Florida Senate - 2022 SENATOR AMENDMENT
Bill No. CS/CS/SB 1950, 1st Eng.
Ì114014hÎ114014
LEGISLATIVE ACTION
Senate . House
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Floor: WD .
03/08/2022 06:19 PM .
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Senator Bean moved the following:
1 Senate Amendment to House Amendment (739505) (with title
2 amendment)
3
4 Delete lines 5 - 986
5 and insert:
6 Section 1. Subsection (1) of section 409.912, Florida
7 Statutes, is amended to read:
8 409.912 Cost-effective purchasing of health care.—The
9 agency shall purchase goods and services for Medicaid recipients
10 in the most cost-effective manner consistent with the delivery
11 of quality medical care. To ensure that medical services are
12 effectively utilized, the agency may, in any case, require a
13 confirmation or second physician’s opinion of the correct
14 diagnosis for purposes of authorizing future services under the
15 Medicaid program. This section does not restrict access to
16 emergency services or poststabilization care services as defined
17 in 42 C.F.R. s. 438.114. Such confirmation or second opinion
18 shall be rendered in a manner approved by the agency. The agency
19 shall maximize the use of prepaid per capita and prepaid
20 aggregate fixed-sum basis services when appropriate and other
21 alternative service delivery and reimbursement methodologies,
22 including competitive bidding pursuant to s. 287.057, designed
23 to facilitate the cost-effective purchase of a case-managed
24 continuum of care. The agency shall also require providers to
25 minimize the exposure of recipients to the need for acute
26 inpatient, custodial, and other institutional care and the
27 inappropriate or unnecessary use of high-cost services. The
28 agency shall contract with a vendor to monitor and evaluate the
29 clinical practice patterns of providers in order to identify
30 trends that are outside the normal practice patterns of a
31 provider’s professional peers or the national guidelines of a
32 provider’s professional association. The vendor must be able to
33 provide information and counseling to a provider whose practice
34 patterns are outside the norms, in consultation with the agency,
35 to improve patient care and reduce inappropriate utilization.
36 The agency may mandate prior authorization, drug therapy
37 management, or disease management participation for certain
38 populations of Medicaid beneficiaries, certain drug classes, or
39 particular drugs to prevent fraud, abuse, overuse, and possible
40 dangerous drug interactions. The Pharmaceutical and Therapeutics
41 Committee shall make recommendations to the agency on drugs for
42 which prior authorization is required. The agency shall inform
43 the Pharmaceutical and Therapeutics Committee of its decisions
44 regarding drugs subject to prior authorization. The agency is
45 authorized to limit the entities it contracts with or enrolls as
46 Medicaid providers by developing a provider network through
47 provider credentialing. The agency may competitively bid single
48 source-provider contracts if procurement of goods or services
49 results in demonstrated cost savings to the state without
50 limiting access to care. The agency may limit its network based
51 on the assessment of beneficiary access to care, provider
52 availability, provider quality standards, time and distance
53 standards for access to care, the cultural competence of the
54 provider network, demographic characteristics of Medicaid
55 beneficiaries, practice and provider-to-beneficiary standards,
56 appointment wait times, beneficiary use of services, provider
57 turnover, provider profiling, provider licensure history,
58 previous program integrity investigations and findings, peer
59 review, provider Medicaid policy and billing compliance records,
60 clinical and medical record audits, and other factors. Providers
61 are not entitled to enrollment in the Medicaid provider network.
62 The agency shall determine instances in which allowing Medicaid
63 beneficiaries to purchase durable medical equipment and other
64 goods is less expensive to the Medicaid program than long-term
65 rental of the equipment or goods. The agency may establish rules
66 to facilitate purchases in lieu of long-term rentals in order to
67 protect against fraud and abuse in the Medicaid program as
68 defined in s. 409.913. The agency may seek federal waivers
69 necessary to administer these policies.
70 (1) The agency may contract with a provider service
71 network, which must may be reimbursed on a fee-for-service or
72 prepaid basis. Prepaid Provider service networks shall receive
73 per-member, per-month payments. A provider service network that
74 does not choose to be a prepaid plan shall receive fee-for
75 service rates with a shared savings settlement. The fee-for
76 service option shall be available to a provider service network
77 only for the first 2 years of the plan’s operation or until the
78 contract year beginning September 1, 2014, whichever is later.
79 The agency shall annually conduct cost reconciliations to
80 determine the amount of cost savings achieved by fee-for-service
81 provider service networks for the dates of service in the period
82 being reconciled. Only payments for covered services for dates
83 of service within the reconciliation period and paid within 6
84 months after the last date of service in the reconciliation
85 period shall be included. The agency shall perform the necessary
86 adjustments for the inclusion of claims incurred but not
87 reported within the reconciliation for claims that could be
88 received and paid by the agency after the 6-month claims
89 processing time lag. The agency shall provide the results of the
90 reconciliations to the fee-for-service provider service networks
91 within 45 days after the end of the reconciliation period. The
92 fee-for-service provider service networks shall review and
93 provide written comments or a letter of concurrence to the
94 agency within 45 days after receipt of the reconciliation
95 results. This reconciliation shall be considered final.
96 (a) A provider service network which is reimbursed by the
97 agency on a prepaid basis shall be exempt from parts I and III
98 of chapter 641 but must comply with the solvency requirements in
99 s. 641.2261(2) and meet appropriate financial reserve, quality
100 assurance, and patient rights requirements as established by the
101 agency.
