HB 7107

1	A bill to be entitled
2	An act relating to Medicaid managed care; creating pt. IV
3	of ch. 409, F.S., entitled "Medicaid Managed Care";
4	creating s. 409.961, F.S.; providing for statutory
5	construction; providing applicability of specified
6	provisions throughout the part; providing rulemaking
7	authority for specified agencies; creating s. 409.962,
8	F.S.; providing definitions; creating s. 409.963, F.S.;
9	designating the Agency for Health Care Administration as
10	the single state agency to administer the Medicaid
11	program; providing for specified agency responsibilities;
12	requiring client consent for release of medical records;
13	creating s. 409.964, F.S.; establishing the Medicaid
14	program as the statewide, integrated managed care program
15	for all covered services; authorizing the agency to apply
16	for and implement waivers; providing for public notice and
17	comment; creating s. 409.965, F.S.; providing for
18	mandatory enrollment; providing for exemptions; creating
19	s. 409.966, F.S.; providing requirements for eligible
20	plans that provide services in the Medicaid managed care
21	program; establishing provider service network
22	requirements for eligible plans; providing for eligible
23	plan selection; requiring the agency to use an invitation
24	to negotiate; requiring the agency to compile and publish
25	certain information; establishing seven regions for
26	separate procurement of plans; providing quality criteria
27	for plan selection; providing limitations on serving
28	recipients during the pendency of procurement litigation;
29	creating s. 409.967, F.S.; providing for managed care plan
30	accountability; establishing contract terms; providing for
31	contract extension under certain circumstances;
32	establishing payments to noncontract providers;
33	establishing requirements for access; requiring plans to
34	establish and maintain an electronic database;
35	establishing requirements for the database; requiring
36	plans to provide encounter data; requiring the agency to
37	maintain an encounter data system; requiring the agency to
38	establish performance standards for plans; providing
39	program integrity requirements; establishing a grievance
40	resolution process; providing penalties for early
41	termination of contracts or reduction in enrollment
42	levels; establishing prompt payment requirements;
43	requiring plans to accept electronic claims; requiring
44	fair payment to providers with a controlling interest in a
45	provider service network by other plans; requiring the
46	agency and prepaid plans to use a uniform method for
47	certain financial reports; providing income-sharing
48	ratios; providing a timeframe for a plan to pay an
49	additional rebate under certain circumstances; requiring
50	the agency to return prepaid plan overpayments; creating
51	s. 409.968, F.S.; establishing managed care plan payments;
52	providing payment requirements for provider service
53	networks; requiring the agency to conduct annual cost
54	reconciliations to determine certain cost savings and
55	report the results of the reconciliations to the fee-for-
56	service provider; providing a timeframe for the provider
57	service to respond to the report; creating s. 409.969,
58	F.S.; requiring enrollment in managed care plans by all
59	nonexempt Medicaid recipients; creating requirements for
60	plan selection by recipients; providing for choice
61	counseling; establishing choice counseling vendor
62	requirements; authorizing disenrollment under certain
63	circumstances; defining the term "good cause" for purposes
64	of disenrollment; providing time limits on an internal
65	grievance process; providing requirements for agency
66	determination regarding disenrollment; requiring
67	recipients to stay in plans for a specified time; creating
68	s. 409.97, F.S.; authorizing the agency to accept the
69	transfer of certain revenues from local governments;
70	requiring the agency to contract with a representative of
71	certain entities participating in the low-income pool for
72	the provision of enhanced access to care; providing for
73	support of these activities by the low-income pool as
74	authorized in the General Appropriations Act; establishing
75	the Access to Care Partnership; requiring the agency to
76	seek necessary waivers and plan amendments; providing
77	requirements for prepaid plans to submit data; authorizing
78	the agency to implement a tiered hospital rate system;
79	creating s. 409.971, F.S.; creating the managed medical
80	assistance program; providing deadlines to begin and
81	finalize implementation of the program; creating s.
82	409.972, F.S.; providing eligibility requirements for
83	mandatory and voluntary enrollment; creating s. 409.973,
84	F.S.; establishing minimum benefits for managed care plans
85	to cover; authorizing plans to customize benefit packages;
86	requiring plans to establish a program to encourage
87	healthy behaviors; creating s. 409.974, F.S.; establishing
88	a deadline for issuing invitations to negotiate;
89	establishing a specified number or range of eligible plans
90	to be selected in each region; establishing quality
91	selection criteria; establishing requirements for
92	participation by specialty plans; establishing the
93	Children's Medical Service Network as an eligible plan;
94	creating s. 409.975, F.S.; providing for managed care plan
95	accountability; authorizing plans to limit providers in
96	networks; requiring plans to include essential Medicaid
97	providers in their networks unless an alternative
98	arrangement is approved by the agency; identifying
99	statewide essential providers; specifying provider
100	payments under certain circumstances; requiring plans to
101	include certain statewide essential providers in their
102	networks; requiring good faith negotiations; specifying
103	provider payments under certain circumstances; allowing
104	plans to exclude essential providers under certain
105	circumstances; requiring plans to offer a contract to home
106	medical equipment and supply providers under certain
107	circumstances; establishing the Florida medical school
108	quality network; requiring the agency to contract with a
109	representative of certain entities to establish a clinical
110	outcome improvement program in all plans; providing for
111	support of these activities by certain expenditures and
112	federal matching funds; requiring the agency to seek
113	necessary waivers and plan amendments; providing for
114	eligibility for the quality network; requiring plans to
115	monitor the quality and performance history of providers;
116	establishing the MomCare network; requiring the agency to
117	contract with a representative of all Healthy Start
118	Coalitions to provide certain services to recipients;
119	providing for support of these activities by certain
120	expenditures and federal matching funds; requiring plans
121	to enter into agreements with local Healthy Start
122	Coalitions for certain purposes; requiring specified
123	programs and procedures be established by plans;
124	establishing a screening standard for the Early and
125	Periodic Screening, Diagnosis, and Treatment Service;
126	requiring managed care plans and hospitals to negotiate
127	rates, methods, and terms of payment; providing a limit on
128	payments to hospitals; establishing plan requirements for
129	medically needy recipients; creating s. 409.976, F.S.;
130	providing for managed care plan payment; requiring the
131	agency to establish payment rates for statewide inpatient
132	psychiatric programs; requiring payments to managed care
133	plans to be reconciled to reimburse actual payments to
134	statewide inpatient psychiatric programs; creating s.
135	409.977, F.S.; establishing choice counseling
136	requirements; providing for automatic enrollment in a
137	managed care plan for certain recipients; establishing
138	opt-out opportunities for recipients; creating s. 409.978,
139	F.S.; requiring the agency to be responsible for
140	administering the long-term care managed care program;
141	providing implementation dates for the long-term care
142	managed care program; providing duties of the Department
143	of Elderly Affairs relating to assisting the agency in
144	implementing the program; creating s. 409.979, F.S.;
145	providing eligibility requirements for the long-term care
146	managed care program; creating s. 409.98, F.S.;
147	establishing the benefits covered under a managed care
148	plan participating in the long-term care managed care
149	program; creating s. 409.981, F.S.; providing criteria for
150	eligible plans; designating regions for plan
151	implementation throughout the state; providing criteria
152	for the selection of plans to participate in the long-term
153	care managed care program; providing that participation by
154	the Program of All-Inclusive Care for the Elderly is
155	pursuant to an agency contract; creating s. 409.982, F.S.;
156	requiring the agency to establish uniform accounting and
157	reporting methods for plans; providing for mandatory
158	participation in plans by certain service providers;
159	authorizing the exclusion of certain providers from plans
160	for failure to meet quality or performance criteria;
161	requiring plans to monitor participating providers using
162	specified criteria; requiring certain providers to be
163	included in plan networks; providing provider payment
164	specifications for nursing homes and hospices; creating s.
165	409.983, F.S.; providing for negotiation of rates between
166	the agency and the plans participating in the long-term
167	care managed care program; providing specific criteria for
168	calculating and adjusting plan payments; allowing the
169	CARES program to assign plan enrollees to a level of care;
170	providing incentives for adjustments of payment rates;
171	requiring the agency to establish nursing facility-
172	specific and hospice services payment rates; creating s.
173	409.984, F.S.; providing that before contracting with
174	another vendor, the agency shall offer to contract with
175	the aging resource centers to provide choice counseling
176	for the long-term care managed care program; providing
177	criteria for automatic assignments of plan enrollees who
178	fail to choose a plan; providing for hospice selection
179	within a specified timeframe; providing for a choice of
180	residential setting under certain circumstances; creating
181	s. 409.9841, F.S.; creating the long-term care managed
182	care technical advisory workgroup; providing duties;
183	providing membership; providing for reimbursement for per
184	diem and travel expenses; providing for repeal by a
185	specified date; creating s. 409.985, F.S.; providing that
186	the agency shall operate the Comprehensive Assessment and
187	Review for Long-Term Care Services program through an
188	interagency agreement with the Department of Elderly
189	Affairs; providing duties of the program; defining the
190	term "nursing facility care"; creating s. 409.986, F.S.;
191	providing authority and agency duties regarding long-term
192	care programs for persons with developmental disabilities;
193	authorizing the agency to delegate specific duties to and
194	collaborate with the Agency for Persons with Disabilities;
195	requiring the agency to make payments for long-term care
196	for persons with developmental disabilities under certain
197	conditions; creating s. 409.987, F.S.; providing
198	eligibility requirements for long-term care plans;
199	creating s. 409.988, F.S.; specifying covered benefits for
200	long-term care plans; creating s. 409.989, F.S.;
201	establishing criteria for eligible plans; specifying
202	minimum and maximum number of plans and selection
203	criteria; authorizing participation by the Children's
204	Medical Services Network in long-term care plans under
205	certain conditions; creating s. 409.99, F.S.; providing
206	requirements for managed care plan accountability;
207	specifying limitations on providers in plan networks;
208	providing for evaluation and payment of network providers;
209	requiring managed care plans to establish family advisory
210	committees and offer consumer-directed care services;
211	creating s. 409.991, F.S.; providing for payment of
212	managed care plans; providing duties for the Agency for
213	Persons with Disabilities to assign plan enrollees into a
214	payment-rate level of care; establishing level-of-care
215	criteria; providing payment requirements for intensive
216	behavior residential habilitation providers and
217	intermediate care facilities for the developmentally
218	disabled; creating s. 409.992, F.S.; providing
219	requirements for enrollment and choice counseling;
220	specifying enrollment exceptions for certain Medicaid
221	recipients; providing an effective date.
222
223	Be It Enacted by the Legislature of the State of Florida:
224
225	Section 1.  Sections 409.961 through 409.992, Florida
226	Statutes, are designated as part IV of chapter 409, Florida
227	Statutes, entitled "Medicaid Managed Care."
228	Section 2.  Section 409.961, Florida Statutes, is created
229	to read:
230	409.961  Statutory construction; applicability; rules.-It
231	is the intent of the Legislature that if any conflict exists
232	between the provisions contained in this part and provisions
233	contained in other parts of this chapter, the provisions
234	contained in this part shall control. The provisions of ss.
235	409.961-409.97 apply only to the Medicaid managed medical
236	assistance program, long-term care managed care program, and
237	managed long-term care for persons with developmental
238	disabilities program, as provided in this part. The agency shall
239	adopt any rules necessary to comply with or administer this part
240	and all rules necessary to comply with federal requirements. In
241	addition, the department shall adopt and accept the transfer of
242	any rules necessary to carry out the department's
243	responsibilities for receiving and processing Medicaid
244	applications and determining Medicaid eligibility and for
245	ensuring compliance with and administering this part, as those
246	rules relate to the department's responsibilities, and any other
247	provisions related to the department's responsibility for the
248	determination of Medicaid eligibility.
249	Section 3.  Section 409.962, Florida Statutes, is created
250	to read:
251	409.962  Definitions.-As used in this part, except as
252	otherwise specifically provided, the term:
253	(1)  "Agency" means the Agency for Health Care
254	Administration.
255	(2)  "Aging network service provider" means a provider that
256	participated in a home and community-based waiver administered
257	by the Department of Elderly Affairs or the community care
258	service system pursuant to s. 430.205, as of October 1, 2013.
259	(3)  "Comprehensive long-term care plan" means a managed
260	care plan that provides services described in s. 409.973 and
261	also provides the services described in s. 409.98 or s. 409.988.
262	(4)  "Department" means the Department of Children and
263	Family Services.
264	(5)  "Developmental disability provider service network"
265	means a provider service network, a controlling interest of
266	which includes one or more entities licensed pursuant to s.
267	393.067 or s. 400.962 with 18 or more licensed beds and the
268	owner or owners of which have at least 10 years' experience
269	serving persons with developmental disabilities.
