Bill Text: FL S0542 | 2011 | Regular Session | Introduced
Bill Title: Nursing Home Diversion Program
Spectrum: Bipartisan Bill
Status: (Introduced - Dead) 2011-05-07 - Indefinitely postponed and withdrawn from consideration [S0542 Detail]
Download: Florida-2011-S0542-Introduced.html
Florida Senate - 2011 SB 542
By Senator Bennett
21-00695-11 2011542__
1 A bill to be entitled
2 An act relating to the nursing home diversion program;
3 amending s. 409.912, F.S.; directing the Agency for
4 Health Care Administration to expand the nursing home
5 diversion program to include Medicaid recipients who
6 meet certain criteria; specifying locations for
7 phased-in implementation of the program; revising
8 conditions for enrollment in the program; providing
9 for Medicaid recipient choice with regard to
10 contractors; requiring the nursing home diversion
11 contractor to provide an enrollee with information
12 regarding alternative service providers; requiring
13 certain enrollees to participate in the program;
14 requiring the program to combine funding for Medicaid
15 services provided to specified individuals; removing
16 an exception; excluding specified individuals from
17 participation in the program; revising provisions
18 relating to entities eligible to participate in the
19 program; requiring the Department of Elderly Affairs
20 and the agency to seek federal waivers to limit the
21 number of nursing home diversion contractors in
22 additional locations; directing the agency to impose
23 certain requirements on contractors in the program;
24 requiring the Office of Program Policy Analysis and
25 Government Accountability, in consultation with the
26 Auditor General, to evaluate the nursing home
27 diversion contractors in the program; removing an
28 obsolete provision relating to an appropriation for
29 implementation of a pilot program; amending s.
30 408.040, F.S.; removing a reporting requirement, to
31 conform; providing an effective date.
32
33 Be It Enacted by the Legislature of the State of Florida:
34
35 Section 1. Subsection (5) of section 409.912, Florida
36 Statutes, is amended to read:
37 409.912 Cost-effective purchasing of health care.—The
38 agency shall purchase goods and services for Medicaid recipients
39 in the most cost-effective manner consistent with the delivery
40 of quality medical care. To ensure that medical services are
41 effectively utilized, the agency may, in any case, require a
42 confirmation or second physician’s opinion of the correct
43 diagnosis for purposes of authorizing future services under the
44 Medicaid program. This section does not restrict access to
45 emergency services or poststabilization care services as defined
46 in 42 C.F.R. part 438.114. Such confirmation or second opinion
47 shall be rendered in a manner approved by the agency. The agency
48 shall maximize the use of prepaid per capita and prepaid
49 aggregate fixed-sum basis services when appropriate and other
50 alternative service delivery and reimbursement methodologies,
51 including competitive bidding pursuant to s. 287.057, designed
52 to facilitate the cost-effective purchase of a case-managed
53 continuum of care. The agency shall also require providers to
54 minimize the exposure of recipients to the need for acute
55 inpatient, custodial, and other institutional care and the
56 inappropriate or unnecessary use of high-cost services. The
57 agency shall contract with a vendor to monitor and evaluate the
58 clinical practice patterns of providers in order to identify
59 trends that are outside the normal practice patterns of a
60 provider’s professional peers or the national guidelines of a
61 provider’s professional association. The vendor must be able to
62 provide information and counseling to a provider whose practice
63 patterns are outside the norms, in consultation with the agency,
64 to improve patient care and reduce inappropriate utilization.
65 The agency may mandate prior authorization, drug therapy
66 management, or disease management participation for certain
67 populations of Medicaid beneficiaries, certain drug classes, or
68 particular drugs to prevent fraud, abuse, overuse, and possible
69 dangerous drug interactions. The Pharmaceutical and Therapeutics
70 Committee shall make recommendations to the agency on drugs for
71 which prior authorization is required. The agency shall inform
72 the Pharmaceutical and Therapeutics Committee of its decisions
73 regarding drugs subject to prior authorization. The agency is
74 authorized to limit the entities it contracts with or enrolls as
75 Medicaid providers by developing a provider network through
76 provider credentialing. The agency may competitively bid single
77 source-provider contracts if procurement of goods or services
78 results in demonstrated cost savings to the state without
79 limiting access to care. The agency may limit its network based
80 on the assessment of beneficiary access to care, provider
81 availability, provider quality standards, time and distance
82 standards for access to care, the cultural competence of the
83 provider network, demographic characteristics of Medicaid
84 beneficiaries, practice and provider-to-beneficiary standards,
85 appointment wait times, beneficiary use of services, provider
86 turnover, provider profiling, provider licensure history,
87 previous program integrity investigations and findings, peer
88 review, provider Medicaid policy and billing compliance records,
89 clinical and medical record audits, and other factors. Providers
90 shall not be entitled to enrollment in the Medicaid provider
91 network. The agency shall determine instances in which allowing
92 Medicaid beneficiaries to purchase durable medical equipment and
93 other goods is less expensive to the Medicaid program than long
94 term rental of the equipment or goods. The agency may establish
95 rules to facilitate purchases in lieu of long-term rentals in
96 order to protect against fraud and abuse in the Medicaid program
97 as defined in s. 409.913. The agency may seek federal waivers
98 necessary to administer these policies.
