This comprehensive report is designed to provide you with an update on what transpired during the 2016 legislative session, with a particular focus on FHCA’s legislative agenda and the outcomes as they relate to long term care. The Legislature officially adjourned today, March 11, passing the $82.3 billion budget for the 2016-17 state fiscal year (HB 5001).
While starting with many challenges, the session ended positively for long term care providers. Nursing centers found themselves caught in the crossfire as hospitals faced several legislative proposals that would result in increased regulations. FHCA was able to prevent nursing centers from being negatively affected by transparency legislation, as well as preserve the nursing center Certificate of Need process, which is working well to ensure centers are built in areas where there is the most need.
Despite projections of lower-than-expected state tax revenues, FHCA was able to secure a $1.50 per patient per day Medicaid rate increase for nursing centers. And while we were unable to eliminate the Medicaid rate freeze, FHCA was able to pass legislation that will provide members with better tools to utilize existing resources to enhance resident care.
Passage of the Nurse Licensure Compact will support centers’ workforce recruitment efforts, particularly during seasonal months when additional caregivers are needed to assist with the increased number of "snowbird" seniors requiring long term and post-acute care. Nurse practitioners will have greater ability to manage resident care needs thanks to legislation that authorizes them to order medications in nursing centers. Physicians who practice in nursing centers will be unburdened while managing resident pain thanks to legislation that removes nursing centers, assisted living and rehabilitative facilities from the Prescription Drug Monitoring Program’s reporting requirements.
FHCA’s biggest challenge arose from the expected overhaul to nursing centers’ Medicaid reimbursement system. Last year, lawmakers agreed to give the long term care profession an opportunity to develop and submit a proposal in 2016 that would move nursing centers from a cost-based Medicaid reimbursement methodology to a Prospective Payment System (PPS).
FHCA’s advocacy partner, Our Florida Promise (OFP), took proactive steps to assemble data and run a series of PPS models. Input was gathered from OFP and FHCA members, FHCA’s Reimbursement Committee and Board of Directors; yet, it was difficult for all parties to agree since the new payment system would have varying impacts on providers. While the members of OFP voted on a model, FHCA’s Board of Directors sought to gain consensus from all parties before the Association committed to a plan.
In the early days of session, the lack of consensus among OFP and FHCA made it difficult to communicate our priorities to lawmakers with a unified message. The perceived divide also opened the way for our opponents to take aim at the long term care profession. Although unsuccessful, the Trial Bar lobby identified legislation in an attempt to undo important tort reform that was put into place in 2001.
In the end, FHCA and OFP members rallied together to advance our legislative priorities and fight off potentially harmful legislation. And with the final budget requiring the Agency for Health Care Administration to work with an independent contractor to develop a plan to transition nursing centers to a PPS, FHCA was successful in ensuring this will be an open process that allows stakeholder input.
The work you do is difficult, and it does not go unnoticed. FHCA makes it our priority each year to lay out a legislative agenda that will help you further enhance resident quality care and quality of life, as well as support your operations. We’re proud to represent you at Florida’s Capitol and appreciate your support toward the success of this year’s long term care legislative priorities.
*Please note that although these legislative measures have been approved by both chambers, the Governor must take action for final approval (sign the bill, allow it to become law without his signature or veto the bill). Watch your weekly Focus on Florida e-newsletter for updates on the Governor's action and effective dates on the bills we've reported on below.
BUDGET
Governor Rick Scott released his initial budget in November, funding the estimated fiscal year 2016-2017 expenditures for nursing centers without an inflationary increase because of the required rate freeze stated in s. 409.908, Florida Statutes (F.S). The Governor also proposed fully funding the Nursing Facility Quality Assessment (NFQA), which would ensure a “buyback” of over $632 million in Medicaid rate reductions.
The initial budget released by the House reflected the Governor’s recommendations - no new reductions to nursing center Medicaid rates; however, the Medicaid rate freeze was still in effect. The Senate, led by Appropriations Subcommittee on Health and Human Services Chair Rene Garcia (R-38), included language in its preliminary budget that would repeal the rate freeze effective July 1, 2017. Both the House and Senate also proposed fully funding the NFQA.
