Bill Text: FL H7223 | 2010 | Regular Session | Engrossed

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Bill Title: Medicaid Managed Care

Spectrum: Partisan Bill (Republican 8-0)

Status: (Failed) 2010-04-30 - Died in Messages [H7223 Detail]

Download: Florida-2010-H7223-Engrossed.html

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HB 7223

1	A bill to be entitled
2	An act relating to Medicaid managed care; creating pt. IV
3	of ch. 409, F.S.; creating s. 409.961, F.S.; providing for
4	statutory construction; providing applicability of
5	specified provisions throughout the part; providing
6	rulemaking authority for specified agencies; creating s.
7	409.962, F.S.; providing definitions; creating s. 409.963,
8	F.S.; designating the Agency for Health Care
9	Administration as the single state agency to administer
10	the Medicaid program; providing for specified agency
11	responsibilities; requiring client consent for release of
12	medical records; creating s. 409.964, F.S.; establishing
13	the Medicaid program as the statewide, integrated managed
14	care program for all covered services; authorizing the
15	agency to apply for and implement waivers; providing for
16	public notice and comment; creating s. 409.965, F.S.;
17	providing for mandatory enrollment; providing for
18	exemptions; creating s. 409.966, F.S.; providing
19	requirements for qualified plans that provide services in
20	the Medicaid managed care program; providing for a medical
21	home network to be designated as a qualified plan;
22	establishing provider service network requirements for
23	qualified plans; providing for qualified plan selection;
24	requiring the agency to use an invitation to negotiate;
25	requiring the agency to compile and publish certain
26	information; establishing regions for separate procurement
27	of plans; providing quality selection criteria for plan
28	selection; establishing quality selection criteria;
29	providing limitations on serving recipients during the
30	pendency of litigation; providing that a qualified plan
31	that participates in an invitation to negotiate in more
32	than one region may not serve Medicaid recipients until
33	all administrative challenges are finalized; creating s.
34	409.967, F.S.; providing for managed care plan
35	accountability; establishing contract terms; providing for
36	contract extension under certain circumstances;
37	establishing payments to noncontract providers;
38	establishing requirements for access; requiring plans to
39	establish and maintain an electronic database;
40	establishing requirements for the database; requiring
41	plans to provide encounter data; requiring the agency to
42	establish performance standards for plans; providing
43	program integrity requirements; establishing a grievance
44	resolution process; providing for penalties for early
45	termination of contracts or reduction in enrollment
46	levels; creating s. 409.968, F.S.; establishing managed
47	care plan payments; providing payment requirements for
48	provider service networks; creating s. 409.969, F.S.;
49	requiring enrollment in managed care plans by specified
50	Medicaid recipients; creating requirements for plan
51	selection by recipients; providing for choice counseling;
52	establishing choice counseling requirements; authorizing
53	disenrollment under certain circumstances; defining the
54	term "good cause" for purposes of disenrollment; providing
55	time limits on an internal grievance process; providing
56	requirements for agency determination regarding
57	disenrollment; requiring recipients to stay in plans for a
58	specified time; creating s. 409.970, F.S.; requiring the
59	agency to maintain an encounter data system; providing
60	requirements for prepaid plans to submit data; creating s.
61	409.971, F.S.; creating the managed medical assistance
62	program; providing deadlines to begin and finalize
63	implementation of the program; creating s. 409.972, F.S.;
64	providing for mandatory and voluntary enrollment; creating
65	s. 409.973, F.S.; establishing minimum benefits for
66	managed care plans to cover; authorizing plans to
67	customize benefit packages; requiring plans to establish
68	enhanced benefits programs; providing terms for enhanced
69	benefits package; establishing reserve requirements for
70	plans to fund enhanced benefits programs; creating s.
71	409.974, F.S.; establishing a specified number of
72	qualified plans to be selected in each region;
73	establishing a deadline for issuing invitations to
74	negotiate; establishing quality selection criteria;
75	establishing the Children's Medical Service Network as a
76	qualified plan; creating s. 409.975; establishing managed
77	care plan accountability; creating a medical loss ratio
78	requirement; authorizing plans to limit providers in
79	networks; mandating certain providers be offered contracts
80	in the first year; requiring certain provider types to
81	participate in plans; requiring plans to monitor the
82	quality and performance history of providers; requiring
83	specified programs and procedures be established by plans;
84	establishing provider payments for hospitals; establishing
85	conflict resolution procedures; establishing the Medicaid
86	Resolution Board for specified purposes; establishing plan
87	requirements for medically needy recipients; creating s.
88	409.976, F.S.; providing for managed care plan payment;
89	requiring the agency to establish a methodology to ensure
90	certain types of payments to specified providers;
91	establishing eligibility for payments; requiring the
92	agency to establish payment rates for statewide inpatient
93	psychiatric programs; requiring payments to managed care
94	plans to be reconciled to reimburse actual payments to
95	statewide inpatient psychiatric programs; creating s.
96	409.977, F.S.; providing for enrollment; establishing
97	choice counseling requirements; providing for automatic
98	enrollment of certain recipients; establishing opt-out
99	opportunities for recipients; creating s. 409.978, F.S.;
100	requiring the Agency for Health Care Administration be
101	responsible for administering the long-term care managed
102	care program; providing implementation dates for the long-
103	term care managed care program; providing duties for the
104	Department of Elderly Affairs relating to assisting the
105	agency in implementing the program; creating s. 409.979,
106	F.S.; providing eligibility requirements for the long-term
107	care managed care program; creating s. 409.980, F.S.;
108	providing the benefits that a managed care plan shall
109	provide when participating in the long-term care managed
110	care program; creating s. 409.981, F.S.; providing
111	criteria for qualified plans; designating regions for plan
112	implementation throughout the state; providing criteria
113	for the selection of plans to participate in the long-term
114	care managed care program; creating s. 409.982, F.S.;
115	providing the agency shall establish a uniform accounting
116	and reporting methods for plans; providing spending
117	thresholds and consequences relating to spending
118	thresholds; providing for mandatory participation in plans
119	of certain service providers; providing providers can be
120	excluded from plans for failure to meet quality or
121	performance criteria; providing the plans must monitor
122	participating providers using specified criteria;
123	providing certain providers that must be included in plan
124	networks; providing provider payment specifications for
125	nursing homes and hospices; creating s. 409.983, F.S.;
126	providing for negotiation of rates between the agency and
127	the plans participating in the long-term care managed care
128	program; providing specific criteria for calculating and
129	adjusting plan payments; allowing the CARES program to
130	assign plan enrollees to a level of care ; providing
131	incentives for adjustments of payment rates; providing the
132	agency shall establish nursing facility-specific and
133	hospice services payment rates; creating s. 409.984, F.S.;
134	providing that prior to contracting with another vender,
135	the agency shall offer to contract with the aging resource
136	centers to provide choice counseling for the long-term
137	care managed care program; providing criteria for
138	automatic assignments of plan enrollees who fail to chose
139	a plan; creating s. 409.985, F.S.; providing that the
140	agency shall operate the Comprehensive Assessment and
141	Review for Long-Term Care Services program through an
142	interagency agreement with the Department of Elderly
143	Affairs; providing duties of the program; defining the
144	term "nursing facility care"; creating s. 409.986, F.S.;
145	providing authority and agency duties related to long-term
146	care plans; creating s. 409.987, F.S.; providing
147	eligibility requirements for long-term care plans;
148	creating s. 409.988, F.S.; providing benefits for long-
149	term care plans; creating s. 409.989, F.S.; establishing
150	criteria for qualified plans; specifying minimum and
151	maximum number of plans and selection criteria; creating
152	s. 409.990, F.S.; providing requirements for managed care
153	plan accountability; specifying limitations on providers
154	in plan networks; providing for evaluation and payment of
155	network providers; creating s. 409.991, F.S.; providing
156	for payment of managed care plans; providing duties for
157	the Agency for Persons with Disabilities to assign plan
158	enrollees into a payment rate level of care; establishing
159	level of care criteria; providing payment requirements for
160	intensive behavior residential habilitation providers and
161	intermediate care facilities for the developmentally
162	disabled; creating s. 409.992, F.S.; providing
163	requirements for enrollment and choice counseling;
164	specifying enrollment exceptions for certain Medicaid
165	recipients; providing an effective date.
166
167	Be It Enacted by the Legislature of the State of Florida:
168
169	Section 1. Sections 409.961 through 409.992, Florida
170	Statutes, are designated as part IV of chapter 409, Florida
171	Statutes, entitled "Medicaid Managed Care."
172	Section 2. Section 409.961, Florida Statutes, is created
173	to read:
174	409.961 Statutory construction; applicability; rules.-It
175	is the intent of the Legislature that if any conflict exists
176	between the provisions contained in this part and provisions
177	contained in other parts of this chapter, the provisions
178	contained in this part shall control. The provisions of ss.
179	409.961-409.970 apply only to the Medicaid managed medical
180	assistance program, long-term care managed care program, and
181	managed long-term care for persons with developmental
182	disabilities program, as provided in this part. The agency shall
183	adopt any rules necessary to comply with or administer this part
184	and all rules necessary to comply with federal requirements. In
185	addition, the department shall adopt and accept the transfer of
186	any rules necessary to carry out the department's
187	responsibilities for receiving and processing Medicaid
188	applications and determining Medicaid eligibility and for
189	ensuring compliance with and administering this part, as those
190	rules relate to the department's responsibilities, and any other
191	provisions related to the department's responsibility for the
192	determination of Medicaid eligibility.
193	Section 3. Section 409.962, Florida Statutes, is created
194	to read:
195	409.962 Definitions.-As used in this part, except as
196	otherwise specifically provided, the term:
197	(1) "Agency" means the Agency for Health Care
198	Administration. The agency is the Medicaid agency for the state,
199	as provided under federal law.
200	(2) "Benefit" means any benefit, assistance, aid,
201	obligation, promise, debt, liability, or the like, related to
202	any covered injury, illness, or necessary medical care, goods,
203	or services.
204	(3) "Direct care management" means care management
205	activities that involve direct interaction between providers and
206	patients.
207	(4) "Long-term care comprehensive plan" means a long-term
208	care plan that also provides the services described in s.
209	409.973.
210	(5) "Long-term care plan" means a specialty plan that
211	provides institutional and home and community-based services.
212	(6) "Long term care provider service network" means an
213	entity certified pursuant to s. 409.912(4)(d), of which a
214	controlling interest is owned by one or more licensed nursing
215	homes, assisted living facilities with 17 or more beds, home
216	health agencies, community care for the elderly lead agencies,
217	or hospices.
218	(7) "Managed care plan" means a qualified plan under
219	contract with the agency to provide services in the Medicaid
220	program.
221	(8) "Medicaid" means the medical assistance program
222	authorized by Title XIX of the Social Security Act, 42 U.S.C. s.
223	1396 et seq., and regulations thereunder, as administered in
224	this state by the agency.