102 (b) A provider service network is a network established or
103 organized and operated by a health care provider, or group of
104 affiliated health care providers, which provides a substantial
105 proportion of the health care items and services under a
106 contract directly through the provider or affiliated group of
107 providers and may make arrangements with physicians or other
108 health care professionals, health care institutions, or any
109 combination of such individuals or institutions to assume all or
110 part of the financial risk on a prospective basis for the
111 provision of basic health services by the physicians, by other
112 health professionals, or through the institutions. The health
113 care providers must have a controlling interest in the governing
114 body of the provider service network organization.
115 (a) A provider service network is exempt from parts I and
116 III of chapter 641 but must comply with the solvency
117 requirements in s. 641.2261(2) and meet appropriate financial
118 reserve, quality assurance, and patient rights requirements as
119 established by the agency.
120 (b) This subsection does not authorize the agency to
121 contract with a provider service network outside of the
122 procurement process described in s. 409.966.
123 Section 2. Section 409.9124, Florida Statutes, is repealed.
124 Section 3. Section 409.964, Florida Statutes, is amended to
125 read:
126 409.964 Managed care program; state plan; waivers.—The
127 Medicaid program is established as a statewide, integrated
128 managed care program for all covered services, including long
129 term care services. The agency shall apply for and implement
130 state plan amendments or waivers of applicable federal laws and
131 regulations necessary to implement the program. Before seeking a
132 waiver, the agency shall provide public notice and the
133 opportunity for public comment and include public feedback in
134 the waiver application. The agency shall hold one public meeting
135 in each of the regions described in s. 409.966(2), and the time
136 period for public comment for each region shall end no sooner
137 than 30 days after the completion of the public meeting in that
138 region.
139 Section 4. Subsections (2), (3), and (4) of section
140 409.966, Florida Statutes, are amended to read:
141 409.966 Eligible plans; selection.—
142 (2) ELIGIBLE PLAN SELECTION.—The agency shall select a
143 limited number of eligible plans to participate in the Medicaid
144 program using invitations to negotiate in accordance with s.
145 287.057(1)(c). At least 90 days before issuing an invitation to
146 negotiate, the agency shall compile and publish a databook
147 consisting of a comprehensive set of utilization and spending
148 data consistent with actuarial rate-setting practices and
149 standards for the 3 most recent contract years consistent with
150 the rate-setting periods for all Medicaid recipients by region
151 or county. The source of the data in the databook report must
152 include, at a minimum, the 24 most recent months of both
153 historic fee-for-service claims and validated data from the
154 Medicaid Encounter Data System, and the databook must. The
155 report must be available in electronic form and delineate
156 utilization use by age, gender, eligibility group, geographic
157 area, and aggregate clinical risk score. The statewide managed
158 care program includes Separate and simultaneous procurements
159 shall be conducted in each of the following regions:
160 (a) Region A 1, which consists of Bay, Calhoun, Escambia,
161 Okaloosa, Santa Rosa, and Walton Counties.
162 (b) Region 2, which consists of Bay, Calhoun, Franklin,
163 Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty,
164 Madison, Okaloosa, Santa Rosa, Taylor, Wakulla, Walton, and
165 Washington Counties.
166 (b)(c) Region B 3, which consists of Alachua, Baker,
167 Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler,
168 Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion,
169 Nassau, Putnam, St. Johns, Sumter, Suwannee, and Union Counties.
170 (d) Region 4, which consists of Baker, Clay, Duval,
171 Flagler, Nassau, St. Johns, and Volusia Counties.
172 (c)(e) Region C 5, which consists of Pasco and Pinellas
173 Counties.
174 (d)(f) Region D 6, which consists of Hardee, Highlands,
175 Hillsborough, Manatee, and Polk Counties.
176 (e)(g) Region E 7, which consists of Brevard, Orange,
177 Osceola, and Seminole Counties.
178 (f)(h) Region F 8, which consists of Charlotte, Collier,
179 DeSoto, Glades, Hendry, Lee, and Sarasota Counties.
180 (g)(i) Region G 9, which consists of Indian River, Martin,
181 Okeechobee, Palm Beach, and St. Lucie Counties.
182 (h)(j) Region H 10, which consists of Broward County.
183 (i)(k) Region I 11, which consists of Miami-Dade and Monroe
184 Counties.
185 (3) QUALITY SELECTION CRITERIA.—
186 (a) The invitation to negotiate must specify the criteria
187 and the relative weight of the criteria that will be used for
188 determining the acceptability of the reply and guiding the
189 selection of the organizations with which the agency negotiates.
190 In addition to criteria established by the agency, the agency
191 shall consider the following factors in the selection of
192 eligible plans:
193 1. Accreditation by the National Committee for Quality
194 Assurance, the Joint Commission, or another nationally
195 recognized accrediting body.
196 2. Experience serving similar populations, including the
197 organization’s record in achieving specific quality standards
198 with similar populations.
199 3. Availability and accessibility of primary care and
200 specialty physicians in the provider network.
201 4. Establishment of community partnerships with providers
202 that create opportunities for reinvestment in community-based
203 services.
204 5. Organization commitment to quality improvement and
205 documentation of achievements in specific quality improvement
206 projects, including active involvement by organization
207 leadership.
208 6. Provision of additional benefits, particularly dental
209 care and disease management, and other initiatives that improve
210 health outcomes.
211 7. Evidence that an eligible plan has obtained signed
212 contracts or written agreements or signed contracts or has made
213 substantial progress in establishing relationships with
214 providers before the plan submits submitting a response.
215 8. Comments submitted in writing by any enrolled Medicaid
216 provider relating to a specifically identified plan
217 participating in the procurement in the same region as the
218 submitting provider.
219 9. Documentation of policies and procedures for preventing
220 fraud and abuse.
221 10. The business relationship an eligible plan has with any
222 other eligible plan that responds to the invitation to
223 negotiate.
