| 20 | | - | circumstances; requiring the agency to identify 7 |
|---|
| 21 | | - | certain essential providers by the end of each fiscal 8 |
|---|
| 22 | | - | year; requiring certain providers and managed care 9 |
|---|
| 23 | | - | plans to mediate network contracts and jointly notify 10 |
|---|
| 24 | | - | the agency of mediation commencement by a specified 11 |
|---|
| 25 | | - | date; specifying requirements for mediation; 12 |
|---|
| 26 | | - | specifying the content of a written postmediation 13 |
|---|
| 27 | | - | report and requiring that such report be submitted to 14 |
|---|
| 28 | | - | the agency by a specified date; requiring the agency 15 |
|---|
| 29 | | - | to publish all postmediation reports on its website; 16 |
|---|
| 30 | | - | amending s. 409.912, F.S.; requiring the reimbursement 17 |
|---|
| 31 | | - | of certain provider service networks on a prepaid 18 |
|---|
| 32 | | - | basis; removing obsolete language related to provider 19 |
|---|
| 33 | | - | service network reimbursement; repealing s. 409.9124, 20 |
|---|
| 34 | | - | F.S., relating to managed care re imbursement; amending 21 |
|---|
| 35 | | - | s. 409.964, F.S.; removing obsolete language related 22 |
|---|
| 36 | | - | to requiring the agency to provide public notice 23 |
|---|
| 37 | | - | before seeking a Medicaid waiver; amending s. 409.966, 24 |
|---|
| 38 | | - | F.S.; revising a provision related to a requirement 25 |
|---|
| 20 | + | circumstances; amending s. 409.912, F.S.; requiring 7 |
|---|
| 21 | + | the reimbursement of certain provider service networks 8 |
|---|
| 22 | + | on a prepaid basis; removing obsolete language related 9 |
|---|
| 23 | + | to provider service network reimbursement; repealing 10 |
|---|
| 24 | + | s. 409.9124, F.S., relating to ma naged care 11 |
|---|
| 25 | + | reimbursement; amending s. 409.964, F.S.; removing 12 |
|---|
| 26 | + | obsolete language related to requiring the agency to 13 |
|---|
| 27 | + | provide public notice before seeking a Medicaid 14 |
|---|
| 28 | + | waiver; amending s. 409.966, F.S.; revising a 15 |
|---|
| 29 | + | provision related to a requirement that the age ncy 16 |
|---|
| 30 | + | include certain information in a utilization and 17 |
|---|
| 31 | + | spending databook; requiring the agency to conduct a 18 |
|---|
| 32 | + | single, statewide procurement and negotiate and select 19 |
|---|
| 33 | + | plans on a regional basis; authorizing the agency to 20 |
|---|
| 34 | + | select plans on a statewide basis under ce rtain 21 |
|---|
| 35 | + | circumstances; specifying the procurement regions; 22 |
|---|
| 36 | + | removing obsolete language related to prepaid rates 23 |
|---|
| 37 | + | and an additional procurement award; making conforming 24 |
|---|
| 38 | + | changes; amending s. 409.967, F.S.; removing obsolete 25 |
|---|
| 51 | | - | that the agency include c ertain information in a 26 |
|---|
| 52 | | - | utilization and spending databook; requiring the 27 |
|---|
| 53 | | - | agency to conduct a single, statewide procurement and 28 |
|---|
| 54 | | - | negotiate and select plans on a regional basis; 29 |
|---|
| 55 | | - | authorizing the agency to select plans on a statewide 30 |
|---|
| 56 | | - | basis under certain circums tances; specifying the 31 |
|---|
| 57 | | - | procurement regions; removing obsolete language 32 |
|---|
| 58 | | - | related to prepaid rates and an additional procurement 33 |
|---|
| 59 | | - | award; making conforming changes; amending s. 409.967, 34 |
|---|
| 60 | | - | F.S.; removing obsolete language related to certain 35 |
|---|
| 61 | | - | hospital contracts; req uiring the agency to test 36 |
|---|
| 62 | | - | provider network databases to confirm that enrollees 37 |
|---|
| 63 | | - | have timely access to all covered benefits; removing 38 |
|---|
| 64 | | - | obsolete language related to a request for 39 |
|---|
| 65 | | - | information; authorizing plans to reduce an achieved 40 |
|---|
| 66 | | - | savings rebate under certain circumstances; 41 |
|---|
| 67 | | - | classifying certain expenditures as medical expenses; 42 |
|---|
| 68 | | - | amending s. 409.968, F.S.; removing obsolete language 43 |
|---|
| 69 | | - | related to provider service network reimbursement; 44 |
|---|
| 70 | | - | amending s. 409.973, F.S.; requiring healthy behaviors 45 |
|---|
| 71 | | - | programs to address tobacc o use and opioid abuse; 46 |
|---|
| 72 | | - | removing obsolete language related to primary care 47 |
|---|
| 73 | | - | appointments; requiring managed care plans to 48 |
|---|
| 74 | | - | establish certain programs to improve dental health 49 |
|---|
| 75 | | - | outcomes; requiring the agency to establish 50 |
|---|
| 51 | + | language related to certain hospital c ontracts; 26 |
|---|
| 52 | + | requiring the agency to test provider network 27 |
|---|
| 53 | + | databases to confirm that enrollees have timely access 28 |
|---|
| 54 | + | to all covered benefits; removing obsolete language 29 |
|---|
| 55 | + | related to a request for information; authorizing 30 |
|---|
| 56 | + | plans to reduce an achieved savings rebate under 31 |
|---|
| 57 | + | certain circumstances; classifying certain 32 |
|---|
| 58 | + | expenditures as medical expenses; amending s. 409.968, 33 |
|---|
| 59 | + | F.S.; removing obsolete language related to provider 34 |
|---|
| 60 | + | service network reimbursement; amending s. 409.973, 35 |
|---|
| 61 | + | F.S.; providing for dental services benefits; 36 |
|---|
| 62 | + | requiring healthy behaviors programs to address 37 |
|---|
| 63 | + | tobacco use and opioid abuse; removing obsolete 38 |
|---|
| 64 | + | language related to primary care appointments; 39 |
|---|
| 65 | + | requiring managed care plans to establish certain 40 |
|---|
| 66 | + | programs to improve dental health outcomes; requiring 41 |
|---|
| 67 | + | the agency to establish performance and outcome 42 |
|---|
| 68 | + | measures; removing a requirement to provide dental 43 |
|---|
| 69 | + | benefits separate from the Medicaid managed medical 44 |
|---|
| 70 | + | assistance program; amending s. 409.974, F.S.; 45 |
|---|
| 71 | + | establishing numbers of regional contract awards in 46 |
|---|
| 72 | + | the Medicaid managed medical assistance program; 47 |
|---|
| 73 | + | amending s. 409.975, F.S.; requiring the agency to 48 |
|---|
| 74 | + | assess managed care plan compliance with certain 49 |
|---|
| 75 | + | requirements at least quarterly; specifying that 50 |
|---|
| 88 | | - | performance and outcome measures; requi ring the agency 51 |
|---|
| 89 | | - | to annually review certain data and expenditures for 52 |
|---|
| 90 | | - | dental-related emergency department visits and 53 |
|---|
| 91 | | - | reconcile such expenditures against prepaid dental 54 |
|---|
| 92 | | - | plan capitation payments; requiring prepaid dental 55 |
|---|
| 93 | | - | plans and nondental managed care plans to enter into a 56 |
|---|
| 94 | | - | mutual coordination of benefits agreement for 57 |
|---|
| 95 | | - | specified purposes by a specified date; requiring 58 |
|---|
| 96 | | - | prepaid dental plans and nondental managed care plans 59 |
|---|
| 97 | | - | to meet quarterly for certain purposes beginning on a 60 |
|---|
| 98 | | - | specified date; specifying the part ies' obligations 61 |
|---|
| 99 | | - | for such meetings; requiring the agency to establish 62 |
|---|
| 100 | | - | provider network requirements for dental plans, 63 |
|---|
| 101 | | - | including prepaid dental plan provider network 64 |
|---|
| 102 | | - | requirements regarding sedation dentistry services; 65 |
|---|
| 103 | | - | requiring sanctions under certain circu mstances; 66 |
|---|
| 104 | | - | requiring the agency to assess plan compliance at 67 |
|---|
| 105 | | - | least quarterly and enforce network adequacy 68 |
|---|
| 106 | | - | requirements in a timely manner; amending s. 409.974, 69 |
|---|
| 107 | | - | F.S.; establishing numbers of regional contract awards 70 |
|---|
| 108 | | - | in the Medicaid managed medical assistance program; 71 |
|---|
| 109 | | - | amending s. 409.975, F.S.; providing that regional 72 |
|---|
| 110 | | - | perinatal intensive care centers are regional 73 |
|---|
| 111 | | - | resources and essential providers for managed care 74 |
|---|
| 112 | | - | plans; requiring managed care plans to contract with 75 |
|---|
| 88 | + | certain cancer hospitals are statewide essential 51 |
|---|
| 89 | + | providers; establishing c ertain payments for such 52 |
|---|
| 90 | + | cancer hospitals; amending s. 409.977, F.S.; 53 |
|---|
| 91 | + | prohibiting the agency from automatically enrolling 54 |
|---|
| 92 | + | recipients in managed care plans under certain 55 |
|---|
| 93 | + | circumstances; removing obsolete language related to 56 |
|---|
| 94 | + | automatic enrollment and certain f ederal approvals; 57 |
|---|
| 95 | + | providing that children receiving guardianship 58 |
|---|
| 96 | + | assistance payments are eligible for a specialty plan; 59 |
|---|
| 97 | + | amending s. 409.981, F.S.; specifying the number of 60 |
|---|
| 98 | + | regional contract awards in the long -term care managed 61 |
|---|
| 99 | + | care plan; making a conformin g change; amending ss. 62 |
|---|
| 100 | + | 409.8132 and 409.906, F.S.; conforming cross -63 |
|---|
| 101 | + | references; providing an effective date. 64 |
|---|
| 102 | + | 65 |
|---|
| 103 | + | Be It Enacted by the Legislature of the State of Florida: 66 |
|---|
| 104 | + | 67 |
|---|
| 105 | + | Section 1. Subsection (26) of section 409.908, Florida 68 |
|---|
| 106 | + | Statutes, is amended to read: 69 |
|---|
| 107 | + | 409.908 Reimbursement of Medicaid providers. —Subject to 70 |
|---|
| 108 | + | specific appropriations, the agency shall reimburse Medicaid 71 |
|---|
| 109 | + | providers, in accordance with state and federal law, according 72 |
|---|
| 110 | + | to methodologies set forth in the rules of the agency and in 73 |
|---|
| 111 | + | policy manuals and handbooks incorporated by reference therein. 74 |
|---|
| 112 | + | These methodologies may include fee schedules, reimbursement 75 |
|---|
| 125 | | - | such centers; requiring the agency to assess plan 76 |
|---|
| 126 | | - | compliance with certain requirements at least 77 |
|---|
| 127 | | - | quarterly; requiring the agency to impose contract 78 |
|---|
| 128 | | - | enforcement financial sanctions on or assess contract 79 |
|---|
| 129 | | - | damages against certain plans by a specified date 80 |
|---|
| 130 | | - | annually; removing regional perinatal intensive ca re 81 |
|---|
| 131 | | - | centers from, and including certain cancer hospitals 82 |
|---|
| 132 | | - | in, the list of statewide essential providers; 83 |
|---|
| 133 | | - | providing a payment rate for certain cancer hospitals 84 |
|---|
| 134 | | - | without network contracts; amending s. 409.977, F.S.; 85 |
|---|
| 135 | | - | prohibiting the agency from automatically enr olling 86 |
|---|
| 136 | | - | recipients in managed care plans under certain 87 |
|---|
| 137 | | - | circumstances; removing obsolete language related to 88 |
|---|
| 138 | | - | automatic enrollment and certain federal approvals; 89 |
|---|
| 139 | | - | providing that children receiving guardianship 90 |
|---|
| 140 | | - | assistance payments are eligible for a specialty p lan; 91 |
|---|
| 141 | | - | requiring the agency to amend existing contracts under 92 |
|---|
| 142 | | - | the Statewide Medicaid Managed Care program to 93 |
|---|
| 143 | | - | implement specified provisions of the act; requiring 94 |
|---|
| 144 | | - | the agency to implement specified provisions of the 95 |
|---|
| 145 | | - | act for the 2025 plan year; amending s. 409. 981, F.S.; 96 |
|---|
| 146 | | - | specifying the number of regional contract awards in 97 |
|---|
| 147 | | - | the long-term care managed care plan; making a 98 |
|---|
| 148 | | - | conforming change; amending ss. 409.8132 and 409.906, 99 |
|---|
| 149 | | - | F.S.; conforming cross -references; providing an 100 |
|---|
| 125 | + | methods based on cost reporting, negotiated fees, competitive 76 |
|---|
| 126 | + | bidding pursuant to s. 287.057, and other mechanisms the agency 77 |
|---|
| 127 | + | considers efficient and effective for purchasing services or 78 |
|---|
| 128 | + | goods on behalf of recipients. If a provider is reimbursed based 79 |
|---|
| 129 | + | on cost reporting and submits a cost report late and that cost 80 |
|---|
| 130 | + | report would have been used to set a lower reimbursement rate 81 |
|---|
| 131 | + | for a rate semester, then the provider's rate for that semester 82 |
|---|
| 132 | + | shall be retroactively calculated using the new cost report, and 83 |
|---|
| 133 | + | full payment at the recalculated rate shall be effected 84 |
|---|
| 134 | + | retroactively. Medicare -granted extensions for filing cost 85 |
|---|
| 135 | + | reports, if applicable, shall also apply to Medicaid cost 86 |
|---|
| 136 | + | reports. Payment for Medicaid compensable services made on 87 |
|---|
| 137 | + | behalf of Medicaid-eligible persons is subject to the 88 |
|---|
| 138 | + | availability of moneys and any limitations or directions 89 |
|---|
| 139 | + | provided for in the General Appropriations Act or chapter 216. 90 |
|---|
| 140 | + | Further, nothing in this section shall be construed to prevent 91 |
|---|
| 141 | + | or limit the agency from adjusting fees, reimbursement rates, 92 |
|---|
| 142 | + | lengths of stay, number of visits, or number of services, or 93 |
|---|
| 143 | + | making any other adjustments necessary to comply with the 94 |
|---|
| 144 | + | availability of moneys and any limitations or directions 95 |
|---|
| 145 | + | provided for in the General Appropriations Act, provided the 96 |
|---|
| 146 | + | adjustment is consistent with legislative intent. 97 |
|---|
| 147 | + | (26) The agency may receive funds from state entities, 98 |
|---|
| 148 | + | including, but not limited to, the De partment of Health, local 99 |
|---|
| 149 | + | governments, and other local political subdivisions, for the 100 |
|---|
| 162 | | - | effective date. 101 |
|---|
| 163 | | - | 102 |
|---|
| 164 | | - | Be It Enacted by the L egislature of the State of Florida: 103 |
|---|
| 165 | | - | 104 |
|---|
| 166 | | - | Section 1. Subsection (26) of section 409.908, Florida 105 |
|---|
| 167 | | - | Statutes, is amended to read: 106 |
|---|
| 168 | | - | 409.908 Reimbursement of Medicaid providers. —Subject to 107 |
|---|
| 169 | | - | specific appropriations, the agency shall reimburse Medicaid 108 |
|---|
| 170 | | - | providers, in accordance with state and federal law, according 109 |
|---|
| 171 | | - | to methodologies set forth in the rules of the agency and in 110 |
|---|
| 172 | | - | policy manuals and handbooks incorporated by reference therein. 111 |
|---|
| 173 | | - | These methodologies may include fee schedules, reimbursement 112 |
|---|
| 174 | | - | methods based on cost reporting, negotiated fees, competitive 113 |
|---|
| 175 | | - | bidding pursuant to s. 287.057, and other mechanisms the agency 114 |
|---|
| 176 | | - | considers efficient and effective for purchasing services or 115 |
|---|
| 177 | | - | goods on behalf of recipients. If a provider is reimbursed based 116 |
|---|
| 178 | | - | on cost reporting and submits a cost report late and that cost 117 |
|---|
| 179 | | - | report would have been used to set a lower reimbursement rate 118 |
|---|
| 180 | | - | for a rate semester, then the provider's rate for that semester 119 |
|---|
| 181 | | - | shall be retroactively calculated using the new cost report, and 120 |
|---|
| 182 | | - | full payment at the reca lculated rate shall be effected 121 |
|---|
| 183 | | - | retroactively. Medicare -granted extensions for filing cost 122 |
|---|
| 184 | | - | reports, if applicable, shall also apply to Medicaid cost 123 |
|---|
| 185 | | - | reports. Payment for Medicaid compensable services made on 124 |
|---|
| 186 | | - | behalf of Medicaid-eligible persons is subject t o the 125 |
|---|
| 162 | + | purpose of making special exception payments and Low Income Pool 101 |
|---|
| 163 | + | Program payments, including federal matching funds. Funds 102 |
|---|
| 164 | + | received for this purpose shall be separately accounted for and 103 |
|---|
| 165 | + | may not be commingled with other state or local funds in any 104 |
|---|
| 166 | + | manner. The agency may certify all local governmental funds used 105 |
|---|
| 167 | + | as state match under Title XIX of the Social Security Act to the 106 |
|---|
| 168 | + | extent and in the manner authorized under the G eneral 107 |
|---|
| 169 | + | Appropriations Act and pursuant to an agreement between the 108 |
|---|
| 170 | + | agency and the local governmental entity. In order for the 109 |
|---|
| 171 | + | agency to certify such local governmental funds, a local 110 |
|---|
| 172 | + | governmental entity must submit a final, executed letter of 111 |
|---|
| 173 | + | agreement to the agency, which must be received by October 1 of 112 |
|---|
| 174 | + | each fiscal year and provide the total amount of local 113 |
|---|
| 175 | + | governmental funds authorized by the entity for that fiscal year 114 |
|---|
| 176 | + | under the General Appropriations Act. The local governmental 115 |
|---|
| 177 | + | entity shall use a certi fication form prescribed by the agency. 116 |
|---|
| 178 | + | At a minimum, the certification form must identify the amount 117 |
|---|
| 179 | + | being certified and describe the relationship between the 118 |
|---|
| 180 | + | certifying local governmental entity and the local health care 119 |
|---|
| 181 | + | provider. Local governmental fund s outlined in the letters of 120 |
|---|
| 182 | + | agreement must be received by the agency no later than October 121 |
|---|
| 183 | + | 31 of each fiscal year in which such funds are pledged, unless 122 |
|---|
| 184 | + | an alternative plan is specifically approved by the agency. To 123 |
|---|
| 185 | + | be eligible for low-income pool funding or other forms of 124 |
|---|
| 186 | + | supplemental payments funded by intergovernmental transfers, and 125 |
|---|
| 199 | | - | availability of moneys and any limitations or directions 126 |
|---|
| 200 | | - | provided for in the General Appropriations Act or chapter 216. 127 |
|---|
| 201 | | - | Further, nothing in this section shall be construed to prevent 128 |
|---|
| 202 | | - | or limit the agency from adjusting fees, reimbursement rates, 129 |
|---|
| 203 | | - | lengths of stay, number of visits, or number of services, or 130 |
|---|
| 204 | | - | making any other adjustments necessary to comply with the 131 |
|---|
| 205 | | - | availability of moneys and any limitations or directions 132 |
|---|
| 206 | | - | provided for in the General Appropriations Act, provided the 133 |
|---|
| 207 | | - | adjustment is consistent with legislative intent. 134 |
|---|
| 208 | | - | (26) The agency may receive funds from state entities, 135 |
|---|
| 209 | | - | including, but not limited to, the Department of Health, local 136 |
|---|
| 210 | | - | governments, and other local political subdivisions, for the 137 |
|---|
| 211 | | - | purpose of making special exception payments and Low Income Pool 138 |
|---|
| 212 | | - | Program payments, including federal matching funds. Funds 139 |
|---|
| 213 | | - | received for this purpose shall be separately accounted for and 140 |
|---|
| 214 | | - | may not be commingled with other state or local funds in any 141 |
|---|
| 215 | | - | manner. The agency may certify all local governmental fun ds used 142 |
|---|
| 216 | | - | as state match under Title XIX of the Social Security Act to the 143 |
|---|
| 217 | | - | extent and in the manner authorized under the General 144 |
|---|
| 218 | | - | Appropriations Act and pursuant to an agreement between the 145 |
|---|
| 219 | | - | agency and the local governmental entity. In order for the 146 |
|---|
| 220 | | - | agency to certify such local governmental funds, a local 147 |
|---|
| 221 | | - | governmental entity must submit a final, executed letter of 148 |
|---|
| 222 | | - | agreement to the agency, which must be received by October 1 of 149 |
|---|
| 223 | | - | each fiscal year and provide the total amount of local 150 |
|---|
| 199 | + | in addition to any other applicable requirements, essential 126 |
|---|
| 200 | + | providers identified in s. 409.975(1)(a) s. 409.975(1)(a)2. must 127 |
|---|
| 201 | + | have a network offer to contract with each man aged care plan in 128 |
|---|
| 202 | + | their region and essential providers identified in s. 129 |
|---|
| 203 | + | 409.975(1)(b) s. 409.975(1)(b)1. and 3. must have a network 130 |
|---|
| 204 | + | offer to contract with each managed care plan in the state. 131 |
|---|
| 205 | + | Before releasing such supplemental payments, in the event the 132 |
|---|