225	(9) "Medicaid recipient" or "recipient" means an
226	individual who the department or, for Supplemental Security
227	Income, the Social Security Administration determines is
228	eligible pursuant to federal and state law to receive medical
229	assistance and related services for which the agency may make
230	payments under the Medicaid program. For the purposes of
231	determining third-party liability, the term includes an
232	individual formerly determined to be eligible for Medicaid, an
233	individual who has received medical assistance under the
234	Medicaid program, or an individual on whose behalf Medicaid has
235	become obligated.
236	(10) "Medical home network" means a qualified plan
237	designated by the agency as a medical home network in accordance
238	with the criteria established in s. 409.91207.
239	(11) "Prepaid plan" means a qualified plan that is
240	licensed or certified as a risk-bearing entity in the state and
241	is paid a prospective per-member, per-month payment by the
242	agency.
243	(12) "Provider service network" means an entity certified
244	pursuant to s. 409.912(4)(d) of which a controlling interest is
245	owned by a health care provider, or group of affiliated
246	providers, or a public agency or entity that delivers health
247	services. Health care providers include Florida-licensed health
248	care professionals or licensed health care facilities, federally
249	qualified health care centers, and home health care agencies.
250	(13) "Qualified plan" means a health insurer authorized
251	under chapter 624, an exclusive provider organization authorized
252	under chapter 627, a health maintenance organization authorized
253	under chapter 641, or a provider service network authorized
254	under s. 409.912(4)(d) that is eligible to participate in the
255	statewide managed care program.
256	(14) "Specialty plan" means a qualified plan that serves
257	Medicaid recipients who meet specified criteria based on age,
258	medical condition, or diagnosis.
259	Section 4. Section 409.963, Florida Statutes, is created
260	to read:
261	409.963 Single state agency.-The Agency for Health Care
262	Administration is designated as the single state agency
263	authorized to manage, operate, and make payments for medical
264	assistance and related services under Title XIX of the Social
265	Security Act. Subject to any limitations or directions provided
266	for in the General Appropriations Act, these payments shall be
267	made only for services included in the program, only on behalf
268	of eligible individuals, and only to qualified providers in
269	accordance with federal requirements for Title XIX of the Social
270	Security Act and the provisions of state law. This program of
271	medical assistance is designated as the "Medicaid program." The
272	department is responsible for Medicaid eligibility
273	determinations, including, but not limited to, policy, rules,
274	and the agreement with the Social Security Administration for
275	Medicaid eligibility determinations for Supplemental Security
276	Income recipients, as well as the actual determination of
277	eligibility. As a condition of Medicaid eligibility, subject to
278	federal approval, the agency and the department shall ensure
279	that each Medicaid recipient consents to the release of her or
280	his medical records to the agency and the Medicaid Fraud Control
281	Unit of the Department of Legal Affairs.
282	Section 5. Section 409.964, Florida Statutes is created to
283	read:
284	409.964 Managed care program; state plan; waivers.-The
285	Medicaid program is established as a statewide, integrated
286	managed care program for all covered services, including long-
287	term care services. The agency shall apply for and implement
288	state plan amendments or waivers of applicable federal laws and
289	regulations necessary to implement the program. Prior to seeking
290	a waiver, the agency shall provide public notice and the
291	opportunity for public comment and shall include public feedback
292	in the waiver application. The agency shall include the public
293	feedback in the application. The agency shall hold one public
294	meeting in each of the regions described in s. 409.966(2) and
295	the time period for public comment for each region shall end no
296	sooner than 30 days after the completion of the public meeting
297	in that region.
298	Section 6. Section 409.965, Florida Statutes, is created
299	to read:
300	409.965 Mandatory enrollment.-All Medicaid recipients
301	shall receive covered services through the statewide managed
302	care program, except as provided by this part pursuant to an
303	approved federal waiver. The following Medicaid recipients are
304	exempt from participation in the statewide managed care program:
305	(1) Women who are only eligible for family planning
306	services.
307	(2) Women who are only eligible for breast and cervical
308	cancer services.
309	(3) Persons who are eligible for emergency Medicaid for
310	aliens.
311	Section 7. Section 409.966, Florida Statutes, is created
312	to read:
313	409.966 Qualified plans; selection.-
314	(1) QUALIFIED PLANS.-Services in the Medicaid managed care
315	program shall be provided by qualified plans.
316	(a) A qualified plan may request the agency to designate
317	the plan as a medical home network if it meets the criteria
318	established in s. 409.91207.
319	(b) A provider service network must be capable of
320	providing all covered services to a mandatory Medicaid managed
321	care enrollee or may limit the provision of services to a
322	specific target population based on the age, chronic disease
323	state, or the medical condition of the enrollee to whom the
324	network will provide services. A specialty provider service
325	network must be capable of coordinating care and delivering or
326	arranging for the delivery of all covered services to the target
327	population. A provider service network may partner with an
328	insurer licensed under chapter 627 or a health maintenance
329	organization licensed under chapter 641 to meet the requirements
330	of a Medicaid contract.
331	(2) QUALIFIED PLAN SELECTION.-The agency shall select a
332	limited number of qualified plans to participate in the Medicaid
333	program using invitations to negotiate in accordance with s.
334	287.057(3)(a). At least 30 days prior to issuing an invitation
335	to negotiate, the agency shall compile and publish a databook
336	consisting of a comprehensive set of utilization and spending
337	data for the 3 most recent contract years consistent with the
338	rate-setting periods for all Medicaid recipients by region or
339	county. The source of the data in the report shall include both
340	historic fee-for-service claims and validated data from the
341	Medicaid Encounter Data System. The report shall be made
342	available in electronic form and shall delineate utilization use
343	by age, gender, eligibility group, geographic area, and
344	aggregate clinical risk score. Separate and simultaneous
345	procurements shall be conducted in each of the following
346	regions:
347	(a) Region I, which shall consist of Bay, Calhoun,
348	Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson,
349	Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla,
350	Walton, and Washington Counties.
351	(b) Region II, which shall consist of Alachua, Baker,
352	Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler,
353	Gilchrist, Hamilton, Lafayette, Levy, Marion, Nassau, Putnam,
354	St. Johns, Suwannee, Union, and Volusia Counties.
355	(c) Region III, which shall consist of Charlotte, DeSoto,
356	Hardee, Hernando, Highlands, Hillsborough, Lee, Manatee, Pasco,
357	Pinellas, Polk, and Sarasota Counties.
358	(d) Region IV, which shall consist of Brevard, Indian
359	River, Lake, Orange, Osceola, Seminole, and Sumter Counties.
360	(e) Region V, which shall consist of Broward, Glades,
361	Hendry, Martin, Okeechobee, Palm Beach, and St. Lucie Counties.
362	(f) Region VI, which shall consist of Collier, Dade, and
363	Monroe Counties.
364	(3) QUALITY SELECTION CRITERIA.-The invitation to
365	negotiate must specify the criteria and the relative weight of
366	the criteria that will be used for determining the acceptability
367	of the reply and guiding the selection of the organizations with
368	which the agency negotiates. In addition to criteria established
369	by the agency, the agency shall consider the following factors
370	in the selection of qualified plans:
371	(a) Accreditation by the National Committee for Quality
372	Assurance or another nationally recognized accrediting body.
373	(b) Experience serving similar populations, including the
374	organization's record in achieving specific quality standards
375	with similar populations.
376	(c) Availability and accessibility of primary care and
377	specialty physicians in the provider network.
378	(d) Establishment of community partnerships with providers
379	that create opportunities for reinvestment in community-based
380	services.
381	(e) Organization commitment to quality improvement and
382	documentation of achievements in specific quality improvement
383	projects, including active involvement by organization
384	leadership.
385	(f) Provision of additional benefits, particularly dental
386	care and disease management, and other enhanced-benefit
387	programs.
388	(g) History of voluntary or involuntary withdrawal from
389	any state Medicaid program or program area.
390	(h) Evidence that a qualified plan has written agreements
391	or signed contracts or has made substantial progress in
392	establishing relationships with providers prior to the plan
393	submitting a response. The agency shall evaluate and give
394	special weight to such evidence, and the evaluation shall be
395	based on the following factors:
396	1. Contracts with primary and specialty physicians in
397	sufficient numbers to meet the specific standards established
398	pursuant to s. 409.967(2)(b).
399	2. Specific arrangements that provide evidence that the
400	compensation offered is sufficient to retain primary and
401	specialty physicians in sufficient numbers to continue to comply
402	with the standards established pursuant to s. 409.967(2)
403	throughout the 5-year contract term.
404	3. Contracts with community pharmacies located in rural
405	areas; contracts with community pharmacies servicing specialty
406	disease populations, including, but not limited to, HIV/AIDS
407	patients, hemophiliacs, patients suffering from end-stage renal
408	disease, diabetes, or cancer; community pharmacies located
409	within distinct cultural communities that reflect the unique
410	cultural dynamics of such communities, including, but not
411	limited to, languages spoken, ethnicities served, unique disease
412	states serviced, and geographic location within neighborhoods of
413	such culturally distinct populations; and community pharmacies
414	providing value-added services to patients, such as free
415	delivery, immunizations, disease management, diabetes education,
416	and medication utilization review.
417	4. Contracts with multiple and diverse suppliers of home
418	medical equipment and supplies distributed throughout the region
419	that ensure patient choice, continuity of services, and
420	redundant capacity to prevent service disruption during disaster
421	response. The network of home medical equipment and supply
422	providers shall include fully accredited and locally owned and
423	operated companies with a proven ability to provide quality
424	products, personalized service, 24-hour access to service, and
425	appropriate response time.
426
427	After negotiations are conducted, the agency shall select the
428	qualified plans that are determined to be responsive and provide
429	the best value to the state. Preference shall be given to
430	organizations designated as medical home networks pursuant to s.
431	409.91207 or organizations with the greatest number of primary
432	care providers that are recognized as patient-centered medical
433	homes by the National Committee for Quality Assurance or
434	organizations with networks that reflect recruitment of minority
435	physicians and other minority providers.
436	(4) ADMINISTRATIVE CHALLENGE.-Any qualified plan that
437	participates in an invitation to negotiate in more than one
438	region and is selected in at least one region may not begin
439	serving Medicaid recipients in any region for which it was
440	selected until all administrative challenges to procurements
441	required by this section to which the qualified plan is a party
442	have been finalized. For purposes of this subsection, an
443	administrative challenge is finalized if an order granting
444	voluntary dismissal with prejudice has been entered by any court
445	established under Article V of the State Constitution or by the
446	Division of Administrative Hearings, a final order has been
447	entered into by the agency and the deadline for appeal has
448	expired, a final order has been entered by the First District
449	Court of Appeal and the time to seek any available review by the
450	Florida Supreme Court has expired, or a final order has been
451	entered by the Florida Supreme Court and a warrant has been
452	issued.
453	Section 8. Section 409.967, Florida Statutes, is created
454	to read:
455	409.967 Managed care plan accountability.-
456	(1) The agency shall establish a 5-year contract with each
457	of the qualified plans selected through the procurement process
458	described in s. 409.966. A plan contract may not be renewed;
459	however, the agency may extend the terms of a plan contract to
460	cover any delays in transition to a new plan.
