Florida Senate - 2022 CS for SB 1950
By the Committee on Health Policy; and Senator Brodeur
588-02344-22 20221950c1
1 A bill to be entitled
2 An act relating to the statewide Medicaid managed care
3 program; amending s. 409.912, F.S.; requiring, rather
4 than authorizing, that the reimbursement method for
5 provider service networks be on a prepaid basis;
6 deleting the authority to reimburse provider service
7 networks on a fee-for-service basis; conforming
8 provisions to changes made by the act; providing that
9 provider service networks are subject to and exempt
10 from certain requirements; providing construction;
11 repealing s. 409.9124, F.S., relating to managed care
12 reimbursement; amending s. 409.964, F.S.; deleting a
13 requirement that the Agency for Health Care
14 Administration provide the opportunity for public
15 feedback on a certain waiver application; amending s.
16 409.966, F.S.; revising requirements relating to the
17 databook published by the agency consisting of
18 Medicaid utilization and spending data; reallocating
19 regions within the statewide managed care program;
20 deleting a requirement that the agency negotiate plan
21 rates or payments to guarantee a certain savings
22 amount; deleting a requirement for the agency to award
23 additional contracts to plans in specified regions for
24 certain purposes; revising a limitation on when plans
25 may begin serving Medicaid recipients to apply to any
26 eligible plan that participates in an invitation to
27 negotiate, rather than plans participating in certain
28 regions; making technical changes; amending s.
29 409.967, F.S.; deleting obsolete provisions; revising
30 provisions relating to agency-defined quality measures
31 under the achieved savings rebate program for Medicaid
32 prepaid plans; amending s. 409.968, F.S.; conforming
33 provisions to changes made by the act; amending s.
34 409.973, F.S.; revising requirements for healthy
35 behaviors programs established by plans; deleting an
36 obsolete provision; amending s. 409.974, F.S.;
37 requiring the agency to select plans for the managed
38 medical assistance program through a single statewide
39 procurement; authorizing the agency to award contracts
40 to plans on a regional or statewide basis; specifying
41 requirements for minimum numbers of plans which the
42 agency must procure for each specified region;
43 conforming provisions to changes made by the act;
44 deleting a requirement for the agency to exercise a
45 preference for certain plans; amending s. 409.975,
46 F.S.; providing that cancer hospitals meeting certain
47 criteria are statewide essential providers; amending
48 s. 409.977, F.S.; revising the circumstances for
49 maintaining a recipient’s enrollment in a plan;
50 deleting obsolete language; authorizing specialty
51 plans to serve certain children who receive
52 guardianship assistance payments under the
53 Guardianship Assistance Program; amending s. 409.981,
54 F.S.; requiring the agency to select plans for the
55 long-term care managed medical assistance program
56 through a single statewide procurement; authorizing
57 the agency to award contracts to plans on a regional
58 or statewide basis; specifying requirements for
59 minimum numbers of plans which the agency must procure
60 for each specified region; conforming provisions to
61 changes made by the act; amending s. 409.8132, F.S.;
62 conforming a cross-reference; reenacting ss.
63 409.962(1), (7), (13), and (14) and 641.19(22)
64 relating to definitions, to incorporate the amendments
65 made by this act to s. 409.912, F.S., in references
66 thereto; reenacting s. 430.2053(3)(h), (i), and (j)
67 and (11), relating to aging resource centers, to
68 incorporate the amendments made by this act to s.
69 409.981, F.S., in references thereto; providing an
70 effective date.
71
72 Be It Enacted by the Legislature of the State of Florida:
73
74 Section 1. Subsection (1) of section 409.912, Florida
75 Statutes, is amended to read:
76 409.912 Cost-effective purchasing of health care.—The
77 agency shall purchase goods and services for Medicaid recipients
78 in the most cost-effective manner consistent with the delivery
79 of quality medical care. To ensure that medical services are
80 effectively utilized, the agency may, in any case, require a
81 confirmation or second physician’s opinion of the correct
82 diagnosis for purposes of authorizing future services under the
83 Medicaid program. This section does not restrict access to
84 emergency services or poststabilization care services as defined
85 in 42 C.F.R. s. 438.114. Such confirmation or second opinion
86 shall be rendered in a manner approved by the agency. The agency
87 shall maximize the use of prepaid per capita and prepaid
88 aggregate fixed-sum basis services when appropriate and other
89 alternative service delivery and reimbursement methodologies,
90 including competitive bidding pursuant to s. 287.057, designed
91 to facilitate the cost-effective purchase of a case-managed
92 continuum of care. The agency shall also require providers to
93 minimize the exposure of recipients to the need for acute
94 inpatient, custodial, and other institutional care and the
95 inappropriate or unnecessary use of high-cost services. The
96 agency shall contract with a vendor to monitor and evaluate the
97 clinical practice patterns of providers in order to identify
98 trends that are outside the normal practice patterns of a
99 provider’s professional peers or the national guidelines of a
100 provider’s professional association. The vendor must be able to
101 provide information and counseling to a provider whose practice
102 patterns are outside the norms, in consultation with the agency,
103 to improve patient care and reduce inappropriate utilization.
104 The agency may mandate prior authorization, drug therapy
105 management, or disease management participation for certain
106 populations of Medicaid beneficiaries, certain drug classes, or
107 particular drugs to prevent fraud, abuse, overuse, and possible
108 dangerous drug interactions. The Pharmaceutical and Therapeutics
109 Committee shall make recommendations to the agency on drugs for
110 which prior authorization is required. The agency shall inform
111 the Pharmaceutical and Therapeutics Committee of its decisions
112 regarding drugs subject to prior authorization. The agency is
113 authorized to limit the entities it contracts with or enrolls as
114 Medicaid providers by developing a provider network through
115 provider credentialing. The agency may competitively bid single
116 source-provider contracts if procurement of goods or services
117 results in demonstrated cost savings to the state without
118 limiting access to care. The agency may limit its network based
119 on the assessment of beneficiary access to care, provider
120 availability, provider quality standards, time and distance
121 standards for access to care, the cultural competence of the
122 provider network, demographic characteristics of Medicaid
123 beneficiaries, practice and provider-to-beneficiary standards,
124 appointment wait times, beneficiary use of services, provider
125 turnover, provider profiling, provider licensure history,
126 previous program integrity investigations and findings, peer
127 review, provider Medicaid policy and billing compliance records,
128 clinical and medical record audits, and other factors. Providers
129 are not entitled to enrollment in the Medicaid provider network.
