This document does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h7047z.FFS.DOCX
DATE: 3/28/2022
HOUSE OF REPRESENTATIVES STAFF FINAL BILL ANALYSIS
BILL #: CS/HB 7047 PCB FFS 22-01 Medicaid Managed Care
SPONSOR(S): Health & Human Services Committee and Finance & Facilities Subcommittee, Garrison
TIED BILLS: IDEN./SIM. BILLS:
FINAL HOUSE FLOOR ACTION: 115 Y’s
0 N’s GOVERNOR’S ACTION: Pending
SUMMARY ANALYSIS
CS/HB 7047 passed the House on March 8, 2022, as CS/CS/SB 1950, as amended, and was returned to the
Senate. On March 11, 2022, the Senate concurred in the House amendment, as amended by the Senate, and
returned the bill to the House. The House concurred in the amendment, as amended by the Senate, and
subsequently passed the bill, as amended, on March 11, 2022.
Medicaid is the health care safety net for low-income Floridians. Medicaid is a partnership of the federal and
state governments established to provide coverage for health services for eligible persons. The program is
administered by the Agency for Health Care Administration (AHCA) and financed by federal and state funds.
Most Medicaid recipients receive services in a managed care model: the Statewide Medicaid Managed Care
(SMMC) program. The SMMC program has three components: managed medical assistance (MMA) which
provides traditional primary and acute care services; long-term care managed care (LTC), which provides
residential and home care for people eligible for nursing home care; and dental. AHCA competitively procures
contracts with managed care plans in each of 11 regions of the state to provide comprehensive health care
coverage. The bill makes changes to the SMMC program in anticipation of the next procurement cycle, for plan
year 2025. The bill:
Consolidates the 11 service regions into nine and adjusts the number of plans per region,
Requires a single statewide procurement and authorizes regional or statewide contract awards,
Removes a requirement to rebid the procurement, in part, in regions where a provider service network
does not submit a responsive bid,
Specifies procurement related data posting requirements,
Expands the Healthy Behaviors Program to include focuses on smokeless tobacco and opioid abuse,
Requires plans to contract with Florida cancer hospitals as statewide essential providers and provides a
payment rate for services provided without a contract,
Allows children in the child welfare Guardian Assistance Program to enroll in the child welfare specialty
plan as an alternative to a non-specialty plan,
Provides times for AHCA to implement specific provisions of the bill, and
Deletes obsolete provisions and makes conforming changes to reflect the bill’s requirements.
The bill will have state or no fiscal impact on local government.
Subject to the Governor’s veto powers, the effective date of the bill is July 1, 2022.
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I. SUBSTANTIVE INFORMATION
A. EFFECT OF CHANGES:
Background
Florida Medicaid
Medicaid is the health care safety net for low-income Floridians. Medicaid is a partnership of the federal
and state governments established to provide coverage for health services for eligible persons. The
program is administered by the Agency for Health Care Administration (AHCA) and financed by federal
and state funds. AHCA delegates certain functions to other state agencies, including the Department of
Children and Families (DCF), the Department of Health, the Agency for Persons with Disabilities, and
the Department of Elderly Affairs (DOEA).
The structure of each state’s Medicaid program varies and what states must pay for is largely
determined by the federal government, as a condition of receiving federal funds.
1
Federal law sets the
amount, scope, and duration of services offered in the program, among other requirements. These
federal requirements create an entitlement that comes with constitutional due process protections. The
entitlement means that two parts of the Medicaid cost equation – people and utilization – are largely
predetermined for the states. The federal government sets the minimum mandatory populations to be
included in every state Medicaid program. The federal government also sets the minimum mandatory
benefits to be covered in every state Medicaid program. These benefits include physician services,
hospital services, home health services, and family planning.
2
States can add benefits, with federal
approval. Florida has added many optional benefits, including prescription drugs, adult dental services,
and dialysis.
3
States have some flexibility in the provision of Medicaid services. Section 1915(b) of the Social Security
Act provides authority for the Secretary of the U.S. Department of Health and Human Services (HHS) to
waive requirements to the extent that he or she “finds it to be cost-effective and efficient and not
inconsistent with the purposes of this title.” Section 1115 of the Social Security Act allows states to
implement demonstrations of innovative service delivery systems that improve care, increase efficiency,
and reduce costs. These laws allow HHS to waive federal requirements to expand populations or
services, or to try new ways of service delivery.
Florida operates under a Section 1115 waiver to use a comprehensive managed care delivery model
for primary and acute care services, the Statewide Medicaid Managed Care (SMMC) Managed Medical
Assistance (MMA) program. Florida also has a waiver under Sections 1915(b) and (c) of the Social
Security Act to operate the SMMC Long-Term Care (LTC) program.
