January 19, 2021
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Amendment CaShTmL-905236.HTM
    Florida Senate - 2005                      COMMITTEE AMENDMENT
    Bill No. PCS for SB 838 (394008)
                        Barcode 905236
                            CHAMBER ACTION
              Senate                               House
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11  The Committee on Health Care (Saunders) recommended the
12  following amendment:
13  
14         Senate Amendment (with title amendment) 
15         On page 56, line 14, through
16            page 64, line 9, delete those lines
17  
18  and insert:  
19         Section 2.  Section 409.91211, Florida Statutes, is
20  created to read:
21         409.91211  Medicaid managed care pilot program.--
22         (1)(a)  The agency shall develop a pilot program to
23  deliver health care services specified in ss. 409.905 and
24  409.906 through capitated managed care networks under the
25  Medicaid program to persons in Medicaid fee-for-service or the
26  MediPass program, contingent upon federal approval to preserve
27  the upper-payment-limit funding mechanism for hospitals,
28  including a guarantee of a reasonable growth factor, a
29  methodology to allow the use of a portion of these funds to
30  serve as risk pool for pilot sites, provisions to preserve the
31  state's ability to use intergovernmental transfers, and
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    10:10 AM   04/11/05                            s0838c-he37-vb2

Florida Senate - 2005 COMMITTEE AMENDMENT Bill No. PCS for SB 838 (394008) Barcode 905236 1 provisions to protect the disproportionate share program 2 authorized pursuant to this chapter. 3 (b) The agency may include, as part of the waiver 4 request, an alternative methodology for making additional 5 Medicaid payments to hospitals based on the level of Medicaid 6 or care provided to the uninsured. Any alternative 7 methodology, however, must provide the same level of federal 8 funding as the current upper payment limit and include a 9 reasonable growth factor. Absent federal approval of a 10 reasonable growth factor, the Agency for Health Care 11 Administration shall provide the Legislature, pursuant to the 12 implementation plan provided for in section 3 of this act, the 13 following: 14 1. Based on the historical growth and current federal 15 rules governing the upper-payment-limit funding, an estimate 16 of the projected growth of funding over the next 10 years and 17 an estimate of the loss of federal funding which can be 18 attributed to the implementation of any Medicaid waiver. 19 2. An analysis showing the amount of additional 20 upper-payment-limit-funds that this state would have received 21 if it had been granted the exceptions to the 22 upper-payment-limit cap provided to other states in 42 C.F.R. 23 s. 447.272 from the 2002 through 2009 state fiscal years. 24 3. An analysis with accompanying rationale supporting 25 the implementation of any waiver that would result in 26 hospitals in this state which provide safety net services 27 receiving less federal funds relative to the federal support 28 given to similar hospitals in other states. 29 (2) The Legislature intends for the capitated managed 30 care pilot program to: 31 (a) Provide recipients in Medicaid fee-for-service or 2 10:10 AM 04/11/05 s0838c-he37-vb2
Florida Senate - 2005 COMMITTEE AMENDMENT Bill No. PCS for SB 838 (394008) Barcode 905236 1 the MediPass program a comprehensive and coordinated capitated 2 managed care system for all medically necessary health care 3 services specified in ss. 409.905 and 409.906. 4 (b) Stabilize Medicaid expenditures under the pilot 5 program compared to Medicaid expenditures for the 3 years 6 before implementation of the pilot program. 7 (c) Provide an opportunity to evaluate the feasibility 8 of statewide implementation of capitated managed care networks 9 as a replacement for the current Medicaid fee-for-service and 10 MediPass systems. 11 (3) The agency shall have the following powers, 12 duties, and responsibilities with respect to the development 13 of a pilot program to deliver all health care services 14 specified in ss. 409.905 and 409.906 in the form of capitated 15 managed care networks under the Medicaid program to persons in 16 Medicaid fee-for-service or the MediPass program: 17 (a) To define and recommend the medical and financial 18 eligibility standards for capitated managed care networks in 19 the pilot program. This paragraph does not relieve an entity 20 that qualifies as a capitated managed care network under this 21 section from any other licensure or regulatory requirements 22 contained in state or federal law which would otherwise apply 23 to the entity. 