270	(6)  "Direct care management" means care management
271	activities that involve direct interaction with Medicaid
272	recipients.
273	(7)  "Eligible plan" means a health insurer authorized
274	under chapter 624, an exclusive provider organization authorized
275	under chapter 627, a health maintenance organization authorized
276	under chapter 641, or a provider service network authorized
277	under s. 409.912(4)(d). For purposes of the managed medical
278	assistance program, the term also includes the Children's
279	Medical Services Network authorized under chapter 391. For
280	purposes of the long-term care managed care program, the term
281	also includes entities qualified under 42 C.F.R. part 422 as
282	Medicare Advantage Preferred Provider Organizations, Medicare
283	Advantage Provider-sponsored Organizations, and Medicare
284	Advantage Special Needs Plans, and the Program of All-Inclusive
285	Care for the Elderly.
286	(8)  "Long-term care plan" means a managed care plan that
287	provides the services described in s. 409.98 for the long-term
288	care managed care program or the services described in s.
289	409.988 for the long-term care managed care program for persons
290	with developmental disabilities.
291	(9)  "Long-term care provider service network" means a
292	provider service network a controlling interest of which is
293	owned by one or more licensed nursing homes, assisted living
294	facilities with 17 or more beds, home health agencies, community
295	care for the elderly lead agencies, or hospices.
296	(10)  "Managed care plan" means an eligible plan under
297	contract with the agency to provide services in the Medicaid
298	program.
299	(11)  "Medicaid" means the medical assistance program
300	authorized by Title XIX of the Social Security Act, 42 U.S.C.
301	ss. 1396 et seq., and regulations thereunder, as administered in
302	this state by the agency.
303	(12)  "Medicaid recipient" or "recipient" means an
304	individual who the department or, for Supplemental Security
305	Income, the Social Security Administration determines is
306	eligible pursuant to federal and state law to receive medical
307	assistance and related services for which the agency may make
308	payments under the Medicaid program. For the purposes of
309	determining third-party liability, the term includes an
310	individual formerly determined to be eligible for Medicaid, an
311	individual who has received medical assistance under the
312	Medicaid program, or an individual on whose behalf Medicaid has
313	become obligated.
314	(13)  "Prepaid plan" means a managed care plan that is
315	licensed or certified as a risk-bearing entity in the state and
316	is paid a prospective per-member, per-month payment by the
317	agency.
318	(14)  "Provider service network" means an entity certified
319	pursuant to s. 409.912(4)(d) of which a controlling interest is
320	owned by a health care provider, or group of affiliated
321	providers, or a public agency or entity that delivers health
322	services. Health care providers include Florida-licensed health
323	care professionals or licensed health care facilities, federally
324	qualified health care centers, and home health care agencies.
325	(15)  "Specialty plan" means a managed care plan that
326	serves Medicaid recipients who meet specified criteria based on
327	age, medical condition, or diagnosis.
328	Section 4.  Section 409.963, Florida Statutes, is created
329	to read:
330	409.963  Single state agency.-The Agency for Health Care
331	Administration is designated as the single state agency
332	authorized to manage, operate, and make payments for medical
333	assistance and related services under Title XIX of the Social
334	Security Act. Subject to any limitations or directions provided
335	for in the General Appropriations Act, these payments may be
336	made only for services included in the program, only on behalf
337	of eligible individuals, and only to qualified providers in
338	accordance with federal requirements for Title XIX of the Social
339	Security Act and the provisions of state law. This program of
340	medical assistance is designated as the "Medicaid program." The
341	department is responsible for Medicaid eligibility
342	determinations, including, but not limited to, policy, rules,
343	and the agreement with the Social Security Administration for
344	Medicaid eligibility determinations for Supplemental Security
345	Income recipients, as well as the actual determination of
346	eligibility. As a condition of Medicaid eligibility, subject to
347	federal approval, the agency and the department shall ensure
348	that each Medicaid recipient consents to the release of her or
349	his medical records to the agency and the Medicaid Fraud Control
350	Unit of the Department of Legal Affairs.
351	Section 5.  Section 409.964, Florida Statutes is created to
352	read:
353	409.964  Managed care program; state plan; waivers.-The
354	Medicaid program is established as a statewide, integrated
355	managed care program for all covered services, including long-
356	term care services. The agency shall apply for and implement
357	state plan amendments or waivers of applicable federal laws and
358	regulations necessary to implement the program. Before seeking a
359	waiver, the agency shall provide public notice and the
360	opportunity for public comment and shall include public feedback
361	in the waiver application. The agency shall hold one public
362	meeting in each of the regions described in s. 409.966(2) and
363	the time period for public comment for each region shall end no
364	sooner than 30 days after the completion of the public meeting
365	in that region.
366	Section 6.  Section 409.965, Florida Statutes, is created
367	to read:
368	409.965  Mandatory enrollment.-All Medicaid recipients
369	shall receive covered services through the statewide managed
370	care program, except as provided by this part pursuant to an
371	approved federal waiver. The following Medicaid recipients are
372	exempt from participation in the statewide managed care program:
373	(1)  Women who are only eligible for family planning
374	services.
375	(2)  Women who are only eligible for breast and cervical
376	cancer services.
377	(3)  Persons who are eligible for emergency Medicaid for
378	aliens.
379	Section 7.  Section 409.966, Florida Statutes, is created
380	to read:
381	409.966  Eligible plans; selection.-
382	(1)  ELIGIBLE PLANS.-Services in the Medicaid managed care
383	program shall be provided by eligible plans. A provider service
384	network must be capable of providing all covered services to a
385	mandatory Medicaid managed care enrollee or may limit the
386	provision of services to a specific target population based on
387	the age, chronic disease state, or medical condition of the
388	enrollee to whom the network will provide services. A specialty
389	provider service network must be capable of coordinating care
390	and delivering or arranging for the delivery of all covered
391	services to the target population. A provider service network
392	may partner with an insurer licensed under chapter 627 or a
393	health maintenance organization licensed under chapter 641 to
394	meet the requirements of a Medicaid contract.
395	(2)  ELIGIBLE PLAN SELECTION.-The agency shall select a
396	limited number of eligible plans to participate in the Medicaid
397	program using invitations to negotiate in accordance with s.
398	287.057(3)(a). At least 90 days before issuing an invitation to
399	negotiate, the agency shall compile and publish a databook
400	consisting of a comprehensive set of utilization and spending
401	data for the 3 most recent contract years consistent with the
402	rate-setting periods for all Medicaid recipients by region or
403	county. The source of the data in the report shall include both
404	historic fee-for-service claims and validated data from the
405	Medicaid Encounter Data System. The report shall be made
406	available in electronic form and shall delineate utilization use
407	by age, gender, eligibility group, geographic area, and
408	aggregate clinical risk score. Separate and simultaneous
409	procurements shall be conducted in each of the following
410	regions:
411	(a)  Region I, which shall consist of Bay, Calhoun,
412	Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson,
413	Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla,
414	Walton, and Washington Counties.
415	(b)  Region II, which shall consist of Alachua, Baker,
416	Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler,
417	Gilchrist, Hamilton, Lafayette, Levy, Nassau, Putnam, St. Johns,
418	Suwannee, Union, and Volusia Counties.
419	(c)  Region III, which shall consist of Hernando,
420	Hillsborough, Pasco, Pinellas, and Polk Counties.
421	(d)  Region IV, which shall consist of Brevard, Lake,
422	Marion, Orange, Osceola, Seminole, and Sumter Counties.
423	(e)  Region V, which shall consist of Charlotte, Collier,
424	DeSoto, Hardee, Highlands, Lee, Manatee, and Sarasota Counties.
425	(f)  Region VI, which shall consist of Broward, Glades,
426	Hendry, Indian River, Martin, Okeechobee, Palm Beach, and St.
427	Lucie Counties.
428	(g)  Region VII, which shall consist of Miami-Dade and
429	Monroe Counties.
430	(3)  QUALITY SELECTION CRITERIA.-
431	(a)  The invitation to negotiate must specify the criteria
432	and the relative weight of the criteria that will be used for
433	determining the acceptability of the reply and guiding the
434	selection of the organizations with which the agency negotiates.
435	In addition to criteria established by the agency, the agency
436	shall consider the following factors in the selection of
437	eligible plans:
438	1.  Accreditation by the National Committee for Quality
439	Assurance or another nationally recognized accrediting body.
440	2.  Experience serving similar populations, including the
441	organization's record in achieving specific quality standards
442	with similar populations.
443	3.  Availability and accessibility of primary care and
444	specialty physicians in the provider network.
445	4.  Establishment of community partnerships with providers
446	that create opportunities for reinvestment in community-based
447	services.
448	5.  Organization commitment to quality improvement and
449	documentation of achievements in specific quality improvement
450	projects, including active involvement by organization
451	leadership.
452	6.  Provision of additional benefits, particularly dental
453	care and disease management, and other initiatives that improve
454	health outcomes.
455	7.  Evidence that a qualified plan has written agreements
456	or signed contracts or has made substantial progress in
457	establishing relationships with providers before the plan
458	submitting a response.
459	8.  Comments submitted in writing by any enrolled Medicaid
460	provider relating to a specifically identified plan
461	participating in the procurement in the same region as the
462	submitting provider.
463	9.  The business relationship a qualified plan has with any
464	other qualified plan that responds to the invitation to
465	negotiate.
466
467	A qualified plan must disclose any business relationship it has
468	with any other qualified plan that responds to the invitation to
469	negotiate. For the purpose of this section, "business
470	relationship" means an ownership or controlling interest, an
471	affiliate or subsidiary relationship, a common parent, or any
472	mutual interest in any limited partnership, limited liability
473	partnership, limited liability company, or other entity or
474	business association, including all wholly or partially owned
475	subsidiaries, majority-owned subsidiaries, parent companies, or
476	affiliates of such entities, business associations, or other
477	enterprises, that exists for the purpose of making a profit.
478	Failure to disclose any business relationship shall result in
479	disqualification.
480	(b)  After negotiations are conducted, the agency shall
481	select the eligible plans that are determined to be responsive
482	and provide the best value to the state. Preference shall be
483	given to plans that demonstrate the following:
484	1.  Signed contracts with primary and specialty physicians
485	in sufficient numbers to meet the specific standards established
486	pursuant to s. 409.967(2)(b).
487	2.  Well-defined programs for recognizing patient-centered
488	medical homes or accountable care organizations, and providing
489	for increased compensation for recognized medical homes or
490	accountable care organizations, as defined by the plan.
491	3.  Greater net economic benefit to Florida compared to
492	other bidders through employment of, or subcontracting with
493	firms that employ, Floridians in order to accomplish the
494	contract requirements. Contracts with such bidders shall specify
495	performance measures to evaluate the plan's employment-based
496	economic impact. Valuation of the net economic benefit may not
497	include employment of or subcontracts with providers.
498	(c)  To ensure managed care plan participation in Region I,
499	the agency shall award contracts in Region VII to each managed
500	care plan selected in Region I for such plans which submitted
501	responsive bids in Region VII.
502	(4)  ADMINISTRATIVE CHALLENGE.-Any eligible plan that
503	participates in an invitation to negotiate in more than one
504	region and is selected in at least one region may not begin
505	serving Medicaid recipients in any region for which it was
506	selected until all administrative challenges to procurements
507	required by this section to which the eligible plan is a party
508	have been finalized. If the number of plans selected is less
509	than the maximum amount of plans permitted in the region, the
510	agency may contract with other selected plans in the region not
511	participating in the administrative challenge before resolution
512	of the administrative challenge. For purposes of this
513	subsection, an administrative challenge is finalized if an order
514	granting voluntary dismissal with prejudice has been entered by
515	any court established under Article V of the State Constitution
516	or by the Division of Administrative Hearings, a final order has
517	been entered into by the agency and the deadline for appeal has
518	expired, a final order has been entered by the First District
519	Court of Appeal and the time to seek any available review by the
520	Florida Supreme Court has expired, or a final order has been
521	entered by the Florida Supreme Court and a warrant has been
522	issued.
523	Section 8.  Section 409.967, Florida Statutes, is created
524	to read:
525	409.967  Managed care plan accountability.-
526	(1)  The agency shall establish a 5-year contract with each
527	managed care plan selected through the procurement process
528	described in s. 409.966. A plan contract may not be renewed;
529	however, the agency may extend the terms of a plan contract to
530	cover any delays in transition to a new plan.