4
Florida Medicaid does not cover all low-income Floridians. Current eligibility prioritizes low-income
children, disabled persons, and elders, and sets income eligibility by reference to the annual federal
poverty level. Some clinical eligibility provisions apply, as well.
The Florida Medicaid program covers approximately 5 million low-income individuals, including
approximately 2.5 million, or 58.4%, of the children in Florida.
5
Medicaid is the second largest single
program in the state, behind public education, representing approximately one-third of the total FY
1
Title 42 U.S.C. §§ 1396-1396w-5; Title 42 C.F.R. Part 430-456 (§§ 430.0-456.725) (2016).
2
S. 409.905, F.S.
3
S. 409.906, F.S.
4
S. 409.964, F.S.
5
Agency for Health Care Administration, Florida Statewide Medicaid Monthly Enrollment Report, December 2021,
available at https://ahca.myflorida.com/medicaid/Finance/data_analytics/enrollment_report/index.shtml (last visited
January 18, 2022). United States Census Bureau, QuickFacts, Florida,
https://www.census.gov/quickfacts/fact/table/FL/PST045221 (last visited January 18, 2022).
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2021-2022 state budget.
6
As of June 2021, Florida’s program is the 4th largest in the nation by
enrollment and, for FY 2019-2020, the program is the 5th largest in terms of expenditures.
7
Statewide Medicaid Managed Care (SMMC)
Florida delivers medical assistance to most Medicaid recipients – approximately 78% - using a
comprehensive managed care model, the SMMC program.
8
The SMMC program was intended to
provide comprehensive, coordinated benefits coverage to the Medicaid population, leveraging
economic incentives to ensure provider participation and quality performance impossible under the
former, federally prescribed, fee-for-service delivery model.
The SMMC program has three components: the integrated Managed Medical Assistance (MMA)
program that provides primary care, acute care and behavioral health care services; Long-Term Care
(LTC) program
9
that provides long-term care services, including nursing facility and home and
community-based services; and the dental component.
Medicaid covers mandatory benefits prescribed by s. 409.973, F.S., for the MMA program and s.
409.98, F.S., for the LTC program, as indicated below. Managed care plans also offer an expanded
menu of optional benefits at no cost to the state.
Mandatory Benefits - Statewide Medicaid Managed Care
Managed Medical Assistance Long-Term Care
Advanced registered nurse practitioner services Nursing facility care
Ambulatory surgical treatment center services Services provided in an ALF
Birthing center services Hospice
Chiropractic services Adult day care
Dental services Personal care
Early periodic screening diagnosis & treatment (age<21) Home accessibility adaption
Emergency services Behavior management
Family planning services and supplies Home-delivered meals
Healthy Start services (with exceptions) Case management
Hearing services Therapies
Home health agency services Occupational therapy
Hospice services Speech therapy
Hospital inpatient services Respiratory therapy
Hospital outpatient services Physical therapy
Laboratory and imaging services Intermittent and skilled nursing
Medical supplies, equipment, prostheses, and orthoses Medication administration
Mental health services Medication management
Nursing care Nutritional assessment & risk reduction
Optical services and supplies Caregiver training
Optometrist services Respite care
Physical, occupational, respiratory, speech therapies Personal emergency response system
Physician services, including PA Transportation
Podiatric services Medical equipment and supplies
6
Ch. 2020-111, L.O.F. See also Fiscal Analysis in Brief: 2021 Legislative Session, available at
http://edr.state.fl.us/content/revenues/reports/fiscal-analysis-in-brief/FiscalAnalysisinBrief2021.pdf (last visited January 6,
2022).
7
The Henry J. Kaiser Family Foundation, State Health Facts, Total Medicaid Spending FY 2020 and Total Monthly
Medicaid and CHIP Enrollment Jun. 2021, available at http://kff.org/statedata/ (last visited January 18, 2022).
8
Supra, FN 5.
9
The LTC program provides services in two settings: nursing facilities or home and community based services (HCBS)
provided in a recipient’s home, an assisted living facility, or an adult family care home. Enrollment in the LTC program is
based on a clinical priority system and includes a wait list. The state is approved for 62,000 recipients in the HCBS portion
of LTC. In order to be eligible for the program, a recipient must be both clinically eligible under s. 409.979, F.S., and
financially eligible for Medicaid under s. 409.904, F.S.
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Mandatory Benefits - Statewide Medicaid Managed Care
Managed Medical Assistance Long-Term Care
Prescription drugs
Renal dialysis services
Respiratory equipment and supplies
Rural health clinic services
Substance abuse treatment services
Transportation
The chart below shows the current enrollment in MMA and LTC.
