Amendment
Bill No. CS/HB 7107

Amendment No. 064189

CHAMBER ACTION
Senate		House
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1	Representative Pafford offered the following:
2
3	Amendment (with title amendment)
4	Remove everything after the enacting clause and insert:
5	Section 1.  It is the intent of the Legislature to ensure
6	that all Medicaid recipients receive medically necessary,
7	quality care through the provider of their choice. In Florida's
8	medical marketplace, managed care plans are responsible for the
9	health care of almost 50 percent of Medicaid recipients.
10	Therefore, the Legislature finds it is in the state's interest
11	to ensure managed care plans are delivering appropriate quality
12	services and are held accountable for the proper use of taxpayer
13	dollars.
14	Section 2.  Sections 409.961 through 409.697, Florida
15	Statutes, are designated as part IV of chapter 409, Florida
16	Statutes, entitled "Medicaid Managed Care Accountability Act."
17	Section 3.  Section 409.961, Florida Statutes, is created
18	to read:
19	409.961  Definitions.-As used in this part, except as
20	otherwise specifically provided, the term:
21	(1)  "Agency" means the Agency for Health Care
22	Administration.
23	(2)  "Department" means the Department of Children and
24	Family Services.
25	(3)  "Direct care management" means care management
26	activities that involve direct interaction with Medicaid
27	recipients.
28	(4)  "Eligible plan" means a health insurer authorized
29	under chapter 624, an exclusive provider organization authorized
30	under chapter 627, a health maintenance organization authorized
31	under chapter 641, or a provider service network authorized
32	under s. 409.912(4)(d).
33	(5)  "Managed care plan" means an eligible plan under
34	contract with the agency to provide services in the Medicaid
35	program.
36	(6)  "Medicaid" means the medical assistance program
37	authorized by Title XIX of the Social Security Act, 42 U.S.C. 81
38	ss. 1396 et seq., and regulations thereunder, as administered in
39	this state by the agency.
40	(7)  "Medicaid recipient" or "recipient" means an
41	individual who the department or, for Supplemental Security
42	Income, the Social Security Administration, determines is
43	eligible pursuant to federal and state law to receive medical
44	assistance and related services for which the agency may make
45	payments under the Medicaid program. For the purposes of
46	determining third-party liability, the term includes an
47	individual formerly determined to be eligible for Medicaid, an
48	individual who has received medical assistance under the
49	Medicaid program, or an individual on whose behalf Medicaid has
50	become obligated.
51	(8)  "Prepaid plan" means a managed care plan that is
52	licensed or certified as a risk-bearing entity, or qualified
53	pursuant to s. 409.912(4)(d), in the state and is paid a
54	prospective per-member, per-month payment by the agency.
55	(9)  "Provider service network" means an entity qualified
56	pursuant to s. 409.912(4)(d) of which a controlling interest is
57	owned by a health care provider, or group of affiliated
58	providers, or a public agency or entity that delivers health
59	services. Health care providers include Florida-licensed health
60	care professionals or licensed health care facilities, federally
61	qualified health care centers, and home health care agencies.
62	(10)  "Specialty plan" means a managed care plan that
63	serves Medicaid recipients who meet specified criteria based on
64	age, medical condition, or diagnosis.
65	Section 4.  Section 409.962, Florida Statutes, is created
66	to read:
67	409.962  Single state agency.-The Agency for Health Care
68	Administration is designated as the single state agency
69	authorized to manage, operate, and make payments for medical
70	assistance and related services under Title XIX of the Social
71	Security Act. Subject to any limitations or directions provided
72	for in the General Appropriations Act, these payments may be
73	made only for services included in the program, only on behalf
74	of eligible individuals, and only to qualified providers in
75	accordance with federal requirements for Title XIX of the Social
76	Security Act and the provisions of state law. This program of
77	medical assistance is designated as the "Medicaid program." The
78	department is responsible for Medicaid eligibility
79	determinations, including, but not limited to, policy, rules,
80	and the agreement with the Social Security Administration for
81	Medicaid eligibility determinations for Supplemental Security
82	Income recipients, as well as the actual determination of
83	eligibility. As a condition of Medicaid eligibility, subject to
84	federal approval, the agency and the department shall ensure
85	that each Medicaid recipient consents to the release of her or
86	his medical records to the agency and the Medicaid Fraud Control
87	Unit of the Department of Legal Affairs.
88	Section 5.  Section 409.963, Florida Statutes, is created
89	to read:
90	409.963  Medicaid managed care contracting accountability.-
91	(1)  The agency shall establish such contract requirements
92	as are necessary for the operation of the managed care program.
