Florida Senate - 2017 SB 916
By Senator Grimsley
1 A bill to be entitled
2 An act relating to the statewide Medicaid managed care
3 program; amending s. 409.912, F.S.; deleting the fee
4 for-service option as a basis for the reimbursement of
5 Medicaid provider service networks; amending s.
6 409.964, F.S.; deleting an obsolete provision;
7 amending s. 409.966, F.S.; requiring that a required
8 databook consist of data that is consistent with
9 actuarial rate-setting practices and standards;
10 revising the designation and county makeup of regions
11 of the state for purposes of procuring health plans
12 that may participate in the Medicaid program; adding a
13 factor that the Agency for Health Care Administration
14 must consider in the selection of eligible plans;
15 deleting a requirement related to fee-for-service
16 provider service networks; amending s. 409.968, F.S.;
17 requiring provider service networks to be prepaid
18 plans; deleting a fee-for-service option for Medicaid
19 reimbursement for provider service networks; amending
20 s. 409.971, F.S.; deleting an obsolete provision;
21 amending s. 409.974, F.S.; revising the number of
22 eligible Medicaid health care plans the agency must
23 procure for certain regions in the state; deleting an
24 obsolete provision; amending s. 409.978, F.S.;
25 deleting an obsolete provision; amending s. 409.981,
26 F.S.; revising the number of eligible Medicaid health
27 care plans the agency must procure for certain regions
28 in the state; deleting a requirement that the agency
29 consider a specific factor relating to the selection
30 of managed medical assistance plans; providing an
31 effective date.
33 Be It Enacted by the Legislature of the State of Florida:
35 Section 1. Subsection (2) of section 409.912, Florida
36 Statutes, is amended to read:
37 409.912 Cost-effective purchasing of health care.—The
38 agency shall purchase goods and services for Medicaid recipients
39 in the most cost-effective manner consistent with the delivery
40 of quality medical care. To ensure that medical services are
41 effectively utilized, the agency may, in any case, require a
42 confirmation or second physician’s opinion of the correct
43 diagnosis for purposes of authorizing future services under the
44 Medicaid program. This section does not restrict access to
45 emergency services or poststabilization care services as defined
46 in 42 C.F.R. s. 438.114. Such confirmation or second opinion
47 shall be rendered in a manner approved by the agency. The agency
48 shall maximize the use of prepaid per capita and prepaid
49 aggregate fixed-sum basis services when appropriate and other
50 alternative service delivery and reimbursement methodologies,
51 including competitive bidding pursuant to s. 287.057, designed
52 to facilitate the cost-effective purchase of a case-managed
53 continuum of care. The agency shall also require providers to
54 minimize the exposure of recipients to the need for acute
55 inpatient, custodial, and other institutional care and the
56 inappropriate or unnecessary use of high-cost services. The
57 agency shall contract with a vendor to monitor and evaluate the
58 clinical practice patterns of providers in order to identify
59 trends that are outside the normal practice patterns of a
60 provider’s professional peers or the national guidelines of a
61 provider’s professional association. The vendor must be able to
62 provide information and counseling to a provider whose practice
63 patterns are outside the norms, in consultation with the agency,
64 to improve patient care and reduce inappropriate utilization.
65 The agency may mandate prior authorization, drug therapy
66 management, or disease management participation for certain
67 populations of Medicaid beneficiaries, certain drug classes, or
68 particular drugs to prevent fraud, abuse, overuse, and possible
69 dangerous drug interactions. The Pharmaceutical and Therapeutics
70 Committee shall make recommendations to the agency on drugs for
71 which prior authorization is required. The agency shall inform
72 the Pharmaceutical and Therapeutics Committee of its decisions
73 regarding drugs subject to prior authorization. The agency is
74 authorized to limit the entities it contracts with or enrolls as
75 Medicaid providers by developing a provider network through
76 provider credentialing. The agency may competitively bid single
77 source-provider contracts if procurement of goods or services
78 results in demonstrated cost savings to the state without
79 limiting access to care. The agency may limit its network based
80 on the assessment of beneficiary access to care, provider
81 availability, provider quality standards, time and distance
82 standards for access to care, the cultural competence of the
83 provider network, demographic characteristics of Medicaid
84 beneficiaries, practice and provider-to-beneficiary standards,
85 appointment wait times, beneficiary use of services, provider
86 turnover, provider profiling, provider licensure history,
87 previous program integrity investigations and findings, peer
88 review, provider Medicaid policy and billing compliance records,
89 clinical and medical record audits, and other factors. Providers
90 are not entitled to enrollment in the Medicaid provider network.
