Florida Senate - 2022 CS for CS for SB 1950 By the Committees on Appropriations; and Health Policy; and Senator Brodeur 576-03528-22 20221950c2 1 A bill to be entitled 2 An act relating to the statewide Medicaid managed care 3 program; amending s. 409.912, F.S.; requiring, rather 4 than authorizing, that the reimbursement method for 5 provider service networks be on a prepaid basis; 6 deleting the authority to reimburse provider service 7 networks on a fee-for-service basis; conforming 8 provisions to changes made by the act; providing that 9 provider service networks are subject to and exempt 10 from certain requirements; providing construction; 11 repealing s. 409.9124, F.S., relating to managed care 12 reimbursement; amending s. 409.964, F.S.; deleting a 13 requirement that the Agency for Health Care 14 Administration provide the opportunity for public 15 feedback on a certain waiver application; amending s. 16 409.966, F.S.; revising requirements relating to the 17 databook published by the agency consisting of 18 Medicaid utilization and spending data; reallocating 19 regions within the statewide managed care program; 20 deleting a requirement that the agency negotiate plan 21 rates or payments to guarantee a certain savings 22 amount; deleting a requirement for the agency to award 23 additional contracts to plans in specified regions for 24 certain purposes; revising a limitation on when plans 25 may begin serving Medicaid recipients to apply to any 26 eligible plan that participates in an invitation to 27 negotiate, rather than plans participating in certain 28 regions; making technical changes; amending s. 29 409.967, F.S.; deleting obsolete provisions; amending 30 s. 409.968, F.S.; conforming provisions to changes 31 made by the act; amending s. 409.973, F.S.; revising 32 requirements for healthy behaviors programs 33 established by plans; deleting an obsolete provision; 34 amending s. 409.974, F.S.; requiring the agency to 35 select plans for the managed medical assistance 36 program through a single statewide procurement; 37 authorizing the agency to award contracts to plans on 38 a regional or statewide basis; specifying requirements 39 for minimum numbers of plans which the agency must 40 procure for each specified region; conforming 41 provisions to changes made by the act; deleting 42 procedures for plan procurements when no provider 43 service networks submit bids; deleting a requirement 44 for the agency to exercise a preference for certain 45 plans; amending s. 409.975, F.S.; providing that 46 cancer hospitals meeting certain criteria are 47 statewide essential providers; requiring payments to 48 such hospitals to equal a certain rate; amending s. 49 409.977, F.S.; revising the circumstances for 50 maintaining a recipients enrollment in a plan; 51 deleting obsolete language; authorizing specialty 52 plans to serve certain children who receive 53 guardianship assistance payments under the 54 Guardianship Assistance Program; amending s. 409.981, 55 F.S.; requiring the agency to select plans for the 56 long-term care managed medical assistance program 57 through a single statewide procurement; authorizing 58 the agency to award contracts to plans on a regional 59 or statewide basis; specifying requirements for 60 minimum numbers of plans which the agency must procure 61 for each specified region; conforming provisions to 62 changes made by the act; deleting procedures for plan 63 procurements when no provider service networks submit 64 bids; amending s. 409.8132, F.S.; conforming a cross 65 reference; reenacting ss. 409.962(1), (7), (13), and 66 (14) and 641.19(22) relating to definitions, to 67 incorporate the amendments made by this act to s. 68 409.912, F.S., in references thereto; reenacting s. 69 430.2053(3)(h), (i), and (j) and (11), relating to 70 aging resource centers, to incorporate the amendments 71 made by this act to s. 409.981, F.S., in references 72 thereto; requiring the agency to amend existing 73 Statewide Medicaid Managed Care contracts to implement 74 changes made by the act; requiring the agency to 75 implement changes made by the act for a specified plan 76 year; providing an effective date. 77 78 Be It Enacted by the Legislature of the State of Florida: 79 80 Section 1.Subsection (1) of section 409.912, Florida 81 Statutes, is amended to read: 82 409.912Cost-effective purchasing of health care.The 83 agency shall purchase goods and services for Medicaid recipients 84 in the most cost-effective manner consistent with the delivery 85 of quality medical care. To ensure that medical services are 86 effectively utilized, the agency may, in any case, require a 87 confirmation or second physicians opinion of the correct 88 diagnosis for purposes of authorizing future services under the 89 Medicaid program. This section does not restrict access to 90 emergency services or poststabilization care services as defined 91 in 42 C.F.R. s. 438.114. Such confirmation or second opinion 92 shall be rendered in a manner approved by the agency. The agency 93 shall maximize the use of prepaid per capita and prepaid 94 aggregate fixed-sum basis services when appropriate and other 95 alternative service delivery and reimbursement methodologies, 96 including competitive bidding pursuant to s. 287.057, designed 97 to facilitate the cost-effective purchase of a case-managed 98 continuum of care. The agency shall also require providers to 99 minimize the exposure of recipients to the need for acute 100 inpatient, custodial, and other institutional care and the 101 inappropriate or unnecessary use of high-cost services. The 102 agency shall contract with a vendor to monitor and evaluate the 103 clinical practice patterns of providers in order to identify 104 trends that are outside the normal practice patterns of a 105 providers professional peers or the national guidelines of a 106 providers professional association. The vendor must be able to 107 provide information and counseling to a provider whose practice 108 patterns are outside the norms, in consultation with the agency, 109 to improve patient care and reduce inappropriate utilization. 