93	In addition to any other provisions the agency may deem
94	necessary, the contract shall require:
95	(a)  Emergency services.-Managed care plans shall pay for
96	services required by ss. 395.1041 and 401.45 and rendered by a
97	noncontracted provider pursuant to s. 641.3155. Reimbursement
98	for services under this paragraph shall be the lesser of:
99	1.  The provider's charges;
100	2.  The usual and customary provider charges for similar
101	services in the community where the services were provided;
102	3.  The charge mutually agreed to by the entity and the
103	provider within 60 days after submittal of the claim; or
104	4.  The rate the agency would have paid on the first day of
105	the contract between the provider and the plan.
106	(b)  Access.-The agency shall establish specific standards
107	for the number, type, and distribution of providers in managed
108	care plan networks to ensure access to care for both adults and
109	children. Each plan must maintain a network of providers in
110	sufficient numbers to meet the access standards for specific
111	medical services for all recipients enrolled in the plan.
112	Consistent with the standards established by the agency,
113	provider networks may include providers located throughout the
114	state. Plans may contract with a new hospital facility before
115	the date it becomes operational if the hospital has commenced
116	construction, will be licensed and operational by January 1,
117	2013, and a final order has issued in any civil or
118	administrative challenge. Each plan shall establish and maintain
119	an accurate and complete electronic database of contracted
120	providers, including information about licensure or
121	registration, locations and hours of operation, specialty
122	credentials and other certifications, specific performance
123	indicators, including complaints as defined by s. 641.47 and
124	action taken on such complaints, and such other information as
125	the agency deems necessary. The database shall be available
126	online to both the agency and the public and compare the
127	availability of providers to network adequacy standards and
128	shall display feedback from each provider's patients. Each plan
129	shall submit quarterly reports to the agency identifying the
130	number of enrollees assigned to each primary care provider.
131	(c)  Encounter data.-The agency shall maintain and operate
132	a Medicaid Encounter Data System to collect, process, store, and
133	report on covered services provided to all Medicaid recipients.
134	The system shall provide a standard consistent methodology for
135	reporting such data.
136	1.  Each prepaid plan must comply with the agency's
137	reporting requirements for the Medicaid Encounter Data System.
138	Prepaid plans must submit encounter data electronically in a
139	format that complies with the Health Insurance Portability and
140	Accountability Act provisions for electronic claims and in
141	accordance with deadlines established by the agency. Prepaid
142	plans must certify that the data reported is accurate and
143	complete.
144	2.  The agency is responsible for validating the data
145	submitted by the plans. The agency shall develop methods and
146	protocols for ongoing analysis of the encounter data that
147	adjusts for differences in characteristics of prepaid plan
148	enrollees to allow comparison of service utilization among plans
149	and other Medicaid providers such as MediPass and other non-
150	prepaid Medicaid providers against expected levels of use. The
151	analysis shall be used to identify possible cases of systemic
152	underutilization or denials of claims and inappropriate service
153	utilization such as higher-than-expected emergency department
154	encounters. The analysis shall provide quarterly feedback to the
155	plans and enable the agency to establish corrective action plans
156	when necessary. One of the focus areas for the analysis shall be
157	the use of prescription drugs.
158	3.  The agency shall make encounter data available to those
159	plans accepting enrollees who are assigned to them from other
160	plans.
161	(d)  Continuous improvement.-The agency shall establish
162	specific performance standards and expected milestones or
163	timelines for improving performance over the term of the
164	contract. By the end of the first year of the first contract
165	term, the agency shall issue a request for information to
166	determine whether cost savings could be achieved by contracting
167	for plan oversight and monitoring, including analysis of
168	encounter data, assessment of performance measures, and
169	compliance with other contractual requirements. Each managed
170	care plan shall establish an internal health care quality
171	improvement system, including enrollee satisfaction and
172	disenrollment surveys. The quality improvement system shall
173	include incentives and disincentives for network providers.
174	(e)  Program integrity.-Each managed care plan shall
175	establish program integrity functions and activities to reduce
176	the incidence of fraud and abuse, including, at a minimum:
177	1.  A provider credentialing system and ongoing provider
178	monitoring;
179	2.  An effective prepayment and postpayment review process
180	including, but not limited to, data analysis, system editing,
181	and auditing of network providers;
182	3.  Procedures for reporting instances of fraud and abuse
183	pursuant to chapter 641;
184	4.  Administrative and management arrangements or
185	procedures, including a mandatory compliance plan, designed to
186	prevent fraud and abuse; and
187	5.  Designation of a program integrity compliance officer.