224 (b) An eligible plan must disclose any business
225 relationship it has with any other eligible plan that responds
226 to the invitation to negotiate. The agency may not select plans
227 in the same region for the same managed care program that have a
228 business relationship with each other. Failure to disclose any
229 business relationship shall result in disqualification from
230 participation in any region for the first full contract period
231 after the discovery of the business relationship by the agency.
232 For the purpose of this section, “business relationship” means
233 an ownership or controlling interest, an affiliate or subsidiary
234 relationship, a common parent, or any mutual interest in any
235 limited partnership, limited liability partnership, limited
236 liability company, or other entity or business association,
237 including all wholly or partially owned subsidiaries, majority
238 owned subsidiaries, parent companies, or affiliates of such
239 entities, business associations, or other enterprises, that
240 exists for the purpose of making a profit.
241 (c) After negotiations are conducted, the agency shall
242 select the eligible plans that are determined to be responsive
243 and provide the best value to the state. Preference shall be
244 given to plans that:
245 1. Have signed contracts with primary and specialty
246 physicians in sufficient numbers to meet the specific standards
247 established pursuant to s. 409.967(2)(c).
248 2. Have well-defined programs for recognizing patient
249 centered medical homes and providing for increased compensation
250 for recognized medical homes, as defined by the plan.
251 3. Are organizations that are based in and perform
252 operational functions in this state, in-house or through
253 contractual arrangements, by staff located in this state. Using
254 a tiered approach, the highest number of points shall be awarded
255 to a plan that has all or substantially all of its operational
256 functions performed in the state. The second highest number of
257 points shall be awarded to a plan that has a majority of its
258 operational functions performed in the state. The agency may
259 establish a third tier; however, preference points may not be
260 awarded to plans that perform only community outreach, medical
261 director functions, and state administrative functions in the
262 state. For purposes of this subparagraph, operational functions
263 include corporate headquarters, claims processing, member
264 services, provider relations, utilization and prior
265 authorization, case management, disease and quality functions,
266 and finance and administration. For purposes of this
267 subparagraph, the term “corporate headquarters” means the
268 principal office of the organization, which may not be a
269 subsidiary, directly or indirectly through one or more
270 subsidiaries of, or a joint venture with, any other entity whose
271 principal office is not located in the state.
272 4. Have contracts or other arrangements for cancer disease
273 management programs that have a proven record of clinical
274 efficiencies and cost savings.
275 5. Have contracts or other arrangements for diabetes
276 disease management programs that have a proven record of
277 clinical efficiencies and cost savings.
278 6. Have a claims payment process that ensures that claims
279 that are not contested or denied will be promptly paid pursuant
280 to s. 641.3155.
281 (d) For the first year of the first contract term, the
282 agency shall negotiate capitation rates or fee for service
283 payments with each plan in order to guarantee aggregate savings
284 of at least 5 percent.
285 1. For prepaid plans, determination of the amount of
286 savings shall be calculated by comparison to the Medicaid rates
287 that the agency paid managed care plans for similar populations
288 in the same areas in the prior year. In regions containing no
289 prepaid plans in the prior year, determination of the amount of
290 savings shall be calculated by comparison to the Medicaid rates
291 established and certified for those regions in the prior year.
292 2. For provider service networks operating on a fee-for
293 service basis, determination of the amount of savings shall be
294 calculated by comparison to the Medicaid rates that the agency
295 paid on a fee-for-service basis for the same services in the
296 prior year.
297 (e) To ensure managed care plan participation in Regions 1
298 and 2, the agency shall award an additional contract to each
299 plan with a contract award in Region 1 or Region 2. Such
300 contract shall be in any other region in which the plan
301 submitted a responsive bid and negotiates a rate acceptable to
302 the agency. If a plan that is awarded an additional contract
303 pursuant to this paragraph is subject to penalties pursuant to
304 s. 409.967(2)(i) for activities in Region 1 or Region 2, the
305 additional contract is automatically terminated 180 days after
306 the imposition of the penalties. The plan must reimburse the
307 agency for the cost of enrollment changes and other transition
308 activities.
309 (d)(f) The agency may not execute contracts with managed
310 care plans at payment rates not supported by the General
311 Appropriations Act.
312 (4) ADMINISTRATIVE CHALLENGE.—Any eligible plan that
313 participates in an invitation to negotiate in more than one
314 region and is selected in at least one region may not begin
315 serving Medicaid recipients in any region for which it was
316 selected until all administrative challenges to procurements
317 required by this section to which the eligible plan is a party
318 have been finalized. If the number of plans selected is less
319 than the maximum amount of plans permitted in the region, the
320 agency may contract with other selected plans in the region not
321 participating in the administrative challenge before resolution
322 of the administrative challenge. For purposes of this
323 subsection, an administrative challenge is finalized if an order
324 granting voluntary dismissal with prejudice has been entered by
325 any court established under Article V of the State Constitution
326 or by the Division of Administrative Hearings, a final order has
327 been entered into by the agency and the deadline for appeal has
328 expired, a final order has been entered by the First District
329 Court of Appeal and the time to seek any available review by the
330 Florida Supreme Court has expired, or a final order has been
331 entered by the Florida Supreme Court and a warrant has been
332 issued.
