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Emergency Medicine
Specific Summary
The Medicaid managed care pilot program must cover emergency
services and care as a required benefit and comply with current
statutory requirements found in s. 409.9128.
The pilot program must include a provision for continuing
fee-for-service payments for emergency services, including but
not limited to, individuals who access ambulance services or
emergency departments and who are subsequently determined to be
eligible for Medicaid services.
The legislation also directs AHCA to work with local hospitals,
emergency medical services providers, public and private health
care providers and local communities to work together and enter
into agreements to provide alternative sources of care for
Medicaid-recipients for those who need non-emergency care.
The bill also requires AHCA to contract with an entity to design
a database of clinical utilization information or electronic
medical records and a prescription drug management system for
Medicaid providers.
Medicaid Managed Care Pilot Program Creates s. 409.91211, F.S., authorizing AHCA to seek an 1115
waiver from the federal government to create a statewide
capitated managed care pilot program. Phase one of the
demonstration shall be implemented in two geographic areas- one
site Broward County and one site to initially include Duval
County and shall be expanded to include Baker, Clay, and Nassau
Counties within 1 year after the Duval County program becomes
operational. Waiver authority is contingent upon federal
approval to preserve the upper-payment-limit funding mechanism
and the disproportionate share program for hospitals. Upon
completion of the evaluation conducted by OPPAGA and in
consultation with the Auditor General, AHCA may request
statewide expansion of the demonstration projects. Statewide
phase-in to additional counties shall be contingent upon review
and approval by the Legislature. AHCA is given the following powers, duties, and
responsibilities with respect to the Medicaid Managed Care Pilot
Program:
To develop and recommend a system to deliver all mandatory
services specified in s. 409.905, F.S., and optional services
specified in s. 409.906, F.S., as approved by CMS and the
Legislature in the waiver, and specifies that services to
recipients under plan benefits shall include emergency services
provided under s. 409.9128, F.S.
To recommend Medicaid eligibility categories from those
specified in ss. 409.903, F.S., and 409.904, F.S.
To design the managed care pilot program to maximize all
available funds.
To set actuarially sound, risk-adjusted capitation rates for
Medicaid recipients in the pilot which can be separated to cover
comprehensive care, enhanced services, and catastrophic care.
To determine and recommend program standards and credentialing
requirements for capitated managed care networks to participate
in the pilot program. Specifies minimum standards and
credentialing requirements to be included.
To develop and recommend a mechanism for providing information
to Medicaid recipients for the purpose of selecting a capitated
managed care plan. Sets minimum standards for information that
must be provide to a recipient about each plan. Also requires
that there is a record of recipient acknowledgment that choice
counseling has been provided. Specifies Choice Counseling
minimum requirements.
To develop and recommend descriptions of the eligibility
assignment process which will be used to facilitate client
choice while ensuring pilot programs adequate enrollment levels.
To develop and recommend a system to monitor the provisions of
health care services in the pilot program, including utilization
and quality of health care services for the purpose of ensuring
access to medically necessary services. This system shall
include an encounter data-information system that collects and
reports utilization information. The system shall include a
method for verifying data integrity within the database and
within the provider’s medical records.
To recommend a grievance-resolution process for Medicaid
recipients enrolled in a capitated managed care network under
the pilot program modeled after the subscriber assistance panel
as created in s. 408.7056, F.S.
To recommend a grievance-resolution process for health care
providers employed by or contracted with capitated managed care
network under the pilot program in order to settle disputes
among the provider and the managed care network or the provider
and the agency.
To develop and recommend criteria to designate health care
providers as eligible to participate in the pilot program. Sets
minimum criteria as those specified in s. 409.907, F.S. Also
requires that all health care providers under contract with the
pilot program be duly licensed in the state.
To develop and recommend health care provider agreements for
participation in the pilot program. Also to develop and
recommend agreements with other state or local governmental
programs or institutions for the coordination of health care.
To develop and recommend a system to oversee the activities of
the pilot program participants, health care providers, and
capitated managed care networks in order to prevent fraud and
abuse, over-utilization or duplicative utilization,
underutilization or inappropriate denial of services, neglect of
participants and to recover overpayments as appropriate.
To develop and provide actuarial and benefit design analysis
that indicate the effect on capitation rates and benefits
offered in the pilot program over a prospective 5-year period
based.
