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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
A bill to be entitled 1
An act relating to Medicaid managed care; amending s. 2
409.908, F.S.; requiring the Agency for Health Care 3
Administration to determine compliance with essential 4
provider contracting requirements; requiring the 5
agency to withhold supplemental payments under certain 6
circumstances; amending s. 409.912, F.S.; requiring 7
the reimbursement of certain provider service networks 8
on a prepaid basis; removing obsolete language related 9
to provider service network reimbursement; repealing 10
s. 409.9124, F.S., relating to ma naged care 11
reimbursement; amending s. 409.964, F.S.; removing 12
obsolete language related to requiring the agency to 13
provide public notice before seeking a Medicaid 14
waiver; amending s. 409.966, F.S.; revising a 15
provision related to a requirement that the age ncy 16
include certain information in a utilization and 17
spending databook; requiring the agency to conduct a 18
single, statewide procurement and negotiate and select 19
plans on a regional basis; authorizing the agency to 20
select plans on a statewide basis under ce rtain 21
circumstances; specifying the procurement regions; 22
removing obsolete language related to prepaid rates 23
and an additional procurement award; making conforming 24
changes; amending s. 409.967, F.S.; removing obsolete 25
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language related to certain hospital c ontracts; 26
requiring the agency to test provider network 27
databases to confirm that enrollees have timely access 28
to all covered benefits; removing obsolete language 29
related to a request for information; authorizing 30
plans to reduce an achieved savings rebate under 31
certain circumstances; classifying certain 32
expenditures as medical expenses; amending s. 409.968, 33
F.S.; removing obsolete language related to provider 34
service network reimbursement; amending s. 409.973, 35
F.S.; providing for dental services benefits; 36
requiring healthy behaviors programs to address 37
tobacco use and opioid abuse; removing obsolete 38
language related to primary care appointments; 39
requiring managed care plans to establish certain 40
programs to improve dental health outcomes; requiring 41
the agency to establish performance and outcome 42
measures; removing a requirement to provide dental 43
benefits separate from the Medicaid managed medical 44
assistance program; amending s. 409.974, F.S.; 45
establishing numbers of regional contract awards in 46
the Medicaid managed medical assistance program; 47
amending s. 409.975, F.S.; requiring the agency to 48
assess managed care plan compliance with certain 49
requirements at least quarterly; specifying that 50
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certain cancer hospitals are statewide essential 51
providers; establishing c ertain payments for such 52
cancer hospitals; amending s. 409.977, F.S.; 53
prohibiting the agency from automatically enrolling 54
recipients in managed care plans under certain 55
circumstances; removing obsolete language related to 56
automatic enrollment and certain f ederal approvals; 57
providing that children receiving guardianship 58
assistance payments are eligible for a specialty plan; 59
amending s. 409.981, F.S.; specifying the number of 60
regional contract awards in the long -term care managed 61
care plan; making a conformin g change; amending ss. 62
409.8132 and 409.906, F.S.; conforming cross -63
references; providing an effective date. 64
65
Be It Enacted by the Legislature of the State of Florida: 66
67
Section 1. Subsection (26) of section 409.908, Florida 68
Statutes, is amended to read: 69
409.908 Reimbursement of Medicaid providers. —Subject to 70
specific appropriations, the agency shall reimburse Medicaid 71
providers, in accordance with state and federal law, according 72
to methodologies set forth in the rules of the agency and in 73
policy manuals and handbooks incorporated by reference therein. 74
These methodologies may include fee schedules, reimbursement 75
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methods based on cost reporting, negotiated fees, competitive 76
bidding pursuant to s. 287.057, and other mechanisms the agency 77
considers efficient and effective for purchasing services or 78
goods on behalf of recipients. If a provider is reimbursed based 79
on cost reporting and submits a cost report late and that cost 80
report would have been used to set a lower reimbursement rate 81
for a rate semester, then the provider's rate for that semester 82
shall be retroactively calculated using the new cost report, and 83
full payment at the recalculated rate shall be effected 84
retroactively. Medicare -granted extensions for filing cost 85
reports, if applicable, shall also apply to Medicaid cost 86
reports. Payment for Medicaid compensable services made on 87
behalf of Medicaid-eligible persons is subject to the 88
availability of moneys and any limitations or directions 89
provided for in the General Appropriations Act or chapter 216. 90
Further, nothing in this section shall be construed to prevent 91
or limit the agency from adjusting fees, reimbursement rates, 92
lengths of stay, number of visits, or number of services, or 93
making any other adjustments necessary to comply with the 94
availability of moneys and any limitations or directions 95
provided for in the General Appropriations Act, provided the 96
adjustment is consistent with legislative intent. 97
(26) The agency may receive funds from state entities, 98
including, but not limited to, the De partment of Health, local 99
governments, and other local political subdivisions, for the 100
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purpose of making special exception payments and Low Income Pool 101
Program payments, including federal matching funds. Funds 102
received for this purpose shall be separately accounted for and 103
may not be commingled with other state or local funds in any 104
manner. The agency may certify all local governmental funds used 105
as state match under Title XIX of the Social Security Act to the 106
extent and in the manner authorized under the G eneral 107
Appropriations Act and pursuant to an agreement between the 108
agency and the local governmental entity. In order for the 109
agency to certify such local governmental funds, a local 110
governmental entity must submit a final, executed letter of 111
agreement to the agency, which must be received by October 1 of 112
each fiscal year and provide the total amount of local 113
governmental funds authorized by the entity for that fiscal year 114
under the General Appropriations Act. The local governmental 115
entity shall use a certi fication form prescribed by the agency. 116
At a minimum, the certification form must identify the amount 117
being certified and describe the relationship between the 118
certifying local governmental entity and the local health care 119
provider. Local governmental fund s outlined in the letters of 120
agreement must be received by the agency no later than October 121
31 of each fiscal year in which such funds are pledged, unless 122
an alternative plan is specifically approved by the agency. To 123
be eligible for low-income pool funding or other forms of 124
supplemental payments funded by intergovernmental transfers, and 125
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in addition to any other applicable requirements, essential 126
providers identified in s. 409.975(1)(a) s. 409.975(1)(a)2. must 127
have a network offer to contract with each man aged care plan in 128