99 (5) The Agency for Health Care Administration, in
100 partnership with the Department of Elderly Affairs, shall expand
101 the nursing home diversion program into create an integrated,
102 fixed-payment delivery program for all Medicaid recipients who
103 meet nursing home admission criteria and are 60 years of age or
104 older and or dually eligible for Medicare and Medicaid. The
105 Agency for Health Care Administration shall implement the
106 integrated program initially in on a pilot basis in two Areas 5,
107 6, and 7 of the state. The program shall be implemented in Areas
108 8, 9, 10, and 11 in 2013 and in Areas 1, 2, 3, and 4 in 2014.
109 All Medicaid recipients shall be given a choice of nursing home
110 diversion contractors in each area. In order to ensure enrollee
111 choice, when an enrollee is determined to be likely to require
112 the level of care provided in a hospital or nursing home, the
113 enrollee shall be informed by the nursing home diversion
114 contractor of any feasible alternatives available and given the
115 choice of either institutional or home and community-based
116 services pilot areas shall be Area 7 and Area 11 of the Agency
117 for Health Care Administration. Enrollment in the pilot areas
118 shall be on a voluntary basis and in accordance with approved
119 federal waivers and this section. The agency and its program
120 contractors and providers shall not enroll any individual in the
121 integrated program because the individual or the person legally
122 responsible for the individual fails to choose to enroll in the
123 integrated program. Enrollment in the integrated program shall
124 be exclusively by affirmative choice of the eligible individual
125 or by the person legally responsible for the individual. The
126 integrated program must transfer all Medicaid services for
127 eligible elderly individuals who choose to participate into an
128 integrated-care management model designed to serve Medicaid
129 recipients in the community. The integrated program must combine
130 all funding for Medicaid services provided to individuals who
131 are 60 years of age or older and or dually eligible for Medicare
132 and Medicaid into the integrated program, including funds for
133 Medicaid home and community-based waiver services; all Medicaid
134 services authorized in ss. 409.905 and 409.906, including
135 excluding funds for Medicaid nursing home services unless the
136 agency is able to demonstrate how the integration of the funds
137 will improve coordinated care for these services in a less
138 costly manner; and Medicare coinsurance and deductibles for
139 persons dually eligible for Medicaid and Medicare as prescribed
140 in s. 409.908(13).
141 (a) Individuals who are 60 years of age or older, or dually
142 eligible for Medicare and Medicaid, and enrolled in the
143 developmental disabilities waiver program, the family and
144 supported-living waiver program, the project AIDS care waiver
145 program, the traumatic brain injury and spinal cord injury
146 waiver program, the consumer-directed care waiver program, and
147 the program of all-inclusive care for the elderly program, and
148 residents of institutional care facilities for the
149 developmentally disabled, must be excluded from the integrated
150 program.
151 (b) Managed care entities who meet or exceed the agency’s
152 minimum standards are eligible to operate the integrated
153 program. Entities eligible to participate include managed care
154 organizations licensed under chapter 641, including entities
155 eligible to participate in the nursing home diversion program
156 contractors, other qualified providers as defined in s.
157 430.703(6) and (7). The Department of Elderly Affairs and the
158 agency shall comply with s. 430.705(3) prior to approval of any
159 additional contractors, community care for the elderly lead
160 agencies, and other state-certified community service networks
161 that meet comparable standards as defined by the agency, in
162 consultation with the Department of Elderly Affairs and the
163 Office of Insurance Regulation, to be financially solvent and
164 able to take on financial risk for managed care. Community
165 service networks that are certified pursuant to the comparable
166 standards defined by the agency are not required to be licensed
167 under chapter 641. Managed care entities who operate the
168 integrated program shall be subject to s. 408.7056. Eligible
169 entities shall choose to serve enrollees who are dually eligible
170 for Medicare and Medicaid, enrollees who are 60 years of age or
171 older, or both.
