House Medicaid Reform Bill - Long Term Care Analysis

On Friday, the House released two proposed committee bills establishing the Medicaid program as a statewide, integrated managed care program for all covered services, including long term care services. The proposal would be fully implemented by October 1, 2016. The long term care component of the plan would require implementation to begin by July 1, 2012 with full implementation by October 1, 2013.


PCB HHSC 11-01 creates a new section of law entitled “Medicaid Managed Care” which creates provisions for the Medicaid managed medical assistance program, the long term care managed care program, and the managed long term care for persons with developmental disabilities program. The agency is required to adopt any rules necessary to comply with or administer the program and to apply for and implement state plan amendments or waivers of federal laws and regulations necessary to implement the program.

Specifically, sections 409.978-409.985 is created to describe the long term care managed care program. As noted, the agency shall begin implementation of the statewide program by July 1, 2012, with full implementation by October 1, 2013. Medicaid recipients requiring nursing facility care as determined by the CARES Program and who are either 65 years of age or older or eligible for Medicaid by reason of disability are eligible for the program. All Medicaid recipients who are either residing in a nursing facility or enrolled in a Medicaid waiver program on the date long term care managed care plans become available in their region are automatically eligible to participate for up to 24 months without being re-evaluated for their need of nursing facility care. The bill further defines the benefits available under the program.

The state will be divided into seven regions and a specified number of qualified plans will be procured for each of the seven regions. Qualified plans may be managed care entities or long term care provider service networks (owned by health care providers) or entities qualified under 42 C.F.R. part 422 as Medicare Advantage Preferred Provider Organizations, Medicare Advantage Provider-sponsored Organizations, or Medicare Advantage Special Needs Plans. Selected plans must offer a network contract to all nursing homes, hospices, and aging network service providers in their region for the period between October 1, 2013 and September 30, 2014 after a qualified plan is selected, but may exclude the provider from the network after 12 months of active participation for failure to meet quality or performance criteria. Nursing homes and hospices are required to participate in all qualified plans in the region in which the provider is located.

Plans are required to monitor the quality and performance of each participating provider using measures adopted by and collected by the agency, but may use additional measures that are mutually agreed upon by the provider and the plan.

Plans are required to pay nursing homes an amount equal to the nursing facility-specific payment rates set by the agency, but are allowed to pay mutually acceptable higher rates that may be negotiated for medically complex care. Incentives are provided to Plans to reduce institutional placement and increase the utilization of home and community based services with a stated goal of achieving no more than 35 percent institutional placement.

The bill also establishes a long term care managed care technical advisory workgroup to assist in developing Medicaid eligibility criteria, provider payment requirements (methodology and prompt payment), uniform requirements for claims submission and payments, and Medicaid enrollment pending determination of Medicaid eligibility.

PCB HHSC 11-02 is contingent on the passage of PCB 10-03 and makes the statutory changes necessary to implement the managed care program. This bill eliminates the language that created Florida Senior Care, extends the CON moratorium for additional community nursing home beds until October 1, 2016 or until after Medicaid managed long term care is implemented statewide, whichever is earlier, and prevents the agency from considering or imposing conditions related to patient day Medicaid utilization in making certificate of need determination effective July 1, 2012. (This appears to be intended to relieve providers of current licensure conditions related to minimum Medicaid utilization, but would need to be amended to clarify.)

PCB HHSC 11-02 also deletes many sections of current statute upon the implementation of the statewide managed care program including the long term care community diversion pilot program.