2023 Florida Statutes › Title XXX - Social Welfare › Chapter 409 - Social and Economic Assistance › Part III - Medicaid (Ss. 409.901-409.9205) › 409.9122 - Medicaid managed care enrollment; HIV/AIDS patients; procedures; data collection; accounting; information system; medical loss ratio.

409.9122 Medicaid managed care enrollment; HIV/AIDS patients; procedures; data collection; accounting; information system; medical loss ratio.—
(1) Notwithstanding s. 409.961, if a Medicaid recipient is diagnosed with HIV/AIDS, the agency shall assign the recipient to a managed care plan that is a health maintenance organization authorized under chapter 641, that is under contract with the agency as an HIV/AIDS specialty plan as of January 1, 2013, and that offers a delivery system through a university-based teaching and research-oriented organization that specializes in providing health care services and treatment for individuals diagnosed with HIV/AIDS. This subsection applies to recipients who are subject to mandatory managed care enrollment and have failed to choose a managed care option.
(2) The agency shall include in its calculation of the hospital inpatient component of a Medicaid health maintenance organization’s capitation rate any special payments, including, but not limited to, upper payment limit or disproportionate share hospital payments, made to qualifying hospitals through the fee-for-service program. The agency may seek federal waiver approval or state plan amendment as needed to implement this adjustment.
(3) The agency shall develop a process to enable any recipient with access to employer-sponsored health care coverage to opt out of all eligible plans in the Medicaid program and to use Medicaid financial assistance to pay for the recipient’s share of cost in any such employer-sponsored coverage. Contingent on federal approval, the agency shall also enable recipients with access to other insurance or related products that provide access to health care services created pursuant to state law, including any plan or product available pursuant to the Florida Health Choices Program or any health exchange, to opt out. The amount of financial assistance provided for each recipient may not exceed the amount of the Medicaid premium that would have been paid to a plan for that recipient.
(4) The agency shall maintain and operate the Medicaid Encounter Data System to collect, process, store, and report on covered services provided to all Florida Medicaid recipients enrolled in prepaid managed care plans.
(a) Prepaid managed care plans shall submit encounter data electronically in a format that complies with the Health Insurance Portability and Accountability Act provisions for electronic claims and in accordance with deadlines established by the agency. Prepaid managed care plans must certify that the data reported is accurate and complete.
(b) The agency is responsible for validating the data submitted by the plans. The agency shall develop methods and protocols for ongoing analysis of the encounter data that adjusts for differences in characteristics of prepaid plan enrollees to allow comparison of service utilization among plans and against expected levels of use. The analysis shall be used to identify possible cases of systemic underutilization or denials of claims and inappropriate service utilization such as higher-than-expected emergency department encounters. The analysis shall provide periodic feedback to the plans and enable the agency to establish corrective action plans when necessary. One of the focus areas for the analysis shall be the use of prescription drugs.
(5) The agency may establish a per-member, per-month payment for Medicare Advantage Special Needs members that are also eligible for Medicaid as a mechanism for meeting the state’s cost-sharing obligation. The agency may also develop a per-member, per-month payment only for Medicaid-covered services for which the state is responsible. The agency shall develop a mechanism to ensure that such per-member, per-month payment enhances the value to the state and enrolled members by limiting cost sharing, enhances the scope of Medicare supplemental benefits that are equal to or greater than Medicaid coverage for select services, and improves care coordination.
(6) The agency shall establish, and managed care plans shall use, a uniform method of accounting for and reporting medical and nonmedical costs.
(a) Managed care plans shall submit financial data electronically in a format that complies with the uniform accounting procedures established by the agency. Managed care plans must certify that the data reported is accurate and complete.
(b) The agency is responsible for validating the financial data submitted by the plans. The agency shall develop methods and protocols for ongoing analysis of data that adjusts for differences in characteristics of plan enrollees to allow comparison among plans and against expected levels of expenditures. The analysis shall be used to identify possible cases of overspending on administrative costs or underspending on medical services.
(7) The agency shall establish and maintain an information system to make encounter data, financial data, and other measures of plan performance available to the public and any interested party.
(a) Information submitted by the managed care plans shall be available online as well as in other formats.
(b) Periodic agency reports shall be published that include summary as well as plan specific measures of financial performance and service utilization.
(c) Any release of the financial and encounter data submitted by managed care plans shall ensure the confidentiality of personal health information.
(8) The agency may, on a case-by-case basis, exempt a recipient from mandatory enrollment in a managed care plan when the recipient has a unique, time-limited disease or condition-related circumstance and managed care enrollment will interfere with ongoing care because the recipient’s provider does not participate in the managed care plans available in the recipient’s area.
(9) If required as a condition of a waiver, the agency may calculate a medical loss ratio for managed care plans. The calculation shall utilize uniform financial data collected from all plans and shall be computed for each plan on a statewide basis. The method for calculating the medical loss ratio shall meet the following criteria:
(a) Except as provided in paragraphs (b) and (c), expenditures shall be classified in a manner consistent with 45 C.F.R. part 158.
(b) Funds provided by plans to graduate medical education institutions to underwrite the costs of residency positions shall be classified as medical expenditures, provided the funding is sufficient to sustain the positions for the number of years necessary to complete the residency requirements and the residency positions funded by the plans are active providers of care to Medicaid and uninsured patients.
(c) Prior to final determination of the medical loss ratio for any period, a plan may contribute to a designated state trust fund for the purpose of supporting Medicaid and indigent care and have the contribution counted as a medical expenditure for the period.
History.—s. 51, ch. 93-129; s. 1, ch. 95-281; s. 7, ch. 96-199; s. 203, ch. 97-101; s. 4, ch. 97-168; s. 190, ch. 97-264; s. 3, ch. 97-290; s. 31, ch. 98-191; s. 29, ch. 2000-171; s. 53, ch. 2001-62; s. 10, ch. 2001-104; ss. 10, 11, ch. 2001-377; s. 997, ch. 2002-387; ss. 28, 29, ch. 2002-400; s. 19, ch. 2003-405; s. 56, ch. 2004-5; s. 18, ch. 2004-270; s. 23, ch. 2004-344; s. 17, ch. 2005-60; s. 6, ch. 2005-133; s. 19, ch. 2006-28; ss. 5, 6, ch. 2007-331; s. 12, ch. 2008-143; s. 16, ch. 2009-55; s. 13, ch. 2011-61; s. 21, ch. 2011-135; s. 49, ch. 2012-5; s. 11, ch. 2012-33; s. 3, ch. 2012-44; s. 9, ch. 2013-48; s. 209, ch. 2014-19; s. 16, ch. 2015-3.