2016 Florida Statutes
Managed care plan payments.
Managed care plan payments.
409.968 Managed care plan payments.—
(1) Prepaid plans shall receive per-member, per-month payments negotiated pursuant to the procurements described in s. 409.966. Payments shall be risk-adjusted rates based on historical utilization and spending data, projected forward, and adjusted to reflect the eligibility category, geographic area, and clinical risk profile of the recipients. In negotiating rates with the plans, the agency shall consider any adjustments necessary to encourage plans to use the most cost-effective modalities for treatment of chronic disease such as peritoneal dialysis.
(2) Provider service networks may be prepaid plans and receive per-member, per-month payments negotiated pursuant to the procurement process described in s. 409.966. Provider service networks that choose not to be prepaid plans shall receive fee-for-service rates with a shared savings settlement. The fee-for-service option shall be available to a provider service network only for the first 2 years of its operation. The agency shall annually conduct cost reconciliations to determine the amount of cost savings achieved by fee-for-service provider service networks for the dates of service within the period being reconciled. Only payments for covered services for dates of service within the reconciliation period and paid within 6 months after the last date of service in the reconciliation period must be included. The agency shall perform the necessary adjustments for the inclusion of claims incurred but not reported within the reconciliation period for claims that could be received and paid by the agency after the 6-month claims processing time lag. The agency shall provide the results of the reconciliations to the fee-for-service provider service networks within 45 days after the end of the reconciliation period. The fee-for-service provider service networks shall review and provide written comments or a letter of concurrence to the agency within 45 days after receipt of the reconciliation results. This reconciliation is considered final.
(3) Reimbursement for prescribed pediatric extended care services provided to children enrolled in a managed care plan under s. 409.972(1)(g) shall be paid to the prescribed pediatric extended care services provider by the agency on a fee-for-service basis.
(4)(a) Subject to a specific appropriation and federal approval under s. 409.906(13)(e), the agency shall establish a payment methodology to fund managed care plans for flexible services for persons with severe mental illness and substance use disorders, including, but not limited to, temporary housing assistance. A managed care plan eligible for these payments must do all of the following:
1. Participate as a specialty plan for severe mental illness or substance use disorders or participate in counties designated by the General Appropriations Act;
2. Include providers of behavioral health services pursuant to chapters 394 and 397 in the managed care plan’s provider network; and
3. Document a capability to provide housing assistance through agreements with housing providers, relationships with local housing coalitions, and other appropriate arrangements.
(b) After receiving payments authorized by this subsection for at least 1 year, a managed care plan must document the results of its efforts to maintain the target population in stable housing up to the maximum duration allowed under federal approval.
(5) The agency may not approve any plan request for a rate increase unless sufficient funds to support the increase have been authorized in the General Appropriations Act.
History.—s. 9, ch. 2011-134; s. 5, ch. 2014-57; s. 22, ch. 2016-65.