Florida Senate - 2010                      CS for CS for SB 1484
       
       
       
       By the Policy and Steering Committee on Ways and Means; the
       Committee on Health and Human Services Appropriations; and
       Senator Peaden
       
       
       576-03795-10                                          20101484c2
    1                        A bill to be entitled                      
    2         An act relating to Medicaid; amending s. 409.912,
    3         F.S.; authorizing the Agency for Health Care
    4         Administration to contract with an entity for the
    5         provision of comprehensive behavioral health care
    6         services to certain Medicaid recipients who are not
    7         enrolled in a Medicaid managed care plan or a Medicaid
    8         provider service network under certain circumstances;
    9         requiring the agency to impose a fine against a person
   10         under contract with the agency who violates certain
   11         provisions; requiring an entity that contracts with
   12         the agency as a managed care plan to post a surety
   13         bond with the agency or maintain an account of a
   14         specified sum; requiring the agency to pursue the
   15         entity if the entity terminates the contract with the
   16         agency before the end date of the contract; amending
   17         s. 409.91211, F.S.; extending by 3 years the statewide
   18         implementation of an enhanced service delivery system
   19         for the Florida Medicaid program; providing for the
   20         expansion of the pilot project into counties that have
   21         two or more plans and the capacity to serve the
   22         designated population; requiring that the agency
   23         provide certain specified data to the recipient when
   24         selecting a capitated managed care plan; revising
   25         certain requirements for entities performing choice
   26         counseling for recipients; requiring the agency to
   27         provide behavioral health care services to Medicaid
   28         eligible children; extending a date by which the
   29         behavioral health care services will be delivered to
   30         children; deleting a provision under which certain
   31         Medicaid recipients who are not currently enrolled in
   32         a capitated managed care plan upon implementation are
   33         not eligible for specified services for the amount of
   34         time that the recipients do not enroll in a capitated
   35         managed care network; authorizing the agency to extend
   36         the time to continue operation of the pilot program;
   37         requiring that the agency seek public input on
   38         extending and expanding the managed care pilot program
   39         and post certain information on its website; amending
   40         s. 409.9122, F.S.; providing that time allotted to any
   41         Medicaid recipient for the selection of, enrollment
   42         in, or disenrollment from a managed care plan or
   43         MediPass is tolled throughout any month in which the
   44         enrollment broker or choice counseling provider
   45         adversely affects a beneficiary’s ability to access
   46         choice counseling or enrollment broker services by its
   47         failure to comply with the terms and conditions of its
   48         contract with the agency or has otherwise acted or
   49         failed to act in a manner that the agency deems likely
   50         to jeopardize its ability to perform certain assigned
   51         responsibilities; requiring the agency to incorporate
   52         certain provisions after a specified date in its
   53         contracts related to sanctions or fines for any action
   54         or the failure to act on the part of an enrollment
   55         broker or choice counselor provider; providing an
   56         effective date.
   57  
   58  Be It Enacted by the Legislature of the State of Florida:
   59  
   60         Section 1. Paragraph (b) of subsection (4) of section
   61  409.912, Florida Statutes, is amended, paragraph (d) of
   62  subsection (4) of that section is reenacted, present subsections
   63  (23) through (53) of that section are renumbered as subsections
   64  (24) through (54), respectively, a new subsection (23) is added
   65  to that section, and present subsections (21) and (22) of that
   66  section are amended, to read:
   67         409.912 Cost-effective purchasing of health care.—The
   68  agency shall purchase goods and services for Medicaid recipients
   69  in the most cost-effective manner consistent with the delivery
   70  of quality medical care. To ensure that medical services are
   71  effectively utilized, the agency may, in any case, require a
   72  confirmation or second physician’s opinion of the correct
   73  diagnosis for purposes of authorizing future services under the
   74  Medicaid program. This section does not restrict access to
   75  emergency services or poststabilization care services as defined
   76  in 42 C.F.R. part 438.114. Such confirmation or second opinion
   77  shall be rendered in a manner approved by the agency. The agency
   78  shall maximize the use of prepaid per capita and prepaid
   79  aggregate fixed-sum basis services when appropriate and other
   80  alternative service delivery and reimbursement methodologies,
   81  including competitive bidding pursuant to s. 287.057, designed
   82  to facilitate the cost-effective purchase of a case-managed
   83  continuum of care. The agency shall also require providers to
   84  minimize the exposure of recipients to the need for acute
   85  inpatient, custodial, and other institutional care and the
   86  inappropriate or unnecessary use of high-cost services. The
   87  agency shall contract with a vendor to monitor and evaluate the
   88  clinical practice patterns of providers in order to identify
   89  trends that are outside the normal practice patterns of a
   90  provider’s professional peers or the national guidelines of a
   91  provider’s professional association. The vendor must be able to
   92  provide information and counseling to a provider whose practice
   93  patterns are outside the norms, in consultation with the agency,
   94  to improve patient care and reduce inappropriate utilization.
   95  The agency may mandate prior authorization, drug therapy
   96  management, or disease management participation for certain
   97  populations of Medicaid beneficiaries, certain drug classes, or
   98  particular drugs to prevent fraud, abuse, overuse, and possible
   99  dangerous drug interactions. The Pharmaceutical and Therapeutics
  100  Committee shall make recommendations to the agency on drugs for
  101  which prior authorization is required. The agency shall inform
  102  the Pharmaceutical and Therapeutics Committee of its decisions
  103  regarding drugs subject to prior authorization. The agency is
  104  authorized to limit the entities it contracts with or enrolls as
  105  Medicaid providers by developing a provider network through
  106  provider credentialing. The agency may competitively bid single
  107  source-provider contracts if procurement of goods or services
  108  results in demonstrated cost savings to the state without
  109  limiting access to care. The agency may limit its network based
  110  on the assessment of beneficiary access to care, provider
  111  availability, provider quality standards, time and distance
  112  standards for access to care, the cultural competence of the
  113  provider network, demographic characteristics of Medicaid
  114  beneficiaries, practice and provider-to-beneficiary standards,
  115  appointment wait times, beneficiary use of services, provider
  116  turnover, provider profiling, provider licensure history,
  117  previous program integrity investigations and findings, peer
  118  review, provider Medicaid policy and billing compliance records,
  119  clinical and medical record audits, and other factors. Providers
  120  shall not be entitled to enrollment in the Medicaid provider
  121  network. The agency shall determine instances in which allowing
  122  Medicaid beneficiaries to purchase durable medical equipment and
  123  other goods is less expensive to the Medicaid program than long
  124  term rental of the equipment or goods. The agency may establish
  125  rules to facilitate purchases in lieu of long-term rentals in
  126  order to protect against fraud and abuse in the Medicaid program
  127  as defined in s. 409.913. The agency may seek federal waivers
  128  necessary to administer these policies.