Statewide Medicaid Managed Care Enrollment,
as of December 2021
Component Budget
10
Enrollment
11
Long-Term Care Plan $5.25 billion 122,659
Managed Medical Assistance $17.8 billion 3,982,511
Services in SMMC are delivered by two types of managed care plans: traditional managed care
organizations and provider service networks (PSNs). Traditional managed care organizations, such as
HMOs, are reimbursed as prepaid plans – they are risk-bearing entities that are paid capitated rates
(prospective, per-member, per-month payments) by AHCA. PSNs are managed care plans controlled
by health care providers, such as physician groups or hospitals. Because health care practitioners and
facilities did not previously operate managed care plans or use capitated payment arrangements,
SMMC allowed an alternative risk-bearing arrangement for PSNs.
Current law allowed PSNs to be reimbursed on a fee-for-service basis, but only for the first 2 years of
the plan’s operation or until the contract year beginning September 1, 2014, whichever was later. Under
that option, PSNs bear risk through a shared savings model. AHCA conducted cost reconciliations for
the fee-for-service PSNs to determine any savings or amounts owed by the PSN. PSNs in SMMC have
fully transitioned to risk-bearing entities, when participating. No fee-for-service PSNs remain.
SMMC Plan Procurement
The SMMC uses managed care plans to provide services to recipients – both health maintenance
organizations (HMOs) and provider service networks (PSNs), which are managed care plans majority-
owned by health care providers.
AHCA initially procured SMMC contracts in 2012 for the LTC program and 2013 for the MMA program,
completing the rollout of the first SMMC contract term in 2014. These contracts were re-procured in
2017 with implementation in 2018. In 2020, the Legislature extended the SMMC contract period from
five to six years, resulting in contract expirations in 2024.
AHCA will begin the next procurement process in 2022 for implementation in the 2025 plan year. The
following table illustrates AHCA’s proposed procurement timeline.
10
Ch. 2020-36, L.O.F.
https://www.myfloridahouse.gov/Sections/Documents/loaddoc.aspx?FileName=CRA_.pdf&DocumentType=Amendments
&BillNumber=2500&Session=2021 (last visited January 6, 2022). MMA is appropriation 210, pg. 68, and LTC is
appropriation 221, pg. 71.
11
Agency for Health Care Administration, SMMC MMA Enrollment by County by Plan (as of December 2021), available at
https://ahca.myflorida.com/medicaid/Finance/data_analytics/enrollment_report/index.shtml (last visited January 22, 2022).
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Procurement Timeline
Activity Date
Posting Date Late Fall 2022
Q&A Posting Date Winter 2023
Responses Due Spring 2023
Responses Opened Spring 2023
Evaluations Begin Late Spring 2023
Evaluations End Late Summer 2023
Negotiations Begin Fall 2023
Negotiations End Fall 2023/Winter 2024
Regional Procurement
Current law requires AHCA to competitively procure contracts with managed care plans in 11 regions of
the state. The following map illustrates the current SMMC regions.
12
Current law requires AHCA to issue a procurement in each region. To ensure recipient choice of plans
while also ensuring enrollment levels significant enough to attract bidders, ss. 409.974 and 409.981,
F.S., specifies the minimum and maximum number of plans AHCA must procure in each region for
MMA and LTC, respectively. Currently, the same ranges apply for each program. The following table
illustrates the number of plans allowed per region and the current regional enrollment for all plans, by
program type.
12
Agency for Health Care Administration, https://ahca.myflorida.com/medicaid/statewide_mc/pdf/SMMC_Region_Map.pdf
(last visited January 22, 2022).
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SMMC Enrollment, by Region
Min/Max
# Plans
MMA LTC
Region 1 2 135,670 3,471
Region 2 2 142,006 3,602
Region 3 3 to 5 349,337 8,714
Region 4 3 to 5 417,654 9,633
Region 5 2 to 4 233,032 10,688
Region 6 4 to 7 568,861 14,316
Region 7 3 to 6 537,679 10,432
Region 8 2 to 4 272,543 7,234
Region 9 2 to 4 353,458 11,349
Region 10 2 to 4 338,684 10,240
Region 11 5 to 10 605,902 32,791
To bid for a SMMC contract, managed care plans must negotiate with AHCA over proposed benefits,
rates, and provider networks. To facilitate the rate negotiations, current law requires AHCA to publish a
databook of a comprehensive set of utilization and spending data for the most recent three contract
years, including historic fee-for-service claims and validated encounter data.
13
AHCA must publish this
databook at least 90 days before issuing the procurement. Plans submitting bids will use the databook
to calculate proposed capitation rates for their bids.
MMA Plans
During the initial SMMC procurement, AHCA awarded contracts to 18 MMA plans, including seven
PSNs. By the end of the first contract period, due to various mergers, acquisitions, and HMO
conversions, only one PSN remained (South Florida Community Care Network, DBA Community Care
Plan). During the second procurement, AHCA awarded contracts to 16 plans, including five PSNs,
(Community Care Plan, Florida Community Care, Lighthouse, Miami Children’s, and Vivida) but only
three of the PSNs currently remain in the program due to mergers and acquisitions with a total of 10
health plans.