their region and essential providers identified in s. 129
409.975(1)(b) s. 409.975(1)(b)1. and 3. must have a network 130
offer to contract with each managed care plan in the state. 131
Before releasing such supplemental payments, in the event the 132
parties have not executed network contracts, the agency shall 133
determine whether such contracts are in place and evaluate the 134
parties' efforts to complete negotiations. If such efforts 135
continue to fail, the agency must withhold such supplemental 136
payments beginning no later than January 1 of each fiscal year 137
for essential providers without such contracts in place in the 138
third quarter of the fiscal year if it determines that, based 139
upon the totality of the circumstances, the essential provider 140
has negotiated with the managed care plan in bad faith. If the 141
agency determines that an essential provider has negotiated in 142
bad faith, it must notify the essential provider at least 90 143
days in advance of the start of the third quarter of the fiscal 144
year and afford the ess ential provider hearing rights in 145
accordance with chapter 120 . 146
Section 2. Subsection (1) of section 409.912, Florida 147
Statutes, is amended to read: 148
409.912 Cost-effective purchasing of health care. —The 149
agency shall purchase goods and services for Medi caid recipients 150
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in the most cost-effective manner consistent with the delivery 151
of quality medical care. To ensure that medical services are 152
effectively utilized, the agency may, in any case, require a 153
confirmation or second physician's opinion of the corre ct 154
diagnosis for purposes of authorizing future services under the 155
Medicaid program. This section does not restrict access to 156
emergency services or poststabilization care services as defined 157
in 42 C.F.R. s. 438.114. Such confirmation or second opinion 158
shall be rendered in a manner approved by the agency. The agency 159
shall maximize the use of prepaid per capita and prepaid 160
aggregate fixed-sum basis services when appropriate and other 161
alternative service delivery and reimbursement methodologies, 162
including competitive bidding pursuant to s. 287.057, designed 163
to facilitate the cost -effective purchase of a case -managed 164
continuum of care. The agency shall also require providers to 165
minimize the exposure of recipients to the need for acute 166
inpatient, custodial, and o ther institutional care and the 167
inappropriate or unnecessary use of high -cost services. The 168
agency shall contract with a vendor to monitor and evaluate the 169
clinical practice patterns of providers in order to identify 170
trends that are outside the normal prac tice patterns of a 171
provider's professional peers or the national guidelines of a 172
provider's professional association. The vendor must be able to 173
provide information and counseling to a provider whose practice 174
patterns are outside the norms, in consultation with the agency, 175
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to improve patient care and reduce inappropriate utilization. 176
The agency may mandate prior authorization, drug therapy 177
management, or disease management participation for certain 178
populations of Medicaid beneficiaries, certain drug classes , or 179
particular drugs to prevent fraud, abuse, overuse, and possible 180
dangerous drug interactions. The Pharmaceutical and Therapeutics 181
Committee shall make recommendations to the agency on drugs for 182
which prior authorization is required. The agency shall in form 183
the Pharmaceutical and Therapeutics Committee of its decisions 184
regarding drugs subject to prior authorization. The agency is 185
authorized to limit the entities it contracts with or enrolls as 186
Medicaid providers by developing a provider network through 187
provider credentialing. The agency may competitively bid single -188
source-provider contracts if procurement of goods or services 189
results in demonstrated cost savings to the state without 190
limiting access to care. The agency may limit its network based 191
on the assessment of beneficiary access to care, provider 192
availability, provider quality standards, time and distance 193
standards for access to care, the cultural competence of the 194
provider network, demographic characteristics of Medicaid 195
beneficiaries, practice and provider-to-beneficiary standards, 196
appointment wait times, beneficiary use of services, provider 197
turnover, provider profiling, provider licensure history, 198
previous program integrity investigations and findings, peer 199
review, provider Medicaid policy and bil ling compliance records, 200
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clinical and medical record audits, and other factors. Providers 201
are not entitled to enrollment in the Medicaid provider network. 202
The agency shall determine instances in which allowing Medicaid 203
beneficiaries to purchase durable med ical equipment and other 204
goods is less expensive to the Medicaid program than long -term 205
rental of the equipment or goods. The agency may establish rules 206
to facilitate purchases in lieu of long -term rentals in order to 207
protect against fraud and abuse in the Medicaid program as 208
defined in s. 409.913. The agency may seek federal waivers 209
necessary to administer these policies. 210
(1) The agency may contract with a provider service 211
network, which must may be reimbursed on a fee-for-service or 212
prepaid basis. Prepa id provider service networks shall receive 213
per-member, per-month payments. A provider service network that 214
does not choose to be a prepaid plan shall receive fee -for-215
service rates with a shared savings settlement. The fee -for-216
service option shall be availa ble to a provider service network 217
only for the first 2 years of the plan's operation or until the 218
contract year beginning September 1, 2014, whichever is later. 219
The agency shall annually conduct cost reconciliations to 220
determine the amount of cost savings achieved by fee-for-service 221
provider service networks for the dates of service in the period 222
being reconciled. Only payments for covered services for dates 223
of service within the reconciliation period and paid within 6 224
months after the last date of service in the reconciliation 225
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period shall be included. The agency shall perform the necessary 226
adjustments for the inclusion of claims incurred but not 227
reported within the reconciliation for claims that could be 228
received and paid by the agency after the 6 -month claims 229
processing time lag. The agency shall provide the results of the 230
reconciliations to the fee -for-service provider service networks 231
within 45 days after the end of the reconciliation period. The 232
fee-for-service provider service networks shall review and 233
provide written comments or a letter of concurrence to the 234
agency within 45 days after receipt of the reconciliation 235
results. This reconciliation shall be considered final. 236
(a) A provider service network which is reimbursed by the 237
agency on a prepaid ba sis shall be exempt from parts I and III 238
of chapter 641 but must comply with the solvency requirements in 239
s. 641.2261(2) and meet appropriate financial reserve, quality 240
assurance, and patient rights requirements as established by the 241
agency. 242
(b) A provider service network is a network established or 243
organized and operated by a health care provider, or group of 244
