Bill Text: FL S0730 | 2012 | Regular Session | Enrolled
Bill Title: Medicaid Managed Care
Spectrum: Slight Partisan Bill (Republican 3-1)
Status: (Enrolled - Dead) 2012-03-08 - Ordered engrossed, then enrolled -SJ 1134 [S0730 Detail]
Download: Florida-2012-S0730-Enrolled.html
ENROLLED 2012 Legislature CS for SB 730, 1st Engrossed 2012730er 1 2 An act relating to Medicaid managed care; amending s. 3 408.7056, F.S.; specifying which health plan entities 4 are subject to the subscriber assistance program; 5 amending s. 409.912, F.S.; authorizing the Agency for 6 Health Care Administration to extend or modify certain 7 contracts with behavioral health care providers under 8 specified circumstances; removing the expiration of 9 the authority of the agency to impose fines against 10 entities under contract with the department under 11 specified circumstances; amending s. 409.9122, F.S.; 12 directing the agency to calculate a medical loss ratio 13 for managed care plans under specified circumstances 14 and providing the method of calculation; amending s. 15 409.961, F.S.; specifying that contracts necessary to 16 administer the Medicaid program are not rules and are 17 not subject to ch. 120, F.S., the Administrative 18 Procedure Act; amending s. 409.962, F.S.; including 19 certain Medicare plans in the definition of the term 20 “comprehensive long-term care plan”; including certain 21 Medicare plans in the managed medical assistance 22 program by amending the definition of the term 23 “eligible plan”; amending s. 409.966, F.S.; modifying 24 a preference for plans with in-state operations; 25 revising a definition; amending s. 409.967, F.S.; 26 limiting the penalty that a plan must pay if it leaves 27 a region before the end of the contract term; 28 directing the agency to calculate a medical loss ratio 29 for managed care plans under specified circumstances 30 and providing the method of calculation; amending s. 31 409.973, F.S.; requiring a managed care plan to inform 32 the enrollee of the importance of having a primary 33 care provider; amending s. 409.974, F.S.; revising 34 requirements for participation by specialty plans; 35 revising requirements for participation by certain 36 Medicare plans; requiring contracts to meet certain 37 standards; setting enrollment requirements; amending 38 s. 409.981, F.S.; modifying requirements for 39 participation by Medicare Advantage Special Needs 40 Plans; requiring contracts to meet certain standards; 41 establishing enrollment requirements; amending s. 42 627.602, F.S.; applying federal internal grievance 43 procedures to certain health insurance policies; 44 providing exceptions; creating s. 627.6513, F.S.; 45 applying federal internal grievance procedures to 46 certain group health insurance policies; providing 47 exceptions; creating s. 641.312, F.S.; authorizing the 48 Office of Insurance Regulation to adopt rules to 49 administer the federal procedures; providing effective 50 dates. 51 52 Be It Enacted by the Legislature of the State of Florida: 53 54 Section 1. Effective May 12, 2012, subsection (15) is added 55 to section 408.7056, Florida Statutes, to read: 56 408.7056 Subscriber Assistance Program.— 57 (15) This section applies only to prepaid health clinics 58 certified under chapter 641, Florida Healthy Kids plans, and 59 health plan health insurance policies or health maintenance 60 contracts that meet the requirements of 45 C.F.R. s. 147.140, 61 but only if the health plan does not elect to have all of its 62 health insurance policies or health maintenance contracts 63 subject to applicable internal grievance and external review 64 processes by an independent review organization. A health plan 65 must notify the agency in writing if it elects to have all of 66 its health insurance policies or health maintenance contracts 67 subject to such external review. 68 Section 2. Paragraph (b) of subsection (4) and subsection 69 (21) of section 409.912, Florida Statutes, are amended to read: 70 409.912 Cost-effective purchasing of health care.—The 71 agency shall purchase goods and services for Medicaid recipients 72 in the most cost-effective manner consistent with the delivery 73 of quality medical care. To ensure that medical services are 74 effectively utilized, the agency may, in any case, require a 75 confirmation or second physician’s opinion of the correct 76 diagnosis for purposes of authorizing future services under the 77 Medicaid program. This section does not restrict access to 78 emergency services or poststabilization care services as defined 79 in 42 C.F.R. part 438.114. Such confirmation or second opinion 80 shall be rendered in a manner approved by the agency. The agency 81 shall maximize the use of prepaid per capita and prepaid 82 aggregate fixed-sum basis services when appropriate and other 83 alternative service delivery and reimbursement methodologies, 84 including competitive bidding pursuant to s. 287.057, designed 85 to facilitate the cost-effective purchase of a case-managed 86 continuum of care. The agency shall also require providers to 87 minimize the exposure of recipients to the need for acute 88 inpatient, custodial, and other institutional care and the 89 inappropriate or unnecessary use of high-cost services. The 90 agency shall contract with a vendor to monitor and evaluate the 91 clinical practice patterns of providers in order to identify 92 trends that are outside the normal practice patterns of a 93 provider’s professional peers or the national guidelines of a 94 provider’s professional association. The vendor must be able to 95 provide information and counseling to a provider whose practice 96 patterns are outside the norms, in consultation with the agency, 97 to improve patient care and reduce inappropriate utilization. 