130 The agency shall determine instances in which allowing Medicaid
131 beneficiaries to purchase durable medical equipment and other
132 goods is less expensive to the Medicaid program than long-term
133 rental of the equipment or goods. The agency may establish rules
134 to facilitate purchases in lieu of long-term rentals in order to
135 protect against fraud and abuse in the Medicaid program as
136 defined in s. 409.913. The agency may seek federal waivers
137 necessary to administer these policies.
138 (1) The agency may contract with a provider service
139 network, which must may be reimbursed on a fee-for-service or
140 prepaid basis. Prepaid Provider service networks shall receive
141 per-member, per-month payments. A provider service network that
142 does not choose to be a prepaid plan shall receive fee-for
143 service rates with a shared savings settlement. The fee-for
144 service option shall be available to a provider service network
145 only for the first 2 years of the plan’s operation or until the
146 contract year beginning September 1, 2014, whichever is later.
147 The agency shall annually conduct cost reconciliations to
148 determine the amount of cost savings achieved by fee-for-service
149 provider service networks for the dates of service in the period
150 being reconciled. Only payments for covered services for dates
151 of service within the reconciliation period and paid within 6
152 months after the last date of service in the reconciliation
153 period shall be included. The agency shall perform the necessary
154 adjustments for the inclusion of claims incurred but not
155 reported within the reconciliation for claims that could be
156 received and paid by the agency after the 6-month claims
157 processing time lag. The agency shall provide the results of the
158 reconciliations to the fee-for-service provider service networks
159 within 45 days after the end of the reconciliation period. The
160 fee-for-service provider service networks shall review and
161 provide written comments or a letter of concurrence to the
162 agency within 45 days after receipt of the reconciliation
163 results. This reconciliation shall be considered final.
164 (a) A provider service network which is reimbursed by the
165 agency on a prepaid basis shall be exempt from parts I and III
166 of chapter 641 but must comply with the solvency requirements in
167 s. 641.2261(2) and meet appropriate financial reserve, quality
168 assurance, and patient rights requirements as established by the
169 agency.
170 (b) A provider service network is a network established or
171 organized and operated by a health care provider, or group of
172 affiliated health care providers, which provides a substantial
173 proportion of the health care items and services under a
174 contract directly through the provider or affiliated group of
175 providers and may make arrangements with physicians or other
176 health care professionals, health care institutions, or any
177 combination of such individuals or institutions to assume all or
178 part of the financial risk on a prospective basis for the
179 provision of basic health services by the physicians, by other
180 health professionals, or through the institutions. The health
181 care providers must have a controlling interest in the governing
182 body of the provider service network organization.
183 (a) A provider service network is exempt from parts I and
184 III of chapter 641 but must comply with the solvency
185 requirements in s. 641.2261(2) and meet appropriate financial
186 reserve, quality assurance, and patient rights requirements as
187 established by the agency.
188 (b) This subsection does not authorize the agency to
189 contract with a provider service network outside of the
190 procurement process described in s. 409.966.
191 Section 2. Section 409.9124, Florida Statutes, is repealed.
192 Section 3. Section 409.964, Florida Statutes, is amended to
193 read:
194 409.964 Managed care program; state plan; waivers.—The
195 Medicaid program is established as a statewide, integrated
196 managed care program for all covered services, including long
197 term care services. The agency shall apply for and implement
198 state plan amendments or waivers of applicable federal laws and
199 regulations necessary to implement the program. Before seeking a
200 waiver, the agency shall provide public notice and the
201 opportunity for public comment and include public feedback in
202 the waiver application. The agency shall hold one public meeting
203 in each of the regions described in s. 409.966(2), and the time
204 period for public comment for each region shall end no sooner
205 than 30 days after the completion of the public meeting in that
206 region.
207 Section 4. Subsections (2), (3), and (4) of section
208 409.966, Florida Statutes, are amended to read:
209 409.966 Eligible plans; selection.—
210 (2) ELIGIBLE PLAN SELECTION.—The agency shall select a
211 limited number of eligible plans to participate in the Medicaid
212 program using invitations to negotiate in accordance with s.
213 287.057(1)(c). At least 90 days before issuing an invitation to
214 negotiate, the agency shall compile and publish a databook
215 consisting of a comprehensive set of utilization and spending
216 data consistent with actuarial rate-setting practices and
217 standards for the 3 most recent contract years consistent with
218 the rate-setting periods for all Medicaid recipients by region
219 or county. The source of the data in the databook report must
220 include, at a minimum, the 24 most recent months of both
221 historic fee-for-service claims and validated data from the
222 Medicaid Encounter Data System. The statewide managed care
223 program includes report must be available in electronic form and
224 delineate utilization use by age, gender, eligibility group,
225 geographic area, and aggregate clinical risk score. Separate and
226 simultaneous procurements shall be conducted in each of the
227 following regions:
228 (a) Region A 1, which consists of Bay, Calhoun, Escambia,
229 Okaloosa, Santa Rosa, and Walton Counties.
230 (b) Region 2, which consists of Bay, Calhoun, Franklin,
231 Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty,
232 Madison, Okaloosa, Santa Rosa, Taylor, Wakulla, Walton, and
233 Washington Counties.
234 (b)(c) Region B 3, which consists of Alachua, Baker,
235 Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler,
236 Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion,
237 Nassau, Putnam, St. Johns, Sumter, Suwannee, and Union Counties.
238 (d) Region 4, which consists of Baker, Clay, Duval,
239 Flagler, Nassau, St. Johns, and Volusia Counties.
240 (c)(e) Region C 5, which consists of Pasco and Pinellas
241 Counties.
242 (f) Region 6, which consists of Hardee, Highlands,
243 Hillsborough, Manatee, Pasco, Pinellas, and Polk Counties.
244 (d)(g) Region D 7, which consists of Brevard, Orange,
245 Osceola, and Seminole Counties.
246 (e)(h) Region E 8, which consists of Charlotte, Collier,
247 DeSoto, Glades, Hendry, Lee, and Sarasota Counties.
248 (f)(i) Region F 9, which consists of Indian River, Martin,
249 Okeechobee, Palm Beach, and St. Lucie Counties.
250 (g)(j) Region G 10, which consists of Broward County.
