Florida § 409.983 - Long-term care managed care plan payment.

§ 409.983. Long-term care managed care plan payment.

In addition to the payment provisions of s. 409.968, the agency shall provide payment to plans in the long-term care managed care program pursuant to this section. (1) Prepaid payment rates for long-term care managed care plans shall be negotiated between the agency and the eligible plans as part of the procurement process described in s. 409.966. (2) Payment rates for comprehensive long-term care plans covering services described in s. 409.973 shall be blended with rates for long-term care plans for services specified in s. 409.98. (3) Payment rates for plans must reflect historic utilization and spending for covered services projected forward and adjusted to reflect the level of care profile for enrollees in each plan. The payment shall be adjusted to provide an incentive for reducing institutional placements and increasing the utilization of home and community-based services. (4) The initial assessment of an enrollee’s level of care shall be reviewed or performed by the Comprehensive Assessment and Review for Long-Term Care Services (CARES) program, which shall assign the recipient into one of the following levels of care: (a) Level of care 1 consists of recipients residing in or who must be placed in a nursing home. (b) Level of care 2 consists of recipients at imminent risk of nursing home placement, as evidenced by the need for the constant availability of routine medical and nursing treatment and care, and who require extensive health-related care and services because of mental or physical incapacitation. (c) Level of care 3 consists of recipients at imminent risk of nursing home placement, as evidenced by the need for the constant availability of routine medical and nursing treatment and care, who have a limited need for health-related care and services and are mildly medically or physically incapacitated. The agency shall periodically adjust payment rates to account for changes in the level of care profile for each managed care plan based on encounter data. (5) The agency shall make an incentive adjustment in payment rates to encourage the increased utilization of home and community-based services and a commensurate reduction of institutional placement. The incentive adjustment shall be modified in each successive rate period during the first contract period, as follows: (a) A 2-percentage point shift in the first rate-setting period; (b) A 2-percentage point shift in the second rate-setting period, as compared to the utilization mix at the end of the first rate-setting period; or (c) A 3-percentage point shift in the third rate-setting period, and in each subsequent rate-setting period during the first contract period, as compared to the utilization mix at the end of the immediately preceding rate-setting period. The incentive adjustment shall continue in subsequent contract periods, at a rate of 3 percentage points per year as compared to the utilization mix at the end of the immediately preceding rate-setting period, until no more than 35 percent of the plan’s enrollees are placed in institutional settings. The agency shall annually report to the Legislature the actual change in the utilization mix of home and community-based services compared to institutional placements and provide a recommendation for utilization mix requirements for future contracts. (6) The agency shall establish nursing-facility-specific payment rates for each licensed nursing home as authorized in the General Appropriations Act. Payments to long-term care managed care plans shall be reconciled, as necessary, to reimburse actual payments to nursing facilities resulting from changes in nursing home per diem rates, but may not be reconciled to actual days experienced by the long-term care managed care plans. (7) The agency shall establish hospice payment rates pursuant to Title XVIII of the Social Security Act. Payments to long-term care managed care plans shall be reconciled to reimburse actual payments to hospices.