24 (b) To include two geographic areas in the pilot 25 program and recommend Medicaid-eligibility categories, from 26 those specified in ss. 409.903 and 409.904, which shall be 27 included in the pilot program. One pilot program must include 28 only Broward County. A second pilot program must initially 29 include Duval County and may be expanded to Baker, Clay, and 30 Nassau Counties after the Duval County program has been 31 operating for at least 1 year. A Medicaid recipient may not be 3 10:10 AM 04/11/05 s0838c-he37-vb2
Florida Senate - 2005 COMMITTEE AMENDMENT Bill No. PCS for SB 838 (394008) Barcode 905236 1 enrolled in or assigned to a capitated managed care plan 2 unless the capitated managed care plan has complied with the 3 standards and credentialing requirements specified in 4 paragraph (e). 5 (c) To determine and recommend how to design the 6 managed care delivery system in order to take maximum 7 advantage of all available state and federal funds, including 8 those obtained through intergovernmental transfers, the 9 upper-payment-level funding systems, and the disproportionate 10 share program. 11 (d) To determine and recommend actuarially sound, 12 risk-adjusted capitation rates for Medicaid recipients in the 13 pilot program which can be separated to cover comprehensive 14 care, enhanced services, and catastrophic care. 15 (e) To determine and recommend policies and guidelines 16 for phasing in financial risk for approved provider service 17 networks over a 3-year period. These shall include an option 18 to pay fee-for-service rates that may include a 19 savings-settlement option for at least 2 years. This model may 20 be converted to a risk adjusted capitated rate in the third 21 year of operation. 22 (f) To determine and recommend provisions related to 23 stop-loss requirements and the transfer of excess cost to 24 catastrophic coverage that accommodates the risks associated 25 with the development of the pilot projects. 26 (g) To determine and recommend a process to be used by 27 the Social Services Estimating Conference to determine and 28 validate the rate of growth of the per-member costs of 29 providing Medicaid services under the managed care initiative. 30 (h) To determine and recommend descriptions of the 31 eligibility assignment processes that will be used to 4 10:10 AM 04/11/05 s0838c-he37-vb2
Florida Senate - 2005 COMMITTEE AMENDMENT Bill No. PCS for SB 838 (394008) Barcode 905236 1 facilitate client choice while ensuring pilot projects of 2 adequate enrollment levels. These processes shall ensure that 3 pilot sites have sufficient levels of enrollment to conduct a 4 valid test of the managed care pilot project model within a 5 2-year timeframe. 6 (i) To determine and recommend program standards and 7 credentialing requirements for capitated managed care networks 8 to participate in the pilot program, including those related 9 to fiscal solvency, quality of care, and adequacy of access to 10 health care providers. This paragraph does not relieve an 11 entity that qualifies as a capitated managed care network 12 under this section from any other licensure or regulatory 13 requirements contained in state or federal law that would 14 otherwise apply to the entity. These standards must address, 15 but are not limited to: 16 1. Compliance with the accreditation requirements as 17 provided in s. 641.512. 18 2. Compliance with early and periodic screening, 19 diagnosis, and treatment screening requirements under federal 20 law. 21 3. The percentage of voluntary disenrollments. 22 4. Immunization rates. 23 5. Standards of the National Committee for Quality 24 Assurance and other approved accrediting bodies. 25 6. Recommendations of other authoritative bodies. 26 7. Specific requirements of the Medicaid program, or 27 standards designed to specifically meet the unique needs of 28 Medicaid recipients. 29 8. Compliance with the health quality improvement 30 system as established by the agency, which incorporates 31 standards and guidelines developed by the Centers for Medicare 5 10:10 AM 04/11/05 s0838c-he37-vb2
