Florida Senate - 2022 SB 1950 By Senator Brodeur 9-01655-22 20221950__ Page 1 of 36 CODING: Words stricken are deletions; words underlined are additions. A bill to be entitled 1

An act relating to the statewide Medicaid managed care 2 program; amending s. 409.912, F.S.; requiring, rather 3 than authorizing, that the reimbursement method for 4 provider service networks be on a prepaid basis; 5 deleting the authority to reimburse provider service 6 networks on a fee-for-service basis; conforming 7 provisions to changes made by the act; providing that 8 provider service networks are subject to and exempt 9 from certain requirements; providing construction; 10 repealing s. 409.9124, F.S., relating to managed care 11 reimbursement; amending s. 409.964, F.S.; deleting a 12 requirement that the Agency for Health Care 13 Administration provide the opportunity for public 14 feedback on a certain waiver application; amending s. 15 409.966, F.S.; revising requirements relating to the 16 databook published by the agency consisting of 17 Medicaid utilization and spending data; reallocating 18 regions within the statewide managed care program; 19 deleting a requirement that the agency negotiate plan 20 rates or payments to guarantee a certain savings 21 amount; deleting a requirement for the agency to award 22 additional contracts to plans in specified regions for 23 certain purposes; revising a limitation on when plans 24 may begin serving Medicaid recipients to apply to any 25 eligible plan that participates in an invitation to 26 negotiate, rather than plans participating in certain 27 regions; making technical changes; amending s. 28 409.967, F.S.; deleting obsolete provisions; revising 29

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 2 of 36 CODING: Words stricken are deletions; words underlined are additions. provisions relating to agency-defined quality measures 30 under the achieved savings rebate program for Medicaid 31 prepaid plans; amending s. 409.968, F.S.; conforming 32 provisions to changes made by the act; amending s. 33 409.973, F.S.; revising requirements for healthy 34 behaviors programs established by plans; deleting an 35 obsolete provision; amending s. 409.974, F.S.; 36 requiring the agency to select plans for the managed 37 medical assistance program through a single statewide 38 procurement; authorizing the agency to award contracts 39 to plans on a regional or statewide basis; specifying 40 requirements for minimum numbers of plans which the 41 agency must procure for each specified region; 42 conforming provisions to changes made by the act; 43 deleting a requirement for the agency to exercise a 44 preference for certain plans; amending s. 409.975, 45 F.S.; providing that cancer hospitals meeting certain 46 criteria are statewide essential providers; amending 47 s. 409.977, F.S.; revising the circumstances for 48 maintaining a recipient’s enrollment in a plan; 49 deleting a requirement for the agency to develop a 50 process for certain recipients to opt out of managed 51 care plans; conforming provisions to changes made by 52 the act; authorizing specialty plans to serve certain 53 children; amending s. 409.981, F.S.; requiring the 54 agency to select plans for the long-term care managed 55 medical assistance program through a single statewide 56 procurement; authorizing the agency to award contracts 57 to plans on a regional or statewide basis; specifying 58

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 3 of 36 CODING: Words stricken are deletions; words underlined are additions. requirements for minimum numbers of plans which the 59 agency must procure for each specified region; 60 conforming provisions to changes made by the act; 61 amending s. 409.8132, F.S.; conforming a cross-62 reference; reenacting ss. 409.962(1), (7), (13), and 63 (14) and 641.19(22) relating to

definitions, to 64 incorporate the amendments made by this act to s. 65 409.912, F.S., in references thereto; reenacting s. 66 430.2053(3)(h), (i), and (

j) and (11), relating to 67 aging resource centers, to incorporate the amendments 68 made by this act to s. 409.981, F.S., in references 69 thereto; providing an effective date. 70 71 Be It Enacted by the Legislature of the State of Florida: 72 73

Section 1. Subsection (1) of

section 409.912, Florida 74 Statutes, is amended to read: 75 409.912 Cost-effective purchasing of health care.—The 76 agency shall purchase goods and services for Medicaid recipients 77 in the most cost-effective manner consistent with the delivery 78 of quality medical care. To ensure that medical services are 79 effectively utilized, the agency may, in any case, require a 80 confirmation or second physician’s opinion of the correct 81 diagnosis for purposes of authorizing future services under the 82 Medicaid program. This

section does not restrict access to 83 emergency services or poststabilization care services as defined 84 in 42 C.F.R. s. 438.114. Such confirmation or second opinion 85 shall be rendered in a manner approved by the agency. The agency 86 shall maximize the use of prepaid per capita and prepaid 87

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 4 of 36 CODING: Words stricken are deletions; words underlined are additions. aggregate fixed-sum basis services when appropriate and other 88 alternative service delivery and reimbursement methodologies, 89 including competitive bidding pursuant to s. 287.057, designed 90 to facilitate the cost-effective purchase of a case-managed 91 continuum of care.

The agency shall also require providers to 92 minimize the exposure of recipients to the need for acute 93 inpatient, custodial, and other institutional care and the 94 inappropriate or unnecessary use of high-cost services. The 95 agency shall contract with a vendor to monitor and evaluate the 96 clinical practice patterns of providers in order to identify 97 trends that are outside the normal practice patterns of a 98 provider’s professional peers or the national guidelines of a 99 provider’s professional association.

The vendor must be able to 100 provide information and counseling to a provider whose practice 101 patterns are outside the norms, in consultation with the agency, 102 to improve patient care and reduce inappropriate utilization. 103 The agency may mandate prior authorization, drug therapy 104 management, or disease management participation for certain 105 populations of Medicaid beneficiaries, certain drug classes, or 106 particular drugs to prevent fraud, abuse, overuse, and possible 107 dangerous drug interactions.

The Pharmaceutical and Therapeutics 108 Committee shall make recommendations to the agency on drugs for 109 which prior authorization is required. The agency shall inform 110 the Pharmaceutical and Therapeutics Committee of its decisions 111 regarding drugs subject to prior authorization. The agency is 112 authorized to limit the entities it contracts with or enrolls as 113 Medicaid providers by developing a provider network through 114 provider credentialing. The agency may competitively bid single -115 source-provider contracts if procurement of goods or services 116

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 5 of 36 CODING: Words stricken are deletions; words underlined are additions. results in demonstrated cost savings to the state without 117 limiting access to care.

The agency may limit its network based 118 on the assessment of beneficiary access to care, provider 119 availability, provider quality standards, time and distance 120 standards for access to care, the cultural competence of the 121 provider network, demographic characteristics of Medicaid 122 beneficiaries, practice and provider-to-beneficiary standards, 123 appointment wait times, beneficiary use of services, provider 124 turnover, provider profiling, provider licensure history, 125 previous program integrity investigations and findings, peer 126 review, provider Medicaid policy and billing compliance records, 127 clinical and medical record audits, and other factors.