91 The agency shall determine instances in which allowing Medicaid
92 beneficiaries to purchase durable medical equipment and other
93 goods is less expensive to the Medicaid program than long-term
94 rental of the equipment or goods. The agency may establish rules
95 to facilitate purchases in lieu of long-term rentals in order to
96 protect against fraud and abuse in the Medicaid program as
97 defined in s. 409.913. The agency may seek federal waivers
98 necessary to administer these policies.
99 (2) The agency may contract with a provider service
, which may be reimbursed on a fee-for-service or prepaid
101 basis. Prepaid provider service networks shall receive per
102 member, per-month payments. A provider service network that does
103 not choose to be a prepaid plan shall receive fee-for-service
104 rates with a shared savings settlement. The fee-for-service
105 option shall be available to a provider service network only for
106 the first 2 years of the plan’s operation or until the contract
107 year beginning September 1, 2014, whichever is later. The agency
108 shall annually conduct cost reconciliations to determine the
109 amount of cost savings achieved by fee-for-service provider
110 service networks for the dates of service in the period being
111 reconciled. Only payments for covered services for dates of
112 service within the reconciliation period and paid within 6
113 months after the last date of service in the reconciliation
114 period shall be included. The agency shall perform the necessary
115 adjustments for the inclusion of claims incurred but not
116 reported within the reconciliation for claims that could be
117 received and paid by the agency after the 6-month claims
118 processing time lag. The agency shall provide the results of the
119 reconciliations to the fee-for-service provider service networks
120 within 45 days after the end of the reconciliation period. The
121 fee-for-service provider service networks shall review and
122 provide written comments or a letter of concurrence to the
123 agency within 45 days after receipt of the reconciliation
124 results. This reconciliation shall be considered final.
125 (a) A provider service network that which is reimbursed by
126 the agency on a prepaid basis shall be exempt from parts I and
127 III of chapter 641, but must comply with the solvency
128 requirements in s. 641.2261(2) and meet appropriate financial
129 reserve, quality assurance, and patient rights requirements as
130 established by the agency.
131 (b) A provider service network is a network established or
132 organized and operated by a health care provider, or group of
133 affiliated health care providers, which provides a substantial
134 proportion of the health care items and services under a
135 contract directly through the provider or affiliated group of
136 providers and may make arrangements with physicians or other
137 health care professionals, health care institutions, or any
138 combination of such individuals or institutions to assume all or
139 part of the financial risk on a prospective basis for the
140 provision of basic health services by the physicians, by other
141 health professionals, or through the institutions. The health
142 care providers must have a controlling interest in the governing
143 body of the provider service network organization.
144 Section 2. Section 409.964, Florida Statutes, is amended to
146 409.964 Managed care program; state plan; waivers.—The
147 Medicaid program is established as a statewide, integrated
148 managed care program for all covered services, including long
149 term care services. The agency shall apply for and implement
150 state plan amendments or waivers of applicable federal laws and
151 regulations necessary to implement the program. Before seeking a
152 waiver, the agency shall provide public notice and the
153 opportunity for public comment and include public feedback in
154 the waiver application. The agency shall hold one public meeting
155 in each of the regions described in s. 409.966(2), and the time
156 period for public comment for each region shall end no sooner
157 than 30 days after the completion of the public meeting in that
158 region. The agency shall submit any state plan amendments, new
159 waiver requests, or requests for extensions or expansions for
160 existing waivers, needed to implement the managed care program
161 by August 1, 2011.
162 Section 3. Subsection (2) and paragraphs (a), (d), and (e)
163 of subsection (3) of section 409.966, Florida Statutes, are
164 amended to read:
165 409.966 Eligible plans; selection.—
166 (2) ELIGIBLE PLAN SELECTION.—The agency shall select a
167 limited number of eligible plans to participate in the Medicaid
168 program using invitations to negotiate in accordance with s.
169 287.057(1)(c). At least 90 days before issuing an invitation to
170 negotiate, the agency shall compile and publish a databook
171 consisting of a comprehensive set of utilization and spending
172 data consistent with actuarial rate-setting practices and
173 standards for the 3 most recent contract years consistent with
174 the rate-setting periods for all Medicaid recipients by region
175 or county. The source of the data in the report must include
176 both historic fee-for-service claims and validated data from the
177 Medicaid Encounter Data System. The report must be available in
178 electronic form and delineate utilization use by age, gender,
179 eligibility group, geographic area, and aggregate clinical risk
180 score. Separate and simultaneous procurements shall be conducted
181 in each of the following regions:
182 (a) Region A Region 1, which consists of Bay, Calhoun,
183 Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson,
184 Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla,
185 and Walton, and Washington Counties.