Florida Senate - 2005 COMMITTEE AMENDMENT Bill No. PCS for SB 838 (394008) Barcode 905236 1 and Medicaid Services as part of the quality assurance reform 2 initiative. 3 (j) To develop and recommend a mechanism for providing 4 information to Medicaid recipients for the purpose of 5 selecting a capitated managed care plan. Examples of such 6 mechanisms may include, but need not be limited to, 7 interactive information systems, mailings, and mass-marketing 8 materials. Capitated managed care plans, their 9 representatives, and providers employed by or contracted with 10 the capitated managed care plans may not provide inducements 11 to Medicaid recipients to select their plans and may not 12 prejudice Medicaid recipients against other capitated managed 13 care plans. 14 (k) To develop and recommend a system to monitor the 15 provision of health care services in the pilot program, 16 including utilization and quality of health care services for 17 the purpose of ensuring access to medically necessary 18 services. This system may include an encounter 19 data-information system that collects and reports utilization 20 information. The system shall include a method for verifying 21 data integrity within the database and within the provider's 22 medical records. 23 (l) To recommend a grievance-resolution process for 24 Medicaid recipients enrolled in a capitated managed care 25 network under the pilot program modeled after the subscriber 26 assistance panel, as created in s. 408.7056. This process 27 shall include a mechanism for an expedited review of no 28 greater than 24 hours after notification of a grievance if the 29 life of a Medicaid recipient is in imminent and emergent 30 jeopardy. 31 (m) To recommend a grievance-resolution process for 6 10:10 AM 04/11/05 s0838c-he37-vb2
Florida Senate - 2005 COMMITTEE AMENDMENT Bill No. PCS for SB 838 (394008) Barcode 905236 1 health care providers employed by or contracted with a 2 capitated managed care network under the pilot program in 3 order to settle disputes among the provider and the managed 4 care network or the provider and the agency. 5 (n) To develop and recommend criteria to designate 6 health care providers as eligible to participate in the pilot 7 program. The agency and capitated managed care networks must 8 follow national guidelines for selecting health care 9 providers, whenever available. These criteria must include at 10 a minimum those criteria specified in s. 409.907. 11 (o) To develop and recommend health care provider 12 agreements for participation in the pilot program. 13 (p) To require that all health care providers under 14 contract with the pilot program be duly licensed in the state, 15 if such licensure is available, and meet other criteria as may 16 be established by the agency. These criteria shall include at 17 a minimum those criteria specified in s. 409.907. 18 (q) To develop and recommend agreements with other 19 state or local governmental programs or institutions for the 20 coordination of health care to eligible individuals receiving 21 services from such programs or institutions. 22 (r) To develop and recommend a system to oversee the 23 activities of pilot program participants, health care 24 providers, capitated managed care networks, and their 25 representatives in order to prevent fraud or abuse, 26 overutilization or duplicative utilization, underutilization 27 or inappropriate denial of services, and neglect of 28 participants and to recover overpayments as appropriate. For 29 the purposes of this paragraph, the terms "abuse" and "fraud" 30 have the meanings as provided in s. 409.913. The agency must 31 refer incidents of suspected fraud, abuse, overutilization and 7 10:10 AM 04/11/05 s0838c-he37-vb2
Florida Senate - 2005 COMMITTEE AMENDMENT Bill No. PCS for SB 838 (394008) Barcode 905236 1 duplicative utilization, and underutilization or inappropriate 2 denial of services to the appropriate regulatory agency. 3 (s) To develop and provide actuarial and benefit 4 design analyses that indicate the effect on capitation rates 5 and benefits offered in the pilot program over a prospective 6 5-year period based on the following assumptions: 7 1. Growth in capitation rates which is limited to the 8 estimated growth rate in general revenue. 9 2. Growth in capitation rates which is limited to the 10 average growth rate over the last 3 years in per-recipient 11 Medicaid expenditures. 