  129         (4) The agency may contract with:
  130         (b) An entity that is providing comprehensive behavioral
  131  health care services to certain Medicaid recipients through a
  132  capitated, prepaid arrangement pursuant to the federal waiver
  133  provided for by s. 409.905(5). Such entity must be licensed
  134  under chapter 624, chapter 636, or chapter 641, or authorized
  135  under paragraph (c) or paragraph (d), and must possess the
  136  clinical systems and operational competence to manage risk and
  137  provide comprehensive behavioral health care to Medicaid
  138  recipients. As used in this paragraph, the term “comprehensive
  139  behavioral health care services” means covered mental health and
  140  substance abuse treatment services that are available to
  141  Medicaid recipients. The secretary of the Department of Children
  142  and Family Services shall approve provisions of procurements
  143  related to children in the department’s care or custody before
  144  enrolling such children in a prepaid behavioral health plan. Any
  145  contract awarded under this paragraph must be competitively
  146  procured. In developing the behavioral health care prepaid plan
  147  procurement document, the agency shall ensure that the
  148  procurement document requires the contractor to develop and
  149  implement a plan to ensure compliance with s. 394.4574 related
  150  to services provided to residents of licensed assisted living
  151  facilities that hold a limited mental health license. Except as
  152  provided in subparagraph 8., and except in counties where the
  153  Medicaid managed care pilot program is authorized pursuant to s.
  154  409.91211, the agency shall seek federal approval to contract
  155  with a single entity meeting these requirements to provide
  156  comprehensive behavioral health care services to all Medicaid
  157  recipients not enrolled in a Medicaid managed care plan
  158  authorized under s. 409.91211, a provider service network
  159  authorized under paragraph (d), or a Medicaid health maintenance
  160  organization in an AHCA area. In an AHCA area where the Medicaid
  161  managed care pilot program is authorized pursuant to s.
  162  409.91211 in one or more counties, the agency may procure a
  163  contract with a single entity to serve the remaining counties as
  164  an AHCA area or the remaining counties may be included with an
  165  adjacent AHCA area and are subject to this paragraph. Each
  166  entity must offer a sufficient choice of providers in its
  167  network to ensure recipient access to care and the opportunity
  168  to select a provider with whom they are satisfied. The network
  169  shall include all public mental health hospitals. To ensure
  170  unimpaired access to behavioral health care services by Medicaid
  171  recipients, all contracts issued pursuant to this paragraph must
  172  require 80 percent of the capitation paid to the managed care
  173  plan, including health maintenance organizations and capitated
  174  provider service networks, to be expended for the provision of
  175  behavioral health care services. If the managed care plan
  176  expends less than 80 percent of the capitation paid for the
  177  provision of behavioral health care services, the difference
  178  shall be returned to the agency. The agency shall provide the
  179  plan with a certification letter indicating the amount of
  180  capitation paid during each calendar year for behavioral health
  181  care services pursuant to this section. The agency may reimburse
  182  for substance abuse treatment services on a fee-for-service
  183  basis until the agency finds that adequate funds are available
  184  for capitated, prepaid arrangements.
  185         1. By January 1, 2001, the agency shall modify the
  186  contracts with the entities providing comprehensive inpatient
  187  and outpatient mental health care services to Medicaid
  188  recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
  189  Counties, to include substance abuse treatment services.
  190         2. By July 1, 2003, the agency and the Department of
  191  Children and Family Services shall execute a written agreement
  192  that requires collaboration and joint development of all policy,
  193  budgets, procurement documents, contracts, and monitoring plans
  194  that have an impact on the state and Medicaid community mental
  195  health and targeted case management programs.
  196         3. Except as provided in subparagraph 8., by July 1, 2006,
  197  the agency and the Department of Children and Family Services
  198  shall contract with managed care entities in each AHCA area
  199  except area 6 or arrange to provide comprehensive inpatient and
  200  outpatient mental health and substance abuse services through
  201  capitated prepaid arrangements to all Medicaid recipients who
  202  are eligible to participate in such plans under federal law and
  203  regulation. In AHCA areas where eligible individuals number less
  204  than 150,000, the agency shall contract with a single managed
  205  care plan to provide comprehensive behavioral health services to
  206  all recipients who are not enrolled in a Medicaid health
  207  maintenance organization, a provider service network authorized
  208  under paragraph (d), or a Medicaid capitated managed care plan
  209  authorized under s. 409.91211. The agency may contract with more
  210  than one comprehensive behavioral health provider to provide
  211  care to recipients who are not enrolled in a Medicaid capitated
  212  managed care plan authorized under s. 409.91211, a provider
  213  service network authorized under paragraph (d), or a Medicaid
  214  health maintenance organization in AHCA areas where the eligible
  215  population exceeds 150,000. In an AHCA area where the Medicaid
  216  managed care pilot program is authorized pursuant to s.
  217  409.91211 in one or more counties, the agency may procure a
  218  contract with a single entity to serve the remaining counties as
  219  an AHCA area or the remaining counties may be included with an
  220  adjacent AHCA area and shall be subject to this paragraph.
  221  Contracts for comprehensive behavioral health providers awarded
  222  pursuant to this section shall be competitively procured. Both
  223  for-profit and not-for-profit corporations are eligible to
  224  compete. Managed care plans contracting with the agency under
  225  subsection (3) or paragraph (d), shall provide and receive
  226  payment for the same comprehensive behavioral health benefits as
  227  provided in AHCA rules, including handbooks incorporated by
  228  reference. In AHCA area 11, the agency shall contract with at
  229  least two comprehensive behavioral health care providers to
  230  provide behavioral health care to recipients in that area who
  231  are enrolled in, or assigned to, the MediPass program. One of
  232  the behavioral health care contracts must be with the existing
  233  provider service network pilot project, as described in
  234  paragraph (d), for the purpose of demonstrating the cost
  235  effectiveness of the provision of quality mental health services
  236  through a public hospital-operated managed care model. Payment
  237  shall be at an agreed-upon capitated rate to ensure cost
  238  savings. Of the recipients in area 11 who are assigned to
  239  MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
  240  MediPass-enrolled recipients shall be assigned to the existing
  241  provider service network in area 11 for their behavioral care.
  242         4. By October 1, 2003, the agency and the department shall
  243  submit a plan to the Governor, the President of the Senate, and
  244  the Speaker of the House of Representatives which provides for
  245  the full implementation of capitated prepaid behavioral health
  246  care in all areas of the state.
  247         a. Implementation shall begin in 2003 in those AHCA areas
  248  of the state where the agency is able to establish sufficient
  249  capitation rates.
  250         b. If the agency determines that the proposed capitation
  251  rate in any area is insufficient to provide appropriate
  252  services, the agency may adjust the capitation rate to ensure
  253  that care will be available. The agency and the department may
  254  use existing general revenue to address any additional required
  255  match but may not over-obligate existing funds on an annualized
  256  basis.
  257         c. Subject to any limitations provided in the General
  258  Appropriations Act, the agency, in compliance with appropriate
  259  federal authorization, shall develop policies and procedures
  260  that allow for certification of local and state funds.