333 Section 5. Paragraphs (c) and (f) of subsection (2) of
334 section 409.967, Florida Statutes, are amended to read:
335 409.967 Managed care plan accountability.—
336 (2) The agency shall establish such contract requirements
337 as are necessary for the operation of the statewide managed care
338 program. In addition to any other provisions the agency may deem
339 necessary, the contract must require:
340 (c) Access.—
341 1. The agency shall establish specific standards for the
342 number, type, and regional distribution of providers in managed
343 care plan networks to ensure access to care for both adults and
344 children. Each plan must maintain a regionwide network of
345 providers in sufficient numbers to meet the access standards for
346 specific medical services for all recipients enrolled in the
347 plan. The exclusive use of mail-order pharmacies may not be
348 sufficient to meet network access standards. Consistent with the
349 standards established by the agency, provider networks may
350 include providers located outside the region. A plan may
351 contract with a new hospital facility before the date the
352 hospital becomes operational if the hospital has commenced
353 construction, will be licensed and operational by January 1,
354 2013, and a final order has issued in any civil or
355 administrative challenge. Each plan shall establish and maintain
356 an accurate and complete electronic database of contracted
357 providers, including information about licensure or
358 registration, locations and hours of operation, specialty
359 credentials and other certifications, specific performance
360 indicators, and such other information as the agency deems
361 necessary. The database must be available online to both the
362 agency and the public and have the capability to compare the
363 availability of providers to network adequacy standards and to
364 accept and display feedback from each provider’s patients. Each
365 plan shall submit quarterly reports to the agency identifying
366 the number of enrollees assigned to each primary care provider.
367 The agency shall conduct, or contract for, systematic and
368 continuous testing of the provider network databases maintained
369 by each plan to confirm accuracy, confirm that behavioral health
370 providers are accepting enrollees, and confirm that enrollees
371 have access to behavioral health services.
372 2. Each managed care plan must publish any prescribed drug
373 formulary or preferred drug list on the plan’s website in a
374 manner that is accessible to and searchable by enrollees and
375 providers. The plan must update the list within 24 hours after
376 making a change. Each plan must ensure that the prior
377 authorization process for prescribed drugs is readily accessible
378 to health care providers, including posting appropriate contact
379 information on its website and providing timely responses to
380 providers. For Medicaid recipients diagnosed with hemophilia who
381 have been prescribed anti-hemophilic-factor replacement
382 products, the agency shall provide for those products and
383 hemophilia overlay services through the agency’s hemophilia
384 disease management program.
385 3. Managed care plans, and their fiscal agents or
386 intermediaries, must accept prior authorization requests for any
387 service electronically.
388 4. Managed care plans serving children in the care and
389 custody of the Department of Children and Families must maintain
390 complete medical, dental, and behavioral health encounter
391 information and participate in making such information available
392 to the department or the applicable contracted community-based
393 care lead agency for use in providing comprehensive and
394 coordinated case management. The agency and the department shall
395 establish an interagency agreement to provide guidance for the
396 format, confidentiality, recipient, scope, and method of
397 information to be made available and the deadlines for
398 submission of the data. The scope of information available to
399 the department shall be the data that managed care plans are
400 required to submit to the agency. The agency shall determine the
401 plan’s compliance with standards for access to medical, dental,
402 and behavioral health services; the use of medications; and
403 followup on all medically necessary services recommended as a
404 result of early and periodic screening, diagnosis, and
405 treatment.
406 (f) Continuous improvement.—The agency shall establish
407 specific performance standards and expected milestones or
408 timelines for improving performance over the term of the
409 contract.
410 1. Each managed care plan shall establish an internal
411 health care quality improvement system, including enrollee
412 satisfaction and disenrollment surveys. The quality improvement
413 system must include incentives and disincentives for network
414 providers.
415 2. Each plan must collect and report the Health Plan
416 Employer Data and Information Set (HEDIS) measures, as specified
417 by the agency. These measures must be published on the plan’s
418 website in a manner that allows recipients to reliably compare
419 the performance of plans. The agency shall use the HEDIS
420 measures as a tool to monitor plan performance.
421 3. Each managed care plan must be accredited by the
422 National Committee for Quality Assurance, the Joint Commission,
423 or another nationally recognized accrediting body, or have
424 initiated the accreditation process, within 1 year after the
425 contract is executed. For any plan not accredited within 18
426 months after executing the contract, the agency shall suspend
427 automatic assignment under s. 409.977 and 409.984.
428 4. By the end of the fourth year of the first contract
429 term, the agency shall issue a request for information to
430 determine whether cost savings could be achieved by contracting
431 for plan oversight and monitoring, including analysis of
432 encounter data, assessment of performance measures, and
433 compliance with other contractual requirements.
434 Section 6. Subsection (2) of section 409.968, Florida
435 Statutes, is amended to read:
436 409.968 Managed care plan payments.—
437 (2) Provider service networks must may be prepaid plans and
438 receive per-member, per-month payments negotiated pursuant to
439 the procurement process described in s. 409.966. Provider
440 service networks that choose not to be prepaid plans shall
441 receive fee-for-service rates with a shared savings settlement.
442 The fee-for-service option shall be available to a provider
443 service network only for the first 2 years of its operation. The
444 agency shall annually conduct cost reconciliations to determine
445 the amount of cost savings achieved by fee-for-service provider
446 service networks for the dates of service within the period
447 being reconciled. Only payments for covered services for dates
448 of service within the reconciliation period and paid within 6
449 months after the last date of service in the reconciliation
450 period must be included. The agency shall perform the necessary
451 adjustments for the inclusion of claims incurred but not
452 reported within the reconciliation period for claims that could
453 be received and paid by the agency after the 6-month claims
454 processing time lag. The agency shall provide the results of the
455 reconciliations to the fee-for-service provider service networks
456 within 45 days after the end of the reconciliation period. The
457 fee-for-service provider service networks shall review and
458 provide written comments or a letter of concurrence to the
459 agency within 45 days after receipt of the reconciliation
460 results. This reconciliation is considered final.