12 3. Growth in capitation rates which is limited to the 13 growth rate of aggregate Medicaid expenditures between the 14 2003-2004 fiscal year and the 2004-2005 fiscal year. 15 (t) To develop a system whereby school districts 16 participating in the certified school match program pursuant 17 to ss. 409.908(21) and 1011.70 shall be reimbursed by 18 Medicaid, subject to the limitations of s. 1011.70(1), for a 19 Medicaid-eligible child participating in the services as 20 authorized in s. 1011.70, as provided for in s. 409.9071, 21 regardless of whether the child is enrolled in a capitated 22 managed care network. Capitated managed care networks must 23 make a good-faith effort to execute agreements with school 24 districts regarding the coordinated provision of services 25 authorized under s. 1011.70. County health departments 26 delivering school-based services pursuant to ss. 381.0056 and 27 381.0057 must be reimbursed by Medicaid for the federal share 28 for a Medicaid-eligible child who receives Medicaid-covered 29 services in a school setting, regardless of whether the child 30 is enrolled in a capitated managed care network. Capitated 31 managed care networks must make a good-faith effort to execute 8 10:10 AM 04/11/05 s0838c-he37-vb2
Florida Senate - 2005 COMMITTEE AMENDMENT Bill No. PCS for SB 838 (394008) Barcode 905236 1 agreements with county health departments regarding the 2 coordinated provision of services to a Medicaid-eligible 3 child. To ensure continuity of care for Medicaid patients, the 4 agency, the Department of Health, and the Department of 5 Education shall develop procedures for ensuring that a 6 student's capitated managed care network provider receives 7 information relating to services provided in accordance with 8 ss. 381.0056, 381.0057, 409.9071, and 1011.70. 9 (u) To develop and recommend a mechanism whereby 10 Medicaid recipients who are already enrolled in a managed care 11 plan or the MediPass program in the pilot areas shall be 12 offered the opportunity to change to capitated managed care 13 plans on a staggered basis, as defined by the agency. All 14 Medicaid recipients shall have 30 days in which to make a 15 choice of capitated managed care plans. Those Medicaid 16 recipients who do not make a choice shall be assigned to a 17 capitated managed care plan in accordance with paragraph 18 (4)(a). To facilitate continuity of care for a Medicaid 19 recipient who is also a recipient of Supplemental Security 20 Income (SSI), prior to assigning the SSI recipient to a 21 capitated managed care plan, the agency shall determine 22 whether the SSI recipient has an ongoing relationship with a 23 provider or capitated managed care plan, and if so, the agency 24 shall assign the SSI recipient to that provider or capitated 25 managed care plan where feasible. Those SSI recipients who do 26 not have such a provider relationship shall be assigned to a 27 capitated managed care plan provider in accordance with 28 paragraph (4)(a). 29 (v) To develop and recommend a service delivery 30 alternative for children having chronic medical conditions 31 which establishes a medical home project to provide primary 9 10:10 AM 04/11/05 s0838c-he37-vb2
Florida Senate - 2005 COMMITTEE AMENDMENT Bill No. PCS for SB 838 (394008) Barcode 905236 1 care services to this population. The project shall provide 2 community-based primary care services that are integrated with 3 other subspecialties to meet the medical, developmental, and 4 emotional needs for children and their families. This project 5 shall include an evaluation component to determine impacts on 6 hospitalizations, length of stays, emergency room visits, 7 costs, and access to care, including specialty care and 8 patient, and family satisfaction. 9 (4)(a) A Medicaid recipient in the pilot area who is 10 not currently enrolled in a capitated managed care plan upon 11 implementation is not eligible for services as specified in 12 ss. 409.905 and 409.906, for the amount of time that the 13 recipient does not enroll in a capitated managed care network. 14 If a Medicaid recipient has not enrolled in a capitated 15 managed care plan within 30 days after eligibility, the agency 16 shall assign the Medicaid recipient to a capitated managed 17 care plan based on the assessed needs of the recipient as 18 determined by the agency. When making assignments, the agency 19 shall take into account the following criteria: 20 1. A capitated managed care network has sufficient 21 network capacity to meet the need of members. 22 2. The capitated managed care network has previously 23 enrolled the recipient as a member, or one of the capitated 24 managed care network's primary care providers has previously 25 provided health care to the recipient. 26 3. The agency has knowledge that the member has 27 previously expressed a preference for a particular capitated 28 managed care network as indicated by Medicaid fee-for-service 29 claims data, but has failed to make a choice. 30 4. The capitated managed care network's primary care 31 providers are geographically accessible to the recipient's 10 10:10 AM 04/11/05 s0838c-he37-vb2