110 The agency may mandate prior authorization, drug therapy 111 management, or disease management participation for certain 112 populations of Medicaid beneficiaries, certain drug classes, or 113 particular drugs to prevent fraud, abuse, overuse, and possible 114 dangerous drug interactions. The Pharmaceutical and Therapeutics 115 Committee shall make recommendations to the agency on drugs for 116 which prior authorization is required. The agency shall inform 117 the Pharmaceutical and Therapeutics Committee of its decisions 118 regarding drugs subject to prior authorization. The agency is 119 authorized to limit the entities it contracts with or enrolls as 120 Medicaid providers by developing a provider network through 121 provider credentialing. The agency may competitively bid single 122 source-provider contracts if procurement of goods or services 123 results in demonstrated cost savings to the state without 124 limiting access to care. The agency may limit its network based 125 on the assessment of beneficiary access to care, provider 126 availability, provider quality standards, time and distance 127 standards for access to care, the cultural competence of the 128 provider network, demographic characteristics of Medicaid 129 beneficiaries, practice and provider-to-beneficiary standards, 130 appointment wait times, beneficiary use of services, provider 131 turnover, provider profiling, provider licensure history, 132 previous program integrity investigations and findings, peer 133 review, provider Medicaid policy and billing compliance records, 134 clinical and medical record audits, and other factors. Providers 135 are not entitled to enrollment in the Medicaid provider network. 136 The agency shall determine instances in which allowing Medicaid 137 beneficiaries to purchase durable medical equipment and other 138 goods is less expensive to the Medicaid program than long-term 139 rental of the equipment or goods. The agency may establish rules 140 to facilitate purchases in lieu of long-term rentals in order to 141 protect against fraud and abuse in the Medicaid program as 142 defined in s. 409.913. The agency may seek federal waivers 143 necessary to administer these policies. 144 (1)The agency may contract with a provider service 145 network, which must may be reimbursed on a fee-for-service or 146 prepaid basis. Prepaid Provider service networks shall receive 147 per-member, per-month payments. A provider service network that 148 does not choose to be a prepaid plan shall receive fee-for 149 service rates with a shared savings settlement. The fee-for 150 service option shall be available to a provider service network 151 only for the first 2 years of the plans operation or until the 152 contract year beginning September 1, 2014, whichever is later. 153 The agency shall annually conduct cost reconciliations to 154 determine the amount of cost savings achieved by fee-for-service 155 provider service networks for the dates of service in the period 156 being reconciled. Only payments for covered services for dates 157 of service within the reconciliation period and paid within 6 158 months after the last date of service in the reconciliation 159 period shall be included. The agency shall perform the necessary 160 adjustments for the inclusion of claims incurred but not 161 reported within the reconciliation for claims that could be 162 received and paid by the agency after the 6-month claims 163 processing time lag. The agency shall provide the results of the 164 reconciliations to the fee-for-service provider service networks 165 within 45 days after the end of the reconciliation period. The 166 fee-for-service provider service networks shall review and 167 provide written comments or a letter of concurrence to the 168 agency within 45 days after receipt of the reconciliation 169 results. This reconciliation shall be considered final. 170 (a)A provider service network which is reimbursed by the 171 agency on a prepaid basis shall be exempt from parts I and III 172 of chapter 641 but must comply with the solvency requirements in 173 s. 641.2261(2) and meet appropriate financial reserve, quality 174 assurance, and patient rights requirements as established by the 175 agency. 176 (b)A provider service network is a network established or 177 organized and operated by a health care provider, or group of 178 affiliated health care providers, which provides a substantial 179 proportion of the health care items and services under a 180 contract directly through the provider or affiliated group of 181 providers and may make arrangements with physicians or other 182 health care professionals, health care institutions, or any 183 combination of such individuals or institutions to assume all or 184 part of the financial risk on a prospective basis for the 185 provision of basic health services by the physicians, by other 186 health professionals, or through the institutions. The health 187 care providers must have a controlling interest in the governing 188 body of the provider service network organization. 189 (a)A provider service network is exempt from parts I and 190 III of chapter 641 but must comply with the solvency 191 requirements in s. 641.2261(2) and meet appropriate financial 192 reserve, quality assurance, and patient rights requirements as 193 established by the agency. 194 (b)This subsection does not authorize the agency to 195 contract with a provider service network outside of the 196 procurement process described in s. 409.966. 197 Section 2.Section 409.9124, Florida Statutes, is repealed. 198 Section 3.Section 409.964, Florida Statutes, is amended to 199 read: 200 409.964Managed care program; state plan; waivers.The 201 Medicaid program is established as a statewide, integrated 202 managed care program for all covered services, including long 203 term care services. The agency shall apply for and implement 204 state plan amendments or waivers of applicable federal laws and 205 regulations necessary to implement the program. Before seeking a 206 waiver, the agency shall provide public notice and the 207 opportunity for public comment and include public feedback in 208 the waiver application. The agency shall hold one public meeting 209 in each of the regions described in s. 409.966(2), and the time 210 period for public comment for each region shall end no sooner 211 than 30 days after the completion of the public meeting in that 212 region. 213 Section 4.Subsections (2), (3), and (4) of section 214 409.966, Florida Statutes, are amended to read: 215 409.966Eligible plans; selection. 216 (2)ELIGIBLE PLAN SELECTION.The agency shall select a 217 limited number of eligible plans to participate in the Medicaid 218 program using invitations to negotiate in accordance with s. 219 287.057(1)(c). At least 90 days before issuing an invitation to 220 negotiate, the agency shall compile and publish a databook 221 consisting of a comprehensive set of utilization and spending 222 data consistent with actuarial rate-setting practices and 223 standards for the 3 most recent contract years consistent with 224 the rate-setting periods for all Medicaid recipients by region 225 or county. The source of the data in the databook report must 226 include, at a minimum, the 24 most recent months of both 227 historic fee-for-service claims and validated data from the 228 Medicaid Encounter Data System, and the databook must. The 229 report must be available in electronic form and delineate 230 utilization use by age, gender, eligibility group, geographic 231 area, and aggregate clinical risk score. The statewide managed 232 care program includes Separate and simultaneous procurements 233 shall be conducted in each of the following regions: 234 (a)Region A 1, which consists of Bay, Calhoun, Escambia, 235 Okaloosa, Santa Rosa, and Walton Counties. 