531	(2)  The agency shall establish such contract requirements
532	as are necessary for the operation of the statewide managed care
533	program. In addition to any other provisions the agency may deem
534	necessary, the contract shall require:
535	(a)  Emergency services.-Managed care plans shall pay for
536	services required by ss. 395.1041 and 401.45 and rendered by a
537	noncontracted provider within 30 days after receipt of a
538	complete and correct claim. Plans must give providers of these
539	services a specific explanation for each claim denied for being
540	incomplete or incorrect. Providers may resubmit corrected claims
541	for reconsideration within 30 days after receiving notice from
542	the managed care plans that the claims are incomplete or
543	incorrect. Claims from noncontracted providers shall be accepted
544	by the managed care plan for at least 1 year after the date the
545	services are provided. Reimbursement for services under this
546	paragraph shall be the lesser of:
547	1.  The provider's charges;
548	2.  The usual and customary provider charges for similar
549	services in the community where the services were provided;
550	3.  The charge mutually agreed to by the entity and the
551	provider within 60 days after submittal of the claim; or
552	4.  The rate the agency would have paid on the first day of
553	the contract between the provider and the plan.
554	(b)  Access.-The agency shall establish specific standards
555	for the number, type, and regional distribution of providers in
556	managed care plan networks to ensure access to care. Each plan
557	must maintain a region-wide network of providers in sufficient
558	numbers to meet the access standards for specific medical
559	services for all recipients enrolled in the plan. Consistent
560	with the standards established by the agency, provider networks
561	may include providers located outside the region. Each plan
562	shall establish and maintain an accurate and complete electronic
563	database of contracted providers, including information about
564	licensure or registration, locations and hours of operation,
565	specialty credentials and other certifications, specific
566	performance indicators, and such other information as the agency
567	deems necessary. The database shall be available online to both
568	the agency and the public and shall have the capability to
569	compare the availability of providers to network adequacy
570	standards and to accept and display feedback from each
571	provider's patients. Each plan shall submit quarterly reports to
572	the agency identifying the number of enrollees assigned to each
573	primary care provider.
574	(c)  Encounter data.-The agency shall maintain and operate
575	a Medicaid Encounter Data System to collect, process, store, and
576	report on covered services provided to all Medicaid recipients
577	enrolled in prepaid plans.
578	1.  Each prepaid plan must comply with the agency's
579	reporting requirements for the Medicaid Encounter Data System.
580	Prepaid plans must submit encounter data electronically in a
581	format that complies with the Health Insurance Portability and
582	Accountability Act provisions for electronic claims and in
583	accordance with deadlines established by the agency. Prepaid
584	plans must certify that the data reported is accurate and
585	complete.
586	2.  The agency is responsible for validating the data
587	submitted by the plans. The agency shall develop methods and
588	protocols for ongoing analysis of the encounter data that
589	adjusts for differences in characteristics of prepaid plan
590	enrollees to allow comparison of service utilization among plans
591	and against expected levels of use. The analysis shall be used
592	to identify possible cases of systemic underutilization or
593	denials of claims and inappropriate service utilization such as
594	higher-than-expected emergency department encounters. The
595	analysis shall provide periodic feedback to the plans and enable
596	the agency to establish corrective action plans when necessary.
597	One of the focus areas for the analysis shall be the use of
598	prescription drugs.
599	3.  The agency shall make encounter data available to those
600	plans accepting enrollees who are assigned to them from other
601	plans leaving a region.
602	(d)  Continuous improvement.-The agency shall establish
603	specific performance standards and expected milestones or
604	timelines for improving performance over the term of the
605	contract. By the end of the fourth year of the first contract
606	term, the agency shall issue a request for information to
607	determine whether cost savings could be achieved by contracting
608	for plan oversight and monitoring, including analysis of
609	encounter data, assessment of performance measures, and
610	compliance with other contractual requirements. Each managed
611	care plan shall establish an internal health care quality
612	improvement system, including enrollee satisfaction and
613	disenrollment surveys. The quality improvement system shall
614	include incentives and disincentives for network providers.
615	(e)  Program integrity.-Each managed care plan shall
616	establish program integrity functions and activities to reduce
617	the incidence of fraud and abuse, including, at a minimum:
618	1.  A provider credentialing system and ongoing provider
619	monitoring;
620	2.  An effective prepayment and postpayment review process
621	including, but not limited to, data analysis, system editing,
622	and auditing of network providers;
623	3.  Procedures for reporting instances of fraud and abuse
624	pursuant to chapter 641;
625	4.  Administrative and management arrangements or
626	procedures, including a mandatory compliance plan, designed to
627	prevent fraud and abuse; and
628	5.  Designation of a program integrity compliance officer.
629	(f)  Grievance resolution.-Each managed care plan shall
630	establish and the agency shall approve an internal process for
631	reviewing and responding to grievances from enrollees consistent
632	with the requirements of s. 641.511. Each plan shall submit
633	quarterly reports on the number, description, and outcome of
634	grievances filed by enrollees. The agency shall maintain a
635	process for provider service networks consistent with s.
636	408.7056.
637	(g)  Penalties.-Managed care plans that reduce enrollment
638	levels or leave a region before the end of the contract term
639	shall reimburse the agency for the cost of enrollment changes
640	and other transition activities, including the cost of
641	additional choice counseling services. If more than one plan
642	leaves a region at the same time, costs shall be shared by the
643	departing plans proportionate to their enrollments. In addition
644	to the payment of costs, departing plans shall pay a per
645	enrollee penalty not to exceed 1 month's payment. Plans shall
646	provide the agency notice no less than 180 days before
647	withdrawing from a region.
648	(h)  Prompt payment.-Managed care plans shall comply with
649	ss. 641.315, 641.3155, and 641.513.
650	(i)  Electronic claims.-Managed care plans shall accept
651	electronic claims in compliance with federal standards.
652	(j)  Fair payment.-Provider service networks must ensure
653	that no network provider with a controlling interest in the
654	network charges any Medicaid managed care plan more than the
655	amount paid to that provider by the provider service network for
656	the same service.
657	(3)  ACHIEVED SAVINGS REBATE.-
658	(a)  The agency shall establish and the prepaid plans shall
659	use a uniform method for annually reporting premium revenue,
660	medical and administrative costs, and income or losses, across
661	all Florida Medicaid prepaid plan lines of business in all
662	regions. The reports shall be due to the agency within 270 days
663	after the conclusion of the reporting period and the agency may
664	audit the reports. Achieved savings rebates shall be due within
665	30 days after the report is submitted. Except as provided in
666	paragraph (b), the achieved savings rebate will be established
667	by determining pretax income as a percentage of revenues and
668	applying the following income sharing ratios:
669	1.  One hundred percent of income up to and including 5
670	percent of revenue shall be retained by the plan.
671	2.  Fifty percent of income above 5 percent and up to 9
672	percent shall be retained by the plan, with the other 50 percent
673	refunded to the state.
674	3.  One hundred percent of income above 9 percent of
675	revenue shall be refunded to the state.
676	(b)  For any plan that meets or exceeds agency-defined
677	quality measures in the reporting period, the achieved savings
678	rebate shall be established by determining pretax income as a
679	percentage of revenues and applying the following income-sharing
680	ratios:
681	1.  One hundred percent of income up to and including 6
682	percent of revenue shall be retained by the plan.
683	2.  Fifty percent of income above 6 percent and up to 10
684	percent shall be retained by the plan, with the other 50 percent
685	refunded to the state.
686	3.  One hundred percent of income above 10 percent of
687	revenue shall be refunded to the state.
688	(c)  The following expenses may not be included in
689	calculating income to the plan:
690	1.  Payment of achieved savings rebates.
691	2.  Any financial incentive payments made to the plan
692	outside of the capitation rate.
693	3.  Any financial disincentive payments levied by the state
694	or federal governments.
695	4.  Expenses associated with lobbying activities.
696	5.  Administrative, reinsurance, and outstanding claims
697	expenses in excess of actuarially sound maximum amounts set by
698	the agency.
699	(d)  Prepaid plans that incur a loss in the first contract
700	year may apply the full amount of the loss as an offset to
701	income in the second contract year.
702	(e)  If, after an audit or other reconciliation, the agency
703	determines that a prepaid plan owes an additional rebate, the
704	plan shall have 30 days after notification to make the payment.
705	Upon failure to timely pay the rebate, the agency shall withhold
706	future payments to the plan until the entire amount is recouped.
707	If the agency determines that a prepaid plan has made an
708	overpayment, the agency shall return the overpayment within 30
709	days.
710	Section 9.  Section 409.968, Florida Statutes, is created
711	to read:
712	409.968  Managed care plan payments.-
713	(1)  Prepaid plans shall receive per-member, per-month
714	payments negotiated pursuant to the procurements described in s.
715	409.966. Payments shall be risk-adjusted rates based on
716	historical utilization and spending data, projected forward, and
717	adjusted to reflect the eligibility category, geographic area,
718	and clinical risk profile of the recipients.
719	(2)  Provider service networks may be prepaid plans and
720	receive per-member, per-month payments negotiated pursuant to
721	the procurement process described in s. 409.966. Provider
722	service networks that choose not to be prepaid plans shall
723	receive fee-for-service rates with a shared savings settlement.
724	The fee-for-service option shall be available to a provider
725	service network only for the first 5 years of its operation in a
726	given region. The agency shall annually conduct cost
727	reconciliations to determine the amount of cost savings achieved
728	by fee-for-service provider service networks for the dates of
729	service within the period being reconciled. Only payments for
730	covered services for dates of service within the reconciliation
731	period and paid within 6 months after the last date of service
732	in the reconciliation period shall be included. The agency shall
733	perform the necessary adjustments for the inclusion of claims
734	incurred but not reported within the reconciliation period for
735	claims that could be received and paid by the agency after the
736	6-month claims processing time lag. The agency shall provide the
737	results of the reconciliations to the fee-for-service provider
738	service networks within 45 days after the end of the
739	reconciliation period. The fee-for-service provider service
740	networks shall review and provide written comments or a letter
741	of concurrence to the agency within 45 days after receipt of the
742	reconciliation results. This reconciliation shall be considered
743	final.
744	Section 10.  Section 409.969, Florida Statutes, is created
745	to read:
746	409.969  Enrollment; choice counseling; automatic
747	assignment; disenrollment.-
748	(1)  ENROLLMENT.-All Medicaid recipients shall be enrolled
749	in a managed care plan unless specifically exempted under this
750	part. Each recipient shall have a choice of plans and may select
751	any available plan unless that plan is restricted by contract to
752	a specific population that does not include the recipient.
753	Medicaid recipients shall have 30 days in which to make a choice
754	of plans. All recipients shall be offered choice counseling
755	services in accordance with this section.
756	(2)  CHOICE COUNSELING.-The agency shall provide choice
757	counseling for Medicaid recipients. The agency may contract for
758	the provision of choice counseling. Any such contract shall be
759	with a vendor that employs Floridians to accomplish the contract
760	requirements and shall be for a period of 5 years. The agency
761	may renew a contract for an additional 5-year period; however,
762	before renewal of the contract the agency shall hold at least
763	one public meeting in each of the regions covered by the choice
764	counseling vendor. The agency may extend the term of the
765	contract to cover any delays in transition to a new contractor.
766	Printed choice information and choice counseling shall be
767	offered in the native or preferred language of the recipient,
768	consistent with federal requirements. The manner and method of
769	choice counseling shall be modified as necessary to ensure
770	culturally competent, effective communication with people from
771	diverse cultural backgrounds. The agency shall maintain a record
772	of the recipients who receive such services, identifying the
773	scope and method of the services provided. The agency shall make
774	available clear and easily understandable choice information to
775	Medicaid recipients that includes:
776	(a)  An explanation that each recipient has the right to
777	choose a managed care plan at the time of enrollment in Medicaid
778	and again at regular intervals set by the agency, and that if a
779	recipient does not choose a plan, the agency will assign the
780	recipient to a plan according to the criteria specified in this
781	section.
782	(b)  A list and description of the benefits provided in
783	each managed care plan.
784	(c)  An explanation of benefit limits.
785	(d)  A current list of providers participating in the
786	network, including location and contact information.
787	(e)  Managed care plan performance data.
788	(3)  DISENROLLMENT; GRIEVANCES.-After a recipient has
789	enrolled in a managed care plan, the recipient shall have 90
790	days to voluntarily disenroll and select another plan. After 90
791	days, no further changes may be made except for good cause. For
792	purposes of this section, the term "good cause" includes, but is
793	not limited to, poor quality of care, lack of access to
794	necessary specialty services, an unreasonable delay or denial of
795	service, or fraudulent enrollment. The agency must make a
796	determination as to whether good cause exists. The agency may
797	require a recipient to use the plan's grievance process before
798	the agency's determination of good cause, except in cases in
799	which immediate risk of permanent damage to the recipient's
800	health is alleged.