461	(2) The agency shall establish such contract requirements
462	as are necessary for the operation of the statewide managed care
463	program. In addition to any other provisions the agency may deem
464	necessary, the contract shall require:
465	(a) Emergency services.-Plans shall pay for services
466	required by ss. 395.1041 and 401.45 and rendered by a
467	noncontracted provider within 30 days after receipt of a
468	complete and correct claim. Plans must give providers of these
469	services a specific explanation for each claim denied for being
470	incomplete or incorrect. Providers shall have an opportunity to
471	resubmit corrected claims for reconsideration within 30 days
472	after receiving notice from the managed care plans of the claims
473	being incomplete or incorrect. Payments for noncontracted
474	emergency services and care shall be made at the rate the agency
475	would pay for such services from the same provider. Claims from
476	noncontracted providers shall be accepted by the qualified plan
477	for at least 1 year after the date the services are provided.
478	(b) Access.-The agency shall establish specific standards
479	for the number, type, and regional distribution of providers in
480	plan networks to ensure access to care. Each plan must maintain
481	a region-wide network of providers in sufficient numbers to meet
482	the access standards for specific medical services for all
483	recipients enrolled in the plan. Each plan shall establish and
484	maintain an accurate and complete electronic database of
485	contracted providers, including information about licensure or
486	registration, locations and hours of operation, specialty
487	credentials and other certifications, specific performance
488	indicators, and such other information as the agency deems
489	necessary. The database shall be available online to both the
490	agency and the public and shall have the capability to compare
491	the availability of providers to network adequacy standards and
492	to accept and display feedback from each provider's patients.
493	Each plan shall submit quarterly reports to the agency
494	identifying the number of enrollees assigned to each primary
495	care provider.
496	(c) Encounter data.-Each prepaid plan must comply with the
497	agency's reporting requirements for the Medicaid Encounter Data
498	System. The agency shall develop methods and protocols for
499	ongoing analysis of the encounter data that adjusts for
500	differences in characteristics of plans' enrollees to allow
501	comparison of service utilization among plans and against
502	expected levels of use. The analysis shall be used to identify
503	possible cases of systemic under-utilization or denials of
504	claims and inappropriate service utilization such as higher than
505	expected emergency department encounters. The analysis shall
506	provide periodic feedback to the plans and enable the agency to
507	establish corrective action plans when necessary. One of the
508	primary focus areas for the analysis shall be the use of
509	prescription drugs.
510	(d) Continuous improvement.-The agency shall establish
511	specific performance standards and expected milestones or
512	timelines for improving performance over the term of the
513	contract. Each plan shall establish an internal health care
514	quality improvement system, including enrollee satisfaction and
515	disenrollment surveys. The quality improvement system shall
516	include incentives and disincentives for network providers.
517	(e) Program integrity.-Each plan shall establish program
518	integrity functions and activities to reduce the incidence of
519	fraud and abuse, including, at a minimum:
520	1. A provider credentialing system and ongoing provider
521	monitoring;
522	2. An effective prepayment and postpayment review process
523	including, but not limited to, data analysis, system editing,
524	and auditing of network providers;
525	3. Procedures for reporting instances of fraud and abuse
526	pursuant to chapter 641;
527	4. Administrative and management arrangements or
528	procedures, including a mandatory compliance plan, designed to
529	prevent fraud and abuse; and
530	5. Designation of a program integrity compliance officer.
531	(f) Grievance resolution.-Each plan shall establish and
532	the agency shall approve an internal process for reviewing and
533	responding to grievances from enrollees consistent with the
534	requirements of s. 641.511. Each plan shall submit quarterly
535	reports on the number, description, and outcome of grievances
536	filed by enrollees. The agency shall maintain a process for
537	provider service networks consistent with s. 408.7056.
538	(g) Penalties.-Plans that reduce enrollment levels or
539	leave a region prior to the end of the contract term shall
540	reimburse the agency for the cost of enrollment changes and
541	other transition activities, including the cost of additional
542	choice counseling services. If more than one plan leaves a
543	region at the same time, costs shall be shared by the departing
544	plans proportionate to their enrollments. In addition to the
545	payment of costs, departing plans shall pay a per enrollee
546	penalty not to exceed 5 percent of 1 month's payment. Plans
547	shall provide the agency notice no less than 180 days prior to
548	withdrawing from a region.
549	(h) Prompt payment.-All managed care plans shall comply
550	with ss. 641.315, 641.3155, and 641.513.
551	(i) Electronic claims.-Plans shall accept electronic
552	claims in compliance with federal standards.
553	(j) Medical home development.-The managed care plan, if
554	not designated as a medical home network pursuant to s.
555	409.91207, must develop a plan to assist and to provide
556	incentives for its primary care providers to become recognized
557	as patient-centered medical homes by the National Committee for
558	Quality Assurance.
559	Section 9. Section 409.968, Florida Statutes, is created
560	to read:
561	409.968 Managed care plan payment.-
562	(1) Prepaid plans shall receive per-member, per-month
563	payments negotiated pursuant to the procurements described in s.
564	409.966. Payments shall be risk-adjusted rates based on
565	historical utilization and spending data, projected forward, and
566	adjusted to reflect the eligibility category, geographic area,
567	and the clinical risk profile of the recipients.
568	(2) Beginning September 1, 2010, the agency shall update
569	the rate-setting methodology by initiating a transition to rates
570	based on statewide encounter data submitted by Medicaid managed
571	care plans pursuant to s. 409.970. Prior to this transition, the
572	agency shall conduct appropriate tests and establish specific
573	milestones in order to determine that the Medicaid Encounter
574	Data system consists of valid, complete, and sound data for a
575	sufficient period of time to provide a reliable basis for
576	establishing actuarially sound payment rates. The transition
577	shall be implemented within 3 years or less, and shall utilize
578	such other data sources as necessary and reliable to make
579	appropriate adjustments during the transition. The agency shall
580	establish a technical advisory panel to obtain input from the
581	prepaid plans regarding the incorporation of encounter data in
582	the rate setting process.
583	(3) Provider service networks may be prepaid plans and
584	receive per-member, per-month payments negotiated pursuant to
585	the procurement process described in s. 409.966. Provider
586	service networks that choose not to be prepaid plans shall
587	receive fee-for-service rates with a shared savings settlement.
588	The fee-for-service option shall be available to a provider
589	service network only for the first 5 years of the plan's
590	operation in a given region or until the contract year that
591	begins on October 1, 2015, whichever is later. The agency shall
592	annually conduct cost reconciliations to determine the amount of
593	cost savings achieved by fee-for-service provider service
594	networks for the dates of service within the period being
595	reconciled. Only payments for covered services for dates of
596	service within the reconciliation period and paid within 6
597	months after the last date of service in the reconciliation
598	period shall be included. The agency shall perform the necessary
599	adjustments for the inclusion of incurred but not reported
600	claims within the reconciliation period for claims that could be
601	received and paid by the agency after the 6-month claims
602	processing time lag. The agency shall provide the results of the
603	reconciliations to the fee-for-service provider service networks
604	within 45 days after the end of the reconciliation period. The
605	fee-for-service provider service networks shall review and
606	provide written comments or a letter of concurrence to the
607	agency within 45 days after receipt of the reconciliation
608	results. This reconciliation shall be considered final.
609	Section 10. Section 409.969, Florida Statutes, is created
610	to read:
611	409.969 Enrollment; choice counseling; automatic
612	assignment; disenrollment.-
613	(1) ENROLLMENT.-All Medicaid recipients shall be enrolled
614	in a managed care plan unless specifically exempted in this
615	part. Each recipient shall have a choice of plans and may select
616	any available plan unless that plan is restricted by contract to
617	a specific population that does not include the recipient.
618	Medicaid recipients shall have 30 days in which to make a choice
619	of plans. All recipients shall be offered choice counseling
620	services in accordance with this section.
621	(2) CHOICE COUNSELING.-The agency shall provide choice
622	counseling for Medicaid recipients. The agency may contract for
623	the provision of choice counseling. Any such contract shall be
624	for a period of 5 years. The agency may renew a contract for an
625	additional 5-year period; however, prior to renewal of the
626	contract the agency shall hold at least one public meeting in
627	each of the regions covered by the choice counseling vendor. The
628	agency may extend the term of the contract to cover any delays
629	in transition to a new contractor. Printed choice information
630	and choice counseling shall be offered in the native or
631	preferred language of the recipient, consistent with federal
632	requirements. The manner and method of choice counseling shall
633	be modified as necessary to assure culturally competent,
634	effective communication with people from diverse cultural
635	backgrounds. The agency shall maintain a record of the
636	recipients who receive such services, identifying the scope and
637	method of the services provided. The agency shall make available
638	clear and easily understandable choice information to Medicaid
639	recipients that includes:
640	(a) An explanation that each recipient has the right to
641	choose a managed care plan at the time of enrollment in Medicaid
642	and again at regular intervals set by the agency, and that if a
643	recipient does not choose a plan, the agency will assign the
644	recipient to a plan according to the criteria specified in this
645	section.
646	(b) A list and description of the benefits provided in
647	each plan.
648	(c) An explanation of benefit limits.
649	(d) A current list of providers participating in the
650	network, including location and contact information.
651	(e) Plan performance data.
652	(3) DISENROLLMENT; GRIEVANCES.-After a recipient has
653	enrolled in a managed care plan, the recipient shall have 90
654	days to voluntarily disenroll and select another plan. After 90
655	days, no further changes may be made except for good cause. Good
656	cause includes, but is not limited to, poor quality of care,
657	lack of access to necessary specialty services, an unreasonable
658	delay or denial of service, or fraudulent enrollment. The agency
659	must make a determination as to whether good cause exists. The
660	agency may require a recipient to use the plan's grievance
661	process prior to the agency's determination of good cause,
662	except in cases in which immediate risk of permanent damage to
663	the recipient's health is alleged.
664	(a) The managed care plan internal grievance process, when
665	utilized, must be completed in time to permit the recipient to
666	disenroll by the first day of the second month after the month
667	the disenrollment request was made. If the result of the
668	grievance process is approval of an enrollee's request to
669	disenroll, the agency is not required to make a determination in
670	the case.
671	(b) The agency must make a determination and take final
672	action on a recipient's request so that disenrollment occurs no
673	later than the first day of the second month after the month the
674	request was made. If the agency fails to act within the
675	specified timeframe, the recipient's request to disenroll is
676	deemed to be approved as of the date agency action was required.
677	Recipients who disagree with the agency's finding that good
678	cause does not exist for disenrollment shall be advised of their
679	right to pursue a Medicaid fair hearing to dispute the agency's
680	finding.
681	(c) Medicaid recipients enrolled in a managed care plan
682	after the 90-day period shall remain in the plan for the
683	remainder of the 12-month period. After 12 months, the recipient
684	may select another plan. However, nothing shall prevent a
685	Medicaid recipient from changing primary care providers within
686	the plan during that period.
687	(d) On the first day of the next month after receiving
688	notice from a recipient that the recipient has moved to another
689	region, the agency shall automatically disenroll the recipient
690	from the plan the recipient is currently enrolled in and treat
691	the recipient as if the recipient is a new Medicaid enrollee. At
692	that time, the recipient may choose another plan pursuant to the
693	enrollment process established in this section.