98 The agency may mandate prior authorization, drug therapy 99 management, or disease management participation for certain 100 populations of Medicaid beneficiaries, certain drug classes, or 101 particular drugs to prevent fraud, abuse, overuse, and possible 102 dangerous drug interactions. The Pharmaceutical and Therapeutics 103 Committee shall make recommendations to the agency on drugs for 104 which prior authorization is required. The agency shall inform 105 the Pharmaceutical and Therapeutics Committee of its decisions 106 regarding drugs subject to prior authorization. The agency is 107 authorized to limit the entities it contracts with or enrolls as 108 Medicaid providers by developing a provider network through 109 provider credentialing. The agency may competitively bid single 110 source-provider contracts if procurement of goods or services 111 results in demonstrated cost savings to the state without 112 limiting access to care. The agency may limit its network based 113 on the assessment of beneficiary access to care, provider 114 availability, provider quality standards, time and distance 115 standards for access to care, the cultural competence of the 116 provider network, demographic characteristics of Medicaid 117 beneficiaries, practice and provider-to-beneficiary standards, 118 appointment wait times, beneficiary use of services, provider 119 turnover, provider profiling, provider licensure history, 120 previous program integrity investigations and findings, peer 121 review, provider Medicaid policy and billing compliance records, 122 clinical and medical record audits, and other factors. Providers 123 are not entitled to enrollment in the Medicaid provider network. 124 The agency shall determine instances in which allowing Medicaid 125 beneficiaries to purchase durable medical equipment and other 126 goods is less expensive to the Medicaid program than long-term 127 rental of the equipment or goods. The agency may establish rules 128 to facilitate purchases in lieu of long-term rentals in order to 129 protect against fraud and abuse in the Medicaid program as 130 defined in s. 409.913. The agency may seek federal waivers 131 necessary to administer these policies. 132 (4) The agency may contract with: 133 (b) An entity that is providing comprehensive behavioral 134 health care services to certain Medicaid recipients through a 135 capitated, prepaid arrangement pursuant to the federal waiver 136 provided for by s. 409.905(5). Such entity must be licensed 137 under chapter 624, chapter 636, or chapter 641, or authorized 138 under paragraph (c) or paragraph (d), and must possess the 139 clinical systems and operational competence to manage risk and 140 provide comprehensive behavioral health care to Medicaid 141 recipients. As used in this paragraph, the term “comprehensive 142 behavioral health care services” means covered mental health and 143 substance abuse treatment services that are available to 144 Medicaid recipients. The secretary of the Department of Children 145 and Family Services shall approve provisions of procurements 146 related to children in the department’s care or custody before 147 enrolling such children in a prepaid behavioral health plan. Any 148 contract awarded under this paragraph must be competitively 149 procured. In developing the behavioral health care prepaid plan 150 procurement document, the agency shall ensure that the 151 procurement document requires the contractor to develop and 152 implement a plan to ensure compliance with s. 394.4574 related 153 to services provided to residents of licensed assisted living 154 facilities that hold a limited mental health license. Except as 155 provided in subparagraph 5., and except in counties where the 156 Medicaid managed care pilot program is authorized pursuant to s. 157 409.91211, the agency shall seek federal approval to contract 158 with a single entity meeting these requirements to provide 159 comprehensive behavioral health care services to all Medicaid 160 recipients not enrolled in a Medicaid managed care plan 161 authorized under s. 409.91211, a provider service network 162 authorized under paragraph (d), or a Medicaid health maintenance 163 organization in an AHCA area. In an AHCA area where the Medicaid 164 managed care pilot program is authorized pursuant to s. 165 409.91211 in one or more counties, the agency may procure a 166 contract with a single entity to serve