236 (b)Region 2, which consists of Bay, Calhoun, Franklin, 237 Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, 238 Madison, Okaloosa, Santa Rosa, Taylor, Wakulla, Walton, and 239 Washington Counties. 240 (b)(c)Region B 3, which consists of Alachua, Baker, 241 Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler, 242 Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, 243 Nassau, Putnam, St. Johns, Sumter, Suwannee, and Union Counties. 244 (d)Region 4, which consists of Baker, Clay, Duval, 245 Flagler, Nassau, St. Johns, and Volusia Counties. 246 (c)(e)Region C 5, which consists of Pasco and Pinellas 247 Counties. 248 (d)(f)Region D 6, which consists of Hardee, Highlands, 249 Hillsborough, Manatee, and Polk Counties. 250 (e)(g)Region E 7, which consists of Brevard, Orange, 251 Osceola, and Seminole Counties. 252 (f)(h)Region F 8, which consists of Charlotte, Collier, 253 DeSoto, Glades, Hendry, Lee, and Sarasota Counties. 254 (g)(i)Region G 9, which consists of Indian River, Martin, 255 Okeechobee, Palm Beach, and St. Lucie Counties. 256 (h)(j)Region H 10, which consists of Broward County. 257 (i)(k)Region I 11, which consists of Miami-Dade and Monroe 258 Counties. 259 (3)QUALITY SELECTION CRITERIA. 260 (a)The invitation to negotiate must specify the criteria 261 and the relative weight of the criteria that will be used for 262 determining the acceptability of the reply and guiding the 263 selection of the organizations with which the agency negotiates. 264 In addition to criteria established by the agency, the agency 265 shall consider the following factors in the selection of 266 eligible plans: 267 1.Accreditation by the National Committee for Quality 268 Assurance, the Joint Commission, or another nationally 269 recognized accrediting body. 270 2.Experience serving similar populations, including the 271 organizations record in achieving specific quality standards 272 with similar populations. 273 3.Availability and accessibility of primary care and 274 specialty physicians in the provider network. 275 4.Establishment of community partnerships with providers 276 that create opportunities for reinvestment in community-based 277 services. 278 5.Organization commitment to quality improvement and 279 documentation of achievements in specific quality improvement 280 projects, including active involvement by organization 281 leadership. 282 6.Provision of additional benefits, particularly dental 283 care and disease management, and other initiatives that improve 284 health outcomes. 285 7.Evidence that an eligible plan has obtained signed 286 contracts or written agreements or signed contracts or has made 287 substantial progress in establishing relationships with 288 providers before the plan submits submitting a response. 289 8.Comments submitted in writing by any enrolled Medicaid 290 provider relating to a specifically identified plan 291 participating in the procurement in the same region as the 292 submitting provider. 293 9.Documentation of policies and procedures for preventing 294 fraud and abuse. 295 10.The business relationship an eligible plan has with any 296 other eligible plan that responds to the invitation to 297 negotiate. 298 (b)An eligible plan must disclose any business 299 relationship it has with any other eligible plan that responds 300 to the invitation to negotiate. The agency may not select plans 301 in the same region for the same managed care program that have a 302 business relationship with each other. Failure to disclose any 303 business relationship shall result in disqualification from 304 participation in any region for the first full contract period 305 after the discovery of the business relationship by the agency. 306 For the purpose of this section, business relationship means 307 an ownership or controlling interest, an affiliate or subsidiary 308 relationship, a common parent, or any mutual interest in any 309 limited partnership, limited liability partnership, limited 310 liability company, or other entity or business association, 311 including all wholly or partially owned subsidiaries, majority 312 owned subsidiaries, parent companies, or affiliates of such 313 entities, business associations, or other enterprises, that 314 exists for the purpose of making a profit. 315 (c)After negotiations are conducted, the agency shall 316 select the eligible plans that are determined to be responsive 317 and provide the best value to the state. Preference shall be 318 given to plans that: 319 1.Have signed contracts with primary and specialty 320 physicians in sufficient numbers to meet the specific standards 321 established pursuant to s. 409.967(2)(c). 322 2.Have well-defined programs for recognizing patient 323 centered medical homes and providing for increased compensation 324 for recognized medical homes, as defined by the plan. 325 3.Are organizations that are based in and perform 326 operational functions in this state, in-house or through 327 contractual arrangements, by staff located in this state. Using 328 a tiered approach, the highest number of points shall be awarded 329 to a plan that has all or substantially all of its operational 330 functions performed in the state. The second highest number of 331 points shall be awarded to a plan that has a majority of its 332 operational functions performed in the state. The agency may 333 establish a third tier; however, preference points may not be 334 awarded to plans that perform only community outreach, medical 335 director functions, and state administrative functions in the 336 state. For purposes of this subparagraph, operational functions 337 include corporate headquarters, claims processing, member 338 services, provider relations, utilization and prior 339 authorization, case management, disease and quality functions, 340 and finance and administration. For purposes of this 341 subparagraph, the term corporate headquarters means the 342 principal office of the organization, which may not be a 343 subsidiary, directly or indirectly through one or more 344 subsidiaries of, or a joint venture with, any other entity whose 345 principal office is not located in the state. 