Bill Text: FL S1484 | 2010 | Regular Session | Comm Sub
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Medicaid [WPSC]
Spectrum: Partisan Bill (Republican 1-0)
Status: (Passed) 2010-05-28 - Approved by Governor; Chapter No. 2010-144 [S1484 Detail]
Download: Florida-2010-S1484-Comm_Sub.html
Bill Title: Medicaid [WPSC]
Spectrum: Partisan Bill (Republican 1-0)
Status: (Passed) 2010-05-28 - Approved by Governor; Chapter No. 2010-144 [S1484 Detail]
Download: Florida-2010-S1484-Comm_Sub.html
Florida Senate - 2010 CS for CS for SB 1484 By the Policy and Steering Committee on Ways and Means; the Committee on Health and Human Services Appropriations; and Senator Peaden 576-03795-10 20101484c2 1 A bill to be entitled 2 An act relating to Medicaid; amending s. 409.912, 3 F.S.; authorizing the Agency for Health Care 4 Administration to contract with an entity for the 5 provision of comprehensive behavioral health care 6 services to certain Medicaid recipients who are not 7 enrolled in a Medicaid managed care plan or a Medicaid 8 provider service network under certain circumstances; 9 requiring the agency to impose a fine against a person 10 under contract with the agency who violates certain 11 provisions; requiring an entity that contracts with 12 the agency as a managed care plan to post a surety 13 bond with the agency or maintain an account of a 14 specified sum; requiring the agency to pursue the 15 entity if the entity terminates the contract with the 16 agency before the end date of the contract; amending 17 s. 409.91211, F.S.; extending by 3 years the statewide 18 implementation of an enhanced service delivery system 19 for the Florida Medicaid program; providing for the 20 expansion of the pilot project into counties that have 21 two or more plans and the capacity to serve the 22 designated population; requiring that the agency 23 provide certain specified data to the recipient when 24 selecting a capitated managed care plan; revising 25 certain requirements for entities performing choice 26 counseling for recipients; requiring the agency to 27 provide behavioral health care services to Medicaid 28 eligible children; extending a date by which the 29 behavioral health care services will be delivered to 30 children; deleting a provision under which certain 31 Medicaid recipients who are not currently enrolled in 32 a capitated managed care plan upon implementation are 33 not eligible for specified services for the amount of 34 time that the recipients do not enroll in a capitated 35 managed care network; authorizing the agency to extend 36 the time to continue operation of the pilot program; 37 requiring that the agency seek public input on 38 extending and expanding the managed care pilot program 39 and post certain information on its website; amending 40 s. 409.9122, F.S.; providing that time allotted to any 41 Medicaid recipient for the selection of, enrollment 42 in, or disenrollment from a managed care plan or 43 MediPass is tolled throughout any month in which the 44 enrollment broker or choice counseling provider 45 adversely affects a beneficiary’s ability to access 46 choice counseling or enrollment broker services by its 47 failure to comply with the terms and conditions of its 48 contract with the agency or has otherwise acted or 49 failed to act in a manner that the agency deems likely 50 to jeopardize its ability to perform certain assigned 51 responsibilities; requiring the agency to incorporate 52 certain provisions after a specified date in its 53 contracts related to sanctions or fines for any action 54 or the failure to act on the part of an enrollment 55 broker or choice counselor provider; providing an 56 effective date. 57 58 Be It Enacted by the Legislature of the State of Florida: 59 60 Section 1. Paragraph (b) of subsection (4) of section 61 409.912, Florida Statutes, is amended, paragraph (d) of 62 subsection (4) of that section is reenacted, present subsections 63 (23) through (53) of that section are renumbered as subsections 64 (24) through (54), respectively, a new subsection (23) is added 65 to that section, and present subsections (21) and (22) of that 66 section are amended, to read: 67 409.912 Cost-effective purchasing of health care.—The 68 agency shall purchase goods and services for Medicaid recipients 69 in the most cost-effective manner consistent with the delivery 70 of quality medical care. To ensure that medical services are 71 effectively utilized, the agency may, in any case, require a 72 confirmation or second physician’s opinion of the correct 73 diagnosis for purposes of authorizing future services under the 74 Medicaid program. This section does not restrict access to 75 emergency services or poststabilization care services as defined 76 in 42 C.F.R. part 438.114. Such confirmation or second opinion 77 shall be rendered in a manner approved by the agency. The agency 78 shall maximize the use of prepaid per capita and prepaid 79 aggregate fixed-sum basis services when appropriate and other 80 alternative service delivery and reimbursement methodologies, 81 including competitive bidding pursuant to s. 287.057, designed 82 to facilitate the cost-effective purchase of a case-managed 83 continuum of care. The agency shall also require providers to 84 minimize the exposure of recipients to the need for acute 85 inpatient, custodial, and other institutional care and the 86 inappropriate or unnecessary use of high-cost services. The 87 agency shall contract with a vendor to monitor and evaluate the 88 clinical practice patterns of providers in order to identify 89 trends that are outside the normal practice patterns of a 90 provider’s professional peers or the national guidelines of a 91 provider’s professional association. The vendor must be able to 92 provide information and counseling to a provider whose practice 93 patterns are outside the norms, in consultation with the agency, 94 to improve patient care and reduce inappropriate utilization. 95 The agency may mandate prior authorization, drug therapy 96 management, or disease management participation for certain 97 populations of Medicaid beneficiaries, certain drug classes, or 98 particular drugs to prevent fraud, abuse, overuse, and possible 99 dangerous drug interactions. The Pharmaceutical and Therapeutics 100 Committee shall make recommendations to the agency on drugs for 101 which prior authorization is required. The agency shall inform 102 the Pharmaceutical and Therapeutics Committee of its decisions 103 regarding drugs subject to prior authorization. The agency is 104 authorized to limit the entities it contracts with or enrolls as 105 Medicaid providers by developing a provider network through 106 provider credentialing. The agency may competitively bid single 107 source-provider contracts if procurement of goods or services 108 results in demonstrated cost savings to the state without 109 limiting access to care. The agency may limit its network based 110 on the assessment of beneficiary access to care, provider 111 availability, provider quality standards, time and distance 112 standards for access to care, the cultural competence of the 113 provider network, demographic characteristics of Medicaid 114 beneficiaries, practice and provider-to-beneficiary standards, 115 appointment wait times, beneficiary use of services, provider 116 turnover, provider profiling, provider licensure history, 117 previous program integrity investigations and findings, peer 118 review, provider Medicaid policy and billing compliance records, 119 clinical and medical record audits, and other factors. Providers 120 shall not be entitled to enrollment in the Medicaid provider 121 network. The agency shall determine instances in which allowing 122 Medicaid beneficiaries to purchase durable medical equipment and 123 other goods is less expensive to the Medicaid program than long 124 term rental of the equipment or goods. The agency may establish 125 rules to facilitate purchases in lieu of long-term rentals in 126 order to protect against fraud and abuse in the Medicaid program 127 as defined in s. 409.913. The agency may seek federal waivers 128 necessary to administer these policies. 