December 06, 2019
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_h7187__
HB 7187

1
A bill to be entitled
2An act relating to Medicaid; amending s. 409.907, F.S.;
3revising the requirements of a Medicaid provider agreement
4to include compliance with the Medicaid Encounter Data
5System; requiring the Agency for Health Care
6Administration to submit an annual report on the system to
7the Governor and Legislature; amending s. 409.908, F.S.;
8requiring the agency to adjust capitation rates for
9certain Medicaid providers; providing criteria for the
10adjustments; providing a phase-in schedule; requiring the
11Secretary of Health Care Administration to establish a
12technical advisory panel to advise the agency in the area
13of risk-adjusted rate setting; providing membership and
14duties; amending s. 409.912, F.S.; providing instructions
15to the agency regarding seeking federal approval for
16certain contracts that provide behavioral health care
17services; providing for certain contracts to remain in
18effect until a specified date; prohibiting the
19cancellation of certain contracts with provider service
20networks without specified notice; providing additional
21terms for cancellation; requiring contracts for Medicaid
22services that are on a prepaid or fixed-sum basis to meet
23certain medical loss ratios; providing for the agency to
24recoup and redistribute payments under certain
25circumstances; amending s. 409.91207, F.S.; providing
26purposes and principles for creating medical homes;
27providing definitions; providing for the organization of
28medical home networks and provider service networks
29certified as medical homes; requiring a provider service
30network to provide certain notice to the agency prior to
31ceasing participation as a medical home; requiring each
32medical home to provide specified services; providing for
33abolishment of a task force upon the creation of a
34statewide advisory panel; providing for the establishment
35of the statewide advisory panel; providing membership,
36terms, and duties; directing the agency to provide staff
37support to the panel; directing the panel to establish a
38medical advisory group to assist in the establishment of
39medical home networks and provider service networks
40certified as medical homes; providing for travel expenses
41and per diem for members of the panel and the medical
42advisory group; providing for enrollment of MediPass
43beneficiaries in medical homes; providing for financing of
44medical home networks; providing duties of the agency;
45providing for distribution of savings achieved by network
46providers under certain circumstances; requiring the
47agency to collaborate with the Office of Insurance
48Regulation to encourage licensed insurers to incorporate
49the principles of the medical home network into insurance
50plans; requiring the Department of Management Services to
51develop a medical home option in the state group insurance
52program; requiring medical home network providers to
53maintain certain records and data; amending s. 409.91211,
54F.S.; requiring a provider that receives low-income pool
55funds to serve Medicaid recipients regardless of county of
56residence; revising the period for phasing in financial
57risk for certain provider service networks; amending s.
58409.9122, F.S.; revising the assignment of Medicaid
59recipients eligible for managed care plan enrollment who
60are subject to mandatory assignment but who fail to make a
61choice; providing an effective date.
62
63Be It Enacted by the Legislature of the State of Florida:
64
65     Section 1.  Paragraph (k) is added to subsection (3) of
66section 409.907, Florida Statutes, and subsection (13) is added
67to that section, to read:
68     409.907  Medicaid provider agreements.-The agency may make
69payments for medical assistance and related services rendered to
70Medicaid recipients only to an individual or entity who has a
71provider agreement in effect with the agency, who is performing
72services or supplying goods in accordance with federal, state,
73and local law, and who agrees that no person shall, on the
74grounds of handicap, race, color, or national origin, or for any
75other reason, be subjected to discrimination under any program
76or activity for which the provider receives payment from the
77agency.
78     (3)  The provider agreement developed by the agency, in
79addition to the requirements specified in subsections (1) and
80(2), shall require the provider to:
81     (k)  Fully comply with the agency's Medicaid Encounter Data
82System.
83     (13)  By January 1, 2011, and annually thereafter until
84full compliance is reached, the agency shall submit to the
85Governor, the President of the Senate, and the Speaker of the
86House of Representatives a report that summarizes data regarding
87the agency's Medicaid Encounter Data System, including the
88number of participating providers, the level of compliance of
89each provider, and an analysis of service utilization, service
90trends, and specific problem areas.
91     Section 2.  Subsection (4) of section 409.908, Florida
92Statutes, is amended to read:
93     409.908  Reimbursement of Medicaid providers.-Subject to
94specific appropriations, the agency shall reimburse Medicaid
95providers, in accordance with state and federal law, according
96to methodologies set forth in the rules of the agency and in
97policy manuals and handbooks incorporated by reference therein.
98These methodologies may include fee schedules, reimbursement
99methods based on cost reporting, negotiated fees, competitive
100bidding pursuant to s. 287.057, and other mechanisms the agency
101considers efficient and effective for purchasing services or
102goods on behalf of recipients. If a provider is reimbursed based
103on cost reporting and submits a cost report late and that cost
104report would have been used to set a lower reimbursement rate
105for a rate semester, then the provider's rate for that semester
106shall be retroactively calculated using the new cost report, and
107full payment at the recalculated rate shall be effected
108retroactively. Medicare-granted extensions for filing cost
109reports, if applicable, shall also apply to Medicaid cost
110reports. Payment for Medicaid compensable services made on
111behalf of Medicaid eligible persons is subject to the
112availability of moneys and any limitations or directions
113provided for in the General Appropriations Act or chapter 216.