694	Section 11. Section 409.970, Florida Statutes, is created
695	to read:
696	409.970 Encounter data.-The agency shall maintain and
697	operate the Medicaid Encounter Data System to collect, process,
698	store, and report on covered services provided to all Medicaid
699	recipients enrolled in prepaid plans. Prepaid plans shall submit
700	encounter data electronically in a format that complies with the
701	Health Insurance Portability and Accountability Act provisions
702	for electronic claims and in accordance with deadlines
703	established by the agency. Prepaid plans must certify that the
704	data reported is accurate and complete. The agency is
705	responsible for validating the data submitted by the plans. The
706	agency shall make encounter data available to those plans
707	accepting enrollees who are assigned to them from other plans
708	leaving a region.
709	Section 12. Section 409.971, Florida Statutes, is created
710	to read:
711	409.971 Managed medical assistance program.-The agency
712	shall make payments for primary and acute medical assistance and
713	related services using a managed care model. By January 1, 2012,
714	the agency shall begin implementation of the statewide managed
715	medical assistance program, with full implementation in all
716	regions by October 1, 2013.
717	Section 13. Section 409.972, Florida Statutes, is created
718	to read:
719	409.972 Mandatory and voluntary enrollment.-
720	(1) Persons eligible for the program known as "medically
721	needy" pursuant to s. 409.904(2)(a) shall enroll in managed care
722	plans. Medically needy recipients shall meet the share of cost
723	by paying the plan premium, up to the share of cost amount,
724	contingent upon federal approval.
725	(2) The following Medicaid-eligible persons are exempt
726	from mandatory managed care enrollment required by s. 409.965,
727	and may voluntarily choose to participate in the managed medical
728	assistance program:
729	(a) Medicaid recipients who have other creditable health
730	care coverage, excluding Medicare.
731	(b) Medicaid recipients residing in residential commitment
732	facilities operated through the Department of Juvenile Justice,
733	group care facilities operated by the Department of Children and
734	Families, and treatment facilities funded through the Substance
735	Abuse and Mental Health program of the Department of Children
736	and Families.
737	(c) Persons eligible for refugee assistance.
738	(d) Medicaid recipients who are residents of a
739	developmental disability center including Sunland Center in
740	Marianna and Tacachale in Gainesville.
741	(3) Persons eligible for Medicaid but exempt from
742	mandatory participation who do not choose to enroll in managed
743	care shall be served in the Medicaid fee-for-service program as
744	provided in part III of this chapter.
745	Section 14. Section 409.973, Florida Statutes, is created
746	to read:
747	409.973 Benefits.-
748	(1) MINIMUM BENEFITS.-Managed care plans shall cover, at a
749	minimum, the following services:
750	(a) Advanced registered nurse practitioner services.
751	(b) Ambulatory surgical treatment center services.
752	(c) Birthing center services.
753	(d) Chiropractic services.
754	(e) Dental services.
755	(f) Early periodic screening diagnosis and treatment
756	services for recipients under age 21.
757	(g) Emergency services.
758	(h) Family planning services and supplies.
759	(i) Healthy start services.
760	(j) Hearing services.
761	(k) Home health agency services.
762	(l) Hospice services.
763	(m) Hospital inpatient services.
764	(n) Hospital outpatient services.
765	(o) Laboratory and imaging services.
766	(p) Medical supplies, equipment, prostheses, and orthoses.
767	(q) Mental health services.
768	(r) Nursing care.
769	(s) Optical services and supplies.
770	(t) Optometrist services.
771	(u) Physical, occupational, respiratory, and speech
772	therapy services.
773	(v) Physician services.
774	(w) Podiatric services.
775	(x) Prescription drugs.
776	(y) Renal dialysis services.
777	(z) Respiratory equipment and supplies.
778	(aa) Rural health clinic services.
779	(bb) Substance abuse treatment services.
780	(cc) Transportation to access covered services.
781	(2) CUSTOMIZED BENEFITS.-Managed care plans may customize
782	benefit packages for nonpregnant adults, vary cost-sharing
783	provisions, and provide coverage for additional services. The
784	agency shall evaluate the proposed benefit packages to ensure
785	services are sufficient to meet the needs of the plans'
786	enrollees and to verify actuarial equivalence.
787	(3) ENHANCED BENEFITS.-Each plan operating in the managed
788	medical assistance program shall establish an incentive program
789	that rewards specific healthy behaviors with credits in a
790	flexible spending account.
791	(a) At the discretion of the recipient, credits shall be
792	used to purchase otherwise uncovered health and related services
793	during the entire period of, and for a maximum of 3 years after,
794	the recipient's Medicaid eligibility, whether or not the
795	recipient remains continuously enrolled in the plan in which the
796	credits were earned.
797	(b) Enhanced benefits shall be structured to provide
798	greater incentives for those diseases linked with lifestyle and
799	conditions or behaviors associated with avoidable utilization of
800	high-cost services.
801	(c) To fund these credits, each plan must maintain a
802	reserve account in an amount of up to 2 percent of the plan's
803	Medicaid premium revenue, or benchmark premium revenue in the
804	case of provider service networks, based on an actuarial
805	assessment of the value of the enhanced benefits program.
806	Section 15. Section 409.974, Florida Statutes, is created
807	to read:
808	409.974 Qualified plans.-
809	(1) QUALIFIED PLAN SELECTION.-The agency shall select
810	qualified plans through the procurement described in s. 409.966.
811	The agency shall notice invitations to negotiate no later than
812	January 1, 2012.
813	(a) The agency shall procure three plans for Region I. At
814	least one plan shall be a provider service network, if any
815	provider service network submits a responsive bid.
816	(b) The agency shall procure at least four and no more
817	than seven plans for Region II. At least one plan shall be a
818	provider service network, if any provider service network
819	submits a responsive bid.
820	(c) The agency shall procure at least five plans and no
821	more than ten plans for Region III. At least two plans shall be
822	provider service networks, if any two provider service networks
823	submit a responsive bid.
824	(d) The agency shall procure at least four plans and no
825	more than eight plans for Region IV. At least one plan shall be
826	a provider service network if any provider service network
827	submits a responsive bid.
828	(e) The agency shall procure at least four plans and no
829	more than seven plans for Region V. At least one plan shall be a
830	provider service network, if any provider service network
831	submits a responsive bid.
832	(f) The agency shall procure at least five plans and no
833	more than ten plans for Region VI. At least two plans shall be
834	provider service networks, if any two provider service networks
835	submit a responsive bid.
836	If no provider service network submits a responsive bid, the
837	agency shall procure no more than one less than the maximum
838	number of qualified plans permitted in that region. Within 12
839	months after the initial invitation to negotiate, the agency
840	shall attempt to procure a qualified plan that is a provider
841	service network. The agency shall notice another invitation to
842	negotiate only with provider service networks in such region
843	where no provider service network has been selected.
844	(2) QUALITY SELECTION CRITERIA.-In addition to the
845	criteria established in s. 409.966, the agency shall consider
846	evidence that a qualified plan has written agreements or signed
847	contracts or has made substantial progress in establishing
848	relationships with providers prior to the plan submitting a
849	response. The agency shall evaluate and give special weight to
850	evidence of signed contracts with providers of critical services
851	pursuant to s. 409.975(3)(a)-(d). The agency shall also consider
852	whether the organization is a specialty plan. When all other
853	factors are equal, the agency shall consider whether the
854	organization has a contract to provide managed long-term care
855	services in the same region and shall exercise a preference for
856	such plans.
857	(3) CHILDREN'S MEDICAL SERVICES NETWORK.-The Children's
858	Medical Services Network authorized under chapter 391 is a
859	qualified plan for purposes of the managed medical assistance
860	program. Participation by the Children's Medical Services
861	Network shall be pursuant to a single, statewide contract with
862	the agency that is not subject to the procurement requirements
863	or regional plan number limits of this section. The Children's
864	Medical Services Network must meet all other plan requirements
865	for the managed medical assistance program.
866	Section 16. Section 409.975, Florida Statutes, is created
867	to read:
868	409.975 Managed care plan accountability.-In addition to
869	the requirements of s. 409.967, plans and providers
870	participating in the managed medical assistance program shall
871	comply with the requirements of this section.
872	(1) MEDICAL LOSS RATIO.-The agency shall establish and
873	implement managed care plans that shall use a uniform method of
874	accounting for and reporting medical, direct care management,
875	and nonmedical costs. The agency shall evaluate plan spending
876	patterns beginning after the plan completes 2 full years of
877	operation and at least annually thereafter. The agency shall
878	implement the following thresholds and consequences of various
879	spending patterns:
880	(a) Plans that spend less than 75 percent of Medicaid
881	premium revenue on medical services and direct care management
882	as determined by the agency shall be excluded from automatic
883	enrollments and shall be required to pay back the amount between
884	actual spending and 85 percent of the Medicaid premium revenue.
885	(b) Plans that spend less than 85 percent of Medicaid
886	premium revenue on medical services and direct care management
887	as determined by the agency shall be required to pay back the
888	amount between actual spending and 85 percent of the Medicaid
889	premium revenue.
890	(c) Plans that spend more than 92 percent of Medicaid
891	premium revenue on medical services and direct care management
892	as determined by the agency shall be evaluated by the agency to
893	determine whether higher expenditures are the result of failures
894	in care management.
895	(d) Plans that spend 95 percent or more of Medicaid
896	premium revenue on medical services and direct care management
897	and are determined to be failing to appropriately manage care
898	shall be excluded from automatic enrollments.
899	(2) PROVIDER NETWORKS.-Plans may limit the providers in
900	their networks based on credentials, quality indicators, and
901	price. However, in the first contract period after a qualified
902	plan is selected in a region by the agency, the plan must offer
903	a network contract to the following providers in the region:
904	(a) Federally qualified health centers.
905	(b) Primary care providers certified as medical homes.
906	(c) Providers listed in paragraphs (3)(a)-(d).
907
908	After 12 months of active participation in a plan's network, the
909	plan may exclude any of the above-named providers from the
910	network for failure to meet quality or performance criteria. If
911	the plan excludes a provider from the plan, the plan must
912	provide written notice to all recipients who have chosen that
913	provider for care. The notice shall be provided at least 30 days
914	prior to the effective date of the exclusion.
915	(3) SELECT PROVIDER PARTICIPATION.-Providers may not be
916	required to participate in any qualified plan selected by the
917	agency except as provided in this subsection. The following
918	providers must agree to participate with each qualified plan
919	selected by the agency in the regions where they are located:
920	(a) Statutory teaching hospitals as defined in s.
921	408.07(45).
922	(b) Hospitals that are trauma centers as defined in s.
923	395.4001(14).
924	(c) Hospitals that are regional perinatal intensive care
925	centers as defined in s. 383.16(2).
926	(d) Hospitals licensed as specialty children's hospitals
927	as defined in s. 395.002(28).
928	(e) Hospitals with both an active Medicaid provider
929	agreement under s. 409.907 and a certificate of need.