  261         5. Children residing in a statewide inpatient psychiatric
  262  program, or in a Department of Juvenile Justice or a Department
  263  of Children and Family Services residential program approved as
  264  a Medicaid behavioral health overlay services provider may not
  265  be included in a behavioral health care prepaid health plan or
  266  any other Medicaid managed care plan pursuant to this paragraph.
  267         6. In converting to a prepaid system of delivery, the
  268  agency shall in its procurement document require an entity
  269  providing only comprehensive behavioral health care services to
  270  prevent the displacement of indigent care patients by enrollees
  271  in the Medicaid prepaid health plan providing behavioral health
  272  care services from facilities receiving state funding to provide
  273  indigent behavioral health care, to facilities licensed under
  274  chapter 395 which do not receive state funding for indigent
  275  behavioral health care, or reimburse the unsubsidized facility
  276  for the cost of behavioral health care provided to the displaced
  277  indigent care patient.
  278         7. Traditional community mental health providers under
  279  contract with the Department of Children and Family Services
  280  pursuant to part IV of chapter 394, child welfare providers
  281  under contract with the Department of Children and Family
  282  Services in areas 1 and 6, and inpatient mental health providers
  283  licensed pursuant to chapter 395 must be offered an opportunity
  284  to accept or decline a contract to participate in any provider
  285  network for prepaid behavioral health services.
  286         8. All Medicaid-eligible children, except children in area
  287  1 and children in Highlands County, Hardee County, Polk County,
  288  or Manatee County of area 6, that are open for child welfare
  289  services in the HomeSafeNet system, shall receive their
  290  behavioral health care services through a specialty prepaid plan
  291  operated by community-based lead agencies through a single
  292  agency or formal agreements among several agencies. The
  293  specialty prepaid plan must result in savings to the state
  294  comparable to savings achieved in other Medicaid managed care
  295  and prepaid programs. Such plan must provide mechanisms to
  296  maximize state and local revenues. The specialty prepaid plan
  297  shall be developed by the agency and the Department of Children
  298  and Family Services. The agency may seek federal waivers to
  299  implement this initiative. Medicaid-eligible children whose
  300  cases are open for child welfare services in the HomeSafeNet
  301  system and who reside in AHCA area 10 are exempt from the
  302  specialty prepaid plan upon the development of a service
  303  delivery mechanism for children who reside in area 10 as
  304  specified in s. 409.91211(3)(dd).
  305         (d) A provider service network may be reimbursed on a fee
  306  for-service or prepaid basis. A provider service network which
  307  is reimbursed by the agency on a prepaid basis shall be exempt
  308  from parts I and III of chapter 641, but must comply with the
  309  solvency requirements in s. 641.2261(2) and meet appropriate
  310  financial reserve, quality assurance, and patient rights
  311  requirements as established by the agency. Medicaid recipients
  312  assigned to a provider service network shall be chosen equally
  313  from those who would otherwise have been assigned to prepaid
  314  plans and MediPass. The agency is authorized to seek federal
  315  Medicaid waivers as necessary to implement the provisions of
  316  this section. Any contract previously awarded to a provider
  317  service network operated by a hospital pursuant to this
  318  subsection shall remain in effect for a period of 3 years
  319  following the current contract expiration date, regardless of
  320  any contractual provisions to the contrary. A provider service
  321  network is a network established or organized and operated by a
  322  health care provider, or group of affiliated health care
  323  providers, including minority physician networks and emergency
  324  room diversion programs that meet the requirements of s.
  325  409.91211, which provides a substantial proportion of the health
  326  care items and services under a contract directly through the
  327  provider or affiliated group of providers and may make
  328  arrangements with physicians or other health care professionals,
  329  health care institutions, or any combination of such individuals
  330  or institutions to assume all or part of the financial risk on a
  331  prospective basis for the provision of basic health services by
  332  the physicians, by other health professionals, or through the
  333  institutions. The health care providers must have a controlling
  334  interest in the governing body of the provider service network
  335  organization.
  336         (21) Any entity contracting with the agency pursuant to
  337  this section to provide health care services to Medicaid
  338  recipients is prohibited from engaging in any of the following
  339  practices or activities:
  340         (a) Practices that are discriminatory, including, but not
  341  limited to, attempts to discourage participation on the basis of
  342  actual or perceived health status.
  343         (b) Activities that could mislead or confuse recipients, or
  344  misrepresent the organization, its marketing representatives, or
  345  the agency. Violations of this paragraph include, but are not
  346  limited to:
  347         1. False or misleading claims that marketing
  348  representatives are employees or representatives of the state or
  349  county, or of anyone other than the entity or the organization
  350  by whom they are reimbursed.
  351         2. False or misleading claims that the entity is
  352  recommended or endorsed by any state or county agency, or by any
  353  other organization which has not certified its endorsement in
  354  writing to the entity.
  355         3. False or misleading claims that the state or county
  356  recommends that a Medicaid recipient enroll with an entity.
  357         4. Claims that a Medicaid recipient will lose benefits
  358  under the Medicaid program, or any other health or welfare
  359  benefits to which the recipient is legally entitled, if the
  360  recipient does not enroll with the entity.
  361         (c) Granting or offering of any monetary or other valuable
  362  consideration for enrollment, except as authorized by subsection
  363  (25) (24).
  364         (d) Door-to-door solicitation of recipients who have not
  365  contacted the entity or who have not invited the entity to make
  366  a presentation.
  367         (e) Solicitation of Medicaid recipients by marketing
  368  representatives stationed in state offices unless approved and
  369  supervised by the agency or its agent and approved by the
  370  affected state agency when solicitation occurs in an office of
  371  the state agency. The agency shall ensure that marketing
  372  representatives stationed in state offices shall market their
  373  managed care plans to Medicaid recipients only in designated
  374  areas and in such a way as to not interfere with the recipients’
  375  activities in the state office.
  376         (f) Enrollment of Medicaid recipients.
  377         (22) The agency shall may impose a fine for a violation of
  378  this section or the contract with the agency by a person or
  379  entity that is under contract with the agency. With respect to
  380  any nonwillful violation, such fine shall not exceed $2,500 per
  381  violation. In no event shall such fine exceed an aggregate
  382  amount of $10,000 for all nonwillful violations arising out of
  383  the same action. With respect to any knowing and willful
  384  violation of this section or the contract with the agency, the
  385  agency may impose a fine upon the entity in an amount not to
  386  exceed $20,000 for each such violation. In no event shall such
  387  fine exceed an aggregate amount of $100,000 for all knowing and
  388  willful violations arising out of the same action.
  389         (23)Any entity that contracts with the agency on a prepaid
  390  or fixed-sum basis as a managed care plan as defined in s.