114Further, nothing in this section shall be construed to prevent
115or limit the agency from adjusting fees, reimbursement rates,
116lengths of stay, number of visits, or number of services, or
117making any other adjustments necessary to comply with the
118availability of moneys and any limitations or directions
119provided for in the General Appropriations Act, provided the
120adjustment is consistent with legislative intent.
121     (4)  Subject to any limitations or directions provided for
122in the General Appropriations Act, alternative health plans,
123health maintenance organizations, and prepaid health plans shall
124be reimbursed a fixed, prepaid amount negotiated, or
125competitively bid pursuant to s. 287.057, by the agency and
126prospectively paid to the provider monthly for each Medicaid
127recipient enrolled. The amount may not exceed the average amount
128the agency determines it would have paid, based on claims
129experience, for recipients in the same or similar category of
130eligibility. The agency shall calculate capitation rates on a
131regional basis and, beginning September 1, 1995, shall include
132age-band differentials in such calculations.
133     (a)  Beginning October 1, 2010, the agency shall begin a
134budget-neutral adjustment of capitation rates based on aggregate
135risk scores for each provider's enrollees. During the first 2
136years of the adjustment, the agency shall ensure that no
137provider has an aggregate risk score that varies by more than 10
138percent from the aggregate weighted average for all providers.
139The risk-adjusted capitation rates shall be phased in as
140follows:
141     1.  In the first contract year, 75 percent of the
142capitation rate shall be based on the current methodology and 25
143percent shall be based on the risk-adjusted capitation rate
144methodology.
145     2.  In the second contract year, 50 percent of the
146capitation rate shall be based on the current methodology and 50
147percent shall be based on the risk-adjusted capitation rate
148methodology.
149     3.  In the third contract year, the risk-adjusted
150capitation rate methodology shall be fully implemented.
151     (b)  The Secretary of Health Care Administration shall
152convene a technical advisory panel to advise the agency in the
153area of risk-adjusted rate setting during the transition to
154risk-adjusted capitation rates described in paragraph (a). The
155panel shall include representatives of prepaid plans in counties
156that are not included as demonstration sites under s.
157409.91211(1). The panel shall advise the agency regarding:
158     1.  The selection of a base year of encounter data to be
159used to set risk-adjusted capitation rates.
160     2.  The completeness and accuracy of the encounter data
161set.
162     3.  The effect of risk-adjusted capitation rates on prepaid
163plans based on a review of a simulated rate-setting process.
164     Section 3.  Paragraphs (b) and (d) of subsection (4) of
165section 409.912, Florida Statutes, are amended, and subsection
166(54) is added to that section, to read:
167     409.912  Cost-effective purchasing of health care.-The
168agency shall purchase goods and services for Medicaid recipients
169in the most cost-effective manner consistent with the delivery
170of quality medical care. To ensure that medical services are
171effectively utilized, the agency may, in any case, require a
172confirmation or second physician's opinion of the correct
173diagnosis for purposes of authorizing future services under the
174Medicaid program. This section does not restrict access to
175emergency services or poststabilization care services as defined
176in 42 C.F.R. part 438.114. Such confirmation or second opinion
177shall be rendered in a manner approved by the agency. The agency
178shall maximize the use of prepaid per capita and prepaid
179aggregate fixed-sum basis services when appropriate and other
180alternative service delivery and reimbursement methodologies,
181including competitive bidding pursuant to s. 287.057, designed
182to facilitate the cost-effective purchase of a case-managed
183continuum of care. The agency shall also require providers to
184minimize the exposure of recipients to the need for acute
185inpatient, custodial, and other institutional care and the
186inappropriate or unnecessary use of high-cost services. The
187agency shall contract with a vendor to monitor and evaluate the
188clinical practice patterns of providers in order to identify
189trends that are outside the normal practice patterns of a
190provider's professional peers or the national guidelines of a
191provider's professional association. The vendor must be able to
192provide information and counseling to a provider whose practice
193patterns are outside the norms, in consultation with the agency,
194to improve patient care and reduce inappropriate utilization.
195The agency may mandate prior authorization, drug therapy
196management, or disease management participation for certain
197populations of Medicaid beneficiaries, certain drug classes, or
198particular drugs to prevent fraud, abuse, overuse, and possible
199dangerous drug interactions. The Pharmaceutical and Therapeutics
200Committee shall make recommendations to the agency on drugs for
201which prior authorization is required. The agency shall inform
202the Pharmaceutical and Therapeutics Committee of its decisions
203regarding drugs subject to prior authorization. The agency is
204authorized to limit the entities it contracts with or enrolls as
205Medicaid providers by developing a provider network through
206provider credentialing. The agency may competitively bid single-
207source-provider contracts if procurement of goods or services
208results in demonstrated cost savings to the state without
209limiting access to care. The agency may limit its network based
210on the assessment of beneficiary access to care, provider
211availability, provider quality standards, time and distance
212standards for access to care, the cultural competence of the
213provider network, demographic characteristics of Medicaid
214beneficiaries, practice and provider-to-beneficiary standards,
215appointment wait times, beneficiary use of services, provider
216turnover, provider profiling, provider licensure history,
217previous program integrity investigations and findings, peer
218review, provider Medicaid policy and billing compliance records,
219clinical and medical record audits, and other factors. Providers
220shall not be entitled to enrollment in the Medicaid provider
221network. The agency shall determine instances in which allowing
222Medicaid beneficiaries to purchase durable medical equipment and
223other goods is less expensive to the Medicaid program than long-
224term rental of the equipment or goods. The agency may establish
225rules to facilitate purchases in lieu of long-term rentals in
226order to protect against fraud and abuse in the Medicaid program
227as defined in s. 409.913. The agency may seek federal waivers
228necessary to administer these policies.