Despite FHCA’s best efforts, the House ultimately won out during budget conference negotiations. While the final budget did not repeal the Medicaid rate freeze, FHCA was successful in advocating for an increase in the NFQA which will result in a Medicaid rate increase for providers.
Despite FHCA’s best efforts, the House ultimately won out during budget conference negotiations. While the final budget did not repeal the Medicaid rate freeze, FHCA was successful in advocating for an increase in the NFQA which will result in a Medicaid rate increase for providers.
The final budget (HB 5001) provides $4.2 billion for Long Term Care, including fee-for-service nursing center care paid by the Medicaid contractor and Managed Long Term Care paid by managed care plans.
The NFQA is increased by over $21 million compared to fiscal year 2015-2016. The per-day assessment rate would increase to approximately $24.72 per non-Medicare patient day ($2.24 per non-Medicare patient day for high volume Medicaid facilities) which provides for rate “buyback” of an additional $18.7 million compared to the current year.
The result of the additional funding and changes to the Federal Medical Assistance Percentage (FMAP) leads to increased Medicaid rates for nursing centers of approximately $1.50 per patient day when set September 1, 2016.
Other budget items of note include funding for 200 additional slots for the Program of All-Inclusive Care for the Elderly (PACE) in Palm Beach County, 134 additional slots in Miami-Dade County and 60 additional slots in Pinellas County, as well as an additional $8.1 million to reduce the Medicaid Long Term Care Waiver Wait List. Funding was also provided for the Agency for Health Care Administration (AHCA) to contract for the development of a consolidated repository for tracking Statewide Medicaid Managed Care plan contract oversight activities across the agency.
Lastly, the budget includes $150,000 for the Department of Health to create a Ventilated Quadriplegic Workforce Participation Pilot Program. This pilot program will provide necessary equipment and supplies to assist nursing center residents, who are quadriplegic and require a ventilator, with joining the workforce in their respective communities.
CERTIFICATE OF NEED
HB 437 by Rep. Chris Sprowls (R-65)/SB 1144 by Sen. Don Gaetz (R-1) failed to pass. FHCA led an effective lobbying effort and grassroots campaign to ensure that nursing centers were not included in the Certificate of Need (CON) deregulation bill proposed by the House and that the Senate's version, which deregulated nursing center CON, would not pass. Midway through session, the Senate bill was voted down in a lopsided 6-2 vote in the Senate Health and Human Services Subcommittee.
Several members of the Legislature philosophically do not support Certificate of Need (CON). With lawmakers expected to address the hospital CON process this year, FHCA made preserving nursing center CON a legislative priority. Messaging addressed the nursing center CON reforms that passed in 2014 and how these reforms are working to ensure centers are built in areas of the state with the most need. As the debate over hospital CON unfolded, concerns arose that some lawmakers would look to eliminate all health care CON as a starting point.
The initial draft language in HB 437 proposed to deregulate CON for all providers, including hospitals, nursing centers and hospices. Rep. Sprowls and the House Health and Human Services Committee Chair Jason Brodeur (R-28) asked FHCA to make the case as to why CON should be preserved for nursing centers. FHCA worked with CON consultant Sharon Gordon-Girvin to prepare a presentation that addressed the business and policy reasons for preserving nursing center CON. After the presentation, Rep. Sprowls decided to focus solely on hospital CON law.
SB 1144, however, included a requirement for nursing centers and other providers to receive an exemption based on paying 1.5% of gross revenue for the first year of operation and providing a level of “charity care” to residents in subsequent years. FHCA was concerned the legislation would have created a widely-used exemption to our current CON process, resulting in unmanaged growth and low occupancy rates for nursing centers.