| 206 | + | parties have not executed network contracts, the agency shall 133 |
|---|
| 207 | + | determine whether such contracts are in place and evaluate the 134 |
|---|
| 208 | + | parties' efforts to complete negotiations. If such efforts 135 |
|---|
| 209 | + | continue to fail, the agency must withhold such supplemental 136 |
|---|
| 210 | + | payments beginning no later than January 1 of each fiscal year 137 |
|---|
| 211 | + | for essential providers without such contracts in place in the 138 |
|---|
| 212 | + | third quarter of the fiscal year if it determines that, based 139 |
|---|
| 213 | + | upon the totality of the circumstances, the essential provider 140 |
|---|
| 214 | + | has negotiated with the managed care plan in bad faith. If the 141 |
|---|
| 215 | + | agency determines that an essential provider has negotiated in 142 |
|---|
| 216 | + | bad faith, it must notify the essential provider at least 90 143 |
|---|
| 217 | + | days in advance of the start of the third quarter of the fiscal 144 |
|---|
| 218 | + | year and afford the ess ential provider hearing rights in 145 |
|---|
| 219 | + | accordance with chapter 120 . 146 |
|---|
| 220 | + | Section 2. Subsection (1) of section 409.912, Florida 147 |
|---|
| 221 | + | Statutes, is amended to read: 148 |
|---|
| 222 | + | 409.912 Cost-effective purchasing of health care. —The 149 |
|---|
| 223 | + | agency shall purchase goods and services for Medi caid recipients 150 |
|---|
| 236 | | - | governmental funds authorized by the entity for that fiscal year 151 |
|---|
| 237 | | - | under the General Appropriations Act. The local governmental 152 |
|---|
| 238 | | - | entity shall use a certification form prescribed by the agency. 153 |
|---|
| 239 | | - | At a minimum, the certification form must identify the amount 154 |
|---|
| 240 | | - | being certified and describe the r elationship between the 155 |
|---|
| 241 | | - | certifying local governmental entity and the local health care 156 |
|---|
| 242 | | - | provider. Local governmental funds outlined in the letters of 157 |
|---|
| 243 | | - | agreement must be received by the agency no later than October 158 |
|---|
| 244 | | - | 31 of each fiscal year in which such funds a re pledged, unless 159 |
|---|
| 245 | | - | an alternative plan is specifically approved by the agency. To 160 |
|---|
| 246 | | - | be eligible for low-income pool funding or other forms of 161 |
|---|
| 247 | | - | supplemental payments funded by intergovernmental transfers, and 162 |
|---|
| 248 | | - | in addition to any other applicable requirements, e ssential 163 |
|---|
| 249 | | - | providers identified in s. 409.975(1)(a) s. 409.975(1)(a)2. must 164 |
|---|
| 250 | | - | have a network offer to contract with each managed care plan in 165 |
|---|
| 251 | | - | their region and essential providers identified in s. 166 |
|---|
| 252 | | - | 409.975(1)(b) s. 409.975(1)(b)1. and 3. must have a network 167 |
|---|
| 253 | | - | offer to contract with each managed care plan in the state. 168 |
|---|
| 254 | | - | Before releasing such supplemental payments, in the event the 169 |
|---|
| 255 | | - | parties have not executed network contracts, the agency shall 170 |
|---|
| 256 | | - | determine whether such contracts are in place and evaluate the 171 |
|---|
| 257 | | - | parties' efforts to complete negotiations. If such efforts 172 |
|---|
| 258 | | - | continue to fail, the agency must withhold such supplemental 173 |
|---|
| 259 | | - | payments beginning no later than January 1 of each fiscal year 174 |
|---|
| 260 | | - | for essential providers without such contracts in place. By the 175 |
|---|
| 236 | + | in the most cost-effective manner consistent with the delivery 151 |
|---|
| 237 | + | of quality medical care. To ensure that medical services are 152 |
|---|
| 238 | + | effectively utilized, the agency may, in any case, require a 153 |
|---|
| 239 | + | confirmation or second physician's opinion of the corre ct 154 |
|---|
| 240 | + | diagnosis for purposes of authorizing future services under the 155 |
|---|
| 241 | + | Medicaid program. This section does not restrict access to 156 |
|---|
| 242 | + | emergency services or poststabilization care services as defined 157 |
|---|
| 243 | + | in 42 C.F.R. s. 438.114. Such confirmation or second opinion 158 |
|---|
| 244 | + | shall be rendered in a manner approved by the agency. The agency 159 |
|---|
| 245 | + | shall maximize the use of prepaid per capita and prepaid 160 |
|---|
| 246 | + | aggregate fixed-sum basis services when appropriate and other 161 |
|---|
| 247 | + | alternative service delivery and reimbursement methodologies, 162 |
|---|
| 248 | + | including competitive bidding pursuant to s. 287.057, designed 163 |
|---|
| 249 | + | to facilitate the cost -effective purchase of a case -managed 164 |
|---|
| 250 | + | continuum of care. The agency shall also require providers to 165 |
|---|
| 251 | + | minimize the exposure of recipients to the need for acute 166 |
|---|
| 252 | + | inpatient, custodial, and o ther institutional care and the 167 |
|---|
| 253 | + | inappropriate or unnecessary use of high -cost services. The 168 |
|---|
| 254 | + | agency shall contract with a vendor to monitor and evaluate the 169 |
|---|
| 255 | + | clinical practice patterns of providers in order to identify 170 |
|---|
| 256 | + | trends that are outside the normal prac tice patterns of a 171 |
|---|
| 257 | + | provider's professional peers or the national guidelines of a 172 |
|---|
| 258 | + | provider's professional association. The vendor must be able to 173 |
|---|
| 259 | + | provide information and counseling to a provider whose practice 174 |
|---|
| 260 | + | patterns are outside the norms, in consultation with the agency, 175 |
|---|
| 273 | | - | end of each fiscal yea r, the agency shall identify essential 176 |
|---|
| 274 | | - | providers who have not executed required network contracts with 177 |
|---|
| 275 | | - | the applicable managed care plans for the next fiscal year. By 178 |
|---|
| 276 | | - | July 30, such providers and plans must enter into mediation and 179 |
|---|
| 277 | | - | jointly notify the agency of mediation commencement. Selection 180 |
|---|
| 278 | | - | of a mediator must be by mutual agreement of the plan and 181 |
|---|
| 279 | | - | provider, or, if they cannot agree, by the agency from a list of 182 |
|---|
| 280 | | - | at least four mediators submitted by the parties. The costs of 183 |
|---|
| 281 | | - | the mediation shall be borne equa lly by the parties. The 184 |
|---|
| 282 | | - | mediation must be completed before September 30. On or before 185 |
|---|
| 283 | | - | October 1, the mediator must submit a written postmediation 186 |
|---|
| 284 | | - | report to the agency, including the outcome of the mediation 187 |
|---|
| 285 | | - | and, if mediation resulted in an impasse, conclus ions and 188 |
|---|
| 286 | | - | recommendations as to the cause of the impasse, the party most 189 |
|---|
| 287 | | - | responsible for the impasse, and whether the mediator believes 190 |
|---|
| 288 | | - | that either party negotiated in bad faith. If the mediator 191 |
|---|
| 289 | | - | recommends to the agency that a party or both parties negotiat ed 192 |
|---|
| 290 | | - | in bad faith, the postmediation report must state the basis for 193 |
|---|
| 291 | | - | such recommendation, cite all relevant information forming the 194 |
|---|
| 292 | | - | basis of the recommendation, and attach any relevant 195 |
|---|
| 293 | | - | documentation. The agency must promptly publish all 196 |
|---|
| 294 | | - | postmediation reports on its website in the third quarter of the 197 |
|---|
| 295 | | - | fiscal year if it determines that, based upon the totality of 198 |
|---|
| 296 | | - | the circumstances, the essential provider has negotiated with 199 |
|---|
| 297 | | - | the managed care plan in bad faith. If the agency determines 200 |
|---|
| 273 | + | to improve patient care and reduce inappropriate utilization. 176 |
|---|
| 274 | + | The agency may mandate prior authorization, drug therapy 177 |
|---|
| 275 | + | management, or disease management participation for certain 178 |
|---|
| 276 | + | populations of Medicaid beneficiaries, certain drug classes , or 179 |
|---|
| 277 | + | particular drugs to prevent fraud, abuse, overuse, and possible 180 |
|---|
| 278 | + | dangerous drug interactions. The Pharmaceutical and Therapeutics 181 |
|---|
| 279 | + | Committee shall make recommendations to the agency on drugs for 182 |
|---|
| 280 | + | which prior authorization is required. The agency shall in form 183 |
|---|
| 281 | + | the Pharmaceutical and Therapeutics Committee of its decisions 184 |
|---|
| 282 | + | regarding drugs subject to prior authorization. The agency is 185 |
|---|
| 283 | + | authorized to limit the entities it contracts with or enrolls as 186 |
|---|
| 284 | + | Medicaid providers by developing a provider network through 187 |
|---|
| 285 | + | provider credentialing. The agency may competitively bid single -188 |
|---|
| 286 | + | source-provider contracts if procurement of goods or services 189 |
|---|
| 287 | + | results in demonstrated cost savings to the state without 190 |
|---|
| 288 | + | limiting access to care. The agency may limit its network based 191 |
|---|
| 289 | + | on the assessment of beneficiary access to care, provider 192 |
|---|
| 290 | + | availability, provider quality standards, time and distance 193 |
|---|
| 291 | + | standards for access to care, the cultural competence of the 194 |
|---|
| 292 | + | provider network, demographic characteristics of Medicaid 195 |
|---|
| 293 | + | beneficiaries, practice and provider-to-beneficiary standards, 196 |
|---|
| 294 | + | appointment wait times, beneficiary use of services, provider 197 |
|---|
| 295 | + | turnover, provider profiling, provider licensure history, 198 |
|---|
| 296 | + | previous program integrity investigations and findings, peer 199 |
|---|
| 297 | + | review, provider Medicaid policy and bil ling compliance records, 200 |
|---|
| 310 | | - | that an essential provider has negotiated in bad faith, it must 201 |
|---|
| 311 | | - | notify the essential provider at least 90 days in advance of the 202 |
|---|
| 312 | | - | start of the third quarter of the fiscal year and afford the 203 |
|---|
| 313 | | - | essential provider hearing rights in accordance with chapter 204 |
|---|
| 314 | | - | 120. 205 |
|---|
| 315 | | - | Section 2. Subsection ( 1) of section 409.912, Florida 206 |
|---|
| 316 | | - | Statutes, is amended to read: 207 |
|---|
| 317 | | - | 409.912 Cost-effective purchasing of health care. —The 208 |
|---|
| 318 | | - | agency shall purchase goods and services for Medicaid recipients 209 |
|---|
| 319 | | - | in the most cost-effective manner consistent with the delivery 210 |
|---|
| 320 | | - | of quality medical care. To ensure that medical services are 211 |
|---|
| 321 | | - | effectively utilized, the agency may, in any case, require a 212 |
|---|
| 322 | | - | confirmation or second physician's opinion of the correct 213 |
|---|
| 323 | | - | diagnosis for purposes of authorizing future services under the 214 |
|---|
| 324 | | - | Medicaid program. This section does not restrict access to 215 |
|---|
| 325 | | - | emergency services or poststabilization care services as defined 216 |
|---|
| 326 | | - | in 42 C.F.R. s. 438.114. Such confirmation or second opinion 217 |
|---|
| 327 | | - | shall be rendered in a manner approved by the agency. The agency 218 |
|---|
| 328 | | - | shall maximize the use of pre paid per capita and prepaid 219 |
|---|
| 329 | | - | aggregate fixed-sum basis services when appropriate and other 220 |
|---|
| 330 | | - | alternative service delivery and reimbursement methodologies, 221 |
|---|
| 331 | | - | including competitive bidding pursuant to s. 287.057, designed 222 |
|---|
| 332 | | - | to facilitate the cost -effective purchase of a case-managed 223 |
|---|
| 333 | | - | continuum of care. The agency shall also require providers to 224 |
|---|
| 334 | | - | minimize the exposure of recipients to the need for acute 225 |
|---|
| 310 | + | clinical and medical record audits, and other factors. Providers 201 |
|---|
| 311 | + | are not entitled to enrollment in the Medicaid provider network. 202 |
|---|
| 312 | + | The agency shall determine instances in which allowing Medicaid 203 |
|---|
| 313 | + | beneficiaries to purchase durable med ical equipment and other 204 |
|---|
| 314 | + | goods is less expensive to the Medicaid program than long -term 205 |
|---|
| 315 | + | rental of the equipment or goods. The agency may establish rules 206 |
|---|
| 316 | + | to facilitate purchases in lieu of long -term rentals in order to 207 |
|---|
| 317 | + | protect against fraud and abuse in the Medicaid program as 208 |
|---|
| 318 | + | defined in s. 409.913. The agency may seek federal waivers 209 |
|---|
| 319 | + | necessary to administer these policies. 210 |
|---|
| 320 | + | (1) The agency may contract with a provider service 211 |
|---|
| 321 | + | network, which must may be reimbursed on a fee-for-service or 212 |
|---|
| 322 | + | prepaid basis. Prepa id provider service networks shall receive 213 |
|---|
| 323 | + | per-member, per-month payments. A provider service network that 214 |
|---|
| 324 | + | does not choose to be a prepaid plan shall receive fee -for-215 |
|---|
| 325 | + | service rates with a shared savings settlement. The fee -for-216 |
|---|
| 326 | + | service option shall be availa ble to a provider service network 217 |
|---|
| 327 | + | only for the first 2 years of the plan's operation or until the 218 |
|---|
| 328 | + | contract year beginning September 1, 2014, whichever is later. 219 |
|---|
| 329 | + | The agency shall annually conduct cost reconciliations to 220 |
|---|
| 330 | + | determine the amount of cost savings achieved by fee-for-service 221 |
|---|
| 331 | + | provider service networks for the dates of service in the period 222 |
|---|
| 332 | + | being reconciled. Only payments for covered services for dates 223 |
|---|
| 333 | + | of service within the reconciliation period and paid within 6 224 |
|---|
| 334 | + | months after the last date of service in the reconciliation 225 |
|---|
| 347 | | - | inpatient, custodial, and other institutional care and the 226 |
|---|
| 348 | | - | inappropriate or unnecessary use of high -cost services. The 227 |
|---|
| 349 | | - | agency shall contract with a vendor to monitor and evaluate the 228 |
|---|
| 350 | | - | clinical practice patterns of providers in order to identify 229 |
|---|
| 351 | | - | trends that are outside the normal practice patterns of a 230 |
|---|
| 352 | | - | provider's professional peers or the national guidelines of a 231 |
|---|
| 353 | | - | provider's professional association. The vendor must be able to 232 |
|---|
| 354 | | - | provide information and counseling to a provider whose practice 233 |
|---|
| 355 | | - | patterns are outside the norms, in consultation with the agency, 234 |
|---|
| 356 | | - | to improve patient care and reduce inappropriate utilization. 235 |
|---|
| 357 | | - | The agency may mandate prior authorization, drug therapy 236 |
|---|
| 358 | | - | management, or disease management participation for certain 237 |
|---|
| 359 | | - | populations of Medicaid beneficiaries, certain drug classes, or 238 |
|---|
| 360 | | - | particular drugs to prevent fraud, abuse, overuse, and possible 239 |
|---|
| 361 | | - | dangerous drug intera ctions. The Pharmaceutical and Therapeutics 240 |
|---|
| 362 | | - | Committee shall make recommendations to the agency on drugs for 241 |
|---|
| 363 | | - | which prior authorization is required. The agency shall inform 242 |
|---|
| 364 | | - | the Pharmaceutical and Therapeutics Committee of its decisions 243 |
|---|
| 365 | | - | regarding drugs subjec t to prior authorization. The agency is 244 |
|---|
| 366 | | - | authorized to limit the entities it contracts with or enrolls as 245 |
|---|
| 367 | | - | Medicaid providers by developing a provider network through 246 |
|---|
| 368 | | - | provider credentialing. The agency may competitively bid single -247 |
|---|
| 369 | | - | source-provider contracts i f procurement of goods or services 248 |
|---|
| 370 | | - | results in demonstrated cost savings to the state without 249 |
|---|
| 371 | | - | limiting access to care. The agency may limit its network based 250 |
|---|
| 347 | + | period shall be included. The agency shall perform the necessary 226 |
|---|
| 348 | + | adjustments for the inclusion of claims incurred but not 227 |
|---|
| 349 | + | reported within the reconciliation for claims that could be 228 |
|---|
| 350 | + | received and paid by the agency after the 6 -month claims 229 |
|---|
| 351 | + | processing time lag. The agency shall provide the results of the 230 |
|---|
| 352 | + | reconciliations to the fee -for-service provider service networks 231 |
|---|
| 353 | + | within 45 days after the end of the reconciliation period. The 232 |
|---|
| 354 | + | fee-for-service provider service networks shall review and 233 |
|---|
| 355 | + | provide written comments or a letter of concurrence to the 234 |
|---|
| 356 | + | agency within 45 days after receipt of the reconciliation 235 |
|---|
| 357 | + | results. This reconciliation shall be considered final. 236 |
|---|
| 358 | + | (a) A provider service network which is reimbursed by the 237 |
|---|
| 359 | + | agency on a prepaid ba sis shall be exempt from parts I and III 238 |
|---|
| 360 | + | of chapter 641 but must comply with the solvency requirements in 239 |
|---|
| 361 | + | s. 641.2261(2) and meet appropriate financial reserve, quality 240 |
|---|
| 362 | + | assurance, and patient rights requirements as established by the 241 |
|---|
| 363 | + | agency. 242 |
|---|
| 364 | + | (b) A provider service network is a network established or 243 |
|---|
| 365 | + | organized and operated by a health care provider, or group of 244 |
|---|
| 366 | + | affiliated health care providers, which provides a substantial 245 |
|---|
| 367 | + | proportion of the health care items and services under a 246 |
|---|
| 368 | + | contract directly through t he provider or affiliated group of 247 |
|---|
| 369 | + | providers and may make arrangements with physicians or other 248 |
|---|
| 370 | + | health care professionals, health care institutions, or any 249 |
|---|
| 371 | + | combination of such individuals or institutions to assume all or 250 |
|---|
| 384 | | - | on the assessment of beneficiary access to care, provider 251 |
|---|
| 385 | | - | availability, provider quality standards, time and distance 252 |
|---|
| 386 | | - | standards for access to care, the cultural competence of the 253 |
|---|
| 387 | | - | provider network, demographic characteristics of Medicaid 254 |
|---|
| 388 | | - | beneficiaries, practice and provider -to-beneficiary standards, 255 |
|---|
| 389 | | - | appointment wait times, beneficiary use of services, pr ovider 256 |
|---|
| 390 | | - | turnover, provider profiling, provider licensure history, 257 |
|---|
| 391 | | - | previous program integrity investigations and findings, peer 258 |
|---|
| 392 | | - | review, provider Medicaid policy and billing compliance records, 259 |
|---|
| 393 | | - | clinical and medical record audits, and other factors. Providers 260 |
|---|
| 394 | | - | are not entitled to enrollment in the Medicaid provider network. 261 |
|---|
| 395 | | - | The agency shall determine instances in which allowing Medicaid 262 |
|---|
| 396 | | - | beneficiaries to purchase durable medical equipment and other 263 |
|---|
| 397 | | - | goods is less expensive to the Medicaid program than long -term 264 |
|---|
| 398 | | - | rental of the equipment or goods. The agency may establish rules 265 |
|---|
| 399 | | - | to facilitate purchases in lieu of long -term rentals in order to 266 |
|---|
| 400 | | - | protect against fraud and abuse in the Medicaid program as 267 |
|---|
| 401 | | - | defined in s. 409.913. The agency may seek federal waivers 268 |
|---|
| 402 | | - | necessary to administer these policies. 269 |
|---|
| 403 | | - | (1) The agency may contract with a provider service 270 |
|---|
| 404 | | - | network, which must may be reimbursed on a fee-for-service or 271 |
|---|
| 405 | | - | prepaid basis. Prepaid provider service networks shall receive 272 |
|---|
| 406 | | - | per-member, per-month payments. A provider service network that 273 |
|---|
| 407 | | - | does not choose to be a prepaid plan shall receive fee -for-274 |
|---|
| 408 | | - | service rates with a shared savings settlement. The fee -for-275 |
|---|
| 384 | + | part of the financial risk on a pro spective basis for the 251 |
|---|
| 385 | + | provision of basic health services by the physicians, by other 252 |
|---|
| 386 | + | health professionals, or through the institutions. The health 253 |