  391  409.9122(2)(f) or s. 409.91211 shall post a surety bond with the
  392  agency in an amount that is equivalent to a 1-year guaranteed
  393  savings amount as specified in the contract. In lieu of a surety
  394  bond, the agency may establish an irrevocable account in which
  395  the vendor funds an equivalent amount over a 6-month period. The
  396  purpose of the surety bond or account is to protect the agency
  397  if the entity terminates its contract with the agency before the
  398  scheduled end date for the contract. If the contract is
  399  terminated by the vendor for any reason, the agency shall pursue
  400  a claim against the surety bond or account for an early
  401  termination fee. The early termination fee must be equal to
  402  administrative costs incurred by the state due to the early
  403  termination and the differential of the guaranteed savings based
  404  on the original contract term and the corresponding termination
  405  date. The agency shall terminate a vendor who does not reimburse
  406  the state within 30 days after any early termination involving
  407  administrative costs and requiring reimbursement of lost savings
  408  from the Medicaid program.
  409         Section 2. Subsections (1) through (6) of section
  410  409.91211, Florida Statutes, are amended to read:
  411         409.91211 Medicaid managed care pilot program.—
  412         (1)(a) The agency is authorized to seek and implement
  413  experimental, pilot, or demonstration project waivers, pursuant
  414  to s. 1115 of the Social Security Act, to create a statewide
  415  initiative to provide for a more efficient and effective service
  416  delivery system that enhances quality of care and client
  417  outcomes in the Florida Medicaid program pursuant to this
  418  section. Phase one of the demonstration shall be implemented in
  419  two geographic areas. One demonstration site shall include only
  420  Broward County. A second demonstration site shall initially
  421  include Duval County and shall be expanded to include Baker,
  422  Clay, and Nassau Counties within 1 year after the Duval County
  423  program becomes operational. The agency shall implement
  424  expansion of the program to include the remaining counties of
  425  the state and remaining eligibility groups in accordance with
  426  the process specified in the federally approved special terms
  427  and conditions numbered 11-W-00206/4, as approved by the federal
  428  Centers for Medicare and Medicaid Services on October 19, 2005,
  429  with a goal of full statewide implementation by June 30, 2014
  430  2011.
  431         (b) This waiver extension shall authority is contingent
  432  upon federal approval to preserve the low-income pool upper
  433  payment-limit funding mechanism for providers and hospitals,
  434  including a guarantee of a reasonable growth factor, a
  435  methodology to allow the use of a portion of these funds to
  436  serve as a risk pool for demonstration sites, provisions to
  437  preserve the state’s ability to use intergovernmental transfers,
  438  and provisions to protect the disproportionate share program
  439  authorized pursuant to this chapter. Upon completion of the
  440  evaluation conducted under s. 3, ch. 2005-133, Laws of Florida,
  441  The agency shall expand may request statewide expansion of the
  442  demonstration to counties that have two or more plans and that
  443  have capacity to serve the designated population projects. The
  444  agency may expand to additional counties as plan capacity is
  445  developed. Statewide phase-in to additional counties shall be
  446  contingent upon review and approval by the Legislature. Under
  447  the upper-payment-limit program, or the low-income pool as
  448  implemented by the Agency for Health Care Administration
  449  pursuant to federal waiver, the state matching funds required
  450  for the program shall be provided by local governmental entities
  451  through intergovernmental transfers in accordance with published
  452  federal statutes and regulations. The Agency for Health Care
  453  Administration shall distribute upper-payment-limit,
  454  disproportionate share hospital, and low-income pool funds
  455  according to published federal statutes, regulations, and
  456  waivers and the low-income pool methodology approved by the
  457  federal Centers for Medicare and Medicaid Services.
  458         (c) It is the intent of the Legislature that the low-income
  459  pool plan required by the terms and conditions of the Medicaid
  460  reform waiver and submitted to the federal Centers for Medicare
  461  and Medicaid Services propose the distribution of the above
  462  mentioned program funds based on the following objectives:
  463         1. Assure a broad and fair distribution of available funds
  464  based on the access provided by Medicaid participating
  465  hospitals, regardless of their ownership status, through their
  466  delivery of inpatient or outpatient care for Medicaid
  467  beneficiaries and uninsured and underinsured individuals;
  468         2. Assure accessible emergency inpatient and outpatient
  469  care for Medicaid beneficiaries and uninsured and underinsured
  470  individuals;
  471         3. Enhance primary, preventive, and other ambulatory care
  472  coverages for uninsured individuals;
  473         4. Promote teaching and specialty hospital programs;
  474         5. Promote the stability and viability of statutorily
  475  defined rural hospitals and hospitals that serve as sole
  476  community hospitals;
  477         6. Recognize the extent of hospital uncompensated care
  478  costs;
  479         7. Maintain and enhance essential community hospital care;
  480         8. Maintain incentives for local governmental entities to
  481  contribute to the cost of uncompensated care;
  482         9. Promote measures to avoid preventable hospitalizations;
  483         10. Account for hospital efficiency; and
  484         11. Contribute to a community’s overall health system.
  485         (2) The Legislature intends for the capitated managed care
  486  pilot program to:
  487         (a) Provide recipients in Medicaid fee-for-service or the
  488  MediPass program a comprehensive and coordinated capitated
  489  managed care system for all health care services specified in
  490  ss. 409.905 and 409.906.
  491         (b) Stabilize Medicaid expenditures under the pilot program
  492  compared to Medicaid expenditures in the pilot area for the 3
  493  years before implementation of the pilot program, while
  494  ensuring:
  495         1. Consumer education and choice.
  496         2. Access to medically necessary services.
  497         3. Coordination of preventative, acute, and long-term care.
  498         4. Reductions in unnecessary service utilization.
  499         (c) Provide an opportunity to evaluate the feasibility of
  500  statewide implementation of capitated managed care networks as a
  501  replacement for the current Medicaid fee-for-service and
  502  MediPass systems.
  503         (3) The agency shall have the following powers, duties, and
  504  responsibilities with respect to the pilot program:
  505         (a) To implement a system to deliver all mandatory services
  506  specified in s. 409.905 and optional services specified in s.
  507  409.906, as approved by the Centers for Medicare and Medicaid
  508  Services and the Legislature in the waiver pursuant to this
  509  section. Services to recipients under plan benefits shall
  510  include emergency services provided under s. 409.9128.
  511         (b) To implement a pilot program, including Medicaid
  512  eligibility categories specified in ss. 409.903 and 409.904, as
  513  authorized in an approved federal waiver.
  514         (c) To implement the managed care pilot program that
  515  maximizes all available state and federal funds, including those
  516  obtained through intergovernmental transfers, the low-income
  517  pool, supplemental Medicaid payments, and the disproportionate
  518  share program. Within the parameters allowed by federal statute
  519  and rule, the agency may seek options for making direct payments
  520  to hospitals and physicians employed by or under contract with
  521  the state’s medical schools for the costs associated with
  522  graduate medical education under Medicaid reform.
  523         (d) To implement actuarially sound, risk-adjusted
  524  capitation rates for Medicaid recipients in the pilot program
  525  which cover comprehensive care, enhanced services, and
  526  catastrophic care.