To develop a mechanism to require capitated managed care
plans to reimburse qualified emergency service providers,
including, but not limited to, ambulance services, in accordance
with ss. 409.908 and 409.9128, F.S. The pilot program must
include a provision for continuing fee-for-service payments for
emergency services, including but not limited to, individuals
who access ambulance services or emergency departments and who
are subsequently determined to be eligible for Medicaid
services.
Provides for continuation of the Certified School Match program.
To develop and recommend a mechanism whereby Medicaid recipients
who are already enrolled in a managed care plan or the Medipass
program in the pilot areas shall be offered the opportunity to
change to capitated managed care plans on a staggered basis.
Gives all Medicaid recipients 30 days in which to make a choice
of capitated managed care plans or they are assigned a plan.
Gives the recipient 90 days in which to voluntarily disenroll
and select another capitated managed care network. Allows AHCA
to apply for a federal waiver to lock eligible Medicaid
recipients into a capitated managed care network for 12 months
after an open enrollment period. After 12 months of enrollment,
a recipient may select another capitated managed care network.
To develop and recommend a service delivery alternative for
children having chronic medical conditions which establishes a
medical home project to provide primary care services to this
population. This project shall include an evaluation component
to determine impacts on hospitalization, length of stays,
emergency room visits, costs, and access to care, including
specialty care and patient and family satisfaction.
To develop a recommend a service delivery mechanism with in the
capitated managed care plans to provide Medicaid services to
persons with developmental disabilities and Medicaid eligible
children in foster care.
Medicaid Opt-Out Option: Allows AHCA to apply for a federal
waiver to allow recipients to purchase health care coverage
through an employer-sponsored health insurance plan instead of
through a Medicaid certified plan.
Requires AHCA to post all waiver applications on its website for
30 days before submitting the application to CMS, and all waiver
applications shall be provided for review and comment to the
appropriate committees of the Senate and House for at least 10
working days prior to submission. All waivers submitted to and
approved by CMS must be approved by the Legislature. Federally
approved waivers must be submitted to the President of the
Senate and Speaker of the House for referral to the appropriate
legislative committees. The appropriate committees shall
recommend whether to approve the implementation of any waivers
to the Legislature as a whole. AHCA shall submit a plan
containing a recommended timeline for implementation of any
waivers and budgetary projections of the effect of the pilot
program on the total Medicaid budget for the 2006-2007 through
2009-2010 state fiscal years. This implementation plan shall be
submitted to the Senate President and House Speaker at the same
time any waivers are submitted for consideration by the
Legislature. Integrated Care Pilots for Those 60
or Older Requires AHCA in partnership with the Department of Elderly
Affairs (DOEA) to create by December 1, 2005, an integrated,
capitated delivery system for Medicaid recipients who are 60
years of age or older. Though AHCA is granted the authority to
seek federal waivers for the pilots, AHCA must receive specific
authorization from the Legislature prior to implementing the
waiver. The integrated-care management model will initially be a
pilot in two areas of the state with one of the area’s
enrollment being on a voluntary basis. The program must combine
all funding for Medicaid services provided to individuals 60
years of age or older into the integrated system, including
funds for: Medicaid home and community based waiver services;
all Medicaid services authorized in ss. 409.905 and 409.906,
excluding funds for Medicaid nursing home services unless it can
be demonstrated as cost effective; and the collection of
Medicare coinsurance and deductibles for persons dually eligible
for Medicaid and Medicare. Excluded from the integrated pilot
are those individuals 60 years or older that are enrolled in the
following programs: developmental disabilities waiver, family
and supported-living waiver, the project AIDS care waiver,
traumatic brain injury and spinal cord injury waiver,
consumer-directed care waiver, program of all-inclusive care for
the elderly, residents of institutional care for the elderly,
and residents of institutional care facilities for the
developmentally disabled. The program must use a
competitive-procurement process to select entities to operate
the integrated system, and defines which entities are eligible
to submit bids. Provides additional operating procedures for
program. Requires OPPAGA in consultation with the Auditor
General, to conduct within 24 months after implementation, a
comprehensive evaluation of the pilot projected to included:
assessment of cost savings; consumer education, choice, and
access to services; coordinated care; and quality of care. The Medicaid Reform bill also includes
the following revisions to the Medicaid Program:
Medicaid Electronic Medical Records: Requires AHCA to contract
by April 1, 2006 with an entity to design a database of clinical
utilization information or electronic medical records for
Medicaid providers. This system must be web-based and allow
providers to review on a real-time basis the utilization of
Medicaid services, including, but not limited to, physician
office visits, inpatient and outpatient hospitalizations,
laboratory and pathology services, radiological and other
imaging services, dental care, and patterns of dispensing
prescription drugs in order to coordinate care and identify
potential fraud and abuse.