188	(f)  Complaint and grievance resolution.-Each managed care
189	plan shall establish and the agency shall approve an internal
190	process for reviewing and responding to complaints and
191	grievances from enrollees consistent with the requirements of
192	ss. 641.47 and 641.511. Each plan shall submit quarterly reports
193	on the number, description, and outcome of complaints and
194	grievances filed by enrollees. The agency shall maintain a
195	process for provider service networks consistent with s.
196	408.7056. Such reports from each plan shall be posted online
197	through the agency website in an easily accessible location.
198	(g)  Penalties.-Managed care plans that reduce enrollment
199	levels before the end of the contract term shall reimburse the
200	agency for the cost of enrollment changes and other transition
201	activities, including the cost of additional choice counseling
202	services. If more than one plan leaves at the same time, costs
203	shall be shared by the departing plans proportionate to their
204	enrollments. In addition to the payment of costs, departing
205	provider services networks shall pay a per-enrollee penalty not
206	to exceed 3 months' payment and shall continue to provide
207	services to the enrollee for 90 days or until the enrollee is
208	enrolled in another plan, whichever is sooner. In addition to
209	payment of costs, all other plans shall pay a penalty equal to
210	25 percent of the minimum surplus requirement pursuant to s.
211	641.225(1). Plans shall provide the agency notice no less than
212	180 days before withdrawing.
213	(h)  Prompt payment.-Managed care plans shall comply with
214	ss. 641.315, 641.3155, and 641.513.
215	(i)  Electronic claims.-Managed care plans shall accept
216	electronic claims in compliance with federal standards.
217	(j)  Fair payment.-Provider service networks must ensure
218	that no network provider with a controlling interest in the
219	network charges any Medicaid managed care plan more than the
220	amount paid to that provider by the provider service network for
221	the same service.
222	(k)  Medical loss ratio.-The agency shall implement the
223	following thresholds and consequences regarding various spending
224	patterns for qualified plans under the managed medical
225	assistance component of the Medicaid managed care program:
226	1.  The minimum medical loss ratio shall be 90 percent.
227	2.  A plan that spends less than 90 percent of its Medicaid
228	capitation revenue on medical services and direct care
229	management, as determined by the agency, must pay back to the
230	agency a share of the dollar difference between the plan's
231	actual medical loss ratio and the minimum medical loss ratio, as
232	follows:
233	a.  If the plan's actual medical loss ratio is not lower
234	than 87 percent, the plan must pay back 50 percent of the dollar
235	difference between the actual medical loss ratio and the minimum
236	medical loss ratio of 90 percent.
237	b.  If the plan's actual medical loss ratio is lower than
238	87 percent, the plan must pay back 50 percent of the dollar
239	difference between a medical loss ratio of 87 percent and the
240	minimum medical loss ratio of 90 percent, plus 100 percent of
241	the dollar difference between the actual medical loss ratio and
242	a medical loss ratio of 87 percent.
243	(2)  The agency shall adopt rules that specify a
244	methodology for calculating medical loss ratios and the
245	requirements for plans to annually report information related to
246	medical loss ratios. Repayments required under this section must
247	be made annually.
248	Section 6.  Section 409.964, Florida Statutes, is created
249	to read:
250	409.964  Enrollment; choice counseling; automatic
251	assignment; disenrollment.-
252	(1)  ENROLLMENT.-Medicaid recipients may enroll in a
253	managed care plan. Each recipient shall have a choice of plans
254	including MediPass and may select any available plan unless that
255	plan is restricted by contract to a specific population that
256	does not include the recipient. Medicaid recipients shall have
257	30 days in which to make a choice of plans. All recipients shall
258	be offered choice counseling services in accordance with this
259	section. For any month during which the choice counseling vendor
260	described in subsection (3) is found to be out of compliance
261	with its contract with the agency, the 30-day limit shall be
262	suspended.