  527         (e) To implement policies and guidelines for phasing in
  528  financial risk for approved provider service networks that, for
  529  purposes of this paragraph, include the Children’s Medical
  530  Services Network, over a 5-year period. These policies and
  531  guidelines must include an option for a provider service network
  532  to be paid fee-for-service rates. For any provider service
  533  network established in a managed care pilot area, the option to
  534  be paid fee-for-service rates must include a savings-settlement
  535  mechanism that is consistent with s. 409.912(44). This model
  536  must be converted to a risk-adjusted capitated rate by the
  537  beginning of the sixth year of operation, and may be converted
  538  earlier at the option of the provider service network. Federally
  539  qualified health centers may be offered an opportunity to accept
  540  or decline a contract to participate in any provider network for
  541  prepaid primary care services.
  542         (f) To implement stop-loss requirements and the transfer of
  543  excess cost to catastrophic coverage that accommodates the risks
  544  associated with the development of the pilot program.
  545         (g) To recommend a process to be used by the Social
  546  Services Estimating Conference to determine and validate the
  547  rate of growth of the per-member costs of providing Medicaid
  548  services under the managed care pilot program.
  549         (h) To implement program standards and credentialing
  550  requirements for capitated managed care networks to participate
  551  in the pilot program, including those related to fiscal
  552  solvency, quality of care, and adequacy of access to health care
  553  providers. It is the intent of the Legislature that, to the
  554  extent possible, any pilot program authorized by the state under
  555  this section include any federally qualified health center,
  556  federally qualified rural health clinic, county health
  557  department, the Children’s Medical Services Network within the
  558  Department of Health, or other federally, state, or locally
  559  funded entity that serves the geographic areas within the
  560  boundaries of the pilot program that requests to participate.
  561  This paragraph does not relieve an entity that qualifies as a
  562  capitated managed care network under this section from any other
  563  licensure or regulatory requirements contained in state or
  564  federal law which would otherwise apply to the entity. The
  565  standards and credentialing requirements shall be based upon,
  566  but are not limited to:
  567         1. Compliance with the accreditation requirements as
  568  provided in s. 641.512.
  569         2. Compliance with early and periodic screening, diagnosis,
  570  and treatment screening requirements under federal law.
  571         3. The percentage of voluntary disenrollments.
  572         4. Immunization rates.
  573         5. Standards of the National Committee for Quality
  574  Assurance and other approved accrediting bodies.
  575         6. Recommendations of other authoritative bodies.
  576         7. Specific requirements of the Medicaid program, or
  577  standards designed to specifically meet the unique needs of
  578  Medicaid recipients.
  579         8. Compliance with the health quality improvement system as
  580  established by the agency, which incorporates standards and
  581  guidelines developed by the Centers for Medicare and Medicaid
  582  Services as part of the quality assurance reform initiative.
  583         9. The network’s infrastructure capacity to manage
  584  financial transactions, recordkeeping, data collection, and
  585  other administrative functions.
  586         10. The network’s ability to submit any financial,
  587  programmatic, or patient-encounter data or other information
  588  required by the agency to determine the actual services provided
  589  and the cost of administering the plan.
  590         (i) To implement a mechanism for providing information to
  591  Medicaid recipients for the purpose of selecting a capitated
  592  managed care plan. For each plan available to a recipient, the
  593  agency, at a minimum, shall ensure that the recipient is
  594  provided with:
  595         1. A list and description of the benefits provided.
  596         2. Information about cost sharing.
  597         3. A list of providers participating in the plan networks.
  598         4.3. Plan performance data, if available.
  599         4.An explanation of benefit limitations.
  600         5.Contact information, including identification of
  601  providers participating in the network, geographic locations,
  602  and transportation limitations.
  603         6.Any other information the agency determines would
  604  facilitate a recipient’s understanding of the plan or insurance
  605  that would best meet his or her needs.
  606         (j) To implement a system to ensure that there is a record
  607  of recipient acknowledgment that plan choice counseling has been
  608  provided.
  609         (k) To implement a choice counseling system to ensure that
  610  the choice counseling process and related material are designed
  611  to provide counseling through face-to-face interaction, by
  612  telephone or, and in writing and through other forms of relevant
  613  media. Materials shall be written at the fourth-grade reading
  614  level and available in a language other than English when 5
  615  percent of the county speaks a language other than English.
  616  Choice counseling shall also use language lines and other
  617  services for impaired recipients, such as TTD/TTY.
  618         (l) To implement a system that prohibits capitated managed
  619  care plans, their representatives, and providers employed by or
  620  contracted with the capitated managed care plans from recruiting
  621  persons eligible for or enrolled in Medicaid, from providing
  622  inducements to Medicaid recipients to select a particular
  623  capitated managed care plan, and from prejudicing Medicaid
  624  recipients against other capitated managed care plans. The
  625  system shall require the entity performing choice counseling to
  626  determine if the recipient has made a choice of a plan or has
  627  opted out because of duress, threats, payment to the recipient,
  628  or incentives promised to the recipient by a third party. If the
  629  choice counseling entity determines that the decision to choose
  630  a plan was unlawfully influenced or a plan violated any of the
  631  provisions of s. 409.912(21), the choice counseling entity shall
  632  immediately report the violation to the agency’s program
  633  integrity section for investigation. Verification of choice
  634  counseling by the recipient shall include a stipulation that the
  635  recipient acknowledges the provisions of this subsection.
  636         (m) To implement a choice counseling system that promotes
  637  health literacy, uses technology effectively, and provides
  638  information intended aimed to reduce minority health disparities
  639  through outreach activities for Medicaid recipients.
  640         (n) To contract with entities to perform choice counseling.
  641  The agency may establish standards and performance contracts,
  642  including standards requiring the contractor to hire choice
  643  counselors who are representative of the state’s diverse
  644  population and to train choice counselors in working with
  645  culturally diverse populations.
  646         (o) To implement eligibility assignment processes to
  647  facilitate client choice while ensuring pilot programs of
  648  adequate enrollment levels. These processes shall ensure that
  649  pilot sites have sufficient levels of enrollment to conduct a
  650  valid test of the managed care pilot program within a 2-year
  651  timeframe.
  652         (p) To implement standards for plan compliance, including,
  653  but not limited to, standards for quality assurance and
  654  performance improvement, standards for peer or professional
  655  reviews, grievance policies, and policies for maintaining
  656  program integrity. The agency shall develop a data-reporting
  657  system, seek input from managed care plans in order to establish
  658  requirements for patient-encounter reporting, and ensure that
  659  the data reported is accurate and complete.
  660         1. In performing the duties required under this section,
  661  the agency shall work with managed care plans to establish a
  662  uniform system to measure and monitor outcomes for a recipient
  663  of Medicaid services.
  664         2. The system shall use financial, clinical, and other
  665  criteria based on pharmacy, medical services, and other data
  666  that is related to the provision of Medicaid services,
  667  including, but not limited to:
  668         a. The Health Plan Employer Data and Information Set
  669  (HEDIS) or measures that are similar to HEDIS.
  670         b. Member satisfaction.
  671         c. Provider satisfaction.
  672         d. Report cards on plan performance and best practices.