The following tables show the managed care plans currently participating in the MMA program,
including the plans that offer a comprehensive plan, and the available specialty plans.
14
MMA Standard and Comprehensive Plans, by Region
SMMC PLANS
REGION
1 2 3 4 5 6 7 8 9 10 11
MMA HEALTH PLANS
AmeriHealth Caritas X X
Community Care Plan X
Simply Healthcare X X X
Vivida Health X
13
S. 409.966(2), F.S.
14
Agency for Health Care Administration, Presentation to Finance & Facilities Subcommittee, November 3, 2021,
Medicaid Quality Updates, slide 25,
https://www.myfloridahouse.gov/Sections/Documents/loaddoc.aspx?PublicationType=Committees&CommitteeId=3090&S
ession=2022&DocumentType=Meeting+Packets&FileName=ffs+11 -3-21.pdf (last visited January 23, 2022); Agency for
Health Care Administration, Specialty Plan Management, Specialty Plan Management (myflorida.com) (last visited
January 20, 2022).
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COMPREHENSIVE PLANS (MMA and LTC Combined)
Aetna Better Health X X X
Humana Medical Plan X X X X X X X X X X X
Molina Healthcare X X
Simply Healthcare X X X X X
Sunshine Health X X X X X X X X X X X
United Healthcare X X X X
MMA Specialty Plans, by Region
SMMC PLANS
REGION
1 2 3 4 5 6 7 8 9 10 11
SPECIALTY PLANS
CMS Plan
Children with Chronic Health Conditions
X X X X X X X X X X X
Clear Health Alliance
HIV/AIDS Specialty
X X X X X X X X X X X
Molina SMI Specialty
Serious Mental Illness
X X X
Sunshine SMI Specialty
Serious Mental Illness
X X X X X X X X X X X
Sunshine Child Welfare
Child Welfare
X X X X X X X X X X X
LTC Plans
The LTC enrollees who are not eligible for Medicare also receive their medical services through an
MMA plan. Some plans participate in both components in the same regions, and a recipient may elect
the same managed care plan for both components. These plans are referred to as comprehensive
plans. The following chart shows the managed care plans that participate in the LTC program.
15
LTC Plans, by Region
SMMC PLANS
REGION
1 2 3 4 5 6 7 8 9 10 11
LONG TERM CARE PLAN
Florida Community Care X X X X X X X X X X X
COMPREHENSIVE PLANS (MMA and LTC Combined)
Aetna Better Health X X X
Humana Medical Plan X X X X X X X X X X X
Molina Healthcare X X
Simply Healthcare X X X X X
Sunshine Health X X X X X X X X X X X
United Healthcare X X X X
Provider Networks
Essential Providers
15
Id., slide 45.
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Current law considers some health care providers “essential providers” in the Medicaid program. These
providers offer services not available from other providers within a reasonable access distance within a
region, or are unique or rare statewide.
Regional essential providers include the following, as individually designated by AHCA:
Federally qualified health centers;
Statutory teaching hospitals;
Hospitals that are trauma centers; and
Hospitals located at least 25 miles from any other hospital with similar services.
AHCA has not designated any provider as a regional essential provider, so there are none with which
plans are required to contract.
16
Statewide essential providers include the following:
Faculty plans of Florida medical schools.
Regional perinatal intensive care centers as defined in s. 383.16(2).
Hospitals licensed as specialty children’s hospitals as defined in s. 395.002(28).
17
Plan networks must include all essential providers, by contract.
18
If plans selected through the procurement process do not already have contracts with regional essential
providers, they must negotiate with them for one year or until an agreement is reached. The non-
participating payment rates during the negotiation process are set at 100 percent of the Medicaid rate.
After one year, the plan may request agency approval of an alternative arrangement; but, if that
alternative is not approved, the new payment rate is set at 110 percent of the Medicaid rate. For
statewide essential providers, the plans must continue to negotiate in good faith, and the non-
participating payment rate is set at 100 percent of the Medicaid rate (or, in the case of children’s
hospitals, the highest rate established in an existing Medicaid plan contract with that facility).
Healthy Behaviors Program
Each plan operating in the MMA program shall establish a program to encourage and reward healthy
behaviors. At a minimum, each plan must establish a medically approved smoking cessation program,
a medically directed weight loss program, and a medically approved alcohol or substance abuse
recovery program. Each plan must identify enrollees who smoke, are morbidly obese, or are diagnosed
with alcohol or substance abuse, in order to establish written agreements to secure the enrollees’
commitment to participation in these programs.