346 4.Have contracts or other arrangements for cancer disease 347 management programs that have a proven record of clinical 348 efficiencies and cost savings. 349 5.Have contracts or other arrangements for diabetes 350 disease management programs that have a proven record of 351 clinical efficiencies and cost savings. 352 6.Have a claims payment process that ensures that claims 353 that are not contested or denied will be promptly paid pursuant 354 to s. 641.3155. 355 (d)For the first year of the first contract term, the 356 agency shall negotiate capitation rates or fee for service 357 payments with each plan in order to guarantee aggregate savings 358 of at least 5 percent. 359 1.For prepaid plans, determination of the amount of 360 savings shall be calculated by comparison to the Medicaid rates 361 that the agency paid managed care plans for similar populations 362 in the same areas in the prior year. In regions containing no 363 prepaid plans in the prior year, determination of the amount of 364 savings shall be calculated by comparison to the Medicaid rates 365 established and certified for those regions in the prior year. 366 2.For provider service networks operating on a fee-for 367 service basis, determination of the amount of savings shall be 368 calculated by comparison to the Medicaid rates that the agency 369 paid on a fee-for-service basis for the same services in the 370 prior year. 371 (e)To ensure managed care plan participation in Regions 1 372 and 2, the agency shall award an additional contract to each 373 plan with a contract award in Region 1 or Region 2. Such 374 contract shall be in any other region in which the plan 375 submitted a responsive bid and negotiates a rate acceptable to 376 the agency. If a plan that is awarded an additional contract 377 pursuant to this paragraph is subject to penalties pursuant to 378 s. 409.967(2)(i) for activities in Region 1 or Region 2, the 379 additional contract is automatically terminated 180 days after 380 the imposition of the penalties. The plan must reimburse the 381 agency for the cost of enrollment changes and other transition 382 activities. 383 (d)(f)The agency may not execute contracts with managed 384 care plans at payment rates not supported by the General 385 Appropriations Act. 386 (4)ADMINISTRATIVE CHALLENGE.Any eligible plan that 387 participates in an invitation to negotiate in more than one 388 region and is selected in at least one region may not begin 389 serving Medicaid recipients in any region for which it was 390 selected until all administrative challenges to procurements 391 required by this section to which the eligible plan is a party 392 have been finalized. If the number of plans selected is less 393 than the maximum amount of plans permitted in the region, the 394 agency may contract with other selected plans in the region not 395 participating in the administrative challenge before resolution 396 of the administrative challenge. For purposes of this 397 subsection, an administrative challenge is finalized if an order 398 granting voluntary dismissal with prejudice has been entered by 399 any court established under Article V of the State Constitution 400 or by the Division of Administrative Hearings, a final order has 401 been entered into by the agency and the deadline for appeal has 402 expired, a final order has been entered by the First District 403 Court of Appeal and the time to seek any available review by the 404 Florida Supreme Court has expired, or a final order has been 405 entered by the Florida Supreme Court and a warrant has been 406 issued. 407 Section 5.Paragraphs (c) and (f) of subsection (2) of 408 section 409.967, Florida Statutes, are amended to read: 409 409.967Managed care plan accountability. 410 (2)The agency shall establish such contract requirements 411 as are necessary for the operation of the statewide managed care 412 program. In addition to any other provisions the agency may deem 413 necessary, the contract must require: 414 (c)Access. 415 1.The agency shall establish specific standards for the 416 number, type, and regional distribution of providers in managed 417 care plan networks to ensure access to care for both adults and 418 children. Each plan must maintain a regionwide network of 419 providers in sufficient numbers to meet the access standards for 420 specific medical services for all recipients enrolled in the 421 plan. The exclusive use of mail-order pharmacies may not be 422 sufficient to meet network access standards. Consistent with the 423 standards established by the agency, provider networks may 424 include providers located outside the region. A plan may 425 contract with a new hospital facility before the date the 426 hospital becomes operational if the hospital has commenced 427 construction, will be licensed and operational by January 1, 428 2013, and a final order has issued in any civil or 429 administrative challenge. Each plan shall establish and maintain 430 an accurate and complete electronic database of contracted 431 providers, including information about licensure or 432 registration, locations and hours of operation, specialty 433 credentials and other certifications, specific performance 434 indicators, and such other information as the agency deems 435 necessary. The database must be available online to both the 436 agency and the public and have the capability to compare the 437 availability of providers to network adequacy standards and to 438 accept and display feedback from each providers patients. Each 439 plan shall submit quarterly reports to the agency identifying 440 the number of enrollees assigned to each primary care provider. 441 The agency shall conduct, or contract for, systematic and 442 continuous testing of the provider network databases maintained 443 by each plan to confirm accuracy, confirm that behavioral health 444 providers are accepting enrollees, and confirm that enrollees 445 have access to behavioral health services. 446 2.Each managed care plan must publish any prescribed drug 447 formulary or preferred drug list on the plans website in a 448 manner that is accessible to and searchable by enrollees and 449 providers. The plan must update the list within 24 hours after 450 making a change. Each plan must ensure that the prior 451 authorization process for prescribed drugs is readily accessible 452 to health care providers, including posting appropriate contact 453 information on its website and providing timely responses to 454 providers. For Medicaid recipients diagnosed with hemophilia who 455 have been prescribed anti-hemophilic-factor replacement 456 products, the agency shall provide for those products and 457 hemophilia overlay services through the agencys hemophilia 458 disease management program. 