129 (4) The agency may contract with: 130 (b) An entity that is providing comprehensive behavioral 131 health care services to certain Medicaid recipients through a 132 capitated, prepaid arrangement pursuant to the federal waiver 133 provided for by s. 409.905(5). Such entity must be licensed 134 under chapter 624, chapter 636, or chapter 641, or authorized 135 under paragraph (c) or paragraph (d), and must possess the 136 clinical systems and operational competence to manage risk and 137 provide comprehensive behavioral health care to Medicaid 138 recipients. As used in this paragraph, the term “comprehensive 139 behavioral health care services” means covered mental health and 140 substance abuse treatment services that are available to 141 Medicaid recipients. The secretary of the Department of Children 142 and Family Services shall approve provisions of procurements 143 related to children in the department’s care or custody before 144 enrolling such children in a prepaid behavioral health plan. Any 145 contract awarded under this paragraph must be competitively 146 procured. In developing the behavioral health care prepaid plan 147 procurement document, the agency shall ensure that the 148 procurement document requires the contractor to develop and 149 implement a plan to ensure compliance with s. 394.4574 related 150 to services provided to residents of licensed assisted living 151 facilities that hold a limited mental health license. Except as 152 provided in subparagraph 8., and except in counties where the 153 Medicaid managed care pilot program is authorized pursuant to s. 154 409.91211, the agency shall seek federal approval to contract 155 with a single entity meeting these requirements to provide 156 comprehensive behavioral health care services to all Medicaid 157 recipients not enrolled in a Medicaid managed care plan 158 authorized under s. 409.91211, a provider service network 159 authorized under paragraph (d), or a Medicaid health maintenance 160 organization in an AHCA area. In an AHCA area where the Medicaid 161 managed care pilot program is authorized pursuant to s. 162 409.91211 in one or more counties, the agency may procure a 163 contract with a single entity to serve the remaining counties as 164 an AHCA area or the remaining counties may be included with an 165 adjacent AHCA area and are subject to this paragraph. Each 166 entity must offer a sufficient choice of providers in its 167 network to ensure recipient access to care and the opportunity 168 to select a provider with whom they are satisfied. The network 169 shall include all public mental health hospitals. To ensure 170 unimpaired access to behavioral health care services by Medicaid 171 recipients, all contracts issued pursuant to this paragraph must 172 require 80 percent of the capitation paid to the managed care 173 plan, including health maintenance organizations and capitated 174 provider service networks, to be expended for the provision of 175 behavioral health care services. If the managed care plan 176 expends less than 80 percent of the capitation paid for the 177 provision of behavioral health care services, the difference 178 shall be returned to the agency. The agency shall provide the 179 plan with a certification letter indicating the amount of 180 capitation paid during each calendar year for behavioral health 181 care services pursuant to this section. The agency may reimburse 182 for substance abuse treatment services on a fee-for-service 183 basis until the agency finds that adequate funds are available 184 for capitated, prepaid arrangements. 185 1. By January 1, 2001, the agency shall modify the 186 contracts with the entities providing comprehensive inpatient 187 and outpatient mental health care services to Medicaid 188 recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk 189 Counties, to include substance abuse treatment services. 190 2. By July 1, 2003, the agency and the Department of 191 Children and Family Services shall execute a written agreement 192 that requires collaboration and joint development of all policy, 193 budgets, procurement documents, contracts, and monitoring plans 194 that have an impact on the state and Medicaid community mental 195 health and targeted case management programs. 196 3. Except as provided in subparagraph 8., by July 1, 2006, 197 the agency and the Department of Children and Family Services 198 shall contract with managed care entities in each AHCA area 199 except area 6 or arrange to provide comprehensive inpatient and 200 outpatient mental health and substance abuse services through 201 capitated prepaid arrangements to all Medicaid recipients who 202 are eligible to participate in such plans under federal law and 203 regulation. In AHCA areas where eligible individuals number less 204 than 150,000, the agency shall contract with a single managed 205 care plan to provide comprehensive behavioral health services to 206 all recipients who are not enrolled in a Medicaid health 207 maintenance organization, a provider service network authorized 208 under paragraph (d), or a Medicaid capitated managed care plan 209 authorized under s. 409.91211. The agency may contract with more 210 than one comprehensive behavioral health provider to provide 211 care to recipients who are not enrolled in a Medicaid capitated 212 managed care plan authorized under s. 409.91211, a provider 213 service network authorized under paragraph (d), or a Medicaid 214 health maintenance organization in AHCA areas where the eligible 215 population exceeds 150,000. In an AHCA area where the Medicaid 216 managed care pilot program is authorized pursuant to s. 217 409.91211 in one or more counties, the agency may procure a 218 contract with a single entity to serve the remaining counties as 219 an AHCA area or the remaining counties may be included with an 220 adjacent AHCA area and shall be subject to this paragraph. 221 Contracts for comprehensive behavioral health providers awarded 222 pursuant to this section shall be competitively procured. Both 223 for-profit and not-for-profit corporations are eligible to 224 compete. Managed care plans contracting with the agency under 225 subsection (3) or paragraph (d), shall provide and receive 226 payment for the same comprehensive behavioral health benefits as 227 provided in AHCA rules, including handbooks incorporated by 228 reference. In AHCA area 11, the agency shall contract with at 229 least two comprehensive behavioral health care providers to 230 provide behavioral health care to recipients in that area who 231 are enrolled in, or assigned to, the MediPass program. One of 232 the behavioral health care contracts must be with the existing 233 provider service network pilot project, as described in 234 paragraph (d), for the purpose of demonstrating the cost 235 effectiveness of the provision of quality mental health services 236 through a public hospital-operated managed care model. Payment 237 shall be at an agreed-upon capitated rate to ensure cost 238 savings. Of the recipients in area 11 who are assigned to 239 MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those 240 MediPass-enrolled recipients shall be assigned to the existing 241 provider service network in area 11 for their behavioral care. 242 4. By October 1, 2003, the agency and the department shall 243 submit a plan to the Governor, the President of the Senate, and 244 the Speaker of the House of Representatives which provides for 245 the full implementation of capitated prepaid behavioral health 246 care in all areas of the state. 247 a. Implementation shall begin in 2003 in those AHCA areas 248 of the state where the agency is able to establish sufficient 249 capitation rates. 250 b. If the agency determines that the proposed capitation 251 rate in any area is insufficient to provide appropriate 252 services, the agency may adjust the capitation rate to ensure 253 that care will be available. The agency and the department may 254 use existing general revenue to address any additional required 255 match but may not over-obligate existing funds on an annualized 256 basis. 