affiliated health care providers, which provides a substantial 245
proportion of the health care items and services under a 246
contract directly through t he provider or affiliated group of 247
providers and may make arrangements with physicians or other 248
health care professionals, health care institutions, or any 249
combination of such individuals or institutions to assume all or 250
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part of the financial risk on a pro spective basis for the 251
provision of basic health services by the physicians, by other 252
health professionals, or through the institutions. The health 253
care providers must have a controlling interest in the governing 254
body of the provider service network organi zation. 255
Section 3. Section 409.9124, Florida Statutes, is 256
repealed. 257
Section 4. Section 409.964, Florida Statutes, is amended 258
to read: 259
409.964 Managed care program; state plan; waivers. —The 260
Medicaid program is established as a statewide, integrate d 261
managed care program for all covered services, including long -262
term care services. The agency shall apply for and implement 263
state plan amendments or waivers of applicable federal laws and 264
regulations necessary to implement the program. Before seeking a 265
waiver, the agency shall provide public notice and the 266
opportunity for public comment and include public feedback in 267
the waiver application. The agency shall hold one public meeting 268
in each of the regions described in s. 409.966(2), and the time 269
period for public comment for each region shall end no sooner 270
than 30 days after the completion of the public meeting in that 271
region. 272
Section 5. Paragraph (f) of subsection (3) of section 273
409.966, Florida Statutes, is redesignated as paragraph (d), and 274
subsection (2), present paragraphs (a), (d), and (e) of 275
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subsection (3), and subsection (4) of that section are amended 276
to read: 277
409.966 Eligible plans; selection. — 278
(2) ELIGIBLE PLAN SELECTION. —The agency shall select a 279
limited number of eligible plans to participate in the Medicaid 280
program using invitations to negotiate in accordance with s. 281
287.057(1)(c). At least 90 days before issuing an invitation to 282
negotiate, the agency shall compile and publish a databook 283
consisting of a comprehensive set of utilization and spending 284
data consistent with actuarial rate -setting practices and 285
standards for at least the most recent 24 months 3 most recent 286
contract years consistent with the rate-setting periods for all 287
Medicaid recipients by region or county. The source of the data 288
in the report must include both historic fee-for-service claims 289
and validated data from the Medicaid Encounter Data System. The 290
report must be available in electronic form and delineate 291
utilization use by age, gender, eligibility group, geographic 292
area, and aggregate clinical risk score. The agency shall 293
conduct a single, statewide procurement, shall negotiate and 294
select plans on a regional basis, and may select plans on a 295
statewide basis if deemed the best value for the state and 296
Medicaid recipients. Plan selection separate and simultaneous 297
procurements shall be conducted in each of the following 298
regions: 299
(a) Region A, which consists of Bay, Calhoun, Esc ambia, 300
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Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, 301
Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla, Walton, 302
and Washington Counties. 303
(b) Region B, which consists of Alachua, Baker, Bradford, 304
Citrus, Clay, Columbia, Dixie, Duval, Fl agler, Gilchrist, 305
Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Nassau, 306
Putnam, St. Johns, Sumter, Suwannee, Union, and Volusia 307
Counties. 308
(c) Region C, which consists of Hardee, Highlands, 309
Hillsborough, Manatee, Pasco, Pinellas, and Polk Counties. 310
(d) Region D, which consists of Brevard, Orange, Osceola, 311
and Seminole Counties. 312
(e) Region E, which consists of Charlotte, Collier, 313
DeSoto, Glades, Hendry, Lee, and Sarasota Counties. 314
(f) Region F, which consists of Indian River, Martin, 315
Okeechobee, Palm Beach, and St. Lucie Counties. 316
(g) Region G, which consists of Broward County. 317
(h) Region H, which consists of Miami -Dade and Monroe 318
Counties. 319
(a) Region 1, which consists of Escambia, Okaloosa, Santa 320
Rosa, and Walton Counties. 321
(b) Region 2, which consists of Bay, Calhoun, Franklin, 322
Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, 323
Madison, Taylor, Wakulla, and Washington Counties. 324
(c) Region 3, which consists of Alachua, Bradford, Citrus, 325
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Columbia, Dixie, Gilchrist, Hamilton, Hernan do, Lafayette, Lake, 326
Levy, Marion, Putnam, Sumter, Suwannee, and Union Counties. 327
(d) Region 4, which consists of Baker, Clay, Duval, 328
Flagler, Nassau, St. Johns, and Volusia Counties. 329
(e) Region 5, which consists of Pasco and Pinellas 330
Counties. 331
(f) Region 6, which consists of Hardee, Highlands, 332
Hillsborough, Manatee, and Polk Counties. 333
(g) Region 7, which consists of Brevard, Orange, Osceola, 334
and Seminole Counties. 335
(h) Region 8, which consists of Charlotte, Collier, 336
DeSoto, Glades, Hendry, Lee, and Sarasota Counties. 337
(i) Region 9, which consists of Indian River, Martin, 338
Okeechobee, Palm Beach, and St. Lucie Counties. 339
(j) Region 10, which consists of Broward County. 340
(k) Region 11, which consists of Miami -Dade and Monroe 341
Counties. 342
(3) QUALITY SELECTION CRITERIA.— 343
(a) The invitation to negotiate must specify the criteria 344
and the relative weight of the criteria that will be used for 345
determining the acceptability of the reply and guiding the 346
selection of the organizations with which the agency n egotiates. 347
In addition to criteria established by the agency, the agency 348
shall consider the following factors in the selection of 349
eligible plans: 350
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1. Accreditation by the National Committee for Quality 351
Assurance, the Joint Commission, or another nationall y 352
recognized accrediting body. 353
2. Experience serving similar populations, including the 354
organization's record in achieving specific quality standards 355
with similar populations. 356
3. Availability and accessibility of primary care and 357
specialty physicians i n the provider network. 358
4. Establishment of community partnerships with providers 359
that create opportunities for reinvestment in community -based 360
services. 361
5. Organization commitment to quality improvement and 362
documentation of achievements in specific qu ality improvement 363
projects, including active involvement by organization 364
leadership. 365
6. Provision of additional benefits, particularly dental 366
care and disease management, and other initiatives that improve 367
health outcomes. 368
7. Evidence that an eligible plan has obtained signed 369
contracts or written agreements or signed contracts or has made 370
substantial progress in establishing relationships with 371
providers before the plan submits submitting a response. 372
8. Comments submitted in writing by any enrolled Medicaid 373
provider relating to a specifically identified plan 374
participating in the procurement in the same region as the 375
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submitting provider. 376
9. Documentation of policies and procedures for preventing 377
fraud and abuse. 378