186 (b) Region B Region 2, which consists of Alachua, Baker,
187 Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler,
188 Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion,
189 Nassau, Putnam, St. Johns, Sumter, Suwannee, Union, and Volusia
190 Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson,
191 Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and
192 Washington Counties.
193 (c) Region C Region 3, which consists of Hardee, Highlands,
194 Hillsborough, Manatee, Pasco, Pinellas, and Polk Alachua,
195 Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton,
196 Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter,
197 Suwannee, and Union Counties.
198 (d) Region D Region 4, which consists of Brevard, Orange,
199 Osceola, and Seminole Baker, Clay, Duval, Flagler, Nassau, St.
200 Johns, and Volusia Counties.
201 (e) Region E Region 5, which consists of Charlotte,
202 Collier, DeSoto, Glades, Hendry, Lee, and Sarasota Pasco and
203 Pinellas Counties.
204 (f) Region F Region 6, which consists of Indian River,
205 Martin, Okeechobee, Palm Beach, and St. Lucie Hardee, Highlands,
206 Hillsborough, Manatee, and Polk Counties.
207 (g) Region G Region 7, which consists of Broward County
208 Brevard, Orange, Osceola, and Seminole Counties.
209 (h) Region H Region 8, which consists of Miami-Dade and
210 Monroe Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and
211 Sarasota Counties.
212 (i) Region 9, which consists of Indian River, Martin,
213 Okeechobee, Palm Beach, and St. Lucie Counties.
214 (j) Region 10, which consists of Broward County.
215 (k) Region 11, which consists of Miami-Dade and Monroe
217 (3) QUALITY SELECTION CRITERIA.—
218 (a) The invitation to negotiate must specify the criteria
219 and the relative weight of the criteria that will be used for
220 determining the acceptability of the reply and guiding the
221 selection of the organizations with which the agency negotiates.
222 In addition to criteria established by the agency, the agency
223 shall consider the following factors in the selection of
224 eligible plans:
225 1. Accreditation by the National Committee for Quality
226 Assurance, the Joint Commission, or another nationally
227 recognized accrediting body.
228 2. Experience serving similar populations, including the
229 organization’s record in achieving specific quality standards
230 with similar populations.
231 3. Availability and accessibility of primary care and
232 specialty physicians in the provider network.
233 4. Establishment of community partnerships with providers
234 that create opportunities for reinvestment in community-based
236 5. Organization commitment to quality improvement and
237 documentation of achievements in specific quality improvement
238 projects, including active involvement by organization
240 6. Provision of additional benefits, particularly dental
241 care and disease management, and other initiatives that improve
242 health outcomes.
243 7. Evidence that an eligible plan has written agreements or
244 signed contracts or has made substantial progress in
245 establishing relationships with providers before the plan
246 submitting a response.
247 8. Comments submitted in writing by any enrolled Medicaid
248 provider relating to a specifically identified plan
249 participating in the procurement in the same region as the
250 submitting provider.
251 9. Documentation of policies and procedures for preventing
252 fraud and abuse.
253 10. The business relationship an eligible plan has with any
254 other eligible plan that responds to the invitation to
256 11. Whether a plan is proposing to establish a
257 comprehensive long-term care plan.
258 (d) For the first year of the first contract term, the
259 agency shall negotiate capitation rates or fee for service
260 payments with each plan in order to guarantee aggregate savings
261 of at least 5 percent.
262 1. For prepaid plans, determination of the amount of
263 savings shall be calculated by comparison to the Medicaid rates
264 that the agency paid managed care plans for similar populations
265 in the same areas in the prior year. In regions containing no
266 prepaid plans in the prior year, determination of the amount of
267 savings shall be calculated by comparison to the Medicaid rates
268 established and certified for those regions in the prior year.
269 2. For provider service networks operating on a fee-for
270 service basis, determination of the amount of savings shall be
271 calculated by comparison to the Medicaid rates that the agency
272 paid on a fee-for-service basis for the same services in the
273 prior year.