  673         e. Compliance with the requirements for prompt payment of
  674  claims under ss. 627.613, 641.3155, and 641.513.
  675         f. Utilization and quality data for the purpose of ensuring
  676  access to medically necessary services, including
  677  underutilization or inappropriate denial of services.
  678         3. The agency shall require the managed care plans that
  679  have contracted with the agency to establish a quality assurance
  680  system that incorporates the provisions of s. 409.912(27) and
  681  any standards, rules, and guidelines developed by the agency.
  682         4. The agency shall establish an encounter database in
  683  order to compile data on health services rendered by health care
  684  practitioners who provide services to patients enrolled in
  685  managed care plans in the demonstration sites. The encounter
  686  database shall:
  687         a. Collect the following for each type of patient encounter
  688  with a health care practitioner or facility, including:
  689         (I) The demographic characteristics of the patient.
  690         (II) The principal, secondary, and tertiary diagnosis.
  691         (III) The procedure performed.
  692         (IV) The date and location where the procedure was
  693  performed.
  694         (V) The payment for the procedure, if any.
  695         (VI) If applicable, the health care practitioner’s
  696  universal identification number.
  697         (VII) If the health care practitioner rendering the service
  698  is a dependent practitioner, the modifiers appropriate to
  699  indicate that the service was delivered by the dependent
  700  practitioner.
  701         b. Collect appropriate information relating to prescription
  702  drugs for each type of patient encounter.
  703         c. Collect appropriate information related to health care
  704  costs and utilization from managed care plans participating in
  705  the demonstration sites.
  706         5. To the extent practicable, when collecting the data the
  707  agency shall use a standardized claim form or electronic
  708  transfer system that is used by health care practitioners,
  709  facilities, and payors.
  710         6. Health care practitioners and facilities in the
  711  demonstration sites shall electronically submit, and managed
  712  care plans participating in the demonstration sites shall
  713  electronically receive, information concerning claims payments
  714  and any other information reasonably related to the encounter
  715  database using a standard format as required by the agency.
  716         7. The agency shall establish reasonable deadlines for
  717  phasing in the electronic transmittal of full encounter data.
  718         8. The system must ensure that the data reported is
  719  accurate and complete.
  720         (q) To implement a grievance resolution process for
  721  Medicaid recipients enrolled in a capitated managed care network
  722  under the pilot program modeled after the subscriber assistance
  723  panel, as created in s. 408.7056. This process shall include a
  724  mechanism for an expedited review of no greater than 24 hours
  725  after notification of a grievance if the life of a Medicaid
  726  recipient is in imminent and emergent jeopardy.
  727         (r) To implement a grievance resolution process for health
  728  care providers employed by or contracted with a capitated
  729  managed care network under the pilot program in order to settle
  730  disputes among the provider and the managed care network or the
  731  provider and the agency.
  732         (s) To implement criteria in an approved federal waiver to
  733  designate health care providers as eligible to participate in
  734  the pilot program. These criteria must include at a minimum
  735  those criteria specified in s. 409.907.
  736         (t) To use health care provider agreements for
  737  participation in the pilot program.
  738         (u) To require that all health care providers under
  739  contract with the pilot program be duly licensed in the state,
  740  if such licensure is available, and meet other criteria as may
  741  be established by the agency. These criteria shall include at a
  742  minimum those criteria specified in s. 409.907.
  743         (v) To ensure that managed care organizations work
  744  collaboratively with other state or local governmental programs
  745  or institutions for the coordination of health care to eligible
  746  individuals receiving services from such programs or
  747  institutions.
  748         (w) To implement procedures to minimize the risk of
  749  Medicaid fraud and abuse in all plans operating in the Medicaid
  750  managed care pilot program authorized in this section.
  751         1. The agency shall ensure that applicable provisions of
  752  this chapter and chapters 414, 626, 641, and 932 which relate to
  753  Medicaid fraud and abuse are applied and enforced at the
  754  demonstration project sites.
  755         2. Providers must have the certification, license, and
  756  credentials that are required by law and waiver requirements.
  757         3. The agency shall ensure that the plan is in compliance
  758  with s. 409.912(21) and (22).
  759         4. The agency shall require that each plan establish
  760  functions and activities governing program integrity in order to
  761  reduce the incidence of fraud and abuse. Plans must report
  762  instances of fraud and abuse pursuant to chapter 641.
  763         5. The plan shall have written administrative and
  764  management arrangements or procedures, including a mandatory
  765  compliance plan, which are designed to guard against fraud and
  766  abuse. The plan shall designate a compliance officer who has
  767  sufficient experience in health care.
  768         6.a. The agency shall require all managed care plan
  769  contractors in the pilot program to report all instances of
  770  suspected fraud and abuse. A failure to report instances of
  771  suspected fraud and abuse is a violation of law and subject to
  772  the penalties provided by law.
  773         b. An instance of fraud and abuse in the managed care plan,
  774  including, but not limited to, defrauding the state health care
  775  benefit program by misrepresentation of fact in reports, claims,
  776  certifications, enrollment claims, demographic statistics, or
  777  patient-encounter data; misrepresentation of the qualifications
  778  of persons rendering health care and ancillary services; bribery
  779  and false statements relating to the delivery of health care;
  780  unfair and deceptive marketing practices; and false claims
  781  actions in the provision of managed care, is a violation of law
  782  and subject to the penalties provided by law.
  783         c. The agency shall require that all contractors make all
  784  files and relevant billing and claims data accessible to state
  785  regulators and investigators and that all such data is linked
  786  into a unified system to ensure consistent reviews and
  787  investigations.
  788         (x) To develop and provide actuarial and benefit design
  789  analyses that indicate the effect on capitation rates and
  790  benefits offered in the pilot program over a prospective 5-year
  791  period based on the following assumptions:
  792         1. Growth in capitation rates which is limited to the
  793  estimated growth rate in general revenue.
  794         2. Growth in capitation rates which is limited to the
  795  average growth rate over the last 3 years in per-recipient
  796  Medicaid expenditures.
  797         3. Growth in capitation rates which is limited to the
  798  growth rate of aggregate Medicaid expenditures between the 2003
  799  2004 fiscal year and the 2004-2005 fiscal year.
  800         (y) To develop a mechanism to require capitated managed
  801  care plans to reimburse qualified emergency service providers,
  802  including, but not limited to, ambulance services, in accordance
  803  with ss. 409.908 and 409.9128. The pilot program must include a
  804  provision for continuing fee-for-service payments for emergency
  805  services, including, but not limited to, individuals who access
  806  ambulance services or emergency departments and who are
  807  subsequently determined to be eligible for Medicaid services.