|---|
| 387 | + | care providers must have a controlling interest in the governing 254 |
|---|
| 388 | + | body of the provider service network organi zation. 255 |
|---|
| 389 | + | Section 3. Section 409.9124, Florida Statutes, is 256 |
|---|
| 390 | + | repealed. 257 |
|---|
| 391 | + | Section 4. Section 409.964, Florida Statutes, is amended 258 |
|---|
| 392 | + | to read: 259 |
|---|
| 393 | + | 409.964 Managed care program; state plan; waivers. —The 260 |
|---|
| 394 | + | Medicaid program is established as a statewide, integrate d 261 |
|---|
| 395 | + | managed care program for all covered services, including long -262 |
|---|
| 396 | + | term care services. The agency shall apply for and implement 263 |
|---|
| 397 | + | state plan amendments or waivers of applicable federal laws and 264 |
|---|
| 398 | + | regulations necessary to implement the program. Before seeking a 265 |
|---|
| 399 | + | waiver, the agency shall provide public notice and the 266 |
|---|
| 400 | + | opportunity for public comment and include public feedback in 267 |
|---|
| 401 | + | the waiver application. The agency shall hold one public meeting 268 |
|---|
| 402 | + | in each of the regions described in s. 409.966(2), and the time 269 |
|---|
| 403 | + | period for public comment for each region shall end no sooner 270 |
|---|
| 404 | + | than 30 days after the completion of the public meeting in that 271 |
|---|
| 405 | + | region. 272 |
|---|
| 406 | + | Section 5. Paragraph (f) of subsection (3) of section 273 |
|---|
| 407 | + | 409.966, Florida Statutes, is redesignated as paragraph (d), and 274 |
|---|
| 408 | + | subsection (2), present paragraphs (a), (d), and (e) of 275 |
|---|
| 421 | | - | service option shall be available to a provider service network 276 |
|---|
| 422 | | - | only for the first 2 years of the plan's operation or un til the 277 |
|---|
| 423 | | - | contract year beginning September 1, 2014, whichever is later. 278 |
|---|
| 424 | | - | The agency shall annually conduct cost reconciliations to 279 |
|---|
| 425 | | - | determine the amount of cost savings achieved by fee -for-service 280 |
|---|
| 426 | | - | provider service networks for the dates of service in the peri od 281 |
|---|
| 427 | | - | being reconciled. Only payments for covered services for dates 282 |
|---|
| 428 | | - | of service within the reconciliation period and paid within 6 283 |
|---|
| 429 | | - | months after the last date of service in the reconciliation 284 |
|---|
| 430 | | - | period shall be included. The agency shall perform the necessary 285 |
|---|
| 431 | | - | adjustments for the inclusion of claims incurred but not 286 |
|---|
| 432 | | - | reported within the reconciliation for claims that could be 287 |
|---|
| 433 | | - | received and paid by the agency after the 6 -month claims 288 |
|---|
| 434 | | - | processing time lag. The agency shall provide the results of the 289 |
|---|
| 435 | | - | reconciliations to t he fee-for-service provider service networks 290 |
|---|
| 436 | | - | within 45 days after the end of the reconciliation period. The 291 |
|---|
| 437 | | - | fee-for-service provider service networks shall review and 292 |
|---|
| 438 | | - | provide written comments or a letter of concurrence to the 293 |
|---|
| 439 | | - | agency within 45 days after re ceipt of the reconciliation 294 |
|---|
| 440 | | - | results. This reconciliation shall be considered final. 295 |
|---|
| 441 | | - | (a) A provider service network which is reimbursed by the 296 |
|---|
| 442 | | - | agency on a prepaid basis shall be exempt from parts I and III 297 |
|---|
| 443 | | - | of chapter 641 but must comply with the solvency requirements in 298 |
|---|
| 444 | | - | s. 641.2261(2) and meet appropriate financial reserve, quality 299 |
|---|
| 445 | | - | assurance, and patient rights requirements as established by the 300 |
|---|
| 421 | + | subsection (3), and subsection (4) of that section are amended 276 |
|---|
| 422 | + | to read: 277 |
|---|
| 423 | + | 409.966 Eligible plans; selection. — 278 |
|---|
| 424 | + | (2) ELIGIBLE PLAN SELECTION. —The agency shall select a 279 |
|---|
| 425 | + | limited number of eligible plans to participate in the Medicaid 280 |
|---|
| 426 | + | program using invitations to negotiate in accordance with s. 281 |
|---|
| 427 | + | 287.057(1)(c). At least 90 days before issuing an invitation to 282 |
|---|
| 428 | + | negotiate, the agency shall compile and publish a databook 283 |
|---|
| 429 | + | consisting of a comprehensive set of utilization and spending 284 |
|---|
| 430 | + | data consistent with actuarial rate -setting practices and 285 |
|---|
| 431 | + | standards for at least the most recent 24 months 3 most recent 286 |
|---|
| 432 | + | contract years consistent with the rate-setting periods for all 287 |
|---|
| 433 | + | Medicaid recipients by region or county. The source of the data 288 |
|---|
| 434 | + | in the report must include both historic fee-for-service claims 289 |
|---|
| 435 | + | and validated data from the Medicaid Encounter Data System. The 290 |
|---|
| 436 | + | report must be available in electronic form and delineate 291 |
|---|
| 437 | + | utilization use by age, gender, eligibility group, geographic 292 |
|---|
| 438 | + | area, and aggregate clinical risk score. The agency shall 293 |
|---|
| 439 | + | conduct a single, statewide procurement, shall negotiate and 294 |
|---|
| 440 | + | select plans on a regional basis, and may select plans on a 295 |
|---|
| 441 | + | statewide basis if deemed the best value for the state and 296 |
|---|
| 442 | + | Medicaid recipients. Plan selection separate and simultaneous 297 |
|---|
| 443 | + | procurements shall be conducted in each of the following 298 |
|---|
| 444 | + | regions: 299 |
|---|
| 445 | + | (a) Region A, which consists of Bay, Calhoun, Esc ambia, 300 |
|---|
| 458 | | - | agency. 301 |
|---|
| 459 | | - | (b) A provider service network is a network established or 302 |
|---|
| 460 | | - | organized and operated by a health care pro vider, or group of 303 |
|---|
| 461 | | - | affiliated health care providers, which provides a substantial 304 |
|---|
| 462 | | - | proportion of the health care items and services under a 305 |
|---|
| 463 | | - | contract directly through the provider or affiliated group of 306 |
|---|
| 464 | | - | providers and may make arrangements with physicians or other 307 |
|---|
| 465 | | - | health care professionals, health care institutions, or any 308 |
|---|
| 466 | | - | combination of such individuals or institutions to assume all or 309 |
|---|
| 467 | | - | part of the financial risk on a prospective basis for the 310 |
|---|
| 468 | | - | provision of basic health services by the physicians, by other 311 |
|---|
| 469 | | - | health professionals, or through the institutions. The health 312 |
|---|
| 470 | | - | care providers must have a controlling interest in the governing 313 |
|---|
| 471 | | - | body of the provider service network organization. 314 |
|---|
| 472 | | - | Section 3. Section 409.9124, Florida Statutes, is 315 |
|---|
| 473 | | - | repealed. 316 |
|---|
| 474 | | - | Section 4. Section 409.964, Florida Statutes, is amended 317 |
|---|
| 475 | | - | to read: 318 |
|---|
| 476 | | - | 409.964 Managed care program; state plan; waivers. —The 319 |
|---|
| 477 | | - | Medicaid program is established as a statewide, integrated 320 |
|---|
| 478 | | - | managed care program for all covered services, including long -321 |
|---|
| 479 | | - | term care services. The ag ency shall apply for and implement 322 |
|---|
| 480 | | - | state plan amendments or waivers of applicable federal laws and 323 |
|---|
| 481 | | - | regulations necessary to implement the program. Before seeking a 324 |
|---|
| 482 | | - | waiver, the agency shall provide public notice and the 325 |
|---|
| 458 | + | Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, 301 |
|---|
| 459 | + | Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla, Walton, 302 |
|---|
| 460 | + | and Washington Counties. 303 |
|---|
| 461 | + | (b) Region B, which consists of Alachua, Baker, Bradford, 304 |
|---|
| 462 | + | Citrus, Clay, Columbia, Dixie, Duval, Fl agler, Gilchrist, 305 |
|---|
| 463 | + | Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Nassau, 306 |
|---|
| 464 | + | Putnam, St. Johns, Sumter, Suwannee, Union, and Volusia 307 |
|---|
| 465 | + | Counties. 308 |
|---|
| 466 | + | (c) Region C, which consists of Hardee, Highlands, 309 |
|---|
| 467 | + | Hillsborough, Manatee, Pasco, Pinellas, and Polk Counties. 310 |
|---|
| 468 | + | (d) Region D, which consists of Brevard, Orange, Osceola, 311 |
|---|
| 469 | + | and Seminole Counties. 312 |
|---|
| 470 | + | (e) Region E, which consists of Charlotte, Collier, 313 |
|---|
| 471 | + | DeSoto, Glades, Hendry, Lee, and Sarasota Counties. 314 |
|---|
| 472 | + | (f) Region F, which consists of Indian River, Martin, 315 |
|---|
| 473 | + | Okeechobee, Palm Beach, and St. Lucie Counties. 316 |
|---|
| 474 | + | (g) Region G, which consists of Broward County. 317 |
|---|
| 475 | + | (h) Region H, which consists of Miami -Dade and Monroe 318 |
|---|
| 476 | + | Counties. 319 |
|---|
| 477 | + | (a) Region 1, which consists of Escambia, Okaloosa, Santa 320 |
|---|
| 478 | + | Rosa, and Walton Counties. 321 |
|---|
| 479 | + | (b) Region 2, which consists of Bay, Calhoun, Franklin, 322 |
|---|
| 480 | + | Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, 323 |
|---|
| 481 | + | Madison, Taylor, Wakulla, and Washington Counties. 324 |
|---|
| 482 | + | (c) Region 3, which consists of Alachua, Bradford, Citrus, 325 |
|---|
| 495 | | - | opportunity for public comment and in clude public feedback in 326 |
|---|
| 496 | | - | the waiver application. The agency shall hold one public meeting 327 |
|---|
| 497 | | - | in each of the regions described in s. 409.966(2), and the time 328 |
|---|
| 498 | | - | period for public comment for each region shall end no sooner 329 |
|---|
| 499 | | - | than 30 days after the completion of the public meeting in that 330 |
|---|
| 500 | | - | region. 331 |
|---|
| 501 | | - | Section 5. Paragraph (f) of subsection (3) of section 332 |
|---|
| 502 | | - | 409.966, Florida Statutes, is redesignated as paragraph (d), and 333 |
|---|
| 503 | | - | subsection (2), present paragraphs (a), (d), and (e) of 334 |
|---|
| 504 | | - | subsection (3), and subsection (4) of that section are amended 335 |
|---|
| 505 | | - | to read: 336 |
|---|
| 506 | | - | 409.966 Eligible plans; selection. — 337 |
|---|
| 507 | | - | (2) ELIGIBLE PLAN SELECTION. —The agency shall select a 338 |
|---|
| 508 | | - | limited number of eligible plans to participate in the Medicaid 339 |
|---|
| 509 | | - | program using invitations to negotiate in accordance with s. 340 |
|---|
| 510 | | - | 287.057(1)(c). At least 90 days before issuing an invitation to 341 |
|---|
| 511 | | - | negotiate, the agency shall compile and publish a databook 342 |
|---|
| 512 | | - | consisting of a comprehensive set of utilization and spending 343 |
|---|
| 513 | | - | data consistent with actuarial rate -setting practices and 344 |
|---|
| 514 | | - | standards for at least the most recent 24 months 3 most recent 345 |
|---|
| 515 | | - | contract years consistent with the rate -setting periods for all 346 |
|---|
| 516 | | - | Medicaid recipients by region or county. The source of the data 347 |
|---|
| 517 | | - | in the report must include both historic fee-for-service claims 348 |
|---|
| 518 | | - | and validated data from the Medicaid Encounter Data System. The 349 |
|---|
| 519 | | - | report must be available in electronic form and delineate 350 |
|---|
| 495 | + | Columbia, Dixie, Gilchrist, Hamilton, Hernan do, Lafayette, Lake, 326 |
|---|
| 496 | + | Levy, Marion, Putnam, Sumter, Suwannee, and Union Counties. 327 |
|---|
| 497 | + | (d) Region 4, which consists of Baker, Clay, Duval, 328 |
|---|
| 498 | + | Flagler, Nassau, St. Johns, and Volusia Counties. 329 |
|---|
| 499 | + | (e) Region 5, which consists of Pasco and Pinellas 330 |
|---|
| 500 | + | Counties. 331 |
|---|
| 501 | + | (f) Region 6, which consists of Hardee, Highlands, 332 |
|---|
| 502 | + | Hillsborough, Manatee, and Polk Counties. 333 |
|---|
| 503 | + | (g) Region 7, which consists of Brevard, Orange, Osceola, 334 |
|---|
| 504 | + | and Seminole Counties. 335 |
|---|
| 505 | + | (h) Region 8, which consists of Charlotte, Collier, 336 |
|---|
| 506 | + | DeSoto, Glades, Hendry, Lee, and Sarasota Counties. 337 |
|---|
| 507 | + | (i) Region 9, which consists of Indian River, Martin, 338 |
|---|
| 508 | + | Okeechobee, Palm Beach, and St. Lucie Counties. 339 |
|---|
| 509 | + | (j) Region 10, which consists of Broward County. 340 |
|---|
| 510 | + | (k) Region 11, which consists of Miami -Dade and Monroe 341 |
|---|
| 511 | + | Counties. 342 |
|---|
| 512 | + | (3) QUALITY SELECTION CRITERIA.— 343 |
|---|
| 513 | + | (a) The invitation to negotiate must specify the criteria 344 |
|---|
| 514 | + | and the relative weight of the criteria that will be used for 345 |
|---|
| 515 | + | determining the acceptability of the reply and guiding the 346 |
|---|
| 516 | + | selection of the organizations with which the agency n egotiates. 347 |
|---|
| 517 | + | In addition to criteria established by the agency, the agency 348 |
|---|
| 518 | + | shall consider the following factors in the selection of 349 |
|---|
| 519 | + | eligible plans: 350 |
|---|
| 532 | | - | utilization use by age, gender, eligibility group, geographic 351 |
|---|
| 533 | | - | area, and aggregate clinical risk score. The agency shall 352 |
|---|
| 534 | | - | conduct a single, statewide procure ment, shall negotiate and 353 |
|---|
| 535 | | - | select plans on a regional basis, and may select plans on a 354 |
|---|
| 536 | | - | statewide basis if deemed the best value for the state and 355 |
|---|
| 537 | | - | Medicaid recipients. Plan selection separate and simultaneous 356 |
|---|
| 538 | | - | procurements shall be conducted in each of the fo llowing 357 |
|---|
| 539 | | - | regions: 358 |
|---|
| 540 | | - | (a) Region A, which consists of Bay, Calhoun, Escambia, 359 |
|---|
| 541 | | - | Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, 360 |
|---|
| 542 | | - | Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla, Walton, 361 |
|---|
| 543 | | - | and Washington Counties. 362 |
|---|
| 544 | | - | (b) Region B, which consists o f Alachua, Baker, Bradford, 363 |
|---|
| 545 | | - | Citrus, Clay, Columbia, Dixie, Duval, Flagler, Gilchrist, 364 |
|---|
| 546 | | - | Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Nassau, 365 |
|---|
| 547 | | - | Putnam, St. Johns, Sumter, Suwannee, Union, and Volusia 366 |
|---|
| 548 | | - | Counties. 367 |
|---|
| 549 | | - | (c) Region C, which consists of Hardee, Hig hlands, 368 |
|---|
| 550 | | - | Hillsborough, Manatee, Pasco, Pinellas, and Polk Counties. 369 |
|---|
| 551 | | - | (d) Region D, which consists of Brevard, Orange, Osceola, 370 |
|---|
| 552 | | - | and Seminole Counties. 371 |
|---|
| 553 | | - | (e) Region E, which consists of Charlotte, Collier, 372 |
|---|
| 554 | | - | DeSoto, Glades, Hendry, Lee, and Sarasota Counties. 373 |
|---|
| 555 | | - | (f) Region F, which consists of Indian River, Martin, 374 |
|---|
| 556 | | - | Okeechobee, Palm Beach, and St. Lucie Counties. 375 |
|---|
| 532 | + | 1. Accreditation by the National Committee for Quality 351 |
|---|
| 533 | + | Assurance, the Joint Commission, or another nationall y 352 |
|---|
| 534 | + | recognized accrediting body. 353 |
|---|
| 535 | + | 2. Experience serving similar populations, including the 354 |
|---|
| 536 | + | organization's record in achieving specific quality standards 355 |
|---|
| 537 | + | with similar populations. 356 |
|---|
| 538 | + | 3. Availability and accessibility of primary care and 357 |
|---|
| 539 | + | specialty physicians i n the provider network. 358 |
|---|
| 540 | + | 4. Establishment of community partnerships with providers 359 |
|---|
| 541 | + | that create opportunities for reinvestment in community -based 360 |
|---|
| 542 | + | services. 361 |
|---|
| 543 | + | 5. Organization commitment to quality improvement and 362 |
|---|
| 544 | + | documentation of achievements in specific qu ality improvement 363 |
|---|
| 545 | + | projects, including active involvement by organization 364 |
|---|
| 546 | + | leadership. 365 |
|---|
| 547 | + | 6. Provision of additional benefits, particularly dental 366 |
|---|
| 548 | + | care and disease management, and other initiatives that improve 367 |
|---|
| 549 | + | health outcomes. 368 |
|---|
| 550 | + | 7. Evidence that an eligible plan has obtained signed 369 |
|---|
| 551 | + | contracts or written agreements or signed contracts or has made 370 |
|---|
| 552 | + | substantial progress in establishing relationships with 371 |
|---|
| 553 | + | providers before the plan submits submitting a response. 372 |
|---|
| 554 | + | 8. Comments submitted in writing by any enrolled Medicaid 373 |
|---|
| 555 | + | provider relating to a specifically identified plan 374 |
|---|
| 556 | + | participating in the procurement in the same region as the 375 |
|---|
| 569 | | - | (g) Region G, which consists of Broward County. 376 |
|---|
| 570 | | - | (h) Region H, which consists of Miami -Dade and Monroe 377 |
|---|
| 571 | | - | Counties. 378 |
|---|
| 572 | | - | (a) Region 1, which consists of Escambia, Okaloosa, Santa 379 |
|---|
| 573 | | - | Rosa, and Walton Counties. 380 |
|---|
| 574 | | - | (b) Region 2, which consists of Bay, Calhoun, Franklin, 381 |
|---|
| 575 | | - | Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, 382 |
|---|
| 576 | | - | Madison, Taylor, Wakulla, and Washington Counties. 383 |
|---|
| 577 | | - | (c) Region 3, which consists of Al achua, Bradford, Citrus, 384 |
|---|
| 578 | | - | Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, 385 |
|---|
| 579 | | - | Levy, Marion, Putnam, Sumter, Suwannee, and Union Counties. 386 |
|---|
| 580 | | - | (d) Region 4, which consists of Baker, Clay, Duval, 387 |
|---|
| 581 | | - | Flagler, Nassau, St. Johns, and Volusia Counties. 388 |
|---|
| 582 | | - | (e) Region 5, which consists of Pasco and Pinellas 389 |
|---|
| 583 | | - | Counties. 390 |
|---|
| 584 | | - | (f) Region 6, which consists of Hardee, Highlands, 391 |
|---|
| 585 | | - | Hillsborough, Manatee, and Polk Counties. 392 |
|---|
| 586 | | - | (g) Region 7, which consists of Brevard, Orange, Osceola, 393 |
|---|
| 587 | | - | and Seminole Counties. 394 |
|---|
| 588 | | - | (h) Region 8, which consists of Charlotte, Collier, 395 |
|---|
| 589 | | - | DeSoto, Glades, Hendry, Lee, and Sarasota Counties. 396 |
|---|
| 590 | | - | (i) Region 9, which consists of Indian River, Martin, 397 |
|---|
| 591 | | - | Okeechobee, Palm Beach, and St. Lucie Counties. 398 |
|---|
| 592 | | - | (j) Region 10, which consists of Broward County. 399 |
|---|
| 593 | | - | (k) Region 11, which consists of Miami -Dade and Monroe 400 |
|---|
| 569 | + | submitting provider. 376 |
|---|
| 570 | + | 9. Documentation of policies and procedures for preventing 377 |
|---|
| 571 | + | fraud and abuse. 378 |
|---|
| 572 | + | 10. The business relationship an eligible plan has with 379 |
|---|
| 573 | + | any other eligible plan that responds to the invitation to 380 |
|---|
| 574 | + | negotiate. 381 |
|---|
| 575 | + | (d) For the first year of the first contract term, the 382 |
|---|
| 576 | + | agency shall negotiate capitation rates or fee for service 383 |
|---|
| 577 | + | payments with each plan in order to guarantee aggregate savings 384 |
|---|
| 578 | + | of at least 5 percent. 385 |
|---|
| 579 | + | 1. For prepaid plans, determination of the amount of 386 |
|---|
| 580 | + | savings shall be calculated by comparison to the Medicaid rates 387 |
|---|
| 581 | + | that the agency paid managed care plans for simil ar populations 388 |
|---|
| 582 | + | in the same areas in the prior year. In regions containing no 389 |
|---|
| 583 | + | prepaid plans in the prior year, determination of the amount of 390 |
|---|
| 584 | + | savings shall be calculated by comparison to the Medicaid rates 391 |
|---|
| 585 | + | established and certified for those regions in the prior year. 392 |
|---|
| 586 | + | 2. For provider service networks operating on a fee -for-393 |
|---|
| 587 | + | service basis, determination of the amount of savings shall be 394 |
|---|
| 588 | + | calculated by comparison to the Medicaid rates that the agency 395 |
|---|
| 589 | + | paid on a fee-for-service basis for the same services in the 396 |
|---|
| 590 | + | prior year. 397 |
|---|
| 591 | + | (e) To ensure managed care plan participation in Regions 1 398 |
|---|
| 592 | + | and 2, the agency shall award an additional contract to each 399 |
|---|
| 593 | + | plan with a contract award in Region 1 or Region 2. Such 400 |