172 (c) The agency must ensure that the capitation-rate-setting
173 methodology for the integrated program is actuarially sound and
174 reflects the intent to provide quality care in the least
175 restrictive setting. The agency must also require nursing home
176 diversion contractors integrated-program providers to develop a
177 credentialing system for service providers and to contract with
178 all Gold Seal nursing homes, where feasible, and exclude, where
179 feasible, chronically poor-performing facilities and providers
180 as defined by the agency. The integrated program must develop
181 and maintain an informal provider grievance system that
182 addresses provider payment and contract problems. The agency
183 shall also establish a formal grievance system to address those
184 issues that were not resolved through the informal grievance
185 system. The integrated program must provide that if the
186 recipient resides in a noncontracted residential facility
187 licensed under chapter 400 or chapter 429 at the time of
188 enrollment in the integrated program and the recipient’s needs
189 cannot be met in a less restrictive environment, the recipient
190 must be permitted to continue to reside in the noncontracted
191 facility as long as the recipient desires. The integrated
192 program must also provide that, in the absence of a contract
193 between the nursing home diversion contractor integrated-program
194 provider and the residential facility licensed under chapter 400
195 or chapter 429, current Medicaid rates must prevail. The nursing
196 home diversion contractor integrated-program provider must
197 ensure that electronic nursing home claims that contain
198 sufficient information for processing are paid within 10
199 business days after receipt. Alternately, the nursing home
200 diversion contractor integrated-program provider may establish a
201 capitated payment mechanism to prospectively pay nursing homes
202 at the beginning of each month. The agency and the Department of
203 Elderly Affairs must jointly develop procedures to manage the
204 services provided through the integrated program in order to
205 ensure quality and recipient choice.
206 (d) The Office of Program Policy Analysis and Government
207 Accountability, in consultation with the Auditor General, shall
208 comprehensively evaluate the pilot project for the integrated,
209 fixed-payment delivery program for Medicaid recipients created
210 under this subsection. The evaluation shall begin as soon as
211 Medicaid recipients are enrolled in the managed care pilot
212 program plans and shall continue for 24 months thereafter. The
213 evaluation must include assessments of each nursing home
214 diversion contractor managed care plan in the integrated program
215 with regard to cost savings; consumer education, choice, and
216 access to services; coordination of care; and quality of care.
217 The evaluation must describe administrative or legal barriers to
218 the implementation and operation of the pilot program and
219 include recommendations regarding statewide expansion of the
220 pilot program. The office shall submit its evaluation report to
221 the Governor, the President of the Senate, and the Speaker of
222 the House of Representatives no later than December 31, 2014
223 2009.
224 (e) The agency may seek federal waivers or Medicaid state
225 plan amendments and adopt rules as necessary to administer the
226 integrated program. The agency may implement the approved
227 federal waivers and other provisions as specified in this
228 subsection.
229 (f) The implementation of the integrated, fixed-payment
230 delivery program created under this subsection is subject to an
231 appropriation in the General Appropriations Act.
232 Section 2. Paragraph (e) of subsection (1) of section
233 408.040, Florida Statutes, is redesignated as paragraph (d), and
234 present paragraph (d) of that subsection is amended to read:
235 408.040 Conditions and monitoring.—
236 (1)
237 (d) If a nursing home is located in a county in which a
238 long-term care community diversion pilot project has been
239 implemented under s. 430.705 or in a county in which an
240 integrated, fixed-payment delivery program for Medicaid
241 recipients who are 60 years of age or older or dually eligible
242 for Medicare and Medicaid has been implemented under s.
243 409.912(5), the nursing home may request a reduction in the
244 percentage of annual patient days used by residents who are
245 eligible for care under Title XIX of the Social Security Act,
246 which is a condition of the nursing home’s certificate of need.
247 The agency shall automatically grant the nursing home’s request
248 if the reduction is not more than 15 percent of the nursing
249 home’s annual Medicaid-patient-days condition. A nursing home
250 may submit only one request every 2 years for an automatic
251 reduction. A requesting nursing home must notify the agency in
252 writing at least 60 days in advance of its intent to reduce its
253 annual Medicaid-patient-days condition by not more than 15
254 percent. The agency must acknowledge the request in writing and
255 must change its records to reflect the revised certificate-of
256 need condition. This paragraph expires June 30, 2011.
257 Section 3. This act shall take effect July 1, 2011.