  808         (z) To ensure that school districts participating in the
  809  certified school match program pursuant to ss. 409.908(21) and
  810  1011.70 shall be reimbursed by Medicaid, subject to the
  811  limitations of s. 1011.70(1), for a Medicaid-eligible child
  812  participating in the services as authorized in s. 1011.70, as
  813  provided for in s. 409.9071, regardless of whether the child is
  814  enrolled in a capitated managed care network. Capitated managed
  815  care networks must make a good faith effort to execute
  816  agreements with school districts regarding the coordinated
  817  provision of services authorized under s. 1011.70. County health
  818  departments and federally qualified health centers delivering
  819  school-based services pursuant to ss. 381.0056 and 381.0057 must
  820  be reimbursed by Medicaid for the federal share for a Medicaid
  821  eligible child who receives Medicaid-covered services in a
  822  school setting, regardless of whether the child is enrolled in a
  823  capitated managed care network. Capitated managed care networks
  824  must make a good faith effort to execute agreements with county
  825  health departments and federally qualified health centers
  826  regarding the coordinated provision of services to a Medicaid
  827  eligible child. To ensure continuity of care for Medicaid
  828  patients, the agency, the Department of Health, and the
  829  Department of Education shall develop procedures for ensuring
  830  that a student’s capitated managed care network provider
  831  receives information relating to services provided in accordance
  832  with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
  833         (aa) To implement a mechanism whereby Medicaid recipients
  834  who are already enrolled in a managed care plan or the MediPass
  835  program in the pilot areas shall be offered the opportunity to
  836  change to capitated managed care plans on a staggered basis, as
  837  defined by the agency. All Medicaid recipients shall have 30
  838  days in which to make a choice of capitated managed care plans.
  839  Those Medicaid recipients who do not make a choice shall be
  840  assigned to a capitated managed care plan in accordance with
  841  paragraph (4)(a) and shall be exempt from s. 409.9122. To
  842  facilitate continuity of care for a Medicaid recipient who is
  843  also a recipient of Supplemental Security Income (SSI), prior to
  844  assigning the SSI recipient to a capitated managed care plan,
  845  the agency shall determine whether the SSI recipient has an
  846  ongoing relationship with a provider or capitated managed care
  847  plan, and, if so, the agency shall assign the SSI recipient to
  848  that provider or capitated managed care plan where feasible.
  849  Those SSI recipients who do not have such a provider
  850  relationship shall be assigned to a capitated managed care plan
  851  provider in accordance with paragraph (4)(a) and shall be exempt
  852  from s. 409.9122.
  853         (bb) To develop and recommend a service delivery
  854  alternative for children having chronic medical conditions which
  855  establishes a medical home project to provide primary care
  856  services to this population. The project shall provide
  857  community-based primary care services that are integrated with
  858  other subspecialties to meet the medical, developmental, and
  859  emotional needs for children and their families. This project
  860  shall include an evaluation component to determine impacts on
  861  hospitalizations, length of stays, emergency room visits, costs,
  862  and access to care, including specialty care and patient and
  863  family satisfaction.
  864         (cc) To develop and recommend service delivery mechanisms
  865  within capitated managed care plans to provide Medicaid services
  866  as specified in ss. 409.905 and 409.906 to persons with
  867  developmental disabilities sufficient to meet the medical,
  868  developmental, and emotional needs of these persons.
  869         (dd) To implement service delivery mechanisms within a
  870  specialty plan in area 10 capitated managed care plans to
  871  provide behavioral health care services Medicaid services as
  872  specified in ss. 409.905 and 409.906 to Medicaid-eligible
  873  children whose cases are open for child welfare services in the
  874  HomeSafeNet system. These services must be coordinated with
  875  community-based care providers as specified in s. 409.1671,
  876  where available, and be sufficient to meet the medical,
  877  developmental, behavioral, and emotional needs of these
  878  children. Children in area 10 who have an open case in the
  879  HomeSafeNet system shall be enrolled into the specialty plan.
  880  These service delivery mechanisms must be implemented no later
  881  than July 1, 2011 2008, in AHCA area 10 in order for the
  882  children in AHCA area 10 to remain exempt from the statewide
  883  plan under s. 409.912(4)(b)8. An administrative fee may be paid
  884  to the specialty plan for the coordination of services based on
  885  the receipt of the state share of that fee being provided
  886  through intergovernmental transfers.
  887         (4)(a) A Medicaid recipient in the pilot area who is not
  888  currently enrolled in a capitated managed care plan upon
  889  implementation is not eligible for services as specified in ss.
  890  409.905 and 409.906, for the amount of time that the recipient
  891  does not enroll in a capitated managed care network. If a
  892  Medicaid recipient has not enrolled in a capitated managed care
  893  plan within 30 days after eligibility, the agency shall assign
  894  the Medicaid recipient to a capitated managed care plan based on
  895  the assessed needs of the recipient as determined by the agency
  896  and the recipient shall be exempt from s. 409.9122. When making
  897  assignments, the agency shall take into account the following
  898  criteria:
  899         1. A capitated managed care network has sufficient network
  900  capacity to meet the needs of members.
  901         2. The capitated managed care network has previously
  902  enrolled the recipient as a member, or one of the capitated
  903  managed care network’s primary care providers has previously
  904  provided health care to the recipient.
  905         3. The agency has knowledge that the member has previously
  906  expressed a preference for a particular capitated managed care
  907  network as indicated by Medicaid fee-for-service claims data,
  908  but has failed to make a choice.
  909         4. The capitated managed care network’s primary care
  910  providers are geographically accessible to the recipient’s
  911  residence.
  912         5.Plan performance as designed by the agency.
  913         (b) When more than one capitated managed care network
  914  provider meets the criteria specified in paragraph (3)(h), the
  915  agency shall make recipient assignments consecutively by family
  916  unit.
  917         (c) If a recipient is currently enrolled with a Medicaid
  918  managed care organization that also operates an approved reform
  919  plan within a demonstration area and the recipient fails to
  920  choose a plan during the reform enrollment process or during
  921  redetermination of eligibility, the recipient shall be
  922  automatically assigned by the agency into the most appropriate
  923  reform plan operated by the recipient’s current Medicaid managed
  924  care plan. If the recipient’s current managed care plan does not
  925  operate a reform plan in the demonstration area which adequately
  926  meets the needs of the Medicaid recipient, the agency shall use
  927  the automatic assignment process as prescribed in the special
  928  terms and conditions numbered 11-W-00206/4. All enrollment and
  929  choice counseling materials provided by the agency must contain
  930  an explanation of the provisions of this paragraph for current
  931  managed care recipients.
  932         (d) Except for plan performance as provided for in
  933  paragraph (a), the agency may not engage in practices that are
  934  designed to favor one capitated managed care plan over another
  935  or that are designed to influence Medicaid recipients to enroll
  936  in a particular capitated managed care network in order to
  937  strengthen its particular fiscal viability.