257 c. Subject to any limitations provided in the General 258 Appropriations Act, the agency, in compliance with appropriate 259 federal authorization, shall develop policies and procedures 260 that allow for certification of local and state funds. 261 5. Children residing in a statewide inpatient psychiatric 262 program, or in a Department of Juvenile Justice or a Department 263 of Children and Family Services residential program approved as 264 a Medicaid behavioral health overlay services provider may not 265 be included in a behavioral health care prepaid health plan or 266 any other Medicaid managed care plan pursuant to this paragraph. 267 6. In converting to a prepaid system of delivery, the 268 agency shall in its procurement document require an entity 269 providing only comprehensive behavioral health care services to 270 prevent the displacement of indigent care patients by enrollees 271 in the Medicaid prepaid health plan providing behavioral health 272 care services from facilities receiving state funding to provide 273 indigent behavioral health care, to facilities licensed under 274 chapter 395 which do not receive state funding for indigent 275 behavioral health care, or reimburse the unsubsidized facility 276 for the cost of behavioral health care provided to the displaced 277 indigent care patient. 278 7. Traditional community mental health providers under 279 contract with the Department of Children and Family Services 280 pursuant to part IV of chapter 394, child welfare providers 281 under contract with the Department of Children and Family 282 Services in areas 1 and 6, and inpatient mental health providers 283 licensed pursuant to chapter 395 must be offered an opportunity 284 to accept or decline a contract to participate in any provider 285 network for prepaid behavioral health services. 286 8. All Medicaid-eligible children, except children in area 287 1 and children in Highlands County, Hardee County, Polk County, 288 or Manatee County of area 6, that are open for child welfare 289 services in the HomeSafeNet system, shall receive their 290 behavioral health care services through a specialty prepaid plan 291 operated by community-based lead agencies through a single 292 agency or formal agreements among several agencies. The 293 specialty prepaid plan must result in savings to the state 294 comparable to savings achieved in other Medicaid managed care 295 and prepaid programs. Such plan must provide mechanisms to 296 maximize state and local revenues. The specialty prepaid plan 297 shall be developed by the agency and the Department of Children 298 and Family Services. The agency may seek federal waivers to 299 implement this initiative. Medicaid-eligible children whose 300 cases are open for child welfare services in the HomeSafeNet 301 system and who reside in AHCA area 10 are exempt from the 302 specialty prepaid plan upon the development of a service 303 delivery mechanism for children who reside in area 10 as 304 specified in s. 409.91211(3)(dd). 305 (d) A provider service network may be reimbursed on a fee 306 for-service or prepaid basis. A provider service network which 307 is reimbursed by the agency on a prepaid basis shall be exempt 308 from parts I and III of chapter 641, but must comply with the 309 solvency requirements in s. 641.2261(2) and meet appropriate 310 financial reserve, quality assurance, and patient rights 311 requirements as established by the agency. Medicaid recipients 312 assigned to a provider service network shall be chosen equally 313 from those who would otherwise have been assigned to prepaid 314 plans and MediPass. The agency is authorized to seek federal 315 Medicaid waivers as necessary to implement the provisions of 316 this section. Any contract previously awarded to a provider 317 service network operated by a hospital pursuant to this 318 subsection shall remain in effect for a period of 3 years 319 following the current contract expiration date, regardless of 320 any contractual provisions to the contrary. A provider service 321 network is a network established or organized and operated by a 322 health care provider, or group of affiliated health care 323 providers, including minority physician networks and emergency 324 room diversion programs that meet the requirements of s. 325 409.91211, which provides a substantial proportion of the health 326 care items and services under a contract directly through the 327 provider or affiliated group of providers and may make 328 arrangements with physicians or other health care professionals, 329 health care institutions, or any combination of such individuals 330 or institutions to assume all or part of the financial risk on a 331 prospective basis for the provision of basic health services by 332 the physicians, by other health professionals, or through the 333 institutions. The health care providers must have a controlling 334 interest in the governing body of the provider service network 335 organization. 336 (21) Any entity contracting with the agency pursuant to 337 this section to provide health care services to Medicaid 338 recipients is prohibited from engaging in any of the following 339 practices or activities: 340 (a) Practices that are discriminatory, including, but not 341 limited to, attempts to discourage participation on the basis of 342 actual or perceived health status. 343 (b) Activities that could mislead or confuse recipients, or 344 misrepresent the organization, its marketing representatives, or 345 the agency. Violations of this paragraph include, but are not 346 limited to: 347 1. False or misleading claims that marketing 348 representatives are employees or representatives of the state or 349 county, or of anyone other than the entity or the organization 350 by whom they are reimbursed. 351 2. False or misleading claims that the entity is 352 recommended or endorsed by any state or county agency, or by any 353 other organization which has not certified its endorsement in 354 writing to the entity. 355 3. False or misleading claims that the state or county 356 recommends that a Medicaid recipient enroll with an entity. 357 4. Claims that a Medicaid recipient will lose benefits 358 under the Medicaid program, or any other health or welfare 359 benefits to which the recipient is legally entitled, if the 360 recipient does not enroll with the entity. 361 (c) Granting or offering of any monetary or other valuable 362 consideration for enrollment, except as authorized by subsection 363 (25)(24). 364 (d) Door-to-door solicitation of recipients who have not 365 contacted the entity or who have not invited the entity to make 366 a presentation. 367 (e) Solicitation of Medicaid recipients by marketing 368 representatives stationed in state offices unless approved and 369 supervised by the agency or its agent and approved by the 370 affected state agency when solicitation occurs in an office of 371 the state agency. The agency shall ensure that marketing 372 representatives stationed in state offices shall market their 373 managed care plans to Medicaid recipients only in designated 374 areas and in such a way as to not interfere with the recipients’ 375 activities in the state office. 376 (f) Enrollment of Medicaid recipients. 377 (22) The agency shallmayimpose a fine for a violation of 378 this section or the contract with the agency by a person or 379 entity that is under contract with the agency. With respect to 380 any nonwillful violation, such fine shall not exceed $2,500 per 381 violation. In no event shall such fine exceed an aggregate 382 amount of $10,000 for all nonwillful violations arising out of 383 the same action. With respect to any knowing and willful 384 violation of this section or the contract with the agency, the 385 agency may impose a fine upon the entity in an amount not to 386 exceed $20,000 for each such violation. In no event shall such 387 fine exceed an aggregate amount of $100,000 for all knowing and 388 willful violations arising out of the same action. 