Providers 128 are not entitled to enrollment in the Medicaid provider network. 129 The agency shall determine instances in which allowing Medicaid 130 beneficiaries to purchase durable medical equipment and other 131 goods is less expensive to the Medicaid program than long -term 132 rental of the equipment or goods. The agency may establish rules 133 to facilitate purchases in lieu of long-term rentals in order to 134 protect against fraud and abuse in the Medicaid program as 135 defined in s. 409.913. The agency may seek federal waivers 136 necessary to administer these policies. 137

(1) The agency may contract with a provider service 138 network, which must may be reimbursed on a fee-for-service or 139 prepaid basis. Prepaid Provider service networks shall receive 140 per-member, per-month payments. A provider service network that 141 does not choose to be a prepaid plan shall receive fee -for-142 service rates with a shared savings settlement. The fee -for-143 service option shall be available to a provider service network 144 only for the first 2 years of the plan’s operation or until the 145

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 6 of 36 CODING: Words stricken are deletions; words underlined are additions. contract year beginning September 1, 2014, whichever is later. 146 The agency shall annually conduct cost reconciliations to 147 determine the amount of cost savings achieved by fee -for-service 148 provider service networks for the dates of service in the period 149 being reconciled.

Only payments for covered services for dates 150 of service within the reconciliation period and paid within 6 151 months after the last date of service in the reconciliation 152 period shall be included. The agency shall perform the necessary 153 adjustments for the inclusion of claims incurred but not 154 reported within the reconciliation for claims that could be 155 received and paid by the agency after the 6-month claims 156 processing time lag.

The agency shall provide the results of the 157 reconciliations to the fee-for-service provider service networks 158 within 45 days after the end of the reconciliation period. The 159 fee-for-service provider service networks shall review and 160 provide written comments or a letter of concurrence to the 161 agency within 45 days after receipt of the reconcil iation 162 results. This reconciliation shall be considered final. 163 (

a) A provider service network which is reimbursed by the 164 agency on a prepaid basis shall be exempt from parts I and III 165 of

chapter 641 but must comply with the solvency requirements in 166 s. 641.2261(2) and meet appropriate financial reserve, quality 167 assurance, and patient rights requirements as established by the 168 agency. 169 (

b) A provider service network is a network established or 170 organized and operated by a health care provider, or group of 171 affiliated health care providers, which provides a substantial 172 proportion of the health care items and services under a 173 contract directly through the provider or affiliated group of 174

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 7 of 36 CODING: Words stricken are deletions; words underlined are additions. providers and may make arrangements with physicians or other 175 health care professionals, health care institutions, or any 176 combination of such individuals or institutions to assume all or 177 part of the financial risk on a prospective basis for the 178 provision of basic health services by the physicians, by other 179 health professionals, or through the institutions. The health 180 care providers must have a controlling interest in the governing 181 body of the provider service network organization. 182 (

a) A provider service network is exempt from parts I and 183 III of

chapter 641 but must comply with the solve ncy 184 requirements in s. 641.2261(2) and meet appropriate financial 185 reserve, quality assurance, and patient rights requirements as 186 established by the agency. 187 (

b) This subsection does not authorize the agency to 188 contract with a provider service network outsid e of the 189 procurement process described in s. 409.966. 190

Section

Section 409.9124, Florida Statutes, is repealed. 191

Section

Section 409.964, Florida Statutes, is amended to 192 read: 193 409.964 Managed care program; state plan; waivers.—The 194 Medicaid program is established as a statewide, integrated 195 managed care program for all covered services, including long -196 term care services. The agency shall apply for and implement 197 state plan amendments or waivers of applicable federal laws and 198 regulations necessary to implement the program. Before seeking a 199 waiver, the agency shall provide public notice and the 200 opportunity for public comment and include public feedback in 201 the waiver application.

The agency shall hold one public meeting 202 in each of the regions described in s. 409.966(2), and the time 203

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 8 of 36 CODING: Words stricken are deletions; words underlined are additions. period for public comment for each region shall end no sooner 204 than 30 days after the completion of the public meeting in that 205 region. 206

Section 4. Subsections (2), (3), and (4) of

section 207 409.966, Florida Statutes, are amended to read: 208 409.966 Eligible plans; selection.— 209

(2) ELIGIBLE PLAN SELECTION.—The agency shall select a 210 limited number of eligible plans to participate in the Medicaid 211 program using invitations to negotiate in accordance with s. 212 287.057(1)(c). At least 90 days before issuing an invitation to 213 negotiate, the agency shall compile and publish a databook 214 consisting of a comprehensive set of utilization and spending 215 data consistent with actuarial rate-setting practices and 216 standards for the 3 most recent contract years consistent with 217 the rate-setting periods for all Medicaid recipients by region 218 or county.

The source of the data in the databook report must 219 include, at a minimum, the 24 most recent months of both 220 historic fee-for-service claims and validated data from the 221 Medicaid Encounter Data System. The statewide managed care 222 program includes report must be available in electronic form and 223 delineate utilization use by age, gender, eligibility group, 224 geographic area, and aggregate clinical risk score . Separate and 225 simultaneous procurements shall be conducted in each of the 226 following regions: 227 (

a) Region A 1, which consists of Bay, Calhoun, Escambia, 228 Okaloosa, Santa Rosa, and Walton Counties. 229 (

b) Region 2, which consists of Bay, Calhoun, Franklin, 230 Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, 231 Madison, Okaloosa, Santa Rosa, Taylor, Wakulla, Walton, and 232

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 9 of 36 CODING: Words stricken are deletions; words underlined are additions. Washington Counties. 233 (b)(

c) Region B 3, which consists of Alachua, Baker, 234 Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler, 235 Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, 236 Nassau, Putnam, St. Johns, Sumter, Suwannee, and Union Counties. 237 (

d) Region 4, which consists of Baker, Clay, Duval, 238 Flagler, Nassau, St. Johns, and Volusia Counties. 239 (c)(

e) Region C 5, which consists of Pasco and Pinellas 240 Counties. 241 (

f) Region 6, which consists of Hardee, Highlands, 242 Hillsborough, Manatee, Pasco, Pinellas, and Polk Counties. 243 (d)(

g) Region D 7, which consists of Brevard, Orange, 244 Osceola, and Seminole Counties. 245 (e)(

h) Region E 8, which consists of Charlotte, Collier, 246 DeSoto, Glades, Hendry, Lee, and Sarasota Counties. 247 (f)(

i) Region F 9, which consists of Indian River, Martin, 248 Okeechobee, Palm Beach, and St. Lucie Counties. 249 (g)(

j) Region G 10, which consists of Broward County. 250 (h)(

k) Region H 11, which consists of Miami-Dade and Monroe 251 Counties. 252

(3) QUALITY SELECTION CRITERIA.— 253 (

a) The invitation to negotiate must specify the criteria 254 and the relative weight of the criteria that will be used for 255 determining the acceptability of the reply and guiding the 256 selection of the organizations with which the agency negotiates. 257 In addition to criteria established by the agency, the agency 258 shall consider the following factors in the selection of 259 eligible plans: 260 1. Accreditation by the National Committee for Quality 261

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 10 of 36 CODING: Words stricken are deletions; words underlined are additions. Assurance, the Joint Commission, or another nationally 262 recognized accrediting body. 263 2. Experience serving similar populations, including the 264 organization’s record in achieving specific quality standards 265 with similar populations. 266 3. Availability and accessibility of primary care and 267 specialty physicians in the provider network. 268 4.