the remaining counties as 167 an AHCA area or the remaining counties may be included with an 168 adjacent AHCA area and are subject to this paragraph. Each 169 entity must offer a sufficient choice of providers in its 170 network to ensure recipient access to care and the opportunity 171 to select a provider with whom they are satisfied. The network 172 shall include all public mental health hospitals. To ensure 173 unimpaired access to behavioral health care services by Medicaid 174 recipients, all contracts issued pursuant to this paragraph must 175 require 80 percent of the capitation paid to the managed care 176 plan, including health maintenance organizations and capitated 177 provider service networks, to be expended for the provision of 178 behavioral health care services. If the managed care plan 179 expends less than 80 percent of the capitation paid for the 180 provision of behavioral health care services, the difference 181 shall be returned to the agency. The agency shall provide the 182 plan with a certification letter indicating the amount of 183 capitation paid during each calendar year for behavioral health 184 care services pursuant to this section. The agency may reimburse 185 for substance abuse treatment services on a fee-for-service 186 basis until the agency finds that adequate funds are available 187 for capitated, prepaid arrangements. 188 1. The agency shall modify the contracts with the entities 189 providing comprehensive inpatient and outpatient mental health 190 care services to Medicaid recipients in Hillsborough, Highlands, 191 Hardee, Manatee, and Polk Counties, to include substance abuse 192 treatment services. 193 2. Except as provided in subparagraph 5., the agency and 194 the Department of Children and Family Services shall contract 195 with managed care entities in each AHCA area except area 6 or 196 arrange to provide comprehensive inpatient and outpatient mental 197 health and substance abuse services through capitated prepaid 198 arrangements to all Medicaid recipients who are eligible to 199 participate in such plans under federal law and regulation. In 200 AHCA areas where eligible individuals number less than 150,000, 201 the agency shall contract with a single managed care plan to 202 provide comprehensive behavioral health services to all 203 recipients who are not enrolled in a Medicaid health maintenance 204 organization, a provider service network authorized under 205 paragraph (d), or a Medicaid capitated managed care plan 206 authorized under s. 409.91211. The agency may contract with more 207 than one comprehensive behavioral health provider to provide 208 care to recipients who are not enrolled in a Medicaid capitated 209 managed care plan authorized under s. 409.91211, a provider 210 service network authorized under paragraph (d), or a Medicaid 211 health maintenance organization in AHCA areas where the eligible 212 population exceeds 150,000. In an AHCA area where the Medicaid 213 managed care pilot program is authorized pursuant to s. 214 409.91211 in one or more counties, the agency may procure a 215 contract with a single entity to serve the remaining counties as 216 an AHCA area or the remaining counties may be included with an 217 adjacent AHCA area and shall be subject to this paragraph. 218 Contracts for comprehensive behavioral health providers awarded 219 pursuant to this section shall be competitively procured. Both 220 for-profit and not-for-profit corporations are eligible to 221 compete. Managed care plans contracting with the agency under 222 subsection (3) or paragraph (d) shall provide and receive 223 payment for the same comprehensive behavioral health benefits as 224 provided in AHCA rules, including handbooks incorporated by 225 reference. In AHCA area 11, the agency shall contract with at 226 least two comprehensive behavioral health care providers to 227 provide behavioral health care to recipients in that area who 228 are enrolled in, or assigned to, the MediPass program. One of 229 the behavioral health care contracts must be with the existing 230 provider service network pilot project, as described in 231 paragraph (d), for the purpose of demonstrating the cost 232 effectiveness of the provision of quality mental health services 233 through a public hospital-operated managed care model. Payment 234 shall be at an agreed-upon capitated rate to ensure cost 235 savings. Of the recipients in area 11 who are assigned to 236 MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those 237 MediPass-enrolled recipients shall be assigned to the existing 238 provider service network in area 11 for their behavioral care. 239 3. Children residing in a statewide inpatient psychiatric 240 program, or in a Department of Juvenile Justice or a Department 241 of Children and Family Services residential program approved as 242 a Medicaid behavioral health overlay services provider may not 243 be included in a behavioral health care prepaid health plan or 244 any other Medicaid managed care plan pursuant to this paragraph. 