FHCA members rallied together in opposition and were successful in defeating the bill in committee. CON was a key issue in Lobby Wednesday discussions between long term care providers and legislators. FHCA leaders traveled to Tallahassee to testify in committee; FHCA and Our Florida Promise leaders also called and met with key lawmakers. Members also sent nearly 4,000 emails, made phone calls and shared their concerns as part of FHCA’s extensive CON social media campaign.
PROSPECTIVE PAYMENT SYSTEM
Governor Scott released his FY 2016-17 Legislative Budget Request in November, which included $500,000 for the Agency for Health Care Administration (AHCA) to work with an independent contractor to develop a plan to transition nursing centers from a cost-based reimbursement methodology to a Prospective Payment System (PPS). The House and the Senate agreed with the Governor and allocated the recommended funding for the PPS plan. The final language in the budget requires the study to be presented to the Governor, the President of the Senate and the Speaker of the House by January 1, 2017, and shall also address the impact of a PPS on Hospice providers.
In the early weeks of session, members of FHCA's Executive Committee and Our Florida Promise came together with AHCA Secretary Elizabeth Dudek, Florida Medicaid Director Justin Senior and other agency representatives to discuss the state's plans for moving to a PPS. In the end, FHCA was successful in ensuring this will be an open process that allows stakeholder input.
During FHCA’s recent Board of Directors meeting, FHCA President Joe Mitchell formed a task force to be chaired by Deborah Franklin, FHCA Past President, to work collaboratively with AHCA on the development of a PPS. The task force will focus on designing quality metrics related to payments and on an updated Fair Rental Value reimbursement model.
GOVERNOR’S GOLD SEAL AWARD
HB 127 by Rep. Travis Cummings (R-18)/Sen. Kelli Stargel (R-15) passed and was signed by the Governor on March 8, 2016. Effective immediately, nursing centers applying for the Governor’s Gold Seal Award now have the option to submit a consolidated financial statement.
Florida Health Care Association members are dedicated to delivering the highest quality care to Florida's nursing center residents. Of the 32 Gold Seal Award recipients in Florida, currently 19 are FHCA members. The Association brought this concept to Sen. Stargel and Rep. Cummings last fall, when many of our centers expressed concern over the complex process involved with applying for this prestigious award.
A legislative priority for FHCA, this revision to the Gold Seal application process will now provide nurses, aides and thousands of other long term care professionals with another opportunity to be recognized for the important work they do in providing exceptional care to seniors and people with disabilities in Florida's nursing centers
EXPAND THE SCOPE OF PRACTICE FOR NURSE PRACTITIONERS/PHYSICIAN ASSISTANTS
This session saw numerous bills filed in both chambers related to expanding the scope of practice for Advanced Registered Nurse Practitioners (ARNPs) and Physician Assistants (PAs) in various health care settings. FHCA actively supported these bills, which help enhance care at the bedside for nursing center residents and allow for more comprehensive care to be provided in rural/underserved areas. FHCA worked diligently in the final hours to ensure the bills successfully passing out of the Legislature will benefit nursing center caregivers and residents.
HB 1241 by Rep. Rene Plascencia (R-49)/Sen. Denise Grimsley (R-21) passed and is on its way to the Governor. This bill gives ARNPs and PAs in nursing centers, hospitals and surgical centers the authority to order medications, including controlled substances.
HB 423 by Rep. Cary Pigman (R-55)/Sen. Denise Grimsley (R-21) passed, giving ARNPs and PAs in any health care setting, including nursing centers, the authority to order and prescribe medically necessary controlled substances, with a seven-day limit on prescriptions.
HB 375 by Rep. Greg Steube (R-73)/Sen. Anitere Flores (R-37) passed, allowing a PA to perform duties delegated by the supervising physician unless prohibited by law or rule. The bill also allows the PA, who already has prescribing authority, to acknowledge completion of the required continuing medical education hours, rather than submitting a signed affidavit attesting to the completion of the requirement at the time of license renewal. Prescriptions can be written or electronic as long as they are in compliance with prescription labeling information requirements.