251 (h)(k) Region H 11, which consists of Miami-Dade and Monroe
252 Counties.
253 (3) QUALITY SELECTION CRITERIA.—
254 (a) The invitation to negotiate must specify the criteria
255 and the relative weight of the criteria that will be used for
256 determining the acceptability of the reply and guiding the
257 selection of the organizations with which the agency negotiates.
258 In addition to criteria established by the agency, the agency
259 shall consider the following factors in the selection of
260 eligible plans:
261 1. Accreditation by the National Committee for Quality
262 Assurance, the Joint Commission, or another nationally
263 recognized accrediting body.
264 2. Experience serving similar populations, including the
265 organization’s record in achieving specific quality standards
266 with similar populations.
267 3. Availability and accessibility of primary care and
268 specialty physicians in the provider network.
269 4. Establishment of community partnerships with providers
270 that create opportunities for reinvestment in community-based
271 services.
272 5. Organization commitment to quality improvement and
273 documentation of achievements in specific quality improvement
274 projects, including active involvement by organization
275 leadership.
276 6. Provision of additional benefits, particularly dental
277 care and disease management, and other initiatives that improve
278 health outcomes.
279 7. Evidence that an eligible plan has obtained signed
280 contracts or written agreements or signed contracts or has made
281 substantial progress in establishing relationships with
282 providers before the plan submits submitting a response.
283 8. Comments submitted in writing by any enrolled Medicaid
284 provider relating to a specifically identified plan
285 participating in the procurement in the same region as the
286 submitting provider.
287 9. Documentation of policies and procedures for preventing
288 fraud and abuse.
289 10. The business relationship an eligible plan has with any
290 other eligible plan that responds to the invitation to
291 negotiate.
292 (b) An eligible plan must disclose any business
293 relationship it has with any other eligible plan that responds
294 to the invitation to negotiate. The agency may not select plans
295 in the same region for the same managed care program that have a
296 business relationship with each other. Failure to disclose any
297 business relationship shall result in disqualification from
298 participation in any region for the first full contract period
299 after the discovery of the business relationship by the agency.
300 For the purpose of this section, “business relationship” means
301 an ownership or controlling interest, an affiliate or subsidiary
302 relationship, a common parent, or any mutual interest in any
303 limited partnership, limited liability partnership, limited
304 liability company, or other entity or business association,
305 including all wholly or partially owned subsidiaries, majority
306 owned subsidiaries, parent companies, or affiliates of such
307 entities, business associations, or other enterprises, that
308 exists for the purpose of making a profit.
309 (c) After negotiations are conducted, the agency shall
310 select the eligible plans that are determined to be responsive
311 and provide the best value to the state. Preference shall be
312 given to plans that:
313 1. Have signed contracts with primary and specialty
314 physicians in sufficient numbers to meet the specific standards
315 established pursuant to s. 409.967(2)(c).
316 2. Have well-defined programs for recognizing patient
317 centered medical homes and providing for increased compensation
318 for recognized medical homes, as defined by the plan.
319 3. Are organizations that are based in and perform
320 operational functions in this state, in-house or through
321 contractual arrangements, by staff located in this state. Using
322 a tiered approach, the highest number of points shall be awarded
323 to a plan that has all or substantially all of its operational
324 functions performed in the state. The second highest number of
325 points shall be awarded to a plan that has a majority of its
326 operational functions performed in the state. The agency may
327 establish a third tier; however, preference points may not be
328 awarded to plans that perform only community outreach, medical
329 director functions, and state administrative functions in the
330 state. For purposes of this subparagraph, operational functions
331 include corporate headquarters, claims processing, member
332 services, provider relations, utilization and prior
333 authorization, case management, disease and quality functions,
334 and finance and administration. For purposes of this
335 subparagraph, the term “corporate headquarters” means the
336 principal office of the organization, which may not be a
337 subsidiary, directly or indirectly through one or more
338 subsidiaries of, or a joint venture with, any other entity whose
339 principal office is not located in the state.
340 4. Have contracts or other arrangements for cancer disease
341 management programs that have a proven record of clinical
342 efficiencies and cost savings.
343 5. Have contracts or other arrangements for diabetes
344 disease management programs that have a proven record of
345 clinical efficiencies and cost savings.
346 6. Have a claims payment process that ensures that claims
347 that are not contested or denied will be promptly paid pursuant
348 to s. 641.3155.
349 (d) For the first year of the first contract term, the
350 agency shall negotiate capitation rates or fee for service
351 payments with each plan in order to guarantee aggregate savings
352 of at least 5 percent.
353 1. For prepaid plans, determination of the amount of
354 savings shall be calculated by comparison to the Medicaid rates
355 that the agency paid managed care plans for similar populations
356 in the same areas in the prior year. In regions containing no
357 prepaid plans in the prior year, determination of the amount of
358 savings shall be calculated by comparison to the Medicaid rates
359 established and certified for those regions in the prior year.
360 2. For provider service networks operating on a fee-for
361 service basis, determination of the amount of savings shall be
362 calculated by comparison to the Medicaid rates that the agency
363 paid on a fee-for-service basis for the same services in the
364 prior year.
365 (e) To ensure managed care plan participation in Regions 1
366 and 2, the agency shall award an additional contract to each
367 plan with a contract award in Region 1 or Region 2. Such
368 contract shall be in any other region in which the plan
369 submitted a responsive bid and negotiates a rate acceptable to
370 the agency. If a plan that is awarded an additional contract
371 pursuant to this paragraph is subject to penalties pursuant to
372 s. 409.967(2)(i) for activities in Region 1 or Region 2, the
373 additional contract is automatically terminated 180 days after
374 the imposition of the penalties. The plan must reimburse the
375 agency for the cost of enrollment changes and other transition
376 activities.