459 3.Managed care plans, and their fiscal agents or 460 intermediaries, must accept prior authorization requests for any 461 service electronically. 462 4.Managed care plans serving children in the care and 463 custody of the Department of Children and Families must maintain 464 complete medical, dental, and behavioral health encounter 465 information and participate in making such information available 466 to the department or the applicable contracted community-based 467 care lead agency for use in providing comprehensive and 468 coordinated case management. The agency and the department shall 469 establish an interagency agreement to provide guidance for the 470 format, confidentiality, recipient, scope, and method of 471 information to be made available and the deadlines for 472 submission of the data. The scope of information available to 473 the department shall be the data that managed care plans are 474 required to submit to the agency. The agency shall determine the 475 plans compliance with standards for access to medical, dental, 476 and behavioral health services; the use of medications; and 477 followup on all medically necessary services recommended as a 478 result of early and periodic screening, diagnosis, and 479 treatment. 480 (f)Continuous improvement.The agency shall establish 481 specific performance standards and expected milestones or 482 timelines for improving performance over the term of the 483 contract. 484 1.Each managed care plan shall establish an internal 485 health care quality improvement system, including enrollee 486 satisfaction and disenrollment surveys. The quality improvement 487 system must include incentives and disincentives for network 488 providers. 489 2.Each plan must collect and report the Health Plan 490 Employer Data and Information Set (HEDIS) measures, as specified 491 by the agency. These measures must be published on the plans 492 website in a manner that allows recipients to reliably compare 493 the performance of plans. The agency shall use the HEDIS 494 measures as a tool to monitor plan performance. 495 3.Each managed care plan must be accredited by the 496 National Committee for Quality Assurance, the Joint Commission, 497 or another nationally recognized accrediting body, or have 498 initiated the accreditation process, within 1 year after the 499 contract is executed. For any plan not accredited within 18 500 months after executing the contract, the agency shall suspend 501 automatic assignment under s. 409.977 and 409.984. 502 4.By the end of the fourth year of the first contract 503 term, the agency shall issue a request for information to 504 determine whether cost savings could be achieved by contracting 505 for plan oversight and monitoring, including analysis of 506 encounter data, assessment of performance measures, and 507 compliance with other contractual requirements. 508 Section 6.Subsection (2) of section 409.968, Florida 509 Statutes, is amended to read: 510 409.968Managed care plan payments. 511 (2)Provider service networks must may be prepaid plans and 512 receive per-member, per-month payments negotiated pursuant to 513 the procurement process described in s. 409.966. Provider 514 service networks that choose not to be prepaid plans shall 515 receive fee-for-service rates with a shared savings settlement. 516 The fee-for-service option shall be available to a provider 517 service network only for the first 2 years of its operation. The 518 agency shall annually conduct cost reconciliations to determine 519 the amount of cost savings achieved by fee-for-service provider 520 service networks for the dates of service within the period 521 being reconciled. Only payments for covered services for dates 522 of service within the reconciliation period and paid within 6 523 months after the last date of service in the reconciliation 524 period must be included. The agency shall perform the necessary 525 adjustments for the inclusion of claims incurred but not 526 reported within the reconciliation period for claims that could 527 be received and paid by the agency after the 6-month claims 528 processing time lag. The agency shall provide the results of the 529 reconciliations to the fee-for-service provider service networks 530 within 45 days after the end of the reconciliation period. The 531 fee-for-service provider service networks shall review and 532 provide written comments or a letter of concurrence to the 533 agency within 45 days after receipt of the reconciliation 534 results. This reconciliation is considered final. 535 Section 7.Subsections (3) and (4) of section 409.973, 536 Florida Statutes, are amended to read: 537 409.973Benefits. 538 (3)HEALTHY BEHAVIORS.Each plan operating in the managed 539 medical assistance program shall establish a program to 540 encourage and reward healthy behaviors. At a minimum, each plan 541 must establish a medically approved tobacco smoking cessation 542 program, a medically directed weight loss program, and a 543 medically approved alcohol recovery program or substance abuse 544 recovery program that must include, but may not be limited to, 545 opioid abuse recovery. Each plan must identify enrollees who 546 smoke, are morbidly obese, or are diagnosed with alcohol or 547 substance abuse in order to establish written agreements to 548 secure the enrollees commitment to participation in these 549 programs. 550 (4)PRIMARY CARE INITIATIVE.Each plan operating in the 551 managed medical assistance program shall establish a program to 552 encourage enrollees to establish a relationship with their 553 primary care provider. Each plan shall: 554 (a)Provide information to each enrollee on the importance 555 of and procedure for selecting a primary care provider, and 556 thereafter automatically assign to a primary care provider any 557 enrollee who fails to choose a primary care provider. 558 (b)If the enrollee was not a Medicaid recipient before 559 enrollment in the plan, assist the enrollee in scheduling an 560 appointment with the primary care provider. If possible the 561 appointment should be made within 30 days after enrollment in 562 the plan. For enrollees who become eligible for Medicaid between 563 January 1, 2014, and December 31, 2015, the appointment should 564 be scheduled within 6 months after enrollment in the plan. 565 (c)Report to the agency the number of enrollees assigned 566 to each primary care provider within the plans network. 567 (d)Report to the agency the number of enrollees who have 568 not had an appointment with their primary care provider within 569 their first year of enrollment. 