10. The business relationship an eligible plan has with 379
any other eligible plan that responds to the invitation to 380
negotiate. 381
(d) For the first year of the first contract term, the 382
agency shall negotiate capitation rates or fee for service 383
payments with each plan in order to guarantee aggregate savings 384
of at least 5 percent. 385
1. For prepaid plans, determination of the amount of 386
savings shall be calculated by comparison to the Medicaid rates 387
that the agency paid managed care plans for simil ar populations 388
in the same areas in the prior year. In regions containing no 389
prepaid plans in the prior year, determination of the amount of 390
savings shall be calculated by comparison to the Medicaid rates 391
established and certified for those regions in the prior year. 392
2. For provider service networks operating on a fee -for-393
service basis, determination of the amount of savings shall be 394
calculated by comparison to the Medicaid rates that the agency 395
paid on a fee-for-service basis for the same services in the 396
prior year. 397
(e) To ensure managed care plan participation in Regions 1 398
and 2, the agency shall award an additional contract to each 399
plan with a contract award in Region 1 or Region 2. Such 400
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contract shall be in any other region in which the plan 401
submitted a responsive bid and negotiates a rate acceptable to 402
the agency. If a plan that is awarded an additional contract 403
pursuant to this paragraph is subject to penalties pursuant to 404
s. 409.967(2)(i) for activities in Region 1 or Region 2, the 405
additional contract is automatically terminated 180 days after 406
the imposition of the penalties. the plan must reimburse the 407
agency for the cost of enrollment changes and other transition 408
activities. 409
(4) ADMINISTRATIVE CHALLENGE. —Any eligible plan that 410
participates in an invitation to negotiate in more than one 411
region and is selected in at least one region may not begin 412
serving Medicaid recipients in any region for which it was 413
selected until all administrative challenges to procurements 414
required by this section to which the eligible plan is a party 415
have been finalized. If the number of plans selected is less 416
than the maximum amount of plans permitted in the region, the 417
agency may contract with other selected plans in the region not 418
participating in the administrative chal lenge before resolution 419
of the administrative challenge. For purposes of this 420
subsection, an administrative challenge is finalized if an order 421
granting voluntary dismissal with prejudice has been entered by 422
any court established under Article V of the Stat e Constitution 423
or by the Division of Administrative Hearings, a final order has 424
been entered into by the agency and the deadline for appeal has 425
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expired, a final order has been entered by the First District 426
Court of Appeal and the time to seek any available review by the 427
Florida Supreme Court has expired, or a final order has been 428
entered by the Florida Supreme Court and a warrant has been 429
issued. 430
Section 6. Paragraphs (c) and (f) of subsection (2) and 431
paragraph (b) of subsection (4) of section 409.967, Florida 432
Statutes, are amended, and paragraph (k) is added to subsection 433
(3) of that section, to read: 434
409.967 Managed care plan accountability. — 435
(2) The agency shall establish such contract requirements 436
as are necessary for the operation of the statewi de managed care 437
program. In addition to any other provisions the agency may deem 438
necessary, the contract must require: 439
(c) Access.— 440
1. The agency shall establish specific standards for the 441
number, type, and regional distribution of providers in managed 442
care plan networks to ensure access to care for both adults and 443
children. Each plan must maintain a regionwide network of 444
providers in sufficient numbers to meet the access standards for 445
specific medical services for all recipients enrolled in the 446
plan. The exclusive use of mail -order pharmacies may not be 447
sufficient to meet network access standards. Consistent with the 448
standards established by the agency, provider networks may 449
include providers located outside the region. A plan may 450
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contract with a new ho spital facility before the date the 451
hospital becomes operational if the hospital has commenced 452
construction, will be licensed and operational by January 1, 453
2013, and a final order has issued in any civil or 454
administrative challenge. Each plan shall establi sh and maintain 455
an accurate and complete electronic database of contracted 456
providers, including information about licensure or 457
registration, locations and hours of operation, specialty 458
credentials and other certifications, specific performance 459
indicators, and such other information as the agency deems 460
necessary. The database must be available online to both the 461
agency and the public and have the capability to compare the 462
availability of providers to network adequacy standards and to 463
accept and display feedb ack from each provider's patients. Each 464
plan shall submit quarterly reports to the agency identifying 465
the number of enrollees assigned to each primary care provider. 466
The agency shall conduct, or contract for, systematic and 467
continuous testing of the provid er network databases maintained 468
by each plan to confirm accuracy, confirm that behavioral health 469
providers are accepting enrollees, and confirm that enrollees 470
have timely access to all covered benefits behavioral health 471
services. 472
2. Each managed care pla n must publish any prescribed drug 473
formulary or preferred drug list on the plan's website in a 474
manner that is accessible to and searchable by enrollees and 475
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providers. The plan must update the list within 24 hours after 476
making a change. Each plan must ensur e that the prior 477
authorization process for prescribed drugs is readily accessible 478
to health care providers, including posting appropriate contact 479
information on its website and providing timely responses to 480
providers. For Medicaid recipients diagnosed with hemophilia who 481
have been prescribed anti -hemophilic-factor replacement 482
products, the agency shall provide for those products and 483
hemophilia overlay services through the agency's hemophilia 484
disease management program. 485
3. Managed care plans, and their fis cal agents or 486
intermediaries, must accept prior authorization requests for any 487
service electronically. 488
4. Managed care plans serving children in the care and 489
custody of the Department of Children and Families must maintain 490
complete medical, dental, and b ehavioral health encounter 491
information and participate in making such information available 492
to the department or the applicable contracted community -based 493
care lead agency for use in providing comprehensive and 494
coordinated case management. The agency and t he department shall 495
establish an interagency agreement to provide guidance for the 496
format, confidentiality, recipient, scope, and method of 497
information to be made available and the deadlines for 498
submission of the data. The scope of information available to 499
the department shall be the data that managed care plans are 500
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required to submit to the agency. The agency shall determine the 501