801	(a)  The managed care plan internal grievance process, when
802	used, must be completed in time to permit the recipient to
803	disenroll by the first day of the second month after the month
804	the disenrollment request was made. If the result of the
805	grievance process is approval of an enrollee's request to
806	disenroll, the agency is not required to make a determination in
807	the case.
808	(b)  The agency must make a determination and take final
809	action on a recipient's request so that disenrollment occurs no
810	later than the first day of the second month after the month the
811	request was made. If the agency fails to act within the
812	specified timeframe, the recipient's request to disenroll is
813	deemed to be approved as of the date agency action was required.
814	Recipients who disagree with the agency's finding that good
815	cause does not exist for disenrollment shall be advised of their
816	right to pursue a Medicaid fair hearing to dispute the agency's
817	finding.
818	(c)  Medicaid recipients enrolled in a managed care plan
819	after the 90-day period shall remain in the plan for the
820	remainder of the 12-month period. After 12 months, the recipient
821	may select another plan. However, nothing shall prevent a
822	Medicaid recipient from changing providers within the plan
823	during that period.
824	(d)  On the first day of the month after receiving notice
825	from a recipient that the recipient has moved to another region,
826	the agency shall automatically disenroll the recipient from the
827	managed care plan the recipient is currently enrolled in and
828	treat the recipient as if the recipient is a new Medicaid
829	enrollee. At that time, the recipient may choose another plan
830	pursuant to the enrollment process established in this section.
831	(e)  The agency must monitor plan disenrollment throughout
832	the contract term to identify any discriminatory practices.
833	Section 11.  Section 409.97, Florida Statutes, is created
834	to read:
835	409.97  State and local Medicaid partnerships.-
836	(1)  INTERGOVERNMENTAL TRANSFERS.-In addition to the
837	contributions required pursuant to s. 409.915, beginning in the
838	2014-2015 fiscal year, the agency may accept voluntary transfers
839	of local taxes and other qualified revenue from counties,
840	municipalities, and special taxing districts. Such transfers
841	must be contributed to advance the general goals of the Florida
842	Medicaid program without restriction and must be executed
843	pursuant to a contract between the agency and the local funding
844	source. Contracts executed before October 31 shall result in
845	contributions to Medicaid for that same state fiscal year.
846	Contracts executed between November 1 and June 30 shall result
847	in contributions for the following state fiscal year. Based on
848	the date of the signed contracts, the agency shall allocate to
849	the low-income pool the first contributions received up to the
850	limit established by subsection (2). No more than 40 percent of
851	the low-income pool funding shall come from any single funding
852	source. Contributions in excess of the low-income pool shall be
853	allocated to the disproportionate share programs defined in ss.
854	409.911(3) and 409.9113 and to hospital rates pursuant to
855	subsection (4). The local funding source shall designate in the
856	contract which Medicaid providers ensure access to care for low-
857	income and uninsured people within the applicable jurisdiction
858	and are eligible for low-income pool funding. Eligible providers
859	may include both hospitals and primary care providers.
860	(2)  LOW-INCOME POOL.-The agency shall establish and
861	maintain a low-income pool in a manner authorized by federal
862	waiver. The low-income pool is created to compensate a network
863	of providers designated pursuant to subsection (1). Funding of
864	the low-income pool shall be limited to the maximum amount
865	permitted by federal waiver minus a percentage specified in the
866	General Appropriations Act. The low-income pool must be used to
867	support enhanced access to services by offsetting shortfalls in
868	Medicaid reimbursement, paying for otherwise uncompensated care,
869	and financing coverage for the uninsured. The low-income pool
870	shall be distributed in periodic payments to the Access to Care
871	Partnership throughout the fiscal year. Distribution of low-
872	income pool funds by the Access to Care Partnership to
873	participating providers may be made through capitated payments,
874	fees for services, or contracts for specific deliverables. The
875	agency shall include the distribution amount for each provider
876	in the contract with the Access to Care Partnership pursuant to
877	subsection (3). Regardless of the method of distribution,
878	providers participating in the Access to Care Partnership shall
879	receive payments such that the aggregate benefit in the
880	jurisdiction of each local funding source, as defined in
881	subsection (1), equals the amount of the contribution plus a
882	factor specified in the General Appropriations Act.
883	(3)  ACCESS TO CARE PARTNERSHIP.-The agency shall contract
884	with an administrative services organization that has operating
885	agreements with all health care facilities, programs, and
886	providers supported with local taxes or certified public
887	expenditures and designated pursuant to subsection (1). The
888	contract shall provide for enhanced access to care for Medicaid,
889	low-income, and uninsured Floridians. The partnership shall be
890	responsible for an ongoing program of activities that provides
891	needed, but uncovered or undercompensated, health services to
892	Medicaid enrollees and persons receiving charity care, as
893	defined in s. 409.911. Accountability for services rendered
894	under this contract must be based on the number of services
895	provided to unduplicated qualified beneficiaries, the total
896	units of service provided to these persons, and the
897	effectiveness of services provided as measured by specific
898	standards of care. The agency shall seek such plan amendments or
899	waivers as may be necessary to authorize the implementation of
900	the low-income pool as the Access to Care Partnership pursuant
901	to this section.
902	(4)  HOSPITAL RATE DISTRIBUTION.-
903	(a)  The agency is authorized to implement a tiered
904	hospital rate system to enhance Medicaid payments to all
905	hospitals when resources for the tiered rates are available from
906	general revenue and such contributions pursuant to subsection
907	(1) as are authorized under the General Appropriations Act.
908	1.  Tier 1 hospitals are statutory rural hospitals as
909	defined in s. 395.602, statutory teaching hospitals as defined
910	in s. 408.07(45), and specialty children's hospitals as defined
911	in s. 395.002(28).
912	2.  Tier 2 hospitals are community hospitals not included
913	in Tier 1 that provided more than 9 percent of the hospital's
914	total inpatient days to Medicaid patients and charity patients,
915	as defined in s. 409.911, and are located in the jurisdiction of
916	a local funding source pursuant to subsection (1).
917	3.  Tier 3 hospitals include all community hospitals.
918	(b)  When rates are increased pursuant to this section, the
919	Total Tier Allocation (TTA) shall be distributed as follows:
920	1.  Tier 1 (T1A) = 0.15 x TTA.
921	2.  Tier 2 (T2A) = 0.35 x TTA.
922	3.  Tier 3 (T3A) = 0.50 x TTA.
923	(c)  The tier allocation shall be distributed as a
924	percentage increase to the hospital specific base rate (HSBR)
925	established pursuant to s. 409.905(5)(c). The increase in each
926	tier shall be calculated according to the proportion of tier-
927	specific allocation to the total estimated inpatient spending
928	(TEIS) for all hospitals in each tier:
929	1.  Tier 1 percent increase (T1PI) = T1A/Tier 1 total
930	estimated inpatient spending (T1TEIS).
931	2.  Tier 2 percent increase (T2PI) = T2A /Tier 2 total
932	estimated inpatient spending (T2TEIS).
933	3.  Tier 3 percent increase (T3PI) = T3A/ Tier 3 total
934	estimated inpatient spending (T3TEIS).
935	(d)  The hospital-specific tiered rate (HSTR) shall be
936	calculated as follows:
937	1.  For hospitals in Tier 3: HSTR = (1 + T3PI) x HSBR.
938	2.  For hospitals in Tier 2: HSTR = (1 + T2PI) x HSBR.
939	3.  For hospitals in Tier 1: HSTR = (1 + T1PI) x HSBR.
940	Section 12.  Section 409.971, Florida Statutes, is created
941	to read:
942	409.971  Managed medical assistance program.-The agency
943	shall make payments for primary and acute medical assistance and
944	related services using a managed care model. By January 1, 2013,
945	the agency shall begin implementation of the statewide managed
946	medical assistance program, with full implementation in all
947	regions by October 1, 2014.
948	Section 13.  Section 409.972, Florida Statutes, is created
949	to read:
950	409.972  Mandatory and voluntary enrollment.-
951	(1)  Persons eligible for the program known as "medically
952	needy" pursuant to s. 409.904(2)(a) shall enroll in managed care
953	plans. Medically needy recipients shall meet the share of the
954	cost by paying the plan premium, up to the share of the cost
955	amount, contingent upon federal approval.
956	(2)  The following Medicaid-eligible persons are exempt
957	from mandatory managed care enrollment required by s. 409.965,
958	and may voluntarily choose to participate in the managed medical
959	assistance program:
960	(a)  Medicaid recipients who have other creditable health
961	care coverage, excluding Medicare.
962	(b)  Medicaid recipients residing in residential commitment
963	facilities operated through the Department of Juvenile Justice
964	or mental health treatment facilities as defined by s.
965	394.455(32).
966	(c)  Persons eligible for refugee assistance.
967	(d)  Medicaid recipients who are residents of a
968	developmental disability center, including Sunland Center in
969	Marianna and Tacachale in Gainesville.
970	(3)  Persons eligible for Medicaid but exempt from
971	mandatory participation who do not choose to enroll in managed
972	care shall be served in the Medicaid fee-for-service program as
973	provided in part III of this chapter.
974	Section 14.  Section 409.973, Florida Statutes, is created
975	to read:
976	409.973  Benefits.-
977	(1)  MINIMUM BENEFITS.-Managed care plans shall cover, at a
978	minimum, the following services:
979	(a)  Advanced registered nurse practitioner services.
980	(b)  Ambulatory surgical treatment center services.
981	(c)  Birthing center services.
982	(d)  Chiropractic services.
983	(e)  Dental services.
984	(f)  Early periodic screening diagnosis and treatment
985	services for recipients under age 21.
986	(g)  Emergency services.
987	(h)  Family planning services and supplies.
988	(i)  Healthy start services.
989	(j)  Hearing services.
990	(k)  Home health agency services.
991	(l)  Hospice services.
992	(m)  Hospital inpatient services.
993	(n)  Hospital outpatient services.
994	(o)  Laboratory and imaging services.
995	(p)  Medical supplies, equipment, prostheses, and orthoses.
996	(q)  Mental health services.
997	(r)  Nursing care.
998	(s)  Optical services and supplies.
999	(t)  Optometrist services.
1000	(u)  Physical, occupational, respiratory, and speech
1001	therapy services.
1002	(v)  Physician services.
1003	(w)  Podiatric services.
1004	(x)  Prescription drugs.
1005	(y)  Renal dialysis services.
1006	(z)  Respiratory equipment and supplies.
1007	(aa)  Rural health clinic services.
1008	(bb)  Substance abuse treatment services.
1009	(cc)  Transportation to access covered services.
1010	(2)  CUSTOMIZED BENEFITS.-Managed care plans may customize
1011	benefit packages for nonpregnant adults, vary cost-sharing
1012	provisions, and provide coverage for additional services. The
1013	agency shall evaluate the proposed benefit packages to ensure
1014	services are sufficient to meet the needs of the plan's
1015	enrollees and to verify actuarial equivalence.
1016	(3)  HEALTHY BEHAVIORS.-Each plan operating in the managed
1017	medical assistance program shall establish a program to
1018	encourage and reward healthy behaviors.
1019	Section 15.  Section 409.974, Florida Statutes, is created
1020	to read:
1021	409.974  Eligible plans.-
1022	(1)  ELIGIBLE PLAN SELECTION.-The agency shall select
1023	eligible plans through the procurement process described in s.
1024	409.966. The agency shall notice invitations to negotiate no
1025	later than January 1, 2013.
1026	(a)  The agency shall procure three plans for Region I. At
1027	least one plan shall be a provider service network, if any
1028	provider service network submits a responsive bid.
1029	(b)  The agency shall procure at least three and no more
1030	than six plans for Region II. At least one plan shall be a
1031	provider service network, if any provider service network
1032	submits a responsive bid.
1033	(c)  The agency shall procure at least four plans and no
1034	more than eight plans for Region III. At least two plans shall
1035	be provider service networks, if any two provider service
1036	networks submit responsive bids.
1037	(d)  The agency shall procure at least four plans and no
1038	more than seven plans for Region IV. At least two plans shall be
1039	provider service networks if any two provider service networks
1040	submit responsive bids.
1041	(e)  The agency shall procure three plans for Region V. At
1042	least one plan shall be a provider service network, if any
1043	provider service network submits a responsive bid.
1044	(f)  The agency shall procure at least four plans and no
1045	more than seven plans for Region VI. At least two plans shall be
1046	provider service networks, if any two provider service networks
1047	submit a responsive bid.
1048	(g)  The agency shall procure at least five plans and no
1049	more than nine plans for Region VII. At least two plans shall be
1050	provider service networks, if any two provider service network
1051	submit responsive bids.