570 (e)Report to the agency the number of emergency room 571 visits by enrollees who have not had at least one appointment 572 with their primary care provider. 573 Section 8.Subsections (1) and (2) of section 409.974, 574 Florida Statutes, are amended to read: 575 409.974Eligible plans. 576 (1)ELIGIBLE PLAN SELECTION.The agency shall select 577 eligible plans for the managed medical assistance program 578 through the procurement process described in s. 409.966 through 579 a single statewide procurement. The agency may award contracts 580 to plans selected through the procurement process either on a 581 regional or statewide basis. The awards must include at least 582 one provider service network in each of the nine regions 583 outlined in this subsection. The agency shall procure: 584 (a)At least 3 plans and up to 4 plans for Region A. 585 (b)At least 3 plans and up to 6 plans for Region B. 586 (c)At least 3 plans and up to 5 plans for Region C. 587 (d)At least 4 plans and up to 7 plans for Region D. 588 (e)At least 3 plans and up to 6 plans for Region E. 589 (f)At least 3 plans and up to 4 plans for Region F. 590 (g)At least 3 plans and up to 5 plans for Region G. 591 (h)At least 3 plans and up to 5 plans for Region H. 592 (i)At least 5 plans and up to 10 plans for Region I. The 593 agency shall notice invitations to negotiate no later than 594 January 1, 2013. 595 (a)The agency shall procure two plans for Region 1. At 596 least one plan shall be a provider service network if any 597 provider service networks submit a responsive bid. 598 (b)The agency shall procure two plans for Region 2. At 599 least one plan shall be a provider service network if any 600 provider service networks submit a responsive bid. 601 (c)The agency shall procure at least three plans and up to 602 five plans for Region 3. At least one plan must be a provider 603 service network if any provider service networks submit a 604 responsive bid. 605 (d)The agency shall procure at least three plans and up to 606 five plans for Region 4. At least one plan must be a provider 607 service network if any provider service networks submit a 608 responsive bid. 609 (e)The agency shall procure at least two plans and up to 610 four plans for Region 5. At least one plan must be a provider 611 service network if any provider service networks submit a 612 responsive bid. 613 (f)The agency shall procure at least four plans and up to 614 seven plans for Region 6. At least one plan must be a provider 615 service network if any provider service networks submit a 616 responsive bid. 617 (g)The agency shall procure at least three plans and up to 618 six plans for Region 7. At least one plan must be a provider 619 service network if any provider service networks submit a 620 responsive bid. 621 (h)The agency shall procure at least two plans and up to 622 four plans for Region 8. At least one plan must be a provider 623 service network if any provider service networks submit a 624 responsive bid. 625 (i)The agency shall procure at least two plans and up to 626 four plans for Region 9. At least one plan must be a provider 627 service network if any provider service networks submit a 628 responsive bid. 629 (j)The agency shall procure at least two plans and up to 630 four plans for Region 10. At least one plan must be a provider 631 service network if any provider service networks submit a 632 responsive bid. 633 (k)The agency shall procure at least five plans and up to 634 10 plans for Region 11. At least one plan must be a provider 635 service network if any provider service networks submit a 636 responsive bid. 637 638 If no provider service network submits a responsive bid, the 639 agency shall procure no more than one less than the maximum 640 number of eligible plans permitted in that region. Within 12 641 months after the initial invitation to negotiate, the agency 642 shall attempt to procure a provider service network. The agency 643 shall notice another invitation to negotiate only with provider 644 service networks in those regions where no provider service 645 network has been selected. 646 (2)QUALITY SELECTION CRITERIA.In addition to the criteria 647 established in s. 409.966, the agency shall consider evidence 648 that an eligible plan has written agreements or signed contracts 649 or has made substantial progress in establishing relationships 650 with providers before the plan submitting a response. The agency 651 shall evaluate and give special weight to evidence of signed 652 contracts with essential providers as defined by the agency 653 pursuant to s. 409.975(1). The agency shall exercise a 654 preference for plans with a provider network in which over 10 655 percent of the providers use electronic health records, as 656 defined in s. 408.051. When all other factors are equal, the 657 agency shall consider whether the organization has a contract to 658 provide managed long-term care services in the same region and 659 shall exercise a preference for such plans. 660 Section 9.Paragraph (b) of subsection (1) of section 661 409.975, Florida Statutes, is amended to read: 662 409.975Managed care plan accountability.In addition to 663 the requirements of s. 409.967, plans and providers 664 participating in the managed medical assistance program shall 665 comply with the requirements of this section. 666 (1)PROVIDER NETWORKS.Managed care plans must develop and 667 maintain provider networks that meet the medical needs of their 668 enrollees in accordance with standards established pursuant to 669 s. 409.967(2)(c). Except as provided in this section, managed 670 care plans may limit the providers in their networks based on 671 credentials, quality indicators, and price. 672 (b)Certain providers are statewide resources and essential 673 providers for all managed care plans in all regions. All managed 674 care plans must include these essential providers in their 675 networks. Statewide essential providers include: 676 1.Faculty plans of Florida medical schools. 677 2.Regional perinatal intensive care centers as defined in 678 s. 383.16(2). 679 3.Hospitals licensed as specialty childrens hospitals as 680 defined in s. 395.002(28). 681 4.Accredited and integrated systems serving medically 682 complex children which comprise separately licensed, but 683 commonly owned, health care providers delivering at least the 684 following services: medical group home, in-home and outpatient 685 nursing care and therapies, pharmacy services, durable medical 686 equipment, and Prescribed Pediatric Extended Care. 687 5.Florida cancer hospitals that meet the criteria in 42 688 U.S.C. s. 1395ww(d)(1)(B)(v). 689 690 Managed care plans that have not contracted with all statewide 691 essential providers in all regions as of the first date of 692 recipient enrollment must continue to negotiate in good faith. 