389 (23) Any entity that contracts with the agency on a prepaid 390 or fixed-sum basis as a managed care plan as defined in s. 391 409.9122(2)(f) or s. 409.91211 shall post a surety bond with the 392 agency in an amount that is equivalent to a 1-year guaranteed 393 savings amount as specified in the contract. In lieu of a surety 394 bond, the agency may establish an irrevocable account in which 395 the vendor funds an equivalent amount over a 6-month period. The 396 purpose of the surety bond or account is to protect the agency 397 if the entity terminates its contract with the agency before the 398 scheduled end date for the contract. If the contract is 399 terminated by the vendor for any reason, the agency shall pursue 400 a claim against the surety bond or account for an early 401 termination fee. The early termination fee must be equal to 402 administrative costs incurred by the state due to the early 403 termination and the differential of the guaranteed savings based 404 on the original contract term and the corresponding termination 405 date. The agency shall terminate a vendor who does not reimburse 406 the state within 30 days after any early termination involving 407 administrative costs and requiring reimbursement of lost savings 408 from the Medicaid program. 409 Section 2. Subsections (1) through (6) of section 410 409.91211, Florida Statutes, are amended to read: 411 409.91211 Medicaid managed care pilot program.— 412 (1)(a) The agency is authorized to seek and implement 413 experimental, pilot, or demonstration project waivers, pursuant 414 to s. 1115 of the Social Security Act, to create a statewide 415 initiative to provide for a more efficient and effective service 416 delivery system that enhances quality of care and client 417 outcomes in the Florida Medicaid program pursuant to this 418 section. Phase one of the demonstration shall be implemented in 419 two geographic areas. One demonstration site shall include only 420 Broward County. A second demonstration site shall initially 421 include Duval County and shall be expanded to include Baker, 422 Clay, and Nassau Counties within 1 year after the Duval County 423 program becomes operational. The agency shall implement 424 expansion of the program to include the remaining counties of 425 the state and remaining eligibility groups in accordance with 426 the process specified in the federally approved special terms 427 and conditions numbered 11-W-00206/4, as approved by the federal 428 Centers for Medicare and Medicaid Serviceson October 19, 2005,429 with a goal of full statewide implementation by June 30, 2014 4302011. 431 (b) This waiver extension shallauthority is contingent432upon federal approval topreserve the low-income poolupper433payment-limitfunding mechanism for providers and hospitals, 434 includinga guarantee of a reasonable growth factor,a 435 methodology to allow the use of a portion of these funds to 436 serve as a risk pool for demonstration sites, provisions to 437 preserve the state’s ability to use intergovernmental transfers, 438 and provisions to protect the disproportionate share program 439 authorized pursuant to this chapter.Upon completion of the440evaluation conducted under s. 3, ch. 2005-133, Laws of Florida,441 The agency shall expandmay request statewide expansion ofthe 442 demonstration to counties that have two or more plans and that 443 have capacity to serve the designated populationprojects. The 444 agency may expand to additional counties as plan capacity is 445 developed.Statewide phase-in to additional counties shall be446contingent upon review and approval by the Legislature.Under 447the upper-payment-limit program, orthe low-income pool as 448 implemented by the Agency for Health Care Administration 449 pursuant to federal waiver, the state matching funds required 450 for the program shall be provided by local governmental entities 451 through intergovernmental transfers in accordance with published 452 federal statutes and regulations. The Agency for Health Care 453 Administration shall distributeupper-payment-limit,454 disproportionate share hospital,and low-income pool funds 455 according to published federal statutes, regulations, and 456 waivers and the low-income pool methodology approved by the 457 federal Centers for Medicare and Medicaid Services. 458 (c) It is the intent of the Legislature that the low-income 459 pool plan required by the terms and conditions of the Medicaid 460 reform waiver and submitted to the federal Centers for Medicare 461 and Medicaid Services propose the distribution of the above 462 mentioned program funds based on the following objectives: 463 1. Assure a broad and fair distribution of available funds 464 based on the access provided by Medicaid participating 465 hospitals, regardless of their ownership status, through their 466 delivery of inpatient or outpatient care for Medicaid 467 beneficiaries and uninsured and underinsured individuals; 468 2. Assure accessible emergency inpatient and outpatient 469 care for Medicaid beneficiaries and uninsured and underinsured 470 individuals; 471 3. Enhance primary, preventive, and other ambulatory care 472 coverages for uninsured individuals; 473 4. Promote teaching and specialty hospital programs; 474 5. Promote the stability and viability of statutorily 475 defined rural hospitals and hospitals that serve as sole 476 community hospitals; 477 6. Recognize the extent of hospital uncompensated care 478 costs; 479 7. Maintain and enhance essential community hospital care; 480 8. Maintain incentives for local governmental entities to 481 contribute to the cost of uncompensated care; 482 9. Promote measures to avoid preventable hospitalizations; 483 10. Account for hospital efficiency; and 484 11. Contribute to a community’s overall health system. 485 (2) The Legislature intends for the capitated managed care 486 pilot program to: 487 (a) Provide recipients in Medicaid fee-for-service or the 488 MediPass program a comprehensive and coordinated capitated 489 managed care system for all health care services specified in 490 ss. 409.905 and 409.906. 491 (b) Stabilize Medicaid expenditures under the pilot program 492 compared to Medicaid expenditures in the pilot area for the 3 493 years before implementation of the pilot program, while 494 ensuring: 495 1. Consumer education and choice. 496 2. Access to medically necessary services. 497 3. Coordination of preventative, acute, and long-term care. 498 4. Reductions in unnecessary service utilization. 499 (c) Provide an opportunity to evaluate the feasibility of 500 statewide implementation of capitated managed care networks as a 501 replacement for the current Medicaid fee-for-service and 502 MediPass systems. 503 (3) The agency shall have the following powers, duties, and 504 responsibilities with respect to the pilot program: 505 (a) To implement a system to deliver all mandatory services 506 specified in s. 409.905 and optional services specified in s. 507 409.906, as approved by the Centers for Medicare and Medicaid 508 Services and the Legislature in the waiver pursuant to this 509 section. Services to recipients under plan benefits shall 510 include emergency services provided under s. 409.9128. 511 (b) To implement a pilot program, including Medicaid 512 eligibility categories specified in ss. 409.903 and 409.904, as 513 authorized in an approved federal waiver. 514 (c) To implement the managed care pilot program that 515 maximizes all available state and federal funds, including those 516 obtained through intergovernmental transfers, the low-income 517 pool, supplemental Medicaid payments, and the disproportionate 518 share program. Within the parameters allowed by federal statute 519 and rule, the agency may seek options for making direct payments 520 to hospitals and physicians employed by or under contract with 521 the state’s medical schools for the costs associated with 522 graduate medical education under Medicaid reform. 