HB 267

1	A bill to be entitled
2	An act relating to the nursing home diversion program;
3	amending s. 409.912, F.S.; directing the Agency for Health
4	Care Administration to expand the nursing home diversion
5	program to include Medicaid recipients who meet certain
6	criteria; specifying locations for phased-in
7	implementation of the program; revising conditions for
8	enrollment in the program; providing for Medicaid
9	recipient choice with regard to contractors; requiring the
10	nursing home diversion contractor to provide an enrollee
11	with information regarding alternative service providers;
12	requiring certain enrollees to participate in the program;
13	requiring the program to combine funding for Medicaid
14	services provided to specified individuals; removing an
15	exception; excluding specified individuals from
16	participation in the program; revising provisions relating
17	to entities eligible to participate in the program;
18	requiring the Department of Elderly Affairs and the agency
19	to seek federal waivers to limit the number of nursing
20	home diversion contractors in additional locations;
21	directing the agency to impose certain requirements on
22	contractors in the program; requiring the Office of
23	Program Policy Analysis and Government Accountability, in
24	consultation with the Auditor General, to evaluate the
25	nursing home diversion contractors in the program;
26	removing an obsolete provision relating to an
27	appropriation for implementation of a pilot program;
28	amending s. 408.040, F.S.; removing a reporting
29	requirement, to conform; providing an effective date.
30
31	Be It Enacted by the Legislature of the State of Florida:
32
33	Section 1.  Subsection (5) of section 409.912, Florida
34	Statutes, is amended to read:
35	409.912  Cost-effective purchasing of health care.-The
36	agency shall purchase goods and services for Medicaid recipients
37	in the most cost-effective manner consistent with the delivery
38	of quality medical care. To ensure that medical services are
39	effectively utilized, the agency may, in any case, require a
40	confirmation or second physician's opinion of the correct
41	diagnosis for purposes of authorizing future services under the
42	Medicaid program. This section does not restrict access to
43	emergency services or poststabilization care services as defined
44	in 42 C.F.R. part 438.114. Such confirmation or second opinion
45	shall be rendered in a manner approved by the agency. The agency
46	shall maximize the use of prepaid per capita and prepaid
47	aggregate fixed-sum basis services when appropriate and other
48	alternative service delivery and reimbursement methodologies,
49	including competitive bidding pursuant to s. 287.057, designed
50	to facilitate the cost-effective purchase of a case-managed
51	continuum of care. The agency shall also require providers to
52	minimize the exposure of recipients to the need for acute
53	inpatient, custodial, and other institutional care and the
54	inappropriate or unnecessary use of high-cost services. The
55	agency shall contract with a vendor to monitor and evaluate the
56	clinical practice patterns of providers in order to identify
57	trends that are outside the normal practice patterns of a
58	provider's professional peers or the national guidelines of a
59	provider's professional association. The vendor must be able to
60	provide information and counseling to a provider whose practice
61	patterns are outside the norms, in consultation with the agency,
62	to improve patient care and reduce inappropriate utilization.
63	The agency may mandate prior authorization, drug therapy
64	management, or disease management participation for certain
65	populations of Medicaid beneficiaries, certain drug classes, or
66	particular drugs to prevent fraud, abuse, overuse, and possible
67	dangerous drug interactions. The Pharmaceutical and Therapeutics
68	Committee shall make recommendations to the agency on drugs for
69	which prior authorization is required. The agency shall inform
70	the Pharmaceutical and Therapeutics Committee of its decisions
71	regarding drugs subject to prior authorization. The agency is
72	authorized to limit the entities it contracts with or enrolls as
73	Medicaid providers by developing a provider network through
74	provider credentialing. The agency may competitively bid single-
75	source-provider contracts if procurement of goods or services
76	results in demonstrated cost savings to the state without
77	limiting access to care. The agency may limit its network based
78	on the assessment of beneficiary access to care, provider
79	availability, provider quality standards, time and distance
80	standards for access to care, the cultural competence of the
81	provider network, demographic characteristics of Medicaid
82	beneficiaries, practice and provider-to-beneficiary standards,
83	appointment wait times, beneficiary use of services, provider
84	turnover, provider profiling, provider licensure history,
85	previous program integrity investigations and findings, peer
86	review, provider Medicaid policy and billing compliance records,
87	clinical and medical record audits, and other factors. Providers
88	shall not be entitled to enrollment in the Medicaid provider
89	network. The agency shall determine instances in which allowing
90	Medicaid beneficiaries to purchase durable medical equipment and
91	other goods is less expensive to the Medicaid program than long-
92	term rental of the equipment or goods. The agency may establish
93	rules to facilitate purchases in lieu of long-term rentals in
94	order to protect against fraud and abuse in the Medicaid program
95	as defined in s. 409.913. The agency may seek federal waivers
96	necessary to administer these policies.
