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