274 (e) To ensure managed care plan participation in Regions A
275 and E Regions 1 and 2, the agency shall award an additional
276 contract to each plan with a contract award in Region A Region 1
277 or Region E Region 2. Such contract shall be in any other region
278 in which the plan submitted a responsive bid and negotiates a
279 rate acceptable to the agency. If a plan that is awarded an
280 additional contract pursuant to this paragraph is subject to
281 penalties pursuant to s. 409.967(2)(i) for activities in Region
282 A Region 1 or Region E Region 2, the additional contract is
283 automatically terminated 180 days after the imposition of the
284 penalties. The plan must reimburse the agency for the cost of
285 enrollment changes and other transition activities.
286 Section 4. Subsection (2) of section 409.968, Florida
287 Statutes, is amended to read:
288 409.968 Managed care plan payments.—
289 (2) Provider service networks shall may be prepaid plans
290 and receive per-member, per-month payments negotiated pursuant
291 to the procurement process described in s. 409.966. Provider
292 service networks that choose not to be prepaid plans shall
293 receive fee-for-service rates with a shared savings settlement.
294 The fee-for-service option shall be available to a provider
295 service network only for the first 2 years of its operation. The
296 agency shall annually conduct cost reconciliations to determine
297 the amount of cost savings achieved by fee-for-service provider
298 service networks for the dates of service within the period
299 being reconciled. Only payments for covered services for dates
300 of service within the reconciliation period and paid within 6
301 months after the last date of service in the reconciliation
302 period must be included. The agency shall perform the necessary
303 adjustments for the inclusion of claims incurred but not
304 reported within the reconciliation period for claims that could
305 be received and paid by the agency after the 6-month claims
306 processing time lag. The agency shall provide the results of the
307 reconciliations to the fee-for-service provider service networks
308 within 45 days after the end of the reconciliation period. The
309 fee-for-service provider service networks shall review and
310 provide written comments or a letter of concurrence to the
311 agency within 45 days after receipt of the reconciliation
312 results. This reconciliation is considered final.
313 Section 5. Section 409.971, Florida Statutes, is amended to
315 409.971 Managed medical assistance program.—The agency
316 shall make payments for primary and acute medical assistance and
317 related services using a managed care model. By January 1, 2013,
318 the agency shall begin implementation of the statewide managed
319 medical assistance program, with full implementation in all
320 regions by October 1, 2014.
321 Section 6. Subsections (1) and (2) of section 409.974,
322 Florida Statutes, are amended to read:
323 409.974 Eligible plans.—
324 (1) ELIGIBLE PLAN SELECTION.—The agency shall select
325 eligible plans through the procurement process described in s.
326 409.966. The agency shall notice invitations to negotiate no
327 later than January 1, 2013.
328 (a) The agency shall procure at least two plans and up to
329 four plans for Region A Region 1. At least one plan shall be a
330 provider service network if any provider service networks submit
331 a responsive bid.
332 (b) The agency shall procure at least three plans and up to
333 five two plans for Region B Region 2. At least one plan shall be
334 a provider service network if any provider service networks
335 submit a responsive bid.
336 (c) The agency shall procure at least four three plans and
337 up to seven five plans for Region C Region 3. At least one plan
338 must be a provider service network if any provider service
339 networks submit a responsive bid.
340 (d) The agency shall procure at least three plans and up to
341 six five plans for Region D Region 4. At least one plan must be
342 a provider service network if any provider service networks
343 submit a responsive bid.
344 (e) The agency shall procure at least two plans and up to
345 four plans for Region E Region 5. At least one plan must be a
346 provider service network if any provider service networks submit
347 a responsive bid.
348 (f) The agency shall procure at least two four plans and up
349 to four seven plans for Region F Region 6. At least one plan
350 must be a provider service network if any provider service
351 networks submit a responsive bid.
352 (g) The agency shall procure at least two three plans and
353 up to four six plans for Region G Region 7. At least one plan
354 must be a provider service network if any provider service
355 networks submit a responsive bid.
356 (h) The agency shall procure at least five two plans and up
357 to 10 four plans for Region H Region 8. At least one plan must
358 be a provider service network if any provider service networks
359 submit a responsive bid.
360 (i) The agency shall procure at least two plans and up to
361 four plans for Region 9. At least one plan must be a provider
362 service network if any provider service networks submit a
363 responsive bid.
364 (j) The agency shall procure at least two plans and up to
365 four plans for Region 10. At least one plan must be a provider
366 service network if any provider service networks submit a
367 responsive bid.
368 (k) The agency shall procure at least five plans and up to
369 10 plans for Region 11. At least one plan must be a provider
370 service network if any provider service networks submit a
371 responsive bid.