Medicaid Prescription-Drug-Management System: Requires AHCA to
implement a Medicaid prescription-drug-management system. The
management system must rely on cooperation between physicians
and pharmacists to determine appropriate practice patterns and
clinical guidelines to improve the prescribing, dispensing, and
use of drugs in the Medicaid program. Provides additional
requirement regarding the administration of the system,
including: development of best-practice guidelines for the use
and prescribing of drugs and determining deviations from
best-practice guidelines; review of prescribing patterns by
using clinical peer prescribing comparisons; access to Medicaid
recipients who are outliers in their use and alerts to
practitioners for patients who fail to refill their
prescriptions or who are prescribed multiple drugs that may be
redundant, contraindicated, or may have other potential
medication problems; track spending trends for drugs; provider
education and feedback; statewide and regional conferences; and
implement disease-management programs in cooperation with
physicians and pharmacists, along with a model quality-based
medication component for individuals having chronic medical
conditions.
Emergency Department Diversion Programs: Requires AHCA to
encourage hospitals, emergency medical services providers, and
other public and private health care providers to work together
in their local communities to enter into agreements or
arrangements to ensure access to alternatives to emergency
services and care for those Medicaid recipients who need
non-emergency care. The agency shall coordinate with hospitals,
emergency medical services providers, private health plans,
capitated managed care networks, and other public and private
health care providers to develop and implement emergency
department diversion programs for Medicaid recipients.
Clinical Practice Patterns: Requires AHCA to contract with a
vendor to monitor and evaluate the clinical practice patterns of
providers in order to identify trends that are outside the
normal practice patterns. Requires that the vendor is able to
provide information and counseling to a providers outside the
norms in order to improve patient care and reduce inappropriate
utilization.
Explanation of Benefits: Requires AHCA to provide to each
Medicaid recipient an explanation of benefits in the form of a
letter. The explanation of benefits must include the patient’s
name, the name of the health care provider and the address of
the location where the service was provided, a description of
all services billed to Medicaid in terminology that should be
understood by a reasonable person, and information on how to
report inappropriate or incorrect billing.
Collection of Co-payments: Requires AHCA to submit to the
Legislature by December 15, 2005, a report on the legal and
administrative barriers to enforcing sect 409.9081, F.S., This
report must describe how many services require co-payments,
which providers collect co-payments, and the total amount of
co-payments collected from recipients for all services required
under sect 409.9081, by provider type for the 2001-2002 through
2004-2005 fiscal years. Requires AHCA to recommend a mechanism
to enforce the requirements for Medicaid recipients to make
co-payments which does not shift the co-payment amount to the
provider. Requires AHCA to also identify the federal or state
laws or regulation that permit Medicaid recipients to declare
impoverishment in order to avoid paying the co-payment and
extent to which these statements of impoverishment are verified.
If claims of impoverishment are not currently verified, requires
AHCA to recommend a system for such verification. The report
must also identify any other cost-sharing measures that could
imposed on Medicaid recipients.
Allows AHCA to competitively bid single-source-provider
contracts if procurement results in demonstrated cost savings to
the state without limiting access to care.
Requires AHCA to determine instances in which allowing Medicaid
beneficiaries to purchase durable medical equipment and other
goods is less expensive to the Medicaid program than long-term
rental of the equipment. Requires AHCA to develop rules to
facilitate the purchases in lieu of long-term rentals.
Requires AHCA, to the extent permitted by federal law and as
allowed under s. 409.906, to provide reimbursement for emergency
mental health care services for Medicaid recipients in
crisis-stabilization facilities licensed under s. 394.875 as
long as those services are less expensive than the same services
provided in a hospital setting.