245 4. Traditional community mental health providers under 246 contract with the Department of Children and Family Services 247 pursuant to part IV of chapter 394, child welfare providers 248 under contract with the Department of Children and Family 249 Services in areas 1 and 6, and inpatient mental health providers 250 licensed pursuant to chapter 395 must be offered an opportunity 251 to accept or decline a contract to participate in any provider 252 network for prepaid behavioral health services. 253 5. All Medicaid-eligible children, except children in area 254 1 and children in Highlands County, Hardee County, Polk County, 255 or Manatee County of area 6, that are open for child welfare 256 services in the statewide automated child welfare information 257 system, shall receive their behavioral health care services 258 through a specialty prepaid plan operated by community-based 259 lead agencies through a single agency or formal agreements among 260 several agencies. The agency shall work with the specialty plan 261 to develop clinically effective, evidence-based alternatives as 262 a downward substitution for the statewide inpatient psychiatric 263 program and similar residential care and institutional services. 264 The specialty prepaid plan must result in savings to the state 265 comparable to savings achieved in other Medicaid managed care 266 and prepaid programs. Such plan must provide mechanisms to 267 maximize state and local revenues. The specialty prepaid plan 268 shall be developed by the agency and the Department of Children 269 and Family Services. The agency may seek federal waivers to 270 implement this initiative. Medicaid-eligible children whose 271 cases are open for child welfare services in the statewide 272 automated child welfare information system and who reside in 273 AHCA area 10 shall be enrolled in a capitated provider service 274 network or other capitated managed care plan, which, in 275 coordination with available community-based care providers 276 specified in s. 409.1671, shall provide sufficient medical, 277 developmental, and behavioral health services to meet the needs 278 of these children. 279 280 Effective July, 1, 2012, in order to ensure continuity of care, 281 the agency is authorized to extend or modify current contracts 282 based on current service areas or on a regional basis, as 283 determined appropriate by the agency, with comprehensive 284 behavioral health care providers as described in this paragraph 285 during the period prior to its expiration. This paragraph 286 expires October 1, 2014. 287 (21) The agency may impose a fine for a violation of this 288 section or the contract with the agency by a person or entity 289 that is under contract with the agency. With respect to any 290 nonwillful violation, such fine shall not exceed $2,500 per 291 violation. In no event shall such fine exceed an aggregate 292 amount of $10,000 for all nonwillful violations arising out of 293 the same action. With respect to any knowing and willful 294 violation of this section or the contract with the agency, the 295 agency may impose a fine upon the entity in an amount not to 296 exceed $20,000 for each such violation. In no event shall such 297 fine exceed an aggregate amount of $100,000 for all knowing and 298 willful violations arising out of the same action.This299subsection expires October 1, 2014.300 Section 3. Subsection (21) is added to section 409.9122, 301 Florida Statutes, to read: 302 409.9122 Mandatory Medicaid managed care enrollment; 303 programs and procedures.— 304 (21) If required as a condition of a waiver, the agency may 305 calculate a medical loss ratio for managed care plans. The 306 calculation shall utilize uniform financial data collected from 307 all plans and shall be computed for each plan on a statewide 308 basis. The method for calculating the medical loss ratio shall 309 meet the following criteria: 310 (a) Except as provided in paragraphs (b) and (c), 311 expenditures shall be classified in a manner consistent with 45 312 C.F.R. part 158. 313 (b) Funds provided by plans to graduate medical education 314 institutions to underwrite the costs of residency positions 315 shall be classified as medical expenditures, provided the 316 funding is sufficient to sustain the position for the number of 317 years necessary to complete the residency requirements and the 318 residency positions funded by the plans are active providers of 319 care to Medicaid and uninsured patients. 320 (c) Prior to final determination of the medical loss ratio 321 for any period, a plan may contribute to a designated state 322 trust fund for the purpose of supporting Medicaid and indigent 323 care and have the contribution counted as a medical expenditure 324 for the period. 325 Section 4. Section 409.961, Florida Statutes, is amended to 326 read: 327 409.961 Statutory construction; applicability; rules.