|---|
| 606 | | - | Counties. 401 |
|---|
| 607 | | - | (3) QUALITY SELECTION CRITERIA. — 402 |
|---|
| 608 | | - | (a) The invitation to negotiate must specify the criteria 403 |
|---|
| 609 | | - | and the relative weight of the criteria that will be used for 404 |
|---|
| 610 | | - | determining the acceptability of the reply a nd guiding the 405 |
|---|
| 611 | | - | selection of the organizations with which the agency negotiates. 406 |
|---|
| 612 | | - | In addition to criteria established by the agency, the agency 407 |
|---|
| 613 | | - | shall consider the following factors in the selection of 408 |
|---|
| 614 | | - | eligible plans: 409 |
|---|
| 615 | | - | 1. Accreditation by the National Commit tee for Quality 410 |
|---|
| 616 | | - | Assurance, the Joint Commission, or another nationally 411 |
|---|
| 617 | | - | recognized accrediting body. 412 |
|---|
| 618 | | - | 2. Experience serving similar populations, including the 413 |
|---|
| 619 | | - | organization's record in achieving specific quality standards 414 |
|---|
| 620 | | - | with similar populations. 415 |
|---|
| 621 | | - | 3. Availability and accessibility of primary care and 416 |
|---|
| 622 | | - | specialty physicians in the provider network. 417 |
|---|
| 623 | | - | 4. Establishment of community partnerships with providers 418 |
|---|
| 624 | | - | that create opportunities for reinvestment in community -based 419 |
|---|
| 625 | | - | services. 420 |
|---|
| 626 | | - | 5. Organization commitment to quality improvement and 421 |
|---|
| 627 | | - | documentation of achievements in specific quality improvement 422 |
|---|
| 628 | | - | projects, including active involvement by organization 423 |
|---|
| 629 | | - | leadership. 424 |
|---|
| 630 | | - | 6. Provision of additional benefits, particularly dental 425 |
|---|
| 606 | + | contract shall be in any other region in which the plan 401 |
|---|
| 607 | + | submitted a responsive bid and negotiates a rate acceptable to 402 |
|---|
| 608 | + | the agency. If a plan that is awarded an additional contract 403 |
|---|
| 609 | + | pursuant to this paragraph is subject to penalties pursuant to 404 |
|---|
| 610 | + | s. 409.967(2)(i) for activities in Region 1 or Region 2, the 405 |
|---|
| 611 | + | additional contract is automatically terminated 180 days after 406 |
|---|
| 612 | + | the imposition of the penalties. the plan must reimburse the 407 |
|---|
| 613 | + | agency for the cost of enrollment changes and other transition 408 |
|---|
| 614 | + | activities. 409 |
|---|
| 615 | + | (4) ADMINISTRATIVE CHALLENGE. —Any eligible plan that 410 |
|---|
| 616 | + | participates in an invitation to negotiate in more than one 411 |
|---|
| 617 | + | region and is selected in at least one region may not begin 412 |
|---|
| 618 | + | serving Medicaid recipients in any region for which it was 413 |
|---|
| 619 | + | selected until all administrative challenges to procurements 414 |
|---|
| 620 | + | required by this section to which the eligible plan is a party 415 |
|---|
| 621 | + | have been finalized. If the number of plans selected is less 416 |
|---|
| 622 | + | than the maximum amount of plans permitted in the region, the 417 |
|---|
| 623 | + | agency may contract with other selected plans in the region not 418 |
|---|
| 624 | + | participating in the administrative chal lenge before resolution 419 |
|---|
| 625 | + | of the administrative challenge. For purposes of this 420 |
|---|
| 626 | + | subsection, an administrative challenge is finalized if an order 421 |
|---|
| 627 | + | granting voluntary dismissal with prejudice has been entered by 422 |
|---|
| 628 | + | any court established under Article V of the Stat e Constitution 423 |
|---|
| 629 | + | or by the Division of Administrative Hearings, a final order has 424 |
|---|
| 630 | + | been entered into by the agency and the deadline for appeal has 425 |
|---|
| 643 | | - | care and disease management, and other initiatives that improve 426 |
|---|
| 644 | | - | health outcomes. 427 |
|---|
| 645 | | - | 7. Evidence that an eligible plan has obtained signed 428 |
|---|
| 646 | | - | contracts or written agreements or signed contracts or has made 429 |
|---|
| 647 | | - | substantial progress in establishing relationships with 430 |
|---|
| 648 | | - | providers before the plan submits submitting a response. 431 |
|---|
| 649 | | - | 8. Comments submitted in writing by any enrolled Medicaid 432 |
|---|
| 650 | | - | provider relating to a specifically identified plan 433 |
|---|
| 651 | | - | participating in the procurement in the same region as the 434 |
|---|
| 652 | | - | submitting provider. 435 |
|---|
| 653 | | - | 9. Documentation of policies and procedures for preventing 436 |
|---|
| 654 | | - | fraud and abuse. 437 |
|---|
| 655 | | - | 10. The business relationship an eligible plan has with 438 |
|---|
| 656 | | - | any other eligible plan that responds to the invitation to 439 |
|---|
| 657 | | - | negotiate. 440 |
|---|
| 658 | | - | (d) For the first year of the first contract term, the 441 |
|---|
| 659 | | - | agency shall negotiate capitation rate s or fee for service 442 |
|---|
| 660 | | - | payments with each plan in order to guarantee aggregate savings 443 |
|---|
| 661 | | - | of at least 5 percent. 444 |
|---|
| 662 | | - | 1. For prepaid plans, determination of the amount of 445 |
|---|
| 663 | | - | savings shall be calculated by comparison to the Medicaid rates 446 |
|---|
| 664 | | - | that the agency paid managed care plans for similar populations 447 |
|---|
| 665 | | - | in the same areas in the prior year. In regions containing no 448 |
|---|
| 666 | | - | prepaid plans in the prior year, determination of the amount of 449 |
|---|
| 667 | | - | savings shall be calculated by comparison to the Medicaid rates 450 |
|---|
| 643 | + | expired, a final order has been entered by the First District 426 |
|---|
| 644 | + | Court of Appeal and the time to seek any available review by the 427 |
|---|
| 645 | + | Florida Supreme Court has expired, or a final order has been 428 |
|---|
| 646 | + | entered by the Florida Supreme Court and a warrant has been 429 |
|---|
| 647 | + | issued. 430 |
|---|
| 648 | + | Section 6. Paragraphs (c) and (f) of subsection (2) and 431 |
|---|
| 649 | + | paragraph (b) of subsection (4) of section 409.967, Florida 432 |
|---|
| 650 | + | Statutes, are amended, and paragraph (k) is added to subsection 433 |
|---|
| 651 | + | (3) of that section, to read: 434 |
|---|
| 652 | + | 409.967 Managed care plan accountability. — 435 |
|---|
| 653 | + | (2) The agency shall establish such contract requirements 436 |
|---|
| 654 | + | as are necessary for the operation of the statewi de managed care 437 |
|---|
| 655 | + | program. In addition to any other provisions the agency may deem 438 |
|---|
| 656 | + | necessary, the contract must require: 439 |
|---|
| 657 | + | (c) Access.— 440 |
|---|
| 658 | + | 1. The agency shall establish specific standards for the 441 |
|---|
| 659 | + | number, type, and regional distribution of providers in managed 442 |
|---|
| 660 | + | care plan networks to ensure access to care for both adults and 443 |
|---|
| 661 | + | children. Each plan must maintain a regionwide network of 444 |
|---|
| 662 | + | providers in sufficient numbers to meet the access standards for 445 |
|---|
| 663 | + | specific medical services for all recipients enrolled in the 446 |
|---|
| 664 | + | plan. The exclusive use of mail -order pharmacies may not be 447 |
|---|
| 665 | + | sufficient to meet network access standards. Consistent with the 448 |
|---|
| 666 | + | standards established by the agency, provider networks may 449 |
|---|
| 667 | + | include providers located outside the region. A plan may 450 |
|---|
| 680 | | - | established and certified for t hose regions in the prior year. 451 |
|---|
| 681 | | - | 2. For provider service networks operating on a fee -for-452 |
|---|
| 682 | | - | service basis, determination of the amount of savings shall be 453 |
|---|
| 683 | | - | calculated by comparison to the Medicaid rates that the agency 454 |
|---|
| 684 | | - | paid on a fee-for-service basis for the same services in the 455 |
|---|
| 685 | | - | prior year. 456 |
|---|
| 686 | | - | (e) To ensure managed care plan participation in Regions 1 457 |
|---|
| 687 | | - | and 2, the agency shall award an additional contract to each 458 |
|---|
| 688 | | - | plan with a contract award in Region 1 or Region 2. Such 459 |
|---|
| 689 | | - | contract shall be in any other region in whi ch the plan 460 |
|---|
| 690 | | - | submitted a responsive bid and negotiates a rate acceptable to 461 |
|---|
| 691 | | - | the agency. If a plan that is awarded an additional contract 462 |
|---|
| 692 | | - | pursuant to this paragraph is subject to penalties pursuant to 463 |
|---|
| 693 | | - | s. 409.967(2)(i) for activities in Region 1 or Region 2, the 464 |
|---|
| 694 | | - | additional contract is automatically terminated 180 days after 465 |
|---|
| 695 | | - | the imposition of the penalties. the plan must reimburse the 466 |
|---|
| 696 | | - | agency for the cost of enrollment changes and other transition 467 |
|---|
| 697 | | - | activities. 468 |
|---|
| 698 | | - | (4) ADMINISTRATIVE CHALLENGE. —Any eligible plan tha t 469 |
|---|
| 699 | | - | participates in an invitation to negotiate in more than one 470 |
|---|
| 700 | | - | region and is selected in at least one region may not begin 471 |
|---|
| 701 | | - | serving Medicaid recipients in any region for which it was 472 |
|---|
| 702 | | - | selected until all administrative challenges to procurements 473 |
|---|
| 703 | | - | required by this section to which the eligible plan is a party 474 |
|---|
| 704 | | - | have been finalized. If the number of plans selected is less 475 |
|---|
| 680 | + | contract with a new ho spital facility before the date the 451 |
|---|
| 681 | + | hospital becomes operational if the hospital has commenced 452 |
|---|
| 682 | + | construction, will be licensed and operational by January 1, 453 |
|---|
| 683 | + | 2013, and a final order has issued in any civil or 454 |
|---|
| 684 | + | administrative challenge. Each plan shall establi sh and maintain 455 |
|---|
| 685 | + | an accurate and complete electronic database of contracted 456 |
|---|
| 686 | + | providers, including information about licensure or 457 |
|---|
| 687 | + | registration, locations and hours of operation, specialty 458 |
|---|
| 688 | + | credentials and other certifications, specific performance 459 |
|---|
| 689 | + | indicators, and such other information as the agency deems 460 |
|---|
| 690 | + | necessary. The database must be available online to both the 461 |
|---|
| 691 | + | agency and the public and have the capability to compare the 462 |
|---|
| 692 | + | availability of providers to network adequacy standards and to 463 |
|---|
| 693 | + | accept and display feedb ack from each provider's patients. Each 464 |
|---|
| 694 | + | plan shall submit quarterly reports to the agency identifying 465 |
|---|
| 695 | + | the number of enrollees assigned to each primary care provider. 466 |
|---|
| 696 | + | The agency shall conduct, or contract for, systematic and 467 |
|---|
| 697 | + | continuous testing of the provid er network databases maintained 468 |
|---|
| 698 | + | by each plan to confirm accuracy, confirm that behavioral health 469 |
|---|
| 699 | + | providers are accepting enrollees, and confirm that enrollees 470 |
|---|
| 700 | + | have timely access to all covered benefits behavioral health 471 |
|---|
| 701 | + | services. 472 |
|---|
| 702 | + | 2. Each managed care pla n must publish any prescribed drug 473 |
|---|
| 703 | + | formulary or preferred drug list on the plan's website in a 474 |
|---|
| 704 | + | manner that is accessible to and searchable by enrollees and 475 |
|---|
| 717 | | - | than the maximum amount of plans permitted in the region, the 476 |
|---|
| 718 | | - | agency may contract with other selected plans in the region not 477 |
|---|
| 719 | | - | participating in the administrative challenge before resolution 478 |
|---|
| 720 | | - | of the administrative challenge. For purposes of this 479 |
|---|
| 721 | | - | subsection, an administrative challenge is finalized if an order 480 |
|---|
| 722 | | - | granting voluntary dismissal with prejudice has been entered by 481 |
|---|
| 723 | | - | any court established under A rticle V of the State Constitution 482 |
|---|
| 724 | | - | or by the Division of Administrative Hearings, a final order has 483 |
|---|
| 725 | | - | been entered into by the agency and the deadline for appeal has 484 |
|---|
| 726 | | - | expired, a final order has been entered by the First District 485 |
|---|
| 727 | | - | Court of Appeal and the time t o seek any available review by the 486 |
|---|
| 728 | | - | Florida Supreme Court has expired, or a final order has been 487 |
|---|
| 729 | | - | entered by the Florida Supreme Court and a warrant has been 488 |
|---|
| 730 | | - | issued. 489 |
|---|
| 731 | | - | Section 6. Paragraphs (c) and (f) of subsection (2) and 490 |
|---|
| 732 | | - | paragraph (b) of subsection (4) of section 409.967, Florida 491 |
|---|
| 733 | | - | Statutes, are amended, and paragraph (k) is added to subsection 492 |
|---|
| 734 | | - | (3) of that section, to read: 493 |
|---|
| 735 | | - | 409.967 Managed care plan accountability. — 494 |
|---|
| 736 | | - | (2) The agency shall establish such contract requirements 495 |
|---|
| 737 | | - | as are necessary for the oper ation of the statewide managed care 496 |
|---|
| 738 | | - | program. In addition to any other provisions the agency may deem 497 |
|---|
| 739 | | - | necessary, the contract must require: 498 |
|---|
| 740 | | - | (c) Access.— 499 |
|---|
| 741 | | - | 1. The agency shall establish specific standards for the 500 |
|---|
| 717 | + | providers. The plan must update the list within 24 hours after 476 |
|---|
| 718 | + | making a change. Each plan must ensur e that the prior 477 |
|---|
| 719 | + | authorization process for prescribed drugs is readily accessible 478 |
|---|
| 720 | + | to health care providers, including posting appropriate contact 479 |
|---|
| 721 | + | information on its website and providing timely responses to 480 |
|---|
| 722 | + | providers. For Medicaid recipients diagnosed with hemophilia who 481 |
|---|
| 723 | + | have been prescribed anti -hemophilic-factor replacement 482 |
|---|
| 724 | + | products, the agency shall provide for those products and 483 |
|---|
| 725 | + | hemophilia overlay services through the agency's hemophilia 484 |
|---|
| 726 | + | disease management program. 485 |
|---|
| 727 | + | 3. Managed care plans, and their fis cal agents or 486 |
|---|
| 728 | + | intermediaries, must accept prior authorization requests for any 487 |
|---|
| 729 | + | service electronically. 488 |
|---|
| 730 | + | 4. Managed care plans serving children in the care and 489 |
|---|
| 731 | + | custody of the Department of Children and Families must maintain 490 |
|---|
| 732 | + | complete medical, dental, and b ehavioral health encounter 491 |
|---|
| 733 | + | information and participate in making such information available 492 |
|---|
| 734 | + | to the department or the applicable contracted community -based 493 |
|---|
| 735 | + | care lead agency for use in providing comprehensive and 494 |
|---|
| 736 | + | coordinated case management. The agency and t he department shall 495 |
|---|
| 737 | + | establish an interagency agreement to provide guidance for the 496 |
|---|
| 738 | + | format, confidentiality, recipient, scope, and method of 497 |
|---|
| 739 | + | information to be made available and the deadlines for 498 |
|---|
| 740 | + | submission of the data. The scope of information available to 499 |
|---|
| 741 | + | the department shall be the data that managed care plans are 500 |
|---|
| 754 | | - | number, type, and regional distribution of providers in managed 501 |
|---|
| 755 | | - | care plan networks to ensure access to care for both adults and 502 |
|---|
| 756 | | - | children. Each plan must maintain a regionwide network of 503 |
|---|
| 757 | | - | providers in sufficient numbers to meet the access standards for 504 |
|---|
| 758 | | - | specific medical services for all recipients enr olled in the 505 |
|---|
| 759 | | - | plan. The exclusive use of mail -order pharmacies may not be 506 |
|---|
| 760 | | - | sufficient to meet network access standards. Consistent with the 507 |
|---|
| 761 | | - | standards established by the agency, provider networks may 508 |
|---|
| 762 | | - | include providers located outside the region. A plan may 509 |
|---|
| 763 | | - | contract with a new hospital facility before the date the 510 |
|---|
| 764 | | - | hospital becomes operational if the hospital has commenced 511 |
|---|
| 765 | | - | construction, will be licensed and operational by January 1, 512 |
|---|
| 766 | | - | 2013, and a final order has issued in any civil or 513 |
|---|
| 767 | | - | administrative challenge. Each plan shall establish and maintain 514 |
|---|
| 768 | | - | an accurate and complete electronic database of contracted 515 |
|---|
| 769 | | - | providers, including information about licensure or 516 |
|---|
| 770 | | - | registration, locations and hours of operation, specialty 517 |
|---|
| 771 | | - | credentials and other certifications, specific perf ormance 518 |
|---|
| 772 | | - | indicators, and such other information as the agency deems 519 |
|---|
| 773 | | - | necessary. The database must be available online to both the 520 |
|---|
| 774 | | - | agency and the public and have the capability to compare the 521 |
|---|
| 775 | | - | availability of providers to network adequacy standards and to 522 |
|---|
| 776 | | - | accept and display feedback from each provider's patients. Each 523 |
|---|
| 777 | | - | plan shall submit quarterly reports to the agency identifying 524 |
|---|
| 778 | | - | the number of enrollees assigned to each primary care provider. 525 |
|---|
| 754 | + | required to submit to the agency. The agency shall determine the 501 |
|---|
| 755 | + | plan's compliance with standards for access to medical, dental, 502 |
|---|
| 756 | + | and behavioral health services; the use of medications; and 503 |
|---|
| 757 | + | followup on all medically necessary services recommended as a 504 |
|---|
| 758 | + | result of early and periodic screening, diagnosis, and 505 |
|---|
| 759 | + | treatment. 506 |
|---|
| 760 | + | (f) Continuous improvement. —The agency shall establish 507 |
|---|
| 761 | + | specific performance standards and expected milestones or 508 |
|---|
| 762 | + | timelines for improving performance over the term of the 509 |
|---|
| 763 | + | contract. 510 |
|---|
| 764 | + | 1. Each managed care plan shall establish an internal 511 |
|---|
| 765 | + | health care quality improvement system, including enrollee 512 |
|---|
| 766 | + | satisfaction and disenrollment surveys. The quality improvement 513 |
|---|
| 767 | + | system must include incentiv es and disincentives for network 514 |
|---|
| 768 | + | providers. 515 |
|---|
| 769 | + | 2. Each plan must collect and report the Health Plan 516 |
|---|
| 770 | + | Employer Data and Information Set (HEDIS) measures, as specified 517 |
|---|
| 771 | + | by the agency. These measures must be published on the plan's 518 |
|---|
| 772 | + | website in a manner that allow s recipients to reliably compare 519 |
|---|
| 773 | + | the performance of plans. The agency shall use the HEDIS 520 |
|---|
| 774 | + | measures as a tool to monitor plan performance. 521 |
|---|
| 775 | + | 3. Each managed care plan must be accredited by the 522 |
|---|
| 776 | + | National Committee for Quality Assurance, the Joint Commission, 523 |
|---|
| 777 | + | or another nationally recognized accrediting body, or have 524 |
|---|
| 778 | + | initiated the accreditation process, within 1 year after the 525 |
|---|
| 791 | | - | The agency shall conduct, or contract for, systematic and 526 |
|---|
| 792 | | - | continuous testing of the provider network databases maintained 527 |
|---|
| 793 | | - | by each plan to confirm accuracy, confirm that behavioral health 528 |
|---|
| 794 | | - | providers are accepting enrollees, and confirm that enrollees 529 |
|---|
| 795 | | - | have timely access to all covered benefits behavioral health 530 |
|---|
| 796 | | - | services. 531 |
|---|
| 797 | | - | 2. Each managed care plan must publish any prescribed drug 532 |
|---|
| 798 | | - | formulary or preferred drug list on the plan's website in a 533 |
|---|
| 799 | | - | manner that is accessible to and searchable by enrollees and 534 |
|---|
| 800 | | - | providers. The plan must update the list within 24 hours after 535 |
|---|
| 801 | | - | making a change. Each plan must ensure that the prior 536 |
|---|