461 Section 7. Subsections (3) and (4) of section 409.973,
462 Florida Statutes, are amended to read:
463 409.973 Benefits.—
464 (3) HEALTHY BEHAVIORS.—Each plan operating in the managed
465 medical assistance program shall establish a program to
466 encourage and reward healthy behaviors. At a minimum, each plan
467 must establish a medically approved tobacco smoking cessation
468 program, a medically directed weight loss program, and a
469 medically approved alcohol recovery program or substance abuse
470 recovery program that must include, but may not be limited to,
471 opioid abuse recovery. Each plan must identify enrollees who
472 smoke, are morbidly obese, or are diagnosed with alcohol or
473 substance abuse in order to establish written agreements to
474 secure the enrollees’ commitment to participation in these
475 programs.
476 (4) PRIMARY CARE INITIATIVE.—Each plan operating in the
477 managed medical assistance program shall establish a program to
478 encourage enrollees to establish a relationship with their
479 primary care provider. Each plan shall:
480 (a) Provide information to each enrollee on the importance
481 of and procedure for selecting a primary care provider, and
482 thereafter automatically assign to a primary care provider any
483 enrollee who fails to choose a primary care provider.
484 (b) If the enrollee was not a Medicaid recipient before
485 enrollment in the plan, assist the enrollee in scheduling an
486 appointment with the primary care provider. If possible the
487 appointment should be made within 30 days after enrollment in
488 the plan. For enrollees who become eligible for Medicaid between
489 January 1, 2014, and December 31, 2015, the appointment should
490 be scheduled within 6 months after enrollment in the plan.
491 (c) Report to the agency the number of enrollees assigned
492 to each primary care provider within the plan’s network.
493 (d) Report to the agency the number of enrollees who have
494 not had an appointment with their primary care provider within
495 their first year of enrollment.
496 (e) Report to the agency the number of emergency room
497 visits by enrollees who have not had at least one appointment
498 with their primary care provider.
499 Section 8. Subsections (1) and (2) of section 409.974,
500 Florida Statutes, are amended to read:
501 409.974 Eligible plans.—
502 (1) ELIGIBLE PLAN SELECTION.—The agency shall select
503 eligible plans for the managed medical assistance program
504 through the procurement process described in s. 409.966 through
505 a single statewide procurement. The agency may award contracts
506 to plans selected through the procurement process either on a
507 regional or statewide basis. The awards must include at least
508 one provider service network in each of the nine regions
509 outlined in this subsection. The agency shall procure:
510 (a) At least 3 plans and up to 4 plans for Region A.
511 (b) At least 3 plans and up to 6 plans for Region B.
512 (c) At least 3 plans and up to 5 plans for Region C.
513 (d) At least 4 plans and up to 7 plans for Region D.
514 (e) At least 3 plans and up to 6 plans for Region E.
515 (f) At least 3 plans and up to 4 plans for Region F.
516 (g) At least 3 plans and up to 5 plans for Region G.
517 (h) At least 3 plans and up to 5 plans for Region H.
518 (i) At least 5 plans and up to 10 plans for Region I. The
519 agency shall notice invitations to negotiate no later than
520 January 1, 2013.
521 (a) The agency shall procure two plans for Region 1. At
522 least one plan shall be a provider service network if any
523 provider service networks submit a responsive bid.
524 (b) The agency shall procure two plans for Region 2. At
525 least one plan shall be a provider service network if any
526 provider service networks submit a responsive bid.
527 (c) The agency shall procure at least three plans and up to
528 five plans for Region 3. At least one plan must be a provider
529 service network if any provider service networks submit a
530 responsive bid.
531 (d) The agency shall procure at least three plans and up to
532 five plans for Region 4. At least one plan must be a provider
533 service network if any provider service networks submit a
534 responsive bid.
535 (e) The agency shall procure at least two plans and up to
536 four plans for Region 5. At least one plan must be a provider
537 service network if any provider service networks submit a
538 responsive bid.
539 (f) The agency shall procure at least four plans and up to
540 seven plans for Region 6. At least one plan must be a provider
541 service network if any provider service networks submit a
542 responsive bid.
543 (g) The agency shall procure at least three plans and up to
544 six plans for Region 7. At least one plan must be a provider
545 service network if any provider service networks submit a
546 responsive bid.
547 (h) The agency shall procure at least two plans and up to
548 four plans for Region 8. At least one plan must be a provider
549 service network if any provider service networks submit a
550 responsive bid.
551 (i) The agency shall procure at least two plans and up to
552 four plans for Region 9. At least one plan must be a provider
553 service network if any provider service networks submit a
554 responsive bid.
555 (j) The agency shall procure at least two plans and up to
556 four plans for Region 10. At least one plan must be a provider
557 service network if any provider service networks submit a
558 responsive bid.
559 (k) The agency shall procure at least five plans and up to
560 10 plans for Region 11. At least one plan must be a provider
561 service network if any provider service networks submit a
562 responsive bid.
563
564 If no provider service network submits a responsive bid, the
565 agency shall procure no more than one less than the maximum
566 number of eligible plans permitted in that region. Within 12
567 months after the initial invitation to negotiate, the agency
568 shall attempt to procure a provider service network. The agency
569 shall notice another invitation to negotiate only with provider
570 service networks in those regions where no provider service
571 network has been selected.
572 (2) QUALITY SELECTION CRITERIA.—In addition to the criteria
573 established in s. 409.966, the agency shall consider evidence
574 that an eligible plan has obtained signed contracts or written
575 agreements or signed contracts or has made substantial progress
576 in establishing relationships with providers before the plan
577 submits submitting a response. The agency shall evaluate and
578 give special weight to evidence of signed contracts with
579 essential providers as defined by the agency pursuant to s.
580 409.975(1). The agency shall exercise a preference for plans
581 with a provider network in which over 10 percent of the
582 providers use electronic health records, as defined in s.