—It is 328 the intent of the Legislature that if any conflict exists 329 between the provisions contained in this part and in other parts 330 of this chapter, the provisions in this part control. Sections 331 409.961–409.985 apply only to the Medicaid managed medical 332 assistance program and long-term care managed care program, as 333 provided in this part. The agency shall adopt any rules 334 necessary to comply with or administer this part and all rules 335 necessary to comply with federal requirements. In addition, the 336 department shall adopt and accept the transfer of any rules 337 necessary to carry out the department’s responsibilities for 338 receiving and processing Medicaid applications and determining 339 Medicaid eligibility and for ensuring compliance with and 340 administering this part, as those rules relate to the 341 department’s responsibilities, and any other provisions related 342 to the department’s responsibility for the determination of 343 Medicaid eligibility. Contracts with the agency and a person or 344 entity, including Medicaid providers and managed care plans, 345 necessary to administer the Medicaid program are not rules and 346 are not subject to chapter 120. 347 Section 5. Subsections (4) and (6) of section 409.962, 348 Florida Statutes, are amended to read: 349 409.962 Definitions.—As used in this part, except as 350 otherwise specifically provided, the term: 351 (4) “Comprehensive long-term care plan” means a managed 352 care plan, including a Medicare Advantage Special Needs Plan 353 organized as a preferred provider organization, provider 354 sponsored organization, health maintenance organization, or 355 coordinated care plan, that provides services described in s. 356 409.973 and also provides the services described in s. 409.98. 357 (6) “Eligible plan” means a health insurer authorized under 358 chapter 624, an exclusive provider organization authorized under 359 chapter 627, a health maintenance organization authorized under 360 chapter 641, or a provider service network authorized under s. 361 409.912(4)(d) or an accountable care organization authorized 362 under federal law. For purposes of the managed medical 363 assistance program, the term also includes the Children’s 364 Medical Services Network authorized under chapter 391 and. For365purposes of the long-term care managed care program, the term366also includesentities qualified under 42 C.F.R. part 422 as 367 Medicare Advantage Preferred Provider Organizations, Medicare 368 Advantage Provider-sponsored Organizations, Medicare Advantage 369 Health Maintenance Organizations, Medicare Advantage Coordinated 370 Care Plans, and Medicare Advantage Special Needs Plans, and the 371 Program of All-inclusive Care for the Elderly. 372 Section 6. Paragraph (c) of subsection (3) of section 373 409.966, Florida Statutes, is amended to read: 374 409.966 Eligible plans; selection.— 375 (3) QUALITY SELECTION CRITERIA.— 376 (c) After negotiations are conducted, the agency shall 377 select the eligible plans that are determined to be responsive 378 and provide the best value to the state. Preference shall be 379 given to plans that: 380 1. Have signed contracts with primary and specialty 381 physicians in sufficient numbers to meet the specific standards 382 established pursuant to s. 409.967(2)(b). 383 2. Have well-defined programs for recognizing patient 384 centered medical homes and providing for increased compensation 385 for recognized medical homes, as defined by the plan. 386 3. Are organizations that are based in and perform 387 operational functions in this state, in-house or through 388 contractual arrangements, by staff located in this state. Using 389 a tiered approach, the highest number of points shall be awarded 390 to a plan that has all or substantially all of its operational 391 functions performed in the state. The second highest number of 392 points shall be awarded to a plan that has a majority of its 393 operational functions performed in the state. The agency may 394 establish a third tier; however, preference points may not be 395 awarded to plans that perform only community outreach, medical 396 director functions, and state administrative functions in the 397 state. For purposes of this subparagraph, operational functions 398 include corporate headquarters, claims processing, member 399 services, provider relations, utilization and prior 400 authorization, case management, disease and quality functions, 401 and finance and administration. For purposes of this 402 subparagraph, the term “corporate headquarters”“based in this403state”meansthattheentity’sprincipal office ofis in this404state andthe organization, which may not beplan is nota 405 subsidiary, directly or indirectly through one or more 406 subsidiaries of, or a joint venture with, any other entity whose 407 principal office is not located in the state. 408 4. Have contracts or other arrangements for cancer disease 409 management programs that have a proven record of clinical 410 efficiencies and cost savings. 411 5. Have contracts or other arrangements for diabetes 412 disease management programs that have a proven record of 413 clinical efficiencies and cost savings. 414 6. Have a claims payment process that ensures that claims 415 that are not contested or denied will be promptly paid pursuant 416 to s. 641.3155. 