Requires AHCA to develop a procedure for determining whether
health care providers and service vendors can provide the
Medicaid program using a business case that demonstrates whether
a particular good or service can offset the cost of providing
the good or service in an alternative setting or through other
means and therefore should receive a higher reimbursement.
Specifies what the case model must include. Allows AHCA to
recommend a change in the reimbursement schedule if it is found
to be cost-effective under the business care.
CARES- Comprehensive Assessment and Review for Long-Term Care
Services nursing facility preadmission screening program:
Requires CARES staff to consult with the person making the
determination that a nursing home resident is no longer eligible
for Medicare because of lack of progress towards rehabilitation,
and if the CARES staff disagrees with that determination,
authorizes the CARES staff to assist the Medicare beneficiary
with an appeal of the disqualification from Medicare coverage,
subject to federal matching funds through Medicaid.
Return and Reuse Program for drugs dispensed by pharmacies to
institutional recipients: Requires AHCA to determine if the
program has reduced the amount of Medicaid prescription drugs
which are destroyed on an annual basis and if there are
additional ways to ensure more prescription drugs are not
destroyed which could safely be reused. Requires AHCA’s
conclusion and recommendations to be reported to the Legislature
by December 1, 2005.
Medicaid Lung Transplants: Requires AHCA to reimbursement using
a global reimbursement fee to approved lung transplant
facilities for providing lung transplant services to Medicaid
recipients.
Provider Service Networks or PSNs: Stipulates that any contract
previously awarded to a PSN operated by a hospital pursuant to
sect 409, F.S., shall remain in effect for a period of 3 years
following the current contract-expiration date, and providers a
definition of a provider service network.
Payer of Last Resort Report: Requires AHCA to submit to the
Legislature by January 15, 2006, recommendations to ensure that
Medicaid is the payer of last resort. The report must identify
the public and private entities that are liable for primary
payment of health care services and recommend methods to improve
enforcement of third party liability responsibility and
repayment of benefits to the state Medicaid program.
Study of the Long-term Care Community Diversion Pilot Project:
Requires OPPAGA to submit by January 15, 2006, a study of the
long-term care community diversion pilot project authorized
under sect 430.701-430.709, F.S. Provides criteria for study.
Also requires AHCA to identify how many individuals in the
long-term care diversion programs who receive care at home have
a patient-responsibility payment associated with their
participation in the diversion program. If no system is
available to assess this information, AHCA shall determine the
cost of creating a system to identify and collect these payments
and whether the cost of developing a system for this purpose is
offset by the amount of patient responsibility payments which
could be collected with the system. Requires AHCA to report this
information to the Legislature by December 1, 2005.
Medicaid Buy-In Study: Requires OPPAGA to conduct a study of
state programs that allow non-Medicaid eligible persons under a
certain income level to buy into the Medicaid program as if it
were private insurance. Provides criteria for study including if
the Medically Needy program could be redesigned to be a Medicaid
buy-in program. Study to be submitted to the Legislature by
January 1, 2006.
Medicaid Prescription Drug Study: Requires OPPAGA, in
consultation with the Office of Attorney General, Medicaid Fraud
Control Unit and the Auditor General, to conduct a study to
examine issues related to the amount of state and federal
dollars lost due to fraud and abuse in the Medicaid Prescription
drug program. Provides criteria for the study. Requires
submission of the study by January 1, 2006, and specifies who
receives the report.
Repeal of provisions in SB 404: Repeals provision in SB 404, the
Medicaid Conforming bill, that dealt with Medicaid provider
reimbursement. Specifically repeals sections of SB 404 that
amended sects 393.0661, 409.907, 409.9082, sect 23 of SB 404 and
introductory provisions of sect 409.908, F.S. Also repeals
requirements in SB 404 that dealt with HMO capitated payment and
requires the adjustment in rates must result in an increase of
2.8% in the average per-member, per-month rate paid to prepaid
health plans. Requires the Senate Select Committee on Medicaid
Reform to study how provider rates are established and modified,
how provider agreements and administrative rulemaking effect
those rates, the discretion allowed by federal law for the
setting of rates by the state, and the impact of litigation on
provider rates. Requires the Committee to issue a report
containing recommendation by March 1, 2006, and specifies who
receives the report.
Provides Appropriations for the Act and provides the effective
date of July 1, 2005. |