229     (4)  The agency may contract with:
230     (b)  An entity that is providing comprehensive behavioral
231health care services to certain Medicaid recipients through a
232capitated, prepaid arrangement pursuant to the federal waiver
233provided for by s. 409.905(5). Such entity must be licensed
234under chapter 624, chapter 636, or chapter 641, or authorized
235under paragraph (c), and must possess the clinical systems and
236operational competence to manage risk and provide comprehensive
237behavioral health care to Medicaid recipients. As used in this
238paragraph, the term "comprehensive behavioral health care
239services" means covered mental health and substance abuse
240treatment services that are available to Medicaid recipients.
241The secretary of the Department of Children and Family Services
242shall approve provisions of procurements related to children in
243the department's care or custody before enrolling such children
244in a prepaid behavioral health plan. Any contract awarded under
245this paragraph must be competitively procured. In developing the
246behavioral health care prepaid plan procurement document, the
247agency shall ensure that the procurement document requires the
248contractor to develop and implement a plan to ensure compliance
249with s. 394.4574 related to services provided to residents of
250licensed assisted living facilities that hold a limited mental
251health license. Except as provided in subparagraph 8., and
252except in counties where the Medicaid managed care pilot program
253is authorized pursuant to s. 409.91211, the agency shall seek
254federal approval to contract with a single entity meeting these
255requirements to provide comprehensive behavioral health care
256services to all Medicaid recipients not enrolled in a Medicaid
257managed care plan authorized under s. 409.91211, a Medicaid
258provider service network authorized under paragraph (d), or a
259Medicaid health maintenance organization in an AHCA area. In an
260AHCA area where the Medicaid managed care pilot program is
261authorized pursuant to s. 409.91211 in one or more counties, the
262agency may procure a contract with a single entity to serve the
263remaining counties as an AHCA area or the remaining counties may
264be included with an adjacent AHCA area and are subject to this
265paragraph. Each entity must offer a sufficient choice of
266providers in its network to ensure recipient access to care and
267the opportunity to select a provider with whom they are
268satisfied. The network shall include all public mental health
269hospitals. To ensure unimpaired access to behavioral health care
270services by Medicaid recipients, all contracts issued pursuant
271to this paragraph must require 80 percent of the capitation paid
272to the managed care plan, including health maintenance
273organizations or provider service networks, to be expended for
274the provision of behavioral health care services. If the managed
275care plan expends less than 80 percent of the capitation paid
276for the provision of behavioral health care services, the
277difference shall be returned to the agency. The agency shall
278provide the plan with a certification letter indicating the
279amount of capitation paid during each calendar year for
280behavioral health care services pursuant to this section. The
281agency may reimburse for substance abuse treatment services on a
282fee-for-service basis until the agency finds that adequate funds
283are available for capitated, prepaid arrangements.
284     1.  By January 1, 2001, the agency shall modify the
285contracts with the entities providing comprehensive inpatient
286and outpatient mental health care services to Medicaid
287recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
288Counties, to include substance abuse treatment services.
289     2.  By July 1, 2003, the agency and the Department of
290Children and Family Services shall execute a written agreement
291that requires collaboration and joint development of all policy,
292budgets, procurement documents, contracts, and monitoring plans
293that have an impact on the state and Medicaid community mental
294health and targeted case management programs.
295     3.  Except as provided in subparagraph 8., by July 1, 2006,
296the agency and the Department of Children and Family Services
297shall contract with managed care entities in each AHCA area
298except area 6 or arrange to provide comprehensive inpatient and
299outpatient mental health and substance abuse services through
300capitated prepaid arrangements to all Medicaid recipients who
301are eligible to participate in such plans under federal law and
302regulation. In AHCA areas where eligible individuals number less
303than 150,000, the agency shall contract with a single managed
304care plan to provide comprehensive behavioral health services to
305all recipients who are not enrolled in a Medicaid health
306maintenance organization or a Medicaid capitated managed care
307plan authorized under s. 409.91211. The agency may contract with
308more than one comprehensive behavioral health provider to
309provide care to recipients who are not enrolled in a Medicaid
310capitated managed care plan authorized under s. 409.91211 or a
311Medicaid health maintenance organization in AHCA areas where the
312eligible population exceeds 150,000. In an AHCA area where the
313Medicaid managed care pilot program is authorized pursuant to s.
314409.91211 in one or more counties, the agency may procure a
315contract with a single entity to serve the remaining counties as
316an AHCA area or the remaining counties may be included with an
317adjacent AHCA area and shall be subject to this paragraph.
318Contracts for comprehensive behavioral health providers awarded
319pursuant to this section shall be competitively procured. Both
320for-profit and not-for-profit corporations are eligible to
321compete. Managed care plans contracting with the agency under
322subsection (3) shall provide and receive payment for the same
323comprehensive behavioral health benefits as provided in AHCA
324rules, including handbooks incorporated by reference. In AHCA
325area 11, the agency shall contract with at least two
326comprehensive behavioral health care providers to provide
327behavioral health care to recipients in that area who are
328enrolled in, or assigned to, the MediPass program. One of the
329behavioral health care contracts must be with the existing
330provider service network pilot project, as described in
331paragraph (d), for the purpose of demonstrating the cost-
332effectiveness of the provision of quality mental health services
333through a public hospital-operated managed care model. Payment
334shall be at an agreed-upon capitated rate to ensure cost
335savings. Of the recipients in area 11 who are assigned to
336MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
337MediPass-enrolled recipients shall be assigned to the existing
338provider service network in area 11 for their behavioral care.