NURSE LICENSURE COMPACT
HB 1061 by Rep. Cary Pigman (R-55)/Sen. Denise Grimsley (R-21) passed, adding Florida to the list of more than two dozen states already part of the Nurse Licensure Compact. This legislation will give Florida nurses the ability to obtain multi-state licenses and practice in other compact states, with out-of-state nurses able to practice in Florida. The nurse who holds a multi-state license, however, must still comply with the laws in the state where he or she practices.
FHCA actively supported this legislation, which will help members expand their recruitment pool and assist with the shortage of qualified, long term care nurses. This is of particular importance during seasonal months when additional caregivers are needed to assist with the increased number of "snowbird" seniors requiring long term and post-acute care in Florida.
PRESCRIPTION DRUG MONITORING PROGRAM
SB 964 by Sen. Denise Grimsley (R-21)/Rep. Ray Pilon (R-72) passed, exempting nursing centers, assisted living communities and rehabilitative facilities from reporting to the Prescription Drug Monitoring Program.
Unfortunately, nursing centers fell under the sweeping law passed in 2010 to regulate pain management clinics and clamp down on “pill mills” which had proliferated, particularly in the south Florida area. This year, FHCA successfully worked to educate legislators about the importance of amending the law to alleviate the burdens that physicians who practice in nursing centers have when prescribing pain medication to residents due to requirements under the Prescription Drug Monitoring Program.
MANAGED CARE
HB 819 by Rep. Jose Felix Diaz (R-116)/Sen. Joe Negron (R-32) passed, removing dental services as a required benefit from the Medicaid Managed Assistance (MMA) program component of the Statewide Medicaid Managed Care (SMMC) program, effective March 1, 2019. The Agency for Health Care Administration (AHCA) is required to provide the Governor, President of the Senate and Speaker of the House, by December 1, 2016, a comprehensive report that examines how effective the Medicaid managed care plans have been in improving access, satisfaction, delivery and value in dental services. The report must also examine historical trends in costs, utilization and rates by plan and statewide.
The Legislature may use this report to determine if the program should continue under the managed care organizations. However, if the Legislature takes no action on the report’s findings before July 1, 2017, AHCA shall then implement a statewide Medicaid prepaid dental health program for children and adults, with a choice of at least two licensed dental managed care providers.
HB 1335 by Rep. MaryLynn Magar (R-82) and the Senate Health Policy Committee led by Chair Aaron Bean (R-4) passed, establishing in statute a process for the Department of Elder Affairs (DOEA) to prioritize individuals for enrollment in the Statewide Medicaid Managed Care Long Term Care program. The DOEA is required to adopt, by rule, a screening tool that will be used to generate a frailty-based score for prioritizing individuals on the Wait List for home and community-based services through the SMMC LTC program and for rescreening wait-listed individuals annually.
TELEHEALTH
HB 7087 by Rep. Chris Sprowls (R-65)/Sen. Aaron Bean (R-4) passed. Of interest to long term care, the bill creates a Telehealth Advisory Council within the Agency for Health Care Administration (AHCA). The council must make recommendations in a report that must be submitted to the Governor, President of the Senate and Speaker of the House on or before October 31, 2017.
Given the important role telemedicine may play in reducing hospital readmission rates and improving patient outcomes, FHCA worked with both bill sponsors to ensure long term care was represented on the council created by this legislation. Both bills were amended at FHCA’s request to include two representatives, one from a nursing center and one from a community-based health services setting or home health agency.
FHCA will keep members informed on the implementation of this council and the process for appointments.
ASSISTED LIVING FACILITIES
Throughout session, FHCA worked on issues of importance to the assisted living community. HB 965 by Rep. Shawn Harrison (R-63)/Sen. John Legg (R-17) passed, updating the version of fire safety standards used by the State Fire Marshal to set standards for assisted living communities. This change removes the static reference to the 1994 edition of the Life Safety Code and, instead, points to current version (2012). According to State Fire Marshal officials, existing assisted living communities would not be subject to modifications due to this updated reference until such time as they undergo renovations.