19
Financial Accountability – Supplemental Payment Programs
Federal Medicaid managed care programs are required to use actuarily sound capitation rates which
represent the entirety of the Medicaid expenditures for such services. However, federal law or Florida
waiver approvals authorize certain exceptions, allowing additional Medicaid payments to take place
16
Agency for Health Care Administration, 2022 Agency Legislative Bill Analysis, HB 7047, pp. 8, (February 3, 2022), p.
11.
17
S. 409.975(1)(b), F.S. A fourth provider type is listed in statute, but AHCA states that no provider has met the statutory
qualifications, which follow: Accredited and integrated systems serving medically complex children which comprise
separately licensed, but commonly owned, health care providers delivering at least the following services: medical group
home, in-home and outpatient nursing care and therapies, pharmacy services, durable medical equipment, and
Prescribed Pediatric Extended Care. Supra, FN 16, p. 12.
18
S. 409.975(1), F.S.
19
S. 409,973(3), F.S.
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outside the managed care relationship for some provider types. These arrangements are called
supplemental payment programs.
Florida currently has ten supplemental payment programs to fund payments to Medicaid providers that
are in addition to reimbursement they receive for services rendered to Medicaid enrollees. They are
either authorized by statute or by the General Appropriations Act and are approved by the federal
government. The payments are generally funded through non-General Revenue sources to make up
the state share of Medicaid funds, which is used to draw down the federal matching payment. However,
some supplemental payments are funded through General Revenue.
AHCA collects local intergovernmental transfers (IGTs) to fund the state share of the Medicaid match
funds. IGTs come from counties, local health care taxing districts, and publicly operated providers.
Governmental sources of IGTs sign pledge letters with AHCA specifying their contribution amount.
AHCA then uses the IGTs to draw down the federal matching funds. AHCA then distributes the
combined local (state share) and federal funds through a legislatively approved funding model.
Use of local funds to assist with funding Medicaid began in 1992 with the Disproportionate Share
Hospital (DSH) supplemental payment. DSH provides supplemental payments to facilities that bear a
disproportionate share of indigent care costs. In FY 1992-93, three local governments contributed IGTs.
The Low Income Pool (LIP) was created as part of the initial Medicaid managed care waiver in 2006.
LIP is used to provide supplemental payments to providers who provide services to Medicaid and
uninsured patients. In FY 2017-18, 41 local government contributed IGTs to help fund DSH, LIP, and
other supplemental payment programs. As of FY 2020-21, 97 local governments were providing IGTs.
20
Florida’s Medicaid supplemental payment programs (along with their FY 2021-22 funding) are listed in
the tables below.
State Share Funded by IGTs
Program FY 21-22 Funding
Low Income Pool (LIP) $1.5 billion
Physician Supplemental Payment (PSP) $404.7 million
Multi-Visceral Transplant $7.4 million
Florida Cancer Hospital Program (FCHP) $154.0 million
Public Emergency Medical Transportation (PEMT) $136.1 million
Hospital Directed Payment Program (DPP) $1.8 billion
Indirect Medical Education (IME) $500.9 million
State Share Funded by IGT and General Revenue
Program FY 21-22 Funding
Disproportionate Share Hospital (DSH) $338.9 million
Medical Education (GME) $283.9 million
Hospital Automatic Rate Enhancements $309.6 million
Total funds distributed in supplemental payments for FY 2021-22 were $5.488 billion.
21
20
Agency for Health Care Administration, Presentation to the Health Care Appropriations Subcommittee, Medicaid
Supplemental Payment Overview, February 15, 2021,
https://ahca.myflorida.com/Medicaid/recent_presentations/2021/House_Health_Care_Appropriations_Medicaid_Presentat
ion_Supplemental_Payments_20210215.pdf (last visited January 24, 2022).
21
Supra, FN 10.
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Supplemental Payments and Essential Providers
Some supplemental payment recipients are also statewide essential providers, with which all Medicaid
plans must contract to meet network adequacy requirements. Supplemental payment program
participation varies by provider type. For example, medical school faculty plans receive supplemental
payments through PSP and LIP, while children’s hospitals receive supplemental payments through LIP,
DSH, and GME, as follows.
22
To be eligible for supplemental payments, statutory teaching hospitals (if designated as a regional
essential provider
23
), faculty plans of Florida medical schools, and specialty children’s hospitals must
offer to contract with all applicable Medicaid plans. In the event of a failure to contract, AHCA must
evaluate whether the providers negotiated in good faith and withhold supplemental payments if the
provider has negotiated in bad faith.
24
In the last two years, AHCA developed a process for assessing
compliance with this law and identified three providers acting in bad faith. AHCA did not withhold
supplemental payments from them, finding they were making progress in contract negotiations with
plans.
25
Supplemental Payments to Florida Cancer Hospitals
Federal law allows a cancer hospital to be recognized as a National Cancer Institute–Designated
Cancer Center (NCI-Cancer Center). There are 71 NCI-Cancer Centers, nationally.