417 Section 7. Paragraph (h) of subsection (2) of section 418 409.967, Florida Statutes, is amended, and subsection (4) is 419 added to that section, to read: 420 409.967 Managed care plan accountability.— 421 (2) The agency shall establish such contract requirements 422 as are necessary for the operation of the statewide managed care 423 program. In addition to any other provisions the agency may deem 424 necessary, the contract must require: 425 (h) Penalties.— 426 1. Withdrawal and enrollment reduction.—Managed care plans 427 that reduce enrollment levels or leave a region before the end 428 of the contract term must reimburse the agency for the cost of 429 enrollment changes and other transition activities. If more than 430 one plan leaves a region at the same time, costs must be shared 431 by the departing plans proportionate to their enrollments. In 432 addition to the payment of costs, departing provider services 433 networks must pay a per-enrolleeper enrolleepenalty of up to 3 434 months’ payment and continue to provide services to the enrollee 435 for 90 days or until the enrollee is enrolled in another plan, 436 whichever occurs first. In addition to payment of costs, all 437 other departing plans must pay a penalty of 25 percent of that 438 portion of the minimum surplus maintainedrequirementpursuant 439 to s. 641.225(1) which is attributable to the provision of 440 coverage to Medicaid enrollees. Plans shall provide at least 180 441 days’ notice to the agency before withdrawing from a region. If 442 a managed care plan leaves a region before the end of the 443 contract term, the agency shall terminate all contracts with 444 that plan in other regions,pursuant to the termination 445 procedures in subparagraph 3. 446 2. Encounter data.—If a plan fails to comply with the 447 encounter data reporting requirements of this section for 30 448 days, the agency must assess a fine of $5,000 per day for each 449 day of noncompliance beginning on the 31st day. On the 31st day, 450 the agency must notify the plan that the agency will initiate 451 contract termination procedures on the 90th day unless the plan 452 comes into compliance before that date. 453 3. Termination.—If the agency terminates more than one 454 regional contract with the same managed care plan due to 455 noncompliance with the requirements of this section, the agency 456 shall terminate all the regional contracts held by that plan. 457 When terminating multiple contracts, the agency must develop a 458 plan to provide for the transition of enrollees to other plans, 459 and phase inphase-inthe terminations over a time period 460 sufficient to ensure a smooth transition. 461 (4) MEDICAL LOSS RATIO.—If required as a condition of a 462 waiver, the agency may calculate a medical loss ratio for 463 managed care plans. The calculation shall use uniform financial 464 data collected from all plans and shall be computed for each 465 plan on a statewide basis. The method for calculating the 466 medical loss ratio shall meet the following criteria: 467 (a) Except as provided in paragraphs (b) and (c), 468 expenditures shall be classified in a manner consistent with 45 469 C.F.R. part 158. 470 (b) Funds provided by plans to graduate medical education 471 institutions to underwrite the costs of residency positions 472 shall be classified as medical expenditures, provided the 473 funding is sufficient to sustain the position for the number of 474 years necessary to complete the residency requirements and the 475 residency positions funded by the plans are active providers of 476 care to Medicaid and uninsured patients. 477 (c) Prior to final determination of the medical loss ratio 478 for any period, a plan may contribute to a designated state 479 trust fund for the purpose of supporting Medicaid and indigent 480 care and have the contribution counted as a medical expenditure 481 for the period. 482 Section 8. Subsection (4) of section 409.973, Florida 483 Statutes, is amended to read: 484 409.973 Benefits.— 485 (4) PRIMARY CARE INITIATIVE.—Each plan operating in the 486 managed medical assistance program shall establish a program to 487 encourage enrollees to establish a relationship with their 488 primary care provider. Each plan shall: 489 (a) Provide information to each enrollee on the importance 490 of and procedure for selecting a primary care provider 491physician, and thereafter automatically assign to a primary care 492 provider any enrollee who fails to choose a primary care 493 provider. 494 (b) If the enrollee was not a Medicaid recipient before 495 enrollment in the plan, assist the enrollee in scheduling an 496 appointment with the primary care provider. If possible the 497 appointment should be made within 30 days after enrollment in 498 the plan. For enrollees who become eligible for Medicaid between 499 January 1, 2014, and December 31, 2015, the appointment should 500 be scheduled within 6 months after enrollment in the plan. 501 (c) Report to the agency the number of enrollees assigned 502 to each primary care provider within the plan’s network. 