| 802 | | - | authorization process for prescribed drugs is readily accessible 537 |
|---|
| 803 | | - | to health care providers, including posting appropriate contact 538 |
|---|
| 804 | | - | information on its website and providing timely responses to 539 |
|---|
| 805 | | - | providers. For Medicaid recip ients diagnosed with hemophilia who 540 |
|---|
| 806 | | - | have been prescribed anti -hemophilic-factor replacement 541 |
|---|
| 807 | | - | products, the agency shall provide for those products and 542 |
|---|
| 808 | | - | hemophilia overlay services through the agency's hemophilia 543 |
|---|
| 809 | | - | disease management program. 544 |
|---|
| 810 | | - | 3. Managed care plans, and their fiscal agents or 545 |
|---|
| 811 | | - | intermediaries, must accept prior authorization requests for any 546 |
|---|
| 812 | | - | service electronically. 547 |
|---|
| 813 | | - | 4. Managed care plans serving children in the care and 548 |
|---|
| 814 | | - | custody of the Department of Children and Families must maintain 549 |
|---|
| 815 | | - | complete medical, dental, and behavioral health encounter 550 |
|---|
| 791 | + | contract is executed. For any plan not accredited within 18 526 |
|---|
| 792 | + | months after executing the contract, the agency shall suspend 527 |
|---|
| 793 | + | automatic assignment under s. 409.977 and 409.984. 528 |
|---|
| 794 | + | 4. By the end of the fourth year of the first contract 529 |
|---|
| 795 | + | term, the agency shall issue a request for information to 530 |
|---|
| 796 | + | determine whether cost savings could be achieved by contracting 531 |
|---|
| 797 | + | for plan oversight and monitoring, inclu ding analysis of 532 |
|---|
| 798 | + | encounter data, assessment of performance measures, and 533 |
|---|
| 799 | + | compliance with other contractual requirements. 534 |
|---|
| 800 | + | (3) ACHIEVED SAVINGS REBATE. — 535 |
|---|
| 801 | + | (k) Plans that contribute funds pursuant to paragraph 536 |
|---|
| 802 | + | (4)(b) or paragraph (4)(c) may reduce the rebat e owed by an 537 |
|---|
| 803 | + | amount equal to the amount of the contribution. 538 |
|---|
| 804 | + | (4) MEDICAL LOSS RATIO. —If required as a condition of a 539 |
|---|
| 805 | + | waiver, the agency may calculate a medical loss ratio for 540 |
|---|
| 806 | + | managed care plans. The calculation shall use uniform financial 541 |
|---|
| 807 | + | data collected from all plans and shall be computed for each 542 |
|---|
| 808 | + | plan on a statewide basis. The method for calculating the 543 |
|---|
| 809 | + | medical loss ratio shall meet the following criteria: 544 |
|---|
| 810 | + | (b) Funds provided by plans to graduate medical education 545 |
|---|
| 811 | + | institutions to underwrite the costs o f residency positions in 546 |
|---|
| 812 | + | graduate medical education programs, undergraduate and graduate 547 |
|---|
| 813 | + | student positions in nursing education programs, or student 548 |
|---|
| 814 | + | positions in any degree or technical program deemed a critical 549 |
|---|
| 815 | + | shortage area by the agency shall be classified as medical 550 |
|---|
| 828 | | - | information and participate in making such information available 551 |
|---|
| 829 | | - | to the department or the applicable contracted community -based 552 |
|---|
| 830 | | - | care lead agency for use in providing comprehensive and 553 |
|---|
| 831 | | - | coordinated case manageme nt. The agency and the department shall 554 |
|---|
| 832 | | - | establish an interagency agreement to provide guidance for the 555 |
|---|
| 833 | | - | format, confidentiality, recipient, scope, and method of 556 |
|---|
| 834 | | - | information to be made available and the deadlines for 557 |
|---|
| 835 | | - | submission of the data. The scope of info rmation available to 558 |
|---|
| 836 | | - | the department shall be the data that managed care plans are 559 |
|---|
| 837 | | - | required to submit to the agency. The agency shall determine the 560 |
|---|
| 838 | | - | plan's compliance with standards for access to medical, dental, 561 |
|---|
| 839 | | - | and behavioral health services; the use of me dications; and 562 |
|---|
| 840 | | - | followup on all medically necessary services recommended as a 563 |
|---|
| 841 | | - | result of early and periodic screening, diagnosis, and 564 |
|---|
| 842 | | - | treatment. 565 |
|---|
| 843 | | - | (f) Continuous improvement. —The agency shall establish 566 |
|---|
| 844 | | - | specific performance standards and expected milestones o r 567 |
|---|
| 845 | | - | timelines for improving performance over the term of the 568 |
|---|
| 846 | | - | contract. 569 |
|---|
| 847 | | - | 1. Each managed care plan shall establish an internal 570 |
|---|
| 848 | | - | health care quality improvement system, including enrollee 571 |
|---|
| 849 | | - | satisfaction and disenrollment surveys. The quality improvement 572 |
|---|
| 850 | | - | system must include incentives and disincentives for network 573 |
|---|
| 851 | | - | providers. 574 |
|---|
| 852 | | - | 2. Each plan must collect and report the Health Plan 575 |
|---|
| 828 | + | expenditures, provided that the funding is sufficient to sustain 551 |
|---|
| 829 | + | the positions for the number of years necessary to complete the 552 |
|---|
| 830 | + | program residency requirements and the residency or student 553 |
|---|
| 831 | + | positions funded by the plans are actively involved in the 554 |
|---|
| 832 | + | institution's provision active providers of care to Medicaid and 555 |
|---|
| 833 | + | uninsured patients. 556 |
|---|
| 834 | + | Section 7. Subsection (2) of section 409.968, Florida 557 |
|---|
| 835 | + | Statutes, is amended to read: 558 |
|---|
| 836 | + | 409.968 Managed care plan payments. — 559 |
|---|
| 837 | + | (2) Provider service networks may b e prepaid plans and 560 |
|---|
| 838 | + | receive per-member, per-month payments negotiated pursuant to 561 |
|---|
| 839 | + | the procurement process described in s. 409.966. Provider 562 |
|---|
| 840 | + | service networks that choose not to be prepaid plans shall 563 |
|---|
| 841 | + | receive fee-for-service rates with a shared savings settl ement. 564 |
|---|
| 842 | + | The fee-for-service option shall be available to a provider 565 |
|---|
| 843 | + | service network only for the first 2 years of its operation. The 566 |
|---|
| 844 | + | agency shall annually conduct cost reconciliations to determine 567 |
|---|
| 845 | + | the amount of cost savings achieved by fee -for-service provider 568 |
|---|
| 846 | + | service networks for the dates of service within the period 569 |
|---|
| 847 | + | being reconciled. Only payments for covered services for dates 570 |
|---|
| 848 | + | of service within the reconciliation period and paid within 6 571 |
|---|
| 849 | + | months after the last date of service in the reconciliation 572 |
|---|
| 850 | + | period must be included. The agency shall perform the necessary 573 |
|---|
| 851 | + | adjustments for the inclusion of claims incurred but not 574 |
|---|
| 852 | + | reported within the reconciliation period for claims that could 575 |
|---|
| 865 | | - | Employer Data and Information Set (HEDIS) measures, as specified 576 |
|---|
| 866 | | - | by the agency. These measures must be published on the plan's 577 |
|---|
| 867 | | - | website in a manner that allows recipients to reliably compare 578 |
|---|
| 868 | | - | the performance of plans. The agency shall use the HEDIS 579 |
|---|
| 869 | | - | measures as a tool to monitor plan performance. 580 |
|---|
| 870 | | - | 3. Each managed care plan must be accredited by the 581 |
|---|
| 871 | | - | National Committee for Quality Assurance, th e Joint Commission, 582 |
|---|
| 872 | | - | or another nationally recognized accrediting body, or have 583 |
|---|
| 873 | | - | initiated the accreditation process, within 1 year after the 584 |
|---|
| 874 | | - | contract is executed. For any plan not accredited within 18 585 |
|---|
| 875 | | - | months after executing the contract, the agency shall su spend 586 |
|---|
| 876 | | - | automatic assignment under s. 409.977 and 409.984. 587 |
|---|
| 877 | | - | 4. By the end of the fourth year of the first contract 588 |
|---|
| 878 | | - | term, the agency shall issue a request for information to 589 |
|---|
| 879 | | - | determine whether cost savings could be achieved by contracting 590 |
|---|
| 880 | | - | for plan oversight a nd monitoring, including analysis of 591 |
|---|
| 881 | | - | encounter data, assessment of performance measures, and 592 |
|---|
| 882 | | - | compliance with other contractual requirements. 593 |
|---|
| 883 | | - | (3) ACHIEVED SAVINGS REBATE. — 594 |
|---|
| 884 | | - | (k) Plans that contribute funds pursuant to paragraph 595 |
|---|
| 885 | | - | (4)(b) or paragraph (4)(c) may reduce the rebate owed by an 596 |
|---|
| 886 | | - | amount equal to the amount of the contribution. 597 |
|---|
| 887 | | - | (4) MEDICAL LOSS RATIO. —If required as a condition of a 598 |
|---|
| 888 | | - | waiver, the agency may calculate a medical loss ratio for 599 |
|---|
| 889 | | - | managed care plans. The calculation shall use uniform finan cial 600 |
|---|
| 865 | + | be received and paid by the agency after the 6 -month claims 576 |
|---|
| 866 | + | processing time lag. The agency shall provide the results of the 577 |
|---|
| 867 | + | reconciliations to the fee -for-service provider service networks 578 |
|---|
| 868 | + | within 45 days after the end of the reconciliation period. The 579 |
|---|
| 869 | + | fee-for-service provider service networks shall review and 580 |
|---|
| 870 | + | provide written commen ts or a letter of concurrence to the 581 |
|---|
| 871 | + | agency within 45 days after receipt of the reconciliation 582 |
|---|
| 872 | + | results. This reconciliation is considered final. 583 |
|---|
| 873 | + | Section 8. Paragraphs (e) through (bb) of subsection (1) 584 |
|---|
| 874 | + | of section 409.973, Florida Statutes, are redesign ated as 585 |
|---|
| 875 | + | paragraphs (f) through (cc), respectively, subsection (3), 586 |
|---|
| 876 | + | paragraph (b) of subsection (4), and subsection (5) are amended, 587 |
|---|
| 877 | + | and a new paragraph (e) is added to subsection (1) of that 588 |
|---|
| 878 | + | section, to read: 589 |
|---|
| 879 | + | 409.973 Benefits.— 590 |
|---|
| 880 | + | (1) MINIMUM BENEFITS.—Managed care plans shall cover, at a 591 |
|---|
| 881 | + | minimum, the following services: 592 |
|---|
| 882 | + | (e) Dental services. 593 |
|---|
| 883 | + | (3) HEALTHY BEHAVIORS. —Each plan operating in the managed 594 |
|---|
| 884 | + | medical assistance program shall establish a program to 595 |
|---|
| 885 | + | encourage and reward healthy behavior s. At a minimum, each plan 596 |
|---|
| 886 | + | must establish a medically approved tobacco use smoking 597 |
|---|
| 887 | + | cessation program, a medically directed weight loss program, and 598 |
|---|
| 888 | + | a medically approved alcohol or substance abuse recovery 599 |
|---|
| 889 | + | program, which shall include, at a minimum, a focus on opioid 600 |
|---|
| 902 | | - | data collected from all plans and shall be computed for each 601 |
|---|
| 903 | | - | plan on a statewide basis. The method for calculating the 602 |
|---|
| 904 | | - | medical loss ratio shall meet the following criteria: 603 |
|---|
| 905 | | - | (b) Funds provided by plans to graduate medical education 604 |
|---|
| 906 | | - | institutions to underwrite the costs of residency positions in 605 |
|---|
| 907 | | - | graduate medical education programs, undergraduate and graduate 606 |
|---|
| 908 | | - | student positions in nursing education programs, or student 607 |
|---|
| 909 | | - | positions in any degree or technical program deemed a critical 608 |
|---|
| 910 | | - | shortage area by the age ncy shall be classified as medical 609 |
|---|
| 911 | | - | expenditures, provided that the funding is sufficient to sustain 610 |
|---|
| 912 | | - | the positions for the number of years necessary to complete the 611 |
|---|
| 913 | | - | program residency requirements and the residency or student 612 |
|---|
| 914 | | - | positions funded by the plans ar e actively involved in the 613 |
|---|
| 915 | | - | institution's provision active providers of care to Medicaid and 614 |
|---|
| 916 | | - | uninsured patients. 615 |
|---|
| 917 | | - | Section 7. Subsection (2) of section 409.968, Florida 616 |
|---|
| 918 | | - | Statutes, is amended to read: 617 |
|---|
| 919 | | - | 409.968 Managed care plan payments. — 618 |
|---|
| 920 | | - | (2) Provider service networks may be prepaid plans and 619 |
|---|
| 921 | | - | receive per-member, per-month payments negotiated pursuant to 620 |
|---|
| 922 | | - | the procurement process described in s. 409.966. Provider 621 |
|---|
| 923 | | - | service networks that choose not to be prepaid plans shall 622 |
|---|
| 924 | | - | receive fee-for-service rates with a shared savings settlement. 623 |
|---|
| 925 | | - | The fee-for-service option shall be available to a provider 624 |
|---|
| 926 | | - | service network only for the first 2 years of its operation. The 625 |
|---|
| 902 | + | abuse recovery. Each plan must identify enrollees who use 601 |
|---|
| 903 | + | tobacco smoke, are morbidly obese, or are diagnosed with alcohol 602 |
|---|
| 904 | + | or substance abuse in order to establish written agreements to 603 |
|---|
| 905 | + | secure the enrollees' commitment to participation in these 604 |
|---|
| 906 | + | programs. 605 |
|---|
| 907 | + | (4) PRIMARY CARE INITIATIVE. —Each plan operating in the 606 |
|---|
| 908 | + | managed medical assistance program shall establish a program to 607 |
|---|
| 909 | + | encourage enrollees to establish a relationship with their 608 |
|---|
| 910 | + | primary care provider . Each plan shall: 609 |
|---|
| 911 | + | (b) If the enrollee was not a Medicaid recipient before 610 |
|---|
| 912 | + | enrollment in the plan, assist the enrollee in scheduling an 611 |
|---|
| 913 | + | appointment with the primary care provider. If possible the 612 |
|---|
| 914 | + | appointment should be made within 30 days after enrollment in 613 |
|---|
| 915 | + | the plan. For enrollees who become eligible for Medicaid between 614 |
|---|
| 916 | + | January 1, 2014, and December 31, 2015, the appointment should 615 |
|---|
| 917 | + | be scheduled within 6 months after enrollment in the plan. 616 |
|---|
| 918 | + | (5) DENTAL PERFORMANCE IMPROVEMENT. —Given the effect of 617 |
|---|
| 919 | + | oral health on overall health, each plan shall establish a 618 |
|---|
| 920 | + | program to improve dental health outcomes and increase 619 |
|---|
| 921 | + | utilization of preventive dental services. The agency shall 620 |
|---|
| 922 | + | establish performance and outcome measures, regularly assess 621 |
|---|
| 923 | + | plan performance, and publis h data on such measures. Program 622 |
|---|
| 924 | + | components shall, at a minimum, include: 623 |
|---|
| 925 | + | (a) An education program to inform enrollees of the 624 |
|---|
| 926 | + | connection between oral health and overall health and preventive 625 |
|---|
| 939 | | - | agency shall annually conduct cost reconciliations to determine 626 |
|---|
| 940 | | - | the amount of cost savin gs achieved by fee-for-service provider 627 |
|---|
| 941 | | - | service networks for the dates of service within the period 628 |
|---|
| 942 | | - | being reconciled. Only payments for covered services for dates 629 |
|---|
| 943 | | - | of service within the reconciliation period and paid within 6 630 |
|---|
| 944 | | - | months after the last date of s ervice in the reconciliation 631 |
|---|
| 945 | | - | period must be included. The agency shall perform the necessary 632 |
|---|
| 946 | | - | adjustments for the inclusion of claims incurred but not 633 |
|---|
| 947 | | - | reported within the reconciliation period for claims that could 634 |
|---|
| 948 | | - | be received and paid by the agency after t he 6-month claims 635 |
|---|
| 949 | | - | processing time lag. The agency shall provide the results of the 636 |
|---|
| 950 | | - | reconciliations to the fee -for-service provider service networks 637 |
|---|
| 951 | | - | within 45 days after the end of the reconciliation period. The 638 |
|---|
| 952 | | - | fee-for-service provider service networks sha ll review and 639 |
|---|
| 953 | | - | provide written comments or a letter of concurrence to the 640 |
|---|
| 954 | | - | agency within 45 days after receipt of the reconciliation 641 |
|---|
| 955 | | - | results. This reconciliation is considered final. 642 |
|---|
| 956 | | - | Section 8. Subsection (3) and paragraph (b) of subsection 643 |
|---|
| 957 | | - | (4) of section 409.973, Florida Statutes, are amended, and 644 |
|---|
| 958 | | - | paragraphs (c) through (g) are added to subsection (5) of that 645 |
|---|
| 959 | | - | section, to read: 646 |
|---|
| 960 | | - | 409.973 Benefits.— 647 |
|---|
| 961 | | - | (3) HEALTHY BEHAVIORS. —Each plan operating in the managed 648 |
|---|
| 962 | | - | medical assistance program shall establish a pro gram to 649 |
|---|
| 963 | | - | encourage and reward healthy behaviors. At a minimum, each plan 650 |
|---|
| 939 | + | steps to improve dental health. 626 |
|---|
| 940 | + | (b) An enrollee incentive pro gram designed to increase 627 |
|---|
| 941 | + | utilization of preventive dental services. PROVISION OF DENTAL 628 |
|---|
| 942 | + | SERVICES.— 629 |
|---|
| 943 | + | (a) The Legislature may use the findings of the Office of 630 |
|---|
| 944 | + | Program Policy Analysis and Government Accountability's report 631 |
|---|
| 945 | + | no. 16-07, December 2016, in sett ing the scope of minimum 632 |
|---|
| 946 | + | benefits set forth in this section for future procurements of 633 |
|---|
| 947 | + | eligible plans as described in s. 409.966. Specifically, the 634 |
|---|
| 948 | + | decision to include dental services as a minimum benefit under 635 |
|---|
| 949 | + | this section, or to provide Medicaid recipien ts with dental 636 |
|---|
| 950 | + | benefits separate from the Medicaid managed medical assistance 637 |
|---|
| 951 | + | program described in this part, may take into consideration the 638 |
|---|
| 952 | + | data and findings of the report. 639 |
|---|
| 953 | + | (b) In the event the Legislature takes no action before 640 |
|---|
| 954 | + | July 1, 2017, with resp ect to the report findings required under 641 |
|---|
| 955 | + | paragraph (a), the agency shall implement a statewide Medicaid 642 |
|---|
| 956 | + | prepaid dental health program for children and adults with a 643 |
|---|
| 957 | + | choice of at least two licensed dental managed care providers 644 |
|---|
| 958 | + | who must have substantial ex perience in providing dental care to 645 |
|---|
| 959 | + | Medicaid enrollees and children eligible for medical assistance 646 |
|---|
| 960 | + | under Title XXI of the Social Security Act and who meet all 647 |
|---|
| 961 | + | agency standards and requirements. To qualify as a provider 648 |
|---|
| 962 | + | under the prepaid dental health pro gram, the entity must be 649 |
|---|
| 963 | + | licensed as a prepaid limited health service organization under 650 |
|---|
| 976 | | - | must establish a medically approved tobacco use smoking 651 |
|---|
| 977 | | - | cessation program, a medically directed weight loss program, and 652 |
|---|
| 978 | | - | a medically approved alcohol or substance abuse recovery 653 |
|---|
| 979 | | - | program, which shall include, at a minimum, a focus on opioid 654 |
|---|
| 980 | | - | abuse recovery. Each plan must identify enrollees who use 655 |
|---|
| 981 | | - | tobacco smoke, are morbidly obese, or are diagnosed with alcohol 656 |
|---|
| 982 | | - | or substance abuse in order to establish written agreements to 657 |
|---|
| 983 | | - | secure the enrollees' commitment to participation in these 658 |
|---|
| 984 | | - | programs. 659 |
|---|
| 985 | | - | (4) PRIMARY CARE INITIATIVE. —Each plan operating in the 660 |
|---|
| 986 | | - | managed medical assistance program shall establish a program to 661 |
|---|
| 987 | | - | encourage enrollees to establish a relationship with their 662 |
|---|
| 988 | | - | primary care provider. Each plan shall: 663 |
|---|
| 989 | | - | (b) If the enrollee was not a Medicaid recipient before 664 |
|---|
| 990 | | - | enrollment in the plan, assist the enrollee in scheduling an 665 |
|---|
| 991 | | - | appointment with the primary care provider. If possible the 666 |
|---|
| 992 | | - | appointment should be made within 30 days after enroll ment in 667 |
|---|
| 993 | | - | the plan. For enrollees who become eligible for Medicaid between 668 |
|---|
| 994 | | - | January 1, 2014, and December 31, 2015, the appointment should 669 |
|---|
| 995 | | - | be scheduled within 6 months after enrollment in the plan. 670 |