1052
1053	If no provider service network submits a responsive bid, the
1054	agency shall procure no more than one less than the maximum
1055	number of eligible plans permitted in that region. Within 12
1056	months after the initial invitation to negotiate, the agency
1057	shall attempt to procure a provider service network. The agency
1058	shall notice another invitation to negotiate only with provider
1059	service networks in such region where no provider service
1060	network has been selected.
1061	(2)  QUALITY SELECTION CRITERIA.-In addition to the
1062	criteria established in s. 409.966, the agency shall consider
1063	evidence that an eligible plan has written agreements or signed
1064	contracts or has made substantial progress in establishing
1065	relationships with providers before the plan submitting a
1066	response. The agency shall evaluate and give special weight to
1067	evidence of signed contracts with essential providers as defined
1068	by the agency pursuant to s. 409.975(2). The agency shall
1069	exercise a preference for plans with a provider network in which
1070	over 10 percent of the providers use electronic health records,
1071	as defined in s. 408.051. When all other factors are equal, the
1072	agency shall consider whether the organization has a contract to
1073	provide managed long-term care services in the same region and
1074	shall exercise a preference for such plans.
1075	(3)  SPECIALTY PLANS.-Participation by specialty plans
1076	shall be subject to the procurement requirements and regional
1077	plan number limits of this section. However, a specialty plan
1078	whose target population includes no more than 10 percent of the
1079	enrollees of that region is not subject to the regional plan
1080	number limits of this section.
1081	(4)  CHILDREN'S MEDICAL SERVICES NETWORK.-Participation by
1082	the Children's Medical Services Network shall be pursuant to a
1083	single, statewide contract with the agency that is not subject
1084	to the procurement requirements or regional plan number limits
1085	of this section. The Children's Medical Services Network must
1086	meet all other plan requirements for the managed medical
1087	assistance program.
1088	Section 16.  Section 409.975, Florida Statutes, is created
1089	to read:
1090	409.975  Managed care plan accountability.-In addition to
1091	the requirements of s. 409.967, plans and providers
1092	participating in the managed medical assistance program shall
1093	comply with the requirements of this section.
1094	(1)  PROVIDER NETWORKS.-Managed care plans must develop and
1095	maintain provider networks that meet the medical needs of their
1096	enrollees in accordance with standards established pursuant to
1097	409.967(2)(b). Except as provided in this section, managed care
1098	plans may limit the providers in their networks based on
1099	credentials, quality indicators, and price.
1100	(a)  Plans must include all providers in the region that
1101	are classified by the agency as essential Medicaid providers,
1102	unless the agency approves, in writing, an alternative
1103	arrangement for securing the types of services offered by the
1104	essential providers. Providers are essential for serving
1105	Medicaid enrollees if they offer services that are not available
1106	from any other provider within a reasonable access standard, or
1107	if they provided a substantial share of the total units of a
1108	particular service used by Medicaid patients within the region
1109	during the last 3 years and the combined capacity of other
1110	service providers in the region is insufficient to meet the
1111	total needs of the Medicaid patients. The agency may not
1112	classify physicians and other practitioners as essential
1113	providers. The agency, at a minimum, shall determine which
1114	providers in the following categories are essential Medicaid
1115	providers:
1116	1.  Federally qualified health centers.
1117	2.  Statutory teaching hospitals as defined in s.
1118	408.07(45).
1119	3.  Hospitals that are trauma centers as defined in s.
1120	395.4001(14).
1121	4.  Hospitals located at least 25 miles from any other
1122	hospital with similar services.
1123
1124	Managed care plans that have not contracted with all essential
1125	providers in the region as of the first date of recipient
1126	enrollment, or with whom an essential provider has terminated
1127	its contract, must negotiate in good faith with such essential
1128	providers for 1 year or until an agreement is reached, whichever
1129	is first. Payments for services rendered by a nonparticipating
1130	essential provider shall be made at the applicable Medicaid rate
1131	as of the first day of the contract between the agency and the
1132	plan. A rate schedule for all essential providers shall be
1133	attached to the contract between the agency and the plan. After
1134	1 year, managed care plans that are unable to contract with
1135	essential providers shall notify the agency and propose an
1136	alternative arrangement for securing the essential services for
1137	Medicaid enrollees. The arrangement must rely on contracts with
1138	other participating providers, regardless of whether those
1139	providers are located within the same region as the
1140	nonparticipating essential service provider. If the alternative
1141	arrangement is approved by the agency, payments to
1142	nonparticipating essential providers after the date of the
1143	agency's approval shall equal 90 percent of the applicable
1144	Medicaid rate. If the alternative arrangement is not approved by
1145	the agency, payment to nonparticipating essential providers
1146	shall equal 110 percent of the applicable Medicaid rate.
1147	(b)  Certain providers are statewide resources and
1148	essential providers for all managed care plans in all regions.
1149	All managed care plans must include these essential providers in
1150	their networks. Statewide essential providers include:
1151	1.  Faculty plans of Florida medical schools.
1152	2.  Regional perinatal intensive care centers as defined in
1153	s. 383.16(2).
1154	3.  Hospitals licensed as specialty children's hospitals as
1155	defined in s. 395.002(28).
1156
1157	Managed care plans that have not contracted with all statewide
1158	essential providers in all regions as of the first date of
1159	recipient enrollment must continue to negotiate in good faith.
1160	Payments to physicians on the faculty of nonparticipating
1161	Florida medical schools shall be made at the applicable Medicaid
1162	rate. Payments for services rendered by a regional perinatal
1163	intensive care centers shall be made at the applicable Medicaid
1164	rate as of the first day of the contract between the agency and
1165	the plan. Payments to nonparticipating specialty children's
1166	hospitals shall equal the highest rate established by contract
1167	between that provider and any other Medicaid managed care plan.
1168	(c)  After 12 months of active participation in a plan's
1169	network, the plan may exclude any essential provider from the
1170	network for failure to meet quality or performance criteria. If
1171	the plan excludes an essential provider from the plan, the plan
1172	must provide written notice to all recipients who have chosen
1173	that provider for care. The notice shall be provided at least 30
1174	days before the effective date of the exclusion.
1175	(d)  Each managed care plan must offer a network contract
1176	to each home medical equipment and supplies provider in the
1177	region which meets quality and fraud prevention and detection
1178	standards established by the plan and which agrees to accept the
1179	lowest price previously negotiated between the plan and another
1180	such provider.
1181	(2)  FLORIDA MEDICAL SCHOOLS QUALITY NETWORK.-The agency
1182	shall contract with a single organization representing medical
1183	schools and graduate medical education programs in the state for
1184	the purpose of establishing an active and ongoing program to
1185	improve clinical outcomes in all managed care plans. Contracted
1186	activities must support greater clinical integration for
1187	Medicaid enrollees through interdependent and cooperative
1188	efforts of all providers participating in managed care plans.
1189	The agency shall support these activities with certified public
1190	expenditures of general revenue appropriated to the
1191	participating medical schools and any earned federal matching
1192	funds and shall seek any plan amendments or waivers necessary to
1193	comply with this subsection. To be eligible to participate in
1194	the quality network, a medical school must contract with each
1195	managed care plan in its region.
1196	(3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
1197	monitor the quality and performance of each participating
1198	provider. At the beginning of the contract period, each plan
1199	shall notify all its network providers of the metrics used by
1200	the plan for evaluating the provider's performance and
1201	determining continued participation in the network.
1202	(4)  MOMCARE NETWORK.-
1203	(a)  The agency shall contract with an administrative
1204	services organization representing all Healthy Start Coalitions
1205	providing risk appropriate care coordination and other services
1206	in accordance with a federal waiver and pursuant to s. 409.906.
1207	The contract shall require the network of coalitions to provide
1208	choice counseling, education, risk-reduction and case management
1209	services, and quality assurance for all enrollees of the waiver.
1210	The agency shall evaluate the impact of the MomCare network by
1211	monitoring each plan's performance on specific measures to
1212	determine the adequacy, timeliness, and quality of services for
1213	pregnant women and infants. The agency shall support this
1214	contract with certified public expenditures of general revenue
1215	appropriated for Healthy Start services and any earned federal
1216	matching funds.
1217	(b)  Each managed care plan shall establish specific
1218	programs and procedures to improve pregnancy outcomes and infant
1219	health, including, but not limited to, coordination with the
1220	Healthy Start program, immunization programs, and referral to
1221	the Special Supplemental Nutrition Program for Women, Infants,
1222	and Children, and the Children's Medical Services program for
1223	children with special health care needs. Each plan's programs
1224	and procedures shall include agreements with each local Healthy
1225	Start Coalition in the region to provide risk-appropriate care
1226	coordination for pregnant women and infants, consistent with
1227	agency policies and the MomCare network.
1228	(5)  TRANSPORTATION.-Nonemergency transportation services
1229	shall be provided pursuant to a single, statewide contract
1230	between the agency and the Commission for the Transportation
1231	Disadvantaged. The agency shall establish performance standards
1232	in the contract and shall evaluate the performance of the
1233	Commission for the Transportation Disadvantaged.
1234	(6)  SCREENING RATE.-After the end of the second contract
1235	year, each managed care plan shall achieve an annual Early and
1236	Periodic Screening, Diagnosis, and Treatment Service screening
1237	rate of at least 80 percent of those recipients continuously
1238	enrolled for at least 8 months.
1239	(7)  PROVIDER PAYMENT.-Managed care plan and hospitals
1240	shall negotiate mutually acceptable rates, methods, and terms of
1241	payment. For rates, methods, and terms of payment negotiated
1242	after the contract between the agency and the plan is executed,
1243	plans shall pay hospitals, at a minimum, the rate the agency
1244	would have paid on the first day of the contract between the
1245	provider and the plan. Such payments to hospitals may not exceed
1246	120 percent of the rate the agency would have paid on the first
1247	day of the contract between the provider and the plan, unless
1248	specifically approved by the agency. Payment rates may be
1249	updated periodically.
1250	(8)  MEDICALLY NEEDY ENROLLEES.-Each managed care plan
1251	shall accept any medically needy recipient who selects or is
1252	assigned to the plan and provide that recipient with continuous
1253	enrollment for 12 months. After the first month of qualifying as
1254	a medically needy recipient and enrolling in a plan, and
1255	contingent upon federal approval, the enrollee shall pay the
1256	plan a portion of the monthly premium equal to the enrollee's
1257	share of the cost as determined by the department. The agency
1258	shall pay any remaining portion of the monthly premium. Plans
1259	are not obligated to pay claims for medically needy patients for
1260	services provided before enrollment in the plan. Medically needy
1261	patients are responsible for payment of incurred claims that are
1262	used to determine eligibility. Plans must provide a grace period
1263	of at least 90 days before disenrolling recipients who fail to
1264	pay their shares of the premium.
1265	Section 17.  Section 409.976, Florida Statutes, is created
1266	to read:
1267	409.976  Managed care plan payment.-In addition to the
1268	payment provisions of s. 409.968, the agency shall provide
1269	payment to plans in the managed medical assistance program
1270	pursuant to this section.
1271	(1)  Prepaid payment rates shall be negotiated between the
1272	agency and the eligible plans as part of the procurement process
1273	described in s. 409.966.
1274	(2)  The agency shall establish payment rates for statewide
1275	inpatient psychiatric programs. Payments to managed care plans
1276	shall be reconciled to reimburse actual payments to statewide
1277	inpatient psychiatric programs.
1278	Section 18.  Section 409.977, Florida Statutes, is created
1279	to read:
1280	409.977  Choice counseling and enrollment.-
1281	(1)  CHOICE COUNSELING.-In addition to the choice
1282	counseling information required by s. 409.969, the agency shall
1283	make available clear and easily understandable choice
1284	information to Medicaid recipients that includes information
1285	about the cost-sharing requirements of each managed care plan.
1286	(2)  AUTOMATIC ENROLLMENT.-The agency shall automatically
1287	enroll into a managed care plan those Medicaid recipients who do
1288	not voluntarily choose a plan pursuant to s. 409.969. The agency
1289	shall automatically enroll recipients in plans that meet or
1290	exceed the performance or quality standards established pursuant
1291	to s. 409.967 and may not automatically enroll recipients in a
1292	plan that is deficient in those performance or quality
1293	standards. When a specialty plan is available to accommodate a
1294	specific condition or diagnosis of a recipient, the agency shall
1295	assign the recipient to that plan. In the first year of the
1296	first contract term only, if a recipient was previously enrolled
1297	in a plan that is still available in the region, the agency
1298	shall automatically enroll the recipient in that plan unless an
1299	applicable specialty plan is available. Except as otherwise
1300	provided in this part, the agency may not engage in practices
1301	that are designed to favor one managed care plan over another.