339     4.  By October 1, 2003, the agency and the department shall
340submit a plan to the Governor, the President of the Senate, and
341the Speaker of the House of Representatives which provides for
342the full implementation of capitated prepaid behavioral health
343care in all areas of the state.
344     a.  Implementation shall begin in 2003 in those AHCA areas
345of the state where the agency is able to establish sufficient
346capitation rates.
347     b.  If the agency determines that the proposed capitation
348rate in any area is insufficient to provide appropriate
349services, the agency may adjust the capitation rate to ensure
350that care will be available. The agency and the department may
351use existing general revenue to address any additional required
352match but may not over-obligate existing funds on an annualized
353basis.
354     c.  Subject to any limitations provided in the General
355Appropriations Act, the agency, in compliance with appropriate
356federal authorization, shall develop policies and procedures
357that allow for certification of local and state funds.
358     5.  Children residing in a statewide inpatient psychiatric
359program, or in a Department of Juvenile Justice or a Department
360of Children and Family Services residential program approved as
361a Medicaid behavioral health overlay services provider may not
362be included in a behavioral health care prepaid health plan or
363any other Medicaid managed care plan pursuant to this paragraph.
364     6.  In converting to a prepaid system of delivery, the
365agency shall in its procurement document require an entity
366providing only comprehensive behavioral health care services to
367prevent the displacement of indigent care patients by enrollees
368in the Medicaid prepaid health plan providing behavioral health
369care services from facilities receiving state funding to provide
370indigent behavioral health care, to facilities licensed under
371chapter 395 which do not receive state funding for indigent
372behavioral health care, or reimburse the unsubsidized facility
373for the cost of behavioral health care provided to the displaced
374indigent care patient.
375     7.  Traditional community mental health providers under
376contract with the Department of Children and Family Services
377pursuant to part IV of chapter 394, child welfare providers
378under contract with the Department of Children and Family
379Services in areas 1 and 6, and inpatient mental health providers
380licensed pursuant to chapter 395 must be offered an opportunity
381to accept or decline a contract to participate in any provider
382network for prepaid behavioral health services.
383     8.  All Medicaid-eligible children, except children in area
3841 and children in Highlands County, Hardee County, Polk County,
385or Manatee County of area 6, that are open for child welfare
386services in the HomeSafeNet system, shall receive their
387behavioral health care services through a specialty prepaid plan
388operated by community-based lead agencies through a single
389agency or formal agreements among several agencies. The
390specialty prepaid plan must result in savings to the state
391comparable to savings achieved in other Medicaid managed care
392and prepaid programs. Such plan must provide mechanisms to
393maximize state and local revenues. The specialty prepaid plan
394shall be developed by the agency and the Department of Children
395and Family Services. The agency may seek federal waivers to
396implement this initiative. Medicaid-eligible children whose
397cases are open for child welfare services in the HomeSafeNet
398system and who reside in AHCA area 10 are exempt from the
399specialty prepaid plan upon the development of a service
400delivery mechanism for children who reside in area 10 as
401specified in s. 409.91211(3)(dd).
402     (d)  A provider service network may be reimbursed on a fee-
403for-service or prepaid basis. A provider service network that
404which is reimbursed by the agency on a prepaid basis shall be
405exempt from parts I and III of chapter 641, but must comply with
406the solvency requirements in s. 641.2261(2) and meet appropriate
407financial reserve, quality assurance, and patient rights
408requirements as established by the agency. Medicaid recipients
409assigned to a provider service network shall be chosen equally
410from those who would otherwise have been assigned to prepaid
411plans and MediPass. The agency may is authorized to seek federal
412Medicaid waivers as necessary to implement the provisions of
413this section. Any contract previously awarded to a provider
414service network operated by a hospital pursuant to this
415subsection shall remain in effect through June 30, 2015 for a
416period of 3 years following the current contract expiration
417date, regardless of any contractual provisions to the contrary.
418A contract awarded or renewed on or after July 1, 2010, to a
419provider service network shall prohibit the cancellation of the
420contract unless the network provides the agency with at least 90
421days' notice. All members of the network must continue to
422provide services to Medicaid recipients assigned to that network
423during that 90-day period. A provider service network is a
424network established or organized and operated by a health care
425provider, or group of affiliated health care providers,
426including minority physician networks and emergency room
427diversion programs that meet the requirements of s. 409.91211,
428which provides a substantial proportion of the health care items
429and services under a contract directly through the provider or
430affiliated group of providers and may make arrangements with
431physicians or other health care professionals, health care
432institutions, or any combination of such individuals or
433institutions to assume all or part of the financial risk on a
434prospective basis for the provision of basic health services by
435the physicians, by other health professionals, or through the
436institutions. The health care providers must have a controlling
437interest in the governing body of the provider service network
438organization.