  938         (e) After a recipient has made a selection or has been
  939  enrolled in a capitated managed care network, the recipient
  940  shall have 90 days in which to voluntarily disenroll and select
  941  another capitated managed care network. After 90 days, no
  942  further changes may be made except for cause. Cause shall
  943  include, but not be limited to, poor quality of care, lack of
  944  access to necessary specialty services, an unreasonable delay or
  945  denial of service, inordinate or inappropriate changes of
  946  primary care providers, service access impairments due to
  947  significant changes in the geographic location of services, or
  948  fraudulent enrollment. The agency may require a recipient to use
  949  the capitated managed care network’s grievance process as
  950  specified in paragraph (3)(q) prior to the agency’s
  951  determination of cause, except in cases in which immediate risk
  952  of permanent damage to the recipient’s health is alleged. The
  953  grievance process, when used, must be completed in time to
  954  permit the recipient to disenroll no later than the first day of
  955  the second month after the month the disenrollment request was
  956  made. If the capitated managed care network, as a result of the
  957  grievance process, approves an enrollee’s request to disenroll,
  958  the agency is not required to make a determination in the case.
  959  The agency must make a determination and take final action on a
  960  recipient’s request so that disenrollment occurs no later than
  961  the first day of the second month after the month the request
  962  was made. If the agency fails to act within the specified
  963  timeframe, the recipient’s request to disenroll is deemed to be
  964  approved as of the date agency action was required. Recipients
  965  who disagree with the agency’s finding that cause does not exist
  966  for disenrollment shall be advised of their right to pursue a
  967  Medicaid fair hearing to dispute the agency’s finding.
  968         (f) The agency shall apply for federal waivers from the
  969  Centers for Medicare and Medicaid Services to lock eligible
  970  Medicaid recipients into a capitated managed care network for 12
  971  months after an open enrollment period. After 12 months of
  972  enrollment, a recipient may select another capitated managed
  973  care network. However, nothing shall prevent a Medicaid
  974  recipient from changing primary care providers within the
  975  capitated managed care network during the 12-month period.
  976         (g) The agency shall apply for federal waivers from the
  977  Centers for Medicare and Medicaid Services to allow recipients
  978  to purchase health care coverage through an employer-sponsored
  979  health insurance plan instead of through a Medicaid-certified
  980  plan. This provision shall be known as the opt-out option.
  981         1. A recipient who chooses the Medicaid opt-out option
  982  shall have an opportunity for a specified period of time, as
  983  authorized under a waiver granted by the Centers for Medicare
  984  and Medicaid Services, to select and enroll in a Medicaid
  985  certified plan. If the recipient remains in the employer
  986  sponsored plan after the specified period, the recipient shall
  987  remain in the opt-out program for at least 1 year or until the
  988  recipient no longer has access to employer-sponsored coverage,
  989  until the employer’s open enrollment period for a person who
  990  opts out in order to participate in employer-sponsored coverage,
  991  or until the person is no longer eligible for Medicaid,
  992  whichever time period is shorter.
  993         2. Notwithstanding any other provision of this section,
  994  coverage, cost sharing, and any other component of employer
  995  sponsored health insurance shall be governed by applicable state
  996  and federal laws.
  997         (5) This section authorizes does not authorize the agency
  998  to seek an extension amendment and to continue operation
  999  implement any provision of the s. 1115 of the Social Security
 1000  Act experimental, pilot, or demonstration project waiver to
 1001  reform the state Medicaid program in any part of the state other
 1002  than the two geographic areas specified in this section unless
 1003  approved by the Legislature.
 1004         (6) The agency shall develop and submit for approval
 1005  applications for waivers of applicable federal laws and
 1006  regulations as necessary to extend and expand implement the
 1007  managed care pilot project as defined in this section. The
 1008  agency shall seek public input on the waiver and post all waiver
 1009  applications under this section on its Internet website for 30
 1010  days before submitting the applications to the United States
 1011  Centers for Medicare and Medicaid Services. The 30 days shall
 1012  commence with the initial posting and must conclude 30 days
 1013  prior to approval by the United States Centers for Medicare and
 1014  Medicaid Services. All waiver applications shall be provided for
 1015  review and comment to the appropriate committees of the Senate
 1016  and House of Representatives for at least 10 working days prior
 1017  to submission. All waivers submitted to and approved by the
 1018  United States Centers for Medicare and Medicaid Services under
 1019  this section must be approved by the Legislature. Federally
 1020  approved waivers must be submitted to the President of the
 1021  Senate and the Speaker of the House of Representatives for
 1022  referral to the appropriate legislative committees. The
 1023  appropriate committees shall recommend whether to approve the
 1024  implementation of any waivers to the Legislature as a whole. The
 1025  agency shall submit a plan containing a recommended timeline for
 1026  implementation of any waivers and budgetary projections of the
 1027  effect of the pilot program under this section on the total
 1028  Medicaid budget for the 2006-2007 through 2009-2010 state fiscal
 1029  years. This implementation plan shall be submitted to the
 1030  President of the Senate and the Speaker of the House of
 1031  Representatives at the same time any waivers are submitted for
 1032  consideration by the Legislature. The agency may implement the
 1033  waiver and special terms and conditions numbered 11-W-00206/4,
 1034  as approved by the federal Centers for Medicare and Medicaid
 1035  Services. If the agency seeks approval by the Federal Government
 1036  of any modifications to these special terms and conditions, the
 1037  agency must provide written notification of its intent to modify
 1038  these terms and conditions to the President of the Senate and
 1039  the Speaker of the House of Representatives at least 15 days
 1040  before submitting the modifications to the Federal Government
 1041  for consideration. The notification must identify all
 1042  modifications being pursued and the reason the modifications are
 1043  needed. Upon receiving federal approval of any modifications to
 1044  the special terms and conditions, the agency shall provide a
 1045  report to the Legislature describing the federally approved
 1046  modifications to the special terms and conditions within 7 days
 1047  after approval by the Federal Government.
 1048         Section 3. Paragraph (m) is added to subsection (2) of
 1049  section 409.9122, Florida Statutes, to read:
 1050         409.9122 Mandatory Medicaid managed care enrollment;
 1051  programs and procedures.—
 1052         (2)
 1053         (m)1. Time allotted pursuant to this subsection to any
 1054  Medicaid recipient for the selection of, enrollment in, or
 1055  disenrollment from a managed care plan or MediPass is tolled
 1056  throughout any month in which the enrollment broker or choice
 1057  counseling provider, whichever is applicable, has adversely
 1058  affected a beneficiary’s ability to access choice counseling or
 1059  enrollment broker services by its failure to comply with the
 1060  terms and conditions of its contract or has otherwise acted or
 1061  failed to act in a manner that the agency deems likely to
 1062  jeopardize its ability to perform its assigned responsibilities
 1063  as set forth in paragraphs (c) and (d). During any month in
 1064  which time is tolled for a recipient, he or she must be afforded
 1065  uninterrupted access to benefits and services in the same
 1066  delivery system available prior to such tolling.
 1067         2. The agency shall incorporate into all pertinent
 1068  contracts that are executed or renewed on or after July 1, 2010,
 1069  provisions authorizing and requiring the agency to impose
 1070  sanctions or fines against an enrollment broker or choice
 1071  counselor if a recipient is adversely affected due to any action
 1072  or failure to act on the part of the enrollment broker or choice
 1073  counselor.
 1074         Section 4. This act shall take effect July 1, 2010.


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