377 (d)(f) The agency may not execute contracts with managed
378 care plans at payment rates not supported by the General
379 Appropriations Act.
380 (4) ADMINISTRATIVE CHALLENGE.—Any eligible plan that
381 participates in an invitation to negotiate in more than one
382 region and is selected in at least one region may not begin
383 serving Medicaid recipients in any region for which it was
384 selected until all administrative challenges to procurements
385 required by this section to which the eligible plan is a party
386 have been finalized. If the number of plans selected is less
387 than the maximum amount of plans permitted in the region, the
388 agency may contract with other selected plans in the region not
389 participating in the administrative challenge before resolution
390 of the administrative challenge. For purposes of this
391 subsection, an administrative challenge is finalized if an order
392 granting voluntary dismissal with prejudice has been entered by
393 any court established under Article V of the State Constitution
394 or by the Division of Administrative Hearings, a final order has
395 been entered into by the agency and the deadline for appeal has
396 expired, a final order has been entered by the First District
397 Court of Appeal and the time to seek any available review by the
398 Florida Supreme Court has expired, or a final order has been
399 entered by the Florida Supreme Court and a warrant has been
400 issued.
401 Section 5. Paragraphs (c) and (f) of subsection (2) and
402 subsection (3) of section 409.967, Florida Statutes, are amended
403 to read:
404 409.967 Managed care plan accountability.—
405 (2) The agency shall establish such contract requirements
406 as are necessary for the operation of the statewide managed care
407 program. In addition to any other provisions the agency may deem
408 necessary, the contract must require:
409 (c) Access.—
410 1. The agency shall establish specific standards for the
411 number, type, and regional distribution of providers in managed
412 care plan networks to ensure access to care for both adults and
413 children. Each plan must maintain a regionwide network of
414 providers in sufficient numbers to meet the access standards for
415 specific medical services for all recipients enrolled in the
416 plan. The exclusive use of mail-order pharmacies may not be
417 sufficient to meet network access standards. Consistent with the
418 standards established by the agency, provider networks may
419 include providers located outside the region. A plan may
420 contract with a new hospital facility before the date the
421 hospital becomes operational if the hospital has commenced
422 construction, will be licensed and operational by January 1,
423 2013, and a final order has issued in any civil or
424 administrative challenge. Each plan shall establish and maintain
425 an accurate and complete electronic database of contracted
426 providers, including information about licensure or
427 registration, locations and hours of operation, specialty
428 credentials and other certifications, specific performance
429 indicators, and such other information as the agency deems
430 necessary. The database must be available online to both the
431 agency and the public and have the capability to compare the
432 availability of providers to network adequacy standards and to
433 accept and display feedback from each provider’s patients. Each
434 plan shall submit quarterly reports to the agency identifying
435 the number of enrollees assigned to each primary care provider.
436 The agency shall conduct, or contract for, systematic and
437 continuous testing of the provider network databases maintained
438 by each plan to confirm accuracy, confirm that behavioral health
439 providers are accepting enrollees, and confirm that enrollees
440 have access to behavioral health services.
441 2. Each managed care plan must publish any prescribed drug
442 formulary or preferred drug list on the plan’s website in a
443 manner that is accessible to and searchable by enrollees and
444 providers. The plan must update the list within 24 hours after
445 making a change. Each plan must ensure that the prior
446 authorization process for prescribed drugs is readily accessible
447 to health care providers, including posting appropriate contact
448 information on its website and providing timely responses to
449 providers. For Medicaid recipients diagnosed with hemophilia who
450 have been prescribed anti-hemophilic-factor replacement
451 products, the agency shall provide for those products and
452 hemophilia overlay services through the agency’s hemophilia
453 disease management program.
454 3. Managed care plans, and their fiscal agents or
455 intermediaries, must accept prior authorization requests for any
456 service electronically.
457 4. Managed care plans serving children in the care and
458 custody of the Department of Children and Families must maintain
459 complete medical, dental, and behavioral health encounter
460 information and participate in making such information available
461 to the department or the applicable contracted community-based
462 care lead agency for use in providing comprehensive and
463 coordinated case management. The agency and the department shall
464 establish an interagency agreement to provide guidance for the
465 format, confidentiality, recipient, scope, and method of
466 information to be made available and the deadlines for
467 submission of the data. The scope of information available to
468 the department shall be the data that managed care plans are
469 required to submit to the agency. The agency shall determine the
470 plan’s compliance with standards for access to medical, dental,
471 and behavioral health services; the use of medications; and
472 followup on all medically necessary services recommended as a
473 result of early and periodic screening, diagnosis, and
474 treatment.
475 (f) Continuous improvement.—The agency shall establish
476 specific performance standards and expected milestones or
477 timelines for improving performance over the term of the
478 contract.
479 1. Each managed care plan shall establish an internal
480 health care quality improvement system, including enrollee
481 satisfaction and disenrollment surveys. The quality improvement
482 system must include incentives and disincentives for network
483 providers.
484 2. Each plan must collect and report the Health Plan
485 Employer Data and Information Set (HEDIS) measures, as specified
486 by the agency. These measures must be published on the plan’s
487 website in a manner that allows recipients to reliably compare
488 the performance of plans. The agency shall use the HEDIS
489 measures as a tool to monitor plan performance.
490 3. Each managed care plan must be accredited by the
491 National Committee for Quality Assurance, the Joint Commission,
492 or another nationally recognized accrediting body, or have
493 initiated the accreditation process, within 1 year after the
494 contract is executed. For any plan not accredited within 18
495 months after executing the contract, the agency shall suspend
496 automatic assignment under s. 409.977 and 409.984.
497 4. By the end of the fourth year of the first contract
498 term, the agency shall issue a request for information to
499 determine whether cost savings could be achieved by contracting
500 for plan oversight and monitoring, including analysis of
501 encounter data, assessment of performance measures, and
502 compliance with other contractual requirements.
503 (3) ACHIEVED SAVINGS REBATE.—
504 (a) The agency is responsible for verifying the achieved
505 savings rebate for all Medicaid prepaid plans. To assist the
506 agency, a prepaid plan shall:
507 1. Submit an annual financial audit conducted by an
508 independent certified public accountant in accordance with
509 generally accepted auditing standards to the agency on or before
510 June 1 for the preceding year; and
511 2. Submit an annual statement prepared in accordance with
512 statutory accounting principles on or before March 1 pursuant to
513 s. 624.424 if the plan is regulated by the Office of Insurance
514 Regulation.
515 (b) The agency shall contract with independent certified
516 public accountants to conduct compliance audits for the purpose
517 of auditing financial information, including but not limited to:
518 annual premium revenue, medical and administrative costs, and
519 income or losses reported by each prepaid plan, in order to
520 determine and validate the achieved savings rebate.