plan's compliance with standards for access to medical, dental, 502
and behavioral health services; the use of medications; and 503
followup on all medically necessary services recommended as a 504
result of early and periodic screening, diagnosis, and 505
treatment. 506
(f) Continuous improvement. —The agency shall establish 507
specific performance standards and expected milestones or 508
timelines for improving performance over the term of the 509
contract. 510
1. Each managed care plan shall establish an internal 511
health care quality improvement system, including enrollee 512
satisfaction and disenrollment surveys. The quality improvement 513
system must include incentiv es and disincentives for network 514
providers. 515
2. Each plan must collect and report the Health Plan 516
Employer Data and Information Set (HEDIS) measures, as specified 517
by the agency. These measures must be published on the plan's 518
website in a manner that allow s recipients to reliably compare 519
the performance of plans. The agency shall use the HEDIS 520
measures as a tool to monitor plan performance. 521
3. Each managed care plan must be accredited by the 522
National Committee for Quality Assurance, the Joint Commission, 523
or another nationally recognized accrediting body, or have 524
initiated the accreditation process, within 1 year after the 525
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contract is executed. For any plan not accredited within 18 526
months after executing the contract, the agency shall suspend 527
automatic assignment under s. 409.977 and 409.984. 528
4. By the end of the fourth year of the first contract 529
term, the agency shall issue a request for information to 530
determine whether cost savings could be achieved by contracting 531
for plan oversight and monitoring, inclu ding analysis of 532
encounter data, assessment of performance measures, and 533
compliance with other contractual requirements. 534
(3) ACHIEVED SAVINGS REBATE. — 535
(k) Plans that contribute funds pursuant to paragraph 536
(4)(b) or paragraph (4)(c) may reduce the rebat e owed by an 537
amount equal to the amount of the contribution. 538
(4) MEDICAL LOSS RATIO. —If required as a condition of a 539
waiver, the agency may calculate a medical loss ratio for 540
managed care plans. The calculation shall use uniform financial 541
data collected from all plans and shall be computed for each 542
plan on a statewide basis. The method for calculating the 543
medical loss ratio shall meet the following criteria: 544
(b) Funds provided by plans to graduate medical education 545
institutions to underwrite the costs o f residency positions in 546
graduate medical education programs, undergraduate and graduate 547
student positions in nursing education programs, or student 548
positions in any degree or technical program deemed a critical 549
shortage area by the agency shall be classified as medical 550
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expenditures, provided that the funding is sufficient to sustain 551
the positions for the number of years necessary to complete the 552
program residency requirements and the residency or student 553
positions funded by the plans are actively involved in the 554
institution's provision active providers of care to Medicaid and 555
uninsured patients. 556
Section 7. Subsection (2) of section 409.968, Florida 557
Statutes, is amended to read: 558
409.968 Managed care plan payments. — 559
(2) Provider service networks may b e prepaid plans and 560
receive per-member, per-month payments negotiated pursuant to 561
the procurement process described in s. 409.966. Provider 562
service networks that choose not to be prepaid plans shall 563
receive fee-for-service rates with a shared savings settl ement. 564
The fee-for-service option shall be available to a provider 565
service network only for the first 2 years of its operation. The 566
agency shall annually conduct cost reconciliations to determine 567
the amount of cost savings achieved by fee -for-service provider 568
service networks for the dates of service within the period 569
being reconciled. Only payments for covered services for dates 570
of service within the reconciliation period and paid within 6 571
months after the last date of service in the reconciliation 572
period must be included. The agency shall perform the necessary 573
adjustments for the inclusion of claims incurred but not 574
reported within the reconciliation period for claims that could 575
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be received and paid by the agency after the 6 -month claims 576
processing time lag. The agency shall provide the results of the 577
reconciliations to the fee -for-service provider service networks 578
within 45 days after the end of the reconciliation period. The 579
fee-for-service provider service networks shall review and 580
provide written commen ts or a letter of concurrence to the 581
agency within 45 days after receipt of the reconciliation 582
results. This reconciliation is considered final. 583
Section 8. Paragraphs (e) through (bb) of subsection (1) 584
of section 409.973, Florida Statutes, are redesign ated as 585
paragraphs (f) through (cc), respectively, subsection (3), 586
paragraph (b) of subsection (4), and subsection (5) are amended, 587
and a new paragraph (e) is added to subsection (1) of that 588
section, to read: 589
409.973 Benefits.— 590
(1) MINIMUM BENEFITS.—Managed care plans shall cover, at a 591
minimum, the following services: 592
(e) Dental services. 593
(3) HEALTHY BEHAVIORS. —Each plan operating in the managed 594
medical assistance program shall establish a program to 595
encourage and reward healthy behavior s. At a minimum, each plan 596
must establish a medically approved tobacco use smoking 597
cessation program, a medically directed weight loss program, and 598
a medically approved alcohol or substance abuse recovery 599
program, which shall include, at a minimum, a focus on opioid 600
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abuse recovery. Each plan must identify enrollees who use 601
tobacco smoke, are morbidly obese, or are diagnosed with alcohol 602
or substance abuse in order to establish written agreements to 603
secure the enrollees' commitment to participation in these 604
programs. 605
(4) PRIMARY CARE INITIATIVE. —Each plan operating in the 606
managed medical assistance program shall establish a program to 607
encourage enrollees to establish a relationship with their 608
primary care provider . Each plan shall: 609
(b) If the enrollee was not a Medicaid recipient before 610
enrollment in the plan, assist the enrollee in scheduling an 611
appointment with the primary care provider. If possible the 612
appointment should be made within 30 days after enrollment in 613
the plan. For enrollees who become eligible for Medicaid between 614
January 1, 2014, and December 31, 2015, the appointment should 615
be scheduled within 6 months after enrollment in the plan. 616
(5) DENTAL PERFORMANCE IMPROVEMENT. —Given the effect of 617
oral health on overall health, each plan shall establish a 618
program to improve dental health outcomes and increase 619
utilization of preventive dental services. The agency shall 620
establish performance and outcome measures, regularly assess 621
plan performance, and publis h data on such measures. Program 622
components shall, at a minimum, include: 623
(a) An education program to inform enrollees of the 624
connection between oral health and overall health and preventive 625
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steps to improve dental health. 626