|---|
| 996 | | - | (5) PROVISION OF DENTAL SERVICES. — 671 |
|---|
| 997 | | - | (c) Given the effect o f oral health on overall health, 672 |
|---|
| 998 | | - | each prepaid dental plan shall establish a program to improve 673 |
|---|
| 999 | | - | dental health outcomes and increase utilization of preventive 674 |
|---|
| 1000 | | - | dental services. The agency shall establish performance and 675 |
|---|
| 976 | + | part I of chapter 636 or as a health maintenance organization 651 |
|---|
| 977 | + | under part I of chapter 641. The contracts for program providers 652 |
|---|
| 978 | + | shall be awarded through a competitive p rocurement process. 653 |
|---|
| 979 | + | Beginning with the contract procurement process initiated during 654 |
|---|
| 980 | + | the 2023 calendar year, the contracts must be for 6 years and 655 |
|---|
| 981 | + | may not be renewed; however, the agency may extend the term of a 656 |
|---|
| 982 | + | plan contract to cover delays during a trans ition to a new plan 657 |
|---|
| 983 | + | provider. The agency shall include in the contracts a medical 658 |
|---|
| 984 | + | loss ratio provision consistent with s. 409.967(4). The agency 659 |
|---|
| 985 | + | is authorized to seek any necessary state plan amendment or 660 |
|---|
| 986 | + | federal waiver to commence enrollment in the Medica id prepaid 661 |
|---|
| 987 | + | dental health program no later than March 1, 2019. The agency 662 |
|---|
| 988 | + | shall extend until December 31, 2024, the term of existing plan 663 |
|---|
| 989 | + | contracts awarded pursuant to the invitation to negotiate 664 |
|---|
| 990 | + | published in October 2017. 665 |
|---|
| 991 | + | Section 9. Subsections (1) and (2) of section 409.974, 666 |
|---|
| 992 | + | Florida Statutes, are amended to read: 667 |
|---|
| 993 | + | 409.974 Eligible plans. — 668 |
|---|
| 994 | + | (1) ELIGIBLE PLAN SELECTION. —The agency shall select 669 |
|---|
| 995 | + | eligible plans for the managed medical assistance program 670 |
|---|
| 996 | + | through the procurement process described in s. 409. 966. The 671 |
|---|
| 997 | + | agency shall select at least one provider service network for 672 |
|---|
| 998 | + | each region, if any submit a responsive bid. The agency shall 673 |
|---|
| 999 | + | procure the number of plans, inclusive of statewide plans, if 674 |
|---|
| 1000 | + | any, for each region as follows: 675 |
|---|
| 1013 | | - | outcome measures, regularly assess plan performance, and publish 676 |
|---|
| 1014 | | - | data on such measures. Program components shall, at a minimum, 677 |
|---|
| 1015 | | - | include: 678 |
|---|
| 1016 | | - | 1. An education program to inform enrollees of the 679 |
|---|
| 1017 | | - | connection between oral health and overall health and preventive 680 |
|---|
| 1018 | | - | steps to improve dental health. 681 |
|---|
| 1019 | | - | 2. An enrollee incentive program designed to increase 682 |
|---|
| 1020 | | - | utilization of preventive dental services. 683 |
|---|
| 1021 | | - | (d) The agency shall annually review encounter data and 684 |
|---|
| 1022 | | - | claims expenditures in the Statewide Medicaid Managed Care 685 |
|---|
| 1023 | | - | program for emergency department visits relating to nontraumatic 686 |
|---|
| 1024 | | - | and ambulatory sensitive dental conditions and reconcile service 687 |
|---|
| 1025 | | - | expenditures for these visits against capitation payments made 688 |
|---|
| 1026 | | - | to the prepaid dental plans. 689 |
|---|
| 1027 | | - | (e) By October 1, 2022, each prepaid dental plan and each 690 |
|---|
| 1028 | | - | nondental managed care plan shall enter into a mutual 691 |
|---|
| 1029 | | - | coordination of benefits agreement that includes data sharing 692 |
|---|
| 1030 | | - | requirements and coordination protocols to support the provision 693 |
|---|
| 1031 | | - | of dental services and reduction of potentially preventable 694 |
|---|
| 1032 | | - | events. 695 |
|---|
| 1033 | | - | (f) Beginning July 2022, ea ch prepaid dental plan and each 696 |
|---|
| 1034 | | - | nondental managed care plan must meet quarterly to collaborate 697 |
|---|
| 1035 | | - | on specific goals to improve quality of care and enrollee 698 |
|---|
| 1036 | | - | health. Plans shall mutually establish, in writing, shared 699 |
|---|
| 1037 | | - | goals, specific and measurable objectives, a nd complementary 700 |
|---|
| 1013 | + | (a) At least three plans a nd up to four plans for Region 676 |
|---|
| 1014 | + | A. 677 |
|---|
| 1015 | + | (b) At least five plans and up to six plans for Region B. 678 |
|---|
| 1016 | + | (c) At least six plans and up to ten plans for Region C. 679 |
|---|
| 1017 | + | (d) At least five plans and up to six plans for Region D. 680 |
|---|
| 1018 | + | (e) At least three plans and up to four p lans for Region 681 |
|---|
| 1019 | + | E. 682 |
|---|
| 1020 | + | (f) At least three plans and up to five plans for Region 683 |
|---|
| 1021 | + | F. 684 |
|---|
| 1022 | + | (g) At least three plans and up to five plans for Region 685 |
|---|
| 1023 | + | G. 686 |
|---|
| 1024 | + | (h) At least five plans and up to ten plans for Region H 687 |
|---|
| 1025 | + | The agency shall notice invitations to negotiate no la ter than 688 |
|---|
| 1026 | + | January 1, 2013. 689 |
|---|
| 1027 | + | (a) The agency shall procure two plans for Region 1. At 690 |
|---|
| 1028 | + | least one plan shall be a provider service network if any 691 |
|---|
| 1029 | + | provider service networks submit a responsive bid. 692 |
|---|
| 1030 | + | (b) The agency shall procure two plans for Region 2. At 693 |
|---|
| 1031 | + | least one plan shall be a provider service network if any 694 |
|---|
| 1032 | + | provider service networks submit a responsive bid. 695 |
|---|
| 1033 | + | (c) The agency shall procure at least three plans and up 696 |
|---|
| 1034 | + | to five plans for Region 3. At least one plan must be a provider 697 |
|---|
| 1035 | + | service network if any provi der service networks submit a 698 |
|---|
| 1036 | + | responsive bid. 699 |
|---|
| 1037 | + | (d) The agency shall procure at least three plans and up 700 |
|---|
| 1050 | | - | strategies pertinent to state Medicaid priorities. The goals, 701 |
|---|
| 1051 | | - | objectives, and strategies must address improving access and 702 |
|---|
| 1052 | | - | appropriate utilization, maximizing efficiency by integrating 703 |
|---|
| 1053 | | - | health and dental care, improving patient experiences, attending 704 |
|---|
| 1054 | | - | to unmet social needs that affect preventive care utilization 705 |
|---|
| 1055 | | - | and early disease detection, and identifying and reducing 706 |
|---|
| 1056 | | - | disparities. 707 |
|---|
| 1057 | | - | (g) The agency shall establish provider network 708 |
|---|
| 1058 | | - | requirements for dental plans. In addition, the agency must 709 |
|---|
| 1059 | | - | establish provider network requirements sufficient to ensure 710 |
|---|
| 1060 | | - | access to medically necessary sedation services, including, but 711 |
|---|
| 1061 | | - | not limited to, network participation by dentists credentialed 712 |
|---|
| 1062 | | - | to provide services in inpatient and outpatient settings and by 713 |
|---|
| 1063 | | - | inpatient and outpatient facilities and anesthesia service 714 |
|---|
| 1064 | | - | providers. The agency shall assess plan compliance with network 715 |
|---|
| 1065 | | - | adequacy requirements at least quarterly and shall enforce such 716 |
|---|
| 1066 | | - | requirements in a timely manner. 717 |
|---|
| 1067 | | - | Section 9. Subsections (1) and (2) of section 409.974, 718 |
|---|
| 1068 | | - | Florida Statutes, are amended to read: 719 |
|---|
| 1069 | | - | 409.974 Eligible plans. — 720 |
|---|
| 1070 | | - | (1) ELIGIBLE PLAN SELECTION. —The agency shall select 721 |
|---|
| 1071 | | - | eligible plans for the managed medical assistance program 722 |
|---|
| 1072 | | - | through the procurement process described in s. 409.966. The 723 |
|---|
| 1073 | | - | agency shall select at least one provider service network for 724 |
|---|
| 1074 | | - | each region, if any submit a responsive bid. The agency shall 725 |
|---|
| 1050 | + | to five plans for Region 4. At least one plan must be a provider 701 |
|---|
| 1051 | + | service network if any provider service networks submit a 702 |
|---|
| 1052 | + | responsive bid. 703 |
|---|
| 1053 | + | (e) The agency shall procure at least two plans and up to 704 |
|---|
| 1054 | + | four plans for Region 5. At least one plan must be a provider 705 |
|---|
| 1055 | + | service network if any provider service networks submit a 706 |
|---|
| 1056 | + | responsive bid. 707 |
|---|
| 1057 | + | (f) The agency shall procure at least four plans and up to 708 |
|---|
| 1058 | + | seven plans for Region 6. At least one plan must be a provider 709 |
|---|
| 1059 | + | service network if any provider service networks submit a 710 |
|---|
| 1060 | + | responsive bid. 711 |
|---|
| 1061 | + | (g) The agency shall procure at least three plans and up 712 |
|---|
| 1062 | + | to six plans for Region 7. At least one plan must be a provider 713 |
|---|
| 1063 | + | service network if any provider service networks submit a 714 |
|---|
| 1064 | + | responsive bid. 715 |
|---|
| 1065 | + | (h) The agency shall procure at least two plans and up to 716 |
|---|
| 1066 | + | four plans for Region 8. At least one plan must be a provider 717 |
|---|
| 1067 | + | service network if any provider service networks submit a 718 |
|---|
| 1068 | + | responsive bid. 719 |
|---|
| 1069 | + | (i) The agency shall procure at least two plans and up to 720 |
|---|
| 1070 | + | four plans for Region 9. At least one plan must be a provider 721 |
|---|
| 1071 | + | service network if any provider service networks submit a 722 |
|---|
| 1072 | + | responsive bid. 723 |
|---|
| 1073 | + | (j) The agency shall procure at least two plans and up to 724 |
|---|
| 1074 | + | four plans for Region 10. At least one plan must be a provider 725 |
|---|
| 1087 | | - | procure the number of plans, inclusive of statewide plans, if 726 |
|---|
| 1088 | | - | any, for each region as follows: 727 |
|---|
| 1089 | | - | (a) At least three plans and up to four plans for Region 728 |
|---|
| 1090 | | - | A. 729 |
|---|
| 1091 | | - | (b) At least five plans and up to six plans for Region B. 730 |
|---|
| 1092 | | - | (c) At least six plans and up to ten plans for Region C. 731 |
|---|
| 1093 | | - | (d) At least five plans and up to six plans for Region D. 732 |
|---|
| 1094 | | - | (e) At least three plans and up to four plans for Region 733 |
|---|
| 1095 | | - | E. 734 |
|---|
| 1096 | | - | (f) At least three plans and up to five plans for Region 735 |
|---|
| 1097 | | - | F. 736 |
|---|
| 1098 | | - | (g) At least three plans and up to five plans for Region 737 |
|---|
| 1099 | | - | G. 738 |
|---|
| 1100 | | - | (h) At least five plans and up to ten plans for Region H 739 |
|---|
| 1101 | | - | The agency shall notice invitations to negotiate no later than 740 |
|---|
| 1102 | | - | January 1, 2013. 741 |
|---|
| 1103 | | - | (a) The agency shall procure two plans for Region 1. At 742 |
|---|
| 1104 | | - | least one plan shall be a provider service network if any 743 |
|---|
| 1105 | | - | provider service networks submit a responsive bid. 744 |
|---|
| 1106 | | - | (b) The agency shall procure two plans for Region 2. At 745 |
|---|
| 1107 | | - | least one plan shall be a provider service network if any 746 |
|---|
| 1108 | | - | provider service networks submit a responsive bid. 747 |
|---|
| 1109 | | - | (c) The agency shall procure at least three plans and up 748 |
|---|
| 1110 | | - | to five plans for Region 3. At least one plan must be a provider 749 |
|---|
| 1111 | | - | service network if any provider serv ice networks submit a 750 |
|---|
| 1087 | + | service network if any provider service networks submit a 726 |
|---|
| 1088 | + | responsive bid. 727 |
|---|
| 1089 | + | (k) The agency shall procure at least five plans and up to 728 |
|---|
| 1090 | + | 10 plans for Region 11. At least one plan must be a provider 729 |
|---|
| 1091 | + | service network if any provider service networks submit a 730 |
|---|
| 1092 | + | responsive bid. 731 |
|---|
| 1093 | + | 732 |
|---|
| 1094 | + | If no provider service network submits a responsive bid, the 733 |
|---|
| 1095 | + | agency shall procure no more than one less than the maximum 734 |
|---|
| 1096 | + | number of eligible plans permitted in tha t region. Within 12 735 |
|---|
| 1097 | + | months after the initial invitation to negotiate, the agency 736 |
|---|
| 1098 | + | shall attempt to procure a provider service network. The agency 737 |
|---|
| 1099 | + | shall notice another invitation to negotiate only with provider 738 |
|---|
| 1100 | + | service networks in those regions where no prov ider service 739 |
|---|
| 1101 | + | network has been selected. 740 |
|---|
| 1102 | + | (2) QUALITY SELECTION CRITERIA. —In addition to the 741 |
|---|
| 1103 | + | criteria established in s. 409.966, the agency shall consider 742 |
|---|
| 1104 | + | evidence that an eligible plan has obtained signed contracts or 743 |
|---|
| 1105 | + | written agreements or signed contract s or has made substantial 744 |
|---|
| 1106 | + | progress in establishing relationships with providers before the 745 |
|---|
| 1107 | + | plan submits submitting a response. The agency shall evaluate 746 |
|---|
| 1108 | + | and give special weight to evidence of signed contracts with 747 |
|---|
| 1109 | + | essential providers as defined by the agen cy pursuant to s. 748 |
|---|
| 1110 | + | 409.975(1). The agency shall exercise a preference for plans 749 |
|---|
| 1111 | + | with a provider network in which over 10 percent of the 750 |
|---|
| 1124 | | - | responsive bid. 751 |
|---|
| 1125 | | - | (d) The agency shall procure at least three plans and up 752 |
|---|
| 1126 | | - | to five plans for Region 4. At least one plan must be a provider 753 |
|---|
| 1127 | | - | service network if any provider service networks submit a 754 |
|---|
| 1128 | | - | responsive bid. 755 |
|---|
| 1129 | | - | (e) The agency shall procure at least two plans and up to 756 |
|---|
| 1130 | | - | four plans for Region 5. At least one plan must be a provider 757 |
|---|
| 1131 | | - | service network if any provider service networks submit a 758 |
|---|
| 1132 | | - | responsive bid. 759 |
|---|
| 1133 | | - | (f) The agency shall procure at least four plans and up to 760 |
|---|
| 1134 | | - | seven plans for Region 6. At least one plan must be a provider 761 |
|---|
| 1135 | | - | service network if any provider service networks submit a 762 |
|---|
| 1136 | | - | responsive bid. 763 |
|---|
| 1137 | | - | (g) The agency shall procure at least three plans and up 764 |
|---|
| 1138 | | - | to six plans for Region 7. At least one plan must be a provider 765 |
|---|
| 1139 | | - | service network if any provider service networks submit a 766 |
|---|
| 1140 | | - | responsive bid. 767 |
|---|
| 1141 | | - | (h) The agency shall procure at least two plans and up to 768 |
|---|
| 1142 | | - | four plans for Region 8. At least one plan must be a provider 769 |
|---|
| 1143 | | - | service network if any provider service networks submit a 770 |
|---|
| 1144 | | - | responsive bid. 771 |
|---|
| 1145 | | - | (i) The agency shall procure at least two plans and up to 772 |
|---|
| 1146 | | - | four plans for Region 9. At least one plan must be a provider 773 |
|---|
| 1147 | | - | service network if any provider service networks submit a 774 |
|---|
| 1148 | | - | responsive bid. 775 |
|---|
| 1124 | + | providers use electronic health records, as defined in s. 751 |
|---|
| 1125 | + | 408.051. When all other factors are equal, the agency shall 752 |
|---|
| 1126 | + | consider whether the organization has a contract to provide 753 |
|---|
| 1127 | + | managed long-term care services in the same region and shall 754 |
|---|
| 1128 | + | exercise a preference for such plans. 755 |
|---|
| 1129 | + | Section 10. Paragraphs (a) and (b) of subsection (1) of 756 |
|---|
| 1130 | + | section 409.975, Florida Statutes, are a mended to read: 757 |
|---|
| 1131 | + | 409.975 Managed care plan accountability. —In addition to 758 |
|---|
| 1132 | + | the requirements of s. 409.967, plans and providers 759 |
|---|
| 1133 | + | participating in the managed medical assistance program shall 760 |
|---|
| 1134 | + | comply with the requirements of this section. 761 |
|---|
| 1135 | + | (1) PROVIDER NETWOR KS.—Managed care plans must develop and 762 |
|---|
| 1136 | + | maintain provider networks that meet the medical needs of their 763 |
|---|
| 1137 | + | enrollees in accordance with standards established pursuant to 764 |
|---|
| 1138 | + | s. 409.967(2)(c). Except as provided in this section, managed 765 |
|---|
| 1139 | + | care plans may limit the pr oviders in their networks based on 766 |
|---|
| 1140 | + | credentials, quality indicators, and price. 767 |
|---|
| 1141 | + | (a) Plans must include all providers in the region that 768 |
|---|
| 1142 | + | are classified by the agency as essential Medicaid providers, 769 |
|---|
| 1143 | + | unless the agency approves, in writing, an alternative 770 |
|---|
| 1144 | + | arrangement for securing the types of services offered by the 771 |
|---|
| 1145 | + | essential providers. The agency shall assess plan compliance 772 |
|---|
| 1146 | + | with such requirement at least quarterly. Providers are 773 |
|---|
| 1147 | + | essential for serving Medicaid enrollees if they offer services 774 |
|---|
| 1148 | + | that are not available from any other provider within a 775 |
|---|
| 1161 | | - | (j) The agency shall procure at least two plans and up t o 776 |
|---|
| 1162 | | - | four plans for Region 10. At least one plan must be a provider 777 |
|---|
| 1163 | | - | service network if any provider service networks submit a 778 |
|---|
| 1164 | | - | responsive bid. 779 |
|---|
| 1165 | | - | (k) The agency shall procure at least five plans and up to 780 |
|---|
| 1166 | | - | 10 plans for Region 11. At least one plan must be a prov ider 781 |
|---|
| 1167 | | - | service network if any provider service networks submit a 782 |
|---|
| 1168 | | - | responsive bid. 783 |
|---|
| 1169 | | - | 784 |
|---|
| 1170 | | - | If no provider service network submits a responsive bid, the 785 |
|---|
| 1171 | | - | agency shall procure no more than one less than the maximum 786 |
|---|
| 1172 | | - | number of eligible plans permitted in that region. With in 12 787 |
|---|
| 1173 | | - | months after the initial invitation to negotiate, the agency 788 |
|---|
| 1174 | | - | shall attempt to procure a provider service network. The agency 789 |
|---|
| 1175 | | - | shall notice another invitation to negotiate only with provider 790 |
|---|
| 1176 | | - | service networks in those regions where no provider service 791 |
|---|
| 1177 | | - | network has been selected. 792 |
|---|
| 1178 | | - | (2) QUALITY SELECTION CRITERIA. —In addition to the 793 |
|---|
| 1179 | | - | criteria established in s. 409.966, the agency shall consider 794 |
|---|
| 1180 | | - | evidence that an eligible plan has obtained signed contracts or 795 |
|---|
| 1181 | | - | written agreements or signed contracts or has made substantial 796 |
|---|
| 1182 | | - | progress in establishing relationships with providers before the 797 |
|---|
| 1183 | | - | plan submits submitting a response. The agency shall evaluate 798 |
|---|
| 1184 | | - | and give special weight to evidence of signed contracts with 799 |
|---|
| 1185 | | - | essential providers as defined by the agency pursuant to s. 800 |
|---|
| 1161 | + | reasonable access standard, or if they provided a substantial 776 |
|---|
| 1162 | + | share of the total units of a particular service used by 777 |
|---|
| 1163 | + | Medicaid patients within the region during the last 3 years and 778 |
|---|
| 1164 | + | the combined capacity of other s ervice providers in the region 779 |
|---|
| 1165 | + | is insufficient to meet the total needs of the Medicaid 780 |
|---|
| 1166 | + | patients. The agency may not classify physicians and other 781 |
|---|
| 1167 | + | practitioners as essential providers. The agency, at a minimum, 782 |
|---|
| 1168 | + | shall determine which providers in the followi ng categories are 783 |
|---|
| 1169 | + | essential Medicaid providers: 784 |
|---|
| 1170 | + | 1. Federally qualified health centers. 785 |
|---|
| 1171 | + | 2. Statutory teaching hospitals as defined in s. 786 |
|---|
| 1172 | + | 408.07(46). 787 |
|---|
| 1173 | + | 3. Hospitals that are trauma centers as defined in s. 788 |
|---|
| 1174 | + | 395.4001(15). 789 |
|---|
| 1175 | + | 4. Hospitals located at least 25 miles from any other 790 |
|---|
| 1176 | + | hospital with similar services. 791 |
|---|
| 1177 | + | 792 |