521 (c) Any audit required under this subsection must be
522 conducted by an independent certified public accountant who
523 meets criteria specified by rule. The rules must also provide
524 that:
525 1. The entity selected by the agency to conduct the audit
526 may not have a conflict of interest that might affect its
527 ability to perform its responsibilities with respect to an
528 examination.
529 2. The rates charged to the prepaid plan being audited are
530 consistent with rates charged by other certified public
531 accountants and are comparable with the rates charged for
532 comparable examinations.
533 3. Each prepaid plan audited shall pay to the agency the
534 expenses of the audit at the rates established by the agency by
535 rule. Such expenses include actual travel expenses, reasonable
536 living expense allowances, compensation of the certified public
537 accountant, and necessary attendant administrative costs of the
538 agency directly related to the examination. Travel expense and
539 living expense allowances are limited to those expenses incurred
540 on account of the audit and must be paid by the examined prepaid
541 plan together with compensation upon presentation by the agency
542 to the prepaid plan of a detailed account of the charges and
543 expenses after a detailed statement has been filed by the
544 auditor and approved by the agency.
545 4. All moneys collected from prepaid plans for such audits
546 shall be deposited into the Grants and Donations Trust Fund, and
547 the agency may make deposits into such fund from moneys
548 appropriated for the operation of the agency.
549 (d) At a location in this state, the prepaid plan shall
550 make available to the agency and the agency’s contracted
551 certified public accountant all books, accounts, documents,
552 files, and information that relate to the prepaid plan’s
553 Medicaid transactions. Records not in the prepaid plan’s
554 immediate possession must be made available to the agency or the
555 certified public accountant in this state within 3 days after a
556 request is made by the agency or certified public accountant
557 engaged by the agency. A prepaid plan has an obligation to
558 cooperate in good faith with the agency and the certified public
559 accountant. Failure to comply to such record requests shall be
560 deemed a breach of contract.
561 (e) Once the certified public accountant completes the
562 audit, the certified public accountant shall submit an audit
563 report to the agency attesting to the achieved savings of the
564 plan. The results of the audit report are dispositive.
565 (f) Achieved savings rebates validated by the certified
566 public accountant are due within 30 days after the report is
567 submitted. Except as provided in paragraph (h), the achieved
568 savings rebate is established by determining pretax income as a
569 percentage of revenues and applying the following income sharing
570 ratios:
571 1. One hundred percent of income up to and including 3 5
572 percent of revenue shall be retained by the plan.
573 2. Fifty percent of income above 3 5 percent and up to 10
574 percent shall be retained by the plan, and the other 50 percent
575 refunded to the state and transferred to the General Revenue
576 Fund, unallocated.
577 3. One hundred percent of income above 10 percent of
578 revenue shall be refunded to the state and transferred to the
579 General Revenue Fund, unallocated.
580 (g) A plan that exceeds agency-defined quality measures in
581 the reporting period may retain up to an additional 2 1 percent
582 of revenue. For the purpose of this paragraph, the quality
583 measures must include two tiers and must include plan
584 performance for preventing or managing complex, chronic
585 conditions that are associated with an elevated likelihood of
586 requiring high-cost medical treatments.
587 1. If the agency-defined quality or performance targets
588 identified in tier one are met, the plan may retain up to 4
589 percent of revenue. Fifty percent of income above 4 percent and
590 up to 10 percent must be retained by the plan, and the other 50
591 percent refunded to the state and transferred to the General
592 Revenue Fund, unallocated.
593 2. If the agency-defined quality or performance targets
594 identified in tier two are met, the plan may retain up to 5
595 percent of revenue. Fifty percent of income above 5 percent and
596 up to 10 percent must be retained by the plan, and the other 50
597 percent refunded to the state and transferred to the General
598 Revenue Fund, unallocated.
599 (h) The following may not be included as allowable expenses
600 in calculating income for determining the achieved savings
601 rebate:
602 1. Payment of achieved savings rebates.
603 2. Any financial incentive payments made to the plan
604 outside of the capitation rate.
605 3. Any financial disincentive payments levied by the state
606 or federal government.
607 4. Expenses associated with any lobbying or political
608 activities.
609 5. The cash value or equivalent cash value of bonuses of
610 any type paid or awarded to the plan’s executive staff, other
611 than base salary.
612 6. Reserves and reserve accounts.
613 7. Administrative costs, including, but not limited to,
614 reinsurance expenses, interest payments, depreciation expenses,
615 bad debt expenses, and outstanding claims expenses in excess of
616 actuarially sound maximum amounts set by the agency.
617
618 The agency shall consider these and other factors in developing
619 contracts that establish shared savings arrangements.
620 (i) Prepaid plans that incur a loss in the first contract
621 year may apply the full amount of the loss as an offset to
622 income in the second contract year.
623 (j) If, after an audit, the agency determines that a
624 prepaid plan owes an additional rebate, the plan has 30 days
625 after notification to make the payment. Upon failure to timely
626 pay the rebate, the agency shall withhold future payments to the
627 plan until the entire amount is recouped. If the agency
628 determines that a prepaid plan has made an overpayment, the
629 agency shall return the overpayment within 30 days.
630 Section 6. Subsection (2) of section 409.968, Florida
631 Statutes, is amended to read:
632 409.968 Managed care plan payments.—
633 (2) Provider service networks must may be prepaid plans and
634 receive per-member, per-month payments negotiated pursuant to
635 the procurement process described in s. 409.966. Provider
636 service networks that choose not to be prepaid plans shall
637 receive fee-for-service rates with a shared savings settlement.
638 The fee-for-service option shall be available to a provider
639 service network only for the first 2 years of its operation. The
640 agency shall annually conduct cost reconciliations to determine
641 the amount of cost savings achieved by fee-for-service provider
642 service networks for the dates of service within the period
643 being reconciled. Only payments for covered services for dates
644 of service within the reconciliation period and paid within 6
645 months after the last date of service in the reconciliation
646 period must be included. The agency shall perform the necessary
647 adjustments for the inclusion of claims incurred but not
648 reported within the reconciliation period for claims that could
649 be received and paid by the agency after the 6-month claims
650 processing time lag. The agency shall provide the results of the
651 reconciliations to the fee-for-service provider service networks
652 within 45 days after the end of the reconciliation period. The
653 fee-for-service provider service networks shall review and
654 provide written comments or a letter of concurrence to the
655 agency within 45 days after receipt of the reconciliation
656 results. This reconciliation is considered final.