930
931	The hospitals described in paragraphs (a)-(d) shall make
932	adequate arrangements for medical staff sufficient to fulfill
933	their contractual obligations with the plans.
934	(4) PERFORMANCE MEASUREMENT.-Each plan shall monitor the
935	quality and performance of each participating provider. At the
936	beginning of the contract period, each plan shall notify all its
937	network providers of the metrics used by the plan for evaluating
938	the provider's performance and determining continued
939	participation in the network.
940	(5) PREGNANCY AND INFANT HEALTH.-Each plan shall establish
941	specific programs and procedures to improve pregnancy outcomes
942	and infant health, including, but not limited to, coordination
943	with the Healthy Start program, immunization programs, and
944	referral to the Special Supplemental Nutrition Program for
945	Women, Infants, and Children, and the Children's Medical
946	Services program for children with special health care needs.
947	(6) SCREENING RATE.-Each plan shall achieve an annual
948	Early and Periodic Screening, Diagnosis, and Treatment Service
949	screening rate of at least 80 percent of those recipients
950	continuously enrolled for at least 8 months.
951	(7) PROVIDER PAYMENT.-Plans and hospitals shall negotiate
952	mutually acceptable rates, methods, and terms of payment. At a
953	minimum, plans shall pay hospitals the Medicaid rate. Payments
954	to hospitals shall not exceed 150 percent of the rate the agency
955	would have paid on the first day of the contract between the
956	provider and the plan, unless specifically approved by the
957	agency. Payment rates may be updated periodically.
958	(8) CONFLICT RESOLUTION.-In order to protect the continued
959	statewide operation of the Medicaid managed care program, the
960	Medicaid Resolution Board is established to resolve disputes
961	between managed care plans and hospitals and between managed
962	care plans and the medical staff of the providers listed in s.
963	409.975(3)(a)-(d). The board shall consist of two members
964	appointed by the Speaker of the House of Representatives, two
965	members appointed by the President of the Senate, and three
966	members appointed by the Governor. The costs of the board's
967	activities to review and resolve disputes shall be shared
968	equally by the parties to the dispute. Any managed care plan or
969	above-named provider may initiate a review by the board for any
970	conflict related to payment rates, contract terms, or other
971	conditions. The board shall make recommendations to the agency
972	regarding payment rates, procedures, or other contract terms to
973	resolve such conflicts. The agency may amend the terms of the
974	contracts with the parties to ensure compliance with these
975	recommendations. This process shall not be used to review and
976	reverse any managed care plan decision to exclude any provider
977	that fails to meet quality standards.
978	(9) MEDICALLY NEEDY ENROLLEES.-Each selected plan shall
979	accept any medically needy recipient who selects or is assigned
980	to the plan and provide that recipient with continuous
981	enrollment for 12 months. After the first month of qualifying as
982	a medically needy recipient and enrolling in a plan, and
983	contingent upon federal approval, the enrollee shall pay the
984	plan a portion of the monthly premium equal to the enrollee's
985	share of the cost as determined by the department. The agency
986	shall pay the remainder of the monthly premium. Plans must
987	provide a grace period of at least 120 days before disenrolling
988	recipients who fail to pay their shares of the premium.
989	Section 17. Section 409.976, Florida Statutes, is created
990	to read:
991	409.976 Managed care plan payment.-In addition to the
992	payment provisions of s. 409.968, the agency shall provide
993	payment to plans in the managed medical assistance program
994	pursuant to this section.
995	(1) Prepaid payment rates shall be negotiated between the
996	agency and the qualified plans as part of the procurement
997	described in s. 409.966.
998	(2) The agency shall develop a methodology to ensure the
999	availability of intergovernmental transfers in the statewide
1000	integrated managed care program to support providers that have
1001	historically served Medicaid recipients. Such providers include,
1002	but are not limited to, safety net providers, trauma hospitals,
1003	children's hospitals, statutory teaching hospitals, and medical
1004	and osteopathic physicians employed by or under contract with a
1005	medical school in this state. The agency may develop a
1006	supplemental capitation rate, risk pool, or incentive payment to
1007	plans that contract with these providers. A plan is eligible for
1008	a supplemental payment only if there are sufficient
1009	intergovernmental transfers available from allowable sources and
1010	the plan can demonstrate that it pays a reimbursement rate not
1011	less than the equivalent fee-for-service rate. The agency may
1012	develop the supplemental capitation rate to consider rates
1013	higher than the fee-for-service Medicaid rate when needed to
1014	ensure access and supported by funds provided by a locality. The
1015	agency shall evaluate the development of the rate cell to
1016	accurately reflect the underlying utilization to the maximum
1017	extent possible. This methodology may include interim rate
1018	adjustments as permitted under federal regulations. Any such
1019	methodology shall preserve federal funding to these entities and
1020	must be actuarially sound. In the absence of federal approval
1021	for the above methodology, the agency is authorized to set an
1022	enhanced rate and require that plans pay the enhanced rate, if
1023	the agency determines the enhanced rate is necessary to ensure
1024	access to care by the providers described in this subsection.
1025	The amount paid to the plans to make supplemental payments or to
1026	enhance provider rates pursuant to this subsection shall be
1027	reconciled to the exact amounts the plans are required to pay to
1028	providers. The plans shall make the designated payments to
1029	providers within 15 business days of notification by the agency
1030	regarding provider-specific distributions.
1031	(3) The agency shall establish payment rates for statewide
1032	inpatient psychiatric programs. Payments to managed care plans
1033	shall be reconciled to reimburse actual payments to statewide
1034	inpatient psychiatric programs.
1035	Section 18. Section 409.977, Florida Statutes, is created
1036	to read:
1037	409.977 Choice counseling and enrollment.-
1038	(1) CHOICE COUNSELING.-In addition to the choice
1039	counseling information required by s. 409.969, the agency shall
1040	make available clear and easily understandable choice
1041	information to Medicaid recipients that includes:
1042	(a) Information about earning credits in the plan's
1043	enhanced benefit program.
1044	(b) Information about cost sharing requirements of each
1045	plan.
1046	(2) AUTOMATIC ENROLLMENT.-The agency shall automatically
1047	enroll into a managed care plan those Medicaid recipients who do
1048	not voluntarily choose a plan pursuant to s. 409.969. The agency
1049	shall automatically enroll recipients in plans that meet or
1050	exceed the performance or quality standards established pursuant
1051	to s. 409.967, and shall not automatically enroll recipients in
1052	a plan that is deficient in those performance or quality
1053	standards. When a specialty plan is available to accommodate a
1054	specific condition or diagnosis of a recipient, the agency shall
1055	assign the recipient to that plan. The agency may not engage in
1056	practices that are designed to favor one managed care plan over
1057	another. When automatically enrolling recipients in plans, the
1058	agency shall automatically enroll based on the following
1059	criteria:
1060	(a) Whether the plan has sufficient network capacity to
1061	meet the needs of the recipients.
1062	(b) Whether the recipient has previously received services
1063	from one of the plan's primary care providers.
1064	(c) Whether primary care providers in one plan are more
1065	geographically accessible to the recipient's residence than
1066	those in other plans.
1067	(3) OPT-OUT OPTION.-The agency shall develop a process to
1068	enable any recipient with access to employer-sponsored insurance
1069	to opt out of all qualified plans in the Medicaid program and to
1070	use Medicaid financial assistance to pay for the recipient's
1071	share of the cost in any such plan. Contingent upon federal
1072	approval, the agency shall also enable recipients with access to
1073	other insurance or related products providing access to health
1074	care services created pursuant to state law, including any
1075	product available under the Cover Florida Health Access Program,
1076	the Florida Health Choices Program, or any health exchange, to
1077	opt out. The amount of financial assistance provided for each
1078	recipient may not exceed the amount of the Medicaid premium that
1079	would have been paid to a plan for that recipient.
1080	Section 19. Section 409.978, Florida Statutes, is created
1081	to read:
1082	409.978 Long-term care managed care program.-
1083	(1) Pursuant to s. 409.963, the agency shall administer
1084	the long-term care managed care program described in ss.
1085	409.978-409.985, but may delegate specific duties and
1086	responsibilities for the program to the Department of Elderly
1087	Affairs and other state agencies. By July 1, 2011, the agency
1088	shall begin implementation of the statewide long-term care
1089	managed care program, with full implementation in all regions by
1090	October 1, 2012.
1091	(2) The agency shall make payments for long-term care,
1092	including home and community-based services, using a managed
1093	care model. Unless otherwise specified, the provisions of ss.
1094	409.961-409.970 apply to the long-term care managed care
1095	program.
1096	(3) The Department of Elderly Affairs shall assist the
1097	agency to develop specifications for use in the invitation to
1098	negotiate and the model contract; determine clinical eligibility
1099	for enrollment in managed long-term care plans; monitor plan
1100	performance and measure quality of service delivery; assist
1101	clients and families to address complaints with the plans;
1102	facilitate working relationships between plans and providers
1103	serving elders and disabled adults; and perform other functions
1104	specified in a memorandum of agreement.
1105	Section 20. Section 409.979, Florida Statutes, is created
1106	to read:
1107	409.979 Eligibility.-
1108	(1) Medicaid recipients who meet all of the following
1109	criteria are eligible to participate in the long-term care
1110	managed care program. The recipient must be:
1111	(a) Sixty-five years of age or older or eligible for
1112	Medicaid by reason of a disability.
1113	(b) Determined by the Comprehensive Assessment Review and
1114	Evaluation for Long-Term Care Services (CARES) Program to
1115	require nursing facility care.
1116	(2) Medicaid recipients who on the date long-term care
1117	managed care plans becomes available in the recipient's region,
1118	are residing in a nursing home facility or enrolled in one of
1119	the following long-term care Medicaid waiver programs are
1120	eligible to participate in the long-term care managed care
1121	program:
1122	(a) The Assisted Living for the Frail Elderly Waiver.
1123	(b) The Aged and Disabled Adult Waiver.
1124	(c) The Adult Day Health Care Waiver.
1125	(d) The Consumer-Directed Care Plus Program as described
1126	in s. 409.221.
1127	(e) The Program of All-inclusive Care for the Elderly.
1128	(f) The Long-Term Care Community-Based Diversion Pilot
1129	Project as described in s. 430.705.
1130	(g) The Channeling Services Waiver for Frail Elders.
1131	Section 21. Section 409.980, Florida Statutes, is created
1132	to read:
1133	409.980 Benefits.-Managed care plans shall cover, at a
1134	minimum, the following services:
1135	(1) Nursing facility.
1136	(2) Assisted living facility.
1137	(3) Hospice.
1138	(4) Adult day care.
1139	(5) Medical equipment and supplies, including incontinence
1140	supplies.
1141	(5) Personal care.
1142	(7) Home accessibility adaptation.
1143	(9) Behavior management.
1144	(9) Home delivered meals.
1145	(10) Case management.
1146	(11) Therapies:
1147	(a) Occupational therapy
1148	(b) Speech therapy
1149	(c) Respiratory therapy
1150	(d) Physical therapy.
1151	(12) Intermittent and skilled nursing.
1152	(13) Medication administration.
1153	(14) Medication management.