(b) An enrollee incentive pro gram designed to increase 627
utilization of preventive dental services. PROVISION OF DENTAL 628
SERVICES.— 629
(a) The Legislature may use the findings of the Office of 630
Program Policy Analysis and Government Accountability's report 631
no. 16-07, December 2016, in sett ing the scope of minimum 632
benefits set forth in this section for future procurements of 633
eligible plans as described in s. 409.966. Specifically, the 634
decision to include dental services as a minimum benefit under 635
this section, or to provide Medicaid recipien ts with dental 636
benefits separate from the Medicaid managed medical assistance 637
program described in this part, may take into consideration the 638
data and findings of the report. 639
(b) In the event the Legislature takes no action before 640
July 1, 2017, with resp ect to the report findings required under 641
paragraph (a), the agency shall implement a statewide Medicaid 642
prepaid dental health program for children and adults with a 643
choice of at least two licensed dental managed care providers 644
who must have substantial ex perience in providing dental care to 645
Medicaid enrollees and children eligible for medical assistance 646
under Title XXI of the Social Security Act and who meet all 647
agency standards and requirements. To qualify as a provider 648
under the prepaid dental health pro gram, the entity must be 649
licensed as a prepaid limited health service organization under 650
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part I of chapter 636 or as a health maintenance organization 651
under part I of chapter 641. The contracts for program providers 652
shall be awarded through a competitive p rocurement process. 653
Beginning with the contract procurement process initiated during 654
the 2023 calendar year, the contracts must be for 6 years and 655
may not be renewed; however, the agency may extend the term of a 656
plan contract to cover delays during a trans ition to a new plan 657
provider. The agency shall include in the contracts a medical 658
loss ratio provision consistent with s. 409.967(4). The agency 659
is authorized to seek any necessary state plan amendment or 660
federal waiver to commence enrollment in the Medica id prepaid 661
dental health program no later than March 1, 2019. The agency 662
shall extend until December 31, 2024, the term of existing plan 663
contracts awarded pursuant to the invitation to negotiate 664
published in October 2017. 665
Section 9. Subsections (1) and (2) of section 409.974, 666
Florida Statutes, are amended to read: 667
409.974 Eligible plans. — 668
(1) ELIGIBLE PLAN SELECTION. —The agency shall select 669
eligible plans for the managed medical assistance program 670
through the procurement process described in s. 409. 966. The 671
agency shall select at least one provider service network for 672
each region, if any submit a responsive bid. The agency shall 673
procure the number of plans, inclusive of statewide plans, if 674
any, for each region as follows: 675
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(a) At least three plans a nd up to four plans for Region 676
A. 677
(b) At least five plans and up to six plans for Region B. 678
(c) At least six plans and up to ten plans for Region C. 679
(d) At least five plans and up to six plans for Region D. 680
(e) At least three plans and up to four p lans for Region 681
E. 682
(f) At least three plans and up to five plans for Region 683
F. 684
(g) At least three plans and up to five plans for Region 685
G. 686
(h) At least five plans and up to ten plans for Region H 687
The agency shall notice invitations to negotiate no la ter than 688
January 1, 2013. 689
(a) The agency shall procure two plans for Region 1. At 690
least one plan shall be a provider service network if any 691
provider service networks submit a responsive bid. 692
(b) The agency shall procure two plans for Region 2. At 693
least one plan shall be a provider service network if any 694
provider service networks submit a responsive bid. 695
(c) The agency shall procure at least three plans and up 696
to five plans for Region 3. At least one plan must be a provider 697
service network if any provi der service networks submit a 698
responsive bid. 699
(d) The agency shall procure at least three plans and up 700
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to five plans for Region 4. At least one plan must be a provider 701
service network if any provider service networks submit a 702
responsive bid. 703
(e) The agency shall procure at least two plans and up to 704
four plans for Region 5. At least one plan must be a provider 705
service network if any provider service networks submit a 706
responsive bid. 707
(f) The agency shall procure at least four plans and up to 708
seven plans for Region 6. At least one plan must be a provider 709
service network if any provider service networks submit a 710
responsive bid. 711
(g) The agency shall procure at least three plans and up 712
to six plans for Region 7. At least one plan must be a provider 713
service network if any provider service networks submit a 714
responsive bid. 715
(h) The agency shall procure at least two plans and up to 716
four plans for Region 8. At least one plan must be a provider 717
service network if any provider service networks submit a 718
responsive bid. 719
(i) The agency shall procure at least two plans and up to 720
four plans for Region 9. At least one plan must be a provider 721
service network if any provider service networks submit a 722
responsive bid. 723
(j) The agency shall procure at least two plans and up to 724
four plans for Region 10. At least one plan must be a provider 725
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service network if any provider service networks submit a 726
responsive bid. 727
(k) The agency shall procure at least five plans and up to 728
10 plans for Region 11. At least one plan must be a provider 729
service network if any provider service networks submit a 730
responsive bid. 731
732
If no provider service network submits a responsive bid, the 733
agency shall procure no more than one less than the maximum 734
number of eligible plans permitted in tha t region. Within 12 735
months after the initial invitation to negotiate, the agency 736
shall attempt to procure a provider service network. The agency 737
shall notice another invitation to negotiate only with provider 738
service networks in those regions where no prov ider service 739
network has been selected. 740
(2) QUALITY SELECTION CRITERIA. —In addition to the 741
criteria established in s. 409.966, the agency shall consider 742
evidence that an eligible plan has obtained signed contracts or 743
written agreements or signed contract s or has made substantial 744
progress in establishing relationships with providers before the 745
plan submits submitting a response. The agency shall evaluate 746
and give special weight to evidence of signed contracts with 747
essential providers as defined by the agen cy pursuant to s. 748
409.975(1). The agency shall exercise a preference for plans 749
with a provider network in which over 10 percent of the 750
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providers use electronic health records, as defined in s. 751
408.051. When all other factors are equal, the agency shall 752
consider whether the organization has a contract to provide 753
managed long-term care services in the same region and shall 754
exercise a preference for such plans. 755
Section 10. Paragraphs (a) and (b) of subsection (1) of 756