657 Section 7. Subsections (3) and (4) of section 409.973,
658 Florida Statutes, are amended to read:
659 409.973 Benefits.—
660 (3) HEALTHY BEHAVIORS.—Each plan operating in the managed
661 medical assistance program shall establish a program to
662 encourage and reward healthy behaviors. At a minimum, each plan
663 must establish a medically approved tobacco smoking cessation
664 program, a medically directed weight loss program, and a
665 medically approved alcohol recovery program or substance abuse
666 recovery program that must include, but may not be limited to,
667 opioid abuse recovery. Each plan must identify enrollees who
668 smoke, are morbidly obese, or are diagnosed with alcohol or
669 substance abuse in order to establish written agreements to
670 secure the enrollees’ commitment to participation in these
671 programs.
672 (4) PRIMARY CARE INITIATIVE.—Each plan operating in the
673 managed medical assistance program shall establish a program to
674 encourage enrollees to establish a relationship with their
675 primary care provider. Each plan shall:
676 (a) Provide information to each enrollee on the importance
677 of and procedure for selecting a primary care provider, and
678 thereafter automatically assign to a primary care provider any
679 enrollee who fails to choose a primary care provider.
680 (b) If the enrollee was not a Medicaid recipient before
681 enrollment in the plan, assist the enrollee in scheduling an
682 appointment with the primary care provider. If possible the
683 appointment should be made within 30 days after enrollment in
684 the plan. For enrollees who become eligible for Medicaid between
685 January 1, 2014, and December 31, 2015, the appointment should
686 be scheduled within 6 months after enrollment in the plan.
687 (c) Report to the agency the number of enrollees assigned
688 to each primary care provider within the plan’s network.
689 (d) Report to the agency the number of enrollees who have
690 not had an appointment with their primary care provider within
691 their first year of enrollment.
692 (e) Report to the agency the number of emergency room
693 visits by enrollees who have not had at least one appointment
694 with their primary care provider.
695 Section 8. Subsections (1) and (2) of section 409.974,
696 Florida Statutes, are amended to read:
697 409.974 Eligible plans.—
698 (1) ELIGIBLE PLAN SELECTION.—The agency shall select
699 eligible plans for the managed medical assistance program
700 through the procurement process described in s. 409.966 through
701 a single statewide procurement. The agency may award contracts
702 to plans selected through the procurement process either on a
703 regional or statewide basis. The awards must include at least
704 one provider service network in each of the eight regions
705 outlined in this subsection. The agency shall procure:
706 (a) At least 3 plans and up to 4 plans for Region A.
707 (b) At least 3 plans and up to 6 plans for Region B.
708 (c) At least 5 plans and up to 10 plans for Region C.
709 (d) At least 3 plans and up to 6 plans for Region D.
710 (e) At least 3 plans and up to 4 plans for Region E.
711 (f) At least 3 plans and up to 5 plans for Region F.
712 (g) At least 3 plans and up to 5 plans for Region G.
713 (h) At least 5 plans and up to 10 plans for Region H. The
714 agency shall notice invitations to negotiate no later than
715 January 1, 2013.
716 (a) The agency shall procure two plans for Region 1. At
717 least one plan shall be a provider service network if any
718 provider service networks submit a responsive bid.
719 (b) The agency shall procure two plans for Region 2. At
720 least one plan shall be a provider service network if any
721 provider service networks submit a responsive bid.
722 (c) The agency shall procure at least three plans and up to
723 five plans for Region 3. At least one plan must be a provider
724 service network if any provider service networks submit a
725 responsive bid.
726 (d) The agency shall procure at least three plans and up to
727 five plans for Region 4. At least one plan must be a provider
728 service network if any provider service networks submit a
729 responsive bid.
730 (e) The agency shall procure at least two plans and up to
731 four plans for Region 5. At least one plan must be a provider
732 service network if any provider service networks submit a
733 responsive bid.
734 (f) The agency shall procure at least four plans and up to
735 seven plans for Region 6. At least one plan must be a provider
736 service network if any provider service networks submit a
737 responsive bid.
738 (g) The agency shall procure at least three plans and up to
739 six plans for Region 7. At least one plan must be a provider
740 service network if any provider service networks submit a
741 responsive bid.
742 (h) The agency shall procure at least two plans and up to
743 four plans for Region 8. At least one plan must be a provider
744 service network if any provider service networks submit a
745 responsive bid.
746 (i) The agency shall procure at least two plans and up to
747 four plans for Region 9. At least one plan must be a provider
748 service network if any provider service networks submit a
749 responsive bid.
750 (j) The agency shall procure at least two plans and up to
751 four plans for Region 10. At least one plan must be a provider
752 service network if any provider service networks submit a
753 responsive bid.
754 (k) The agency shall procure at least five plans and up to
755 10 plans for Region 11. At least one plan must be a provider
756 service network if any provider service networks submit a
757 responsive bid.
758
759 If no provider service network submits a responsive bid, the
760 agency shall procure no more than one less than the maximum
761 number of eligible plans permitted in that region. Within 12
762 months after the initial invitation to negotiate, the agency
763 shall attempt to procure a provider service network. The agency
764 shall notice another invitation to negotiate only with provider
765 service networks in those regions where no provider service
766 network has been selected.
767 (2) QUALITY SELECTION CRITERIA.—In addition to the criteria
768 established in s. 409.966, the agency shall consider evidence
769 that an eligible plan has written agreements or signed contracts
770 or has made substantial progress in establishing relationships
771 with providers before the plan submitting a response. The agency
772 shall evaluate and give special weight to evidence of signed
773 contracts with essential providers as defined by the agency
774 pursuant to s. 409.975(1). The agency shall exercise a
775 preference for plans with a provider network in which over 10
776 percent of the providers use electronic health records, as
777 defined in s. 408.051. When all other factors are equal, the
778 agency shall consider whether the organization has a contract to
779 provide managed long-term care services in the same region and
780 shall exercise a preference for such plans.