Establishment of community partnerships with providers 269 that create opportunities for reinvestment in community -based 270 services. 271 5. Organization commitment to quality improvement and 272 documentation of achievements in specific quality improvement 273 projects, including active involvement by organization 274 leadership. 275 6. Provision of additional benefits, particularly dental 276 care and disease management, and other initiatives that improve 277 health outcomes. 278 7.

Evidence that an eligible plan has obtained signed 279 contracts or written agreements or signed contracts or has made 280 substantial progress in establishing relationships with 281 providers before the plan submits submitting a response. 282 8. Comments submitted in writing by any enrolled Medicaid 283 provider relating to a specifically identified plan 284 participating in the procurement in the same region as the 285 submitting provider. 286 9. Documentation of policies and procedures for pre venting 287 fraud and abuse. 288 10.

The business relationship an eligible plan has with any 289 other eligible plan that responds to the invitation to 290

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 11 of 36 CODING: Words stricken are deletions; words underlined are additions. negotiate. 291 (

b) An eligible plan must disclose any business 292 relationship it has with any other eligible plan that res ponds 293 to the invitation to negotiate. The agency may not select plans 294 in the same region for the same managed care program that have a 295 business relationship with each other.

Failure to disclose any 296 business relationship shall result in disqualification fro m 297 participation in any region for the first full contract period 298 after the discovery of the business relationship by the agency. 299 For the purpose of this section, “business relationship” means 300 an ownership or controlling interest, an affiliate or subsidiary 301 relationship, a common parent, or any mutual interest in any 302 limited partnership, limited liability partnership, limited 303 liability company, or other entity or business association, 304 including all wholly or partially owned subsidiaries, majority -305 owned subsidiaries, parent companies, or affiliates of such 306 entities, business associations, or other enterprises, that 307 exists for the purpose of making a profit. 308 (

c) After negotiations are conducted, the agency shall 309 select the eligible plans that are determined to be responsive 310 and provide the best value to the state. Preference shall be 311 given to plans that: 312 1. Have signed contracts with primary and specialty 313 physicians in sufficient numbers to meet the specific standards 314 established pursuant to s. 409.967(2)(c). 315 2. Have well-defined programs for recognizing patient-316 centered medical homes and providing for increased compensation 317 for recognized medical homes, as defined by the plan. 318 3. Are organizations that are based in and perform 319

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 12 of 36 CODING: Words stricken are deletions; words underlined are additions. operational functions in this state, in-house or through 320 contractual arrangements, by staff located in this state. Using 321 a tiered approach, the highest number of points shall be awarded 322 to a plan that has all or substantially all of its operational 323 functions performed in the state. The second highest number of 324 points shall be awarded to a plan that has a majority of its 325 operational functions performed in the state.

The agency may 326 establish a third tier; however, preference points may not be 327 awarded to plans that perform only community outrea ch, medical 328 director functions, and state administrative functions in the 329 state. For purposes of this subparagraph, operational functions 330 include corporate headquarters, claims processing, member 331 services, provider relations, utilization and prior 332 authorization, case management, disease and quality functions, 333 and finance and administration.

For purposes of this 334 subparagraph, the term “corporate headquarters” means the 335 principal office of the organization, which may not be a 336 subsidiary, directly or indirectly through one or more 337 subsidiaries of, or a joint venture with, any other entity whose 338 principal office is not located in the state. 339 4. Have contracts or other arrangements for cancer disease 340 management programs that have a proven record of clinical 341 efficiencies and cost savings. 342 5.

Have contracts or other arrangements for diabetes 343 disease management programs that have a proven record of 344 clinical efficiencies and cost savings. 345 6. Have a claims payment process that ensures that claims 346 that are not contested or denied will be promptly paid pursuant 347 to s. 641.3155. 348

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 13 of 36 CODING: Words stricken are deletions; words underlined are additions. (

d) For the first year of the first contract term, the 349 agency shall negotiate capitation rates or fee for service 350 payments with each plan in order to guarantee aggregate savings 351 of at least 5 percent. 352 1. For prepaid plans, determination of the amount of 353 savings shall be calculated by comparison to the Medicaid rates 354 that the agency paid managed care plans for similar populations 355 in the same areas in the prior year.

In regions containing no 356 prepaid plans in the prior year, determination of the amount of 357 savings shall be calculated by comparison to the Medicaid rates 358 established and certified for those regions in the prior year. 359 2. For provider service networks operating on a fee -for-360 service basis, determination of the amount of savings shall be 361 calculated by comparison to the Medicaid rates that the agency 362 paid on a fee-for-service basis for the same services in the 363 prior year. 364 (

e) To ensure managed care plan participation in Regions 1 365 and 2, the agency shall award an additional contract to each 366 plan with a contract award in Region 1 or Region 2. Such 367 contract shall be in any other region in which the plan 368 submitted a responsive bid and negotiates a rate acceptable to 369 the agency. If a plan that is awarded an additional contract 370 pursuant to this paragraph is subject to penalties pursuant to 371 s. 409.967(2)(

i) for activities in Region 1 or Region 2, the 372 additional contract is automatically terminated 180 days after 373 the imposition of the penalties. The plan must reimburse the 374 agency for the cost of enrollment changes and other transition 375 activities. 376 (d)(

f) The agency may not execute contracts with managed 377

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 14 of 36 CODING: Words stricken are deletions; words underlined are additions. care plans at payment rates not supported by the General 378 Appropriations Act. 379

