(1) In designing and implementing the community diversion pilot projects, the department shall work in consultation with the agency.
(2)(a) The department shall select projects whose design and providers demonstrate capacity to maximize the placement of participants in the least restrictive appropriate care setting.
(b) The department shall select providers that meet all of the following criteria. Providers shall:
1. Have a plan administrator who is dedicated to the diversion pilot project and project staff who perform the necessary project administrative functions, including data collection, reporting, and analysis.
2. Demonstrate the ability to provide program enrollees with a choice of care provider by contracting with multiple providers that provide the same type of service.
3. Demonstrate through performance or other documented means the capacity for prompt payment of claims as specified under s. 641.3155.
4. Maintain an insolvency protection account in a bank or savings and loan association located in the state with a balance of at least $100,000 into which monthly deposits equal to at least 5 percent of premiums received under the project are made until the balance equals 2 percent of the total contract amount. The account shall be established with such terms as to ensure that funds may only be withdrawn with the signature approval of designated department representatives.
5. Maintain a surplus of at least $1.5 million as determined by the department. Each applicant and each provider shall furnish to the department initial and annual unqualified audited financial statements prepared by a certified public accountant that expressly confirm that the applicant or provider satisfies this surplus requirement. The department may approve a waiver of compliance with the surplus requirement for an existing diversion provider. The department’s approval of this waiver must be contingent on the provider demonstrating proof to the department that the entity has posted and maintains a $1.5 million performance bond, which is written by an insurer licensed to transact insurance in this state, in lieu of meeting the surplus requirement. The department may not approve a waiver of compliance with the surplus requirement that extends beyond June 30, 2006. As used in this subparagraph, the term: a. “Existing diversion provider” means an entity that is approved by the department on or before June 30, 2005, to provide services to consumers through any long-term care community diversion pilot project authorized under ss. 430.701-430.709. b. “Surplus” has the same meaning as in s. 641.19(19). (c) The requirements of paragraph (b) do not apply to entities selected to provide services to the pilot projects authorized under s. 430.205(6)(b)2. The department, in consultation with the agency, shall develop by rule minimum financial solvency and reporting standards for these providers that are reflective of the amount of risk the provider will assume under the pilot project. The standards adopted by rule shall ensure safety for the pilot project enrollees and financial protection for the state in the event of a provider’s inability to continue providing services to the project.
(3) The agency shall seek federal waivers necessary to place a cap on the number of diversion pilot project providers in each geographic area.
(4) Pursuant to 42 C.F.R. s. 438.6(c), the agency, in consultation with the department, shall annually reevaluate and recertify the capitation rates for the diversion pilot projects. The agency, in consultation with the department, shall secure the utilization and cost data for Medicaid and Medicare beneficiaries served by the program which shall be used in developing rates for the diversion pilot projects.
(5) A prospective participant who applies for the long-term care community diversion pilot project and is determined by the Comprehensive Assessment Review and Evaluation for Long-Term Care Services (CARES) Program within the Department of Elderly Affairs to be medically eligible, but has not been determined financially eligible by the Department of Children and Family Services, shall be designated “Medicaid Pending.” CARES shall determine each applicant’s eligibility within 22 days after receiving the application. Contractors may elect to provide services to Medicaid Pending individuals until their financial eligibility is determined. If the individual is determined financially eligible, the agency shall pay the contractor that provided the services a capitated rate retroactive to the first of the month following the CARES eligibility determination. If the individual is not financially eligible for Medicaid, the contractor may terminate services and seek reimbursement from the individual.
(6) The department shall provide to prospective participants a choice of participating in a community diversion pilot project or any other appropriate placement available. To the extent possible, individuals shall be allowed to choose their care providers, including long-term care service providers affiliated with an individual’s religious faith or denomination.
(7) The department shall enroll participants. Providers shall not directly enroll participants in community diversion pilot projects.
(8) The department may require participants to contribute to their cost of care in an amount not to exceed the cost-sharing required of Medicaid-eligible nursing home residents.
(9) Community diversion pilot projects must:
(a) Provide services for participants that are of sufficient quality, quantity, type, and duration to prevent or delay nursing facility placement.
(b) Integrate acute and long-term care services, and the funding sources for such services, as feasible.
(c) Encourage individuals, families, and communities to plan for their long-term care needs.
(d) Provide skilled and intermediate nursing facility care for participants who cannot be adequately cared for in noninstitutional settings.
(10) The department, in consultation with the agency, is authorized to adopt any rules necessary to implement and administer the long-term care community diversion pilot projects authorized under ss. 430.701-430.709.