781 Section 9. Paragraph (b) of subsection (1) of section
782 409.975, Florida Statutes, is amended to read:
783 409.975 Managed care plan accountability.—In addition to
784 the requirements of s. 409.967, plans and providers
785 participating in the managed medical assistance program shall
786 comply with the requirements of this section.
787 (1) PROVIDER NETWORKS.—Managed care plans must develop and
788 maintain provider networks that meet the medical needs of their
789 enrollees in accordance with standards established pursuant to
790 s. 409.967(2)(c). Except as provided in this section, managed
791 care plans may limit the providers in their networks based on
792 credentials, quality indicators, and price.
793 (b) Certain providers are statewide resources and essential
794 providers for all managed care plans in all regions. All managed
795 care plans must include these essential providers in their
796 networks. Statewide essential providers include:
797 1. Faculty plans of Florida medical schools.
798 2. Regional perinatal intensive care centers as defined in
799 s. 383.16(2).
800 3. Hospitals licensed as specialty children’s hospitals as
801 defined in s. 395.002(28).
802 4. Accredited and integrated systems serving medically
803 complex children which comprise separately licensed, but
804 commonly owned, health care providers delivering at least the
805 following services: medical group home, in-home and outpatient
806 nursing care and therapies, pharmacy services, durable medical
807 equipment, and Prescribed Pediatric Extended Care.
808 5. Florida cancer hospitals that meet the criteria in 42
809 U.S.C. s. 1395ww(d)(1)(B)(v).
810
811 Managed care plans that have not contracted with all statewide
812 essential providers in all regions as of the first date of
813 recipient enrollment must continue to negotiate in good faith.
814 Payments to physicians on the faculty of nonparticipating
815 Florida medical schools shall be made at the applicable Medicaid
816 rate. Payments for services rendered by regional perinatal
817 intensive care centers shall be made at the applicable Medicaid
818 rate as of the first day of the contract between the agency and
819 the plan. Except for payments for emergency services, payments
820 to nonparticipating specialty children’s hospitals shall equal
821 the highest rate established by contract between that provider
822 and any other Medicaid managed care plan.
823 Section 10. Subsections (1), (2), (4), and (5) of section
824 409.977, Florida Statutes, are amended to read:
825 409.977 Enrollment.—
826 (1) The agency shall automatically enroll into a managed
827 care plan those Medicaid recipients who do not voluntarily
828 choose a plan pursuant to s. 409.969. The agency shall
829 automatically enroll recipients in plans that meet or exceed the
830 performance or quality standards established pursuant to s.
831 409.967 and may not automatically enroll recipients in a plan
832 that is deficient in those performance or quality standards.
833 When a specialty plan is available to accommodate a specific
834 condition or diagnosis of a recipient, the agency shall assign
835 the recipient to that plan. In the first year of the first
836 contract term only, if a recipient was previously enrolled in a
837 plan that is still available in the region, the agency shall
838 automatically enroll the recipient in that plan unless an
839 applicable specialty plan is available. Except as otherwise
840 provided in this part, the agency may not engage in practices
841 that are designed to favor one managed care plan over another.
842 (2) When automatically enrolling recipients in managed care
843 plans, if a recipient was enrolled in a plan immediately before
844 the recipient′s choice period and that plan is still available
845 in the region, the agency must maintain the recipient′s
846 enrollment in that plan unless an applicable specialty plan is
847 available. Otherwise, the agency shall automatically enroll
848 based on the following criteria:
849 (a) Whether the plan has sufficient network capacity to
850 meet the needs of the recipients.
851 (b) Whether the recipient has previously received services
852 from one of the plan’s primary care providers.
853 (c) Whether primary care providers in one plan are more
854 geographically accessible to the recipient’s residence than
855 those in other plans.
856 (4) The agency shall develop a process to enable a
857 recipient with access to employer-sponsored health care coverage
858 to opt out of all managed care plans and to use Medicaid
859 financial assistance to pay for the recipient’s share of the
860 cost in such employer-sponsored coverage. Contingent upon
861 federal approval, The agency shall also enable recipients with
862 access to other insurance or related products providing access
863 to health care services created pursuant to state law, including
864 any product available under the Florida Health Choices Program,
865 or any health exchange, to opt out. The amount of financial
866 assistance provided for each recipient may not exceed the amount
867 of the Medicaid premium that would have been paid to a managed
868 care plan for that recipient. The agency shall seek federal
869 approval to require Medicaid recipients with access to employer
870 sponsored health care coverage to enroll in that coverage and
871 use Medicaid financial assistance to pay for the recipient’s
872 share of the cost for such coverage. The amount of financial
873 assistance provided for each recipient may not exceed the amount
874 of the Medicaid premium that would have been paid to a managed
875 care plan for that recipient.
876 (5) Specialty plans serving children in the care and
877 custody of the department may serve such children as long as
878 they remain in care, including those remaining in extended
879 foster care pursuant to s. 39.6251, or are in subsidized
880 adoption and continue to be eligible for Medicaid pursuant to s.
881 409.903, or are receiving guardianship assistance payments and
882 continue to be eligible for Medicaid pursuant to s. 409.903.
883 Section 11. Subsection (2) of section 409.981, Florida
884 Statutes, is amended to read:
885 409.981 Eligible long-term care plans.—
886 (2) ELIGIBLE PLAN SELECTION.—The agency shall select
887 eligible plans for the long-term care managed care program
888 through the procurement process described in s. 409.966 through
889 a single statewide procurement. The agency may award contracts
890 to plans selected through the procurement process on a regional
891 or statewide basis. The awards must include at least one
892 provider service network in each of the eight regions outlined
893 in this subsection. The agency shall procure:
894 (a) At least 3 plans and up to 4 plans for Region A.
895 (b) At least 3 plans and up to 6 plans for Region B.
896 (c) At least 5 plans and up to 10 plans for Region C.
897 (d) At least 3 plans and up to 6 plans for Region D.
898 (e) At least 3 plans and up to 4 plans for Region E.
899 (f) At least 3 plans and up to 5 plans for Region F.
900 (g) At least 3 plans and up to 4 plans for Region G.
901 (h) At least 5 plans and up to 10 plans for Region H.
902 Two plans for Region 1. At least one plan must be a
903 provider service network if any provider service networks submit
904 a responsive bid.