(4) ADMINISTRATIVE CHALLENGE.—Any eligible plan that 380 participates in an invitation to negotiate in more than one 381 region and is selected in at least one region may not begin 382 serving Medicaid recipients in any region for which it was 383 selected until all administrative challenges to procurements 384 required by this

section to which the eligible plan is a party 385 have been finalized. If the number of plans selected is less 386 than the maximum amount of plans permitted in the region, the 387 agency may contract with other selected plans in the region not 388 participating in the administrative challenge before resolution 389 of the administrative challenge. For purposes of this 390 subsection, an administrative challenge is finalized if an order 391 granting voluntary dismissal with prejudice has been entered by 392 any court established under

Article V of the State Constitution 393 or by the Division of Administrative Hearings, a final order has 394 been entered into by the agency and the deadline for appeal has 395 expired, a final order has been entered by the First District 396 Court of Appeal and the time to seek any available review by the 397 Florida Supreme Court has expired, or a final order has been 398 entered by the Florida Supreme Court and a warrant has been 399 issued. 400

Section 5. Paragraphs (

c) and (

f) of subsection (2) and 401 subsection (3) of

section 409.967, Florida Statutes, are amended 402 to read: 403 409.967 Managed care plan accountability.— 404

(2) The agency shall establish such contract requirements 405 as are necessary for the operation of the statewide managed care 406

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 15 of 36 CODING: Words stricken are deletions; words underlined are additions. program. In addition to any other provisions the agency may deem 407 necessary, the contract must require: 408 (

c) Access.— 409 1. The agency shall establish specific standards for the 410 number, type, and regional distribution of providers in managed 411 care plan networks to ensure access to care for b oth adults and 412 children. Each plan must maintain a regionwide network of 413 providers in sufficient numbers to meet the access standards for 414 specific medical services for all recipients enrolled in the 415 plan. The exclusive use of mail-order pharmacies may not be 416 sufficient to meet network access standards.

Consistent with the 417 standards established by the agency, provider networks may 418 include providers located outside the region. A plan may 419 contract with a new hospital facility before the date the 420 hospital becomes operational if the hospital has commenced 421 construction, will be licensed and operational by January 1, 422 2013, and a final order has issued in any civil or 423 administrative challenge.

Each plan shall establish and maintain 424 an accurate and complete electronic database of contracted 425 providers, including information about licensure or 426 registration, locations and hours of operation, specialty 427 credentials and other certifications, specific performance 428 indicators, and such other information as the agency deems 429 necessary. The database must be available online to both the 430 agency and the public and have the capability to compare the 431 availability of providers to network adequacy standards and to 432 accept and display feedback from each provider’s patients.

Each 433 plan shall submit quarterly reports to the agency identifying 434 the number of enrollees assigned to each primary care provider. 435

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 16 of 36 CODING: Words stricken are deletions; words underlined are additions. The agency shall conduct, or contract for, systematic and 436 continuous testing of the provider network databases maintained 437 by each plan to confirm accuracy, confirm that behavioral health 438 providers are accepting enrollees, and confirm that enrollees 439 have access to behavioral health services. 440 2.

Each managed care plan must publish any prescribed drug 441 formulary or preferred drug list on the plan’s website in a 442 manner that is accessible to and searchable by enrollees and 443 providers. The plan must update the list within 24 hours after 444 making a change. Each plan must ensure that the prior 445 authorization process for prescribed drugs is readily accessibl e 446 to health care providers, including posting appropriate contact 447 information on its website and providing timely responses to 448 providers.

For Medicaid recipients diagnosed with hemophilia who 449 have been prescribed anti-hemophilic-factor replacement 450 products, the agency shall provide for those products and 451 hemophilia overlay services through the agency’s hemophilia 452 disease management program. 453 3. Managed care plans, and their fiscal agents or 454 intermediaries, must accept prior authorization requests for any 455 service electronically. 456 4.

Managed care plans serving children in the care and 457 custody of the Department of Children and Families must maintain 458 complete medical, dental, and behavioral health encounter 459 information and participate in making such information av ailable 460 to the department or the applicable contracted community -based 461 care lead agency for use in providing comprehensive and 462 coordinated case management. The agency and the department shall 463 establish an interagency agreement to provide guidance for the 464

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 17 of 36 CODING: Words stricken are deletions; words underlined are additions. format, confidentiality, recipient, scope, and method of 465 information to be made available and the deadlines for 466 submission of the data. The scope of information available to 467 the department shall be the data that managed care plans are 468 required to submit to the agency.

The agency shall determine the 469 plan’s compliance with standards for access to medical, dental, 470 and behavioral health services; the use of medications; and 471 followup on all medically necessary services recommended as a 472 result of early and periodic screening, diagnosis, and 473 treatment. 474 (

f) Continuous improvement.—The agency shall establish 475 specific performance standards and expected milestones or 476 timelines for improving performance over the term of the 477 contract. 478 1. Each managed care plan shall establish an internal 479 health care quality improvement system, including enrollee 480 satisfaction and disenrollment surveys. The quality improvement 481 system must include incentives and disincentives for network 482 providers. 483 2. Each plan must collect and report the Health Plan 484 Employer Data and Information Set (HEDIS) measures, as specified 485 by the agency.

These measures must be published on the plan’s 486 website in a manner that allows recipients to reliably compare 487 the performance of plans. The agency shall use the HEDIS 488 measures as a tool to monitor plan performance. 489 3. Each managed care plan must be accredited by the 490 National Committee for Quality Assurance, the Joint Commission, 491 or another nationally recognized accrediting body, or have 492 initiated the accreditation process, within 1 year after the 493

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 18 of 36 CODING: Words stricken are deletions; words underlined are additions. contract is executed. For any plan not accredited within 18 494 months after executing the contract, the agency shall suspend 495 automatic assignment under s. 409.977 and 409.984. 496 4. By the end of the fourth year of the first contract 497 term, the agency shall issue a request for information to 498 determine whether cost savings could be achieved by contracting 499 for plan oversight and monitoring, including analysis of 500 encounter data, assessment of performance measures, and 501 compliance with other contractual requirements. 502

(3) ACHIEVED SAVINGS REBATE.— 503 (

a) The agency is responsible for verifying the achieved 504 savings rebate for all Medicaid prepaid plans. To assist the 505 agency, a prepaid plan shall: 506 1. Submit an annual financial audit conducted by an 507 independent certified public accountant in accordance with 508 generally accepted auditing standards to the agency on or before 509 June 1 for the preceding year; and 510 2. Submit an annual statement prepared in accordance with 511 statutory accounting principles on or before March 1 pursuant to 512 s. 624.424 if the plan is regulated by the Office of Insurance 513 Regulation. 514 (

b) The agency shall contract with independent certified 515 public accountants to conduct compliance audits for the purpose 516 of auditing financial information, including but not limited to: 517 annual premium revenue, medical and administrative costs, and 518 income or losses reported by each prepaid plan, in order to 519 determine and validate the achieved savings rebate. 520 (

c) Any audit required under this subsection must be 521 conducted by an independent certified public accountant who 522

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 19 of 36 CODING: Words stricken are deletions; words underlined are additions. meets criteria specified by rule. The rules must also provide 523 that: 524 1. The entity selected by the agency to conduct the audit 525 may not have a conflict of interest that might affect its 526 ability to perform its responsibilities with respect to an 527 examination. 528 2.