section 409.975, Florida Statutes, are a mended to read: 757
409.975 Managed care plan accountability. —In addition to 758
the requirements of s. 409.967, plans and providers 759
participating in the managed medical assistance program shall 760
comply with the requirements of this section. 761
(1) PROVIDER NETWOR KS.—Managed care plans must develop and 762
maintain provider networks that meet the medical needs of their 763
enrollees in accordance with standards established pursuant to 764
s. 409.967(2)(c). Except as provided in this section, managed 765
care plans may limit the pr oviders in their networks based on 766
credentials, quality indicators, and price. 767
(a) Plans must include all providers in the region that 768
are classified by the agency as essential Medicaid providers, 769
unless the agency approves, in writing, an alternative 770
arrangement for securing the types of services offered by the 771
essential providers. The agency shall assess plan compliance 772
with such requirement at least quarterly. Providers are 773
essential for serving Medicaid enrollees if they offer services 774
that are not available from any other provider within a 775
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reasonable access standard, or if they provided a substantial 776
share of the total units of a particular service used by 777
Medicaid patients within the region during the last 3 years and 778
the combined capacity of other s ervice providers in the region 779
is insufficient to meet the total needs of the Medicaid 780
patients. The agency may not classify physicians and other 781
practitioners as essential providers. The agency, at a minimum, 782
shall determine which providers in the followi ng categories are 783
essential Medicaid providers: 784
1. Federally qualified health centers. 785
2. Statutory teaching hospitals as defined in s. 786
408.07(46). 787
3. Hospitals that are trauma centers as defined in s. 788
395.4001(15). 789
4. Hospitals located at least 25 miles from any other 790
hospital with similar services. 791
792
Managed care plans that have not contracted with all essential 793
providers in the region as of the first date of recipient 794
enrollment, or with whom an essential provider has terminated 795
its contract, must negotiate in good faith with such essential 796
providers for 1 year or until an agreement is reached, whichever 797
is first. Payments for services rendered by a nonparticipating 798
essential provider shall be made at the applicable Medicaid rate 799
as of the first day of the contract between the agency and the 800
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plan. A rate schedule for all essential providers shall be 801
attached to the contract between the agency and the plan. After 802
1 year, managed care plans that are unable to contract with 803
essential providers shall no tify the agency and propose an 804
alternative arrangement for securing the essential services for 805
Medicaid enrollees. The arrangement must rely on contracts with 806
other participating providers, regardless of whether those 807
providers are located within the same region as the 808
nonparticipating essential service provider. If the alternative 809
arrangement is approved by the agency, payments to 810
nonparticipating essential providers after the date of the 811
agency's approval shall equal 90 percent of the applicable 812
Medicaid rate. Except for payment for emergency services, if the 813
alternative arrangement is not approved by the agency, payment 814
to nonparticipating essential providers shall equal 110 percent 815
of the applicable Medicaid rate. 816
(b) Certain providers are statewide re sources and 817
essential providers for all managed care plans in all regions. 818
All managed care plans must include these essential providers in 819
their networks. The agency shall assess plan compliance with 820
such requirement at least quarterly. Statewide essential 821
providers include: 822
1. Faculty plans of Florida medical schools. 823
2. Regional perinatal intensive care centers as defined in 824
s. 383.16(2). 825
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3. Hospitals licensed as specialty children's hospitals as 826
defined in s. 395.002(28). 827
4. Accredited and integ rated systems serving medically 828
complex children which comprise separately licensed, but 829
commonly owned, health care providers delivering at least the 830
following services: medical group home, in -home and outpatient 831
nursing care and therapies, pharmacy servi ces, durable medical 832
equipment, and Prescribed Pediatric Extended Care. 833
5. Florida cancer hospitals that meet the criteria in 42 834
U.S.C. s. 1395ww(d)(1)(B)(v). 835
836
Managed care plans that have not contracted with all statewide 837
essential providers in all regi ons as of the first date of 838
recipient enrollment must continue to negotiate in good faith. 839
Payments to physicians on the faculty of nonparticipating 840
Florida medical schools shall be made at the applicable Medicaid 841
rate. Payments for services rendered by re gional perinatal 842
intensive care centers shall be made at the applicable Medicaid 843
rate as of the first day of the contract between the agency and 844
the plan. Except for payments for emergency services, payments 845
to nonparticipating specialty children's hospita ls shall equal 846
the highest rate established by contract between that provider 847
and any other Medicaid managed care plan. Payments for services 848
rendered by Florida cancer hospitals that meet the criteria in 849
42 U.S.C. s. 1395ww(d)(1)(B)(v) shall be made at th e applicable 850
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Medicaid rate as of the first day of the contract between the 851
agency and the plan. 852
Section 11. Subsections (1), (4), and (5) of section 853
409.977, Florida Statutes, are amended to read: 854
409.977 Enrollment. — 855
(1) The agency shall automatic ally enroll into a managed 856
care plan those Medicaid recipients who do not voluntarily 857
choose a plan pursuant to s. 409.969. The agency shall 858
automatically enroll recipients in plans that meet or exceed the 859
performance or quality standards established pursu ant to s. 860
409.967 and may not automatically enroll recipients in a plan 861
that is deficient in those performance or quality standards. 862
When a specialty plan is available to accommodate a specific 863
condition or diagnosis of a recipient, the agency shall assign 864
the recipient to that plan. The agency may not automatically 865
enroll recipients in a managed medical assistance plan that has 866
more than 45 percent of the enrollees in the region. In the 867
first year of the first contract term only, if a recipient was 868
previously enrolled in a plan that is still available in the 869
region, the agency shall automatically enroll the recipient in 870
that plan unless an applicable specialty plan is available. 871
Except as otherwise provided in this part, the agency may not 872
engage in practices that are designed to favor one managed care 873
plan over another. 874
(4) The agency shall develop a process to enable a 875
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recipient with access to employer -sponsored health care coverage 876
to opt out of all managed care plans and to use Medicaid 877
financial assistance to pay for the recipient's share of the 878
cost in such employer -sponsored coverage. Contingent upon 879
federal approval, The agency shall also enable recipients with 880
access to other insurance or related products providing access 881
to health care services cr eated pursuant to state law, including 882