97	(5)  The Agency for Health Care Administration, in
98	partnership with the Department of Elderly Affairs, shall expand
99	the nursing home diversion program into create an integrated,
100	fixed-payment delivery program for all Medicaid recipients who
101	meet nursing home admission criteria and are 60 years of age or
102	older and or dually eligible for Medicare and Medicaid. The
103	Agency for Health Care Administration shall implement the
104	integrated program initially in on a pilot basis in two Areas 5,
105	6, and 7 of the state. The program shall be implemented in Areas
106	8, 9, 10, and 11 in 2013 and in Areas 1, 2, 3, and 4 in 2014.
107	All Medicaid recipients shall be given a choice of nursing home
108	diversion contractors in each area. In order to ensure enrollee
109	choice, when an enrollee is determined to be likely to require
110	the level of care provided in a hospital or nursing home, the
111	enrollee shall be informed by the nursing home diversion
112	contractor of any feasible alternatives available and given the
113	choice of either institutional or home and community-based
114	services pilot areas shall be Area 7 and Area 11 of the Agency
115	for Health Care Administration. Enrollment in the pilot areas
116	shall be on a voluntary basis and in accordance with approved
117	federal waivers and this section. The agency and its program
118	contractors and providers shall not enroll any individual in the
119	integrated program because the individual or the person legally
120	responsible for the individual fails to choose to enroll in the
121	integrated program. Enrollment in the integrated program shall
122	be exclusively by affirmative choice of the eligible individual
123	or by the person legally responsible for the individual. The
124	integrated program must transfer all Medicaid services for
125	eligible elderly individuals who choose to participate into an
126	integrated-care management model designed to serve Medicaid
127	recipients in the community. The integrated program must combine
128	all funding for Medicaid services provided to individuals who
129	are 60 years of age or older and or dually eligible for Medicare
130	and Medicaid into the integrated program, including funds for
131	Medicaid home and community-based waiver services; all Medicaid
132	services authorized in ss. 409.905 and 409.906, including
133	excluding funds for Medicaid nursing home services unless the
134	agency is able to demonstrate how the integration of the funds
135	will improve coordinated care for these services in a less
136	costly manner; and Medicare coinsurance and deductibles for
137	persons dually eligible for Medicaid and Medicare as prescribed
138	in s. 409.908(13).
139	(a)  Individuals who are 60 years of age or older, or
140	dually eligible for Medicare and Medicaid, and enrolled in
141	developmental disabilities waiver program, the family and
142	supported-living waiver program, the project AIDS care waiver
143	program, the traumatic brain injury and spinal cord injury
144	waiver program, the consumer-directed care waiver program, and
145	the program of all-inclusive care for the elderly program, and
146	residents of institutional care facilities for the
147	developmentally disabled, must be excluded from the integrated
148	program.
149	(b)  Managed care entities who meet or exceed the agency's
150	minimum standards are eligible to operate the integrated
151	program. Entities eligible to participate include managed care
152	organizations licensed under chapter 641, including entities
153	eligible to participate in the nursing home diversion program
154	contractors, other qualified providers as defined in s.
155	430.703(6) and (7). The Department of Elderly Affairs and the
156	agency shall comply with s. 430.705(3) prior to approval of any
157	additional contractors, community care for the elderly lead
158	agencies, and other state-certified community service networks
159	that meet comparable standards as defined by the agency, in
160	consultation with the Department of Elderly Affairs and the
161	Office of Insurance Regulation, to be financially solvent and
162	able to take on financial risk for managed care. Community
163	service networks that are certified pursuant to the comparable
164	standards defined by the agency are not required to be licensed
165	under chapter 641. Managed care entities who operate the
166	integrated program shall be subject to s. 408.7056. Eligible
167	entities shall choose to serve enrollees who are dually eligible
168	for Medicare and Medicaid, enrollees who are 60 years of age or
169	older, or both.