583 408.051. When all other factors are equal, the agency shall
584 consider whether the organization has a contract to provide
585 managed long-term care services in the same region and shall
586 exercise a preference for such plans.
587 Section 9. Paragraph (b) of subsection (1) of section
588 409.975, Florida Statutes, is amended to read:
589 409.975 Managed care plan accountability.—In addition to
590 the requirements of s. 409.967, plans and providers
591 participating in the managed medical assistance program shall
592 comply with the requirements of this section.
593 (1) PROVIDER NETWORKS.—Managed care plans must develop and
594 maintain provider networks that meet the medical needs of their
595 enrollees in accordance with standards established pursuant to
596 s. 409.967(2)(c). Except as provided in this section, managed
597 care plans may limit the providers in their networks based on
598 credentials, quality indicators, and price.
599 (b) Certain providers are statewide resources and essential
600 providers for all managed care plans in all regions. All managed
601 care plans must include these essential providers in their
602 networks. Statewide essential providers include:
603 1. Faculty plans of Florida medical schools.
604 2. Regional perinatal intensive care centers as defined in
605 s. 383.16(2).
606 3. Hospitals licensed as specialty children’s hospitals as
607 defined in s. 395.002(28).
608 4. Accredited and integrated systems serving medically
609 complex children which comprise separately licensed, but
610 commonly owned, health care providers delivering at least the
611 following services: medical group home, in-home and outpatient
612 nursing care and therapies, pharmacy services, durable medical
613 equipment, and Prescribed Pediatric Extended Care.
614 5. Florida cancer hospitals that meet the criteria in 42
615 U.S.C. s. 1395ww(d)(1)(B)(v).
616
617 Managed care plans that have not contracted with all statewide
618 essential providers in all regions as of the first date of
619 recipient enrollment must continue to negotiate in good faith.
620 Payments to physicians on the faculty of nonparticipating
621 Florida medical schools shall be made at the applicable Medicaid
622 rate. Payments for services rendered by regional perinatal
623 intensive care centers shall be made at the applicable Medicaid
624 rate as of the first day of the contract between the agency and
625 the plan. Except for payments for emergency services, payments
626 to nonparticipating specialty children’s hospitals, and payments
627 to nonparticipating Florida cancer hospitals that meet the
628 criteria in 42 U.S.C. s. 1395ww(d)(1)(B)(v), shall equal the
629 highest rate established by contract between that provider and
630 any other Medicaid managed care plan.
631 Section 10. Subsections (1), (2), (4), and (5) of section
632 409.977, Florida Statutes, are amended to read:
633 409.977 Enrollment.—
634 (1) The agency shall automatically enroll into a managed
635 care plan those Medicaid recipients who do not voluntarily
636 choose a plan pursuant to s. 409.969. The agency shall
637 automatically enroll recipients in plans that meet or exceed the
638 performance or quality standards established pursuant to s.
639 409.967 and may not automatically enroll recipients in a plan
640 that is deficient in those performance or quality standards.
641 When a specialty plan is available to accommodate a specific
642 condition or diagnosis of a recipient, the agency shall assign
643 the recipient to that plan. In the first year of the first
644 contract term only, if a recipient was previously enrolled in a
645 plan that is still available in the region, the agency shall
646 automatically enroll the recipient in that plan unless an
647 applicable specialty plan is available. Except as otherwise
648 provided in this part, the agency may not engage in practices
649 that are designed to favor one managed care plan over another.
650 (2) When automatically enrolling recipients in managed care
651 plans, if a recipient was enrolled in a plan immediately before
652 the recipient′s choice period and that plan is still available
653 in the region, the agency must maintain the recipient′s
654 enrollment in that plan unless an applicable specialty plan is
655 available. Otherwise, the agency shall automatically enroll
656 based on the following criteria:
657 (a) Whether the plan has sufficient network capacity to
658 meet the needs of the recipients.
659 (b) Whether the recipient has previously received services
660 from one of the plan’s primary care providers.
661 (c) Whether primary care providers in one plan are more
662 geographically accessible to the recipient’s residence than
663 those in other plans.
664 (4) The agency shall develop a process to enable a
665 recipient with access to employer-sponsored health care coverage
666 to opt out of all managed care plans and to use Medicaid
667 financial assistance to pay for the recipient’s share of the
668 cost in such employer-sponsored coverage. Contingent upon
669 federal approval, The agency shall also enable recipients with
670 access to other insurance or related products providing access
671 to health care services created pursuant to state law, including
672 any product available under the Florida Health Choices Program,
673 or any health exchange, to opt out. The amount of financial
674 assistance provided for each recipient may not exceed the amount
675 of the Medicaid premium that would have been paid to a managed
676 care plan for that recipient. The agency shall seek federal
677 approval to require Medicaid recipients with access to employer
678 sponsored health care coverage to enroll in that coverage and
679 use Medicaid financial assistance to pay for the recipient’s
680 share of the cost for such coverage. The amount of financial
681 assistance provided for each recipient may not exceed the amount
682 of the Medicaid premium that would have been paid to a managed
683 care plan for that recipient.
684 (5) Specialty plans serving children in the care and
685 custody of the department may serve such children as long as
686 they remain in care, including those remaining in extended
687 foster care pursuant to s. 39.6251, or are in subsidized
688 adoption and continue to be eligible for Medicaid pursuant to s.
689 409.903, or are receiving guardianship assistance payments and
690 continue to be eligible for Medicaid pursuant to s. 409.903.