The rates charged to the prepaid plan being audited are 529 consistent with rates charged by other certified public 530 accountants and are comparable with the rates charged for 531 comparable examinations. 532 3. Each prepaid plan audited shall pay to the agency the 533 expenses of the audit at the rates established by the agency by 534 rule. Such expenses include actual travel expenses, reasonable 535 living expense allowances, compensation of the certified public 536 accountant, and necessary attendant administrative costs of the 537 agency directly related to the examination.

Travel expense and 538 living expense allowances are limited to those expenses incurred 539 on account of the audit and must be paid by the examined prepaid 540 plan together with compensation upon presentation by the agency 541 to the prepaid plan of a detailed account of the charges and 542 expenses after a detailed statement has been filed by the 543 auditor and approved by the agency. 544 4.

All moneys collected from prepaid plans for such audits 545 shall be deposited into the Grants and Donations Trust Fund, and 546 the agency may make deposits into such fund from moneys 547 appropriated for the operation of the agency. 548 (

d) At a location in this state, the prepaid plan shall 549 make available to the agency and the agency’s contracted 550 certified public accountant all books, accounts, documents, 551

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 20 of 36 CODING: Words stricken are deletions; words underlined are additions. files, and information that relate to the prepaid plan’s 552 Medicaid transactions. Records not in the prepaid plan’s 553 immediate possession must be made available to the agency or the 554 certified public accountant in this state within 3 days after a 555 request is made by the agency or certified public accountant 556 engaged by the agency. A prepaid plan has an obligation to 557 cooperate in good faith with the agency and the certified public 558 accountant. Failure to comply to such record requests shall be 559 deemed a breach of contract. 560 (

e) Once the certified public accountant completes the 561 audit, the certified public accountant shall submit an audit 562 report to the agency attesting to the achieved savings of the 563 plan. The results of the audit report are dispositive. 564 (

f) Achieved savings rebates validated by the certified 565 public accountant are due within 30 days after the report is 566 submitted. Except as provided in paragraph (h), the achieved 567 savings rebate is established by determining pretax income as a 568 percentage of revenues and applying the following income sharing 569 ratios: 570 1. One hundred percent of income up to and including 3 5 571 percent of revenue shall be retained by the plan . 572 2.

Fifty percent of income above 3 5 percent and up to 10 573 percent shall be retained by the plan, and the other 50 percent 574 refunded to the state and transferred to the General Revenue 575 Fund, unallocated. 576 3. One hundred percent of income above 10 percent of 577 revenue shall be refunded to the state and transferred to the 578 General Revenue Fund, unallocated. 579 (

g) A plan that exceeds agency-defined quality measures in 580

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 21 of 36 CODING: Words stricken are deletions; words underlined are additions. the reporting period may retain up to an additional 2 1 percent 581 of revenue. For the purpose of this paragraph, the quality 582 measures must include two tiers and must include plan 583 performance for preventing or managing complex, chronic 584 conditions that are associated with an elevated likelihood of 585 requiring high-cost medical treatments. 586 1.

If the agency-defined quality or performance targets 587 identified in tier one are met, the plan may retain up to 4 588 percent of revenue. Fifty percent of income above 4 percent and 589 up to 10 percent must be retained by the plan, and t he other 50 590 percent refunded to the state and transferred to the General 591 Revenue Fund, unallocated. 592 2. If the agency-defined quality or performance targets 593 identified in tier two are met, the plan may retain up to 5 594 percent of revenue.

Fifty percent of income above 5 percent and 595 up to 10 percent must be retained by the plan, and the other 50 596 percent refunded to the state and transferred to the General 597 Revenue Fund, unallocated. 598 (

h) The following may not be included as allowable expenses 599 in calculating income for determining the achieved savings 600 rebate: 601 1. Payment of achieved savings rebates. 602 2. Any financial incentive payments made to the plan 603 outside of the capitation rate. 604 3. Any financial disincentive payments levied by the state 605 or federal government. 606 4. Expenses associated with any lobbying or political 607 activities. 608 5. The cash value or equivalent cash value of bonuses of 609

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 22 of 36 CODING: Words stricken are deletions; words underlined are additions. any type paid or awarded to the plan’s executive staff, other 610 than base salary. 611 6. Reserves and reserve accounts. 612 7. Administrative costs, including, but not limited to, 613 reinsurance expenses, interest payments, depreciation expenses, 614 bad debt expenses, and outstanding claims expenses in excess of 615 actuarially sound maximum amounts set by the agency. 616 617 The agency shall consider these and other factors in developing 618 contracts that establish shared savings arrangements. 619 (

i) Prepaid plans that incur a loss in the first contract 620 year may apply the full amount of the loss as an offset to 621 income in the second contract year. 622 (

j) If, after an audit, the agency determines that a 623 prepaid plan owes an additional rebate, the plan has 30 days 624 after notification to make the payment. Upon failure to timely 625 pay the rebate, the agency shall withhold future payments to the 626 plan until the entire amount is recouped. If the agency 627 determines that a prepaid plan has made an overpayment, the 628 agency shall return the overpayment within 30 days. 629

Section 6. Subsection (2) of

section 409.968, Florida 630 Statutes, is amended to read: 631 409.968 Managed care plan payments.— 632

(2) Provider service networks must may be prepaid plans and 633 receive per-member, per-month payments negotiated pursuant to 634 the procurement process described in s. 409.966. Provider 635 service networks that choose not to be prepaid plans shall 636 receive fee-for-service rates with a shared savings settlement. 637 The fee-for-service option shall be available to a provider 638

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 23 of 36 CODING: Words stricken are deletions; words underlined are additions. service network only for the first 2 years of its operation. The 639 agency shall annually conduct cost reconciliations to determine 640 the amount of cost savings achieved by fee-for-service provider 641 service networks for the dates of service within the period 642 being reconciled.

Only payments for covered services for dates 643 of service within the reconciliation period and paid within 6 644 months after the last date of service in the reconciliation 645 period must be included. The agency shall perform the necessary 646 adjustments for the inclusion of claims incurred but not 647 reported within the reconciliation period for claims that could 648 be received and paid by the agency after the 6-month claims 649 processing time lag.