170	(c)  The agency must ensure that the capitation-rate-
171	setting methodology for the integrated program is actuarially
172	sound and reflects the intent to provide quality care in the
173	least restrictive setting. The agency must also require nursing
174	home diversion contractors integrated-program providers to
175	develop a credentialing system for service providers and to
176	contract with all Gold Seal nursing homes, where feasible, and
177	exclude, where feasible, chronically poor-performing facilities
178	and providers as defined by the agency. The integrated program
179	must develop and maintain an informal provider grievance system
180	that addresses provider payment and contract problems. The
181	agency shall also establish a formal grievance system to address
182	those issues that were not resolved through the informal
183	grievance system. The integrated program must provide that if
184	the recipient resides in a noncontracted residential facility
185	licensed under chapter 400 or chapter 429 at the time of
186	enrollment in the integrated program and the recipient's needs
187	cannot be met in a less restrictive environment, the recipient
188	must be permitted to continue to reside in the noncontracted
189	facility as long as the recipient desires. The integrated
190	program must also provide that, in the absence of a contract
191	between the nursing home diversion contractor integrated-program
192	provider and the residential facility licensed under chapter 400
193	or chapter 429, current Medicaid rates must prevail. The nursing
194	home diversion contractor integrated-program provider must
195	ensure that electronic nursing home claims that contain
196	sufficient information for processing are paid within 10
197	business days after receipt. Alternately, the nursing home
198	diversion contractor integrated-program provider may establish a
199	capitated payment mechanism to prospectively pay nursing homes
200	at the beginning of each month. The agency and the Department of
201	Elderly Affairs must jointly develop procedures to manage the
202	services provided through the integrated program in order to
203	ensure quality and recipient choice.
204	(d)  The Office of Program Policy Analysis and Government
205	Accountability, in consultation with the Auditor General, shall
206	comprehensively evaluate the pilot project for the integrated,
207	fixed-payment delivery program for Medicaid recipients created
208	under this subsection. The evaluation shall begin as soon as
209	Medicaid recipients are enrolled in the managed care pilot
210	program plans and shall continue for 24 months thereafter. The
211	evaluation must include assessments of each nursing home
212	diversion contractor managed care plan in the integrated program
213	with regard to cost savings; consumer education, choice, and
214	access to services; coordination of care; and quality of care.
215	The evaluation must describe administrative or legal barriers to
216	the implementation and operation of the pilot program and
217	include recommendations regarding statewide expansion of the
218	pilot program. The office shall submit its evaluation report to
219	the Governor, the President of the Senate, and the Speaker of
220	the House of Representatives no later than December 31, 2014
221	2009.
222	(e)  The agency may seek federal waivers or Medicaid state
223	plan amendments and adopt rules as necessary to administer the
224	integrated program. The agency may implement the approved
225	federal waivers and other provisions as specified in this
226	subsection.
227	(f)  The implementation of the integrated, fixed-payment
228	delivery program created under this subsection is subject to an
229	appropriation in the General Appropriations Act.
230	Section 2.  Paragraph (e) of subsection (1) of section
231	408.040, Florida Statutes, is redesignated as paragraph (d), and
232	present paragraph (d) of that subsection is amended to read:
233	408.040  Conditions and monitoring.-
234	(1)
235	(d)  If a nursing home is located in a county in which a
236	long-term care community diversion pilot project has been
237	implemented under s. 430.705 or in a county in which an
238	integrated, fixed-payment delivery program for Medicaid
239	recipients who are 60 years of age or older or dually eligible
240	for Medicare and Medicaid has been implemented under s.
241	409.912(5), the nursing home may request a reduction in the
242	percentage of annual patient days used by residents who are
243	eligible for care under Title XIX of the Social Security Act,
244	which is a condition of the nursing home's certificate of need.
245	The agency shall automatically grant the nursing home's request
246	if the reduction is not more than 15 percent of the nursing
247	home's annual Medicaid-patient-days condition. A nursing home
248	may submit only one request every 2 years for an automatic
249	reduction. A requesting nursing home must notify the agency in
250	writing at least 60 days in advance of its intent to reduce its
251	annual Medicaid-patient-days condition by not more than 15
252	percent. The agency must acknowledge the request in writing and
253	must change its records to reflect the revised certificate-of-
254	need condition. This paragraph expires June 30, 2011.
255	Section 3.  This act shall take effect July 1, 2011.

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