1154	(15) Nutritional assessment and risk reduction.
1155	(16) Caregiver training.
1156	(17) Respite care.
1157	(18) Transportation.
1158	(19) Personal emergency response system.
1159	Section 22. Section 409.981, Florida Statutes, is created
1160	to read:
1161	409.981 Qualified plans.-
1162	(1) QUALIFIED PLANS.-For purposes of the long-term care
1163	managed care program, qualified plans also include entities who
1164	are qualified under 42 C.F.R. part 422 as Medicare Advantage
1165	Preferred Provider Organizations, Medicare Advantage Provider-
1166	sponsored Organizations, and Medicare Advantage Special Needs
1167	Plans. Such plans are eligible to participate in the statewide
1168	long-term care managed care program. Qualified plans that are
1169	provider service networks must be long-term care provider
1170	service networks. Qualified plans may either be long-term care
1171	plans that cover benefits pursuant to s. 409.980, or
1172	comprehensive long-term care plans that cover benefits pursuant
1173	to ss. 409.973 and 409.980.
1174	(2) QUALIFIED PLAN SELECTION.-The agency shall select
1175	qualified plans through the procurement described in s. 409.966.
1176	The agency shall notice invitations to negotiate no later than
1177	July 1, 2011.
1178	(a) The agency shall procure three plans for Region I. At
1179	least one plan shall be a provider service network, if any
1180	submit a responsive bid.
1181	(b) The agency shall procure at least four and no more
1182	than seven plans for Region II. At least one plan shall be a
1183	provider service network, if any submit a responsive bid.
1184	(c) The agency shall procure at least five plans and no
1185	more than ten plans for Region III. At least two plans shall be
1186	provider service networks, if any two submit a responsive bid.
1187	(d) The agency shall procure at least four plans and no
1188	more than eight plans for Region IV. At least one plan shall be
1189	a provider service network if any submit a responsive bid.
1190	(e) The agency shall procure at least four plans and no
1191	more than seven plans for Region V. At least one plan shall be a
1192	provider service network, if any submit a responsive bid.
1193	(f) The agency shall procure at least five plans and no
1194	more than ten plans for Region VI. At least two plans shall be
1195	provider service networks, if any two submit a responsive bid.
1196	If no provider service network submits a responsive bid, the
1197	agency shall procure one less qualified plan in each of the
1198	regions. Within 12 months after the initial invitation to
1199	negotiate, the agency shall attempt to procure a qualified plan
1200	that is a provider service network. The agency shall notice
1201	another invitation to negotiate only with provider service
1202	networks in such region where no provider service network has
1203	been selected.
1204	(3) QUALITY SELECTION CRITERIA.-In addition to the criteria
1205	established in s. 409.966, the agency shall consider the
1206	following factors in the selection of qualified plans:
1207	(a) Specialized staffing. Plan employment of executive
1208	managers with expertise and experience in serving aged and
1209	disabled persons who require long-term care.
1210	(b) Network qualifications. Plan establishment of a
1211	network of service providers dispersed throughout the region and
1212	in sufficient numbers to meet specific service standards
1213	established by the agency for specialty services for persons
1214	receiving home and community-based care.
1215	(c) Whether a plan is proposing to establish a
1216	comprehensive long-term care plan and whether the qualified plan
1217	has a contract to provide managed medical assistance services in
1218	the same region. The agency shall exercise a preference for such
1219	plans.
1220	(d) Whether a plan is designated as a medical home network
1221	pursuant to s. 409.91207 or offers consumer-directed care
1222	services to enrollees pursuant to s. 409.221. Consumer-directed
1223	care services provide a flexible budget which is managed by
1224	enrolled individuals and their families or representatives and
1225	allows them to choose providers of services, determine provider
1226	rates of payment and direct the delivery of services to best
1227	meet their special long-term care needs. When all other factors
1228	are equal among competing qualified plans, the agency shall
1229	exercise a preference for such plans.
1230	(e) Evidence that a qualified plan has written agreements
1231	or signed contracts or has made substantial progress in
1232	establishing relationships with providers prior to the plan
1233	submitting a response. The agency shall evaluate and give
1234	special weight to evidence of signed contracts with providers of
1235	critical services pursuant to s. 409.982(2)(a)-(c).
1236	(4) PROGRAM FOR ALL-INCLUSIVE CARE FOR THE ELDERLY.-The
1237	Program for All-Inclusive Care for the Elderly (PACE) is a
1238	qualified plan for purposes of the long-term care managed care
1239	program. Participation by PACE shall be pursuant to a contract
1240	with the agency and not subject to the procurement requirements
1241	or regional plan number limits of this section. PACE plans may
1242	continue to provide services to individuals at such levels and
1243	enrollment caps as authorized by the General Appropriations Act.
1244	Section 23. Section 409.982, Florida Statutes, is created
1245	to read:
1246	409.982 Managed care plan accountability.-In addition to
1247	the requirements of s. 409.967, plans and providers
1248	participating in the long-term care managed care program shall
1249	comply with the requirements of this section.
1250	(1) MEDICAL LOSS RATIO.-The agency shall establish and
1251	plans shall use a uniform method of accounting and reporting
1252	long-term care service costs, direct care management costs, and
1253	administrative costs. The agency shall evaluate plan spending
1254	patterns beginning after the plan completes 2 full years of
1255	operation and at least annually thereafter. The agency shall
1256	implement the following thresholds and consequences of various
1257	spending patterns:
1258	(a) Plans that spend less than 75 percent of Medicaid
1259	premium revenue on long-term care services, including direct
1260	care management as determined by the agency shall be excluded
1261	from automatic enrollments and shall be required to pay back the
1262	amount between actual spending and 85 percent of the Medicaid
1263	premium revenue.
1264	(b) Plans that spend less than 85 percent of Medicaid
1265	premium revenue on long-term care services, including direct
1266	care management as determined by the agency shall be required to
1267	pay back the amount of the difference between actual spending
1268	and 85 percent of Medicaid premium revenue.
1269	(c) Plans that spend more than 92 percent of Medicaid
1270	premium revenue on long-term care services, including direct
1271	care management as determined by the agency, shall be evaluated
1272	by the agency to determine whether higher expenditures are the
1273	result of failures in care management.
1274	(d) Plans that spend 95 percent or more of Medicaid
1275	premium revenue on long-term care services, including direct
1276	care management as determined by the agency, and are determined
1277	to be failing to appropriately manage care shall be excluded
1278	from automatic enrollments.
1279	(2) PROVIDER NETWORKS.-Plans may limit the providers in
1280	their networks based on credentials, quality indicators, and
1281	price. However, in the first contract period after a qualified
1282	plan is selected in a region by the agency, the plan must offer
1283	a network contract to the following providers in the region:
1284	(a) Nursing homes.
1285	(b) Hospices.
1286	(c) Aging network service providers that have previously
1287	participated in home and community-based waivers serving elders
1288	or community-service programs administered by the Department of
1289	Elderly Affairs.
1290
1291	After 12 months of active participation in a plan's network, the
1292	plan may exclude any of the providers named in this subsection
1293	from the network for failure to meet quality or performance
1294	criteria. If the plan excludes a provider from the plan, the
1295	plan must provide written notice to all recipients who have
1296	chosen that provider for care. The notice shall be provided at
1297	least 30 days prior to the effective date of the exclusion.
1298	(3) SELECT PROVIDER PARTICIPATION.-Except as provided in
1299	this subsection, providers may limit the plans they join.
1300	Nursing homes and hospices must participate in all qualified
1301	plans selected by the agency in the region in which the provider
1302	is located.
1303	(4) PERFORMANCE MEASUREMENT.-Each plan shall monitor the
1304	quality and performance of each participating provider. At the
1305	beginning of the contract period, each plan shall notify all its
1306	network providers of the metrics used by the plan for evaluating
1307	the provider's performance and determining continued
1308	participation in the network.
1309	(5) PROVIDER NETWORK STANDARDS.-The agency shall establish
1310	and each plan must comply with specific standards for the
1311	number, type, and regional distribution of providers in the
1312	plan's network, which must include:
1313	(a) Adult day centers.
1314	(b) Adult family care homes.
1315	(c) Assisted living facilities.
1316	(d) Health care services pools.
1317	(e) Home health agencies.
1318	(f) Homemaker and companion services.
1319	(g) Hospices.
1320	(h) Community Care for the Elderly Lead Agencies.
1321	(i) Nurse registries.
1322	(j) Nursing homes.
1323	(6) PROVIDER PAYMENT.-Plans and providers shall negotiate
1324	mutually acceptable rates, methods, and terms of payment. Plans
1325	shall pay nursing homes an amount equal to the nursing facility-
1326	specific payment rates set by the agency. Plans shall pay
1327	hospice providers an amount equal to the per diem rate set by
1328	the agency. For recipients residing in a nursing facility and
1329	receiving hospice services, the plan shall pay the hospice
1330	provider the per diem rate set by the agency minus the nursing
1331	facility component and shall pay the nursing facility the
1332	appropriate state rate.
1333	Section 24. Section 409.983, Florida Statutes, is created
1334	to read:
1335	409.983 Managed care plan payment.-In addition to the
1336	payment provisions of s. 409.968, the agency shall provide
1337	payment to plans in the long-term care managed care program
1338	pursuant to this section.
1339	(1) Prepaid payment rates for long-term care managed care
1340	plans shall be negotiated between the agency and the qualified
1341	plans as part of the procurement described in s. 409.966.
1342	(2) Payment rates for comprehensive long-term care plans
1343	covering services described in s. 409.973 shall be combined with
1344	rates for long-term care plans for services specified in s.
1345	409.980.
1346	(3) Payment rates for plans shall reflect historic
1347	utilization and spending for covered services projected forward
1348	and adjusted to reflect the level of care profile for enrollees
1349	of each plan. The payment shall be adjusted to provide an
1350	incentive for reducing institutional placements and increasing
1351	the utilization of home and community-based services.
1352	(4) The initial assessment of an enrollee's level of care
1353	shall be made by the Comprehensive Assessment and Review for
1354	Long-Term-Care Services (CARES) program, which shall assign the
1355	recipient into one of the following levels of care:
1356	(a) Level of care 1 consists of recipients residing in
1357	nursing homes or needing immediate placement in a nursing home.
1358	(b) Level of care 2 consists of recipients who require the
1359	constant availability of routine medical and nursing treatment
1360	and care, and require extensive health-related care and services
1361	because of mental or physical incapacitation.
1362	(c) Level of care 3 consists of recipients who require the
1363	constant availability of routine medical and nursing treatment
1364	and care, have a limited need for health-related care and
1365	services, are mildly medically or physically incapacitated, and
1366	have a priority score of 5 or above.
1367
1368	The agency shall periodically adjust payment rates to account
1369	for changes in the level of care profile for each plan based on
1370	encounter data.
1371	(5) The incentive adjustment for reducing institutional
1372	placements shall be modified in each successive rate period
1373	during the contract in order to encourage a progressive
1374	rebalancing of the spending distribution for institutional and
1375	community services. The expected change toward more home and
1376	community-based services shall be at least a 3 percent, up to a
1377	5 percent, annual increase in the ratio of home and community-
1378	based service expenditures compared to nursing facility
1379	expenditures.
