Florida Statutes 409.9855 – Pilot program for individuals with developmental disabilities
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(1) PILOT PROGRAM IMPLEMENTATION.–
(a) Using a managed care model, the agency shall implement a pilot program for individuals with developmental disabilities in Statewide Medicaid Managed Care Regions D and I to provide coverage of comprehensive services.
Terms Used In Florida Statutes 409.9855
- Agency: means the Agency for Health Care Administration. See Florida Statutes 409.962
- Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
- Contract: A legal written agreement that becomes binding when signed.
- Eligible plan: means a health insurer authorized under chapter 624, an exclusive provider organization authorized under chapter 627, a health maintenance organization authorized under chapter 641, or a provider service network authorized under…. See Florida Statutes 409.962
- Managed care plan: means an eligible plan under contract with the agency to provide services in the Medicaid program. See Florida Statutes 409.962
- Medicaid: means the medical assistance program authorized by Title XIX of the Social Security Act, 42 U. See Florida Statutes 409.962
(b) The agency may seek federal approval through a state plan amendment or Medicaid waiver as necessary to implement the pilot program. The agency shall submit a request for any federal approval needed to implement the pilot program by September 1, 2023.
(c) Pursuant to s. 409.963, the agency shall administer the pilot program in consultation with the Agency for Persons with Disabilities.
(d) The agency shall make capitated payments to managed care organizations for comprehensive coverage, including community-based services described in s. 393.066(3) and approved through the state’s home and community-based services Medicaid waiver program for individuals with developmental disabilities. Unless otherwise specified, ss. 409.961–409.969 apply to the pilot program.
(e) The agency shall evaluate the feasibility of statewide implementation of the capitated managed care model used by the pilot program to serve individuals with developmental disabilities.
(2) ELIGIBILITY; VOLUNTARY ENROLLMENT; DISENROLLMENT.–
(a) Participation in the pilot program is voluntary and limited to the maximum number of enrollees specified in the General Appropriations Act.
(b) The Agency for Persons with Disabilities shall approve a needs assessment methodology to determine functional, behavioral, and physical needs of prospective enrollees. The assessment methodology may be administered by persons who have completed such training as may be offered by the agency. Eligibility to participate in the pilot program is determined based on all of the following criteria:
1. Whether the individual is eligible for Medicaid.
2. Whether the individual is 18 years of age or older and is on the waiting list for individual budget waiver services under chapter 393 and assigned to one of categories 1 through 6 as specified in s. 393.065(5).
3. Whether the individual resides in a pilot program region.
(c) The agency shall enroll individuals in the pilot program based on verification that the individual has met the criteria in paragraph (b).
(d) Notwithstanding any provisions of s. 393.065 to the contrary, an enrollee must be afforded an opportunity to enroll in any appropriate existing Medicaid waiver program if any of the following conditions occur:
1. At any point during the operation of the pilot program, an enrollee declares an intent to voluntarily disenroll, provided that he or she has been covered for the entire previous plan year by the pilot program.
2. The agency determines the enrollee has a good cause reason to disenroll.
3. The pilot program ceases to operate.
Such enrollees must receive an individualized transition plan to assist him or her in accessing sufficient services and supports for the enrollee’s safety, well-being, and continuity of care.
(3) PILOT PROGRAM BENEFITS.–
(a) Plans participating in the pilot program must, at a minimum, cover the following:
1. All benefits included in s. 409.973.
2. All benefits included in s. 409.98.
3. All benefits included in s. 393.066(3), and all of the following:
a. Adult day training.
b. Behavior analysis services.
c. Behavior assistant services.
d. Companion services.
e. Consumable medical supplies.
f. Dietitian services.
g. Durable medical equipment and supplies.
h. Environmental accessibility adaptations.
i. Occupational therapy.
j. Personal emergency response systems.
k. Personal supports.
l. Physical therapy.
m. Prevocational services.
n. Private duty nursing.
o. Residential habilitation, including the following levels:
(I) Standard level.
(II) Behavior-focused level.
(III) Intensive-behavior level.
(IV) Enhanced intensive-behavior level.
p. Residential nursing services.
q. Respiratory therapy.
r. Respite care.
s. Skilled nursing.
t. Specialized medical home care.
u. Specialized mental health counseling.
v. Speech therapy.
w. Support coordination.
x. Supported employment.
y. Supported living coaching.
z. Transportation.
(b) All providers of the services listed under paragraph (a) must meet the provider qualifications outlined in the Florida Medicaid Developmental Disabilities Individual Budgeting Waiver Services Coverage and Limitations Handbook as adopted by reference in rule 59G-13.070, Florida Administrative Code.
(c) Support coordination services must maximize the use of natural supports and community partnerships.
(d) The plans participating in the pilot program must provide all categories of benefits through a single, integrated model of care.
(e) Services must be provided to enrollees in accordance with an individualized care plan which is evaluated and updated at least quarterly and as warranted by changes in an enrollee’s circumstances.
