April 19, 2010(Key vote)
Title: HMO Plans for Medicaid Coverage
Vote Smart's Synopsis:
Vote to pass a bill that amends the state Medicaid program.
Establishes that the Agency for Health Care Administration is designated as the single state agency authorized to manage, operate and make payments on behalf of eligible individuals to qualified providers for medical assistance and related services (Sec. 4).
Establishes the "Medicaid program" as a statewide, integrated managed care program for all covered services, including long-term care services and places the responsibility of Medicaid eligibility determination, policy, and rules on the department (Sec. 4 & 5).
Specifies that all Medicaid recipients will receive covered services through the statewide managed care program except for the following exempt participants (Sec. 6):
Women who are only eligible for family planning services;
Women who are only eligible for breast and cervical cancer services; and
Persons who are eligible for emergency Medicaid for aliens.
Specifies that provider service networks must be capable of providing all covered services to a mandatory Medicaid managed care enrollee or may limit the provision of services to a specific target population based on age, chronic disease state, or the medical condition of the enrollee (Sec. 7).
Authorizes the agency to establish a 5-year contract with each of the qualified plans selected through the procurement process, but prohibits the contract from being renewed and may only be extended to cover any delays in transition to a new plan (Sec. 8).
Requires plans to pay for services within 30 days after receipt of a complete and correct claim and to give providers an opportunity to resubmit corrected claims for reconsideration within 30 days after receiving a notice of denial (Sec. 8).
Requires each plan to maintain a region-wide network of providers in sufficient numbers to meet the access standards for specific medical services for all recipients enrolled in the plan (Sec. 8).
Specifies that, beginning September 1, 2010, the agency shall update the rate-setting methodology by initiating a transition to rates based on statewide encounter data submitted by Medicaid managed care plans (Sec. 9).
Authorizes provider service networks to be prepaid plans and ones that choose not to be prepaid plans shall receive fee-for-service rates with a shared savings settlement (Sec. 9).
Requires all Medicaid recipients to be enrolled in a managed care plan unless specifically exempted and have 30 days to make a choice of plans or they will be automatically enrolled into a managed care plan (Sec. 10, 18, 33).
Specifies that recipients have 90 days to voluntarily disenroll and select another plan, which then may only be changed for good cause including reasons such as poor quality of care, lack of access to necessary specialty services, an unreasonable delay or denial of service, or fraudulent enrollment. (Sec. 10).
Requires the agency to maintain and operate the Medicaid Encounter Data System to collect, process, store, and report on covered services provided to all Medicaid recipients enrolled in prepaid plans (Sec. 11).
Specifies that the following Medicaid-eligible persons are exempt from mandatory managed care and may voluntarily choose to participate in the managed medical assistance program (Sec. 13):
Medicaid recipients who have other creditable health care coverage;
Medicaid recipients residing in residential commitment facilities operated through the Department of Juvenile Justice, group care facilities operated by the Department of Children and Families, and treatment facilities funded through the Substance Abuse and Mental Health program of the Department of Children and Families;
Persons eligible for refugee assistance; and
Medicaid recipients who are residents of a developmental disability center including Sunland Center in Marianna and Tacachale in Gainesville.
Specifies that the Children's Medical Services Network is a qualified plan for purposes of the managed medical assistance program (Sec. 15 & 30).
Specifies that plans that spend 95% or more of Medicaid premium revenue on medical services and direct care management or on long-term care services and are determined to be failing to appropriately manage care shall be excluded from automatic enrollments (Sec. 16 & 23).
Authorizes a plan to exclude providers, but the plan must provide written notices to all recipients who have chosen that provider at least 30 days prior to the effective date of the exclusion (Sec. 16 & 23).
Establishes the Medicaid Resolution Board to resolve disputes between managed care plans and hospitals and between managed care plans and the medical staff of the providers (Sec. 16).
Requires the agency to develop a process to enable any recipient with access to employer-sponsored insurance to opt out of all qualified plans in the Medicaid program and to use Medicaid financial assistance to pay for the recipient's share of the cost in any such plan (Sec. 18).
Requires the agency to make payments for long-term care, including home and community-based services (Sec. 19).
Specifies the minimum benefits managed care programs must cover including transportation (Sec. 21 & 29). -Requires payments for managed care plans to be adjusted to provide an incentive for reducing institutional placements and increasing the utilization of home and community-based services (Sec. 24).
Requires the agency to operate the Comprehensive Assessment and Review for Long-Term Care Services (CARES) preadmission screening program to ensure that only individuals whose conditions require long-term care services are enrolled in the long-term care managed care program (Sec. 26).