Florida Senate - 2005 COMMITTEE AMENDMENT Bill No. PCS for SB 838 (394008) Barcode 905236 1 residence. 2 (b) When more than one capitated managed care network 3 provider meets the criteria specified in paragraph (3)(j), the 4 agency shall make recipient assignments consecutively by 5 family unit. 6 (c) The agency may not engage in practices that are 7 designed to favor one capitated managed care plan over another 8 or that are designed to influence Medicaid recipients to 9 enroll in a particular capitated managed care network in order 10 to strengthen its particular fiscal viability. 11 (d) After a recipient has made a selection or has been 12 enrolled in a capitated managed care network, the recipient 13 shall have 90 days in which to voluntarily disenroll and 14 select another capitated managed care network. After 90 days, 15 no further changes may be made except for cause. Cause shall 16 include, but not be limited to, poor quality of care, lack of 17 access to necessary specialty services, an unreasonable delay 18 or denial of service, inordinate or inappropriate changes of 19 primary care providers, service access impairments due to 20 significant changes in the geographic location of services, or 21 fraudulent enrollment. The agency may 22 23 24 ================ T I T L E A M E N D M E N T =============== 25 And the title is amended as follows: 26 On page 1, line 12, through 27 page 2, line 28, delete those lines 28 29 and insert: 30 equipment; providing that a contract awarded to 31 a provider service network remains in effect 11 10:10 AM 04/11/05 s0838c-he37-vb2
Florida Senate - 2005 COMMITTEE AMENDMENT Bill No. PCS for SB 838 (394008) Barcode 905236 1 for a certain period; defining a provider 2 service network; providing health care 3 providers with a controlling interest in the 4 governing body of the provider service network 5 organization; requiring that the agency, in 6 partnership with the Department of Elderly 7 Affairs, develop an integrated, fixed-payment 8 delivery system for Medicaid recipients age 60 9 and older; deleting an obsolete provision 10 requiring the agency to develop a plan for 11 implementing emergency and crisis care; 12 requiring the agency to develop a system where 13 health care vendors may provide data 14 demonstrating that higher reimbursement for a 15 good or service will be offset by cost savings 16 in other goods or services; requiring the 17 Comprehensive Assessment and Review for 18 Long-Term Care Services (CARES) teams to 19 consult with any person making a determination 20 that a nursing home resident funded by Medicare 21 is not making progress toward rehabilitation 22 and assist in any appeals of the decision; 23 requiring the agency to contract with an entity 24 to design a clinical-utilization information 25 database or electronic medical record for 26 Medicaid providers; requiring that the agency 27 develop a plan to expand disease-management 28 programs; requiring the agency to coordinate 29 with other entities to create emergency room 30 diversion programs for Medicaid recipients; 31 revising the Medicaid prescription drug 12 10:10 AM 04/11/05 s0838c-he37-vb2
Florida Senate - 2005 COMMITTEE AMENDMENT Bill No. PCS for SB 838 (394008) Barcode 905236 1 spending control program to reduce costs and 2 improve Medicaid recipient safety; requiring 3 that the agency implement a Medicaid 4 prescription drug management system; allowing 5 the agency to require age-related prior 6 authorizations for certain prescription drugs; 7 requiring the agency to determine the extent 8 that prescription drugs are returned and reused 9 in institutional settings and whether this 10 program could be expanded; requiring the agency 11 to develop an in-home, all-inclusive program of 12 services for Medicaid children with 13 life-threatening illnesses; authorizing the 14 agency to pay for emergency mental health 15 services provided through licensed crisis 16 stabilization centers; creating s. 409.91211, 17 F.S.; requiring that the agency develop a pilot 18 program for capitated managed care networks to 19 deliver Medicaid health care services for all 20 eligible Medicaid recipients in Medicaid 21 fee-for-service or the MediPass program; 22 authorizing the agency to include an 23 alternative methodology for making additional 24 Medicaid payments to hospitals; 25 26 27 28 29 30 31 13 10:10 AM 04/11/05 s0838c-he37-vb2
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