|---|
| 1178 | + | Managed care plans that have not contracted with all essential 793 |
|---|
| 1179 | + | providers in the region as of the first date of recipient 794 |
|---|
| 1180 | + | enrollment, or with whom an essential provider has terminated 795 |
|---|
| 1181 | + | its contract, must negotiate in good faith with such essential 796 |
|---|
| 1182 | + | providers for 1 year or until an agreement is reached, whichever 797 |
|---|
| 1183 | + | is first. Payments for services rendered by a nonparticipating 798 |
|---|
| 1184 | + | essential provider shall be made at the applicable Medicaid rate 799 |
|---|
| 1185 | + | as of the first day of the contract between the agency and the 800 |
|---|
| 1198 | | - | 409.975(1). The agency shall exercise a preference for plans 801 |
|---|
| 1199 | | - | with a provider network in which over 10 percent of the 802 |
|---|
| 1200 | | - | providers use electronic health records, as defined in s. 803 |
|---|
| 1201 | | - | 408.051. When all other factors are equal, the agency shall 804 |
|---|
| 1202 | | - | consider whether the organization has a contract to provide 805 |
|---|
| 1203 | | - | managed long-term care services in the same region and shall 806 |
|---|
| 1204 | | - | exercise a preference for such plans. 807 |
|---|
| 1205 | | - | Section 10. Paragraphs (a) and (b) of subsection (1) of 808 |
|---|
| 1206 | | - | section 409.975, Florida Statutes, are amended to read : 809 |
|---|
| 1207 | | - | 409.975 Managed care plan accountability. —In addition to 810 |
|---|
| 1208 | | - | the requirements of s. 409.967, plans and providers 811 |
|---|
| 1209 | | - | participating in the managed medical assistance program shall 812 |
|---|
| 1210 | | - | comply with the requirements of this section. 813 |
|---|
| 1211 | | - | (1) PROVIDER NETWORKS. —Managed care plans must develop and 814 |
|---|
| 1212 | | - | maintain provider networks that meet the medical needs of their 815 |
|---|
| 1213 | | - | enrollees in accordance with standards established pursuant to 816 |
|---|
| 1214 | | - | s. 409.967(2)(c). Except as provided in this section, managed 817 |
|---|
| 1215 | | - | care plans may limit the providers in the ir networks based on 818 |
|---|
| 1216 | | - | credentials, quality indicators, and price. 819 |
|---|
| 1217 | | - | (a) Plans must include all providers in the region that 820 |
|---|
| 1218 | | - | are classified by the agency as essential Medicaid providers, 821 |
|---|
| 1219 | | - | unless the agency approves, in writing, an alternative 822 |
|---|
| 1220 | | - | arrangement for securing the types of services offered by the 823 |
|---|
| 1221 | | - | essential providers. Providers are essential for serving 824 |
|---|
| 1222 | | - | Medicaid enrollees if they offer services that are not available 825 |
|---|
| 1198 | + | plan. A rate schedule for all essential providers shall be 801 |
|---|
| 1199 | + | attached to the contract between the agency and the plan. After 802 |
|---|
| 1200 | + | 1 year, managed care plans that are unable to contract with 803 |
|---|
| 1201 | + | essential providers shall no tify the agency and propose an 804 |
|---|
| 1202 | + | alternative arrangement for securing the essential services for 805 |
|---|
| 1203 | + | Medicaid enrollees. The arrangement must rely on contracts with 806 |
|---|
| 1204 | + | other participating providers, regardless of whether those 807 |
|---|
| 1205 | + | providers are located within the same region as the 808 |
|---|
| 1206 | + | nonparticipating essential service provider. If the alternative 809 |
|---|
| 1207 | + | arrangement is approved by the agency, payments to 810 |
|---|
| 1208 | + | nonparticipating essential providers after the date of the 811 |
|---|
| 1209 | + | agency's approval shall equal 90 percent of the applicable 812 |
|---|
| 1210 | + | Medicaid rate. Except for payment for emergency services, if the 813 |
|---|
| 1211 | + | alternative arrangement is not approved by the agency, payment 814 |
|---|
| 1212 | + | to nonparticipating essential providers shall equal 110 percent 815 |
|---|
| 1213 | + | of the applicable Medicaid rate. 816 |
|---|
| 1214 | + | (b) Certain providers are statewide re sources and 817 |
|---|
| 1215 | + | essential providers for all managed care plans in all regions. 818 |
|---|
| 1216 | + | All managed care plans must include these essential providers in 819 |
|---|
| 1217 | + | their networks. The agency shall assess plan compliance with 820 |
|---|
| 1218 | + | such requirement at least quarterly. Statewide essential 821 |
|---|
| 1219 | + | providers include: 822 |
|---|
| 1220 | + | 1. Faculty plans of Florida medical schools. 823 |
|---|
| 1221 | + | 2. Regional perinatal intensive care centers as defined in 824 |
|---|
| 1222 | + | s. 383.16(2). 825 |
|---|
| 1235 | | - | from any other provider within a reasonable access standard, or 826 |
|---|
| 1236 | | - | if they provided a subst antial share of the total units of a 827 |
|---|
| 1237 | | - | particular service used by Medicaid patients within the region 828 |
|---|
| 1238 | | - | during the last 3 years and the combined capacity of other 829 |
|---|
| 1239 | | - | service providers in the region is insufficient to meet the 830 |
|---|
| 1240 | | - | total needs of the Medicaid patients. The agency may not 831 |
|---|
| 1241 | | - | classify physicians and other practitioners as essential 832 |
|---|
| 1242 | | - | providers. 833 |
|---|
| 1243 | | - | 1. The agency, at a minimum, shall determine which 834 |
|---|
| 1244 | | - | providers in the following categories are essential Medicaid 835 |
|---|
| 1245 | | - | providers: 836 |
|---|
| 1246 | | - | a.1. Federally qualified health centers. 837 |
|---|
| 1247 | | - | b.2. Statutory teaching hospitals as defined in s. 838 |
|---|
| 1248 | | - | 408.07(46). 839 |
|---|
| 1249 | | - | c.3. Hospitals that are trauma centers as defined in s. 840 |
|---|
| 1250 | | - | 395.4001(15). 841 |
|---|
| 1251 | | - | d.4. Hospitals located at least 25 miles from any other 842 |
|---|
| 1252 | | - | hospital with similar services. 843 |
|---|
| 1253 | | - | 2. Regional perinatal intensive care centers as defined in 844 |
|---|
| 1254 | | - | s. 383.16(2) are regional resources and essential providers for 845 |
|---|
| 1255 | | - | all managed care plans in the applicable region. All managed 846 |
|---|
| 1256 | | - | care plans in a region must have a network contract with each 847 |
|---|
| 1257 | | - | regional perinatal intensive car e center in the region. 848 |
|---|
| 1258 | | - | 3. Managed care plans that have not contracted with all 849 |
|---|
| 1259 | | - | essential providers in the region as of the first date of 850 |
|---|
| 1235 | + | 3. Hospitals licensed as specialty children's hospitals as 826 |
|---|
| 1236 | + | defined in s. 395.002(28). 827 |
|---|
| 1237 | + | 4. Accredited and integ rated systems serving medically 828 |
|---|
| 1238 | + | complex children which comprise separately licensed, but 829 |
|---|
| 1239 | + | commonly owned, health care providers delivering at least the 830 |
|---|
| 1240 | + | following services: medical group home, in -home and outpatient 831 |
|---|
| 1241 | + | nursing care and therapies, pharmacy servi ces, durable medical 832 |
|---|
| 1242 | + | equipment, and Prescribed Pediatric Extended Care. 833 |
|---|
| 1243 | + | 5. Florida cancer hospitals that meet the criteria in 42 834 |
|---|
| 1244 | + | U.S.C. s. 1395ww(d)(1)(B)(v). 835 |
|---|
| 1245 | + | 836 |
|---|
| 1246 | + | Managed care plans that have not contracted with all statewide 837 |
|---|
| 1247 | + | essential providers in all regi ons as of the first date of 838 |
|---|
| 1248 | + | recipient enrollment must continue to negotiate in good faith. 839 |
|---|
| 1249 | + | Payments to physicians on the faculty of nonparticipating 840 |
|---|
| 1250 | + | Florida medical schools shall be made at the applicable Medicaid 841 |
|---|
| 1251 | + | rate. Payments for services rendered by re gional perinatal 842 |
|---|
| 1252 | + | intensive care centers shall be made at the applicable Medicaid 843 |
|---|
| 1253 | + | rate as of the first day of the contract between the agency and 844 |
|---|
| 1254 | + | the plan. Except for payments for emergency services, payments 845 |
|---|
| 1255 | + | to nonparticipating specialty children's hospita ls shall equal 846 |
|---|
| 1256 | + | the highest rate established by contract between that provider 847 |
|---|
| 1257 | + | and any other Medicaid managed care plan. Payments for services 848 |
|---|
| 1258 | + | rendered by Florida cancer hospitals that meet the criteria in 849 |
|---|
| 1259 | + | 42 U.S.C. s. 1395ww(d)(1)(B)(v) shall be made at th e applicable 850 |
|---|
| 1272 | | - | recipient enrollment, or with whom an essential provider has 851 |
|---|
| 1273 | | - | terminated its contract, must negotiate in good faith w ith such 852 |
|---|
| 1274 | | - | essential providers for 1 year or until an agreement is reached, 853 |
|---|
| 1275 | | - | whichever is first. Payments for services rendered by a 854 |
|---|
| 1276 | | - | nonparticipating essential provider shall be made at the 855 |
|---|
| 1277 | | - | applicable Medicaid rate as of the first day of the contract 856 |
|---|
| 1278 | | - | between the agency and the plan. A rate schedule for all 857 |
|---|
| 1279 | | - | essential providers shall be attached to the contract between 858 |
|---|
| 1280 | | - | the agency and the plan. After 1 year, managed care plans that 859 |
|---|
| 1281 | | - | are unable to contract with essential providers shall notify the 860 |
|---|
| 1282 | | - | agency and propose an alternative arrangement for securing the 861 |
|---|
| 1283 | | - | essential services for Medicaid enrollees. The arrangement must 862 |
|---|
| 1284 | | - | rely on contracts with other participating providers, regardless 863 |
|---|
| 1285 | | - | of whether those providers are located within the same region as 864 |
|---|
| 1286 | | - | the nonparticipating essential service provider. If the 865 |
|---|
| 1287 | | - | alternative arrangement is approved by the agency, payments to 866 |
|---|
| 1288 | | - | nonparticipating essential providers after the date of the 867 |
|---|
| 1289 | | - | agency's approval shall equal 90 percent of the applicable 868 |
|---|
| 1290 | | - | Medicaid rate. Except for payment f or emergency services, if the 869 |
|---|
| 1291 | | - | alternative arrangement is not approved by the agency, payment 870 |
|---|
| 1292 | | - | to nonparticipating essential providers shall equal 110 percent 871 |
|---|
| 1293 | | - | of the applicable Medicaid rate. 872 |
|---|
| 1294 | | - | 873 |
|---|
| 1295 | | - | The agency shall assess plan compliance with this paragraph at 874 |
|---|
| 1296 | | - | least quarterly. No later than January 1 of each year, the 875 |
|---|
| 1272 | + | Medicaid rate as of the first day of the contract between the 851 |
|---|
| 1273 | + | agency and the plan. 852 |
|---|
| 1274 | + | Section 11. Subsections (1), (4), and (5) of section 853 |
|---|
| 1275 | + | 409.977, Florida Statutes, are amended to read: 854 |
|---|
| 1276 | + | 409.977 Enrollment. — 855 |
|---|
| 1277 | + | (1) The agency shall automatic ally enroll into a managed 856 |
|---|
| 1278 | + | care plan those Medicaid recipients who do not voluntarily 857 |
|---|
| 1279 | + | choose a plan pursuant to s. 409.969. The agency shall 858 |
|---|
| 1280 | + | automatically enroll recipients in plans that meet or exceed the 859 |
|---|
| 1281 | + | performance or quality standards established pursu ant to s. 860 |
|---|
| 1282 | + | 409.967 and may not automatically enroll recipients in a plan 861 |
|---|
| 1283 | + | that is deficient in those performance or quality standards. 862 |
|---|
| 1284 | + | When a specialty plan is available to accommodate a specific 863 |
|---|
| 1285 | + | condition or diagnosis of a recipient, the agency shall assign 864 |
|---|
| 1286 | + | the recipient to that plan. The agency may not automatically 865 |
|---|
| 1287 | + | enroll recipients in a managed medical assistance plan that has 866 |
|---|
| 1288 | + | more than 45 percent of the enrollees in the region. In the 867 |
|---|
| 1289 | + | first year of the first contract term only, if a recipient was 868 |
|---|
| 1290 | + | previously enrolled in a plan that is still available in the 869 |
|---|
| 1291 | + | region, the agency shall automatically enroll the recipient in 870 |
|---|
| 1292 | + | that plan unless an applicable specialty plan is available. 871 |
|---|
| 1293 | + | Except as otherwise provided in this part, the agency may not 872 |
|---|
| 1294 | + | engage in practices that are designed to favor one managed care 873 |
|---|
| 1295 | + | plan over another. 874 |
|---|
| 1296 | + | (4) The agency shall develop a process to enable a 875 |
|---|
| 1309 | | - | agency must impose contract enforcement financial sanctions on, 876 |
|---|
| 1310 | | - | or assess contract damages against, a plan without a network 877 |
|---|
| 1311 | | - | contract as required by this subsection with an essential 878 |
|---|
| 1312 | | - | provider subject to the requirements of s. 409.908(26). 879 |
|---|
| 1313 | | - | (b) Certain providers are statewide resources and 880 |
|---|
| 1314 | | - | essential providers for all managed care plans in all regions. 881 |
|---|
| 1315 | | - | All managed care plans must include these essential providers in 882 |
|---|
| 1316 | | - | their networks. 883 |
|---|
| 1317 | | - | 1. Statewide essential providers include: 884 |
|---|
| 1318 | | - | a.1. Faculty plans of Florida medical schools. 885 |
|---|
| 1319 | | - | 2. Regional perinatal intensive care centers as defined in 886 |
|---|
| 1320 | | - | s. 383.16(2). 887 |
|---|
| 1321 | | - | b.3. Hospitals licensed as specialty children's hospitals 888 |
|---|
| 1322 | | - | as defined in s. 395.002(28). 889 |
|---|
| 1323 | | - | c. Florida cancer hospitals that meet the criteria in 42 890 |
|---|
| 1324 | | - | U.S.C. s. 1395ww(d)(1)(B)(v). 891 |
|---|
| 1325 | | - | 4. Accredited and integrated systems serving medically 892 |
|---|
| 1326 | | - | complex children which comprise separately licensed, but 893 |
|---|
| 1327 | | - | commonly owned, health care providers delivering at least the 894 |
|---|
| 1328 | | - | following services: medical group home, in -home and outpatient 895 |
|---|
| 1329 | | - | nursing care and therapies, pharmacy services, durable medical 896 |
|---|
| 1330 | | - | equipment, and Prescribed Pediatric Extended Care. 897 |
|---|
| 1331 | | - | 2. Managed care plans that have not contracted with all 898 |
|---|
| 1332 | | - | statewide essential provi ders in all regions as of the first 899 |
|---|
| 1333 | | - | date of recipient enrollment must continue to negotiate in good 900 |
|---|
| 1309 | + | recipient with access to employer -sponsored health care coverage 876 |
|---|
| 1310 | + | to opt out of all managed care plans and to use Medicaid 877 |
|---|
| 1311 | + | financial assistance to pay for the recipient's share of the 878 |
|---|
| 1312 | + | cost in such employer -sponsored coverage. Contingent upon 879 |
|---|
| 1313 | + | federal approval, The agency shall also enable recipients with 880 |
|---|
| 1314 | + | access to other insurance or related products providing access 881 |
|---|
| 1315 | + | to health care services cr eated pursuant to state law, including 882 |
|---|
| 1316 | + | any product available under the Florida Health Choices Program, 883 |
|---|
| 1317 | + | or any health exchange, to opt out. The amount of financial 884 |
|---|
| 1318 | + | assistance provided for each recipient may not exceed the amount 885 |
|---|
| 1319 | + | of the Medicaid premium that would have been paid to a managed 886 |
|---|
| 1320 | + | care plan for that recipient. The agency shall seek federal 887 |
|---|
| 1321 | + | approval to require Medicaid recipients with access to employer -888 |
|---|
| 1322 | + | sponsored health care coverage to enroll in that coverage and 889 |
|---|
| 1323 | + | use Medicaid financial assistance to pay for the recipient's 890 |
|---|
| 1324 | + | share of the cost for such coverage. The amount of financial 891 |
|---|
| 1325 | + | assistance provided for each recipient may not exceed the amount 892 |
|---|
| 1326 | + | of the Medicaid premium that would have been paid to a managed 893 |
|---|
| 1327 | + | care plan for that recipient. 894 |
|---|
| 1328 | + | (5) Specialty plans serving children in the care and 895 |
|---|
| 1329 | + | custody of the department may serve such children as long as 896 |
|---|
| 1330 | + | they remain in care, including those remaining in extended 897 |
|---|
| 1331 | + | foster care pursuant to s. 39.6251, or are in subsidized 898 |
|---|
| 1332 | + | adoption and continue to be eligible for Medicaid pursuant to s. 899 |
|---|
| 1333 | + | 409.903, or are receiving guardianship assistance payments and 900 |
|---|
| 1346 | | - | faith. Payments to physicians on the faculty of nonparticipating 901 |
|---|
| 1347 | | - | Florida medical schools shall be made at the applicable Medicaid 902 |
|---|
| 1348 | | - | rate. Payments for service s rendered by regional perinatal 903 |
|---|
| 1349 | | - | intensive care centers shall be made at the applicable Medicaid 904 |
|---|
| 1350 | | - | rate as of the first day of the contract between the agency and 905 |
|---|
| 1351 | | - | the plan. Except for payments for emergency services, payments 906 |
|---|
| 1352 | | - | to nonparticipating specialty ch ildren's hospitals and payments 907 |
|---|
| 1353 | | - | to nonparticipating Florida cancer hospitals that meet the 908 |
|---|
| 1354 | | - | criteria in 42 U.S.C. s. 1395ww(d)(1)(B)(v) shall equal the 909 |
|---|
| 1355 | | - | highest rate established by contract between that provider and 910 |
|---|
| 1356 | | - | any other Medicaid managed care plan. 911 |
|---|
| 1357 | | - | 912 |
|---|
| 1358 | | - | The agency shall assess plan compliance with this paragraph at 913 |
|---|
| 1359 | | - | least quarterly. No later than January 1 of each year, the 914 |
|---|
| 1360 | | - | agency must impose contract enforcement financial sanctions on, 915 |
|---|
| 1361 | | - | or assess contract damages against, a plan without a network 916 |
|---|
| 1362 | | - | contract as required by this subsection with an essential 917 |
|---|
| 1363 | | - | provider subject to the requirements of s. 409.908(26). 918 |
|---|
| 1364 | | - | Section 11. Subsections (1), (4), and (5) of section 919 |
|---|
| 1365 | | - | 409.977, Florida Statutes, are amended to read: 920 |
|---|
| 1366 | | - | 409.977 Enrollment. — 921 |
|---|
| 1367 | | - | (1) The agency shall aut omatically enroll into a managed 922 |
|---|
| 1368 | | - | care plan those Medicaid recipients who do not voluntarily 923 |
|---|
| 1369 | | - | choose a plan pursuant to s. 409.969. The agency shall 924 |
|---|
| 1370 | | - | automatically enroll recipients in plans that meet or exceed the 925 |
|---|
| 1346 | + | continue to be eligible for Medicaid pursuant to s. 409.903 . 901 |
|---|
| 1347 | + | Section 12. Subsection (2) of section 409.981, Florida 902 |
|---|
| 1348 | + | Statutes, is amended to read: 903 |
|---|
| 1349 | + | 409.981 Eligible long -term care plans.— 904 |
|---|
| 1350 | + | (2) ELIGIBLE PLAN SELECTION. —The agency shall select 905 |
|---|
| 1351 | + | eligible plans for the long-term care managed care program 906 |
|---|
| 1352 | + | through the procurement process described in s. 409.966. The 907 |
|---|
| 1353 | + | agency shall select at least one provider service network for 908 |
|---|
| 1354 | + | each region, if any provider service network submits a 909 |
|---|
| 1355 | + | responsive bid. The agency shall procure the number of plans, 910 |
|---|
| 1356 | + | inclusive of statewide plans, if any, for each region as 911 |
|---|
| 1357 | + | follows: 912 |
|---|
| 1358 | + | (a) At least three plans and up to four plans for Region 913 |
|---|
| 1359 | + | A. 914 |
|---|
| 1360 | + | (b) At least three plans and up to six plans for Region B. 915 |
|---|
| 1361 | + | (c) At least five plans and up to ten plans for Region C. 916 |
|---|
| 1362 | + | (d) At least three plans and up to six plans for Region D. 917 |
|---|
| 1363 | + | (e) At least three plans and up to four plans for Region 918 |
|---|
| 1364 | + | E. 919 |
|---|
| 1365 | + | (f) At least three plans and up to five plans for Region 920 |
|---|
| 1366 | + | F. 921 |
|---|
| 1367 | + | (g) At least three plans and up to four plans for Regi on 922 |
|---|
| 1368 | + | G. 923 |
|---|
| 1369 | + | (h) At least five plans and up to ten plans for Region H. 924 |
|---|
| 1370 | + | (a) Two plans for Region 1. At least one plan must be a 925 |
|---|
| 1383 | | - | performance or quality standards established pursuant to s. 926 |
|---|
| 1384 | | - | 409.967 and may not automatically enroll recipients in a plan 927 |
|---|