373 If no provider service network submits a responsive bid, the
374 agency shall procure no more than one less than the maximum
375 number of eligible plans permitted in that region. Within 12
376 months after the initial invitation to negotiate, the agency
377 shall attempt to procure a provider service network. The agency
378 shall notice another invitation to negotiate only with provider
379 service networks in those regions where no provider service
380 network has been selected.
381 (2) QUALITY SELECTION CRITERIA.—In addition to the criteria
382 established in s. 409.966, the agency shall consider evidence
383 that an eligible plan has written agreements or signed contracts
384 or has made substantial progress in establishing relationships
385 with providers before the plan submits submitting a response.
386 The agency shall evaluate and give special weight to evidence of
387 signed contracts with essential providers as defined by the
388 agency pursuant to s. 409.975(1). The agency shall exercise a
389 preference for plans with a provider network in which more than
390 over 10 percent of the providers use electronic health records,
391 as defined in s. 408.051. When all other factors are equal, the
392 agency shall consider whether the organization has a contract to
393 provide managed long-term care services in the same region and
394 shall exercise a preference for such plans.
395 Section 7. Subsection (1) of section 409.978, Florida
396 Statutes, is amended to read:
397 409.978 Long-term care managed care program.—
398 (1) Pursuant to s. 409.963, the agency shall administer the
399 long-term care managed care program described in ss. 409.978
400 409.985, but may delegate specific duties and responsibilities
401 for the program to the Department of Elderly Affairs and other
402 state agencies. By July 1, 2012, the agency shall begin
403 implementation of the statewide long-term care managed care
404 program, with full implementation in all regions by October 1,
406 Section 8. Subsection (2) and paragraphs (c), (d), and (e)
407 of subsection (3) of section 409.981, Florida Statutes, are
408 amended to read:
409 409.981 Eligible long-term care plans.—
410 (2) ELIGIBLE PLAN SELECTION.—The agency shall select
411 eligible plans through the procurement process described in s.
412 409.966. The agency shall procure:
413 (a) At least two plans and up to four plans for Region A
414 Region 1. At least one plan must be a provider service network
415 if any provider service networks submit a responsive bid.
416 (b) At least three Two plans and up to five plans for
417 Region B Region 2. At least one plan must be a provider service
418 network if any provider service networks submit a responsive
420 (c) At least four three plans and up to seven five plans
421 for Region C Region 3. At least one plan must be a provider
422 service network if any provider service networks submit a
423 responsive bid.
424 (d) At least three plans and up to six five plans for
425 Region D Region 4. At least one plan must be a provider service
426 network if any provider service network submits a responsive
428 (e) At least two plans and up to four plans for Region E
429 Region 5. At least one plan must be a provider service network
430 if any provider service networks submit a responsive bid.
431 (f) At least two four plans and up to four seven plans for
432 Region F Region 6. At least one plan must be a provider service
433 network if any provider service networks submit a responsive
435 (g) At least two three plans and up to four six plans for
436 Region G Region 7. At least one plan must be a provider service
437 network if any provider service networks submit a responsive
439 (h) At least five two plans and up to 10 four plans for
440 Region H Region 8. At least one plan must be a provider service
441 network if any provider service networks submit a responsive
443 (i) At least two plans and up to four plans for Region 9.
444 At least one plan must be a provider service network if any
445 provider service networks submit a responsive bid.
446 (j) At least two plans and up to four plans for Region 10.
447 At least one plan must be a provider service network if any
448 provider service networks submit a responsive bid.
449 (k) At least five plans and up to 10 plans for Region 11.
450 At least one plan must be a provider service network if any
451 provider service networks submit a responsive bid.
453 If no provider service network submits a responsive bid in a
454 region other than Region 1 or Region 2, the agency shall procure
455 no more than one less than the maximum number of eligible plans
456 permitted in that region. Within 12 months after the initial
457 invitation to negotiate, the agency shall attempt to procure a
458 provider service network. The agency shall notice another
459 invitation to negotiate only with provider service networks in
460 regions where no provider service network has been selected.
461 (3) QUALITY SELECTION CRITERIA.—In addition to the criteria
462 established in s. 409.966, the agency shall consider the
463 following factors in the selection of eligible plans:
464 (c) Whether a plan is proposing to establish a
465 comprehensive long-term care plan and whether the eligible plan
466 has a contract to provide managed medical assistance services in
467 the same region.
468 (c) (d) Whether a plan offers consumer-directed care
469 services to enrollees pursuant to s. 409.221.
470 (d) (e) Whether a plan is proposing to provide home and
471 community-based services in addition to the minimum benefits
472 required by s. 409.98.
473 Section 9. This act shall take effect July 1, 2017.