691 Section 11. Subsection (2) of section 409.981, Florida
692 Statutes, is amended to read:
693 409.981 Eligible long-term care plans.—
694 (2) ELIGIBLE PLAN SELECTION.—The agency shall select
695 eligible plans for the long-term care managed care program
696 through the procurement process described in s. 409.966 through
697 a single statewide procurement. The agency may award contracts
698 to plans selected through the procurement process on a regional
699 or statewide basis. The awards must include at least one
700 provider service network in each of the nine regions outlined in
701 this subsection. The agency shall procure:
702 (a) At least 3 plans and up to 4 plans for Region A.
703 (b) At least 3 plans and up to 6 plans for Region B.
704 (c) At least 3 plans and up to 5 plans for Region C.
705 (d) At least 4 plans and up to 7 plans for Region D.
706 (e) At least 3 plans and up to 6 plans for Region E.
707 (f) At least 3 plans and up to 4 plans for Region F.
708 (g) At least 3 plans and up to 5 plans for Region G.
709 (h) At least 3 plans and up to 4 plans for Region H.
710 (i) At least 5 plans and up to 10 plans for Region I Two
711 plans for Region 1. At least one plan must be a provider service
712 network if any provider service networks submit a responsive
713 bid.
714 (b) Two plans for Region 2. At least one plan must be a
715 provider service network if any provider service networks submit
716 a responsive bid.
717 (c) At least three plans and up to five plans for Region 3.
718 At least one plan must be a provider service network if any
719 provider service networks submit a responsive bid.
720 (d) At least three plans and up to five plans for Region 4.
721 At least one plan must be a provider service network if any
722 provider service network submits a responsive bid.
723 (e) At least two plans and up to four plans for Region 5.
724 At least one plan must be a provider service network if any
725 provider service networks submit a responsive bid.
726 (f) At least four plans and up to seven plans for Region 6.
727 At least one plan must be a provider service network if any
728 provider service networks submit a responsive bid.
729 (g) At least three plans and up to six plans for Region 7.
730 At least one plan must be a provider service network if any
731 provider service networks submit a responsive bid.
732 (h) At least two plans and up to four plans for Region 8.
733 At least one plan must be a provider service network if any
734 provider service networks submit a responsive bid.
735 (i) At least two plans and up to four plans for Region 9.
736 At least one plan must be a provider service network if any
737 provider service networks submit a responsive bid.
738 (j) At least two plans and up to four plans for Region 10.
739 At least one plan must be a provider service network if any
740 provider service networks submit a responsive bid.
741 (k) At least five plans and up to 10 plans for Region 11.
742 At least one plan must be a provider service network if any
743 provider service networks submit a responsive bid.
744
745 If no provider service network submits a responsive bid in a
746 region other than Region 1 or Region 2, the agency shall procure
747 no more than one less than the maximum number of eligible plans
748 permitted in that region. Within 12 months after the initial
749 invitation to negotiate, the agency shall attempt to procure a
750 provider service network. The agency shall notice another
751 invitation to negotiate only with provider service networks in
752 regions where no provider service network has been selected.
753 Section 12. Subsection (4) of section 409.8132, Florida
754 Statutes, is amended to read:
755 409.8132 Medikids program component.—
756 (4) APPLICABILITY OF LAWS RELATING TO MEDICAID.—The
757 provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
758 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
759 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205 apply
760 to the administration of the Medikids program component of the
761 Florida Kidcare program, except that s. 409.9122 applies to
762 Medikids as modified by the provisions of subsection (7).
763 Section 13. For the purpose of incorporating the amendment
764 made by this act to section 409.912, Florida Statutes, in
765 references thereto, subsections (1), (7), (13), and (14) of
766 section 409.962, Florida Statutes, are reenacted to read:
767 409.962 Definitions.—As used in this part, except as
768 otherwise specifically provided, the term:
769 (1) “Accountable care organization” means an entity
770 qualified as an accountable care organization in accordance with
771 federal regulations, and which meets the requirements of a
772 provider service network as described in s. 409.912(1).
773 (7) “Eligible plan” means a health insurer authorized under
774 chapter 624, an exclusive provider organization authorized under
775 chapter 627, a health maintenance organization authorized under
776 chapter 641, or a provider service network authorized under s.
777 409.912(1) or an accountable care organization authorized under
778 federal law. For purposes of the managed medical assistance
779 program, the term also includes the Children’s Medical Services
780 Network authorized under chapter 391 and entities qualified
781 under 42 C.F.R. part 422 as Medicare Advantage Preferred
782 Provider Organizations, Medicare Advantage Provider-sponsored
783 Organizations, Medicare Advantage Health Maintenance
784 Organizations, Medicare Advantage Coordinated Care Plans, and
785 Medicare Advantage Special Needs Plans, and the Program of All
786 inclusive Care for the Elderly.
787 (13) “Prepaid plan” means a managed care plan that is
788 licensed or certified as a risk-bearing entity, or qualified
789 pursuant to s. 409.912(1), in the state and is paid a
790 prospective per-member, per-month payment by the agency.
791 (14) “Provider service network” means an entity qualified
792 pursuant to s. 409.912(1) of which a controlling interest is
793 owned by a health care provider, or group of affiliated
794 providers, or a public agency or entity that delivers health
795 services. Health care providers include Florida-licensed health
796 care professionals or licensed health care facilities, federally
797 qualified health care centers, and home health care agencies.
798 Section 14. For the purpose of incorporating the amendment
799 made by this act to section 409.912, Florida Statutes, in a
800 reference thereto, subsection (22) of section 641.19, Florida
801 Statutes, is reenacted to read:
802 641.19 Definitions.—As used in this part, the term:
803 (22) “Provider service network” means a network authorized
804 under s. 409.912(1), reimbursed on a prepaid basis, operated by
805 a health care provider or group of affiliated health care
806 providers, and which directly provides health care services
807 under a Medicare, Medicaid, or Healthy Kids contract.