The agency shall provide the results of the 650 reconciliations to the fee-for-service provider service networks 651 within 45 days after the end of the reconciliation period. The 652 fee-for-service provider service networks shall review and 653 provide written comments or a letter of concurrence to the 654 agency within 45 days after receipt of the reconciliation 655 results. This reconciliation is considered final. 656

Section 7. Subsections (3) and (4) of

section 409.973, 657 Florida Statutes, are amended to read: 658 409.973 Benefits.— 659

(3) HEALTHY BEHAVIORS.—Each plan operating in the managed 660 medical assistance program shall establish a program to 661 encourage and reward healthy behaviors. At a minimum, each plan 662 must establish a medically approved tobacco smoking cessation 663 program, a medically directed weight loss program, and a 664 medically approved alcohol recovery program or substance abuse 665 recovery program that must include, but may not be limited to, 666 opioid abuse recovery. Each plan must identify enrollees who 667

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 24 of 36 CODING: Words stricken are deletions; words underlined are additions. smoke, are morbidly obese, or are diagnosed with alcohol or 668 substance abuse in order to establish written agreements to 669 secure the enrollees’ commitment to participation in these 670 programs. 671

(4) PRIMARY CARE INITIATIVE.—Each plan operating in the 672 managed medical assistance program shall establish a program to 673 encourage enrollees to establish a relationship with their 674 primary care provider. Each plan shall: 675 (

a) Provide information to each enrollee on the importance 676 of and procedure for selecting a primary care provider, and 677 thereafter automatically assign to a primary care provider any 678 enrollee who fails to choose a primary care provider. 679 (

b) If the enrollee was not a Medicaid recipient before 680 enrollment in the plan, assist the enrollee in schedul ing an 681 appointment with the primary care provider. If possible the 682 appointment should be made within 30 days after enrollment in 683 the plan. For enrollees who become eligible for Medicaid between 684 January 1, 2014, and December 31, 2015, the appointment should 685 be scheduled within 6 months after enrollment in the plan. 686 (

c) Report to the agency the number of enrollees assigned 687 to each primary care provider within the plan’s network. 688 (

d) Report to the agency the number of enrollees who have 689 not had an appointment with their primary care provider within 690 their first year of enrollment. 691 (

e) Report to the agency the number of emergency room 692 visits by enrollees who have not had at least one appointment 693 with their primary care provider. 694

Section 8. Subsections (1) and (2) of

section 409.974, 695 Florida Statutes, are amended to read: 696

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 25 of 36 CODING: Words stricken are deletions; words underlined are additions. 409.974 Eligible plans.— 697

(1) ELIGIBLE PLAN SELECTION.—The agency shall select 698 eligible plans for the managed medical assistance program 699 through the procurement process described in s. 409.966 through 700 a single statewide procurement. The agency may award contracts 701 to plans selected through the procurement process either on a 702 regional or statewide basis. The awards must include at least 703 one provider service network in each of the eight regions 704 outlined in this subsection. The agency shall procure: 705 (

a) At least 3 plans and up to 4 plans for Region A. 706 (

b) At least 3 plans and up to 6 plans for Region B. 707 (

c) At least 5 plans and up to 10 plans for Region C. 708 (

d) At least 3 plans and up to 6 plans for Region D. 709 (

e) At least 3 plans and up to 4 plans for Region E. 710 (

f) At least 3 plans and up to 5 plans for Region F. 711 (

g) At least 3 plans and up to 5 plans for Region G. 712 (

h) At least 5 plans and up to 10 plans for Region H . The 713 agency shall notice invitations to negotiate no later than 714 January 1, 2013. 715 (

a) The agency shall procure two plans for Region 1. At 716 least one plan shall be a provider service network if any 717 provider service networks submit a responsive bid. 718 (

b) The agency shall procure two plans for Region 2. At 719 least one plan shall be a provider service network if any 720 provider service networks submit a responsive bid. 721 (

c) The agency shall procure at least three plans and up to 722 five plans for Region 3. At least one plan must be a provider 723 service network if any provider service networks submit a 724 responsive bid. 725

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 26 of 36 CODING: Words stricken are deletions; words underlined are additions. (

d) The agency shall procure at least three plans and up to 726 five plans for Region 4. At least one plan must be a provider 727 service network if any provider service networks submit a 728 responsive bid. 729 (

e) The agency shall procure at least two plans and up to 730 four plans for Region 5. At least one plan must be a provider 731 service network if any provider service networks submit a 732 responsive bid. 733 (

f) The agency shall procure at least four plans and up to 734 seven plans for Region 6. At least one plan must be a provider 735 service network if any provider service networks submit a 736 responsive bid. 737 (

g) The agency shall procure at least three plans and up to 738 six plans for Region 7. At least one plan must be a provider 739 service network if any provider service networks submit a 740 responsive bid. 741 (

h) The agency shall procure at least two plans and up to 742 four plans for Region 8. At least one plan must be a provider 743 service network if any provider service networks submit a 744 responsive bid. 745 (

i) The agency shall procure at least two plans and up to 746 four plans for Region 9. At least one plan must be a provider 747 service network if any provider service networks submit a 748 responsive bid. 749 (

j) The agency shall procure at least two plans and up to 750 four plans for Region 10. At least one plan must be a provider 751 service network if any provider service networks submit a 752 responsive bid. 753 (

k) The agency shall procure at least five plans and up to 754

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 27 of 36 CODING: Words stricken are deletions; words underlined are additions. 10 plans for Region 11. At least one plan must be a provider 755 service network if any provider service networks submit a 756 responsive bid. 757 758 If no provider service network submits a responsive bid, the 759 agency shall procure no more than one less than the maximum 760 number of eligible plans permitted in that region. Within 12 761 months after the initial invitation to negotiate, the agency 762 shall attempt to procure a provider service network.

The agency 763 shall notice another invitation to negotiate only with provider 764 service networks in those regions where no provider servi ce 765 network has been selected. 766

(2) QUALITY SELECTION CRITERIA.—In addition to the criteria 767 established in s. 409.966, the agency shall consider evidence 768 that an eligible plan has written agreements or signed contracts 769 or has made substantial progress in establishing relationships 770 with providers before the plan submitting a response. The agency 771 shall evaluate and give special weight to evidence of signed 772 contracts with essential providers as defined by the agency 773 pursuant to s. 409.975(1).

