Friday, May 13, 2011

2011 Legislative Session: Medicaid Reform and Long Term Care

In the final week leading up to the end of the 60-day session, legislators held closed negotiations before reaching an agreement on how to overhaul the state’s $22 billion Medicaid program. HBs 7107 and 7109 passed along mostly party lines, and FHCA is pleased to report that the final legislation includes most of the important long term care provisions that were developed by the Association’s Long Term Care Reform Task Force and adopted by the FHCA Board of Directors and Our Florida Promise Steering Committee. Below is an analysis of what's included in the final legislation:

  • Establishes the statewide, integrated managed care program for all covered Medicaid services, including long term care services.
  • AHCA shall begin implementation of the long term care managed care program by July 1, 2012 (required to provide notice of invitations to negotiate), with full implementation in all regions by October 1, 2013.
  • Medicaid recipients 65 years of age or older or eligible for Medicaid by reason of a disability and determined by the CARES Program to meet the requirements for nursing facility care are eligible. 
  • 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 12 months without being re-evaluated for their need of nursing facility care.
  • Establishes eleven (11) regions with a minimum of two plans for each region.
  • Plans must offer network contracts to all nursing homes, hospices and aging network service providers that have previously participated in home and community-based waivers in their region for the initial period between October 1, 2013 and September 30, 2014. Plans may exclude providers after this period for failure to meet quality or performance criteria.
  • Nursing homes and hospices that are enrolled Medicaid providers must participate in all eligible plans selected in their region.
  • Plans shall monitor quality and performance of each participating provider using measures adopted by and collected by AHCA and any additional measures mutually agreed upon by the provider and the plan. (This provision should prevent duplicative surveys.)
  • Plans must pay nursing homes an amount equal to the nursing facility-specific payment rates set by AHCA; however, mutually acceptable higher rates may be negotiated for medically complex care.
  • For recipients residing in a nursing facility and receiving hospice services, the plan must pay the hospice provider a per diem rate set by AHCA minus the nursing facility component and shall pay the nursing facility the applicable state rate.
  • Plans must ensure that electronic nursing home and hospice claims that contain sufficient information for processing are paid within 10 business days after receipt.
  • AHCA must establish nursing facility specific payment rates for each licensed nursing home based on facility costs adjusted for inflation and other factors as authorized in the General Appropriations Act. Payments to long term care managed care plans shall be reconciled to reimburse actual payments to nursing facilities.
  • AHCA must establish hospice payment rates and payments to long term care managed care plans shall be reconciled to reimburse actual payments to hospices.
  • AHCA shall periodically adjust payment rates to the managed care plans to account for changes in the level of care for each managed care plan and shall make an incentive adjustment to encourage the increased use of home and community-based services. (Specific percentage adjustments are detailed in the bill until such time that no more than 35% of the plan’s enrollees are placed in institutional settings.)
  • By August 1, 2011, AHCA must establish the technical advisory workgroup to assist in the development of the long term care managed care program. The workgroup will address the following:
    • Method of determining Medicaid eligibility.
    • Method for managing Medicare coinsurance crossover claims.
    • Uniform requirements for claims submissions and payments, including electronic funds transfers and claims processing.
    • Process for enrollment of and payment for individuals pending determination of Medicaid eligibility.
  • Continues the Comprehensive Assessment and Review for Long Term Care Services (CARES) program. Allows for the contracting of any function of the CARES program.
  • Effective July 1, 2012, AHCA may not impose conditions or sanction on providers for failure to meet CON conditions related to minimum Medicaid occupancy.
  • Extends the CON moratorium on nursing home beds.
To read more about how long term care fared in the 2011 legislative session, click here to read FHCA's 2011 Legislative Session Wrap-Up Report.

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