523 (d) To implement actuarially sound, risk-adjusted 524 capitation rates for Medicaid recipients in the pilot program 525 which cover comprehensive care, enhanced services, and 526 catastrophic care. 527 (e) To implement policies and guidelines for phasing in 528 financial risk for approved provider service networks that, for 529 purposes of this paragraph, include the Children’s Medical 530 Services Network, over a 5-year period. These policies and 531 guidelines must include an option for a provider service network 532 to be paid fee-for-service rates. For any provider service 533 network established in a managed care pilot area, the option to 534 be paid fee-for-service rates must include a savings-settlement 535 mechanism that is consistent with s. 409.912(44). This model 536 must be converted to a risk-adjusted capitated rate by the 537 beginning of the sixth year of operation, and may be converted 538 earlier at the option of the provider service network. Federally 539 qualified health centers may be offered an opportunity to accept 540 or decline a contract to participate in any provider network for 541 prepaid primary care services. 542 (f) To implement stop-loss requirements and the transfer of 543 excess cost to catastrophic coverage that accommodates the risks 544 associated with the development of the pilot program. 545 (g) To recommend a process to be used by the Social 546 Services Estimating Conference to determine and validate the 547 rate of growth of the per-member costs of providing Medicaid 548 services under the managed care pilot program. 549 (h) To implement program standards and credentialing 550 requirements for capitated managed care networks to participate 551 in the pilot program, including those related to fiscal 552 solvency, quality of care, and adequacy of access to health care 553 providers. It is the intent of the Legislature that, to the 554 extent possible, any pilot program authorized by the state under 555 this section include any federally qualified health center, 556 federally qualified rural health clinic, county health 557 department, the Children’s Medical Services Network within the 558 Department of Health, or other federally, state, or locally 559 funded entity that serves the geographic areas within the 560 boundaries of the pilot program that requests to participate. 561 This paragraph does not relieve an entity that qualifies as a 562 capitated managed care network under this section from any other 563 licensure or regulatory requirements contained in state or 564 federal law which would otherwise apply to the entity. The 565 standards and credentialing requirements shall be based upon, 566 but are not limited to: 567 1. Compliance with the accreditation requirements as 568 provided in s. 641.512. 569 2. Compliance with early and periodic screening, diagnosis, 570 and treatment screening requirements under federal law. 571 3. The percentage of voluntary disenrollments. 572 4. Immunization rates. 573 5. Standards of the National Committee for Quality 574 Assurance and other approved accrediting bodies. 575 6. Recommendations of other authoritative bodies. 576 7. Specific requirements of the Medicaid program, or 577 standards designed to specifically meet the unique needs of 578 Medicaid recipients. 579 8. Compliance with the health quality improvement system as 580 established by the agency, which incorporates standards and 581 guidelines developed by the Centers for Medicare and Medicaid 582 Services as part of the quality assurance reform initiative. 583 9. The network’s infrastructure capacity to manage 584 financial transactions, recordkeeping, data collection, and 585 other administrative functions. 586 10. The network’s ability to submit any financial, 587 programmatic, or patient-encounter data or other information 588 required by the agency to determine the actual services provided 589 and the cost of administering the plan. 590 (i) To implement a mechanism for providing information to 591 Medicaid recipients for the purpose of selecting a capitated 592 managed care plan. For each plan available to a recipient, the 593 agency, at a minimum, shall ensure that the recipient is 594 provided with: 595 1. A listand descriptionof the benefits provided. 596 2. Information about cost sharing. 597 3. A list of providers participating in the plan networks. 598 4.3.Plan performance data, if available. 5994.An explanation of benefit limitations.6005.Contact information, including identification of601providers participating in the network, geographic locations,602and transportation limitations.6036.Any other information the agency determines would604facilitate a recipient’s understanding of the plan or insurance605that would best meet his or her needs.606 (j) To implement a system to ensure that there is a record 607 of recipient acknowledgment that plan choicecounselinghas been 608 provided. 609 (k) To implement a choice counseling system to ensure that 610 the choice counseling process and related material are designed 611 to provide counselingthrough face-to-face interaction,by 612 telephone or,andin writing and through other forms of relevant 613 media. Materials shall be written at the fourth-grade reading 614 level and available in a language other than English when 5 615 percent of the county speaks a language other than English. 616 Choice counseling shall also use language lines and other 617 services for impaired recipients, such as TTD/TTY. 618 (l) To implement a system that prohibits capitated managed 619 care plans, their representatives, and providers employed by or 620 contracted with the capitated managed care plans from recruiting 621 persons eligible for or enrolled in Medicaid, from providing 622 inducements to Medicaid recipients to select a particular 623 capitated managed care plan, and from prejudicing Medicaid 624 recipients against other capitated managed care plans.The625system shall require the entity performing choice counseling to626determine if the recipient has made a choice of a plan or has627opted out because of duress, threats, payment to the recipient,628or incentives promised to the recipient by a third party.If the 629 choice counseling entity determines that the decision to choose 630 a plan was unlawfully influenced or a plan violated any of the 631 provisions of s. 409.912(21), the choice counseling entity shall 632 immediately report the violation to the agency’s program 633 integrity section for investigation.Verification of choice634counseling by the recipient shall include a stipulation that the635recipient acknowledges the provisions of this subsection.636 (m) To implement a choice counseling system that promotes 637 health literacy, uses technology effectively, and provides 638 information intendedaimedto reduce minority health disparities 639 through outreach activities for Medicaid recipients. 640 (n) Tocontract with entities to perform choice counseling.641The agency mayestablish standards and performance contracts, 642 including standards requiring the contractor to hire choice 643 counselors who are representative of the state’s diverse 644 population andtotrain choice counselors in working with 645 culturally diverse populations. 646 (o) To implement eligibility assignment processes to 647 facilitate client choice while ensuring pilot programs of 648 adequate enrollment levels. These processes shall ensure that 649 pilot sites have sufficient levels of enrollment to conduct a 650 valid test of the managed care pilot program within a 2-year 651 timeframe. 652 (p) To implement standards for plan compliance, including, 653 but not limited to, standards for quality assurance and 654 performance improvement, standards for peer or professional 655 reviews, grievance policies, and policies for maintaining 656 program integrity. The agency shall develop a data-reporting 657 system, seek input from managed care plans in order to establish 658 requirements for patient-encounter reporting, and ensure that 659 the data reported is accurate and complete. 660 1. In performing the duties required under this section, 661 the agency shall work with managed care plans to establish a 662 uniform system to measure and monitor outcomes for a recipient 663 of Medicaid services. 664 2. The system shall use financial, clinical, and other 665 criteria based on pharmacy, medical services, and other data 666 that is related to the provision of Medicaid services, 667 including, but not limited to: 668 a. The Health Plan Employer Data and Information Set 669 (HEDIS) or measures that are similar to HEDIS. 