The agency shall exercise a 774 preference for plans with a provider network in which over 10 775 percent of the providers use electronic health records, as 776 defined in s. 408.051. When all other factors are equal, the 777 agency shall consider whether the organization has a contract to 778 provide managed long-term care services in the same region and 779 shall exercise a preference for such plans. 780

Section 9. Paragraph (

b) of subsection (1) of

section 781 409.975, Florida Statutes, is amended to read: 782 409.975 Managed care plan accountability.—In addition to 783

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 28 of 36 CODING: Words stricken are deletions; words underlined are additions. the requirements of s. 409.967, plans and providers 784 participating in the managed medical assistance program shall 785 comply with the requirements of this section. 786

(1) PROVIDER NETWORKS.—Managed care plans must develop and 787 maintain provider networks that meet the medical needs of their 788 enrollees in accordance with standards established pursuant to 789 s. 409.967(2)(c). Except as provided in this section, managed 790 care plans may limit the providers in their networks based on 791 credentials, quality indicators, and price. 792 (

b) Certain providers are statewide resources and essential 793 providers for all managed care plans in all regions. All managed 794 care plans must include these essential providers in their 795 networks. Statewide essential providers include: 796 1. Faculty plans of Florida medical schools. 797 2. Regional perinatal intensive care centers as defined in 798 s. 383.16(2). 799 3. Hospitals licensed as specialty children’s hospitals as 800 defined in s. 395.002(28). 801 4.

Accredited and integrated systems serving medically 802 complex children which comprise separately licensed, but 803 commonly owned, health care providers delivering at least the 804 following services: medical group home, in-home and outpatient 805 nursing care and therapies, pharmacy services, durable medical 806 equipment, and Prescribed Pediatric Extended Care. 807 5. Florida cancer hospitals that meet the criteria in 42 808 U.S.C. s. 1395ww(d)(1)(B)(v). 809 810 Managed care plans that have not contracted with all statewide 811 essential providers in all regions as of the first date of 812

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 29 of 36 CODING: Words stricken are deletions; words underlined are additions. recipient enrollment must continue to negotiate in good faith. 813 Payments to physicians on the faculty of nonparticipating 814 Florida medical schools shall be made at the applicable Medicaid 815 rate. Payments for services rendered by regional perinatal 816 intensive care centers shall be made at the applicable Medicaid 817 rate as of the first day of the contract between the agency and 818 the plan.

Except for payments for emergency services, payments 819 to nonparticipating specialty children’s hospitals shall equal 820 the highest rate established by contract between that provider 821 and any other Medicaid managed care plan. 822

Section 10. Subsections (1), (2), (4), and (5) of

section 823 409.977, Florida Statutes, are amended to read: 824 409.977 Enrollment.— 825

(1) The agency shall automatically enroll into a managed 826 care plan those Medicaid recipients who do not voluntarily 827 choose a plan pursuant to s. 409.969. The agency shall 828 automatically enroll recipients in plans that meet or exceed the 829 performance or quality standards established pursuant to s. 830 409.967 and may not automatically enroll recipients in a plan 831 that is deficient in those performance or quality standards. 832 When a specialty plan is available to accommodate a specific 833 condition or diagnosis of a recipient, the agency shall assign 834 the recipient to that plan.

In the first year of the first 835 contract term only, if a recipient was previously enrolled in a 836 plan that is still available in the region, the agency shall 837 automatically enroll the recipient in that plan unless an 838 applicable specialty plan is available. Except as otherwise 839 provided in this part, the agency may not engage in practices 840 that are designed to favor one managed care plan over another. 841

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 30 of 36 CODING: Words stricken are deletions; words underlined are additions.

(2) When automatically enrolling recipients in managed care 842 plans, if a recipient was enrolled in a plan immediately before 843 the recipient′s choice period and that plan is still available 844 in the region, the agency must maintain the recipient′s 845 enrollment in that plan unless an applicable specialty plan is 846 available. Otherwise, the agency shall automatically enroll 847 based on the following criteria: 848 (

a) Whether the plan has sufficient network capacity to 849 meet the needs of the recipients. 850 (

b) Whether the recipient has previously received services 851 from one of the plan’s primary care providers. 852 (

c) Whether primary care providers in one plan are more 853 geographically accessible to the recipient’s residence than 854 those in other plans. 855

(4) The agency shall develop a process to enable a 856 recipient with access to employer-sponsored health care coverage 857 to opt out of all managed care plans and to use Medicaid 858 financial assistance to pay for the recipient’s share of the 859 cost in such employer-sponsored coverage. Contingent upon 860 federal approval, the agency shall also enable recipients with 861 access to other insurance or related products providing access 862 to health care services created pursuant to state law, including 863 any product available under the Florida Health Choices Program, 864 or any health exchange, to opt out.

The amount of financial 865 assistance provided for each recipient may not exceed the amount 866 of the Medicaid premium that would have been paid to a managed 867 care plan for that recipient. The agency shall seek federal 868 approval to require Medicaid recipients with access to employer -869 sponsored health care coverage to enroll in that coverage and 870

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 31 of 36 CODING: Words stricken are deletions; words underlined are additions. use Medicaid financial assistance to pay for the recipient’s 871 share of the cost for such coverage. The amount of financial 872 assistance provided for each recipient may not exceed the amount 873 of the Medicaid premium that would have been paid to a managed 874 care plan for that recipient. 875 (4)

(5) Specialty plans serving children in the care and 876 custody of the department may serve such children as long as 877 they remain in care, including those remaining in extended 878 foster care pursuant to s. 39.6251, or are in subsidized 879 adoption and continue to be eligible for Medicaid pursuant to s. 880 409.903, or are receiving guardianship assistance payments and 881 continue to be eligible for Medicaid pursuant to s. 409.903 . 882

Section 11. Subsection (2) of

section 409.981, Florida 883 Statutes, is amended to read: 884 409.981 Eligible long-term care plans.— 885

(2) ELIGIBLE PLAN SELECTION.—The agency shall select 886 eligible plans for the long-term care managed care program 887 through the procurement process described in s. 409.966 through 888 a single statewide procurement. The agency may award contracts 889 to plans selected through the procurement process on a regional 890 or statewide basis. The awards must include at least one 891 provider service network in each of the eight regions outlined 892 in this subsection. The agency shall procure: 893 (

a) At least 3 plans and up to 4 plans for Region A. 894 (

b) At least 3 plans and up to 6 plans for Region B. 895 (

c) At least 5 plans and up to 10 plans for Region C. 896 (

d) At least 3 plans and up to 6 plans for Region D. 897 (

e) At least 3 plans and up to 4 plans for Region E. 898 (

f) At least 3 plans and up to 5 plans for Region F. 899

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 32 of 36 CODING: Words stricken are deletions; words underlined are additions. (

g) At least 3 plans and up to 4 plans for Region G. 900 (

h) At least 5 plans and up to 10 plans for Region H . 901 Two plans for Region 1. At least one plan must be a 902 provider service network if any provider service networks submit 903 a responsive bid. 904 (