439     (54)  An entity that contracts with the agency on a prepaid
440or fixed-sum basis for the provision of Medicaid services shall
441spend 85 percent of the Medicaid capitation revenue for health
442services to enrollees. The agency shall monitor medical loss
443ratios for all prepaid plans on a county-by-county basis. When a
444plan's 3-year average medical loss ratio in a county is less
445than 85 percent, the agency may recoup an amount equivalent to
446the difference between 85 percent of the capitation paid to the
447plan and the amount the plan paid for provision of services over
448the 3-year period. These recouped funds shall be dispersed in
449proportionate amounts to plans that have spent in excess of 85
450percent of their capitation on the provision of medical
451services.
452     Section 4.  Section 409.91207, Florida Statutes, is amended
453to read:
454(Substantial rewording of section. See
455s. 409.91207, F.S., for present text.)
456     409.91207  Medical homes.-
457     (1)  PURPOSE AND PRINCIPLES.-The agency shall develop a
458method for recognizing the certification of a primary care
459provider or a provider service network as a medical home. The
460purpose of this certification is to foster and support improved
461care management through enhanced primary care case management
462and dissemination of best practices for coordinated and cost-
463effective care. The medical home modifies the processes and
464patterns of health care service delivery by applying the
465following principles:
466     (a)  A personal medical provider leads an interdisciplinary
467team of professionals who share the responsibility of providing
468ongoing care to a specific panel of patients.
469     (b)  The personal medical provider identifies a patient's
470health care needs and responds to those needs through direct
471care or arrangements with other qualified providers.
472     (c)  Care is coordinated or integrated across all areas of
473health service delivery.
474     (d)  Information technology is integrated into delivery
475systems to enhance clinical performance and monitor patient
476outcomes.
477     (2)  DEFINITIONS.-As used in this section, the term:
478     (a)  "Case manager" means a person or persons employed by a
479medical home network or provider service network, or a member of
480such network, to work with primary care providers in the
481delivery of outreach, support services, and care coordination
482for medical home patients.
483     (b)  "Medical home network" means a group of primary care
484providers and other health professionals and facilities who
485agree to cooperate with one another in order to coordinate care
486for Medicaid beneficiaries assigned to primary care providers in
487the network.
488     (c)  "Primary care provider" means a health professional
489practicing in the field of family medicine, general internal
490medicine, geriatric medicine, or pediatric medicine who is
491licensed as a physician under chapter 458 or chapter 459, a
492physician's assistant performing services delegated by a
493supervising physician pursuant to s. 458.347 or s. 459.022, or a
494registered nurse certified as an advanced registered  nurse
495practitioner performing services pursuant to a protocol
496established with a supervising physician in accordance with s.
497464.012. The term "primary care provider" also means a federally
498qualified health center.
499     (d)  "Principal network provider" means a member of a
500medical home network or a provider service network who serves as
501the principal liaison between the agency and that network and
502who accepts responsibility for communicating the agency's
503directives concerning the project to all other network members.
504     (e)  "Provider service network" has the same meaning as
505provided in s. 409.912(4)(d).
506     (f)  "Tier One medical home" means:
507     1.  A primary care provider that certifies to the agency
508that the provider meets the service capabilities established in
509paragraph (4)(a); or
510     2.  A provider service network that certifies to the agency
511that all of its members who are primary care providers meet the
512service capabilities established in paragraph (4)(a).
513     (g)  "Tier Two medical home" means:
514     1.  A primary care provider that certifies to the agency
515that the provider meets the service capabilities established in
516paragraph (4)(b); or
517     2.  A provider service network that certifies to the agency
518that at least 85 percent of its members who are primary care
519providers meet the service capabilities established in paragraph
520(4)(b) and the remainder of the primary care providers meet the
521service capabilities established in paragraph (4)(a).
522     (h)  "Tier Three medical home" means:
523     1.  A primary care provider that certifies to the agency
524that the provider meets the service capabilities established in
525paragraph (4)(c); or
526     2.  A provider service network that certifies to the agency
527that at least 85 percent of its members who are primary care
528providers meet the service capabilities established in paragraph
529(4)(c) and the remainder of the primary care providers meet the
530service capabilities established in paragraph (4)(b).
531     (3)  ORGANIZATION.-
532     (a)  Each participating primary care provider shall be a
533member of a medical home network or a provider service network
534and shall be classified by the agency as a Tier One, Tier Two,
535or Tier Three medical home upon certification by the provider of
536compliance with the service capabilities for that tier. A
537primary care provider or a provider service network may change
538classification by certifying service capabilities consistent
539with the standards for another tier. Certifications shall be
540made annually.
541     (b)  Each participating provider service network shall be
542classified by the agency as a Tier One, Tier Two, or Tier Three
543medical home upon certification by the network that the
544network's primary care providers meet the service capabilities
545for that tier. The provider service network may also certify to
546the agency that it intends to serve a specific target population
547based on disease, condition, or age.
548     (c)  The members of each medical home network or provider
549service network shall designate a principal network provider who
550shall be responsible for maintaining an accurate list of
551participating providers, forwarding this list to the agency,
552updating the list as requested by the agency, and facilitating
553communication between the agency and the participating
554providers.
555     (d)  A provider service network may only cease
556participation as a medical home after providing at least 90
557days' notice to the agency. All members of the provider service
558network must continue to serve the enrollees during this 90-day
559period. A provider service network that is reimbursed by the
560agency on a prepaid basis may not receive any additional
561reimbursements for this 90-day period.