| 1385 | | - | that is deficient in those performance or quality standards. 928 |
|---|
| 1386 | | - | When a specialty plan is available to accommodate a specific 929 |
|---|
| 1387 | | - | condition or diagnosis of a recipient, the agency shall assign 930 |
|---|
| 1388 | | - | the recipient to that plan. The agency may not automatically 931 |
|---|
| 1389 | | - | enroll recipients in a managed medical assistance plan that has 932 |
|---|
| 1390 | | - | more than 50 percent of the enrollees in the region. In the 933 |
|---|
| 1391 | | - | first year of the first contract term only, if a recipient was 934 |
|---|
| 1392 | | - | previously enrolled in a plan that is still available in the 935 |
|---|
| 1393 | | - | region, the agency shall automatically enroll the recipient in 936 |
|---|
| 1394 | | - | that plan unless an applicable specialty plan is available. 937 |
|---|
| 1395 | | - | Except as otherwise provided in this part, the agency may not 938 |
|---|
| 1396 | | - | engage in practices that are designed to favor one managed care 939 |
|---|
| 1397 | | - | plan over another. 940 |
|---|
| 1398 | | - | (4) The agency shall develop a process to enable a 941 |
|---|
| 1399 | | - | recipient with access to employer -sponsored health care coverage 942 |
|---|
| 1400 | | - | to opt out of all managed care plans and to use Medicaid 943 |
|---|
| 1401 | | - | financial assistance to pay for the recipient's share of the 944 |
|---|
| 1402 | | - | cost in such employer -sponsored coverage. Contingent upon 945 |
|---|
| 1403 | | - | federal approval, The agency shall also enable recipients with 946 |
|---|
| 1404 | | - | access to other insurance or related products providing access 947 |
|---|
| 1405 | | - | to health care servi ces created pursuant to state law, including 948 |
|---|
| 1406 | | - | any product available under the Florida Health Choices Program, 949 |
|---|
| 1407 | | - | or any health exchange, to opt out. The amount of financial 950 |
|---|
| 1383 | + | provider service network if any provider service networks submit 926 |
|---|
| 1384 | + | a responsive bid. 927 |
|---|
| 1385 | + | (b) Two plans for Region 2. At least one plan m ust be a 928 |
|---|
| 1386 | + | provider service network if any provider service networks submit 929 |
|---|
| 1387 | + | a responsive bid. 930 |
|---|
| 1388 | + | (c) At least three plans and up to five plans for Region 931 |
|---|
| 1389 | + | 3. At least one plan must be a provider service network if any 932 |
|---|
| 1390 | + | provider service networks submit a respons ive bid. 933 |
|---|
| 1391 | + | (d) At least three plans and up to five plans for Region 934 |
|---|
| 1392 | + | 4. At least one plan must be a provider service network if any 935 |
|---|
| 1393 | + | provider service network submits a responsive bid. 936 |
|---|
| 1394 | + | (e) At least two plans and up to four plans for Region 5. 937 |
|---|
| 1395 | + | At least one plan must be a provider service network if any 938 |
|---|
| 1396 | + | provider service networks submit a responsive bid. 939 |
|---|
| 1397 | + | (f) At least four plans and up to seven plans for Region 940 |
|---|
| 1398 | + | 6. At least one plan must be a provider service network if any 941 |
|---|
| 1399 | + | provider service networks submit a re sponsive bid. 942 |
|---|
| 1400 | + | (g) At least three plans and up to six plans for Region 7. 943 |
|---|
| 1401 | + | At least one plan must be a provider service network if any 944 |
|---|
| 1402 | + | provider service networks submit a responsive bid. 945 |
|---|
| 1403 | + | (h) At least two plans and up to four plans for Region 8. 946 |
|---|
| 1404 | + | At least one plan must be a provider service network if any 947 |
|---|
| 1405 | + | provider service networks submit a responsive bid. 948 |
|---|
| 1406 | + | (i) At least two plans and up to four plans for Region 9. 949 |
|---|
| 1407 | + | At least one plan must be a provider service network if any 950 |
|---|
| 1420 | | - | assistance provided for each recipient may not exceed the amount 951 |
|---|
| 1421 | | - | of the Medicaid premiu m that would have been paid to a managed 952 |
|---|
| 1422 | | - | care plan for that recipient. The agency shall seek federal 953 |
|---|
| 1423 | | - | approval to require Medicaid recipients with access to employer -954 |
|---|
| 1424 | | - | sponsored health care coverage to enroll in that coverage and 955 |
|---|
| 1425 | | - | use Medicaid financial assist ance to pay for the recipient's 956 |
|---|
| 1426 | | - | share of the cost for such coverage. The amount of financial 957 |
|---|
| 1427 | | - | assistance provided for each recipient may not exceed the amount 958 |
|---|
| 1428 | | - | of the Medicaid premium that would have been paid to a managed 959 |
|---|
| 1429 | | - | care plan for that recipient. 960 |
|---|
| 1430 | | - | (5) Specialty plans serving children in the care and 961 |
|---|
| 1431 | | - | custody of the department may serve such children as long as 962 |
|---|
| 1432 | | - | they remain in care, including those remaining in extended 963 |
|---|
| 1433 | | - | foster care pursuant to s. 39.6251, or are in subsidized 964 |
|---|
| 1434 | | - | adoption and continue to be e ligible for Medicaid pursuant to s. 965 |
|---|
| 1435 | | - | 409.903, or are receiving guardianship assistance payments and 966 |
|---|
| 1436 | | - | continue to be eligible for Medicaid pursuant to s. 409.903 . 967 |
|---|
| 1437 | | - | Section 12. The Agency for Health Care Administration must 968 |
|---|
| 1438 | | - | amend existing contracts under th e Statewide Medicaid Managed 969 |
|---|
| 1439 | | - | Care program to implement the amendments made by this act to ss. 970 |
|---|
| 1440 | | - | 409.908, 409.967, 409.973, 409.975, and 409.977, Florida 971 |
|---|
| 1441 | | - | Statutes. The agency must implement the amendments made by this 972 |
|---|
| 1442 | | - | act to ss. 409.966, 409.974, and 409.981, Florida Statutes, for 973 |
|---|
| 1443 | | - | the 2025 plan year. 974 |
|---|
| 1444 | | - | Section 13. Subsection (2) of section 409.981, Florida 975 |
|---|
| 1420 | + | provider service networks submit a responsive bid. 951 |
|---|
| 1421 | + | (j) At least two plans and up to four plans for Region 10. 952 |
|---|
| 1422 | + | At least one plan must be a provider service network if any 953 |
|---|
| 1423 | + | provider service networks submit a responsive bid. 954 |
|---|
| 1424 | + | (k) At least five plans and up to 10 plans for Region 11. 955 |
|---|
| 1425 | + | At least one plan must be a provider service network if any 956 |
|---|
| 1426 | + | provider service networks submit a responsive bid. 957 |
|---|
| 1427 | + | 958 |
|---|
| 1428 | + | If no provider service network submits a responsive bid in a 959 |
|---|
| 1429 | + | region other than Region A 1 or Region 2, the agency shall 960 |
|---|
| 1430 | + | procure no more than one fewer less than the maximum number of 961 |
|---|
| 1431 | + | eligible plans permitted in that region. Within 12 months after 962 |
|---|
| 1432 | + | the initial invitation to negotiate, the agency shall attempt to 963 |
|---|
| 1433 | + | procure a provider service network. The agency shall notice 964 |
|---|
| 1434 | + | another invitation to negotiate only with provider service 965 |
|---|
| 1435 | + | networks in regions where no provider service network has been 966 |
|---|
| 1436 | + | selected. 967 |
|---|
| 1437 | + | Section 13. Subsection (4) of section 409.8132, Florida 968 |
|---|
| 1438 | + | Statutes, is amended to read: 969 |
|---|
| 1439 | + | 409.8132 Medikids program component. — 970 |
|---|
| 1440 | + | (4) APPLICABILITY OF LAWS RE LATING TO MEDICAID.—The 971 |
|---|
| 1441 | + | provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908, 972 |
|---|
| 1442 | + | 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127, 973 |
|---|
| 1443 | + | 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205 apply 974 |
|---|
| 1444 | + | to the administration of the Medikids program component of the 975 |
|---|
| 1457 | | - | Statutes, is amended to read: 976 |
|---|
| 1458 | | - | 409.981 Eligible long -term care plans.— 977 |
|---|
| 1459 | | - | (2) ELIGIBLE PLAN SELECTION. —The agency shall select 978 |
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| 1460 | | - | eligible plans for the long-term care managed care program 979 |
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| 1461 | | - | through the procurement process described in s. 409.966. The 980 |
|---|
| 1462 | | - | agency shall select at least one provider service network for 981 |
|---|
| 1463 | | - | each region, if any provider service network submits a 982 |
|---|
| 1464 | | - | responsive bid. The agency shall procure the number of plans, 983 |
|---|
| 1465 | | - | inclusive of statewide plans, if any, for each region as 984 |
|---|
| 1466 | | - | follows: 985 |
|---|
| 1467 | | - | (a) At least three plans and up to four plans for Region 986 |
|---|
| 1468 | | - | A. 987 |
|---|
| 1469 | | - | (b) At least three plans and up to six plans for Region B. 988 |
|---|
| 1470 | | - | (c) At least five plans and up to ten plans for R egion C. 989 |
|---|
| 1471 | | - | (d) At least three plans and up to six plans for Region D. 990 |
|---|
| 1472 | | - | (e) At least three plans and up to four plans for Region 991 |
|---|
| 1473 | | - | E. 992 |
|---|
| 1474 | | - | (f) At least three plans and up to five plans for Region 993 |
|---|
| 1475 | | - | F. 994 |
|---|
| 1476 | | - | (g) At least three plans and up to four plans for Region 995 |
|---|
| 1477 | | - | G. 996 |
|---|
| 1478 | | - | (h) At least five plans and up to ten plans for Region H. 997 |
|---|
| 1479 | | - | (a) Two plans for Region 1. At least one plan must be a 998 |
|---|
| 1480 | | - | provider service network if any provider service networks submit 999 |
|---|
| 1481 | | - | a responsive bid. 1000 |
|---|
| 1457 | + | Florida Kidcare program, except that s. 409.9122 applies to 976 |
|---|
| 1458 | + | Medikids as modified by the provisions of subsection (7). 977 |
|---|
| 1459 | + | Section 14. Paragraph (d) of subsection (13) of section 978 |
|---|
| 1460 | + | 409.906, Florida Statutes, is amended to read: 979 |
|---|
| 1461 | + | 409.906 Optional Medicaid services. —Subject to specific 980 |
|---|
| 1462 | + | appropriations, the agency may make payments for services which 981 |
|---|
| 1463 | + | are optional to the state under Title XIX of the Social Security 982 |
|---|
| 1464 | + | Act and are furnished by Medicaid providers to recipients who 983 |
|---|
| 1465 | + | are determined to be eligible on the dates on which the services 984 |
|---|
| 1466 | + | were provided. Any optional service that is provided shall be 985 |
|---|
| 1467 | + | provided only when medically necessary and in accordance with 986 |
|---|
| 1468 | + | state and federal law. Optional services rendered by providers 987 |
|---|
| 1469 | + | in mobile units to Medicaid recipients may be restricted or 988 |
|---|
| 1470 | + | prohibited by the agency. Nothing in this section shall be 989 |
|---|
| 1471 | + | construed to prevent or limit the agency from adjusting fees, 990 |
|---|
| 1472 | + | reimbursement rates, lengths of stay, number of visits, or 991 |
|---|
| 1473 | + | number of services, or making any o ther adjustments necessary to 992 |
|---|
| 1474 | + | comply with the availability of moneys and any limitations or 993 |
|---|
| 1475 | + | directions provided for in the General Appropriations Act or 994 |
|---|
| 1476 | + | chapter 216. If necessary to safeguard the state's systems of 995 |
|---|
| 1477 | + | providing services to elderly and disable d persons and subject 996 |
|---|
| 1478 | + | to the notice and review provisions of s. 216.177, the Governor 997 |
|---|
| 1479 | + | may direct the Agency for Health Care Administration to amend 998 |
|---|
| 1480 | + | the Medicaid state plan to delete the optional Medicaid service 999 |
|---|
| 1481 | + | known as "Intermediate Care Facilities for t he Developmentally 1000 |
|---|
| 1494 | | - | (b) Two plans for Region 2. At least one plan must be a 1001 |
|---|
| 1495 | | - | provider service network if any provider service networks submit 1002 |
|---|
| 1496 | | - | a responsive bid. 1003 |
|---|
| 1497 | | - | (c) At least three plans and up to five plans for Region 1004 |
|---|
| 1498 | | - | 3. At least one plan must be a provider service network if any 1005 |
|---|
| 1499 | | - | provider service networks submit a responsive bi d. 1006 |
|---|
| 1500 | | - | (d) At least three plans and up to five plans for Region 1007 |
|---|
| 1501 | | - | 4. At least one plan must be a provider service network if any 1008 |
|---|
| 1502 | | - | provider service network submits a responsive bid. 1009 |
|---|
| 1503 | | - | (e) At least two plans and up to four plans for Region 5. 1010 |
|---|
| 1504 | | - | At least one plan must be a provider service network if any 1011 |
|---|
| 1505 | | - | provider service networks submit a responsive bid. 1012 |
|---|
| 1506 | | - | (f) At least four plans and up to seven plans for Region 1013 |
|---|
| 1507 | | - | 6. At least one plan must be a provider service network if any 1014 |
|---|
| 1508 | | - | provider service networks submit a respon sive bid. 1015 |
|---|
| 1509 | | - | (g) At least three plans and up to six plans for Region 7. 1016 |
|---|
| 1510 | | - | At least one plan must be a provider service network if any 1017 |
|---|
| 1511 | | - | provider service networks submit a responsive bid. 1018 |
|---|
| 1512 | | - | (h) At least two plans and up to four plans for Region 8. 1019 |
|---|
| 1513 | | - | At least one plan must be a provider service network if any 1020 |
|---|
| 1514 | | - | provider service networks submit a responsive bid. 1021 |
|---|
| 1515 | | - | (i) At least two plans and up to four plans for Region 9. 1022 |
|---|
| 1516 | | - | At least one plan must be a provider service network if any 1023 |
|---|
| 1517 | | - | provider service networks submit a resp onsive bid. 1024 |
|---|
| 1518 | | - | (j) At least two plans and up to four plans for Region 10. 1025 |
|---|
| 1519 | | - | |
|---|
| 1520 | | - | CS/HB 7047 2022 |
|---|
| 1521 | | - | |
|---|
| 1522 | | - | |
|---|
| 1523 | | - | |
|---|
| 1524 | | - | CODING: Words stricken are deletions; words underlined are additions. |
|---|
| 1525 | | - | hb7047-01-c1 |
|---|
| 1526 | | - | Page 42 of 44 |
|---|
| 1527 | | - | 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 |
|---|
| 1528 | | - | |
|---|
| 1529 | | - | |
|---|
| 1530 | | - | |
|---|
| 1531 | | - | At least one plan must be a provider service network if any 1026 |
|---|
| 1532 | | - | provider service networks submit a responsive bid. 1027 |
|---|
| 1533 | | - | (k) At least five plans and up to 10 plans for Region 11. 1028 |
|---|
| 1534 | | - | At least one plan must be a provider service network if any 1029 |
|---|
| 1535 | | - | provider service networks submit a responsive bid. 1030 |
|---|
| 1536 | | - | 1031 |
|---|
| 1537 | | - | If no provider service network submits a responsive bid in a 1032 |
|---|
| 1538 | | - | region other than Region A 1 or Region 2, the agency shall 1033 |
|---|
| 1539 | | - | procure no more than one fewer less than the maximum number of 1034 |
|---|
| 1540 | | - | eligible plans permitted in that region. Within 12 months after 1035 |
|---|
| 1541 | | - | the initial invitation to negotiate, the agency shall attempt to 1036 |
|---|
| 1542 | | - | procure a provider service network. The agency shall notice 1037 |
|---|
| 1543 | | - | another invitation to negotiate only wi th provider service 1038 |
|---|
| 1544 | | - | networks in regions where no provider service network has been 1039 |
|---|
| 1545 | | - | selected. 1040 |
|---|
| 1546 | | - | Section 14. Subsection (4) of section 409.8132, Florida 1041 |
|---|
| 1547 | | - | Statutes, is amended to read: 1042 |
|---|
| 1548 | | - | 409.8132 Medikids program component. — 1043 |
|---|
| 1549 | | - | (4) APPLICABILITY OF LAWS RELAT ING TO MEDICAID.—The 1044 |
|---|
| 1550 | | - | provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908, 1045 |
|---|
| 1551 | | - | 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127, 1046 |
|---|
| 1552 | | - | 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205 apply 1047 |
|---|
| 1553 | | - | to the administration of the Medikids program co mponent of the 1048 |
|---|
| 1554 | | - | Florida Kidcare program, except that s. 409.9122 applies to 1049 |
|---|
| 1555 | | - | Medikids as modified by the provisions of subsection (7). 1050 |
|---|
| 1556 | | - | |
|---|
| 1557 | | - | CS/HB 7047 2022 |
|---|
| 1558 | | - | |
|---|
| 1559 | | - | |
|---|
| 1560 | | - | |
|---|
| 1561 | | - | CODING: Words stricken are deletions; words underlined are additions. |
|---|
| 1562 | | - | hb7047-01-c1 |
|---|
| 1563 | | - | Page 43 of 44 |
|---|
| 1564 | | - | 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 |
|---|
| 1565 | | - | |
|---|
| 1566 | | - | |
|---|
| 1567 | | - | |
|---|
| 1568 | | - | Section 15. Paragraph (d) of subsection (13) of section 1051 |
|---|
| 1569 | | - | 409.906, Florida Statutes, is amended to read: 1052 |
|---|
| 1570 | | - | 409.906 Optional Medicaid services. —Subject to specific 1053 |
|---|
| 1571 | | - | appropriations, the agency may make payments for services which 1054 |
|---|
| 1572 | | - | are optional to the state under Title XIX of the Social Security 1055 |
|---|
| 1573 | | - | Act and are furnished by Medicaid providers to recipients who 1056 |
|---|
| 1574 | | - | are determined to be el igible on the dates on which the services 1057 |
|---|
| 1575 | | - | were provided. Any optional service that is provided shall be 1058 |
|---|
| 1576 | | - | provided only when medically necessary and in accordance with 1059 |
|---|
| 1577 | | - | state and federal law. Optional services rendered by providers 1060 |
|---|
| 1578 | | - | in mobile units to Medicaid recipients may be restricted or 1061 |
|---|
| 1579 | | - | prohibited by the agency. Nothing in this section shall be 1062 |
|---|
| 1580 | | - | construed to prevent or limit the agency from adjusting fees, 1063 |
|---|
| 1581 | | - | reimbursement rates, lengths of stay, number of visits, or 1064 |
|---|
| 1582 | | - | number of services, or making any other adj ustments necessary to 1065 |
|---|
| 1583 | | - | comply with the availability of moneys and any limitations or 1066 |
|---|
| 1584 | | - | directions provided for in the General Appropriations Act or 1067 |
|---|
| 1585 | | - | chapter 216. If necessary to safeguard the state's systems of 1068 |
|---|
| 1586 | | - | providing services to elderly and disabled person s and subject 1069 |
|---|
| 1587 | | - | to the notice and review provisions of s. 216.177, the Governor 1070 |
|---|
| 1588 | | - | may direct the Agency for Health Care Administration to amend 1071 |
|---|
| 1589 | | - | the Medicaid state plan to delete the optional Medicaid service 1072 |
|---|
| 1590 | | - | known as "Intermediate Care Facilities for the Devel opmentally 1073 |
|---|
| 1591 | | - | Disabled." Optional services may include: 1074 |
|---|
| 1592 | | - | (13) HOME AND COMMUNITY -BASED SERVICES.— 1075 |
|---|
| 1593 | | - | |
|---|
| 1594 | | - | CS/HB 7047 2022 |
|---|
| 1595 | | - | |
|---|
| 1596 | | - | |
|---|
| 1597 | | - | |
|---|
| 1598 | | - | CODING: Words stricken are deletions; words underlined are additions. |
|---|
| 1599 | | - | hb7047-01-c1 |
|---|
| 1600 | | - | Page 44 of 44 |
|---|
| 1601 | | - | 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 |
|---|
| 1602 | | - | |
|---|
| 1603 | | - | |
|---|
| 1604 | | - | |
|---|
| 1605 | | - | (d) The agency shall seek federal approval to pay for 1076 |
|---|
| 1606 | | - | flexible services for persons with severe mental illness or 1077 |
|---|
| 1607 | | - | substance use disorders, including, but not limited to, 1078 |
|---|
| 1608 | | - | temporary housing assistance. Payments may be made as enhanced 1079 |
|---|
| 1609 | | - | capitation rates or incentive payments to managed care plans 1080 |
|---|
| 1610 | | - | that meet the requirements of s. 409.968(3) s. 409.968(4). 1081 |
|---|
| 1611 | | - | Section 16. This act shall take effect July 1, 2022. 1082 |
|---|
| 1494 | + | Disabled." Optional services may include: 1001 |
|---|
| 1495 | + | (13) HOME AND COMMUNITY -BASED SERVICES.— 1002 |
|---|
| 1496 | + | (d) The agency shall seek federal approval to pay for 1003 |
|---|
| 1497 | + | flexible services for persons with severe mental illness or 1004 |
|---|
| 1498 | + | substance use disorders, including, but not limited to, 1005 |
|---|
| 1499 | + | temporary housing assistance. Payments may be made as enhanced 1006 |
|---|
| 1500 | + | capitation rates or incentive payments to managed care plans 1007 |
|---|
| 1501 | + | that meet the requirements of s. 409.968(3) s. 409.968(4). 1008 |
|---|
| 1502 | + | Section 15. This act shall take effect July 1, 2022. 1009 |
|---|