1302	When automatically enrolling recipients in managed care plans,
1303	the agency shall automatically enroll based on the following
1304	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 primary care providers.
1309	(c)  Whether primary care providers in one plan are more
1310	geographically accessible to the recipient's residence than
1311	those in other plans.
1312	(3)  OPT-OUT OPTION.-The agency shall develop a process to
1313	enable any recipient with access to employer-sponsored health
1314	care coverage to opt out of all managed care plans and to use
1315	Medicaid financial assistance to pay for the recipient's share
1316	of the cost in such employer-sponsored coverage. Contingent upon
1317	federal approval, the agency shall also enable recipients with
1318	access to other insurance or related products providing access
1319	to health care services created pursuant to state law, including
1320	any product available under the Florida Health Choices Program,
1321	or any health exchange, to opt out. The amount of financial
1322	assistance provided for each recipient may not exceed the amount
1323	of the Medicaid premium that would have been paid to a managed
1324	care plan for that recipient.
1325	Section 19.  Section 409.978, Florida Statutes, is created
1326	to read:
1327	409.978  Long-term care managed care program.-
1328	(1)  Pursuant to s. 409.963, the agency shall administer
1329	the long-term care managed care program described in ss.
1330	409.978-409.985, but may delegate specific duties and
1331	responsibilities for the program to the Department of Elderly
1332	Affairs and other state agencies. By July 1, 2012, the agency
1333	shall begin implementation of the statewide long-term care
1334	managed care program, with full implementation in all regions by
1335	October 1, 2013.
1336	(2)  The agency shall make payments for long-term care,
1337	including home and community-based services, using a managed
1338	care model. Unless otherwise specified, the provisions of ss.
1339	409.961-409.97 apply to the long-term care managed care program.
1340	(3)  The Department of Elderly Affairs shall assist the
1341	agency to develop specifications for use in the invitation to
1342	negotiate and the model contract, determine clinical eligibility
1343	for enrollment in managed long-term care plans, monitor plan
1344	performance and measure quality of service delivery, assist
1345	clients and families to address complaints with the plans,
1346	facilitate working relationships between plans and providers
1347	serving elders and disabled adults, and perform other functions
1348	specified in a memorandum of agreement.
1349	Section 20.  Section 409.979, Florida Statutes, is created
1350	to read:
1351	409.979  Eligibility.-
1352	(1)  Medicaid recipients who meet all of the following
1353	criteria are eligible to receive long-term care services and
1354	must receive long-term care services by participating in the
1355	long-term care managed care program. The recipient must be:
1356	(a)  Sixty-five years of age or older or eligible for
1357	Medicaid by reason of a disability.
1358	(b)  Determined by the Comprehensive Assessment Review and
1359	Evaluation for Long-Term Care Services (CARES) Program to
1360	require nursing facility care as defined in s. 409.985(3).
1361	(2)  Medicaid recipients who, on the date long-term care
1362	managed care plans become available in their region, reside in a
1363	nursing home facility or are enrolled in one of the following
1364	long-term care Medicaid waiver programs are eligible to
1365	participate in the long-term care managed care program for up to
1366	24 months without being reevaluated for their need of nursing
1367	facility care as defined in s. 409.985(3):
1368	(a)  The Assisted Living for the Frail Elderly Waiver.
1369	(b)  The Aged and Disabled Adult Waiver.
1370	(c)  The Adult Day Health Care Waiver.
1371	(d)  The Consumer-Directed Care Plus Program as described
1372	in s. 409.221.
1373	(e)  The Program of All-inclusive Care for the Elderly.
1374	(f)  The long-term care community-based diversion pilot
1375	project as described in s. 430.705.
1376	(g)  The Channeling Services Waiver for Frail Elders.
1377	Section 21.  Section 409.98, Florida Statutes, is created
1378	to read:
1379	409.98  Benefits.-Long-term care plans shall cover, at a
1380	minimum, the following:
1381	(1)  Nursing facility care.
1382	(2)  Services provided in assisted living facilities.
1383	(3)  Hospice.
1384	(4)  Adult day care.
1385	(5)  Medical equipment and supplies, including incontinence
1386	supplies.
1387	(6)  Personal care.
1388	(7)  Home accessibility adaptation.
1389	(8)  Behavior management.
1390	(9)  Home-delivered meals.
1391	(10)  Case management.
1392	(11)  Therapies:
1393	(a)  Occupational therapy.
1394	(b)  Speech therapy.
1395	(c)  Respiratory therapy.
1396	(d)  Physical therapy.
1397	(12)  Intermittent and skilled nursing.
1398	(13)  Medication administration.
1399	(14)  Medication management.
1400	(15)  Nutritional assessment and risk reduction.
1401	(16)  Caregiver training.
1402	(17)  Respite care.
1403	(18)  Transportation.
1404	(19)  Personal emergency response system.
1405	Section 22.  Section 409.981, Florida Statutes, is created
1406	to read:
1407	409.981  Eligible plans.-
1408	(1)  ELIGIBLE PLANS.-Provider service networks must be
1409	long-term care provider service networks. Other eligible plans
1410	may either be long-term care plans or comprehensive long-term
1411	care plans.
1412	(2)  ELIGIBLE PLAN SELECTION.-The agency shall select
1413	eligible plans through the procurement process described in s.
1414	409.966. The agency shall provide notice of invitations to
1415	negotiate no later than July 1, 2012.
1416	(a)  The agency shall procure three plans for Region I. At
1417	least one plan shall be a provider service network, if any
1418	submit a responsive bid.
1419	(b)  The agency shall procure at least three and no more
1420	than six plans for Region II. At least one plan shall be a
1421	provider service network, if any submit a responsive bid.
1422	(c)  The agency shall procure at least four plans and no
1423	more than eight plans for Region III. At least two plans shall
1424	be provider service networks, if any two submit responsive bids.
1425	(d)  The agency shall procure at least four plans and no
1426	more than seven plans for Region IV. At least two plans shall be
1427	provider service networks, if any two submit responsive bids.
1428	(e)  The agency shall procure three plans for Region V. At
1429	least one plan shall be a provider service network, if any
1430	submit a responsive bid.
1431	(f)  The agency shall procure at least four plans and no
1432	more than seven plans for Region VI. At least two plans shall be
1433	provider service networks, if any two submit a responsive bid.
1434	(g)  The agency shall procure at least five plans and no
1435	more than 10 plans for Region VII. At least two plans shall be
1436	provider service networks, if any two submit responsive bids.
1437
1438	If no provider service network submits a responsive bid, the
1439	agency shall procure one fewer eligible plan in each of the
1440	regions. Within 12 months after the initial invitation to
1441	negotiate, the agency shall attempt to procure an eligible plan
1442	that is a provider service network. The agency shall notice
1443	another invitation to negotiate only with provider service
1444	networks in a region where no provider service network has been
1445	selected.
1446	(3)  QUALITY SELECTION CRITERIA.-In addition to the
1447	criteria established in s. 409.966, the agency shall consider
1448	the following factors in the selection of eligible plans:
1449	(a)  Evidence of the employment of executive managers with
1450	expertise and experience in serving aged and disabled persons
1451	who require long-term care.
1452	(b)  Whether a plan has established a network of service
1453	providers dispersed throughout the region and in sufficient
1454	numbers to meet specific service standards established by the
1455	agency for specialty services for persons receiving home and
1456	community-based care.
1457	(c)  Whether a plan is proposing to establish a
1458	comprehensive long-term care plan and whether the eligible plan
1459	has a contract to provide managed medical assistance services in
1460	the same region.
1461	(d)  Whether a plan offers consumer-directed care services
1462	to enrollees pursuant to s. 409.221.
1463	(e)  Whether a plan is proposing to provide home and
1464	community-based services in addition to the minimum benefits
1465	required by s. 409.98.
1466	(4)  PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY.-
1467	Participation by the Program of All-Inclusive Care for the
1468	Elderly (PACE) shall be pursuant to a contract with the agency
1469	and not subject to the procurement requirements or regional plan
1470	number limits of this section. PACE plans may continue to
1471	provide services to individuals at such levels and enrollment
1472	caps as authorized by the General Appropriations Act.
1473	Section 23.  Section 409.982, Florida Statutes, is created
1474	to read:
1475	409.982  Managed care plan accountability.-In addition to
1476	the requirements of s. 409.967, plans and providers
1477	participating in the long-term care managed care program shall
1478	comply with the requirements of this section.
1479	(1)  PROVIDER NETWORKS.-Managed care plans may limit the
1480	providers in their networks based on credentials, quality
1481	indicators, and price. For the period between October 1, 2013,
1482	and September 30, 2014, each selected plan must offer a network
1483	contract to all the following providers in the region:
1484	(a)  Nursing homes.
1485	(b)  Hospices.
1486	(c)  Aging network service providers that have previously
1487	participated in home and community-based waivers serving elders
1488	or community-service programs administered by the Department of
1489	Elderly Affairs.
1490
1491	After 12 months of active participation in a managed care plan's
1492	network, the plan may exclude any of the providers named in this
1493	subsection from the network for failure to meet quality or
1494	performance criteria. If the plan excludes a provider from the
1495	plan, the plan must provide written notice to all recipients who
1496	have chosen that provider for care. The notice shall be provided
1497	at least 30 days before the effective date of the exclusion. The
1498	agency shall establish contract provisions governing the
1499	transfer of recipients from excluded residential providers.
1500	(2)  SELECT PROVIDER PARTICIPATION.-Except as provided in
1501	this subsection, providers may limit the managed care plans they
1502	join. Nursing homes and hospices that are enrolled Medicaid
1503	providers must participate in all eligible plans selected by the
1504	agency in the region in which the provider is located.
1505	(3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
1506	monitor the quality and performance of each participating
1507	provider using measures adopted by and collected by the agency
1508	and any additional measures mutually agreed upon by the provider
1509	and the plan
1510	(4)  PROVIDER NETWORK STANDARDS.-The agency shall establish
1511	and each managed care plan must comply with specific standards
1512	for the number, type, and regional distribution of providers in
1513	the plan's network, which must include:
1514	(a)  Adult day care centers.
1515	(b)  Adult family-care homes.
1516	(c)  Assisted living facilities.
1517	(d)  Health care services pools.
1518	(e)  Home health agencies.
1519	(f)  Homemaker and companion services.
1520	(g)  Hospices.
1521	(h)  Community care for the elderly lead agencies.
1522	(i)  Nurse registries.
1523	(j)  Nursing homes.
1524	(5)  PROVIDER PAYMENT.-Managed care plans and providers
1525	shall negotiate mutually acceptable rates, methods, and terms of
1526	payment. Plans shall pay nursing homes an amount equal to the
1527	nursing facility-specific payment rates set by the agency;
1528	however, mutually acceptable higher rates may be negotiated for
1529	medically complex care. Plans shall pay hospice providers an
1530	amount equal to the per diem rate set by the agency. For
1531	recipients residing in a nursing facility and receiving hospice
1532	services, the plan shall pay the hospice provider the per diem
1533	rate set by the agency minus the nursing facility component and
1534	shall pay the nursing facility the applicable state rate. Plans
1535	shall ensure that electronic nursing home and hospice claims
1536	that contain sufficient information for processing are paid
1537	within 10 business days after receipt.
1538	Section 24.  Section 409.983, Florida Statutes, is created
1539	to read:
1540	409.983  Managed care plan payment.-In addition to the
1541	payment provisions of s. 409.968, the agency shall provide
1542	payment to plans in the long-term care managed care program
1543	pursuant to this section.
1544	(1)  Prepaid payment rates for long-term care managed care
1545	plans shall be negotiated between the agency and the eligible
1546	plans as part of the procurement process described in s.
1547	409.966.
1548	(2)  Payment rates for comprehensive long-term care plans
1549	covering services described in s. 409.973 shall be blended with
1550	rates for long-term care plans for services specified in s.
1551	409.98.
1552	(3)  Payment rates for plans shall reflect historic
1553	utilization and spending for covered services projected forward
1554	and adjusted to reflect the level of care profile for enrollees
1555	in each plan. The payment shall be adjusted to provide an
1556	incentive for reducing institutional placements and increasing
1557	the utilization of home and community-based services.
1558	(4)  The initial assessment of an enrollee's level of care
1559	shall be made by the Comprehensive Assessment and Review for
1560	Long-Term-Care Services (CARES) program, which shall assign the
1561	recipient into one of the following levels of care:
1562	(a)  Level of care 1 consists of recipients residing in or
1563	who must be placed in a nursing home.