1380	(6) The agency shall establish nursing facility-specific
1381	payment rates for each licensed nursing home based on facility
1382	costs adjusted for inflation and other factors. Payments to
1383	long-term care managed care plans shall be reconciled to
1384	reimburse actual payments to nursing facilities.
1385	(7) The agency shall establish hospice payment rates.
1386	Payments to long-term care managed care plans shall be
1387	reconciled to reimburse actual payments to hospices.
1388	Section 25. Section 409.984, Florida Statutes, is created
1389	to read:
1390	409.984 Choice counseling; enrollment.-
1391	(1) CHOICE COUNSELING.-Before contracting with a vendor to
1392	provide choice counseling as authorized under s. 409.969, the
1393	agency shall offer to contract with aging resource centers
1394	established under s. 430.2053 for choice counseling services. If
1395	the aging resource center is determined not to be the vendor
1396	that provides choice counseling, the agency shall establish a
1397	memorandum of understanding with the aging resource center to
1398	coordinate staffing and collaborate with the choice counseling
1399	vendor.
1400	(2) AUTOMATIC ENROLLMENT.-The agency shall automatically
1401	enroll into a long-term care managed care plan those Medicaid
1402	recipients who do not voluntarily choose a plan pursuant to s.
1403	409.969. The agency shall automatically enroll recipients in
1404	plans that meet or exceed the performance or quality standards
1405	established pursuant to s. 409.967, and shall not automatically
1406	enroll recipients in a plan that is deficient in those
1407	performance or quality standards. The agency shall assign
1408	individuals who are deemed dually eligible for Medicaid and
1409	Medicare to a plan that provides both Medicaid and Medicare
1410	services. The agency may not engage in practices that are
1411	designed to favor one managed care plan over another. When
1412	automatically enrolling recipients in plans, the agency shall
1413	take into account the following criteria:
1414	(a) Whether the plan has sufficient network capacity to
1415	meet the needs of the recipients.
1416	(b) Whether the recipient has previously received services
1417	from one of the plan's home and community-based service
1418	providers.
1419	(c) Whether the home and community-based providers in one
1420	plan are more geographically accessible to the recipient's
1421	residence than those in other plans.
1422	(3) Notwithstanding the provisions of s. 409.969(3)(c),
1423	when a recipient is referred for hospice services, the recipient
1424	shall have a 30-day period during which the recipient may select
1425	to enroll in another plan to access the hospice provider of the
1426	recipient's choice.
1427	Section 26. Section 409.985, Florida Statutes, is created
1428	to read:
1429	409.985 Comprehensive Assessment and Review for Long-Term
1430	Care Services (CARES) Program.-
1431	(1) The agency shall operate the Comprehensive Assessment
1432	and Review for Long-Term Care Services (CARES) preadmission
1433	screening program to ensure that only individuals whose
1434	conditions require long-term care services are enrolled in the
1435	long-term care managed care program.
1436	(2) The agency shall operate the CARES program through an
1437	interagency agreement with the Department of Elderly Affairs.
1438	The agency, in consultation with the Department of Elderly
1439	Affairs, may contract for any function or activity of the CARES
1440	program, including any function or activity required by 42
1441	C.F.R. part 483.20, relating to preadmission screening and
1442	review.
1443	(3) The CARES program shall determine if an individual
1444	requires nursing facility care and, if the individual requires
1445	such care, assign the individual to a level of care as described
1446	in s. 409.983(4). For the purposes of the long-term care managed
1447	care program, "nursing facility care" means the individual:
1448	(a) Requires the constant availability of routine medical
1449	and nursing treatment and care, and requires extensive health-
1450	related care and services because of mental or physical
1451	incapacitation; or
1452	(b) Requires the constant availability of routine medical
1453	and nursing treatment and care, has a limited need for health-
1454	related care and services, is mildly medically or physically
1455	incapacitated, and has a priority score of 5 or above.
1456	(4) For individuals whose nursing home stay is initially
1457	funded by Medicare and Medicare coverage is being terminated for
1458	lack of progress towards rehabilitation, CARES staff shall
1459	consult with the person making the determination of progress
1460	toward rehabilitation to ensure that the recipient is not being
1461	inappropriately disqualified from Medicare coverage. If, in
1462	their professional judgment, CARES staff believes that a
1463	Medicare beneficiary is still making progress toward
1464	rehabilitation, they may assist the Medicare beneficiary with an
1465	appeal of the disqualification from Medicare coverage. The use
1466	of CARES teams to review Medicare denials for coverage under
1467	this section is authorized only if it is determined that such
1468	reviews qualify for federal matching funds through Medicaid. The
1469	agency shall seek or amend federal waivers as necessary to
1470	implement this section.
1471	Section 27. Section 409.986, Florida Statutes, is created
1472	to read:
1473	409.986 Managed long-term care for persons with
1474	developmental disabilities.-
1475	(1) Pursuant to s. 409.963, the agency is responsible for
1476	administering the long-term care managed care program for
1477	persons with developmental disabilities described in ss.
1478	409.986-409.992, but may delegate specific duties and
1479	responsibilities for the program to the Agency for Persons with
1480	Disabilities and other state agencies. By January 1, 2014, the
1481	agency shall begin implementation of statewide long-term care
1482	managed care for persons with developmental disabilities, with
1483	full implementation in all regions by October 1, 2015.
1484	(2) The agency shall make payments for long-term care for
1485	persons with developmental disabilities, including home and
1486	community-based services, using a managed care model. Unless
1487	otherwise specified, the provisions of ss. 409.961-409.970 apply
1488	to the long-term care managed care program for persons with
1489	developmental disabilities.
1490	(3) The Agency for Persons with Disabilities shall assist
1491	the agency to develop the specifications for use in the
1492	invitations to negotiate and the model contract; determine
1493	clinical eligibility for enrollment in long-term care plans for
1494	persons with developmental disabilities; assist the agency to
1495	monitor plan performance and measure quality; assist clients and
1496	families to address complaints with the plans; facilitate
1497	working relationships between plans and providers serving
1498	persons with developmental disabilities; and perform other
1499	functions specified in a memorandum of agreement.
1500	Section 28. Section 409.987, Florida Statutes, is created
1501	to read:
1502	409.987 Eligibility.-
1503	(1) Medicaid recipients who meet all of the following
1504	criteria are eligible to be enrolled in a developmental
1505	disabilities comprehensive long-term care plan or developmental
1506	disabilities long-term care plan:
1507	(a) Medicaid eligible pursuant to income and asset tests
1508	in state and federal law.
1509	(b) A Florida resident who has a developmental disability
1510	as defined in s. 393.063.
1511	(c) Meets the level of care need including:
1512	1. The recipient's intelligence quotient is 59 or less;
1513	2. The recipient's intelligence quotient is 60-69,
1514	inclusive, and the recipient has a secondary handicapping
1515	condition that includes cerebral palsy, spina bifida, Prader-
1516	Willi syndrome, epilepsy, or autism; or ambulation, sensory,
1517	chronic health, and behavioral problems;
1518	3. The recipient's intelligence quotient is 60-69,
1519	inclusive, and the recipient has severe functional limitations
1520	in at least three major life activities including self-care,
1521	learning, mobility, self-direction, understanding and use of
1522	language, and capacity for independent living; or
1523	4. The recipient is eligible under a primary disability of
1524	autism, cerebral palsy, spina bifida, or Prader-Willi syndrome.
1525	In addition, the condition must result in substantial functional
1526	limitations in three or more major life activities, including
1527	self-care, learning, mobility, self-direction, understanding and
1528	use of language, and capacity for independent living.
1529	(d) Meets the level of care need for services in an
1530	intermediate care facility for the developmentally disabled.
1531	(e) Is enrolled or has been offered enrollment in one of
1532	the four tier waivers established in s. 393.0661(3) or the
1533	recipient is a Medicaid-funded resident of a private
1534	intermediate care facility for the developmentally disabled on
1535	the date the managed long-term care plans for persons with
1536	disabilities become available in the recipient's region or the
1537	recipient has been offered enrollment in a developmental
1538	disabilities comprehensive long-term care plan or developmental
1539	disabilities long-term care plan.
1540	(2) Unless specifically exempted, all eligible persons
1541	must be enrolled in a developmental disabilities comprehensive
1542	long-term care plan or a developmental disabilities long-term
1543	care plan. Medicaid recipients who are residents of a
1544	developmental disability center, including Sunland Center in
1545	Marianna and Tacachale Center in Gainesville, are exempt from
1546	mandatory enrollment but may voluntarily enroll in a long-term
1547	care plan.
1548	Section 29. Section 409.988, Florida Statutes, is created
1549	to read:
1550	409.988 Benefits.-Managed care plans shall cover, at a
1551	minimum, the services in this section. Plans may customize
1552	benefit packages or offer additional benefits to meet the needs
1553	of enrollees in the plan.
1554	(1) Intermediate care for the developmentally disabled.
1555	(2) Alternative residential services, including, but not
1556	limited to:
1557	(a) Group homes and foster care homes licensed pursuant to
1558	chapters 393 and 409.
1559	(b) Comprehensive transitional education programs licensed
1560	pursuant to chapter 393.
1561	(c) Residential habilitation centers licensed pursuant to
1562	chapter 393.
1563	(d) Assisted living facilities, and transitional living
1564	facilities licensed pursuant to chapters 400 and 429.
1565	(3) Adult day training.
1566	(4) Behavior analysis services.
1567	(5) Companion services.
1568	(6) Consumable medical supplies.
1569	(7) Durable medical equipment and supplies.
1570	(8) Environmental accessibility adaptations.
1571	(9) In-home support services.
1572	(10) Therapies, including occupational, speech,
1573	respiratory, and physical therapy.
1574	(11) Personal care assistance.
1575	(12) Residential habilitation services.
1576	(13) Intensive behavioral residential habilitation
1577	services.
1578	(14) Behavior focus residential habilitation services.
1579	(15) Residential nursing services.
1580	(16) Respite care.
1581	(17) Case management.
1582	(18) Supported employment.
1583	(19) Supported living coaching.
1584	(20) Transportation.
1585	Section 30. Section 409.989, Florida Statutes, is created
1586	to read:
1587	409.989 Qualified plans.-
1588	(1) QUALIFIED PLANS.-Qualified plans that are a provider
1589	service network or the Children's Medical Services Network
1590	authorized under chapter 391 may be either developmental
1591	disabilities long-term care plans that cover benefits pursuant
1592	to s. 409.988, or developmental disabilities comprehensive long-
1593	term care plans that cover benefits pursuant to ss. 409.973 and
1594	409.988. Other qualified plans may only be developmental
1595	disabilities comprehensive long-term care plans that cover
1596	benefits pursuant to ss. 409.973 and 409.988.
1597	(2) SPECIALTY PROVIDER SERVICE NETWORKS.-Provider service
1598	networks targeted to serve persons with disabilities must
1599	include one or more owners licensed pursuant to s. 393.067 or s.
1600	400.962 and with at least 10 years experience in serving this
1601	population.