FHCA met with the Division of State Fire Marshal’s office to discuss this legislation, with members of FHCA’s Florida Center for Assisted Living Committee (FCAL) assessing the risks/benefits perceived and offering recommendations to ensure the final bill would have no negative effects on providers.
OTHER BILLS OF INTEREST
Transparency
HB 1175 by Rep. Chris Sprowls (R-65)/Sen. Rob Bradley (R-7) passed, requiring hospital facilities to post payments and provide an estimate of charges for service to consumers.
In 2015, Governor Scott appointed a Commission on Healthcare and Hospital Funding to review the role of taxpayer funding for hospitals, insurers and health care providers. In the early weeks of session, the Commission sent proposed recommendations for potential 2016 legislation, with one consideration being criminal prosecution of hospitals which charge patients beyond the allowable amount for health care. The result was legislation filed calling for greater transparency in hospital pricing.
Early on, the Senate bill included a provision mandating nursing centers provide pricing information to a "resident, prospective resident or his or her legal guardian" upon request. FHCA testified in committee, noting that current law already requires nursing centers to provide this information in resident's admissions packet. FHCA educated lawmakers about the duplicative language in the bill and was successful in working with the Senate sponsor, who at the Association's request, amended the bill to eliminate nursing centers from this requirement.
Ambulatory Surgical Centers/Recovery Care Centers
HB 85 by Rep. Heather Fitzenhagen (R-78)/Sen. Don Gaetz (R-1) failed to pass. This bill would have initially allowed patients to receive services up to 24 hours in an Ambulatory Surgical Center (ASC) and would have created a new Recovery Care Center license in Florida. FHCA worked to ensure that Ambulatory Surgical Centers and Recovery Care Centers remain focused on post-surgical recovery rather than provide rehabilitative care that would typically be delivered in a skilled nursing center.
Unpaid Debt Collection
HB 557 by Rep. Shawn Harrison (R-63)/SB 1536 by Sen. Garrett Richter (R-23) failed to advance. This bill gave nursing centers and other health care facilities the ability to collect unpaid debt for care delivered when there is a case of financial wrongdoing. FHCA worked with Rep. Harrison, legislators, members of the Florida Bar and other stakeholders on suitable language that would protects residents from financial abuse while relieving nursing centers and other health care facilities from the burdens of providing care that goes unpaid.
In the end, additional discussion was needed with the Bar and other stakeholders to find common ground on this issue, and the bill failed to advance.
Medical Marijuana
HB 307 by Rep. Matt Gaetz (R-4)/Sen. Rob Bradley (R-7) passed, expanding existing law to allow terminally ill patients with less than one year to live, as determined by two doctors, to use full-strength (non-euphoric) medical marijuana. While this will be legal in Florida upon the Governor’s signature, the use of medical marijuana remains illegal at the federal level and, therefore, cannot be used in a nursing center setting. FHCA prepared a “Green Paper” outlining the challenges of why Florida nursing centers cannot utilize this law. The paper was shared with legislators as the bill moved through the House and Senate.
Mental Health and Baker Act
There were multiple bills heard this session related to mental health and the Baker and Marchman Acts. FHCA monitored these bills closely, since some contained language that could have negatively impacted long term care providers.
SB 12 by Sen. Rene Garcia (R-38) and the House Children Families and Senior Subcommittee passed. This bill overhauls the mental health programs in the state of Florida. Specific to the long term care profession, the bills states that licensed, qualified professionals should be authorized to practice to the full extent of their education and training when performing the professional functions necessary to carry out the intent of the Baker and Marchman Acts.
HB 325 by Rep. Daphne Campbell (D-108)/SB 572 by Sen. Thad Altman (R-16) did not pass. This bill would have allowed ARNPs and PAs to be included in the list of health care practitioners who may initiate the involuntary examination of a person under the Baker Act.
FHCA will continue to work on these types of issues, as we know those related to the Baker Act are important to members.