1564	(b)  Level of care 2 consists of recipients at imminent
1565	risk of nursing home placement, as evidenced by the need for the
1566	constant availability of routine medical and nursing treatment
1567	and care, and require extensive health-related care and services
1568	because of mental or physical incapacitation.
1569	(c)  Level of care 3 consists of recipients at imminent
1570	risk of nursing home placement, as evidenced by the need for the
1571	constant availability of routine medical and nursing treatment
1572	and care, who have a limited need for health-related care and
1573	services and are mildly medically or physically incapacitated.
1574
1575	The agency shall periodically adjust payment rates to account
1576	for changes in the level of care profile for each managed care
1577	plan based on encounter data.
1578	(5)  The agency shall make an incentive adjustment in
1579	payment rates to encourage the increased utilization of home and
1580	community-based services and a commensurate reduction of
1581	institutional placement. The incentive adjustment shall be
1582	modified in each successive rate period during the first
1583	contract period, as follows:
1584	(a)  A 2 percentage point shift in the first rate-setting
1585	period;
1586	(b)  A 2 percentage point shift in the second rate-setting
1587	period, as compared to the utilization mix at the end of the
1588	first rate-setting period;
1589	(c)  A 3 percentage point shift in the third rate-setting
1590	period, and in each subsequent rate-setting period during the
1591	first contract period, as compared to the utilization mix at the
1592	end of the immediately preceding rate-setting period.
1593
1594	The incentive adjustment shall continue in subsequent contract
1595	periods, at a rate of 3 percentage points per year as compared
1596	to the utilization mix at the end of the immediately preceding
1597	rate-setting period, until no more than 35 percent of the plan's
1598	enrollees are placed in institutional settings. The agency shall
1599	annually report to the Legislature the actual change in the
1600	utilization mix of home and community-based services compared to
1601	institutional placements and provide a recommendation for
1602	utilization mix requirements for future contracts.
1603	(6)  The agency shall establish nursing-facility-specific
1604	payment rates for each licensed nursing home based on facility
1605	costs adjusted for inflation and other factors as authorized in
1606	the General Appropriations Act. Payments to long-term care
1607	managed care plans shall be reconciled to reimburse actual
1608	payments to nursing facilities.
1609	(7)  The agency shall establish hospice payment rates.
1610	Payments to long-term care managed care plans shall be
1611	reconciled to reimburse actual payments to hospices.
1612	Section 25.  Section 409.984, Florida Statutes, is created
1613	to read:
1614	409.984  Choice counseling; enrollment.-
1615	(1)  CHOICE COUNSELING.-Before contracting with a vendor to
1616	provide choice counseling as authorized under s. 409.969, the
1617	agency shall offer to contract with aging resource centers
1618	established under s. 430.2053 for choice counseling services. If
1619	the aging resource center is determined not to be the vendor
1620	that provides choice counseling, the agency shall establish a
1621	memorandum of understanding with the aging resource center to
1622	coordinate staffing and collaborate with the choice counseling
1623	vendor. In addition to the requirements of s. 409.969, any
1624	contract to provide choice counseling for the long-term care
1625	managed care program shall provide that each recipient be given
1626	the option of having in-person choice counseling.
1627	(2)  AUTOMATIC ENROLLMENT.-The agency shall automatically
1628	enroll into a long-term care managed care plan those Medicaid
1629	recipients who do not voluntarily choose a plan pursuant to s.
1630	409.969. The agency shall automatically enroll recipients in
1631	plans that meet or exceed the performance or quality standards
1632	established pursuant to s. 409.967 and may not automatically
1633	enroll recipients in a plan that is deficient in those
1634	performance or quality standards. If a recipient is deemed
1635	dually eligible for Medicaid and Medicare services and is
1636	currently receiving Medicare services from an entity qualified
1637	under 42 C.F.R. part 422 as a Medicare Advantage Preferred
1638	Provider Organization, Medicare Advantage Provider-sponsored
1639	Organization, or Medicare Advantage Special Needs Plan, the
1640	agency shall automatically enroll the recipient in such plan for
1641	Medicaid services if the plan is currently participating in the
1642	long-term care managed care program. Except as otherwise
1643	provided in this part, the agency may not engage in practices
1644	that are designed to favor one managed care plan over another.
1645	When automatically enrolling recipients in plans, the agency
1646	shall take into account the following criteria:
1647	(a)  Whether the plan has sufficient network capacity to
1648	meet the needs of the recipients.
1649	(b)  Whether the recipient has previously received services
1650	from one of the plan's home and community-based service
1651	providers.
1652	(c)  Whether the home and community-based providers in one
1653	plan are more geographically accessible to the recipient's
1654	residence than those in other plans.
1655	(3)  HOSPICE SELECTION.-Notwithstanding the provisions of
1656	s. 409.969(3)(c), when a recipient is referred for hospice
1657	services, the recipient shall have a 30-day period during which
1658	the recipient may select to enroll in another managed care plan
1659	to access the hospice provider of the recipient's choice.
1660	(4)  CHOICE OF RESIDENTIAL SETTING.-When a recipient is
1661	referred for placement in a nursing home or assisted living
1662	facility, the plan shall inform the recipient of any facilities
1663	within the plan that have specific cultural or religious
1664	affiliations and, if requested by the recipient, make a
1665	reasonable effort to place the recipient in the facility of the
1666	recipient's choice.
1667	Section 26.  Section 409.9841, Florida Statutes, is created
1668	to read:
1669	409.9841  Long-term care managed care technical advisory
1670	workgroup.-
1671	(1)  Before August 1, 2011, the agency shall establish a
1672	technical advisory workgroup to assist in developing:
1673	(a)  The method of determining Medicaid eligibility
1674	pursuant to s. 409.985(3).
1675	(b)  The requirements for provider payments to nursing
1676	homes under s. 409.982(6).
1677	(c)  The method for managing nonpayment of Medicare
1678	coinsurance crossover claims.
1679	(d)  Uniform requirements for claims submissions and
1680	payments, including electronic funds transfers and claims
1681	processing.
1682	(e)  The process for enrollment of and payment for
1683	individuals pending determination of Medicaid eligibility.
1684	(2)  The advisory workgroup shall include, but is not
1685	limited to, representatives of providers and plans who could
1686	potentially participate in long-term care managed care. Members
1687	of the workgroup shall serve without compensation but may be
1688	reimbursed for per diem and travel expenses as provided in s.
1689	112.061.
1690	(3)  This section is repealed on June 30, 2013.
1691	Section 27.  Section 409.985, Florida Statutes, is created
1692	to read:
1693	409.985  Comprehensive Assessment and Review for Long-Term
1694	Care Services (CARES) Program.-
1695	(1)  The agency shall operate the Comprehensive Assessment
1696	and Review for Long-Term Care Services (CARES) preadmission
1697	screening program to ensure that only individuals whose
1698	conditions require long-term care services are enrolled in the
1699	long-term care managed care program.
1700	(2)  The agency shall operate the CARES program through an
1701	interagency agreement with the Department of Elderly Affairs.
1702	The agency, in consultation with the Department of Elderly
1703	Affairs, may contract for any function or activity of the CARES
1704	program, including any function or activity required by 42
1705	C.F.R. part 483.20, relating to preadmission screening and
1706	review.
1707	(3)  The CARES program shall determine if an individual
1708	requires nursing facility care and, if the individual requires
1709	such care, assign the individual to a level of care as described
1710	in s. 409.983(4). When determining the need for nursing facility
1711	care, consideration shall be given to the nature of the services
1712	prescribed and which level of nursing or other health care
1713	personnel meets the qualifications necessary to provide such
1714	services and the availability to and access by the individual of
1715	community or alternative resources. For the purposes of the
1716	long-term care managed care program, the term "nursing facility
1717	care" means the individual:
1718	(a)  Requires nursing home placement as evidenced by the
1719	need for medical observation throughout a 24-hour period and
1720	care required to be performed on a daily basis by, or under the
1721	direct supervision of, a registered nurse or other health care
1722	professional and requires services that are sufficiently
1723	medically complex to require supervision, assessment, planning,
1724	or intervention by a registered nurse because of a mental or
1725	physical incapacitation by the individual;
1726	(b)  Requires or is at imminent risk of nursing home
1727	placement as evidenced by the need for observation throughout a
1728	24-hour period and care and the constant availability of medical
1729	and nursing treatment and requires services on a daily or
1730	intermittent basis that are to be performed under the
1731	supervision of licensed nursing or other health professionals
1732	because the individual who is incapacitated mentally or
1733	physically; or
1734	(c)  Requires or is at imminent risk of nursing home
1735	placement as evidenced by the need for observation throughout a
1736	24-hour period and care and the constant availability of medical
1737	and nursing treatment and requires limited services that are to
1738	be performed under the supervision of licensed nursing or other
1739	health professionals because the individual is mildly
1740	incapacitated mentally or physically.
1741	(4)  For individuals whose nursing home stay is initially
1742	funded by Medicare and Medicare coverage and is being terminated
1743	for lack of progress towards rehabilitation, CARES staff shall
1744	consult with the person making the determination of progress
1745	toward rehabilitation to ensure that the recipient is not being
1746	inappropriately disqualified from Medicare coverage. If, in
1747	their professional judgment, CARES staff believe that a Medicare
1748	beneficiary is still making progress toward rehabilitation, they
1749	may assist the Medicare beneficiary with an appeal of the
1750	disqualification from Medicare coverage. The use of CARES teams
1751	to review Medicare denials for coverage under this section is
1752	authorized only if it is determined that such reviews qualify
1753	for federal matching funds through Medicaid. The agency shall
1754	seek or amend federal waivers as necessary to implement this
1755	section.
1756	Section 28.  Section 409.986, Florida Statutes, is created
1757	to read:
1758	409.986  Managed long-term care for persons with
1759	developmental disabilities.-
1760	(1)  Pursuant to s. 409.963, the agency is responsible for
1761	administering the long-term care managed care program for
1762	persons with developmental disabilities described in ss.
1763	409.986-409.992, but may delegate specific duties and
1764	responsibilities for the program to the Agency for Persons with
1765	Disabilities and other state agencies. By January 1, 2015, the
1766	agency shall begin implementation of statewide long-term care
1767	managed care for persons with developmental disabilities, with
1768	full implementation in all regions by October 1, 2016.
1769	(2)  The agency shall make payments for long-term care for
1770	persons with developmental disabilities, including home and
1771	community-based services, using a managed care model. Unless
1772	otherwise specified, the provisions of ss. 409.961-409.97 apply
1773	to the long-term care managed care program for persons with
1774	developmental disabilities.
1775	(3)  The Agency for Persons with Disabilities shall assist
1776	the agency to develop the specifications for use in the
1777	invitations to negotiate and the model contract, determine
1778	clinical eligibility for enrollment in long-term care plans for
1779	persons with developmental disabilities, assist the agency to
1780	monitor plan performance and measure quality, assist clients and
1781	families to address complaints with the plans, facilitate
1782	working relationships between plans and providers serving
1783	persons with developmental disabilities, and perform other
1784	functions specified in a memorandum of agreement.
1785	Section 29.  Section 409.987, Florida Statutes, is created
1786	to read:
1787	409.987  Eligibility.-
1788	(1)  Medicaid recipients who meet all of the following
1789	criteria are eligible and shall be enrolled in a comprehensive
1790	long-term care plan or long-term care plan:
1791	(a)  Is Medicaid eligible pursuant to s. 409.904.
1792	(b)  Is a Florida resident who has a developmental
1793	disability as defined in s. 393.063.
1794	(c)  Meets the level of care need, including:
1795	1.  The recipient's intelligence quotient is 59 or less;
1796	2.  The recipient's intelligence quotient is 60-69,
1797	inclusive, and the recipient has a secondary condition that
1798	includes cerebral palsy, spina bifida, Prader-Willi syndrome,
1799	epilepsy, or autistic disorder or has ambulation, sensory,
1800	chronic health, and behavioral problems;
1801	3.  The recipient's intelligence quotient is 60-69,
1802	inclusive, and the recipient has severe functional limitations
1803	in at least three major life activities, including self-care,
1804	learning, mobility, self-direction, understanding and use of
1805	language, and capacity for independent living; or
1806	4.  The recipient is eligible under a primary disability of
1807	autistic disorder, cerebral palsy, spina bifida, or Prader-Willi
1808	syndrome. In addition, the condition must result in substantial
1809	functional limitations in three or more major life activities,
1810	including self-care, learning, mobility, self-direction,
1811	understanding and use of language, and capacity for independent
1812	living.
1813	(d)  Meets the level of care need to receive services in an
1814	intermediate care facility for the developmentally disabled.