562     (4)  SERVICE CAPABILITIES.-A medical home network or a
563provider service network certified as a medical home shall
564provide primary care; coordinate services to control chronic
565illnesses; provide disease management and patient education;
566provide or arrange for pharmacy, outpatient diagnostic, and
567specialty physician services; and provide for or coordinate with
568inpatient facilities and behavioral health, mental health, and
569rehabilitative service providers. The network shall place a
570priority on methods to manage pharmacy and behavioral health
571services.
572     (a)  Tier One medical homes shall have the capability to:
573     1.  Maintain a written copy of the mutual agreement between
574the medical home and the patient in the patient's medical
575record.
576     2.  Supply all medically necessary primary and preventive
577services and provide all scheduled immunizations.
578     3.  Organize clinical data in paper or electronic form
579using a patient-centered charting system.
580     4.  Maintain and update patients' medication lists and
581review all medications during each office visit.
582     5.  Maintain a system to track diagnostic tests and provide
583followup services regarding test results.
584     6.  Maintain a system to track referrals, including self-
585referrals by members.
586     7.  Supply care coordination and continuity of care through
587proactive contact with members and encourage family
588participation in care.
589     8.  Supply education and support using various materials
590and processes appropriate for individual patient needs.
591     (b)  Tier Two medical homes shall have all of the
592capabilities of a Tier One medical home and shall have the
593additional capability to:
594     1.  Communicate electronically.
595     2.  Supply voice-to-voice telephone coverage to panel
596members 24 hours per day, 7 days per week, to enable patients to
597speak to a licensed health care professional who triages and
598forwards calls, as appropriate.
599     3.  Maintain an office schedule of at least 30 scheduled
600hours per week.
601     4.  Use scheduling processes to promote continuity with
602clinicians, including providing care for walk-in, routine, and
603urgent care visits.
604     5.  Implement and document behavioral health and substance
605abuse screening procedures and make referrals as needed.
606     6.  Use data to identify and track patients' health and
607service use patterns.
608     7.  Coordinate care and followup for patients receiving
609services in inpatient and outpatient facilities.
610     8.  Implement processes to promote access to care and
611member communication.
612     (c)  Tier Three medical homes shall have all of the
613capabilities of Tier One and Tier Two medical homes and shall
614have the additional capability to:
615     1.  Maintain electronic medical records.
616     2.  Develop a health care team that provides ongoing
617support, oversight, and guidance for all medical care received
618by the patient and documents contact with specialists and other
619health care providers caring for the patient.
620     3.  Supply postvisit followup care for patients.
621     4.  Implement specific evidence-based clinical practice
622guidelines for preventive and chronic care.
623     5.  Implement a medication reconciliation procedure to
624avoid interactions or duplications.
625     6.  Use personalized screening, brief intervention, and
626referral to treatment procedures for appropriate patients
627requiring specialty treatment.
628     7.  Offer at least 4 hours per week of after-hours care to
629patients.
630     8.  Use health assessment tools to identify patient needs
631and risks.
632     (5)  TASK FORCE; ADVISORY PANEL.-
633     (a)  The Secretary of Health Care Administration shall
634appoint a task force by August 1, 2009, to assist the agency in
635the development and implementation of the medical home pilot
636project. The task force must include, but is not limited to,
637representatives of providers who could potentially participate
638in a medical home network, Medicaid recipients, and existing
639MediPass and managed care providers. Members of the task force
640shall serve without compensation but are may be reimbursed for
641per diem and travel expenses as provided in s. 112.061. When the
642statewide advisory panel created pursuant to paragraph (b) has
643been appointed, the task force shall dissolve.
644     (b)  A statewide advisory panel shall be established to
645advise and assist the agency in developing a methodology for an
646annual evaluation of each medical home network and provider
647service network certified as a medical home. The panel shall
648promote communication among medical home networks and provider
649service networks certified as medical homes. The panel shall
650consist of seven members, as follows:
651     1.  Two members appointed by the Speaker of the House of
652Representatives, one of whom shall be a primary care physician
653licensed under chapter 458 or chapter 459 and one of whom shall
654be a representative of a hospital licensed under chapter 395.
655     2.  Two members appointed by the President of the Senate,
656one of whom shall be a physician licensed under chapter 458 or
657chapter 459 who is a board-certified specialist and one of whom
658shall be a representative of a Florida medical school.
659     3.  Two members appointed by the Governor, one of whom
660shall be a representative of an insurer licensed to do business
661in this state or a health maintenance organization licensed
662under part I of chapter 641 and one of whom shall be a
663representative of Medicaid consumers.
664     4.  The Secretary of Health Care Administration or his or
665her designee.
666     (c)  Appointed members of the panel shall serve 4-year
667terms, except that the initial terms shall be staggered as
668follows:
669     1.  The Governor shall appoint one member for a term of 2
670years and one member for a term of 4 years.
671     2.  The President of the Senate shall appoint one member
672for a term of 2 years and one member for a term of 4 years.
673     3.  The Speaker of the House of Representatives shall
674appoint one member for a term of 2 years and one member for a
675term of 4 years.
676     (d)  A vacancy in an appointed member's position shall be
677filled by appointment by the original appointing authority for
678the unexpired portion of the term.
679     (e)  Members of the statewide advisory panel shall serve
680without compensation but may be reimbursed for per diem and
681travel expenses as provided in s. 112.061.
682     (f)  The agency shall provide staff support to assist the
683panel in the performance of its duties.
