Qualified plans may either be
1475	developmental disabilities long-term care plans that cover
1476	benefits pursuant to s. 409.988, or developmental disabilities
1477	comprehensive long- term care plans that cover benefits pursuant
1478	to ss. 409.973 and 409.988.
1479	(2)  SPECIALTY PROVIDER SERVICE NETWORKS.-Provider service
1480	networks targeted to serve persons with disabilities must
1481	include one or more owners licensed pursuant to s. 393.067 or s.
1482	400.962 and with at least 10 years experience in serving this
1483	population.
1484	(3)  QUALIFIED PLAN SELECTION.-The agency shall select
1485	qualified plans through the procurement described in s. 409.966.
1486	The agency shall notice invitations to negotiate no later than
1487	January 1, 2014.
1488	(a)  The agency shall procure two plans for Region I. At
1489	least one plan shall be a provider service network, if any
1490	submit a responsive bid.
1491	(b)  The agency shall procure at least two and no more than
1492	five plans for Region II. At least one plan shall be a provider
1493	service network, if any submit a responsive bid.
1494	(c)  The agency shall procure at least three plans and no
1495	more than six plans for Region III. At least one plan shall be a
1496	provider service network, if any submit a responsive bid.
1497	(d)  The agency shall procure at least three plans and no
1498	more than six plans for Region IV. At least one plan shall be a
1499	provider service network if any submit a responsive bid.
1500	(e)  The agency shall procure at least three plans and no
1501	more than six plans for Region V. At least one plan shall be a
1502	provider service network, if any submit a responsive bid.
1503	(f)  The agency shall procure at least three plans and no
1504	more than six plans for Region VI. At least one plan shall be a
1505	provider service network, if any submit a responsive bid.
1506	(4)  QUALITY SELECTION CRITERIA.-In addition to the
1507	criteria established in s. 409.966, the agency shall consider
1508	the following factors in the selection of qualified plans:
1509	(a)  Specialized staffing. Plan employment of executive
1510	managers with expertise and experience in serving persons with
1511	developmental disabilities.
1512	(b)  Network qualifications. Plan establishment of a
1513	network of service providers dispersed throughout the region and
1514	in sufficient numbers to meet specific accessibility standards
1515	established by the agency for specialty services for persons
1516	with developmental disabilities.
1517	(c)  Whether the plan has proposed to be a developmental
1518	disabilities comprehensive long-term care plan and has a
1519	contract to provide managed medical assistance services in the
1520	same region. The agency shall exercise a preference for such
1521	plans.
1522	(d)  Whether the plan offers consumer-directed care
1523	services to enrollees pursuant to s. 409.221. Consumer-directed
1524	care services provide a flexible budget which is managed by
1525	enrolled individuals and their families or representatives and
1526	allows them to choose providers of services, determine provider
1527	rates of payment and direct the delivery of services to best
1528	meet their special long-term care needs. When all other factors
1529	are equal among competing qualified plans, the agency shall
1530	exercise a preference for such plans.
1531	(e)  Evidence that a qualified plan has written agreements
1532	or signed contracts or has made substantial progress in
1533	establishing relationships with providers prior to the plan
1534	submitting a response. The agency shall evaluate and give
1535	special weight to evidence of signed contracts with providers of
1536	critical services pursuant to s. 409.990(2)a)-(b).
1537	(5)  CHILDREN'S MEDICAL SERVICES NETWORK.-The Children's
1538	Medical Services Network authorized under chapter 391 is a
1539	qualified plan for purposes of the developmental disabilities
1540	long-term care plans and developmental disabilities
1541	comprehensive long-term care plans. Participation by the
1542	Children's Medical Services Network shall be pursuant to a
1543	single, statewide contract with the agency not subject to the
1544	procurement requirements or regional plan number limits of this
1545	section. The Children's Medical Services Network must meet all
1546	other plan requirements.
1547	Section 31.  Section 409.990, Florida Statutes, is created
1548	to read:
1549	409.990  Managed care plan accountability.-In addition to
1550	the requirements of s. 409.967, qualified plans and providers
1551	shall comply with the requirements of this section.
1552	(1)  MEDICAL LOSS RATIO.-The agency shall establish and
1553	plans shall use a uniform method of accounting and reporting
1554	long-term care service costs, direct care management costs, and
1555	administrative costs. The agency shall evaluate plan spending
1556	patterns beginning after the plan completes 2 full years of
1557	operation and at least annually thereafter. The agency shall
1558	implement the following thresholds and consequences of various
1559	spending patterns:
1560	(a)  Plans that spend less than 75 percent of Medicaid
1561	premium revenue on long-term care services, including direct
1562	care management as determined by the agency shall be excluded
1563	from automatic enrollments and shall be required to pay back the
1564	amount between actual spending and 85 percent of the Medicaid
1565	premium revenue.
1566	(b)  Plans that spend less than 85 percent of Medicaid
1567	premium revenue on long-term care services, including direct
1568	care management as determined by the agency shall be required to
1569	pay back the amount between actual spending and 85 percent of
1570	the Medicaid premium revenue.
1571	(c)  Plans that spend more than 92 percent of Medicaid
1572	premium revenue on long-term care services including direct care
1573	management shall be evaluated by the agency to determine whether
1574	higher expenditures are the result of failures in care
1575	management. Such a determination may result in the plan being
1576	excluded from automatic enrollments.
1577	(2)  PROVIDER NETWORKS.-Plans may limit the providers in
1578	their networks based on credentials, quality indicators, and
1579	price. However, in the first contract period after a qualified
1580	plan is selected in a region by the agency, the plan must offer
1581	a network contract to the following providers in the region:
1582	(a)  Providers with licensed institutional care facilities
1583	for the developmentally disabled.