1815	(e)  Is enrolled in a home and community-based Medicaid
1816	waiver established in chapter 393 or the Consumer Directed Care
1817	Plus program for persons with developmental disabilities under
1818	the Medicaid state plan, is a Medicaid-funded resident of a
1819	private intermediate care facility for the developmentally
1820	disabled on the date the managed long-term care plans for
1821	persons with disabilities becomes available in the recipient's
1822	region, or has been offered enrollment in a comprehensive long-
1823	term care plan or a long-term care plan.
1824	(2)  The Agency for Persons with Disabilities shall make
1825	offers for enrollment to eligible individuals based on the wait-
1826	list prioritization in s. 393.065(5) and subject to availability
1827	of funds. Before enrollment offers, the agency shall determine
1828	that sufficient funds exist to support additional enrollment
1829	into plans.
1830	(3)  Unless specifically exempted, all eligible persons
1831	must be enrolled in a comprehensive long-term care plan or a
1832	long-term care plan. Medicaid recipients who are residents of a
1833	developmental disability center, including Sunland Center in
1834	Marianna and Tacachale Center in Gainesville, are exempt from
1835	mandatory enrollment but may voluntarily enroll in a long-term
1836	care plan.
1837	Section 30.  Section 409.988, Florida Statutes, is created
1838	to read:
1839	409.988  Benefits.-Managed care plans shall cover, at a
1840	minimum, the services in this section. Plans may customize
1841	benefit packages or offer additional benefits to meet the needs
1842	of enrollees in the plan.
1843	(1)  Intermediate care for the developmentally disabled.
1844	(2)  Services in alternative residential settings,
1845	including, but not limited to:
1846	(a)  Group homes licensed under chapter 393 and foster care
1847	homes licensed under chapter 409.
1848	(b)  Comprehensive transitional education programs licensed
1849	under chapter 393.
1850	(c)  Residential habilitation centers licensed under
1851	chapter 393.
1852	(d)  Assisted living facilities licensed under chapter 429
1853	and transitional living facilities licensed under part V of
1854	chapter 400.
1855	(3)  Adult day training.
1856	(4)  Behavior analysis services.
1857	(5)  Companion services.
1858	(6)  Consumable medical supplies.
1859	(7)  Durable medical equipment and supplies.
1860	(8)  Environmental accessibility adaptations.
1861	(9)  In-home support services.
1862	(10)  Therapies, including occupational, speech,
1863	respiratory, and physical therapy.
1864	(11)  Personal care assistance.
1865	(12)  Residential habilitation services.
1866	(13)  Intensive behavioral residential habilitation
1867	services.
1868	(14)  Behavior focus residential habilitation services.
1869	(15)  Residential nursing services.
1870	(16)  Respite care.
1871	(17)  Support coordination.
1872	(18)  Supported employment.
1873	(19)  Supported living coaching.
1874	(20)  Transportation.
1875	Section 31.  Section 409.989, Florida Statutes, is created
1876	to read:
1877	409.989  Eligible plans.-
1878	(1)  ELIGIBLE PLANS.-Provider service networks may be
1879	either long-term care plans or comprehensive long-term care
1880	plans. Other plans must be comprehensive long-term care plans
1881	and under contract to provide services pursuant to s. 409.973 or
1882	s. 409.98 in any of the regions that form the combined region as
1883	defined in this section.
1884	(2)  PROVIDER SERVICE NETWORKS.-Provider service networks
1885	targeted to serve persons with disabilities must include one or
1886	more owners licensed pursuant to s. 393.067 or s. 400.962 and
1887	with at least 10 years' experience in serving this population.
1888	(3)  ELIGIBLE PLAN SELECTION.-The agency shall select
1889	eligible plans through the procurement process described in s.
1890	409.966. The agency shall notice invitations to negotiate no
1891	later than January 1, 2015.
1892	(a)  The agency shall procure at least two plans and no
1893	more than three plans for services in combined Regions I and II.
1894	At least one plan shall be a provider service network, if any
1895	submit a responsive bid.
1896	(b)  The agency shall procure at least two plans and no
1897	more than three plans for services in combined Regions III and
1898	IV. At least one plan shall be a provider service network, if
1899	any submit a responsive bid.
1900	(c)  The agency shall procure at least two plans and no
1901	more than four plans for services in combined Regions V, VI, and
1902	VII. At least one plan shall be a provider service network, if
1903	any submit a responsive bid.
1904
1905	If no provider service network submits a responsive bid, the
1906	agency shall procure no more than one less than the maximum
1907	number of eligible plans permitted in the combined region.
1908	Within 12 months after the initial invitation to negotiate, the
1909	agency shall attempt to procure an eligible plan that is a
1910	provider service network. The agency shall notice another
1911	invitation to negotiate only with provider service networks in
1912	such combined region where no provider service network has been
1913	selected.
1914	(4)  QUALITY SELECTION CRITERIA.-In addition to the
1915	criteria established in s. 409.966, the agency shall consider
1916	the following factors in the selection of eligible plans:
1917	(a)  Whether the plan has sufficient specialized staffing,
1918	including employment of executive managers with expertise and
1919	experience in serving persons with developmental disabilities.
1920	(b)  Whether the plan has sufficient network
1921	qualifications, including establishment of a network of service
1922	providers dispersed throughout the combined region and in
1923	sufficient numbers to meet specific accessibility standards
1924	established by the agency for specialty services for persons
1925	with developmental disabilities.
1926	(c)  Whether the plan has written agreements or signed
1927	contracts or has made substantial progress in establishing
1928	relationships with providers before the plan submitting a
1929	response. The agency shall give preference to plans with
1930	evidence of signed contracts with providers listed in s.
1931	409.99(1).
1932	(5)  CHILDREN'S MEDICAL SERVICES NETWORK.-The Children's
1933	Medical Services Network may provide either long-term care plans
1934	or comprehensive long-term care plans. Participation by the
1935	Children's Medical Services Network shall be pursuant to a
1936	single, statewide contract with the agency not subject to the
1937	procurement requirements or regional plan number limits of this
1938	section. The Children's Medical Services Network must meet all
1939	other plan requirements.
1940	Section 32.  Section 409.99, Florida Statutes, is created
1941	to read:
1942	409.99  Managed care plan accountability.-In addition to
1943	the requirements of s. 409.967, managed care plans and providers
1944	shall comply with the requirements of this section.
1945	(1)  PROVIDER NETWORKS.-Managed care plans may limit the
1946	providers in their networks based on credentials, quality
1947	indicators, and price. However, in the first contract period
1948	after an eligible plan is selected in a region by the agency,
1949	the plan must offer a network contract to the following
1950	providers in the region:
1951	(a)  Providers with licensed institutional care facilities
1952	for the developmentally disabled.
1953	(b)  Providers of alternative residential facilities
1954	specified in s. 409.988.
1955
1956	After 12 months of active participation in a managed care plan
1957	network, the plan may exclude any of the above-named providers
1958	from the network for failure to meet quality or performance
1959	criteria. If the plan excludes a provider from the plan, the
1960	plan must provide written notice to all recipients who have
1961	chosen that provider for care. The notice shall be issued at
1962	least 90 days before the effective date of the exclusion.
1963	(2)  SELECT PROVIDER PARTICIPATION.-Except as provided in
1964	this subsection, providers may limit the managed care plans they
1965	join. Licensed institutional care facilities for the
1966	developmentally disabled and licensed residential settings
1967	providing Intensive Behavioral Residential Habilitation services
1968	with an active Medicaid provider agreement must agree to
1969	participate in any eligible plan selected by the agency.
1970	(3)  PERFORMANCE MEASUREMENT.-Each managed care plan shall
1971	monitor the quality and performance of each participating
1972	provider. At the beginning of the contract period, each plan
1973	shall notify all its network providers of the metrics used by
1974	the plan for evaluating the provider's performance and
1975	determining continued participation in the network.
1976	(4)  PROVIDER PAYMENT.-Managed care plans and providers
1977	shall negotiate mutually acceptable rates, methods, and terms of
1978	payment. Plans shall pay intermediate care facilities for the
1979	developmentally disabled and intensive behavior residential
1980	habilitation providers an amount equal to the facility-specific
1981	payment rate set by the agency.
1982	(5)  CONSUMER AND FAMILY INVOLVEMENT.-Each managed care
1983	plan must establish a family advisory committee to participate
1984	in program design and oversight.
1985	(6)  CONSUMER-DIRECTED CARE.-Each managed care plan must
1986	offer consumer-directed care services to enrollees pursuant to
1987	s. 409.221.
1988	Section 33.  Section 409.991, Florida Statutes, is created
1989	to read:
1990	409.991  Managed care plan payment.-In addition to the
1991	payment provisions of s. 409.968, the agency shall provide
1992	payment to comprehensive long-term care plans and long-term care
1993	plans pursuant to this section.
1994	(1)  Prepaid payment rates shall be negotiated between the
1995	agency and the eligible plans as part of the procurement process
1996	described in s. 409.966.
1997	(2)  Payment for comprehensive long-term care plans
1998	covering services pursuant to s. 409.973 shall be blended with
1999	payments for long-term care plans for services specified in s.
2000	409.988.
2001	(3)  Payment rates for plans covering services specified in
2002	s. 409.988 shall be based on historical utilization and spending
2003	for covered services projected forward and adjusted to reflect
2004	the level-of-care profile of each plan's enrollees.
2005	(4)  The Agency for Persons with Disabilities shall conduct
2006	the initial assessment of an enrollee's level of care. The
2007	evaluation of level of care shall be based on assessment and
2008	service utilization information from the most recent version of
2009	the Questionnaire for Situational Information and encounter
2010	data.
2011	(5)  The agency shall assign enrollees of developmental
2012	disabilities long-term care plans into one of five levels of
2013	care to account for variations in risk status and service needs
2014	among enrollees.
2015	(a)  Level of care 1 consists of individuals receiving
2016	services in an intermediate care facility for the
2017	developmentally disabled.
2018	(b)  Level of care 2 consists of individuals with intensive
2019	medical or adaptive needs and who require essential services to
2020	avoid institutionalization or who possess behavioral problems
2021	that are exceptional in intensity, duration, or frequency and
2022	present a substantial risk of harm to themselves or others.
2023	(c)  Level of care 3 consists of individuals with service
2024	needs, including a licensed residential facility and a moderate
2025	level of support for standard residential habilitation services
2026	or a minimal level of support for behavior focus residential
2027	habilitation services, or individuals in supported living who
2028	require more than 6 hours a day of in-home support services.
2029	(d)  Level of care 4 consists of individuals requiring less
2030	than a moderate level of residential habilitation support in a
2031	residential placement or individuals in supported living who
2032	require 6 hours a day or less of in-home support services.
2033	(e)  Level of care 5 consists of individuals who do not
2034	receive in-home support services and need minimal support
2035	services while living in independent or supported living
2036	situations or in their family home.
2037
2038	The agency shall periodically adjust aggregate payments to plans
2039	based on encounter data to account for variations in risk levels
2040	among plans' enrollees.
2041	(6)  The agency shall establish intensive behavior
2042	residential habilitation rates for providers approved by the
2043	agency to provide this service. The agency shall also establish
2044	intermediate care facility for the developmentally disabled-
2045	specific payment rates for each licensed intermediate care
2046	facility. Payments to intermediate care facilities for the
2047	developmentally disabled and providers of intensive behavior
2048	residential habilitation services shall be reconciled to
2049	reimburse the plan's actual payments to the facilities.
2050	Section 34.  Section 409.992, Florida Statutes, is created
2051	to read:
2052	409.992  Automatic enrollment.-The agency shall
2053	automatically enroll into a comprehensive long-term care plan or
2054	a long-term care plan those Medicaid recipients who do not
2055	voluntarily choose a plan pursuant to s. 409.969. The agency
2056	shall automatically enroll recipients in plans that meet or
2057	exceed the performance or quality standards established pursuant
2058	to s. 409.967 and shall not automatically enroll recipients in a
2059	plan that is deficient in those performance or quality
2060	standards. Except as otherwise provided in this part, the agency
2061	shall assign individuals who are deemed dually eligible for
2062	Medicaid and Medicare to a plan that provides both Medicaid and
2063	Medicare services. The agency may not engage in practices that
2064	are designed to favor one managed care plan over another. When
2065	automatically enrolling recipients in plans, the agency shall
2066	take into account the following criteria:
2067	(1)  Whether the plan has sufficient network capacity to
2068	meet the needs of the recipients.
2069	(2)  Whether the recipient has previously received services
2070	from one of the plan's home and community-based service
2071	providers.
2072	(3)  Whether home and community-based providers in one plan
2073	are more geographically accessible to the recipient's residence
2074	than those in other plans.
2075	Section 35.  This act shall take effect July 1, 2011.

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