CS for CS for SB 1950                           Second Engrossed
       
       
       
       
       
       
       
       
       20221950e2
       
    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.; deleting a
   50         requirement 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), F.S., 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), F.S., relating
   70         to aging resource centers, to incorporate the
   71         amendments made by this act to s. 409.981, F.S., in
   72         references thereto; requiring the agency to amend
   73         existing Statewide Medicaid Managed Care contracts to
   74         implement changes made by the act; requiring the
   75         agency to implement changes made by the act for a
   76         specified plan year; providing an effective date.
   77          
   78  Be It Enacted by the Legislature of the State of Florida:
   79  
   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
  175  agency.
  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
  199  read:
  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
  247  Counties.
  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
  258  Counties.
  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
  277  services.
  278         5. Organization commitment to quality improvement and
  279  documentation of achievements in specific quality improvement
  280  projects, including active involvement by organization
  281  leadership.
  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
  297  negotiate.
  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
  382  activities.
  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
  406  issued.
  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
  479  treatment.
  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
  483  contract.
  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
  488  providers.
  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
  549  programs.
  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.
  637  
  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).
  690  
  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, the agency shall automatically enroll based on the
  726  following criteria:
  727         (a) Whether the plan has sufficient network capacity to
  728  meet the needs of the recipients.
  729         (b) Whether the recipient has previously received services
  730  from one of the plan’s primary care providers.
  731         (c) Whether primary care providers in one plan are more
  732  geographically accessible to the recipient’s residence than
  733  those in other plans.
  734         (4) The agency shall develop a process to enable a
  735  recipient with access to employer-sponsored health care coverage
  736  to opt out of all managed care plans and to use Medicaid
  737  financial assistance to pay for the recipient’s share of the
  738  cost in such employer-sponsored coverage. Contingent upon
  739  federal approval, The agency shall also enable recipients with
  740  access to other insurance or related products providing access
  741  to health care services created pursuant to state law, including
  742  any product available under the Florida Health Choices Program,
  743  or any health exchange, to opt out. The amount of financial
  744  assistance provided for each recipient may not exceed the amount
  745  of the Medicaid premium that would have been paid to a managed
  746  care plan for that recipient. The agency shall seek federal
  747  approval to require Medicaid recipients with access to employer
  748  sponsored health care coverage to enroll in that coverage and
  749  use Medicaid financial assistance to pay for the recipient’s
  750  share of the cost for such coverage. The amount of financial
  751  assistance provided for each recipient may not exceed the amount
  752  of the Medicaid premium that would have been paid to a managed
  753  care plan for that recipient.
  754         (5) Specialty plans serving children in the care and
  755  custody of the department may serve such children as long as
  756  they remain in care, including those remaining in extended
  757  foster care pursuant to s. 39.6251, or are in subsidized
  758  adoption and continue to be eligible for Medicaid pursuant to s.
  759  409.903, or are receiving guardianship assistance payments and
  760  continue to be eligible for Medicaid pursuant to s. 409.903.
  761         Section 11. Subsection (2) of section 409.981, Florida
  762  Statutes, is amended to read:
  763         409.981 Eligible long-term care plans.—
  764         (2) ELIGIBLE PLAN SELECTION.—The agency shall select
  765  eligible plans for the long-term care managed care program
  766  through the procurement process described in s. 409.966 through
  767  a single statewide procurement. The agency may award contracts
  768  to plans selected through the procurement process on a regional
  769  or statewide basis. The awards must include at least one
  770  provider service network in each of the nine regions outlined in
  771  this subsection. The agency shall procure:
  772         (a) At least 3 plans and up to 4 plans for Region A.
  773         (b) At least 3 plans and up to 6 plans for Region B.
  774         (c) At least 3 plans and up to 5 plans for Region C.
  775         (d) At least 4 plans and up to 7 plans for Region D.
  776         (e) At least 3 plans and up to 6 plans for Region E.
  777         (f) At least 3 plans and up to 4 plans for Region F.
  778         (g) At least 3 plans and up to 5 plans for Region G.
  779         (h) At least 3 plans and up to 4 plans for Region H.
  780         (i) At least 5 plans and up to 10 plans for Region I Two
  781  plans for Region 1. At least one plan must be a provider service
  782  network if any provider service networks submit a responsive
  783  bid.
  784         (b) Two plans for Region 2. At least one plan must be a
  785  provider service network if any provider service networks submit
  786  a responsive bid.
  787         (c) At least three plans and up to five plans for Region 3.
  788  At least one plan must be a provider service network if any
  789  provider service networks submit a responsive bid.
  790         (d) At least three plans and up to five plans for Region 4.
  791  At least one plan must be a provider service network if any
  792  provider service network submits a responsive bid.
  793         (e) At least two plans and up to four plans for Region 5.
  794  At least one plan must be a provider service network if any
  795  provider service networks submit a responsive bid.
  796         (f) At least four plans and up to seven plans for Region 6.
  797  At least one plan must be a provider service network if any
  798  provider service networks submit a responsive bid.
  799         (g) At least three plans and up to six plans for Region 7.
  800  At least one plan must be a provider service network if any
  801  provider service networks submit a responsive bid.
  802         (h) At least two plans and up to four plans for Region 8.