26
Two are in
Florida; Sylvester Cancer Center in Miami and Moffitt Cancer Center in Tampa. Currently, the Florida
NCI-Cancer Centers are not Medicaid essential providers. However, they do receive Medicaid funds via
supplemental payments, as follows.
27
Cancer Hospital Supplemental Payments FY 2020-21
Provider FCHP LIP DSH IME GME Total
Sylvester Cancer Center $104,590,018 $6,007,767 $3,191,548 $743,462 $13,798,598 $128,331,393
Moffitt Cancer Center $ 32,457,037 $11,467,051 $2,694,650 $312,358 $4,380,728 $51,311,824
Total $137,047,055 $17,474,818 $5,886,198 $1,055,820 $18,179,326 $179,643,217
Of the 15 plans operating in the state, Sylvester Cancer Center contracts with three plans. Moffitt
Cancer Center is contracted with two plans.
28
Medicaid services make up 5 percent of Moffitt’s case
mix, which is disproportionately low compared to the percentage of Florida’s population with Medicaid
coverage.
22
Supra, FN 16, p. 12.
23
AHCA has never designated any provider as a regional essential provider.
24
S. 409.908(26), F.S.
25
Supra, FN 16, p. 12.
26
Of the 71 NCI-Designated Cancer Centers, 12 are Cancer Centers, 52 are Comprehensive Cancer Centers, and 7 are
Basic Laboratory Cancer Centers. NIH NATIONAL CANCER INSTITUTE, NCI-Designated Cancer Centers,
https://www.cancer.gov/research/infrastructure/cancer-centers (last visited Mar. 28, 2022). Cancer Centers are
recognized for their scientific leadership, resources, and the depth and breadth of their research in basic, clinical, and/or
prevention, cancer control, and population science. Comprehensive Cancer Centers are also recognized for their
leadership and resources, in addition to demonstrating an added depth and breadth of research, as well as substantial
transdisciplinary research that bridges these scientific areas. Basic Laboratory Cancer Centers are primarily focused on
laboratory research and often conduct preclinical translation while working collaboratively with other institutions to apply
these laboratory findings to new and better treatments.
27
Email from Agency for Health Care Administration staff, Re: [no subject], Feb. 4, 2022 (on file with the Finance &
Facilities Subcommittee).
28
Email from Agency for Health Care Administration staff, Re: [no subject], Feb. 15, 2022 (on file with the Finance &
Facilities Subcommittee).
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Child Welfare Specialty Plan
The Sunshine Health Child Welfare Specialty Plan serves children in Florida’s child welfare system of
care. It is available statewide to children in the child welfare system until age 21 and children adopted
from the child welfare system through the child’s 18
th
birthday, if the adopted family is receiving a state
adoption subsidy.
29
All children with an open child welfare case become eligible for the child welfare specialty plan upon
their entry into the child welfare system. Children are automatically enrolled in the child welfare
specialty plan unless a different MMA plan is selected. Under s. 409.977, F.S., specialty plans serving
children in the care and custody of the DCF may serve such children as long as they remain in care,
including those remaining in extended foster care or are in subsidized adoption and continue to be
eligible for Medicaid pursuant to s. 409.903, F.S.
Like an MMA plan, the child welfare specialty plan must cover the minimum benefits outlined in s.
409.973, F.S. The following benefits are available under the child welfare specialty plan:
Medical foster care
Statewide Inpatient Psychiatric Program (SIPP)
Specialized therapeutic foster care and therapeutic group care
Targeted case management
Private duty nursing
Individual and family therapy
Behavioral Health Overlay Services
Comprehensive behavioral health assessments
Emergency transportation
Non-medical/non-emergency transportation with up to three round trips per month
Care grants of up to $150 per child per calendar year for services and supplies for social or
physical activities, such as gym memberships, swim lessons, sports equipment, art supplies or
application fees for post high school
Transition assistance up to $500 in one-time assistance for young adults transitioning out of
foster care at age 18 or extended foster care at age 21
Life skills development education for children ages 12 and up with developmental disabilities to
help them keep, learn, or improve skills and functioning for daily living
Over-the counter medication up to $25 per household per month
Home-delivered meals for 10 days after being discharged from a facility
Doula services
A 24-hour nurse advice line
A 24-hour behavioral health line
Because children in the child welfare system have greater clinical and behavioral health needs, the
capitated rate for the specialty plan is higher than for children in regular MMA plans.
Child Welfare Guardianship Assistance Program
Florida’s child welfare system, administered by the Department of Children and Families (DCF),
identifies families whose children are in danger of suffering or have suffered abuse, abandonment, or
neglect, and works with those families to address the problems that are endangering children, if
possible. If the problems cannot be addressed, the child welfare system finds safe out-of-home
placements for these children.