263	(2)  AUTOMATIC ASSIGNMENT.-The agency shall automatically
264	enroll into a managed care plan 50 percent of those Medicaid
265	recipients who do not voluntarily choose a plan. The remaining
266	50 percent shall be enrolled in the MediPass program. The agency
267	shall automatically enroll recipients in plans that meet or
268	exceed the performance or quality standards established in this
269	part and may not automatically enroll recipients in a plan that
270	is deficient in those performance or quality standards. When a
271	specialty plan is available to accommodate a specific condition
272	or diagnosis of a recipient, the agency shall assign the
273	recipient to that plan. In the first year of the first contract
274	term only, if a recipient was previously enrolled in a plan that
275	is still available, the agency shall automatically enroll the
276	recipient in that plan unless an applicable specialty plan is
277	available. Except as otherwise provided in this part, the agency
278	may not engage in practices that are designed to favor one
279	managed care plan over another. When automatically enrolling
280	recipients in managed care plans, the agency shall automatically
281	enroll based on the following criteria:
282	(a)  Whether the plan has sufficient network capacity to
283	meet the needs of the recipients.
284	(b)  Whether the recipient has previously received services
285	from one of the plan's primary care providers.
286	(c)  Whether primary care providers in one plan are more
287	geographically accessible to the recipient's residence than
288	those in other plans.
289	(3)  CHOICE COUNSELING.-The agency shall provide choice
290	counseling for Medicaid recipients. The agency may contract for
291	the provision of choice counseling. Any such contract shall be
292	with a vendor that employs Floridians to accomplish the contract
293	requirements and shall be for a period of 2 years. The agency
294	may renew a contract for an additional 2-year period; however,
295	before renewal of the contract the agency shall hold at least
296	one public meeting in each of the areas covered by the choice
297	counseling vendor. The agency may extend the term of the
298	contract to cover any delays in transition to a new contractor.
299	Printed choice information and choice counseling shall be
300	offered in the native or preferred language of the recipient,
301	consistent with federal requirements. The manner and method of
302	choice counseling shall be modified as necessary to ensure
303	culturally competent, effective communication with people from
304	diverse cultural backgrounds. The agency shall maintain a record
305	of the recipients who receive such services, identifying the
306	scope and method of the services provided. The agency shall make
307	available clear and easily understandable choice information to
308	Medicaid recipients that includes:
309	(a)  An explanation that each recipient has the right to
310	choose a managed care plan including MediPass at the time of
311	enrollment in Medicaid and again at regular intervals set by the
312	agency, and that if a recipient does not choose a plan, the
313	agency shall assign the recipient according to the criteria
314	specified in this section.
315	(b)  A list and description of the benefits provided and
316	excluded by each managed care plan.
317	(c)  An explanation of benefit limits.
318	(d)  A current list of providers participating in the
319	network, including location and contact information. Such lists
320	shall be updated monthly.
321	(e)  Managed care plan performance and encounter data.
322	(f)  A list of complaints filed and action taken.
323	(4)  DISENROLLMENT.-After a recipient has enrolled in a
324	managed care plan, the recipient may change providers within the
325	plan. The recipient may disenroll and select another plan with a
326	30-day notice to the agency and the plan from which the
327	recipient is disenrolling. The agency must monitor plan
328	disenrollment throughout the contract term to identify any
329	discriminatory practices.
330	Section 7.  Section 409.965, Florida Statutes, is created
331	to read:
332	409.965  Benefits.-
333	(1)  MINIMUM BENEFITS.-Managed care plans shall cover, at a
334	minimum, the following services:
335	(a)  Advanced registered nurse practitioner services.
336	(b)  Ambulatory surgical treatment center services.
337	(c)  Birthing center services.
338	(d)  Chiropractic services.
339	(e)  Dental services.
340	(f)  Early periodic screening diagnosis and treatment
341	services for recipients under age 21.
342	(g)  Emergency services.
343	(h)  Family planning services and supplies.
344	(i)  Healthy start services.
345	(j)  Hearing services.
346	(k)  Home health agency services.
347	(l)  Hospice services.
348	(m)  Hospital inpatient services.
349	(n)  Hospital outpatient services.
350	(o)  Laboratory and imaging services.
351	(p)  Medical supplies, equipment, prostheses, and orthoses.
352	(q)  Mental health services.
353	(r)  Nursing care.
354	(s)  Optical services and supplies.
355	(t)  Optometrist services.
356	(u)  Physical, occupational, respiratory, and speech
357	therapy services.
358	(v)  Physician services, including physician assistant
359	services.
360	(w)  Podiatric services.
361	(x)  Prescription drugs.
362	(y)  Renal dialysis services.
363	(z)  Respiratory equipment and supplies.