905 (b) Two plans for Region 2. At least one plan must be a
906 provider service network if any provider service networks submit
907 a responsive bid.
908 (c) At least three plans and up to five plans for Region 3.
909 At least one plan must be a provider service network if any
910 provider service networks submit a responsive bid.
911 (d) At least three plans and up to five plans for Region 4.
912 At least one plan must be a provider service network if any
913 provider service network submits a responsive bid.
914 (e) At least two plans and up to four plans for Region 5.
915 At least one plan must be a provider service network if any
916 provider service networks submit a responsive bid.
917 (f) At least four plans and up to seven plans for Region 6.
918 At least one plan must be a provider service network if any
919 provider service networks submit a responsive bid.
920 (g) At least three plans and up to six plans for Region 7.
921 At least one plan must be a provider service network if any
922 provider service networks submit a responsive bid.
923 (h) At least two plans and up to four plans for Region 8.
924 At least one plan must be a provider service network if any
925 provider service networks submit a responsive bid.
926 (i) At least two plans and up to four plans for Region 9.
927 At least one plan must be a provider service network if any
928 provider service networks submit a responsive bid.
929 (j) At least two plans and up to four plans for Region 10.
930 At least one plan must be a provider service network if any
931 provider service networks submit a responsive bid.
932 (k) At least five plans and up to 10 plans for Region 11.
933 At least one plan must be a provider service network if any
934 provider service networks submit a responsive bid.
935
936 If no provider service network submits a responsive bid in a
937 region other than Region 1 or Region 2, the agency shall procure
938 no more than one less than the maximum number of eligible plans
939 permitted in that region. Within 12 months after the initial
940 invitation to negotiate, the agency shall attempt to procure a
941 provider service network. The agency shall notice another
942 invitation to negotiate only with provider service networks in
943 regions where no provider service network has been selected.
944 Section 12. Subsection (4) of section 409.8132, Florida
945 Statutes, is amended to read:
946 409.8132 Medikids program component.—
947 (4) APPLICABILITY OF LAWS RELATING TO MEDICAID.—The
948 provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
949 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
950 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205 apply
951 to the administration of the Medikids program component of the
952 Florida Kidcare program, except that s. 409.9122 applies to
953 Medikids as modified by the provisions of subsection (7).
954 Section 13. For the purpose of incorporating the amendment
955 made by this act to section 409.912, Florida Statutes, in
956 references thereto, subsections (1), (7), (13), and (14) of
957 section 409.962, Florida Statutes, are reenacted to read:
958 409.962 Definitions.—As used in this part, except as
959 otherwise specifically provided, the term:
960 (1) “Accountable care organization” means an entity
961 qualified as an accountable care organization in accordance with
962 federal regulations, and which meets the requirements of a
963 provider service network as described in s. 409.912(1).
964 (7) “Eligible plan” means a health insurer authorized under
965 chapter 624, an exclusive provider organization authorized under
966 chapter 627, a health maintenance organization authorized under
967 chapter 641, or a provider service network authorized under s.
968 409.912(1) or an accountable care organization authorized under
969 federal law. For purposes of the managed medical assistance
970 program, the term also includes the Children’s Medical Services
971 Network authorized under chapter 391 and entities qualified
972 under 42 C.F.R. part 422 as Medicare Advantage Preferred
973 Provider Organizations, Medicare Advantage Provider-sponsored
974 Organizations, Medicare Advantage Health Maintenance
975 Organizations, Medicare Advantage Coordinated Care Plans, and
976 Medicare Advantage Special Needs Plans, and the Program of All
977 inclusive Care for the Elderly.
978 (13) “Prepaid plan” means a managed care plan that is
979 licensed or certified as a risk-bearing entity, or qualified
980 pursuant to s. 409.912(1), in the state and is paid a
981 prospective per-member, per-month payment by the agency.
982 (14) “Provider service network” means an entity qualified
983 pursuant to s. 409.912(1) of which a controlling interest is
984 owned by a health care provider, or group of affiliated
985 providers, or a public agency or entity that delivers health
986 services. Health care providers include Florida-licensed health
987 care professionals or licensed health care facilities, federally
988 qualified health care centers, and home health care agencies.
989 Section 14. For the purpose of incorporating the amendment
990 made by this act to section 409.912, Florida Statutes, in a
991 reference thereto, subsection (22) of section 641.19, Florida
992 Statutes, is reenacted to read:
993 641.19 Definitions.—As used in this part, the term:
994 (22) “Provider service network” means a network authorized
995 under s. 409.912(1), reimbursed on a prepaid basis, operated by
996 a health care provider or group of affiliated health care
997 providers, and which directly provides health care services
998 under a Medicare, Medicaid, or Healthy Kids contract.
999 Section 15. For the purpose of incorporating the amendments
1000 made by this act to section 409.981, Florida Statutes, in
1001 references thereto, paragraphs (h), (i), and (j) of subsection
1002 (3) and subsection (11) of section 430.2053, Florida Statutes,
1003 are reenacted to read:
1004 430.2053 Aging resource centers.—
1005 (3) The duties of an aging resource center are to:
1006 (h) Assist clients who request long-term care services in
1007 being evaluated for eligibility for enrollment in the Medicaid
1008 long-term care managed care program as eligible plans become
1009 available in each of the regions pursuant to s. 409.981(2).
1010 (i) Provide enrollment and coverage information to Medicaid
1011 managed long-term care enrollees as qualified plans become
1012 available in each of the regions pursuant to s. 409.981(2).
1013 (j) Assist Medicaid recipients enrolled in the Medicaid
1014 long-term care managed care program with informally resolving
1015 grievances with a managed care network and assist Medicaid
1016 recipients in accessing the managed care network’s formal
1017 grievance process as eligible plans become available in each of
1018 the regions defined in s. 409.981(2).
1019 (11) In an area in which the department has designated an
1020 area agency on aging as an aging resource center, the department
1021 and the agency shall not make payments for the services listed
1022 in subsection (9) and the Long-Term Care Community Diversion
1023 Project for such persons who were not screened and enrolled
1024 through the aging resource center. The department shall cease
1025 making payments for recipients in eligible plans as eligible
1026 plans become available in each of the regions defined in s.
1027 409.981(2).
1028 Section 16. This act shall take effect July 1, 2022.