29
S. 409.977(5), F.S.
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The DCF Guardianship Assistance Program (GAP) is a federally-funded program to support relatives
and fictive kin
30
who are guardians of children who were removed from their homes due to abuse or
neglect.
31
GAP was implemented in Florida in 2019. Section s. 39.6225, F.S., sets the eligibility
requirements to participate in Florida’s GAP. In keeping with federal requirements, for a guardian to
qualify to receive benefits on behalf of the child, the guardian must:
Have the child’s placement approved by the court;
Have the court grant legal custody of the child to the guardian;
Be licensed as a Level I provider of foster care under s. 409.175, F.S.; and,
Be a guardian for the child who was eligible for federal foster care maintenance payments under
Title IV-E for at least six consecutive months while the child resided in the home of the guardian
and the guardian was licensed as a provider of foster care.
DCF provides GAP participants assistance payments of $4,000 annually, or another amount specified
in a written agreement, paid on a monthly basis.
32
Participants are also eligible for a one-time payment
of up to $2,000 for expenses associated with obtaining legal guardianship of a child.
As of November 2021, there are 1,122 children in Florida’s GAP program.
33
Under current law, children in GAP are not eligible to continue in the child welfare specialty plan. A
child’s dependency case is closed to permanent guardianship by the court when it grants legal custody
to the guardian who is participating in GAP. Because current law limits specialty plan eligibility to
children in DCF custody, permanent guardianship causes the child to lose eligibility for that plan, and
enroll in a regular MMA plan.
Effect of Proposed Changes
SMMC Plan Procurement
The bill requires AHCA to conduct a single, statewide procurement; rather than separate and
simultaneous regional procurements. However, it allows AHCA to award plan contracts on a regional or
statewide basis. This preserves regional competition and bidding, while allowing AHCA to negotiate
based on statewide effect for a plan that would win in all regions, and issue a single statewide contract
award instead of separate regional contracts. It also avoids a systemic shift that could favor large,
market dominant plans if procurement were entirely conducted based on a statewide focus, to the
detriment of regional preferences or conditions.
Under current law, at least 90 days before issuing an ITN to procure MMA and LTC plans under the
SMMC program, AHCA compiles and publishes a databook that includes utilization and spending data
for the program from the 3 most recent contract years and includes historic fee-for-service claims. The
bill requires AHCA to produce data for at least the most recent 24 months, eliminates the obsolete
requirement to include fee-for-service data, and requires the data to be presented consistent with
actuarial rate-setting practices and standards.
Regional Procurement
The bill proposes consolidating the eleven SMMC program regions into nine regions. According to
AHCA, this configuration is based on enrollee utilization patterns and provider referral patterns over
30
S. 39.01(28), F.S., defines “fictive kin” as a person who is unrelated to the child but has such a close emotional
relationship with the child that he or she may be considered family.
31
Department of Children and Families, Office of Children Welfare, Guardianship Assistance Program (GAP),
Guardianship Assistance Program Community Supports - Florida Department of Children and Families (myflfamilies.com)
(last visited January 20, 2022).
32
S. 39.6225(5)(d), F.S.
33
Email from Department of Children and Families staff, Re: GAP, Jan. 20, 2022 (on file with the House Finance &
Facilities Subcommittee).
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recent years.
34
The chart and map below show the current regions and the proposed consolidated
regions.
SMMC Proposed Regions
Current Counties within the Region Proposed
Region 1 Escambia, Okaloosa, Santa Rosa, Walton
Region A
Region 2
Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson,
Leon, Liberty, Madison, Taylor, Wakulla, Washington
Region 3
Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton,
Hernando, Lafayette, Levy, Marion, Putnam, Sumter, Suwannee, Union Region B
Region 4 Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia
Region 5 Pasco, Pinellas Region C
Region 6 Hardee, Highlands, Hillsborough, Manatee, Polk Region D
Region 7 Brevard, Orange, Osceola, Seminole Region E
Region 8 Charlotte, Collier, DeSoto, Glades, Hendry, Lee, Sarasota Region F
Region 9 Indian River, Martin, Okeechobee, Palm Beach, St. Lucie Region G
Region 10 Broward Region H
Region 11 Miami-Dade, Monroe Region I
34
Supra, FN 16, pp. 16-17.
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The bill proposes to increase the minimum or maximum number of plans with which AHCA will contract
to provide services to MMA and LTC enrollees. Each region will have at least three plans to provide
services in the SMMC program, to ensure recipient choice of plans and increase AHCA’s ability to
enforce contract requirements. Enforcing contract requirements in a region with only two plans presents
difficulties. For example, an enrollment freeze sanction would eliminate recipients’ ability to have a
choice of at least two plans, which is a federal requirement. With at least three plans, AHCA will be able
to impose the full range of penalties available against noncompliant plans, including imposing an
enrollment freeze.