670 b. Member satisfaction. 671 c. Provider satisfaction. 672 d. Report cards on plan performance and best practices. 673 e. Compliance with the requirements for prompt payment of 674 claims under ss. 627.613, 641.3155, and 641.513. 675 f. Utilization and quality data for the purpose of ensuring 676 access to medically necessary services, including 677 underutilization or inappropriate denial of services. 678 3. The agency shall require the managed care plans that 679 have contracted with the agency to establish a quality assurance 680 system that incorporates the provisions of s. 409.912(27) and 681 any standards, rules, and guidelines developed by the agency. 682 4. The agency shall establish an encounter database in 683 order to compile data on health services rendered by health care 684 practitioners who provide services to patients enrolled in 685 managed care plans in the demonstration sites. The encounter 686 database shall: 687 a. Collect the following for each type of patient encounter 688 with a health care practitioner or facility, including: 689 (I) The demographic characteristics of the patient. 690 (II) The principal, secondary, and tertiary diagnosis. 691 (III) The procedure performed. 692 (IV) The date and location where the procedure was 693 performed. 694 (V) The payment for the procedure, if any. 695 (VI) If applicable, the health care practitioner’s 696 universal identification number. 697 (VII) If the health care practitioner rendering the service 698 is a dependent practitioner, the modifiers appropriate to 699 indicate that the service was delivered by the dependent 700 practitioner. 701 b. Collect appropriate information relating to prescription 702 drugs for each type of patient encounter. 703 c. Collect appropriate information related to health care 704 costs and utilization from managed care plans participating in 705 the demonstration sites. 706 5. To the extent practicable, when collecting the data the 707 agency shall use a standardized claim form or electronic 708 transfer system that is used by health care practitioners, 709 facilities, and payors. 710 6. Health care practitioners and facilities in the 711 demonstration sites shall electronically submit, and managed 712 care plans participating in the demonstration sites shall 713 electronically receive, information concerning claims payments 714 and any other information reasonably related to the encounter 715 database using a standard format as required by the agency. 716 7. The agency shall establish reasonable deadlines for 717 phasing in the electronic transmittal of full encounter data. 718 8. The system must ensure that the data reported is 719 accurate and complete. 720 (q) To implement a grievance resolution process for 721 Medicaid recipients enrolled in a capitated managed care network 722 under the pilot program modeled after the subscriber assistance 723 panel, as created in s. 408.7056. This process shall include a 724 mechanism for an expedited review of no greater than 24 hours 725 after notification of a grievance if the life of a Medicaid 726 recipient is in imminent and emergent jeopardy. 727 (r) To implement a grievance resolution process for health 728 care providers employed by or contracted with a capitated 729 managed care network under the pilot program in order to settle 730 disputes among the provider and the managed care network or the 731 provider and the agency. 732 (s) To implement criteria in an approved federal waiver to 733 designate health care providers as eligible to participate in 734 the pilot program. These criteria must include at a minimum 735 those criteria specified in s. 409.907. 736 (t) To use health care provider agreements for 737 participation in the pilot program. 738 (u) To require that all health care providers under 739 contract with the pilot program be duly licensed in the state, 740 if such licensure is available, and meet other criteria as may 741 be established by the agency. These criteria shall include at a 742 minimum those criteria specified in s. 409.907. 743 (v) To ensure that managed care organizations work 744 collaboratively with other state or local governmental programs 745 or institutions for the coordination of health care to eligible 746 individuals receiving services from such programs or 747 institutions. 748 (w) To implement procedures to minimize the risk of 749 Medicaid fraud and abuse in all plans operating in the Medicaid 750 managed care pilot program authorized in this section. 751 1. The agency shall ensure that applicable provisions of 752 this chapter and chapters 414, 626, 641, and 932 which relate to 753 Medicaid fraud and abuse are applied and enforced at the 754 demonstration project sites. 755 2. Providers must have the certification, license, and 756 credentials that are required by law and waiver requirements. 757 3. The agency shall ensure that the plan is in compliance 758 with s. 409.912(21) and (22). 759 4. The agency shall require that each plan establish 760 functions and activities governing program integrity in order to 761 reduce the incidence of fraud and abuse. Plans must report 762 instances of fraud and abuse pursuant to chapter 641. 763 5. The plan shall have written administrative and 764 management arrangements or procedures, including a mandatory 765 compliance plan, which are designed to guard against fraud and 766 abuse. The plan shall designate a compliance officer who has 767 sufficient experience in health care. 768 6.a. The agency shall require all managed care plan 769 contractors in the pilot program to report all instances of 770 suspected fraud and abuse. A failure to report instances of 771 suspected fraud and abuse is a violation of law and subject to 772 the penalties provided by law. 773 b. An instance of fraud and abuse in the managed care plan, 774 including, but not limited to, defrauding the state health care 775 benefit program by misrepresentation of fact in reports, claims, 776 certifications, enrollment claims, demographic statistics, or 777 patient-encounter data; misrepresentation of the qualifications 778 of persons rendering health care and ancillary services; bribery 779 and false statements relating to the delivery of health care; 780 unfair and deceptive marketing practices; and false claims 781 actions in the provision of managed care, is a violation of law 782 and subject to the penalties provided by law. 783 c. The agency shall require that all contractors make all 784 files and relevant billing and claims data accessible to state 785 regulators and investigators and that all such data is linked 786 into a unified system to ensure consistent reviews and 787 investigations. 788 (x) To develop and provide actuarial and benefit design 789 analyses that indicate the effect on capitation rates and 790 benefits offered in the pilot program over a prospective 5-year 791 period based on the following assumptions: 792 1. Growth in capitation rates which is limited to the 793 estimated growth rate in general revenue. 794 2. Growth in capitation rates which is limited to the 795 average growth rate over the last 3 years in per-recipient 796 Medicaid expenditures. 797 3. Growth in capitation rates which is limited to the 798 growth rate of aggregate Medicaid expenditures between the 2003 799 2004 fiscal year and the 2004-2005 fiscal year. 800 (y) To develop a mechanism to require capitated managed 801 care plans to reimburse qualified emergency service providers, 802 including, but not limited to, ambulance services, in accordance 803 with ss. 409.908 and 409.9128. The pilot program must include a 804 provision for continuing fee-for-service payments for emergency 805 services, including, but not limited to, individuals who access 806 ambulance services or emergency departments and who are 807 subsequently determined to be eligible for Medicaid services. 