364	(aa)  Rural health clinic services.
365	(bb)  Substance abuse treatment services.
366	(cc)  Transportation to access-covered services.
367	(2)  AMOUNT, DURATION AND SCOPE.-Benefits and services
368	shall be provided in the amount and for the period of time
369	needed to achieve the health outcomes sought by the treating
370	health care provider.
371	Section 8.  Section 409.966, Florida Statutes, is created
372	to read:
373	409.966  Managed care plan accountability.-In addition to
374	the requirements of s. 409.963, plans and providers
375	participating in the managed care program shall comply with the
376	requirements of this section.
377	(1)  PROVIDER NETWORKS.-Plan provider networks must be
378	adequate to meet the needs of all recipients. To that end, plans
379	must enroll any willing provider in good standing with the
380	Medicaid program. For purposes of this subsection, a plan
381	provider network is adequate if any recipient in need of a
382	medically necessary service can access such service without
383	facing time, travel, or administrative constraints more
384	burdensome than would apply if such recipient were enrolled in
385	MediPass.
386	(2)  COMPLAINT AND GRIEVANCE PROCESS.-Each plan must have
387	in place a process to address complaints and grievances
388	submitted by network providers. Such complaints and grievances
389	and their outcomes shall be posted on the plan's website.
390	(3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
391	monitor the quality and performance of each participating
392	provider. At the beginning of the contract period, each plan
393	shall notify all its network providers of the metrics used by
394	the plan for evaluating the provider's performance and
395	determining continued participation in the network.
396	(4)  TRANSPORTATION.-Nonemergency transportation services
397	shall be provided pursuant to a single, statewide contract
398	between the agency and the Commission for the Transportation
399	Disadvantaged. The agency shall establish performance standards
400	in the contract and shall evaluate the performance of the
401	Commission for the Transportation Disadvantaged. For the
402	purposes to this subsection, nonemergency transportation does
403	not include transportation by ambulance and any medical services
404	received during transport.
405	(5)  SCREENING RATE.-Each managed care plan shall achieve
406	an annual Early and Periodic Screening, Diagnosis, and Treatment
407	Service screening rate of at least 90 percent of those
408	recipients continuously enrolled for at least 8 months.
409	Section 9.  Section 409.967, Florida Statutes, is created
410	to read:
411	409.967  Statutory construction; rules.-It is the intent of
412	the Legislature that if any conflict exists between the
413	provisions contained in ss. 409.962-409.967 and other provisions
414	of this chapter, the provisions contained in ss. 409.962-409.967
415	shall control. The agency shall adopt any rules necessary to
416	comply with or administer this part and all rules necessary to
417	comply with federal requirements.
418	Section 10.  This act shall take effect July 1, 2011.
419
420
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422	T I T L E  A M E N D M E N T
423	Remove the entire title and insert:
424	A bill to be entitled
425	An act relating to Medicaid managed care; providing
426	legislative intent; creating pt. IV of ch. 409, F.S.,
427	entitled the "Medicaid Managed Care Accountability Act";
428	creating s. 409.961, F.S.; providing definitions; creating
429	s. 409.962, F.S.; designating the Agency for Health Care
430	Administration as the single state agency to administer
431	the Medicaid program; providing for specified agency
432	responsibilities; requiring client consent for release of
433	medical records; creating s. 409.963, F.S.; providing for
434	Medicaid  managed care contracting accountability;
435	requiring plans to establish and maintain an electronic
436	database; establishing requirements for the database;
437	requiring plans to provide encounter data; requiring the
438	agency to maintain an encounter data system; requiring the
439	agency to establish performance standards for plans;
440	providing penalties for departing provider service
441	networks under certain circumstances; authorizing the
442	agency to adopt rules; requiring certain plans to make
443	repayments to based on medical loss ratios as determined
444	by the agency; creating s. 409.964, F.S.; providing for
445	enrollment, choice counseling, automatic assignment, and
446	disenrollment; creating s. 409.965, F.S.; providing for
447	minimum benefits and the amount, scope, and duration
448	thereof; creating s. 409.966, F.S.; providing for managed
449	care plan accountability; establishing a complaint and
450	grievance resolution process; requiring managed care plans
451	to monitor the quality and performance of participating
452	providers; providing for nonemergency transportation
453	services; providing screening rate standards; creating s.
454	409.967, F.S.; providing for statutory construction;
455	providing for the agency to adopt rules; providing an
456	effective date.

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