(4) ELIGIBLE PLANS; PLAN SELECTION.–
(a) To be eligible to participate in the pilot program, a plan must have been awarded a contract to provide long-term care services pursuant to s. 409.981 as a result of an invitation to negotiate.
(b) The agency shall select, as provided in s. 287.057(1), one plan to participate in the pilot program for each of the two regions. The director of the Agency for Persons with Disabilities or his or her designee must be a member of the negotiating team.
1. The invitation to negotiate must specify the criteria and the relative weight assigned to each criterion that will be used for determining the acceptability of submitted responses and guiding the selection of the plans with which the agency and the Agency for Persons with Disabilities negotiate. In addition to any other criteria established by the agency, in consultation with the Agency for Persons with Disabilities, the agency shall consider the following factors in the selection of eligible plans:
a. Experience serving similar populations, including the plan’s record in achieving specific quality standards with similar populations.
b. Establishment of community partnerships with providers which create opportunities for reinvestment in community-based services.
c. Provision of additional benefits, particularly behavioral health services, the coordination of dental care, and other initiatives that improve overall well-being.
d. Provision of and capacity to provide mental health therapies and analysis designed to meet the needs of individuals with developmental disabilities.
e. Evidence that an eligible plan has written agreements or signed contracts or has made substantial progress in establishing relationships with providers before submitting its response.
f. Experience in the provision of person-centered planning as described in 42 C.F.R. 441.301(c)(1).
g. Experience in robust provider development programs that result in increased availability of Medicaid providers to serve the developmental disabilities community.
2. After negotiations are conducted, the agency shall select the eligible plans that are determined to be responsive and provide the best value to the state. Preference must be given to plans that:
a. Have signed contracts in sufficient numbers to meet the specific standards established under s. 409.967(2)(c), including contracts for personal supports, skilled nursing, residential habilitation, adult day training, mental health services, respite care, companion services, and supported employment, as those services are defined in the Florida Medicaid Developmental Disabilities Individual Budgeting Waiver Services Coverage and Limitations Handbook as adopted by reference in rule 59G-13.070, Florida Administrative Code.
b. Have well-defined programs for recognizing patient-centered medical homes and providing increased compensation to recognized medical homes, as defined by the plan.
c. Have well-defined programs related to person-centered planning as described in 42 C.F.R. 441.301(c)(1).
d. Have robust and innovative programs for provider development and collaboration with the Agency for Persons with Disabilities.
(5) PAYMENT.–
(a) The selected plans must receive a per-member, per-month payment based on a rate developed specifically for the unique needs of the developmentally disabled population.
(b) The agency must ensure that the rate for the integrated system is actuarially sound.
(c) The revenues and expenditures of the selected plan which are associated with the implementation of the pilot program must be included in the reporting and regulatory requirements established in s. 409.967(3).
(6) PROGRAM IMPLEMENTATION AND EVALUATION.–
(a) The agency shall select participating plans and begin enrollment no later than January 31, 2024, with coverage for enrollees becoming effective upon authorization and availability of sufficient state and federal resources.
(b) Upon implementation of the program, the agency, in consultation with the Agency for Persons with Disabilities, shall conduct audits of the selected plans’ implementation of person-centered planning.
(c) The agency, in consultation with the Agency for Persons with Disabilities, shall submit progress reports to the Governor, the President of the Senate, and the Speaker of the House of Representatives upon the federal approval, implementation, and operation of the pilot program, as follows:
1. By December 31, 2023, a status report on progress made toward federal approval of the waiver or waiver amendment needed to implement the pilot program.
2. By December 31, 2024, a status report on implementation of the pilot program.
3. By December 31, 2025, and annually thereafter, a status report on the operation of the pilot program, including, but not limited to, all of the following:
a. Program enrollment, including the number and demographics of enrollees.
b. Any complaints received.
c. Access to approved services.
(d) The agency, in consultation with the Agency for Persons with Disabilities, shall establish specific measures of access, quality, and costs of the pilot program. The agency may contract with an independent evaluator to conduct such evaluation. The evaluation must include assessments of cost savings; consumer education, choice, and access to services; plans for future capacity and the enrollment of new Medicaid providers; coordination of care; person-centered planning and person-centered well-being outcomes; health and quality-of-life outcomes; and quality of care by each eligibility category and managed care plan in each pilot program site. The evaluation must describe any administrative or legal barriers to the implementation and operation of the pilot program in each region.
1. The agency, in consultation with the Agency for Persons with Disabilities, shall conduct quality assurance monitoring of the pilot program to include client satisfaction with services, client health and safety outcomes, client well-being outcomes, and service delivery in accordance with the client’s care plan.
2. The agency shall submit the results of the evaluation to the Governor, the President of the Senate, and the Speaker of the House of Representatives by October 1, 2029.
(7) MANAGED CARE PLAN ACCOUNTABILITY.–Plans participating in the pilot program must consult with the Agency for Persons with Disabilities for the express purpose of ensuring adequate provider capacity before placing an enrollee of the pilot program in a group home licensed by the Agency for Persons with Disabilities.