808 (z) To ensure that school districts participating in the 809 certified school match program pursuant to ss. 409.908(21) and 810 1011.70 shall be reimbursed by Medicaid, subject to the 811 limitations of s. 1011.70(1), for a Medicaid-eligible child 812 participating in the services as authorized in s. 1011.70, as 813 provided for in s. 409.9071, regardless of whether the child is 814 enrolled in a capitated managed care network. Capitated managed 815 care networks must make a good faith effort to execute 816 agreements with school districts regarding the coordinated 817 provision of services authorized under s. 1011.70. County health 818 departments and federally qualified health centers delivering 819 school-based services pursuant to ss. 381.0056 and 381.0057 must 820 be reimbursed by Medicaid for the federal share for a Medicaid 821 eligible child who receives Medicaid-covered services in a 822 school setting, regardless of whether the child is enrolled in a 823 capitated managed care network. Capitated managed care networks 824 must make a good faith effort to execute agreements with county 825 health departments and federally qualified health centers 826 regarding the coordinated provision of services to a Medicaid 827 eligible child. To ensure continuity of care for Medicaid 828 patients, the agency, the Department of Health, and the 829 Department of Education shall develop procedures for ensuring 830 that a student’s capitated managed care network provider 831 receives information relating to services provided in accordance 832 with ss. 381.0056, 381.0057, 409.9071, and 1011.70. 833 (aa) To implement a mechanism whereby Medicaid recipients 834 who are already enrolled in a managed care plan or the MediPass 835 program in the pilot areas shall be offered the opportunity to 836 change to capitated managed care plans on a staggered basis, as 837 defined by the agency. All Medicaid recipients shall have 30 838 days in which to make a choice of capitated managed care plans. 839 Those Medicaid recipients who do not make a choice shall be 840 assigned to a capitated managed care plan in accordance with 841 paragraph (4)(a) and shall be exempt from s. 409.9122. To 842 facilitate continuity of care for a Medicaid recipient who is 843 also a recipient of Supplemental Security Income (SSI), prior to 844 assigning the SSI recipient to a capitated managed care plan, 845 the agency shall determine whether the SSI recipient has an 846 ongoing relationship with a provider or capitated managed care 847 plan, and, if so, the agency shall assign the SSI recipient to 848 that provider or capitated managed care plan where feasible. 849 Those SSI recipients who do not have such a provider 850 relationship shall be assigned to a capitated managed care plan 851 provider in accordance with paragraph (4)(a) and shall be exempt 852 from s. 409.9122. 853 (bb) To develop and recommend a service delivery 854 alternative for children having chronic medical conditions which 855 establishes a medical home project to provide primary care 856 services to this population. The project shall provide 857 community-based primary care services that are integrated with 858 other subspecialties to meet the medical, developmental, and 859 emotional needs for children and their families. This project 860 shall include an evaluation component to determine impacts on 861 hospitalizations, length of stays, emergency room visits, costs, 862 and access to care, including specialty care and patient and 863 family satisfaction. 864 (cc) To develop and recommend service delivery mechanisms 865 within capitated managed care plans to provide Medicaid services 866 as specified in ss. 409.905 and 409.906 to persons with 867 developmental disabilities sufficient to meet the medical, 868 developmental, and emotional needs of these persons. 869 (dd) To implement service delivery mechanisms within a 870 specialty plan in area 10capitated managed care plansto 871 provide behavioral health care servicesMedicaid services as872specified in ss.409.905and409.906to Medicaid-eligible 873 children whose cases are open for child welfare services in the 874 HomeSafeNet system. These services must be coordinated with 875 community-based care providers as specified in s. 409.1671, 876 where available, and be sufficient to meet themedical,877 developmental, behavioral, and emotional needs of these 878 children. Children in area 10 who have an open case in the 879 HomeSafeNet system shall be enrolled into the specialty plan. 880 These service delivery mechanisms must be implemented no later 881 than July 1, 20112008, in AHCA area 10 in order for the 882 children in AHCA area 10 to remain exempt from the statewide 883 plan under s. 409.912(4)(b)8. An administrative fee may be paid 884 to the specialty plan for the coordination of services based on 885 the receipt of the state share of that fee being provided 886 through intergovernmental transfers. 887 (4)(a)A Medicaid recipient in the pilot area who is not888currently enrolled in a capitated managed care plan upon889implementation is not eligible for services as specified in ss.890409.905and409.906, for the amount of time that the recipient891does not enroll in a capitated managed care network.If a 892 Medicaid recipient has not enrolled in a capitated managed care 893 plan within 30 days after eligibility, the agency shall assign 894 the Medicaid recipient to a capitated managed care plan based on 895 the assessed needs of the recipient as determined by the agency 896 and the recipient shall be exempt from s. 409.9122. When making 897 assignments, the agency shall take into account the following 898 criteria: 899 1. A capitated managed care network has sufficient network 900 capacity to meet the needs of members. 901 2. The capitated managed care network has previously 902 enrolled the recipient as a member, or one of the capitated 903 managed care network’s primary care providers has previously 904 provided health care to the recipient. 905 3. The agency has knowledge that the member has previously 906 expressed a preference for a particular capitated managed care 907 network as indicated by Medicaid fee-for-service claims data, 908 but has failed to make a choice. 909 4. The capitated managed care network’s primary care 910 providers are geographically accessible to the recipient’s 911 residence. 912 5. Plan performance as designed by the agency. 913 (b) When more than one capitated managed care network 914 provider meets the criteria specified in paragraph (3)(h), the 915 agency shall make recipient assignments consecutively by family 916 unit. 917 (c) If a recipient is currently enrolled with a Medicaid 918 managed care organization that also operates an approved reform 919 plan within a demonstration area and the recipient fails to 920 choose a plan during the reform enrollment process or during 921 redetermination of eligibility, the recipient shall be 922 automatically assigned by the agency into the most appropriate 923 reform plan operated by the recipient’s current Medicaid managed 924 care plan. If the recipient’s current managed care plan does not 925 operate a reform plan in the demonstration area which adequately 926 meets the needs of the Medicaid recipient, the agency shall use 927 the automatic assignment process as prescribed in the special 928 terms and conditions numbered 11-W-00206/4. All enrollment and 929 choice counseling materials provided by the agency must contain 930 an explanation of the provisions of this paragraph for current 931 managed care recipients. 932 (d) Except for plan performance as provided for in 933 paragraph (a), the agency may not engage in practices that are 934 designed to favor one capitated managed care plan over another 935 or that are designed to influence Medicaid recipients to enroll 936 in a particular capitated managed care network in order to 937 strengthen its particular fiscal viability. 