1602	(3) QUALIFIED PLAN SELECTION.-The agency shall select
1603	qualified plans through the procurement described in s. 409.966.
1604	The agency shall notice invitations to negotiate no later than
1605	January 1, 2014.
1606	(a) The agency shall procure two plans for Region I. At
1607	least one plan shall be a provider service network, if any
1608	submit a responsive bid.
1609	(b) The agency shall procure at least two and no more than
1610	five plans for Region II. At least one plan shall be a provider
1611	service network, if any submit a responsive bid.
1612	(c) The agency shall procure at least three plans and no
1613	more than six plans for Region III. At least one plan shall be a
1614	provider service network, if any submit a responsive bid.
1615	(d) The agency shall procure at least three plans and no
1616	more than six plans for Region IV. At least one plan shall be a
1617	provider service network if any submit a responsive bid.
1618	(e) The agency shall procure at least three plans and no
1619	more than six plans for Region V. At least one plan shall be a
1620	provider service network, if any submit a responsive bid.
1621	(f) The agency shall procure at least three plans and no
1622	more than six plans for Region VI. At least one plan shall be a
1623	provider service network, if any submit a responsive bid.
1624	If no provider service network submits a responsive bid, the
1625	agency shall procure no more than one less than the maximum
1626	number of qualified plans permitted in that region. Within 12
1627	months after the initial invitation to negotiate, the agency
1628	shall attempt to procure a qualified plan that is a provider
1629	service network. The agency shall notice another invitation to
1630	negotiate only with provider service networks in such region
1631	where no provider service network has been selected.
1632	(4) QUALITY SELECTION CRITERIA.-In addition to the
1633	criteria established in s. 409.966, the agency shall consider
1634	the following factors in the selection of qualified plans:
1635	(a) Specialized staffing. Plan employment of executive
1636	managers with expertise and experience in serving persons with
1637	developmental disabilities.
1638	(b) Network qualifications. Plan establishment of a
1639	network of service providers dispersed throughout the region and
1640	in sufficient numbers to meet specific accessibility standards
1641	established by the agency for specialty services for persons
1642	with developmental disabilities.
1643	(c) Whether the plan has proposed to be a developmental
1644	disabilities comprehensive long-term care plan and has a
1645	contract to provide managed medical assistance services in the
1646	same region. The agency shall exercise a preference for such
1647	plans.
1648	(d) Whether the plan offers consumer-directed care
1649	services to enrollees pursuant to s. 409.221. Consumer-directed
1650	care services provide a flexible budget which is managed by
1651	enrolled individuals and their families or representatives and
1652	allows them to choose providers of services, determine provider
1653	rates of payment and direct the delivery of services to best
1654	meet their special long-term care needs. When all other factors
1655	are equal among competing qualified plans, the agency shall
1656	exercise a preference for such plans.
1657	(e) Evidence that a qualified plan has written agreements
1658	or signed contracts or has made substantial progress in
1659	establishing relationships with providers prior to the plan
1660	submitting a response. The agency shall evaluate and give
1661	special weight to evidence of signed contracts with providers of
1662	critical services pursuant to s. 409.990(2)a)-(b).
1663	(5) CHILDREN'S MEDICAL SERVICES NETWORK.-The Children's
1664	Medical Services Network authorized under chapter 391 is a
1665	qualified plan for purposes of the developmental disabilities
1666	long-term care plans and developmental disabilities
1667	comprehensive long-term care plans. Participation by the
1668	Children's Medical Services Network shall be pursuant to a
1669	single, statewide contract with the agency not subject to the
1670	procurement requirements or regional plan number limits of this
1671	section. The Children's Medical Services Network must meet all
1672	other plan requirements.
1673	Section 31. Section 409.990, Florida Statutes, is created
1674	to read:
1675	409.990 Managed care plan accountability.-In addition to
1676	the requirements of s. 409.967, qualified plans and providers
1677	shall comply with the requirements of this section.
1678	(1) MEDICAL LOSS RATIO.-The agency shall establish and
1679	plans shall use a uniform method of accounting and reporting
1680	long-term care service costs, direct care management costs, and
1681	administrative costs. The agency shall evaluate plan spending
1682	patterns beginning after the plan completes 2 full years of
1683	operation and at least annually thereafter. The agency shall
1684	implement the following thresholds and consequences of various
1685	spending patterns:
1686	(a) Plans that spend less than 75 percent of Medicaid
1687	premium revenue on long-term care services, including direct
1688	care management as determined by the agency shall be excluded
1689	from automatic enrollments and shall be required to pay back the
1690	amount between actual spending and 92 percent of the Medicaid
1691	premium revenue.
1692	(b) Plans that spend less than 92 percent of Medicaid
1693	premium revenue on long-term care services, including direct
1694	care management as determined by the agency shall be required to
1695	pay back the amount between actual spending and 92 percent of
1696	the Medicaid premium revenue.
1697	(2) PROVIDER NETWORKS.-Plans may limit the providers in
1698	their networks based on credentials, quality indicators, and
1699	price. However, in the first contract period after a qualified
1700	plan is selected in a region by the agency, the plan must offer
1701	a network contract to the following providers in the region:
1702	(a) Providers with licensed institutional care facilities
1703	for the developmentally disabled.
1704	(b) Providers of alternative residential facilities
1705	specified in s.409.988.
1706
1707	After 12 months of active participation in a plan's network, the
1708	plan may exclude any of the above-named providers from the
1709	network for failure to meet quality or performance criteria. If
1710	the plan excludes a provider from the plan, the plan must
1711	provide written notice to all recipients who have chosen that
1712	provider for care. The notice shall be issued at least 90 days
1713	before the effective date of the exclusion.
1714	(3) SELECT PROVIDER PARTICIPATION.-Except as provided in
1715	this subsection, providers may limit the plans they join.
1716	Licensed institutional care facilities for the developmentally
1717	disabled with an active Medicaid provider agreement must agree
1718	to participate in any qualified plan selected by the agency in
1719	the region in which the provider is located.
1720	(4) PERFORMANCE MEASUREMENT.-Each plan shall monitor the
1721	quality and performance of each participating provider. At the
1722	beginning of the contract period, each plan shall notify all its
1723	network providers of the metrics used by the plan for evaluating
1724	the provider's performance and determining continued
1725	participation in the network.
1726	(5) PROVIDER PAYMENT.-Plans and providers shall negotiate
1727	mutually acceptable rates, methods, and terms of payment. Plans
1728	shall pay intermediate care facilities for the developmentally
1729	disabled an amount equal to the facility-specific payment rate
1730	set by the agency.
1731	(6) CONSUMER AND FAMILY INVOLVEMENT.-Plans must establish
1732	a family advisory committee to participate in program design and
1733	oversight.
1734	Section 32. Section 409.991, Florida Statutes, is created
1735	to read:
1736	409.991 Managed care plan payment.-In addition to the
1737	payment provisions of s. 409.968, the agency shall provide
1738	payment to developmental disabilities comprehensive long-term
1739	care plans and developmental disabilities long-term care plans
1740	pursuant to this section.
1741	(1) Prepaid payment rates shall be negotiated between the
1742	agency and the qualified plans as part of the procurement
1743	described in s. 409.966.
1744	(2) Payment for developmental disabilities comprehensive
1745	long-term care plans covering services pursuant to s. 409.973
1746	shall be combined with payments for developmental disabilities
1747	long-term care plans for services specified in s. 409.988.
1748	(3) Payment rates for plans covering service specified in
1749	s. 409.988 shall be based on historical utilization and spending
1750	for covered services projected forward and adjusted to reflect
1751	the level of care profile of each plan's enrollees.
1752	(4) The Agency for Persons with Disabilities shall conduct
1753	the initial assessment of an enrollee's level of care. The
1754	evaluation of level of care shall be based on assessment and
1755	service utilization information from the most recent version of
1756	the Questionnaire for Situational Information and encounter
1757	data.
1758	(5) Payment rates for developmental disabilities long-term
1759	care plans shall be classified into five levels of care to
1760	account for variations in risk status and service needs among
1761	enrollees.
1762	(a) Level of care 1 consists of individuals receiving
1763	services in an intermediate care facility for the
1764	developmentally disabled.
1765	(b) Level of care 2 consists of individuals with intensive
1766	medical or adaptive needs and that are essential for avoiding
1767	institutionalization, or who possess behavioral problems that
1768	are exceptional in intensity, duration, or frequency and present
1769	a substantial risk of harm to themselves or others.
1770	(c) Level of care 3 consists of individuals with service
1771	needs, including a licensed residential facility and a moderate
1772	level of support for standard residential habilitation services
1773	or a minimal level of support for behavior focus residential
1774	habilitation services, or individuals in supported living who
1775	require more than 6 hours a day of in-home support services.
1776	(d) Level of care 4 consists of individuals requiring less
1777	than moderate level of residential habilitation support in a
1778	residential placement, or individuals in independent or
1779	supported living situations, or who live in their family home.
1780	(e) Level of care 5 consists of individuals requiring
1781	minimal support services while living in independent or
1782	supported living situations and individuals who live in their
1783	family home.
1784
1785	The agency shall periodically adjust payment rates to account
1786	for changes in the level of care profile of each plan's
1787	enrollees based on encounter data.
1788	(6) The agency shall establish intensive behavior
1789	residential habilitation rates for providers approved by the
1790	agency to provide this service. The agency shall also establish
1791	intermediate care facility for the developmentally disabled-
1792	specific payment rates for each licensed intermediate care
1793	facility based on facility costs adjusted for inflation and
1794	other factors. Payments to intermediate care facilities for the
1795	developmentally disabled and providers of intensive behavior
1796	residential habilitation service shall be reconciled to
1797	reimburse the plan's actual payments to the facilities.
1798	Section 33. Section 409.992, Florida Statutes, is created
1799	to read:
1800	409.992 Automatic enrollment.-
1801	(1) The agency shall automatically enroll into a
1802	developmental disabilities comprehensive long-term care plan or
1803	a developmental disabilities long-term care plan those Medicaid
1804	recipients who do not voluntarily choose a plan pursuant to s.
1805	409.969. The agency shall automatically enroll recipients in
1806	plans that meet or exceed the performance or quality standards
1807	established pursuant to s. 409.967, and shall not automatically
1808	enroll recipients in a plan that is deficient in those
1809	performance or quality standards. The agency shall assign
1810	individuals who are deemed dually eligible for Medicaid and
1811	Medicare, to a plan that provides both Medicaid and Medicare
1812	services. The agency may not engage in practices that are
1813	designed to favor one managed care plan over another. When
1814	automatically enrolling recipients in plans, the agency shall
1815	take into account the following criteria:
1816	(a) Whether the plan has sufficient network capacity to
1817	meet the needs of the recipients.
1818	(b) Whether the recipient has previously received services
1819	from one of the plan's home and community-based service
1820	providers.
1821	(c) Whether home and community-based providers in one plan
1822	are more geographically accessible to the recipient's residence
1823	than those in other plans.
1824	Section 34. This act shall take effect July 1, 2010.

CODING: Words stricken are deletions; words underlined are additions.