any product available under the Florida Health Choices Program, 883
or any health exchange, to opt out. The amount of financial 884
assistance provided for each recipient may not exceed the amount 885
of the Medicaid premium that would have been paid to a managed 886
care plan for that recipient. The agency shall seek federal 887
approval to require Medicaid recipients with access to employer -888
sponsored health care coverage to enroll in that coverage and 889
use Medicaid financial assistance to pay for the recipient's 890
share of the cost for such coverage. The amount of financial 891
assistance provided for each recipient may not exceed the amount 892
of the Medicaid premium that would have been paid to a managed 893
care plan for that recipient. 894
(5) Specialty plans serving children in the care and 895
custody of the department may serve such children as long as 896
they remain in care, including those remaining in extended 897
foster care pursuant to s. 39.6251, or are in subsidized 898
adoption and continue to be eligible for Medicaid pursuant to s. 899
409.903, or are receiving guardianship assistance payments and 900
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continue to be eligible for Medicaid pursuant to s. 409.903 . 901
Section 12. Subsection (2) of section 409.981, Florida 902
Statutes, is amended to read: 903
409.981 Eligible long -term care plans.— 904
(2) ELIGIBLE PLAN SELECTION. —The agency shall select 905
eligible plans for the long-term care managed care program 906
through the procurement process described in s. 409.966. The 907
agency shall select at least one provider service network for 908
each region, if any provider service network submits a 909
responsive bid. The agency shall procure the number of plans, 910
inclusive of statewide plans, if any, for each region as 911
follows: 912
(a) At least three plans and up to four plans for Region 913
A. 914
(b) At least three plans and up to six plans for Region B. 915
(c) At least five plans and up to ten plans for Region C. 916
(d) At least three plans and up to six plans for Region D. 917
(e) At least three plans and up to four plans for Region 918
E. 919
(f) At least three plans and up to five plans for Region 920
F. 921
(g) At least three plans and up to four plans for Regi on 922
G. 923
(h) At least five plans and up to ten plans for Region H. 924
(a) Two plans for Region 1. At least one plan must be a 925
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provider service network if any provider service networks submit 926
a responsive bid. 927
(b) Two plans for Region 2. At least one plan m ust be a 928
provider service network if any provider service networks submit 929
a responsive bid. 930
(c) At least three plans and up to five plans for Region 931
3. At least one plan must be a provider service network if any 932
provider service networks submit a respons ive bid. 933
(d) At least three plans and up to five plans for Region 934
4. At least one plan must be a provider service network if any 935
provider service network submits a responsive bid. 936
(e) At least two plans and up to four plans for Region 5. 937
At least one plan must be a provider service network if any 938
provider service networks submit a responsive bid. 939
(f) At least four plans and up to seven plans for Region 940
6. At least one plan must be a provider service network if any 941
provider service networks submit a re sponsive bid. 942
(g) At least three plans and up to six plans for Region 7. 943
At least one plan must be a provider service network if any 944
provider service networks submit a responsive bid. 945
(h) At least two plans and up to four plans for Region 8. 946
At least one plan must be a provider service network if any 947
provider service networks submit a responsive bid. 948
(i) At least two plans and up to four plans for Region 9. 949
At least one plan must be a provider service network if any 950
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provider service networks submit a responsive bid. 951
(j) At least two plans and up to four plans for Region 10. 952
At least one plan must be a provider service network if any 953
provider service networks submit a responsive bid. 954
(k) At least five plans and up to 10 plans for Region 11. 955
At least one plan must be a provider service network if any 956
provider service networks submit a responsive bid. 957
958
If no provider service network submits a responsive bid in a 959
region other than Region A 1 or Region 2, the agency shall 960
procure no more than one fewer less than the maximum number of 961
eligible plans permitted in that region. Within 12 months after 962
the initial invitation to negotiate, the agency shall attempt to 963
procure a provider service network. The agency shall notice 964
another invitation to negotiate only with provider service 965
networks in regions where no provider service network has been 966
selected. 967
Section 13. Subsection (4) of section 409.8132, Florida 968
Statutes, is amended to read: 969
409.8132 Medikids program component. — 970
(4) APPLICABILITY OF LAWS RE LATING TO MEDICAID.—The 971
provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908, 972
409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127, 973
409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205 apply 974
to the administration of the Medikids program component of the 975
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Florida Kidcare program, except that s. 409.9122 applies to 976
Medikids as modified by the provisions of subsection (7). 977
Section 14. Paragraph (d) of subsection (13) of section 978
409.906, Florida Statutes, is amended to read: 979
409.906 Optional Medicaid services. —Subject to specific 980
appropriations, the agency may make payments for services which 981
are optional to the state under Title XIX of the Social Security 982
Act and are furnished by Medicaid providers to recipients who 983
are determined to be eligible on the dates on which the services 984
were provided. Any optional service that is provided shall be 985
provided only when medically necessary and in accordance with 986
state and federal law. Optional services rendered by providers 987
in mobile units to Medicaid recipients may be restricted or 988
prohibited by the agency. Nothing in this section shall be 989
construed to prevent or limit the agency from adjusting fees, 990
reimbursement rates, lengths of stay, number of visits, or 991
number of services, or making any o ther adjustments necessary to 992
comply with the availability of moneys and any limitations or 993
directions provided for in the General Appropriations Act or 994
chapter 216. If necessary to safeguard the state's systems of 995
providing services to elderly and disable d persons and subject 996
to the notice and review provisions of s. 216.177, the Governor 997
may direct the Agency for Health Care Administration to amend 998
the Medicaid state plan to delete the optional Medicaid service 999
known as "Intermediate Care Facilities for t he Developmentally 1000
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Disabled." Optional services may include: 1001
(13) HOME AND COMMUNITY -BASED SERVICES.— 1002
(d) The agency shall seek federal approval to pay for 1003
flexible services for persons with severe mental illness or 1004
substance use disorders, including, but not limited to, 1005
temporary housing assistance. Payments may be made as enhanced 1006
capitation rates or incentive payments to managed care plans 1007
that meet the requirements of s. 409.968(3) s. 409.968(4). 1008
Section 15. This act shall take effect July 1, 2022. 1009