808 Section 15. For the purpose of incorporating the amendments
809 made by this act to section 409.981, Florida Statutes, in
810 references thereto, paragraphs (h), (i), and (j) of subsection
811 (3) and subsection (11) of section 430.2053, Florida Statutes,
812 are reenacted to read:
813 430.2053 Aging resource centers.—
814 (3) The duties of an aging resource center are to:
815 (h) Assist clients who request long-term care services in
816 being evaluated for eligibility for enrollment in the Medicaid
817 long-term care managed care program as eligible plans become
818 available in each of the regions pursuant to s. 409.981(2).
819 (i) Provide enrollment and coverage information to Medicaid
820 managed long-term care enrollees as qualified plans become
821 available in each of the regions pursuant to s. 409.981(2).
822 (j) Assist Medicaid recipients enrolled in the Medicaid
823 long-term care managed care program with informally resolving
824 grievances with a managed care network and assist Medicaid
825 recipients in accessing the managed care network’s formal
826 grievance process as eligible plans become available in each of
827 the regions defined in s. 409.981(2).
828 (11) In an area in which the department has designated an
829 area agency on aging as an aging resource center, the department
830 and the agency shall not make payments for the services listed
831 in subsection (9) and the Long-Term Care Community Diversion
832 Project for such persons who were not screened and enrolled
833 through the aging resource center. The department shall cease
834 making payments for recipients in eligible plans as eligible
835 plans become available in each of the regions defined in s.
836 409.981(2).
837 Section 16. The Agency for Health Care Administration shall
838 amend existing Statewide Medicaid Managed Care contracts to
839 implement the changes made by this act to sections 409.973,
840 409.975, and 409.977, Florida Statutes. The agency shall
841 implement the changes made by this act to sections 409.966,
842 409.974, and 409.981, Florida Statutes, for the 2025 plan year.
843 Section 17. This act shall take effect July 1, 2022.
844
845 ================= T I T L E A M E N D M E N T ================
846 And the title is amended as follows:
847 Delete lines 992 - 1091
848 and insert:
849 An act relating to the statewide Medicaid managed care
850 program; amending s. 409.912, F.S.; requiring, rather
851 than authorizing, that the reimbursement method for
852 provider service networks be on a prepaid basis;
853 deleting the authority to reimburse provider service
854 networks on a fee-for-service basis; conforming
855 provisions to changes made by the act; providing that
856 provider service networks are subject to and exempt
857 from certain requirements; providing construction;
858 repealing s. 409.9124, F.S., relating to managed care
859 reimbursement; amending s. 409.964, F.S.; deleting a
860 requirement that the Agency for Health Care
861 Administration provide the opportunity for public
862 feedback on a certain waiver application; amending s.
863 409.966, F.S.; revising requirements relating to the
864 databook published by the agency consisting of
865 Medicaid utilization and spending data; reallocating
866 regions within the statewide managed care program;
867 deleting a requirement that the agency negotiate plan
868 rates or payments to guarantee a certain savings
869 amount; deleting a requirement for the agency to award
870 additional contracts to plans in specified regions for
871 certain purposes; revising a limitation on when plans
872 may begin serving Medicaid recipients to apply to any
873 eligible plan that participates in an invitation to
874 negotiate, rather than plans participating in certain
875 regions; making technical changes; amending s.
876 409.967, F.S.; deleting obsolete provisions; amending
877 s. 409.968, F.S.; conforming provisions to changes
878 made by the act; amending s. 409.973, F.S.; revising
879 requirements for healthy behaviors programs
880 established by plans; deleting an obsolete provision;
881 amending s. 409.974, F.S.; requiring the agency to
882 select plans for the managed medical assistance
883 program through a single statewide procurement;
884 authorizing the agency to award contracts to plans on
885 a regional or statewide basis; specifying requirements
886 for minimum numbers of plans which the agency must
887 procure for each specified region; conforming
888 provisions to changes made by the act; deleting
889 procedures for plan procurements when no provider
890 service networks submit bids; making technical
891 changes; deleting a requirement for the agency to
892 exercise a preference for certain plans; amending s.
893 409.975, F.S.; providing that cancer hospitals meeting
894 certain criteria are statewide essential providers;
895 requiring payments to such hospitals to equal a
896 certain rate; amending s. 409.977, F.S.; revising the
897 circumstances for maintaining a recipient’s enrollment
898 in a plan; deleting obsolete language; authorizing
899 specialty plans to serve certain children who receive
900 guardianship assistance payments under the
901 Guardianship Assistance Program; amending s. 409.981,
902 F.S.; requiring the agency to select plans for the
903 long-term care managed medical assistance program
904 through a single statewide procurement; authorizing
905 the agency to award contracts to plans on a regional
906 or statewide basis; specifying requirements for
907 minimum numbers of plans which the agency must procure
908 for each specified region; conforming provisions to
909 changes made by the act; deleting procedures for plan
910 procurements when no provider service networks submit
911 bids; amending s. 409.8132, F.S.; conforming a cross
912 reference; reenacting ss. 409.962(1), (7), (13), and
913 (14) and 641.19(22) relating to definitions, to
914 incorporate the amendments made by this act to s.
915 409.912, F.S., in references thereto; reenacting s.
916 430.2053(3)(h), (i), and (j) and (11), relating to
917 aging resource centers, to incorporate the amendments
918 made by this act to s. 409.981, F.S., in references
919 thereto; requiring the agency to amend existing
920 Statewide Medicaid Managed Care contracts to implement
921 changes made by the act; requiring the agency to
922 implement changes made by the act for a specified plan
923 year; providing an effective date.