1584	(b)  Providers of alternative residential facilities
1585	specified in s.409.988.
1586
1587	After 12 months of active participation in a plan's network, the
1588	plan may exclude any of the above-named providers from the
1589	network for failure to meet quality or performance criteria.
1590	(3)  SELECT PROVIDER PARTICIPATION.-Except as provided in
1591	this subsection, providers may limit the plans they join.
1592	Licensed institutional care facilities for the developmentally
1593	disabled with an active Medicaid provider agreement must agree
1594	to participate in any qualified plan selected by the agency in
1595	the region in which the provider is located.
1596	(4)  PERFORMANCE MEASUREMENT.-Each plan shall monitor the
1597	quality and performance of each participating provider. At the
1598	beginning of the contract period, each plan shall notify all its
1599	network providers of the metrics used by the plan for evaluating
1600	the provider's performance and determining continued
1601	participation in the network.
1602	(5)  PROVIDER PAYMENT.-Plans and providers shall negotiate
1603	mutually acceptable rates, methods, and terms of payment. Plans
1604	shall pay intermediate care facilities for the developmentally
1605	disabled an amount equal to the facility-specific payment rate
1606	set by the agency.
1607	(6)  CONSUMER AND FAMILY INVOLVEMENT.-Plans must establish
1608	a family advisory committee to participate in program design and
1609	oversight.
1610	Section 32.  Section 409.991, Florida Statutes, is created
1611	to read:
1612	409.991  Managed care plan payment.-In addition to the
1613	payment provisions of s. 409.968, the agency shall provide
1614	payment to developmental disabilities comprehensive long-term
1615	care plans and developmental disabilities long-term care plans
1616	pursuant to this section.
1617	(1)  Prepaid payment rates shall be negotiated between the
1618	agency and the qualified plans as part of the procurement
1619	described in s. 409.966.
1620	(2)  Payment for developmental disabilities comprehensive
1621	long-term care plans covering services pursuant to s. 409.973
1622	shall be combined with payments for developmental disabilities
1623	long-term care plans for services specified in s. 409.988.
1624	(3)  Payment rates for plans covering service specified in
1625	s. 409.988 shall be based on historical utilization and spending
1626	for covered services projected forward and adjusted to reflect
1627	the level of care profile of each plan's enrollees.
1628	(4)  The Agency for Persons with Disabilities shall conduct
1629	the initial assessment of an enrollee's level of care. The
1630	evaluation of level of care shall be based on assessment and
1631	service utilization information from the most recent version of
1632	the Questionnaire for Situational Information and encounter
1633	data.
1634	(5)  Payment rates for developmental disabilities long-term
1635	care plans shall be classified into five levels of care to
1636	account for variations in risk status and service needs among
1637	enrollees.
1638	(a)  Level of care 1 consists of individuals receiving
1639	services in an intermediate care facility for the
1640	developmentally disabled.
1641	(b)  Level of care 2 consists of individuals with intensive
1642	medical or adaptive needs and that are essential for avoiding
1643	institutionalization, or who possess behavioral problems that
1644	are exceptional in intensity, duration, or frequency and present
1645	a substantial risk of harm to themselves or others.
1646	(c)  Level of care 3 consists of individuals with service
1647	needs, including a licensed residential facility and a moderate
1648	level of support for standard residential habilitation services
1649	or a minimal level of support for behavior focus residential
1650	habilitation services, or individuals in supported living who
1651	require more than 6 hours a day of in-home support services.
1652	(d)  Level of care 4 consists of individuals requiring less
1653	than moderate level of residential habilitation support in a
1654	residential placement, or individuals in independent or
1655	supported living situations, or who live in their family home.
1656	(e)  Level of care 5 consists of individuals requiring
1657	minimal support services while living in independent or
1658	supported living situations and individuals who live in their
1659	family home.
1660
1661	The agency shall periodically adjust payment rates to account
1662	for changes in the level of care profile of each plan's
1663	enrollees based on encounter data.
1664	(6)  The agency will establish intermediate care facility
1665	for the developmentally disabled-specific payment rates for each
1666	licensed intermediate care facility based on facility costs
1667	adjusted for inflation and other factors. Payments to
1668	intermediate care facilities for the developmentally disabled
1669	shall be reconciled to reimburse the plan's actual payments to
1670	the facilities.
1671	Section 33.  Section 409.992, Florida Statutes, is created
1672	to read:
1673	409.992  Automatic enrollment.-
1674	(1)  The agency shall automatically enroll into a
1675	developmental disabilities comprehensive long-term care plan or
1676	a developmental disabilities long-term care plan those Medicaid
1677	recipients who do not voluntarily choose a plan pursuant to s.
1678	409.969. The agency shall automatically enroll recipients in
1679	plans that meet or exceed the performance or quality standards
1680	established pursuant to s. 409.967, and shall not automatically
1681	enroll recipients in a plan that is deficient in those
1682	performance or quality standards. The agency shall assign
1683	individuals who are deemed dually eligible for Medicaid and
1684	Medicare, to a plan that provides both Medicaid and Medicare
1685	services. The agency may not engage in practices that are
1686	designed to favor one managed care plan over another. When
1687	automatically enrolling recipients in plans, the agency shall
1688	take into account the following criteria:
1689	(a)  Whether the plan has sufficient network capacity to
1690	meet the needs of the recipients.
1691	(b)  Whether the recipient has previously received services
1692	from one of the plan's home and community-based service
1693	providers.
1694	(c)  Whether home and community-based providers in one plan
1695	are more geographically accessible to the recipient's residence
1696	than those in other plans.
1697	Section 34.  This act shall take effect July 1, 2010.

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