Overpayments
HB 1245 by Rep. Kathleen Peters (R-69)/Sen. Denise Grimsley (R-21) passed, authorizing the Agency for Health Care Administration (AHCA) to certify that a Medicaid provider is out of business and that overpayments cannot be collected. By doing so, Florida avoids having to return the federal share of overpayments to CMS, resulting in future savings to the state.
Senior Guardian Care
SB 232 by Sen. Nancy Detert (R-28)/Rep Larry Ahern (R-66) passed and was signed by the Governor on March 10, 2016. Effective immediately, this legislation provides reforms to the state Guardianship program in an effort to protect the frail and elderly population from bad actors. The Department of Elder Affairs is given the authority to discipline professional guardians for misconduct and the Statewide Public Guardianship Office will be renamed to the Office of Public and Professional Guardians. The duties of this office are also expanded, giving them oversight of both public and private guardians.
SB 232 by Sen. Nancy Detert (R-28)/Rep Larry Ahern (R-66) passed and was signed by the Governor on March 10, 2016. Effective immediately, this legislation provides reforms to the state Guardianship program in an effort to protect the frail and elderly population from bad actors. The Department of Elder Affairs is given the authority to discipline professional guardians for misconduct and the Statewide Public Guardianship Office will be renamed to the Office of Public and Professional Guardians. The duties of this office are also expanded, giving them oversight of both public and private guardians.
IMAGE CAMPAIGN
FHCA conducted a public awareness campaign during session to promote the high-quality care being delivered in Florida’s long term care centers, with a particular emphasis on the nurses who are dedicated to caring for residents and patients. Activities included a social media video campaign using Facebook, Twitter and YouTube. These videos, featuring member nurses sharing passionate stories about their residents, were viewed more than 41,000 times, generated over 4 million impressions and were shared across Facebook nearly 500 times.
As the debate over Certificate of Need intensified, FHCA ramped up its grassroots activity with a more aggressive campaign that included digital advertising with key political news services, guest editorials and social media posts placed into the personal news feeds of legislators, who saw these posts on Facebook and via Twitter 54 times on average (over 7,000 total impressions). FHCA also engaged members to contact their legislators, and more than 4,000 emails were sent with our key messages.
THANK YOU
FHCA is extremely grateful to our members for your ongoing support both before and during session. Your active involvement in the Association and your support of Our Florida Promise and the FHC PAC plays a critical role in keeping our issues front and center with legislators.
Our ability to advocate for a Medicaid rate increase, overcome legislation that would have negatively affected the Certificate of Need process and pass legislative priorities that enhance your care delivery is a combined result of the strength of our Government Affairs team, the support from FHCA’s Board of Directors and Legislative Committee, and the extensive reach of our members’ grassroots advocacy.
We saw more than 500 members travel to Tallahassee for Lobby Wednesdays to discuss our legislative priorities with lawmakers. First-time participants and seasoned veterans were among those who joined us, including owners, executives, administrators, frontline caregivers, family members and volunteers sharing their stories. Those who made the trip were also supported by members back home advocating on behalf of FHCA by sending thousands of emails and making telephone calls to their legislators.
Many of our business partners also joined us in our efforts. We had tremendous support from Bouchard Insurance and Cotler Healthcare and Development, who co-sponsored Lobby Wednesdays, and Bouchard Insurance, who sponsored the Provider Program, giving these grassroots initiatives an even greater presence. Click here to watch our Lobby Wednesday wrap up video with week-by-week highlights of our member involvement.
Now that legislators are returning to their districts, FHCA wants to encourage you to invite them into your center so we can continue educating them about what’s important to the long term care profession and the residents cared for every day. In the coming weeks, we will be compiling the 2016 Legislative Scorecard. This is an effective grassroots advocacy tool that measures lawmakers’ support of our issues and offers more information about the outcomes from session.
Peter Drucker says, "The best way to predict the future is to create it." On behalf of the entire team at Florida Health Care Association, thank you for providing us the resources to aggressively work on your behalf and protect the future of the delivery of long term care.
FHCA knows what is at stake, will continue to fight the good fight, and as always, is honored for the opportunity to advocate on your behalf.
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