693 Payments to physicians on the faculty of nonparticipating 694 Florida medical schools shall be made at the applicable Medicaid 695 rate. Payments for services rendered by regional perinatal 696 intensive care centers shall be made at the applicable Medicaid 697 rate as of the first day of the contract between the agency and 698 the plan. Except for payments for emergency services, payments 699 to nonparticipating specialty childrens hospitals, and payments 700 to nonparticipating Florida cancer hospitals that meet the 701 criteria in 42 U.S.C. s. 1395ww(d)(1)(B)(v), shall equal the 702 highest rate established by contract between that provider and 703 any other Medicaid managed care plan. 704 Section 10.Subsections (1), (2), (4), and (5) of section 705 409.977, Florida Statutes, are amended to read: 706 409.977Enrollment. 707 (1)The agency shall automatically enroll into a managed 708 care plan those Medicaid recipients who do not voluntarily 709 choose a plan pursuant to s. 409.969. The agency shall 710 automatically enroll recipients in plans that meet or exceed the 711 performance or quality standards established pursuant to s. 712 409.967 and may not automatically enroll recipients in a plan 713 that is deficient in those performance or quality standards. 714 When a specialty plan is available to accommodate a specific 715 condition or diagnosis of a recipient, the agency shall assign 716 the recipient to that plan. In the first year of the first 717 contract term only, if a recipient was previously enrolled in a 718 plan that is still available in the region, the agency shall 719 automatically enroll the recipient in that plan unless an 720 applicable specialty plan is available. Except as otherwise 721 provided in this part, the agency may not engage in practices 722 that are designed to favor one managed care plan over another. 723 (2)When automatically enrolling recipients in managed care 724 plans, if a recipient was enrolled in a plan immediately before 725 the recipients choice period and that plan is still available 726 in the region, the agency must maintain the recipients 727 enrollment in that plan unless an applicable specialty plan is 728 available. Otherwise, the agency shall automatically enroll 729 based on the following criteria: 730 (a)Whether the plan has sufficient network capacity to 731 meet the needs of the recipients. 732 (b)Whether the recipient has previously received services 733 from one of the plans primary care providers. 734 (c)Whether primary care providers in one plan are more 735 geographically accessible to the recipients residence than 736 those in other plans. 737 (4)The agency shall develop a process to enable a 738 recipient with access to employer-sponsored health care coverage 739 to opt out of all managed care plans and to use Medicaid 740 financial assistance to pay for the recipients share of the 741 cost in such employer-sponsored coverage. Contingent upon 742 federal approval, The agency shall also enable recipients with 743 access to other insurance or related products providing access 744 to health care services created pursuant to state law, including 745 any product available under the Florida Health Choices Program, 746 or any health exchange, to opt out. The amount of financial 747 assistance provided for each recipient may not exceed the amount 748 of the Medicaid premium that would have been paid to a managed 749 care plan for that recipient. The agency shall seek federal 750 approval to require Medicaid recipients with access to employer 751 sponsored health care coverage to enroll in that coverage and 752 use Medicaid financial assistance to pay for the recipients 753 share of the cost for such coverage. The amount of financial 754 assistance provided for each recipient may not exceed the amount 755 of the Medicaid premium that would have been paid to a managed 756 care plan for that recipient. 757 (5)Specialty plans serving children in the care and 758 custody of the department may serve such children as long as 759 they remain in care, including those remaining in extended 760 foster care pursuant to s. 39.6251, or are in subsidized 761 adoption and continue to be eligible for Medicaid pursuant to s. 762 409.903, or are receiving guardianship assistance payments and 763 continue to be eligible for Medicaid pursuant to s. 409.903. 764 Section 11.Subsection (2) of section 409.981, Florida 765 Statutes, is amended to read: 766 409.981Eligible long-term care plans. 767 (2)ELIGIBLE PLAN SELECTION.The agency shall select 768 eligible plans for the long-term care managed care program 769 through the procurement process described in s. 409.966 through 770 a single statewide procurement. The agency may award contracts 771 to plans selected through the procurement process on a regional 772 or statewide basis. The awards must include at least one 773 provider service network in each of the nine regions outlined in 774 this subsection. The agency shall procure: 775 (a)At least 3 plans and up to 4 plans for Region A. 776 (b)At least 3 plans and up to 6 plans for Region B. 777 (c)At least 3 plans and up to 5 plans for Region C. 778 (d)At least 4 plans and up to 7 plans for Region D. 779 (e)At least 3 plans and up to 6 plans for Region E. 780 (f)At least 3 plans and up to 4 plans for Region F. 781 (g)At least 3 plans and up to 5 plans for Region G. 782 (h)At least 3 plans and up to 4 plans for Region H. 783 (i)At least 5 plans and up to 10 plans for Region I Two 784 plans for Region 1. At least one plan must be a provider service 785 network if any provider service networks submit a responsive 786 bid. 787 (b)Two plans for Region 2. At least one plan must be a 788 provider service network if any provider service networks submit 789 a responsive bid. 790 (c)At least three plans and up to five plans for Region 3. 791 At least one plan must be a provider service network if any 792 provider service networks submit a responsive bid. 793 (d)At least three plans and up to five plans for Region 4. 794 At least one plan must be a provider service network if any 795 provider service network submits a responsive bid. 796 (e)At least two plans and up to four plans for Region 5. 797 At least one plan must be a provider service network if any 798 provider service networks submit a responsive bid. 799 (f)At least four plans and up to seven plans for Region 6. 800 At least one plan must be a provider service network if any 801 provider service networks submit a responsive bid. 802 (g)At least three plans and up to six plans for Region 7. 803 At least one plan must be a provider service network if any 804 provider service networks submit a responsive bid. 805 (h)At least two plans and up to four plans for Region 8. 