b) Two plans for Region 2. At least one plan must be a 905 provider service network if any provider service networks submit 906 a responsive bid. 907 (

c) At least three plans and up to five plans for Region 3. 908 At least one plan must be a provider service network if any 909 provider service networks submit a responsive bid. 910 (

d) At least three plans and up to five plans for Region 4. 911 At least one plan must be a provider service ne twork if any 912 provider service network submits a responsive bid. 913 (

e) At least two plans and up to four plans for Region 5. 914 At least one plan must be a provider service network if any 915 provider service networks submit a responsive bid. 916 (

f) At least four plans and up to seven plans for Region 6. 917 At least one plan must be a provider service network if any 918 provider service networks submit a responsive bid. 919 (

g) At least three plans and up to six plans for Region 7. 920 At least one plan must be a provider service netw ork if any 921 provider service networks submit a responsive bid. 922 (

h) At least two plans and up to four plans for Region 8. 923 At least one plan must be a provider service network if any 924 provider service networks submit a responsive bid. 925 (

i) At least two plans and up to four plans for Region 9. 926 At least one plan must be a provider service network if any 927 provider service networks submit a responsive bid. 928

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 33 of 36 CODING: Words stricken are deletions; words underlined are additions. (

j) At least two plans and up to four plans for Region 10. 929 At least one plan must be a provider service network if any 930 provider service networks submit a responsive bid. 931 (

k) At least five plans and up to 10 plans for Region 11. 932 At least one plan must be a provider service network if any 933 provider service networks submit a responsive bid. 934 935 If no provider service network submits a responsive bid in a 936 region other than Region 1 or Region 2, the agency shall procure 937 no more than one less than the maximum number of eligible plans 938 permitted in that region. Within 12 months after the initial 939 invitation to negotiate, the agency shall attempt to procure a 940 provider service network.

The agency shall notice another 941 invitation to negotiate only with provider service networks in 942 regions where no provider service network has been selected. 943

Section 12. Subsection (4) of

section 409.8132, Florida 944 Statutes, is amended to read: 945 409.8132 Medikids program component.— 946

(4) APPLICABILITY OF LAWS RELATING TO MEDICAID.—The 947 provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908, 948 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127, 949 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205 apply 950 to the administration of the Medikids program component of the 951 Florida Kidcare program, except that s. 409.9122 applies to 952 Medikids as modified by the provisions of subsection (7). 953

Section 13. For the purpose of incorporating the amendment 954 made by this act to

section 409.912, Florida Statutes, in 955 references thereto, subsections (1), (7), (13), and (14) of 956

section 409.962, Florida Statutes, are reenacted to read: 957

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 34 of 36 CODING: Words stricken are deletions; words underlined are additions. 409.962

Definitions.—As used in this part, except as 958 otherwise specifically provided, the term: 959 (1) “Accountable care organization” means an entity 960 qualified as an accountable care organization in accordance with 961 federal regulations, and which meets the requirements of a 962 provider service network as described in s. 409.912(1). 963 (7) “Eligible plan” means a health insurer authorized under 964

chapter 624, an exclusive provider organization authorized under 965

chapter 627, a health maintenance organization authorized under 966

chapter 641, or a provider service network authorized under s. 967 409.912(1) or an accountable care organization authorized under 968 federal law. For purposes of the managed medical assistance 969 program, the term also includes the Children’s Medical Services 970 Network authorized under

chapter 391 and entities qualified 971 under 42 C.F.R.

part 422 as Medicare Advantage Preferred 972 Provider Organizations, Medicare Advantage Provider -sponsored 973 Organizations, Medicare Advantage Health Maintenance 974 Organizations, Medicare Advantage Coordinated Care Pl ans, and 975 Medicare Advantage Special Needs Plans, and the Program of All -976 inclusive Care for the Elderly. 977 (13) “Prepaid plan” means a managed care plan that is 978 licensed or certified as a risk-bearing entity, or qualified 979 pursuant to s. 409.912(1), in the state and is paid a 980 prospective per-member, per-month payment by the agency. 981 (14) “Provider service network” means an entity qualified 982 pursuant to s. 409.912(1) of which a controlling interest is 983 owned by a health care provider, or group of affiliated 984 providers, or a public agency or entity that delivers health 985 services.

Health care providers include Florida -licensed health 986

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 35 of 36 CODING: Words stricken are deletions; words underlined are additions. care professionals or licensed health care facilities, federally 987 qualified health care centers, and home health care agencies. 988

Section 14. For the purpose of incorporating the amendment 989 made by this act to

section 409.912, Florida Statutes, in a 990 reference thereto, subsection (22) of

section 641.19, Florida 991 Statutes, is reenacted to read: 992 641.19

Definitions.—As used in this part, the term: 993 (22) “Provider service network” means a network authorized 994 under s. 409.912(1), reimbursed on a prepaid basis, operated by 995 a health care provider or group of affiliated health care 996 providers, and which directly provides health care services 997 under a Medicare, Medicaid, or Healthy Kids contract. 998

Section 15. For the purpose of incorporating the amendments 999 made by this act to

section 409.981, Florida Statutes, in 1000 references thereto, paragraphs (h), (i), and (

j) of subsection 1001 (3) and subsection (11) of

section 430.2053, Florida Statutes, 1002 are reenacted to read: 1003 430.2053 Aging resource centers.— 1004

(3) The duties of an aging resource center are to: 1005 (

h) Assist clients who request long-term care services in 1006 being evaluated for eligibility for enrollment in the Medica id 1007 long-term care managed care program as eligible plans become 1008 available in each of the regions pursuant to s. 409.981(2). 1009 (

i) Provide enrollment and coverage information to Medicaid 1010 managed long-term care enrollees as qualified plans become 1011 available in each of the regions pursuant to s. 409.981(2). 1012 (

j) Assist Medicaid recipients enrolled in the Medicaid 1013 long-term care managed care program with informally resolving 1014 grievances with a managed care network and assist Medicaid 1015

Florida Senate - 2022 SB 1950 9-01655-22 20221950__ Page 36 of 36 CODING: Words stricken are deletions; words underlined are additions. recipients in accessing the managed care network’s formal 1016 grievance process as eligible plans become available in each of 1017 the regions defined in s. 409.981(2). 1018

(11) In an area in which the department has designated an 1019 area agency on aging as an aging resource center, the department 1020 and the agency shall not make payments for the services listed 1021 in subsection (9) and the Long-Term Care Community Diversion 1022 Project for such persons who were not screened and enrolled 1023 through the aging resource center. The department shall cease 1024 making payments for recipients in eligible plans as eligible 1025 plans become available in each of the regions defined in s. 1026 409.981(2). 1027

Section 16. This act shall take effect July 1, 2022. 1028