684     (g)  The statewide advisory panel shall establish a medical
685advisory group consisting of physicians licensed under chapter
686458 or chapter 459 who shall act as ambassadors to their
687communities for the promotion of and assistance in the
688establishment of medical home networks and provider service
689networks certified as medical homes. Members of the medical
690advisory group shall serve without compensation but may be
691reimbursed for per diem and travel expenses as provided in s.
692112.061.
693     (6)  ENROLLMENT.-Each MediPass beneficiary served by a
694certified Tier One, Tier Two, or Tier Three medical home shall
695be given a choice to enroll in a medical home network or
696provider service network certified as a medical home. Enrollment
697shall be effective upon the agency's receipt of a participation
698agreement signed by the beneficiary.
699     (7)  FINANCING.-
700     (a)  Subject to a specific appropriation provided for in
701the General Appropriations Act, medical home network members
702shall be eligible to receive a monthly enhanced case management
703fee, as follows:
704     1.  Tier One medical homes shall receive $3.58 per child in
705a panel of enrollees and $5.02 per adult in a panel of
706enrollees.
707     2.  Tier Two medical homes shall receive $4.65 per child in
708a panel of enrollees and $6.52 per adult in a panel of
709enrollees.
710     3.  Tier Three medical homes shall receive $6.12 per child
711in a panel of enrollees and $8.69 per adult in a panel of
712enrollees.
713     (b)  Services provided by a medical home network or a
714provider service network with a fee-for-service contract with
715the agency shall be reimbursed based on claims filed for
716Medicaid fee-for-service payments. Services by a provider
717service network with a contract with the agency for prepaid
718services shall be paid pursuant to the contract and shall be
719eligible to receive the credit provided in this subsection.
720     (c)  Any hospital, as defined in s. 395.002(12),
721participating in a medical home network or service provider
722network certified as a medical home that employs case managers
723for the network shall be eligible to receive a credit against
724the assessment imposed under s. 395.701. The credit is
725compensation for participating in the network by providing case
726management and other network services.
727     1.  The credit shall be prorated based on the number of
728full-time equivalent case managers hired but shall not be more
729than $75,000 for each full-time equivalent case manager. The
730total credit may not exceed $450,000 for any hospital for any
731state fiscal year.
732     2.  To qualify for the credit, the hospital must employ
733each full-time equivalent case manager for the entire hospital
734fiscal year for which the credit is claimed.
735     3.  The hospital must certify the number of full-time
736equivalent case managers for whom it is entitled to a credit
737using the certification process required under s. 395.701(2)(a).
738     4.  The agency shall calculate the amount of the credit and
739reduce the certified assessment for the hospital by the amount
740of the credit.
741     (d)  The enhanced payments to primary care providers shall
742not affect the calculation of capitated rates under this
743chapter.
744     (8)  AGENCY DUTIES.-The agency shall:
745     (a)  Maintain a record of certified primary care providers
746and provider service networks by classification as Tier One,
747Tier Two, or Tier Three medical homes.
748     (b)  Develop a standard form to be used by primary care
749providers and provider service networks to certify to the agency
750that they meet the necessary principles and service capabilities
751for the tier in which they seek to be classified. The form shall
752have a check box for each of the three tiers, a line to indicate
753whether a primary care network intends to specialize in a target
754population, a line to specify the target population, if any, and
755a line for the signature of the provider or principal of an
756entity. Checking the appropriate tier box and signing the form
757shall be deemed certification for the purposes of this section.
758     (c)  Develop a process for managed care organizations to
759certify themselves as Tier One, Tier Two, or Tier Three medical
760homes based on established policies and procedures consistent
761with the principles and corresponding service capabilities
762provided under subsections (1) and (4).
763     (d)  Establish a participation agreement to be executed by
764Medipass recipients who choose to participate in the medical
765home pilot project.
766     (e)  Track the spending for and utilization of services by
767all enrolled medical home network patients.
768     (f)  Evaluate each provider service network at least
769annually to ensure that the network is cost-effective as defined
770in s. 409.912(44).
771     (9)  ACHIEVED SAVINGS.-Each medical home network or
772provider service network certified as a medical home that
773participates on a fee-for-service basis and achieves savings
774equal to or greater than the spending that would have occurred
775if its enrollees participated in prepaid health plans is
776eligible to receive funding based on the identified savings
777pursuant to a specific appropriation provided for in the General
778Appropriations Act. The funds must be distributed on a pro rata
779basis to the physicians who are members of the medical home
780network so that the compensation for their services is as close
781as possible to 100 percent of Medicare rates. Subject to a
782specific appropriation, it is the intent of the Legislature that
783the savings that result from the implementation of the medical
784home network model be used to enable Medicaid fees to physicians
785participating in medical home networks to be equivalent to 100
786percent of Medicare rates as soon as possible.
787     (10)  COLLABORATION WITH PRIVATE INSURERS.-To enable the
788state to participate in federal gainsharing initiatives, the
789agency shall collaborate with the Office of Insurance Regulation
790to encourage insurers licensed in this state to incorporate
791medical home network principles into the design of their
792individual and employment-based plans. The Department of
793Management Services is directed to develop a medical home option
794in the state group insurance program.
795     (11)  QUALITY ASSURANCE AND ACCOUNTABILITY.-Each primary
796care and principal network provider participating in a medical
797home network or provider service network certified as a medical
798home shall maintain medical records and clinical data necessary
799for the network to assess the use, cost, and outcome of services
800provided to enrollees.