  803  At least one plan must be a provider service network if any
  804  provider service networks submit a responsive bid.
  805         (i) At least two plans and up to four plans for Region 9.
  806  At least one plan must be a provider service network if any
  807  provider service networks submit a responsive bid.
  808         (j) At least two plans and up to four plans for Region 10.
  809  At least one plan must be a provider service network if any
  810  provider service networks submit a responsive bid.
  811         (k) At least five plans and up to 10 plans for Region 11.
  812  At least one plan must be a provider service network if any
  813  provider service networks submit a responsive bid.
  814  
  815  If no provider service network submits a responsive bid in a
  816  region other than Region 1 or Region 2, the agency shall procure
  817  no more than one less than the maximum number of eligible plans
  818  permitted in that region. Within 12 months after the initial
  819  invitation to negotiate, the agency shall attempt to procure a
  820  provider service network. The agency shall notice another
  821  invitation to negotiate only with provider service networks in
  822  regions where no provider service network has been selected.
  823         Section 12. Subsection (4) of section 409.8132, Florida
  824  Statutes, is amended to read:
  825         409.8132 Medikids program component.—
  826         (4) APPLICABILITY OF LAWS RELATING TO MEDICAID.—The
  827  provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
  828  409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
  829  409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205 apply
  830  to the administration of the Medikids program component of the
  831  Florida Kidcare program, except that s. 409.9122 applies to
  832  Medikids as modified by the provisions of subsection (7).
  833         Section 13. For the purpose of incorporating the amendment
  834  made by this act to section 409.912, Florida Statutes, in
  835  references thereto, subsections (1), (7), (13), and (14) of
  836  section 409.962, Florida Statutes, are reenacted to read:
  837         409.962 Definitions.—As used in this part, except as
  838  otherwise specifically provided, the term:
  839         (1) “Accountable care organization” means an entity
  840  qualified as an accountable care organization in accordance with
  841  federal regulations, and which meets the requirements of a
  842  provider service network as described in s. 409.912(1).
  843         (7) “Eligible plan” means a health insurer authorized under
  844  chapter 624, an exclusive provider organization authorized under
  845  chapter 627, a health maintenance organization authorized under
  846  chapter 641, or a provider service network authorized under s.
  847  409.912(1) or an accountable care organization authorized under
  848  federal law. For purposes of the managed medical assistance
  849  program, the term also includes the Children’s Medical Services
  850  Network authorized under chapter 391 and entities qualified
  851  under 42 C.F.R. part 422 as Medicare Advantage Preferred
  852  Provider Organizations, Medicare Advantage Provider-sponsored
  853  Organizations, Medicare Advantage Health Maintenance
  854  Organizations, Medicare Advantage Coordinated Care Plans, and
  855  Medicare Advantage Special Needs Plans, and the Program of All
  856  inclusive Care for the Elderly.
  857         (13) “Prepaid plan” means a managed care plan that is
  858  licensed or certified as a risk-bearing entity, or qualified
  859  pursuant to s. 409.912(1), in the state and is paid a
  860  prospective per-member, per-month payment by the agency.
  861         (14) “Provider service network” means an entity qualified
  862  pursuant to s. 409.912(1) of which a controlling interest is
  863  owned by a health care provider, or group of affiliated
  864  providers, or a public agency or entity that delivers health
  865  services. Health care providers include Florida-licensed health
  866  care professionals or licensed health care facilities, federally
  867  qualified health care centers, and home health care agencies.
  868         Section 14. For the purpose of incorporating the amendment
  869  made by this act to section 409.912, Florida Statutes, in a
  870  reference thereto, subsection (22) of section 641.19, Florida
  871  Statutes, is reenacted to read:
  872         641.19 Definitions.—As used in this part, the term:
  873         (22) “Provider service network” means a network authorized
  874  under s. 409.912(1), reimbursed on a prepaid basis, operated by
  875  a health care provider or group of affiliated health care
  876  providers, and which directly provides health care services
  877  under a Medicare, Medicaid, or Healthy Kids contract.
  878         Section 15. For the purpose of incorporating the amendments
  879  made by this act to section 409.981, Florida Statutes, in
  880  references thereto, paragraphs (h), (i), and (j) of subsection
  881  (3) and subsection (11) of section 430.2053, Florida Statutes,
  882  are reenacted to read:
  883         430.2053 Aging resource centers.—
  884         (3) The duties of an aging resource center are to:
  885         (h) Assist clients who request long-term care services in
  886  being evaluated for eligibility for enrollment in the Medicaid
  887  long-term care managed care program as eligible plans become
  888  available in each of the regions pursuant to s. 409.981(2).
  889         (i) Provide enrollment and coverage information to Medicaid
  890  managed long-term care enrollees as qualified plans become
  891  available in each of the regions pursuant to s. 409.981(2).
  892         (j) Assist Medicaid recipients enrolled in the Medicaid
  893  long-term care managed care program with informally resolving
  894  grievances with a managed care network and assist Medicaid
  895  recipients in accessing the managed care network’s formal
  896  grievance process as eligible plans become available in each of
  897  the regions defined in s. 409.981(2).
  898         (11) In an area in which the department has designated an
  899  area agency on aging as an aging resource center, the department
  900  and the agency shall not make payments for the services listed
  901  in subsection (9) and the Long-Term Care Community Diversion
  902  Project for such persons who were not screened and enrolled
  903  through the aging resource center. The department shall cease
  904  making payments for recipients in eligible plans as eligible
  905  plans become available in each of the regions defined in s.
  906  409.981(2).
  907         Section 16. The Agency for Health Care Administration shall
  908  amend existing Statewide Medicaid Managed Care contracts to
  909  implement the changes made by this act to sections 409.973,
  910  409.975, and 409.977, Florida Statutes. The agency shall
  911  implement the changes made by this act to sections 409.966,
  912  409.974, and 409.981, Florida Statutes, for the 2025 plan year.
  913         Section 17. This act shall take effect July 1, 2022.