938 (e) After a recipient has made a selection or has been 939 enrolled in a capitated managed care network, the recipient 940 shall have 90 days in which to voluntarily disenroll and select 941 another capitated managed care network. After 90 days, no 942 further changes may be made except for cause. Cause shall 943 include, but not be limited to, poor quality of care, lack of 944 access to necessary specialty services, an unreasonable delay or 945 denial of service, inordinate or inappropriate changes of 946 primary care providers, service access impairments due to 947 significant changes in the geographic location of services, or 948 fraudulent enrollment. The agency may require a recipient to use 949 the capitated managed care network’s grievance process as 950 specified in paragraph (3)(q) prior to the agency’s 951 determination of cause, except in cases in which immediate risk 952 of permanent damage to the recipient’s health is alleged. The 953 grievance process, when used, must be completed in time to 954 permit the recipient to disenroll no later than the first day of 955 the second month after the month the disenrollment request was 956 made. If the capitated managed care network, as a result of the 957 grievance process, approves an enrollee’s request to disenroll, 958 the agency is not required to make a determination in the case. 959 The agency must make a determination and take final action on a 960 recipient’s request so that disenrollment occurs no later than 961 the first day of the second month after the month the request 962 was made. If the agency fails to act within the specified 963 timeframe, the recipient’s request to disenroll is deemed to be 964 approved as of the date agency action was required. Recipients 965 who disagree with the agency’s finding that cause does not exist 966 for disenrollment shall be advised of their right to pursue a 967 Medicaid fair hearing to dispute the agency’s finding. 968 (f) The agency shall apply for federal waivers from the 969 Centers for Medicare and Medicaid Services to lock eligible 970 Medicaid recipients into a capitated managed care network for 12 971 months after an open enrollment period. After 12 months of 972 enrollment, a recipient may select another capitated managed 973 care network. However, nothing shall prevent a Medicaid 974 recipient from changing primary care providers within the 975 capitated managed care network during the 12-month period. 976 (g) The agency shall apply for federal waivers from the 977 Centers for Medicare and Medicaid Services to allow recipients 978 to purchase health care coverage through an employer-sponsored 979 health insurance plan instead of through a Medicaid-certified 980 plan. This provision shall be known as the opt-out option. 981 1. A recipient who chooses the Medicaid opt-out option 982 shall have an opportunity for a specified period of time, as 983 authorized under a waiver granted by the Centers for Medicare 984 and Medicaid Services, to select and enroll in a Medicaid 985 certified plan. If the recipient remains in the employer 986 sponsored plan after the specified period, the recipient shall 987 remain in the opt-out program for at least 1 year or until the 988 recipient no longer has access to employer-sponsored coverage, 989 until the employer’s open enrollment period for a person who 990 opts out in order to participate in employer-sponsored coverage, 991 or until the person is no longer eligible for Medicaid, 992 whichever time period is shorter. 993 2. Notwithstanding any other provision of this section, 994 coverage, cost sharing, and any other component of employer 995 sponsored health insurance shall be governed by applicable state 996 and federal laws. 997 (5) This section authorizesdoes not authorizethe agency 998 to seek an extension amendment and to continue operation 999implement any provisionof the s. 1115 of the Social Security 1000 Act experimental, pilot, or demonstration project waiver to 1001 reform the state Medicaid programin any part of the state other1002than the two geographic areas specified in this section unless1003approved by the Legislature. 1004 (6) The agency shall develop and submit for approval 1005 applications for waivers of applicable federal laws and 1006 regulations as necessary to extend and expandimplementthe 1007 managed care pilot project as defined in this section. The 1008 agency shall seek public input on the waiver and post all waiver 1009 applications under this section on its Internet website for 30 1010 daysbefore submitting the applications to the United States1011Centers for Medicare and Medicaid Services. The 30 days shall 1012 commence with the initial posting and must conclude 30 days 1013 prior to approval by the United States Centers for Medicare and 1014 Medicaid Services. All waiver applications shall be provided for 1015 review and comment to the appropriate committees of the Senate 1016 and House of Representatives for at least 10 working days prior 1017 to submission. All waivers submitted to and approved by the 1018 United States Centers for Medicare and Medicaid Services under 1019 this section must be approved by the Legislature. Federally 1020 approved waivers must be submitted to the President of the 1021 Senate and the Speaker of the House of Representatives for 1022 referral to the appropriate legislative committees. The 1023 appropriate committees shall recommend whether to approve the 1024 implementation of any waivers to the Legislature as a whole. The 1025 agency shall submit a plan containing a recommended timeline for 1026 implementation of any waivers and budgetary projections of the 1027 effect of the pilot program under this section on the total 1028 Medicaid budget for the 2006-2007 through 2009-2010 state fiscal 1029 years. This implementation plan shall be submitted to the 1030 President of the Senate and the Speaker of the House of 1031 Representatives at the same time any waivers are submitted for 1032 consideration by the Legislature. The agency may implement the 1033 waiver and special terms and conditions numbered 11-W-00206/4, 1034 as approved by the federal Centers for Medicare and Medicaid 1035 Services. If the agency seeks approval by the Federal Government 1036 of any modifications to these special terms and conditions, the 1037 agency must provide written notification of its intent to modify 1038 these terms and conditions to the President of the Senate and 1039 the Speaker of the House of Representatives at least 15 days 1040 before submitting the modifications to the Federal Government 1041 for consideration. The notification must identify all 1042 modifications being pursued and the reason the modifications are 1043 needed. Upon receiving federal approval of any modifications to 1044 the special terms and conditions, the agency shall provide a 1045 report to the Legislature describing the federally approved 1046 modifications to the special terms and conditions within 7 days 1047 after approval by the Federal Government. 1048 Section 3. Paragraph (m) is added to subsection (2) of 1049 section 409.9122, Florida Statutes, to read: 1050 409.9122 Mandatory Medicaid managed care enrollment; 1051 programs and procedures.— 1052 (2) 1053 (m)1. Time allotted pursuant to this subsection to any 1054 Medicaid recipient for the selection of, enrollment in, or 1055 disenrollment from a managed care plan or MediPass is tolled 1056 throughout any month in which the enrollment broker or choice 1057 counseling provider, whichever is applicable, has adversely 1058 affected a beneficiary’s ability to access choice counseling or 1059 enrollment broker services by its failure to comply with the 1060 terms and conditions of its contract or has otherwise acted or 1061 failed to act in a manner that the agency deems likely to 1062 jeopardize its ability to perform its assigned responsibilities 1063 as set forth in paragraphs (c) and (d). During any month in 1064 which time is tolled for a recipient, he or she must be afforded 1065 uninterrupted access to benefits and services in the same 1066 delivery system available prior to such tolling. 1067 2. The agency shall incorporate into all pertinent 1068 contracts that are executed or renewed on or after July 1, 2010, 1069 provisions authorizing and requiring the agency to impose 1070 sanctions or fines against an enrollment broker or choice 1071 counselor if a recipient is adversely affected due to any action 1072 or failure to act on the part of the enrollment broker or choice 1073 counselor. 1074 Section 4. This act shall take effect July 1, 2010.