806 At least one plan must be a provider service network if any 807 provider service networks submit a responsive bid. 808 (i)At least two plans and up to four plans for Region 9. 809 At least one plan must be a provider service network if any 810 provider service networks submit a responsive bid. 811 (j)At least two plans and up to four plans for Region 10. 812 At least one plan must be a provider service network if any 813 provider service networks submit a responsive bid. 814 (k)At least five plans and up to 10 plans for Region 11. 815 At least one plan must be a provider service network if any 816 provider service networks submit a responsive bid. 817 818 If no provider service network submits a responsive bid in a 819 region other than Region 1 or Region 2, the agency shall procure 820 no more than one less than the maximum number of eligible plans 821 permitted in that region. Within 12 months after the initial 822 invitation to negotiate, the agency shall attempt to procure a 823 provider service network. The agency shall notice another 824 invitation to negotiate only with provider service networks in 825 regions where no provider service network has been selected. 826 Section 12.Subsection (4) of section 409.8132, Florida 827 Statutes, is amended to read: 828 409.8132Medikids program component. 829 (4)APPLICABILITY OF LAWS RELATING TO MEDICAID.The 830 provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908, 831 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127, 832 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205 apply 833 to the administration of the Medikids program component of the 834 Florida Kidcare program, except that s. 409.9122 applies to 835 Medikids as modified by the provisions of subsection (7). 836 Section 13.For the purpose of incorporating the amendment 837 made by this act to section 409.912, Florida Statutes, in 838 references thereto, subsections (1), (7), (13), and (14) of 839 section 409.962, Florida Statutes, are reenacted to read: 840 409.962Definitions.As used in this part, except as 841 otherwise specifically provided, the term: 842 (1)Accountable care organization means an entity 843 qualified as an accountable care organization in accordance with 844 federal regulations, and which meets the requirements of a 845 provider service network as described in s. 409.912(1). 846 (7)Eligible plan means a health insurer authorized under 847 chapter 624, an exclusive provider organization authorized under 848 chapter 627, a health maintenance organization authorized under 849 chapter 641, or a provider service network authorized under s. 850 409.912(1) or an accountable care organization authorized under 851 federal law. For purposes of the managed medical assistance 852 program, the term also includes the Childrens Medical Services 853 Network authorized under chapter 391 and entities qualified 854 under 42 C.F.R. part 422 as Medicare Advantage Preferred 855 Provider Organizations, Medicare Advantage Provider-sponsored 856 Organizations, Medicare Advantage Health Maintenance 857 Organizations, Medicare Advantage Coordinated Care Plans, and 858 Medicare Advantage Special Needs Plans, and the Program of All 859 inclusive Care for the Elderly. 860 (13)Prepaid plan means a managed care plan that is 861 licensed or certified as a risk-bearing entity, or qualified 862 pursuant to s. 409.912(1), in the state and is paid a 863 prospective per-member, per-month payment by the agency. 864 (14)Provider service network means an entity qualified 865 pursuant to s. 409.912(1) of which a controlling interest is 866 owned by a health care provider, or group of affiliated 867 providers, or a public agency or entity that delivers health 868 services. Health care providers include Florida-licensed health 869 care professionals or licensed health care facilities, federally 870 qualified health care centers, and home health care agencies. 871 Section 14.For the purpose of incorporating the amendment 872 made by this act to section 409.912, Florida Statutes, in a 873 reference thereto, subsection (22) of section 641.19, Florida 874 Statutes, is reenacted to read: 875 641.19Definitions.As used in this part, the term: 876 (22)Provider service network means a network authorized 877 under s. 409.912(1), reimbursed on a prepaid basis, operated by 878 a health care provider or group of affiliated health care 879 providers, and which directly provides health care services 880 under a Medicare, Medicaid, or Healthy Kids contract. 881 Section 15.For the purpose of incorporating the amendments 882 made by this act to section 409.981, Florida Statutes, in 883 references thereto, paragraphs (h), (i), and (j) of subsection 884 (3) and subsection (11) of section 430.2053, Florida Statutes, 885 are reenacted to read: 886 430.2053Aging resource centers. 887 (3)The duties of an aging resource center are to: 888 (h)Assist clients who request long-term care services in 889 being evaluated for eligibility for enrollment in the Medicaid 890 long-term care managed care program as eligible plans become 891 available in each of the regions pursuant to s. 409.981(2). 892 (i)Provide enrollment and coverage information to Medicaid 893 managed long-term care enrollees as qualified plans become 894 available in each of the regions pursuant to s. 409.981(2). 895 (j)Assist Medicaid recipients enrolled in the Medicaid 896 long-term care managed care program with informally resolving 897 grievances with a managed care network and assist Medicaid 898 recipients in accessing the managed care networks formal 899 grievance process as eligible plans become available in each of 900 the regions defined in s. 409.981(2). 901 (11)In an area in which the department has designated an 902 area agency on aging as an aging resource center, the department 903 and the agency shall not make payments for the services listed 904 in subsection (9) and the Long-Term Care Community Diversion 905 Project for such persons who were not screened and enrolled 906 through the aging resource center. The department shall cease 907 making payments for recipients in eligible plans as eligible 908 plans become available in each of the regions defined in s. 909 409.981(2). 910 Section 16.The Agency for Health Care Administration shall 911 amend existing Statewide Medicaid Managed Care contracts to 912 implement the changes made by this act to sections 409.973, 913 409.975, and 409.977, Florida Statutes. The agency shall 914 implement the changes made by this act to sections 409.966, 915 409.974, and 409.981, Florida Statutes, for the 2025 plan year. 916 Section 17.This act shall take effect July 1, 2022.