The chart below shows the current number of plans and the proposed number of plans in each region.
The chart also demonstrates enrollment distribution based on the proposed minimum and maximum
number of plans per region, per program.
35
35
Note that this simple demonstration assumes equal enrollment in each plan, which is highly unlikely, but is used to
demonstrate recipient distribution across regions based on the plan numbers.
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MMA LTC
Proposed
Regions
Current
Min/Max # Plans
Proposed
Min/Max#
Plans
Regional
Enrollment
Enrollment:
Proposed
Minimum #
Plans
Enrollment:
Proposed
Maximum
# Plans
Regional
Enrollment
Enrollment:
Proposed
Minimum #
Plans
Enrollment:
Proposed
Maximum
# Plans
Region A
Region 1: 2
Region 2: 2
3 - 4 277,676 92,559 69,419 7,073 2,358 1,768
Region B
Region 3: 3 - 5
Region 4: 3 - 5
3 - 6 766,991 153,398 127,832 18,347 6,116 3,058
Region C Region 5: 2 - 4 3-5 229,734 77,677 46,606 10,688 3,563 2,138
Region D Region 6: 4 - 7 4-7 558,316 142,215 81,266 14,316 3,579 2,045
Region E Region 7: 3 - 6 3-6 537,679 179,226 89,613 10,432 3,477 1,739
Region F Region 8: 2 - 4 3-4 272,543 90,848 68,136 7,234 2,411 1,809
Region G Region 9: 2 - 4 3-5 353,458 117,819 70,692 11,349 3,783 2,270
Region H Region 10: 2 - 4
MMA 3-5
LTC 3-4
338,684 112,895 67,737 10,240 3,413 2,560
Region I Region 11: 5 - 10 5-10 605,902 121,180 60,590 32,791 6,558 3,279
Provider Service Networks
The bill removes the option for new PSNs to be paid under a fee-for-service/shared savings model, for
the first two years of operation, after which they would be capitated. PSNs will be paid on a capitated
basis from the beginning of their contract terms.
It removes a requirement for AHCA to under award the maximum number of contracts by one in any
region where no PSN submits a responsive bid. However, it retains the requirement that the award
must include at least one PSN in each region.
Essential Providers
The bill adds Florida’s NCI-Cancer Centers to the statutory list of statewide essential providers,
requiring all plans in the state to contract with them. Currently, there are two NCI-Cancer Centers:
Moffitt Cancer Center (Tampa) and Sylvester Comprehensive Cancer Center (Miami). As with other
statewide essential providers, the bill sets the payment rate in the event these hospitals do not enter
into a network contract with a plan: the highest Medicaid payment rate they have contracted for with
another Medicaid plan. Qualifying Florida cancer hospitals are not added to the list of providers whom
AHCA must suspend supplemental payments to for lack of required plan network contracts nor are their
supplemental payments made contingent upon providing covered Medicaid services to plan
participants.
Healthy Behaviors Program
The bill expands the required scope of the Healthy Behaviors program to include:
Cessation of tobacco use, rather than merely smoking cessation. This addresses the use of
smokeless and other non-smokable tobacco products.
A focus on opioid abuse recovery within the medically approved alcohol and substance
recovery program.
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Child Welfare Specialty Plan and Guardianship Assistance
The bill authorizes a child welfare specialty care plan under contract with the MMA program to serve a
child who continues to be eligible for Medicaid and whose parents or guardians receive GAP payments.
This allows a child in the GAP program to choose either a child welfare specialty plan or an MMA plan.
Implementation Timeline
The bill directs AHCA to amend existing managed care contracts to implement specific provisions of the
bill that affect current performance obligations, such as the provisions addressing the health behaviors
program, designation of NCI-Cancer Centers as essential providers, and child welfare plan eligibility. It
also directs AHCA to implement the procurement-related provisions for the 2025 plan year.
Miscellaneous
Finally, the bill deletes obsolete provisions, such as the use of fee-for-service contracts to transition
PSNs to the risk bearing capitated contract model, removing a reference to the defunct Florida Health
Choices Program, removing a preference for plans that with provider networks in which over 10 percent
of the providers use electronic health records, and repealing a managed care rate statute applicable to
pre-SMMC managed care, which is no longer operable.
The bill provides an effective date of July 1, 2022.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
2. Expenditures:
AHCA estimates that allowing the GAP children to select the child welfare specialty plan, rather
than remaining in or selecting a non-specialty MMA plan, may result in a negative fiscal impact of
$4.6 million, annually ($1.8 million, General Revenue).
36
B. FISCAL IMPACT ON LOCAL GOVERNMENTS:
1. Revenues:
None.
2. Expenditures:
None.
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
None.
D. FISCAL COMMENTS:
None.
36
Supra, FN 16, p. 21.