503 (d) Report to the agency the number of enrollees who have 504 not had an appointment with their primary care provider within 505 their first year of enrollment. 506 (e) Report to the agency the number of emergency room 507 visits by enrollees who have not had at least one appointment 508 with their primary care provider. 509 Section 9. Subsection (3) of section 409.974, Florida 510 Statutes, is amended, and subsection (5) is added to that 511 section, to read: 512 409.974 Eligible plans.— 513 (3) SPECIALTY PLANS.—Participation by specialty plans shall 514 be subject to the procurement requirementsand regional plan515number limitsof this section. The aggregate enrollment of all 516 specialty plans in a region may not exceed 10 percent of the 517 total enrollees of that region.However, a specialty plan whose518target population includes no more than 10 percent of the519enrollees of that region is not subject to the regional plan520number limits of this section.521 (5) MEDICARE PLANS.—Participation by a Medicare Advantage 522 Preferred Provider Organization, Medicare Advantage Provider 523 sponsored Organization, Medicare Advantage Health Maintenance 524 Organization, Medicare Advantage Coordinated Care Plan, or 525 Medicare Advantage Special Needs Plan shall be pursuant to a 526 contract with the agency that is consistent with the Medicare 527 Improvement for Patients and Providers Act of 2008, Pub. L. No. 528 110-275. Such plans are not subject to the procurement 529 requirements if the plan’s Medicaid enrollees consist 530 exclusively of dually eligible recipients who are enrolled in 531 the plan in order to receive Medicare benefits as of the date 532 that the invitation to negotiate is issued. Otherwise, such 533 plans are subject to all procurement requirements. 534 Section 10. Subsection (5) of section 409.981, Florida 535 Statutes, is amended to read: 536 409.981 Eligible long-term care plans.— 537 (5) MEDICARE ADVANTAGE SPECIAL NEEDS PLANS.—Participation 538 by aMedicare Advantage Preferred Provider Organization,539Medicare Advantage Provider-sponsored Organization, orMedicare 540 Advantage Special Needs Plan shall be pursuant to a contract 541 with the agency that is consistent with the Medicare Improvement 542 for Patients and Providers Act of 2008, Pub. L. No. 110-275. 543 Such plans areandnot subject to the procurement requirements 544 if the plan’s Medicaid enrollees consist exclusively of dually 545 eligible recipients who are enrolled in the plan in order to 546 receive Medicare benefits as of the date the invitation to 547 negotiate is issueddeemed dually eligible for Medicaid and548Medicare services. Otherwise,Medicare Advantage Preferred549Provider Organizations, Medicare Advantage Provider-sponsored550Organizations, andMedicare Advantage Special Needs Plans are 551 subject to all procurement requirements. 552 Section 11. Effective May 12, 2012, paragraph (h) is added 553 to subsection (1) of section 627.602, Florida Statutes, to read: 554 627.602 Scope, format of policy.— 555 (1) Each health insurance policy delivered or issued for 556 delivery to any person in this state must comply with all 557 applicable provisions of this code and all of the following 558 requirements: 559 (h) Section 641.312 and the provisions of the Employee 560 Retirement Income Security Act of 1974, as implemented by 29 561 C.F.R. s. 2560.503-1, relating to internal grievances. This 562 paragraph does not apply to a health insurance policy that is 563 subject to the subscriber assistance program under s. 408.7056 564 or to the types of benefits or coverages provided under s. 565 627.6561(5)(b)-(e) issued in any market. 566 Section 12. Effective May 12, 2012, section 627.6513, 567 Florida Statutes, is created to read: 568 627.6513 Scope.—Section 641.312 and the provisions of the 569 Employee Retirement Income Security Act of 1974, as implemented 570 by 29 C.F.R. s. 2560.503-1, relating to internal grievances, 571 apply to all group health insurance policies issued under this 572 part. This section does not apply to a group health insurance 573 policy that is subject to the subscriber assistance program in 574 s. 408.7056 or to the types of benefits or coverages provided 575 under s. 627.6561(5)(b)-(e) issued in any market. 576 Section 13. Effective May 12, 2012, section 641.312, 577 Florida Statutes, is created to read: 578 641.312 Scope.—The Office of Insurance Regulation may adopt 579 rules to administer the provisions of the National Association 580 of Insurance Commissioners’ Uniform Health Carrier External 581 Review Model Act, issued by the National Association of 582 Insurance Commissioners and dated April 2010. This section does 583 not apply to a health maintenance contract that is subject to 584 the subscriber assistance program under s. 408.7056 or to the 585 types of benefits or coverages provided under s. 625.6561(5)(b) 586 (e) issued in any market. 587 Section 14. Except as otherwise expressly provided in this 588 act and except for this section, which shall take effect upon 589 this act becoming a law, this act shall take effect July 1, 590 2012.