801     Section 5.  Paragraph (b) of subsection (1) and paragraph
802(e) of subsection (3) of section 409.91211, Florida Statutes,
803are amended to read:
804     409.91211  Medicaid managed care pilot program.-
805     (1)
806     (b)  This waiver authority is contingent upon federal
807approval to preserve the upper-payment-limit funding mechanism
808for hospitals, including a guarantee of a reasonable growth
809factor, a methodology to allow the use of a portion of these
810funds to serve as a risk pool for demonstration sites,
811provisions to preserve the state's ability to use
812intergovernmental transfers, and provisions to protect the
813disproportionate share program authorized pursuant to this
814chapter. Upon completion of the evaluation conducted under s. 3,
815ch. 2005-133, Laws of Florida, the agency may request statewide
816expansion of the demonstration projects. Statewide phase-in to
817additional counties shall be contingent upon review and approval
818by the Legislature. Under the upper-payment-limit program, or
819the low-income pool as implemented by the Agency for Health Care
820Administration pursuant to federal waiver, the state matching
821funds required for the program shall be provided by local
822governmental entities through intergovernmental transfers in
823accordance with published federal statutes and regulations. The
824Agency for Health Care Administration shall distribute upper-
825payment-limit, disproportionate share hospital, and low-income
826pool funds according to published federal statutes, regulations,
827and waivers and the low-income pool methodology approved by the
828federal Centers for Medicare and Medicaid Services. A provider
829who receives low-income pool funds shall serve Medicaid
830recipients regardless of the recipient's county of residence in
831the state and may not restrict access to care based on residency
832in a county in the state other than the one in which the
833provider is located.
834     (3)  The agency shall have the following powers, duties,
835and responsibilities with respect to the pilot program:
836     (e)  To implement policies and guidelines for phasing in
837financial risk for approved provider service networks that, for
838purposes of this paragraph, include the Children's Medical
839Services Network, over the longer of a 5-year period or through
840October 1, 2015. These policies and guidelines must include an
841option for a provider service network to be paid fee-for-service
842rates. For any provider service network established in a managed
843care pilot area, the option to be paid fee-for-service rates
844must include a savings-settlement mechanism that is consistent
845with s. 409.912(44). As of October 1, 2015, or after 5 years of
846operation, whichever is the longer period, this model must be
847converted to a risk-adjusted capitated rate by the beginning of
848the sixth year of operation, and may be converted earlier at the
849option of the provider service network. Federally qualified
850health centers may be offered an opportunity to accept or
851decline a contract to participate in any provider network for
852prepaid primary care services.
853     Section 6.  Paragraph (f) of subsection (2) of section
854409.9122, Florida Statutes, is amended to read:
855     409.9122  Mandatory Medicaid managed care enrollment;
856programs and procedures.-
857     (2)
858     (f)  If a Medicaid recipient does not choose a managed care
859plan or MediPass provider, the agency shall assign the Medicaid
860recipient to a managed care plan or MediPass provider. Medicaid
861recipients eligible for managed care plan enrollment who are
862subject to mandatory assignment but who fail to make a choice
863shall be assigned to managed care plans until an enrollment of
86465 percent in provider service networks certified as medical
865homes under s. 409.91207 and 35 percent in other managed care
866plans 35 percent in MediPass and 65 percent in managed care
867plans, of all those eligible to choose managed care, is
868achieved. Once this enrollment is achieved, the assignments
869shall be divided in the same manner order to maintain the same
870an enrollment ratio in MediPass and managed care plans which is
871in a 35 percent and 65 percent proportion, respectively.
872Thereafter, assignment of Medicaid recipients who fail to make a
873choice shall be based proportionally on the preferences of
874recipients who have made a choice in the previous period. Such
875proportions shall be revised at least quarterly to reflect an
876update of the preferences of Medicaid recipients. The agency
877shall disproportionately assign Medicaid-eligible recipients who
878are required to but have failed to make a choice of managed care
879plan or MediPass, including children, and who would be assigned
880to the MediPass program to children's networks as described in
881s. 409.912(4)(g), Children's Medical Services Network as defined
882in s. 391.021, exclusive provider organizations, provider
883service networks, minority physician networks, and pediatric
884emergency department diversion programs authorized by this
885chapter or the General Appropriations Act, in such manner as the
886agency deems appropriate, until the agency has determined that
887the networks and programs have sufficient numbers to be operated
888economically. For purposes of this paragraph, when referring to
889assignment, the term "managed care plans" includes health
890maintenance organizations, exclusive provider organizations,
891provider service networks, minority physician networks,
892Children's Medical Services Network, and pediatric emergency
893department diversion programs authorized by this chapter or the
894General Appropriations Act. When making assignments, the agency
895shall take into account the following criteria:
896     1.  A managed care plan has sufficient network capacity to
897meet the need of members.
898     2.  The managed care plan or MediPass has previously
899enrolled the recipient as a member, or one of the managed care
900plan's primary care providers or MediPass providers has
901previously provided health care to the recipient.
902     3.  The agency has knowledge that the member has previously
903expressed a preference for a particular managed care plan or
904MediPass provider as indicated by Medicaid fee-for-service
905claims data, but has failed to make a choice.
906     4.  The managed care plan's or MediPass primary care
907providers are geographically accessible to the recipient's
908residence.
909     Section 7.  This act shall take effect July 1, 2010.


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